That’s not stopping Florida lawmakers from trying to adopt Medicaid work requirements anyway. It’s the only legislative body in a nonexpansion state to even consider it so far.

“You need to go to work if you want your friends and neighbors to pay for your health care,” said , the Republican sponsor of a Medicaid work requirement proposal making its way through the legislature.

The move baffles health care advocates and Medicaid experts. Some doubt it’s even legal under President Donald Trump’s signature domestic policy law.

“You cannot change the terms of the work requirement,” said , an attorney and a professor at Georgetown University’s McCourt School of Public Policy, issued by the Centers for Medicare & Medicaid Services. For Cuello, the answer is clear: “It’s a pretty easy no.”

Medicaid work requirements affect Washington, D.C., and the 40 states that have expanded Medicaid eligibility to all nondisabled adults ages 19 through 64 with incomes up to 138% of the federal poverty level, as prescribed under the Affordable Care Act. That’s an income of $22,025 a year for a single person.

Starting next January, those states must require people in their expansion groups to report at least 80 hours a month of work, education, or community service to qualify for and maintain Medicaid coverage.

About 4 million people are enrolled in Florida’s program, and Gaetz estimates that about 147,000 of them are adults who “could work and should work.”

They “are able-bodied and they don’t have small children at home, and they aren’t taking care of an elderly person or a disabled person,” he said. “Yet they receive Medicaid benefits.”

People affected by would primarily be parents of children 14 and older, and some 19- and 20-year-olds, he said. A in the Florida House would apply Medicaid work requirements to parents of children ages 6 and older.

To qualify for Medicaid in Florida, a working-age adult without a disability must generally be caring for a child or an older or disabled family member and cannot earn more than 26% of the federal poverty level, or about $592 a month for a family of three.

Most adults who are not disabled and receive Medicaid already work, and many people in low-paying jobs do not receive health insurance through an employer, , a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. Among single adults ages 19 to 64 in Florida who made under $15,000 a year in 2024, through work.

Critics say Florida’s proposal would likely force some people to become uninsured, even if they meet the work requirement. That’s because the state’s Medicaid income limit is so low that working the mandated 80 hours a month would likely cause those individuals to exceed the income eligibility limit but also leave them earning too little to qualify for subsidized coverage on the Affordable Care Act marketplace.

Michelle Mastrototaro said she lost her Medicaid coverage in November after taking a part-time job as a teaching assistant at a Tampa elementary school last year. Mastrototaro, 47, cares for a disabled teenage son and likely would not need to meet Florida’s proposed work requirement.

But she said her biweekly wages from working about 17 hours a week pushed her past the Medicaid income limit. She has struggled to afford her prescription medications since.

“What I’m making is nothing,” Mastrototaro said. “I am scavenging just to make ends meet.”

The Gaetz-led proposal ignores “the hard realities of what it takes to be qualifying for Medicaid in Florida,” said , executive director of Florida Voices for Health, a nonprofit that advocates for Medicaid expansion. “On its face,” he said, “it doesn’t make sense.”

Medicaid experts say the holds that nonexpansion states cannot adopt work requirements.

A state that hasn’t added more low-income adults to its Medicaid program can’t impose work requirements on those who are already covered, Cuello said. States must cover specific categories of low-income people — such as children, pregnant women, some parents, older adults, and people with disabilities — to receive federal funding for their programs.

States that have expanded Medicaid eligibility to a limited group of low-income adults, namely Georgia and Wisconsin, will be required to impose work requirements on those enrollees.

, launched in July 2023, already includes a requirement that newly eligible adults report at least 80 hours of work or community engagement. Federal approval for the program expires at the end of December, and the state . will have to implement a work requirement by Jan. 1.

South Carolina applied in June for federal approval to to nondisabled parents and caregivers ages 19 to 64 who earn 67-100% of the federal poverty level. That’s about $18,300 to $27,300 a year for a family of three. The state’s application is pending with CMS, and if approved would implement work requirements for those newly eligible adults.

Gaetz said if the Florida legislation were approved, the state would develop a “business plan” for implementing work requirements and seek CMS approval.

It is unclear how much it would cost, but experience in states with Medicaid work requirements suggests that implementation would be expensive. States must upgrade their eligibility and enrollment systems, hire additional staff, and inform the public of the new mandate.

For its program, Georgia spent about $54.2 million on administrative changes out of $80.3 million in total spending for the program from October 2020 to March 2025, according to from the U.S. Government Accountability Office. Most of the administrative spending — about $47.4 million, or 88% — came from the federal government.

Georgia’s experience echoes others’, according to a 2019 of states that received approval to implement Medicaid work requirements during the first Trump administration. That report focused on five states — Arkansas, Indiana, Kentucky, New Hampshire, and Wisconsin — and estimated costs would total $408 million. They ranged from $6 million in New Hampshire to more than $270 million in Kentucky, though those figures did not reflect all the state costs.

Florida’s computer infrastructure for collecting and verifying information and determining eligibility is more than 30 years old and is being replaced. That is anticipated to be completed in 2028 and cost more than $180 million.

A legislative analysis of Gaetz’s bill estimated that if 1 in 4 people affected by the proposed work requirement were to lose Medicaid coverage, the state could save about $80 million a year.

Darius, with Florida Voices for Health, said those potential savings hardly seem worth the effort.

“It requires the state to build this giant regulatory-like framework and to rebuild systems, and to employ a whole set of people to chase down the very small number of folks who would ultimately be touched by this,” he said.

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

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The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House .

But, in reality, adults ages 50 to 64, particularly women, are likely to be , said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, .

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told Ñî¹óåú´«Ã½Ò•îl Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to . Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you’re going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The nurse who took the call at the Sono Bello center in Addison, Texas, told her she “absolutely should not” go to the ER — even though Farris “had a large gush of foul fluid” leaking from the incision, according to records in the malpractice case she filed against the cosmetic surgery chain in 2024.

The nurse told Farris she “only needed to reinforce her dressing to collect the fluid drainage and give it time,” filings in the lawsuit alleged.

“Thankfully, Ms. Farris did go to the ER where she was diagnosed with sepsis from her surgery complications,” a medical expert for her legal team wrote in a court filing. Left untreated, sepsis can lead to death.

Sono Bello officials declined to discuss malpractice cases filed against the company, citing patient privacy laws. But in court filings, the company has disputed Farris’ claims. The case is set for trial early next year.

The Farris lawsuit is one of dozens of medical malpractice cases filed over the past three years that accuse cosmetic surgery chains of failing to provide adequate care for patients in the days and weeks after their procedures — in many cases by allegedly neglecting to promptly treat painful infections and other serious complications — including for four patients who died, a Ñî¹óåú´«Ã½Ò•îl Health News investigation found.

In some cases, patients who traveled hundreds of miles or more for seemingly routine surgeries allegedly suffered painful complications while recuperating in hotel rooms or unlicensed “recovery homes,” which they said lacked adequate medical staff and supervision, according to court filings.

While complications, such as infections, can occur after any surgical procedure, problems related to postoperative care are blamed for contributing to injuries in over two-thirds of the cosmetic surgery cases Ñî¹óåú´«Ã½Ò•îl Health News reviewed.

The surgery companies involved — some, like Sono Bello, financed by — offer elective procedures such as liposuction and “” to patients who pay thousands of dollars out-of-pocket or on credit. Ads promise life-changing body reshaping techniques with minimal risk and .

Medical malpractice lawsuits have trailed behind the growth of these companies. Suits have accused the chains of hiring doctors who lacked adequate training or had , and of using high-pressure sales tactics and misleading advertising pitches that downplay safety risks, court records show. The companies dispute these allegations and have won dismissal of some suits.

Patrick Schaner, a plastic surgeon and a Sono Bello medical director, stressed that the company has performed more than 300,000 cosmetic operations with minimal complications. “That context is very important,” he said in an interview.

Schaner said Sono Bello surgeons are “good at what they do” because of the large numbers of procedures they perform. “We do a great job of getting safety protocols in place,” he said.

Many patients who file lawsuits blame disfiguring injuries on what happened after their operations, such as office visits in which medical staff allegedly didn’t recognize, or dismissed, evidence of worsening surgical complications, court records show.

A nurse at a Sono Bello center outside Chicago allegedly failed to alert doctors when Mary Anne Garcia, a patient who had had liposuction at the center about three weeks earlier, showed up there with her aunt. Garcia was dizzy and so weak she required a wheelchair to get back to the car, according to a lawsuit her estate filed in September.

Rather than tell Garcia to go to an emergency room, the Sono Bello nurse told her to “drink more fluids and try to eat something,” according to the complaint.

Garcia died the next day from cardiac arrest, according to the lawsuit. Sono Bello has yet to file a response to the lawsuit in court.

‘It Was Horrifying’

Susan Easley, 59, a veteran U.S. Agency for International Development executive who spent two decades working on AIDS projects in Africa, died in a Washington, D.C., short-term apartment last year.

Her son Gavin found her body May 13, 2024, four days after she had an AirSculpt liposuction and fat transfer operation at Elite Body Sculpture in nearby Vienna, Virginia, according to a lawsuit filed in November.

“It was horrifying,” Gavin Easley told Ñî¹óåú´«Ã½Ò•îl Health News in an interview. “My mother was the definition of kind, caring, and unconditionally loving. She was the most incredible woman I’ve ever known,” said Easley, 29, who runs an organic farm in Arkansas with his wife.

The suit alleges that surgeon Dare Ajibade gave Easley an excessive amount of the anesthetic lidocaine during the 6½-hour procedure and failed to recognize persistent vomiting afterward as a sign of toxicity. She called the clinic to report her condition, but her concerns were dismissed, the suit alleges.

“When she called to report complications, they didn’t take it seriously,” said Virginia attorney Peter Anderson, who filed the suit. He said Easley presented “clear signs and symptoms” of problems.

is a brand of Elite Body Sculpture, a Miami Beach-based chain founded by cosmetic surgeon Aaron Rollins. The company, which is financed by private equity investors, has about 30 branches across the country. Neither the company nor Rollins responded to repeated requests for comment on patient lawsuits. In court filings, the company has denied the allegations.

Ajibade has since relocated to Texas, where he works for Sono Bello in San Antonio, according to the company. Neither the surgeon nor the Virginia surgery office, which is also a defendant in the case, returned calls for comment. The defendants have yet to file an answer in court.

A Booming Business

Sono Bello, with more than 100 centers nationwide, bills itself as “America’s #1 Cosmetic Surgery Specialist.”

Patients filed seven malpractice cases against Sono Bello in September — each in a different state. In an interview, Marcy Norwood Lynch, a Sono Bello executive vice president and chief legal officer, speculated that the spurt in cases was related to reporting by Ñî¹óåú´«Ã½Ò•îl Health News and NBC News about the company. There “could be alignment” between the coverage and the filing of the suits, she said. The company has denied the allegations in court.

Ñî¹óåú´«Ã½Ò•îl Health News reviewed a sample of more than 100 medical malpractice cases filed against multistate surgery chains from the start of February 2023 through November 2025. Malpractice suits do not by themselves prove substandard care, though many medical authorities and licensing boards consider them a tool for helping to judge medical quality.

Heather Faulkner, a plastic surgeon and associate professor at Emory University School of Medicine in Atlanta, said surgeons must quickly recognize before they progress and become serious, even life-threatening conditions.

At Emory, she said, surgeons must attend their patients’ first visit after cosmetic surgery. “Ultimately, the physician is the one responsible,” she said. “The patient has to be seen by the person who did the operation and knows how to recognize something is wrong,” Faulkner said in an interview.

Patients suing cosmetic surgery chains often argue that they were seen by nurses or other staff members who, they allege, lacked the training to recognize and deal with problems before they required emergency wound care.

Schaner, the Sono Bello medical director, said the company has a phone messaging system that ensures patients can get in touch with their surgeon or other company physicians. While nurses see some patients, the “ultimate decision-making is passed to the surgeon,” he said.

Five patients treated at Sono Bello centers who sued the company during 2025 alleged that surgical wound complications were dismissed after medical staff, including surgeons, viewed pictures of the injuries, court records show. The cases are pending.

Schaner said Sono Bello sometimes has patients submit photos of wounds but the images are “not the sole means of triage” of patient injuries or complications.

Joshua Kiernan sued Sono Bello after having liposuction on May 28, 2024, at the branch in Columbia, South Carolina. On June 8, 2024, he stumbled and fell in a gym parking lot, causing drainage around the incision in his stomach, according to the suit. On June 17, 2024, Kiernan visited the office complaining of “redness and pain” around the incision, according to his suit.

The surgeon, Stancie Rhodes, didn’t examine him in person but had an office staff member take a picture “so that she could view it from another part of the office,” according to the complaint.

The surgeon sent back word that the photo “looked fine,” and Kiernan was told to take Tylenol for the pain and follow up at the office a week later, the complaint alleged.

Two days before his appointment, Kiernan required emergency hospital treatment for “abdominal hematoma and infection,” according to the suit.

Kiernan underwent six surgical procedures and ran up medical bills of more than $325,000 to treat his condition, according to the suit. In court filings, Sono Bello denied the allegations.

“Surgical care does not end at the last stitch,” said Mark Domanski, a plastic surgeon in Virginia, who believes the chain clinics in general are more adept at marketing than providing patients with top-notch care. “It involves postoperative visits with the surgeon who did the procedure, who is there to respond to the patient’s concerns, questions, especially if things are not going well,” he said.

Recovery Houses

Many patients who travel for cosmetic surgery, either to save money or because services aren’t available in their area, can’t return home right away.

Yet there’s little agreement on where patients should recuperate, for how long, and what medical services should be readily available to them.

Scott Hollenbeck, immediate past president of the American Society of Plastic Surgeons, said laws or regulations in most states don’t spell out requirements.

“This can create a wide variation of oversight, staff qualifications, and available medical support,” he said.

The plastic surgery society has a cottage industry of recovery houses that often charge patients hundreds of dollars a night while they recuperate, even though they may lack medical staff capable of handling possible surgical complications.

Court filings in Florida show patients staying in recovery houses and hotels have died or suffered untreated complications, mostly in South Florida, where officials have struggled for a decade or more to regulate unlicensed facilities. One local lawmaker recently to rein them in.

Hollenbeck said patients who recuperate in a hotel or other facility need to find out in advance what “level of care” will be available. He said ads touting “luxury” accommodations or “conveniently located” do not make a hotel “clinically qualified to provide recovery care.”

Easley, whose mother died in Washington, D.C., said he is struggling to understand what happened after a medical transportation service took her from the Virginia surgery center to a temporary apartment.

He said his mother, who was born in a small village in Uganda before emigrating to the U.S. as a teen and joining the U.S. Army, “had so many plans” for the future.

Susan Easley had been medically cleared for a . After that, she planned to retire and start a farm in Tanzania, among other things, according to her son.

The lawsuit alleges the surgery center discharged her prematurely given signs of a dangerous condition called caused by an overdose of lidocaine.

Susan Easley called the surgery center that day and reported “multiple instances of nausea and vomiting,” but there’s “no evidence” that anyone told her to head to an emergency room, according to the suit.

“I don’t know what they said to her,” Gavin Easley said. “It’s a horrifying thought for me. I have no idea how to get to the bottom of that mystery.”

‘Preventable Death’

Some lawsuits take aim at decisions made by support staff members, who help monitor patients after surgery.

That’s a critical issue in the case of Mary Anne Garcia, the Illinois woman who died after her aunt drove her to the Sono Bello office in Oakbrook Terrace, Illinois, on June 4, 2024.

Garcia “was feeling sluggish, dizzy, and nauseated,” according to the suit. She also had a rapid heartbeat and low blood pressure, according to the complaint. But registered nurse Lucia Raddatz did not notify the surgeon or urge Garcia to seek emergency care even though Raddatz had to help her back to the car in a wheelchair due to Garcia’s “severely weakened condition,” according to the suit.

Filed on behalf of Garcia’s estate, the suit names Raddatz and Sono Bello as defendants. An emergency room physician hired as an expert in the case opined that had Garcia gone to the emergency room on June 4, “she would have received care which would have avoided her death,” court records state. Sono Bello had no comment and has yet to file an answer in court.

Established plastic surgeons say they are often called upon to treat patients who arrive in the emergency room with complications because surgeons working for the chains may lack local hospital privileges or are otherwise not available for consultations.

“There is not one colleague of mine who has not dealt with the complications of these types of facilities or med spas on more than one occasion,” said Charles Pierce, president-elect of the New Jersey Society of Plastic Surgeons.

‘Angry and Betrayed’

Doctors at an Austin, Texas, hospital expressed such frustration while caring for Anna Palko, a 33-year-old mother of four, according to a malpractice suit she filed in November against surgeon Rambod Charepoo and his employer, Mia Aesthetics. The Miami-based cosmetic surgery company, which operates in about a dozen cities, including Austin, advertises that it delivers the .

A doctor at St. David’s Medical Center in Austin wrote in Palko’s medical record: “Unfortunately patient has had postoperative complications from a physician who is well-known to our emergency department for similar post-op complications associated with cosmetic surgery through MIA (sic) Aesthetics,” according to the suit.

Palko is one of five Texas women who sued Charepoo and Mia Aesthetics for malpractice this year, between mid-July and the end of November, court records show.

Four women allege the surgeon and the company failed to adequately treat infections that developed after surgery, while the fifth alleged other complications. Mia Aesthetics was dismissed from one case. The surgeon and the company have denied the allegations in court filings, court records show.

Charepoo also has been the subject of a lengthy investigation by the Texas Medical Board, which licenses doctors.

In August 2021, the board alleged that the surgeon “failed to meet the standards of care” in treating six patients, including one he placed “at risk” by allowing the patient to leave the surgery center for the emergency room in a private vehicle after the person “experienced significant hypotension and hemorrhagic shock.”

In October 2024, the medical board found that Charepoo had failed to meet standards of care for five of the six patients. The board required him to have a surgical proctor oversee 20 of his operations per quarter for two years. The board also ordered him to take medical education courses, pass an exam, and pay a fine of $4,000.

Charepoo is fighting the order in court. Charepoo, Mia Aesthetics, and lawyers representing Charepoo and the company did not respond to requests for comment.

In January, he sued the Texas Medical Board, arguing the penalty is “both excessive and unjustified” and should be invalidated. The medical board declined to comment on the suit, which is pending in Travis County District Court.

Hearing of the surgeon’s problems came as a shock to patient Palko, who said she had chosen Mia Aesthetics because of ads promising high-quality doctors.

“I felt so disgusted, angry, and betrayed,” Palko said in an email sent through her attorney.

Have you had liposuction, a “Mommy Makeover,” a tummy tuck, a Brazilian butt lift, or another type of cosmetic surgery? We’d like to hear about your experience. Click here to contact our reporting team.

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Most of the lawyers work either for the Department of Justice or for disability rights agencies that Congress set up in every state decades ago. Many of the Justice Department lawyers quit in 2025 after being reassigned to other duties, their supporters say. And Trump budget officials proposed deep cuts to federal grants supporting the state-based legal groups.

People with disabilities have the right to live in their communities if possible. Federal laws and court decisions say they may attend school, work jobs, and go to restaurants, movie theaters, and other public places. If they can find lawyers, they can file legal challenges when those rights are denied.

The federally funded attorneys quietly work to ensure the U.S. lives up to promises made by the Americans with Disabilities Act and other laws, said Alison Barkoff, a health law professor at George Washington University.

“I think many families of people with disabilities, or even many people with disabilities themselves, don’t hear about it until they Google, ‘Where can I get help?’” said Barkoff, who helped lead such efforts under Presidents Joe Biden and Barack Obama.

The attorneys’ goals include ensuring that people with disabilities have the services they need to live in their own homes, instead of having to move into nursing homes or other types of institutions, Barkoff said.

“These are people who, if these supports are ripped away, are going to have to leave their communities and their families, at a higher cost for taxpayers,” she said.

The state-based disability rights groups are known as “protection and advocacy” organizations. Most of them are nonprofit groups.

Congress approved the federally financed system in the 1970s after TV journalist Geraldo Rivera in a New York institution for people with mental and intellectual disabilities, revelations that ignited a national outcry.

President Donald Trump proposed cutting the system’s federal funding from $148 million to $69 million for fiscal year 2026, according to the National Disability Rights Network, which represents the state-based groups.

Appropriations committees in the U.S. House and Senate have recommended Congress maintain funding at the previous level. But advocates for the agencies worry that even if Congress maintains current support, the administration will try again to slash their support in future years. “It definitely would put people in our communities in harm’s way,” said Marlene Sallo, the national network’s executive director.

White House officials declined to comment on why the Trump administration proposed the deep cuts.

Isaac Schreier’s family can attest to the value of the state-based legal groups.

Isaac, 7, lives in Ankeny, Iowa. He has a rare condition called osteogenesis imperfecta, also known as brittle bone disease. The condition has caused about 60 bone fractures, including in his limbs, spine, and skull. It can cause intense pain and leave him unable to walk.

At times, Isaac’s disability is practically invisible, said his father, Jake Schreier. Unless he has recently suffered a broken leg bone, he walks well. “But he tires much more quickly than you or I would.”

Isaac’s doctor said he needed a special wheelchair that could be adjusted to put him in different positions depending on which bones were broken. But the private insurer that manages his Medicaid coverage declined to pay for the $3,500 wheelchair. “They required proof that it was a permanent and long-standing condition,” Jake Schreier said. “We were very frustrated.”

Schreier appealed the denial but lost. A nurse at a specialty clinic then recommended he reach out to Disability Rights Iowa, a federally funded protection and advocacy group that had helped other families in similar straits.

The group linked Schreier with two of its attorneys, who filed a new appeal. The lawyers wrote a detailed letter explaining why Isaac was legally entitled to the new wheelchair, and they cited specific Iowa codes and court precedents.

The insurer wound up paying for Isaac’s special wheelchair.

The chair allows Isaac to participate in school and community activities even when he has broken bones. “It’s absolutely night and day. I can’t imagine a world where we didn’t have it,” his father said.

Isaac may again need people like the disability rights lawyers to fight for him, so he won’t be shunted away from society, Schreier said. “We’re really trying to keep as many doors open as possible for him.”

The threat to the state-based groups’ funding comes as the more people with mental illness or addictions into institutions.

David Hutt, deputy executive director for legal services at the National Disability Rights Network, noted that the groups have legal authority to go into facilities where people with disabilities live, to check conditions and treatment. Those facilities include state institutions and privately owned nursing homes.

More Americans could wind up living in such settings if Trump succeeds in his quest to institutionalize people with mental illness who are living on the streets, Hutt said.

At the same time, in federal contributions to Medicaid, the public health coverage program for people with low incomes or disabilities. In response, they may be tempted to reduce Medicaid coverage of , many of which are considered optional under federal law, Hutt said. If that happens, “you’re going to get increased institutionalization, which actually costs more,” he said.

Disability rights organizations often have stepped in when states failed to provide care and services that people with disabilities are entitled to. So have lawyers from the Justice Department’s civil rights division.

For example, Disability Rights Iowa filed a lawsuit in 2023 alleging the state failed to provide proper mental health resources for children on the Medicaid program. The state that advocates said could bring “radical change” to the system.

In 2021, the Justice Department that their lack of support for community services meant too many people with intellectual disabilities had to live in facilities. State officials vowed to do better.

Since Trump returned to office, many of the Justice Department’s most experienced disability rights lawyers have taken buyouts or been reassigned to other areas, said Jennifer Mathis, a former top administrator at the Justice Department under Biden. “There’s really skeleton staffing at this point,” said Mathis, now deputy director of , which advocates for rights of people with mental disabilities.

The overall civil rights division is down to about 300 people, fewer than half the number it had under Biden, Mathis said.

The civil rights division’s new director, Harmeet Dhillon, in April that more than 100 attorneys had left the division, but that they didn’t support Trump’s priorities. “The job here is to enforce the federal civil rights laws, not woke ideology,” she told Beck.

In a statement to Ñî¹óåú´«Ã½Ò•îl Health News, Dhillon said the division continues to be “a vocal and active advocate for Americans with disabilities.”

Dhillon noted the department recently over complaints that the ride-hailing service was turning away customers with service dogs or wheelchairs; has secured agreements with and to improve treatment of imprisoned people with disabilities; and over allegations of failing to provide proper accommodations for people with disabilities.

The department declined to comment on the record about the number of attorneys it has working on disability rights issues. However, “civil rights warriors,” including lawyers, to join the civil rights division.

Jake Schreier, the Iowa parent, hopes the issue will be worked out nationally. “I really can’t believe this is anything that would be partisan,” he said.

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The Trump administration, which has promised “radical transparency,” that it plans to publish the “project summary” for states that win awards. Following the lead of federal regulators, many states are withholding their complete applications, and some have refused to release any details.

“Let’s be clear,” said Alan Morgan, chief executive of the National Rural Health Association. “The hospital CEOs, the clinic administrators, the community leaders: They’re going to want to know what their states are doing.” The NRHA’s members include struggling rural hospitals and clinics, which would benefit from the Trump administration’s Rural Health Transformation Program.

Morgan said his members are interested in what states propose, which of their ideas are approved or rejected, and their budget narratives, which detail how the money could be spent.

Improving rural health care is an “insanely complicated and difficult task,” Morgan said.

The five-year Rural Health Transformation Program was approved by Congress in a law — the One Big Beautiful Bill Act — that also drastically cuts Medicaid spending, on which rural providers heavily depend. It’s being watched closely because it’s a much-needed influx of funds — with a caveat from the Trump administration that the money be spent on transformational ideas, not just to prop up ailing rural hospitals.

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be distributed through a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Health and Human Services Secretary Robert F. Kennedy Jr. has repeatedly promised to open the government to the American people. His agency has devoted to “radical transparency.”

“We’re working to make this the most transparent HHS in its 70-year history,” in written testimony to lawmakers in September.

Lawrence Gostin, a professor of public health law at Georgetown University, said HHS is “acting in a way that utterly lacks transparency” and that the public has the right to demand “greater openness and clarity.” Without transparency, the public cannot hold HHS accountable, he said.

Centers for Medicare & Medicaid Services spokesperson Catherine Howden said the agency will follow the federal regulations when releasing information about the rural health program.

Grant applications are “not released to the public during the merit review process,” Howden said, adding, “The purpose of this policy is to protect the integrity of evaluations, applicant confidentiality, and the competitive nature of the process.”

Democrats and many health care advocates are concerned politics will affect how much money states get.

“I am very concerned about retaliation,” said Rep. Nikki Budzinski (D-Ill.). Because Democrats control her state’s politics, “our application might not be as seriously considered as other states that have Republican leadership,” she added.

Illinois’ Democratic members of the U.S. House to CMS Administrator Mehmet Oz in November asking for “full and fair consideration” of their state application. Illinois officials have not yet released their state’s proposal to Ñî¹óåú´«Ã½Ò•îl Health News, which has a pending public records request.

Heather Howard, a professor of the practice at Princeton University, said she is “pleasantly surprised at how transparent the states have been.”

Howard directs the university’s State Health and Value Strategies program, which the rural health fund, and praised most states for publicly posting their project summaries.

“To me, it speaks to the intense interest in this program,” Howard said. Her team, reviewing about two dozen state summaries, found themes including expansion of home-based and mobile services, increased use of technology, and workforce development initiatives like scholarships, signing bonuses, and child care assistance for high-demand positions.

“I think it’s exciting,” Howard said. “What’s great here is the experimentation we’re going to learn from.”

Telerobotics appeared in Georgia’s and Alabama’s applications, she said, including a proposal to use robotic equipment for remote ultrasounds.

Another theme that “warms my heart,” Howard said, was the effort among states to create advisory groups or committees, including in Idaho, where work groups are expected to focus on technology, workforce development, tribal collaboration, and behavioral health.

All 50 states submitted applications to federal regulators by the Nov. 5 deadline and awards will be announced by the end of the year, according to CMS.

As of late November, nearly 40 states had released their project narrative, the main part of the application, which describes proposed initiatives, according to Ñî¹óåú´«Ã½Ò•îl Health News tracking. More than a dozen states have also released their budget narratives.

Also as of late November, only a handful of states — Idaho, Iowa, Kansas, Minnesota, New Mexico, North Dakota, South Carolina, and Wyoming — had released all parts of the application.

Ñî¹óåú´«Ã½Ò•îl Health News filed public records requests for states’ complete applications. Some states have refused to release any of their application materials.

Nebraska, for example, rejected a public records request, saying its application materials are “proprietary or commercial information” that “would give advantage to business competitors.”

Kentucky shared its application summary but said the remainder of the application is a “preliminary draft” not subject to release under state laws.

Erika Engle, a spokesperson for Hawaii Gov. Josh Green, said the governor “is committed to transparency” but declined to share any of the state’s proposal.

Hawaii and other states are still processing formal public records requests.

The rural health program is part of the July law projected to reduce federal Medicaid spending in rural areas by 10 years.

Those cuts are expected to affect rural health facilities’ bottom lines, threatening their ability to stay open. A recent Commonwealth Fund report found that rural areas continue to to primary care. But the guidelines for the rural health program say states can use only 15% of their new funding to pay providers for patient care.

Between the Medicaid cuts and funding boost from the new program, “there’s real opportunity for national policy to impact rural, both in the negative and the positive potentially,” said Celli Horstman, a senior research associate at the New York-based policy think tank who co-authored the report.

Among the publicly available rural health transformation proposals, Democratic-leaning states show support, or are willing to adopt, some of the administration’s goals but will lose out on points from eschewing others.

For example, New Mexico said it would introduce legislation requiring students to take the Presidential Fitness Test and physicians to complete continuing education courses on nutrition. But it won’t prevent people from using their Supplemental Nutrition Assistance Program benefits to buy “non-nutritious” foods such as soda and candy.

Many states want to invest in technology, including telehealth, cybersecurity, and remote patient monitoring equipment. Other themes include increasing access to healthy food, improving emergency services, preventing and managing chronic illnesses, and enlisting community health workers and paramedics for home visits.

Specific proposals include:

• Arkansas wants to spend $5 million through its “FAITH” program — Faith-based Access, Interventions, Transportation, & Health — to enlist rural religious institutions to host education and preventive screening events. Congregations could also install walking circuits and fitness equipment.
• Alaska, which historically relied on dogsled teams to bring medication to remote areas, is looking to test the use of “unmanned aerial systems” to speed up pharmacy deliveries to such communities.
• Tennessee wants to increase access to healthy activities by spending money on parks, trails, and farmers markets.
• Maryland wants to start mobile markets and install refrigerators and freezers to improve access to fresh, healthy food that often spoils in rural areas with few grocery stores.

State Sen. Stephen Meredith, a Republican who represents part of western Kentucky, said he still expects rural hospitals to close despite his state’s rural health transformation program.

“I think we’re treating symptoms without curing the disease,” he said after listening to a presentation on Kentucky’s proposal at .

Morgan, whose organization represents rural hospitals likely to close, said the state’s ideas may sound good.

“You can craft a narrative that sounds wonderful,” he said. “But then translating the aspirational goals to a functioning program? That’s difficult.”

Ñî¹óåú´«Ã½Ò•îl Health News staffers Phil Galewitz, Katheryn Houghton, Tony Leys, Jazmin Orozco Rodriguez, Maia Rosenfeld, Bram Sable-Smith, and Lauren Sausser contributed to this report.

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The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs , according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told Ñî¹óåú´«Ã½Ò•îl Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to , no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, .

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. and in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to .

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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WASHINGTON — Nationwide, states are racing to win their share of a new $50 billion rural health fund. But helping rural hospitals, , is quickly becoming a quaint idea.

Rather, states should submit applications that “rebuild and reshape” how health care is delivered in rural communities, Centers for Medicare & Medicaid Services official Abe Sutton said late last month during a daylong meeting at Washington, D.C.’s Watergate Hotel. Simply changing the way government pays hospitals has been tried and has failed, Sutton told the audience of more than 40 governors’ office staffers and state health agency leaders — some from as far away as Hawaii.

“This isn’t a backfill of operating budgets,” said Sutton, CMS’ innovation director. “We’ve been really clear on that.”

Rural hospitals and clinics nationwide face a looming financial catastrophe, with President Donald Trump’s massive tax-and-spending law expected to slash federal Medicaid spending on health care in rural areas by . Congressional Republicans added the one-time, five-year Rural Health Transformation Program as a last-minute sweetener to win the support of conservative holdouts who worried about the bill’s financial fallout for rural hospitals.

Yet, the words used by CMS Administrator Mehmet Oz and his agency’s leaders to describe the new pot of cash are generating tension between legacy hospital and clinic providers and new technology-focused companies stepping in to offer new ways to deliver health care.

It’s “what I would call incumbents versus insurgents in the rural space,” said Kody Kinsley, a senior policy adviser at the Institute for Policy Solutions at the Johns Hopkins School of Nursing.

Applications are due Nov. 5. The money will be awarded to states by the end of the year and distributed over five years.

Half of the $50 billion will be divided equally among all states with an approved application; the other half will go to states that win points. Of , $12.5 billion will be allotted based on a formula that calculates each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that mirror the Trump administration’s objectives.

The specific policy goals such as implementing the Presidential Fitness Test and restrictions to food assistance, as well as broader investment strategies around remote care services, data infrastructure, and consumer-facing technology tools, which CMS identified as “symptom checkers and AI chatbots.”

In September, after CMS officials released the application, Republican members of Congress from states with Democratic governors , concerned their states might direct the money to urban areas. In a letter to Oz and Health and Human Services Secretary Robert F. Kennedy Jr., they said the money “will serve as a lifeline for rural and at-risk hospitals in our communities that are already struggling to keep their doors open.”

Smaller hospitals fear they will get “a tiny little slice” of each state’s share, said Emily Felder, who leads the health care practice at Brownstein Hyatt Farber Schreck, a law firm whose clients include rural hospital systems.

“There’s a lot of frustration,” Felder said.

But Kinsley, who was previously North Carolina’s secretary of health and human services, said using this money only to shore up a balance sheet “is really just throwing good money after bad.” In contrast, he said, insurgents such as technology-driven startups can offer new strategies.

One of those companies vying for funding is , a Silicon Valley-based company that contracts with Medicare managed care insurers. Using artificial intelligence analytics, Homeward helps patients get care in their home and with local providers.

The company manages the health of 100,000 rural Michigan patients enrolled in insurance, said Homeward co-founder and chief executive Jennifer Schneider. The company was a sponsor for the Watergate summit. It also has ongoing meetings with Oz and his team, Schneider said.

“They’re doing their job, and they’re talking to a lot of people in the ecosystem and really eager to learn from those of us that have been in the system,” Schneider said. “We’re one of many in that position.”

Ñî¹óåú´«Ã½Ò•îl Health News requested an interview with Alina Czekai, director of the Office of Rural Health Transformation. CMS spokesperson Alexx Pons said the agency was “unable to accommodate facilitation of any interview.”

Instead, CMS provided an emailed statement from Oz saying the program “will help states and communities reimagine what’s possible for rural healthcare.”

Brock Slabach, chief operations officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics, said the money would best be used to help pay for transformation that isn’t “sexy” or “revolutionary.”

“If what we end up with is we have a wearable for every rural patient, I don’t think that’s transformational,” Slabach said, referring to digital health monitors such as fitness-tracking watches.

Slabach, a onetime small-hospital chief executive and an unofficial adviser to hundreds of rural facilities nationwide, named a few ideas for the money — including paying for capital improvements such as electronic health records or equipment, loan repayment programs to aid workforce development, and creating “SWAT” teams that rescue rural hospitals on the brink of closure.

More than 150 rural hospitals nationwide since 2010 — a statistic cited by CMS’ Sutton that is well known among industry watchers. The Sheps Center at the University of North Carolina, which compiles the closure data, also released to help states calculate how rural they are for their applications.

State applications will be reviewed by a panel, with some reviewers from within the government but others outside it, said Kate Sapra, acting deputy director of the Office of Rural Health Transformation, speaking at the Watergate.

“We will train them in the scoring criteria,” Sapra said, adding that the panelists will not be coming from “your state” and will need to fill out conflict-of-interest forms. A portion of money each state gets will be reevaluated annually based on the progress it makes on its goals and priorities, .

States are creating stakeholder groups, asking for public comment, and working with their health agencies. Some, such as and , are hiring consultants.

In Montana, a collection of health providers and associations proposed a list of ideas for the cash, including creating a loan repayment fund for rural clinicians to try to ease worker shortages.

“It’s one-time money, and it’s a little bit of money,” said David Mark, a doctor who is the CEO of One Health, which has clinics dotted across eastern Montana and Wyoming. A state could receive a minimum of $100 million a year for five years if all 50 states have applications approved.

“How do you accomplish goals of a health care system transformation with an infusion of money like that?” Mark said.

Neither Montana nor Wyoming — vast, rural states — sent leaders to the Watergate summit, according to a copy of the attendees list. In the afternoon, attendees could rotate among planning tables and meet with corporate sponsors such as the electronic health records behemoth Epic and the emergency services company Global Medical Response.

Wyoming Department of Health Deputy Director Franz Fuchs confirmed his state did not send representatives to the event, because they were “stretched with other commitments.” Montana, Wyoming, and other states submitted signaling they will apply for the funds. CMS did not respond to questions about how many and which states have submitted letters.

During the Watergate event, hints of brewing competition among states began to surface.

“I think Arkansas’ application is going to be better than yours,” seasoned political adviser Jack Sisson said with a smile during a morning panel.

The audience laughed. Sisson, who recently left his job as health adviser for Arkansas Gov. Sarah Sanders, had interrupted Michael Hendrix, policy adviser to another Republican governor, Tennessee’s Bill Lee.

“See, this is the kind of friendly competition that CMS is hoping for,” Hendrix said. He grinned, thanked Sisson, and added, “I look forward to us both winning.”

Ñî¹óåú´«Ã½Ò•îl Health News Montana correspondent Katheryn Houghton contributed to this report.

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By January 2027, President Donald Trump’s far-reaching will require many adult, nondisabled Medicaid enrollees in 42 states and Washington, D.C., to work or volunteer 80 hours a month or go to school.

But under the law, Medicaid enrollees in counties where unemployment is at least 8% or 1.5 times the national unemployment rate could be shielded from the work requirement, if their state applies for an exemption.

A shows that exemption in the GOP’s could offer a reprieve to potentially millions of Americans caught in a tough spot — needing to work to secure health insurance but having trouble finding a job.

The Congressional Budget Office projected the work requirement would apply to 18.5 million Medicaid enrollees, causing about 5.3 million to lose their government health coverage by 2034. CBO spokesperson Caitlin Emma confirmed to Ñî¹óåú´«Ã½Ò•îl Health News that analysts factored the unemployment rate exemption into their projections. Only states that expanded Medicaid under the 2010 Affordable Care Act or a special waiver must enact a work requirement, under the federal law.

But how many people could be exempt depends on how the Trump administration interprets the law, in addition to whether their states’ officials apply.

For example, if Trump officials exempt people in counties where the unemployment rate has been above the law’s thresholds for any month over a 12-month period, about 4.6 million Medicaid enrollees in 386 counties could qualify for an exemption today based on the latest unemployment data, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

That amounts to just under a quarter of all Medicaid enrollees subject to the work requirement.

Under that one-month threshold, “the impact could be fairly significant,” said Jennifer Tolbert, a co-author of the analysis and the deputy director of KFF’s Program on Medicaid and the Uninsured.

But, she said, the Trump administration is more likely to adopt a stricter threshold based on average unemployment over a 12-month period. That would align with work requirements under the federal Supplemental Nutrition Assistance Program, the food assistance commonly known as food stamps.

Only about 1.4 million Medicaid enrollees living in 158 counties could be exempted under that standard, or about 7% of the total subject to work requirements, KFF found. That’s about 7% of enrollees who live in expansion states who would otherwise need to meet the new requirement.

Based on the 12-month criteria, about 90% of Medicaid enrollees who could be exempted based on high unemployment reside in five states, according to KFF: California, New York, Michigan, Kentucky, and Ohio. California alone accounts for over half of those who could be exempted.

The unemployment rate exemption is one of several carve-outs from the Medicaid work requirement in the GOP’s law. The law also exempts parents with children under 14, people who are disabled or frail, and those who are pregnant, incarcerated, or in a substance use disorder program, among others. The high unemployment provision is different than most because it exempts people living in entire counties.

Two top Republicans key to the bill’s passage — House Speaker Mike Johnson and Sen. Mike Crapo, chair of the Senate Finance Committee — did not respond to requests for comment.

To qualify for the Medicaid exemption, states would have to apply to the federal government on behalf of individuals in eligible counties. And if a county earned an exemption, the government would determine how long it applies.

Even if the federal government grants exemptions broadly, health advocates fear some Republican-led states could balk at applying for exemptions in order to keep enrollment down, as they say has been the case with SNAP exemptions. As of 2023, 18 states did not have an exemption under the SNAP program, even though some of their residents might be eligible.

“It’s not a guarantee that people can rely on,” said Emily Beauregard, executive director of Kentucky Voices for Health, an advocacy group that intends to push for the broadest possible exemptions to help people maintain their coverage. Eastern Kentucky has several counties with perennially high unemployment.

In advocating for Trump’s bill, that most people who gained Medicaid benefits under the Affordable Care Act should be working to get off of government assistance.

But as have shown, Medicaid work requirements can be costly for states to run and . About 18,000 people in Arkansas, or nearly a quarter of the state’s adults who gained Medicaid coverage through the ACA expansion, lost coverage when the state had a work requirement in 2018 and 2019. A court ended the state’s work requirement program.

Critics point out that or have a disability or caregiving responsibilities, and they argue the reporting requirements merely serve as a bureaucratic hurdle to obtaining and keeping coverage. Under the GOP law, enrollees’ work status needs to be verified at least twice a year.

Most of the coverage losses due to work requirements occur among people who work or should qualify for an exemption but nevertheless lose coverage due to red tape, .

Not every state must implement a work requirement under Trump’s law, only those that chose to expand Medicaid coverage to more low-income people through the ACA or a federal waiver. The ACA has provided hundreds of billions in federal dollars to help states cover everyone making up to 138% of the federal poverty level — $21,597 for an individual in 2025.

Forty states and Washington, D.C., took up the expansion. Georgia and Wisconsin partly expanded their Medicaid eligibility by getting a federal waiver, adding them to the list of states subject to the work requirement. These two states were not included in the KFF analysis because of a lack of county-level enrollment data.

Jennifer Wagner, director of Medicaid eligibility and enrollment at the left-leaning Center on Budget and Policy Priorities, said she is pleased the law makes some exceptions for places where jobs are scarce. It could limit how many people lose coverage because of the work requirement, she said.

Wagner said SNAP’s unemployment rate exemption has helped millions of people avoid losing their food assistance, but its impact also depends on whether a state seeks the waiver.

She is concerned the Trump administration may make it difficult for counties to get exempted under the Medicaid law.

“I’m glad it’s in there as it will certainly help people, but it’s still a terrible bill,” she said. “This will not really blunt the harm of the bill.”

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That’s not stopping Florida lawmakers from trying to adopt Medicaid work requirements anyway. It’s the only legislative body in a nonexpansion state to even consider it so far.

“You need to go to work if you want your friends and neighbors to pay for your health care,” said , the Republican sponsor of a Medicaid work requirement proposal making its way through the legislature.

The move baffles health care advocates and Medicaid experts. Some doubt it’s even legal under President Donald Trump’s signature domestic policy law.

“You cannot change the terms of the work requirement,” said , an attorney and a professor at Georgetown University’s McCourt School of Public Policy, issued by the Centers for Medicare & Medicaid Services. For Cuello, the answer is clear: “It’s a pretty easy no.”

Medicaid work requirements affect Washington, D.C., and the 40 states that have expanded Medicaid eligibility to all nondisabled adults ages 19 through 64 with incomes up to 138% of the federal poverty level, as prescribed under the Affordable Care Act. That’s an income of $22,025 a year for a single person.

Starting next January, those states must require people in their expansion groups to report at least 80 hours a month of work, education, or community service to qualify for and maintain Medicaid coverage.

About 4 million people are enrolled in Florida’s program, and Gaetz estimates that about 147,000 of them are adults who “could work and should work.”

They “are able-bodied and they don’t have small children at home, and they aren’t taking care of an elderly person or a disabled person,” he said. “Yet they receive Medicaid benefits.”

People affected by would primarily be parents of children 14 and older, and some 19- and 20-year-olds, he said. A in the Florida House would apply Medicaid work requirements to parents of children ages 6 and older.

To qualify for Medicaid in Florida, a working-age adult without a disability must generally be caring for a child or an older or disabled family member and cannot earn more than 26% of the federal poverty level, or about $592 a month for a family of three.

Most adults who are not disabled and receive Medicaid already work, and many people in low-paying jobs do not receive health insurance through an employer, , a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. Among single adults ages 19 to 64 in Florida who made under $15,000 a year in 2024, through work.

Critics say Florida’s proposal would likely force some people to become uninsured, even if they meet the work requirement. That’s because the state’s Medicaid income limit is so low that working the mandated 80 hours a month would likely cause those individuals to exceed the income eligibility limit but also leave them earning too little to qualify for subsidized coverage on the Affordable Care Act marketplace.

Michelle Mastrototaro said she lost her Medicaid coverage in November after taking a part-time job as a teaching assistant at a Tampa elementary school last year. Mastrototaro, 47, cares for a disabled teenage son and likely would not need to meet Florida’s proposed work requirement.

But she said her biweekly wages from working about 17 hours a week pushed her past the Medicaid income limit. She has struggled to afford her prescription medications since.

“What I’m making is nothing,” Mastrototaro said. “I am scavenging just to make ends meet.”

The Gaetz-led proposal ignores “the hard realities of what it takes to be qualifying for Medicaid in Florida,” said , executive director of Florida Voices for Health, a nonprofit that advocates for Medicaid expansion. “On its face,” he said, “it doesn’t make sense.”

Medicaid experts say the holds that nonexpansion states cannot adopt work requirements.

A state that hasn’t added more low-income adults to its Medicaid program can’t impose work requirements on those who are already covered, Cuello said. States must cover specific categories of low-income people — such as children, pregnant women, some parents, older adults, and people with disabilities — to receive federal funding for their programs.

States that have expanded Medicaid eligibility to a limited group of low-income adults, namely Georgia and Wisconsin, will be required to impose work requirements on those enrollees.

, launched in July 2023, already includes a requirement that newly eligible adults report at least 80 hours of work or community engagement. Federal approval for the program expires at the end of December, and the state . will have to implement a work requirement by Jan. 1.

South Carolina applied in June for federal approval to to nondisabled parents and caregivers ages 19 to 64 who earn 67-100% of the federal poverty level. That’s about $18,300 to $27,300 a year for a family of three. The state’s application is pending with CMS, and if approved would implement work requirements for those newly eligible adults.

Gaetz said if the Florida legislation were approved, the state would develop a “business plan” for implementing work requirements and seek CMS approval.

It is unclear how much it would cost, but experience in states with Medicaid work requirements suggests that implementation would be expensive. States must upgrade their eligibility and enrollment systems, hire additional staff, and inform the public of the new mandate.

For its program, Georgia spent about $54.2 million on administrative changes out of $80.3 million in total spending for the program from October 2020 to March 2025, according to from the U.S. Government Accountability Office. Most of the administrative spending — about $47.4 million, or 88% — came from the federal government.

Georgia’s experience echoes others’, according to a 2019 of states that received approval to implement Medicaid work requirements during the first Trump administration. That report focused on five states — Arkansas, Indiana, Kentucky, New Hampshire, and Wisconsin — and estimated costs would total $408 million. They ranged from $6 million in New Hampshire to more than $270 million in Kentucky, though those figures did not reflect all the state costs.

Florida’s computer infrastructure for collecting and verifying information and determining eligibility is more than 30 years old and is being replaced. That is anticipated to be completed in 2028 and cost more than $180 million.

A legislative analysis of Gaetz’s bill estimated that if 1 in 4 people affected by the proposed work requirement were to lose Medicaid coverage, the state could save about $80 million a year.

Darius, with Florida Voices for Health, said those potential savings hardly seem worth the effort.

“It requires the state to build this giant regulatory-like framework and to rebuild systems, and to employ a whole set of people to chase down the very small number of folks who would ultimately be touched by this,” he said.

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

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The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House .

But, in reality, adults ages 50 to 64, particularly women, are likely to be , said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, .

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told Ñî¹óåú´«Ã½Ò•îl Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to . Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you’re going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The nurse who took the call at the Sono Bello center in Addison, Texas, told her she “absolutely should not” go to the ER — even though Farris “had a large gush of foul fluid” leaking from the incision, according to records in the malpractice case she filed against the cosmetic surgery chain in 2024.

The nurse told Farris she “only needed to reinforce her dressing to collect the fluid drainage and give it time,” filings in the lawsuit alleged.

“Thankfully, Ms. Farris did go to the ER where she was diagnosed with sepsis from her surgery complications,” a medical expert for her legal team wrote in a court filing. Left untreated, sepsis can lead to death.

Sono Bello officials declined to discuss malpractice cases filed against the company, citing patient privacy laws. But in court filings, the company has disputed Farris’ claims. The case is set for trial early next year.

The Farris lawsuit is one of dozens of medical malpractice cases filed over the past three years that accuse cosmetic surgery chains of failing to provide adequate care for patients in the days and weeks after their procedures — in many cases by allegedly neglecting to promptly treat painful infections and other serious complications — including for four patients who died, a Ñî¹óåú´«Ã½Ò•îl Health News investigation found.

In some cases, patients who traveled hundreds of miles or more for seemingly routine surgeries allegedly suffered painful complications while recuperating in hotel rooms or unlicensed “recovery homes,” which they said lacked adequate medical staff and supervision, according to court filings.

While complications, such as infections, can occur after any surgical procedure, problems related to postoperative care are blamed for contributing to injuries in over two-thirds of the cosmetic surgery cases Ñî¹óåú´«Ã½Ò•îl Health News reviewed.

The surgery companies involved — some, like Sono Bello, financed by — offer elective procedures such as liposuction and “” to patients who pay thousands of dollars out-of-pocket or on credit. Ads promise life-changing body reshaping techniques with minimal risk and .

Medical malpractice lawsuits have trailed behind the growth of these companies. Suits have accused the chains of hiring doctors who lacked adequate training or had , and of using high-pressure sales tactics and misleading advertising pitches that downplay safety risks, court records show. The companies dispute these allegations and have won dismissal of some suits.

Patrick Schaner, a plastic surgeon and a Sono Bello medical director, stressed that the company has performed more than 300,000 cosmetic operations with minimal complications. “That context is very important,” he said in an interview.

Schaner said Sono Bello surgeons are “good at what they do” because of the large numbers of procedures they perform. “We do a great job of getting safety protocols in place,” he said.

Many patients who file lawsuits blame disfiguring injuries on what happened after their operations, such as office visits in which medical staff allegedly didn’t recognize, or dismissed, evidence of worsening surgical complications, court records show.

A nurse at a Sono Bello center outside Chicago allegedly failed to alert doctors when Mary Anne Garcia, a patient who had had liposuction at the center about three weeks earlier, showed up there with her aunt. Garcia was dizzy and so weak she required a wheelchair to get back to the car, according to a lawsuit her estate filed in September.

Rather than tell Garcia to go to an emergency room, the Sono Bello nurse told her to “drink more fluids and try to eat something,” according to the complaint.

Garcia died the next day from cardiac arrest, according to the lawsuit. Sono Bello has yet to file a response to the lawsuit in court.

‘It Was Horrifying’

Susan Easley, 59, a veteran U.S. Agency for International Development executive who spent two decades working on AIDS projects in Africa, died in a Washington, D.C., short-term apartment last year.

Her son Gavin found her body May 13, 2024, four days after she had an AirSculpt liposuction and fat transfer operation at Elite Body Sculpture in nearby Vienna, Virginia, according to a lawsuit filed in November.

“It was horrifying,” Gavin Easley told Ñî¹óåú´«Ã½Ò•îl Health News in an interview. “My mother was the definition of kind, caring, and unconditionally loving. She was the most incredible woman I’ve ever known,” said Easley, 29, who runs an organic farm in Arkansas with his wife.

The suit alleges that surgeon Dare Ajibade gave Easley an excessive amount of the anesthetic lidocaine during the 6½-hour procedure and failed to recognize persistent vomiting afterward as a sign of toxicity. She called the clinic to report her condition, but her concerns were dismissed, the suit alleges.

“When she called to report complications, they didn’t take it seriously,” said Virginia attorney Peter Anderson, who filed the suit. He said Easley presented “clear signs and symptoms” of problems.

is a brand of Elite Body Sculpture, a Miami Beach-based chain founded by cosmetic surgeon Aaron Rollins. The company, which is financed by private equity investors, has about 30 branches across the country. Neither the company nor Rollins responded to repeated requests for comment on patient lawsuits. In court filings, the company has denied the allegations.

Ajibade has since relocated to Texas, where he works for Sono Bello in San Antonio, according to the company. Neither the surgeon nor the Virginia surgery office, which is also a defendant in the case, returned calls for comment. The defendants have yet to file an answer in court.

A Booming Business

Sono Bello, with more than 100 centers nationwide, bills itself as “America’s #1 Cosmetic Surgery Specialist.”

Patients filed seven malpractice cases against Sono Bello in September — each in a different state. In an interview, Marcy Norwood Lynch, a Sono Bello executive vice president and chief legal officer, speculated that the spurt in cases was related to reporting by Ñî¹óåú´«Ã½Ò•îl Health News and NBC News about the company. There “could be alignment” between the coverage and the filing of the suits, she said. The company has denied the allegations in court.

Ñî¹óåú´«Ã½Ò•îl Health News reviewed a sample of more than 100 medical malpractice cases filed against multistate surgery chains from the start of February 2023 through November 2025. Malpractice suits do not by themselves prove substandard care, though many medical authorities and licensing boards consider them a tool for helping to judge medical quality.

Heather Faulkner, a plastic surgeon and associate professor at Emory University School of Medicine in Atlanta, said surgeons must quickly recognize before they progress and become serious, even life-threatening conditions.

At Emory, she said, surgeons must attend their patients’ first visit after cosmetic surgery. “Ultimately, the physician is the one responsible,” she said. “The patient has to be seen by the person who did the operation and knows how to recognize something is wrong,” Faulkner said in an interview.

Patients suing cosmetic surgery chains often argue that they were seen by nurses or other staff members who, they allege, lacked the training to recognize and deal with problems before they required emergency wound care.

Schaner, the Sono Bello medical director, said the company has a phone messaging system that ensures patients can get in touch with their surgeon or other company physicians. While nurses see some patients, the “ultimate decision-making is passed to the surgeon,” he said.

Five patients treated at Sono Bello centers who sued the company during 2025 alleged that surgical wound complications were dismissed after medical staff, including surgeons, viewed pictures of the injuries, court records show. The cases are pending.

Schaner said Sono Bello sometimes has patients submit photos of wounds but the images are “not the sole means of triage” of patient injuries or complications.

Joshua Kiernan sued Sono Bello after having liposuction on May 28, 2024, at the branch in Columbia, South Carolina. On June 8, 2024, he stumbled and fell in a gym parking lot, causing drainage around the incision in his stomach, according to the suit. On June 17, 2024, Kiernan visited the office complaining of “redness and pain” around the incision, according to his suit.

The surgeon, Stancie Rhodes, didn’t examine him in person but had an office staff member take a picture “so that she could view it from another part of the office,” according to the complaint.

The surgeon sent back word that the photo “looked fine,” and Kiernan was told to take Tylenol for the pain and follow up at the office a week later, the complaint alleged.

Two days before his appointment, Kiernan required emergency hospital treatment for “abdominal hematoma and infection,” according to the suit.

Kiernan underwent six surgical procedures and ran up medical bills of more than $325,000 to treat his condition, according to the suit. In court filings, Sono Bello denied the allegations.

“Surgical care does not end at the last stitch,” said Mark Domanski, a plastic surgeon in Virginia, who believes the chain clinics in general are more adept at marketing than providing patients with top-notch care. “It involves postoperative visits with the surgeon who did the procedure, who is there to respond to the patient’s concerns, questions, especially if things are not going well,” he said.

Recovery Houses

Many patients who travel for cosmetic surgery, either to save money or because services aren’t available in their area, can’t return home right away.

Yet there’s little agreement on where patients should recuperate, for how long, and what medical services should be readily available to them.

Scott Hollenbeck, immediate past president of the American Society of Plastic Surgeons, said laws or regulations in most states don’t spell out requirements.

“This can create a wide variation of oversight, staff qualifications, and available medical support,” he said.

The plastic surgery society has a cottage industry of recovery houses that often charge patients hundreds of dollars a night while they recuperate, even though they may lack medical staff capable of handling possible surgical complications.

Court filings in Florida show patients staying in recovery houses and hotels have died or suffered untreated complications, mostly in South Florida, where officials have struggled for a decade or more to regulate unlicensed facilities. One local lawmaker recently to rein them in.

Hollenbeck said patients who recuperate in a hotel or other facility need to find out in advance what “level of care” will be available. He said ads touting “luxury” accommodations or “conveniently located” do not make a hotel “clinically qualified to provide recovery care.”

Easley, whose mother died in Washington, D.C., said he is struggling to understand what happened after a medical transportation service took her from the Virginia surgery center to a temporary apartment.

He said his mother, who was born in a small village in Uganda before emigrating to the U.S. as a teen and joining the U.S. Army, “had so many plans” for the future.

Susan Easley had been medically cleared for a . After that, she planned to retire and start a farm in Tanzania, among other things, according to her son.

The lawsuit alleges the surgery center discharged her prematurely given signs of a dangerous condition called caused by an overdose of lidocaine.

Susan Easley called the surgery center that day and reported “multiple instances of nausea and vomiting,” but there’s “no evidence” that anyone told her to head to an emergency room, according to the suit.

“I don’t know what they said to her,” Gavin Easley said. “It’s a horrifying thought for me. I have no idea how to get to the bottom of that mystery.”

‘Preventable Death’

Some lawsuits take aim at decisions made by support staff members, who help monitor patients after surgery.

That’s a critical issue in the case of Mary Anne Garcia, the Illinois woman who died after her aunt drove her to the Sono Bello office in Oakbrook Terrace, Illinois, on June 4, 2024.

Garcia “was feeling sluggish, dizzy, and nauseated,” according to the suit. She also had a rapid heartbeat and low blood pressure, according to the complaint. But registered nurse Lucia Raddatz did not notify the surgeon or urge Garcia to seek emergency care even though Raddatz had to help her back to the car in a wheelchair due to Garcia’s “severely weakened condition,” according to the suit.

Filed on behalf of Garcia’s estate, the suit names Raddatz and Sono Bello as defendants. An emergency room physician hired as an expert in the case opined that had Garcia gone to the emergency room on June 4, “she would have received care which would have avoided her death,” court records state. Sono Bello had no comment and has yet to file an answer in court.

Established plastic surgeons say they are often called upon to treat patients who arrive in the emergency room with complications because surgeons working for the chains may lack local hospital privileges or are otherwise not available for consultations.

“There is not one colleague of mine who has not dealt with the complications of these types of facilities or med spas on more than one occasion,” said Charles Pierce, president-elect of the New Jersey Society of Plastic Surgeons.

‘Angry and Betrayed’

Doctors at an Austin, Texas, hospital expressed such frustration while caring for Anna Palko, a 33-year-old mother of four, according to a malpractice suit she filed in November against surgeon Rambod Charepoo and his employer, Mia Aesthetics. The Miami-based cosmetic surgery company, which operates in about a dozen cities, including Austin, advertises that it delivers the .

A doctor at St. David’s Medical Center in Austin wrote in Palko’s medical record: “Unfortunately patient has had postoperative complications from a physician who is well-known to our emergency department for similar post-op complications associated with cosmetic surgery through MIA (sic) Aesthetics,” according to the suit.

Palko is one of five Texas women who sued Charepoo and Mia Aesthetics for malpractice this year, between mid-July and the end of November, court records show.

Four women allege the surgeon and the company failed to adequately treat infections that developed after surgery, while the fifth alleged other complications. Mia Aesthetics was dismissed from one case. The surgeon and the company have denied the allegations in court filings, court records show.

Charepoo also has been the subject of a lengthy investigation by the Texas Medical Board, which licenses doctors.

In August 2021, the board alleged that the surgeon “failed to meet the standards of care” in treating six patients, including one he placed “at risk” by allowing the patient to leave the surgery center for the emergency room in a private vehicle after the person “experienced significant hypotension and hemorrhagic shock.”

In October 2024, the medical board found that Charepoo had failed to meet standards of care for five of the six patients. The board required him to have a surgical proctor oversee 20 of his operations per quarter for two years. The board also ordered him to take medical education courses, pass an exam, and pay a fine of $4,000.

Charepoo is fighting the order in court. Charepoo, Mia Aesthetics, and lawyers representing Charepoo and the company did not respond to requests for comment.

In January, he sued the Texas Medical Board, arguing the penalty is “both excessive and unjustified” and should be invalidated. The medical board declined to comment on the suit, which is pending in Travis County District Court.

Hearing of the surgeon’s problems came as a shock to patient Palko, who said she had chosen Mia Aesthetics because of ads promising high-quality doctors.

“I felt so disgusted, angry, and betrayed,” Palko said in an email sent through her attorney.

Have you had liposuction, a “Mommy Makeover,” a tummy tuck, a Brazilian butt lift, or another type of cosmetic surgery? We’d like to hear about your experience. Click here to contact our reporting team.

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Most of the lawyers work either for the Department of Justice or for disability rights agencies that Congress set up in every state decades ago. Many of the Justice Department lawyers quit in 2025 after being reassigned to other duties, their supporters say. And Trump budget officials proposed deep cuts to federal grants supporting the state-based legal groups.

People with disabilities have the right to live in their communities if possible. Federal laws and court decisions say they may attend school, work jobs, and go to restaurants, movie theaters, and other public places. If they can find lawyers, they can file legal challenges when those rights are denied.

The federally funded attorneys quietly work to ensure the U.S. lives up to promises made by the Americans with Disabilities Act and other laws, said Alison Barkoff, a health law professor at George Washington University.

“I think many families of people with disabilities, or even many people with disabilities themselves, don’t hear about it until they Google, ‘Where can I get help?’” said Barkoff, who helped lead such efforts under Presidents Joe Biden and Barack Obama.

The attorneys’ goals include ensuring that people with disabilities have the services they need to live in their own homes, instead of having to move into nursing homes or other types of institutions, Barkoff said.

“These are people who, if these supports are ripped away, are going to have to leave their communities and their families, at a higher cost for taxpayers,” she said.

The state-based disability rights groups are known as “protection and advocacy” organizations. Most of them are nonprofit groups.

Congress approved the federally financed system in the 1970s after TV journalist Geraldo Rivera in a New York institution for people with mental and intellectual disabilities, revelations that ignited a national outcry.

President Donald Trump proposed cutting the system’s federal funding from $148 million to $69 million for fiscal year 2026, according to the National Disability Rights Network, which represents the state-based groups.

Appropriations committees in the U.S. House and Senate have recommended Congress maintain funding at the previous level. But advocates for the agencies worry that even if Congress maintains current support, the administration will try again to slash their support in future years. “It definitely would put people in our communities in harm’s way,” said Marlene Sallo, the national network’s executive director.

White House officials declined to comment on why the Trump administration proposed the deep cuts.

Isaac Schreier’s family can attest to the value of the state-based legal groups.

Isaac, 7, lives in Ankeny, Iowa. He has a rare condition called osteogenesis imperfecta, also known as brittle bone disease. The condition has caused about 60 bone fractures, including in his limbs, spine, and skull. It can cause intense pain and leave him unable to walk.

At times, Isaac’s disability is practically invisible, said his father, Jake Schreier. Unless he has recently suffered a broken leg bone, he walks well. “But he tires much more quickly than you or I would.”

Isaac’s doctor said he needed a special wheelchair that could be adjusted to put him in different positions depending on which bones were broken. But the private insurer that manages his Medicaid coverage declined to pay for the $3,500 wheelchair. “They required proof that it was a permanent and long-standing condition,” Jake Schreier said. “We were very frustrated.”

Schreier appealed the denial but lost. A nurse at a specialty clinic then recommended he reach out to Disability Rights Iowa, a federally funded protection and advocacy group that had helped other families in similar straits.

The group linked Schreier with two of its attorneys, who filed a new appeal. The lawyers wrote a detailed letter explaining why Isaac was legally entitled to the new wheelchair, and they cited specific Iowa codes and court precedents.

The insurer wound up paying for Isaac’s special wheelchair.

The chair allows Isaac to participate in school and community activities even when he has broken bones. “It’s absolutely night and day. I can’t imagine a world where we didn’t have it,” his father said.

Isaac may again need people like the disability rights lawyers to fight for him, so he won’t be shunted away from society, Schreier said. “We’re really trying to keep as many doors open as possible for him.”

The threat to the state-based groups’ funding comes as the more people with mental illness or addictions into institutions.

David Hutt, deputy executive director for legal services at the National Disability Rights Network, noted that the groups have legal authority to go into facilities where people with disabilities live, to check conditions and treatment. Those facilities include state institutions and privately owned nursing homes.

More Americans could wind up living in such settings if Trump succeeds in his quest to institutionalize people with mental illness who are living on the streets, Hutt said.

At the same time, in federal contributions to Medicaid, the public health coverage program for people with low incomes or disabilities. In response, they may be tempted to reduce Medicaid coverage of , many of which are considered optional under federal law, Hutt said. If that happens, “you’re going to get increased institutionalization, which actually costs more,” he said.

Disability rights organizations often have stepped in when states failed to provide care and services that people with disabilities are entitled to. So have lawyers from the Justice Department’s civil rights division.

For example, Disability Rights Iowa filed a lawsuit in 2023 alleging the state failed to provide proper mental health resources for children on the Medicaid program. The state that advocates said could bring “radical change” to the system.

In 2021, the Justice Department that their lack of support for community services meant too many people with intellectual disabilities had to live in facilities. State officials vowed to do better.

Since Trump returned to office, many of the Justice Department’s most experienced disability rights lawyers have taken buyouts or been reassigned to other areas, said Jennifer Mathis, a former top administrator at the Justice Department under Biden. “There’s really skeleton staffing at this point,” said Mathis, now deputy director of , which advocates for rights of people with mental disabilities.

The overall civil rights division is down to about 300 people, fewer than half the number it had under Biden, Mathis said.

The civil rights division’s new director, Harmeet Dhillon, in April that more than 100 attorneys had left the division, but that they didn’t support Trump’s priorities. “The job here is to enforce the federal civil rights laws, not woke ideology,” she told Beck.

In a statement to Ñî¹óåú´«Ã½Ò•îl Health News, Dhillon said the division continues to be “a vocal and active advocate for Americans with disabilities.”

Dhillon noted the department recently over complaints that the ride-hailing service was turning away customers with service dogs or wheelchairs; has secured agreements with and to improve treatment of imprisoned people with disabilities; and over allegations of failing to provide proper accommodations for people with disabilities.

The department declined to comment on the record about the number of attorneys it has working on disability rights issues. However, “civil rights warriors,” including lawyers, to join the civil rights division.

Jake Schreier, the Iowa parent, hopes the issue will be worked out nationally. “I really can’t believe this is anything that would be partisan,” he said.

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The Trump administration, which has promised “radical transparency,” that it plans to publish the “project summary” for states that win awards. Following the lead of federal regulators, many states are withholding their complete applications, and some have refused to release any details.

“Let’s be clear,” said Alan Morgan, chief executive of the National Rural Health Association. “The hospital CEOs, the clinic administrators, the community leaders: They’re going to want to know what their states are doing.” The NRHA’s members include struggling rural hospitals and clinics, which would benefit from the Trump administration’s Rural Health Transformation Program.

Morgan said his members are interested in what states propose, which of their ideas are approved or rejected, and their budget narratives, which detail how the money could be spent.

Improving rural health care is an “insanely complicated and difficult task,” Morgan said.

The five-year Rural Health Transformation Program was approved by Congress in a law — the One Big Beautiful Bill Act — that also drastically cuts Medicaid spending, on which rural providers heavily depend. It’s being watched closely because it’s a much-needed influx of funds — with a caveat from the Trump administration that the money be spent on transformational ideas, not just to prop up ailing rural hospitals.

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be distributed through a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Health and Human Services Secretary Robert F. Kennedy Jr. has repeatedly promised to open the government to the American people. His agency has devoted to “radical transparency.”

“We’re working to make this the most transparent HHS in its 70-year history,” in written testimony to lawmakers in September.

Lawrence Gostin, a professor of public health law at Georgetown University, said HHS is “acting in a way that utterly lacks transparency” and that the public has the right to demand “greater openness and clarity.” Without transparency, the public cannot hold HHS accountable, he said.

Centers for Medicare & Medicaid Services spokesperson Catherine Howden said the agency will follow the federal regulations when releasing information about the rural health program.

Grant applications are “not released to the public during the merit review process,” Howden said, adding, “The purpose of this policy is to protect the integrity of evaluations, applicant confidentiality, and the competitive nature of the process.”

Democrats and many health care advocates are concerned politics will affect how much money states get.

“I am very concerned about retaliation,” said Rep. Nikki Budzinski (D-Ill.). Because Democrats control her state’s politics, “our application might not be as seriously considered as other states that have Republican leadership,” she added.

Illinois’ Democratic members of the U.S. House to CMS Administrator Mehmet Oz in November asking for “full and fair consideration” of their state application. Illinois officials have not yet released their state’s proposal to Ñî¹óåú´«Ã½Ò•îl Health News, which has a pending public records request.

Heather Howard, a professor of the practice at Princeton University, said she is “pleasantly surprised at how transparent the states have been.”

Howard directs the university’s State Health and Value Strategies program, which the rural health fund, and praised most states for publicly posting their project summaries.

“To me, it speaks to the intense interest in this program,” Howard said. Her team, reviewing about two dozen state summaries, found themes including expansion of home-based and mobile services, increased use of technology, and workforce development initiatives like scholarships, signing bonuses, and child care assistance for high-demand positions.

“I think it’s exciting,” Howard said. “What’s great here is the experimentation we’re going to learn from.”

Telerobotics appeared in Georgia’s and Alabama’s applications, she said, including a proposal to use robotic equipment for remote ultrasounds.

Another theme that “warms my heart,” Howard said, was the effort among states to create advisory groups or committees, including in Idaho, where work groups are expected to focus on technology, workforce development, tribal collaboration, and behavioral health.

All 50 states submitted applications to federal regulators by the Nov. 5 deadline and awards will be announced by the end of the year, according to CMS.

As of late November, nearly 40 states had released their project narrative, the main part of the application, which describes proposed initiatives, according to Ñî¹óåú´«Ã½Ò•îl Health News tracking. More than a dozen states have also released their budget narratives.

Also as of late November, only a handful of states — Idaho, Iowa, Kansas, Minnesota, New Mexico, North Dakota, South Carolina, and Wyoming — had released all parts of the application.

Ñî¹óåú´«Ã½Ò•îl Health News filed public records requests for states’ complete applications. Some states have refused to release any of their application materials.

Nebraska, for example, rejected a public records request, saying its application materials are “proprietary or commercial information” that “would give advantage to business competitors.”

Kentucky shared its application summary but said the remainder of the application is a “preliminary draft” not subject to release under state laws.

Erika Engle, a spokesperson for Hawaii Gov. Josh Green, said the governor “is committed to transparency” but declined to share any of the state’s proposal.

Hawaii and other states are still processing formal public records requests.

The rural health program is part of the July law projected to reduce federal Medicaid spending in rural areas by 10 years.

Those cuts are expected to affect rural health facilities’ bottom lines, threatening their ability to stay open. A recent Commonwealth Fund report found that rural areas continue to to primary care. But the guidelines for the rural health program say states can use only 15% of their new funding to pay providers for patient care.

Between the Medicaid cuts and funding boost from the new program, “there’s real opportunity for national policy to impact rural, both in the negative and the positive potentially,” said Celli Horstman, a senior research associate at the New York-based policy think tank who co-authored the report.

Among the publicly available rural health transformation proposals, Democratic-leaning states show support, or are willing to adopt, some of the administration’s goals but will lose out on points from eschewing others.

For example, New Mexico said it would introduce legislation requiring students to take the Presidential Fitness Test and physicians to complete continuing education courses on nutrition. But it won’t prevent people from using their Supplemental Nutrition Assistance Program benefits to buy “non-nutritious” foods such as soda and candy.

Many states want to invest in technology, including telehealth, cybersecurity, and remote patient monitoring equipment. Other themes include increasing access to healthy food, improving emergency services, preventing and managing chronic illnesses, and enlisting community health workers and paramedics for home visits.

Specific proposals include:

• Arkansas wants to spend $5 million through its “FAITH” program — Faith-based Access, Interventions, Transportation, & Health — to enlist rural religious institutions to host education and preventive screening events. Congregations could also install walking circuits and fitness equipment.
• Alaska, which historically relied on dogsled teams to bring medication to remote areas, is looking to test the use of “unmanned aerial systems” to speed up pharmacy deliveries to such communities.
• Tennessee wants to increase access to healthy activities by spending money on parks, trails, and farmers markets.
• Maryland wants to start mobile markets and install refrigerators and freezers to improve access to fresh, healthy food that often spoils in rural areas with few grocery stores.

State Sen. Stephen Meredith, a Republican who represents part of western Kentucky, said he still expects rural hospitals to close despite his state’s rural health transformation program.

“I think we’re treating symptoms without curing the disease,” he said after listening to a presentation on Kentucky’s proposal at .

Morgan, whose organization represents rural hospitals likely to close, said the state’s ideas may sound good.

“You can craft a narrative that sounds wonderful,” he said. “But then translating the aspirational goals to a functioning program? That’s difficult.”

Ñî¹óåú´«Ã½Ò•îl Health News staffers Phil Galewitz, Katheryn Houghton, Tony Leys, Jazmin Orozco Rodriguez, Maia Rosenfeld, Bram Sable-Smith, and Lauren Sausser contributed to this report.

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The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs , according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told Ñî¹óåú´«Ã½Ò•îl Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to , no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, .

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. and in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to .

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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WASHINGTON — Nationwide, states are racing to win their share of a new $50 billion rural health fund. But helping rural hospitals, , is quickly becoming a quaint idea.

Rather, states should submit applications that “rebuild and reshape” how health care is delivered in rural communities, Centers for Medicare & Medicaid Services official Abe Sutton said late last month during a daylong meeting at Washington, D.C.’s Watergate Hotel. Simply changing the way government pays hospitals has been tried and has failed, Sutton told the audience of more than 40 governors’ office staffers and state health agency leaders — some from as far away as Hawaii.

“This isn’t a backfill of operating budgets,” said Sutton, CMS’ innovation director. “We’ve been really clear on that.”

Rural hospitals and clinics nationwide face a looming financial catastrophe, with President Donald Trump’s massive tax-and-spending law expected to slash federal Medicaid spending on health care in rural areas by . Congressional Republicans added the one-time, five-year Rural Health Transformation Program as a last-minute sweetener to win the support of conservative holdouts who worried about the bill’s financial fallout for rural hospitals.

Yet, the words used by CMS Administrator Mehmet Oz and his agency’s leaders to describe the new pot of cash are generating tension between legacy hospital and clinic providers and new technology-focused companies stepping in to offer new ways to deliver health care.

It’s “what I would call incumbents versus insurgents in the rural space,” said Kody Kinsley, a senior policy adviser at the Institute for Policy Solutions at the Johns Hopkins School of Nursing.

Applications are due Nov. 5. The money will be awarded to states by the end of the year and distributed over five years.

Half of the $50 billion will be divided equally among all states with an approved application; the other half will go to states that win points. Of , $12.5 billion will be allotted based on a formula that calculates each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that mirror the Trump administration’s objectives.

The specific policy goals such as implementing the Presidential Fitness Test and restrictions to food assistance, as well as broader investment strategies around remote care services, data infrastructure, and consumer-facing technology tools, which CMS identified as “symptom checkers and AI chatbots.”

In September, after CMS officials released the application, Republican members of Congress from states with Democratic governors , concerned their states might direct the money to urban areas. In a letter to Oz and Health and Human Services Secretary Robert F. Kennedy Jr., they said the money “will serve as a lifeline for rural and at-risk hospitals in our communities that are already struggling to keep their doors open.”

Smaller hospitals fear they will get “a tiny little slice” of each state’s share, said Emily Felder, who leads the health care practice at Brownstein Hyatt Farber Schreck, a law firm whose clients include rural hospital systems.

“There’s a lot of frustration,” Felder said.

But Kinsley, who was previously North Carolina’s secretary of health and human services, said using this money only to shore up a balance sheet “is really just throwing good money after bad.” In contrast, he said, insurgents such as technology-driven startups can offer new strategies.

One of those companies vying for funding is , a Silicon Valley-based company that contracts with Medicare managed care insurers. Using artificial intelligence analytics, Homeward helps patients get care in their home and with local providers.

The company manages the health of 100,000 rural Michigan patients enrolled in insurance, said Homeward co-founder and chief executive Jennifer Schneider. The company was a sponsor for the Watergate summit. It also has ongoing meetings with Oz and his team, Schneider said.

“They’re doing their job, and they’re talking to a lot of people in the ecosystem and really eager to learn from those of us that have been in the system,” Schneider said. “We’re one of many in that position.”

Ñî¹óåú´«Ã½Ò•îl Health News requested an interview with Alina Czekai, director of the Office of Rural Health Transformation. CMS spokesperson Alexx Pons said the agency was “unable to accommodate facilitation of any interview.”

Instead, CMS provided an emailed statement from Oz saying the program “will help states and communities reimagine what’s possible for rural healthcare.”

Brock Slabach, chief operations officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics, said the money would best be used to help pay for transformation that isn’t “sexy” or “revolutionary.”

“If what we end up with is we have a wearable for every rural patient, I don’t think that’s transformational,” Slabach said, referring to digital health monitors such as fitness-tracking watches.

Slabach, a onetime small-hospital chief executive and an unofficial adviser to hundreds of rural facilities nationwide, named a few ideas for the money — including paying for capital improvements such as electronic health records or equipment, loan repayment programs to aid workforce development, and creating “SWAT” teams that rescue rural hospitals on the brink of closure.

More than 150 rural hospitals nationwide since 2010 — a statistic cited by CMS’ Sutton that is well known among industry watchers. The Sheps Center at the University of North Carolina, which compiles the closure data, also released to help states calculate how rural they are for their applications.

State applications will be reviewed by a panel, with some reviewers from within the government but others outside it, said Kate Sapra, acting deputy director of the Office of Rural Health Transformation, speaking at the Watergate.

“We will train them in the scoring criteria,” Sapra said, adding that the panelists will not be coming from “your state” and will need to fill out conflict-of-interest forms. A portion of money each state gets will be reevaluated annually based on the progress it makes on its goals and priorities, .

States are creating stakeholder groups, asking for public comment, and working with their health agencies. Some, such as and , are hiring consultants.

In Montana, a collection of health providers and associations proposed a list of ideas for the cash, including creating a loan repayment fund for rural clinicians to try to ease worker shortages.

“It’s one-time money, and it’s a little bit of money,” said David Mark, a doctor who is the CEO of One Health, which has clinics dotted across eastern Montana and Wyoming. A state could receive a minimum of $100 million a year for five years if all 50 states have applications approved.

“How do you accomplish goals of a health care system transformation with an infusion of money like that?” Mark said.

Neither Montana nor Wyoming — vast, rural states — sent leaders to the Watergate summit, according to a copy of the attendees list. In the afternoon, attendees could rotate among planning tables and meet with corporate sponsors such as the electronic health records behemoth Epic and the emergency services company Global Medical Response.

Wyoming Department of Health Deputy Director Franz Fuchs confirmed his state did not send representatives to the event, because they were “stretched with other commitments.” Montana, Wyoming, and other states submitted signaling they will apply for the funds. CMS did not respond to questions about how many and which states have submitted letters.

During the Watergate event, hints of brewing competition among states began to surface.

“I think Arkansas’ application is going to be better than yours,” seasoned political adviser Jack Sisson said with a smile during a morning panel.

The audience laughed. Sisson, who recently left his job as health adviser for Arkansas Gov. Sarah Sanders, had interrupted Michael Hendrix, policy adviser to another Republican governor, Tennessee’s Bill Lee.

“See, this is the kind of friendly competition that CMS is hoping for,” Hendrix said. He grinned, thanked Sisson, and added, “I look forward to us both winning.”

Ñî¹óåú´«Ã½Ò•îl Health News Montana correspondent Katheryn Houghton contributed to this report.

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By January 2027, President Donald Trump’s far-reaching will require many adult, nondisabled Medicaid enrollees in 42 states and Washington, D.C., to work or volunteer 80 hours a month or go to school.

But under the law, Medicaid enrollees in counties where unemployment is at least 8% or 1.5 times the national unemployment rate could be shielded from the work requirement, if their state applies for an exemption.

A shows that exemption in the GOP’s could offer a reprieve to potentially millions of Americans caught in a tough spot — needing to work to secure health insurance but having trouble finding a job.

The Congressional Budget Office projected the work requirement would apply to 18.5 million Medicaid enrollees, causing about 5.3 million to lose their government health coverage by 2034. CBO spokesperson Caitlin Emma confirmed to Ñî¹óåú´«Ã½Ò•îl Health News that analysts factored the unemployment rate exemption into their projections. Only states that expanded Medicaid under the 2010 Affordable Care Act or a special waiver must enact a work requirement, under the federal law.

But how many people could be exempt depends on how the Trump administration interprets the law, in addition to whether their states’ officials apply.

For example, if Trump officials exempt people in counties where the unemployment rate has been above the law’s thresholds for any month over a 12-month period, about 4.6 million Medicaid enrollees in 386 counties could qualify for an exemption today based on the latest unemployment data, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

That amounts to just under a quarter of all Medicaid enrollees subject to the work requirement.

Under that one-month threshold, “the impact could be fairly significant,” said Jennifer Tolbert, a co-author of the analysis and the deputy director of KFF’s Program on Medicaid and the Uninsured.

But, she said, the Trump administration is more likely to adopt a stricter threshold based on average unemployment over a 12-month period. That would align with work requirements under the federal Supplemental Nutrition Assistance Program, the food assistance commonly known as food stamps.

Only about 1.4 million Medicaid enrollees living in 158 counties could be exempted under that standard, or about 7% of the total subject to work requirements, KFF found. That’s about 7% of enrollees who live in expansion states who would otherwise need to meet the new requirement.

Based on the 12-month criteria, about 90% of Medicaid enrollees who could be exempted based on high unemployment reside in five states, according to KFF: California, New York, Michigan, Kentucky, and Ohio. California alone accounts for over half of those who could be exempted.

The unemployment rate exemption is one of several carve-outs from the Medicaid work requirement in the GOP’s law. The law also exempts parents with children under 14, people who are disabled or frail, and those who are pregnant, incarcerated, or in a substance use disorder program, among others. The high unemployment provision is different than most because it exempts people living in entire counties.

Two top Republicans key to the bill’s passage — House Speaker Mike Johnson and Sen. Mike Crapo, chair of the Senate Finance Committee — did not respond to requests for comment.

To qualify for the Medicaid exemption, states would have to apply to the federal government on behalf of individuals in eligible counties. And if a county earned an exemption, the government would determine how long it applies.

Even if the federal government grants exemptions broadly, health advocates fear some Republican-led states could balk at applying for exemptions in order to keep enrollment down, as they say has been the case with SNAP exemptions. As of 2023, 18 states did not have an exemption under the SNAP program, even though some of their residents might be eligible.

“It’s not a guarantee that people can rely on,” said Emily Beauregard, executive director of Kentucky Voices for Health, an advocacy group that intends to push for the broadest possible exemptions to help people maintain their coverage. Eastern Kentucky has several counties with perennially high unemployment.

In advocating for Trump’s bill, that most people who gained Medicaid benefits under the Affordable Care Act should be working to get off of government assistance.

But as have shown, Medicaid work requirements can be costly for states to run and . About 18,000 people in Arkansas, or nearly a quarter of the state’s adults who gained Medicaid coverage through the ACA expansion, lost coverage when the state had a work requirement in 2018 and 2019. A court ended the state’s work requirement program.

Critics point out that or have a disability or caregiving responsibilities, and they argue the reporting requirements merely serve as a bureaucratic hurdle to obtaining and keeping coverage. Under the GOP law, enrollees’ work status needs to be verified at least twice a year.

Most of the coverage losses due to work requirements occur among people who work or should qualify for an exemption but nevertheless lose coverage due to red tape, .

Not every state must implement a work requirement under Trump’s law, only those that chose to expand Medicaid coverage to more low-income people through the ACA or a federal waiver. The ACA has provided hundreds of billions in federal dollars to help states cover everyone making up to 138% of the federal poverty level — $21,597 for an individual in 2025.

Forty states and Washington, D.C., took up the expansion. Georgia and Wisconsin partly expanded their Medicaid eligibility by getting a federal waiver, adding them to the list of states subject to the work requirement. These two states were not included in the KFF analysis because of a lack of county-level enrollment data.

Jennifer Wagner, director of Medicaid eligibility and enrollment at the left-leaning Center on Budget and Policy Priorities, said she is pleased the law makes some exceptions for places where jobs are scarce. It could limit how many people lose coverage because of the work requirement, she said.

Wagner said SNAP’s unemployment rate exemption has helped millions of people avoid losing their food assistance, but its impact also depends on whether a state seeks the waiver.

She is concerned the Trump administration may make it difficult for counties to get exempted under the Medicaid law.

“I’m glad it’s in there as it will certainly help people, but it’s still a terrible bill,” she said. “This will not really blunt the harm of the bill.”

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