“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.

Ñî¹óåú´«Ã½Ò•îl 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) 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 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 .

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 Ñî¹óåú´«Ã½Ò•îl 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,

“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 Ñî¹óåú´«Ã½Ò•îl 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 Ñî¹óåú´«Ã½Ò•îl Health News Katheryn Houghton y Samantha Liss contribuyeron con este artículo.

Ñî¹óåú´«Ã½Ò•îl 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 .

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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.

Ñî¹óåú´«Ã½Ò•îl 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 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 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 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 Ñî¹óåú´«Ã½Ò•îl 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 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 Ñî¹óåú´«Ã½Ò•îl 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.

Ñî¹óåú´«Ã½Ò•îl Health News correspondents Katheryn Houghton and Samantha Liss contributed to this report.

Ñî¹óåú´«Ã½Ò•îl 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 .

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Oz, who heads the U.S. Centers for Medicare & Medicaid Services, there was approximately $3.5 billion of fraud in the hospice and home health care industry in Los Angeles County alone. “This administration under President [Donald] Trump is not going to tolerate taxpayer dollars being stolen because people aren’t paying attention anymore. We’re focused on this,” . He claimed the fraud was largely orchestrated by the “Russian, Armenian mafia” and said that most of the money spent on home and community-based services across California “might be fraudulent.”

Ñî¹óåú´«Ã½Ò•îl 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 .

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But there are strings attached.

In late December, President Donald Trump’s administration announced how much all 50 states would get under its new Rural Health Transformation Program, assigning them to use the money to fix systemic problems that leave rural Americans without access to good health care. Now, the clock is ticking.

Within eight months, states must submit revised budgets, begin spending, and show the money is going to good use. Federal officials will begin reviewing state progress in late summer and announce 2027 funding levels by the end of October.

The money — divided into unique allocations for each state, ranging from $147 million for New Jersey to $281 million for Texas — represents the first $10 billion installment from the five-year, $50 billion program. Congress created the fund as a last-minute sweetener in Trump’s One Big Beautiful Bill Act last summer to offset the anticipated in rural communities from the statute’s nearly $1 trillion in Medicaid spending cuts over the next decade.

Federal officials crafted the fund to give states “space to be creative,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said on a call with reporters after announcing the funding Dec. 29. “Some states will fail, and we will learn from that.”

The money was divided according to a complicated formula.

In 2026, each state will receive an equal $100 million share for the first half of the money, plus additional funding from the second half. Oz’s staff steered payouts from the second portion based on each state’s rural score, as well as results from a “technical” scoring system for project proposals.

Within hours of the announcement, academics and researchers began to parse the awards to better understand why some states received more than others, including whether the awards reflected any partisanship or political favoritism.

At first glance, total awards do not appear to favor states governed by either Republicans or Democrats. But teased out the amount awarded for each state’s technical score, which is the part determined by the discretion of agency officials.

The analysis was performed at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which specializes in rural health. A Ñî¹óåú´«Ã½Ò•îl Health News review of the Sheps Center data found that states with Republican governors tended to receive more money for the parts of their application based on the technical score. Democratic-controlled states crowded the bottom quarter of those technical score awards.

Overall, though, the state awards reveal wild variation in how much money each state will get per rural resident, almost a hundredfold difference between the top and bottom.

In an emailed statement to , a spokesperson for Arizona’s Democratic Gov. Katie Hobbs accused the administration of shortchanging rural residents in the state, which was awarded $167 million this year from the program.

CMS spokesperson Chris Krepich said in an emailed statement to Ñî¹óåú´«Ã½Ò•îl Health News that “politics played no role in funding decisions.”

On the December call, Oz pushed states to start working on policy actions championed by the administration — such as approving presidential fitness tests and restricting food benefits — that could require legislative approval.

Half of states promised to mandate the presidential fitness test, Oz said. Many states also proposed food waivers under the Supplemental Nutrition Assistance Program, known as SNAP, which would limit low-nutrition items such as soda. He also said some states promised to teach health care professionals about nutrition. And others confirmed they will repeal certificate-of-need laws, which require companies to prove that new health facilities they want to open are necessary.

Krepich said CMS’ new Office of Rural Health Transformation is hiring program officers to serve as point people for three or four states. Many states are setting up their own offices to oversee the new funding.

Oz highlighted Alabama’s “big maternity initiative with robotics doing ultrasounds” and said states are tackling issues ranging from behavioral health to obesity.

A Ñî¹óåú´«Ã½Ò•îl Health News review of state “” and “” released by CMS shows that many states plan to address the workforce challenges in rural areas. Delaware, for example, plans to use its funding to create the state’s first four-year medical school with a rural primary care track.

A third of states said they want to improve electronic health records, and every state mentioned telehealth.

Many state legislatures to distribute the funding to their state offices. Meanwhile, state officials are hiring staff, , and .

“I’m excited about what’s next,” said Terry Scoggin, former interim chief executive of the Texas Organization of Rural & Community Hospitals, or TORCH. Texas was awarded the biggest allocation. The money will bolster a rural hospital funding bill Republican Texas Gov. Greg Abbott signed last year, Scoggin said.

More than two dozen cash-strapped rural hospitals in Texas to clinics since 2005, a nationwide trend that hit the Lone Star State particularly hard. The state has the largest rural population in the United States. Texas’ allocation amounts to about $66 per rural resident, . By contrast, Rhode Island was granted about $6,300 per rural resident.

Scoggin said he has “a ton of concerns” about companies taking the money instead of it helping rural hospitals and residents. “I was blown away about how many for-profit companies reached out.” The companies have also called rural hospitals and asked to work with them to apply for state money, he said.

The awards should be judged on how they benefit rural residents because “the stated goal of the program is to improve rural health,” said Paula Chatterjee, an assistant professor of medicine at the University of Pennsylvania who co-authored on the transformation fund.

Researchers at the Sheps Center conducted the analysis to estimate how much money states received from the technical score, which is the portion of funding based on the quality of their proposals and state policy actions that align with "Make America Healthy Again" priorities.

New Mexico won the least amount of technical funding, with less than 10% of its award based on the discretionary metrics. Alaska won the largest technical award, according to the Sheps Center data.

Texas, Nebraska, New Hampshire, and Hawaii rounded out the top five recipients of technical funding. In addition to New Mexico, the other lowest technical awards went to Michigan, New Jersey, Arizona, and California.

Mark Holmes, director of the Sheps Center, declined to comment on whether he saw any political bias in the awards but said the nuance in the final portion of discretionary awards based on technical scores is important because those dollars can be redistributed and potentially clawed back in future years.

“We can be fairly certain that every state will get at least a slightly, if not a vastly, different amount next year based on this re-pooling and reallocation piece,” Holmes said.

States now have a limited time to show they’re using the money effectively to secure future funding.

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But 5 pounds would come off and then invariably reappear, said Bucklew, 75, a public transit retiree in Ocean View, Delaware. Nothing seemed to make much difference — until 2023, when her body mass index slightly exceeded 40, the threshold for severe obesity.

“There’s this new drug I’d like you to try, if your insurance will pay for it,” the nurse practitioner advised. She was talking about Ozempic.

Medicare covered it for treating Type 2 diabetes but not for weight loss, and it cost more than $1,000 a month out-of-pocket. But to Bucklew’s surprise, her Medicare Advantage plan covered it even though she wasn’t diabetic, charging just a $25 monthly copay.

Pizza, pasta, and red wine suddenly became unappealing. The drug “changed what I wanted to eat,” she said. As 25 pounds slid away over six months, she felt less tired and found herself walking and biking more.

Then her Medicare plan notified her that it would no longer cover the drug. Calls and letters from her health care team, arguing that Ozempic was necessary for her health, had no effect.

With coverage denied, Bucklew became part of an unsettlingly large group: older adults who begin taking GLP-1s and related drugs — highly effective for diabetes, obesity, and several other serious health problems — and then stop taking them within months.

That usually means regaining weight and losing the associated health benefits, including lower blood pressure, cholesterol, and A1c, a measure of blood sugar levels over time.

Widely portrayed as wonder drugs, semaglutide (Ozempic, Wegovy, Rybelsus), tirzepatide (Zepbound, Mounjaro), and related medications have transformed the treatment of diabetes and obesity.

The FDA has approved several GLP-1s for additional uses, too — including to treat and , and and strokes.

“They’re being studied for every purpose you can conceive of,” said Timothy Anderson, a health services researcher at the University of Pittsburgh and author of a recent JAMA Internal Medicine .

(Drug trials have found , however.)

People 65 and older represent prime targets for such medications. “The prevalence of obesity hovers around 40%” in older adults, as measured by body mass index, said John Batsis, a geriatrician and obesity specialist at the University of North Carolina School of Medicine.

The proportion of people with , too, to nearly 30% at age 65 and older. Yet a recent JAMA Cardiology study found that among Americans 65 and up with diabetes, about within a year.

Another study of 125,474 people with obesity or who are overweight found that almost 47% of those with Type 2 diabetes and nearly 65% of those without diabetes stopped taking GLP-1s within a year — a high rate, said Ezekiel Emanuel, a health services researcher at the University of Pennsylvania and senior author of the study.

Patients 65 and older were 20% to 30% the drugs and less likely to return to them.

What explains this pattern? As many as 20% of patients may experience . “Nausea, sometimes vomiting, bloating, diarrhea,” Anderson said, ticking off the most common side effects.

Linda Burghardt, a researcher in Great Neck, New York, started taking Wegovy because her doctor thought it might reduce arthritis pain in her knees and hips. “It was an experiment,” said Burghardt, 79, who couldn’t walk far and had stopped playing pickleball.

Within a month, she suffered several bouts of stomach upset that “went on for hours,” she said. “I was crying on the bathroom floor.” She stopped the drug.

Some patients find that medication-induced weight loss lessens rather than improves fitness, because another side effect is muscle loss. Several trials have reported that , but “lean mass” including muscle and bone.

Bill Colbert’s cherished hobby for 50 years, reenacting medieval combat, involves “putting on 90 pounds of steel-plate armor and fighting with broadswords.” A retired computer systems analyst in Churchill, Pennsylvania, he started on Mounjaro, successfully lowered his blood glucose, and lost 18 pounds in two months.

But “you could almost see the muscles melting away,” he recalled. Feeling too weak to fight well at age 78, he also discontinued the drug and now relies on other diabetes medications.

“During the aging process, we begin to lose muscle,” typically half a percent to 1% of muscle weight per year, said Zhenqi Liu, an endocrinologist at the University of Virginia who . “For people on these medications, the process is much more accelerated.”

Losing muscle can lead to frailty, falls, and fractures, so doctors advise GLP-1 users to exercise, including strength training, and to eat enough protein.

The high rate of GLP-1 discontinuation may also reflect shortages; from 2022 to 2024, these drugs temporarily became hard to find. Further, patients may not grasp that they will most likely need the medications indefinitely, even after they meet their blood glucose or weight goals.

Re-initiating treatment involves its own hazards, Batsis cautioned. “If weight goes up and down, up and down, metabolically it sets people up for functional decline down the road.”

Of course, in considering why patients discontinue, “a large part of it is money,” Emanuel said. “Expensive drugs, not necessarily covered” by insurers. Indeed, in of patients who discontinued semaglutide or tirzepatide, nearly half cited cost or insurance issues as the reason.

Some moderation in price has already occurred. The Biden administration capped out-of-pocket payments for all prescriptions that a Medicare beneficiary receives ($2,100 is the 2026 limit), and authorized annual price negotiations with manufacturers.

The Ozempic, Wegovy, and Rybelsus, though not until 2027. Medicare Part D drug plans will then pay $274, and since most beneficiaries pay 25% in coinsurance, their out-of-pocket monthly cost will sink to $68.50.

Perhaps even lower, if agreements announced in November between the Trump administration and drugmakers Eli Lilly and Novo Nordisk pan out.

The bigger question is whether Medicare will amend its original 2003 regulations, which prohibit Part D coverage for weight loss drugs. “An archaic policy,” said Stacie Dusetzina, a health policy researcher at the Vanderbilt University School of Medicine.

The Trump administration’s would expand Medicare eligibility for GLP-1s and related medications to include obesity, perhaps as early as spring. But key details remain unclear, Dusetzina said.

Medicare should cover anti-obesity drugs, many doctors argue. Americans still tend to think that “diabetes is a disease and obesity is a personal problem,” Emanuel said. “Wrong. Obesity is a disease, and it reduces life span and compromises health.”

But given the expense to insurers, Dusetzina warned, “if you expand the indications and extent of coverage, you’ll see premiums go up.”

For older patients, often underrepresented in clinical trials, questions about GLP-1s remain. Might a lower maintenance dose stabilize their weight? Can doses be spaced out? Could nutritional counseling and physical therapy offset muscle loss?

Bucklew, whose coverage was denied, would still like to resume Ozempic. But because of a recent sleep apnea diagnosis, she now qualifies for Zepbound with a $50 monthly copay.

She has seen no weight loss after three months. But as the dose increases, she said, “I’ll stay the course and give it a shot.”

The New Old Age is produced through a partnership with .

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“When you get shot,” he said, “you stop thinking about the future.”

He is anchored by his wife and child and faith. He once wanted to work as a forklift driver but has built a stable career in information technology. He finds camaraderie with other gunshot survivors and in advocacy.

Still, trauma remains lodged in his daily life. As gun violence surged in the shadows of the covid pandemic, it shook Harris’ fragile sense of security. He moved his family out of Philadelphia to a leafy suburb in Delaware. But a nagging fear of crime persists.

Now he is thinking about buying a gun.

Harris is one of tens of thousands of Americans killed or injured each year by gun violence, a public health crisis that escalated in the pandemic and churns a into a hospital emergency room every half hour.

Over the past two decades, the firearm industry has and stepped up sales campaigns through social media influencers, conference presentations, . An industry trade group acknowledged that its traditional customer was “” and in recent years began targeting and who are disproportionately victimized by gun violence.

The Trump administration has moved to reduce federal oversight of gun businesses, announced by the Bureau of Alcohol, Tobacco, Firearms and Explosives as “marked by transparency, accountability, and partnership with the firearms industry.”

The pain of gun violence crosses political, cultural, and geographic divides — but no group has suffered as much as Black people, such as Harris. They were nearly 14 times as likely to die by gun homicide than white people in 2021, , citing federal data. Black men and boys are 6% of the population but of homicide victims.

Washington has offered little relief: Guns remain one of few consumer products the federal government for health and safety.

“The politics of guns in the U.S. are so out of whack with proper priorities that should focus on health and safety and most fundamental rights to live,” said attorney Jon Lowy, founder of , who helped represent Mexico in an unsuccessful lawsuit against Smith & Wesson and other gunmakers that reached the Supreme Court. “The U.S. allows and enables gun industry practices that would be totally unacceptable anywhere else in the world.”

Ñî¹óåú´«Ã½Ò•îl Health News undertook an examination of gun violence during the pandemic, a period when firearm deaths reached an all-time high. Reporters reviewed academic research, congressional reports, and hospital data and interviewed dozens of gun violence and public health experts, gun owners, and victims or their relatives.

The examination found that while public officials imposed restrictions intended to prevent covid’s spread, politicians and regulators helped fuel gun sales — and another public health crisis.

As state and local governments schools, advised residents to stay home, and closed gyms, theaters, malls, and other businesses to stop covid’s spread, President Donald Trump kept gun stores open, critical to the functioning of society.

White House spokesperson Kush Desai did not respond to interview requests or answer questions about the Trump administration’s efforts to reduce regulation of the firearm industry.

During the pandemic, the federal government gave firearm businesses and groups more than $150 million in financial assistance through the Paycheck Protection Program, even as some businesses reported brisk sales, according to from Everytown for Gun Safety, an advocacy group.

Federal officials said the program would keep people employed, but millions of dollars went to firearm companies that did not say whether it would save any jobs, the report said.

About bought a gun during the first two years of the pandemic, including millions of first-time buyers, according to survey data from NORC at the University of Chicago.

Harris is keenly aware of what drives the demand.

“Guns aren’t going away unless we get to the root of people’s fears,” he said.

most Americans who own a gun feel it makes them safer. But public health data suggests that owning a gun of homicide and triples chances of suicide in a home.

“There’s no evidence that guns provide an increase in protection,” said Kelly Drane, research director for the . “We have been told a fundamental lie.”

Record Deaths

Less than a year into the pandemic, 20-year-old Jacquez Anlage was shot dead in a Jacksonville, Florida, apartment. Five years later, the killing remains unsolved.

His mother, Crystal Anlage, said she fell to her knees and wailed in grief on her lawn when police delivered the news.

She said Jacquez overcame years in the foster care system — living in 36 homes — before she and her husband, Matt, adopted him at age 16.

Jacquez Anlage had just moved into his own apartment when he was shot. He loved animals and wanted to become a veterinary technician. He was kind and loving, Crystal Anlage said, with the 6-foot-4, 215-pound physique of the football and basketball player he’d been.

“He was just getting to a point in life where he felt safe,” Crystal Anlage said.

Gun violence researchers say parents like Crystal Anlage carry trauma that destroys their sense of security.

Anlage said she endures post-traumatic stress disorder and anxiety. She is terrified of guns and fireworks.

But she has made something meaningful of her son’s killing: She co-founded the Jacksonville Survivors Foundation, which works to raise awareness about the impact of homicide and to support grieving parents.

“Jacquez’s death can’t be in vain,” she said. “I want his legacy to be love.”

His legacy and that of other young men killed by guns is muted by firearm manufacturers’ powerful message of fear.

During the pandemic, gun marketers told Americans they needed firearms to defend themselves against criminals, protesters, unreliable cops, and , filed by gun control advocacy groups with the Federal Trade Commission.

In a since-deleted June 18, 2020, from Lone Wolf Arms, an Idaho-based manufacturer, a protester is depicted being confronted by police officers in riot gear between the words “Defund Police? Defend Yourself,” the petition shows. The caption says, “10% to 25% off demo guns and complete pistols.”

Impact Arms, an online gun seller, on Instagram on Aug. 3, 2020, showing a person putting a rifle in a backpack, the document says. “The world is pretty crazy right now,” the caption reads. “Not a bad idea to pack something more efficient than a handgun.”

The National Rifle Association in 2020 posted on YouTube a of a Black woman holding a rifle and telling viewers they need a gun in the pandemic. “You might be stockpiling up on food right now to get through this current crisis,” she said, “but if you aren’t preparing to defend your property when everything goes wrong, you’re really just stockpiling for somebody else.”

The messaging worked. Background checks for firearm sales soared 60% from , the year the federal government declared a public health emergency.

The same year, more than , the highest number up till then. In 2021, was broken again.

Weapons sold at the beginning of the pandemic were more likely to wind up at crime scenes within a year than in any previous period, according to by Democrats on Congress’ Joint Economic Committee, citing ATF data.

Gun manufacturers “used disturbing sales tactics” following mass shootings in Buffalo, New York, and Uvalde, Texas, “while failing to take even basic steps to monitor the violence and destruction their products have unleashed,” according to a released by congressional Democrats in July 2022 following a House Oversight and Reform Committee investigation of industry practices and profits.

The firearm industry has marketed “to white supremacist and extremist organizations for years, playing on fears of government repression against gun owners and fomenting racial tensions,” the House investigation said. “The increase in racially motivated violence has also led to rising rates of gun ownership among Black Americans, allowing the industry to profit from both white supremacists and their targets.”

In 2024, then-President Joe Biden’s Department of the Interior provided a to the National Shooting Sports Foundation, a leading , to help companies market guns to Black Americans.

The Federal Trade Commission is responsible for protecting consumers from deceptive and unfair business practices and has the power to take enforcement action. It issued warnings to companies that made unsubstantiated claims their products could prevent or treat covid, for instance.

But when families of gun violence victims, lawmakers, and advocacy groups in 2022, during Biden’s term, how firearms were marketed to children, people of color, and groups that espouse white supremacy, officials did not announce any public action.

This summer, the National Shooting Sports Foundation pressed its and derided “a coordinated ‘lawfare’ campaign” that it said gun control groups have waged against “constitutionally-protected firearm advertising.”

FTC spokesperson Mitchell Katz declined to comment, saying in an email that the agency does not acknowledge or deny the existence of investigations.

Serena Viswanathan, who retired as an FTC associate director in June, told Ñî¹óåú´«Ã½Ò•îl Health News that the agency lost at least a quarter of the staff in its advertising practices division after Trump came into office in January.

Gun companies Smith & Wesson, Lone Wolf Arms, and Impact Arms did not respond to requests for comment. Neither did the National Shooting Sports Foundation or the NRA.

In an August 2022 , Smith & Wesson President and CEO Mark Smith said gun manufacturers were being wrongly blamed by some politicians for the pandemic surge in violence, saying cities experiencing violent crime had “promoted irresponsible, soft-on-crime policies that often treat criminals as victims and victims as criminals.”

He added, “Some now seek to prohibit firearm manufacturers and supporters of the 2nd Amendment from advertising products in a manner designed to remind law-abiding citizens that they have a Constitutional right to bear arms in defense of themselves and their families.”

Guns and Race

In 2015, the National Shooting Sports Foundation gathered supporters at a conference in Savannah, Georgia, and urged the firearm industry to diversify its customer base, according to a and reports from and the .

Competitive shooter Chris Cheng gave a presentation called “Diversity: The Next Big Opportunity.” Screenshots from the conference include slides purporting to show “demographics,” “psychographics,” and “technographics” of Black and Hispanic shooters.

The slides described Black shooters as “expressive and confident socially, in a crowd” and “less likely to be married and to be a college grad.” They said Hispanic shooters were “much more trusting of advertising and celebrities.”

Nick Suplina, senior vice president for law and policy at Everytown for Gun Safety, said industry marketing shifted in the latter half of the 20th century as the popularity of hunting declined. The new sales pitch: guns for personal safety.

“They said, ‘We need to break into new markets,’” Suplina said. “They identified women and people of color. They didn’t have a lot of success until the pandemic, the Black Lives Matter movement, and the death of George Floyd. The marketing says, ‘You deserve the Second Amendment too.’ They are selling the product as an antidote to fear and anxiety.”

Gun manufacturers were harshly criticized in the Oversight Committee’s 2022 investigation for marketing products to people of color, as gun violence remains a leading cause of death for young Black and Latino men.

At the same time, some companies also promoted assault rifles to white supremacist groups who believe a race war is imminent, the investigation found. One company sold an AK-47-style rifle called the “Big Igloo Aloha,” a reference to an anti-government movement, it said.

Still, Philip Smith wants more Black people to get guns for protection.

Smith said he was working as a human resources consultant a decade ago when he got the idea to form the , which helped the National Shooting Sports Foundation compile its report on communicating with Black consumers.

Smith encourages Black people to buy firearms for self-defense and get proper training on how to use them.

After 10 years, Smith said, his group has about 45,000 members nationwide. Single members pay $39 a year and couples $59, which gives them access to discounts from the organization’s corporate partners, including gunmakers, and raffles for gun giveaways, according to its website.

The police killing of Michael Brown in Ferguson, Missouri, and the shooting death of Florida teenager Trayvon Martin helped spark early interest from doctors, lawyers, and others in joining the group, he said. But interest took off during the pandemic, he said, even among Democrats who had resisted the idea of owning a gun.

“Hundreds of people called me and said, ‘I don’t agree with anything you’re saying, but what kind of gun should I buy,’” Smith recalled.

Smith, describing himself as “quiet, nerdy, and Afrocentric,” said criticism of guns misses the point.

“My ancestors bled for us to have this right,” he said. “Are there some racist white people? Yes. But we should buy guns because there is a need. No one is forcing us to buy guns.”

‘American Amnesia’

During the pandemic, gun violence took its greatest toll on racially segregated neighborhoods in places such as Philadelphia, where roughly residents live in poverty.

A says a one-year period in the pandemic saw more than 2,300 shootings, or about six a day. Many of the cases haven’t been solved by police.

City officials cited the boom in gun sales in the report: Fewer than 400,000 sales took place in Pennsylvania in 2000, but in 2020 it was more than 1 million.

Gun sales since the pandemic ended, but the harm they’ve caused persists.

At a conference last year inside the Eagles’ football stadium, victims of firearm violence or their relatives joined activists to share accounts of near-death experiences and the grief of losing loved ones.

Paintings flanked the stage and the meeting space to commemorate people who had been fatally shot, nearly all young people of color, under messages such as “You are loved and missed forever” and “Those we love never leave.”

Marion Wilson, a community activist, said he believes the nation has forgotten the suffering Philadelphia and other cities endured during the pandemic.

“We suffer from the disease of American amnesia,” he said.

Harris was on his way home from a job at Burlington Coat Factory nearly two decades ago when robbers followed him from a bus stop and demanded money. He said he had none and was shot.

Harris had spent his early life fixing cars with his grandfather, when he wasn’t at school or attending church. He remembers lying in a hospital bed, overcome with a sense of helplessness.

“I had to learn to feed myself again,” he said. “I was like a baby. I had to learn to sit up so I could use a wheelchair. The only way I got through it was my faith in God.”

Harris endured years of rehabilitation and counseling for PTSD. As someone in a wheelchair, he said, he sometimes fears for his safety — and a gun may be one of the few ways to protect himself and his family.

“I’m mulling it over,” Harris said. “I’m afraid of my trauma hurting someone else. That’s the only reason I haven’t gotten one yet.”

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Bre Dolan, a 35-year-old resident of Hardy County, West Virginia, understands why. Throughout her childhood, when her dad had addiction and mental health crises, police officers were often the first ones to respond. Dolan calls them “good men and women” who “care about seeing their community recover.”

But she’s skeptical that they can mitigate the root causes of an addiction epidemic that has racked her home state for decades.

“Most of the busts that go down are addicts,” she said — people who need treatment, not prison.

Dolan’s father was one of them. And so was she.

Now 14 years into recovery, she’s been surprised to see many local officials spending opioid settlement money — an influx of cash from companies accused of fueling the overdose crisis — on police Tasers, cruisers, night vision gear, and more.

“How is that really tackling an issue?” Dolan said. “How will it help families battling addiction?”

Nationwide, more than $61 million in opioid settlement funds were spent on law enforcement-related efforts in 2024, according to a yearlong investigation by Ñî¹óåú´«Ã½Ò•îl Health News and researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction. That included initiatives that public health experts largely support, such as hiring social workers to accompany officers on overdose calls, as well as actions they’re more skeptical of, such as beefing up police arsenals.

Over nearly two decades, state and local governments are set to receive in opioid settlement money, which is intended to be used to fight addiction. The settlement agreements even and established other guardrails to limit unrelated uses of the funds — as the Tobacco Master Settlement Agreement of the 1990s.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

To , an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits, some law enforcement expenses fall into that second category.

and are not “in the spirit of what we wanted to use the money for when we were fighting for it,” Loyd said.

“People died for this money. Families were torn apart for this money. And to not spend it to try to make our system better, so that people don’t have to experience those losses going forward, to me, is unconscionable,” he said.

As part of this investigation, Ñî¹óåú´«Ã½Ò•îl Health News and its partners compiled the most comprehensive national database of opioid settlement spending to date, featuring more than 10,500 examples of how the money was used (or not) last year. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories, such as treatment or prevention. The findings include:

• Nearly $2.7 billion — that’s the amount states and localities spent or committed in 2024, according to public records. The lion’s share went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement initiatives — such as creating a shooting range and tinting patrol car windows — and prevention programs that experts called questionable, such as putting on a fishing tournament.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including the expenditures and untrackable percentages, should not be compared with the one Ñî¹óåú´«Ã½Ò•îl Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract the in charge among those tracking it.

‘How My Population Would Like Me To Vote’

Dolan has seen intergenerational addiction up close. When her father was high, he sometimes kicked teenage Dolan out of the house with her toddler siblings. She started drinking early and progressed to other drugs, eventually landing in prison.

Although she managed to find recovery on her own, even landing a job as an EMT, she wants to make the path easier for others.

If settlement money were used to hire social workers or build family recovery programs, it could change the course of a kid’s life, she said.

“Maybe people could have helped my dad get into recovery and gave him therapy,” she said. “Anything could have happened.”

But many local officials say law enforcement is one of the few tools they have, especially in rural areas. And their constituents believe it’s effective.

“If the goal was treatment and prevention, it would have been better to throw [the money] into a big grant system and give it to treatment centers,” said , city manager of Oak Hill, West Virginia, which for a drone and surveillance cameras for its police department. “Unfortunately, local governments are really not set up to do that.”

Clarkdale, Arizona, Town Manager said her town bought because they help with enforcement — such as recording crime scenes and conducting search-and-rescue operations — as well as education, when officers interact with kids at community events.

Similar perspectives nationwide have led to spending that includes:

• About (also known as silencers) in Alexandria, Indiana.
• About in Mooresville, Indiana.
• About and Tasers in Hardy County, West Virginia.
• Nearly , to add a police officer to the county’s drug task force, replace that officer locally, buy guns and vehicles, and tint car windows.

Several elected officials said their choices reflect local politics.

That’s “how my population would like me to vote,” Hardy County Commissioner said of his commission’s goal to spend about a quarter of its settlement money on law enforcement.

Mooresville Town Council President told Ñî¹óåú´«Ã½Ò•îl Health News, “People have petitioned our government for less taxes but have never petitioned for less services” from the local police force. With federal and state budget cuts looming, the town must be resourceful, he said, adding that the Tasers were bought with a portion of settlement funds that have no restrictions.

After these purchases, an Indiana commission of law enforcement equipment that it cautioned against buying with restricted settlement dollars. , , and have released similar lists.

Research backs those restrictions. Studies have shown that drug busts and arrests can . Officers often , making people who use drugs or through police.

In contrast, equipping police officers with overdose reversal medications has been . That’s a key component of in Texas, the state with the highest percentage of reported law enforcement spending.

Police and Firefighter Salaries

Some places used settlement funds to maintain basic first responder services.

For example, Mantua Township, New Jersey, to “offset police salary and wages” and, according to its public spending report, . Township officials did not respond to requests for comment.

Los Angeles County to cover a portion of firefighter salaries and benefits last year and estimates it will use another $1 million this year.

County fire department spokesperson Heidi Oliva said opioid funds were used to fill a budget gap until revenue kicked in from a last November.

The use of funds was “appropriate,” she said in an email, because “the opioid crisis presents a significant burden to EMS response, from dispatch through arrival at hospitals, clinician mental health/burnout, and a variety of other factors.”

Using opioid money to replace other revenue is legal in most places. But it’s .

“I don’t want to see this money used to make up for stuff that would be paid for anyway,” said , chair of the FED UP! Coalition, a national advocacy organization representing many parents who’ve lost children to addiction.

Settlement dollars are “the only financial representation from the governments and from the drug companies” of families’ losses, Busch said. To see that money used to maintain the status quo is “painful” and “distressing.”

Busch fears this practice will become more common as states grapple with federal budget cuts.

Already in New Jersey, lawmakers in settlement funds to health systems to cushion against anticipated Medicaid losses — a move opposed by the state’s , , and .

However, some states are taking proactive steps.

Colorado this year against such actions.

“These dollars can’t be part of budget games where we simply backfill existing programs,” state Attorney General Phil Weiser told Ñî¹óåú´«Ã½Ò•îl Health News. “We have to build on whatever we’re doing because it hasn’t been enough.”

Other states, such as , , and , are newly requiring local governments to report how they spend the money, which may make it easier to spot disputed practices. Officials in Delaware, Hawaii, Massachusetts, and Missouri said they expect to revamp their public reporting systems to increase transparency by early 2026.

In Mississippi, which produced no substantive public reports last year, the attorney general’s office has that will host spending information after Dec. 1.

Jennifer Twyman is anxious to see some positive changes.

“We have people literally dying on our sidewalks,” said the Louisville, Kentucky, advocate.

Twyman struggled with opioid misuse for 20 years and now works with to end homelessness and the war on drugs. To her, any spending that doesn’t directly help people with addiction betrays the settlement’s purpose.

“It is the blood from many of my friends, people that I care deeply about,” she said. “That money could have been me, could have been my life.”

Read the methodology behind this project.

Ñî¹óåú´«Ã½Ò•îl Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

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

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

Shatterproof is partnering with some states on projects funded by opioid settlements. Ñî¹óåú´«Ã½Ò•îl Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

Ñî¹óåú´«Ã½Ò•îl 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 .

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Hasta este año.

El plan de la administración Trump de en fondos federales para salud pública y pandemias en Texas hizo que se cancelara el evento, justo antes de su inicio programado para el 21 de julio.

“Hay personas que vienen todos los años y dependen de este evento”, dijo Dairen Sarmiento Rangel, directora del Departamento de Salud y Servicios Humanos del condado de Hidalgo. “Algunas personas incluso acampan afuera de Operación Salud Fronteriza para ser las primeras en recibir servicios. Este evento es muy importante para nuestra comunidad”.

Los gobiernos estatales y locales ya han tenido que hacer dolorosos recortes a sus programas, luego de importantes reducciones en la financiación federal para salud que ya han entrado en vigor. Ahora, se preparan para enfrentar los golpes financieros que están por venir —algunos no ocurrirán hasta finales del próximo año o incluso después— como resultado de la ley fiscal y de gasto aprobada por los republicanos en el Congreso en julio, conocida como la , que pone en marcha gran parte de la agenda nacional del presidente Donald Trump.

Texas, por ejemplo, anticipa una reducción de hasta en fondos federales para Medicaid durante los próximos 10 años debido a nuevas barreras para la inscripción, como revisiones de elegibilidad más frecuentes, según un análisis publicado en julio por KFF.

En conjunto, estas reducciones representan un cambio radical en la forma en que se financian y se ofrecen los programas estatales de salud. En la práctica, la administración está trasladando una parte importante de los costos de salud a los estados. Esto obligará a sus líderes a tomar decisiones difíciles, ya que muchos presupuestos estatales ya están presionados por la disminución en la recaudación de impuestos, la desaceleración del gasto federal por covid y la incertidumbre económica.

han bajado sus proyecciones de ingresos para el año próximo, según un informe .

“Es casi inevitable que los estados recorten varios servicios de salud debido a la presión fiscal”, dijo Wesley Tharpe, asesor principal en política fiscal estatal del Centro para Prioridades Presupuestarias y Políticas (CBPP), una organización de tendencia progresista.

Algunos estados tratan de suavizar el impacto de forma proactiva.

En Hawaii, los legisladores se han propuesto ayudar a organizaciones sin fines de lucro que ya enfrentan disminución en fondos federales. Repartirán en subvenciones a organizaciones de salud, servicios sociales y otras que hayan sufrido recortes. Para acceder a los fondos, deben demostrar que su financiación fue eliminada, reducida o afectada por los recortes.

“No es justo que organizaciones dedicadas a ayudar al pueblo de Hawaii se vean obligadas a reducir sus servicios por los recortes federales”, declaró el gobernador demócrata Josh Green en .

Otros estados recortan proyectos para enfrentar la situación.

El gobernador de Delaware, Matt Meyer, demócrata, supo en marzo que la administración Trump retiraría en fondos de salud pública al estado. Como consecuencia, un mes después, los líderes legislativos estatales frenaron un proyecto para renovar y ampliar el complejo del Capitolio estatal.

“Reconocimos que los recortes federales irresponsables a la red de protección social de miles de habitantes de Delaware nos obligaban a ahorrar recursos para proteger a los más vulnerables”, dijo , presidente temporal del Senado estatal.

En Nuevo México, el estado con el , un grupo bipartidista de legisladores votó a favor de crear un fondo fiduciario para reforzar el financiamiento del programa. Según , aproximadamente el 10% de los que están cubiertos por Medicaid y el Programa de Seguro Médico para Niños (CHIP, en inglés) podrían perder su cobertura bajo esta nueva ley federal.

Algunos líderes estatales advierten a sus comunidades que lo peor está por venir.

En un evento realizado el 18 de agosto en un hospital del sur del Bronx, en la ciudad de Nueva York, la gobernadora demócrata Kathy Hochul subió al escenario junto a trabajadores de salud para criticar la nueva ley de Trump.

“Lo que los republicanos en Washington han hecho con la ‘Ley Más Horrible’ que he visto es, literalmente, perjudicar a los neoyorquinos”, dijo. El sistema de salud del estado se prepara para enfrentar recortes cercanos a los .

En California, los legisladores analizaron el impacto de los recortes en del comité de la Asamblea General el 20 de agosto, donde algunos legisladores demócratas señalaron que programas estatales como los de salud reproductiva estaban en peligro.

“Nos hemos preparado para esta realidad: la llamada ‘Big Beautiful Bill’ del presidente Trump ahora es ley”, dijo el legislador demócrata Gregg Hart durante la audiencia, calificándola como “un ataque directo a los programas fundamentales de California y a nuestros valores”.

“Lamentablemente, la realidad es que el estado no tiene la capacidad para compensar todos estos recortes federales draconianos con el presupuesto actual”, agregó. “No podemos simplemente firmar un cheque y hacer que esto desaparezca”.

La radical ley presupuestaria, que fue aprobada sin apoyo demócrata, reducirá el gasto federal en Medicaid en aproximadamen $1.000 millones durante la próxima década, según estimaciones de la (CBO). Las reducciones en el gasto vienen en gran medida de la imposición de un para las personas que obtuvieron Medicaid con la expansión promovida por la Ley de Cuidado de Salud a Bajo Precio (ACA), además de otras nuevas barreras para acceder a la cobertura.

Según la CBO, más de 7,5 millones de personas perderán la cobertura de Medicaid y quedarán sin seguro, mientras se extienden recortes fiscales para personas ricas que, según los demócratas, no los necesitan.

Por su parte, los republicanos y el presidente Trump afirman que el paquete fiscal y los recortes en los programas son necesarios para evitar el fraude y el despilfarro, y para garantizar la sostenibilidad de Medicaid, un programa federal-estatal que brinda cobertura a personas con discapacidades y de bajos ingresos.

“La One Big Beautiful Bill elimina a los inmigrantes ilegales, aplica requisitos laborales y protege a Medicaid para los verdaderamente vulnerables”, anunció la Casa Blanca en un .

Los recortes a Medicaid no comenzarán hasta después de las elecciones legislativas de mitad de mandato en noviembre de 2026, pero ya se han aplicado otros recortes.

La administración Trump ha intentado recuperar destinados a los estados durante la pandemia, lo que provocó una con una coalición de estados gobernados por demócratas. También recortó unos en para servicios de salud mental en las escuelas y detuvo los fondos de los Institutos Nacionales de Salud (NIH) que financiaban a más de 90 universidades públicas.

Un análisis de Ñî¹óåú´«Ã½Ò•îl Health News demuestra que las cancelaciones han afectado a todo el país, sin importar la afiliación política o la ubicación geográfica. De las organizaciones que sufrieron recortes en el primer mes, aproximadamente el 40% se encuentran en estados que Trump ganó en noviembre.

La secretaria de prensa del Departamento de Salud y Servicios Humanos (HHS), Emily Hilliard, dijo que la agencia prioriza las inversiones que respalden el mandato de Trump de enfrentar las enfermedades crónicas. Defendió algunos de los recortes y afirmó, erróneamente, que la nueva ley no reduce Medicaid.

“La pandemia de covid-19 ya terminó, y el HHS no seguirá desperdiciando miles de millones de dólares de los contribuyentes en una crisis que los estadounidenses superaron hace años”, dijo.

Líderes estatales señalan que los fondos federales por la pandemia, que la administración busca recuperar, se habían destinado a otras medidas de salud pública, como la vigilancia de enfermedades emergentes, la respuesta ante brotes y la contratación de personal. En mayo, fiscales estatales ganaron una contra la administración.

“Lo que estamos viendo ahora es que los estados anticipan grandes recortes a Medicaid, pero también enfrentan una serie de recortes federales más pequeños, pero significativos, en programas de salud pública”, dijo , vicepresidente ejecutivo de políticas de salud en KFF. (Ñî¹óåú´«Ã½Ò•îl Health News es uno de los programas de KFF)

Parte del desafío para los estados es simplemente entender los cambios.

“Creo que es justo decir que hay preocupación, confusión e incertidumbre”, afirmó Kathryn Costanza, experta en Medicaid en la Conferencia Nacional de Legislaturas Estatales.

Los estados intentan entenderlo todo, creando para , presentando demandas para intentar bloquear los recortes y reasignando fondos.

En Colorado, los legisladores que permite que fondos estatales de Medicaid se usen para servicios de salud —excluyendo abortos— en clínicas de Planned Parenthood of America, después de que la nueva ley de Trump prohibiera la financiación federal para este tipo de atención. Aún está por verse en los tribunales.

La legislatura de Louisiana asignó a universidades estatales para compensar los recortes en financiación federal para la investigación, gran parte de ella relacionada con temas de salud.

Y en Dakota del Sur, el banco de alimentos más grande del estado pidió a los legisladores para compensar recortes en fondos del Departamento de Agricultura de Estados Unidos.

Los estados deben equilibrar sus presupuestos cada año, por lo que los recortes ponen en riesgo muchos servicios si los legisladores no están dispuestos a aumentar impuestos. El trabajo comenzará en serio en enero, cuando muchos estados inicien sus nuevas sesiones legislativas.

Y es probable que las decisiones difíciles continúen. Los republicanos en la Cámara de Representantes del Congreso consideran nuevas leyes que podrían , como la reducción al generoso financiamiento federal que actualmente reciben 20 millones de adultos inscritos en Medicaid gracias a la expansión de ACA.

Como resultado, algunos estados revertirán sus expansiones de Medicaid y recortarán aún más programas de salud.

Ñî¹óåú´«Ã½Ò•îl 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 .

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Until this year. The Trump administration’s plan to strip in federal public health and pandemic funds from Texas helped prompt just before its scheduled July 21 start.

“Some people come every year and rely on it,” said Hidalgo County Health and Human Services Director Dairen Sarmiento Rangel. “Some people even camp out outside of Border Health so they can be the first in line to receive services. This event is very important to our community.”

States and local governments have made painful program cuts in the wake of major reductions in federal health funding that have already taken effect. Now, they’re sizing up the financial hits to come — some not until late next year or beyond — from the “,” the tax and spending law congressional Republicans passed in July that enacts much of President Donald Trump’s domestic agenda.

Texas, for instance, expects to see its federal Medicaid funds reduced by as much as over 10 years due to new barriers for enrollment, such as more frequent eligibility checks, according to a July analysis by KFF.

Taken together, the reductions amount to a seismic shift in how state health programs are provided and paid for. The administration is, in effect, pushing a significant amount of health costs to states. That will force their leaders to make difficult choices, as many state budgets are already strained by declining tax revenues, a slowdown in federal pandemic spending, and economic uncertainty.

Revenue forecasters have lowered expectations for the coming year, according to a .

“It’s almost inevitable that states will enact a number of cuts to health services because of the fiscal pressure,” said Wesley Tharpe, senior adviser for state tax policy at the left-leaning .

Some are proactively trying to stanch the impact.

Hawaii lawmakers are looking to aid nonprofits that are already contending with federal funding cuts. They’re in grants to health, social service, and other nonprofits hit by federal funding cuts. To get the money, nonprofits must show a termination or drop in funding, or that they have otherwise been harmed by the cuts.

“It is not fair that organizations dedicated to supporting the people of Hawaii are being forced to scale back due to federal funding cuts,” Democratic Gov. Josh Green .

Other states are scaling back projects to contend with cuts. Delaware Gov. Matt Meyer, a Democrat, received notice in March that the Trump administration was in public health funding from the state. The next month, state legislative leaders halted a planned project to upgrade and expand the Capitol complex as a result.

“We recognized that the reckless federal cuts to the social safety nets of thousands of Delawareans called for us to hold back resources to protect our most vulnerable,” said , president pro tempore of the Delaware Senate.

In New Mexico, the state with the , a bipartisan group of lawmakers voted to create a trust fund to boost funding for the program. About 10% of the more than covered by Medicaid and the related Children’s Health Insurance Program could lose their health coverage under the federal spending law, based on .

Some state leaders are warning constituents that the worst may be yet to come.

At an Aug. 18 event at a hospital in the South Bronx section of New York City, New York Gov. Kathy Hochul, a Democrat, stood on stage among health care workers in white coats to skewer Trump’s new law.

“What Republicans in Washington have done through the ‘Big Ugliest Bill’ I’ve ever seen is literally screwing New Yorkers,” she said. The state’s health system is bracing for in annual cuts.

And in California, lawmakers weighed the impact of the coming cuts from the federal law at a general assembly , where some Democratic legislators said state efforts to protect reproductive health services and other programs were in jeopardy.

“We’ve been bracing for this reality: President Trump’s so-called ‘Big, Beautiful Bill’ is now law,” Democratic lawmaker Gregg Hart said at the hearing, calling it a “direct assault on California’s core programs and our values.”

“Sadly, the reality is, the state does not have the capacity to backfill all of these draconian federal funding cuts in the current budget,” Hart said. “We cannot simply write a check and make this go away.”

The sweeping budget law, which passed without any Democratic support, will reduce federal spending on Medicaid by about over the next decade, based on estimates from the . The spending reductions largely come from the imposition of a on people who’ve obtained Medicaid under the Affordable Care Act’s expansion, as well as other new barriers to coverage.

The law will mean more than 7.5 million people will lose Medicaid coverage and become uninsured, according to the Congressional Budget Office, while extending tax cuts for wealthy people who, Democrats say, don’t need them. Republicans and Trump have said the spending package and its accompanying program cuts were necessary to prevent fraud and waste, and to sustain Medicaid, a state-federal program for people with disabilities and lower incomes.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable,” the White House said in a .

The Medicaid cuts won’t begin until after the midterm elections in November 2026, but other cuts have already hit.

The Trump administration has sought to claw back earmarked to states because of the pandemic, spurring a with a coalition of Democratic-led states. It also in for mental health services in schools, and halted grants from the National Institutes of Health that provided money to more than 90 public universities.

HHS press secretary Emily Hilliard said the agency is prioritizing investments that advance Trump’s mandate to confront chronic disease. She defended some of the cuts and said, erroneously, that the spending law doesn’t cut Medicaid.

“The covid-19 pandemic is over, and HHS will no longer waste billions of taxpayer dollars responding to a crisis that Americans moved on from years ago,” she said.

State leaders say the pandemic funding the administration wants returned was earmarked for other public health measures, such as tracking emerging diseases, outbreak responses, and staffing. State attorneys general in May won a against the administration.

“What we’re seeing now is states anticipating big cuts in Medicaid coming, but they’re also dealing with a whole variety of federal cutbacks in public health programs that are smaller but still quite meaningful,” said , executive vice president for health policy at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

Part of the challenge for states is simply understanding the changes.

“I think it’s fair to say there is concern, confusion, and uncertainty,” said Kathryn Costanza, a Medicaid expert at the National Conference of State Legislatures.

States are struggling to sort it all out, forming that are , suing to try to block the cuts, and reallocating funding.

In Colorado, lawmakers to let state Medicaid dollars pay for non-abortion care at Planned Parenthood of America clinics after Trump’s law banned federal funding for such care. Whether the ban holds up in court .

The Louisiana Legislature to state universities to make up for cuts to federal research funding, much of which goes to health-related research.

And in South Dakota, the state’s largest food bank has to make up for funding cuts to the U.S. Department of Agriculture.

States must balance their budgets every year, so cuts put many services at risk if state lawmakers are unwilling to raise taxes. The work will begin in earnest in January, when many states begin new legislative sessions.

And the tough choices are likely to continue. Congressional House Republicans are considering legislation that could , including by slashing the generous cost sharing the federal government provides for 20 million adults who enrolled in Medicaid under the ACA’s Medicaid expansion.

Some states will roll back their Medicaid expansions and cut more health programs as a result.

Ñî¹óåú´«Ã½Ò•îl 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 .

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The Commerce Department, which runs the massive Broadband Equity, Access, and Deployment Program, in early June requiring states — some of which were ready to begin construction later this year — to solicit new bids from internet service providers.

The delay leaves millions of rural Americans stranded in places where health care is hard to access and telehealth is out of reach.

“This does monumental harm to rural America,” said , a professor of telecommunications at Penn State.

The Biden-era program, known as BEAD, was hailed when created in 2021 as a national plan to bring fast internet to all, including millions in remote rural areas.

A yearlong Ñî¹óåú´«Ã½Ò•îl Health News investigation, with partner Gray Media’s InvestigateTV, found nearly 3 million people live in mostly rural counties that lack broadband as well as primary care and behavioral health care providers. In those same places, the analysis found, people live sicker and die earlier on average.

The program adopts a technology-neutral approach to “guarantee that American taxpayers obtain the greatest return on their broadband investment,” according to the June . The program previously prioritized the use of fiber-optic cable lines, but broadband experts like Ali said the new focus will make it easier for satellite-internet providers such as to win federal funds.

“We are going to connect rural America with technologies that cannot possibly meet the needs of the next generation of digital users,” Ali said. “They’re going to be missing out.”

Republicans have criticized BEAD for taking too long, and Commerce Secretary Howard Lutnick to get rid of its “woke mandates.” The revamped “Benefit of the Bargain BEAD Program,” which was released with a fact sheet titled “,” includes eliminating some labor and employment requirements and obligations to perform climate analyses on projects.

The requirement for states to do a new round of bidding with internet service providers makes it unclear whether states will be able to connect high-speed internet to all homes, said , director of policy engagement at the Benton Institute for Broadband & Society.

Garner said the changes have caused “pure chaos” in state broadband offices. More than half the states have been knocked off their original timeline to deliver broadband to homes, he said.

The change also makes the program more competitive for satellite companies and wireless providers such as Verizon and T-Mobile, Garner said.

Garner what the possible increase in low-Earth-orbit satellites would mean for rural America. He found that fiber networks are generally more expensive to build but that satellites are more costly to maintain and “much more expensive” to consumers.

Commerce Secretary Lutnick said in a June release that the new direction of the program would be efficient and deliver high-speed internet “at the right price.” The National Telecommunications and Information Administration, the Commerce Department agency overseeing BEAD, declined to release a specific amount it hopes to save with the restructuring.

The NTIA also declined to respond on the record to questions about program revisions and delays.

More than 40 states had already begun selecting companies to provide high-speed internet and fill in gaps in underserved areas, according to created to track state progress.

In late May, the website was altered and columns showing the states that had completed their work with federal regulators disappeared. Three states — Delaware, Louisiana, and Nevada — had reached the finish line and were waiting for the federal government to distribute funding.

The tracker, which Ñî¹óåú´«Ã½Ò•îl Health News saved , details the steps each state made in their years-long efforts to create location-based maps and bring high-speed internet to those missing service. West Virginia had completed selection of internet service providers and a of its proposed plan shows the state was set to provide fiber connections to all homes and businesses.

Sen. Shelley Moore Capito (R-W.Va.) praised removal of some of the hurdles that delayed implementation and said she thought her state would not have to make very many changes to existing plans during a .

West Virginia’s broadband council has worked aggressively to expand in a state where 25% of counties lack high-speed internet and health providers, according to Ñî¹óåú´«Ã½Ò•îl Health News’ analysis.

In Lincoln County, West Virginia, Gary Vance owns 21 acres atop a steep ridge that has no internet connection. Vance, who sat in his yard enjoying the sun on a recent day, said he doesn’t want to wait any longer.

Vance said he has various medical conditions: high blood sugar, deteriorating bones, lung problems — “all kinds of crap.” He’s worried about his family’s inability to make a phone call or connect to the internet.

“You can’t call nobody to get out if something happens,” said Vance, who also lacks running water.

Ñî¹óåú´«Ã½Ò•îl Health News, using data from federal and academic sources, found more than 200 counties — with large swaths in the South, Appalachia, and the remote West — lack high-speed internet, behavioral health providers, and primary care doctors who serve low-income patients on Medicaid. On average, residents in those counties experienced higher rates of diabetes, obesity, chronically high blood pressure, and cardiovascular disease.

The gaps in telephone and internet services didn’t cause the higher rates of illness, but Ali said it does not help either.

Ali, who traveled rural America for his book “,” said telehealth, education, banking, and the use of artificial intelligence all require fast download and upload speeds that cannot always be guaranteed with satellite or wireless technology.

It’s “the politics of good enough,” Ali said. “And that is always how we’ve treated rural America.”

Fiber-optic cables, installed underground or on poles, consistently provide broadband speeds that meet the Federal Communications Commission’s requirements for broadband download speed of 100 megabits per second and 20 Mbps upload speed. By contrast, a , performed by Ookla, a private research and analytics company, found that only 17.4% of Starlink satellite internet users nationwide consistently get those minimum speeds. The report also noted Starlink’s speeds were rising nationwide in the first three months of 2025.

In March, West Virginia’s Republican governor, Patrick Morrisey, to collaborate with the Trump administration on the new requirements.

Republican state Del. , who has been working with Morrisey’s office, said his goal is to eventually get fiber everywhere but said other opportunities could be available to get internet faster.

In May, the West Virginia Broadband Enhancement Council signaled it preferred fiber-optic cables to satellite for its residents and signed that noted “fiber connections offer the benefits of faster internet speeds, enhanced data security, and the increased reliability that is necessary to promote economic development and support emerging technologies.”

Ñî¹óåú´«Ã½Ò•îl 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 .

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