“I want to stay here,” she vowed. “And die here.”

She might pull that off. In relatively good health, Jennett still drives to lunch with friends, does her own housekeeping and grocery shopping, and plows through a book a day, usually a mystery. But her children worry about her living alone at 89, especially after she has had a couple of falls.

Enter her new housemate, Susan Beese. Despite working four days a week in retail, Beese could no longer afford her nearby one-bedroom apartment as the rent topped $1,500 a month. She moved out, first staying with friends and then in what she delicately called “a senior women’s facility.”

Now Beese, who is 79, pays Jennett $800 monthly for a bright two-bedroom space, with a bath and a kitchen, on the lower level of her house. As part of the agreement the housemates worked out, she helps plant and water Jennett’s garden, takes out the trash, and cooks occasional meals.

“It’s been a lifesaver,” Beese said. Jennett even welcomed her dog.

Meet the real-life Golden Girls. In the  1980s sitcom, still in perpetual reruns, the four wisecracking women who share a house in Miami met through an ad on a supermarket bulletin board.

In Denver, the housing matchmaker was Sunshine Home Share Colorado, a local nonprofit that Alison Joucovsky, a senior services administrator, founded in 2016 when the problem became urgent. “My phone was ringing off the hook,” she said, recalling anxious pleas from older residents spending most of their Social Security checks on rising rent or facing years-long waiting lists for subsidized senior housing.

Home sharing “is a really efficient way to create affordable housing and to support older people ,” Joucovsky said. Carefully vetting both “home providers,” who may be rattling around in family houses now too big and too empty, and “home sharers” seeking reasonable rents, Sunshine facilitated 31 shares last year, a record for the nonprofit.

“The cost of developing and building new housing is astronomical, and so is the length of time it takes,” said Laura Fanucchi, president of the National Shared Housing Resource Center and an administrator with HIP Housing, a home-share organization in San Mateo County, California. “Why not make use of existing housing stock?”

About  offer these services — and demand is growing, driven by housing shortages, rising rents, and sales prices that affect both the old and the young. Legislators in several states are working to promote home sharing as an option. (Personal care is not part of these arrangements.)

The need is acute. About a third of households headed by someone 65 or older were “cost-burdened” in 2024, according to  by the Harvard Joint Center for Housing Studies. That means they spent more than 30% of their income on housing.

Although nearly 80% of those people were homeowners, the center found, an increasing proportion are still paying off mortgages or home equity loans, and most contend with higher taxes, utility and maintenance costs, and insurance premiums.

“A lot of the people calling me to complain about property taxes and inflation are senior citizens on fixed incomes whose children have left, and maybe their spouse has died,” said Pennsylvania state Rep. Abby Major, a Republican co-sponsor of a bill that would facilitate home sharing. “They’re a single older adult living in a four-bedroom house.”

Yet most don’t want to relocate. Even if they do, many older adults will find that downsizing has also  as home prices rise and very low interest rates become a memory.

Younger people are similarly cost-burdened, including 37% of those age 25 to 34 and 31% of those 35 to 44, the Joint Center has reported.  both older homeowners who need income and people of any age in search of lower-cost housing.

To help increase their reach, some home-share programs now supplement or replace the traditionally labor-intensive matching process with online platforms. (For-profit companies like Nesterly or roommates.com also facilitate shared housing.)

“It’s like online dating, except that people who have rooms can meet people who need rooms,” said Candice Smith, executive director of HomeShare Oregon. “And it’s a lot more secure.” HomeShare’s online platform has drawn close to 7,000 providers and seekers over five years.

Further support has come from the city of Portland, which this year announced  to pay $1,000 to homeowners who make a spare room available (or $1,500 for two rooms) through qualified home-share programs.

In addition, legislators in several states have introduced or passed bills that prohibit municipalities from unduly restricting homeowners who want to rent spare rooms to nonfamily members. Sponsors in Pennsylvania and Connecticut actually call them Golden Girls bills, and they’ve drawn bipartisan support.

“So many young people have basically given up on buying a home,” said Colorado state Rep. Manny Rutinel. The Democrat helped pass  prohibiting cities and counties from limiting the number of unrelated people who could live together in a single dwelling.

In Pennsylvania, state Rep. Tarik Khan steered  through the House in June; it awaits a Senate vote. “It doesn’t make sense that your cousin can move in but someone unrelated to you can’t,” said Khan, a Democrat.

The Pennsylvania bill caps the number of nonfamily occupants in a home at five; Connecticut’s limit would be three.  passed the Senate in April and then died without a vote in the House. But the bill sponsors plan to reintroduce it next session.

Home sharing can’t solve the housing crisis, its fans acknowledge. But it could make a dent, potentially unlocking thousands of spare bedrooms across the country without requiring new construction that would change the character of neighborhoods.

Admittedly, matching homeowners with those who want to rent a room becomes a delicate process. Home-share staff members typically interview the individual parties, run background checks, verify incomes, coordinate initial phone calls and meetings, and mediate if problems later arise.

They also help applicants sift through the myriad lifestyle preferences that can torpedo a match. “Living together isn’t easy,” Fanucchi said. Will the home provider accept smokers, pets, visitors? Does the sharer work from home? Or need to park a car? Who sets the thermostat?

Sometimes the agreement includes a “service exchange,” in which the newcomer does a few hours of chores like snow shoveling, shopping, or some meal preparation in return for reduced rent.

Jenlyn and Larry Boyer, for instance, have lived in their ranch house in suburban Broomfield, Colorado, for 31 years and never want to leave. But Jenlyn, who is 80, has “gotten unsteady” and uses a walker. Her husband, 70, suffers chronic fibromyalgia pain and needs a wheelchair.

Because they now pay for tasks that they used to undertake themselves, and because inflation has undermined their finances, “I had an epiphany,” Jenlyn said. “We need more help and we need more money.”

Six months ago, through Sunshine Home Share, they met a 46-year-old graduate student whose monthly rent had doubled to an unmanageable $2,000.

The student moved into their furnished downstairs bedroom/family room with a bathroom, a small refrigerator, and a microwave. In exchange for about 10 hours of dishwashing a month, she pays a reduced rent of $600.

The additional income has helped the Boyers cover expenses like van repairs and wheelchair batteries. But they also enjoy chatting with their new housemate.

“She turns out to be just a gem,” Jenlyn said. “We laugh together a lot.”

The New Old Age is produced through a partnership with .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

California lawmakers an expired law that would require the state to identify companies that employ 100 or more people and have employees enrolled in Medi-Cal, the state’s Medicaid program. Nevada has had a similar law in place since 2017, though a proposal for one in Oregon stalled when its legislative session ended in March.

The California bill author, Democratic state Sen. Lola Smallwood-Cuevas, said she is deeply troubled by what is going to happen when work requirements kick in. According to the state, out of more than on Medi-Cal will be subject to the rule.

“We think this is a bill that’s about fairness,” Smallwood-Cuevas said. “It’s a basic principle that taxpayers deserve transparency about which large employers are shifting their healthcare costs onto the public.”

Large employers that regularly top Nevada’s list, such as Walmart and Amazon, have said that the state included part-time and seasonal workers in their counts and that their full-time hourly employees to qualify for Medicaid.

Walmart spokesperson Katrina Proffitt said that the company offers affordable medical coverage to most employees, including eligible part-time workers, and that most of its plans include no-cost virtual care options.

“Healthcare affordability and access to quality care remain real barriers for many Americans, and Walmart continues to be committed to being part of the solution,” Proffitt said.

The push to name and shame companies reflects dueling narratives about the biggest abusers of the joint state-federal Medicaid program, which reached nearly in government spending in 2024. The Trump administration, led by Centers for Medicare & Medicaid Services Administrator Mehmet Oz, has called out blue states for not doing enough to fight insurer fraud and abuse. State Democratic leaders, meanwhile, are pushing back by calling attention to big employers that don’t offer affordable health benefits, which leaves taxpayers subsidizing healthcare costs for the low-wage workforce.

Some states have considered financial penalties. Democratic New Jersey Gov. Mikie Sherrill signed a bill in June that have at least 50 Medicaid-enrolled employees. Companies with 50 to 249 workers on Medicaid per person, and those with at least 500 will pay $725.

Bills that would have penalized companies with workers enrolled in Medicaid failed in this year.

In Sacramento, California, Democrats want to figure out a way to make large businesses pay for their employees’ health coverage. State lawmakers struck a deal with Democratic Gov. Gavin Newsom, who is contemplating a presidential bid as he wraps up his final year in the governor’s office, to explore tax options. Any tax hike would be up to the new governor.

States face of dollars under HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, notably through that requires nondisabled Medicaid enrollees ages 19 to 64 in most states to prove they are working, volunteering, or going to school at least 80 hours a month to keep their coverage.

Yet federal work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the . Nebraska and Montana have begun enforcing the rule.

One health policy researcher said employer Medicaid reports highlight the lack of affordable healthcare options available to low-wage workers. More than half of adults enrolled in Medicaid who don’t have dependent children already meet the 80-hour-a-month requirement or face challenges that would likely qualify them for an exemption, .

“There’s a whole set of people who are working — they may not satisfy the work requirement provisions, they may not get the exemption that they’re qualified for, and they don’t have access to that employer-sponsored insurance either,” said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

Employers Push Back

While employer lists haven’t succeeded in bringing down Medicaid costs, supporters say measuring the burden can be the first step and help lawmakers make the case for further action.

In Nevada, Amazon has employed more Medicaid enrollees than any other company since 2020, according to the state’s report . For state fiscal year 2025, Walmart, the Clark County School District, the state government, and Tesla rounded out the top five.

Employers that the reports are misleading because they have included part-time and seasonal employees. The state’s includes only full-time employees, plus those who could not be confirmed as either full- or part-time employees.

That came to 4,914 Amazon employees and 3,503 Walmart workers in Nevada on Medicaid in 2025.

There are no penalties for companies on the list.

Amazon said it pays its workers more than double the $7.25-an-hour federal minimum wage and noted that Medicaid eligibility is based on household income and size rather than an individual’s wage. That means two employees who earn the same pay may have different eligibility depending on whether they have children or live with parents.

“Pointing fingers at Amazon over Medicaid is a red herring,” said spokesperson Alisa Carroll. “What really needs to happen is a significant and large increase in the federal minimum wage — that would be a big boost for American families.”

Nevada Medicaid spent nearly $950 million on healthcare for more than 133,000 full-time employees and more than 140,000 of their dependents. While the total amount spent dipped in fiscal year 2025, the average cost per member per year increased by nearly 17%.

Yvanna Cancela, a former Nevada lawmaker who sponsored the legislation on Medicaid work reports, said the annual reports force an important conversation “about whether or not this is the kind of economy we want and whether or not it is right or just that people who work full-time don’t make enough to have health insurance.”

A Fraying Safety Net

Health researchers say that uninsured people delay or skip and that their children may end up losing coverage, too.

One analysis found that more than were enrolled in Medicaid and the Children’s Health Insurance Program this April than in January 2025. California is among the states with the among children.

The loss in healthcare coverage among residents will be compounded by the loss of public food assistance benefits, Smallwood-Cuevas said. is pending in the legislature.

She compared Medi-Cal to a trampoline that has become a “very tattered kind of fishnet” overwhelmed by people falling into it. President Donald Trump’s spending-and-tax law pulls and rips at the safety net, she said.

When people lose food assistance and health benefits, they must choose between paying for medicine and paying for rent, Smallwood-Cuevas said.

“We’re going to see more people in their cars, more people on the street, and a lot more people in the emergency room,” she said. “That is dangerous for all of California.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The Republican blasted California during back-to-back political attacks in May, saying the heavily Democratic state is committing “outrageous fraud” and “stealing” by spending state and federal Medicaid money meant for basic medical treatment on unconventional services such as housing and nutrition assistance, gym memberships, and even tribal prayers and, he claimed, exorcisms.

“The California Medicaid program will pay for herbal medicines, meal deliveries. They’ll pay for housing,” Kennedy said. “I don’t know what housing has to do with healthcare.”

“California, they’re just setting all kind of records,” he added. “They’re wild people.”

Despite criticism from congressional Republicans and growing scrutiny from the Trump administration, Gov. Gavin Newsom, a Democrat considering a presidential run, said he’s proud of California’s spending on social services in Medi-Cal, the state’s Medicaid program. It’s a multibillion-dollar experiment to help medically frail patients meet their housing, food, and other social needs that Newsom says is not only legal but also a more cost-effective and evidence-backed approach to providing healthcare for Californians with complex health conditions. He counters that investing in services outside clinical settings can help people avoid emergency rooms and hospital admissions, improve their long-term health, and ultimately save taxpayers money.

“It’s about whole-person care,” Newsom said, adding that he hopes President Donald Trump’s administration sees California’s leadership and agrees with the “reforms we’re advancing as national best practices.”

Now one of the governor’s marquee health initiatives is at the center of an intensifying partisan battle with Republicans in Washington, D.C., who have moved to rein in billions in healthcare spending on low-income and disabled people across red and blue states. It’s a philosophical divide: Conservatives say social services are a financial strain on Medicaid and shouldn’t be considered healthcare, while liberals argue that investing in prevention ultimately saves money. While experiments proliferated across the country under President Joe Biden, the Trump administration federal policy encouraging state Medicaid programs to address health-related social needs.

The Medicaid fight is putting patients in limbo.

Lucy Rodriguez teaches Mexican folk dancing in the town of Hollister, in California’s Central Coast region. She said her life turned around this year once an intensive case manager with Titanium Healthcare, which contracts with health insurers to provide services, began helping her manage her chronic diseases and stay on top of her medical appointments and prescriptions, even picking up free food boxes for her. The 73-year-old is on Medicare and Medi-Cal, which offers more extensive benefits. The low-income health program has helped pay her utility bills, and she was recently approved for home-delivered meals.

“This has been a godsend,” said Rodriguez, who has diabetes, high blood pressure, and kidney disease. “I was getting so stressed out and depressed. It’s really hard when you’re on a fixed income. Groceries are so expensive, and with summer, electricity gets even more expensive. But this is really improving my life.”

She worries the Trump administration will cut benefits to low-income older people.

Last year, the Centers for Medicare & Medicaid Services warned states that federal funding for social services would be determined on a . CMS spokesperson Christopher Krepich said the agency is not ending current agreements, known as waivers, that grant states temporary permission to provide social services, which are paid for with state and federal dollars. But future applications, for new services or to extend existing initiatives, could be at risk if they veer too far from traditional healthcare.

“Moving forward, CMS will work with states on innovative waivers that address core healthcare needs, as consistent with evidence-based approaches tied to clinical diagnoses and services, to the goal of ultimately improving health outcomes in the Medicaid population,” Krepich said in a statement.

In a further escalation, the Justice Department put out a allowing states to institutionalize people with disabilities and severe mental illness instead of providing community-based care. Republicans have also targeted states, mostly blue ones, for what they say is a failure to go after waste, fraud, and abuse in Medicaid. In May, CMS Administrator Mehmet Oz stood alongside JD Vance as the vice president announced the deferral of in Medicaid money to California over suspicions of fraud.

California Attorney General Rob Bonta said Republicans are simply trying to score political points while ignoring the healthcare needs of poor people. “The federal government wants to politicize fraud,” Bonta said, “and use it, unfortunately, as a bludgeon and a cajole to beat up on blue states.”

Social Healthcare

Health policy researchers say roughly are linked to socioeconomic, environmental, and behavioral factors, such as housing instability, homelessness, food insecurity, and exposure to violence, whereas 20% is associated with medical care delivered in hospitals and clinics. That evidence to tackle social services.

At least 24 states use their own money while drawing federal Medicaid funds for . Colorado, Massachusetts, New York, North Carolina, Oregon, and Pennsylvania are among those that provide housing and nutrition assistance.

As the Trump administration pulls back on social services, states are rethinking how to fund benefits that have improved preventive care for low-income people. Some have launched new benefits under what’s known as a state plan amendment, a mechanism states use to modify their Medicaid programs that doesn’t need federal waiver approval. and , for example, use this to add recuperative care for homeless patients after hospitalization. These short-term care facilities offer people the opportunity to recover, bridging the gap between hospital discharge and independent living.

This approach “has the advantage of establishing a permanent, statewide benefit that does not require ongoing federal renewals, offering greater stability and predictability,” said Lynn Sutfin, a spokesperson for the Michigan Department of Health and Human Services.

Other states, meanwhile, rely on federal waivers, which require renewal to provide social services. Arizona officials said the state intends to submit a request by the end of September to continue to provide housing and other services to homeless patients, or those at risk of homelessness, with a serious mental illness and a chronic health condition or recent incarceration.

“When members have access to stable housing and supportive services, they are more likely to engage in ongoing care and less likely to experience avoidable emergency department visits and inpatient admissions,” said Roberta Harrison, interim director of the Arizona Health Care Cost Containment System.

California, which has been the most aggressive state in adopting social services, has taken a two-pronged approach to keep its vast offerings funded past this year. The state is using its authority to make most of its existing social services and benefits permanent in Medi-Cal managed-care coverage. That regulatory maneuver bypasses federal waiver approval — a move that could attract further Republican scrutiny.

But not everything the state offers can be funded without permission from the federal government. As some services are made permanent, the Newsom administration is seeking new waivers to continue other social services, while also adding more.

It’s an ambitious approach that would expand California’s social healthcare experiment. Newsom said he’s worried that the federal government will decline the . “How could you not be with this administration?” he said. “I’m always concerned.”

New Front in Healthcare

California offers most of its health-related social services under within Medi-Cal, which has a proposed budget of . Although there are more than 14 million residents on Medi-Cal, the state has been selective about who gets help from in its program, called California Advancing and Innovating Medi-Cal, or . Patients with complex needs can also receive help navigating their health and social needs from specialized social workers under a benefit known as .

Since 2022, California has been offering social services, spending nearly $12 billion in joint state and federal money, long-term Medi-Cal spending by keeping enrollees out of costly institutions including emergency rooms, jails, nursing homes, and mental health crisis centers.

CalAIM had provided social services to more than patients as of September 2025, the most recent state data available. And nearly low-income Californians have received intensive . Some patients receive both services.

Among the services California is making permanent: Homeless patients can get help finding an apartment, with Medi-Cal paying rental and six months of rent. Patients with chronic conditions such as diabetes and heart disease are eligible for home-delivered meals. Asthmatic patients can get mold removed from their homes to control flare-ups. Low-income seniors with disabilities can get a wheelchair ramp installed free of charge. And inmates leaving jail or prison can be connected immediately with primary care, mental health, and substance use treatment.

The social services — especially housing, food assistance, and home modifications — are success in stabilizing the health of the most complex patients, while achieving savings for Medi-Cal through reductions in emergency room visits and hospitalizations and less reliance on institutional care such as nursing homes, the state Department of Health Care Services.

In the Central Valley, for instance, Health Plan of San Joaquin CEO Lizeth Granados said CalAIM has helped place homeless patients who were routinely hospitalized into housing. And patients with uncontrolled diabetes saw their blood sugar drop after receiving nutrition counseling and home-delivered meals.

Overall, Granados said, the health plan has seen major improvements in chronic disease management and reductions in hospital stays, dropping to 44 inpatient hospitalizations per 1,000 members since it launched in 2022, down from 61 per 1,000 before CalAIM.

In Orange County, officials with CalOptima Health credited CalAIM housing services for contributing to a nearly . “We’ve been able to expand our street medicine programs, too,” said Yunkyung Kim, the insurer’s chief operating officer.

Around the state, Medi-Cal health insurers said they’re optimistic that CalAIM will continue to save money and improve patient health. Yet, the fate of some services will be decided by the Trump administration.

California has asked CMS to continue enrolling jail and prison inmates in Medi-Cal 90 days before their release to maintain consistent treatment for substance use, mental disorders, or physical conditions, a .

The state has also proposed a new job assistance benefit that counties could opt into to help patients find and retain work in response to upcoming federal work requirements imposed by congressional Republicans’ One Big Beautiful Bill Act, signed by Trump last summer.

And the state wants to continue its array of traditional healers and natural helpers for Californians with tribal affiliations, including music therapy, dancing, drumming, and referrals to sweat lodges for mental health treatment and substance use recovery. While it covers spiritual services, such as ceremonies, rituals, and herbal remedies, state officials said Medi-Cal does not cover exorcisms.

Already, the Trump administration’s positioning has forced the state to eliminate room-and-board benefits, which is threatening local efforts to provide recovery beds.

The state is cutting short-term post-hospitalization housing, which was meant to prevent hospitals from or those at risk of homelessness onto the streets. The CalAIM service providing up to six months of temporary housing and ongoing care is ending at the close of this year. And the state is cutting recuperative care benefits, no longer paying for beds for patients to recover from illness or injury, instead offering only wraparound services.

In San Francisco, these beds have been crucial in reducing overdose deaths, helping transition homeless people off the streets and into housing, and reducing hospital bed usage, said Neal Sheran, a medical director with the city’s Department of Public Health. The city’s health plan operates a sobering center, and recuperative care facilities where patients can recover from hospitalizations.

“We’re concerned,” Sheran said. “Funding for the overnight piece of these programs is really crucial to their success.”

Cuts on the Horizon

Even without federal threats, state budget pressures have strained CalAIM financing. Newsom has proposed for social services by $68.3 million this fiscal year. The cut will deepen next year and remain at $150.2 million per year beginning in 2028.

Providers worry that Medi-Cal patients will lose access. And services, such as home-delivered meals and housing assistance, will be further restricted.

“It’s moving us back to the old days where our healthcare system is more expensive and reactive, instead of investing in prevention,” said Anwar Zoueihid, a vice president and the chief strategy officer at the Los Angeles-based Partners in Care Foundation, a CalAIM provider. “It’s contradictory to Make America Healthy Again.”

To save money, the state is tightening eligibility to limit services and . For instance, Medi-Cal patients with food insecurity would no longer be eligible for home-delivered healthy meals without a qualifying condition like diabetes. And a homeless patient would get capped at six months for help finding an apartment.

Some of the biggest providers of CalAIM say services should be continuously evaluated and curtailed if health plans were too permissive. In some cases, food and housing services were given to low-income patients who didn’t necessarily qualify as the highest-need.

“It’s important everybody takes a look with a very sober view at whether we’re truly benefiting people so we’re spending money in the right places,” said Charlie Robinson, the chief health equity officer at L.A. Care, one of the state’s largest Medi-Cal health insurers.

Dorothy Seleski, the Medi-Cal president for Health Net, said the health insurer isn’t deterred by state and federal cuts.

“Regardless of what happens at the federal level, we are committed,” she said. “This is a significant transformation of the healthcare system, and we are already seeing major reductions in avoidable emergency room trips, avoidable hospital admissions, and we’ve closed gaps in preventive care.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

He had been targeted by a drive-by shooter in Jacksonville, Florida, and hospitalized with two gunshot wounds. During his weeklong hospitalization, he said, a physician assistant changed the course of his life by visiting his hospital bed each day and warning him that Black men with gunshot wounds often end up paralyzed — or worse.

“I used to run the streets, you know, on the wrong sides of the track,” Pinckney said. “He made me promise that I would never come into his ER that way again. That was the last conversation we had, right before I was discharged.”

His goal since then has been to become a physician assistant. Pinckney, who spent most of his career working for New York City’s Department of Sanitation and as an Army Reserve medic, recently took a step toward achieving it. In May, he graduated with departmental honors from Lehman College with a Bachelor of Science degree.

After moving from New York to Prince George’s County, Maryland, he’d planned on applying for physician assistant school this year. But now, he’s worried his dream may be thwarted by new student loan rules.

Starting July 1, the amount of money graduate students will be allowed to borrow from the federal government . The new student loan limits are part of the GOP’s tax-and-spending legislation known as the One Big Beautiful Bill Act, which President Donald Trump signed into law last year.

The caps are intended to curb the cost of higher education and student loan debt, according to the Trump administration.

But critics widely agree the new limits are too low, especially for students allowed to borrow only $20,500 a year in federal loans due to the law’s controversial definition of a “professional degree.” On June 24, a federal judge temporarily blocked the Department of Education from enforcing that definition. Still, for many students, the new caps won’t cover the combined cost of tuition, housing, and living expenses.

This could leave hundreds of thousands of students who borrow money for graduate school each year at the mercy of private lenders with higher interest rates and fewer repayment options.

Some experts and students also worry that the limits will threaten efforts to diversify the healthcare workforce by deterring minorities and people from low-income households from applying to graduate programs. A drop in incoming students could worsen existing rural and primary care shortages, they argue.

Many politicians and loan experts have acknowledged that the cost of higher education needs to be addressed. But the new federal loan limits are “just not going to achieve that goal,” said Todd Pickard, president of the American Academy of Physician Associates, one of several organizations that have sued the Department of Education over the rules.

“It’d be like if you had a hangnail and I cut your whole arm off instead of just taking care of your hangnail,” Pickard said. “The treatment doesn’t match the problem.”

‘A Rock and a Hard Place’

Students working toward what the law describes as “professional degrees” — including trainee doctors, dentists, pharmacists, and chiropractors — will be allowed to borrow up to $200,000 total, and no more than $50,000 a year.

Meanwhile, the median cost of attending a public medical school is nearly $300,000 over four years, while the median cost of a private medical school education exceeds $400,000, according to the Association of American Medical Colleges.

The caps were set even lower for those pursuing other “graduate” degrees, who face a $100,000 borrowing limit for federal loans over the course of their degree programs. The annual limit for this category of students is only $20,500. Students pursuing physical therapy, physician assistant, and nursing degrees were originally included in this group. But according to new guidance issued by the Department of Education on June 29, some of these students will at least temporarily be able to borrow up to the higher limit, .

The Department of Education, which has been sued by clinician trade groups and about two dozen states over the new rules, did not respond to questions for this article.

As the law was written, a physician assistant student who completed their degree within the average two to three years would not have been eligible to borrow the full $100,000. Meanwhile, physician assistants typically start their careers with an average debt of $112,000, meaning some could be forced to finance their education with higher-interest private loans.

“I feel like I’m between a rock and a hard place,” said Olivia Trull, 24, who is scheduled to begin the physician assistant program at Northwest University in Kirkland, Washington, this summer. The 28-month program costs $137,000, with about $62,000 in tuition and fees estimated for the first year, she said. That doesn’t include living expenses.

Before the court order, Trull said she qualified for the maximum annual allotment under the new rules of $20,500 in federal loans during her first year of graduate school. The balance would need to be financed through a private lender.

She anticipated she would need up to $100,000 in private loans to finance her graduate degree and would face loan payments of more than $3,000 a month when she was done.

“I have to actually sit down and have a conversation with myself,” Trull said, to consider “if I want to be drowning in debt for the next 10 years of my life.” One private bank offered her a loan with an interest rate of nearly 14%, she said.

Pinckney, who said he finished his undergraduate degree with about $10,000 in federal student loan debt, said some of his friends who have already applied for private student loans have been quoted interest rates as high as 13%. Meanwhile, interest rates for federal loans for graduate students, which are set annually, are currently about 8-9%. Federal loans also offer more flexible repayment options than private loans typically do.

In May, 25 states and the District of Columbia against the Department of Education over the new rules. The complaint described the law’s “professional degree” definition as “arbitrary and capricious.”

In a separate filed in June, the American Academy of Physician Associates and the PA Education Association alleged that the new rules deny students the loan amounts needed to attend physician assistant schools. They argue that PA students should be able to access the higher loan limits available to students in medical school and other professional degree programs. (While “physician assistant” and “physician associate” typically refer to the same role, the AAPA in 2021 because of “concern that ‘assistant’ does not reflect the important role of PAs in delivering high-quality healthcare to patients.”)

Meanwhile, Trump administration officials have contended the cost of graduate school is too high across the board. Education Secretary Linda McMahon, speaking before a House committee in May about the new limits, said, “It is our overall goal to bring down the cost of college and education.”

Indeed, some experts acknowledge that the new limits may be helpful in bringing down costs. The federal Grad PLUS loan program, established by Congress 20 years ago, did not cap the amount graduate students could borrow in federal loans. That program was eliminated in the One Big Beautiful Bill Act.

“There is considerable evidence that people borrowed more than they really needed to go to school,” said Sandy Baum, a higher education economist and a senior fellow at the Urban Institute.

Already, some graduate programs have lowered tuition prices, Baum said. In May, for example, the it would lower the cost of its MBA programs by tens of thousands of dollars to fall below the new federal lending thresholds.

And yet Baum doesn’t anticipate many other schools will follow suit.

“I don’t think we’re going to see some dramatic decline in prices,” she said. “I think some programs could close down because they can’t manage.”

‘Tears Have Been Shed’

The new lending limits will also disproportionately affect Black students, Baum said, because they have historically borrowed more than white and Hispanic students.

For some students who borrowed money to finance their undergraduate degrees, the new limits will hit especially hard. Under the new rules, they will be subject to a lifetime limit of $257,000 in federal student loans.

“There will be students who can’t enroll,” Baum said.

Andrei Robu, 26, a medical student at the Medical University of South Carolina, leads the Financial Literacy Interest Group on the Charleston campus. He said many of his peers are worried that the lending limits will make the student body less diverse.

He is also concerned that, because the demand for acceptance into medical school is already so high, schools could prioritize entrance for students from wealthy backgrounds and “still fill up their classes.”

“That’s just not what we want in our physician workforce,” said Robu, who isn’t subject to the new rules as a current student. “We want to represent the population of the country at large.”

Jasmine Vasquez, 26, who has been accepted into the physician assistant program at South College in Atlanta, decided to defer her enrollment until 2027, partly to see if her financing options change. She is worried about taking on too much debt from a private bank.

“Tears have been shed multiple times,” said Vasquez, who is due to give birth in September. “It’s nothing that’s within my control.”

Betsy Mayotte, president of the Institute for Student Loan Advisors, expects the new rules will force some graduates into bankruptcy when they can’t afford to repay private loans.

First, though, she expects enrollment numbers to drop and some graduate programs to close because they can’t recruit enough students. Completion rates will also drop, she expects, as students run into federal loan limits partway through their degree programs.

Beyond that, she predicts healthcare graduates will seek jobs in high-paying specialties, exacerbating shortages in rural and underserved communities.

“They’re going to go where they can make the most money,” Mayotte said.

Pinckney said he is “not really sure” what the future holds. He paid for most of his undergraduate education by working while he was in school, but that’s typically not possible for full-time physician assistant students.

He has considered applying to a biomedical science graduate program instead, which he estimated would cost about $30,000 — an amount that’s “a lot more doable,” he said. It would allow him to potentially work in a lab or in pharmaceuticals, he said. It’s still aligned with medicine, he said, but it wouldn’t help him realize his goal of working with patients.

“Maybe this thing will blow over,” he said of the new federal loan limits. In the meantime, he’s holding out hope.

“If I can influence one person’s life, that would be my way of paying him forward for what he did,” he said, referring to the physician assistant who inspired him back in 1999. “It’s very hard to pivot from that dream.”

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The 59-year-old retired teacher, who recently moved from Ohio to Michigan, now pays $341 a month for a pair of plans, one that covers routine and urgent care and another that pays fixed amounts for hospital stays. Neither meets federal standards for comprehensive coverage.

Though she practices yoga and is healthy, Miller said she still feels “vulnerable.” If she lands in the hospital, her plan pays a flat $2,000, a fraction of the of an average hospital stay.

“I don’t gamble. But I may as well,” she said. “This is gambling.”

Congress’ decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance — plans like Miller’s, which have lower premiums but don’t meet ACA standards for coverage or consumer protections. Unlike plans sold on the exchanges, these options — some sold by major insurers, others by small companies or nonprofits — can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover “essential health benefits,” such as preventive care, and can impose annual or lifetime caps on benefits.

There is debate over whether these options help or harm patients. Consumer advocates dismiss them as “junk insurance,” while proponents say restricting alternatives to pricey marketplace plans risks driving up the number of uninsured. Some states, including Kansas and Florida, and the federal government itself have eased regulations on such plans or created incentives to join them, while other states, including California and Massachusetts, have tried to deter enrollment in alternative insurance. Those regulatory guardrails, however, are now being stress-tested as premiums blow out household budgets.

Alternative insurance takes many forms, including short-term policies, which were designed to bridge temporary gaps in coverage and often exclude preexisting conditions, and fixed-indemnity plans, which pay a flat rate per service regardless of how high costs go and are intended for supplemental use. Arrangements in which people pool their money to cover one another’s bills, including faith-based “healthcare sharing ministries,” also provide a cheaper alternative to the marketplace options. Because they are not considered insurance under federal or state law, they are not legally bound to pay for even .

Enrollment data for alternative plans is mostly confidential, but several indicators point to shifts in the market. Recent estimates suggest marketplace enrollment from 2025, and a of people on the exchanges last year found that 5% switched to private, nonmarketplace individual coverage, including plans that don’t comply with the ACA. Covered California, the state’s marketplace, plans to survey former enrollees to find out where they went.

Insurance industry insiders also report that, amid the expiration of subsidies, alternative plans are making a marketing push. Colorado insurance broker Samantha Albritton said that before ACA open enrollment, she saw more marketing from fixed-indemnity plans than in previous years. One healthcare sharing plan, Zion HealthShare, had more than 75,000 members in February — a 50% increase since last June, it said in a statement.

Critics of these alternative plans say the major issues occur when people use them as primary insurance and don’t realize the coverage is inadequate until they need it most. “Humans have bodies that can fail them,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

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Sign-ups were already down in January by about from last year’s . For this year, enrollees then faced premiums that increased, on average, . On top of that, subsidies that help people purchase coverage shrank or vanished.

Now experts are watching how many of the approximately 23 million people who enrolled will fail to pay their share of premiums.

While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is , which saw a 28% drop in April compared with the same period a year ago, according to an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA.

The news website NOTUS that it had internal Centers for Medicare & Medicaid Services data showing that roughly 21% of people using the federal ACA marketplace — — failed to pay their share of January premiums, which, if correct, is far higher than at the same time last year.

CMS did not answer questions from Ñî¹óåú´«Ã½Ò•îl Health News about the enrollment data.

In looking at the early numbers analysts released, “we can’t yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock,” said Ellen Montz, a managing director with the Manatt Health consultancy, who helped oversee the ACA during her tenure with the Biden administration.

The initial results come amid rising public concern about affordability, that are often .

A KFF analysis , for instance, found that the average ACA plan deductible saw the steepest increase in history — growing by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026 as enhanced premium tax credits expired.

Those rising costs pose a political challenge for President Donald Trump and the broader GOP, which has opposed enhanced subsidies to help people purchase Obamacare coverage. Republican lawmakers also passed a spending package last year — enacted as the One Big Beautiful Bill Act — that included provisions expected to reduce ACA enrollment and fueling higher premiums this year.

The enrollment reductions “are real people with real consequences,” Montz said. “The Affordable Care Act is a political lightning rod, but it’s a critical component of the coverage landscape.”

Following the Numbers

Right now, the drop-off rate aligns with what some policy experts predicted, partly because Congress did not extend generous benefits that expired at the end of last year. Those enhanced subsidies had been in place since 2021.

“Overall, the individual market does appear to be trending toward a significant contraction in 2026, and may well resemble” drops projected by the , said a , an analysis arm of the HMA Co.

Based on its analysis, drawn from data provided by 75 insurers, Wakely estimates that average ACA enrollment will end up being 17% to 26% lower this year than last.

So far, the Wakely report says, an average 86% of enrollees made their first payment in January.

Failure to pay premiums varied by state. Those with the lowest drop-off rates had enacted additional help — such as backfilling part or all of the reduced subsidy amounts with state money — or experienced lower premium increases. States that run their own exchanges had higher payment rates (92%) than those served by the federal marketplace (82% to 84%).

Gaba’s initial analysis of data includes more recent numbers from nine of the 20 states that run their own Obamacare marketplaces.

“Georgia could be fairly representative” of other states that did not enact additional protections, Gaba said. For example, payment failure rates, year over year, were 11.6% as of April in New Jersey, and, as of February, 15.7% in Washington state and 8.5% in California.

Only one state in his sample — New Mexico — saw an increase in the percentage of people making premium payments, according to the latest available monthly data. Unlike most, it to fully make up for the lower federal subsidy amounts.

Enrollment figures for the ACA are never static. Traditionally, more people sign up — either through auto reenrollment or by taking initiative to shop — than actually pay premiums, so the numbers tend to be higher at the start of the year.

People drop out over the course of a year for many reasons, such as finding other coverage through a job or by marrying someone with insurance.

Cost, of course, is a factor. This year, because premiums went up and subsidies went down, many people faced what they previously paid toward their coverage.

And the Trump administration ended a special enrollment program that let low-income people enroll year-round.

drops should not be seen solely in the context of rising costs. Paragon Health Institute, a free-market think tank that has become influential among conservatives on Capitol Hill, has long argued that record enrollment numbers in recent years were fueled by fraudulent sign-ups, perhaps in the millions.

, , and policy experts took issue with the methodology Paragon used to estimate improper enrollments, saying they likely were vastly overestimated.

In a , the organization’s president, Brian Blase, doubled down on the fraud findings. Using data that detailed how many people failed to make premium payments each year, on average, from 2014 to 2019 — the year before covid emerged and two years before enhanced subsidies kicked in — he offered this prediction for 2026: About 19 million people would be enrolled by year’s end. Even at that, the note says, the “market would be 90% higher than the pre-COVID average.”

For other experts, however, the biggest explanation for falling enrollment is cost.

Some people had never experienced the ACA before the enhanced tax credits kicked in, so they faced extra sticker shock.

“In economic theory, no matter whether one is left, right, or center, it’s a simple fact that when you raise prices of something, fewer people will buy it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

The Long View

The expectation of a lower enrollment trend holding up is one of the key factors likely to translate into higher cost estimates as insurers draw up 2027 rates.

For one thing, though it is still unclear how many people will stay enrolled, it is also unknown whether those enrollees will submit more medical claims than insurers projected. It’s generally thought that younger or healthier people are more likely to drop coverage when faced with growing premiums.

Secondly, there has been a sharp shift by consumers to purchase bronze-level plans, which have smaller monthly premiums but higher deductibles — the amount people must pay out-of-pocket for most treatment, except preventive care, before insurers pitch in. The found that sign-ups for bronze plans jumped from 30% to 40% of total plan selections — growing from 7.3 million in 2025 to 9.2 million people this year. Will they pay? Or will hospitals and doctors be on the hook for uncollected copays or deductibles, and then raise prices to compensate?

Insurers base their premiums, in part, on such analyses.

Another troubling factor for actuaries is the late posting of a key regulation that sets the next year’s rules for ACA health plans. The initial 2027 proposal from the Trump administration came out in mid-February and included aggressive new ideas — such as sharply increasing deductibles for certain types of ACA plans or allowing insurers to offer plans with no set networks of medical providers. It was , well into the time when insurers are calculating premiums for the following year. Many of the proposed changes, with some modifications, were approved, such as allowing for higher annual deductibles in some types of coverage.

“This is definitely a challenging year to be an actuary,” said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group, an insurance agency.

“We know for sure that the individual market has gotten smaller and almost certainly sicker, as the people dropping coverage are more likely to be healthy.”

While they “aren’t waving huge red flags” yet, insurers are closely watching trends, said Michelle Anderson, a director at Wakely and co-author of the recent report.

Anderson does not expect an average 26% premium increase like the one seen this year.

Still, Anderson expects the ongoing uncertainty and predicted decline in enrollment, which will vary by state and insurer, to play a role in setting next year’s premium rates.

“It would not surprise me if there were some double-digit increases,” Anderson said.

Ñî¹óåú´«Ã½Ò•îl Health News reporter Rachel Spears contributed to this article.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

As a teenager, Rei Scott spent several weeks living out of a car with four family members and their dog. Each day, Scott worried about where they would spend the following night.

One day at school, Scott snuck away to the bathroom and called the national suicide hotline.

Scott, who is transgender and nonbinary, explained to the hotline counselor that the family had struggled with poverty for years. They had lived in crumbling homes with water leaks, or a family member’s basement with no privacy. Sometimes the family worried about having enough food. The stress and anxiety were constant, and Scott had been suicidal many times.

The counselor seemed shocked into silence, Scott said. Eventually, the person provided reassurance and kindness.

But what Scott really needed that day a decade ago and many times since was a fix for the economic difficulties that had become an unbearable weight.

“It can definitely help to have someone who can listen, but when you’re struggling to eat and you don’t have a roof to be under, I honestly don’t think words can go as far as you need them to,” said Scott, who now studies social work at Capital University in Columbus, Ohio.

Over the years, Scott has been directed to hospitals and therapists. But those generally don’t address core problems, such as a broken-down car or an eviction notice.

“There’s so many times in my life where I’ve thought if I had $5,000, I wouldn’t even be suicidal right now,” Scott said.

People don’t typically think of suicide as an issue of economics, but it often is.

Decades of research shows that , , , , and make people more likely to kill themselves. Conversely, things that bring down people’s cost of living — such as , , , and — are linked to lower suicide rates.

It makes sense. If someone can cover their basic needs, their life will feel better.

Other countries have been incorporating this understanding into their efforts for some time. But because suicide prevention in the U.S. has historically been seen as a medical issue — the responsibility of clinicians who can provide medication or therapy — economic solutions are frequently left out of the equation.

Some advocates and people with suicidal experiences, like Scott, are trying to change that. They say traditional approaches to suicide prevention haven’t succeeded. For decades, the U.S. has had among high-income countries.

To move the needle, “we all need to be challenged to broaden our aperture, to broaden the lens of what is mental health,” said , a national expert in mental health policy and an adjunct professor at the Stanford University School of Medicine.

The highest-impact interventions may not be adding crisis lines or screening more people in emergency rooms, Miller said, though those can be helpful. If he had to pick one strategy, it would be alleviating poverty.

That “allows us to reconcile and solve for these conditions that put people in places of despair,” he said. “I don’t know what stronger intervention one could possibly have.”

To be sure, suicides also occur among wealthy people. It’s a complex issue and almost never boils down to one reason. For most people, the decision to hurt themselves results from an intricate interplay of biological factors, relationship concerns, finances, trauma or abuse, and access to lethal means. That means suicide prevention requires a variety of approaches.

The argument for including economic policy as one of those approaches, many advocates and researchers say, is that policies affect entire populations. So even a small effect can save a significant number of lives.

‘Economic Uncertainty’ Builds

However, the push for an economic lens on suicide prevention is encountering gale-force headwinds from Trump administration policies.

and the have contributed to economic pressures. Meanwhile, the administration has increased hurdles for safety net programs such as the , often called food stamps, and , the state-federal health insurance program for low-income people. Experts estimate will over the coming years.

The administration has also , saying people who are homeless to receive support. The president’s 2027 budget request, which signals his priorities, that helps low-income people pay for heat and air conditioning.

Research suggests increase people’s risk for suicide.

“Anytime there is economic uncertainty, people will fear for their future and livelihood,” Miller said, and “this last few months have been terrifying.”

Notably, the administration’s actions directly contradict strategies that the promotes as having “the best available evidence to reduce suicide.” No. 1 on the page is “Strengthen economic supports.” It lists SNAP benefits and housing-first policies as examples.

, director of the CDC’s injury center, said the agency doesn’t work on economic policy directly but encourages state and local governments to look at the relationship between health and economics.

The Department of Health and Human Services supports suicide prevention through the 988 national crisis hotline, investments in treatment, and the Rural Health Transformation Program, which states can use to expand mental health care in rural areas, HHS spokesperson Emily Hilliard said.

Alec Varsamis, a spokesperson for the Agriculture Department, said the agency is providing states guidance on SNAP changes and “remains deeply committed to supporting the health and mental well‑being of all Americans.”

It’s too soon to tell how recent actions may affect suicide rates. And given the unique combination of factors at play in each death, it’s challenging to draw direct causal links.

The most recent data available shows nearly 49,000 people died by suicide in 2024 — a slight dip from previous years but still among the highest tolls since the late 1990s.

The concept of suicide prevention writ large has historically drawn bipartisan support, said , a New York University researcher who last year highlighting public policies shown to reduce suicide.

The details are where things get murky. For example, strong evidence suggests that increasing the minimum wage reduces suicides. (The is $7.25 per hour, with higher rates in certain states.) But such increases are often a hard sell for lawmakers facing the realities of balancing a budget and small-business owners struggling to stay afloat.

Closely tying suicide prevention initiatives to such politically charged and complicated issues could undermine their chances, Purtle said, adding, “We’ll see suicide get polarized.”

That’s why the focus often stays on areas of agreement, such as funding crisis hotlines.

View From a Crisis Line

is the chief clinical officer at Samaritans, a Boston-based nonprofit that has operated a suicide crisis hotline for more than 50 years and fields upward of 10,000 calls a month, including local calls to 988.

Although people might assume every call is an imminent crisis, Maitland said, many callers are struggling with everyday needs — financial problems, housing concerns, or unemployment.

“Whatever is going on in the world, we absolutely hear about that in real time,” Maitland said.

In November, when during a government shutdown, people affected called Samaritans.

“That in and of itself was a hit to suicide prevention,” Maitland said. “If people don’t have access to eat, to feed their children, to be alive, quite frankly, how are they able to move further through anything else?”

Samaritans volunteers are trained to listen with compassion and make callers feel less alone in what they’re going through. That validation and caring are powerful, Maitland said.

But she often wants to do more, to “dig in and fix” the root issue.

Research supports her instincts. found that increasing the number of people who receive SNAP benefits by 5% could have prevented nearly 32,000 suicides over 15 years. And a $1 increase in minimum wage roughly 8,000 fewer suicide deaths over a decade.

Although Maitland can’t change federal welfare policies, she and her co-workers are applying this approach locally. They recently started an initiative to provide blankets, socks, and water to people living on the streets of Boston.

“Suicide prevention doesn’t always look like a crisis helpline,” she said. “That’s what we imagine it as.” But “having your basic needs is also a form of suicide prevention.”

Continuing To Live

In the years since calling the suicide hotline in high school, Scott has turned to a number of resources to help overcome recurring thoughts of suicide. Crisis lines, hospitalization, medication, and therapy have all played a role.

But, Scott said, the biggest impact came from programs that helped fulfill daily needs — for example, a housing program for LGBTQ+ youths and another for former foster care children attending college.

Scott, who now lives close to campus because of the foster care program, said the ability not to “worry about ‘Where am I going to sleep tomorrow night?’” has provided a significant mental health boost.

Although some programs like those are under threat from the Trump administration, Scott is hopeful they will persist and rebuild.

Surviving difficult times has given Scott confidence to persist through more potential challenges ahead.

Despite “the policies and legislation that harm us, we continue to live, and I think that’s really important,” Scott said. “It gives me a lot of hope that things can be different.”

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More changes lie ahead that make it important for those getting subsidies in 2026 to track their income and take steps to protect against that kind of financial hit.

First, the basics of how the subsidies work.

Enrollees pay a percentage of their household income toward their health insurance premiums based on a sliding scale, ranging in 2025 from nothing for very low-income people to 8.5% at higher income levels. Subsidies, usually paid directly to insurers, cover the rest.

The income calculation done during open enrollment is an estimate of what a household thinks it will earn in the coming year. At tax time, ACA enrollees must reconcile what they received in subsidies with what they actually earned. If their income rose, they might owe some of the subsidies back.

But don’t skip filing! People who get ACA subsidies must file tax returns no matter their income, and that is becoming even more important: The Trump administration people from subsidy eligibility if they have gone two consecutive years without filing, and it is proposing lowering that to one year.

Beware Surprise Tax Bills

All enrollees who received subsidies for ACA coverage in 2025 — — need to include a special form, the , with their tax filings. That form is used to reconcile a person’s actual income with the amount of subsidies they received, information the IRS mails them on a separate, . Subsidy amounts are based in part on the income projections they made when they enrolled in their ACA plans.

And that can lead to surprises. Some may find they get money back if their income was less than they estimated. But, if their income went above their initial or updated estimates, they probably qualify for less in assistance and will have to pay money back.

Groups that help people file their taxes say it’s not always easy for people to accurately estimate their income for the year ahead, especially those who run their own businesses, work multiple jobs, or have work that comes with varying hours.

Clients will say, “I can make anywhere between $20,000 and $45,000 next year. I just don’t know,” said Katie Alexander, director of training and volunteers for the health and economic opportunity program at Pisgah Legal Services, a western North Carolina nonprofit that provides free tax and health insurance help to people with low incomes.

Still, for taxes being filed now for the 2025 tax year, on what many people must repay.

That cap is $375 for a single individual who earned less than $31,300 in 2025, or . The maximum owed under that sliding scale for people whose income is on the higher end of the range is $1,625 for an individual and $3,250 for a family.

There is no repayment cap for people earning more than four times the federal poverty level — totaling $62,600 in 2025 for an individual or $106,600 for a family of three — so they could owe back all amounts that exceeded their eligibility.

“The amount is just so staggering for folks,” Alexander said.

One woman whom Pisgah staff helped with pulling together her taxes for 2025 made just above $50,000, which was more than she initially estimated. Her repayment was capped at $1,625, Alexander said. Without that cap, she would have owed $4,000, a substantial chunk of her annual income.

Plan Ahead: The Rules Will Be Tougher Next Tax Season

Congressional Republicans’ One Big Beautiful Bill Act, signed into law by President Donald Trump last summer, . That means come next year’s tax season, there will be no sliding-scale limit to how much people could owe back in subsidies for 2026 if their income exceeds their projections.

“That’s just going to be absolutely devastating,” Alexander said.

There are at least two other things to keep in mind, both stemming from covid-era enhanced tax credits, which expired at the end of last year because Congress did not extend them. One is that the amount of household income people must pay toward their premiums this year before subsidies kick in has risen to just over 2% on the low end of the income scale and up to nearly 10% for higher-income earners.

The second is that households earning over four times the federal poverty level no longer qualify for ACA subsidies.

The biggest financial hit could be felt by enrollees whose income rises enough during the year to exceed four times the poverty level. In that case, they would owe back all the subsidies they receive in 2026.

And that could be a lot.

In 2025, for example, the average monthly premium for ACA coverage was $619, but the average enrollee received subsidies worth enough to offset all but $74 of that, according to the .

There’s another twist for some. Because the enhanced credits were not extended, people are paying, on average, double the amount toward their premiums this year, so they may be looking to add to their incomes to cover the cost. A found that 43% of people who remained enrolled in coverage this year are planning to work more hours or get additional work to cover those costs.

“That makes sense, but it can also present a risk of being eligible for less subsidy money than they thought, or even mean they would have to repay the entire tax credit,” said Cynthia Cox, senior vice president and director of the Program on the ACA at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

People can update their projected income at the marketplace website as it changes during the year.

Pisgah staff are calling people they’ve worked with and saying, “Please, please, please, if your income changes, call us so we can adjust your income through the marketplace,” Alexander said.

As much as possible, keep track of income during the year. This isn’t easy, especially for workers who don’t have a job with regular paychecks.

“If you’re meeting with a CPA to talk about taxes, have a conversation to make sure you’re making enough money to afford your costs, but not too much to lose eligibility for a subsidy,” Cox said. “Contributing toward a retirement plan or a health savings account can lower part of your income that counts toward subsidy eligibility.”

Others might choose to dial back their work hours or forgo a new client contract.

“If taking that extra shift means putting you over the line of 400% of the federal poverty level and that’s going to cost you $10,000 in repayments, maybe don’t take that shift,” said Jason Levitis, a senior fellow at the Urban Institute who follows ACA and tax policy issues.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

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Scattered visits to free clinics notwithstanding, Guevara hadn’t had a full medical checkup in years. She required dental work. She wanted to start looking for a job. And she was overwhelmed by the maze of paperwork needed simply to get her off the street, much less to make any of the other things happen.

But Guevara had help. The Jamboree Housing Corp., an affordable-housing nonprofit that renovated the former Stanton, California, hotel Guevara now calls home, didn’t just move her in — it also provided her a fleet of wraparound services. Jamboree counselors helped Guevara navigate the health care system to see a doctor and a dentist, buy a few things for her apartment, and get training to become a caregiver.

“I was years on the street before I got the kind of help I needed so I could help myself,” said Guevara, 68.

Amid the Trump administration’s apparent opposition to using Medicaid funding for such social services, staffers at Jamboree and similar affordable housing providers in California have been worried about losing federal money, particularly as the experimental waivers that provide the primary funding for the program they rely on expire at the end of 2026. But as it turns out, the state had the foresight several years ago to designate certain nonhousing social services, such as mental health care, drug counseling, and job training, as a form of Medicaid spending that will continue to be reimbursed.

Catherine Howden, a spokesperson for the federal Centers for Medicare & Medicaid Services, confirmed that California’s use of the “in lieu of services” classification for these wraparound programs is allowed under federal regulations.

“It is starting to sound positive that we will, at the very least, be able to continue billing for these services after the waiver period,” said Natalie Reider, a senior vice president at Jamboree Housing.

During President Donald Trump’s first term, states were permitted to use Medicaid money for social support services not typically covered by health insurance. But the second Trump administration is reeling that policy back in, saying that the intervening Biden administration took the supportive services process too far. Howden said in a statement that the policy “distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans.”

Through CalAIM, a five-year experimental build-out of the Medicaid system, programs like Jamboree were able to leverage federal funding to offer the kinds of nonhousing social services that experts contend are essential to keeping people permanently housed.

However, these wraparound services are only one component of the CalAIM initiative, which is attempting to take Medicaid, known as Medi-Cal in California, in a more holistic direction across all areas of care. And when CalAIM launched, California officials gave the programs the Medicaid “in lieu of services” designation, known as ILOS, effectively putting them outside the waiver process and ensuring that even when CalAIM sunsets, money for those social initiatives will continue to flow.

“California has tried to future-proof many of the policy changes it has made in Medi-Cal by including them in mechanisms like ILOS that do not require federal waiver approval,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. “That allows these policy changes to continue, even with a politically hostile federal administration.”

The designation allows these social services to be funded through Medicaid managed-care plans under existing federal laws because they are cost-effective substitutes for a Medicaid service or reduce the likelihood of patients needing other Medicaid-covered health care services, said Glenn Tsang, policy adviser for homelessness and housing at the state’s Department of Health Care Services. The state could not provide an estimate of the annual funding for these wraparound services because they are not distinguished from other payments made to Medicaid managed-care plans.

“We are full steam ahead with these services,” Tsang said, “and they are authorized.”

Although California was the first state to incorporate the designation for such housing and other health-related social support, Tsang said, several other states — including Arizona, Arkansas, Florida, New York, and North Carolina — are now using the mechanism in a similar fashion.

Early results suggest such support saves on health care spending. When Jamboree, in Northern California, in the Central Valley, and other permanent supportive housing providers employ a holistic approach that includes social services, they have reported higher rates of formerly homeless people remaining in housing, less frequent use of costly emergency health services, and more residents landing jobs that help them pay rent and stay housed.

At the nonprofit MidPen Housing, which serves 12 counties in and around the San Francisco Bay Area, roughly 40% of the units in the program’s pipeline are earmarked for “extremely low-income” people, a group that includes the homeless, said Danielle McCluskey, senior director of resident services.

CalAIM reimbursements help fund the part of MidPen that focuses on supportive services across a wide range of experiences, from chronic homelessness to mental health issues to those leaving the foster care system. McCluskey described it as one leg of a three-legged stool, the others being real estate development and property management.

“If any of those legs are not getting what they need, if they’re not funded or not staffed or resourced, then that stool is kind of wobbly — off-kilter,” the director said.

A recent found that people who used at least one of the housing support services — including navigation into new housing, health care assistance, and a deposit to secure an apartment — saw a 13% reduction in emergency department visits and a 24% reduction in inpatient admissions in the six months that followed.

Documenting those outcomes is critical because the department needs to show federal officials that the services lessen the need for other, often costlier Medicaid-covered care — the essence of the classification.

Advocates for the inclusion of supportive services argue that the American system ultimately saves money on those investments. As California’s homeless population to more than 187,000 on a given night — nearly a quarter of the U.S. total — Jamboree has been allocating more of its resources to permanent supportive housing.

Founded in 1990 in Orange County, Jamboree builds various types of affordable housing using federal, state, and private funding. Reider said about a fifth of the organization’s portfolio is dedicated to permanent supportive housing.

“They’re not going back out to the streets. They’re not going to jail. They’re not going to the hospitals,” Reider said. “Keeping people housed is the No. 1 outcome, and it is the cost-saver, right? We’re using Medicaid dollars, but we’re saving the system money in the long run.”

Guevara, who wound up on the streets after a falling-out with family in 2015, spent years living out of her truck before a shelter worker connected her with Jamboree. There, she was paired with a specialist to help her figure out how to get and see a doctor, and to keep up with scheduling the battery of medical tests she needed after years spent living in temporary shelters.

“I also got a job developer, who helped me get this job with the county so I can pay my rent,” Guevara said of her position as a part-time in-home caregiver. “Now I take care of people kind of the same way people have been taking care of me.”

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Residents share rooms designed to be accessible to those with mobility issues. There are also private bathrooms, which are a big deal for seniors struggling with incontinence.

Unlike the MVP, most homeless shelters aren’t equipped to help seniors, especially those 65 and older. They are the fastest-growing homeless population nationwide, according to , a researcher at the University of Pennsylvania. Not only are people who struggle with chronic homelessness aging, but many seniors are becoming homeless for the first time in their lives.

Getting in and out of bunks, managing medications, and making it to a shared bathroom in time are among the major challenges of shelter life for older adults. Staff at traditional shelters sometimes ask seniors to leave if they’re unable to care for themselves.

The MVP is unusual among shelters because it provides on-site medical care to better serve its residents as they age.

Last spring, Jamie Mangum, who is in her 50s and has lung cancer, tripped and fell in her room. To visit with an emergency medical technician, she needed only to make it downstairs. Her swollen wrist was quickly wrapped, and she returned to her room. She said that wouldn’t have been possible at other shelters she’s stayed in.

“There, I’d have to wait hours as opposed to come in here, be seen,” Mangum said.

Mangum said that in other shelters she’d likely have had to find her own way to an urgent care office or get an ambulance ride. Specialized case managers at the MVP have helped her get treatment for lung cancer as well.

“We have clients that need memory care. Maybe they were living independently before, but they were unable to maintain that and got evicted due to dementia or different things like that,” said Baleigh Dellos, who manages the MVP shelter for , a local nonprofit.

Specialized medical case managers work at the shelter. Primary care doctors and therapists visit weekly. Residents can even receive physical therapy in private spaces on-site.

A Path to Stability

The MVP partnered with the to offer medical care.

The first thing most new residents need help with is medication, said Matt Haroldsen with the Fourth Street Clinic, which provides health services at the shelter.

For people living on the streets, just keeping hold of regular medications is a challenge. “Their medications get jacked when they’re in their camps,” he said.

Diabetes patients without homes often bury their insulin to keep it cold. Haroldsen said they might forget where they buried it, or the vials might get too warm and spoil.

Helping residents at the shelter get those medications can stabilize their conditions, allowing them to focus on other priorities, such as getting an ID and other documents they need to apply for disability, Social Security, and various programs that can help them secure housing.

Nonprofits and local governments have opened similar shelters in Florida, California, and Arizona to meet the needs of older unhoused adults.

Having access to specialized shelters can be the difference between life and death, said , assistant director of the National Health Care for the Homeless Council.

In cold-weather states, denying seniors a bed because of mobility and other health issues can be especially risky. In 2022, a Bozeman, Montana, after he was asked to leave a shelter because of incontinence.

Complex medical needs can pose a danger to other residents that most shelters aren’t prepared to manage.

“A typical shelter doesn’t allow somebody on oxygen to come in because that’s such a fire hazard and risk,” she said.

Synovec said giving seniors better access to health care inside shelters is the best way to help them succeed once they get housing. Health issues are a common reason seniors can’t afford or maintain housing, she said.

A Growing Model

The MVP model is showing promise, both in Utah and elsewhere.

“Over 80% of the people who’ve stayed in our program this past year have moved into stable or permanent housing,” said , vice president of programs for the TaskForce for Ending Homelessness in Fort Lauderdale, Florida. The nonprofit runs a shelter called .

The MVP shelter near Salt Lake City is also marking success. It was able to permanently house 36 seniors as of late last year.

Still, there are more seniors in need of shelter than it can accommodate. Dellos, the shelter’s manager, said the MVP’s waitlist hovers around 200 people. She said the shelter prioritizes people based on medical need, not time spent on the waitlist.

For residents who do get a room, it’s life-changing.

Last spring, 62-year-old Jeff Gregg was playing fetch with his dog, Ruffy, just beyond the lawn in front of the MVP.

An old back injury forced Gregg to hunch over as he threw the ball. It also fueled a decades-long addiction to opioids. That cycle was hard to escape, he said.

“Fighting that, having a job, insurance, then losing the job, not having insurance, going out to the streets and being back in that crap, and I’d be back in the same position,” he said.

Gregg said sobriety took a back seat to more immediate needs like finding food and a bed in a shelter. He said the MVP was the first place where he could relax and focus on recovery.

“I was able to get clean. It took me a couple months, but I just kept plucking away,” he said.

He said the experience paved the way for him to get back surgery. He hopes that with less back pain, he can eventually get a job to help him afford an apartment.

This article is part of a partnership with and .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .