Bannon had difficult end-of-life-care conversations with his parents, both in their mid-80s, before his mother’s diagnosis. During those discussions, held at Bannon’s urging, his parents decided how far they wanted doctors to go to keep them alive should they become too sick to communicate. Bannon then documented their wishes.

“That helped so much, because you knew at least one thing was going to be taken care of,” said Bannon, 65, of San Francisco, whose mother survived and lives with Bannon’s father in Wethersfield, Conn.

Most Americans , although some people may be more likely to make them if a  starts the discussion. In California, the state’s attorney general’s office offers an  on its website. In the past few years, other websites have encouraged those conversations, with their own suggestions on how to get started.

Rebecca Sudore, a geriatrician at the University of California-San Francisco, created , which provides step-by-step instructions and video stories to help people navigate the care they want at the end of their lives. She built the site in 2013 for families unsure how to broach sensitive questions. In a study published in  in May, she and other researchers found that the website — combined with the use of an “advance directive” form — prompted participants to plan ahead.

The website is free, and Sudore makes no money from it. She said she created it as a public service with the idea of studying its effectiveness.

The site guides patients in drafting a “summary of wishes” to help families and other caregivers decide whether their loved ones should undergo life-sustaining medical interventions such as feeding tubes and ventilators.

For the study, Sudore approached 414 San Francisco-area military veterans — including Bannon — who were split into two groups: One received a simplified , a legal document allowing a patient to consent to or decline specific medical procedures well before they occur. The other group was given the directive but also was pointed to prepareforyourcare.org, which is publicly available in English and Spanish.

Almost none of the participants had documented their wishes in the six months before the study. But nine months after the study began, 35 percent of those who received access to the website and the directive had updated their medical record, while 25 percent who received just the directive had done so.

Sudore sees stark contrasts between “deer-in-headlights” families who arrive at the intensive care unit with outdated directives and no specified plans, and those who have had ongoing conversations.

Bannon, a Vietnam War veteran, X-ray technician and colon cancer survivor, praised the site’s simplicity and accessibility and said it persuaded him and his parents to document their wishes before his mother’s cancer treatment.

The website appears to be a useful tool, according to Dr. VJ Periyakoil, associate professor of medicine and director of Stanford University’s . (Periyakoil is friends with the UCSF researchers but was not involved in the study.)

“Clinicians are so hard-pressed for time, so when the patients get activated by web-based tools, I think it’s a wonderful thing,” she said.

Seventy percent of Americans lack an advance care plan, according to the U.S. , and lack of preparation can have undesirable effects, Periyakoil said.

Family members who have not gone through this process sometimes choose life-sustaining options for their loved ones that may cause unnecessary suffering, Periyakoil said.

Children “might be more lured by, ‘I really love Mom. I can’t allow anything bad to happen to her and I want to keep doing whatever I can to extend her life,’” she said. “And by doing so, they might end up subjecting Mom or Dad to a lot of measures that are ineffective and burdensome.”

Periyakoil, who has  to end-of-life care among eight ethnic groups, does not believe there’s a single solution to encouraging end-of-life conversations, because different groups have different approaches to discussing death. She suggested the website might be one of many strategies to consider.

Prepareforyourcare.org has logged more than 1.7 million page views and 85,000 users in 115 countries since its 2013 launch.

For Bannon, the site worked. “Now [my parents are] even more relaxed, because when they do face their final exit, everything’s in place,” he said.

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Adultos jóvenes como Kpangbah estuvieron entre los mayores beneficiarios del Obamacare, lo que ayudó a reducir los índices de millennials no asegurados a mínimos récord y proporcionó a millones de estadounidenses acceso a seguro gratuito o de bajo costo, así como cuidado de maternidad, tratamiento de salud mental y otros servicios.

Ahora, republicanos del Senado proponen la Ley de Cuidado de Salud Asequible (ACA), una medida que podría ayudar a algunos jóvenes reduciendo el costo de sus primas en los mercados de seguros privados, pero podría perjudicar a otros que lograron tener cobertura a través de una expansión masiva del Medicaid. Un análisis del proyecto de ley realizado por la Oficina de Presupuesto del Congreso (CBO) estimó que podrían perder cobertura bajo este proyecto de ley.

La legislación propuesta también mantendría una disposición popular del Obamacare que permitió a los adultos jóvenes hasta los 26 años permanecer en el seguro de sus padres. Pero el proyecto de ley en su forma actual también podría reducir drásticamente la cobertura de salud y el cuidado de otros adultos jóvenes, de acuerdo con críticos del proyecto de ley, que incluyen a la Asociación Médica Americana y la Asociación Americana de Hospitales.

“No se deje engañar”, dijo Jen Mishory, directora ejecutiva de la organización de defensa Young Invincibles. “Esto va a ser un mal negocio, especialmente para los jóvenes más vulnerables”.

Mishory dijo que una de las mayores preocupaciones es que los estados podrán optar por no exigir que las aseguradoras ofrezcan beneficios tales como cuidado de maternidad, atención de salud mental y medicamentos con receta, todos ellos utilizados comúnmente entre adultos jóvenes. “Verán que muchos jóvenes no recibirán el tipo de cobertura que necesitan”, dijo.

Sin embargo, los cambios propuestos en los mercados podrían hacer que la cobertura sea más atractiva para los jóvenes. La CBO informa que el proyecto de ley del Senado daría lugar a un mayor número de personas jóvenes que pagarían menos al comprar planes privados. La propuesta permitiría a las aseguradoras cobrar a las personas mayores hasta cinco veces más que a otras, lo que podría significar primas más bajas para los jóvenes.

Al mismo tiempo, el proyecto de ley del Senado cambia la cantidad que deben pagar de su propio bolsillo por las primas los que califican para subsidios, lo que significa que podrían pagar una porción menor de sus ingresos por cobertura de lo que pagan bajo el Obamacare.

Pero los adultos jóvenes podrían enfrentar otros aumentos de costos debido a mayores deducibles y menos ayuda con los gastos de bolsillo. Algunos ya no calificarían para subsidios en absoluto, porque el proyecto de ley reduciría el umbral de ingresos para elegibilidad.

Millones de adultos jóvenes se han inscrito para tener cobertura a través de los mercados de seguros. En parte debido a un empuje coordinado para conseguir la suficiente cantidad de personas sanas y jóvenes en el mercado para equilibrar a los mayores, los consumidores más enfermos que estaban dispuestos a registrarse de inmediato.

Alrededor del 27% de los 12,2 millones de consumidores que se inscribieron para tener seguro de salud a través de los mercados en todo el país en 2017, tenían de 18 a 34 años. En California, el 37% de los inscritos en 2017 fueron de ese grupo de edad, de acuerdo con Covered California, el mercado estatal de seguros.

Steven Orozco, quien vive en Los Ángeles, fue uno de ellos. Él, su esposa y su hija de 2 años tienen un plan a través de Covered California. Orozco, quien es agente de bienes raíces, dijo que son todos sanos por lo que no lo utilizan a menudo, pero lo tiene sólo en caso que alguien se rompa un brazo, u otras necesidades inesperadas de salud.

Orozco, de 32 años, dijo que le preocupa lo que podría suceder en Washington, DC y cómo eso podría afectar su cobertura, que actualmente cuesta alrededor de $450 al mes.

A pesar de los beneficios potenciales para los adultos jóvenes en el mercado privado, los cambios más perjudiciales bajo la propuesta del Senado serían para los adultos jóvenes cubiertos por el Medicaid, dijo Walter Zelman, presidente del Departamento de Salud Pública en Cal State-Los Ángeles.

Además de la eliminación de la expansión del Medicaid, el proyecto de ley del Senado también se traduciría en la reducción de fondos para el programa, dijo.

“El mayor impacto en los jóvenes es el desmantelamiento del Medicaid”, dijo Zelman.

Desde que ACA entró en vigor, alrededor de 3,8 millones de adultos jóvenes han ganado cobertura a través de la expansión del Medicaid, según Young Invincibles.

Zelman dijo que, sólo en California, cientos de miles de jóvenes no podrán acceder al Medi-Cal, la versión del Medicaid en California, si la expansión desaparece. Zelman, quien trabajó para inscribir a los estudiantes de la Universidad Estatal de California para que tuvieran cobertura de salud bajo el Obamacare, dijo que históricamente los porcentajes más altos de personas no aseguradas son adultos jóvenes, residentes de bajos ingresos, trabajadores de medio tiempo y latinos.

“Esos son mis estudiantes”, dijo. “Y son los jóvenes en general… Cualquier cosa que amenace [su] acceso a la salud es mala para ellos”, dijo.

No está claro si la revisión republicana propuesta resultaría en más o menos jóvenes afiliados.

Sydney Muns, residente de Sacramento de 27 años, quien no tiene seguro, trabaja en una organización sin fines de lucro que no ofrece cobertura de salud y ganó demasiado dinero para calificar para Medi-Cal o recibir subsidios del Obamacare. Muns dijo que espera que, en el futuro, las primas y los gastos de bolsillo bajen para poder obtener cobertura.

“Simplemente no es asequible”, dijo Muns, que enfrenta una deuda de préstamos universitarios de $50,000. “No conozco a nadie de mi edad que tenga seguro médico”.

Pero Chyneise Dailey, de 24 años, dijo que planea comprar seguro, esté o no obligada a hacerlo. Dailey, quien trabaja en la Universidad Estatal de Sacramento, permanece bajo el plan de salud de sus padres, Blue Cross, pero sabe que sólo le quedan un par de años antes que tenga que comprar su propia cobertura.

“Nunca se sabe lo que puede pasar. Tienes un accidente de auto, estás en una sala de emergencia, ¿quieres pagar la tarifa completa o quieres pagar tu copago?”, dijo Dailey. “Prefiero estar a salvo que arrepentida”.

Bajo los planes del Senado y de la Cámara de Representantes para reformar el Obamacare, las mujeres jóvenes que van a Planned Parenthood en busca de servicios de salud reproductiva y otros servicios médicos podrían verse afectadas, debido a una disposición para prohibir la financiación federal de la organización durante un año.

Eso le preocupa a Niki Kangas, de 35 años, quien visita las clínicas de Planned Parenthood con frecuencia, a pesar de que tiene cobertura de Kaiser Permanente a través de su empleador (Kaiser Health News no está afiliada a Kaiser Permanente.) Kangas, de Sacramento, dijo que está “molesta” de que el proyecto de ley del Senado impondría una prohibición de un año de financiación federal a la organización, una meta de los conservadores.

“He usado Planned Parenthood mucho, entre trabajos o, a veces, es más conveniente que ir a Kaiser si sólo necesito control de la natalidad”, dijo Kangas, gerenta de proyecto de una agencia de diseño. “Creo que las personas que no tienen seguro a través de su trabajo dependen de este recurso”.

Mary Agnes Carey, Julie Appleby and Barbara Feder Ostrov contributed to this report.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Young adults like Kpangbah were among the biggest beneficiaries of Obamacare, which helped reduce the rates of uninsured millennials to record lows and provided millions of Americans with access to free or low-cost insurance as well as maternity care, mental health treatment and other services.

Now, Senate Republicans have the Affordable Care Act — a move that could help some young adults by lowering the cost of their premiums in the private insurance marketplaces but could hurt others who gained insurance through a massive expansion to Medicaid. A Congressional Budget Office analysis of the bill released Monday estimated that under the Senate bill, which could change significantly before an expected vote before July 4.

The proposed legislation also would retain a popular Obamacare provision that allowed young adults up to age 26 to stay on their parents’ insurance. But the bill in its current form also could dramatically reduce health coverage and care for other young adults, according to the bill’s many critics, which include the American Medical Association and the American Hospital Association.

“Don’t be fooled,” said Jen Mishory, executive director of the advocacy organization Young Invincibles. “This is going to be a bad deal, particularly for the most vulnerable young people.”

Mishory said one of the biggest concerns is that states could opt out of requiring insurers to provide benefits such as maternity care, mental health care and prescription drugs — all commonly used among young adults. “You will see a lot of young people not getting the kind of coverage they need,” she said.

The proposed changes in the marketplaces, however, could make coverage more attractive to young people. The Congressional Budget Office reports that the Senate bill would result in a larger number of younger people paying lower premiums to buy private plans. The proposal would allow insurers to charge older people up to five times more than others, which could mean lower premiums for younger people.

At the same time, the Senate bill shifts the amount people who qualify for subsidies must pay toward their own premiums, meaning that might pay a smaller portion of their income toward coverage than they do under Obamacare.

But young adults could face other cost increases because of larger deductibles and less help with out-of-pocket expenses. Some no longer would qualify for subsidies at all, because the bill would reduce the income threshold for eligibility.

Millions of young adults have enrolled in coverage through the insurance exchanges, in part because of a coordinated push to get as many healthy, young people into the marketplace to balance out older, sicker consumers who were eager to sign up right away.

About 27 percent of the 12.2 million consumers who enrolled in health insurance through the exchanges across the nation in 2017, were 18 to 34 years old. In California, 37 percent of 2017 enrollees were in that age group, according to Covered California, the state’s insurance exchange.

Steven Orozco, who lives in Los Angeles, is among them. He, his wife and 2-year-old daughter have a plan through Covered California. Orozco, who is a real estate agent, said they are all healthy so they don’t use it often, but he has it just in case of broken arms or other unexpected health needs.

Orozco, 32, said that he is concerned about what could happen in Washington and how that might affect his coverage, which currently costs about $450 a month.

Despite potential benefits to young adults in the private marketplace, the most damaging changes under the Senate proposal would be for young adults covered by Medicaid, said Walter Zelman, chairman of the public health department at Cal State-Los Angeles.

In addition to phasing out the expansion of Medicaid, the Senate bill also would result in reduced funding for the program, he said.

“The biggest impact on young people is the dismantling of Medicaid,” Zelman said.

Since the Affordable Care Act took effect, about 3.8 million young adults have gained coverage through the expansion of Medicaid, according to Young Invincibles.

In California alone, Zelman said, hundreds of thousands of young people won’t be able to access Medi-Cal, California’s version of Medicaid, if the expansion is phased out. Zelman, who worked to enroll California State University students into health coverage under Obamacare, said that historically the highest percentages of uninsured people have been young adults, low-income residents, part-time workers and Latinos.

“Those are my students,” he said. “And, more generally, those are young people overall. … Anything that threatens [their] access to health is bad for them,” he said.

It’s unclear whether the proposed Republican overhaul would result in more or fewer young enrollees.

Uninsured Sacramento resident Sydney Muns, 27, works at a nonprofit that doesn’t offer health coverage, and she earned too much money to qualify for Medi-Cal or receive Obamacare subsidies. Muns said she hopes premiums and out-of-pocket costs will decline in the future so she can get coverage.

“It’s just not affordable,” said Muns, who faces $50,000 in college loan debt. “I don’t know anyone my age who has insurance.”

But Chyneise Dailey, 24, said she plans to purchase health care whether or not she is required to do so. Dailey, who works at Sacramento State, remains on her parents’ Blue Cross health insurance plan, but knows she has only a couple of years before she has to buy her own coverage.

“You never know what can happen. You get into a car accident, you’re in the ER — do you want to pay full rate or do you want to pay your copay?” Dailey said. “I’d just rather be safe than sorry.”

Under both the Senate and House plans to overhaul Obamacare, young women who go to Planned Parenthood for reproductive health and other medical services could be hurt because of a provision to ban federal funding of the organization for a year.

That concerns Niki Kangas, 35, who frequently visits Planned Parenthood clinics even though she has job-based coverage from Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.) Kangas, of Sacramento, said she is “pissed off” that the Senate’s proposed bill would impose a one-year ban on federal funding to the organization, which is a frequent target for conservatives.

“I’ve used Planned Parenthood a lot, either in between jobs or sometimes it’s just more convenient than going out to Kaiser, like if I just need birth control,” said Kangas, a project manager at a design agency. “I think for people who don’t have insurance through their work that it’s a resource they depend on.”

Mary Agnes Carey, Julie Appleby and Barbara Feder Ostrov contributed to this report.

This story was produced by , which publishes , an editorially independent service of the . KHN’s coverage in California is funded in part by .

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Her first reaction was panic, said Thach, speaking through a Vietnamese interpreter. Uninsured at the time, she had no idea how to come up with the money. Then she learned from the hospital staff that as a low-income legal resident, she qualified for Medicaid, which ultimately paid the bill.

At a recent community meeting in this city, the 54-year-old Alameda resident teared up as she expressed her fear of losing Medicaid (known as Medi-Cal in California) under the Republican-sponsored American Health Care Act. The estimates could lead to the loss of health coverage for 23 million Americans.

“I’m scared that Mr. Trump will cut Medi-Cal. How will I take care of my health?” Thach said.

Facing concerns over immigration and GOP-led efforts to dismantle the Obama administration’s signature health care law and cut Medicaid, community groups in Oakland, Bakersfield, Fresno, Houston and other cities with large immigrant populations are holding meetings to allay fears, debunk myths and inform people of their rights.

More than 400 people attended the Oakland forum on Wednesday sponsored by the Oakland-based clinic system . Some came to ask questions, others to share stories they hoped would motivate elected officials to help them. The room was so packed, a group of Chinese attendees had to observe from an overflow room. Most participants were middle-aged or senior citizens, many with notebooks and pens in hand.

With the help of headphones and a tableful of interpreters, the meeting was translated in 10 different Asian languages, including Cantonese, Mandarin, Mongolian and Korean and Tagalog. Questions were fielded by Asian Health Services staff, local politicians and an immigration attorney, who gave advice on interacting with Immigration and Customs Enforcement (ICE) officials.

Some attendees feared the use of government programs like Medi-Cal and CalFresh (food stamps) could prompt ICE inquiries or deportation. The attorney, Nancy Wong with Asian Pacific Islander Legal Outreach, said she’d seen no evidence of that and urged the audience to continue using those programs for now.

Republican Congress members from California contend the Affordable Care Act — also known as Obamacare — is failing and has raised costs to the point that care has become out-of-reach for many Americans.

Devin Nunes (R-Tulare) who supports the GOP replacement bill, favors moving people from the “broken” Medi-Cal program “into better, private coverage plans.” The GOP’s AHCA would reduce federal funding for Medicaid by $834 billion from 2017 to 2026, the .

Many Americans are concerned about major changes to their health coverage, organizers said, but members of Oakland’s Asian immigrant community face additional language, cultural, legal and other barriers to getting the health care they need.

Some at the forum feared that a preexisting condition, or being an immigrant — even a legal one — would disqualify them from future health coverage and other public benefits. In most cases, adults without authorization to live in the U.S. cannot qualify for full Medi-Cal coverage, although permanent residents with green cards can. Children in California whose families meet income limits can receive Medi-Cal regardless of their immigration status.

“Many of you went from worrying … that insurers would not cover you to overnight being entitled to full benefits,” Sherry Hirota, CEO of Asian Health Services, told the audience. “We can’t roll back, and we can’t let immigrants be criminalized for using health services. That’s why we’re here.”

Hirota said the ACA, including the expansion of Medicaid, allowed her clinic system to treat more than 9,000 new patients. More than 90 percent of the center’s patients are on Medi-Cal, she said.

“More [forums like these] are emerging, and they’re important because there are many questions and not enough information out there,” said Doreena Wong, a project director with Asian Americans Advancing Justice-Los Angeles.

The organization has helped put together similar informational events about health care and immigration in Spanish and Asian languages in Los Angeles and Orange counties.

Cary Sanders, director of policy analysis for the California Pan-Ethnic Health Network, an advocacy group, said the difficulty is that immigrants historically have been excluded from certain government health programs.

“California has certainly gone much further than other states to expand health care for immigrant communities,” Sanders said. “For certain groups, it’s still very difficult. They may only be eligible for emergency care. Because of that people often delay care. They have to use home remedies to limp along to take care of and manage health problems that, if left untreated, can become a lot more serious.”

At the forum, Alameda County Supervisor Wilma Chan pointed out that Asians make up close to 30 percent of the population in her county. Together with Latinos, they comprise more than half.

She asked that people not be afraid to access health care services or make use of any other public benefit.

“There is this idea that if you’re not a citizen, you can be deported if you go to a clinic or use food stamps … this has not happened,” Chan said.

One woman said her friends have encouraged her to stop using CalFresh to draw less attention to her family. A man asked whether paying cash at the clinic instead of using his Medi-Cal coverage would be safer for his mixed-status family.

Mandy Xue of Alameda was grateful for the meeting even though her concern had little to do with the goings-on in Washington. She learned two weeks ago at her son’s dentist’s office that his Medi-Cal coverage had ended. When she called the state for an explanation, she was told there was no record of her or her 13-year-old son, even though the Alameda resident says they have been covered since she was pregnant with him.

Xue, 45, was not sure what to do, and worried that she and her son would not be able to continue seeing their doctors.

The event was “very helpful,” Xue said through a Cantonese translator, because now “I know what the next step should [be] and what should I look for.”

Ngoc Nguyen, editor of California Ethnic Media Partnerships, contributed to this story.

This story was produced by , which publishes , an editorially independent service of the .

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