Category: Rehab News

KINGSPORT, Tenn. — Jerry Qualls had a heart attack in 2022 and was rushed by ambulance to Holston Valley Medical Center, where he was hospitalized for a week and kept alive by a ventilator and blood pump, according to his medical records.

His wife, Katherine Qualls, said his doctors offered little hope. In an interview and a written complaint to the Tennessee government, she said doctors at Holston Valley told her that her husband would not qualify for a heart transplant and shouldn’t be expected to recover.

Defiant, she insisted he be transferred hours away to a hospital in Nashville. Within days of leaving Holston Valley, Jerry Qualls was awake and sitting upright, his wife said, and he ultimately received a lifesaving heart transplant.

“How many families don’t know how to get a transfer and their loved one dies?” Katherine Qualls wrote in her complaint to the state. “My husband would have been dead within a few days if I didn’t get him out when I did.”

Holston Valley Medical Center is a flagship of Ballad Health, a 20-hospital system in northeastern Tennessee and southwestern Virginia that is the only option for hospital care in a large swath of Appalachia. Ballad formed six years ago when lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. The merger created the largest state-sanctioned hospital monopoly in the nation.

Since then, Ballad has largely kept those hospitals open. But the monopoly has also fallen short of about three-fourths of the quality-of-care goals set by the states over the last three fiscal years, including failing to meet state benchmarks on infections, mortality, emergency room speed, and patient satisfaction, according to annual reports from the Tennessee Department of Health and Ballad itself.

Some local residents have become wary, afraid, or unwilling to seek care at Ballad hospitals and must drive over an hour to reach other options, according to written complaints to the Tennessee government and state lawmakers, public hearing testimony, and KFF Health News interviews conducted over the past year with patients, family members, local leaders, and some officials who once publicly supported the monopoly, including a former government consultant and one state lawmaker. Many of those who submitted complaints or were interviewed allege that paper-thin staffing at Ballad hospitals and ERs is the root cause of the monopoly’s quality-of-care woes.

In a two-hour interview vigorously defending the company, Ballad Health CEO Alan Levine said the hospitals are rapidly recovering from a quality-of-care slump caused by covid-19 and a subsequent rise in nursing turnover and staff shortages. These issues affected hospitals nationwide, Levine said, and were not related to the Ballad merger or the monopoly it created.

Levine declined to discuss specific complaints from patients. But he said that each of the complaints referenced in this article took issue with medical decisions made by doctors in Ballad hospitals — not “any policy or practice at Ballad.”

“I can understand if the patients, if the wife, was upset about the medical decisions they made if it turned out to be wrong,” Levine said. “But that has nothing to do with the merger, OK? That’s a completely different issue, and it happens in hospitals all over the country.”

In the interview with KFF Health News and in the days that followed, Levine flexed considerable connections to officials in the Tennessee government. As Levine spoke in a boardroom at Ballad’s hilltop headquarters, he was flanked by three local mayors who voiced support for the hospitals and said complaints came from a vocal minority of their constituents. Days later, Levine got two Tennessee state agency directors and a former state health commissioner to provide emails or text messages supporting statements he made during the interview.

Logan Grant, executive director of the Tennessee Health Facilities Commission, which processes complaints against hospitals for the state, said in a statement prompted by Levine that Ballad hospitals are “not an outlier in terms of substantiated survey findings.”

Joe Grandy, the mayor of Tennessee’s Washington County, where Ballad is headquartered, said most residents consider the quality of care in the area “about as good as it gets.”

Brenda Getaz certainly doesn’t.

Getaz, 76, who spent three decades as a hospital official specializing in quality standards before retiring to Washington County, said she plans to move to Atlanta if state governments do not take action to fix Ballad in the coming year. Getaz said local medical professionals she trusts have urged her to move away so she does not have to rely on Ballad for care.

“I’m frightened to be taken to a Ballad facility,” she said.

Glimpses of Government Concern

The Tennessee Department of Health, which has the most direct oversight over Ballad Health, over the past year has declined multiple interview requests to discuss the hospital monopoly. Department emails reviewed by KFF Health News, some of which were obtained through public record requests, offer glimpses of concern inside the agency.

Emails show the health department has attempted to hold Ballad more accountable for its quality of care in closed-door negotiations and is investigating Holston Valley’s treatment of a recent heart patient after receiving detailed complaints from his family. In a 2023 email, Tennessee Health Commissioner Ralph Alvarado reacted to a news story about low job satisfaction among Ballad nurses by writing: “Ouch. … What are they doing to address this?”

In another email from the same year, Alvarado praised an informal report submitted at a public hearing that concluded Ballad’s monopoly had caused more harm than good. The report was written by Wally Hankwitz, a retired health care executive who once led a physician management company in Kingsport. The report levied pages of criticism against Ballad’s “sub-par” performance and called for the monopoly to end.

“THIS communication from the COPA hearing is particularly good,” the health commissioner wrote to some of his staff. “Totally based on data. I would almost like to hear Ballad’s response to this.”

When asked to respond to the Hankwitz report, Levine said it was “full of errors” and that “no credible institution would pay attention to it.”

Despite concerns, Tennessee and Virginia have each year determined that the benefits of the Ballad monopoly outweigh any negative impacts, issuing stamps of approval that allow the monopoly to continue. This has occurred, at least in part, because both states grade Ballad against scoring rubrics that do not prioritize quality of care.

Larry Fitzgerald, a retired Tennessee consultant who monitored the monopoly for the state for more than five years and always gave Ballad high marks, said in an interview that his hands were tied by the state’s lenient grading system, which allowed Ballad to succeed on paper even when it failed to meet the state’s quality-of-care goals.

Fitzgerald said he is unconvinced that the state-sanctioned monopoly had prevented any hospital closures and said the merger had “probably not” benefited local residents overall.

When asked where he would get medical attention if he lived in northeastern Tennessee or southwestern Virginia, Fitzgerald immediately responded, “I’m not going to a Ballad hospital.”

In his interview, Levine alleged Fitzgerald had “basically defrauded the state” by not raising these criticisms of Ballad in his public reports on the monopoly and said it was “irresponsible” and “obscene” to express his concerns about quality of care after retiring.

‘Horror Stories’ From Ballad Patients

Tennessee House member Bud Hulsey, a Republican from Kingsport, wrote in a 2023 letter to the state health department that he “was an avid supporter of the merger” that created Ballad but since then had become “concerned” and “saddened” by the state of the local hospitals.

In a recent interview, Hulsey said that while his family has received excellent care from Ballad, his constituents have told him “horror stories” for years.

“I had people call me from the waiting room after they’ve sat there for 12 or 14 hours,” Hulsey said. “The scales have far more complaints on them than accolades.”

Others have soured on the monopoly, too. Joe Macione, who for years was on the board of Wellmont Health System, one of the rival companies that became Ballad, once publicly advocated for the merger.

In an interview, Macione said state leaders should have admitted years ago that the monopoly was a mistake.

“It has not worked,” said Macione, 87. “All my family knows that, if I have the time, I want to go to a highly graded hospital, either in Asheville or Knoxville.”

Ballad Health was created in 2018 after Tennessee and Virginia officials waived federal anti-monopoly laws and approved the nation’s biggest hospital merger, based on what’s called a Certificate of Public Advantage, or COPA, agreement. Ballad is now the only option for hospital care for most of the approximately 1.1 million people in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.

In the years since, there have been multiple signs of discontent with and within Ballad hospitals. In 2019, protesters gathered daily for eight months outside Holston Valley to oppose the closure of the neonatal intensive care unit and the downgrading of a trauma center. (Ballad has said the NICU closure was necessary and benefited patients, and a study published this year said the trauma changes saved lives.)

In 2020, Bristol Regional Medical Center CEO Greg Neal resigned after it was discovered he made the initial incision in a heart surgery despite not being a doctor, according to Tennessee state records. (Levine said in his interview that the resignation shows Ballad is holding employees accountable.)

In 2022, 14 cardiologists signed a letter warning of “severe limitations” in the Bristol Regional cardiac catheterization lab that were affecting patient safety and delaying procedures for weeks or months. (Ballad said in a letter to the Tennessee government that it worked with the cardiologists, who it said were partly to blame, to make the lab more efficient.)

In 2023, Ballad Health was ranked last among 200 large health care organizations in an analysis of nurse satisfaction published by an MIT business magazine. (Levine dismissed this analysis as unscientific.) This year, the Federal Trade Commission cited Ballad as a cautionary tale while opposing a similar hospital merger under consideration in Indiana, and a longtime Kingsport doctor took a parting shot at Ballad in his obituary. (Ballad declined to comment on either topic.)

And in August, the widow of a Tennessee sheriff filed a lawsuit alleging that Ballad caused her husband’s death and intentionally understaffed hospitals “to save money.” Brenda Tester, the wife of Johnson County Sheriff Eddie Tester, alleged in that lawsuit that Ballad put her husband on blood thinners and then gave him an unnecessary liver biopsy, causing “life ending internal blood loss” that led to “his cardiac arrest and ultimately his sudden death.”

Ballad has yet to respond to the Tester lawsuit in court. Levine said in his interview that the doctors who treated the sheriff were not employed by Ballad but merely contracted to work in its hospitals.

Some of Ballad’s most determined critics are family members of Anton Maki Jr., a former Holston Valley doctor who returned to the hospital as a patient in February. The family has filed complaints with multiple Tennessee agencies and the federal government and provided emails to KFF Health News showing that Tennessee is investigating Maki’s case.

In an interview and in those complaints, Maki’s family members allege Holston Valley gave Maki improper treatment, even though his symptoms and lab tests made it obvious that he was having a serious heart attack that required urgent attention.

The improper care did “permanent damage” to Maki’s heart, the family’s complaints allege. That damage required him to have a permanent mechanical heart pump surgically implanted at a non-Ballad hospital, said one of his daughters, Alexandra Maki, who is a surgeon in Kentucky. She said her father died after a fall three months later while still in a weakened state.

Alexandra Maki said that her father had been alarmed by the Ballad monopoly for years but that she didn’t fully appreciate his warnings until she witnessed his care at Holston Valley firsthand.

“I filed these complaints because it is my duty as a doctor to report what I saw,” Alexandra Maki said. “That was not care. It is a facade of a hospital. It is a well-oiled death machine.”

KFF Health News reporter Samantha Liss contributed to this article.

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. 

Veteran California public servant Will Lightbourne has stepped in as interim executive director of the state’s mental health commission after its previous executive director resigned following conflict of interest allegations.

Lightbourne served as head of the state’s Department of Social Services for seven years before retiring in 2018 and had already returned to service once, as interim head of the Department of Health Care Services at the height of the covid-19 pandemic. On Nov. 4, he was tapped to lead the state’s Mental Health Services Oversight and Accountability Commission after executive director Toby Ewing announced he would step down.

Documents obtained by KFF Health News showed that Ewing took a trip to the U.K. funded by Kooth, a London-based company that the state contracted to build a youth mental health app. At the same time, he was working to protect Kooth’s $271 million contract.

During a public hearing the day he announced his resignation, advocates for mental health services accused the commission of favoring the interests of corporations over those of the people it is supposed to serve.

Lightbourne, 75, is now leading the commission, an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services. He said he’ll focus on making the commission as open as possible, as a nationwide search for the next executive director begins.

He comes to the mental health commission at a moment of change. With the passage of the Behavioral Health Services Act last year and its approval by voters this year as part of Proposition 1, the commission will be integrating 11 new members starting in January. And in July 2026, it will stop overseeing county funds for mental health innovation and will instead get its own bucket of up to $20 million a year to spend on innovation. Conversations are already underway about how to spend the funds.

Lightbourne directed social service agencies in Santa Clara, San Francisco, and Santa Cruz counties before being named director of the state social services department, where he launched an effort to move more foster children out of institutions and into family-based settings.

Lightbourne spoke to KFF Health News correspondent Molly Castle Work about his goals for state mental health services. The interview has been edited for length and clarity.

Q: You already came out of retirement once, to lead DHCS during the pandemic. How were you convinced to take this job?

A: Back when I was at DHCS, quite a bit of what is now the sort of health reconceptualization in California happened.

There’s a point where you feel a sense of paternal relationship for a lot of the initiatives. What the commission does in terms of the detailed finish work is really going to be important for this thing to work.

Q: Executive Director Toby Ewing resigned amid accusations of favoritism with the contracts. How can the public have faith that this won’t happen again?

A: I want to be very careful now, because the way you phrase the question implies that I accept the proposition, and I have no way of knowing. What I’ve always said in any setting that I’ve been in is always deal the cards face up. Just be transparent. Be open. When possible, use competitive processes.

There’s the famous three intersecting points of contracting: You can have speed, you can have quality, you can have a good price. Pick two. You can’t have three. And you know, my instinct is always to be a little bit more skeptical of urgency. I mean, there are huge human needs out there that we want to solve, but to say everything should go by the wayside because things have to happen yesterday — let’s take a beat.

Q: As the interim executive director, are there guardrails that you think need to be in place to ensure that taxpayer money is being spent wisely?

A: I don’t know that there’s anything that I am particularly worried about, but I think it’s my role to help the commission as it transitions into Prop 1, into BHSA, and into a permanent executive director — just make sure that they’ve got all the procedures that they think they need — and that we build a culture where we are sure that they are able to fully see things coming in front of them.

It’s going to be interesting that come January we’re going to add 11 commissioners. It’s a huge jump. And doing it in a way that everybody stays engaged — I don’t have an answer yet.

The value-add of this organization is that it’s got a commission of pretty damn committed people who take it very seriously and bring a lot of skill to it. And you wouldn’t want to see that lost.

Q: Our country has seen the mental health crisis spike over the past few years. Are there specific areas you want to focus on?

A: I always want to be a little careful about having one more bright idea. There is definitely initiative fatigue on the ground. People have got that glazed look. So if there are things that the commission can do to bring more resources, more players, more solutions that help, then that’s great. I just don’t want us to be piling on new ideas.

Some of the things the commission has already invested in, and I’m trying to get more familiar with this, like the early psychosis interventions — that could be a real game changer as I understand it.

Q: How do you think funding for mental health initiatives should be prioritized?

A: Certainly the old notion of full-service partnerships is important. It means whatever takes — put a team together, wrap it around the person, address their core needs, like housing.

Don’t think that with somebody sleeping under the bus shelter that you can address their needs while they’re still sitting there, you know? Move them into a setting where they can feel safe, they have dignity, they have their personal human needs met, and also whatever therapeutic needs or medication needs or medically assisted treatment needs.

Q: What are you most looking forward to in this role?

A: Because of where I’ve been previously, I think there are some obvious connections to make. We don’t want to subordinate the commission to the other systems. It’s got to have its own thing. But just knowing who to dance with can be helpful.

The availability of safe, effective covid vaccines less than a year into the pandemic marked a high point in the 300-year history of vaccination, seemingly heralding an age of protection against infectious diseases.

Now, after backlash against public health interventions culminated in President-elect Donald Trump’s nominating Robert F. Kennedy Jr., the country’s best-known anti-vaccine activist, as its top health official, infectious disease and public health experts and vaccine advocates say a confluence of factors could cause renewed, deadly epidemics of measles, whooping cough, and meningitis, or even polio.

“The litany of things that will start to topple is profound,” said James Hodge, a public health law expert at Arizona State University’s Sandra Day O’Connor College of Law. “We’re going to experience a seminal change in vaccine law and policy.”

“He’ll make America sick again,” said Lawrence Gostin, a professor of public health law at Georgetown University.

State legislators who question vaccine safety are poised to introduce bills to weaken school-entry vaccine requirements or do away with them altogether, said Northe Saunders, who tracks vaccine-related legislation for the SAFE Communities Coalition, a group supporting pro-vaccine legislation and lawmakers.

Even states that keep existing requirements will be vulnerable to decisions made by a Republican-controlled Congress as well as by Kennedy and former House member Dave Weldon, should they be confirmed to lead the Department of Health and Human Services and the Centers for Disease Control and Prevention, respectively.

Both men — Kennedy as an activist, Weldon as a medical doctor and congressman from 1995 to 2009— have endorsed debunked theories blaming vaccines for autism and other chronic diseases. (Weldon has been featured in anti-vaccine films in the years since he left Congress.) Both have accused the CDC of covering up evidence this was so, despite dozens of reputable scientific studies to the contrary.

Kennedy’s staff did not respond to requests for comment. Karoline Leavitt, the Trump campaign’s national press secretary, did not respond to requests for comment or interviews with Kennedy or Weldon.

Kennedy recently told NPR that “we’re not going to take vaccines away from anybody.”

It’s unclear how far the administration would go to discourage vaccination, but if levels drop enough, vaccine-preventable illnesses and deaths might soar.

“It is a fantasy to think we can lower vaccination rates and herd immunity in the U.S. and not suffer recurrence of these diseases,” said Gregory Poland, co-director of the Atria Academy of Science & Medicine. “One in 3,000 kids who gets measles is going to die. There’s no treatment for it. They are going to die.”

During a November 2019 measles epidemic that killed 80 children in Samoa, Kennedy wrote to the country’s prime minister falsely claiming that the measles vaccine was probably causing the deaths. Scott Gottlieb, who was Trump’s first FDA commissioner, said on CNBC on Nov. 29 that Kennedy “will cost lives in this country” if he undercuts vaccination.

Kennedy’s nomination validates and enshrines public mistrust of government health programs, said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

“The notion that he’d even be considered for that position makes people think he knows what he’s talking about,” Offit said. “He appeals to lessened trust, the idea that ‘There are things you don’t see, data they don’t present, that I’m going to find out so you can really make an informed decision.’”

Targets of Anti-Vaccine Groups

Hodge has compiled a list of 20 actions the administration could take to weaken national vaccination programs, from spreading misinformation to delaying FDA vaccine approvals to dropping Department of Justice support for vaccine laws challenged by groups like Children’s Health Defense, which Kennedy founded and led before campaigning for president.

Kennedy could also cripple the National Vaccine Injury Compensation Program, which Congress created in 1986 to take care of children believed harmed by vaccines — while partially protecting vaccine makers from lawsuits.

Before the law passed, the threat of lawsuits had shrunk the number of companies making vaccines in the United States — from 26 in 1967 to 17 in 1980 — and the remaining pertussis vaccine producers were threatening to stop making it. The vaccine injury program “played an integral role in keeping manufacturers in the business,” Poland said.

Kennedy could abolish the CDC’s Advisory Committee on Immunization Practices, whose recommendation for using a vaccine determines whether the government pays for it through the 30-year-old Vaccines for Children program, which makes free immunizations available to more than half the children in the United States. Alternatively, Kennedy could stack the committee with allies who oppose new vaccines, and could, in theory at least, withdraw recommendations for vaccines like the 53-year-old measles-mumps-rubella shot, a favorite target of the anti-vaccine movement.

Meanwhile, infectious disease threats are on the rise or on the horizon. Instead of preparing, as a typical incoming administration might, Kennedy has threatened to shake up the federal health agencies. Once in office, he’ll “give infectious disease a break” to focus on chronic ailments, he said at a Children’s Health Defense conference last month in Georgia.

The H5N1 virus, or bird flu, that has spread through cattle herds and infected at least 55 people could erupt in a new pandemic, and other threats like mosquito-borne dengue fever are rising in the U.S.

Traditional childhood diseases are also making their presence felt, in part because of neglected vaccination. The U.S. has seen 16 measles outbreaks this year — 89% of cases are in unvaccinated people — and a whooping cough epidemic is the worst since 2012.

“So that’s how we’re starting out,” said Peter Hotez, a pediatrician and virologist at the Baylor College of Medicine. “Then you throw into the mix one of the most outspoken and visible anti-vaccine activists at the head of HHS, and that gives me a lot of concern.”

The share prices of drug companies with big vaccine portfolios have plunged since Kennedy’s nomination. Even before Trump’s victory, vaccine exhaustion and skepticism had driven down demand for newer vaccines like GSK’s RSV and shingles shots.

Kennedy has ample options to slow or stop new vaccine releases or to slow sales of existing vaccines — for example, by requiring additional post-market studies or by highlighting questionable studies that suggest safety risks.

Kennedy, who has embraced conspiracy theories such as that HIV does not cause AIDS and that pesticides cause gender dysphoria, told NPR there are “huge deficits” in vaccine safety research. “We’re going to make sure those scientific studies are done and that people can make informed choices,” he said.

Kennedy’s nomination “bodes ill for the development of new vaccines and the use of currently available vaccines,” said Stanley Plotkin, a vaccine industry consultant and inventor of the rubella vaccine in the 1960s. “Vaccine development requires millions of dollars. Unless there is prospect of profit, commercial companies are not going to do it.”

Vaccine advocates, with less money on hand than the better-funded anti-vaccine advocates, see an uphill battle to defend vaccination in courts, legislatures, and the public square. People are rarely inclined to celebrate the absence of a conquered illness, making vaccines a hard sell even when they are working well.

While many wealthy people, including potion and supplement peddlers, have funded the anti-vaccine movement, “there hasn’t been an appetite from science-friendly people to give that kind of money to our side,” said Karen Ernst, director of Voices for Vaccines.

‘He’s Serious as Hell’

“RFK Jr. was a punch line for a lot of people, but he’s serious as hell,” Ernst said. “He has a lot of power, money, and a vast network of anti-vaccine parents who’ll show up at a moment’s notice.” That’s not been the case with groups like hers, Ernst said.

On Oct. 22, when an Idaho health board voted to stop providing covid vaccines in six counties, there were no vaccine advocates at the meeting. “We didn’t even know it was on the agenda,” Ernst said. “Mobilization on our side is always lagging. But I’m not giving up.”

The kaleidoscopic change has been jarring for Walter Orenstein, who persuaded states to tighten school mandates to fight measles outbreaks as head of the CDC’s immunization division from 1988 to 2004.

“People don’t understand the concept of community protection, and if they do they don’t seem to care,” said Orenstein, who saw some of the last cases of smallpox as a CDC epidemiologist in India in the 1970s, and frequently cared for children with meningitis caused by H. influenzae type B bacteria, a disease that has mostly disappeared because of a vaccine introduced in 1987.

“I was so naïve,” he said. “I thought that covid would solidify acceptance of vaccines, but it was the opposite.”

Lawmakers opposed to vaccines could introduce legislation to remove school-entry requirements in nearly every state, Saunders said. One bill to do this has been introduced in Texas, where what’s known as the vaccine choice movement has been growing since 2015 and took off during the pandemic, fusing with parents’ rights and anti-government groups opposed to measures like mandatory shots and masking.

“The genie is out of the bottle, and you can’t put it back in,” said Rekha Lakshmanan, chief strategy officer at the Immunization Partnership in Texas. “It’s become this multiheaded thing that we’re having to reckon with.”

In the last full school year, more than 100,000 Texas public school students were exempted from one or more vaccinations, she said, and many of the 600,000 homeschooled Texas kids are also thought to be unvaccinated.

In Louisiana, the state surgeon general distributed a form letter to hospitals exempting medical professionals from flu vaccination, claiming the vaccine is unlikely to work and has “real and well established” risks. Research on flu vaccination refutes both claims.

The biggest threat to existing vaccination policies could be plans by the Trump administration to remove civil service protections for federal workers. That jeopardizes workers at federal health agencies whose day-to-day jobs are to prepare for and fight diseases and epidemics. “If you overturn the administrative state, the impact on public health will be long-term and serious,” said Dorit Reiss, a professor at the University of California’s Hastings College of Law.

Billionaire Elon Musk, who has the ear of the incoming president, imagines cost-cutting plans that are also seen as a threat.

“If you damage the core functions of the FDA, it’s like killing the goose that laid the golden egg, both for our health and for the economy,” said Jesse Goodman, the director of the Center on Medical Product Access, Safety and Stewardship at Georgetown University and a former chief science officer at the FDA. “It would be the exact opposite of what Kennedy is saying he wants, which is safe medical products. If we don’t have independent skilled scientists and clinicians at the agency, there’s an increased risk Americans will have unsafe foods and medicine.”

Outbreaks of vaccine-preventable illness could be alarming, but would they be enough to boost vaccination again? Ernst of Voices for Vaccines isn’t sure.

“We’re already having outbreaks. It would take years before enough children died before people said, ‘I guess measles is a bad thing,’” she said. “One kid won’t be enough. The story they’ll tell is, ‘There was something wrong with that kid. It can’t happen to my kid.’”

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. 

La disponibilidad de vacunas seguras y eficaces contra covid a menos de un año del inicio de la pandemia marcó un hito en los tres siglos de historia de la vacunación: comenzaba, aparentemente, una era de protección contra las enfermedades infecciosas.

Sin embargo, una reacción generalizada contra las intervenciones del estado en la salud pública permitió que el presidente electo Donald Trump nombrara a Robert F. Kennedy, el más conocido activista antivacunas del país como máximo responsable del área de Salud.

Ahora, expertos afirman que una confluencia de factores podría causar el resurgimiento de epidemias mortales de enfermedades como el sarampión, la tos ferina y la meningitis, o incluso de polio.

 “La cantidad de cosas que empezarán a desmoronarse es abrumadora”, dijo James Hodge, experto en derecho de salud pública en el Colegio de Derecho Sandra Day O’Connor de la Universidad Estatal de Arizona. “Vamos a experimentar un cambio crítico en la legislación y las políticas sobre vacunas”.

“Estas políticas harán que América vuelva a enfermarse”, afirmó Lawrence Gostin, profesor de derecho de la salud pública en la Universidad de Georgetown.

Los legisladores estatales que cuestionan la seguridad de las vacunas están preparados para presentar proyectos de ley que debiliten los requisitos de vacunación para ir a la escuela, o los eliminen por completo, señaló Northe Saunders, quien monitorea la legislación relacionada con vacunas para la SAFE Communities Coalition.

Incluso los estados que mantengan los requisitos que hoy existen podrán ser afectados por las decisiones que tome un Congreso controlado por los republicanos, Kennedy y el ex miembro de la Cámara Dave Weldon, en caso de que sean confirmados para dirigir el Departamento de Salud y Servicios Humanos (HHS) y los Centros para el Control y Prevención de Enfermedades (CDC), respectivamente.

Ambos —Kennedy como activista, Weldon como médico y congresista desde 1995 hasta 2009, y protagonista de documentales antivacunas desde entonces— han respaldado teorías ya desacreditadas que culpan a las vacunas del autismo y otras enfermedades crónicas. Los dos han acusado a los CDC de ocultar las pruebas que confirmarían sus postulados, a pesar de las docenas de estudios científicos de prestigio que demuestran lo contrario.

El equipo de Kennedy no respondió a los pedidos de comentarios o entrevistas.

En noviembre, Robert F. Kennedy Jr. declaró a NPR: “No vamos a quitarle las vacunas a nadie”.

Todavía no está claro hasta qué punto el nuevo gobierno buscaría desalentar la vacunación, pero si los niveles de inmunización caen bastante, las enfermedades y muertes prevenibles por vacunas podrían dispararse.

“Es una fantasía pensar que podemos reducir las tasas de vacunación y la inmunidad colectiva en Estados Unidos sin sufrir la reaparición de estas enfermedades”, dijo Gregory Poland, co-director de la Atria Academy of Science & Medicine. “Uno de cada 3,000 niños que desarrolla sarampión va a morir. No hay tratamiento para evitarlo. Van a morir”.

En noviembre de 2019, una epidemia de sarampión causó la muerte de 80 niños en Samoa. En esa oportunidad, Kennedy escribió al primer ministro de ese país afirmando falsamente que la vacuna contra el sarampión probablemente estaba causando esas muertes.

Scott Gottlieb, que fue el primer comisionado de la Administración de Drogas y Alimentos (FDA) bajo la administración Trump, declaró en CNBC el 29 de noviembre que Kennedy “va a costar vidas en este país” si sabotea la vacunación.

La nominación de Kennedy valida y consagra la desconfianza pública en los programas de salud del gobierno, asegura Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia.

“La idea de que se considere para ocupar un puesto tan importante hace que la gente piense que sabe de lo que habla”, dijo Offit. “Y él apela a generar desconfianza, a la idea de que ‘hay cosas que no ves, datos que no presentan, que yo voy a averiguar para que realmente puedas tomar una decisión informada’”.

Qué quieren los grupos antivacunas

Hodge ha elaborado una lista de 20 acciones que la administración podría llevar a cabo para debilitar los programas nacionales de vacunación, desde difundir información errónea hasta retrasar las aprobaciones de la FDA sobre vacunas. O retirar el apoyo del Departamento de Justicia a las leyes de vacunación que buscan impugnar grupos como Children’s Health Defense, que Kennedy fundó y dirigió antes de postularse para la presidencia.

Kennedy podría eliminar el Comité Asesor sobre Prácticas de Inmunización de los CDC, cuyas recomendaciones sobre el uso de una vacuna determinan si el gobierno la financia a través del programa Vacunas para Niños, que se creó hace 30 años y ofrece inmunizaciones gratuitas a más de la mitad de los niños del país.

Otra opción es que Kennedy coloque en el comité a aliados suyos que se oponen a nuevas vacunas y, al menos en teoría, retire las recomendaciones para vacunas como la triple viral (sarampión, paperas y rubéola), que se usa desde hace 53 años y cuya anulación es uno de los principales objetivos del movimiento antivacunas.

Mientras tanto, siempre hay amenazas de enfermedades infecciosas. Pero en lugar de prepararse para enfrentarlas, como haría una administración entrante común, Kennedy ha amenazado con reestructurar las agencias federales de salud. En una conferencia de Children’s Health Defense en noviembre, en Georgia, declaró que, cuando asuma el cargo, les dará “un respiro a las enfermedades infecciosas” para ocuparse de las afecciones crónicas.

El virus H5N1, o gripe aviar, podría estallar y convertirse en una nueva pandemia. No solo se ha propagado entre el ganado sino que ha infectado por lo menos a 55 personas. El dengue, que se transmite por mosquitos, es otra de las enfermedades que aumenta en el país.

Las enfermedades tradicionales de la infancia también están manifestándose con mayor frecuencia, en parte debido a la baja en la vacunación. Este año hubieron 16 brotes de sarampión —el 89% de los casos en personas no vacunadas— y la epidemia de tos ferina fue la peor desde 2012.

“Así es como estamos empezando”, dijo Peter Hotez, pediatra y virólogo del Baylor College of Medicine. “Y a esta situación se suma el nombramiento a la cabeza del HHS de uno de los activistas antivacunas más contundente y visible, lo que me provoca mucha preocupación”.

Los precios de las acciones de las compañías farmacéuticas con grandes portfolios de vacunas se han desplomado desde la designación de Kennedy. Incluso antes de la victoria de Trump, la escasez de vacunas y el escepticismo habían hecho caer la demanda de las más nuevas, como las vacunas contra el Virus Respiratorio Sincitial (VSR) y el herpes zóster de GSK.

Kennedy tiene varias maneras para retrasar o directamente detener el lanzamiento de nuevas vacunas. También para reducir las ventas de vacunas existentes. Por ejemplo, puede exigir estudios adicionales después que las vacunas ya están en el mercado o difundir estudios que sugieren posibles riesgos de seguridad, aunque esa afirmación sea errónea o no esté comprobada.

Kennedy, quien ha apoyado teorías conspirativas como que el VIH no causa el sida y que los pesticidas provocan disforia de género, declaró a NPR que existen “enormes déficits” en la investigación sobre la seguridad de las vacunas. “Nos aseguraremos de que esos estudios científicos se realicen y de que las personas puedan tomar decisiones informadas”, dijo.

El nombramiento de Kennedy “es un mal pronóstico para el desarrollo de nuevas vacunas y la aplicación de las que están actualmente disponibles”, dijo Stanley Plotkin, quien desarrolló la vacuna contra la rubéola en la década de 1960 y ahora es consultor de la industria de vacunas. “El desarrollo de vacunas requiere millones de dólares. A menos que haya perspectivas de obtener beneficios, las empresas comerciales no van a interesarse en invertir en esas investigaciones”, reflexionó.

Los defensores de las vacunas, que disponen de menos recursos que los grupos antivacunas, mucho mejor financiados, consideran que será muy difícil la batalla para defender la necesidad de la inmunización en los tribunales, las legislaturas y la opinión  pública. Las personas rara vez valoran la ausencia de una enfermedad erradicada, lo que dificulta promover las vacunas, incluso cuando son altamente efectivas.

Una situación muy grave

“Para mucha gente, RFK Jr. era motivo de burla, pero él está absolutamente decidido, habla totalmente en serio”, afirmó Ernst. “Tiene mucho poder, dinero y una vasta red de padres antivacunas que aparecerán en cualquier momento”. Nada similar ha ocurrido en los grupos a favor de las vacunas, dijo Ernst.

El 22 de octubre pasado, cuando una junta sanitaria de Idaho votó a favor de dejar de suministrar vacunas contra covid en seis condados, no había defensores de las vacunas en la reunión. “Ni siquiera sabíamos que esa discusión estaba en el orden del día”, aseguró Ernst. “La movilización por nuestra parte siempre está más retrasada. Pero no me rindo”, concluyó.

Este giro multifacético e impredecible ha sido desconcertante para Walter Orenstein, quien como jefe de la división de inmunización de los CDC entre 1988 y 2004 convenció a los estados de que endurecieran los requisitos de vacunación escolares para luchar contra los brotes de sarampión.

“La gente no entiende el concepto de protección comunitaria y, si lo entiende, no parece importarle”, afirmó Orenstein. Como epidemiólogo de los CDC en la India, Orenstein fue testigo de algunos de los últimos casos de viruela en la década de 1970. También atendió con frecuencia a niños con meningitis causada por la bacteria H. influenzae tipo B, una enfermedad que ha desaparecido casi totalmente gracias a una vacuna introducida en 1987.

“Yo era muy ingenuo”, dijo. “Pensaba que la vacunación contra covid consolidaría la aceptación de las vacunas, pero sucedió todo lo contrario”.

Los legisladores que se oponen a las vacunas podrían presentar leyes para eliminar los requisitos de acceso a la escuela en casi todos los estados, explicó Saunders.

En Texas se ha presentado un proyecto de ley de estas características, donde lo que se conoce como el movimiento de elección de vacunas ha estado creciendo desde 2015 y se intensificó durante la pandemia, fusionándose con los grupos de defensa de los derechos de los padres y grupos antigubernamentales opuestos a medidas como las vacunas obligatorias y el uso de máscaras.

“El genio ya está fuera de la botella y no se puede volver a meter”, dijo Rekha Lakshmanan, directora de estrategia de Immunization Partnership en Texas. “Se ha convertido en un problema con muchos ángulos con el que tenemos que lidiar”, agregó.

En el último año escolar completo, más de 100.000 alumnos de las escuelas públicas de Texas fueron eximidos de aplicarse una o más vacunas, dijo Lakshmanan, y se cree que muchos de los 600.000 niños en el estado que reciben su educación en sus casas tampoco están vacunados.

Los planes del presidente electo Donald Trump, que se propone eliminar las protecciones del servicio civil de los trabajadores federales, podrían ser la mayor amenaza para las políticas de vacunación existentes. Una decisión de ese tipo pondría en peligro a los empleados de las agencias federales de salud cuyo trabajo diario es prepararse para luchar contra las enfermedades y epidemias.

“Si se desmantela el aparato administrativo del estado el impacto en la salud pública será a largo plazo y grave”, dijo Dorit Reiss, profesora de la Facultad de Derecho Hastings de la Universidad de California.

El multimillonario Elon Musk, una persona con gran influencia sobre el presidente electo, planea recortes de gastos que también se consideran una amenaza.

“Dañar las funciones más importantes de la FDA, es como matar a la gallina de los huevos de oro, tanto para nuestra salud como para la economía”, afirmó Jesse Goodman, director del Center on Medical Product Access, Safety and Stewardship de la Universidad de Georgetown y ex director científico de la FDA.

“Sería exactamente lo contrario de lo que Kennedy dice que quiere, que son productos médicos seguros. Si en la agencia carecemos de científicos y clínicos calificados e independientes, el riesgo de que los estadounidenses tengan alimentos y medicamentos inseguros se incrementa.”

Los brotes de enfermedades prevenibles con vacunas podrían ser alarmantes, pero ¿serían suficientes para impulsar de nuevo las tasas de  vacunación? Ernst, de Voices for Vaccines, no está convencido.

“Ya estamos teniendo brotes. Tendrían que pasar años antes de que murieran suficientes niños como para que la gente dijera: ‘Supongo que el sarampión es algo realmente peligroso’”, afirmó. “La muerte de un niño no será suficiente. La historia que contarán será: ‘A ese niño le pasaba algo. A mi hijo no le puede pasar’”.

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. 

The Host

President-elect Donald Trump has continued naming out-of-the-box choices to lead key federal health agencies. Three of those picks — Marty Makary, who would lead the FDA; Jay Bhattacharya, who would head the National Institutes of Health; and Dave Weldon, chosen to administer the Centers for Disease Control and Prevention — have something notable in common: All have proposed major changes to the organizations they would oversee.

 Meanwhile, the Supreme Court heard a case challenging Tennessee’s ban on transgender health care for minors, with the conservative justices seeming likely to support the state’s law.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins University’s schools of public health and nursing and Politico, and Shefali Luthra of The 19th.

Among the takeaways from this week’s episode:

• In recent weeks, Trump has named his picks to lead key federal health agencies, including the FDA, NIH, and CDC. His selections suggest big changes could be in store. For instance, Weldon — a former congressman and a practicing physician — has often advocated against scientific consensus, including on vaccines.
• The Supreme Court this week heard arguments on Tennessee’s law barring transitional care for transgender minors, and from listening to the conservative majority’s remarks, it seems likely they will uphold the law — with implications for those living in the more than 20 states with similar measures on the books. Plus, in a separate case on vaping, the court sounded sympathetic to the FDA’s decisions to reject applications for flavored e-cigarettes that could put children at risk of addiction.
• Meanwhile, the incoming Trump administration is poised to take custody of some health-related lawsuits it could very well drop, as well as some big policies it could end — but it remains to be seen what actions it chooses to take. Medicare drug negotiations, for example, are a Biden administration policy, though Trump and his pick for Health and Human Services secretary, Robert F. Kennedy Jr., have also advocated for cracking down on the drug industry.
• In abortion news, a federal appeals court has cleared the way for Idaho to begin to enforce parts of its law making it a crime to help a minor obtain an abortion in another state. And officials in Texas and Georgia throttled state commissions studying maternal mortality after cases showed the states’ abortion bans were responsible for at least some women’s deaths.

Also this week, Rovner interviews KFF Health News’ Bram Sable-Smith, who reported and wrote the latest KFF Health News-Washington Post Well+Being “Bill of the Month” feature, about an emergency room bill for a visit that didn’t make it past the waiting room. If you have an outrageous or inscrutable medical bill you’d like to send us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: The New Yorker’s “The Texas OB-GYN Exodus,” by Stephania Taladrid.  

Shefali Luthra: The Washington Post’s “Post Reports” podcast’s “A Trans Teen Takes Her Case to the Supreme Court,” by Casey Parks, Emma Talkoff, Ariel Plotnick, and Bishop Sand.  

Joanne Kenen: ProPublica’s “For Decades, Calls for Reform to Idaho’s Troubled Coroner System Have Gone Unanswered,” by Audrey Dutton.  

Sarah Karlin-Smith: Stat’s “What YouTube Health Is Doing To Combat Misinformation and Promote Evidence-Based Content,” by Nicholas St. Fleur.  

Also mentioned in this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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. 

It seems no one is taking covid-19 seriously anymore, said Mollee Loveland, a nursing home aide who lives outside Pittsburgh.

Loveland has seen patients and coworkers at the nursing home where she works die from the viral disease.

Now she has a new worry: bringing home the coronavirus and unwittingly infecting her infant daughter, Maya, born in May.

Loveland’s maternity leave ended in late June, when Maya wasn’t yet 2 months old. Infants cannot be vaccinated against covid until they are 6 months old. Children younger than that suffer the highest rates of hospitalization of any age group except people 75 or older.

Between her patients’ complex medical needs and their close proximity to one another, covid continues to pose a grave threat to Loveland’s nursing home — and to the 15,000 other certified nursing homes in the U.S. where some 1.2 million people live.

Despite this risk, a CDC report published in April found that just 4 in 10 nursing home residents in the U.S. received an updated covid vaccine in the winter of 2023-24. The analysis drew on data from Oct. 16, 2023, through Feb. 11, 2024, and was conducted by the Centers for Disease Control and Prevention.

The CDC report also revealed that during January’s covid peak, the rate of hospitalizations among nursing home residents was more than eight times that of all U.S. adults, age 70 and older.

Billing Complexities and Patient Skepticism

Last winter’s low vaccination rate was partly driven by the end of the federal government’s paying for administering the shots, said Rajeev Kumar, a Chicago-based geriatrician.

While the vaccines remain free to patients, clinicians must now bill each person’s insurer separately. That makes vaccinating an entire nursing home more logistically complicated, Kumar said.

Kumar is president of the Post-Acute and Long-Term Care Medical Association, which represents clinicians who work in nursing homes and similar settings, such as post-acute care, assisted living, and hospice facilities.

“The challenges of navigating through that process and arranging vaccinations, making sure that somebody gets to bill for services and collect money, that’s what has become a little bit more tedious,” he said.

In April, after the study was released, the CDC recommended that adults 65 and older get an additional dose of an updated vaccine if it’s been more than four months since their last dose. That means most nursing home patients who have had only one shot in fall or winter are not considered up to date on the covid vaccines.

Kumar and his colleagues are encountering more skepticism of the covid vaccines, compared with their rollout.

“The long-term care population is a microcosm of what’s happening across the country and, unfortunately, covid vaccine reluctance remains persistent throughout the general public. It’s our most significant challenge,” according to an emailed statement from David Gifford, chief medical officer at AHCA/NCAL, which represents both for-profit and nonprofit nursing homes.

Nursing aide Loveland also has observed doubts and misinformation cropping up among patients at her job: “It’s the Facebook rabbit hole.”

But there are ways to push back against bad information, and states show wide variation in the proportion of nursing home residents who got vaccinated last winter.

For example, in both North and South Dakota, more than 55% of residents at nursing homes that reported data have gotten an updated covid vaccine this fall. Nationally, that share is 32%.

Building Trust Through Relationships

One major medical system operating in the Dakotas, Sanford Health, has managed more than two dozen nursing homes since a 2019 merger with the long-term care chain Good Samaritan Society.

In some of these nursing homes more than 70% of residents were vaccinated last fall and winter — at one Sanford facility in Canton, South Dakota, the rate exceeded 90%.

Sanford achieved this by leveraging the size of the health system to make delivering vaccines more efficient, said Jeremy Cauwels, Sanford’s chief medical officer. He also credited a close working relationship with a South Dakota-based pharmacy chain, Lewis Drug.

But the most crucial factor was that many of Sanford’s nursing home patients are cared for by doctors who are also employed by the health system. At most Sanford’s North and South Dakota nursing homes, these clinicians provide on-site primary care, meaning patients don’t have to leave the facilities to see doctors.

These employed doctors have been critical in persuading patients to stay up to date on their covid shots, Cauwels said. For example, a medical director who worked at the Good Samaritan nursing home in Canton was a long-serving physician with close ties to that community.

“An appropriate one-on-one conversation with someone who cares about you and has a history of doing so in the past, for us, has resulted in much better numbers than other places have been able to get to nationally,” said Cauwels, who added that Sanford still needs to work on reaching more patients.

Sanford’s success shows the onus of getting patients vaccinated extends beyond nursing homes, said Jodi Eyigor, director of nursing home quality and public policy for LeadingAge, which represents nonprofit nursing homes. She said primary care providers, hospitalists, pharmacists, and other health care stakeholders need to step up.

“What conversations have occurred before they walked into a nursing home’s doors, between them and their doctors? Because they’re probably seeing their doctors quite frequently before they come into the nursing home,” said Eyigor, who noted these other clinicians are also regulated by Medicare, the federal health insurance program for adults 65 and older.

Critics: Shot Uptake Linked to Residents’ Dissatisfaction

Nursing homes are required to educate patients — as well as staff — about the importance of the covid vaccines. Industry critics contend that one-on-one conversations, based on trusted relationships with clinicians, are the least that nursing homes should do.

But many facilities don’t seem to be doing even that, according to Richard Mollot, executive director of the Long Term Care Community Coalition, a watchdog group that monitors nursing homes. A 40% recent vaccination rate is inexcusable, he said, given the danger the virus poses to people who live in nursing homes.

A study from the Journal of Health Economics estimates that from the start of the pandemic through Aug. 15, 2021, 21% of covid deaths in the U.S. were among people living in nursing homes.

Mollot said that the alarmingly low covid vaccination rate is a symptom of larger issues throughout the industry. He hears from patients’ families about poor food quality and a general apathy that some nursing homes have toward residents’ concerns. He also cites high rates of staff turnover and substandard, even dangerous, care.

These problems intensified in the years since the start of the covid pandemic, Mollot said, causing extensive stress throughout the industry.

“That has resulted in much lower care, much more disrespectful interactions between residents and staff, and there’s just that lack of trust,” he added.

Loveland, the nursing aide outside Pittsburgh, also thinks the industry has fundamental problems when it comes to daily interactions between workers and residents. She said the managers at her job often ignore patients’ concerns.

“I feel like if the facilities did more with the patients, they would get more respect from the patients,” she said.

That means that when administrators announced it was time for residents to get one of the newest covid vaccines this year, Loveland said, residents often simply ignored the message, even if it meant putting their own health at risk.

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

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. 

With Donald Trump’s return to the White House and Republicans taking full control of Congress in 2025, the Affordable Care Act’s Medicaid expansion is back on the chopping block.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 2017, the Republicans who controlled Congress tried mightily to slash federal spending on Medicaid, the government-funded health program covering low-income families and individuals.

California, like other states, depends heavily on federal dollars to provide care for its poorest residents. Analyses at the time showed the GOP’s proposals would cut Medicaid funds flowing from Washington by tens of billions of dollars, perhaps even more, forcing state officials to rethink the scope of Medi-Cal.

But the GOP efforts ended in failure — iconically crystallized by Arizona Republican Sen. John McCain, sick with terminal brain cancer, issuing his decisive early-morning thumbs-down.

More than seven years later, here we go again.

With Donald Trump preparing to reenter the White House, bolstered once more by Republican majorities in both houses of Congress, expectations are high that the GOP will quickly resurrect its long-desired goal of cutting Medicaid.

Republicans want to finance large tax cuts, and the GOP platform under Trump pledges not to touch Social Security or Medicare. To be sure, that’s not set in stone. But for now, as my KFF colleagues have noted, Medicaid looks an awful lot like low-hanging fruit. (KFF is a health information nonprofit that includes KFF Health News, the publisher of California Healthline.)

Health officials in California and across the nation are on edge about the possibility of large-scale Medicaid cuts being enacted as soon as next year. Such cuts would have an outsize impact in the Golden State, whose 14.7 million Medi-Cal enrollees exceed the entire populations of all but three other U.S. states. Medi-Cal provides health coverage for over 40% of the state’s children and pays for nearly 40% of births. It is a crucial source of funding for safety net hospitals and community clinics.

And over 60% of its $161 billion budget this year comes by way of Washington.

The potential for big federal cuts to Medicaid may have been a factor in Democratic Gov. Gavin Newsom’s decision to call a special session of the state legislature this week.

California could seek to offset a sharp drop in federal dollars with higher taxes or cuts to other state programs. But both those options could be politically untenable. That’s why many health experts think leaders in Sacramento would almost certainly have to consider shrinking Medi-Cal.

That could mean cutting any number of optional benefits, such as dental services, optometry, and physical therapy. It might also mean rolling back some of the ambitious expansion Medi-Cal has undertaken in recent years. That could include some aspects of California Advancing and Innovating Medi-Cal, a $12 billion program of services that address patients’ social and economic needs in addition to their medical ones.

Some observers fear federal cuts could affect the approximately 1.5 million immigrants living in the U.S. without authorization who are enrolled in Medi-Cal at an annual cost of over $6 billion, nearly all of it funded by the state. But others say a more likely route would be to reduce payments across the board to the managed care plans that cover 94% of Medi-Cal enrollees, rather than target any specific groups of people.

“Medicaid is on the chopping block, and I don’t think that’s speculation,” says Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. “It is widely viewed by potential members of Trump’s administration as a program that is too broad and needs to be brought under control.”

Whether they can succeed this time remains to be seen. But more on that later.

People who have followed previous GOP efforts to downsize Medicaid say a variety of previously attempted methods might be back on the table this time. They could include outright caps on federal Medicaid dollars; elimination of the core Affordable Care Act policy under which the feds pay 90% of the cost of expanding coverage to a wider swath of low-income adults; a work requirement, which could depress enrollment; and rule changes intended to make it harder for states to draw federal Medicaid dollars through the use of taxes on health care insurers known as MCOs.

The first Trump administration proposed but later dropped changes to the rules governing such taxes. If similar changes were adopted this time around, they could cause financial headaches in California, which has frequently used MCO taxes to offset Medi-Cal spending from state coffers.

Proposition 35, recently passed by California voters, could also be at risk. The initiative calls for the MCO tax to become a permanent fixture in 2027, pending federal approval, with the goal of financing billions of dollars in new Medi-Cal spending, primarily to increase funding for doctors and other providers. A federal rule change could upend those intentions.

Termination of the federal government’s 90% coverage of the ACA Medicaid expansion would put a gaping hole in the Medi-Cal budget. Medi-Cal spent over $34 billion in fiscal year 2023 covering the roughly 5 million people who enrolled as a result of the expansion, and nearly $31 billion of that amount was paid by the federal government.

If the feds’ share dropped back to its regular Medi-Cal rate of 50%, California would have to pony up nearly $14 billion more to keep the expansion enrollees covered — and that’s just for a year.

A more ambitious GOP push, including both spending caps and a rollback of federal support for the Medicaid expansion, could really send California officials scrambling.

In 2017, the state’s Department of Health Care Services issued an analysis showing that a legislative proposal filed by a group of Republican U.S. senators to cap Medicaid spending and end enhanced funding for the ACA expansion, along with some other cuts, would result in nearly $139 billion of lost federal funding to California from 2020 to 2027.

“There are almost limitless changes state leaders could make to Medi-Cal if they are forced to do that,” says David Kane, a senior attorney at the Western Center on Law & Poverty. “And we fear that burden will almost certainly hurt poor people and immigrants the most.”

But big Medicaid cuts are not a foregone conclusion. After all, when Trump was in the White House in 2017, Republicans also had House and Senate majorities and still did not achieve their goal. The political stars could be aligning differently this time, but the GOP has only a razor-thin majority in the House.

A decade into the ACA’s Medicaid expansion, some 21 million people across the country have coverage through it, embedding the program more deeply in the nation’s health care landscape. According to a 2023 study from Georgetown University, Medicaid and the related Children’s Health Insurance Program cover a higher proportion of the population in rural counties than in urban ones. And as we know, rural America leans strongly Republican.

Will GOP members of Congress, faced with a vote on cutting Medicaid, buck their own constituents?

Edwin Park, one of the authors of that Georgetown study, thinks there’s a chance big cuts can be averted. “Large numbers of Americans are either on Medicaid, have family members on Medicaid, or know somebody on Medicaid,” says Park, a research professor at Georgetown’s McCourt School of Public Policy. “Hopefully its popularity and its importance will win the day.”