Category: Rehab News

Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices.

Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson.

Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

By choosing an Express Scripts plan, she charged, J&J cost employees “millions of dollars in the form of higher payments for prescription drugs, higher premiums, higher deductibles, higher coinsurance, higher copays, and lower wages or limited wage growth.”

Lewandowski, 40, from outside Madison, Wisconsin, relies on an expensive multiple sclerosis drug. She brought the lawsuit, she said, because she “had trouble aligning the policy positions” she reported on as a J&J employee “with the actions I experienced as a health plan user.”

In recent years, the opaque business practices of PBMs have drawn fire. The Federal Trade Commission is conducting a lengthy investigation of the three biggest companies and sued them in September, accusing the firms of driving up insulin prices. Bipartisan bills in Congress would rein them in. And businesses such as Mark Cuban’s Cost Plus Drugs and smaller, “transparent PBMs” have tried to wean pharmaceutical companies and health plans from their reliance on the big PBMs.

But Lewandowski’s lawsuit goes to a sensitive spot that had been overlooked until recently: language in the 2021 appropriations bill that revised the 1974 Employee Retirement Income Security Act, known as ERISA. The original law focused on stopping fraudulent retirement plans.

Her lawsuit is based on congressional language specifying that the law’s requirement of prudent management covers health as well as retirement benefits. By providing workers with a health plan, employers aren’t “doing you a favor. They are holding your money and investing it in your health,” said Barak Richman, a George Washington University health law professor.

In July, a similar lawsuit was filed against Wells Fargo, and more suits are in the works.

PBMs demand discounts and rebates from drugmakers, which leads the manufacturers to charge higher list prices, which can drive up the price patients pay at the pharmacy. At the same time, retail pharmacies say PBMs are driving them out of business by paying them less than what the PBMs charge health plans — a practice known as spread pricing. Patients typically have no idea what they’ll pay for a drug, and neither do their employers, because many PBMs’ contracts contain nondisclosure clauses.

Dissatisfaction with the status quo and fear of liability are pushing employers to switch from the “Big Three” PBMs to “transparent PBMs,” which don’t shroud their pricing and drug choice decisions.

“We brought on nine Fortune 500s this year, 1.2 million patients,” said AJ Loiacono, CEO of New York City-based Capital Rx, a PBM founded in 2017. According to a recent survey, as many as half of U.S. employers are considering switching.

Cuban, in an interview with KFF Health News, said he has told hundreds of Fortune 500 executives, in one-on-one meetings and in groups, that they are overpaying on drug benefit plans skewed to fatten the wallets of big PBMs.

“You’re getting ripped off,” Cuban said he tells them. “You don’t really understand the elements, and that’s costing you money and costing you wellness. And now you are going to get sued. It’s not a question of if but a question of when.”

Pressuring a Purchasing Cartel

The billionaire, who launched Mark Cuban Cost Plus Drugs in 2022 to upend the byzantine $500 billion U.S. drug market, is convinced that the Lewandowski suit and others will end the dominance of the big PBMs, which control 80% of the business.

Cost Plus Drugs charges a straight 15% markup with small processing fees for the 2,500 drugs it sells, most of them generics, said co-founder Alex Oshmyansky. Its nearly 3 million customers — individuals, health plans, and transparent PBMs — appear to be saving money in many cases.

The big PBMs say their buying power and exclusive access to information enable them to save money for insurers, employers, and patients. Critics say they are skimming up to 25% from the drug market, perhaps $100 billion a year, according to Oshmyansky. The opaque strategies and conflicts of interest, critics say, often result in the poorest, sickest patients paying the most for medications.

The three PBMs amount to a “purchasing cartel,” Oshmyansky said in an interview at Cost Plus’ Dallas headquarters, once the office of broadcast.com, the internet radio company that made Cuban his first billion dollars when he sold it to Yahoo in 1999. “They buy all the drugs, they jack up the prices, and then they resell them.”

Richman and Amy Monahan of the University of Minnesota argued in a journal article this year that the Department of Labor, which has previously focused its ERISA oversight on retirement benefits, should issue standards for the use of health care dollars under the law.

When companies “enter into dumb contracts with insurers or PBMs, arguably they are in violation of ERISA,” Richman said. “Taking the law seriously would really require employers, who are spending half the health care dollars in the country, to spend that money in very different ways.”

Some drug market experts, however, doubt the ERISA lawsuits will succeed. Complex PBM money channels “make it hard to build a case,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University School of Medicine. “You might think your company is overpaying, but relative to what?”

The ERISA Industry Committee, which lobbies Congress for some of the biggest U.S. companies, is asking Congress to give PBMs the specific duty to represent their clients’ financial interests, said Melissa Bartlett, the group’s senior vice president for health policy. That could require patients to sue the PBMs rather than their employers.

A few big employers are already changing their drug plans.

In 2019, Connecticut became CVS’ first PBM customer to negotiate a transparent fee structure. Its contract required 100% of drug rebates be passed along to the state and eliminated spread pricing.

The state decided to go further when it sought a new contract for its 214,000 employees this year, said Joshua Wojcik, director of health policy and benefits in the state comptroller’s office. Instead of discounts and rebates, it demanded the lowest net cost per employee.

Of the three big PBMs, only CVS bid on the contract. It edged out a few “transparent PBMs” — a sign, in Wojcik’s view, that CVS at least doesn’t want to be left out as more customers ditch the current PBM business model.

With the change, Wojcik estimates the state will save up to $70 million a year.

$13.40 vs. $2,500

Changing drug benefit policies at big companies takes time, said Oshmyansky of Cost Plus. Their PBM contracts last three to five years, so “you have to capture them in that one year where they are evaluating other options,” he said. PBMs pay benefit plan consultants and the brokers big companies hire to steer business their way.

“We have this weird structure where multiple sclerosis, cancer patients subsidize everybody else’s drugs,” Oshmyansky said. Instead of creating a pool that spreads costs to everyone with insurance, there’s a “disproportionate burden placed on the sickest members.”

Cost Plus generates the biggest savings for its customers on about 50 extraordinarily high-priced generic drugs. The poster child is imatinib, a generic cancer pill that Cost Plus sells for $13.40 for a 30-day supply, compared with the $2,500 it retails for at pharmacies. A study conducted by Dusetzina and colleagues found Medicare could save $662 million a year just by buying imatinib and six other generic cancer drugs from Cost Plus rather than through a big PBM.

Ironically, though, most generic drugs are cheaper in the U.S. than in Europe or Canada — so cheap, in fact, that they fall into shortages as companies get out of the business or stop making needed improvements to their production lines.

In response, Cost Plus has started a compounding pharmacy to make common generics and soon hopes to have a sort of “private reserve” of 70 to 80 products that it can make on short notice if they go into shortage, Oshmyansky said.

While the company hasn’t yet set up purchase agreements for most brand-name drugs, Oshmyansky and Cuban are hopeful. Drugmakers, through their trade group Pharmaceutical Research and Manufacturers of America, have lobbied fiercely to rein in PBMs in the past two years.

At a Sept. 24 hearing at which Sen. Bernie Sanders (I-Vt.) grilled Novo Nordisk CEO Lars Fruergaard Jørgensen over high prices for diabetes and weight loss drugs Ozempic and Wegovy, the executive expressed support for a more transparent pricing model.

“On average for our products we give 74% in rebates to PBMs” for every $1 the company charges, he said. If, instead, “we simply paid the PBMs a small fee for the limited risk and contribution they make, I think patients would be significantly better off.”

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. 

Among the biggest-grossing films in America in February 2002 were a war drama about American troops in Somalia (“Black Hawk Down”), an Arnold Schwarzenegger action movie (“Collateral Damage”), and a future Oscar winner about a brilliant mathematician struggling with schizophrenia (“A Beautiful Mind”).

But none of these films topped the box office that month. That title went to “John Q.,” a movie about health insurance.

Or, more precisely, a story about a desperate father — played by Denzel Washington — who takes a hospital emergency room hostage at gunpoint when his HMO refuses to cover a heart transplant for his young son.

John Q.’s violent quest for justice was, of course, fictional. And even in the film, no one ends up dead.

Tragically, that wasn’t the case on the streets of New York City on Dec. 4 when a gunman fatally shot Brian Thompson, CEO of health insurance giant UnitedHealthcare.

But there was nothing new about the anger at health insurers that Thompson’s shooting unleashed online — and which suspect Luigi Mangione expressed in a document he allegedly wrote.

In fact, eruptions of public rage have shadowed the American health care system for decades.

In the late 1990s and early 2000s, as “John Q.” was hitting movie screens, Americans were revolting against HMOs, whose practice of denying care to plan members to pad their bottom lines made them public enemy No. 1.

Just a few years later, health insurers stoked new ire for rescinding coverage after people were diagnosed with expensive illnesses like cancer. More recently, insurers’ widening use of cumbersome prior authorization procedures that slow patients’ access to care has provoked yet another round of fury.

The cycle of outrage periodically turns on others in the health care industry as well. Exorbitant bills and aggressive collection tactics, such as garnishing patients’ wages, are sapping public trust in hospitals and other medical providers.

And drug companies — perennial poster children for greed and profiteering — have enraged Americans since at least the 1950s, when new “wonder drugs” like steroids were fueling a growing industry.

When Sen. Estes Kefauver, a Tennessee Democrat who had led an investigation of the Mafia, convened hearings in 1959 to probe high prescription prices, his committee received mountains of mail from Americans who reported being fleeced by drugmakers. One retired rail worker told of having to spend more than a third of his retirement income on medicines for himself and his wife.

All this public outcry has occasionally sparked change. President Barack Obama and congressional Democrats leveraged anger at spiking insurance premiums in California to get the Affordable Care Act over the finish line in 2010, a landmark achievement that expanded health coverage to millions of Americans.

But more often, cycles of rage have been so much sound and fury, producing only modest reforms. In some cases, public anger has yielded more headaches for patients.

The HMO backlash in the late 1990s and early 2000s, for example, prompted employers — from whom about half of Americans get their health coverage — to embrace high-deductible health plans. Many employers saw these plans as a way to hold down costs if they couldn’t limit patients’ choice of medical providers through HMOs. These deductibles, which can reach thousands of dollars a year, are driving tens of millions of Americans into debt.

To many on the left who have long argued for a single-payer, government-run health system, the obstacle to more meaningful relief has been the political power of the same industries — health insurers, drug companies, hospitals — that fuel patient anger.

These industries have indeed proven adept at resisting change that threatened their bottom lines. They’ve also benefited from a paradox in how Americans think about their health care.

Patients may get angry. They may even lose faith in the system. This year, public views of health care quality fell to the lowest point since Gallup began asking about it in 2001, with 44% of Americans rating quality as excellent or good, down from a high of 62%.

Yet more than 70% said their own health care is excellent or good.

There is much debate about what accounts for this paradox. Are Americans just grateful to have the health protections they do? Are they satisfied because most don’t have to use the health care system on a regular basis? Do they simply like their doctor, in the way that voters routinely say they like their own member of Congress but hate Washington politicians? Or do they worry that no matter how frustrating the current system can be, any change risks making the situation worse?

The answer is probably a bit of all of this. Together, such sentiments represent a major challenge for those who hope the current wave of anger at health insurers will drive big improvements.

Could that change? Maybe. These are volatile and unpredictable political times. And the pressure of big medical bills is real. Medical debt, in particular, is exacting a fearsome toll on millions of Americans, KFF Health News’ reporting has shown.

But to drive change, advocates looking to harness public anger at the health care industry probably need to rethink their favored solutions. Old ideas like “Medicare for All,” long cherished on the left, or a deregulated health care market, long championed by the right, haven’t swayed Americans so far, no matter how angry they’ve been.

I don’t know when we’ll see meaningful alternatives. One thing that’s almost certainly on the way: Hollywood’s spin on the death of a health insurance executive gunned down in Midtown Manhattan.

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. 

Many of President-elect Donald Trump’s candidates for federal health agencies have promoted policies and goals that put them at odds with one another or with Trump’s choice to run the Department of Health and Human Services, Robert F. Kennedy Jr., setting the stage for internal friction over public health initiatives.

The picks hold different views on matters such as limits on abortion, the safety of childhood vaccines, the covid-19 response, and the use of weight-loss medications. The divide pits Trump picks who adhere to more traditional and orthodox science, such as the long-held, scientifically supported findings that vaccines are safe, against often unsubstantiated views advanced by Kennedy and other selections who have claimed vaccines are linked with autism.

The Trump transition team and the designated nominees mentioned in this article did not respond to requests for comment.

It’s a potential “team of opponents” at the government’s health agencies, said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian policy organization.

Kennedy, he said, is known for rejecting opposing views when confronted with science.

“The heads of the FDA and NIH will be spending all their time explaining to their boss what a confidence interval is,” Cannon said, referring to a statistical term used in medical studies.

Those whose views prevail will have significant power in shaping policy, from who is appointed to sit on federal vaccine advisory committees to federal authorization for covid vaccines to restrictions on abortion medications. If confirmed as HHS secretary, Kennedy is expected to set much of the agenda.

“If President Trump’s nomination of RFK Jr. to be secretary is confirmed, if you don’t subscribe to his views, it will be very hard to rise in that department,” said Amesh Adalja, an infectious disease specialist and senior scholar at the Johns Hopkins Center for Health Security. “They will need to suppress their views to fit with RFK Jr’s. In this administration, and any administration, independent public disagreement isn’t welcome.”

Kennedy is chair of Children’s Health Defense, an anti-vaccine nonprofit. He has vowed to curb the country’s appetite for ultra-processed food and its incidence of chronic disease. He helped select Trump’s choices to lead the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes of Health. If confirmed, he would lead them from the helm of HHS, with its more than $1.7 trillion budget.

Clashes are likely. Kennedy has supported access to abortion until a fetus is viable. That puts him at odds with Dave Weldon, the former Florida congressman whom Trump has chosen to run the CDC. Weldon, a physician, is an abortion opponent who wrote one of the major laws allowing health professionals to opt out of participating in the procedure.

Weldon would head an agency that’s been in the crosshairs of conservatives since the covid pandemic began. He has touted his “100% pro-life voting record” on his campaign website. (He unsuccessfully ran earlier this year for a seat in Florida’s House of Representatives.)

Trump has said he would leave decisions about abortion to the states, but the CDC under Weldon could, for example, fund studies on abortion risks. The agency could require states to provide information about abortions performed within their borders to the federal government or risk the loss of federal funds.

Weldon, like Kennedy, has questioned the safety of vaccines and has said he believes they can cause autism. That’s at odds with the views of Marty Makary, a Johns Hopkins surgeon whom Trump plans to nominate for FDA commissioner. The British American said on the “Brian Kilmeade Show” on Fox News Radio that vaccines “save lives,” although he added that it’s good to question the U.S. vaccine schedule for children.

The American Academy of Pediatricians encourages parents and their children’s doctors to stick to the recommended schedule of childhood vaccines. “Nonstandard schedules that spread out vaccines or start when a child is older put entire communities at risk of serious illnesses, including infants and young children,” the group says in guidance for its members.

Jay Bhattacharya, a doctor and economist who is Trump’s selection to lead NIH, has also supported vaccines.

Kennedy has said on NPR that federal authorities under his leadership wouldn’t “take vaccines away from anybody.” But the FDA oversees approval of vaccines, and, under his leadership, the agency could put vaccine skeptics on advisory panels or could make changes to a program that largely protects vaccine makers from consumer injury lawsuits.

“I do believe that autism does come from vaccines,” Kennedy said in 2023 on Fox News. Many scientific studies have discredited the claim that vaccines cause autism.

Ashish Jha, a doctor who served as the White House covid response coordinator from 2022 to 2023, noted that Bhattacharya and Makary have had long and distinguished careers in medicine and research and would bring decades of experience to these top jobs. But, he said, it “is going to be a lot more difficult than they think” to stand up for their views in the new administration.

It’s hard “to do things that displease your boss, and if [Kennedy] gets confirmed, he will be their boss,” Jha said. “They have their work cut out for them if they’re going to stand up for their opinions on science. If they don’t, it will just demoralize the staff.”

Most of Trump’s picks share the view that federal health agencies bungled the pandemic response, a stance that resonated with many of the president-elect’s voters and supporters — even though Trump led that response until Joe Biden took office in 2021.

Kennedy said in a 2021 Louisiana House oversight meeting that the covid vaccine was the “deadliest” ever made. He has cited no evidence to back the claim.

Federal health officials say the vaccines have saved millions of lives around the globe and offer important protection against covid. Protection lasts even though their effectiveness wanes over time.

The vaccines’ effectiveness against infection stood at 52% after four weeks, according to a May study in The New England Journal of Medicine, and their effectiveness against hospitalization was about 67% after four weeks. The vaccines were produced through Operation Warp Speed, a public-private partnership Trump launched in his first term to fast-track the shots as well as other treatments.

Makary criticized covid vaccine guidance that called for giving young children the shots. He argued that, for many people, natural immunity from infections could substitute for the vaccine. Bhattacharya opposed measures used to curb the spread of covid in 2020 and advised that everyone except the most vulnerable go about their lives as usual. The World Health Organization warned that such an approach would overwhelm hospitals.

Mehmet Oz, Trump’s choice to head the Centers for Medicare & Medicaid Services, an agency within HHS, has said the vaccines were oversold. He promoted the use of the anti-malaria drug hydroxychloroquine as a treatment. The FDA in 2020 revoked emergency authorization of hydroxychloroquine for covid, saying that it was unlikely to be effective against the virus and that the risk of dangerous side effects was too high.

Janette Nesheiwat, meanwhile, a former Fox News contributor and Trump’s pick for surgeon general, has taken a different stance. The doctor described covid vaccines as a gift from God in a Fox News opinion piece.

Kennedy’s qualms about vaccines are likely to be a central issue early in the administration. He has said he wants federal health agencies to shift their focus from preparing for and combating infectious disease to addressing chronic disease.

The shifting focus and questioning of vaccines concern some public health leaders amid the spread of the H5N1 bird flu virus among dairy cattle. There have been 60 human infections reported in the U.S. this year, all but two of them linked to exposure to cattle or poultry.

“Early on, they’re going to have to have a discussion about vaccinating people and animals” against bird flu, said Georges C. Benjamin, executive director of the American Public Health Association. “We all bring opinions to the table. A department’s cohesive policy is driven by the secretary.”

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. 

LOS ÁNGELES, California.— La promesa del presidente electo Donald Trump de deportaciones masivas y restricciones migratorias más severas está aumentando la desconfianza en el sistema de salud entre los inmigrantes en California, y nublando el futuro de los proveedores que atienden a los residentes más empobrecidos del estado.

Al mismo tiempo, inmigrantes que viven en el sur de California sin papeles dijeron a KFF Health News que pensaban que la economía mejoraría y que sus ingresos podrían aumentar bajo Trump. Para algunos, esa esperanza supera a sus preocupaciones sobre la atención de salud.

Trabajadores comunitarios de salud dicen que el miedo a la deportación ya está afectando la participación en Medi-Cal, el programa de Medicaid del estado para residentes de bajos ingresos, que en los últimos años se ha estado expandiendo gradualmente a todos los inmigrantes, independientemente de su estatus migratorio. Esto podría socavar el progreso del estado en la reducción de la tasa de personas sin seguro, que alcanzó un mínimo histórico del 6.4% en 2023.

Los inmigrantes sin papeles han temido durante mucho tiempo que participar en programas gubernamentales los convierta en blanco fácil de las autoridades migratorias, y la elección de Trump ha exacerbado estas preocupaciones, según defensores comunitarios.

Se espera que Medicaid esté en la mira de la nueva administración Trump, con recortes de fondos y restricciones de inscripción, lo que preocupa a activistas, ya que podría amenazar la expansión de Medi-Cal y obstaculizar los esfuerzos para extender los subsidios que ayudan a pagar por los seguros de salud bajo Covered California a todos los inmigrantes.

“El miedo por sí solo tiene tantas consecuencias para la salud de nuestras comunidades”, dijo Mar Vélez, directora de políticas de la Latino Coalition for a Healthy California. “Como ellos dicen, esta no es su primera batalla. Entienden cómo funciona el sistema. Creo que esta maquinaria será, desafortunadamente, mucho más dañina para nuestras comunidades”.

A pesar de estas preocupaciones, también hay una corriente de optimismo de que Trump podría beneficiar a la economía, según entrevistas con inmigrantes en Los Ángeles mientras trabajadores de salud estaban invitándolos a inscribirse en Medi-Cal.

Selvin, de 39 años, quien, como otros entrevistados para este artículo, pidió ser identificado solo por su primer nombre porque no tiene papeles, dijo que aunque cree que a Trump no le gustan las personas como él, piensa que la nueva administración podría ayudar a aumentar sus horas en la planta procesadora de alimentos donde trabaja empacando fideos. “Sí veo cómo podría mejorar la economía. Desde esa perspectiva, creo que es bueno que haya ganado”.

Este año, Selvin se convirtió en elegible para Medi-Cal, pero decidió no inscribirse, preocupado de que pudiera poner en peligro sus posibilidades de cambiar su estatus migratorio.

“Lo he pensado”, dijo Selvin, pero “siento que podría terminar perjudicándome. No negaré que, obviamente, me gustaría beneficiarme: arreglarme los dientes, un chequeo físico”. Pero dijo que el miedo lo frena, y no ha visto a un médico en nueve años.

No es el plan de deportación masiva de Trump en particular lo que lo asusta, sin embargo. “Si no estoy cometiendo ningún crimen o manejando ebrio, creo que no me deportarán”, dijo Selvin.

Petrona, de 55 años, vino de El Salvador buscando asilo y se inscribió en Medi-Cal el año pasado.

Dijo que si se recortan sus beneficios de salud, no podría costear sus visitas al dentista.

Vendedora ambulante de comida, escucha a menudo sobre el plan de deportación de Trump, pero dijo que el nuevo presidente expulsará a los criminales. “He oído decir que va a deshacerse de todos los que están robando”.

Aunque teme que pudiera ser deportada, también tiene esperanza en Trump. “Dice que va a dar mucho trabajo a los hispanos porque los latinos son los que trabajan más duro”, dijo. “Eso es bueno, más trabajo para nosotros, los que vinimos aquí a trabajar”.

El recién electo asambleísta republicano Jeff Gonzalez, quien ganó un escaño históricamente demócrata en la región desértica del sureste del estado, con una gran población latina, dijo que sus electores estaban ansiosos por ver un nuevo rumbo económico.

“Están realmente cansados del statu quo en California”, dijo Gonzalez. “La gente en las calles está diciendo: ‘Tengo esperanza’, porque ahora tenemos una perspectiva diferente. Tenemos a un empresario que está viendo las mismas cosas que nosotros estamos viendo, como el precio de los huevos, el precio de la gasolina, la seguridad”.

Gonzalez dijo que no comentará sobre posibles recortes a Medicaid porque Trump no ha hecho ningún anuncio oficial. A diferencia de la mayoría en su partido, Gonzalez aseguró que apoya la extensión de servicios de salud a todos los residentes, independientemente de su estatus migratorio.

Los proveedores de salud dijeron que enfrentan un doble desafío: la reticencia de las personas a las que deben atender y la amenaza de recortes importantes a Medicaid, el programa federal que proporciona más del 60% del financiamiento para Medi-Cal.

Proveedores de salud e investigadores de políticas dicen que una pérdida en las contribuciones federales podría llevar al estado a reducir o eliminar algunos programas, incluida la expansión para cubrir a quienes no tienen documentos.

California y Oregon son los únicos estados que ofrecen un seguro de salud integral a todos los inmigrantes elegibles, independientemente de su estatus. En California, se han inscrito cerca de 1.5 millones de personas sin papeles, a un costo de más de $6.000 millones al año para los contribuyentes del estado.

“Todo el mundo quiere poner este tipo de servicios en la lista de recortes, lo cual es realmente injusto”, dijo la senadora estatal Lena Gonzalez, demócrata y presidenta del Caucus Legislativo Latino de California. “Haremos todo lo posible para asegurarnos de que esto se priorice”.

La senadora Gonzalez dijo que será un desafío expandir programas como Covered California, el mercado de seguros de salud del estado, para el cual los inmigrantes sin estatus legal no son elegibles. Una gran preocupación para los inmigrantes y sus defensores es que Trump podría restablecer los cambios a la política de carga pública, que habilita para negar tarjetas de residencia o visas basándose en el uso de ciertos beneficios gubernamentales.

“El plan de deportación masiva del presidente Trump pondrá fin al drenaje financiero que representan los inmigrantes ilegales para nuestro sistema de salud y garantizará que nuestro país pueda cuidar a los ciudadanos estadounidenses que dependen de Medicaid, Medicare y el Seguro Social”, dijo Karoline Leavitt, vocera de Trump, en un comunicado para KFF Health News.

Durante su primer mandato, en 2019, Trump amplió la política de carga pública para incluir el uso de Medicaid, así como subsidios de vivienda y para comprar alimentos. La administración Biden rescindió el cambio en 2021.

KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News, encontró que los inmigrantes usan menos servicios de salud que las personas nacidas en los Estados Unidos. Y aproximadamente 1 de cada 4 inmigrantes adultos probablemente indocumentados dijo que ha evitado solicitar asistencia para la atención de salud, alimentos y vivienda debido a temores relacionados con la inmigración, según una encuesta de 2023.

Otra incertidumbre es el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), que se expandió en noviembre a los inmigrantes traídos al país de niños y que están protegidos bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA). Si la elegibilidad de DACA, y la misma ley, fuera revertida bajo Trump, eso dejaría a aproximadamente 40.000 beneficiarios de DACA en California, y alrededor de 100.000 en todo el país, sin acceso a seguros de salud subsidiados.

El 9 de diciembre, un tribunal federal en Dakota del Norte emitió una orden bloqueando el acceso de los beneficiarios de DACA a estos planes de salud en 19 estados que habían impugnado la regla de la administración Biden.

Clínicas y trabajadores comunitarios de salud están alentando a las personas a seguir inscribiéndose para obtener beneficios de salud. Pero en medio del esfuerzo por difundir el mensaje, los efectos disuasorios ya son evidentes a lo largo y ancho del estado.

“¿Ya tiene Medi-Cal?”, preguntaba la trabajadora comunitaria Yanet Martínez a los residentes mientras caminaba por Pico Boulevard recientemente, en un vecindario de Los Ángeles con muchos salvadoreños.

“¡Nosotros podemos ayudarle a solicitar Medi-Cal! ¡Todo gratuito!”, gritaba, ofreciendo ayuda para inscribirse sin costo.

“Gracias, pero no”, respondió una joven, encogiéndose de hombros y evitando el contacto visual bajo una gorra que la cubría del sol dela  media mañana.

Martínez dijo que desde el día de las elecciones, la gente ha estado más reacia a escuchar lo que dice sobre seguros de salud subsidiados o exámenes preventivos de cáncer.

“Creen que voy a compartir su información para deportarlos”, dijo. “No quieren tener nada que ver con esto”.

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. 

Tescha Hawley learned that hospital bills from her son’s birth had been sent to debt collectors only when she checked her credit score while attending a home-buying class. The new mom’s plans to buy a house stalled.

Hawley said she didn’t owe those thousands of dollars in debts. The federal government did.

Hawley, a citizen of the Gros Ventre Tribe, lives on the Fort Belknap Indian Reservation in Montana. The Indian Health Service is a federal agency that provides free health care to Native Americans, but its services are limited by a chronic shortage of funding and staff.

Hawley’s local Indian Health Service hospital wasn’t equipped to deliver babies. But she said staff there agreed that the agency would pay for her care at a privately owned hospital more than an hour away.

That arrangement came through the Purchased/Referred Care program, which pays for services Native Americans can’t get through an agency-funded clinic or hospital. Federal law stresses that patients approved for the program aren’t responsible for any of the costs.

But tribal leaders, health officials, and a new federal report say patients are routinely billed anyway as a result of backlogs or mistakes from the Indian Health Service, financial middlemen, hospitals, and clinics.

The financial consequences for patients can last years. Those sent to collections can face damaged credit scores, which can prevent them from securing loans or require them to pay higher interest rates.

The December report, by the federal Consumer Financial Protection Bureau, found these long-standing problems contribute to people in Native American-majority communities being nearly twice as likely to have medical debt in collections compared with the national average. And their amount of medical debt is significantly higher.

The report found the program is often late to pay bills. In some cases, hospitals or collection agencies hound tribal citizens for more money after bills are paid.

Hawley’s son was born in 2003. She had to wait another year to buy a home, as she struggled to pay off the debt. It took seven years for it to drop from her credit report.

“I don’t think a person ever recovers from debt,” Hawley said.

Hawley, a cancer survivor, still must navigate the referral program. In 2024 alone, she received two notices from clinics about overdue bills.

Frank White Clay, chairman of the Crow Tribe in Montana, testified about the impact of wrongful billing during a U.S. House committee hearing in April. He shared stories of veterans rejected for home loans, elders whose Social Security benefits were reduced, and students denied college loans and federal aid.

“Some of the most vulnerable people are being harassed daily by debt collectors,” White Clay said.

No one is immune from the risk. A high-ranking Indian Health Service official learned during her job’s background check that her credit report contained referred-care debt, the federal report found.

Native Americans face disproportionately high rates of poverty and disease, which researchers link to limited access to health care and the ongoing impact of racist federal policies.

White Clay is among many who say problems with the referred-care program are an example of the U.S. government violating treaties that promised to provide for the health and welfare of tribes in return for their land.

The chairman’s testimony came during a hearing on the Purchased and Referred Care Improvement Act, which would require the Indian Health Service to create a reimbursement process for patients who were wrongfully billed. Committee members approved the bill in November and sent it for consideration by the full House.

A second federal bill, the Protecting Native Americans’ Credit Act, would prevent debt like Hawley’s from affecting patients’ credit scores. The bipartisan bill hadn’t had a hearing by mid-December.

The exact number of people wrongfully billed isn’t clear, but the Indian Health Service has acknowledged it has work to do.

The agency is developing a dashboard to help workers track referrals and to speed up bill processing, spokesperson Brendan White said. It’s also trying to hire more referred-care staff, to address vacancy rates of more than 30%.

Officials say problems with the program also stem from outside health providers that don’t follow the rules.

Melanie Egorin, an assistant secretary at the U.S. Department of Health and Human Services, said at the hearing that the proposed legislation doesn’t include consequences for “bad actors” — health facilities that repeatedly bill patients when they shouldn’t.

“The lack of enforcement is definitely a challenge,” she said.

But tribal leaders warned that penalties could backfire.

White Clay told lawmakers that some clinics already refuse to see patients if the Indian Health Service hasn’t paid for their previous appointments. He’s worried the threat of penalties would lead to more refusals.

If that happens, White Clay said, Crow tribal members who already travel hours to access specialty treatment would have to go even farther.

The Consumer Financial Protection Bureau report found clinics are already refusing to see any referred-care patients due to the program’s payment problems.

The bureau and the Indian Health Service also recently published a letter urging health care providers and debt collectors not to hold patients accountable for program-approved care.

White, the Indian Health Service spokesperson, said the agency recently updated the referred-care forms sent to outside hospitals and clinics to include billing instructions and to stress that patients aren’t liable for any out-of-pocket costs. And he said the staff can help patients get reimbursed if they have already paid for services that were supposed to be covered.

Joe Bryant, an Indian Health Service official who oversees efforts to improve the referral program, said patients can ask credit bureaus to remove debt from their reports if the agency should have covered their bills.

Leaders with the Confederated Tribes of the Colville Reservation in Washington state helped shape the proposed legislation after their citizens were repeatedly harmed by wrongful billing.

Tribal Chairman Jarred-Michael Erickson said problems began in 2017, when a regional Indian Health Service office took over the referred-care program from local staff.

It “created a domino effect of negative outcomes,” Erickson wrote in a letter to Congress.

He said some tribal members whose finances were damaged stopped using the Indian Health Service. Others avoided health care altogether.

Responsibility for the Colville Reservation program transferred back to local staff in 2022. Staffers found the billing process hadn’t been completed for thousands of cases, worth an estimated $24 million in medical care, Erickson told lawmakers.

Workers are making progress on the backlog and they have explained the rules to outside hospitals and clinics, Erickson said. But he said there are still cases of wrongful billing, such as a tribal member who was sent to collections after receiving a $17,000 bill for chemotherapy that the agency was supposed to pay for.

Erickson said the tribe is in the process of taking over its health care facilities instead of having the Indian Health Service run them. He and others who work in Native American health said tribally managed units — which are still funded by the federal agency — tend to have fewer problems with their referred-care programs.

For example, they have more oversight over staff and flexibility to create their own payment tracking systems.

But some Native Americans oppose tribal management because they feel it releases the federal government from its obligations.

Beyond wrongful billing, access to the referred-care program is limited because of underfunding from Congress. The $1 billion budget this year is $9 billion short of the need, according to a committee report by tribal health and government leaders.

Donald Warne, a physician and member of the Oglala Sioux Tribe in South Dakota, called the proposed legislation a “band-aid.” He said the ultimate solution is for Congress to fully fund the Indian Health Service, which would reduce the need for the referred-care program.

Back in Montana, Hawley said she braces for a fight each time she gets a bill that the referral program was supposed to cover.

“I’ve learned not to trust the process,” Hawley said.

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. 

In the past few years, state and local governments across the U.S. have begun spending billions in opioid settlements paid by companies accused of fueling the overdose crisis. But where is that money going, who is getting it, and is it doing any good?

KFF Health News, partnering with the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction, undertook a yearlong investigation to find out.

Dozens of interviews, thousands of pages of documents, an array of public records requests, and outreach to all 50 states resulted in a first-of-its kind database that catalogs more than 7,000 ways opioid settlement cash was used in 2022 and 2023. It’s the most comprehensive resource to date tracking some of the largest public health settlements in American history.

Among the findings:

• States and localities received more than $6 billion in opioid settlement funds in 2022 and 2023. According to public records, they spent or committed about a third of that amount and set aside about another third for future use. The final third was untrackable, as many jurisdictions did not produce public reports on the funds.
• Reports of spending tracked the minuscule to the monumental, from $11.74 to buy postage in Yavapai County, Arizona, to more than $51 million to increase the addiction treatment workforce in California.
• States allotted, on average, about 18% of their funds for addiction and mental health treatment; 14% for recovery services such as housing, transportation, and legal aid; 11% for harm reduction efforts such as overdose reversal medications; and 9% for prevention programs that aim to stop people from developing substance use disorders. States committed, on average, about 2% for syringe service programs, through which people can get sterile needles. (A variety of entities received this money, from law enforcement to nonprofit organizations to government agencies.)
• Governments reported spending more than $240 million on purposes that did not qualify as opioid remediation. (Most settlements allow states to spend up to 15% of their funds this way.) Most of this tranche went to legal fees, but several jurisdictions funneled money to their general fund. One county even sent funds to its road and bridge department.
• Several cities and counties reported expenditures they said addressed the overdose crisis but that would leave an average person scratching their head — such as $33.07 to an anti-abortion pregnancy center in Sandborn, Indiana, and $30,362 to screen first responders for heart disease in Oregon City, Oregon.

“When people know that people aren’t watching and there’s no accountability, then they can kind of do what they want,” said Tonja Myles, a community activist in Baton Rouge, Louisiana, who is in recovery. “That’s why we have to have some kind of database and accountability.”

Despite the recent decline in overall overdose deaths in the U.S., more than 90,000 people still died in the 12 months ending July 2024 and rates are rising in many Black and Native American communities.

“We can’t mess up or miss this moment,” Myles said.

Opioid settlement payouts are expected to total about $50 billion over nearly two decades, paid by more than a dozen companies that made or distributed prescription painkillers, including Johnson & Johnson, Walgreens, and Walmart. Although it’s a large sum, it’s dwarfed by the size of the crisis, making each dollar that’s spent critical.

KFF Health News and its partners reviewed hundreds of settlement spending reports, extracting expenditures line by line, and developed a methodology to sort the expenditures into categories like treatment or prevention. States were given an opportunity to review the data and comment on their spending.

To be sure, the database does not capture the full picture of opioid settlement spending nationwide. Some places do not publish spending reports, while others declined to engage with this project. The data presented here is a snapshot as of the end of 2023 and does not account for further spending in 2024. The differences in how states control, process, and report on the money make apples-to-apples comparisons nearly impossible. Still, the database helps fill a gap left by a lack of national reporting requirements and federal government inaction.

It is “a tool for those who want to objectively measure whether everything that can be done is being done,” said Matthew Myers, a former president of the Campaign for Tobacco-Free Kids, which compiles similar annual reports on tobacco settlement money.

Treatment a Clear Winner

The top priority to emerge from early opioid settlement spending was treatment, with more than $416 million spent or committed to residential rehabs, outpatient counseling, medications for opioid use disorder, and more.

The state of New York — which spent the most on treatment — allocated about $22 million of that for programs that make the gold standard for care as easy as possible for patients: providing same-day prescriptions for buprenorphine, a medication that decreases cravings for opioids.

The result was a program that John Greene said changed his life.

Greene, 57, used to live in the woods down the street from Family & Children’s Counseling Services in Cortland, New York. He cycled through jails and hospitals, overdosing half a dozen times and trying rehab just as many.

But now he has four months of recovery under his belt — the longest stint since he started regularly using drugs at 14.

He said it’s because the counseling center’s new program — funded by a mix of state and local opioid settlement dollars — has a different approach. Counselors aren’t didactic and judgmental. They don’t force him to stop smoking marijuana. Several staff members have experienced addiction themselves. They drive Greene, who doesn’t have a car, to doctor appointments and the pharmacy for his buprenorphine prescription.

Now Greene lives and works with his brother, looks forward to weekly counseling sessions, and is notching small victories — such as buying his nephew toy cars as a stocking stuffer.

“It made me feel good to do something for somebody and not expect nothing back,” Greene said.

Emily Georgia, one of Greene’s counselors, said the center has worked with nearly 200 people like him in the past year. Without the settlements, “the program probably wouldn’t exist,” she said.

Across the country, the money supports other innovative treatment approaches:

• $21 million for a new program in Kentucky that diverts people with mental illness or addiction who face low-level charges away from incarceration and into treatment, education, and workforce training
• More than $3 million for, in part, three new mobile methadone programs in Massachusetts, to bring the medication to rural and underserved areas
• Tens of thousands of dollars each in Iowa and Pennsylvania to cover out-of-pocket treatment costs for people without insurance or those with high deductibles

Philip Rutherford, an expert on substance use disorder at the National Council for Mental Wellbeing, said these efforts “are really positive” and many have been “historically difficult or impossible to achieve with federal or state funding.”

But some funds are also flowing to treatment approaches that defy best practices, such as denying people medications for opioid use disorder.

Some in the recovery community consider methadone and buprenorphine a crutch. But study after study show that the medications help people stay in treatment and reduce the risk of overdose and death. Research even suggests that treatment without these medications can be more harmful than no treatment at all.

Although not everyone will want medication, settlement funds shouldn’t “prop up a system that doesn’t allow people to have that choice,” said Regina LaBelle, a professor of addiction policy at Georgetown University.

Babies, Forgotten Victims of the Epidemic

While treatment received a windfall in early opioid settlement spending, another aspect of the crisis was neglected: neonatal abstinence syndrome, a condition in which babies exposed to drugs in the womb experience withdrawal.

Nationwide, more than 59 newborns a day are diagnosed with it. Yet only about $8.4 million in settlement money was committed to the issue — less than 0.5% of all funds publicly reported as spent or committed in 2022 and 2023.

Experts in public health and addiction, as well as affected families, say it’s due to stigma.

“A mom using drugs and being a parent is a very uncomfortable reality to face,” said Ashley Grant, a 38-year-old mother of three in Mesa, Arizona. “It’s easier to just push it under the rug or let them fall through the cracks, as sad as that is.”

It almost happened to her.

Grant learned she was pregnant with her third child last year. At the time, her partner was in jail and she was using drugs after an eight-year period of recovery, was estranged from her family, and didn’t know how she’d survive the next nine months.

During a visit to a methadone clinic, she saw a booth about Jacob’s Hope, a specialty nursery that cares for substance-exposed newborns and their moms. Nursery staff connected her with a therapist, helped her enroll in parenting classes, and dropped off diapers and a playpen at her home.

After delivering at the hospital, Grant and her baby boy stayed at Jacob’s Hope for about a week. Nurses showed her how skin-to-skin contact calmed his withdrawal symptoms and more frequent feedings and burpings decreased gastrointestinal discomfort, which is common among substance-exposed newborns.

Today, Grant has roughly five months of recovery. She got certified as a peer recovery specialist and hopes to join Jacob’s Hope one day to help moms like her.

But the nursery’s future is uncertain.

After opening in 2019, Jacob’s Hope nearly shut down this summer due to low reimbursements and delayed payments from insurers, said Lyndsey Steele, its associate director. Community donations kept the nursery afloat, but “it’s still hanging on by a thread,” she said.

She’s hoping opioid settlement money can help.

In 2022, Jacob’s Hope received about $250,000 from Arizona’s opioid settlements. But this year, the legislature captured the state’s share of remaining funds and, in a controversial move, gave it to the Department of Corrections.

Jacob’s Hope has now turned to local governments, which control their own settlement dollars. Its home city of Mesa said a first round of grant applications should open in the spring.

Steele prays it won’t be too late for babies in need — the epidemic’s “forgotten victims,” she called them.

Heart Disease Screening, Robot Ambulances, and More

Some opioid settlement expenditures have sparked fierce disagreement. They generally fall into three buckets: money for law enforcement, funding for youth prevention programs, and purchases unrelated to the opioid crisis.

Settlement dollars nationwide have bought body scanners, K-9 units, bulletproof vests, patrol trucks, and laptops and printers for police and sheriffs.

Some spending strayed even further from the spirit of the settlement. In Oregon City, Oregon, more than $30,000 was spent on screening first responders for heart disease. Police Chief Shaun Davis said his staff respond to opioid-related emergencies and experience trauma that increases their risk of heart attack.

But some people question if settlement funds should be footing the bill.

“This looks to me like you’re trying to defray other costs” from the police budget, said Stephen Loyd, chair of Tennessee’s Opioid Abatement Council. “I don’t think that there’s any way that this opioid money was earmarked for stuff like that.”

A second area of contention is youth prevention.

Although most people agree that stopping children from developing addictions is important, the execution is tricky.

Nearly half a million settlement dollars have gone to the Drug Abuse Resistance Education program, commonly known as D.A.R.E. Decades of research suggest its original curriculum is ineffective.

Robeson County, North Carolina, spent about $10,000 in settlement money to buy “Andy the Ambulance,” a robot ambulance with big eyes and an audio system through which a human operator can discuss the dangers of drugs. EMS Director Patrick Cummings said his team has taken the robot to churches and elementary schools.

We “don’t have any studies that show it’s working,” he said, but educating kids seems like a good investment because “if they never try it, they don’t get addicted.”

Then there’s the chunk of money — up to 15% of each state’s funds — that’s a free-for-all.

Flint, Michigan, spent nearly $10,000 on a sign for a community service center. The city reported that the expense did not qualify as “opioid remediation.” In other words, it’s unrelated to addressing the crisis.

But Caitie O’Neill, a city spokesperson, said that “the building sign makes it possible for residents to find” the center, which houses city services, “including Narcan kits, fentanyl testing strips, and substance abuse referrals.”

Jurisdictions across 29 states reported non-remediation spending in 2022 and 2023. Most opioid settlements require such reports but operate on an honor system. No one is checking if the other 21 states and Washington, D.C., were truthful.

Jackie Lewis, an Ohio mother whose 34-year-old son, Shaun, died of an overdose in October 2022, finds that hard to stomach.

“This is blood money,” she said. Some people have “lost sight of that.”

Lewis is raising Shaun’s daughter, ensuring the 9-year-old receives counseling at school and can attend the hip-hop music classes she enjoys — all on Lewis’ Social Security payments. This year they moved to a smaller town with lower costs.

As settlement funds continue flowing, she wants officials in charge of the money to help families like hers.

“We still exist and we’re still struggling,” she said.

KFF Health News’ Henry Larweh and Megan Kalata, Johns Hopkins Bloomberg School of Public Health’s Sara Whaley and Vivian Flanagan, and Shatterproof’s Kristen Pendergrass and Sahvanah Prescott contributed to this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team who worked on this report are not involved in those efforts.

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. 

LOS ANGELES — President-elect Donald Trump’s promise of mass deportations and tougher immigration restrictions is deepening mistrust of the health care system among California’s immigrants and clouding the future for providers serving the state’s most impoverished residents.

At the same time, immigrants living illegally in Southern California told KFF Health News they thought the economy would improve and their incomes might increase under Trump, and for some that outweighed concerns about health care.

Community health workers say fear of deportation is already affecting participation in Medi-Cal, the state’s Medicaid program for low-income residents, which was expanded in phases to all immigrants regardless of residency status over the past several years. That could undercut the state’s progress in reducing the uninsured rate, which reached a record low of 6.4% last year.

Immigrants lacking legal residency have long worried that participation in government programs could make them targets, and Trump’s election has compounded those concerns, community advocates say.

The incoming Trump administration is also expected to target Medicaid with funding cuts and enrollment restrictions, which activists worry could threaten the Medi-Cal expansion and kneecap efforts to extend health insurance subsidies under Covered California to all immigrants.

“The fear alone has so many consequences to the health of our communities,” said Mar Velez, director of policy with the Latino Coalition for a Healthy California. “This is, as they say, not their first rodeo. They understand how the system works. I think this machine is going to be, unfortunately, a lot more harmful to our communities.”

Alongside such worries, though, is a strain of optimism that Trump might be a boon to the economy, according to interviews with immigrants in Los Angeles whom health care workers were soliciting to sign up for Medi-Cal.

Selvin, 39, who, like others interviewed for this article, asked to be identified by only his first name because he’s living here without legal permission, said that even though he believes Trump dislikes people like him, he thinks the new administration could help boost his hours at the food processing facility where he works packing noodles. “I do see how he could improve the economy. From that perspective, I think it’s good that he won.”

He became eligible for Medi-Cal this year but decided not to enroll, worrying it could jeopardize his chances of changing his immigration status.

“I’ve thought about it,” Selvin said, but “I feel like it could end up hurting me. I won’t deny that, obviously, I’d like to benefit — get my teeth fixed, a physical checkup.” But fear holds him back, he said, and he hasn’t seen a doctor in nine years.

It’s not Trump’s mass deportation plan in particular that’s scaring him off, though. “If I’m not committing any crimes or getting a DUI, I think I won’t get deported,” Selvin said.

Petrona, 55, came from El Salvador seeking asylum and enrolled in Medi-Cal last year.

She said that if her health insurance benefits were cut, she wouldn’t be able to afford her visits to the dentist.

A street food vendor, she hears often about Trump’s deportation plan, but she said it will be the criminals the new president pushes out. “I’ve heard people say he’s going to get rid of everyone who’s stealing.”

Although she’s afraid she could be deported, she’s also hopeful about Trump. “He says he’s going to give a lot of work to Hispanics because Latinos are the ones who work the hardest,” she said. “That’s good, more work for us, the ones who came here to work.”

Newly elected Republican Assembly member Jeff Gonzalez, who flipped a seat long held by Democrats in the Latino-heavy desert region in the southeastern part of the state, said his constituents were anxious to see a new economic direction.

“They’re just really kind of fed up with the status quo in California,” Gonzalez said. “People on the ground are saying, ‘I’m hopeful,’ because now we have a different perspective. We have a businessperson who is looking at the very things that we are looking at, which is the price of eggs, the price of gas, the safety.”

Gonzalez said he’s not going to comment about potential Medicaid cuts, because Trump has not made any official announcement. Unlike most in his party, Gonzalez said he supports the extension of health care services to all residents regardless of immigration status.

Health care providers said they are facing a twin challenge of hesitancy among those they are supposed to serve and the threat of major cuts to Medicaid, the federal program that provides over 60% of the funding for Medi-Cal.

Health providers and policy researchers say a loss in federal contributions could lead the state to roll back or downsize some programs, including the expansion to cover those without legal authorization.

California and Oregon are the only states that offer comprehensive health insurance to all income-eligible immigrants regardless of status. About 1.5 million people without authorization have enrolled in California, at a cost of over $6 billion a year to state taxpayers.

“Everyone wants to put these types of services on the chopping block, which is really unfair,” said state Sen. Lena Gonzalez, a Democrat and chair of the California Latino Legislative Caucus. “We will do everything we can to ensure that we prioritize this.”

Sen. Gonzalez said it will be challenging to expand programs such as Covered California, the state’s health insurance marketplace, for which immigrants lacking permanent legal status are not eligible. A big concern for immigrants and their advocates is that Trump could reinstate changes to the public charge policy, which can deny green cards or visas based on the use of government benefits.

“President Trump’s mass deportation plan will end the financial drain posed by illegal immigrants on our healthcare system, and ensure that our country can care for American citizens who rely on Medicaid, Medicare, and Social Security,” Trump spokesperson Karoline Leavitt said in a statement to KFF Health News.

During his first term, in 2019, Trump broadened the policy to include the use of Medicaid, as well as housing and nutrition subsidies. The Biden administration rescinded the change in 2021.

KFF, a health information nonprofit that includes KFF Health News, the publisher of California Healthline, found immigrants use less health care than people born in the United States. And about 1 in 4 likely undocumented immigrant adults said they have avoided applying for assistance with health care, food, and housing because of immigration-related fears, according to a 2023 survey.

Another uncertainty is the fate of the Affordable Care Act, which was opened in November to immigrants who were brought to the U.S. as children and are protected by the Deferred Action Childhood Arrivals program. If DACA eligibility for the act’s plans, or even the act itself, were to be reversed under Trump, that would leave roughly 40,000 California DACA recipients, and about 100,000 nationwide, without access to subsidized health insurance.

On Dec. 9, a federal court in North Dakota issued an order blocking DACA recipients from accessing Affordable Care Act health plans in 19 states that had challenged the Biden administration’s rule.

Clinics and community health workers are encouraging people to continue enrolling in health benefits. But amid the push to spread the message, the chilling effects are already apparent up and down the state.

“¿Ya tiene Medi-Cal?” community health worker Yanet Martinez said, asking residents whether they had Medi-Cal as she walked down Pico Boulevard recently in a Los Angeles neighborhood with many Salvadorans.

“¡Nosotros podemos ayudarle a solicitar Medi-Cal! ¡Todo gratuito!” she shouted, offering help to sign up, free of charge.

“Gracias, pero no,” said one young woman, responding with a no thanks. She shrugged her shoulders and averted her eyes under a cap that covered her from the late-morning sun.

Since Election Day, Martinez said, people have been more reluctant to hear her pitch for subsidized health insurance or cancer prevention screenings.

“They think I’m going to share their information to deport them,” she said. “They don’t want anything to do with it.”