Even as prescription drug costs rise, patients with commercial insurance have slowed their use of manufacturer-sponsored drug coupons in recent years, according to April 6 by the Journal of the American Medical Association.

Manufacturers are offering just as many of them, “but still, we see a lot of affordability issues among this commercially insured population,” said So-Yeon Kang, the study’s main author, who is an assistant professor of health management and policy at Georgetown University.

“Patients are at the intersection and battle place between these payers and manufacturers,” she said.

Drug manufacturers distribute copay coupon cards to consumers online or in person at the pharmacy counter. These manufacturer-sponsored coupons are not the same as discount card services from companies like GoodRx, which negotiate lower bulk pricing for prescription drugs, then pass those savings along to the consumer.

Manufacturers issue the coupons to keep their drugs competitive by offering patients short-term savings. Consumers pay less out-of-pocket, often for brand-name drugs. This encourages patients to use the brand-name version of the drug, even when a cheaper, generic version might be available.

Some insurers say this unfairly puts them on the hook for pricier drugs. They say monthly premiums are higher as a result, punishing consumers and patients, not the manufacturers.

So, should you use manufacturer-sponsored prescription drug coupons when they are offered?

The short answer: It depends.

Here are five things to consider:

1. What if you do not have insurance?

If you are uninsured, using a coupon can be a great way to save money, especially if there is no generic version of the drug.

TrumpRx is a new federally funded initiative that acts as a prescription drug coupon dashboard for patients. Some of the coupons come from manufacturers, while others do not. Not every drug has a coupon offer, but the portal will save consumers money on drugs for those that do, especially in the short term.

Michelle Long, a senior policy manager at KFF who studies patient and consumer protections, said people without insurance can save money by using TrumpRx or manufacturer coupons. (KFF is the health policy research, polling, and news organization that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

“I wouldn’t brush it off entirely because it’s got Trump’s name on it,” Long said. “For a lot of people who take certain medications, there really could be some real savings.”

Still, Long said, TrumpRx lists only about 85 drugs, among thousands approved by the FDA. It is important to note that drug coupons have limitations and guidelines. They do not last forever. When they are exhausted, uninsured consumers may have to pay full price for the drug.

2. What if you have commercial health insurance?

For people with insurance, the answer is a little more complicated.

If the drug isn’t covered by your insurance plan or if you intend to pay cash, then the coupon may be the way to go. If not, be wary.

Insurance coverage varies for certain kinds of drugs, such as GLP-1 obesity drugs. Kang’s study found that coupon use by commercial insurance holders on obesity drugs dropped from 54.6% of prescriptions in 2017 to only 2.5% in 2024, even though use of the drugs has been rising in the United States.

She said this reflects the growing number of patients paying cash for the drugs as prices decline, along with insurers’ reluctance to cover them and manufacturers’ shifting focus from coupon distribution to marketing campaigns.

3. What should you do if you expect high medical costs this year?

If you have insurance and anticipate meeting your deductible for the year through health care visits and treatments, consider using the coupons.

Coupons let you pay less out-of-pocket when you visit the pharmacy, but your insurer likely won’t count the value of the coupon toward your deductible. Only use a coupon if there is no generic option available and if you know you’d otherwise hit your deductible.

4. What if you have insurance but low overall medical costs?

The answer will almost always be: Don’t use the coupon.

Unless the drug you are looking for is not covered by your insurance plan, using coupons will put you at risk for higher indirect costs. It’s also often more advantageous to spend toward your deductible.

Watch out for copay adjustment programs that insurers use to discourage the use of drug coupons. They come in two common forms, Long said.

“” allow the use of drug coupons up to their full value, but the amount of the coupon won’t count toward patients’ deductibles or out-of-pocket maximums. That makes it harder for them to reach the threshold at which insurers will pitch in on prescriptions and other medical care. It can also mean a patient will eventually start paying the full cost of the drug because they haven’t yet met their annual deductible.

“Copay maximizers” use a similar technique that also prevents the coupon value from counting toward deductibles. Maximizer programs use a third party to over the course of a year to match the amount of the manufacturers’ coupons.

Insurers sometimes offer the programs to consumers under euphemistic names like “Employee Savings Program” that sound good in theory, but, in reality, take away some of the value of the coupons, Long said.

Initially, consumers will see savings at the pharmacy counter, but they may end up paying more in the long run.

5. What if you’re on Medicaid or Medicare?

Medicare and Medicaid beneficiaries are prohibited from using manufacturer-sponsored coupons.

A federal anti-kickback law makes it illegal to give someone anything of value to influence their decision to purchase something that will ultimately be paid for by a federal health care program. The law also prevents remuneration, which includes waiving copays and charging less than fair-market value for a product.

Manufacturer drug coupons categories.

Some states, notably California and Massachusetts, prohibit or limit the use of manufacturer drug coupons when a generic version of the drug is available — highlighting the tension among manufacturers, health plans, and the government.

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No surprise. About are “worried about being able to afford prescription drug costs for themselves or their families,” a recent KFF nationwide poll showed. More than 80% consider the price of prescription drugs “unreasonable,” and most support increased regulation to lower costs. Americans pay about three times as much as people in other countries for the same prescription drugs.

Last July, Trump sent letters to 17 drugmakers, demanding they voluntarily lower drug prices. Then the president said he’d negotiated one by one at the White House. In December, that he had compelled them to agree to on Medicaid, the government coverage for low-income Americans.

Then came the , a site where cash-paying patients could find discounted medicines, and a promise to speed biosimilar products — generic versions of certain high-priced specialty drugs — by cutting through FDA red tape.

The scope of these grand gestures remains uncertain. But it’s certainly less than what the announcement promised, partly because many details of the negotiations, even which drugs are covered, are hazy.

White House spokesperson Kush Desai did not answer queries about TrumpRx.

Medicaid already buys drugs at deep discounts. And other patients may well have better options through commercial drug discount programs, which offer far more products, or through their insurance and associated drug company copayment cards.

So, for all Trump’s showmanship, the share of Americans likely to benefit from these options remains slim, even if some people do come out ahead.

“If it makes a difference to any patient, it’s a win,” said Mark Cuban, a billionaire investor on his own mission to bring down drug prices. He pointed to discounted pricing on TrumpRx for branded fertility drugs and GLP-1 weight loss drugs for people without insurance or whose plans don’t include coverage. Cuban launched the Mark Cuban Cost Plus Drug Co., known as Cost Plus Drugs, in 2022 to sell drugs cheaply by eliminating middlemen — buying from factories and selling directly to consumers. Most of the drugs he sells are generics.

Aaron Kesselheim, a professor of medicine at Harvard Medical School whose research focuses on drug prices, said the Trump announcements are “one-off agreements made for publicity purposes. They don’t change anything about the way drugs are priced.”

He added: “The agreements are opaque and unenforceable.”

It was unclear, for example, which drugs would be sold at “most favored nation” prices or how exactly that was defined. But, clearly, not all were.

Doing the Math

46brooklyn, a consulting firm and data project that tracks brand-name drug prices, found that close to 1,000 brand drugs went up in price in January 2026. What’s more, 2025 had the highest number of list price increases ever. “This is not a material change, it’s business as usual,” said Antonio Ciaccia, the company’s co-founder.

In the first week of 2026, Pfizer raised the list prices of 71 drugs by an average of 5% and lowered the price of only one, by 9.8%, the data project found.

The biggest win for patients has likely been the Trump administration’s quiet continuation of a Biden administration program: Medicare drug price negotiation for expensive drugs. The negotiated discounts on the — from blood thinners to insulins to medicines for inflammatory disorders — went into effect Jan. 1. With reductions in price of on some products, the estimated $6 billion in annual savings allowed the program to cap Medicare patients’ out-of-pocket spending on Part D prescription drugs at $2,000 for 2025 and beyond.

An additional 15 high-priced drugs — including popular weight loss and cancer drugs — were subject to negotiation in 2025, with discounted Medicare prices taking effect next year. And 15 more high-priced drugs are . All told, the 40 negotiated drug prices are expected to save Medicare well over $20 billion a year.

Even as these discounts take effect, drug industry lobbyists have been working to limit the impact, with some success. For example, the One Big Beautiful Bill Act from negotiations.

Still, “this is historic because it’s the first time the United States has negotiated prices, like every other developed country,” Kesselheim said. “And guess what? Innovation didn’t stop.”

Of course, these discounts benefit only Medicare enrollees. The newer Trump administration initiatives help some other patients, but they are limited and require knowledge of how to access the discounts.

Trump’s One-on-Ones

The president’s televised appearances with the heads of major drug companies resulted in deals, but few, if any, will mean much to patients. For example, after Trump met with Albert Bourla, CEO of Pfizer, the company announced discounts on 30-plus drugs. Bourla “a win for American patients, a win for American leadership, and a win for Pfizer.”

The discounts are offered via TrumpRx, which, in turn, offer coupons co-branded on GoodRx.com, which already offers discount coupons for many hundreds of medicines.

Pfizer made hay of the deal, announcing it was part of Pfizer’s broader, landmark with the U.S. government, enabling patients to pay lower prices for their prescription medicines “while strengthening America’s role as the global leader in biopharmaceutical innovation.”

Pfizer spokesperson Steven Danehy cited a press release from September noting that the TrumpRx site offers patients savings that “range as high as 85%.”

Most of the list features brand-name drugs, competing with far cheaper generic versions from other manufacturers, such as the cholesterol-lowering drug Colestid, which TrumpRx lists for “50% off” at $127.91. Generic versions cost about $17 on the Cost Plus site.

This means the branded companies aren’t making a sacrifice by offering them at lower costs as reflected on Trump’s portal, said Sean Tu, a patent law expert at the University of Alabama. “That’s a sale they would not have made if not for TrumpRx.”

Others are very old drugs, such as Cortef, or hydrocortisone, whose 5-milligram branded Pfizer version is listed at $45 on TrumpRx, half its list price of $91.80. It sells for far less on Cuban’s Cost Plus site. Still others, such as the $607.20 HIV treatment Viracept, are useful only in combination with other drugs that are not discounted.

Last week, TrumpRx added AbbVie’s Humira, for years the world’s best-selling drug, at $950 a dose, down from a list price of nearly $7,000. But Humira lost its patent protection in 2023, and biosimilars — essentially generic equivalents — have since come to market. More to the point, two of those biosimilars are listed on TrumpRx for as little as $207.60 a dose.

Since most of the TrumpRx products are available only to customers without insurance who pay cash, the arthritis drug Xeljanz’s drop from $2,277 to $1,518 a month would still leave it unaffordable.

A Few Notable Deals

The much-touted TrumpRx site, launched Feb. 6, consists largely of Pfizer’s 30 drugs (30 of roughly 85) with a smattering of discounts likely to generate headlines.

These include three fertility drugs from EMD Serono, a subsidiary of the pharmaceutical giant Merck KGaA, the most expensive of which, Gonal-F, has a list price of $966 but is only $168 per IVF cycle using a TrumpRx coupon.

They will save women thousands of dollars — although the overall cost of fertility treatment will continue to put them beyond the reach of many, since drugs represent only a portion of the payment.

The TrumpRx discounts could reduce the $15,000-to-$25,000 cost of a single fertility treatment cycle — women typically need two or three cycles to become pregnant — by about 10%, said Sean Tipton, spokesperson for the American Society for Reproductive Medicine. In some European countries, each cycle costs about $3,000.

In exchange for lowering those prices, EMD Serono got tariffs lifted on its mostly overseas-produced medications. It also won the right to a sped-up FDA approval process for a fertility drug it’s been marketing heavily in Europe.

Another newsworthy offering on the site resulted from a deal with Novo Nordisk for Wegovy, its GLP-1 drug for weight loss and diabetes, with the price reduced to as little as $199 a month for the pen. (Many insurers cover such drugs only for diabetes, leaving those who are interested in losing weight paying out-of-pocket. Zepbound, Wegovy’s Lilly & Co. competitor, is also on the list, at $299.)

Pressure has been building on Novo and Lilly to lower the U.S. price of their GLP-1 drugs. The compounds have lost patent protection in India, and pressure from customers buying overseas will likely increase when generic Wegovy goes on sale in Canada, for as low as $73 a month, possibly this year.

In the United States, meanwhile, dozens of patents should keep Wegovy generics off the market until 2039, said professor Robin Feldman, a patent expert at the University of California Law-San Francisco. A from the research group I-Mak delved into several ways patent manipulation keeps generics off the U.S. market long after they are available in European countries and Canada.

And while the Trump administration has vowed to approve biosimilars more rapidly to ensure more competition and lower prices, that may not have much impact. The big hurdle in getting generics and biosimilars to market is often not FDA approval, but the time it takes to override the thickets of patents that U.S. law allows manufacturers to deploy to protect their intellectual property.

For example, in 2021, the FDA approved a generic of Otezla, a popular drug for psoriatic arthritis, but it will not hit the market until 2028. Its entry would to Medicare if they charged the program more than other developed countries for “single source” drugs and biologics. That would essentially allow the Medicare program to piggyback on other countries that negotiate the prices of some of the most expensive medicines. Those programs are still going through the rulemaking process and, again, would benefit only those covered by the Medicare program and only indirectly.

The average patient-consumer, if willing to pay cash, may find some bargains. But getting the best deal could take a lot of mixing and matching, forcing patients to become choosy shoppers, eyeing deals for essential medicines as they would for a carton of milk or eggs.

Data reporter Maia Rosenfeld contributed to this article.

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The sweeping 195-page , published May 4, advocates for making access to treatment easier than getting drugs, preventing young people from developing addictions in the first place, increasing support for people in recovery, and reducing overdose deaths.

Those broad goals are widely supported by public health researchers, addiction treatment clinicians, and recovery advocates.

But accomplishing such goals will be difficult in the face of the administration’s , and community grants, that serve people who use drugs, and , the state-federal health insurance program for low-income people that is the largest payer for addiction and mental health care nationwide.

Many components of the National Drug Control Strategy are “things that we would agree with and that we fully support,” said , who leads overdose prevention efforts at the Global Health Advocacy Incubator, a public health advocacy group.

But there are “disconnects in what the strategy says is important and then what they’re actually going to fund,” she said of the Trump administration. “Those inconsistencies feel particularly loud in this strategy.”

The White House’s National Drug Control Strategy, released , is a touchstone document meant to lay out the federal government’s coordinated approach to what in recent decades has been one of the country’s defining problems.

Since 2000, have died of drug overdoses. Although deaths have , the numbers remain elevated compared with earlier decades, and overdose death rates among Black Americans and Native Americans are disproportionately high.

The strategy document published this week is the first of President Donald Trump’s current term. In keeping with the administration’s approach to addiction issues, it places heavy emphasis on law enforcement efforts to reduce the supply of illicit drugs. The document repeatedly refers to the ongoing “war” against “foreign terrorist organizations” — the Trump administration’s term for drug cartels — and touts increased enforcement at U.S. borders.

It also to implement artificial intelligence technologies to screen for illicit drugs brought into the country and wastewater testing to detect illegal drug use nationwide.

The second half of the strategy focuses on reducing the demand for drugs through public health prevention efforts, addiction treatment, and support for people in recovery. It promotes the role of religion in recovery and calls for the widespread use of overdose reversal medications, such as naloxone.

In a news release, the White House’s Office of National Drug Control Policy called the document a “roadmap” that will “continue dismantling the drug supply and defeating the scourge of illicit drugs in our country.”

The Trump administration did not respond to requests for comment about how the strategy aligns with its other actions.

In December, Trump signed a , which continues several grants related to treatment and recovery and the requirement for Medicaid to cover all FDA-approved medications for opioid use disorder. In January, he announced the , including a to address homelessness, opioid addiction, and public safety.

However, few details have been provided about the initiative, and in January, about a month after the SUPPORT Act passed, billions of dollars in addiction-related grants were abruptly within a frantic 24-hour period.

That “whiplash” left “a sense of instability and uncertainty in the field,” said , a national adviser with the Manatt Health consultancy. She led substance use treatment policy at the Substance Abuse and Mental Health Services Administration, or SAMHSA, under the Biden administration and left about six months into Trump’s second term.

That insecurity was exacerbated by the , which proposes cuts to several addiction and mental health programs and the consolidation of key federal agencies working on those matters. Jones’ group and nearly 100 others in the field have asking Congress to reject the proposals, as it did with similar requests last year.

The national drug strategy adds new, potentially contradictory information to this confusing landscape.

Increasing Access to Treatment

One of the most significant public health goals in the strategy, mentioned at least half a dozen times, is to make it easier to get treatment than it is to buy illegal drugs.

National data underscores the necessity: More than who need substance use treatment don’t receive it.

The administration’s actions on health insurance may make it difficult to improve that statistic.

Medicaid is the for adults with opioid use disorder. When implemented, the Medicaid work requirements in Trump’s One Big Beautiful Bill Act are projected to strip that coverage from with substance use disorders.

The last time Medicaid rolls were purged — after — many people who had been receiving medication treatment for opioid addiction stopped it and fewer people started treatment, according to a .

Olsen, who is also an addiction medicine doctor, said she loves the strategy’s emphasis on making treatment readily available to anyone who wants it. But she said that’s “hard to really imagine when now people may have to pay for it themselves because they may be losing their Medicaid insurance coverage.”

the upcoming Medicaid changes could lead 156,000 people to lose access to medications for opioid use disorder and result in more than 1,000 additional fatal overdoses per year.

People with private insurance may be affected, too.

The Trump administration has Biden-era regulations aimed at bolstering mental health parity, the idea that insurers must cover mental illness and addiction treatment comparably to physical treatments. And recently, the administration said it would altogether, raising fears that addiction treatment could become increasingly unaffordable.

The administration did not respond to specific questions about how it reconciles its actions on Medicaid and parity with the goal of increasing treatment.

Prioritizing Prevention

The strategy highlights preventing addictions before they begin as one of the keys to reducing demand for drugs. It calls for “promoting a drug-free America as the social norm” and implementing school and community-based programs that are backed by science.

“Investing in primary prevention, before drug use starts, saves lives and resources,” it says, citing about of such programs.

Yet, the president’s budget proposes cuts to these types of programs, and federal layoffs have decimated the agencies that would implement such work.

The White House’s proposes cutting roughly $220 million from SAMHSA’s and nearly $40 million from the program.

Since the new administration started, SAMHSA has , and the Centers for Disease Control and Prevention is . 

“It’s not clear to me that they’re really going to be able to have the funds or the people to be able to carry that out,” Olsen said of the strategy’s prevention goals.

Another wrinkle appears in the strategy’s discussion of marijuana. The document points to marijuana use as one of the drivers of increasing drug use disorders and reports that “convergent evidence from multiple sources” suggests cannabis use increases the risk of psychosis. It calls for developing new tools to treat marijuana withdrawal and addiction.

However, just two weeks ago, the White House medical marijuana to a lower tier of scheduled substances and is moving to to do the same for marijuana broadly.

“The administration, on the one hand, is moving in a direction of liberalizing access to cannabis,” Jones said, “but at the same time, in the strategy, it talks about the dangers of doing so.”

“There’s a disconnect there that just makes you question: Which one do you believe?” she added.

The administration did not respond to specific questions about its marijuana policies.

Stopping Overdose Deaths

One of the more surprising elements of the National Drug Control Strategy comes in the last paragraph of the final chapter. It focuses on public drug-checking programs, which often involve using test strips to help people who use drugs determine whether there are more-dangerous substances, such as fentanyl or xylazine, in the batch they bought. That helps them determine whether or how to safely use those drugs.

“Rapid test strips and similar technologies that detect fentanyl and other drugs are an important tool that should be legal,” the strategy document says.

However, SAMHSA announced in that it would no longer pay for test strips, as part of the Trump administration’s “clear shift away from harm reduction and practices that facilitate illicit drug use.”

The administration has similarly attacked harm reduction programs in an and its budget . It did not respond to specific questions about how this position interacts with the drug control strategy.

, a Georgetown University professor who served as acting director of the Office of National Drug Control Policy during the Biden administration, wrote about the contradiction in : “It is the height of rhetoric over reality to champion a tool while simultaneously cutting off the funding used to acquire it.”

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It is urging the public to report hospitals and nursing homes that serve sugary drinks, nutrition shakes, or meals that it says don’t meet dietary guidelines established last year by the U.S. Department of Agriculture, with officials vowing to withhold millions of dollars in federal funding if violations occur.

The initiative from Health and Human Services Secretary Robert F. Kennedy Jr. is spurring backlash from some doctors and medical providers who say it fails to account for patients’ unique dietary needs and is anathema to Republicans who have long embraced an anti-regulatory stance.

It’s also not clear that HHS has the regulatory authority to enforce its threat without going through a formal rulemaking process, lawyers and dietitians say.

“Most of this is political theater. HHS doesn’t have the power to do much,” said , a dietitian and research scientist who is an assistant professor at the University of Toronto. “Also, if it’s to the point that you’re trying to control people’s choices, well, you look a little fascist.”

The agency to hospitals asking them to align their food purchases with the administration’s 2025-30 dietary guidelines to ensure continued eligibility for Medicaid and Medicare payments, Kennedy said at a March 30 press event.

“We are going to bring all the hospitals in the country in line with good food,” he said, describing the instructions as “essentially a .”

“If a hospital is serving patients sugary drinks, they are out of compliance with government standards and are putting their reimbursements in jeopardy,” top Kennedy adviser Calley Means “If you see patients being served sugary drinks, please post information below or let CMS know.”

The comment included a link to an HHS webpage with a toll-free number for reporting complaints typically used for medical bills. Withholding federal funding from hospitals is one of the most extreme enforcement tools available to regulators, one the Centers for Medicare & Medicaid Services has seldom deployed.

Even serving liquid nutrition products like Ensure to patients could put hospitals in jeopardy, Means warned. “They need to change or lose reimbursement. Please report them if you see it,” he told an X user.

Medicare and Medicaid, combined, are the of hospital expenditures.

The notice came in the form of a “Conditions of Participation” update released by CMS to ensure hospital patients’ food adheres to the dietary guidelines, HHS spokesperson Andrew Nixon said. “We commend the many hospitals who have made commitments to improve their food offerings, and expect every hospital system to do so,” he said.

Means did not respond directly to requests for comment from Ñî¹óåú´«Ã½Ò•îl Health News, instead posting on X shortly after he was contacted: “‘Trump Derangement Syndrome’ has led Democrats to defend the medical importance of mass-serving soda and junk food to American patients.” In a text with Ñî¹óåú´«Ã½Ò•îl Health News, he said, “That’s to cite if you want. I don’t have a comment.”

Still, some administration officials have made it clear they will not shy away from halting federal funding, a rarely taken step that can imperil the ability of a hospital to remain open.

A Carrot and a Stick

HHS can withhold or threaten federal funding if hospitals violate mandatory minimum health and safety standards set by the agency. The standards stipulate that hospitals must protect patient privacy, for example, and uphold infection control.

The standards do address hospital food, but they don’t explicitly refer to the 2025-30 established by the USDA.

Rather, the standards require that “individual patient nutritional needs must be met in accordance with recognized dietary practices,” and list other requirements for hospitals, such as having access to a qualified dietitian.

“CMS has never before interpreted this requirement as mandating adherence to any set of dietary guidelines,” according to an from law firm .

The CMS memo shows the agency is taking the “notable step” to incorporate the dietary guidelines “into the hospital regulatory framework without new rulemaking,” according to the brief.

Hospitals are likely to comply because they are loath to cross the federal government and want to avoid a legal tussle or enforcement action by Kennedy, some lawyers say.

“He doesn’t have a legal basis to do this, but hospitals and nursing homes can’t afford to ignore it altogether because of what it signals about potential enforcement action,” said , a University of Michigan law professor.

If federal funding were withheld, hospitals could always sue to try and challenge HHS’ authority.

“When the agency goes to the hospital and says, We’re going to take away your money for this, the hospital can sue and say, Look, nothing requires us to fry our fries in beef tallow or whatever,” Bagley said.

For hospitals looking to comply, the agency’s memo provides examples of what should and shouldn’t be served to patients.

Food as Medicine

What the guidance calls “don’ts”: sugar-sweetened beverages or juice. And “do’s”: water, unsweetened tea, milk, or coffee. Meals suggested in the memo include grilled salmon with quinoa or bean-based entrees with leafy greens.

Some nutritionists welcomed the focus on hospital food for patients. Marion Nestle, a public health advocate and molecular biologist, lauded the initiative, saying, “These sound terrific!” in an on her blog, .

Other health leaders and doctors pushed back, noting hospitalized patients often have more individualized nutrition needs that may not conform to federal dietary recommendations.

For “a patient struggling to swallow from just having a stroke, salmon and quinoa is the worst thing for them. They’re going to risk aspirating on it,” said Klatt, the University of Toronto dietitian.

Hospitals that neglect to provide certain standards of care, such as protein shakes to treat malnutrition or an unhealthy weight loss, could open themselves up to possible legal liability. Eighty percent of malnourished elderly patients gained weight and improved muscle mass on nutritional supplements such as Ensure, according to the published in Nutrición Hospitalaria, a peer-reviewed scientific journal.

Abbott, which , makes a range of products including shakes for people who “could be malnourished due to medical treatments, such as chemotherapy, and not be getting the calories they need because they don’t have much of an appetite,” company spokesperson John Koval said in a statement.

“It’s always a struggle to get people to eat. Losing weight in the hospital raises the risk of mortality,” said Mary Talley Bowden, a , who has with Make America Healthy Again causes but on X, posting: “Give me a break Calley. A hospital snitch line for soda?”

“It’s a little tyrannical,” she said in an interview.

The focus on hospital food came in late March as part of Kennedy’s MAHA initiative, in which he has touted changes to federal dietary guidelines that emphasize protein and healthy fats while eschewing processed foods.

Kennedy has leaned heavily into his work on changing eating habits, which fits into the MAHA gestalt and polls well with both Democratic and Republican voters. Eighty-six percent of registered voters surveyed said it should be easier for every American family to access fresh fruits and vegetables, released in September by Navigator Research.

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He’d need to secure tax increases to help cover the high cost of a single-payer system, once pegged at a year, and Republican President Donald Trump, then in his first term, would have to give California permission to use federal funding to convert the system of coverage from one determined by employment, age, or income.

Neither was politically feasible.

Instead, in the years that followed, Newsom muscled through a compassionate healthcare agenda that poured billions into new benefits, including Medi-Cal coverage for low-income immigrants without legal status and incarcerated people leaving jail or prison, as well as programs for people experiencing homelessness in and most populous state. Medi-Cal, the state’s Medicaid program, now includes housing services, including six months of free rent for those in need, and home-delivered healthy meals for low-income Californians with chronic health conditions. He made it a priority to expand mental health and addiction treatment, especially for the tens of thousands living on the streets.

He also tackled the soaring cost of healthcare, including by offering bigger subsidies for low- and middle-income earners to purchase insurance and empowering a new state agency to slow the rise in healthcare spending. Years before , the president’s program to lower prices for some medicines for people without insurance, Newsom signed into law a policy setting up a state-branded generic prescription drug label known as to provide lower-priced drugs. And amid a federal attack on reproductive rights, Newsom .

The liberal values that guided Newsom’s healthcare ambitions were forged early in his life and cultivated during his two terms as mayor of San Francisco. His approach in the governor’s office is described by allies as socially liberal and fiscally pragmatic. The policies he has supported offer a road map for the direction he would lead the nation, should he run for and be elected president in 2028. Now in his final term as governor, Newsom will be scrutinized for his healthcare record, criticized by liberals as too moderate and by Republicans as too radical.

Newsom, 58, is known for his all-out approach, a style that leads him to take on a barrage of flashy and complicated policy proposals at once, earning him a reputation in some political circles of overpromising and underdelivering. Newsom has notched some successes, but his record is also marked by failures. He hasn’t housed as many people as he envisioned — there are nearly in California, according to the most recent federal estimates, more than when he became governor. Medicaid spending has more than doubled under his watch, drawing criticism from Republicans, and patients around the state are experiencing problems getting timely medical appointments and quality care.

Newsom’s closest allies argue that he has balanced efforts to make healthcare more equitable, accessible, and affordable. They argue his unmet policy goals are not failures but investments and long-term strategies to better serve poor and marginalized people while containing healthcare costs.

“We would talk about how you win by losing,” said Mark Ghaly, who served as Newsom’s health and human services secretary until 2024. “The governor isn’t afraid to fail. But by failing you learn about how to make it successful.”

Although voters in the Democratic stronghold of California have supported many of his ideas, residents have grown increasingly weary in their support. An from the University of California-Berkeley Institute of Governmental Studies showed Newsom’s job approval slipping as he has focused on attacking Trump on the national stage.

have become a top concern for voters across the political spectrum. Two-thirds of the public in January said they worried about being able to afford healthcare for themselves and their families, according to a . And a recent found roughly a third of adults in America have made at least one trade-off to afford healthcare, such as driving less, skipping meals, cutting utility use, rationing prescriptions, or borrowing money.

Despite the criticisms, Newsom’s extensive record on healthcare can give him an edge in a presidential primary contest, said , a national Democratic strategist who specializes in healthcare polling. “Newsom has, by far, the most comprehensive and authentic agenda of any Democrat out there,” she said.

Universal Healthcare

Newsom has said that healthcare should be a , not a privilege. Though he backed away from single-payer, he remains steadfast in his support for a universal healthcare system that covers everybody, regardless of immigration status or ability to pay.

When he was mayor of San Francisco, in 2006, he signed into law , a universal health program that extended care to all uninsured adults who had been unable to access coverage. The program, paid for through a combination of public funds, employer contributions, and a sliding fee scale for patients based on income, became immensely popular, extending care to who had been uninsured.

Newsom also waded into the national healthcare debate leading up to the enactment of the Affordable Care Act, pushing for a government-run insurance plan to compete with commercial health insurers. “Healthcare reform without a public option is not reform,” .

In 2017, amid his two terms as lieutenant governor, Newsom had launched his run for governor and gained momentum by making healthcare a central pillar of his campaign. During the gubernatorial primary, he said healthcare “.” He set himself apart by tacking left and earned a critical endorsement from the California Nurses Association, pledging to fight for single-payer.

“It’s time for a new approach,” Newsom said during his campaign. “I’m tired of politicians saying they support single-payer but that it’s too soon, too expensive, or someone else’s problem.”

On his first day in office, he signed a series of directives to explore the feasibility of single-payer, in part by seeking federal healthcare waivers that would be needed to fund a new system. He didn’t deliver, but advisers argued he mimicked some components of single-payer, including cost containment, comprehensive benefits, and universal coverage.

“He looks much more broadly at the healthcare system, and what it can do to help people,” said Newsom Deputy Cabinet Secretary Richard Figueroa. “There is also a role for the government to play in cost containment. The governor has been trying to set up some fundamental changes to move toward a more accountable healthcare system.”

The nurses union, however, blasted Newsom for backtracking, arguing he kept the profit-driven insurance system intact and failed to deliver a critical healthcare promise.

Jasmine Ruddy, director of the National Nurses United and California Nurses Association’s community and Medicare for All campaigns, said Newsom pulled a bait and switch on Californians, purposely mixing up universal healthcare with single-payer. She pointed to commissioned by the Newsom administration that found single-payer could increase taxes but, in one scenario, would save an estimated $16 billion the first year in state healthcare costs.

“Covering everyone is important, but Newsom is supporting a system that still has insurance premiums, deductibles, and copays,” Ruddy said. “And you can still wind up with an enormous hospital bill and medical debt. That is not the same as guaranteeing healthcare for all.”

The pressure is already building for Newsom to get behind single-payer — and nationally. Ruddy said, “If he runs for president as a progressive, he has no choice but to support Medicare for all.”

A Behavioral Health Crisis

Newsom has taken an ambitious approach to homelessness, framing it as a public health crisis fueled by a lack of affordable housing and inadequate mental health and addiction care. Arguing that the state had ignored the problem for too long, he took ownership of the challenge by increasing temporary funding for cities and counties to move people off the streets and into housing. At the same time, he called for a statewide push to dislodge homeless encampments.

Although his policies rankled homeless advocates by sweeping people from their encampments without providing enough services or housing, Newsom considers it his highest calling. “The junction of mental illness, drug addiction, and homelessness was why I had even pursued a life in politics in the first place,” he wrote in his memoir, Young Man in a Hurry, published in February.

Since Newsom took office in 2019, California has doled out an unprecedented for homelessness and housing-related programs.

His interest in mental health and addiction, he said, stems from personal experience, and seeing that it touches so many Californians. “It’s not just about what’s happening on the streets and sidewalks; it’s what’s happening behind closed doors as well,” Newsom said in response to a question from Ñî¹óåú´«Ã½Ò•îl Health News in March. He referenced his grandfather, saying, “He ultimately took his life, committed suicide.”

In his memoir, Newsom alludes to those family issues. He also references his drinking as mayor of San Francisco, a time when his political celebrity was rising and he had an affair with the wife of his campaign manager. Although he , he said he stopped drinking until a family friend who operated a rehabilitation center gave him permission to drink again. For all his investments in the healthcare safety net, Newsom’s critics say his policies have weakened access to basic care and failed to solve homelessness.

“Despite all that spending, there are still so many people who can’t even get in to see a doctor, and who might be covered on paper but aren’t able to actually get the care they need,” said Rep. Kevin Kiley, a Republican-turned-independent who is running in a newly drawn House seat and served in the Democratic-controlled state legislature earlier in Newsom’s tenure as governor. “Billions of dollars have gone to immigrants, when our own citizens haven’t had access to healthcare.”

Assembly member David Tangipa, a Fresno Republican, said Newsom is bankrupting the state, referring to ballooning costs in Medi-Cal, which have grown from $100.7 billion in 2019 to $222.4 billion for the fiscal year starting July 1. “It’s baffling to see this governor attacking the president, when we have our own problems: Doctors are leaving this state, and we have hospitals on the verge of collapse,” he said.

Newsom’s healthcare record could be a political liability. “Single-payer is a perfect example of Gavin Newsom — that when things get tough, he cuts and runs,” said , a health policy fellow at the conservative-leaning Hoover Institution.

Now in his final full year in office, Newsom is confronting massive fiscal challenges.

Recent state financial deficits, worsened by the healthcare cuts in congressional Republicans’ One Big Beautiful Bill Act, have forced Newsom to on his expansion, particularly of Medi-Cal. This year, he froze new enrollments for adult immigrants living in the country without authorization.

Yet he is still framing his healthcare record as one of success. In an , Newsom proclaimed that he had achieved universal healthcare. “We delivered it,” he said.

But California does not have universal healthcare. Before passage of the One Big Beautiful Bill Act, estimates showed nearly 2.6 million , including people who chose to forgo coverage and immigrants without legal status who earned too much money to be eligible for Medi-Cal.

Projections in 2025 showed that remained uninsured, lower than the roughly 8% when Newsom took office. Yet the number of uninsured residents is as a result of Trump administration healthcare policies. Estimates show the GOP bill will cost the state an estimated over the next 10 years and result in up to 3.4 million Californians losing coverage.

Even so, Newsom has been reluctant to raise taxes. He opposes one to backfill federal healthcare funding losses through a on the state’s .

“That’s not what we need right now, at a time of so much uncertainty,” . “Quite the contrary.”

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A from 42 states and the District of Columbia offers insights into key policy decisions state officials face as the Jan. 1, 2027, deadline for implementing the work requirement nears. Lingering questions include which diseases and illnesses will qualify Medicaid beneficiaries for exemptions and how to automate compliance verification. 

Federal guidance is not expected to be released until June. But some states are moving forward with their own definitions of “medical frailty,” which under congressional Republicans’ One Big Beautiful Bill Act will allow Medicaid enrollees to escape the requirement.

The law, President Donald Trump’s signature domestic achievement, revamps Medicaid in more than 40 states that, along with Washington, D.C., fully or partially expanded the program for low-income people to cover adults without children who don’t get insurance through a job. While most adult Medicaid beneficiaries already work or are disabled, caregivers for other people, or in school, many Republicans contend that people enrolled in the program who don’t work sap resources that ought to support low-income children, pregnant women, and disabled people.

gained Medicaid coverage from the expansion, created by the Affordable Care Act — a law that most Republicans still oppose.

The new work rules require that a person be a student at least part-time or work or participate in other qualifying activities, such as community service, for at least 80 hours each month. The requirement could potentially reshape who is eligible for Medicaid and applies to people who are already enrolled.

The Congressional Budget Office will reduce federal Medicaid spending by about $326 billion over 10 years. The agency also estimates that 4.8 million more people will be uninsured in 2034 because of the work requirement.

 “A lot of states are working on a super-condensed timeline,” said Amaya Diana, a policy analyst at KFF who worked on the survey. They are “still making these big decisions with less than a year before implementation.”

KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

The law permits short exemptions from work requirements for enrollees experiencing certain hardships — natural disasters, residing in a county with a high unemployment rate, admission to a hospital or nursing home, or having to travel for an extended period to obtain medical care.

While 28 states and Washington, D.C., will offer hardship exemptions, three of those states won’t adopt all four exemptions allowed by the law and two — Iowa and Indiana — don’t plan to adopt any.

People can also be exempted from the work requirements if they are “medically frail.” But the federal government has not told states how to define that term or how to determine whether an enrollee falls into the category.

The survey showed that 21 states, as of March, had not defined medical frailty. Nebraska, which is implementing its work requirement May 1, recently issued a list of thousands of health conditions that could qualify enrollees as “frail” and exempt them from working.

Some states plan to allow patients to self-attest to medical frailty, while others will require confirmation by a medical professional. The most common way of verifying medical frailty, which will be used in just over 30 states, is by examining Medicaid claims data.

Mehmet Oz, administrator for the federal Centers for Medicare & Medicaid Services, told Ñî¹óåú´«Ã½Ò•îl Health News in an interview this week that “we don’t like self-attesting” and that “documentation is critical.”

Many beneficiaries and their advocates have expressed concerns about losing coverage for administrative reasons. When Arkansas briefly implemented Medicaid work rules, for instance, most lost coverage not because they did not meet the requirements but for failing to correctly submit paperwork in time.

Six states plan to use AI to assist with the work requirement implementation in some way, such as for document processing or comparing beneficiary data from different sources, KFF found. Two states, Maryland and New Mexico, plan to use AI to analyze claims data.

Three states — Arkansas, Missouri, and Oklahoma — plan to use AI to interact directly with people on Medicaid and assist them with identifying and uploading verification documents and data.

Adults on Medicaid will have to reverify that they’re working, or that they’re exempt from the requirement, at least every six months. Some states plan to check quarterly.

When possible, states must use available data sources to verify exemptions or compliance with work requirements.

For example, data from the National Student Clearinghouse will be used by about 10 states to verify school attendance. Some states also plan to tap sources including the Department of Veterans Affairs, AmeriCorps, and service commissions.

But more than half of states told KFF’s researchers that they have insufficient time to add new data sources and cited ongoing costs as a challenge.

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Still, even with three jobs, she worries about losing her health coverage when Nebraska, on May 1, becomes the first state to require certain Medicaid enrollees to work, train, or go to school under a rule mandated by congressional Republicans’ One Big Beautiful Bill Act.

Simpson, 46, has relied on Medicaid since her divorce in 2014. None of her employers offers health coverage. She said she lost her government food assistance after technical problems caused her to miss renewing in time, and she doesn’t trust the state to implement the new work rules without problems.

“Adding more barriers won’t make the program work any better,” she said.

Nebraska Medicaid officials say they are trying to make it as easy as possible for enrollees to comply, so people don’t lose their coverage for administrative reasons, such as failing to file the proper paperwork.

Enrollees with one of thousands of health conditions detailed by the state would be exempt.

“Our top priority is making sure members clearly understand changes to the program and how to maintain their coverage,” Drew Gonshorowski, the state’s Medicaid director, said in an early-April news release.

In a brief interview with Ñî¹óåú´«Ã½Ò•îl Health News on April 28 outside the National Press Club in Washington, D.C., Centers for Medicare & Medicaid Services Administrator Mehmet Oz said he applauds Nebraska for being the first state to begin implementing the work requirements. He acknowledged that the state is still “working out the kinks,” adding that his hope is “by the end of this year they will get into a more sophisticated place.”

But health policy analysts, advocates for the poor, and health industry groups remain skeptical, fearing thousands of Nebraska Medicaid enrollees will lose coverage and, with it, their access to health services and protection from medical debt.

Hospitals also worry an increase in uninsured patients will hurt their bottom lines, said Jeremy Nordquist, the president and CEO of the Nebraska Hospital Association.

“There is a lot of concern on many different levels,” he said. Many enrollees are unaware of the changes and might not realize they have to act to stay insured, he said.

The bill President Donald Trump signed last July requires the 42 states, along with the District of Columbia, that fully or partially expanded Medicaid under the 2010 Affordable Care Act to implement a work requirement starting in 2027. The full expansion enables adults with incomes of up to 138% of the federal poverty level — amounting to $22,025 for a single person this year — to be eligible for Medicaid, the government program covering people with low incomes or disabilities.

More than 20 million people gained coverage from Medicaid through expansion, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. The Congressional Budget Office estimates 4.8 million will become uninsured over the next decade as a result of the work requirement.

Under the law, enrollees must work or volunteer at least 80 hours a month, attend school at least part-time, or participate in job training. Or they must prove they qualify for certain exemptions, such as caring for a child 13 or younger or a disabled parent, or having a health condition that prevents employment.

Some states explored implementing work rules in the years before the GOP law passed. It gave states the option to launch their programs early.

Nebraska’s Plan

In Nebraska, which is implementing the provision eight months before the law requires, about 70,000 Medicaid enrollees will need to meet the requirement, said Collin Spilinek, a spokesperson for the Nebraska Department of Health and Human Services.

About 72% of them probably won’t have to do anything to keep their coverage, because the state already knows their work or exemption status via state or national databases, Spilinek said.

To check whether enrollees meet the requirement, Nebraska and other states plan to tap into various databases, including Medicaid claims information and data controlled by credit rating agencies. Enrollees for whom Nebraska doesn’t have data will be notified and can complete an online form to confirm they meet the new rules.

While a number of states say they plan to hire extra administrative staff, the Nebraska Medicaid agency is not adding any employees to implement its work requirement.

“The fact that they say they do not need additional resources raises questions” as to whether “they will be able to pull this off without future headaches,” Nordquist said.

Proving employment status will require documentation, but Nebraska officials say they will allow enrollees to self-attest that they volunteer, go to school, or qualify for exemptions, such as for poor health or caring for a disabled parent. “Supporting documentation, such as medical records, will not be required,” Spilinek said.

That could make it easier for enrollees to get exempted under the law’s “medical frailty” exception. The long list of health conditions that can be considered for the exemption was posted last week by the state and includes many types of cancers and mental health and heart conditions.

Kelsey Arends, senior staff attorney for Nebraska Appleseed, an advocacy group, said the state’s long list of medical billing codes for conditions that would be exempted is still not long enough. She said different levels of illness severity are not included.

The exemption is crucial for Crystal Schroer, 30, who has been on Medicaid since 2022 and unemployed since 2024. She said it has been difficult to find work near her home in Kearney, Nebraska, that will allow her to take along her psychiatric service dog, Tarot, who helps her with anxiety.

“I am insanely worried,” said Schroer, who lives with a friend. “It’s made my depression way worse.”

Whether self-attestation will broadly be allowed in other states will depend on CMS’ rules for work requirements, expected to be set this summer. Oz told Ñî¹óåú´«Ã½Ò•îl Health News that “we don’t like self-attesting” and that “documentation is critical.”

Several advocacy groups had asked the state to exempt enrollees with specific conditions, including the American Diabetes Association, HIV+Hepatitis Policy Institute, and National Bleeding Disorders Foundation. Losing coverage, the groups said, would mean losing access to medications that keep people healthy and out of the hospital.

Adding a work requirement to Medicaid has been a priority for Trump since his first term. In 2018, his administration became the first to allow states to adopt the policy, but only Arkansas implemented it. In the nine months the policy was in place before a federal judge deemed it unlawful, more than 18,000 people lost coverage — nearly 1 in 4 of those subject to the requirement.

Most lost coverage not because they did not meet the requirements but for failing to correctly submit paperwork in time. 

Georgia has had a work requirement under its partial Medicaid expansion since 2023. Only about 8,000 people signed up for the coverage in its first two years — far fewer than the 25,000 that state officials predicted for the first year alone — and many have been denied benefits because of paperwork issues.

National Mandate

During the congressional debate over the law last year, Republicans pushed a work requirement for Medicaid as a way to get “able-bodied” adults benefiting from government assistance into the workforce. House Speaker Mike Johnson said it would help preserve Medicaid “for people who rightly deserve it,” not young men “sitting on their couches playing video games.”

Republicans have argued mandating employment will nudge people into finding work, leaving Medicaid to help children and people who are pregnant or have disabilities.

They were not swayed by studies showing already work or go to school or have health conditions preventing them from doing so.

A in the Annals of Internal Medicine found about one-third of adults at risk of losing coverage under the new work requirement reported that they have a physical or mental illness or disability.

“This is not a case that we have mostly healthy adults choosing not to work,” said Darshali Vyas, a study co-author and health policy researcher at Beth Israel Deaconess Medical Center in Boston. “It’s a vulnerable group, and I am not sure there are clear protections as we begin to roll out work requirements.”

In Nebraska, about two-thirds of Medicaid expansion enrollees , according to KFF. Nebraska’s unemployment rate is 3%, one of the lowest in the nation.

Andrea Skolkin, the CEO of Omaha-based One World Community Health Centers, said it’s an unsettling time for her clinic and their patients. “We are still concerned about the expanded Medicaid folks losing coverage,” she said.

About 4,000 of their 52,000 patients are covered under the Medicaid expansion, Skolkin said. She said many enrollees received letters from the state about the work requirement, but she worries many did not understand them.

Losing 10% of those patients would mean $500,000 less in revenue for the nonprofit centers, she said. To help patients, they plan to add staff to help people fill out the forms to get and maintain coverage.

Nebraska Appleseed’s Arends said she’s skeptical of the state’s promises to use automation to confirm that enrollees meet the work rules. “We remain very concerned about the early implementation,” she said.

People who lose coverage may have a harder time getting health bills covered if they reenroll in the Medicaid program, because the federal law also reduces retroactive eligibility from three months to one month for expansion enrollees.

Because many people sign up for Medicaid when seeking care for an emergency and it can take weeks or months to complete enrollment, hospitals are concerned the change will leave them to cover the costs when people lose coverage, Nordquist said.

Only two other states plan to implement the work requirement early: Montana, which plans to launch in July, and Iowa, which plans to go live in December.

Many states will be closely watching Nebraska’s implementation to see what lessons they can learn ahead of their own launches in January, said Andrea Maresca, a senior principal at Health Management Associates, a consulting firm.

States are better prepared to enact work requirements than they were when Arkansas tried in 2018, she said. After reconfirming millions of enrollees’ eligibility post-covid, they have more experience using public and private databases to automate the process and more practice communicating with enrollees, Maresca said.

Still, “it won’t be perfect,” and states will have to adapt as they go, she said.

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“They’re the folks that work at restaurants. They’re the teacher’s aides,” said Starr, a registered nurse who became Open Door’s chief executive more than six years ago. Those patients, he said, are “really the heart and soul of rural America.”

He said if his remote health centers don’t get a share of the billions of dollars Congress earmarked to transform health care in rural America, patients may soon lose services. About 50% of Open Door’s 60,000 patients are on Medicaid, the joint state and federal insurance program that, together with the related Children’s Health Insurance Program, covers with low incomes or disabilities.

When Congress approved the One Big Beautiful Bill Act last summer, it cut nearly $1 trillion from Medicaid over the next decade. Now, Starr hopes the $50 billion Rural Health Transformation Program, which was part of the same bill, will help keep his patients covered.

Yet, small community health care providers, such as Open Door, may find they are sharing the billions with an army of corporate giants before it reaches their patients.

Months after federal leaders announced that all 50 states won first-year awards, ranging from $147 million for New Jersey to $281 million for Texas, state plans reveal that a heavy dose of prescribed spending will go to companies that can increase the use of electronic health records, strengthen cybersecurity, and improve state and health system technology platforms.

And at least four large-scale coalitions of companies are now pitching multipronged services to the states. Many of the companies already work with regional health systems and states through Medicaid contracting or mobile and telehealth operations.

How those services will help improve the health care of rural Americans at places such as Open Door remains an open question.

States Stare Down Reporting Deadlines

Federal regulators were “really interested in seeing digital health investments” when they crafted the five-year rural health program rules last year, said Maya Sandalow, an associate director at the Bipartisan Policy Center, a think tank based in Washington, D.C. She co-authored a recent report on how the 50 states plan to invest in technology, including modernizing health care infrastructure and expanding virtual care options such as telehealth and remote patient monitoring.

“The rural health fund isn’t really designed to directly replace or offset the lost Medicaid funding,” Sandalow said, noting that the federal staffers in charge of the program — money that could help rural hospitals and clinics pay for patient care — at 15% of the total funding awarded to a state.

Federal regulators also established tight reporting deadlines, forcing states to move quickly.

States must file progress reports and obligate all first-year funding , according to the Centers for Medicare & Medicaid Services, the federal agency overseeing the program. States could see their awards decreased or terminated at any time if they fail to follow federal requirements, according to the .

As of early April, CMS had not approved or had only partially approved some state budgets, including those of Wyoming, Colorado, and Vermont, according to state officials. CMS spokesperson Catherine Howden, who declined to say which states still needed revised budgets approved, said the agency does not provide “state-by-state updates.”

In Alaska, the budget is approved but the state has not announced when it will release full grant proposals and awards, said Tricia Franklin, program coordinator for Alaska’s rural health transformation.

“Early summer was the target,” Franklin said. But the response from vendors and applicants has been “much greater than expected, so it may take us a little longer.”

Working with consulting companies is an established way for states to “quickly and effectively” meet federal deadlines and roll out grant money, said , national director for population health at the Milbank Memorial Fund, a nonprofit focused on state health policy work.

Upgrading Technology, Modernizing Rural Health

Science Applications International Corp., a Fortune 500 government contractor, pulled together the . SAIC does a variety of technology work such as cybersecurity and engineering support. The alliance also includes Walgreens and Mission Mobile Medical, which turns RVs into primary care clinics. A data analytics company, a telemedicine and software company, and a company that helps place medical graduates in health systems are also part of the coalition.

The SAIC alliance offers “an ecosystem” of companies that can coordinate the work states have promised, said , SAIC’s Rural Health Transformation Program lead and a former chief information officer for the Virginia Department of Health. Each of the companies has representatives focused on the rural program, he said.

A lack of digital infrastructure — such as electronic health records at different clinics and hospitals that can talk to one another — has been a consistent barrier for rural medical care teams, said the Bipartisan Policy Center’s Sandalow.

“The funding hasn’t always been there in order for rural areas to create the infrastructure that’s needed to fully adopt remote patient monitoring, telehealth, artificial intelligence in ways that will really be supportive,” Sandalow said. “It takes things like updating infrastructure, changing workflows.”

Sandalow’s found that Maine and Utah are investing in cybersecurity; Indiana, Missouri, and New Mexico plan to modernize their electronic health records; Oklahoma plans to buy hardware and software, subsidize subscriptions, and give technical support to rural providers; and states such as Arizona and South Carolina will use funds to create telehealth hubs or buy remote patient monitoring equipment.

Federal regulators, when creating the rural program’s spending rules, also said no more than 5% of a state’s total funding awarded could be used to replace electronic medical records systems that already meet federal standards. Sandalow said that means states will focus on enhancements and upgrades to their current systems.

Gainwell Technologies, which operates the systems for dozens of state Medicaid programs, is spearheading . Rushil Desai, a Gainwell senior vice president, said states’ detailed spending plans are “changing in real time.”

Maine’s Medicaid plan contracts with Gainwell, and the state’s initial application listed four contracts worth more than $16 million over five years for the company. The state confirmed it has received federal approval for only its first year of spending, which includes a to implement changes to the state’s Medicaid claims system.

James Lomastro, a senior-care advocate in rural Massachusetts with the nonprofit , said he worries that large vendors and health systems will get the state’s transformation dollars.

Clinics, home care agencies, and nursing homes that “actually provide day-to-day support in the community are mostly on the margins” of state discussions about how to spend the money, he said. A spokesperson for Massachusetts’ Executive Office of Health and Human Services, Olivia James, said state officials would “ensure that everyone has a seat at the table” with training, financial incentives, and direct investments.

Arizona’s rural fund budget, which is $167 million for the first year, allocates for medical diagnostic equipment and technology upgrades, including to electronic health records, specifically for rural health care facilities.

But it also for county public health departments, said Pima County Public Health Director Theresa Cullen. The approved budget includes up to $4 million for grants to support community health workers.

“In these rural communities, you need to be present,” Cullen said.

Alina Czekai, director of the CMS rural health transformation office, said her team plans to visit all 50 states. She spoke at the National Rural Health Association’s policy conference in Washington, D.C., in February and told the audience that her team wants “the money to go to rural communities, rural providers, rural patients.” The association’s members include rural hospitals and clinics, which are expected to suffer big losses under the Medicaid cuts.

In California, Open Door’s Starr said he provided input on his state’s initial application, which won $234 million in first-year funding, but he is not clear on what the next steps will be for getting money from the program.

For his patients, Starr said, money is needed for technology upgrades. After all, he said, updated electronic health systems could operate seamlessly and store the documentation needed to keep a patient enrolled in Medicaid.

Updated technology could be exactly what Open Door and other area clinics need to “help keep people covered,” Starr said.

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Phil Galewitz and rural health care correspondent Arielle Zionts contributed to this report.

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Public schools and her church’s pantry help Lafortune accomplish the first two goals. But insurance to cover doctor visits has been the most difficult to secure.

As nursing assistants at a traumatic brain injury rehab center near Tampa, Florida, Lafortune and her husband cannot afford the health insurance benefits offered by their employer. And they earn too much for their daughters to qualify for subsidized coverage through , the state’s safety net health insurance program for children in low-income families.

Her family also can’t afford the $525 monthly cost to enroll her two daughters in KidCare at full price, so she purchased a family plan for $500 a month on the Affordable Care Act marketplace with no dental coverage and higher out-of-pocket costs.

“KidCare is better for children,” she said. “But at least I have something for them.”

In 2023, Florida lawmakers unanimously approved expanding KidCare to close the gaps for families like Lafortune’s, raising the eligibility threshold so that coverage would extend to more than 40,000 children. But the expanded coverage has not taken effect — even after it was approved by federal regulators following a federal lawsuit — because the administration of Florida Gov. Ron DeSantis, a Republican, has not implemented the changes.

Instead, Florida’s KidCare expansion has been mired in lawsuits and ongoing negotiations between the state and federal regulators. While the delay continues, Florida could be violating the law.

“I don’t know what they’re waiting for,” Lafortune said. “They should see people in Florida have needs.”

Asked to comment on the delay, DeSantis’ office referred Ñî¹óåú´«Ã½Ò•îl Health News to a on March 31, during which the governor directed questions to the state’s Agency for Health Care Administration, which oversees KidCare. The state agency did not respond to Ñî¹óåú´«Ã½Ò•îl Health News’ repeated requests for an interview or information on the delayed expansion.

Entitlement vs. Personal Responsibility

At issue is a , adopted under the Biden administration, that requires all states to continue to provide 12 months of coverage for children in Medicaid and in the Children’s Health Insurance Program, known as KidCare in Florida. That means insurance coverage would not lapse even if parents miss a monthly premium payment.

But only Florida has challenged the rule in court, suing the federal government for the right to disenroll children from KidCare for unpaid premiums and delaying the planned expansion.

“We’ve had to do a lot of back and forth with CMS on various things,” DeSantis said during the March press conference, referring to the Centers for Medicare & Medicaid Services, which regulates public health insurance programs.

In December, Texas also said it opposed the rule. Cecile Erwin Young, who was then the executive commissioner of Texas Health and Human Services, wrote to Mehmet Oz, the CMS administrator, asking him to rescind CHIP rules that require states to keep children enrolled for 12 months at a time, prohibit waiting periods for coverage, and prevent states from imposing financial benefit limits.

“These policy changes effectively redefine CHIP to be more like an entitlement program — a strategy not supported by law and which conflicts with the core program design adopted by Texas,” Young wrote.

Like Texas, Florida views KidCare as a “personal responsibility program” designed to help families by “supporting independence and a ladder towards economic self sufficiency,” according to legal filings and .

“It’s something that goes back to this mentality of people needing to pull themselves up by their bootstraps,” said , policy director for the Florida Health Justice Project. The nonprofit legal aid group, together with the National Health Law Program, on March 9, asking a judge to order the state to implement the approved expansion.

The state agencies had not filed a response to that lawsuit as of April 22. The court ordered the state to explain by mid-May why the expansion should not be implemented.

Williams called the state’s tactic “largely political theater.”

Health policy researchers and advocates also noted that Florida’s refusal to implement the KidCare expansion goes against the Trump administration’s strategy to “.” Last year, a commission appointed by President Donald Trump recommended a series of policy changes, including a collaboration between CMS and state CHIP programs, to promote “evidence-based prevention and wellness initiatives for children at the local level.”

Numerous studies have found that CHIP coverage can improve children’s health by , , and .

“This should go without saying, but you can’t make children healthy again by taking away their health coverage,” said , chief strategy and development officer for Florida Policy Institute, a nonprofit that has advocated for the state to implement the KidCare expansion.

The White House did not respond to a request for comment on Florida’s and Texas’ opposition to the rule requiring continuous enrollment in CHIP.

Those two states have among the . In Texas, more than 1 million children, or 13.5%, have no health insurance, while in Florida more than 400,000 children, or 8.5%, are uninsured.

Texas has followed the federal rule on continuous coverage despite its opposition, but Florida has ignored the requirement and continues to disenroll children for unpaid premiums.

Choosing Between School Supplies and Health Insurance

According to the Florida Healthy Kids Corp., the nonprofit contracted by the state to determine eligibility for and administer KidCare, about 250,000 children received subsidized coverage from Dec. 1, 2024, to Nov. 30, 2025. Of those, 43,000 children were disenrolled after their parents failed to pay the premium.

, director of the Center for Children and Families at Georgetown University, said the Trump administration should act on the evidence that Florida is the only state defying the rule.

“Thousands and thousands of children are routinely losing their coverage in violation of federal law,” she said, “and the Trump administration has done nothing about that. At the same time, they’re pulling money from states like Minnesota for alleged fraud violations that haven’t even been proven yet.”

Families tend to miss premium payments in July and August, when it’s time to buy back-to-school supplies, and again in December and January, around the holidays, Alker said.

“That is very, very sad,” Alker said. “You have working parents here who are struggling and they have to choose between their child’s school supplies and their health insurance.”

This year, enrollment in KidCare has fallen below the state’s projections, leading to a $32 million surplus in the program. On April 17, legislators from the program and redirect it to the general fund, with that the expansion had not yet been implemented.

Lawmakers voted to expand KidCare eligibility to families earning up to 300% of the federal poverty level. The change would raise the income threshold for a family of four from about $5,500 a month to about $8,250 a month. Monthly premiums for subsidized coverage would also rise, from the current $15 to $20 a month to a maximum of $195 a month, regardless of the number of children a family enrolls.

The program provides coverage than ACA marketplace plans. KidCare has no deductible or coinsurance, and maximum copayments of $15. It also includes dental and vision coverage.

With her ACA plan, Lafortune must pay a $35 copayment for doctor visits. Her family deductible is $1,600, and the coinsurance — or the share of covered services she must pay after meeting the deductible — is 20%. The plan’s maximum out-of-pocket cost is $7,250.

“I tried to get something cheaper, but it’s not like I cannot have it,” Lafortune said of the need for health insurance. “I have to do something.”

The state’s initial lawsuit challenging the continuous eligibility rule was dismissed in May 2024, and a second lawsuit was withdrawn this February. The state and CMS told the judge they were “working to determine the most expeditious way to resolve the dispute” and have yet to update the court on their discussions.

But three days after withdrawing the lawsuit, Florida sued CMS for a third time, accusing the federal agency of ignoring the state’s public records request related to CMS’ approval of the KidCare expansion.

As the legal wrangling continues, the cost of health insurance has skyrocketed.

For those with ACA marketplace coverage, the expiration of enhanced subsidies has hit hard. About half of those who re-enrolled in ACA marketplace coverage for 2026 said their healthcare costs are “a lot higher” this year, according to .

For Lafortune, Florida’s KidCare expansion can’t come soon enough.

“Children are the ones who are going to replace everyone here,” she said. “When you give them opportunities — for their health, for school, to eat — you make your country healthy and better.”

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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The patient lived alone, and “really struggles with social isolation,” Guzman said. After a serious fall and subsequent surgery, the woman was using a wheelchair. She confided that she would like to attend services at a church down the road but had no way to get there and did not want to seem “a bother.”

“We called the pastor to see if there was someone who could pick her up” on Sundays, Guzman said. And there was.

The next day, Guzman visited a woman with heart failure who required constant oxygen. She lives in “less than ideal housing,” with no kitchen and only a plug-in heater for warmth.

“We were trying to figure out if she qualifies for HUD housing or assisted living,” Guzman said, referring to the federal Department of Housing and Urban Development. “We spent a lot of time talking about the options and came up with a game plan.”

Wednesday’s schedule included a 20-mile drive to Hood River to see an 81-year-old woman whose partner of nearly 40 years was contending with a serious cancer. Guzman, who speaks to her in Spanish, found her distraught at the possibility of losing him.

Guzman had arranged for the woman to begin seeing a therapist to help her through the crisis — no minor achievement. But on this visit, “I just handed her tissues and tried to give words of comfort,” she said. “Honestly, sometimes just sitting and listening” is the best response.

A community healthcare worker, the , is a “trusted member” of a local community or someone who has “an unusually close understanding” of it, enabling the worker to serve as intermediary between patients and the healthcare system.

These workers have been on the job since the 1960s, particularly in rural and low-income areas. Today, their numbers are growing. The Bureau of Labor Statistics , which the National Association of Community Health Workers says is probably an underestimate.

That partly reflects the difficulty of counting workers who go by a variety of names — community health educators, outreach specialists, promotores de salud — and operate under different state regulations, sometimes with no licensure or certification required.

What they have in common is that “they talk like the people they work with,” said Sam Cotton, who directs the curriculum for several such programs at the University of Louisville in Kentucky.

With shortages of healthcare professionals and an aging population, “there’s a lot of momentum for this,” she said.

In Oregon, for example, five rural clinics employ community health workers, who become state-certified after completing 90 hours of online training, through a program called Connected Care for Older Adults. A sixth clinic employing a community health worker operates in neighboring Washington.

Their frail patients are struggling. “They can’t drive, so they can’t get to a grocery store and shop,” said Elizabeth Eckstrom, chief of geriatrics at Oregon Health & Science University, who helped oversee the program’s start in 2022. “They’re not taking their medications, either for cognitive reasons or because they can’t get to a pharmacy.”

Few have completed an advance directive, specifying the care they want — or don’t want — if they suffer a health crisis.

Connected Care’s community health workers tackle many of those not-exactly-medical problems — from installing wheelchair ramps to helping patients apply for food and housing benefits. They are allotted 90 days to work with each patient, usually during home visits.

They help coordinate follow-up appointments. They administer cognitive and mental health screenings and watch for the use of too many medications, entering their observations into the patients’ electronic health records.

“It’s like being the eyes and ears for the doctors, to see what’s happening outside the 20 minutes they get to spend with patients,” said Guzman, whose work has ranged from ordering a bath mat to reporting suspected financial abuse.

In a  (average age: 77), a subsample found substantial decreases in emergency department visits and hospitalizations among those served by community health workers.

More extensive research, not yet published, supports that finding, Eckstrom said.

“ED visits cost thousands, and hospitalizations are tens of thousands,” she pointed out. The cost per patient for the 90-day program is $1,500. Its workers earn $25 an hour, a fairly typical wage, and receive full employee benefits.

Manali Patel, an oncologist at Stanford University, found for older patients with advanced cancer in a clinical trial at the Department of Veterans Affairs’ Palo Alto Health Care System.

“Lots of people were passing away” in the intensive care unit, she recalled. “If we’d asked, they probably would have wanted to be at home.” Oncologists, she added, are “notoriously bad at engaging in and documenting those conversations.”

But when a lay health worker made regular phone calls to help patients understand their options, discuss their preferences with their care team, and file advance directives, the results — published in JAMA Oncology in 2018 — were “very dramatic,” Patel said.

More than 90% of the participating veterans had their goals documented in their records compared with fewer than 20% of the control group. The lay worker’s patients had significantly fewer emergency room visits and hospitalizations and were more likely to enroll in hospice care.

Patel and her co-authors have gone on to document the benefits of lay health workers, the term they used, in undertaking other tasks in other settings.

In oncology clinics in Arizona and California, for instance, two bilingual lay health workers to cancer patients over age 75 to assess symptoms like pain, nausea, breathlessness, and depression.

Alerting healthcare teams to these patients’ problems substantially reduced their emergency department use and hospitalizations, and the cost savings averaged $12,000 a patient.

“This low-tech, human-administered intervention reaped huge dividends,” said an  in JAMA.

“Community health workers should be part of every healthcare team,” Eckstrom said. “They support the patient in ways the medical system just can’t, no matter how hard we try.”

One obstacle to expanding their use, however, is unstable funding.

In 2024, Medicare began covering some community health worker services, but not all. (The costs of driving 30 miles to remote homes, for example, are not reimbursed.) Medicaid coverage is piecemeal, reimbursing for some services in some states and not others.

“A lot of community health worker roles rely on short-term grants,” said Neena Schultz, a director of the National Association of Community Health Workers. “Sustainability is something we talk about every day.”

The organization and other supporters are pressing for more state and federal funding. The new federal , which is distributing $10 billion a year, will include funding for community health worker programs, but cuts to state Medicaid budgets could more than offset those gains.

The grants funding Connected Care for Older Adults continue, though. Guzman, employed by the nonprofit clinic One Community Health, keeps making her rounds.

One recent victory: A newly widowed patient in his 60s, struggling financially without his wife’s income, lost his housing and was sleeping in his truck. Through another patient, Guzman learned of an unused recreational vehicle whose owner was willing to donate it.

The widower now lives comfortably in a mobile home park.

When you’re in a patient’s home, “there’s a sense of ease,” Guzman said. “They feel safer talking about things. They don’t feel rushed. You develop a relationship, and they feel they have someone to advocate for them.”

The New Old Age is produced through a partnership with .

This <a target="_blank" href="/aging/new-old-age-community-health-workers-promotores-home-visits-senior-support/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">