Perez helped the patient, a homeless, West African immigrant who has HIV and other chronic conditions, get the medications and care he needed. She also did the paperwork that documented his medical needs for the nonprofit that helped him apply for asylum and secure housing.

“I really like whole-person care,” said Perez, 31, who has been based at this New York City health center for most of the past three years. “I wanted to learn and train, dealing with the everyday things I will be seeing as a primary care physician and really immersing myself in the community,” she said.

Few primary care residents get such extensive community-based outpatient training. The vast majority spend most of their residencies in hospitals. But Perez, who is being trained through the Teaching Health Center Graduate Medical Education program, is among those treating patients in federally qualified health centers and community clinics in medically underserved rural and urban areas around the country. After graduating, these residents are more likely than hospital-trained graduates to stay on and practice locally where they are often desperately needed, research has found.

Amid the long-term shift from inpatient to outpatient medical care, training primary care doctors in outpatient clinics rather than hospitals is a no-brainer, according to Robert Schiller, chief academic officer at the , which runs the Harlem THC program and operates dozens of other health center sites in New York. “Care is moving out into the community,” he said, and the THC program is “creating a community-based training environment, and the community is the classroom.”

Yet because the program, established under the 2010 Affordable Care Act, relies on congressional appropriations for funding, it routinely faces financial uncertainty. , it will run out of funds at the end of December unless lawmakers vote to replenish its coffers — no easy task in the current divided Congress in which gaining passage for any type of legislation has proved difficult. Faced with the prospect of not being able to cover three years of residency training, several of the 82 THC programs nationwide recently put their residency training programs on hold or are phasing them out.

That’s what the in New Orleans East, an area that has been slow to recover after Hurricane Katrina in 2005, has done. With a startup grant from the federal Health Resources and Services Administration, the community health center hired staff for the residency program and became accredited last fall. They interviewed more than 50 medical students for residency slots and hoped to enroll their first class of four first-year residents in July. But with funding uncertain, they put the new program on hold this spring, a few weeks before “Match Day,” when residency programs and students are paired.

“It was incredibly disappointing for many reasons,” said Coleman Pratt, the residency program’s director, who was hired two years ago to launch the initiative.

Until we know we’ve got funding, we’re “treading water,” Pratt said.

“In order to have eligible applications in-hand should Congress appropriate new multi-year funds, HRSA will issue a Notice of Funding Opportunity in late summer for both new and expanded programs to apply to be funded in FY 2025, subject to the availability of appropriations,” said Martin Kramer, an HRSA spokesperson, in an email.

For now, the Teaching Health Center program has $215 million to spend through 2024.

By contrast, the Centers for Medicare & Medicaid Services paid hospitals $18 billion to provide residency training for doctors in primary care and other specialties. Unlike THC funding, which must be appropriated by Congress, Medicare graduate medical education funding is guaranteed as a federal entitlement program.

Trying to keep THC’s three-year residency programs afloat when congressional funding comes through in fits and starts weighs heavily on the facilities trying to participate. These pressures are now coming to a head.

“Precariousness of funding is a theme,” said Schiller, noting that the Institute for Family Health put its own plans for a new THC in Brooklyn on hold this year.

The misalignment between the health care needs of the American population and the hospital-based medical training most doctors receive is a long-recognized problem. by the National Academies Press noted that “although the GME system has been producing more physicians, it has not produced an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas.”

The Teaching Health Center program in these areas, with program graduates more likely to practice in medically underserved areas after graduation. that analyzed the practice patterns of family medicine graduates from traditional GME training programs vs. those who participated in the THC program, nearly twice as many THC graduates were practicing in underserved areas three years after graduating, 35.2% vs. 18.6%. In addition, THC graduates were significantly more likely to practice in rural areas, 17.9% vs. 11.8%. They were also more likely to provide substance use treatment, behavioral health care, and outpatient gynecological care than graduates from regular GME programs.

But the lack of reliable, long-term funding is a hurdle to the THC training model’s potential, proponents say. For 2024, the Biden administration had proposed three years of mandatory funding, totaling $841 million, to support more than 2,000 residents.

“HRSA is eager to fund new programs and more residents, which is why the President’s Budget has proposed multi-year increased funding for the Teaching Health Center program,” Kramer said in an email.

The American Hospital Association supports expanding the THC program “to help address general workforce challenges,” said spokesperson Sharon Cohen in an email.

The program appeals to residents interested in pursuing primary and community care in underserved areas.

“There’s definitely a selection bias in who chooses these [THC] programs,” said Candice Chen, an associate professor of health policy and management at George Washington University.

Hospital primary care programs, for instance, their primary care residency slots on Match Day. But in the THC program, “every single year, all of the slots match,” said Cristine Serrano, executive director of the American Association of Teaching Health Centers. On Match Day in March, more than 19,000 primary care positions were available; roughly 300 of those were THC positions.

Amanda Fernandez, 30, always wanted to work with medically underserved patients. She did her family medicine residency training at a THC in Hendersonville, North Carolina. She liked it so much that, after graduating last year, the Miami native took a job in Sylva, about 60 miles away.

Her mostly rural patients are accustomed to feeling like a way station for physicians, who often decamp to bigger metro areas after a few years. But she and her husband, a physician who works at the nearby Cherokee Indian Hospital, bought a house and plan to stay.

“That’s why I loved the THC model,” Fernandez said. “You end up practicing in a community similar to the one that you trained in.”

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After two years of delays due to the coronavirus pandemic, they set sail in December 2022.

The couple chose a cruise destined for the Bahamas in part because it included a trip to CocoCay, a private island accessible to Royal Caribbean passengers that featured a water park, balloon rides, and an excursion swimming with pigs.

It was on that day on CocoCay when Wasney, 31, started feeling off, he said.

The next morning, as the couple made plans in their cabin for the last full day of the trip, Wasney made a pained noise. Eberlein saw him having a seizure in bed, with blood coming out of his mouth from biting his tongue. She opened their door to find help and happened upon another guest, who roused his wife, an emergency room physician.

Wasney was able to climb into a wheelchair brought by the ship’s medical crew to take him down to the medical facility, where he was given anticonvulsants and fluids and monitored before being released.

Wasney had had seizures in the past, starting about 10 years ago, but it had been a while since his last one. Imaging back then showed no tumors, and doctors concluded he was likely epileptic, he said. He took medicine initially, but after two years without another seizure, he said, his doctors took him off the medicine to avoid liver damage.

Wasney had a second seizure on the ship a few hours later, back in his cabin. This time he stopped breathing, and Eberlein remembered his lips being so purple, they almost looked black. Again, she ran to find help but, in her haste, locked herself out. By the time the ship’s medical team got into the cabin, Wasney was breathing again but had broken blood vessels along his chest and neck that he later said resembled tiger stripes.

Wasney was in the ship’s medical center when he had a third seizure — a grand mal, which typically causes a loss of consciousness and violent muscle contractions. By then, the ship was close enough to port that Wasney could be evacuated by rescue boat. He was put on a stretcher to be lowered by ropes off the side of the ship, with Eberlein climbing down a rope ladder to join him.

But before they disembarked, the bill came.

The Patient: Vincent Wasney, 31, who was uninsured at the time.

Medical Services: General and enhanced observation, a blood test, anticonvulsant medicine, and a fee for services performed outside the medical facility.

Service Provider: Independence of the Seas Medical Center, the on-ship medical facility on the .

Total Bill: $2,500.22.

What Gives: As , cruise passengers “agree to pay in full” all expenses incurred on board by the end of the cruise, including those related to medical care. In addition, Royal Caribbean “land-based” health insurance plans.

Wasney said he was surprised to learn that, along with other charges like wireless internet, Royal Caribbean required he pay his medical bills before exiting the ship — even though he was being evacuated urgently.

“Are we being held hostage at this point?” Eberlein remembered asking. “Because, obviously, if he’s had three seizures in 10 hours, it’s an issue.”

Wasney said he has little memory of being on the ship after his first seizure — seizures often leave victims groggy and disoriented for a few hours afterward.

But he certainly remembers being shown a bill, the bulk of which was the $2,500.22 in medical charges, while waiting for the rescue boat.

Still groggy, Wasney recalled saying he couldn’t afford that and a cruise employee responding: “How much can you pay?”

They drained their bank accounts, including money saved for their next house payment, and maxed out Wasney’s credit card but were still about $1,000 short, he said.

Ultimately, they were allowed to leave the ship. He later learned his card was overdrafted to cover the shortfall, he said.

Royal Caribbean International did not respond to multiple inquiries from Ģ��ӰԺ Health News.

Once on land, in Florida, Wasney was taken by ambulance to the emergency room at Broward Health Medical Center in Fort Lauderdale, where he incurred thousands of dollars more in medical expenses.

He still isn’t entirely sure what caused the seizures.

On the ship he was told it could have been extreme dehydration — and he said he does remember being extra thirsty on CocoCay. He also has mused whether trying escargot for the first time the night before could have played a role. Eberlein’s mother is convinced the episode was connected to swimming with pigs, he said. And not to be discounted, Eberlein accidentally broke a pocket mirror three days before their trip.

Wasney, who works in a stone shop, was uninsured when they set sail. He said that one month before they embarked on their voyage, he finally felt he could afford the health plan offered through his employer and signed up, but the plan didn’t start until January 2023, after their return.

They also lacked travel insurance. As inexperienced travelers, Wasney said, they thought it was for lost luggage and canceled trips, not unexpected medical expenses. And because the cruise was a gift, they were never prompted to buy coverage, which often happens when tickets are purchased.

The Resolution: Wasney said the couple returned to Saginaw with essentially no money in their bank account, several thousand dollars of medical debt, and no idea how they would cover their mortgage payment. Because he was uninsured at the time of the cruise, Wasney did not try to collect reimbursement for the cruise bill from his new health plan when his coverage began weeks later.

The couple set up payment plans to cover the medical bills for Wasney’s care after leaving the ship: one each with two doctors he saw at Broward Health, who billed separately from the hospital, and one with the ambulance company. He also made payments on a bill with Broward Health itself. Those plans do not charge interest.

But Broward Health said Wasney missed two payments to the hospital, and that bill was ultimately sent to collections.

In a statement, Broward Health spokesperson Nina Levine said Wasney’s bill was reduced by 73% because he was uninsured.

“We do everything in our power to provide the best care with the least financial impact, but also cannot stress enough the importance of taking advantage of private and Affordable Care Act health insurance plans, as well as travel insurance, to lower risks associated with unplanned medical issues,” she said.

The couple was able to make their house payment with $2,690 they raised through a that Wasney set up. Wasney said a lot of that help came from family as well as friends he met playing disc golf, a sport he picked up during the pandemic.

“A bunch of people came through for us,” Wasney said, still moved to tears by the generosity. “But there’s still the hospital bill.”

The Takeaway: Billing practices differ by cruise line, but , chair of the cruise ship medicine section of the American College of Emergency Physicians, said medical charges are typically added to a cruise passenger’s onboard account, which must be paid before leaving the ship. Individuals can then submit receipts to their insurers for possible reimbursement.

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He recommended that those planning to take a cruise purchase travel insurance that specifically covers their trips. “This will facilitate reimbursement if they do incur charges and potentially cover a costly medical evacuation if needed,” Scott said.

Royal Caribbean passengers who receive onboard care submit their paid bills to their health insurer for possible reimbursement. Many health plans received on cruise ships, however. medically necessary health care services on cruise ships, but not if the ship is more than six hours away from a U.S. port.

Travel insurance can be designed to address , like lost baggage or even transportation and lodging for a loved one to visit if a traveler is hospitalized.

Travel medical insurance, as well as plans that offer “emergency evacuation and repatriation,” are two types that can specifically assist with medical emergencies. Such plans can be purchased individually. Credit cards may offer travel medical insurance among their benefits, as well.

But travel insurance plans come with limitations. For instance, they may not cover care associated with preexisting conditions or what the plans consider “risky” activities, such as rock climbing. Some plans also require that travelers file first with their primary health insurance before seeking reimbursement from travel insurance.

As with other insurance, be sure to read the fine print and understand how reimbursement works.

Wasney said that’s what they plan to do before their next Royal Caribbean cruise. They’d like to go back to the Bahamas on basically the same trip, he said — there’s a lot about CocoCay they didn’t get to explore.

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The first national survey of adults whose Medicaid eligibility was reviewed during the unwinding found nearly half of people who lost their government coverage signed back up weeks or months later — suggesting they should never have been dropped in the first place.

While 23% reported being uninsured, an additional 28% found other coverage — through an employer, Medicare, the Affordable Care Act’s insurance marketplace, or health care for members of the military, the survey by Ģ��ӰԺ found.

“Twenty-three percent is a striking number especially when you think about the number of people who lost Medicaid coverage,” said Chima Ndumele, an associate professor of health policy at the Yale University School of Public Health.

Going without insurance even for a short period of time can lead people to delay seeking care and leave them at financial risk when they do.

Seven in 10 adults who were disenrolled during the unwinding process say they became uninsured at least temporarily when they lost their Medicaid coverage.

Adrienne Hamar, 49, of Plymouth Meeting, Pennsylvania, said she struggled to enroll in an Affordable Care Act marketplace plan this winter after the state informed her that she and her two children no longer qualified for Medicaid. They had been enrolled since 2020. She said phone lines were busy at the state’s marketplace and she couldn’t complete the process online.

Hamar, who works as a home health aide, and her children were uninsured in March. But since April 1, they’ve been enrolled in a marketplace plan that, with the help of government subsidies, costs $50 a month for the family.

“I was very relieved,” she said. Unsure of their insurance status, Hamar said, her 23-year-old daughter delayed getting a dental checkup.

Hamar’s struggles were common, the survey found.

Of adults enrolled in Medicaid before the unwinding, about 35% who tried to renew their coverage described the process as difficult, and about 48% said it was at least somewhat stressful.

About 56% of those disenrolled say they skipped or delayed care or prescriptions while attempting to renew their Medicaid coverage.

“People’s current insurance status is likely to be very much in flux, and we would expect at least some of the people who say they are currently uninsured to reenroll in Medicaid — many say they are still trying — or enroll in other coverage within a short period of time,” said Jennifer Tolbert, a co-author of the Ģ��ӰԺ report and the director of Ģ��ӰԺ’s State Health Reform and Data Program.

The survey didn’t include children, and the Ģ��ӰԺ researchers said their findings therefore couldn’t be extrapolated to determine how the Medicaid unwinding has affected the overall U.S. uninsured rate, which hit a record low of . Nearly half of enrollees in Medicaid and the related Children’s Health Insurance Program are children.

The unwinding, in which states are reassessing eligibility for Medicaid among millions of Americans who enrolled before or during the pandemic and dropping those who no longer qualify or did not complete the renewal process, won’t be completed until later this year. Enrollment in Medicaid and CHIP grew to a record of nearly 94.5 million in April of last year, three years after the federal government prohibited states from cutting people from their rolls during the covid-19 public health emergency.

Nationally, states have disenrolled about 20 million people from Medicaid in the past year, most of them for procedural reasons such as failure to submit required paperwork. That number is expected to grow, as states have a few more months to redetermine enrollees’ eligibility.

Among adults who had Medicaid prior to the start of the unwinding, 83% retained their coverage or reenrolled, while 8% found other insurance and 8% were uninsured. The share left uninsured was larger in states that have not expanded Medicaid under the ACA (17%) than in states that have (6%). Forty states have expanded Medicaid to cover everyone with an income under 138% of the federal poverty rate, or $31,200 for a family of four this year.

The Ģ��ӰԺ survey found that nearly 1 in 3 disenrolled adults discovered only when they sought health care — such as going to a doctor or a pharmacy — that they had been dropped from Medicaid.

Indira Navas of Miami found out that her 6-year-old son, Andres, had been disenrolled from Florida’s Medicaid program when she took him to a doctor appointment in March. She had scheduled Andres’ appointment months in advance and is frustrated that he remains uninsured and his therapy for anxiety and hyperactivity has been disrupted.

Navas said the state could not explain why her 12-year-old daughter, Camila, remained covered by Medicaid even though the children live in the same household with their parents.

“It doesn’t make sense that they would cover one of my children and not the other,” she said.

Kate McEvoy, executive director of the National Association of Medicaid Directors, said the sheer volume of millions of people being redetermined for eligibility has overwhelmed some state call centers trying to support enrollees.

She said states have tried many ways to communicate with enrollees, including through public outreach campaigns, text, email, and apps. “Until the moment your coverage is at stake, it’s hard to penetrate people’s busy lives,” she said.

The Ģ��ӰԺ survey, of 1,227 adults who had Medicaid coverage in early 2023 prior to the start of the unwinding on April 1, 2023, was conducted between Feb. 15, 2024, and March 11, 2024. The margin of sampling error was plus or minus 4 percentage points.

Ģ��ӰԺ Health News correspondent Daniel Chang contributed to this article.

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

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Las protecciones que tuvo el programa durante la pandemia, que impedían que se expulsaran beneficiarios, expiraron la primavera pasada.

La primera encuesta nacional sobre estas desafiliaciones de Medicaid halló que casi la mitad de las personas que perdieron la cobertura volvieron a inscribirse semanas o meses después, lo que sugiere que, en primer lugar, nunca debieron ser expulsadas.

Mientras que el 23% informó no tener seguro, un 28% adicional encontró otra cobertura: a través de un empleador, Medicare, el mercado de seguros de la Ley de Cuidado de Salud a Bajo Precio (ACA) o en programas para miembros de las Fuerzas Armadas, informó la encuesta de Ģ��ӰԺ.

“El 23% es una cifra sorprendente, especialmente si se piensa en la cantidad de personas que perdieron la cobertura de Medicaid”, dijo Chima Ndumele, profesora asociada de políticas de salud en la Escuela de Salud Pública de la Universidad de Yale.

Quedarse sin seguro, incluso por un período corto de tiempo, puede llevar a las personas a retrasar la búsqueda de atención médica, y exponerlas a riesgos financieros.

Siete de cada 10 adultos desafiliados dijeron que se quedaron sin seguro al menos temporalmente cuando perdieron su cobertura de Medicaid.

Adrienne Hamar, de 49 años, de Plymouth Meeting, Pennsylvania, dijo que tuvo dificultades para inscribirse en un plan de ACA este invierno después que el estado le informara que ella y sus dos hijos ya no calificaban para Medicaid. Estaban inscritos desde 2020. Dijo que las líneas telefónicas estaban siempre ocupadas en el mercado estatal y que no podía completar el proceso en línea.

Hamar, que trabaja como asistente de salud a domicilio, y sus hijos, estuvieron sin seguro durante marzo. Pero desde el 1 de abril, están inscritos en un plan del mercado que, con la ayuda de subsidios gubernamentales, cuesta $50 al mes para la familia.

"Me sentí muy aliviada", dijo. Hamar dijo que, por esta situación, su hija de 23 años demoró en hacerse un chequeo dental.

Las luchas de Hamar eran comunes, según la encuesta.

De los adultos inscritos en Medicaid antes de la cancelación, alrededor del 35% que intentó renovar su cobertura describió el proceso como difícil, y cerca del 48% dijo que era al menos algo estresante.

Alrededor del 56% de las personas dadas de baja dicen que omitieron o retrasaron atención médica o buscar una receta mientras intentaban renovar su cobertura de Medicaid.

“Es probable que el estatus actual del seguro de las personas esté cambiando, y esperaríamos que al menos algunas de las que dicen que actualmente no tienen seguro se vuelvan a inscribir en Medicaid (muchos dijeron que todavía lo están intentando) o se inscriban en otra cobertura en poco tiempo”, dijo Jennifer Tolbert, coautora del informe de Ģ��ӰԺ y directora del Programa Estatal de Datos y Reforma de Salud de la fundación.

La encuesta no incluyó a niños, y los investigadores de Ģ��ӰԺ dijeron que, por lo tanto, sus hallazgos no podían extrapolarse para determinar cómo la reducción de Medicaid ha afectado la tasa general de personas sin seguro en el país, que alcanzó un mínimo histórico del . Casi la mitad de los afiliados a Medicaid y al Programa de Seguro Médico Infantil (CHIP) son niños.

El proceso de desafiliación, durante el cual los estados están reevaluando la elegibilidad para Medicaid entre millones de estadounidenses que se inscribieron antes o durante la pandemia —y eliminando a aquellos que ya no califican o no completaron el proceso de renovación— no se completará hasta finales de este año.

La inscripción en Medicaid y CHIP creció a un récord de casi 94,5 millones en abril del año pasado, tres años después que el gobierno federal prohibiera a los estados eliminar a las personas de sus listas durante la emergencia de salud pública de covid-19.

A nivel nacional, los estados cancelaron la inscripción e Medicaid de alrededor de 20 millones de personas el año pasado, la mayoría por razones de procedimiento, como no presentar la documentación requerida. Se espera que ese número aumente, ya que los estados tienen algunos meses más para redeterminar la elegibilidad de los inscritos.

Entre los adultos que tenían Medicaid antes del inicio de las desafiliaciones, el 83% retuvo su cobertura o se volvió a inscribir, mientras que el 8% encontró otro seguro y el 8% no tenía seguro.

La proporción que quedó sin seguro fue mayor en los estados que no han ampliado Medicaid bajo ACA (17%) comparado con los estados que sí lo han hecho (6%). Cuarenta estados han ampliado Medicaid para cubrir a todas las personas con ingresos inferiores al 138% de la tasa federal de pobreza, o $31,200 para una familia de cuatro en 2024.

La encuesta de Ģ��ӰԺ encontró que casi uno de cada 3 adultos a los que se les canceló el seguro descubrió que ya no tenían Medicaid recién cuando buscaron atención médica, como ir a un médico o a una farmacia.

Indira Navas, de Miami, descubrió que a su hijo Andrés, de 6 años, se le había dado de baja del programa de Medicaid de Florida cuando lo llevó a una cita con el médico en marzo. Había programado esa cita con meses de anticipación y está frustrada porque el niño sigue sin seguro y se interrumpió su terapia para la ansiedad y la hiperactividad.

Navas dijo que el estado no pudo explicar por qué su hija Camila, de 12, seguía cubierta por Medicaid a pesar de que los dos niños viven en el mismo hogar que sus padres.

“No tiene sentido que cubran a uno de mis hijos y al otro no”, dijo.

Kate McEvoy, directora ejecutiva de la Asociación Nacional de Directores de Medicaid, dijo que el gran volumen, de millones de personas, a las que se está analizando para determinar su elegibilidad ha abrumado a algunos centros de llamadas estatales que intentan apoyar a los afiliados.

Dijo que los estados han probado muchas formas de comunicarse con los inscritos, incluso a través de campañas de divulgación pública, mensajes de texto, correo electrónico y aplicaciones. "Hasta el momento en que su cobertura está en juego, es difícil penetrar en las vidas ocupadas de las personas", dijo.

La encuesta de Ģ��ӰԺ, de 1,227 adultos que tenían cobertura de Medicaid a principios de 2023 antes del inicio del proceso de desafiliación, el 1 de abril de 2023, se realizó entre el 15 de febrero y el 11 de marzo de 2024. El margen de error de muestreo fue de más o menos 4 puntos porcentuales.

El corresponsal de Ģ��ӰԺ Health News, Daniel Chang, colaboró con este artículo.

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

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“We’re seeing more oral disease than the general population. There is a bigger need,” Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

“Federally qualified health centers have a long history of co-locating dental services within their systems,” Braun said. “We’re taking that next step where care is not just co-located, meaning, say, we’re upstairs and dental is downstairs, but we’re integrated so that it becomes part of the same visit for the patient.”

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

“Providing these services during medical visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge of caring for their child’s teeth.” But obstacles remain.

Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to , which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. “Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states — including California, Texas, and Maryland — integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women gain dental coverage with Medicaid and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the “astronomical cost” of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her three others are uninsured, and they couldn’t otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE’s director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” — the process underway to reexamine post-pandemic eligibility for the government program that provides health coverage for people with low incomes and disabilities — has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they’ll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing — midlevel providers who do preventive and restorative care — to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a, particularly for at-risk children. As part of Braun’s program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2½ years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. “It’s about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider — if they have one.”

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Poco después que Abundis pasara de tener cobertura limitada a una cobertura completa en 2022, bajo la expansión del Medi-Cal de California para adultos mayores sin papeles, fue diagnosticado con leucemia, un tipo de cáncer que afecta las células de la sangre.

El padre de tres hijos, de voz suave, tomó la noticia con calma cuando su médico le dijo que sus análisis de sangre sugerían que su cáncer no estaba en una etapa avanzada. Sus siguientes pasos fueron hacerse más pruebas y tener un plan de tratamiento con un equipo de cáncer en Epic Care, en Emeryville.

Pero todo eso se fue por la borda cuando se presentó en julio pasado para hacerse un análisis de sangre en La Clínica de La Raza en Oakland, y le dijeron que ya no era beneficiario de Medi-Cal.

“Nunca mandaron una carta ni nada de que a mí me la había negado”, dijo Abundis, ahora de 63 años, sobre la pérdida de su cobertura.

Abundis es uno de los cientos de miles de latinos de California que han sido expulsados de Medi-Cal —el programa estatal de Medicaid para personas de bajos ingresos— a medida que los estados reanudaban las verificaciones de elegibilidad, que se habían suspendido en el punto más álgido de la pandemia de covid-19.

El proceso de redeterminación ha afectado de forma desproporcionada a los latinos, que constituyen la mayoría de los beneficiarios de Medi-Cal.

Según el Departamento de Servicios de Salud de California (DHCS), más de 613,000 de los 1,24 millones de residentes que fueron dados de baja se identifican como latinos. Algunos, incluido Abundis, habían obtenido la cobertura poco tiempo antes, cuando el estado comenzó a expandir Medi-Cal para ofrecer cobertura a inmigrantes indocumentados.

El choque entre las políticas estatales y las federales no sólo ha significado un duro golpe para los beneficiarios: también disparó la demanda de asistencia para realizar los trámites de inscripción.

Esto ocurre porque muchas personas son excluidas de Medi-Cal por cuestiones administrativas.

Los grupos de salud que trabajan con las comunidades latinas informan que están inundados de solicitudes de ayuda. Al mismo tiempo, patrocinada por el estado sugiere que los hogares hispanos tienen más probabilidades que otros grupos étnicos o raciales de perder la cobertura porque tienen menos información sobre el proceso de renovación.

También pueden tener dificultades para defenderse por sí solos.

Algunos defensores de salud están presionando para que haya una pausa en este proceso. Advierten que las desafiliaciones no solo socavarán los esfuerzos del estado para reducir el número de personas sin seguro, sino que podrían exacerbar las disparidades en salud, especialmente para un grupo étnico que sufrió fuerte el peso de la pandemia.

Un encontró que los latinos en el país tuvieron tres veces más probabilidades de desarrollar covid y el doble de probabilidades de morir a causa de la enfermedad que la población en general, en parte porque tienden a vivir en hogares más hacinados o multigeneracionales y tienen trabajos en servicios, de cara al público.

“Estas dificultades nos colocan a todos como comunidad en un estatus más frágil, en el cual la red de seguridad es aún más significativa”, dijo Seciah Aquino, directora ejecutiva de la Latino Coalition for a Healthy California, una organización de defensa de salud.

La asambleísta Tasha Boerner (demócrata de Encinitas) ha presentado que desaceleraría las bajas permitiendo que las personas de 19 años o más mantengan automáticamente su cobertura durante 12 meses, y extendiendo las políticas flexibles de la era pandémica, como no requerir prueba de ingresos para renovar la cobertura en ciertos casos. Esto beneficiaría a los hispanos, que representan de la población de Medi-Cal en comparación con del estado.

La oficina del gobernador dijo que no comenta sobre proyectos legislativos que están aún en proceso.

Tony Cava, vocero del Departamento de Servicios de Atención Médica (DHCS), dijo en un correo electrónico que la agencia ha tomado medidas para aumentar el número de personas reinscritas automáticamente en Medi-Cal y no cree que sea necesaria una pausa. La tasa de desafiliación disminuyó un 10% de noviembre a diciembre, apuntó Cava.

Sin embargo, funcionarios estatales reconocen que se podría hacer más para ayudar a las personas a completar sus solicitudes. “Todavía no estamos llegando a ciertos sectores”, dijo Yingjia Huang, subdirectora adjunta de beneficios de atención médica y elegibilidad del DHCS.

California fue el en ampliar la elegibilidad de Medicaid a todos los inmigrantes que calificaran, sin importar su estatus migratorio, implementándolo gradualmente durante varios años: niños en 2016, adultos jóvenes de 19 a 26 años en 2020, personas de 50 años en adelante en 2022, y todos los adultos restantes este año.

Pero California, como otros estados, reanudó las verificaciones de elegibilidad en abril pasado, y se espera que el proceso continúe hasta mayo. El estado ahora está viendo que las tasas de desafiliación vuelven a los niveles previos a la pandemia, o el 19%-20% de la población de Medi-Cal cada año, según el DHCS.

Jane García, directora ejecutiva de La Clínica de La Raza, testificó ante el Comité de Salud de la Junta de Supervisores del condado de Alameda que las desafiliaciones siguen siendo un desafío, justo cuando su equipo intenta inscribir a residentes recién elegibles. “Es una carga enorme para nuestro personal”, les dijo a los supervisores en enero.

Aunque muchos beneficiarios ya no califican porque sus ingresos aumentaron, muchos más han sido eliminados de los registros por no responder a avisos o devolver documentos. En muchos casos, los paquetes de documentos para renovar la cobertura se enviaron a direcciones antiguas. Muchos se enteran de que perdieron la cobertura recién cuando van al médico.

“Sabían que algo estaba pasando”, dijo Janet Anwar, gerenta de elegibilidad en el Tiburcio Vásquez Health Center, en East Bay. “No sabían exactamente qué era, cómo los iba a afectar hasta que llegó el día y fueron desafiliados. Y estaban haciéndose un chequeo, o programando una cita, y luego… ‘Oye, perdiste tu cobertura'”.

Y la reinscripción es un desafío. Una encuesta patrocinada por el estado publicada el 12 de febrero por la California Health Care Foundation halló que el 30% de los hogares hispanos intentaron completar un formulario de renovación sin suerte, en comparación con el 19% de los hogares blancos no hispanos. Y el 43% de los hispanos informaron que les gustaría volver a comenzar con Medi-Cal, pero no sabían cómo, en comparación con el 32% de las personas en hogares blancos no hispanos.

La familia Abundis está entre las que no saben dónde obtener respuestas a sus preguntas. Aunque la esposa de Abundis envió la documentación de renovación de Medi-Cal para toda la familia en octubre, ella y dos hijos que aún viven con ellos pudieron mantener la cobertura; Abundis fue el único que la perdió.

No ha recibido una explicación de por qué lo sacaron de Medi-Cal ni ha sido notificado de cómo apelar o volver a solicitarlo.

Ahora se preocupa de que tal vez no califique por sí solo según sus ingresos anuales de aproximadamente $36,000, ya que el límite es de , pero de $41,400 para una familia de cuatro.

Es probable que un navegador pueda verificar si él y su familia califican como hogar para Medi-Cal. Covered California, el mercado de seguros de salud estatal, ofrece planes privados que pueden costar y permite una inscripción especial cuando las personas pierden Medi-Cal o la cobertura del empleador. Pero los inmigrantes que no viven legalmente en el estado no califican para los subsidios de Covered California. Abundis supone que no podrá pagar las primas ni los copagos, por lo que no presentó la solicitud.

Pero Abundis supone que no podrá pagar primas o copagos, así que no ha presentado una solicitud.

Abundis, quien visitó a un médico por primera vez en mayo de 2022 debido a una fatiga sin causa aparente, dolor constante en la espalda y las rodillas, falta de aliento y pérdida de peso inexplicable, teme no poder pagar la atención médica. La Clínica de La Raza, el centro de salud comunitario en donde le hicieron análisis de sangre, lo ayudó ese día a que no tuviera que pagar por adelantado, pero desde entonces dejó de buscar atención médica.

Más de un año después de su diagnóstico, todavía no sabe en qué etapa del cáncer se encuentra ni cuál debería ser su plan de tratamiento. Aunque la detección temprana del cáncer puede aumentar las , algunos tipos de leucemia . Sin más pruebas, Abundis no conoce su pronóstico.

Yo estoy mentalizado”, dijo Abundis sobre su cáncer. “Lo que pase, pase”.

Incluso aquellos que buscan ayuda se topan con desafíos. Marisol, una inmigrante mexicana sin papeles, de 53 años, que vive en Richmond, California, intentó restablecer la cobertura durante meses. Aunque el estado experimentó una caída del 26% en las bajas de diciembre a enero, la proporción de latinos a los que se les canceló la cobertura durante ese período permaneció casi igual, lo que sugiere que enfrentan más barreras para la renovación.

Marisol, quien pidió que se usara su nombre de pila por temor a la deportación, también calificó para la cobertura completa de Medi-Cal durante la expansión estatal a todos los inmigrantes de 50 años en adelante.

En diciembre, recibió un paquete informándole que los ingresos de su hogar excedían el umbral de Medi-Cal, algo que ella creyó que era un error. El esposo de Marisol está sin trabajo debido a una lesión en la espalda, dijo, y sus dos hijos mantienen a su familia principalmente con trabajos de medio tiempo en Ross Dress for Less.

Ese mes, Marisol visitó una sucursal de Richmond del Departamento de Empleo y Servicios Humanos del condado de Contra Costa, con la esperanza de hablar con un navegador. En cambio, le dijeron que dejara su documentación y que llamara a un número de teléfono para verificar el estatus de su solicitud.

Desde entonces, llamó muchas veces y pasó horas en espera, pero no ha podido hablar con nadie. Los funcionarios del condado reconocieron tiempos de espera más prolongados debido al aumento de llamadas, y dijeron que el tiempo promedio es de 30 minutos.

“Entendemos la frustración de los miembros de la comunidad cuando a veces tienen dificultades para comunicarse”, escribió la vocera Tish Gallegos en un correo electrónico. Gallegos señaló que el centro de llamadas aumenta la dotación de personal durante las horas pico.

Después que El Tímpano contactara al condado para hacer comentarios, Marisol dijo que un trabajador de elegibilidad la contactó, y le explicó que su familia fue dada de baja porque sus hijos habían presentado impuestos por separado, por lo que el sistema de Medi-Cal determinó su elegibilidad individualmente en lugar de como familia.

El condado reintegró a Marisol y a su familia el 15 de marzo. Marisol dijo que recuperar Medi-Cal fue un final alegre pero agridulce para una lucha de meses, especialmente sabiendo que otras personas son desafiliadas por cuestiones de procedimiento. “Tristemente, tiene que haber presión para que arreglen algo”, dijo.

Jasmine Aguilera de está participando de la Journalism & Women Symposium’s Health Journalism Fellowship, apoyada por The Commonwealth Fund. Vanessa Flores, Katherine Nagasawa e Hiram Alejandro Durán de El Tímpano colaboraron con este artículo.

[Corrección: este artículo se actualizó a la 1:30 pm (ET), el 26 de marzo de 2024, para corregir los detalles sobre la elegibilidad para recibir asistencia financiera para pagar las primas de los seguros. Los inmigrantes que no viven legalmente en California no califican para los subsidios de Covered California].

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Shortly after Abundis transitioned from limited to full-scope coverage in 2022 under California’s expansion of Medi-Cal to older residents without legal immigration status, he was diagnosed with leukemia, a cancer affecting the blood cells. The soft-spoken father of three took the news in stride as his doctor said his blood test suggested his cancer wasn’t advanced. His next steps were to get more tests and formulate a treatment plan with a cancer team at Epic Care in Emeryville. But all of that was derailed when he showed up last July for bloodwork at La Clínica de La Raza in Oakland and was told he was no longer on Medi-Cal.

“They never sent me a letter or anything telling me that I was removed,” Abundis, now 63, said in Spanish about losing his insurance.

Abundis is among hundreds of thousands of Latinos who have been kicked off Medi-Cal, California’s Medicaid program for low-income people, as states resume annual eligibility checks that were paused at the height of the covid-19 pandemic. The redetermination process, as it is known, has disproportionately affected Latinos, who make up a majority of Medi-Cal beneficiaries. According to the California Department of Health Care Services, more than 653,000 of the more than 1.3 million residents who have been disenrolled over eight months identify as Latino. Some, including Abundis, had only recently gained coverage as the state expanded Medi-Cal to residents without legal residency.

The collision of state and federal policies has not only set off enrollee whiplash but swelled demand for enrollment assistance as people are dropped from Medi-Cal, often for procedural issues. Health groups serving Latino communities report being inundated by requests for help, but at the same time, a suggests Hispanic households are more likely than other ethnic or racial groups to lose coverage because they’re less knowledgeable of the renewal process. They may also struggle to advocate for themselves.

Some health advocates are pressing for a pause. They warn that disenrollments will not only undercut the state’s effort to reduce the number of uninsured but could exacerbate health disparities, particularly for an ethnic group that bore the brunt of the pandemic. found that Latinos in the U.S. were three times as likely to contract covid and twice as likely to die of it than the general population, in part because they tend to live in more crowded or multigenerational households and work in front-line jobs.

“These difficulties place all of us as a community in this more fragile state where the safety net means even more now,” said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, a health advocacy organization.

Assembly member Tasha Boerner, an Encinitas Democrat, has introduced that would slow disenrollments by allowing people 19 and older to keep their coverage automatically for 12 months and extend flexible pandemic-era policies such as not requiring proof of income in certain cases for renewals. That would benefit Hispanics, who make up of the Medi-Cal population compared with 40% of the overall . The governor’s office said it does not comment on pending legislation.

Tony Cava, a spokesperson for the Department of Health Care Services, said in an email that the agency has taken steps to increase the number of people automatically reenrolled in Medi-Cal and does not consider a pause necessary. The disenrollment rate dropped 10% from November to December, Cava said.

Still, state officials acknowledge more could be done to help people complete their applications. “We’re still not reaching certain pockets,” said Yingjia Huang, assistant deputy director of health care benefits and eligibility at DHCS.

California was the to expand Medicaid eligibility to all qualified immigrants regardless of legal status, phasing it in over several years: children in 2016, young adults ages 19-26 in 2020, people 50 and older in 2022, and all remaining adults this year.

But California, like other states, resumed eligibility checks last April, and the process is expected to continue through May. The state is now seeing disenrollment rates return to pre-pandemic levels, or 19%-20% of the Medi-Cal population each year, according to DHCS.

Jane Garcia, CEO of La Clínica de La Raza, testified before the Alameda County Board of Supervisors’ health committee that disenrollments continue to pose a challenge just as her team tries to enroll newly eligible residents. “It’s a heck of a load on our staff,” she told supervisors in January.

Although many beneficiaries no longer qualify because their incomes rose, more have been dropped from the rolls for failing to respond to notices or return paperwork. Often, renewal packets were sent to old addresses. Many find out they’ve lost coverage only upon seeking medical care.

“They knew something was happening,” said Janet Anwar, eligibility manager at Tiburcio Vasquez Health Center in the East Bay. “They didn’t know exactly what it was, how it was gonna affect them until actually the day came and they were disenrolled. And they were getting checked in or scheduling an appointment, then, ‘Hey, you lost your coverage.’”

But reenrollment is a challenge. A state-sponsored survey published Feb. 12 by the California Health Care Foundation found 30% of Hispanic households tried but were unable to complete a renewal form, compared with 19% for white non-Hispanic households. And 43% of Hispanics reported they would like to restart Medi-Cal but did not know how, versus 32% of people in white non-Hispanic households.��

The Abundis family is among those who don’t know where to get their questions answered. Though Abundis’ wife submitted the family’s Medi-Cal renewal paperwork in October, his wife and two children who still live with them were able to maintain coverage; Abundis was the only one dropped. He hasn’t received an explanation for being disenrolled nor been notified how to appeal or reapply. Now he worries he may not qualify on his own based on his roughly $36,000 annual income since the limit is but $41,400 for a family of four.

It is likely an eligibility worker could check if he and his family qualify as a household for Medi-Cal. Covered California, the state’s health insurance exchange, offers private plans that can run less than����in premiums and allows for special enrollment when people lose Medi-Cal or employer-based coverage. But immigrants who are not living in the state lawfully do not qualify for Covered California subsidies. Abundis assumes he won’t be able to afford premiums or copays, so he hasn’t applied.

Abundis, who first visited a doctor in May 2022 about unrelenting fatigue, constant pain in his back and knees, shortness of breath, and unexplained weight loss, worries he’s unable to afford medical care. La Clínica de La Raza, the community health clinic where he received blood testing, worked with him that day so he didn’t have to pay upfront, but he has since stopped seeking medical care.

More than a year after his diagnosis, Abundis still doesn’t know which stage cancer he has, or what his treatment plan should be. Though early cancer detection can lead to a , some types of leukemia . Without further testing, Abundis does not know his outlook.

“I’ve mentally prepared,” Abundis said of his cancer. “What happens, happens.”

Even those who seek help run into challenges. Marisol, a 53-year-old immigrant from Mexico who lives in Richmond, California, without legal permission, tried to reestablish coverage for months. Although the state saw a 26% drop in disenrollments from December to January, the share of Latinos disenrolled during that period remained nearly the same, suggesting they face more barriers to renewal.

Marisol, who requested her last name be withheld out of fear of deportation, also qualified for full-scope Medi-Cal during the state expansion to all immigrants 50 and older.

She received a packet in December letting her know that her household income exceeded Medi-Cal’s threshold — something she believed was an error. Marisol’s husband is out of work due to a back injury, she said, and her two children primarily support their family with part-time jobs at Ross Dress for Less.

That month, Marisol visited a Richmond branch office of the Contra Costa County Employment and Human Services Department, hoping to speak to an eligibility worker. Instead, she was told to leave her paperwork and to call a phone number to check her application status. Since then, she made numerous calls and spent hours on hold, but has not been able to speak with anyone.

County officials acknowledged longer wait times due to increased calls and said the average wait time is 30 minutes. “We understand community members’ frustration when they have difficulty getting through at times,” spokesperson Tish Gallegos wrote in an email. Gallegos noted the call center increases staffing during peak hours.

After El Tímpano reached out to the county for comment, Marisol said she was contacted by an eligibility worker, who explained that her family was dropped because their children had filed taxes separately, so the Medi-Cal system determined their eligibility individually rather than as one household. The county reinstated Marisol and her family on March 15.

Marisol said regaining Medi-Cal was a joyous but bittersweet ending to a months-long struggle, especially knowing that other people get dropped for procedural issues. “Sadly, there has to be pressure for them to fix something,” she said.

Jasmine Aguilera of is participating in the Journalism & Women Symposium’s Health Journalism Fellowship, supported by The Commonwealth Fund. Vanessa Flores, Katherine Nagasawa, and Hiram Alejandro Durán of El Tímpano contributed to this article.

Medi-Cal Resources (in Spanish):

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UC Health accused Anthem of not negotiating in good faith, while Anthem leaders retorted that UC Health had demanded too much and rebuffed the insurer’s request for administrative efficiencies. In fact, roughly 8 million Anthem members in California were at risk of losing in-network access to UC Health’s vast network of prestigious hospitals and medical facilities, which could have left them with much higher out-of-pocket expenses. While not all patients were made aware of the situation, Anthem notified some enrollees they would be reassigned to new primary care doctors if no deal were reached.

But even as the parties announced an eleventh-hour agreement on Feb. 5, industry analysts say the conflict has become part of a trend in which patients are increasingly caught in the crossfire of contract disputes. Amid negotiations over rising labor and equipment costs, it’s often patients who are ultimately saddled with higher bills as the health industry continues to consolidate.

“This type of contract dispute is a routine feature of the health care system,” said Kristof Stremikis, director of market analysis and insight at the California Health Care Foundation. “At the same time, from a patient’s perspective, it’s an unfortunate feature of our health care system because it creates uncertainty and anxiety.” (California Healthline is an editorially independent service of the California Health Care Foundation.)

Stremikis noted that as mergers occur in the health industry, patients are left with fewer choices. Any time there are disputes, disruptions are felt more widely. And such fights rarely result in lower costs for consumers long-term across California.

A found widespread evidence that consolidation of health providers leads to higher health care prices for private insurance. The same brief from 2020 found some evidence suggesting that large, consolidated insurance companies are able to obtain lower prices from providers, but that has not necessarily led to lower premiums for patients. And a 2022 report from the found that health care costs have grown “at an unsustainable rate,” and noted that between 2010 and 2018 “health insurance premiums for job-based coverage increased more than twice the rate of growth for wages.” State regulators also found that health plans on prescription drugs in 2022 than in 2021.

In trying to slow growth, California in 2022 set up an , which has proposed a 3% spending growth target for the industry for 2025-2029. But enforcement will start in 2028 at the earliest, using spending data from 2026.

Cathy Jordan, 60, a social worker in Yuba City, California, has been a patient at UC Davis Health for two decades. Jordan was diagnosed at the end of 2021 with aggressive small cell carcinoma, a rare form of cancer. She has undergone surgery, chemotherapy, radiation, and other treatments since then, yet her cancer has returned twice.

“I don’t have the luxury of time — my cancer comes back fast,” Jordan said.

She is among the group of Anthem-insured patients at UC Health who were at risk of losing access to in-network care there, and when she got a notice from Anthem, she grew alarmed, she said.

Jordan’s oncologist, Rebecca Brooks, said in an interview prior to the agreement being reached that it would be “incredibly disruptive” for cancer patients to have to switch providers in the middle of their treatments.

“It’s a detriment to their care,” said Brooks, director of the gynecologic oncology division at UC Davis Health. “It’s going to disrupt treatment and cause worse outcomes.”

Jordan said she appreciates that UC Davis Health has a National Cancer Institute comprehensive cancer center designation; the only other cancer center of that caliber in Northern California not part of UC Health is at Stanford University, several hours away in Santa Clara County.

Jordan was worried that she and other UC Health patients would have to compete for treatment elsewhere. She was also uncomfortable with the idea of adjusting to a new setting and routine while undergoing intensive medical treatment.

“Someone needs to say, ‘We need to think about these patients.’ Someone needs to step up and say, ‘What’s going to be best for our patients?’” Jordan said. “This is my life.”

Stremikis said such concerns are ever more urgent as the health care industry consolidates. UC San Francisco recently announced it would in San Francisco, and it is joining Adventist Health in making a new effort to purchase a bankrupt . And UC Irvine recently in Southern California.

“There is consolidation vertically up and down the supply chain and horizontally,” he explained. “So when there are disputes between these large entities, it has a larger and larger impact because there are fewer choices for patients.”

While contract disputes between health care providers and insurers are nothing new, there is some evidence that they are increasing, at least in public view. FTI Consulting last year that found a steady increase in media coverage of rate negotiations between providers and insurers from 2022 to 2023. In addition to the fight with Anthem, UC Health narrowly avoided a break with Aetna last year by in April. And regional hospital systems, including and , have been at odds with Anthem within the last few months.

UC and Anthem have now agreed to extend the current contract to April 1 while terms of the new agreement are being finalized. UC Health spokesperson Heather Harper said the rate increases were below the inflation rate.

Anthem spokesperson Michael Bowman said the new contract would allow Anthem members to access care at UC Health for years to come.

“This underscores our mutual commitment to providing Anthem’s consumers and employers with access to high quality, affordable care at UC Health,” Bowman said in an email.

This article was produced by Ģ��ӰԺ Health News, which publishes , an editorially independent service of the .��

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Medicaid, which covers low-income and disabled people, and the related Children’s Health Insurance Program grew to a record 94 million enrollees as a result of a rule that prohibited states from terminating coverage during the nation’s public health emergency.

But since last April, states have removed from the programs in a process known as the “unwinding,” according to Ģ��ӰԺ estimates compiled from state-level data.

While many beneficiaries no longer qualify because their incomes rose, millions of people have been dropped from the rolls for procedural reasons like failing to respond to notices or return paperwork. But at the same time, millions have been reenrolled or signed up for the first time.

The net result: Enrollment has fallen by about 9.5 million people from the record high reached last April, according to Ģ��ӰԺ. That puts Medicaid and CHIP enrollment on track to look, by the end of the unwinding later this year, a lot like it did at the start of the coronavirus pandemic: about 71 million people.

“What we are seeing is not dissimilar to what we saw before the pandemic — it is just happening on a bigger scale and more quickly,” said Larry Levitt, executive vice president for health policy at Ģ��ӰԺ.

Enrollment churn has long been a feature of Medicaid. Before the pandemic, about 1 million to 1.5 million people nationwide fell off the Medicaid rolls each month — including many who still qualified but failed to renew their coverage, Levitt said.

During the unwinding, many people have been disenrolled in a shorter time. In some ways — and in some states — it’s been worse than expected.

The Biden administration predicted about 15 million people would lose coverage under Medicaid or CHIP during the unwinding period, nearly half due to procedural issues. Both predictions have proven low. Based on data reported so far, disenrollments , according to Ģ��ӰԺ — 70% due to procedural reasons.

But about two-thirds of the 48 million beneficiaries who have had their eligibility reviewed so far got their coverage renewed. About one-third lost it.

The federal government has given most states 12 months to complete their unwinding, starting with the first disenrollments between last April and October.

Timothy McBride, a health economist at Washington University in St. Louis, said the nation’s historically low unemployment rate means people who lose Medicaid coverage are more likely to find job-based coverage or be better able to afford plans on Obamacare marketplaces. “That is one reason why the drop in Medicaid is not a lot worse,” he said.

There are big differences between states. Oregon, for example, has disenrolled just 12% of its beneficiaries. Seventy-five percent have been renewed, according to Ģ��ӰԺ. The rest are pending.

At the other end of the spectrum, Oklahoma has dumped 43% of its beneficiaries in the unwinding, renewing coverage for just 34%. About 24% are pending.

States have varying eligibility rules, and some make it easier to stay enrolled. For instance, Oregon allows children to stay on Medicaid until age 6 without having to reapply. All other enrollees get up to two years of coverage regardless of changes in income.

Jennifer Harris, senior health policy advocate for Alabama Arise, an advocacy group, said her state’s Medicaid agency and other nonprofit organizations communicated well to enrollees about the need to reapply for coverage and that the state also hired more people to handle the surge. About 29% of beneficiaries in Alabama who’ve had eligibility reviews were disenrolled for procedural reasons, Ģ��ӰԺ found.

“Things are even keel in Alabama,” she said, noting that about 66% of enrollees have been renewed.

State officials have told the legislature that about a quarter of people disenrolled during the unwinding were reenrolled within 90 days, she said.

One of a handful of states that have refused to expand Medicaid under the Affordable Care Act, Alabama had about 920,000 enrollees in Medicaid and CHIP in January 2020. That number rose to about 1.2 million in April 2023.

More than halfway into the unwinding, the state is on track for enrollment to return to pre-pandemic levels, Harris said.

Joan Alker, executive director of the Georgetown University Center for Children and Families, said she remains worried the drop in Medicaid enrollment among children is steeper than typical. That’s particularly bothersome because children usually qualify for Medicaid at higher household income levels than their parents or other adults.

During the unwinding 3.8 million children have lost Medicaid coverage, according to the center’s latest data. “Many more kids are falling off now than prior to the pandemic,” Alker said.

And when they’re dropped, many families struggle to get them back on, she said. “The whole system is backlogged and the ability of people to get back on in a timely fashion is more limited,” she said.

The big question, Levitt said, is how many of the millions of people dropped from Medicaid are now uninsured.

The only state to survey those disenrolled — Utah — discovered about 30% were uninsured. Many of the rest found employer health coverage or signed up for subsidized coverage through the Affordable Care Act marketplace.

What’s happened nationwide remains unclear.

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

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This story can be republished for free (details).

Millions of people have been dumped from the rolls since April, often for procedural issues like failing to respond to notices or return paperwork. But at the same time, millions have been re-enrolled or signed up for the first time.��

The net result: Enrollment has fallen by about 9.5 million people from the record high reached last April,��according to the latest estimates by Ģ��ӰԺ, based on state data. That leaves Medicaid on track to look, by the end of the unwinding, a lot like it did at the start of the coronavirus pandemic: covering about��71 million people.

• “What we are seeing is not dissimilar to what we saw before the pandemic — it is just happening on a bigger scale and more quickly,” said��Larry Levitt, executive vice president for health policy at��Ģ��ӰԺ.

Enrollment churn has always been a feature of Medicaid, which covers low-income and disabled Americans. Even before the pandemic, about��1 million��to��1.5 million people��fell off the Medicaid rolls each month — including many who still qualified but failed to renew their coverage, Levitt said.

In the unwinding, a lot of people have been disenrolled in a shorter period of time. In some ways — and in some states — it’s been worse than expected.

The Biden administration predicted about��15 million��people would lose coverage under Medicaid or the related Children’s Health Insurance Program during the unwinding period, nearly half due to procedural issues. Both predictions were low. Based on data reported so far, disenrollments��, according to the Ģ��ӰԺ report,��70 percent��of them��.

But about two-thirds of the��48 million��Medicaid beneficiaries who have had their eligibility reviewed so far got their coverage renewed. About one-third lost it.

Timothy McBride, a health economist at��Washington University in St. Louis, said the nation’s historically low unemployment rate means people who lose Medicaid coverage are more likely to find job-based coverage or better able to afford plans on Obamacare marketplaces. “That is one reason why the drop in Medicaid is not a lot worse,” he said.

There are big differences between states. Oregon, for example, has disenrolled just��12 percent��of its beneficiaries.��Seventy-five percent��were renewed, according to Ģ��ӰԺ. The rest are pending.

At the other end of the spectrum, Oklahoma’s dumped��43 percent��of its Medicaid beneficiaries in the unwinding, renewing coverage for just��34 percent. About��24 percent��are pending.

States have varying eligibility rules, and some make it easier to keep people enrolled. For instance, Oregon allows children to stay on Medicaid until age 6 without having to reapply. Everyone else gets up to two years of coverage regardless of changes in income.

Joan Alker, executive director of the��Georgetown University Center for Children and Families, said she remains worried the drop in Medicaid enrollment among children is steeper than typical. That’s particularly bothersome because children usually qualify for Medicaid at higher household income levels than their parents or other adults.��

More than��3.7 million��children have lost Medicaid coverage during the unwinding, according to the center’s latest data. “Many more kids are falling off now than prior to the pandemic,” Alker said.

And when they’re dropped, many families struggle to get them back on, she said. “The whole system is backlogged and the ability of people to get back on in a timely fashion is more limited,” she said.

The big question, Levitt said, is how many of the millions of people dropped from Medicaid are now uninsured.

The only state to survey those disenrolled — Utah —��discovered��about 30 percent��were uninsured. Many of the rest found employer health coverage or signed up for subsidized coverage through the Affordable Care Act marketplace.

What’s happened nationwide remains unclear.

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

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

USE OUR CONTENT

This story can be republished for free (details).