It’s a heightened concern for the estimated who are U.S. citizens or legal permanent residents, as new work requirements kick in for the federal-state healthcare program that serves low-income and disabled Americans.

Starting next year in most states, many adults enrolled in Medicaid will have to prove they work, are enrolled in college or vocational courses, volunteer, or do unpaid work for at least .

Advocates say this could pose a significant challenge to Medicaid-eligible farmworkers, who frequently work more than 80 hours a month during harvest season but less in other months. What’s more, outside the harvest season, many workers take on informal jobs in construction, landscaping, or home repair for which they don’t receive formal paychecks that would prove their continuing Medicaid eligibility. Still, they can establish eligibility if they prove their average monthly income over six months is equivalent to at least 80 hours of work at the federal minimum wage.

“Having a work requirement — having to create more paperwork and more proof — is certainly extremely challenging for farmworkers and others who are low-income and who may especially have seasonal jobs, not year-round, and do have periods” when there is no work available, said Alexis Guild, vice president of strategy and programs at .

New Requirements, Additional Hurdles

Agriculture is a , and Americans to put food on their tables. Nearly 60% of those workers are U.S. citizens or green-card holders, according to the . The remaining 40% lack legal status or are otherwise ineligible for Medicaid.

Even among farmworkers with citizenship or legal status, the uninsured rate is three times that of the general population, and most farmworkers with insurance are Medicaid beneficiaries, although participation rates vary by state. According to a , 71%-79% of eligible farmworker households report participation in Medicaid.

The new Medicaid work requirements were a key provision of the One Big Beautiful Bill Act signed last July by President Donald Trump. Under the federal law, and the District of Columbia must implement the requirements by Jan. 1. A few states have the work rule early.

The 80-hour rule applies in states that expanded Medicaid, a process that began in 2014 and was tied to the Affordable Care Act. Following the initial expansions, agricultural workers with legal documentation became to have health insurance, according to a 2021 article in the American Journal of Agricultural Economics.

Immigration Anxieties

The work requirements are the latest in a long list of obstacles placed between workers and the healthcare they’re legally entitled to, Guild said. “Medicaid certainly helps because it alleviates the cost issue,” she said. “But there are still other barriers, such as transportation, taking sick leave, and finding time to visit a health center. All these factors can prevent them from actually receiving medical care.”

For farmworkers with green cards and naturalized U.S. citizens, there is another source of stress: the fear that signing up for Medicaid could put personal information in the hands of immigration authorities.

That’s what worries Luis, a 45-year-old green-card holder and Medicaid recipient who dreams of becoming a U.S. citizen. Luis — who asked to be identified by only his middle name — lives with his wife and daughter in North Carolina, where he has worked in agriculture for nearly a decade.

Speaking in Spanish, he said that when he learned about the work requirements, he knew it would be challenging for him to prove that he works 80 hours a month. “I only work on farms for six or seven months; the rest of the year I work in whatever I can find,” he said.

Republicans in Congress argue that work requirements will reduce federal healthcare spending, encourage nondisabled adults to , and preserve safety net resources for the most vulnerable populations.

Among Hispanic adults enrolled in Medicaid, 67% are already working, according to a 2025 .

The Centers for Medicare & Medicaid Services did not respond to requests for comment for this article. But in June, when its “nationwide framework” to implement the Medicaid work requirements, Administrator Mehmet Oz said it would help beneficiaries “build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families.” Federal officials say the new requirements “could reduce poverty by as much as 2.9 million people.”

Chronic Illness

Agricultural work is one of the nation’s , and it is associated with and , including respiratory conditions. A found that 37% of male farmworkers and 47% of female farmworkers in the state had at least one chronic health condition. The new work requirements present one more barrier for those seeking care, advocates said.

“People skip checkups and screenings, and conditions that could be caught early and treated cost-effectively” aren’t, said Adriana Cadena, executive director of .

Emergency rooms often become the “natural” place to go for healthcare, Cadena added. “This drives up waiting times and costs for all of us. … And when people are sick enough that they miss work, it starts a vicious cycle of lost productivity and family economic instability that again threatens all of us.”

A Loss for Families and Children

The new federal rules also require beneficiaries to verify their eligibility at least twice a year, twice as often as previously, creating another potential obstacle.

“Letters can easily be missed, and forms may go unfilled. If people get caught up in the paperwork, they could lose coverage,” said , an assistant vice president at , a nonprofit that promotes an equitable healthcare system.

For farmworkers who travel from state to state, the process can be especially difficult.

“You have to find the time to transfer your coverage and probably find a person or organization that can help you — and that can be really hard when you’re constantly moving,” Cadena said.

The situation highlights the difficulties of navigating a complex system for individuals and families already struggling to make ends meet.

“The result,” Cadena said, “could be the loss of coverage not only for workers, but also for their families and children.”

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“He was on a nasty, dirty ground in front of a store,” recalled Sonja Smith, who is enraged about the circumstances that led to her husband’s heart failure. “He didn’t deserve to die like that.”

Problems started last year when the couple learned the monthly premium payment for their Federal Employees Health Benefits plan would more than double to $307 and their deductible would also go up. They decided to switch Blackman’s primary coverage to CHAMPVA, a health benefits program for dependents of disabled veterans, which had no premium and a $3,000 deductible.

Smith thought she and Blackman had carefully prepared so that the transition between health plans would be seamless. It was anything but.

After the new health plan became active in January, Smith said, Blackman faced one hurdle after another getting approval for the antirejection medications needed to prevent his body from attacking his transplanted heart. Patients who rely on these drugs can develop severe and life-threatening heart issues if they miss even a few days. She said Blackman had enough medication to last only about a month into the new plan year. He told her just before his death that he had run out.

“I screamed at CHAMPVA. I screamed at the Trump administration. I screamed at the overall healthcare system in this godforsaken country,” she said. “Everybody played a part in what happened to my husband.”

The Department of Veterans Affairs declined to comment on the record about Blackman’s case.

While the couple’s situation was extreme, their challenge of trying to continue a treatment is faced by many who shop for cheaper options as health insurance costs have soared across the country. The United States already has a fragmented health system, in which insurers, clinicians, and drugmakers are largely left on their own to hash out the cost of each medication or service. That lack of standardization leads to layers of bureaucracy for patients; moving to a new plan can ensnare patients in a thicket of red tape, keeping them from care.

Making matters more challenging, Congress didn’t renew covid pandemic-era subsidies that helped lower premiums for Affordable Care Act marketplace plans before this year. The Trump administration is also adding hurdles for people to access Medicaid, a state-federal health insurance program for Americans with low incomes or disabilities, so more people may lose their current coverage.

“We’ve basically set up a series of cracks in our healthcare system that we ask people to jump over,” said , an assistant professor of health policy at the Harvard T.H. Chan School of Public Health. “But if you don’t jump over those cracks, you can lose coverage, or lose access to your doctor, or lose access to your medications.”

‘This Is a Lot’

Insurers calibrate plan prices by negotiating rates with individual clinicians, hospital systems, and drugmakers, leading to varying levels of coverage. Plans with lower monthly costs of doctors and hospitals, and less generous drug coverage.

As a result, when patients choose an insurer — or even a new plan with the same insurer — they may lose access to medications or doctors that they have had for years, said , a research professor in health policy at Georgetown University. There are so many ways “patients could get tripped up,” she said. “When you switch to a new insurance company, they’re going to apply their rules.”

In announced by the Trump administration last year, many insurers voluntarily agreed to reduce some red tape by honoring existing prior authorizations for 90 days when a patient switches health plans. As required by law, they also offer resources such as plain-language plan descriptions and searchable online clinician directories to help patients coordinate care, according to , the main health insurance industry trade group.

“The goal is to ensure every member understands their benefits and can access the care they need without interruption,” said Conner Coles, an AHIP spokesperson.

But patients say understanding their benefits can still be a challenge.

Monique Acosta, 54, had to navigate two health insurance changes after she was laid off from her job at a disability nonprofit in October. The heart transplant recipient and cancer survivor said she paid nearly $900 a month to continue her employer coverage under COBRA, the Consolidated Omnibus Budget Reconciliation Act. Then, in January, the Woodbridge, Virginia, resident switched to Medicaid.

During the transitions, Acosta said, she lost coverage for a postchemotherapy drug. So, she changed her care team to qualify for lower-cost medications through a local hospital’s charity program. Then one of her new doctors reduced the frequency of an injection she had gotten for years. During that time, she said, her red and white blood cell counts plummeted and she struggled to recover from a heart catheterization procedure.

Eventually, her new physician upped the frequency of her injections back to twice a month. “He needed to document it so he could see it himself,” Acosta said. “I was very, very fatigued, very weak, and it’s unnecessarily so.”

Acosta said she is putting off a mammogram until she can better understand her Medicaid plan or find a job with better benefits. “This is overwhelming,” she said. “This is a lot.”

Burden on the Patient

Federal regulations, 43 states, and Washington, D.C., have that require health plans to continue covering doctors and drugs when there is a network change, like when a clinician or hospital that a patient goes to is terminated from the insurer’s network of providers.

But Corlette said that not all the protections address the trip wires people face when they switch insurers on their own, such as during open enrollment or after a major life change.

Still, people can be proactive in a few ways about maintaining care when they change plans, said Shelli Quenga, an insurance agent in South Carolina.

She advises patients to keep written records of their medical and drug history for new providers. Quenga tells her customers to get their new insurance information to their doctors as soon as they switch, not to wait until an appointment. In addition, she said patients can request a case manager with their insurer so they don’t have to repeat their concerns to different staffers.

Even when a patient does homework, doctors can drop out of a network and insurers can change the contours of their plans, McIntyre said.

“Nobody has an incentive to make it make sense,” she said. “This puts a lot of burden on the patient.”

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Each year, Amgen, which makes the drug, called , sent the coupon card worth thousands of dollars, and that counted toward Gruber’s health insurance deductible and out-of-pocket maximum.

Using the card, Gruber usually met that maximum by February, leaving his health insurance to fully cover his in-network medical costs and reducing his cost for the drug to $0 for the rest of the year.

But this year, his new health insurer, , pocketed the coupon card and required Gruber to pay for the drug until he satisfied the cost-sharing requirements on his own.

If Oscar Health had applied Amgen’s coupon toward Gruber’s cost sharing, he would have been on the hook for about $3,000 in covered services. Without it, he had to use his savings to meet the plan’s $10,600 out-of-pocket maximum.

“The real insult here is that they’re taking the money that’s intended to help you,” said Gruber, who had planned to buy a home next year with his savings. “I feel desperate, pressed against the wall, and squeezed.”

Oscar Health is one of many commercial health insurers that use what are often called copay accumulator programs to keep funds that are meant to defray patients’ out-of-pocket costs for expensive specialty drugs. Over the past decade, more insurers have to reduce their prescription drug costs, according to Avalere Health, a consulting company.

Patients who rely on copay assistance from drugmakers are typically heavy users of healthcare for whom delays in treatment or worsening conditions can lead to higher costs, according to patient advocates.

, Florida market president for Oscar Health, did not comment on the specifics of Gruber’s case. He said the company uses copay accumulators to manage rising medical and prescription costs and “to keep monthly premiums as low as possible.”

Drugmakers argue that insurers and pharmacy benefit managers use copay accumulators and other strategies to delay or deny care and steer patients toward medicines that insurers prefer instead. Insurers counter that coupon cards and other patient financial assistance from drug manufacturers drive up premiums and encourage patients to use higher-priced, brand-name drugs instead of less-expensive generics.

Meanwhile, patient advocates say it’s difficult for consumers to find out if their plan uses a copay accumulator or to understand how they work. Not only do the programs make medications unaffordable for consumers, critics argue, but they allow insurers to double-dip.

“They’re collecting the money twice and they’re hurting patients,” said , executive director of the HIV+Hepatitis Policy Institute, a patient advocacy group.

“Why does it make a difference to Oscar if they get the money from a drug company or, you know, his mother or him?” he said of Gruber’s experience. “They’re still getting the money.”

Controlling Costs or Harming Patients?

Not all insurance types use copay accumulators. Medicare and Medicaid prohibit copay assistance because federal anti-kickback laws forbid drug manufacturers from offering financial incentives to influence patients’ choices. And the Internal Revenue Service prohibits such help for high-deductible plans with health savings accounts. But individual and commercial group plans can use them.

Regulation of copay accumulator programs has fallen largely to states, which oversee individual and small-group plans sold on the Affordable Care Act marketplace.

For 2026, of ACA marketplace plans have such a program, according to a review from The AIDS Institute, a nonprofit group that opposes the programs. Of the 16 insurers that sell plans on the marketplace in Florida, 10 use copay accumulator programs, the review found.

Patients who take brand-name specialty drugs for conditions such as autoimmune disorders, multiple sclerosis, diabetes, HIV, and cancer are most likely to encounter these programs. Health insurers say that making patients share the costs for specialty drugs encourages them to choose value over brand.

But Gruber doesn’t have a choice because there is no medically equivalent generic for Enbrel. Gruber’s livelihood as a trainer depends on his athleticism. The weekly injections, which he has to take for the rest of his life, prevent his joints from getting stiff. When he was diagnosed in 2010, Gruber said, he couldn’t shake hands or lift his knee to get into bed. Without treatment, he said, “I ache from my neck down to my toes.”

If manufacturers priced their drugs affordably, patients like Gruber wouldn’t need financial assistance, said , a senior vice president for AHIP, a trade association representing insurers.

“Drugmakers offer short-term ‘discounts’ to justify overcharging Americans in the long term, driving up healthcare costs for everyone,” he said in a statement. “Research shows limiting copay coupons can reduce premiums and lower consumers’ out-of-pocket costs.”

Sarah Ryan, a spokesperson for Pharmaceutical Research and Manufacturers of America, a trade association for the pharmaceutical industry, said copay assistance helps patients access medications free of charge or at reduced cost.

“Health insurance is supposed to protect patients,” Ryan said, adding that insurers and pharmacy benefit managers that refuse to count copay assistance toward cost sharing are “leaving patients facing unexpected costs and disrupting their care.”

Insurance companies already have tools to control costs without keeping financial assistance intended for patients, said , deputy executive director for The AIDS Institute.

Insurers choose what drugs to cover, whether they are medically necessary, and if a patient must try a cheaper alternative first.

“They are the ones making the decisions,” Klein said. “Now the individual is left trying to figure out how they’re going to pay for it.”

Consumers Stuck in the Middle

Before moving to Florida in 2024, Gruber said, he had bought coverage on the ACA marketplaces in Illinois and Louisiana, which prohibit copay accumulators. Gruber said he hadn’t encountered one until his experience with Oscar Health.

He complained to the office of Florida’s insurance consumer advocate, which informed him that the practice is legal in the state and that Oscar Health had disclosed its use of a copay accumulator program. Page 127 of his 168-page evidence of coverage states, “Third party assistance will not count towards your out-of-pocket maximum or deductible.”

Gruber said he selected his coverage using a tool on that listed all the Florida ACA plans that cover Enbrel. “I always choose the one with the highest deductible to get the lowest premium,” he said, “because I know I’m going to meet it.” His monthly premium is about $315 after subsidies.

Adding to Gruber’s confusion, he said, was that his patient portal with Oscar Health was counting his coupon card at first. He said he met his out-of-pocket maximum in February, and in March Oscar covered all the cost for the medication.

But when he ordered his refill for April, the pharmacy told him that Oscar would cover only $1,000 of the medication’s cost for that month. He would have to pay the remaining $6,700.

Gruber then received a letter from Oscar Health, telling him that an incorrect amount had been applied to his deductible.

“They sent me a letter that basically stated they made a mistake,” he said. “The fact that they’re allowed to sort of change things midstream is also, I think, a little galling.”

He began rationing the injections, taking them every other week instead of weekly. By May, he had dipped into his savings to pay for the drug.

States Step Up While Federal Oversight Stalls

The first state laws banning copay accumulators were adopted in 2019, and since then more states have moved to regulate the programs, said , public policy director for the Alliance for Patient Access, an advocacy group.

“The goal is to build upon that progress at the federal level and to continue to drive this momentum forward,” he said.

Twenty-six states, Washington, D.C., and Puerto Rico have adopted laws banning copay accumulators or prohibiting them for drugs that do not have a generic equivalent. Colorado also prohibits copay accumulators for drugs without a biosimilar. In states that have not banned or restricted the programs, insurance companies decide whether to use them.

But federal regulation of the programs, which would apply to all states, remains at a standstill.

A federal court in 2023 struck down a policy enacted during President Donald Trump’s first term that had permitted insurers to use copay accumulator programs. As a result, the Department of Health and Human Services reverted to that restricts their use to brand-name drugs with a medically appropriate generic equivalent.

After the court ruling, the Biden administration pledged to address copay accumulators in future rulemaking. But HHS has yet to do so, said Schmid, whose group, the HIV+Hepatitis Policy Institute, led a coalition of patient advocacy groups that sued to overturn the rule.

“The Trump administration can stop this once and for all at the national level,” Schmid said. “If they really care about patient affordability, this is something they can do.”

Bipartisan legislation in Congress called the would require financial assistance to count toward deductibles and other out-of-pocket costs on plans regulated by the federal government, including much employer-sponsored coverage.

Schmid said the bill has not gotten “enough traction on the Hill yet.”

Other ways to obtain medication don’t help patients facing copay accumulators either. The president’s , an online platform through which consumers can buy prescription drugs at a discount, requires patients to pay out-of-pocket, and the cost does not count toward their plan’s cost-sharing requirements.

Christopher Krepich, a Centers for Medicare & Medicaid Services spokesperson, said that HHS, along with the departments of Labor and the Treasury, intend to address the issue of whether copay assistance must apply toward health plan cost sharing.

Until then, he wrote, “the Departments do not intend to take any enforcement action against health insurance issuers or group health plans based on their treatment of such manufacturer assistance.”

Outside of government regulation, consumers have few protections or alternatives.

Patients who rely on expensive medications — and who have a choice in their health insurance plan — should research their coverage options and choose wisely so they’re not caught by surprise, Clingham said.

That may mean reading plan benefit explanation packages, contacting their state’s insurance regulator, or calling an insurance company to ask if their plans use copay accumulator programs.

For Gruber, the extra expense means he won’t take a vacation this year. He’s also concerned that the money he was saving for a home will now go to his medication costs instead.

“It’s the first thing I think of when I wake up in the morning,” he said. “If this happens every year, it would be financially devastating.”

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

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So he didn’t know he had a bill to pay. After he and Tix returned home to Minnesota in April, they got a letter from Wellcare, the insurer that provided his drug plan, saying his coverage had been terminated after three months of unpaid premiums totaling $28.80. Under Medicare’s rules, he can’t enroll in a plan again until the fall, for coverage beginning in 2027.

Pare takes Xarelto, a blood thinner that reduces his risk of strokes, blood clots, and pulmonary embolism. “He could bleed to death without it,” Tix said. A 90-day supply of the drug costs about $1,800 using a coupon from GoodRx, a discount drug website, she said.

Pare is among tens of thousands of Medicare beneficiaries who were on Wellcare’s Value Script drug plan who will likely go without prescription drug coverage for the rest of the year because they didn’t pay premiums for three months.

Next year, thousands more people in 32 states and Washington, D.C., who are enrolled in zero-premium drug plans from Wellcare and other insurance companies may find themselves in the same situation if their premiums go up and they don’t realize it, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of drug plan data. Premiums and other changes for 2027 will be unveiled in September.

Going without medication can be life-threatening, especially for Medicare beneficiaries. take one or more prescription drugs, according to the Centers for Disease Control and Prevention. Almost half live with four or more chronic health conditions that can cause functional or cognitive impairments.

Congress added prescription drug coverage to Medicare in 2003. But the coverage is administered by commercial insurance companies, which compete fiercely with one another for the business of about enrolled in drug plans.

Zero-dollar or very low monthly premiums have helped make Wellcare’s Value Script the bestselling stand-alone prescription drug plan in Medicare, with nearly 6 million customers across the U.S., according to government data. But in 26 states and Washington, D.C., some Value Script members who didn’t have to pay a premium last year were caught off guard by increases in 2026.

After a two-month grace period — which Wellcare extended to three — Medicare drug plans can drop customers who don’t pay their premiums, no matter how small the amount. Some members who lost their coverage in Nevada, for example, owed as little as $8.10 for three months, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of Medicare drug plan data.

Wellcare terminated coverage for about 140,000 Value Script beneficiaries in April, according to a person with knowledge of the matter who was not authorized to speak publicly about it and feared reprisals at work for doing so. About 40,000 of the people who were dropped may be able to enroll in new coverage immediately because they have low incomes and receive financial assistance through a program Medicare calls “.”

Multiple state officials said they had heard the same disenrollment figures, including Nevada’s insurance commissioner, Ned Gaines, who chairs the National Association of Insurance Commissioners’ senior issues task force; Rebecca Gouty, director of the State Health Insurance Assistance Program in West Virginia; and Tim Smolen, director of Washington state’s Statewide Health Insurance Benefits Advisors. The West Virginia and Washington initiatives are part of the federally funded , or SHIP, which provides free, unbiased help navigating Medicare.

Surprise Bills

The Centers for Medicare & Medicaid Services, which oversees Medicare drug plans, declined to provide the number of Value Script members who lost coverage due to unpaid premiums. “The agency does not publicly provide plan-specific disenrollment figures or state-level breakdowns related to the non-payment of premiums,” Christopher Krepich, a spokesperson, said in a written statement to Ñî¹óåú´«Ã½Ò•îl Health News.

Centene Corp., Wellcare’s parent company, also declined to provide disenrollment numbers.

“We recognize how disruptive a loss of coverage can be and are committed to helping members understand their options,” said Sarah Baiocchi, senior vice president for specialty and prescription drug plans at Centene. She acknowledged that “some members in our Value Script plan experienced a premium for the first time, or for the first time in several years.”

Baiocchi said all Value Script members received a CMS-required annual notice of changes in September, before the premium increases took effect.

A sent to members in two states and Washington, D.C., is 21 pages long. The new premium is mentioned on pages 3 and 8, along with changes to out-of-pocket costs and how to find updates on covered drugs and network pharmacies.

The company also informed members about 2026 premium changes through phone calls, text messages, regular mail, or email, Baiocchi said.

People who are dropped are not able to reenroll or join another drug plan until the start of the open enrollment period this fall for coverage beginning Jan. 1, unless they qualify for an exception, Krepich said. And because they will have gone without coverage for at least 63 days, they could be hit with a permanent that increases every year for the rest of their lives.

“Medicare should be doing something about this so that we can go ahead and get coverage now,” said Wayne Bennett, 74, who lives in Durham, North Carolina.

In May, he found out that Wellcare had canceled his Value Script plan because he hadn’t paid his $3.60 monthly premiums. He takes nine prescription drugs to treat his blood pressure, glaucoma, chronic obstructive pulmonary disease, and other health problems. He filled most of his prescriptions — including several at no cost — before he lost coverage. He doesn’t know what he’ll have to pay when his supply runs out.

Gouty, the West Virginia program head, said many Medicare beneficiaries arrange for their monthly drug plan premium to be automatically deducted from their Social Security benefits, and that many likely thought that choice remained in place until they changed it.

“They didn’t realize that when the plan was a zero premium in 2025, that stopped the Social Security premium deduction and they would have had to reelect it for 2026,” Gouty said.

In other words, even if they mistakenly thought the premium was still zero, Medicare beneficiaries would have needed to somehow allow Social Security to make deductions — something the agency doesn’t do — or set up a payment plan through their bank or credit card in case payment was necessary.

“That sounds goofy,” Tix said.

Centene’s Baiocchi blamed the Social Security Administration for the problem: “We believe this was a key driver of non-payment disenrollments and subsequent complaints.”

Spokespeople for the agency referred questions about the matter to CMS.

Krepich said legal requirements for drug plan enrollment and disenrollment limit what CMS can do to help beneficiaries who lose coverage for not paying their premiums.

‘Pretty Upset’

Now that Pare has no prescription drug coverage, his doctor replaced his blood thinner medication with a much less expensive drug that should be just as effective. Pare paid $111 for four other medications that used to be free under his Value Script plan. He hasn’t had to refill four more prescriptions yet and doesn’t know what they will cost, Tix said.

If Wellcare members knew about the premium increases, they could have set up direct billing or an automatic payment plan early this year before the payment grace period ended April 1. But they would have been able to fill prescriptions during the grace period, so if they didn’t see Wellcare’s notices, they likely assumed there was no problem with their coverage.

Bennett, the North Carolina man, said Wellcare used to send him text messages with health tips and reminders when it was time to pick up a prescription. He didn’t know his premium had increased from $0 to $3.60 until it was too late.

“I was pretty upset,” he said, when he called the company. “The premium wasn’t that much, and I was ready to pay it right off the bat. I had my credit card out ready to make the payment.”

The customer service representative wouldn’t let him pay because his coverage had been canceled, Bennett said.

Hoping to restore it, Bennett called , a Durham nonprofit that advises Medicare beneficiaries and is one of more than 2,200 SHIP sites across the country. He was told he must wait until January to restart his drug coverage, said the group’s executive director, Gina Upchurch.

He doesn’t qualify for the “Extra Help” low-income subsidy or meet other CMS criteria for a , which would allow him to change drug plans during the year. CMS typically allows midyear switches for beneficiaries who, for example, move out of their plan’s service area, experience a natural disaster, or get help paying for drugs from a .

Senior PharmAssist was able to help one of its participants join another drug plan after she lost Value Script coverage because she is in North Carolina’s pharmacy assistance program for people with HIV/AIDS and has limited income, Upchurch said.

A further exception allows any Medicare beneficiary to enroll at any time in a drug plan that has earned five stars, the top grade in Medicare’s performance ratings. However, there are no five-star Medicare drug plans available to the general public. Only two insurers offer five-star plans, and only for retirees from certain employers. Their combined enrollment is about 8,700 as of June 1, according to the insurers.

But Upchurch, with more than two decades of Medicare expertise, doesn’t blame beneficiaries for not paying attention or for assuming Wellcare’s messages were bogus. Older adults are particularly vulnerable to identity theft and other scams and are often advised to ignore junk mail and calls from telemarketers.

Since Value Script members such as Bennett continued to get their prescriptions filled during the payment grace period, “why wouldn’t they think this was a scam?” Upchurch asked. “They are constantly bombarded by people selling them something that’s illegitimate or trying to scam them.”

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We’re expecting our first baby boy in end of August. And when I think about what it’s going to feel like to take care of my wife and my new son and my mom, it’s a bit overwhelming.

If you are taking care of a child and you have a parent over 65, you’re among millions across the U.S. in the same life stage.

Nearly a quarter of all American adults — and half of all adults in their 40s — fall into this “sandwich generation” category, . And being in the middle of that sandwich can feel … intense.

“I have kind of prided myself on being self-sufficient. And in this season of life, that’s almost been laughable,” said Jason McAnally, a Nashville father of two who helps care for his aging dad.

HealthQ hosts Cara Anthony of Ñî¹óåú´«Ã½Ò•îl Health News and Blake Farmer of Nashville Public Radio, both in the sandwich generation themselves, are your approachable guides to an unapproachable healthcare system. In this one-hour special about navigating health and caregiving, they tap researchers, physicians, experts, and their own personal experience to explore:

• Identity: When to start calling yourself a caregiver, and why it matters.
• FMLA: How to start a conversation with your boss about taking federally protected leave from work.
• Kids and mental health: How to know it’s time to take an anxious child to therapy.
• Early-onset cancer: What you need to know about spotting diseases that are on the rise among people under 50.

The HealthQ team acknowledges the messiness, the humor, and the beauty of this season of life. Come on the journey with us.

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This installment is part of HealthQ’s reporting on caregiving among the sandwich generation. For more, check out the series archive.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable healthcare system. It’s a collaboration between Nashville Public Radio and Ñî¹óåú´«Ã½Ò•îl Health News.

This <a target="_blank" href="/aging/healthq-special-sandwich-generation-caregiving-fmla-early-onset-cancer/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Researchers this spring discovered in water in several coastal locations across New York’s Long Island, and town officials in the Hamptons vacation destination about the findings. in Florida have been infected this year, and in June urged people to take precautions.

About 1 in 5 people infected by the bacteria die, sometimes within a day or two of becoming ill, according to a Centers for Disease Control and Prevention . The bacteria, Vibrio vulnificus, can enter open wounds and cause tissue death and systemic sepsis.

“Many people with Vibrio vulnificus infection can get seriously ill and need intensive care or limb amputation,” the CDC says.

The risk of such public threats is mounting because climate change is expanding the territory of certain pathogens, but researchers say there’s another concern. The Trump administration has cut investments in programs and agencies that prevent, track, and respond to health hazards the federal government is now confronting.

Consider the , which can infest and kill livestock, in the U.S. in June. The U.S. Department of Agriculture lost in the first six months of 2025, according to a report from the USDA’s Office of Inspector General, and the agency’s winnowed-down inspection service is helping lead the response to the parasite.

Or malaria. A freeze on foreign aid disrupted international malaria prevention efforts, and warned that the U.S. is vulnerable to the reintroduction of the infectious disease.

And when it comes to Vibrio, the Trump administration began removing hundreds of deep-sea instruments that and yield data that helps that can allow the bacteria to flourish. the data to study Vibrio, which can when water temperatures and .

“It is important to track coastal temperatures, and that will relate to the distributions of Vibrio,” said Christopher Gobler, a professor in the School of Marine and Atmospheric Sciences at New York’s Stony Brook University, though he added that there are also other sources of data for researchers.

The Trump administration to dismantle the ocean monitoring system following bipartisan opposition to the effort in Congress.

But it’s still curtailing Vibrio surveillance. The life-threatening species that’s found in water can also sicken or kill people who eat contaminated seafood, such as infected with the bacteria. And infections from Vibrio vulnificus linked to consuming raw or undercooked shellfish as the presence of other pathogens in food decrease.

Since 1995, 10 states have participated in a federal program called the Foodborne Disease Active Disease Surveillance Network, or FoodNet. The program, with the CDC, monitors and track cases of foodborne illness caused by eight specific pathogens, including Vibrio. But last year the Trump administration to report on all but two pathogens, which means states no longer must report cases to the CDC.

Federal officials deny the moves are putting Americans at risk, saying the CDC continues to monitor these pathogens through other national surveillance systems to ensure ongoing visibility into disease trends and outbreaks.

Meanwhile, some former health leaders say the ramifications of sweeping cuts to health agencies and global prevention programs are becoming more apparent, undermining U.S. response efforts and initiatives that aim to safeguard the country from diseases.

“We are letting down defenses that were necessary to protect against microbial threats,” said Tom Frieden, a former CDC director who is now president and chief executive of Resolve to Save Lives, which works to stop preventable disease. “Instead of protecting, we’re doing the opposite.”

Do Limited Resources Mean Higher Risks?

The administration defends its actions, including massive layoffs at government health agencies, as necessary to eliminate wasteful spending.

The Department of Health and Human Services “is advancing the most significant public health reforms in a generation focused on prevention, accountability, scientific transparency, and better health outcomes,” agency spokesperson Emily Hilliard said in an email. “The Department is putting American families at the center of public health decision-making.”

Evidence suggests health risks are rising even as the Trump administration pulls back on resources for research, detection, and response.

Early in his administration, President Donald Trump opted to freeze and review work on global health programs. Trump’s cost-reduction effort, led by billionaire Elon Musk, also dismantled the U.S. Agency for International Development.

As a result, work was disrupted on the President’s Malaria Initiative, a George W. Bush-era program aimed at combating malaria in hard-hit countries that is credited with saving more than . USAID had in the program since 2005.

In addition, for global malaria programs were targeted for termination, , an independent research group that includes Ñî¹óåú´«Ã½Ò•îl Health News. The report didn’t include data on the total value of those specific malaria grants.

And the spending freeze halted research for more effective . The administration dissolved the CDC’s , shuffling staffers to other divisions and on the disease. HHS didn’t respond to an email asking how many staff members had been moved.

The life-threatening infectious disease spread by mosquitos was in 1951. But the CDC’s updated guidance on investigating domestic cases that “the country remains susceptible to malaria reintroduction.”

resulted in 10 people in Arkansas, Florida, Maryland, and Texas becoming infected locally, and mosquitoes capable of transmitting malaria are found throughout most of the country.

“The majority of U.S. residents lack protective immunity against malaria, rendering persons susceptible to severe illness and death if infected,” the CDC said in the May report.

HHS declined to comment on any of the specific cuts but said the CDC works with domestic and international partners to reduce the burden of malaria and prevent its reestablishment in the U.S.

It’s not just cuts to funding that are raising health risks, say researchers and former health officials. Significant staffing cuts mean there are fewer people working on preventing or tracking diseases, they say.

“Yes, the programs have been cut in terms of reduction in staff, but I would say, equally important, you have reductions in expertise,” said Jeanne Marrazzo, CEO of the Infectious Diseases Society of America. “It’s irreplaceable.”

Screwworm is a species of parasitic blowfly producing larvae that can enter open wounds and devour tissue, infecting people and animals. Like malaria, it has long been eliminated in the U.S., and disease monitoring efforts have been key to keeping it out.

The cuts at USAID stripped from the United Nations’ , which focuses on global food security and the such as screwworm.

In the wake of the administration’s cost-cutting initiatives, more than 20,000 employees are gone from the USDA, which develops and implements agriculture policy and provides resources to producers of livestock vulnerable to the parasite.

On June 3, the first new case of screwworm in the U.S. was confirmed, and there have now been infected with parasite. An expanding outbreak could devastate the cattle industry.

Agriculture Secretary Brooke Rollins during the Trump administration have led to screwworm’s return. Instead, she has , saying it didn’t do enough to prevent reintroduction into the U.S. Rollins said on X that “” under the previous Biden administration was partly to blame, providing no evidence.

The USDA did not respond to an email seeking comment.

Ashish Jha, a doctor who served as the White House covid response coordinator during the Biden administration, said there’s no truth to the claim that immigrants lacking legal status have brought screwworm into the U.S.

Investments in tracking and combating diseases have suffered, he said, because HHS Secretary Robert F. Kennedy Jr. is prioritizing the prevention of chronic disease at the expense of efforts to curtail infectious disease.

“Who doesn’t want a healthier country? It sounds great, but it’s kind of a bait and switch,” Jha said. “They’re doing the opposite. They’re letting down our defenses that are necessary to protect us against microbial threats.”

HHS’ Hilliard disagreed, saying Kennedy’s actions are making the agency more effective.

“Secretary Kennedy is delivering that reform by streamlining operations, reducing redundancies, and returning HHS to pre-pandemic staffing levels,” she said. “At the same time, he is dismantling policies and incentives that contributed to a nationwide chronic disease epidemic.”

Surveillance Gaps

Jha pointed to Trump’s decision to withdraw the U.S. from the World Health Organization, which coordinates global responses to public health issues and crises, and to the dismantling of USAID.

The pullback has had implications for the Ebola outbreak in the Democratic Republic of Congo, aid workers say.

Without the same amount of funding from USAID, the International Rescue Committee, which partners to deliver front-line health, surveillance, and outbreak preparedness activities in Congo, .

“Funding cuts have left the region dangerously exposed,” Heather Reoch Kerr, IRC’s country director for Congo, said .

The outbreak is roughly 7,000 miles away, but its spread has the , with stepped-up surveillance and entry restrictions on airline travelers. Federal officials have said that the dismantling of USAID hasn’t hampered detection or response.

“The U.S. government continues to move aggressively to contain the Ebola outbreak at its source in order to protect the American people and prevent further international spread,” the State Department said .

Trump’s decision to disengage with the WHO was criticized by following a hantavirus outbreak this spring on a cruise ship that had set sail from Argentina. the , and they questioned why the president suggested creating a costly new rather than sticking with the WHO — especially, they say, when the U.S. is cutting back on the surveillance programs it already has.

The federal government has tracked Vibrio cases as part of the FoodNet program, which aims in part to identify and curtail outbreaks. Reporting on cases of Vibrio is now optional.

Close to half of the cases of foodborne illness caused by Vibrio vulnificus have , and some within 24 hours after consumption of tainted shellfish such as raw oysters. The bacteria can multiply rapidly, leading to septic shock and blistering skin lesions. The pathogen is becoming to antibiotics.

The CDC estimates that of Vibrio infection occur annually, with infections from the most severe species, Vibrio vulnificus, steadily rising. , that species has led to 429 cases due to infections of open wounds and 135 cases from contaminated food.

“The more surveillance you get, you can connect the dots,” said Bill Marler, a Seattle-area food safety lawyer. “If a tree falls in the woods and you don’t hear it, did the tree fall? It’s easier not to report diseases. Then they can say, ‘Look at how safe our food supply is.’”

This <a target="_blank" href="/public-health/new-disease-threats-follow-trump-administrations-health-program-cuts/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

WINSTON-SALEM, N.C. — Some issues, like immigration or student loans, are too divisive to unite Trinity Moravian Church.

“We’ve got quite a spread of political beliefs,” said the Rev. John Jackman, who leads this 114-year-old red-brick church near Winston-Salem’s old textile mills. Conservative Republicans sit with liberal Democrats. Supporters of President Donald Trump mix with his fierce critics. “It’s definitely a purple congregation,” Jackman said.

But four years ago, when Jackman suggested a new church mission to alleviate medical debt for residents of the wider Winston-Salem area, there was no dissent. “This is the easiest money I’ve ever raised,” he said. “All I do is tell people what we’re doing, and they write me a check.”

Few issues have been more politically explosive in recent years than healthcare, pitting Democrats and Republicans in bitter debates over the Affordable Care Act, Medicaid, and other flash points.

Yet moved by the sense that the medical debts their neighbors faced were deeply unfair, members of Trinity Moravian, no matter their politics, rushed to write $25 or $50 checks to pay off the bills.

They helped advance a movement by churches across the state and the country and inspired North Carolina government officials to tackle medical debt. The effort drew plaudits from conservative radio host Glenn Beck.

The little church’s success also highlighted a patch of common ground in American healthcare — widespread anxiety and frustration that so many patients are ending up in debt.

Earlier this year, Trinity wrapped up its eighth medical debt campaign, part of what the church calls its Debt Jubilee Project. This one raised more than $17,000. That helped retire more than $2.2 million in debt. Medical debt can be bought for pennies on the dollar because creditors believe most debts won’t be paid.

Nationwide, an estimated 100 million adults have some form of healthcare debt. More than half of U.S. adults have had such debt at some point.

At Trinity Moravian Church, which has about 200 members, it wasn’t hard to find stories of crushing medical bills.

“I see people going into debt every minute of every day,” said Catherine Coe, who works in the accounting department of a hospital system. “We’re all just one medical bill from financial ruin.”

Coe grew up coming to Trinity with her grandmother. She drifted away from the church as an adult before rejoining the congregation last year. Coe, who describes herself as a conservative, voted for Trump.

Terri Mabe, who’s been coming to Trinity for decades, is on the other side of the nation’s political divide. She said she can’t stand the president, who she said “had no real concern for the people of this country.”

Mabe, 70, has also seen medical debt up close. She used to work in the construction industry.

“In between projects you are a lot of times without a job,” she said. “Then you get sick. Next thing you know, you owe $5,000, $10,000 that you cannot pay. You’re barely paying your home bills. Then you’re like: ‘I can’t pay it. What do I do now?’”

Both Coe and Mabe said partisan differences don’t matter. “There isn’t a political divide when it comes to medical debt,” Coe said. “It all brings us together.”

Jackman said he got the idea to do something about medical debt during the pandemic, when growing numbers of people turned to the church for help.

“I was hearing about the reason they couldn’t pay their electric bill was because they’d had a few days in the hospital and then they got hit with this huge bill and it snowballed,” he recalled. “And I started hearing this again and again and again.”

Jackman learned about a nonprofit called Undue Medical Debt that buys unpaid medical bills from hospitals and debt collectors so the debts can be retired.

The church’s first campaign, in 2022, set a goal of raising $5,000 to retire about $500,000 in medical debt owed by residents of surrounding Forsyth County. The campaign hit its goal in just six weeks, fueled mostly by donations of less than $50.

Jackman, who’s been a pastor for more than four decades, attributed part of the success to an ethos of the church. “One of our ideas is that we cannot fix everything, but we have to fix what we can in the place where we’re planted,” he said.

Trinity members, no matter their political leanings, also said they see something broken in a system that pushes sick people into debt.

Paul Sluder, 78, who doesn’t identify with a political party, used to work for a credit union. He said he did a lot of debt collecting before he retired.

Most people, he said, wanted to pay what they owed. If they got sick, they often had no choice but to go into debt.

“You have kind of no control. You have to take care of yourself or your loved ones,” Sluder said. “It’s incredibly unfair, and I think the system’s out of whack.”

Polls suggest there’s a lot of common ground around medical debt.

In a for Undue Medical Debt, more than 75% of Republicans and Democrats said collection agencies shouldn’t be allowed to garnish patients’ wages to pay medical debt. And in recent years, bipartisan measures to expand protections from medical debt have passed in blue and red states.

Coe, a Republican, said she would support even more limits on how much medical debt people could be forced to carry. “Why can’t we cap medical debt at a certain dollar amount, and after that it’s either written off or forgiven?” she asked.

After completing the most recent debt campaign, Trinity hosted a special ceremony, assisted by kids from a local Scouting group.

Jackman stood before the congregation and held up a piece of paper with a long list of names, people in the county whose debt had been bought and retired by the church.

“On this day of Jubilee,” Jackman announced, “we act to forgive the debts of many of our neighbors as God has forgiven our debts.”

As the congregation stood, Jackman flicked on a lighter and burned the list of 1,631 names. The paper was consumed by yellow flame. The scouts set off confetti poppers. The choir sang, and the congregation erupted in cheers.

Afterward, members went downstairs for a spaghetti lunch in the church basement, served by the scouts.

Reflecting on the day’s festivities, many members of the congregation said they hoped their work on medical debt could inspire others to bridge political differences and work together.

“There’s just so much division, so much anger,” said Cynthia Tesh, 72.

“We need to look out for one another,” she said. “If we start looking out for one another, things will change. If we start considering other people and not just ourselves, things will change.”

This <a target="_blank" href="/insurance/medical-debt-common-ground-church-north-carolina/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

But after surgery, Bates said, she couldn’t get out of bed or walk to the bathroom without help. She complained of intense pain radiating down her left leg, weakness in her knee, and a numbing sensation below it, according to hospital records. Bates, who worked as an Uber Eats driver, didn’t have the strength to drive a car.

Still, Bates said, the hospital told her it was time to go.

“They didn’t do any further X-rays or CTs or MRIs to figure out why my knee was numb,” she said. “And they were just like, you know, ‘It’ll go away.’”

Doctors said she was medically stable, Bates said, and because she had no health insurance, they could not send her to a rehabilitation hospital or a skilled nursing facility, which can charge thousands of dollars a day for such care.

“They were just like, We need the bed for somebody who has insurance,” she said. “That’s of course, you know, what they say without saying it.”

At least one firearm injury is treated in an American emergency room every . Tens of thousands die from their injuries every year. Many more, like Bates, are left to face long recoveries, steep medical debt, and enduring trauma.

How insurance affects the care of gunshot wound victims has remained shrouded in mystery — until now, due to a new analysis by The Trace and Ñî¹óåú´«Ã½Ò•îl Health News of data that Florida hospitals compile to collect payments from insurance companies and file with the state.

When uninsured patients arrive at hospitals in Florida with gunshot wounds, on average they spend significantly fewer days in the hospital — in some cases half the time — than those with health insurance, according to the data analysis.

Among the most severely injured patients, the uninsured stayed three fewer days in the hospital on average than their counterparts with insurance.

The data was obtained exclusively for this reporting on gun violence hospitalizations in the state, aided by Florida state law.

The newsrooms spent more than a year analyzing the records, which did not identify patients. The data contained patients’ insurance status, their residential ZIP code, their race, and other demographic info. Reporters reviewed academic studies and government documents and interviewed health policy experts, doctors, activists, and victims of gun violence or their relatives.

The results are a first-of-its-kind look at what happens to the insured and the uninsured who are shot and admitted to the hospital for treatment.

Across Florida, the analysis of hospital billing data from 2018 to 2024 obtained from the Florida Agency for Health Care Administration shows:

• Uninsured patients make up a quarter of the more than 20,000 gunshot wound hospitalizations identified, making them the largest single group treated for firearm injuries.
• Uninsured gunshot victims had hospital stays of about six days on average, only three-quarters of the time spent by patients with private insurance and less than half the average stay for patients on traditional Medicaid, the public health insurance program for poor and disabled people.
• The gap in hospital care persisted regardless of hospital size, location, or ownership type, including at facilities that receive taxpayer money with a mandate to treat all patients regardless of their ability to pay.
• Of the gunshot wound patients, nearly half were Black, making the group highly overrepresented. About a quarter of nonwhite patients were uninsured, versus fewer than a fifth of white patients.

The inequality echoes a in U.S. healthcare against Black and Latino patients, groups that and a .

The U.S. has deaths than other wealthy nations, and no group suffers more than Black Americans like Bates. Black people are far to become victims of a firearm homicide than white people, according to the Johns Hopkins Bloomberg School of Public Health.

Patient outreach workers say hospital personnel might perceive gunshot victims as gang members or troublemakers who deserve blame for getting shot. rehab centers refuse to admit gunshot victims more often than other patients, and some medical records from hospitals were littered with racist or insensitive descriptions of patients and their behavior.

The damage can be lasting: Patients who after a traumatic injury have a higher risk of serious complications, including infection, hemorrhage, nerve damage, and death, especially if wounds — and mental health concerns — are left untreated.

, a University of Florida professor and vice chair for research in community health and family medicine, said there’s evidence that financial incentives drive care — for patients and for hospitals.

Regardless of how often the care team is told to follow quality protocols, Mainous said, “ultimately there’s a business aspect to it, whether the physician is thinking about it or not, whether the nurses think about it or not. But somebody is.”

The Florida data findings come at a time when Republican Gov. Ron DeSantis and state lawmakers have pushed to make guns cheaper and more widely available, despite a in the state from 2014 to 2023, and when President Donald Trump’s administration has rolled back legislation from the Joe Biden presidency to curb gun violence and .

allows eligible residents to carry a concealed firearm and to openly carry a firearm without a state-issued license. State law also prevents cities and counties from enacting stricter gun control measures.

In early June, Florida Attorney General James Uthmeier to strike down the state’s three-day waiting period for receiving a purchased gun, arguing it is unconstitutional. Uthmeier’s request is part of a proposed settlement of a lawsuit brought by the National Rifle Association.

Ñî¹óåú´«Ã½Ò•îl Health News and The Trace requested to speak with administrators at nine of Florida’s large hospital systems to ask why the disparities exist. None agreed to an interview.

Sarah Cannon, communications director at Tallahassee Memorial HealthCare, would not agree to an interview or address Bates’ account of her care for gunshot injuries.

“Clinical decisions, including acute medical intervention, readiness for discharge, and post-acute care needs, are guided by the patient’s condition and response to treatment,” she said in an email.

Cannon said the hospital offers support to patients after discharge, including from social workers who coordinate care and access to services including post-acute care placement, home healthcare, and primary care or specialty follow-up.

Bates said she had to coordinate her own care after being released from the hospital. She said nobody called to schedule a follow-up test of her leg’s muscle function, and her medical records show she did not receive one.

“If I had had insurance,” she said, “they would have definitely kept me there for at least another week to work with me on my standing and walking.”

‘It’s a Business’

Some of Florida’s largest hospitals showed huge differences in length of stay for gun injuries, the Ñî¹óåú´«Ã½Ò•îl Health News-Trace analysis showed. In Miami at Jackson Memorial, the average number of days in the hospital for uninsured patients was 6.6; for those with private insurance, it was 10.7; and for those on traditional Medicaid, it was 15.4. Jackson Memorial did not respond to requests for comment.

Tampa General Hospital reported 4.9 days for uninsured patients, 8 days for those with private insurance, and 13.6 days for Medicaid patients. “To suggest that care decisions for trauma-related patients, and in this case, gun shot victims, are influenced by insurance status is not only absurd, it’s inaccurate,” Amanda Bevis, a hospital spokesperson, said in a written statement. “At Tampa General, every patient is treated equally, based on clinical need and urgency, not insurance coverage.”

And at UF Health Jacksonville, it was 7.2 days for the uninsured, 8.5 days for the privately insured, and 13.8 days for patients on traditional Medicaid. UF Health declined to comment.

Broward Health in Fort Lauderdale reported 7.5 days for uninsured patients, 10.5 days for privately insured patients, and 12.2 days for those on traditional Medicaid. “Insurance status does not impact treatment plans for patients,” Jennifer Smith, a Broward Health spokesperson, said in an email. “Our physicians always proceed in the best interest of the patient regardless of reimbursement or what length of stay may be required.”

Memorial Regional Hospital in Hollywood reported 6.7 days for uninsured patients, 8.8 days for privately insured patients, and 9.5 days for those on traditional Medicaid. Tania Ordaz, a hospital spokesperson, said in an email that she disagreed with the findings: “Treatment decisions are based on the patient’s clinical condition and what is necessary to ensure a safe and appropriate transition of care, not on the patient’s insurance status.”

Trauma surgeons and academics said the Florida data aligns with research nationwide on where gun violence occurs and who’s most affected. Some said they fear the differences contribute to long-standing disparities in America’s healthcare system along the lines of race and class.

The Florida hospital data showed gunshot injuries are concentrated in a handful of ZIP codes marked by poverty, disinvestment, redlining, and other injustices stemming from racial discrimination.

“Why would people without insurance be discharged earlier?” Mainous said. “Because they’re in better health? I think we’ve got a lot of data that would suggest that’s not true.”

Once they leave the hospital, people with commercial insurance or traditional Medicaid are more than twice as likely to receive follow-up care from another provider — such as a rehab center or home health service — as uninsured patients.

Those patients are staying longer, in part, because hospital case managers coordinate their transfers to other facilities, which can be time-consuming and take days.

“You have to go through insurance authorization and approval,” said , a trauma surgeon formerly at Jackson Memorial in Miami who now practices in Oregon. He said patients with private insurance might have access to rehab, preventive care, and training for both the patient and their caregiver to “help them transition to a completely new phase of life.”

For patients without insurance, he said, “sometimes our hands are a little bit tied.”

“The hospital is telling us that this patient has to leave the hospital because they’re medically ready,” he said, “and so I guess we’re discharging them to their car or to their tent, and it doesn’t feel right, but I think that would probably explain some of the differences” in length of stay.

, a trauma surgeon at Jackson Memorial, said hospital staff work to ensure that uninsured patients with long recoveries learn to care for wounds and to enlist family help at home.

Valenzuela said the county-owned hospital does not send uninsured patients home to fend for themselves. She goes into neighborhoods and follows up with patients as part of a Miami-Dade County violence intervention program, whose social workers help them access food, employment, and more to heal and feel safe.

“We know that full recovery is beyond just the hospital and even the rehab centers, even the best ones,” Valenzuela said, pointing to housing and navigating the healthcare system as factors.

runs the Miami-Dade program, which connects victims of gun violence with social workers who visit bedside at the hospital and an intensive care unit-trained nurse who visits at home to provide wound care and other services.

Rawlins said young, Black gunshot patients without health insurance are often at a loss when they leave the hospital about how to schedule a follow-up appointment or manage their mental health.

“After they have been shot and they’re getting out of the hospital and they’re still in crisis,” he said, “their concern is more: How am I going to now pay the rent? How am I going to live? Who’s going to take care of me?”

Often, he said, his uninsured clients leave the hospital before they are ready.

“That’s the reality of it: It’s a business,” he said. “It’s like a hotel. You know, checkout time: You got to go. We got to make room for someone, for a next customer.”

How Long Is Long Enough?

Alea Bates said the hospital discharged her with crutches and one prescription: a seven-day supply of the painkiller Percocet.

A family member drove Bates home. She wore a leg brace, with bandages on her back, stomach, hand, forearm, and feet. When she tried to get out of the car, Bates said, her knee gave and she fell.

Surgeons, health policy experts, and researchers say physicians follow evidence-based best practices for treating gunshot wounds and that a shorter hospital stay does not necessarily reflect a lower-level of care.

, an assistant professor of surgery at the University of Pennsylvania who conducts research on violence reduction, offered one explanation.

In published in The Journal of Trauma and Acute Care Surgery, Kaufman and colleagues found that patients who were admitted while uninsured but then enrolled in Medicaid during their hospitalization — and who needed ongoing rehabilitative care after discharge — spent more time in the hospital and had higher costs.

“I have personally been in situations where I felt like I did the best I could for a patient, but they would say, ‘You’re kicking me out,’” she said. “Sometimes, what the doctor is telling you doesn’t match what you are feeling in your body.”

But Kaufman said: “I’m not going to tell you hospitals never discriminate. That would not be realistic. I would say it is more indirect.”

Kaufman said she couldn’t judge whether Bates stayed in the hospital long enough because she was not her doctor. Still, she said, Bates “didn’t get what she needed from our healthcare system.”

Unlike many states, Florida excludes most single adults without children, like Bates, from Medicaid eligibility, making it exceedingly uncommon for a Medicaid patient to have been admitted as an uninsured adult.

Gunshot survivors endure bleeding and oozing flesh wounds and pain, and they experience . “These experiences are common, but they are not talked about,” Kaufman said. “Mental health is part of the recovery process.”

Recovering the ability to walk or use an arm or a leg after a gunshot wound requires rehab and physical therapy that can be out of financial reach for uninsured patients, said , a pediatric surgeon and an associate professor at the University of Maryland who that uninsured patients hospitalized for traumatic injuries have shorter stays than insured patients.

A shorter stay, he said, “suggests that these patients are not getting the same level of care, and that’s going to put them at risk for functional deficits down the road.”

He said it is impossible to arrive at a set number of days that any patient should remain in a hospital. Factors include the severity of their injury, their age, and any other illnesses they have.

“We’re looking for that Goldilocks length of stay,” Englum said, “and unfortunately, it is not perfectly defined for any specific admission, and it’s not perfectly defined for any specific patient.”

‘Oh, Shit. He Shot Me.’

Bates had delivered her last order for the night when she was shot. It was December 2019: As she was walking back to her car, she heard two loud bangs. Just kids playing pranks, she thought to herself. Then she turned toward the sound and saw a gun pointed at her.

“In that split second it registered in my mind, like, ‘Oh, shit. He shot me,’” Bates said. “I had some brief, like, burning, but it wasn’t registering in my brain right away what it was.”

Within seconds, Bates said, the stranger emptied the clip of his handgun into her body, even after she fell to the ground. He shot her seven times — twice in the back and once each in the pelvis, stomach, left forearm, right thumb, and right foot.

Bates screamed. She reached for her cellphone to call 911. She said residents came out of their apartments. Someone took her phone to tell the emergency dispatcher the address. Another person pressed towels on her wounds to slow the bleeding. An ambulance rushed her to Tallahassee Memorial.

Bates said she did not believe race was a factor in the care she received. But she believed that the circumstances surrounding her shooting — that it happened while she was working, and that she did not know the shooter — affected the way doctors and nurses viewed her.

Language in medical records can sometimes signal a bias in clinicians and perpetuate differences in care that patients receive, said , an associate professor at the Boston University School of Public Health who conducts research on exposure to gun violence.

Jay said bias based on patients’ race, income, or insurance status can deny some people necessary treatment once they leave the hospital.

He said his research suggests the healthcare system treats gunshot survivors and motor vehicle accident victims differently based on perceptions of “whether the victim was in no way at fault. They made assumptions when a person was violently shot.”

“The results are consistent with what we hear so much from hospital outreach workers for gunshot victims,” he said. “They say there is substantial bias. There is an assumption that they contributed to their condition with risky behavior.”

The preoperative notes in Bates’ medical records describe her as “a pleasant 39-year-old female who sustained multiple gunshot wounds to her abdomen, pelvis and extremities last night after performing Uber Eats delivery.”

Bates said it mattered to her caregivers what she was doing when she was shot.

“The nurses and doctors, they all talk about that stuff,” she said. “They were like, ‘Oh, my God, you were ambushed. That’s so scary.’

“I was working. Like, I don’t know these people. And the fact that they were teenagers, I think that that is what maybe changed the narrative,” she said. “Because I feel a lot of times people blame you for what happened.

“But when I was asked and I told them what happened and my story and how I got there,” she said, “I think just the shock in people’s eyes of like, ‘Oh, my God. So you really were, like, you know, minding your business.’”

She added: “And it also wasn’t in a sketchy part of town, if I can just say that. I was in a predominantly white complex. So I think that’s what saved me.”

‘Less Than a Human Being’

Bates had received care at the hospital before as an insured patient.

She had lost her job in the legal department of a state agency — along with her insurance — two months before she was shot.

As an uninsured patient, Bates said, “they kind of just dismiss you. It makes you feel like less than a human being.”

She said she felt ignored when she told doctors she didn’t feel safe going home after four days. She said the physical therapist working with her at the hospital had persuaded the facility to let her stay an extra day.

“We would like, as a medical community, I think as a society, to see everybody get the same care,” said Englum, the University of Maryland trauma surgeon. “Regardless of what color their skin is, what insurance status they have — we want them to get appropriate care.”

The reason for racial or ethnic differences in care is hard to tease out, Englum said. Is it that there’s mistrust of the medical system in some Black and Latino communities, leading people to avoid going to rehab because they don’t want to be there? Is it an income issue? Is it that medical providers see some patients and, due to implicit or explicit bias, think, “That’s as good as they’re going to get?”

“Getting that care is what you need to get your full functional outcome back. And if you’re not getting it,” he said, “patients are suffering that didn’t have to.”

At home, Bates said, she depended on family members to help her out of bed, drive her places, even help her feel safe out in public.

“I really didn’t know how to stand or move or walk around,” she said. “I had to figure it out.”

She still fears loud noises, which remind her of being shot. Bates said she and her dog stay indoors on July Fourth and New Year’s Eve.

“The fireworks were going off, and I was paralyzed,” Bates said of her first New Year’s Eve after being shot. “I was literally sitting there crying. My cousin actually came outside and put my noise-canceling headphones on and turned the music on so that I couldn’t hear anymore. That’s the only way that I could move from outside to inside.”

Bates said her follow-up care included getting her stitches removed at an orthopedic clinic that has physicians who work at the hospital and had performed the initial surgery.

During the visit, Bates said, the orthopedic clinic’s staff reminded her of the unpaid balance from her surgery, which was about $1,200 for physician services. She still owed the hospital $52,000 for treatment, according to her medical bills, and an additional $5,300 for the anesthesiologist. Bates was not working at the time.

Bates said a community outpatient clinic provided physical therapy at a reduced cost and that the victim advocate unit at the Tallahassee Police Department helped find her mental health counseling and get her financial aid from Florida’s .

By 2021, Bates developed a cyst on the gunshot wound to her right thumb, which required surgery. But, she said, the clinic would not perform the surgery until she paid her $1,200 balance. She said friends paid the bill so she could have the surgery.

Bates’ knee bothered her. “Even with going through physical therapy,” she said, “it was still like I couldn’t feel it.”

Bates said she now has private health insurance that pays for her mental health therapy. She pays for physical therapy out-of-pocket.

“It’s crazy that in this country somebody else can hurt you,” Bates said, and “you have to pay for what they did to you.”

“So it’s like you’re triple-paying: You’re paying every day mentally, you’re paying with the bills, and you’re paying by them saying, We know that this is not your fault, but we still have to make our money.”

Methodology

The Trace and Ñî¹óåú´«Ã½Ò•îl Health News examined more than 20 million inpatient hospitalizations in Florida from 2018 to 2024, using data obtained from the Florida Agency for Health Care Administration. We identified 20,255 gunshot wound-related visits using the Centers for Disease Control and Prevention’s injury surveillance case definition, which relies on diagnosis codes. We limited the analysis to initial encounters and excluded patients who died in the hospital or left against medical advice. We excluded cases in the top 1% for hospital length of stay (68 days or more) to prevent these outliers from disproportionately influencing results.

Our primary finding compares the average length of stay of uninsured patients with that of privately insured patients. We chose privately insured patients as the reference group because many researchers believe their care on average is long enough to be effective but not longer than medically necessary. Overall, uninsured patients had hospital stays that were about 25% shorter on average than privately insured patients’ and 50% shorter than those of patients on traditional Medicaid. In most cases we also found that, within the same hospital, uninsured patients had shorter stays than privately insured ones.

To assess whether age or injury severity explained the shorter lengths of stay for uninsured patients, we calculated and fit regression models for Florida’s highest-volume gunshot wound hospitals. We found that, in nearly all cases, the gap narrowed slightly but did not disappear.

Ñî¹óåú´«Ã½Ò•îl Health News data editor Holly K. Hacker contributed to this report.

This article was produced in partnership with The Trace, a nonprofit newsroom covering gun violence in America. .

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Her earliest memory is of standing on the passenger seat of her dad’s car as a toddler, wearing a peach-colored blouse, while he drove from their Kentucky home to Florida to pick up drugs. On a stop for a burger, she met Ronald McDonald.

“I grew up with the impression that that’s how you paid your bills,” Madden said. “That’s how your kids got things.”

By 16, she was addicted to pain pills. By 30, methamphetamine. She lost custody of two children and gave up two more for adoption at birth. She served time in the county jail and state prison.

Pregnant again at 40, Madden resolved to stop using. It was then that she learned of The Hub in Whitesburg, a town of 1,575 residents, her hometown.

Over the past two years, the state of Kentucky has sent hundreds of thousands of opioid settlement dollars to the rural eastern region of the state to help minimize the ramifications of drug misuse. The Hub, a program that oversees a network of community centers offering a range of services from recovery peer support to canned food to sterile syringes, is part of that effort.

In April, Kentucky Attorney General Russell Coleman announced $320,000 would be awarded to the Kentucky River District Health Department’s . There are now Hubs in four rural eastern Kentucky counties — Knott, Lee, Letcher, and Owsley, all of which are among the nation’s — addressing substance use disorders, housing, hunger, employment, and other challenges. The program also operates The Hub on Wheels, which provides services throughout the district.

In 2025, The Hub received $545,000 from the same source, facilitating expansion from two to five counties. (The fifth Hub will be in Perry County.) The new $320,000 is a two-year grant to develop a program to help women who’ve been incarcerated reintegrate into society.

Both grants are from Kentucky’s approximately $1 billion share of the $57.8 billion for state and local governments from the to resolve litigation for their role in fueling the opioid overdose crisis.

Madden believes investment in harm reduction services is money well spent. She’s witnessed them work in her own life. She’s found solid footing for recovery at The Hub.

But the Trump administration is cutting federal funding for such efforts, disputing their benefits. A told programs across the country that they could no longer expect federal funding. The order stipulated that discretionary grants issued by the Substance Abuse and Mental Health Services Administration should not be spent on “so-called ‘harm reduction’” efforts, claiming they “only facilitate illegal drug use and its attendant harm.”

Advocates for these services in this rural region, which cast its ballots for President Donald Trump in all three elections, beg to differ.

Meeting Folks Where They Live

Whitesburg — home to a lively cultural scene, including — is a town residents are fiercely proud to call home. The Hub is housed in a storefront on Main Street, neighboring City Hall, Hazard Coffee Company, Cut-Away Barber & Beauty Shop, and the fire station. Like the other Hubs, it provides a range of services targeted to the needs of the community.

The inaugural Hub, launched in 2022 in Beattyville, the Lee County seat, two hours northwest of Whitesburg, offers breakfast and lunch, a food pantry, a clothing closet, a laundry room, and a computer lab. Also: , a medication that can quickly reverse an opioid overdose; drug test strips; hepatitis C treatment; sterile syringes; and wound care.

The program’s motto is “Meeting you where you are but not leaving you there!” It’s founded on the principles of . Harm reduction services are designed to minimize the effects of drug use, keep people safe, and treat them with respect, until they might be ready to enter recovery. The support includes housing, food, healthcare, and overdose prevention tools.

JoAnn Fraley is Kentucky River’s harm reduction program coordinator and its Hub initiative director. “In order for anybody to sustain recovery, they have to have financial stability, they have to have transportation, and they have to have a home,” she said. “We try to fill those gaps.”

While critics suggest that exchanging clean syringes for used ones abets drug use, research published in the Journal of Substance Use and Addiction Treatment indicates that people who participate in syringe services programs are more likely than those who don’t to or stop using drugs altogether, and that they are more likely to enter and remain in treatment. According to the Centers for Disease Control and Prevention, syringe services programs also by about half.

In 2025, Kentucky River’s Hub model was named one of 19 award winners by the National Association of County and City Health Officials.

“What jazzes me about it is it’s a community approach to harm reduction,” said Lauren Carr, who advises the Kentucky Association of Counties on how best to utilize opioid settlement funds. “Whether that’s feeding a hungry stomach, or putting clothes on somebody’s back, or giving them clean [syringes], you’re meeting that person’s needs.”

“It can be that lifeline,” Carr said.

Paying Back for Good

Becky Todd, who leads the Beattyville Hub’s team, is a community health worker and peer support specialist. In April 2024, she was released from jail, having served multiple sentences on drug-related charges. She walked 3 miles from jail to The Hub with nowhere else to go. She’s working toward her bachelor’s degree in social work at Eastern Kentucky University.

“I could not have done it without this place,” Todd said. “It’s my saving grace.”

Amber McDaniel recalls the first time she entered The Hub, after more than a decade of addiction, having lost her home, her kids, and her family’s support. “I didn’t know where to turn, didn’t know what to do,” she said. “I mean, I was about to lose my mind.” She’s now a Hub staff member .

Hannah Stamper was placed in foster care and began using meth at 14. She was drawn to dealing drugs because “I loved for people to need me.” She’s now on staff as a member of , a program that trains AmeriCorps members to work in the recovery field. “People today need me in a good way, and I love that.”

Fraley has witnessed a transition in Lee County. A half-dozen years ago, conversations in public meetings about addiction and homelessness were strained “because nobody wanted to talk about it or acknowledge it.”

The community sees The Hub’s impact, she said, “and now they’re, like, ‘Whoa. We love you.’”

Scott Lockard, the district’s public health director, said a combination of data and anecdotal observations substantiates the initiative’s success, including an increase in the number of people entering treatment and a decline in reported communicable diseases.

“I’ve been in public health for 36 years, and it’s one of the most effective interventions I’ve seen,” Lockard said.

The Kentucky River team worked to educate the community about the potential outcomes of the Hub model, and Fraley said there was little resistance, just concern that the money be well spent. She said the planning has always included people who have lived with addiction.

“Their voice needs to be at every table,” she said.

Lockard agrees. To ensure the community is investing this money wisely, he said, “we’ll talk to those people who are experiencing the problem, find out what they think would help them best, and then look for those evidence-based interventions.”

Jannie Gatlin and Mandy Parker, who both are in recovery, attended a recent crafting class at the Whitesburg Hub. Gatlin, who started taking fentanyl in Colorado after her first son died at 2 months old of a digestive disorder, comes almost every day with her toddler, Hunter.

Parker was prescribed opioids for pain from a kidney disorder. When those pills became less available, she turned to street drugs. “That’s just the nature of the beast,” she said.

She believes The Hub is helping break the stigma of substance use disorder in her community. When people see “real change happening,” she said, there’s a ripple effect. “It makes a difference.”

She appreciates that The Hub is here on Main Street — right, she firmly believes, where it should be.

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“OK, cool,” his mother, J, remembered saying. (J asked to be identified by only her first initial, and Bug by his nickname, because the family fears harassment.)

“‘What do you need to be supported?’” she recalled asking next. “He asked to get healthcare.” 

This was the kind of moment J had been anticipating since the family had moved earlier that year from Texas to Massachusetts, for its more liberal and inclusive politics. She felt confident they could find the right medical experts. But she hadn’t realized that access to gender-affirming treatment could disappear even when their state’s laws and leaders supported it.

Individual hospitals all over the U.S., in red and blue states, have responded to President Donald Trump’s attacks on transgender healthcare by deciding to withdraw care on their own. At least did so in the first months of the Trump administration as it threatened to pull back federal funding or initiate fraud or wrongful-claim investigations, and such services have continued to drop off since.

Bug and his younger sister were born in Austin, Texas, but J and her husband became worried after the state outlawed abortion; dismantled diversity, equity, and inclusion programs; and limited medical and civil rights for queer and transgender people. The parents worried the support services they needed for the siblings, both of whom have autism, might be affected, too.

“I had a fear of being like the frog in the boiling water and not realizing what was happening until it was too late,” J said. “I needed to get the kids out of Texas.”

So when Bug came out as trans, J was relieved they’d landed in a state that not only has a to who offer but also is requiring commercial insurance, which Bug’s family has, to cover it.

After Bug’s gender announcement, J’s queries led her to the largest hospital system in the region, Springfield, Massachusetts-based , where they began the months-long process of getting set up to start hormone therapy.

Bug, an artistic 14-year-old who loves horses, cats, and making short films with friends, was too old for , but he was excited about the prospect of starting on testosterone. That would cause his voice to deepen, facial hair to grow, and muscles to get bigger.

“Every part of it sounds fun,” he said.

But this past February, two weeks before Bug was scheduled to start testosterone, Baystate announced it would no longer provide gender-affirming medications to minors, offering only counseling. A letter to patients’ families did not explain why.

Baystate spokesperson Heather Duggan sent a statement that said the decision to end treatment for minors reflected the fact that Baystate could lose “hundreds of millions of dollars in government reimbursement” as a result of the Trump administration’s plans. “Nearly 70 percent of Baystate Health’s patients rely on Medicaid and Medicare for coverage,” it said.

All Bug knew was that the care he’d eagerly awaited was about to vanish.

“I felt frustrated that they would do that,” Bug said.

“I bet there’s tons and tons of kids who are like: ‘OK, I’m going for trans-affirming healthcare. Yay!’” he said. “And then, like, tons and tons of kids were disappointed and sad and frustrated.”

J said it felt as if the floor had fallen out from under them. “Maybe this is naive, but I didn’t think that would happen in Massachusetts,” she said.

Baystate is among the providers still choosing not to offer puberty blockers and hormones as the issue wends its way through the courts. This spring, in , a federal judge concluded that it was unlawful for the Department of Health and Human Services to threaten federal funding for providers that offered gender-affirming care to minors. In June, another federal judge cleared 16 states, including Massachusetts, with another lawsuit against the administration over its push to criminalize gender-affirming care.

The American Academy of Pediatrics declined an interview request but said in a that young patients and their families should make decisions about gender-affirming care with their doctors, “delivered with compassion, and offered without political interference.”

One mother of a former Baystate patient said that before her child came out as a transgender girl, she had been severely depressed, battling suicidal thoughts. (The mother asked that only her first initial, L, be used, because the family also fears harassment.)

After Baystate doctors prescribed puberty blockers and estrogen, her daughter’s mood and grades rose markedly, L said. So when she received the letter announcing Baystate was ending the medical treatment, she was furious. L said she and other parents filed civil rights complaints with the Massachusetts attorney general.

The attorney general’s office did not respond to a request for comment.

“There’s a sense of, ‘How could you?’” L said. “And there’s also the awareness of the impact just pulling care could have on a youth — from a physical health perspective but also from a mental health perspective.”

L and J both found alternatives for their children. L asked the family’s primary care doctor to take over hormone prescriptions. Bug’s family was referred to in Northampton, Massachusetts, that said it has taken on about 50 of Baystate’s former patients.

“Transhealth has been staffing ourselves up for a while now in anticipation of the fact that this may be happening across the state,” said.

Erwin said Transhealth can weather the funding threats because the clinic gets large private donations and is not as dependent on Medicaid and Medicare as most hospitals. But Erwin said that doesn’t entirely reassure the broader LGBTQ+ community, including transgender adults.

“When you see something like that go down, people get scared that it’s ultimately going to happen to everyone,” Erwin said.

In May, Colorado’s Supreme Court in that state to resume medical treatments for transgender youths, while in Texas compelled a children’s hospital there to do the opposite — start the nation’s first “detransition clinic.” The Trump administration has continued to pressure providers, including by of transgender minors.

After Bug’s false start at Baystate, he was able to start taking testosterone at the new clinic in the spring.

His mother, J, said that the treatment is going smoothly and that Bug has learned how to give himself the injections. But J is nervous that the federal government will find other ways to stop his treatment again. She sometimes second-guesses the family’s move from Texas to Massachusetts, wondering whether they should have gone to Canada instead.

This article is from a partnership that includes , , and Ñî¹óåú´«Ã½Ò•îl Health News.

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