That has meant visits to dozens of doctors and dentists for issues ranging from a tonsillectomy to depression.

While foster parenting has innumerable challenges, health care coverage for the children isn’t one of them. Medicaid, the federal-state health insurance program for the poor, picks up the tab for nearly all children in foster care and often continues to cover them if they are adopted, regardless of their parents’ income. And as a result of the 2010 Affordable Care Act, foster children who have Medicaid at 18 can retain the coverage until they turn 26.

“We would not be able to foster without Medicaid,” said Sherri Croom, 41, of Tallahassee, Fla. “It pays for everything.”

Yet, Croom and other foster parents say that even with the coverage they struggle to meet the extraordinary health needs of their children. Part of the trouble is too few doctors accept Medicaid, most notably mental health specialists.

Families also face the challenge of coordinating treatment decisions between government welfare agencies and foster kids’ biological parents.

Treating The Effects Of Abuse And Neglect

Although foster care children make up only a tiny portion of the 74 million Americans who receive Medicaid, this population faces significantly more health needs than most enrollees. These children often have experienced abuse, neglect, violence and parental substance abuse. About half of them have been diagnosed with mental health disorders, according to the .

Medicaid is the nation’s largest health program, yet its broad reach beyond traditional populations of low-income children and parents and people with disabilities is less known. Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly.

A found that children in foster care were twice as likely as others to have learning disabilities and developmental delays, five times as likely to have anxiety, six times as likely to have behavioral problems and seven times as likely to have depression.

And the number of these enrollees has increased in recent years, largely as the opioid epidemic has devastated many families. Between 2012 and 2016, children in foster care nationally , according to federal data.

Foster children’s health problems frequently demand specialized and consistent care, yet these children’s often unstable lives make it difficult for doctors or other health specialists to care for them, said Dr. Moira Szilagyi, a pediatrician based in Los Angeles. The kids often move between foster homes or from foster homes back and forth to their families.

“Every time they change providers, some information is lost and leads to some duplication of services or children fall out of treatment,” she said.

Melanie Stimmell, a foster parent currently to a dozen children in Winter Garden, Fla., said nearly all the children she and her husband have taken in have had some mental health issues. She recalled it took months to find a nearby, Medicaid-friendly therapist for an 11-year-old who was bipolar and had been hospitalized before coming to her home.

Delays in getting these kids care has lasting consequences, she said.

“The issues snowball into other issues,” she said. “It affects their performance in school, which hurts their ability to make friends, which hurts their self-esteem and then they fall behind in classes and get held back and it affects everything in their life.”

In addition, some experts warn that children who have aged out of foster care at age 18 may delay care because they don’t know that they still have access to Medicaid until they turn 26.

“We are concerned that there are thousands of kids who should be getting Medicaid but aren’t because they are not plugged in to the system,” said Irene Clements, executive director of the National Foster Parent Association.

State performance varies widely on signing up former foster kids through age 25. For example, according to state officials, Florida has signed up about 7,900 of them; Iowa, about 700; Colorado, more than 21,000; and Indiana, 1,685.

An Experiment In Care Coordination

A few states, including Florida, Georgia and Texas, have started to test an idea that might improve foster children’s access to care.

They are placing foster children in their own Medicaid health plan — separate from the coverage offered to most Medicaid families.

These plans are typically run by private, mostly for-profit Medicaid managed care companies, including Centene, Amerigroup and United Healthcare.

Supporters say these plans can be designed to meet the higher health needs — particularly for mental health services — of foster children.

For instance, Florida’s child welfare plan is required to have more primary care doctors and mental health specialists available than traditional Medicaid health plans. It also offers extra benefits such as nutrition counseling, art therapy and a $25 monthly allowance for over-the-counter items such as cough syrup and vitamins. About 34,000 foster kids are in the plan managed by Centene Corp.

“This is a promising model,” said Roxann McNeish, a research assistant professor of child and family studies at the University of South Florida.

She said having health plans with administrators and physicians trained to address the unique needs of foster kids has helped better coordinate care to them. But more study is needed to see if children’s health has improved care compared to traditional health plans, she cautioned.

These plans can also allow children to remain under the same coverage if they move to different parts of the same state.

Szilagyi says getting care to foster children is often difficult because responsibilities vary between state agencies, birth parents and guardians. “Obtaining consent from parents to provide health to the child can be challenging,” she said.

The foster-care only plans try to improve this because they are trained to work with state foster care caseworkers to speed care to children.

But a conducted by researchers at the University of South Florida for the state Agency for Health Care gave the plan mixed results. It found that parents often complained about lack of access to doctors. On the other hand, child welfare agencies reported having more input in health decisions for children. This is important because those agencies are responsible for recruiting and supporting foster parents and coordinating health services for the children.

The report did not examine whether the children in the plan had better outcomes.

Glen Casel, chief executive of , a foster care agency that contracts with the state to provide child welfare services, said these specialized plans have limited benefit. “I don’t think a foster-care-only plan is a silver bullet,” he said.

His nonprofit has worked with Centene to get more mental health providers in the network, particularly in communities that typically don’t have large numbers of Medicaid enrollees but have foster parents.

“It’s a daily fight for us,” he said.

Despite the challenges, foster parents do recount success stories.

Ali and Terry Caliendo, of Las Vegas, said Medicaid has been invaluable since they became foster parents to 7-month-old Anthony in 2013. He had bronchitis and pneumonia his first year and later was repeatedly sent home from day care for being too aggressive toward other children.

“He was so sick as a baby, and then socially and emotionally he really struggled with violent rages and attachment issues,” Ali Caliendo said.

Medicaid paid for him to see psychiatrists, psychologists and physical and occupational therapists.

“Having the support through Medicaid made it an easier decision to be foster parents,” Caliendo said.

The Caliendos adopted Anthony at 18 months and were able to keep his Medicaid coverage. This fall, he begins kindergarten.

“Because we were able to intervene early, he is on a good trajectory, and we are really pleased,” she said.

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Pediatrician Gayle Harrison told his mother to continue to apply antibiotic ointment and reminded them to come back if the swelling and redness worsened.

The appointment at Rehoboth McKinley Christian Health Care Services’ outpatient center comes at no charge for the Toledo family, who live 30 miles away on the Navajo Nation Reservation. That’s because Tyson is covered by Medicaid, the state-federal health insurance program for the poor.

New Mexico leads all other states in Medicaid enrollment, with 43 percent of its residents on the program. That’s partly because the state has a large Native American population, living in communities historically riven with poverty. The numbers offer an eye-popping snapshot of the promotion of Medicaid expansion since 2013: Nearly a third of the 900,000 New Mexico beneficiaries joined as part of the Affordable Care Act’s option to expand Medicaid.

Kaiser Health News is examining Medicaid’s role in the U.S. as the health care program comes under renewed fire from Republicans who generally want to put the brakes on the program, even as many Democrats credit the expansion with reducing the number of uninsured Americans to historic lows. Conservatives view the costs as prohibitive for state and federal budgets.

Nina Owcharenko, a senior research fellow in health policy with the conservative Heritage Foundation, said the enrollment boost is “not a positive story.” While the high enrollment underscores the pervasive poverty in New Mexico, it also signals surging costs for taxpayers, she said.

“I am growing more concerned about the cost of shifting Medicaid dollars to the federal government and without a budget cap on the program. … That is a dangerous fiscal course for the country,” she said.

“This is a problem that needs to be fixed. … We need to find a way that is more rational and more fiscally sustainable,” said Owcharenko, who was a top Health and Human Services official in 2016.

In Gallup, a city of about 23,000 people, Medicaid is as much a part of the fabric as Native American-crafted jewelry and green chile sauce. Recipients include the waitress at the downtown bar, the clerk at a loan store and the maid at the hotel.

And multigenerational families are common in Gallup and surrounding McKinley County. Tyson’s mother, grandmother, aunt and uncle also are enrolled in Medicaid.

Fifty-two percent of the county’s residents have coverage through the program. That’s the highest rate among U.S. counties with at least 65,000 people, according to a KHN analysis of Census data.

“Pretty much everybody is on Medicaid here,” said Libby Garcia, 36, who lives in a trailer overlooking downtown Gallup.

Garcia, who works as a custodian at a local Head Start agency, quit a second job cleaning businesses because that extra income would put her over the eligibility level for coverage. She can’t afford private insurance, and Medicaid gives her free care at a community health center and insulin and other medicines for her diabetes without out-of-pocket costs, she said.

McKinley, where more than 40 percent of the population lives below the federal poverty level ($12,140 for an individual), is the nation’s only county of at least 65,000 people in which more than half the population is on Medicaid. Nationwide, about 23 percent of Americans are enrolled, with more than 16 million people added since the expansion.

In McKinley County, many residents see Medicaid as vital. There’s no stigma around it, and enrollees and providers speak positively about it.

The heavy concentration of Medicaid in this high-altitude desert is a result of two factors: the high poverty rate and the Indian Health Service’s relentless work to enroll patients in the program.

Large swaths of McKinley County lie within the Navajo Nation, the largest Indian reservation in the United States. Nearly 80 percent of McKinley County’s 75,000 residents are Native American.

Medicaid enrollees in Gallup say the coverage has opened up new opportunities for them to get more timely care, especially surgery and mental health services. It has been vital in combating high rates of obesity, teen birth, suicide and diabetes, according to local health officials.

Outside a local Dollar Tree store, Linda James, 55, who sells jewelry she makes, said Medicaid paid for her son’s braces and her teenage daughter’s drug rehabilitation. “It’s a lifesaver for us,” she said, noting it helps her get quicker care than waiting at Indian Health facilities.

‘Safety Net’ For Indian Health Service

For the Gallup Indian Medical Center — the main Indian Health Service facility in the area — Medicaid has stoked the local budget and eased overcrowding. When patients on Medicaid are treated there, the center is reimbursed by the program. That money supplements the Indian Health Service’s annual federal grant, which is set by Congress.

Last year, Medicaid funding made up 34 percent of the center’s $207 million budget. Among all U.S. hospitals, Medicaid provided only 18.5 percent of revenue. “Medicaid has become the safety net for the Indian Health Service,” said John Ratmeyer, deputy chief of pediatrics at the Gallup Indian Medical Center. “It’s providing an extra pod of money to pay for services not within our hospital system.”

Medicaid this year is projected to add hospital funding, supplementing the $4.8 billion in annual federal appropriation.

The medical center in Gallup looks like a relic of the 1960s, with fading-blue exterior walls, sandstone-colored outpatient trailers, cramped nursing stations and hard plastic seats in its emergency room waiting area. The hospital doesn’t have an MRI machine or any designated private patient rooms.

“One of our biggest challenges is just maintaining the building,” said Dr. Kevin Gaines, acting deputy clinical director at the hospital. The extra money coming from patients covered by Medicaid are helping the center pay for a badly needed $13 million modernization of its ER and urgent care unit, he said.

Another problem is a shortage of nurses and doctors, which leads to long wait times for patients — three or four months for primary care appointments or for dental services or eyeglasses. Some patients seeking specialized care need to go 140 miles to Albuquerque, a hardship for many Native Americans, some of whom don’t have access to cars or money for such transportation. But Medicaid will cover some non-emergency transportation for medical appointments.

State Feels The Pinch

The county has a host of medical challenges related to its economic problems. According to a sponsored by Rehoboth McKinley, the county’s suicide rate for ages 10 and up is twice the U.S. average, alcohol-related deaths are nearly four times higher than the national rate, and teen birth rates are three times the U.S. average. Average life expectancy in McKinley is 74 years, four years less than the typical U.S. life span.

Without Medicaid covering doctor visits and substance abuse treatment, the situation would likely be worse, said Larry Curley, director of program development for Rehoboth McKinley.

This kind of care doesn’t come cheap. The federal government paid the full cost of the expansion through 2016, but now New Mexico and other states have to pick up a 5 percent share. To deal with rising costs, the state in 2017 began it pays hospitals, doctors and other providers.

Asked about her Medicaid health plan while at a popular doughnut shop, Corrine Rosales, 60, of Gallup, said it’s invaluable for her and her two young nieces, Mya and Destiny. Medicaid pays for her diabetes medications and helped Mya get treated for attention-deficit disorder.

“I don’t know what we would do without it,” she said.

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The Lone Star State five years ago when state officials said they wanted to specifically exclude Planned Parenthood because the group provides abortions. Dozens of women’s health clinics closed as Texas established a wholly state-funded program that officials say today serves 220,000 women.

Medicaid’s family planning program is optional for states and used by half of them to provide contraception services for low-income women who earn too much to qualify for traditional Medicaid.

Texas, Iowa and Missouri gave up that federal money to avoid supporting groups that offer abortion. Planned Parenthood says it does not use any government money for abortions.

Texas is the first state to appeal to a more conservative White House to restore the funds. The federal government has historically declined to provide Medicaid dollars to states that don’t allow patients to choose between “any willing provider.” Texas is in that position.

As part of its “Medicaid Nation” series, Kaiser Health News is examining the far-reaching impact of Medicaid — which has expanded its services in the past decade — and how millions of American households routinely access health care through its programs.

The provision that covers only family planning is a tiny part of Medicaid, which now serves about 74 million Americans. But it is seen by advocates as a vital way to avoid unwanted pregnancies and for states to save money by reducing Medicaid-covered births and coverage for infants and children.

Nationally, about 2.8 million people were enrolled in the coverage last year, according to a Kaiser Health News survey of state Medicaid officials. California alone had 1.8 million people in the program.

“This is expanding Medicaid to cut Medicaid,” said Elizabeth Momany, associate research scientist at the University of Iowa. “If you avert one childbirth, you save quite a bit,” she said, noting that children on full Medicaid remain in the program for at least five years after birth, on average.

Medicaid began in 1965 as a way to provide for poor children, their mothers and people with disabilities. Maternal benefits are a key part of traditional Medicaid. It pays for half of all U.S. births and of children under the age of 6.

The federal government encourages the benefit limited to family planning— which does not include physician visits or hospital care — by covering 90 percent of the cost. In contrast, Medicaid covers births and related costs at , with states picking up the rest of the tab.

The cost savings help explain why the family planning program is popular among states. Even some of those most opposed to the expansion of Medicaid under the Affordable Care Act — including the entire Southeast — largely take part in the Medicaid family planning program. North Carolina, South Carolina, Alabama and Florida rank in the top five by enrollment, behind California, the Kaiser survey found.

“For two decades, states across the country, red, blue and purple, have expanded Medicaid eligibility for family planning services because doing so helps people to avoid unintended pregnancies and to plan and space wanted pregnancies,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, a reproductive health research organization that supports abortion rights. “In the process, that has also been proven to save the state and federal governments many millions of dollars.”

While eligibility and benefits vary by state, the family planning programs generally provide free coverage for a wide array of contraceptives, including birth control pills and long-acting implants. Some also provide checkups, assistance in kicking tobacco, cancer screenings and testing for sexually transmitted infections.

In family planning programs around the country, Planned Parenthood clinics, county health departments, federally funded community health centers and private physician offices. Critics say prohibiting Planned Parenthood from family planning programs would hurt patients’ access to services.

Eligibility in some states starts as early as age 12, while others automatically enroll women in the programs after their maternity benefit expires, typically 60 days after giving birth.

In California and some other states, both men and women are eligible, but women make up the vast majority of the enrollees.

North Carolina Medicaid officials estimate the program saves the state about $15 million a year, according to spokesman Cobey Culton.Ìý

Alabama has also seen savings. Kari White, a health policy professor at the University of Alabama at Birmingham, said the program covers about 120,000 women in the state with income levels below 141 percent of the federal poverty level, or about $17,000 for an individual.

An for the state last year found the birth rate for women enrolled in the program was one-third of what would have been estimated without the coverage.

“It helps to save Medicaid dollars overall to have these programs,” White said.Ìý

Even the Trump administration, which is seeking to reduce the number of adults on Medicaid rolls, signaled its support of the family planning program in late December when it approved a 10-year extension of Mississippi’s program.

California’s program — called Family Pact (Planning, Access, Care and Treatment) — covers people with incomes up to 200 percent of the federal poverty level (about $24,000) who don’t have other sources of family planning coverage.

“It provides a very essential public health benefit to all Californians who otherwise wouldn’t get these services,” said Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco,Ìýwho California’s program.

A big reason California’s enrollment is so much higher than other states, in addition to its much larger population, is that undocumented immigrants can also receive the services, although their care is paid for only with state funds.Ìý

Marta Mateo of Los Angeles is using the family planning program for a tubal ligation to prevent another pregnancy.

“I’m ready to have my tubes tied,” she said in the lobby at an Eisner Health facility as the youngest of her four children slept in her arms. “I don’t want any more babies.”

Mateo said she’s grateful for the coverage because her factory job doesn’t offer it, and she can’t afford to buy it on her own.

“I just don’t have the money for that,” she said. “This is a good opportunity for us to get care.”

Nationwide, the number of women covered by the Medicaid family planning program dropped from 3.8 million in 2013 to last year’s 2.8 million, as many people gained other coverage through the Affordable Care Act, according to the KHN survey and interviews with state officials. The enrollment decline was also due to several states discontinuing the program.

Three states that expanded Medicaid under the ACA dropped the program — Michigan, Illinois and Ohio. But the Medicaid expansion covers women up to 138 percent of the federal poverty level, which is an annual income of about $16,700 for an individual, while the family planning programs had an average eligibility level of 185 percent of federal poverty level, or $22,400.

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Proximity proved potentially lifesaving last fall when Foster, pregnant with her second child, Holden, felt contractions at 31 weeks — about seven weeks too soon. Genesis was equipped to handle the situation — giving Foster medication and an injection to stave off delivery. After his birth four weeks later – still about a month early, at 5 pounds 12 ounces — Holden was sent to the hospital’s special care nursery for monitoring.

Mother and son went home after a few days. “He was pretty small — but he’s picking up weight fast,” said Foster of Holden, now almost 4 months old.

Medicaid, the federal-state health insurance program for low-income people — including Foster, who most recently worked as a preschool teacher’s aide — is responsible for much of her good fortune.

Started in 1965, the program today is part of the financial bedrock of rural hospitals like Genesis. As treatments have become increasingly sophisticated — and expensive — health care has become inextricably linked to Medicaid in rural areas, which are often home to lower-income and more medically needy people.

Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid covers of rural, nonelderly residents and offers some financial stability to rural facilities by reducing uncompensated care costs at hospitals that would otherwise be in dire straits. In some cases, it enables them to provide costly but vital services, such as high-risk maternity care.

Medicaid pays the tab for close to of all U.S. births annually, and about 51 percent of rural births, according to . Medicaid pays for about 52 percent of births, according to 2016 the most recent available.

But efforts to control Medicaid costs are consistently high on Republicans’ to-do list. The Trump administration has encouraged states to introduce work requirements and other changes to Medicaid — changes that would almost certainly reduce the number of people it covers and the money rural hospitals receive.ÌýOhio lawmakers have Ìýthey intend to require that Medicaid enrollees also be employed.

Matthew Perry, Genesis’ CEO, who identifies as conservative and finds plenty of fault in Obamacare, is concerned about high government spending. But he acknowledges that cuts to Medicaid would be deeply problematic for his hospital, affecting what services it can afford to provide. Perry keeps a map in his office to track local options for medical care, and the next-closest OB ward is an hour away in Columbus. What happens, hypothetically, if you take Genesis Hospital off the map?

“That’s a huge problem,” he said.

Squeezed Hospitals, Cutting Costs

Like many rural hospitals Genesis is this area’s health care hub, the access point for primary care as well as mental health care, routine surgeries and other medical needs.

It is also central to the local economy.

Here in Zanesville, population 25,000, it seems as if almost everybody knows someone employed by the hospital.

Main Street is quiet — a stretch of scattered restaurants and pubs, county buildings and churches. Ten minutes away, across the river, Genesis anchors a stretch that would otherwise claim little more than fast-food chains, used car dealerships and cellphone shops.

This hospital, the flagship of a larger Ohio health system, is the product of a 2015 merger of two older town hospitals: Bethesda and Good Samaritan. Its 300 beds are the main source of health care across six counties — a quarter million people — and it delivers 1,500 babies per year.

Ask a woman in town where she would plan to deliver, and the answer is practically a given: Genesis, of course. Locals say it’s hard to conceive of a reality in which the hospital didn’t deliver babies.

In recent years, it’s also doubled down on other services, like cancer care, neurosurgery and open-heart surgery — which experts say can cushion a rural hospital’s bottom line, even if need isn’t as great.

Still, hospitals like Genesis often struggle with tight budgets and regular debates about whether cash flow can continue to support certain types of services. Rural hospitals have seen a in the past decade. Nationally, 80 have closed since 2010 and the trend is expected to continue.

“When rural hospitals are squeezed, they have to look at what fixed costs they can shed,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who studies obstetrics access. “The fixed costs of providing obstetrics services are very clear, and very distinct.”

Obstetrics requires pricey specialists, expensive malpractice insurance and, in the 21st century, the capacity to deal with extreme preemies and high-risk deliveries. At the same time, Medicaid reimburses hospitals less for this service— often below the cost of the care — than any other insurance program, making it a balance-sheet loss.

Already, about 45 percent of rural communities do not have a hospital with dedicated maternity care. From 2004 to 2014, almost 1 in 10 rural counties lost their hospital-based obstetrics programs, suggests research .

In Ohio, nine rural hospitals have dropped obstetrics since 2007 — including one that closed. The state currently has 73 small and rural hospitals in operation.

“We’ve seen a slow erosion of obstetrics in rural areas,” said Michael Topchik, national leader of the Chartis Center for Rural Health, an analytics and consulting firm. “And I’m afraid that further [Medicaid] cuts would exacerbate that trend.”

That scenario is part of the reason why rural health advocates have fiercely criticized GOP efforts at the federal and state level to cut Medicaid or to eliminate the Affordable Care Act’s option for states to expand eligibility for the program.

Research suggests that states’ expansion of Medicaid eligibility led to greater financial stability for rural hospitals. Also, more generous Medicaid coverage increases the odds that rural areas have any kind of obstetrics program.

Potential cutbacks offer a complicated calculation in this conservative town, with practical considerations bumping into politics.

“Things like trauma and obstetrics and behavioral medicine … they’ve got to be subsidized by other, more profitable things,” said Perry, the hospital CEO. “You can’t repeal the laws of economics.”

Still, Muskingum County backed Donald Trump over Hillary Clinton by more than 2-to-1. Its most recent congressional representative, Republican Pat Tiberi, was a vocal Obamacare critic who, until an early retirement this past January, consistently voted to repeal the ACA and pushed efforts to reduce Medicaid’s size and scope.

A Public Health Concern

When pregnant women are geographically farther from health care, they and their babies are more likely to have poor outcomes, like lower birth weights, research suggests.

Foster said that if she had to travel to Columbus, she likely would not have made as many prenatal appointments. Each visit means scrounging up gas money and finding someone to watch her older son for at least three hours.

“It’s obvious that better prenatal care means better outcomes,” said Bijan Goodarzi, an OB-GYN at Muskingum Valley Health Center, a Genesis affiliate about a five-minute drive from the hospital.

And without an operational delivery unit, hospitals are unlikely to keep on staff obstetricians who are experienced in complicated births, experts said.

Keeping rural maternity services open with Medicaid funding also engages new mothers with the local health system in regions with high rates of chronic illness, drug addiction and smoking. The national opioid epidemic is acute in this corner of Ohio.

“What we see is someone who comes in with no teeth, or all rotted teeth or can’t eat. And she’s not complaining about dental work. She’s here worried about her pregnancy,” Goodarzi said.

Even as Obamacare repeal appears on pause, Medicaid remains vulnerable. many state lawmakers on the state’s expanded Medicaid program — a controversial move that would almost certainly squeeze hospital revenue. Nationally, Republican leaders are weighing cuts to Medicaid, Medicare and other safety-net programs.

“If you pull too many of those foundational blocks out of the system that support the safety net … it can crumble,” said Perry, who worries about the effect of such cuts. “People can assume something’s always going to be there, when in reality, that assumption is not always true.”

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Luego, Gerardo entró a una clase en Oakland Technical High School, en Oakland, California, para estudiantes que tienen problemas de salud mental o de comportamiento. El maestro en esa aula recibe apoyo de Erich Roberts, un trabajador social psiquiátrico asignado al grupo. El Distrito Escolar Unificado de Oakland le factura a Medicaid, el programa de seguro de salud para personas de bajos ingresos, por los servicios de Roberts.

Esos pagos cubren oficialmente el tiempo que Roberts pasa, dentro y fuera del aula, brindando terapia y otros tipos de asistencia a nueve jóvenes cubiertos por Medicaid, así como también las reuniones con miembros de las familias. La presencia de Roberts también beneficia al maestro y a otros cuatro niños de la clase que no tienen seguro del gobierno. Muchos de los estudiantes probablemente abandonarían la escuela sin esta ayuda adicional, dijo Roberts.

Medicaid, creado en 1965 para proporcionar seguro de salud a los más pobres, ahora funciona como un salvavidas para millones de estudiantes como Gerardo, cuyas calificaciones han mejorado y quién quiere convertirse en diseñador de moda, así como para cientos de alumnos en distritos escolares de todo el país.

El programa de seguro público ha evolucionado, y ahora financia un abanico de servicios relacionados con la educación, incluido el transporte para niños con discapacidades, clínicas escolares y asesoramiento para niños que provienen de hogares disfuncionales. Los fondos de Medicaid ahora están entretejidos en el sistema educativo de la nación.

Pero a medida que el Congreso busca recortar el gasto federal en salud, el uso de dólares de Medicaid en las escuelas podría estar bajo un nuevo escrutinio. Los críticos se preguntan si las escuelas son los mejores lugares para proporcionar todos los servicios que ahora ofrecen, y si el sistema educativo se ha vuelto demasiado dependiente del programa. Educadores y defensores argumentan que las escuelas son el lugar oportuno para abordar los problemas relacionados con la salud y que la ley federal les exige que brinden dichos beneficios. Y, dicen, si Medicaid no paga, ¿quién lo hará?

Con una administración republicana que promete recortar Medicaid, Kaiser Health News está examinando cómo los Estados Unidos se han convertido en una “Nación Medicaid”, donde grandes cantidades de estadounidenses confían, directa o indirectamente, en el programa, a menudo sin saberlo. El papel de Medicaid en las escuelas es un ejemplo revelador.

Medicaid gasta solo $4 mil millones de su presupuesto anual de $400 mil millones en las escuelas, una “porción muy pequeña del pastel”, dijo Jessica Schubel, analista de políticas en el Center on Budget and Policy Priorities, una entidad bipartidista. Pero para los distritos escolares que ofrecen una variedad de servicios, los que silenciosamente se han vuelto vitales para estudiantes y familias, perder esta fuente de financiamiento sería “un gran problema”.

Un ámbito ampliado

La naturaleza exacta de las consecuencias dependerá en gran medida del estado y los distritos escolares, ya que las jurisdicciones despliegan fondos de Medicaid de manera diferente.

Generalmente, el programa federal puede ayudar a los distritos a proporcionar una variedad de servicios, personal y equipo para sus estudiantes. Aunque no todos los distritos recurren a la financiación, Medicaid les reembolsará por exámenes de vista y audición realizados en la escuela, terapia ocupacional para estudiantes de educación especial, incluyendo, por ejemplo, el manejo de la diabetes y el control del asma. También cubre sillas de ruedas y otros dispositivos médicos para que un alumno pueda asistir a clase. En el Distrito Escolar Unificado de Oakland, y otros en todo el país, apoya servicios de salud mental.

Según una encuesta de 2017 realizada por la Asociación de Superintendentes Escolares, el 68% de los superintendentes dijeron que los dólares de Medicaid financiaron a enfermeras escolares, consejeros y otros miembros del personal de salud. Estos fondos también les permiten a los distritos pagar salarios del personal como Roberts, comprar equipos médicos y, en general, reforzar sus presupuestos de educación, dijo Schubel.

Pero algunos críticos de Medicaid, especialmente los conservadores, cuestionan este flujo de dinero.

Lindsey Burke, directora del conservador Centro de Política Educativa de la Heritage Foundation, argumenta que, en general, los gastos de Medicaid están creciendo demasiado rápido. Ella dijo que los son necesarios para permitir a los estados y distritos más flexibilidad, y para recompensar las “elecciones sensatas” sobre qué ofrecer con dinero de Medicaid.

“Medicaid requiere que se cubra la atención de salud de los niños pobres, pero no indica que los distritos escolares brinden tal cobertura”, dijo Burke.

En el pasado, el gobierno penalizó a algunos distritos escolares por alejarse de los propósitos previstos. Hace diez años, los investigadores federales descubrieron una por servicios de Medicaid en una escuela y casos de despilfarro y fraude en , y . Los dólares destinados a la atención médica se utilizaron para el transporte de niños, o para salarios o beneficios de los funcionarios escolares. En 2007, se descubrió que Texas había presentado 300 reclamos mal codificados, lo que resultó en casi $19 millones de pagos federales por costos no permitidos en el programa de servicios escolares de Medicaid.

Zanjando brechas

En muchos estados, la creciente dependencia de las escuelas en el Medicaid es en cierto modo una consecuencia de los mandatos federales de ampliar los servicios educativos y la falta de fondos específicos para solventarlos.

En 1975, el Congreso aprobó la , que otorgaba a los estudiantes con discapacidades el derecho a una educación gratuita adaptada a sus necesidades. La ley estipula que el Congreso puede pagar hasta el por cada niño que reciba educación especial. Sin embargo, los pagos nunca alcanzaron ese umbral.

Medicaid ayuda a cerrar la brecha.

Michael Walt, un niño de 10 años con síndrome de Williams, una anomalía genética que causa problemas cardíacos y retrasos graves en el desarrollo, es uno de los estudiantes que recibe apoyo en su clase gracias a Medicaid. Su escuela, Forestdale Elementary en Springfield, Virginia, tiene un equipo de terapeutas vocacionales y del habla para mejorar las habilidades físicas e intelectuales de Michael.

Medicaid contribuye con $1.5 millones por año en promedio para ayudar a pagar los servicios de salud y terapia, dijo John Torre, vocero de las Escuelas Públicas del condado de Fairfax, al que pertenece la escuela de Michael. Sus escuelas facturan a Medicaid por servicios que incluyen terapia física y ocupacional, asesoramiento psicológico y asistencia con el habla y el lenguaje. También paga transporte especial para estudiantes con discapacidades, que Michael usa casi todas las mañanas.

Su madre, Lara Walt, abogada, dijo que los servicios que ofrece la escuela han mejorado el habla, el caminar y las habilidades motrices de Michael. Ahora puede comer avena con una cuchara. Aunque su hijo nunca viva independientemente, apuntó que, sin los fondos de Medicaid, “estaría en un muy peor lugar”.

Al otro lado del país, JP De Oliveira, consejero clínico profesional de East Bay Agency for Children, en Oakland, trabaja en Hoover Elementary School con estudiantes que están en Medi-Cal y tienen diagnósticos por los que califican para recibir asesoramiento. El Medi-Cal le paga por su tiempo con estos niños.

Uno de los estudiantes, Rodney Davis, de 7 años, es un niño extrovertido que el año pasado tuvo una crisis de ansiedad y no quería ir a la escuela. Oliveira aconseja a Rodney, juega con él y lo ayuda con ejercicios de respiración. “Realmente necesita esa tranquilidad… saber que todo va a estar bien”, dijo Oliveira.

Diferentes estados, diferentes gastos

Mientras que algunos condados de California despliegan millones de dólares de Medicaid cada año en las aulas, algunos estados gastan poco o nada. Se desconoce mucho acerca de cómo se gastan los fondos de Medicaid en las escuelas. “No hay muy buena documentación sobre qué políticas tienen los estados y cuánto usan”, dijo Nora Gordon, profesora asociada de la Escuela McCourt de Política Pública de la Universidad de Georgetown.

El Distrito Escolar Unificado de Los Ángeles, que tiene un presupuesto total de $7.5 mil millones y sirve a alrededor de 750,000 niños, recibe más de $20 millones en fondos anuales de Medi-Cal, el nombre de su programa de Medicaid. El dinero ayuda a pagar exámenes médicos, equipos especializados y servicios de salud para estudiantes en clínicas médicas y de salud mental. También se utiliza para ayudar a inscribir a los estudiantes y a sus familias en planes de seguro de salud bajo la Ley de Cuidado de Salud Asequible (ACA).

El distrito tiene enfermeras para atender a cada escuela, incluidos 12 puestos que están completamente financiados por Medi-Cal. Las enfermeras ofrecen una variedad de servicios, como vacunación y tratamiento para el asma.

Por el contrario, Wyoming no factura a Medicaid ningún servicio de salud escolar. En cambio, su Departamento de Educación estatal reembolsa a los distritos escolares para que cubran los servicios de educación especial.

La distribución de pagos federales y estatales varía, dependiendo de cómo los estados priorizan dichos fondos o facturan a Medicaid. En 2015, California cubrió aproximadamente la mitad de casi $180 millones en fondos de Medi-Cal para servicios escolares. En todo el estado de Virginia, los pagos de Medicaid por servicios de salud basados ​​en la escuela totalizaron $58.8 millones en 2015, de los cuales casi la mitad provino de las arcas del estado.

Tom Smith, quien es el enlace legislativo de la Asociación de Superintendentes Escolares de Virginia, dijo que la pérdida de dólares federales de Medicaid podría obligar a los distritos escolares, de Virginia y de otros lugares, o recurrir a fondos estatales y locales, lo que implicaría recortes en otras áreas. “Todos sentirán el dolor de una manera u otra”, dijo.

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Then Gerardo entered a class at Oakland Technical High School for students who have mental health or behavior issues. In that classroom, the teacher gets support from Erich Roberts, a psychiatric social worker assigned to the group. Oakland Unified School District bills Medicaid, the nation’s insurance program for low-income residents, for Roberts’ services.

Those payments officially cover the time he spends — in and out of the classroom — providing therapy and other assistance for nine Medicaid-covered youths as well as meeting with their family members. Roberts’ presence in the classroom is also an asset for the teacher and four other kids in the class who are not on government insurance. Many of the students in the class would likely drop out without the extra help, Roberts said.

Medicaid, created in 1965 to provide health insurance to the poor, now functions as a lifeline for millions of American students such as Gerardo — whose grades have improved and who wants to become a fashion designer — as well as hundreds of school districts across the country like Oakland Unified. The public insurance program has evolved so that it now finances myriad education-related services, including transportation for kids with disabilities, school clinics and counseling for children from turbulent backgrounds. Medicaid funds are now woven into the nation’s educational system.

But as Congress seeks to cut federal health spending, the use of Medicaid dollars in schools could come under new scrutiny. Critics question whether schools are the best entities to provide all the services they now do, and if the educational system has become too reliant on the health program. Educators and advocates counter that schools are the opportune place to address health-related issues and that federal law requires them to provide such benefits. And, they say, if Medicaid doesn’t pay, who will?

With a Republican administration vowing to trim Medicaid, Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where huge swaths of Americans rely on the program, directly and indirectly, often unknowingly. Medicaid’s role in schools is a telling example.

Medicaid spends only $4 billion of its $400 billion annual budget in schools — a “very small portion of the pie,” said Jessica Schubel, a senior policy analyst at the bipartisan Center on Budget and Policy Priorities. But for the school districts providing an array of services that have quietly become vital to students and families, losing this funding source would be immense, she said, “a big deal.”

An Expanded Purview

The exact nature of the consequences would depend largely on the state and school districts, as jurisdictions deploy Medicaid funds differently. Since states must contribute a portion of total Medicaid funding to the federal allocation, the amount of money available for school district spending is in part determined by statehouse politics.

Generally, the federal program can help districts provide a variety of services, staff and equipment for their students. Although not all districts tap into funding, Medicaid will reimburse districts for in-school vision and hearing exams, occupational therapy for special-education students, even diabetes and asthma management. It covers wheelchairs and other medical devices so a student can attend class. In Oakland Unified School District and others around the nation, Medicaid also supports mental health services.

In 2017, a survey by the School Superintendents Association found that 68 percent of superintendents said Medicaid dollars funded school nurses, counselors and other health staff members. More than half of superintendents said they have worked to expand the number of students enrolled in Medicaid, which can increase revenue to the school districts. The funds also enable districts to pay staff salaries like Roberts’, buy medical equipment and generally bolster their education budgets, Schubel said.

But some critics of Medicaid, notably political conservatives, question how funds flow into school districts and whether educators have wrongly plumbed the program to cover budget shortfalls. They argue that because the districts already receive other sources of federal funding for special-education and health services in schools, they don’t need federal Medicaid dollars to pay for them.

Lindsey Burke, director of the Center for Education Policy for the Heritage Foundation, a conservative think tank, argues that Medicaid expenses overall are growing too quickly. She said are needed to allow states and districts more flexibility and to reward “sound choices” about what to deliver using Medicaid money.

“Medicaid requires that poor children’s health care be covered, but does not prescribe that such coverage be delivered by school districts,” Burke said.

In the past, the government penalized some school districts for straying far afield from intended purposes. Ten years ago, federal investigators for school-based Medicaid services, and cases of waste and fraud in , and . Dollars meant for medical care were used for children’s transportation or school officials’ salaries or benefits. Texas, in particular, was found in 2007 to have submitted close to 300 incorrectly coded claims, resulting in nearly $19 million of federal payments for costs not allowed under Medicaid’s in-school services program.

Schubel of the Center on Budget and Policy Priorities, who has studied Medicaid in schools, emphasized that school administrations “are in the business of providing education — they are not in the business of providing medical services.”

Filling Gaps Left By The Feds

The increasing reliance by schools on Medicaid in many states is in some ways a byproduct of federal mandates to broaden educational services and a lack of specific funds to pay for them.

In 1975, Congress passed the (IDEA), which gave students with disabilities the right to a free education adapted to their needs. The law stipulates that Congress can pay up to per student for every child receiving special education. However, payments have never met that threshold.

Medicaid helps bridge the gap.

Among the students served by Medicaid in the classroom is Michael Walt, a 10-year-old with Williams syndrome, a genetic abnormality that causes heart problems and severe developmental delays. His school, Forestdale Elementary in Springfield, Va., provides a team of speech and occupational therapists to improve Michael’s physical and intellectual abilities.

Medicaid contributes $1.5 million a year on average to help pay for health services and therapy, said Fairfax County Public Schools spokesman John Torre. Their schools bill Medicaid for services including physical and occupational therapy, psychological counseling and speech-language assistance. It also pays for specialized transportation for students with disabilities, which Michael uses nearly every morning.

His mother, Lara Walt, an attorney, said services offered at school have improved Michael’s speech, gait and motor skills. He can now eat oatmeal with a spoon. Though her son may never live independently, she said, without Medicaid funds supporting special-education services, “he’d be in a much worse space.”

Across the country, JP De Oliveira, a professional clinical counselor with the Oakland-based East Bay Agency for Children, works at Hoover Elementary School in Oakland with students who are in Medi-Cal and have diagnoses that qualify them for counseling. His time with those kids is billed to Medi-Cal.

One of the students, 7-year-old Rodney Davis, is an outgoing child who became anxious last year and stopped wanting to go to school. Oliveira counsels Rodney, plays games with him and leads him in breathing exercises. “He really needs that reassurance … that everything is going to be OK,” Oliveira said.

Different States, Different Spending

While some California counties in and of themselves deploy millions of Medicaid dollars each year in classrooms, some entire states deploy little — or none. Much is unknown about exactly how Medicaid funds are spent in schools. “There is just not very good documentation of what policies states and locals have and how much they are using it,” said Nora Gordon, an associate professor at Georgetown University’s McCourt School of Public Policy.

Los Angeles Unified School District, which has a total budget of $7.5 billion and serves about 750,000 children, each year receives more than $20 million in funding from Medi-Cal, the name of its Medicaid program. The money helps pay for medical screenings, specialized equipment and health services for students at medical and mental health clinics. It is also used to enroll students and their families in health insurance plans under the Affordable Care Act.

The district has nurses to serve each school, including 12 positions that are fully funded by Medi-Cal. The nurses provide a range of services, such as immunizations and asthma treatment.

In contrast, Wyoming does not bill Medicaid for any school-based health services. Instead, its state Department of Education reimburses school districts to cover special-education services. However, schools can use federal funds available through a separate federal funding stream — IDEA — to pay for additional resources like assistive technology, supplies and some staffing, said Brent Bacon, the department’s chief academic officer. These can range from a pencil grip to hiring a job coach to help students transition out of high school.

Bacon did not give a specific reason why Wyoming does not use Medicaid funding for special-education services. Dallas Myers, director of special education for Fremont County School District 1 in central Wyoming, said these federal dollars may complicate students’ ability to access these services.

“If you use Medicaid, you cap that service at a certain allowable fee,” he said. “And we couldn’t begin to get those professional staff people to serve our kids in a rural state like Wyoming if Medicaid came into the state.”

The federal and state share of payments varies, depending on how states prioritize such funding or bill Medicaid. In 2015, California covered about half of nearly $180 million in Medi-Cal funding for school-based services. Across Virginia, Medicaid payments for school-based health services totaled $58.8 million in 2015, of which nearly half came from the state’s coffers.

Tom Smith, a legislative liaison for the Virginia Association of School Superintendents, said the loss of federal Medicaid dollars could force school districts in Virginia and elsewhere to or dip into state and local funds that will translate into cuts in other sections of the budget, like infrastructure. “Everyone will feel the pain in one way or another,” he said.

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His medications alone cost state taxpayers that much in a single year, not including other health care. The boy, whose identity has not been released, was California’s most expensive Medicaid patient in recent years. His case was singled out in a last year by the state’s top health care official to highlight the public insurance program’s extraordinary obligations as a backstop for low-income patients.

How on earth can a single child’s treatment cost that much? The answer: He has hemophilia and needs large quantities of a pricey drug — known as clotting factor — that makes blood coagulate.

Hemophilia drugs are among the most costly drugs in the nation, and taxpayers are footing the bill for many patients on Medicaid who could never afford them on their own. Officials in California and other states are doing what they can to manage the costs, but it’s a daunting task that highlights the complexity and secrecy of prescription drug pricing.

Kaiser Health News is examining how America has become a “Medicaid Nation” — where tens of millions of poor and disabled people now rely on the support of the federal and state insurance program. Hemophilia is one of those diseases that helps explain its burgeoning cost.

Medications for hemophilia are crucial to patients — overwhelmingly male — with the rare genetic condition that prevents clotting and puts them at great risk of bleeding to death, even from a minor injury. There is no question the drugs prolong and save lives, and state officials are not arguing that they should be withheld.

“It’s a highly vulnerable population,” said Ken Kizer, a veteran federal and state health administrator who formerly oversaw Medi-Cal, California’s version of Medicaid. “If anyone has seen a hemophiliac in crisis, you’re not going to say no.”

But drugmakers profit handsomely, competing vigorously for the limited number of patients.

The U.S. hemophilia market, which serves about 20,000 patients, is worth $4.6 billion a year, according to AllianceBernstein, a research and investment firm.

“There are millions being made out there on these kids — it’s a huge business,” said Dr. Doris Quon, medical director of the Orthopaedic Hemophilia Treatment Center at UCLA.

Contributing to the costs is the fact that there is no cure for hemophilia and no cheaper substitute for blood factor. Factor may be prescribed at high doses for a lifetime, even more so when a patient has an injury or complications.

Nationwide, a third of adults and children living with hemophilia are covered by Medicaid. And the Medicaid program’s , according to an analysis by the Kaiser Family Foundation. (California Healthline is produced by Kaiser Health News, an editorially independent publication of the foundation.)

In 2015 alone, Medicaid paid about $353 million for prescriptions of Advate, the most commonly prescribed blood-clotting medication for hemophilia — from 2011.

Generally speaking, the price of hemophilia drugs rise as rival drugs hit the market. But, in addition, doctors are prescribing ever more clotting factor for prevention of joint-damaging bleeds and for improved long-term health. The increase in the cost of Advate, for example, was nearly all attributed to increased use.

Tab For 145 Kids: $195 Million

The California boy whose drugs cost $21 million in a single year was an extreme case, and the circumstances of his care have not been disclosed because of confidentiality protections. Still, medications to treat hemophilia on average cost more than $270,000 annually per patient, according to a 2015 , and they can easily soar past $1 million annually.

In contrast to more common diseases like hepatitis C, hemophilia treatment is not a state “budget buster” per se: Only about patients live in California. About 1,100 of them are covered by Medi-Cal or two other government-funded programs for chronically ill children in California, according to Jennifer Kent, director of the state Department of Health Care Services and author of last year’s tweet. But the amount of money spent per person dwarfs that spent on people with other serious diseases.

One Stanford University of 34,000 California kids with severe chronic diseases found that the tiny portion of children who needed blood factor accounted for 41% of the state’s outpatient drug spending on this entire patient population. About $195 million was spent on just 145 kids over a three-year period, although some of that money came back to the state in rebates from drug companies — a portion of the cost that Medicaid can recoup after purchase.

Caitlin Carroll, director of public affairs for PhRMA, the pharmaceutical industry lobbying group, said high development costs and a complicated and lengthy manufacturing process play a role in how hemophilia drugs are priced. She added that federally mandated rebates significantly reduce the cost of blood factor. They amount to 17 percent of the average manufacturer price per unit.

Manufacturers also note that some newer and more expensive hemophilia drugs last longer and do not need to be administered as frequently, so they can prove less costly to payers overall.

Even so, some patients require a monumental investment to survive.

‘Extremely Fortunate’

Colleen Tuite’s son Kevin, 7, has severe hemophilia with a complication known as an inhibitor — an antibody that makes his regular blood-factor infusions less effective. Inhibitors can the cost of care, because massive doses of blood factor or expensive, specialized blood products known as bypassing agents may be needed.

Tuite and her husband initially were Kevin’s foster parents, then adopted the boy as a toddler. Because he has been a foster child, Kevin qualifies for Medi-Cal until he is 26.

The Monrovia, Calif., family also has private health insurance, which pays for about half of Kevin’s medical bills. These can run upward of $200,000 per month, Tuite said.

“We definitely would not have been able to adopt him without the help of Medi-Cal,” Tuite said. “We’ve been extremely fortunate.”

With the support of drug manufacturers and hemophilia advocacy groups, patients and their families have significant political clout. Some experts say they also have a moral claim on public resources: In the early days of the AIDS epidemic, thousands of the nation’s hemophilia patients died after they through transfusions before the virus could be eliminated from the blood supply.

State health officials say the costs of hemophilia are hard to anticipate and control, even with rebates.

“We do a really aggressive job of collecting rebates on our pharmacy costs,” said Kent, California’s top Medicaid official. “But there’s just not any way around blood factor. It is just a very, very expensive product. It’s nonnegotiable for people that require it.”

In 2016, California’s Medicaid program paid at least $205 million for medications used to treat hemophilia, according to a Kaiser Health News analysis of federal Medicaid data. That figure doesn’t account for the federal rebates.

States can negotiate “supplemental” rebates with drugmakers for individual medications — but those must be kept secret under federal and some state laws. Such secrecy is becoming increasingly controversial as states continue to confront spiraling drug prices.

Limited Options For States

In 2016, Pfizer Texas’ state health agency for giving data on the drug company’s supplemental Medicaid rebates to state lawmakers who requested it. The drugmaker alleged that releasing the confidential information would undermine the company’s competitiveness and give away trade secrets, and warned that the discounts it gave Texas could disappear.

In early October, a judge that lawmakers should be able to obtain some of that data, that “in Pfizer’s view, legislators are not necessary to carry out the state’s Medicaid program.”

Instead of seeking additional rebates from manufacturers for blood factor, some states, including Washington and Oregon, have chosen to require patients to get their blood factor only from federally designated Hemophilia Treatment Centers. That allows state Medicaid programs to take advantage of a federal drug-discount program known as “340B.”

However, officials in California said they studied that option and determined it wouldn’t save them any more money than the rebates they negotiate with drugmakers.

Whatever their approach, state health officials say they are struggling against forces they are nearly powerless to change.

“There aren’t a lot of options available to Medicaid programs in terms of controlling costs, because we don’t set the initial costs,” said Deborah Weston, pharmacy program manager for Oregon’s Medicaid program.

Kaiser Health News data correspondent Sydney Lupkin contributed to this report.

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Indiana is one of the states poised to enact work requirements for some citizens with Medicaid coverage — a controversial policy and long-sought goal for Republicans. But advocates for the poor have protested loudly in recent months, saying many will lose coverage or be ensnared by bureaucratic mistakes. KHN’s Sarah Varney reports in collaboration with PBS NewsHour.

Read the full transcript:

Judy Woodruff:ÌýRepublicans in Washington and around the nation are poised to achieve a long-sought goal: reshaping Medicaid. That’s medical assistance mainly for those with low incomes.

The Trump administration has given the go-ahead to Indiana and other states to require many adult Medicaid recipients to do work or community service in order to qualify.

The idea is popular in Indiana, but some exemptions will be granted for groups like caregivers, students, those in addiction recovery programs.

Still, as special correspondent Sarah Varney reports, advocates for the poor say they are worried that the requirements will jeopardize medical care for more than 30,000 people there.

This story was produced in collaboration with our partner Kaiser Health News.

Sarah Varney:ÌýKatie Josway is a songwriter and the front woman for the Indianapolis band Gypsy Moonshine. Over the past few years, she’s been covered by Medicaid. The public insurance program is largely free to patients in other states.

But, in Indiana, Josway pays about $25 a month. If she misses too many payments, the state will drop her insurance.

Katie Josway:ÌýI think that it’s fair to expect people to contribute based on their level of income and their ability to do so. So, I think that’s kind of what we do in a society. Right?

Varney:ÌýBut Josway, who also works as a massage therapist, worries about changes coming to Medicaid in Indiana. And even though she earns about $16,000 a year, near the federal poverty level, she will have to prove that she’s working at least 20 hours a week to stay insured, a tough bet when her hours fluctuate each week.

Katie Josway:ÌýI’m trying to get people to book with me, but if they don’t, then I don’t want to be penalized and potentially lose my insurance as well. Like, that seems really harsh.

And I am concerned about that growing trend of assuming that anyone who is on an assistance program somehow is mooching off the government or doesn’t try hard enough.

Varney:ÌýUnder former Gov. Mike Pence, now vice president, Indiana became the first state to enact a much more conservative approach to Medicaid.

But the idea of requiring most adults in the program to work was stopped by the Obama administration. Now the Trump White House is allowing Indiana to move ahead.

Seema Verma:ÌýWhat is going on in the Medicaid program today is that we have a very inflexible system.

Varney:ÌýThe effort is being led by Seema Verma, whom President Trump appointed to lead the Centers for Medicare & Medicaid Services.

Verma once worked for Gov. Pence in Indiana, where she tested out her conservative policies, like coverage lockouts and monthly premiums. Now she’s taking her vision even further, by allowing states to impose work requirements and making smokers pay more for public insurance.

The administration has approved Kentucky and Indiana’s plans and at least eight other states have submitted similar requests. But advocates for the poor have protested loudly in recent months, saying many will lose coverage.

Nationwide, 60 percent of Medicaid recipients already work. And advocates say the ones that don’t usually have a good reason for not having a job, because they’re caregivers, students or in drug recovery.

At the heart of the debate are people like Antonio Berlanga. He’s 60 years old and lives in Clinton, Ind., and spent most of his adult life without health insurance. Indiana first expanded Medicaid coverage to a small number of poor adults in 2008, as the recession decimated the state’s economy.

Then, in 2015, Gov. Pence expanded it even further under the Affordable Care Act to about 442,000 adults. That allowed Berlanga, a janitor at a local church, to enroll in coverage. Now he’s been treated for severe shoulder pain, cirrhosis of the liver and hepatitis C at the Valley Professionals Community Health Center.

Like a lot of Hoosiers, he’s worried about what the changes could mean for him, but he’s willing to do his part.

Antonio Berlanga:ÌýYes, I just don’t want it for nothing. If I’m still able to do something and give something back, then let’s go. I have still got a heart. I might not be able to, you know, totally do things. But I will do what I can, you know?

Varney:ÌýDr. John Wernert, one of the architects of Indiana’s Medicaid plan, says that’s what he’s heard in every part of the state, that people on Medicaid want to feel like they’re contributing in some way.

Dr. John Wernert:ÌýIt doesn’t have to be a lot of money for people to feel like they have some ownership and take some responsibility for the administration of their program.

One of the things I can say with confidence as a psychiatrist that has practiced for 30 years is, stigma is real. And there’s a great stigma that folks that are living at or near the poverty level don’t care about their health. Well, that’s completely wrong. They have just not been put in a position where they could take some ownership of that.

Varney:ÌýRevenues at Indiana’s hospitals have jumped as more Hoosiers have become insured.

The CEO of Margaret Mary Health, Tim Putnam, hired a company called ClaimAid to enroll uninsured patients into Medicaid and help them comply with Indiana’s complicated rules.

Now they will have to add the work requirements to their checklist. Putnam says the new rules aren’t designed to be punitive.

Tim Putnam:ÌýIf it was purposefully trying to get people off of HIP, off of Medicaid and onto no coverage at all, that would be a detrimental program for us.

But as it is, it’s trying to get people to get work experience or get some job training to move on and transition to full employment, full insurance.

Varney:ÌýBut Indiana’s conservative plan has added layers of bureaucracy that has ensnared people like Allen Wilson. He and his wife paid their monthly premium,but a paperwork glitch locked him out of coverage, to the point that his wife started to panic.

Allen Wilson:ÌýAnd she told them two or three times, I think you’re just trying to kill my husband, because he’s going to be too much money out of your pocket.

Varney:ÌýAnd you got stuck with thousands of dollars of bills.

Allen Wilson:ÌýYes, I did. Yes, I did.

Varney:ÌýSome 25,000 Hoosiers were disenrolled from Medicaid from 2015 to 2017 because they didn’t pay their premiums. But it’s unclear why. Some may have moved out of state, found jobs with insurance, or even died.

Advocates like Alan Witchey say, now that Indiana is adding a work requirement, bureaucratic mistakes become much more common, especially for vulnerable populations like the homeless.

Alan Witchey:ÌýEven though we have been told there’s an exemption for homelessness, we haven’t heard, how is that going to work? What does that look like? How are we going to get it? What proof do you have to provide?

Varney:ÌýThose living in isolated rural areas, where jobs are few, have many of the same questions.

Niki Carty moved into her brother’s rented farmhouse here in the town of Dana after getting out of prison in 2015. She was convicted of selling meth, opioids and other drugs. Before prison, she became addicted to fentanyl prescribed by a doctor, and soon her two daughters were hooked on opioids as well.

Now the family is in recovery, and Carty is taking online classes to become an addiction counselor. But even though most students are exempt from the work requirement, Carty worries her courses won’t qualify, and she will be forced to drop out of school and get a dead-end job.

Niki Carty:ÌýI am concerned, because I got screwed once before. I really did get screwed.

Varney:ÌýIn the 1990s, when Indiana forced people on welfare to work, Carty says the state didn’t recognize the classes she was taking then. She quit school and ended up getting injured on the job.

Niki Carty:ÌýI look at this way: If I had not had to go to a full-time job where I was being a full-time student then back in the ’90s, I would have never been in that factory to get hit by two forklifts. I mean, 20-some years later, I’m having this surgery, and this is pretty much the results.

Varney:ÌýState Rep. Ed Clere, a Republican from New Albany, is one of the few lawmakers raising these kinds of issues at the Statehouse.

I know one of your big concerns is creating more bureaucracy here in Indiana.

Rep. Ed Clere:ÌýRight. I think we have to be concerned about that and we need to be realistic. What it’s going to cost to administer this?

Varney:ÌýClere says those added administrative costs will pull money away from medical care. And although he supports the work requirements in theory, he says the new rules are unlikely to improve health outcomes.

Rep. Ed Clere:ÌýAnd, in fact, it may over time take us in the other direction.

Varney:ÌýBut many here say people who work live healthier lives and the changes will benefit the entire state.

Dr. John Wernert:ÌýWe’re now starting to move the big battleship in a different direction, more towards what’s needed in our economy and what’s needed in our society now.

Varney:ÌýBack in Dana, a world away from the booming economy in Indianapolis, Niki Carty says the message from lawmakers to people like her is pretty clear.

Niki Carty:ÌýThey think we’re trash, that we’re just garbage to throw away. They’re all worried about the money and all that. And I can understand that. But at the same time, there’s a lot of us that are trying to pick our lives up and put them back together.

Varney:ÌýFor Carty, that means planning her weekly Narcotics Anonymous meeting with a local pastor. She’s determined, she says, to set her life straight and hopes the upcoming changes to Medicaid won’t get in her way.

For the “PBS NewsHour” and Kaiser Health News, I’m Sarah Varney in Indiana.

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The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called , Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” said Meagan Holt, now 27.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. From its inception, in 1966, Medicaid has been required to transport people to and from such medical services as mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” said Holt. “Now that she’s older and more disabled, it’s crucial.”

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. The numbers have grown dramatically since the program expanded in 32 states plus the District of Columbia to cover prescription drugs, health screening for children, breast and cervical cancer treatment and nursing home care.

With a Republican administration vowing to trim Medicaid, Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid’s role in transportation is a telling example. Included in the NEMT coverage are nearly 104 million trips each year at a cost of nearly $3 billion, according to a , the most recent, by Texas researchers.

Citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

Already, states have wide leeway in how to provide and pay for the transportation.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation. And the mother of a Medicaid patient who was authorized to transport her child for treatment billed Medicaid for trips that didn’t take place. She was sentenced to 30 days in jail and ordered to pay $21,500.

Last March, Rep. Susan Brooks, an Indiana Republican, that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reversed the Affordable Care Act’s Medicaid expansion and reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a to them.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states, Iowa, Indiana and Kentucky, have received federal waivers — and extensions —allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, said Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman called the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

CMS released results of a , which found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman said. “We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is cost-effective. For four of those conditions — prenatal care, asthma, heart disease and diabetes — medical transportation saved money when the total costs for both transportation and health care were tallied.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Most states rely on NEMT brokers or managed-care organizations to administer the transportation services. Other states run the service directly, paying providers on a per-ride basis, while some use local ride services and pay independent taxi firms to shuttle patients.

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Still, Medicaid clients like Fallon Kunz, 29, of Mishawaka, Ind., are often stuck. Kunz, who has cerebral palsy, migraine headaches and chronic pain, uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she said.

Today, she lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she said. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

“The only way I can get rides to and from my doctor’s appointment is to ride the 2 miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she said. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she said on a December Tuesday. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she was shuttled to Seattle Children’s on a rainy Tuesday morning in a medical van driven by Donavan Dunn, a 47-year-old former big-rig trucker. He works for Northwest Transport, one of several regional brokers that manage NEMT services for Washington state.

Dunn said he received special training to transport patients like Maddie, who is loaded onto a motorized platform, wheelchair and all, into the van and then carefully strapped in.

“I have to drive different,” said Dunn. “I have to watch my corners, watch my starts, watch my stops. It’s always in the back of my mind that I have somebody on board that’s fragile.”

The transportation service can be used only for medical visits to the specialists who treat Maddie’s condition, which is caused by mutations in any one of at least 12 genes. If Meagan Holt needs to pick up prescriptions or get groceries, she leaves Maddie and a second daughter, Olivia, 3, at home with their dad and takes the bus or walks to her destinations.

Caring for a severely disabled child is not the life she expected, Meagan Holt said, but she cherishes time with Maddie, who has learned to communicate through tactile sign language spelled into her hand.

“She knows about 100 words. She knows the alphabet,” Meagan said. “She likes Disney princesses. She loves ‘Frozen.’”

Maddie is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” said Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

“The majority of our patients are in survival mode,” Povick added. “You need a lot of handholding.”

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients — and bad for the country.

In a , Verma noted that early analysis of the effects of curtailing NEMT in Indiana showed that more Medicaid patients with access to the program said transportation was a primary reason for missed appointments than did members without access.

“Moreover, 90 percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” she wrote.

But Marsha Simon, a Washington, D.C., health policy consultant who has tracked NEMT for years, said Medicaid is the option of last resort. People who are able to get rides on their own already do.

“If 90 percent can and 10 percent can’t, what about the 10 percent?” Simon said.

It’s a question that haunts Kunz every day.

“I’m a college student, I have a cat,” said Kunz, who is studying psychology online at Southern New Hampshire University. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

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Donna Wall cares for her three adult autistic children at her home in Lewiston, Maine. It’s a full-time job. Sons Christopher and Brandon have frequent outbursts, and the stress of tending to them can be overwhelming.

When her twin sons turned 18 a year and a half ago, Maine’s Medicaid program dropped her health insurance. Wall is considered a “childless adult” in Maine and other states that didn’t expand Medicaid, and so she isn’t eligible for coverage. She can no longer get her antidepressants and anti-anxiety medications. She can’t see her psychologist or a doctor to check up on a troubling spot on her eye.

She needs to stay whole, she said, for her kids.

“I’m 60 years old. Things start going wrong when you get older,” she said. “I haven’t had a Pap smear or breast exam in two years. I’m just worried something will happen to me, because who is going to take care of them? It’s a big job. If I put the boys in a home, it would cost the state a lot more to take care of them than it would be to pay my medical.”

Even on frigid, wintry nights, Wall delivers newspapers, earning $150 a week when her kids are asleep.

“I go out about 2 in the morning. And it usually takes me four to five hours,” she said. “I try really hard not to fall, but I have had a few accidents. One of them was on black ice last winter.”

At one point, Wall thought she might have broken a rib. But she stayed away from the emergency room for fear of a costly medical bill.

At least 70,000 low-income Maine residents like Donna Wall should gain Medicaid health insurance because of the ballot measure that passed last fall. Advocates collected signatures to put the question to voters, and, in November, Maine became the first state to get approval at the ballot box to expand Medicaid, passing with 59 percent approval.

But even though voters here in Maine decided to expand Medicaid, the law’s fate is unclear. Republican Gov. Paul LePage has said that opening up the program to more poor adults threatens the state’s financial stability and that lawmakers shouldn’t raise taxes to pay for it.

“You have to pay for the law,” LePage said. “It’s going to cost money. And I intend to implement it, and the Legislature is required to fund it. If they do not fund it, it will not be implemented.”

LePage has been in power for seven years, and, because of term limits, is heading into his final year in office. He vetoed five Medicaid expansion bills passed by the Legislature before voters approved it.

Lawmakers must now pay for the new law without raising taxes or dipping into the state’s rainy day fund, he said. And he warned that the expansion could threaten services for people with disabilities and the elderly.

“When able-bodied people, who are able and should be working, choose not to work, then I don’t think it’s society’s responsibility to cover their insurance at the expense of our mentally ill, our disabled and our elderly,” he said. “We’re asking hardworking Maine families to pick up the extra tab for people who should be working, but elect not to be.”

Sara Gideon, the speaker of Maine’s House of Representatives and a Democrat, said the governor’s remarks are not true.

“Let’s start with the population of people who will actually be eligible for health insurance now,” she said. “We’re talking about people, almost 70 percent of whom are people who are actually in the workforce, who are earning a living, but not actually able to afford health care with the low income that they earn.”

Gideon said LePage must follow the law. Moreover, she is confident the Legislature will find a way to fund the state’s share of $54 million and keep its promises to the elderly and disabled.

“It’s not a choice between people, one group of people over another. It’s a false choice that this governor is trying to present. And we say, we’re not going to make that choice. It is the law. And we’re simply going to make sure that that law is implemented,” said Gideon.

For rural hospitals in Maine, the Medicaid expansion can’t come fast enough.

“Our rural hospital is struggling,” said Marie Vienneau, CEO of Mayo Regional Hospital in Dover-Foxcroft. “We don’t make money. We lost a million and a half dollars the last two years.”

Maine’s rural towns and their hospitals have been hit hard. Factories have closed and many residents have moved away. As workers lost their jobs, more uninsured patients turned to rural hospitals desperate for medical care but unable to pay. Mayo is facing financial uncertainty, and at least three rural hospitals in Maine have closed in recent years.

Deanna Chevery was laid off after 25 years when the Dexter Shoe Co. factory closed in Dexter, Maine. Now 60 years old and uninsured, she’s recovering from an addiction to pain pills prescribed by her doctor for back pain.

She overdosed five times, costing Mayo Regional Hospital more than $200,000 in unreimbursed care. Before Chevery found the charity recovery program at Mayo Regional, she said she was turned away when she sought help because she couldn’t pay.

“You can only go so many places. Nobody will take you,” said Chevery. “They don’t care if you’re crawling on the ground. I’m just fortunate Dover helps me.”

But Vienneau said the hospital cannot keep up with Maine’s growing opioid epidemic and ever-rising costs without expanded Medicaid.

“You can only go so many years in a row where your business doesn’t lose money, before you depreciate to the point that you have to start closing services, decreasing services,” said Vienneau. “And then access goes away.”

Medicaid advocates, like Maine Equal Justice Partners, are pressuring lawmakers to put the new law into effect quickly. The group has been receiving postcards from around the country congratulating them on becoming the 32nd state to expand Medicaid, and advocates in many other red states that refused to expand Medicaid are eyeing their own ballot measures, including Nebraska, Utah, Idaho, Florida and Missouri.

Patrick Willard, a senior director at Families USA, a progressive advocacy group based in Washington, D.C., said that after years of Republicans attacking the Affordable Care Act, voters are beginning to shift their views.

“What we have heard is that other states suddenly see an opportunity now to figure out a way that they can get around legislatures that have been holding this up,” said Willard.

As state lawmakers in Maine work out the details of the new law, many disagree with LePage about how much it will cost. His administration estimates the price tag will be twice what the Legislature’s nonpartisan fiscal office has projected.

If they can’t resolve the impasse, LePage said, he will take legal action, if necessary.

“We will go to court, because I know — listen, one thing that I know better than the Legislature is financial responsibility. And I have proven it over the last seven years,” said LePage.

Advocates say those who are eligible for Medicaid could enroll as early as this summer. But if there are delays, they too will sue.

Just days after our interview, Donna Wall fell during her middle-of-the-night paper route and broke her ankle. She still doesn’t have health insurance and is unsure how she will care for her autistic children and uncertain what the future will bring.

Jason Kane of PBS Newshour contributed to this story.

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