Paula Andalo, Author at ��ýҕ�l Health News

Health Centers Face Risks as Government Funding Lapses

Paula Andalo — Fri, 03 Oct 2025 09:00:00 +0000

About 1,500 federally funded health centers that serve millions of low-income people face significant financial challenges, their leaders say, as the government shutdown compounds other cuts to their revenue.

Some of these community health centers may have to cut medical and administrative staff or reduce services. Some could eventually close. The result, their advocates warn, may be added pressure on already crowded hospital emergency rooms.

“This is the worst time in all the years I have been working in health care,” said , president and CEO of , a network of that serves more than 144,000 patients in Los Angeles, Riverside, and San Bernardino counties in California. “We are facing federal cuts and extreme state cuts that will impact services.”

St. John’s and other federally qualified health centers offer primary care and a wide range of other services free of charge or on a sliding fee scale. Nationwide, they see in the country’s most underserved areas.

The federal funds come through two primary routes, both of which face challenges: grants paid in part through the and reimbursements for patients’ care through programs like Medicaid, which provides health insurance for low-income people and people with disabilities. Medicaid is jointly funded by states and the federal government.

Congress has approved the grant money in dribs and drabs recently. In March, lawmakers extended the funds until Sept. 30. That money expired after the Republican-controlled Congress did not pass a funding law, leading to a government shutdown.

Advocates say the health centers need long-term funding to help them plan with more certainty, ideally through a multiyear fund.

received $4.4 billion in grants in early 2024. The National Association of Community Health Centers is advocating for in grants annually for two years to keep the centers fully functional.

The health center safety net faces “multiple layers of challenges,” said , vice president of policy and regulatory affairs for the association.

that Republicans call the “One Big Beautiful Bill Act” will significantly cut Medicaid, raising the second set of threats for health centers.

Medicaid of the $46.7 billion in health center revenue in 2023.

Advocates said lower Medicaid payments will exacerbate a gap between funding and operational costs.

Funding for workforce programs also is needed to support the delivery of health care services as centers struggle to hire and retain workers, said , director of the Geiger Gibson Program in Community Health at George Washington University.

The of this type opened in places such as Massachusetts in the 1960s. Congress typically has funded them with bipartisan support, with minor fluctuations.

The struggle this year began when the Trump administration through a January memo, which prevented some centers from receiving already approved grant money. As a consequence, some health centers in states such as Virginia .

The upcoming cuts also are set to arrive at a time when patients will face new demands and challenges. The Medicaid changes in President Donald Trump’s tax-and-spending law include requirements for Medicaid enrollees to report their work or other service hours to keep their benefits.

Meanwhile, the Biden administration and Congress provided consumers to help pay for Affordable Care Act health insurance are set to expire at the end of the year. Some consumers’ costs will spike if Congress doesn’t renew them.

One reason the government shut down is that Democrats want to extend the tax credits, which protect consumers from higher insurance costs. The Republican funding bill did not include an extension; Republican congressional leaders say the issue should be addressed separately.

Consumers “will need more support than ever,” said Jacobs, noting that Medicaid cuts and the expiration of the higher tax credits will both “potentially throw people out of coverage.”

Ninety percent of the centers’ patients have incomes that are twice the or less, and .

“We are also receiving 300 calls per day from patients concerned about their coverage,” said Mangia, from St. John’s.

Republicans are not directly targeting the centers, although they supported the Medicaid cuts that will affect the clinics’ finances. Many Republicans say Medicaid spending has ballooned and that reducing the program’s growth will make it more sustainable.

State and Local Support

While advocating for longer-term federal funding, the centers also are looking to their community and local governments for backing.

Some states already took action while finalizing their annual budgets. , and allocated money for centers. , , and also provided support for the health centers.

The question is how long the money will last.

While some states boosted their support of the centers, others are going in the opposite direction. Anticipating the impact of Medicaid cuts, states such as California made to the program.

California Gov. Gavin Newsom’s office, the federal Department of Health and Human Services, and the federal Health Resources and Services Administration did not respond to requests for comment.

In Los Angeles, Mangia said, one potential solution is to work with partners at the county level, noting that L.A. County has about 10 million residents.

“We can tax ourselves to increase funding for health care services,” he said.

Health center leaders are building a coalition that “hopefully” will include the main stakeholders in the county’s health care system — community health centers, clinics, hospitals, doctors, health plans, unions — to begin the process to fill out a ballot petition, Mangia said. The goal: Put the question about taxes for health centers on the ballot and let voters decide.

“We are learning that the federal government and the state government are not reliable when it comes to continuing to fund health care,” Mangia said.

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

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Checking the Facts on Medicaid Use by Latinos

Paula Andalo — Mon, 17 Mar 2025 09:00:00 +0000

(iStock/Getty Images)

Spending cuts, immigration, and Medicaid are at the top of the Washington agenda. That climate provides fertile ground for misinformation and myths to multiply on social networks. Some of the most common are those surrounding immigrants, Latinos, and Medicaid.

These claims include assertions that Latinos who use Medicaid, the federal-state program for low-income people and those with disabilities, and exaggerations of the percentage of people with Medicaid who are Latinos.

The U.S. House voted narrowly on Feb. 25 in favor of a that could lead to Medicaid cuts of up to $880 billion over a decade.

Medicaid and the Children’s Health Insurance Program are part of the national safety net, covering about . Medicaid enrollment grew under the Affordable Care Act and after the start of the covid-19 pandemic but then started falling during the final two years of the Biden administration.

Immigrants’ impact on the nation’s health care system can be overstated in heated political rhetoric. Now-Vice President JD Vance said on the campaign trail last year that “we’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.” PolitiFact rated that statement “.”

��ýҕ�l Health News, in partnership with , compiled five myths circulating on social media and analyzed them with experts in the field.

1. Do Latinos who receive Medicaid work?

Most do. A KFF analysis of Medicaid data found that almost on Medicaid work, “which is a higher share of Medicaid adults who are working compared to other racial and ethnic groups,” said , deputy director of KFF’s Program on Medicaid and the Uninsured. KFF is a health information nonprofit that includes ��ýҕ�l Health News.

“For many low-income people, the myth is that they are not working, even though we know from a lot of data that many people work but don’t have access to affordable employer-sponsored insurance,” said , co-director at the Center for Advancing Health Services, Policy and Economics Research, part of the Institute for Public Health at Washington University in St. Louis.

Neither the Department of Health and Human Services Office of Minority Health nor the Centers for Medicare & Medicaid Services responded to requests for comment.

2. Are Latinos the largest group enrolled in Medicaid?

No. White people who are not Hispanic represent the biggest demographic group in Medicaid and CHIP. The programs’ enrollment is 42% non-Hispanic white, 28% Latinos, and 18% non-Hispanic Black, with small percentages of other minorities, according to .

Latinos’ share of total Medicaid enrollment “has remained fairly stable for many years — hovering between 26 and 30% since at least 2008,” said , research and data analysis director on the health policy team at the left-leaning Center on Budget and Policy Priorities, a research organization.

In a Feb. 18 , Alex Nowrasteh and Jerome Famularo of the libertarian Cato Institute wrote: “The biggest myth in the debate over immigrant welfare use is that noncitizens — which includes illegal immigrants and those lawfully present on various temporary visas and green cards — disproportionately consume welfare. That is not the case.” They included Medicaid in the term “welfare.”

Although Latinos are not the biggest group in Medicaid, they are the demographic group with the greatest percentage of people receiving Medicaid. There are about in the country, representing 19.5% of the total U.S. population.

Approximately is enrolled in Medicaid, in part because employed Latinos often have jobs that do not offer affordable insurance.

Eligibility for Medicaid is based on factors such as income, age, and pregnancy or disability status, and it varies from state to state, said , associate professor of practice at the Center for Children and Families at Georgetown University’s McCourt School of Public Policy.

“Medicaid eligibility is not based on race or ethnicity,” Whitener said.

3. Do most Latinos living in the country without legal permission use Medicaid?

No. Under federal law, immigrants lacking legal status are .

As of January, 14 states and the District of Columbia had used their own funds to children in the country without regard to immigration status. Of those, seven states and D.C. expanded coverage to some adults regardless of immigration status.

The cost of providing health care to these beneficiaries is covered entirely by the states. The federal government does not put up a penny.

The federal government does pay for Emergency Medicaid, which reimburses hospitals for medical emergencies for people who, because of their immigration status or other factors, do not normally qualify for the program.

Emergency Medicaid began in 1986 under the Emergency Medical Treatment and Labor Act, signed by President Ronald Reagan, a Republican.

In 2023, Emergency Medicaid accounted for Medicaid spending.

Some conservative lawmakers say immigrants in the country illegally should not get any Medicaid benefits.

“Medicaid is meant for American citizens who need it most — seniors, children, pregnant women, and the disabled,” Rep. Dan Crenshaw (R-Texas) said . “But liberal states are finding ways to game the system and make taxpayers cover healthcare for illegal immigrants.”

4. Do Latinos stay on Medicaid for decades?

Experts say there is no analysis by race or ethnicity of the length of time people use the program.

“The people who stay on Medicaid the longest are people who have Medicaid due to a disability and who live with a medical situation that does not change,” Tolbert said.

People who use long-term Medicaid support services of the total number of people in the program.

Many beneficiaries are in the program temporarily, McBride said.

“Some studies indicate that as many as half of the people on Medicaid churn off of Medicaid within a short period of time,” he said, such as within a year.

5. Are Latinos on Medicaid the group that uses medical services the most?

Latinos do not use significantly more Medicaid services than others, experts say. Latinos receive preventive services (such as mammograms, pap smears, and colonoscopies), and mental health care less than other groups, according to documents from CMS and the Medicaid and CHIP Payment and Access Commission, a nonpartisan organization that provides policy and data analysis.

Latinos do account for a disproportionate share of Medicaid services. Latino families and white families each represent about 35% of Medicaid births, although white people make up a bigger share of the overall population.

While Latinos of all Medicaid and CHIP enrollees, they account for 37% of beneficiaries with limited benefits that cover only specific services.

“They actually use health care services less than other groups, because of systemic barriers such as limited English proficiency and difficulty navigating the system,” said , a professor at UCLA’s Fielding School of Public Health and the faculty research director at the university’s Latino Policy and Politics Institute.

Latino people also avoid using services out of fear of the rule and other policies, Vargas Bustamante said. President Donald Trump expanded the public charge policy and strongly enforced it during his first term, though it was softened under President Joe Biden. The policy was intended to make it harder for immigrants who use Medicaid or welfare programs to obtain green cards or become U.S. citizens.

“The chilling effect of public charge persists, but recent orders such as mass deportation or the elimination of birthright citizenship have generated their own chilling effects,” Vargas Bustamante added.

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¿Cómo Se Dice? California Loops In AI To Translate Health Care Information

Paula Andalo — Tue, 18 Jun 2024 09:00:00 +0000

Tener gripe, tener gripa, engriparse, agriparse, estar agripado, estar griposo, agarrar la gripe, coger la influenza. In Spanish, there are at least a dozen ways to say someone has the flu — depending on the country.

Translating “cardiac arrest” into Spanish is also tricky because “arresto” means getting detained by the police. Likewise, “intoxicado” means you have food poisoning, not that you’re drunk.

The examples of how translation could go awry in any language are endless: Words take on new meanings, idioms come and go, and communities adopt slang and dialects for everyday life.

Human translators work hard to keep up with the changes, but California plans to soon entrust that responsibility to technology.

State health policy officials want to harness emerging artificial intelligence technology to translate a broad swath of documents and websites related to “health and social services information, programs, benefits and services,” . Sami Gallegos, a spokesperson for California’s Health and Human Services Agency, declined to elaborate on which documents and languages would be involved, saying that information is “confidential.”

The agency is seeking bids from IT firms for the ambitious initiative, though its timing and cost is not yet clear. Human editors supervising the project will oversee and edit the translations, Gallegos said.

Agency officials said they hope to save money and make critical health care forms, applications, websites, and other information available to more people in what they call the nation’s most linguistically diverse state.

The project will start by translating written material. Agency said the technology, if successful, may be applied more broadly.

“How can we potentially not just transform all of our documents, but our websites, our ability to interact, even some of our call center inputs, around AI?” Ghaly asked during an in Sacramento.

But some translators and scholars fear the technology lacks the nuance of human interaction and isn’t ready for the challenge. Turning this sensitive work over to machines could create errors in wording and understanding, they say — ultimately making information less accurate and less accessible to patients.

“AI cannot replace human compassion, empathy, and transparency, meaningful gestures and tones,” said , a Fresno-based medical and legal interpreter for 30 years who specializes in Khmer, the main language of Cambodia.

is the science of designing computers that emulate human thinking by reasoning, problem-solving, and understanding language. A type of artificial intelligence known as , or GenAI, in which computers are trained using massive amounts of data to “learn” the meaning of things and respond to prompts, is driving a wave of investment, led by such companies as Open AI and Google.

AI is quickly being integrated into health care, including programs that diagnose diabetic retinopathy, analyze mammograms, and connect patients with nurses remotely. Promotors of the technology often make the grandiose claim that soon everyone will have their own “.”

AI also has been a game changer in translation. , and are not only faster than older technologies such as Google Translate, but they can process huge volumes of content and draw upon a vast database of words to nearly mimic human translation.

Whereas a professional human translator might need three hours to translate a 1,600-word document, AI can do it in a minute.

, an assistant professor of biomedical informatics at Harvard Medical School and the deputy editor of , said the use of AI technology represents a natural progression in medical translation, given that patients already use Google Translate and AI platforms to translate for themselves and their loved ones.

“Patients are not waiting,” he said.

He said GenAI could be particularly useful in this context.

These translations “can deliver real value to patients by simplifying complex medical information and making it more accessible,” he said.

In its bidding documents, the state says the goal of the project is to increase “speed, efficiency, and consistency of translations, and generate improvements in language access” in a state where 1 in 3 people speak a language other than English, and more than 200 languages are spoken.

In May 2023, the state Health and Human Services Agency adopted a “” that requires its departments to translate all “vital” documents into at least the top five languages spoken by Californians with limited English proficiency. At the time, those languages were Spanish, Chinese, Tagalog, Vietnamese, and Korean.

Examples of vital documents include application forms for state programs, notices about eligibility for benefits, and public website content.

Currently, human translators produce these translations. With AI, more documents could be translated into more languages.

A by the California Health Care Foundation late last year found that 30% of Spanish speakers have difficulty explaining their health issues and concerns to a doctor, compared with 16% of English speakers.

Health equity advocates say AI will help close that gap.

“This technology is a very powerful tool in the area of language access,” said , president and CEO of the foundation. “In good hands, it has many opportunities to expand the translation capability to address inequities.”

But Hernández cautioned that AI translations must have human oversight to truly capture meaning.

“The human interface is very important to make sure you get the accuracy and the cultural nuances reflected,” she said.

Lim recalled an instance in which a patient’s daughter translated preoperative instructions to her mother the night before surgery. Instead of translating the instructions as “you cannot eat” after a certain hour, she told her mom, “You should not eat.”

The mother ate breakfast, and the surgery had to be rescheduled.

“Even a few words that change meaning could have a drastic impact on the way people consume the information,” said , a doctoral candidate in digital journalism, human-computer interaction, and emerging media at Boston University.

Paik, who grew up speaking Korean, also pointed out that AI models are often trained . The data that drives the translations filters languages through an English perspective, “which could result in misinterpretations of the other language,” she said. Amid this fast-changing landscape, “we need more diverse voices involved, more people thinking about the ethical concepts, how we best forecast the impact of this technology.”

Manrai pointed to other flaws in this nascent technology that must be addressed. For instance, AI sometimes invents sentences or phrases that are not in the original text, potentially creating false information — a phenomenon AI or “confabulation.”

Ching Wong, executive director of the Vietnamese Community Health Promotion Project at the University of California-San Francisco, has been translating health content from English into Vietnamese and Chinese for 30 years.

He provided examples of nuances in language that might confuse AI translation programs. Breast cancer, for instance, is called “chest cancer” in Chinese, he said.

And “you” has different meanings in Vietnamese, depending on a person’s ranking in the family and community. If a doctor uses “you” incorrectly with a patient, it could be offensive, Wong said.

But Ghaly emphasized that the opportunities outweigh the drawbacks. He said the state should “cultivate innovation” to help vulnerable populations gain greater access to care and resources.

And he was clear: “We will not replace humans.”

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Doctors Advocate Fresh Efforts to Combat Chagas Disease, a Silent Killer

Paula Andalo — Tue, 22 Aug 2023 09:00:00 +0000

When Maira Gutiérrez was diagnosed with Chagas disease in 1997, neither she nor her primary care physician had even heard of the malady. She discovered her illness only by chance, after participating in a Red Cross blood drive organized by her employer, Universal Studios.

The Red Cross tests donated blood for a range of diseases, including Chagas, which is caused by a parasite and can develop silently for decades before causing symptoms. The test detected Chagas in her body, and an MRI years later, in 2013, confirmed it had reached her heart.

“They showed me the image with the trace of the parasite to my heart. It was really scary,” Gutiérrez, originally from El Salvador, said in Spanish. Now 50, she remains healthy but undergoes a battery of tests annually to monitor for heart damage.

, the parasite that causes Chagas, is transmitted through an insect called the triatomine bug, known as the kissing bug, because it usually bites close to the lips. The bugs defecate on the skin, and the feces, which can contain the parasite, can enter a person’s body through the nose, mouth, or breaks in the skin.

Chagas disease affects people primarily in rural Latin America, where the insect thrives in thatched roofs and mud walls. It is not transmitted from person to person, except for a mother passing it to a newborn, or through blood transfusions or organ transplants.

But it’s increasingly present in the United States, where it often goes unrecognized: The Centers for Disease Control and Prevention estimates living in the U.S. have Chagas, though lack of awareness and testing means have been identified.

Doctors, researchers, and patient advocates say the nation could be doing far more to combat Chagas, which causes serious heart disease in of infected people and can also lead to crippling digestive problems such as enlargement of the esophagus and colon. They are pushing for increased access to testing and treatment and are optimistic about a new drug that’s set for human trials next year. A bill in Congress to up funding for rare diseases, which supporters hope will be debated in the fall, could help too.

Still, in the U.S., there is “a tremendous lack of awareness about this disease,” said , a cardiologist and the medical director of the , who runs a Chagas testing clinic in northern Virginia. “We were taught that it is something we don’t see in the United States.”

Ronald Drew Etheridge, an assistant professor at the University of Georgia, studies the molecular tools used by the Trypanosoma cruzi parasite to make itself at home in various target environments. He is holding the kissing bug’s favorite food: blood. (Paula Andalo/��ýҕ�l Health News)

Maira Gutiérrez discovered she had Chagas disease when she donated blood to the Red Cross in 1997. She struggled to find a doctor who knew something about the condition. (Carmen Echeverria)

A large proportion of those with Chagas are from Latin America, and many are living in the U.S. without legal permission. Marcus notes that many of those most at risk from Chagas use community health centers that could be testing sites but have limited resources and tend to focus on more common conditions such as high blood pressure and diabetes.

Chagas initially produces flu-like symptoms but can then go unnoticed for decades while it reproduces in the body. Drug treatments can sometimes eradicate the parasite, especially in its first stages, but the window for early detection is short: It does not stay in the bloodstream for long, instead migrating to tissues and organs, where it is harder to detect.

Often by the time a patient sees a doctor, that person has already developed serious complications, including heart rhythm abnormalities or a that doesn’t pump blood well. Patients may eventually need pacemakers or heart transplants.

Author Daisy Hernández experienced Chagas disease in her family. The real barrier for Chagas care is the inaction, she says. (Dhanraj Emanuel)

“It is a disease resulting from systemic failures in the health care system,” said writer Daisy Hernández, author of “: A True Story of a Family, an Insect, and a Nation’s Neglect of a Deadly Disease.” In her book, Hernández tells the story of her aunt Dora, who was diagnosed with Chagas in the U.S. Before, in her country, Colombia, she had an exploratory surgery because of a swollen stomach and the doctors told her that she had “the intestines of 10 people” due to the amount of inflammation. No one suspected it could have been caused by the Chagas parasite.

Hernández said interviews with over 70 doctors and patients convinced her that the real barrier to Chagas care is inaction.

“While a person living in Virginia who is originally from Bolivia [where Chagas is endemic] knows that if diagnosed with Chagas, they should start saving up for a pacemaker,” Hernández said in Spanish, “here, the government does nothing and doesn’t even know what the disease is.”

worldwide live with the parasite. In the U.S., two long-standing drugs have had FDA approval: and , which can beat back the parasite but don’t always eradicate it. The medications can have serious side effects, and are most effective if given early: Babies born with Chagas have a if treated within their first year of life.

To combat the disease, doctors familiar with Chagas recommend testing pregnant women from at-risk communities and urge earlier treatments. They also advocate screening all transplant organs. In 2018, a after receiving a heart infected with the Chagas parasite, prompting a lawsuit and calls for mandatory organ screening. The organization that governs transplant policies in the U.S. to require such testing.

The infected “kissing bugs” sleep in the plastic container for two or three minutes. (Paula Andalo/��ýҕ�l Health News)

Few facilities in the country screen for Chagas. Advocates say that with greater awareness, many health care providers could conduct initial screenings and, if positive, send results to the CDC for confirmation.

However, building awareness has been an uphill battle. The Center of Excellence for Chagas Disease, the only center in the U.S. dedicated to Chagas diagnosis and treatment, recently suspended operations after its longtime director, Sheba Meymandi, retired.

A pioneer in the diagnosis and treatment of Chagas, Meymandi said she is still working as a volunteer at Olive View-UCLA Medical Center in Los Angeles, where the center was based, to ensure her patients receive care. “The political leadership has stopped supporting the center, and we no longer actively conduct tests,” Meymandi said. Now, she refers Chagas patients to the cardiology clinic.

A spokesperson for the county’s Department of Public Health wrote in a statement that the center is not technically closed, and that treatment of Chagas patients with heart conditions had been taken over by the cardiology department at the UCLA hospital. But at least for now it is not offering general screening for Chagas infection. California has the of any state.

Another hope for beating Chagas lies in new drugs. , the head of the in the University of Georgia’s Department of Cellular Biology, said his group had collaborated with Anacor Pharmaceuticals to identify and optimize compounds that could kill the T. cruzi parasites. They had found one.

“It could completely eradicate the infection in mice and in nonhuman primates,” Tarleton said.

The team tested the compound on 19 macaques at a research center in Texas that had acquired the parasite naturally. The infection was defeated, the monkeys had no significant side effects, and they are still clinically healthy after more than five years.

Ruby Harrison, a postdoctoral fellow at the University of Georgia, puts triatomine bugs infected with T. cruzi parasites to sleep with gas. (Paula Andalo/��ýҕ�l Health News)

Rachel Marcus, a cardiologist and the medical director of the Latin American Society of Chagas, runs a Chagas testing clinic in northern Virginia. “We were taught that it is something we don’t see in the United States,” she says. (Paula Andalo/��ýҕ�l Health News)

Tarleton’s team also observed that some of the parasites can become dormant, making them resistant to drug treatment. As a result, Tarleton said, it’s critical not only to develop more effective drugs, but to optimize timing of treatments.

Tarleton and hope to launch a clinical trial of the compound next year.

There is also some hope on the political front. Sen. Cory Booker (D-N.J.) reintroduced the in February to address the growing health problem posed by maladies like Chagas spreading in low-income communities. The list also includes dengue fever, , and chikungunya.

“Whenever we go into low-income communities and look for these illnesses, we usually find them,” said Peter Hotez, who worked with Booker’s office on the legislation and is the dean of the National School of Tropical Medicine at Baylor College of Medicine. “Tragically, too often our nation ignores or neglects these communities, and we fail to look.”

Meanwhile, Maira Gutiérrez, the patient who was lucky to have a diagnosis and a consistent treatment, has some advice for them: “Donate blood; at the very least, you’ll know if you have the parasite, and it’ll cost you nothing.”

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After Medical Bills Broke the Bank, This Family Headed to Mexico for Care

Paula Andalo — Wed, 27 Apr 2022 09:00:00 +0000

The Fierro family of Yuma, Arizona, had a string of bad medical luck that started in December 2020.

That’s when Jesús Fierro Sr. was admitted to the hospital with a serious covid-19 infection. He spent 18 days at Yuma Regional Medical Center, where he lost 60 pounds. He came home weak and dependent on an oxygen tank.

Then, in June 2021, his wife, Claudia, fainted while waiting for a table at the local Olive Garden. She felt dizzy one minute and was in an ambulance on her way to the same medical center the next. She was told her magnesium levels were low and was sent home within 24 hours.

The family has health insurance through Jesús Sr.’s job. But it didn’t protect the Fierros from owing thousands of dollars. So, when their son Jesús Fierro Jr. dislocated his shoulder, the Fierros — who hadn’t yet paid the bills for their own care — opted out of U.S. health care and headed south to the U.S.-Mexico border.

And no other bills came for at least one member of the family.

The Patients: Jesús Fierro Sr., 48; Claudia Fierro, 51; and Jesús Fierro Jr., 17. The family has health insurance through Jesús Sr.’s employment with NOV Inc., formerly National Oilwell Varco, a multinational oil company.

Medical Services: For Jesús Sr., 18 days of inpatient care for a severe covid infection. For Claudia, less than 24 hours of emergency care after fainting. For Jesús Jr., a walk-in appointment for a dislocated shoulder.

Total Bills: Jesús Sr. was charged $3,894.86. The total bill was $107,905.80 for covid treatment. Claudia was charged $3,252.74, including $202.36 for treatment from an out-of-network physician. The total bill was $13,429.50 for less than a day of treatment. Jesús Jr. was charged about $5 (70 pesos) for an outpatient visit that the family paid in cash.

Service Providers: , a 406-bed, nonprofit hospital in Yuma, Arizona. It’s in the Fierros’ insurance network. And a private doctor’s office in Mexicali, Mexico, which is not.

The Fierros have been strapped by unusually high medical bills from the Yuma Regional Medical Center. (Lisa Hornak for KHN)

What Gives: The Fierros were trapped in a situation that more and more Americans find themselves in: They are what some experts term “functionally uninsured.” They have insurance — in this case, through Jesús Sr.’s job, which pays $72,000 a year. But their health plan is expensive, and they to pay their “share” of the bill. The Fierros’ plan says their out-of-pocket maximum is $8,500 a year for the family. And in a country where even a short stay in an emergency room is billed at a staggering sum, that means minor encounters with the medical system can take virtually all of the family’s disposable savings, year after year. And that’s why the Fierros opted out.

According to the terms of the insurance plan, which has a $2,000 family deductible and 20% coinsurance, Jesús Sr. owed $3,894.86 of a total bill of nearly $110,000 for his covid care in late 2020.

The Fierros are paying off that bill — $140 a month — and still owe more than $2,500. In 2020, most insurers agreed to waive for covid-19 treatment after the passage of federal that provided emergency funding to hospitals. But waiving treatment costs was optional under the law. And although Blue Cross Blue Shield of Texas has a it would waive cost sharing through the end of 2020, the insurer didn’t do that for Jesús Sr.’s bill. Carrie Kraft, a spokesperson for the insurer, wouldn’t discuss why his covid bill was not waived.

(More than two years into the pandemic and with vaccines now widely available to reduce the risk of hospitalization and death, most insurers again charge patients their cost sharing.)

On Jan. 1, 2021, the Fierros’ deductible and out-of-pocket maximum reset. So when Claudia fainted — a fairly common occurrence and rarely indicative of a serious problem — she was sent by ambulance to the emergency room, leaving the Fierros with another bill of more than $3,000. That kind of bill is a huge stress on the average American family; fewer than half of U.S. adults have enough savings to cover a . , “unexpected medical bills” ranked second among family budget worries, behind gas prices and other transportation costs.

The new bill for a fainting spell destabilized the Fierros’ household budget. “We thought about taking a second loan on our house,” said Jesús Sr., a Los Angeles native. When he called the hospital to ask for financial assistance, he said, people he spoke with strongly discouraged him from applying. “They told me that I could apply but that it would only lower Claudia’s bill by $100,” he said.

So when Jesús Jr. dislocated his shoulder boxing with his brother, the family headed south.

Jesús Sr. asked his son, “Can you bear the pain for an hour?” The teen replied, “Yes.”

Father and son took the hourlong trip to Mexicali, Mexico, to Dr. Alfredo Acosta’s office.

The Fierros don’t consider themselves “health tourists.” Jesús Sr. crosses the border into Mexicali every day for his work, and Mexicali is Claudia’s hometown. They’ve been traveling to the neighborhood known as La Chinesca (“Chinatown”) for years to see Acosta, a general practitioner, who treats the asthma of their youngest son, Fernando, 15. Treatment for Jesús Jr.’s dislocated shoulder was the first time they had sought emergency care from the physician. The price was right, and the treatment effective.

A visit to a U.S. emergency room likely would have involved a facility fee, expensive X-rays, and perhaps an orthopedic specialist’s evaluation — which would have generated thousands of dollars in bills. Acosta adjusted Jesús Jr.’s shoulder so that the bones aligned in the socket and prescribed him ibuprofen for soreness. The family paid cash on the spot.

Although the Centers for Disease Control and Prevention doesn’t endorse , the Fierros are among each year who do so. Many of them are fleeing expensive care in the U.S., even with health insurance.

Acosta, who is from the Mexican state of Sinaloa and is a graduate of the Autonomous University of Sinaloa, moved to Mexicali 20 years ago. He witnessed firsthand the growth of the medical tourism industry.

Jesús and Claudia review their high medical bills. They report paying $1,000 a month for health insurance premiums yet still owed more than $7,000 in deductibles and coinsurance after two episodes of care at the local hospital. (Lisa Hornak for KHN)

He sees about 14 patients a day (no appointment necessary), and 30% to 40% of those are from the U.S. He charges $8 for typical visits.

In Mexicali, a mile from La Chinesca, where the family doctors have their modest offices, are medical facilities that rival those in the United States. The facilities have international certification and are considered expensive, but they are still cheaper than hospitals in the U.S.

Resolution: Both Blue Cross Blue Shield of Texas and Yuma Regional Medical Center declined to discuss the Fierros’ bills with KHN, even though Jesús Sr. and Claudia gave written permission for them to do so.

In a statement, Yuma Regional Medical Center spokesperson Machele Headington said, “Applying for financial support starts with an application — a service we extended, and still extend, to these patients.”

In an email, Kraft, the Blue Cross Blue Shield of Texas spokesperson, said: “We understand the frustration our members experience when they receive a bill containing COVID-19 charges that they do not understand, or feel may be inappropriate.”

The Fierros are planning to apply to the hospital for financial support for their outstanding debts. But Claudia said never again. “I told Jesús, ‘If I faint again, please drive me home,’” rather than calling an ambulance, she said.

“We pay $1,000 premium monthly for our employment-based insurance,” added Jesús. “We should not have to live with this stress.”

The Takeaway: Be aware that your deductible “meter” starts over every year and that virtually any emergency care can generate a bill in the thousands of dollars and may leave you owing most of your deductible and out-of-pocket maximum.

Also be aware that even if you seem not to qualify for financial assistance based on a hospital’s policy, you can apply and explain your circumstances. Because of the high cost of care in the U.S., even many middle-income people qualify. And many hospitals give their finance departments leeway to adjust bills. Some patients discover that if they offer to pay cash on the spot, the bill can be reduced dramatically.

All nonprofit hospitals have a legal obligation to help patients: They pay no tax in exchange for providing “community benefit.” Make a case for yourself, and ask for a supervisor if you get an initial “no.”

For elective procedures, patients can follow the Fierros’ example, becoming savvy health care shoppers. Recently, Claudia needed an endoscopy to evaluate an ulcer. The family has been calling different facilities and discovered a $500 difference in the cost of an endoscopy. They will soon drive to a medical center in Central Valley, California, two hours from home, for the procedure.

The Fierros didn’t even consider going back to their local hospital. “I don’t want to say ‘hello’ and receive a $3,000 bill,” joked Jesús Sr.

Stephanie O’Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by ��ýҕ�l Health News and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? !

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Behind the Byline: The Quest to Bring Spanish Language to KHN

Paula Andalo — Thu, 13 May 2021 09:00:00 +0000

KHN has never been busier ― and health coverage has never been more vital. The Behind The Byline series on and offers an insider’s view.

Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts.

Paula Andaló — The Quest to Bring Spanish Language to KHN

About 37 million people in the United States speak Spanish at home and consume information in Spanish, according to one estimate.

Knowing this, and building on decades of experience as a health journalist, ethnic media editor Paula Andaló developed a strategy to bring KHN’s coverage to Spanish speakers. She has forged partnerships with Spanish-language news outlets across the United States and in Latin American countries.

“I see this job as a mission,” said Andaló. “We offer reliable health content for free and KHN delivers that information in the way Spanish speakers feel most comfortable consuming it.”

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NYC Nurse Says He’s Not Scared: ‘I Am Only Doing My Job’ For COVID-19 Patients

Paula Andalo — Fri, 17 Apr 2020 09:01:32 +0000

Before the deadly coronavirus hit New York, Francisco Díaz’s job as a gerontological nurse practitioner was educating seniors on managing their diabetes. Now, he’s at the heart of the pandemic, working in a New York City emergency room.

“I have worked during the influenza outbreaks, the swine flu, but never a public health threat of this dimension,” said Díaz. April 8 was “one of the hardest days” at his hospital, Mount Sinai West, he told KHN. Gov. Andrew Cuomo announced nearly 800 people in the state died that day from COVID-19, the disease caused by the novel coronavirus.

Francisco Díaz, a gerontological nurse practitioner, is working in the emergency department at Mount Sinai West hospital in New York City during the coronavirus crisis and says his fluency in Spanish comes in handy for Hispanic patients and their worried families. It is, he says, “very important to offer them information about their loved ones, in a language they can understand.” (Courtesy of Francisco Díaz)

“I am tending to a lot of Latino patients with COVID,” he said. In New York City, by the virus than whites, Asians or African Americans who are not Hispanic, preliminary data from city health officials shows.

Díaz pointed out that many of his Hispanic patients cannot afford to stop working and face a higher risk of contracting the coronavirus.

His ability to speak Spanish and understanding of Latino culture make it easier for him to connect with these patients and their families, Díaz said. “For Latinos, it is particularly difficult because with COVID-19 the patient care is more impersonal,” he said. “We can’t touch the patient, get too close. That is why talking to the family is very important, to offer them information about their loved ones, in a language they can understand.”

There are in the United States, accounting for 10% of the health workforce “despite the fact that Hispanics are 18% of the population,” said Norma Cuellar, president of the National Association of Hispanic Nurses.

Díaz was born in New York City as his family took shelter there from the 1965 civil war in the Dominican Republic. After the war ended, his family moved back to Santo Domingo, where he grew up. At age 25, he moved to New York to pursue a career in health care.

On normal days, Díaz works with seniors at Mount Sinai Morningside on Manhattan’s Upper West Side while studying to earn his doctorate in nursing.

But during the coronavirus crisis, he has been transferred about 60 blocks south to Mount Sinai West. Now, depending on the day, he is in charge of eight to 12 ER patients with symptoms of COVID-19. Díaz accompanies them if they have any tests run, administers medications and takes their vital signs. He also helps describe the process to patients ― in Spanish, if that is their preferred language ― and, although he spends only a short time with each one, tries to keep them comfortable.

“Nurses have a very direct link with the patient,” he said.

During the epidemic, he said, he has been working with patients ranging in age from 21 to over 90. Afterward, he often doesn’t know how they fared.

“I am not working in the ICU,” he said. “I don’t have to see some of them die.”

Díaz said he is careful in his work and anxious to make sure he doesn’t bring home the virus that would hurt his husband. Every night, immediately after arriving home, he removes all his clothes and goes straight to the shower. He said his outlook is positive: “I am 54, but I am healthy, I do not have preexisting conditions.”

“People ask me more than ever if I am scared,” he said. “I am not. I am only doing my job.”

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Price Of A Brace Brings Soccer Player To His Knees

Paula Andalo — Tue, 26 Mar 2019 09:00:14 +0000

Last October, Esteban Serrano wrenched his knee badly during his weekly soccer game with friends.

Serrano, a software engineer, grew up playing soccer in Quito, Ecuador, and he has kept up his sport since moving to the United States two decades ago.

He hobbled off the field and iced the knee. But the pain was so severe, he made an appointment with , a network of orthopedists practicing in Greater Philadelphia, New Jersey and New York.

The doctor diagnosed a strain of the , or MCL, and prescribed over-the-counter pain medication as well as a hinged knee brace, which he used for several weeks until he’d healed.

He expected his insurance to cover his treatment as a plan from a previous job had covered him when he needed surgery to fix a broken nose sustained in another soccer game in 2017.

Then the bill came.

Patient: Esteban Serrano, 41, a software engineer and father of two from Phoenixville, Pa., in suburban Philadelphia.

Esteban Serrano, a software engineer, grew up playing soccer in Quito, Ecuador, and he has kept up his sport since moving to the United States two decades ago. (Paula Andalo/KHN)

Total Bill: $1,197: $210 for the office outpatient visit, $105 for the X-ray and $882 for a hinged knee brace, all billed by the orthopedic practice. His insurer, Aetna, negotiated only $52.59 off the cost of the brace. That left Serrano with a balance of $829.41 because he hadn’t met his $3,000 deductible for the year.

Service Provider: Rothman Orthopaedic Institute in Bryn Mawr, Pa.

Medical Service: A doctor examined Serrano’s knee and sent him for an X-ray. The doctor said he should use a knee brace for four weeks and recommended a hinged one sold through the practice.

What Gives: An MCL injury is a common knee injury occurring . According to the American Academy of Physical Medicine and Rehabilitation, the MCL is involved in at least 42 percent of knee ligament injuries. Although most cases are sports-related, such injuries can also result from everyday activities like tripping on stairs.

“The doctor told me that he thought I didn’t have damage, that it was more of an inflammation, but he ordered an MRI just to make sure,” said Serrano. (The MRI, at a later date, confirmed that suspicion.)

Serrano said the brace did ease the discomfort and stabilized his knee as it healed. However, the shocking bill was almost more painful — he owed the orthopedic practice $829.41.

“You can find the same brace for less than $250 online,” he said.

The bill came close to Christmas, when Serrano’s 12-year-old daughter wanted her first iPhone. “I told her ‘Sorry, honey, but I already paid a price of an iPhone for the hinged knee brace,’” Serrano joked.

Serrano emphasized that he felt lucky to have the money to handle a bill that for many people could equal a month’s rent or three months of groceries.

Knee braces fall into a category of products called “durable medical equipment,” whose prices can vary widely. Items range from slings and braces to wheelchairs and commodes to glucose meters and breast pumps for new mothers. Doctors and hospitals that dispense and prescribe such equipment for patients to take home almost always bill for them and add hefty markups that can catch patients unaware.

Braces and other products “are often marked up two or three times what the cost is, and unfortunately, that is the standard practice,” said , an orthopedic surgeon and chief of sports medicine for Washington University Physicians in St. Louis.

Rothman Orthopaedic didn’t respond to requests for comments.

The type of hinged knee brace Serrano bought was a Playmaker. Donjoy is one of the nation’s largest producers of braces. A customer service representative for the company said it charges a retail price of $242.51 for the model Serrano got. Serrano paid more than three times that price.

When Esteban Serrano injured his knee, his insurer, Aetna, covered the cost of his visit to an orthopedist and an X-ray, but only $52.59 of the cost of the brace. Serrano was left with a balance of $829.41. (Paula Andalo/KHN)

In an emailed statement about the case, an Aetna spokesman wrote that “while the cost of a knee brace, or any other health care service, is determined by the negotiated rate between the health care provider and the health plan, the starting point is the charge from the health care provider.”

It is not even clear that such an elaborate knee brace was needed for Serrano’s injury.

, chief of Women’s Sports Medicine at Brigham and Women’s Hospital in Boston and an assistant professor at Harvard Medical School, said that while it is helpful to give patients some kind of knee brace for support after MCL injuries, the use of a hinged knee brace does not influence recovery, according to studies. She called hinged braces “luxury products.” Simpler, cheaper braces also offer support.

Resolution: Serrano recalled that when he received the brace, the practitioner showed him a form with its estimated cost in writing. He remembered his share was more than $700, but he didn’t pay too much attention because he assumed his insurance would cover it.

After receiving the bill, he made several phone calls to the doctor’s practice to get a copy of the form he’d signed. It stated that the product could be returned within seven days. A month had already passed. Because he had not met his deductible, his $829.41 balance was even more than the estimate.

The Takeaway: These days, many types of equipment dispensed by doctors’ offices or hospitals involve a charge. Don’t assume generosity. Ask the doctor to identify precisely what you need and explain why you need it.

When a doctor or hospital offers you a piece of equipment to help your healing, decide if you really need it or will use it. Say “no” if you will not. Ask if you will be billed for it and how much.

Many items can be purchased at a fraction of the cost online or from a pharmacy just down the block.

Know your insurance plan’s copay for medical equipment (often 20 percent). The cost of purchasing the equipment yourself online may well be less than the copay if you purchase through a medical office.

NPR produced and edited the interview with KHN Editor-in-Chief Elisabeth Rosenthal for broadcast.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.

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Under Trump Proposal, Lawful Immigrants Might Be Inclined To Shun Health Benefits

Christina Jewett — Fri, 11 May 2018 09:00:29 +0000

The Trump administration is considering a policy change that might discourage immigrants who are seeking permanent residency from using government-supported health care, a scenario that is alarming some doctors, hospitals and patient advocates.

Under the proposed plan, a lawful immigrant holding a visa could be passed over for getting permanent residency — a green card — if they use Medicaid, a subsidized Obamacare plan, food stamps, tax credits or a list of other non-cash government benefits, according to a of the plan published by The Washington Post. Even the use of such benefits by a child who is a U.S. citizen could jeopardize a parent’s chances of attaining lawful residency, according to the document.

Health advocates say such a policy could frighten a far broader group of immigrants who will avoid government-supported health coverage, creating public health problems that could prove dire. About 3 million people received green cards from 2014 through 2016, government records show. Immigrants with visas or those who may have no legal status but plan to seek citizenship based on a close would be affected.

“We are very concerned that this rule, if finalized, would have a significant impact on health in this country,” said Erin O’Malley, senior director of policy for America’s Essential Hospitals, which discussed the plan with Trump administration officials in mid-April.

O’Malley said she fears that some visa holders and their families would steer clear of getting routine treatment and resort to going to emergency rooms for medical care. Such a change would “undermine the stability of our hospitals by creating uncompensated care costs and creating sicker patients,” O’Malley said.

Wendy Parmet (Courtesy of Northeastern University)

The policy change could force a mother to weigh the need for hospital inpatient care for an ailing newborn against losing her legal immigration status, said Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University.

“The administration, in the draft, talks about self-sufficiency,” she said. “But we don’t expect that of [babies]” who are U.S. citizens because they were born in this country. “It’s extremely hardhearted.”

Pushback has begun even though the proposal is in the earliest stages of the rulemaking process.

Washington state Gov. Jay Inslee, a Democrat, is sending staff in mid-May to meet with the White House Office of Management and Budget, which is vetting the proposed rule. Inslee sent a letter on April 24 urging OMB Director Mick Mulvaney to consider the impact on tax-paying, lawful immigrants.

Gov. Jay Inslee (D-Wash.) (Courtesy of the Washington Office of the Governor)

“This will undoubtedly lead to people across the U.S. going hungry, not accessing needed medical care, losing economic self-sufficiency, and even becoming homeless,” Inslee wrote.

The leaked draft said immigration officials would count the use of one or more non-cash benefits by the applicant within three years as a “heavily weighed negative factor” in deciding whether to grant permanent residency.

On March 29, the Department of Homeland Security of the proposal to OMB, which reviews it for conflicts with existing law. Next, it will be as a proposed rule that the public can comment on before it’s finalized.

Marilu Cabrera, public affairs officer with the U.S. Citizenship and Immigration Services, declined to comment on whether the draft by the Post mirrors what the OMB is reviewing.

Julie Linton (Courtesy of Wake Forest Baptist Medical Center)

Fear in immigrant communities already weighs on physicians. Dr. Julie Linton, a spokeswoman for the American Academy of Pediatrics, treats many Latino immigrant families at an outpatient clinic in Winston-Salem, N.C. She said one woman from Mexico, who had a newborn baby and three other children, told Linton she was afraid to keep her family enrolled in the nutrition program for Women, Infants, and Children (WIC). “Is it safe to use WIC?” the woman asked her.

Linton said questions like that put pediatricians in a tough position. She said evidence shows enrolling in WIC leads to better health outcomes for kids. But what if it also puts the family at risk of being split apart?

“It feels very frightening to have a family in front of me, and have a child with so much potential … and be uncertain how to advise them” on whether to accept public benefits, Linton said.

Maria Gomez, president of Mary’s Center, which runs health clinics in Washington, D.C., and Maryland, said she’s seeing three to four people a week who are not applying for WIC and are canceling their appointments to re-enroll in Medicaid.

Maria Gomez (Courtesy of Mary’s Center)

The leaked draft of the proposal zeroes in on who is considered a “public charge.” The concept emerged in immigration law in 1882, when Congress sought to bar immigrants who were “idiots, lunatics” or those likely to become a burden on the government.

The notion of a “public charge” last surfaced in 1999, when the immigration service clarified the concept. Then and now, an immigrant considered a “public charge” is inadmissible to the U.S. if the person is likely to rely on the government for income, or lives in a government-funded long-term institution.

Yet the guideline published in 1999 clarified that legal residents were free to access non-cash benefits like Medicaid, food stamps and assistance for heating bills. “These benefits are often provided to low-income working families to sustain and improve their ability to remain self-sufficient,” the .

The proposal, as drafted, would upend that.

Under such a policy, anyone who had recent or ongoing use of a non-cash government benefit in the previous 36 months would likely be deemed a “public charge,” and therefore inadmissible to the U.S. The use of such benefits by a spouse, dependent parent or child would also be taken into account.

Applicants who have “expensive health conditions” such as cancer, heart disease or “mental disorders” and had used a subsidized program would also get a “heavily weighed” negative mark on their application, the draft says.

Marnobia Juarez, 48, battled cancer successfully and is hoping her husband’s green card application is approved; she also dreams of one day getting her own. She said she never wanted to apply for public benefits until she was diagnosed with breast cancer in 2014. Since then, she has been treated at no cost under a program run by the state of Maryland.

“I’m alive thanks to this program,” said Juarez, who is a health volunteer with an immigrant advocacy group. “You don’t play with life, and they are playing with life.”

The draft says immigrants could post a minimum $10,000 bond to help overcome a determination that they are likely to be a “public charge.”

Such changes would affect people sponsored by a U.S. citizen family member, most employment-based immigrants, diversity visa immigrants and “certain non-immigrants,” the draft says. In 2016, 1.2 million people got their lawful permanent residence status, or a green card. Of the total, 566,000 were immediate relatives or spouses of U.S. citizens and 238,000 more were family-sponsored, Department of Homeland Security data show.

Some immigrants, such as refugees and asylees, would not be affected. Nor would the proposed changes apply to undocumented immigrants.

“We’re talking about middle-class and working families,” said Madison Hardee, senior policy attorney with the Center for Law and Social Policy, which has organized the proposal. “This could really put parents in an impossible situation between seeking health assistance for their children and obtaining a permanent legal status in the U.S.”

The list of benefits includes the Children’s Health Insurance Program, known as CHIP; non-emergency Medicaid; the Supplemental Nutrition Assistance Program, or food stamps; WIC; and short-term institutionalization at government expense and others. The notes that foreign-born and native-born Americans use such programs at similar rates.

The draft says the proposal is meant to ensure that people seeking to “change their nonimmigrant status are self-sufficient.” It notes “relevant congressional policy statements,” including one that says “the availability of public benefits [should] not constitute an incentive for immigration to the United States.”

KHN correspondent Emmarie Huetteman contributed to this report.

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Displaced Puerto Ricans Face Obstacles Getting Health Care

Paula Andalo — Tue, 21 Nov 2017 10:00:02 +0000

The federal government has granted people affected by the devastating hurricanes that wracked coastal states and Puerto Rico 15 extra days to sign up for health coverage under the Affordable Care Act.

But Puerto Ricans who fled to the mainland after the destruction face problems well beyond timing.

Many of those Americans have complicated questions about whether the Medicaid or Medicare coverage they had in Puerto Rico will shift with them to their new locations. And for those seeking private coverage, using the ACA’s insurance marketplaces will likely be a new experience because the federal health law didn’t establish those marketplaces in the U.S. territory.

Members of Congress from Florida said Wednesday they are concerned that many of these recent arrivals, as well as insurance companies and navigators, are confused. They , the director of the Centers for Medicare & Medicaid Services (CMS), requesting that federal officials put out a fact sheet to “provide much-needed clarity and alleviate confusion” among Puerto Ricans who have relocated to the States.

Insurance enrollment on the health law’s marketplaces ends for most people Dec. 15. In a bow to the hardships caused by the August and September storms, residents living in hard-hit areas of Texas, Florida and Georgia are allowed to sign up as late as Dec. 31. But waiting until those final 15 days means that the start of their coverage is delayed until Feb. 1.

Many Puerto Ricans driven from their homes, however, are negotiating layers of red tape. In Puerto Rico, nearly three-quarters of Medicare beneficiaries are in private Advantage plans. Many have questions about whether those plans will cover them stateside.

Also, the Medicaid program for low-income residents in Puerto Rico — a rate — but it’s not clear that people moving stateside will continue to qualify because they may not meet the tighter eligibility standards. That is especially true if their new home state did not expand Medicaid under the ACA to all adults earning up to 138 percent of the federal poverty level (about $16,000 for an individual).

At the very least, they will have to reapply for Medicaid coverage. Often the most effective route is through the ACA marketplaces. That process will show them whether they are eligible for Medicaid or perhaps a federal subsidy to purchase a private plan.

According to a released in September, they can call the help line (1-800-318-2596) for help. The memo, which doesn’t provide details about what documentation is needed, also says that “individuals may experience qualifying events due to a hurricane that makes them eligible for a (SEP)” to access another health plan. For example, individuals who temporarily relocated to Florida due to a hurricane and are now out of their health plan coverage area could be eligible for a special enrollment period because of the move.

After the storms hit, the Federal Emergency Management Agency (FEMA) designated all counties in Florida and Georgia, and 53 in Texas, to receive “individual assistance” or “public assistance.” In Puerto Rico, this category was granted to .

Still, Anne Packham, director of the marketplace navigator project at Primary Care Access Network, an organization based in Orlando that is part of , said the focus should be on encouraging consumers to register before Dec. 15, the last day most people can sign up for coverage that begins Jan. 1.

“Everything is already very confusing, and we think that telling consumers that they can register until Dec. 31 during a special period is adding confusion,” she said. “These people need insurance right now, on Jan. 1, not February.”

Since the storms, have arrived in the central area of Florida, according to Gov. Rick Scott’s office. They may stay only for a few months or settle to start a new life. Seeking insurance and medical attention has proven arduous.

Marni Stahlman, president and CEO of , an organization based in Orlando that helps people find coverage and services, recalled one Puerto Rican couple that had a tough time.

He had Medicare and she was a retired teacher who had insurance through her union, Stahlman said. “The husband’s Medicare policy was not applicable on the mainland and the wife’s was not honored either,” she said. “Both have had to start over. He with reapplying for Medicare and she had to apply for the very first time in a marketplace. They are at this time still ‘uninsured,’ something that they have never had to encounter.”

Maria Gotay and her sons, Edwin Rodriguez (left) and Cristian Rodriguez. They came to Orlando, Fla., two weeks after Hurricane Maria hit Puerto Rico. Having important papers helped them through the process to obtain health care. (Courtesy of Maria Gotay)

Complicating the situations for many families is the lack of records and supplies. The hurricanes not only devastated lives, homes and power, but they also took medicines, prescriptions, insurance cards and copies of tax returns.

“Help for everybody, but for Puerto Ricans in particular, it has to be integral because these people only arrive with their passports,” said Jean Zambrano, vice president of medical operations at Shepherd’s Hope.

Among the newcomers to Florida, there are at least 18,000 children and adolescents who need medical attention quickly because they are required to get vision, hearing and immunization screenings to attend school. Stahlman and Zambrano said there is no coordinated effort at the state level to pave the way for them.

Maneuvering between the territories and the States is not a well-oiled machine, and health care can fall through the cracks — which means the last resort for many needing medical attention is the emergency room.

Those who arrive with their important papers help ensure success. María Gotay, 51, arrived in Orlando from Bayamón, Puerto Rico, with her two boys, Cristian, 17, and Edwin, 22, 10 days after Hurricane Maria ravaged the island.

“We keep our documents in a safe place,” she said, so she had them ready when applying for coverage for her children.

Navigator Doris Allen, from Primary Care Access Network, helped sign up Gotay’s younger son for the and the older one in a private insurance plan for $33 a month after a subsidy. Maria Gotay was already covered by Medicare because she has a disability from fibromyalgia.

“We were very fortunate to meet such supportive people,” said Gotay. She recalled arriving at the health center and falling in Allen’s arms crying hysterically. “I never wanted to leave Puerto Rico, I never imagined being at the edge of dying.”

“During the hurricane, we were all together, our house was damaged and flooded, but it withstood Maria’s onslaught,” said Gotay.

She brought her sons to Orlando because her two daughters were already living there. Her husband stayed on the island, caring for his father who shows signs of Alzheimer’s, she said.

She said she has enormous stress and fear following the hurricane, and has been seeing a psychiatrist in Orlando to get help. However, she will return to Puerto Rico this month, while her boys stay in Florida to begin a new life.

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