“La primera vez, el teléfono suena sin parar. La siguiente, te manda al buzón de voz y se corta la llamada”, dijo la mujer de 48 años, que vive en Delaware. “A veces te contesta alguien que dice que no es la persona indicada. Te transfieren y se corta. A veces contestan y no hay nadie en la línea”.

Pasó meses tratando de averiguar si su cobertura de Medicaid había sido renovada. Hasta finales de marzo, todavía no le había llegado la renovación anual para el programa estatal y federal que ofrece seguro de salud a personas con bajos ingresos y con discapacidades.

Crouch, quien sufrió un aneurisma cerebral debilitante hace una década, también tiene Medicare, que cubre a personas de 65 años o más, o a aquellas con discapacidades. Medicaid pagaba sus deducibles mensuales de Medicare de $200, pero en los últimos tres meses ha tenido que cubrirlos ella misma, lo que ha afectado el ingreso fijo de su familia, contó.

Los problemas de Crouch con el centro de llamadas de Medicaid en Delaware no son un caso aislado. Las agencias estatales de Medicaid pueden tener dificultades para mantener suficiente personal que ayude a las personas a inscribirse en los beneficios y atender llamadas de afiliados con preguntas.

La falta de estos trabajadores puede impedir que las personas usen plenamente sus beneficios, dijeron investigadores de políticas de salud.

Ahora, la ley One Big Beautiful Bill Act de los republicanos aprobada por el Congreso, que el presidente Donald Trump firmó el verano pasado, pronto exigirá más al personal de las agencias estatales en los lugares donde los legisladores ampliaron Medicaid a más adultos con bajos ingresos, que son casi todos los estados y el Distrito de Columbia.

Según la ley, que se espera reduzca el gasto de Medicaid en casi $1.000 millones en los próximos ocho años, estos trabajadores deberán no solo determinar si millones de afiliados cumplen con los nuevos requisitos laborales del programa, sino también verificar con mayor frecuencia que califican: cada seis meses en lugar de una vez al año.

KFF Health News contactó a agencias que deberán implementar estas reglas de trabajo, y muchas dijeron que necesitarán más personal.

Estas exigencias pondrán más presión sobre una fuerza laboral ya sobrecargada, lo que podría dificultar que afiliados como Crouch reciban servicios básicos de atención al cliente. Y muchos podrían perder acceso a beneficios a los que tienen derecho por ley, según afirmaron defensores del consumidor e investigadores de políticas de salud, algunos con experiencia directa trabajando en agencias estatales.

Los estados ya están “teniendo grandes dificultades”, dijo Jennifer Wagner, directora de elegibilidad e inscripción de Medicaid en el Center on Budget and Policy Priorities y ex subdirectora del Departamento de Servicios Humanos de Illinois. “Habrá desafíos adicionales importantes por culpa de estos cambios”.

Largos tiempos de espera para recibir ayuda

Los republicanos sostienen que los cambios en Medicaid, que entrarán en vigencia el 1 de enero de 2027 en la mayoría de los estados, incentivarán a los afiliados a conseguir empleo. Investigaciones sobre otros programas con requisitos laborales en Medicaid han encontrado poca evidencia de que aumenten el empleo.

La Oficina de Presupuesto del Congreso (CBO, por sus siglas en inglés) estimó que estas reglas provocarán que más personas pierdan la cobertura de salud para 2034: indicó que más de 5 millones de personas podrían verse afectadas.

Muchos estados no tienen suficiente personal para procesar solicitudes o renovaciones de Medicaid con rapidez, dijeron defensores.

Los Centros de Servicios de Medicare y Medicaid (CMS, por siglas en inglés) supervisan si los estados pueden procesar el tipo más común de solicitud de beneficios dentro de un plazo de 45 días.

En diciembre, alrededor del 30% de todas las solicitudes de Medicaid y del Programa de Seguro de Salud Infantil (CHIP, por sus siglas en inglés) en Washington, D.C., y Georgia tardaron más de 45 días en procesarse. Más de una cuarta parte tardó ese tiempo en Wyoming. En Maine, una de cada 5 solicitudes no cumplió ese plazo.

Los CMS comenzaron a compartir públicamente datos de los centros de llamadas de Medicaid en 2023, lo que mostró un sistema bajo presión, según investigadores y defensores.

En Hawaii, las personas esperaron más de tres horas al teléfono en diciembre. En Oklahoma, casi una hora, y en Nevada, más de una hora.

En 2023, las agencias estatales de Medicaid comenzaron a verificar que todavía calificaban a los afiliados que habían sido protegidos para que no perdieran su cobertura durante la pandemia de covid. Ese proceso no funcionó bien en muchos estados, y más de 25 millones de personas perdieron sus beneficios.

Investigadores y defensores dicen que implementar las nuevas reglas será un reto mayor. Las reglas laborales requerirán cambios amplios en los sistemas informáticos y capacitación para los trabajadores que verifican la elegibilidad en un plazo ajustado.

“Es un nivel mucho mayor de complejidad administrativa”, señaló Sophia Tripoli, directora de políticas en Families USA, una organización de defensa de salud del consumidor.

Después de meses intentando hablar con alguien, Crouch dijo que finalmente obtuvo respuestas sobre sus beneficios de Medicaid luego de escribir a la oficina de la representante federal Sarah McBride (demócrata de Delaware). La oficina contactó a la agencia estatal de Medicaid, que finalmente la llamó con una actualización, dijo.

Crouch en realidad no calificaba para Medicaid. Dijo que eso nunca había surgido en dos años de interacciones con el estado.

“No tiene ningún sentido que el estado no se haya dado cuenta antes”, dijo.

La agencia de Medicaid de Delaware no respondió a solicitudes de comentarios sobre su caso.

Estados con poco personal para Medicaid

A fines de marzo, algunos estados dijeron a KFF Health News, que necesitarán más personal para implementar las reglas laborales de manera efectiva.

Idaho informó que tiene 40 vacantes para trabajadores de elegibilidad. Nueva York estimó que necesitará 80 nuevos empleados para manejar el trabajo administrativo adicional, con un costo de $6,2 millones. Pennsylvania tiene casi 400 puestos vacantes en oficinas de servicios humanos de los condados. La agencia de Medicaid de Indiana tiene 94 vacantes. Maine quiere contratar 90 trabajadores adicionales, y Massachusetts busca sumar 70 más. Montana llenó 39 de los 59 puestos que dice que necesitará.

La agencia de servicios sociales de Missouri ha reducido personal y tiene 1.000 trabajadores de primera línea menos que hace aproximadamente una década, esto con más del doble de afiliados en Medicaid y en el Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés), según comentarios de su directora, Jessica Bax, en una reunión pública en noviembre.

“El departamento pensó que habría una mejora en la eficiencia gracias a las actualizaciones del sistema de elegibilidad”, dijo Bax. “Muchas de esas mejoras no se concretaron”.

Los estados podrían tener dificultades para encontrar personas interesadas en estos trabajos, que requieren meses de capacitación, pueden ser emocionalmente exigentes y generalmente ofrecen salarios bajos, afirmó Tricia Brooks, investigadora del Centro para Niños y Familias de la Universidad de Georgetown.

“Reciben muchos reclamos y gritos”, dijo Brooks, quien antes dirigió el programa de atención al cliente de Medicaid y CHIP en New Hampshire. “Las personas están frustradas. Lloran. Están preocupadas. Están perdiendo acceso a la atención médica, y no es un trabajo fácil cuando es difícil ayudar”.

Los estados están pagando millones de dólares a contratistas del gobierno para ayudar a cumplir con la nueva ley federal.

Maximus, un contratista de servicios gubernamentales, brinda apoyo en elegibilidad, como la gestión de centros de llamadas, en 17 estados que ampliaron Medicaid y atiende a casi 3 de cada 5 personas inscritas en el programa a nivel nacional, según la empresa.

Durante una llamada de resultados en febrero, la empresa dijo que puede cobrar según el número de gestiones que realiza para los afiliados, independientemente de cuántas personas estén inscritas en el programa en un estado.

Maximus no tiene “un enfoque único” para los servicios que ofrece ni para cómo cobra por ellos, dijo su vocera Marci Goldstein a KFF Health News.

La empresa, que reportó ingresos de $1.760 millones en 2025 en el área que incluye trabajo relacionado con Medicaid, espera que esos ingresos sigan creciendo, incluso si menos personas permanecen en el programa, “debido a las gestiones adicionales que serán necesarias”, señaló David Mutryn, director financiero y tesorero de Maximus.

Perder la cobertura de Medicaid no es solo una molestia, ya que muchas personas inscritas probablemente no ganan lo suficiente para pagar atención médica por su cuenta y pueden no calificar para ayuda financiera bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), dijo Elizabeth Edwards, abogada del National Health Law Program.

Las personas podrían no poder pagar medicamentos o recibir atención esencial, lo que podría tener impactos “devastadores” en la salud, dijo.

“Lo que está en juego son las vidas de las personas”, concluyó.

Los corresponsales de KFF Health News Katheryn Houghton y Samantha Liss contribuyeron con este artículo.

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

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“The first time, it’ll ring interminably. Next time, it’ll go to a voicemail that just hangs up on you,” said the 48-year-old, who lives in Delaware. “Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”

She spent months trying to figure out whether her Medicaid coverage had been renewed. As of late March, she hadn’t been reapproved for the year for the state-federal program, which provides health insurance for people with low incomes and disabilities.

Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers people who are 65 or older or have disabilities. Medicaid had been paying her monthly Medicare deductibles of $200, but she’d been on the hook for them for the past three months, straining her family’s fixed income, she said.

Crouch’s challenges with Delaware’s Medicaid call center aren’t unique. State Medicaid agencies can struggle to keep enough staff to help people sign up for benefits and field calls from enrollees with questions. A shortage of such workers can keep people from fully using their benefits, health policy researchers said.

Now, congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will soon demand more from staff at state agencies in places where lawmakers expanded Medicaid to more low-income adults — nearly all states and the District of Columbia.

Under the law, which is expected to reduce Medicaid spending by almost $1 trillion over the next eight years, these staffers will have to not only determine whether millions of enrollees meet the program’s new work requirements but also verify more frequently that they qualify for the program — every six months instead of yearly.

KFF Health News reached out to agencies that will need to stand up the work rules, and many said they’ll need additional staff.

The mandates will put extra strain on an already-stressed workforce, potentially making it harder for enrollees like Crouch to get basic customer service. And many could lose access to benefits they’re legally entitled to, said consumer advocates and health policy researchers, some of them with direct experience working at state agencies.

States are already “struggling significantly,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and a former associate director of the Illinois Department of Human Services. “There will be significant additional challenges caused by these changes.”

Long Wait Times for Help

Republicans argue the Medicaid changes, which will take effect Jan. 1, 2027, in most states, will encourage enrollees to find jobs. Research on other Medicaid work requirement programs has found little evidence they increase employment.

The Congressional Budget Office estimated the rules would cause more people to lose health coverage by 2034 than any other part of the GOP budget law. It said last year more than 5 million people could be affected.

Many states don’t have the staff to process Medicaid applications or renewals quickly, said consumer advocates and researchers.

The Centers for Medicare & Medicaid Services tracks whether states can handle the most common type of benefit application within a 45-day window.

In December, about 30% of all Medicaid and Children’s Health Insurance Program, or CHIP, applications in Washington, D.C., and Georgia took more than 45 days to process. More than a quarter took that long in Wyoming. In Maine, 1 in 5 applications missed that deadline.

CMS began publicly sharing state Medicaid call center data in 2023, revealing a taxed system, researchers and consumer advocates said.

In Hawaii, people waited on the phone for more than three hours in December. They waited for nearly an hour in Oklahoma, and more than an hour in Nevada.

In 2023, state Medicaid agencies began making sure enrollees who were protected from being dropped from the program during the covid pandemic still qualified for coverage. That Medicaid unwinding process didn’t go well in many states, and more than 25 million lost their benefits.

Health policy researchers and consumer advocates say rolling out the new Medicaid rules will be a bigger challenge. The Medicaid work rules will require extensive IT system changes and training for workers verifying eligibility on a tight timeline.

“It is a much larger scale of administrative complexity,” said Sophia Tripoli, senior director of policy at Families USA, a health care consumer advocacy organization.

After months of trying to get someone on the phone, Crouch said, she finally got answers to questions about her Medicaid benefits after writing to the office of U.S. Rep. Sarah McBride (D-Del.). McBride’s office contacted the state’s Medicaid agency, which eventually called with an update, Crouch said.

Crouch didn’t qualify for Medicaid after all. She said that had never come up in two years of interactions with the state.

“It makes absolutely no sense” that the state never realized she shouldn’t have been on the program, Crouch said.

Delaware’s Medicaid agency didn’t respond to requests for comment on Crouch’s situation.

States Short-Staffed for Medicaid

Some states told KFF Health News in late March that they’ll need more staff to roll out the work rules effectively.

Idaho said it has 40 eligibility worker vacancies. New York estimated it will need 80 new employees to handle the additional administrative work, at a cost of $6.2 million. Pennsylvania said it has nearly 400 open positions in county human services offices in the state. Indiana’s Medicaid agency has 94 open positions. Maine wants to hire 90 additional staffers, and Massachusetts wants to hire 70 more.

As of early March, Montana had filled 39 of 59 positions state officials projected it would need. The state still plans to roll out the rules early, starting July 1, despite its long struggle with system backlogs that applicants said have delayed benefits.

Missouri’s social services agency has been cutting staff and has 1,000 fewer front-line workers than it did roughly a decade ago — with more than double the number of enrollees in Medicaid and the Supplemental Nutrition Assistance Program, or SNAP, according to comments Jessica Bax, the agency director, made during a public meeting in November.

“The department thought that there would be a gain in efficiency due to eligibility system upgrades,” Bax said. “Many of those did not come to fruition.”

States could have a hard time finding people interested in taking those jobs, which require months-long training, can be emotionally challenging, and generally offer low pay, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families.

“They get yelled at a lot,” said Brooks, who formerly ran New Hampshire’s Medicaid and CHIP customer service program. “People are frustrated. They’re crying. They’re concerned. They’re losing access to health care, and so sometimes it’s not an easy job to take if it’s hard to help someone.”

States are paying government contractors millions of dollars to help them comply with the new federal law.

Maximus, a government services contractor, provides eligibility support, such as running call centers, in 17 states that expanded Medicaid and interacts with nearly 3 in 5 people enrolled in the program nationally, according to the company.

During a February earnings call, company leadership said Maximus can charge based on the number of transactions it completes for enrollees, independent of how many people are enrolled in a state’s Medicaid program.

Maximus has “no one-size-fits-all approach” to the services it offers or the way it charges for those services, spokesperson Marci Goldstein told KFF Health News.

The company, which reported bringing in $1.76 billion in 2025 from the part of its business that includes Medicaid work, expects that revenue to continue to grow, even as people fall off the Medicaid rolls, “because of the additional transactions that will need to take place,” David Mutryn, Maximus’ chief financial officer and treasurer, said during the earnings call.

Losing Medicaid health coverage isn’t just an inconvenience, since many people enrolled in the program probably don’t make enough money to pay for health care on their own and may not qualify for financial help for Affordable Care Act coverage, said Elizabeth Edwards, a senior attorney with the National Health Law Program.

People could be unable to afford medications or get essential care, which could lead to “devastating” health impacts, she said.

“The human stakes of this are people’s lives,” she said.

KFF Health News correspondents Katheryn Houghton and Samantha Liss contributed to this report.

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

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Estaba pensando en retrasar el estudio, contó, porque este año la prima mensual del seguro de Obamacare se le triplicó a $2.460, lo que es igual a cerca de un tercio de sus ingresos.

Con un deducible de $2.700, habría tenido que pagar de su propio bolsillo la mayor parte del examen diagnóstico, un golpe económico que aseguró no poder asumir.

Galvin vive en North Kingstown, Rhode Island, y se retiró recientemente como director de una empresa de equipos médicos. “La colonoscopía me iba a costar cerca de $3.000. Así que decidí postergarla”, explicó.

También Nancy, la esposa de Galvin, está retrasando una costosa tomografía computarizada por unos años, hasta que pueda aplicar a Medicare y que el programa federal de salud cubra el costo. Medicare ofrece cobertura para todos los estadounidenses de 65 años en adelante.

Las personas con planes de la Ley de Cuidado de Salud a Bajo Precio (ACA) que están cerca de la edad de jubilación fueron de las más afectadas por los aumentos de precios luego de la suspensión de los subsidios federales mejorados, a finales de diciembre.

Quienes tenían ingresos superiores al 400% del nivel federal de pobreza —$86.560 para una familia de dos miembros— habían estado recibiendo ayuda para pagar los planes desde que la administración Biden amplió los subsidios durante la pandemia de covid-19. Los adultos de 50 a 64 años representaban alrededor de la mitad de los inscritos en ACA.

Ahora, sin esa ayuda financiera, algunas personas en este grupo de edad dicen que están pensando si no les conviene retrasar la atención médica hasta que califiquen para Medicare.

Según defensores de pacientes, médicos y expertos en políticas de salud, esta decisión no solo puede poner en riesgo la salud, sino también generar mayores costos para el sistema. Al postergar la atención médica hasta alcanzar la elegibilidad para Medicare, muchas afecciones se pueden agravar, lo que termina trasladando el gasto a los contribuyentes.

“Habrá mucha demanda acumulada y necesidades no atendidas”, dijo Jessica Schubel, consultora de políticas de salud que trabajó en las administraciones de Barack Obama y Joe Biden. “Medicare va a tener que gastar mucho dinero cubriendo y manejando esos tratamientos”.

ACA ha sido una fuente clave de cobertura médica para personas de 50 a 64 años. El acceso a los planes del Obamacare ayudó a reducir a la mitad la tasa de personas sin seguro en este sector, según AARP, un grupo de defensa que representa a adultos mayores.

Esto permitió que algunas personas se jubilaran antes manteniendo cobertura. También ha servido como red de seguridad para los dueños de pequeños negocios y para quienes tienen empleos que no ofrecen seguro médico.

El otoño pasado se produjo el cierre del gobierno más largo de la historia, en medio de un intento fallido de los demócratas por extender los subsidios mejorados. Los republicanos que se opusieron a la medida argumentaron que la ayuda beneficiaba a las aseguradoras e incentivaba el fraude y la oferta de cobertura innecesaria.

El tema seguirá siendo relevante en la política, especialmente ante las elecciones de medio término de este año, incluso entre los estadounidenses mayores, que votan de manera regular, dijo el estratega republicano Gregg Keller, quien dirige Atlas Strategy Group.

“¿El costo de la atención médica va a ser un tema? Sin duda”, dijo. “¿Los precios de la atención médica influirán? Sí”.

Incluso antes de que expiraran los subsidios, los costos de la atención médica, los hogares de adultos mayores y los medicamentos recetados eran algunas de las principales preocupaciones de salud entre las personas mayores de 50 años, según una encuesta de 2024 de la Universidad de Michigan.

Los adultos de mediana edad con planes del Obamacare sienten con más fuerza el impacto de la eliminación de estos subsidios, porque ACA permite que las aseguradoras les cobren a las personas de 60 años primas hasta tres veces mayores que a las de 20, ya que estas últimas, por lo general, usan menos servicios médicos.

Y muchos adultos de mediana edad ya estaban inscriptos en los planes de menor costo disponibles, lo que los deja sin opciones más baratas, señaló Matt McGough, analista de políticas en KFF, una organización sin fines de lucro de información en salud que incluye KFF Health News.

“Esto es muy grave para las personas mayores inscriptas en el mercado de seguros”, dijo.

Quienes ganan apenas unos dólares por encima del 400% del nivel federal de pobreza ahora quedan fuera de los subsidios, y en algunos estados las primas promedio para este grupo llegaron al menos a triplicarse.

 Muchas personas están viendo aumentos anuales de miles de dólares, con primas que pueden representar hasta una cuarta parte de sus ingresos.

John Ayanian, médico de atención primaria e investigador de políticas de salud en la Universidad de Michigan, contó que con frecuencia sus pacientes mayores le hablan de sus esfuerzos para afrontar el pago de su atención médica. Algunos, de poco más de 60 años, probablemente abandonen la cobertura de ACA debido al aumento, dijo.

“Es una apuesta arriesgada”, opinó.

Marci Heinbaugh podría verse obligada a asumir ese riesgo. La trabajadora social de 63 años, que vive en una zona rural de Illinois, contó que su prima mensual superó el doble de su valor, pasando de unos $1.100 a $2.333, por un plan con gasto máximo de bolsillo de $10.150.

Sabía que tendría que pagar más, dijo, pero no imaginaba un aumento de esa magnitud. Después de unos meses, ya no está segura de poder mantener el plan durante el resto del año y dijo que incluso podría quedarse sin seguro. “Me da pánico siquiera pensarlo”, confesó Heinbaugh.

Las personas quieren comprar su propio seguro en el mercado y muchos adultos de mediana edad podrían pagarlo con un poco de ayuda financiera federal, dijo Alan Weil, vicepresidente senior de políticas públicas en AARP. Quienes abandonan la cobertura o retrasan la atención hasta cumplir 65 años pueden estar ahorrando dinero ahora, pero eso podría resultar más costoso para ellos —y para los contribuyentes— más adelante.

“Existe una probabilidad significativa de que los supuestos ahorros por reducir los subsidios a medida que las personas se acercan a la jubilación terminen convirtiéndose en mayores costos para Medicare”, señaló Weil.

Los afiliados a Medicare no están protegidos de los aumentos de costos. Por ejemplo, en enero, las primas estándar de la Parte B de Medicare subieron de $185 al mes a casi $203.

Hasta que Galvin pueda inscribirse en Medicare, prevé gastar los $30.000 de su cuenta de jubilación para cubrir los pagos de primas y el deducible de su plan del mercado.

Una encuesta de AARP de 2024 reveló que 1 de cada 5 adultos mayores de 50 años no tiene ahorros para la jubilación y que a 3 de cada 5 les preocupa no tener suficientes fondos para mantenerse.

La expiración de estos subsidios del Obamacare ejerce una presión financiera adicional sobre los estadounidenses a medida que se acercan a la jubilación, dijeron investigadores de políticas de salud.

“Están obligando a las personas a tomar decisiones imposibles”, dijo Natalie Kean, directora de defensa federal en salud de la organización sin fines de lucro Justice in Aging.

¿Tienes dificultades para pagar tu seguro médico? ¿Has decidido prescindir de la cobertura? Haz clic aquí para contactar a KFF Health News y compartir tu historia.

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He was already thinking about delaying it — then his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income, he said. And with a $2,700 deductible, he’d be on the hook for most of the diagnostic exam, a financial hit he said he couldn’t stomach.

“It was going to cost close to $3,000,” said Galvin, who lives in North Kingstown, Rhode Island, and recently retired as director of a durable medical equipment company. “I put it off.”

Galvin said his wife, Nancy, is delaying a costly CT scan for a few years until she too qualifies for Medicare, so it can foot the bill. The federal health program offers coverage for all Americans 65 and older.

People on Affordable Care Act plans nearing retirement age experienced some of the largest price increases following the expiration of enhanced federal subsidies at the end of December. Those with incomes above 400% of the federal poverty level — $86,560 for a family of two — had been getting help paying for the plans since the Biden administration expanded the subsidies during the covid-19 pandemic. Adults ages 50 through 64 made up around half of those ACA enrollees.

Now, without that federal financial help, some in this age group say they’re wrestling with whether to delay care until they qualify for Medicare. Not only does that put their physical health at risk, said patient advocates, doctors, and health policy researchers, but it potentially just shifts the costs — and could lead to taxpayers’ footing even bigger bills to fix health issues that worsen amid the delays.

“There’s going to be a lot of pent-up demand and unmet need,” said Jessica Schubel, a health policy consultant who worked in the Obama and Biden administrations. “Medicare is going to have to spend a whole heck of a lot of money covering and dealing with their treatment.”

The Affordable Care Act has been a key source of health care coverage for people 50 through 64. Access to Obamacare plans helped cut the uninsured rate for this age group by half, according to AARP, a lobbying group that represents older adults. That allowed some people to retire early while keeping coverage. It also has provided a safety net for small-business owners and those with jobs that don’t offer health insurance.

Last fall, the longest-ever government shutdown occurred amid an unsuccessful effort by Democrats to extend the enhanced subsidies. Republicans opposing the extension had said the assistance went to insurers, incentivizing fraud and wasteful coverage.

Waiting for Medicare

John Galvin, 64North Kingstown, Rhode Island

John Galvin knows he needs a colonoscopy. But he’s waiting until he turns 65 in December to schedule it, so that Medicare will pick up the tab. His monthly Obamacare premium payment jumped this year — from $800 to more than $2,400 — so he’s burning through a $30,000 retirement account to cover the additional costs. And that’s for a plan with a $2,700 deductible, which means he’d be on the hook for most of the pricey diagnostic exam. “It was going to cost close to $3,000,” Galvin says. “I put it off.”

— Sam Whitehead

The issue will continue to have political relevance, especially in this year’s midterm elections, including among older Americans who reliably show up to the polls, said Republican strategist Gregg Keller, who runs the Atlas Strategy Group.

“Is affordability going to be an issue? Absolutely,” he said. “Are health care prices going to factor into that? Yes.”

Even before the subsidies expired, the costs of medical care, nursing homes, and prescription drugs were among the top health-related concerns for people over 50, a 2024 University of Michigan poll found.

Middle-aged adults with Obamacare plans acutely feel the pinch of the expired subsidies, because the ACA allows insurers to charge adults in their 60s up to three times as much for premiums as those in their 20s, who generally use fewer medical services.

And many middle-aged adults were already enrolled in the lowest-cost plans available, which leaves them without cheaper options to fall back on, said Matt McGough, a policy analyst with KFF, a health information nonprofit that includes KFF Health News.

“This is very dire for the older marketplace enrollees,” he said.

Someone making a few dollars over 400% of the federal poverty level earns too much to get a subsidy now, and in some states average premium payments were due to at least triple for this group. Many people are seeing yearly rate increases of thousands of dollars, with premium payments totaling as much as a quarter of their incomes.

John Ayanian, a primary care physician and health policy researcher at the University of Michigan, said he has regular conversations with older patients who are trying to figure out how to afford their medical care. Some in their early 60s are likely to drop ACA coverage because of rising premiums, he said.

“That’s a gamble,” he added.

Marci Heinbaugh may take that bet. The 63-year-old social services worker, who lives in rural Illinois, said her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum.

She knew she’d be paying more, she said, but wasn’t anticipating that kind of increase. A few months in, she’s not sure if she’ll stick with the plan for the rest of the year. She said she may go uninsured.

“I’m petrified to even think about that,” Heinbaugh said.

People want to buy their own insurance on the marketplace, and many middle-aged adults could afford it with just a little federal financial help, said Alan Weil, senior vice president of public policy at AARP. Those who drop coverage or delay care until they reach age 65 might save money now, but that could be more costly for them — and taxpayers — later.

“There’s significant possibility that the purported savings associated with reducing subsidies as people approach retirement end up turning into higher utilization costs for Medicare,” Weil said.

And Medicare enrollees aren’t insulated from rising costs. In January, for example, standard Medicare Part B premiums rose from $185 per month to almost $203.

Until Galvin joins Medicare, he said, he expects to burn through a $30,000 retirement account to cover his marketplace plan’s premium payments and deductible.

A 2024 AARP survey found that 1 in 5 adults over 50 had no retirement savings and 3 in 5 were worried they wouldn’t have enough retirement savings to support themselves.

The expiration of these Obamacare subsidies puts additional financial pressure on Americans as they approach retirement, health policy researchers said.

“It’s forcing people to make impossible choices,” said Natalie Kean, director of federal health advocacy for the national nonprofit Justice in Aging.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.

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Health insurance could be out of reach for many Americans in 2026.

About a million fewer people signed up for Affordable Care Act marketplace coverage this year. The Congressional Budget Office told lawmakers that more could opt out in coming years after the GOP-led Congress let expire subsidies that helped many afford a plan. Meanwhile, plan premiums jumped, and new, stricter Medicaid eligibility rules kicked in.

If you lost health insurance this year, there may be ways to see the doctor without breaking the bank. On March 4, in conversation with WAMU host Esther Ciammachilli, KFF Health News correspondent Sam Whitehead shared tips on navigating care without coverage.

Renuka Rayasam and Taylor Cook contributed reporting.

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

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La mujer de 59 años, que vive en Harrisburg, Carolina del Norte, cerró el año pasado su escuela de artes circenses sin fines de lucro porque ya no veía lo suficientemente bien como para estar al día con todo el papeleo administrativo. Luego trabajó un tiempo haciendo masas en una pizzería. Ahora clasifica materiales reciclables, como latas y botellas, en un lugar de conciertos local. Es su principal fuente de ingresos, pero el trabajo no es durante todo el año.

“Este lugar me conoce, y este lugar me quiere”, dijo Kelley sobre su empleador. “Aquí no tengo que explicar por qué no puedo leer”.

Kelley vive en una casa rodante y sobrevive con menos de $10.000 al año. Dice que eso es posible, en parte, gracias a su cobertura de salud de Medicaid, que le cubre medicamentos para la artritis y la ansiedad, y le permite ir al doctor para controlar su hipertensión.

Pero le preocupa perder esa cobertura el año que viene, cuando entren en vigencia nuevas reglas que exigirán a millones de personas como ella trabajar, hacer voluntariado, ir a la escuela o realizar otras actividades que califiquen durante al menos 80 horas al mes.

“Ahora mismo tengo miedo”, dijo.

Antes de que se promulgaran los cambios para acceder a esta cobertura, legisladores republicanos sugirieron que hombres jóvenes y desempleados estaban abusando del programa gubernamental de salud que ofrece cobertura médica a millones de personas con bajos ingresos o con alguna discapacidad.

Medicaid no está pensado para “hombres de 29 años sentados en el sofá jugando videojuegos”, dijo Mike Johnson, presidente de la Cámara de Representantes, a CNN.

Pero en realidad, los adultos de entre 50 y 64 años, especialmente las mujeres, son quienes probablemente resulten más afectados por las nuevas reglas, según explicó Jennifer Tolbert, subdirectora del Programa sobre Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro de información sobre salud de la cual KFF Health News forma parte.

Para Kelley y otras personas, los requisitos laborales crearán obstáculos para mantener su cobertura, explicó Tolbert. Muchos podrían perder Medicaid, poniendo en riesgo su salud física y financiera.

A partir de enero de 2027, unos 20 millones de estadounidenses de bajos ingresos en 42 estados y el Distrito de Columbia tendrán que cumplir con los requisitos de actividad para obtener o conservar esta cobertura.

Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming no ampliaron sus programas de Medicaid para cubrir a más adultos de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), por lo que no tendrán que implementar las reglas de trabajo.

La no partidista Oficina de Presupuesto del Congreso, prevé que las reglas de trabajo resulten en al menos 5 millones de personas menos bajo Medicaid en la próxima década.

Según críticos, estas reglas son el principal factor de pérdida de cobertura dentro de la ley presupuestaria republicana, la cual recorta cerca de $1.000 millones para compensar reducciones de impuestos que benefician principalmente a personas con mayores ingresos y para aumentar la seguridad fronteriza.

“Estamos hablando de ahorrar dinero a costa de vidas humanas”, dijo Jane Tavares, investigadora en gerontología de la Universidad de Massachusetts en Boston. “El requisito de trabajo es solo una herramienta para lograr eso”.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos, dijo que exigir a los “adultos sin discapacidades” que trabajen garantiza la “sostenibilidad a largo plazo” de Medicaid, mientras protege a las personas más vulnerables.

Las personas con discapacidades, quienes cuidan a familiares, personas embarazadas o en posparto, veteranos con discapacidades totales y otras personas que enfrentan dificultades médicas o personales están exentas de la regla de trabajo, indicó Nixon a KFF Health News.

La expansión de Medicaid ha sido un salvavidas para adultos de mediana edad que, de otro modo, no tendrían seguro médico, según investigadores de la Universidad Georgetown. Medicaid cubre a 1 de cada 5 estadounidenses de entre 50 y 64 años, dándoles acceso a atención médica hasta que califican para Medicare a los 65 años.

Entre las mujeres beneficiarias de Medicaid, las que tienen entre 50 y 64 años enfrentan más desafíos para conservar su cobertura que las más jóvenes, y suelen tener una mayor necesidad de servicios de salud, explicó Tolbert.

Estas mujeres de mediana edad tienen menos probabilidades de trabajar el número requerido de horas porque muchas son cuidadoras familiares o tienen problemas de salud que limitan su capacidad para trabajar, agregó.

Tavares y otros investigadores hallaron que solo el 8% de la población total de Medicaid que se considera “apta para trabajar” no trabaja. Este grupo está compuesto en su mayoría por mujeres muy pobres que han salido de la fuerza laboral para convertirse en cuidadoras. Entre ellas, 1 de cada 4 tiene 50 años o más.

“No son adultos jóvenes saludables simplemente perdiendo el tiempo”, escribieron los investigadores.

Además, dificultar el acceso a la cobertura de Medicaid “podría en realidad dificultar que estas personas trabajen”, ya que sus problemas de salud no recibirían tratamiento, advirtió Tolbert. De todas formas, si este grupo pierde la cobertura, sus condiciones crónicas igual necesitarán atención, señaló.

Muchos adultos empiezan a tener problemas de salud antes de ser elegibles para Medicare.

Si las personas mayores no tienen recursos para tratar sus problemas de salud antes de los 65 años, llegarán más enfermas a Medicare, lo que podría generar mayores costos para ese programa, apuntaron expertos en políticas de salud.

Muchas personas de entre 50 y principios de los 60 años ya no trabajan porque son cuidadoras de tiempo completo de hijos o familiares mayores, explicaron defensores, quienes se refieren a este grupo como “la generación sándwich”.

La ley presupuestaria republicana permite que algunos cuidadores queden exentos de las reglas de trabajo de Medicaid, pero las excepciones son “muy limitadas”, dijo Nicole Jorwic, directora de programas del grupo Caring Across Generations.

Le preocupa que personas que deberían calificar para una exención queden fuera por errores o complicaciones.

“Vamos a ver a más cuidadores familiares enfermándose, dejando de atender su propia salud y a más familias enfrentando crisis”, dijo Jorwic.

Paula Wallace, de 63 años, residente de Chidester, Arkansas, dijo que trabajó la mayor parte de su vida adulta y ahora dedica sus días a cuidar a su esposo, quien tiene cirrosis avanzada.

Después de años sin seguro, recientemente obtuvo cobertura gracias a la expansión de Medicaid en su estado, lo que significa que tendrá que cumplir con los nuevos requisitos laborales para conservarla. Pero le cuesta imaginar cómo podrá hacerlo.

“Como soy su única cuidadora, no puedo salir a trabajar fuera de casa”, dijo.

Su esposo recibe beneficios del Seguro por Incapacidad del Seguro Social, explicó, y la ley dice que ella debería quedar exenta de los requisitos de trabajo como cuidadora de tiempo completo de una persona con discapacidad.

Pero las autoridades federales aún no han emitido instrucciones específicas sobre cómo definir esa exención. Y la experiencia de Arkansas y Georgia —los únicos estados que han implementado programas de trabajo en Medicaid— muestra que muchas personas beneficiarias tienen dificultades para navegar sistemas de beneficios complejos.

“Estoy muy preocupada”, dijo Wallace.

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The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House Speaker Mike Johnson told CNN.

But, in reality, adults ages 50 to 64, particularly women, are likely to be hit hard by the new rules, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, critics say.

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told KFF Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to Georgetown University researchers. Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that just 8% of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you're going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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Brader, de 27 años y residente de Bloomington, Indiana, tiene un marcapasos y una enfermedad dolorosa en las articulaciones. Además, sufre una lesión en la columna que le fusionó las vértebras del cuello, lo que le impide girar la cabeza.

La agencia estatal de Medicaid considera a Brader como “médicamente frágil”, lo que le da acceso a un conjunto ampliado de beneficios, como terapia física.

Pero nuevas reglas federales exigirán que más de 18 millones de personas beneficiarias de Medicaid en todo el país demuestren, a partir de 2027, que trabajan, hacen voluntariado o estudian al menos 80 horas al mes para mantener su cobertura.

Brader está exenta mientras siga siendo considerada médicamente frágil.

Pero ante la falta de directrices claras a nivel federal, los estados deben llegar a un acuerdo sobre cómo definir la fragilidad médica, una decisión de gran impacto que podría hacer que muchas personas pierdan el acceso a Medicaid, según funcionarios estatales, defensores del consumidor y expertos en políticas de salud.

“Estoy aterrada”, dijo Brader. “Ya he luchado mucho para conseguir esta atención médica”.

Mucho en juego

La ley One Big Beautiful Bill Act del presidente Donald Trump recortará casi $1.000 billones de dólares a Medicaid a lo largo de la próxima década. Buena parte de esos ahorros proyectados provendrían de dejar de cubrir a quienes no califiquen bajo las nuevas reglas laborales.

Esos recortes ayudan a financiar otras prioridades del Partido Republicano, como más seguridad fronteriza y recortes de impuestos que benefician sobre todo a personas con altos ingresos.

Legisladores conservadores han argumentado que Medicaid —el programa de seguro médico del gobierno para personas de bajos ingresos o con discapacidades— ha crecido demasiado, especialmente tras su expansión a más personas adultas de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA, por sus siglas en inglés). También afirman que exigirles trabajar a los beneficiarios es una medida de sentido común.

La nueva ley fiscal y presupuestaria de Trump ofrece excepciones a varias personas que podrían tener dificultades para cumplir con las reglas laborales, incluyendo aquellas consideradas “médicamente frágiles”. La ley define ciertas condiciones como fragilidad médica, por ejemplo, ceguera, discapacidad y adicciones. Pero no incluye muchas otras.

En su lugar, la norma exime a quienes tengan una “condición médica seria o compleja”, un término cuya interpretación puede variar según el estado.

Funcionarios estatales señalan que necesitan más claridad para asegurar que las personas que no pueden trabajar por razones de salud mantengan su derecho a Medicaid. También les preocupa que, incluso con una definición clara, muchas personas enfrenten el reto burocrático de tener que probar constantemente  que son médicamente frágiles, lo cual es difícil si no se puede acceder a una atención médica adecuada.

“Hay mucho en juego”, dijo Kinda Serafi, socia de la firma consultora Manatt Health.

Los nuevos requisitos laborales afectarán a beneficiarios de Medicaid en 42 estados y en Washington, DC. Ocho estados —Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming— no expandieron sus programas de Medicaid para incluir a más personas adultas de bajos ingresos, por lo que no tendrán que implementar estas reglas.

Según la Oficina de Presupuesto del Congreso (Congressional Budget Office), una entidad no partidista, se espera que estas reglas laborales de Medicaid sean el principal factor que provoque la pérdida de cobertura médica en la próxima década.

El 44% de las personas adultas cubiertas por los programas de Medicaid en estados que lo ampliaron tienen al menos una afección crónica, según KFF.

Un desafío para los estados

Las agencias estatales de Medicaid se apresuran a implementar las nuevas reglas con poca orientación del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS, por sus siglas en inglés) que aún no ha emitido directrices específicas. Andrew Nixon, vocero de la agencia, dijo que la definición federal de “médicamente frágil” se aclarará el próximo año.

En última instancia, serán los estados los que tengan que decidir quién está lo suficientemente enfermo como para quedar exento de los requisitos laborales. Y no será fácil para el personal estatal ni para los sistemas informáticos hacer ese seguimiento.

Cada año, los sistemas estatales de elegibilidad evalúan a millones de personas solicitantes para determinar si califican para Medicaid y otros programas gubernamentales. Ahora, esos mismos sistemas también tendrán que verificar si personas nuevas o ya inscritas cumplen con los requisitos laborales.

Jessica Kahn, socia en la firma consultora McKinsey & Co., ha instado a los estados a comenzar desde ya a planear cómo adaptar sus sistemas para verificar el estatus laboral. Los estados pueden hacer “muchísimo” incluso sin esperar directrices federales, dijo Kahn —quien fue funcionaria federal de Medicaid— durante una reciente audiencia de asesoría sobre el programa. “El tiempo se acaba”.

Las personas encargadas de Medicaid a nivel estatal evalúan este reto.

“La fragilidad médica es algo muy complejo”, dijo Emma Sandoe, directora de Medicaid en Oregon, durante un panel reciente. Las condiciones que impiden trabajar, como los trastornos de salud mental, son difíciles de demostrar, explicó.

Un estado podría intentar usar información de los expedientes médicos de una persona, por ejemplo, para determinar si es médicamente frágil. Pero esa información puede no reflejar con claridad la salud de alguien, especialmente si no tiene acceso regular a servicios médicos.

Es una tarea difícil para sistemas de elegibilidad que históricamente no han tenido que revisar registros médicos para evaluar solicitudes, señaló Serafi, de Manatt Health.

“Esto es completamente nuevo para los sistemas de inscripción, y simplemente no están preparados”, añadió.

Grupos de cabildeo que representan a compañías privadas de seguros médicos que administran Medicaid en varios estados también han pedido a las autoridades federales que definan claramente qué significa ser médicamente frágil, para que se aplique de manera uniforme.

En una carta enviada el 3 de noviembre, las organizaciones Planes de Salud Medicaid de Estados Unidos (MHPA, en inglés) y la Asociación de Planes Afiliados a la Comunidad (ACAP, en inglés) recomendaron que se permita a las personas solicitantes calificar para la exención simplemente al indicar en su solicitud que tienen condiciones que las hacen médicamente frágiles. Según las dos organizaciones, implementar con éxito estas exenciones será “crucial” dada la “gravedad de los riesgos para la salud que implica perder cobertura” para estas poblaciones.

Algunos funcionarios estatales temen que haya consecuencias imprevistas por estas reglas laborales para personas con enfermedades crónicas.

Jennifer Strohecker, quien recientemente renunció como directora de Medicaid en Utah, reiteró la gravedad de este asunto, especialmente para personas con diabetes afiliadas a Medicaid.

Explicó que, si bien pueden llevar una vida funcional con insulina, eso podría cambiar si pierden la cobertura por no cumplir con los requisitos laborales.

Actualmente, el hecho de que alguien sea considerado médicamente frágil depende en gran medida del lugar donde viva.

Por ejemplo, en Arkansas, las personas deben indicar en sus solicitudes de Medicaid si tienen una discapacidad, son ciegas o necesitan ayuda para realizar actividades diarias.

Según Gavin Lesnick, vocero del Departamento de Servicios Humanos de Arkansas, aproximadamente el 6% de las 221.000 personas inscritas en el programa de expansión de Medicaid del estado se consideran médicamente frágiles.

En West Virginia, el estado acepta la designación de fragilidad médica cuando una persona la reporta por cuenta propia.

En Dakota del Norte, el proceso es más estricto. Quienes solicitan deben completar un cuestionario sobre su salud y presentar documentación adicional, como notas del historial médico y planes de tratamiento. Más de la mitad de las solicitudes fueron rechazadas el año pasado, según Mindy Michaels, vocera del Departamento de Salud y Servicios Humanos.

La Administración de Servicios Familiares y Sociales de Indiana, que gestiona Medicaid en ese estado, se negó a ofrecer entrevistas y dijo que no podía comentar sobre casos individuales, como el de Brader.

Brader teme que la burocracia adicional la haga perder otra vez su cobertura de Medicaid. Contó que en 2019 fue expulsada temporalmente del programa por no cumplir con las reglas laborales del estado, cuando Indiana determinó que su trabajo como estudiante no contaba como empleo.

“Siempre que he intentado recibir ayuda del estado de Indiana, ha sido una pesadilla burocrática”, dijo.

Mientras los estados esperan una guía federal, Kristi Putnam —miembro del conservador Instituto Cicero y ex secretaria del Departamento de Servicios Humanos de Arkansas— dijo que, incluso si un estado crea una lista extensa de condiciones que califican como fragilidad médica, siempre habrá que poner un límite.

“No se puede crear una política de exenciones que lo cubra todo”, afirmó.

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The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the largest driver of health insurance coverage losses over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs have at least one chronic health condition, according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a Nov. 3 letter to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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

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The texts were part of a pilot run to test technology the Trump administration says will make it easier for some Medicaid enrollees to prove they meet new requirements — working, studying, job training, or volunteering at least 80 hours a month — set to take effect in just over a year.

But only 894 people completed the quarterly wage check, or just under 7% of enrollees who got the text, according to Drew Maranto, undersecretary for the Louisiana Department of Health.

“We’re hoping to get more to opt in,” Maranto said. “We plan to raise awareness.”

The clock is ticking for officials in 42 states — excluding those that did not expand Medicaid at all — and Washington, D.C., to figure out how to verify that an estimated 18.5 million Medicaid enrollees meet rules included in President Donald Trump’s tax and spending law. They have until the end of next year, and federal officials are giving those jurisdictions a total of $200 million to do so.

The policy change is one of several to free up money for Trump’s priorities, such as increased border security and tax breaks that mainly benefit the wealthy.

The nonpartisan Congressional Budget Office has said the work rules will be the main reason millions of people won’t be able to access health insurance over the next decade. It estimates changes to the Medicaid program will result in 10 million fewer Americans covered by 2034 — more than half of them because of the eligibility rules.

For now, state officials, health policy researchers, and consumer advocates are watching the pilot program in Louisiana and another in Arizona. Mehmet Oz, director of the Centers for Medicare & Medicaid Services, has touted those test-drives and said they will allow people to verify their incomes “within seven minutes.”

“There have been efforts to do this in the past, but they haven’t been able to achieve what we can achieve because we have technologies now,” said Oz, during a television appearance in August.

Brian Blase, the president of the conservative Paragon Health Institute and a key architect of Medicaid changes in the new law, has chimed in, saying during a recent radio appearance that with today’s artificial intelligence “people should be able to seamlessly enter how they are spending their time.”

KFF Health News found scant evidence to support such claims. Federal and state officials have offered little insight into what new technology the two pilots have tested. They do say, however, that it connects directly with the websites of Medicaid enrollees’ payroll providers, rather than using artificial intelligence to draw conclusions about their activities.

Oz said the Trump administration’s efforts started “as soon as the bill was signed” in July. But work on the pilot programs began under the Biden administration.

And Medicaid is a state-federal program: The federal government contributes most of the funds, but it is up to the states to administer them, not the federal government.

“Oz can say, ‘Oh no, we’re going to fix this. We’re going to do this.’ Well, they don’t actually run the program,” said Joan Alker, a health policy researcher at Georgetown’s Center for Children and Families.

Officials have also offered few details about the pilots’ effectiveness in assisting enrollees in Medicaid or other public benefit programs.

The shortage of information has some state officials and health policy researchers worried that the Trump administration lacks viable solutions to help states implement the work rules. As a result, they say, people with a legal right to Medicaid benefits could lose access to them.

“What actually keeps me up at night is the fear that members that are eligible for Medicaid and are trying to get health care services would fall through the cracks and lose coverage,” said Emma Sandoe, Oregon’s Medicaid director.

Officials involved in the Louisiana and Arizona projects declined to answer many specific questions about their efforts, instead directing KFF Health News to federal officials.

Spokespeople for Arizona’s Medicaid and Economic Security departments — Johnny Córdoba and Brett Bezio, respectively — did not share data on how many people participated in the state’s pilot test nor describe the outcome. They said the pilot had been used to verify eligibility only for the federal Supplemental Nutrition Assistance Program, a smaller program than Medicaid.

The Community Food Bank of Southern Arizona, a nonprofit that helps people sign up for such SNAP benefits, hadn’t heard of the pilot program.

State officials and health policy researchers said neither pilot program could confirm whether a person meets other qualifying activities — such as community service — or any of the numerous exemptions. The tools being tested can verify only income.

Andrew Nixon, director of communications for the U.S. Department of Health and Human Services, which oversees Oz’s agency, wrote in a statement that the digital tools officials aim to share with states “are largely under development.”

One person doing that development is Michael Burstein, who until recently worked at the U.S. Digital Service, which later became known as the Department of Government Efficiency.

As the U.S. Digital Service was turned into DOGE, Burstein and other staffers left and started a nonprofit called Digital Public Works to finish supporting the technology to make it easier for people to verify their incomes for Medicaid enrollment.

But without permission from state officials, Burstein would not describe the tool in development, aside from saying that it’s mobile-first, can quickly verify income for a new or returning client, “and we’re pretty happy with it.”

The state agencies that manage benefit programs, such as Medicaid and SNAP, are understaffed, and they use different eligibility systems, many of which need updating, which makes improving them “a challenging task,” he said.

The $200 million in start-up costs the federal government has earmarked for systems to track work requirements equals roughly four times what it cost to administer Georgia’s Medicaid work requirement program alone.

That state, which has the nation’s only active work requirement program, called Georgia Pathways to Coverage, in September was granted a temporary extension, despite a recent report from a federal watchdog saying it hadn’t received enough federal oversight. A complicated sign-up process has kept enrollment in the program far below Georgia’s own projections.

Trump’s tax and spending law allows states to ask for extra time — until the end of 2028 — to start enforcing the rules, but only with the approval of HHS Secretary Robert F. Kennedy Jr. It also allows counties with high unemployment rates to be exempted, but states must apply for that exemption.

Even with an app that states can use to prove people are eligible for Medicaid, enrollees would still need to know that app existed and how to use it — neither of which is a given, Alker said. There is also no guarantee they’d have reliable cell service or internet access. As KFF Health News has reported, millions of Americans live in rural areas without reliable internet.

Private vendors also have been working on such apps, said Jennifer Wagner, who researches Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. Wagner said she has seen several vendors demonstrate products they plan to pitch to states for the work rules. Many are limited in scope, she said, like those in the pilot tests.

“Nobody has a magical solution that’ll make sure eligible people don’t lose coverage,” she said.

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

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This story can be republished for free (details).