In California Governor Race, Single-Payer Is a Litmus Test. There’s Still No Way To Pay for It.

When Gavin Newsom ran for California governor in 2018, his support for a state-run single-payer healthcare system was considered a risky move and earned him hefty labor endorsements.

Today, leading Democrats in the wide-open race to succeed Newsom have embraced single-payer as a political necessity, an answer to voters fed up with rising premiums and other spiraling healthcare costs.

But with no clear front-runner, they are sparring among themselves in debates and political ads over who is most committed to a government-run model. No candidate has outlined how California would fund comprehensive health coverage for its 40 million residents, leaving voters unable to discern which candidate has a concrete plan for the nation’s most populous state.

Healthcare and political experts said the concept of single-payer has shifted from progressive pipe dream a decade ago to today’s mainstream talking points in a state where Democrats outnumber Republicans nearly 2 to 1. Democrats have pledged the model as the best way to lower costs in an attempt to woo voters worried about affordability as ballots arrive for the June 2 primary. The top two Republicans, meanwhile, have dismissed government-run healthcare as a “disaster” and “socialism.”

“In many ways, single-payer healthcare has become a progressive litmus test,” said Larry Levitt, a former White House policy adviser and a healthcare expert at KFF, a health information nonprofit that includes KFF Health News.

Few voters fully understand the term single-payer, let alone expect the next governor to achieve it, Levitt said. Rather, he added, the term has become more of a signal to voters about a candidate’s approach to healthcare reform.

Xavier Becerra, the former U.S. Health and Human Services secretary, who for decades backed single-payer healthcare in Congress, has come under criticism from opponents for a nuanced but clear shift away from single-payer. It came after Becerra secured an endorsement from the California Medical Association, a powerful group representing doctors and a longtime opponent of single-payer healthcare bills in California.

At a May 5 debate put on by CNN, Becerra declared his support for “Medicare for All,” a proposal for a federally run system that’s been stalled for years, but he declined to say whether he’d pursue a California-led effort. He said his immediate focus would be on mitigating the drastic federal cuts expected to hit low-income and disabled enrollees in Medi-Cal, the state’s Medicaid program, which covers more than a third of residents.

Becerra is counting on voters not to distinguish between the often-confused terms single-payer, Medicare for All, and universal coverage, noting during the debate that “Californians don’t care what you call it, so long as they have affordable healthcare.”

“A lot of people aren’t clear what single-payer is, and they need a metaphor to understand it,” said Celinda Lake, a Democratic strategist and one of the lead pollsters for former President Joe Biden’s 2020 campaign.

Billionaire activist Tom Steyer, who’s touted his self-funding as a signal he can’t be bought, has emerged as the race’s most vocal advocate of single-payer after opposing it during a short-lived 2020 presidential bid.

As governor, Steyer has said, he would pass legislation backed by the California Nurses Association that has failed to come to fruition under Newsom’s tenure. Pressed on how he would cover the estimated $731.4 billion cost, Steyer told KFF Health News that “God is going to be in the details.”

At a forum last year, former U.S. Rep. Katie Porter said she didn’t believe achieving such a system was realistic in the near term, but the Orange County Democrat later told party delegates that she would “deliver single-payer.” Former Los Angeles Mayor Antonio Villaraigosa and San Jose Mayor Matt Mahan, Democrats who are trailing their competitors in the polls, don’t support single-payer. The top two vote-getters — regardless of party — advance to the November general election.

Some of the most seasoned politicians have failed to deliver single-payer. Newsom, who campaigned on the promise of being a “healthcare governor,” dialed back his ambitions upon taking office, choosing instead to pursue “universal access” to health coverage under a series of Medi-Cal expansions and efforts to contain healthcare spending.

The campaign bus for billionaire activist Tom Steyer, who has made single-payer healthcare a central pillar of his run for governor, in downtown Oakland, California. In 2020, Steyer ran for president opposing single-payer healthcare. (Christine Mai-Duc/KFF Health News)

Vermont, which remains the only state to pass a single-payer healthcare law, reversed course when leaders there couldn’t identify a funding source.

To enact single-payer, California would need permission from the federal government to redirect billions of dollars from Medicaid, Medicare, and other funding that currently flows to the system — approval not likely to come from the Trump administration.

More than half of adults nationally say healthcare costs will have a major impact on whom they vote for in November, according an April KFF poll.

Danielle Cendejas, a Los Angeles-based Democratic consultant who works with state legislative candidates, said single-payer healthcare increasingly appears on candidate questionnaires from small-business advocates as well as hyperlocal Democratic clubs, in state legislative races and national union endorsements.

What most California voters want to hear, Cendejas said, is how candidates plan to give them more immediate relief from higher premiums, expensive drug costs, and long waits to access care.

The high price tag doesn’t faze Jennifer Easton, a 63-year-old Democrat from Oakland, who said other countries with similar models have proved they can lower costs. She said she supports a single-payer health system because it’s clear to her that Americans have reached the limits of working within the existing system. But she isn’t expecting any of the current candidates to succeed in implementing one, and she hasn’t decided whom to support.

“No one can in four years,” she said. Seeing a candidate enthusiastically support the concept gives her a good idea of their philosophy. “It is, if we’re lucky, a 20-year, 25-year plan.”

Rob Stutzman, a Republican political consultant who advised former Gov. Arnold Schwarzenegger, said while Americans may be supportive of single-payer in polls, focus groups suggest that approval drops quickly when voters realize it could mean losing their current doctor or insurance plan.

At the CNN debate, Steve Hilton, the Republican candidate President Donald Trump has endorsed, said Californians would end up with subpar patient care and “taxes sky high to pay for it,” like in his native United Kingdom.

Instead, Hilton suggested the state stop providing “free healthcare for illegal immigrants who shouldn’t even be in the country in the first place.”

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

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Trump Promised Cheaper Drugs. Some Prices Dropped. Many Others Shot Up.

Since his second term started, President Donald Trump has announced, negotiated, or floated a flurry of initiatives aimed at taming the excesses of the pharmaceutical industry.

No surprise. About 60% of American adults are “worried about being able to afford prescription drug costs for themselves or their families,” a recent KFF nationwide poll showed. More than 80% consider the price of prescription drugs “unreasonable,” and most support increased regulation to lower costs. Americans pay about three times as much as people in other countries for the same prescription drugs.

Last July, Trump sent letters to 17 drugmakers, demanding they voluntarily lower drug prices. Then the president said he’d negotiated with more than a dozen pharmaceutical executives one by one at the White House. In December, he announced that he had compelled them to agree to “most favored nation” pricing on Medicaid, the government coverage for low-income Americans.

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

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

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

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

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

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

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

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

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

Doing the Math

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

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

The biggest win for patients has likely been the Trump administration’s quiet continuation of a Biden administration program: Medicare drug price negotiation for expensive drugs. The negotiated discounts on the initial 10 drugs — from blood thinners to insulins to medicines for inflammatory disorders — went into effect Jan. 1. With reductions in price of well over 50% on some products, the estimated $6 billion in annual savings allowed the program to cap Medicare patients’ out-of-pocket spending on Part D prescription drugs at $2,000 for 2025 and beyond.

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

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

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

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

Trump’s One-on-Ones

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

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

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

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

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

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

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

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

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

A Few Notable Deals

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

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

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

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

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

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

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

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

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

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

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

Data reporter Maia Rosenfeld contributed to this article.

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

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Trump’s Drug Strategy Aims To Bolster Addiction Services — Despite Gutting of Government Support

The White House’s newly released strategy for tackling the nation’s drug and addiction crisis calls for a number of ambitious public health approaches that some experts say are laudable but will be hampered by the administration’s own actions.

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

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

But accomplishing such goals will be difficult in the face of the administration’s mass layoffs of federal employees, cancellation of research and community grants, attacks on organizations and practices that serve people who use drugs, and cuts to Medicaid, the state-federal health insurance program for low-income people that is the largest payer for addiction and mental health care nationwide.

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

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

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

Since 2000, more than 1.1 million people have died of drug overdoses. Although deaths have decreased recently, the numbers remain elevated compared with earlier decades, and research suggests overdose death rates among Black Americans and Native Americans are disproportionately high.

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

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

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

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

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

In December, Trump signed a reauthorization of the SUPPORT Act, which continues several grants related to treatment and recovery and the requirement for Medicaid to cover all FDA-approved medications for opioid use disorder. In January, he announced the Great American Recovery Initiative, including a $100 million investment to address homelessness, opioid addiction, and public safety.

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

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

That insecurity was exacerbated by the president’s 2027 budget request, which proposes cuts to several addiction and mental health programs and the consolidation of key federal agencies working on those matters. Jones’ group and nearly 100 others in the field have signed a letter asking Congress to reject the proposals, as it did with similar requests last year.

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

Increasing Access to Treatment

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

National data underscores the necessity: More than 80% of Americans who need substance use treatment don’t receive it.

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

Medicaid is the main source of health care coverage for adults with opioid use disorder. When implemented, the Medicaid work requirements in Trump’s One Big Beautiful Bill Act are projected to strip that coverage from about 1.6 million people with substance use disorders.

The last time Medicaid rolls were purged — after covid-era protections expired — many people who had been receiving medication treatment for opioid addiction stopped it and fewer people started treatment, according to a study published last year.

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

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

People with private insurance may be affected, too.

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

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

Prioritizing Prevention

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

“Investing in primary prevention, before drug use starts, saves lives and resources,” it says, citing several studies about the cost-effectiveness of such programs.

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

The White House’s most recent budget request proposes cutting roughly $220 million from SAMHSA’s Center for Substance Abuse Prevention and nearly $40 million from the Drug-Free Communities program.

Since the new administration started, SAMHSA has lost about half of its staff, and the Centers for Disease Control and Prevention is down about a quarter. 

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

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

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

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

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

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

Stopping Overdose Deaths

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

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

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

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

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

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

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States Eye Aid To Prop Up Distressed Hospitals Amid Federal Medicaid Cuts

LOS ANGELES — At Martin Luther King, Jr. Community Hospital, patients on gurneys line the hallways of the emergency department waiting for care, and overflow mental health patients are consigned to outdoor tents.

The 152-bed hospital, which sits on a sprawling medical campus close to the predominantly Latino and Black neighborhood of Watts, is struggling for financial stability. Its patients are poorer and sicker than average, many of them are uninsured, and three-quarters of MLK’s patient care revenue comes from Medi-Cal, the state’s version of the Medicaid program, which pays low rates. For hospitals statewide, by comparison, less than one-third of patient revenue comes from Medi-Cal.

And MLK Community Healthcare, which comprises the hospital and two nearby clinics, is independent, so it cannot fall back on a larger chain to absorb some of the financial pressure.  

Similar problems plague hundreds of financially vulnerable hospitals around the country, in rural and urban areas. And their financial woes are about to get worse.

The Republican budget measure known as the One Big Beautiful Bill Act, signed into law by President Donald Trump last July, is expected to cut federal Medicaid spending by $911 billion over 10 years. And it could contribute to an increase of more than 14 million in the number of uninsured people, many of whom will go to already crowded emergency rooms to get care they can’t pay for.

The law does include a special fund to boost rural healthcare, totaling $50 billion over five years. But that’s far less than the $137 billion it is expected to cut from rural health spending over the next decade. And the rural health fund does little or nothing to help the numerous urban hospitals, such as MLK, that also face serious financial troubles.

MLK, like many other hospitals, is scrambling to secure outside financing to avert serious disruptions of medical services when the brunt of the policies contained in the federal law begins to hit early next year. The hospital’s leadership team projects a revenue hole of $80 million to $100 million annually for the foreseeable future. It would be MLK’s largest budget gap since it opened in 2015.

“Even if we cut services that our community needs — maternity care, behavioral healthcare, diabetes management — it wouldn’t make a significant dent in the gap we’re facing,” said Elaine Batchlor, the CEO of MLK Community Healthcare. ”Many of those same people would still come to us through our emergency department, only they’d be in worse shape and might need more expensive care.”

MLK Community Healthcare CEO Elaine Batchlor stands outside the check-in area for Martin Luther King, Jr. Community Hospital’s emergency department, a long tent outside the main building in Los Angeles. (Bernard J. Wolfson/KFF Health News)

Across the U.S., hospitals and patient advocates are looking to state lawmakers and local officials to help shore up shaky finances. In California, Assembly member Esmeralda Soria, a Democrat representing Fresno, is pushing legislation to expand a 2023 “distressed hospital loan fund” that allocated nearly $300 million in zero-interest loans to 16 hospitals in the state, including $14 million to MLK. The state would pony up another $300 million under Soria’s bill.

At least two other states are weighing similar programs. A bill in Pennsylvania would create a $100 million “distressed hospital grant” program. And a funding bill for the Illinois Department of Healthcare and Family Services contains a provision to create an $85 million loan program for troubled hospitals.

Carmela Coyle, the CEO of the California Hospital Association, said the original $300 million disbursed by the state legislature helped but was not enough.

“This program is focused on those who are standing on the edge of that financial cliff, and it’s intended to give them a little space, brush them a little bit back from the edge,” Coyle said. “But we’ve got many more hospitals that are taking giant leaps toward the edge of that cliff every day.”

Despite the association’s influence, an expansion of the loan program is far from certain, given fiscal constraints that have already induced state leaders to roll back California’s ambitious healthcare agenda, with restrictions on coverage for immigrants and funding cuts for community clinics. Democratic Gov. Gavin Newsom recently warned lawmakers to expect more cuts in his revised May budget — and that’s before the main federal spending reductions kick in.

“This is a very difficult budget environment,” said Kristof Stremikis, director of market analysis and insight at the California Health Care Foundation, a nonprofit that advocates for healthcare improvement. “It is hard to come up with funding for new programs and even existing programs right now.”

MLK Community Hospital is a 152-bed facility in Los Angeles near the predominantly Latino and Black neighborhood of Watts. The hospital’s leadership team projects a revenue hole of $80 million to $100 million annually for the foreseeable future. (Bernard J. Wolfson/KFF Health News)

Some lawmakers noted skeptically that the initial loans are now on their way to at least partial debt cancellation, which is allowed under existing law. Soria’s bill spells out a clearer path to loan forgiveness.

“Are these loans or are these grants? Because they seem to be turning, really, into grants,” Assembly member Pilar Schiavo, a Democrat in Santa Clarita, said during an April 21 hearing on the bill.

Ultimately, it might not be desirable to save struggling institutions by pouring dollars into them, because care is increasingly offered outside of hospitals, Stremikis said.

In the short term, though, the financial health of hospitals that received loans appears to have improved, according to a KFF Health News analysis of state data. The average operating margin of the 15 loan recipients for which comparable data is available shifted from a loss of 15.4% the year before the program to a gain of 2.3% after the money was disbursed.

It is unclear how much of the improvement can be attributed to the loans. Hospitals also secured other sources of funding, and they adopted efficiencies as a condition for the interest-free money.

MLK reduced the use of high-cost temporary labor by hiring more permanent staff, cut the average length of patient hospital stays to decrease staffing hours, streamlined billing, and negotiated more-favorable contracts with insurers, said Atul Nakhasi, a practicing physician who is also MLK’s vice president of government affairs and community relations. Batchlor said that the loan helped MLK get through a cash flow crunch and that a second loan, if it became available, would be used for the same purpose.

This summer, MLK expects to open a psychiatric assessment unit, where patients in mental distress can be stabilized in an environment replete with plush reclining chairs and “calming” rooms. Hospital executives hope the new unit will provide a significant new source of revenue, while taking pressure off the emergency department.

Batchlor sits on a beanbag chair in one of the “calming” rooms in MLK Community Hospital’s new emergency psychiatric assessment, treatment, and healing unit. (Bernard J. Wolfson/KFF Health News)

The main EmPATH patient area contains large reclining chairs for people who need to be evaluated and stabilized. Hospital officials say the unit will be a welcome new revenue source and help take pressure off MLK’s perennially crowded emergency room. (Bernard J. Wolfson/KFF Health News)

Kaweah Health in Visalia, California, suspended some services, temporarily stopped contributing to employees’ retirement, and briefly froze wages in exchange for a loan of just under $21 million, said the organization’s CEO, Marc Mertz.

Madera Community Hospital got a $57 million loan — the largest disbursement from the state fund — to reopen after being shuttered for more than two years. The hospital reopened early last year, but it has not yet stabilized financially, said Matthew Beehler, the chief strategy officer at American Advanced Management, a privately held company that bought Madera out of bankruptcy.

“You can definitely say the hospital would not have been opened without the distressed hospital loan,” though the company has also invested more than $50 million, Beehler said. He said Madera would hope for another loan if the program were extended.

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

This <a target="_blank" href="https://kffhealthnews.org/health-care-costs/medicaid-cuts-distressed-hospitals-aid-california/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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She Survived 2 Shootings. Research Helps Explain Why Her Pain Persists Years Later.

In 2019, Mia Tretta, then a high school freshman at Saugus High School in Santa Clarita, California, was struck in the stomach by a round from a .45-caliber semiautomatic handgun fired by a schoolmate. Two students were killed during the attack, including her best friend, and two others were injured.

When she graduated from high school, she enrolled at Brown University, the scene of another shooting in December 2025, while she was studying for finals in her dorm room.

As messages flooded in about an active shooter on campus, she felt pain where she had been shot in the stomach. The college junior experienced a phenomenon she called “phantom bullet syndrome,” similar to phantom limb syndrome, in which someone senses something is there that is not. It occurs whenever she feels extremely stressed, she said.

“It’s crazy to say that the first time, I was the lucky one because though I got shot, I didn’t get killed,” said Tretta, now an anti-gun violence advocate who is studying public affairs and education. “And the second time, I was the lucky one because I was a few blocks away.”

Tretta represents a small but growing cohort of young people who have lived through more than one shooting. She also embodies the findings of a recent study that links gun violence exposure to chronic pain.

The study, published in BMC Public Health in January, found that both direct and indirect exposure to gun violence are linked to higher rates of chronic pain among American adults.

Rutgers University researchers studied six types of gun violence exposure: being shot, being threatened with a gun, hearing gunshots, witnessing a shooting, knowing a friend or family member who was shot, and knowing someone who died by firearm suicide. Using a nationally representative survey of 8,009 people, they found that 23.9% had pain most days or every day, while 18.8% said they had a lot of pain.

Daniel Semenza, the study’s lead author, told The Trace that whether someone has lost a person to gun violence or they’ve been shot themselves, their mental and physical health are inextricably linked.

“Your body, through the experience of post-traumatic stress, is going to feel as if it’s happening over and over and over again,” said Semenza, the director of research at the New Jersey Gun Violence Research Center and an associate professor at Rutgers University.

Tretta underwent surgeries to remove the bullet, she said, and later received a nerve block to address ongoing pain from her injuries. But the bullet fragments remain in her body years later, she said.

She was also diagnosed with psoriatic arthritis — a chronic disease causing swelling, pain, and stiffness in the joints.

“I have dealt with chronic pain, immunodeficiencies, and bodily differences ever since the shooting happened,” Tretta said. “Every time I get a fever, it’s a completely different thing than anyone else I know, or even pre-shooting for me. I shake uncontrollably, and it hurts to even touch my arm.”

The Rutgers study is one of the first to focus on outcomes like chronic pain as part of an emerging body of work on the physical health toll of gun violence exposure.

“It highlights the fact that, for the thousands of people who are killed every year, there are lots of people who knew those folks,” Semenza said. “The toll of gun violence is much broader than we originally anticipated.”

Efrat Eichenbaum, an inpatient psychologist who has treated gun violence survivors and their families at a Level 1 trauma center in north Minneapolis, said the study accurately reflects what she has seen in her clinical work.

“You can plainly see the trauma that follows an event like that,” she said. “Not just for the survivors, but for their families. It does not even limit itself to family members. This is an issue that touches entire communities.”

David Patterson, an emeritus professor at the University of Washington whose work focuses on pain, says the study shows, in particular, just how far the impact of gun violence fans out and how costly a problem it is for society.

“Chronic pain is a major health problem in itself, and it costs our society billions of dollars because it’s very hard to manage,” he said. “You can’t cure it; it has to be managed.”

Back in her dorm room at Brown, Tretta explained that medical care does not end when someone leaves the hospital after a trauma like hers. It goes on for years.

“Your body will never be the same as it was before,” she said. “There’s no time that you can’t feel the 7 or 8 inches of scar tissue running through the middle of your stomach. It’s just a constant physical reminder, because you can’t leave your body.”

This article was reported by The Trace, a nonprofit newsroom covering gun violence in America. Sign up for its newsletters here.

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

This <a target="_blank" href="https://kffhealthnews.org/public-health/gun-violence-survivor-phantom-pain-research-minnesota/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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States Rush To Figure Out How To Enforce Trump’s Medicaid Work Requirements

State officials remain uncertain on how to enforce a requirement that many adult Medicaid enrollees show they’re working — even as one state launches its program this week — and they’re taking a variety of approaches to the job, including, in a handful of states, using artificial intelligence.

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

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

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

About 20 million people gained Medicaid coverage from the expansion, created by the Affordable Care Act — a law that most Republicans still oppose.

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

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

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

KFF is a health information nonprofit that includes KFF Health News.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This <a target="_blank" href="https://kffhealthnews.org/medicaid/medicaid-work-requirements-kff-survey-state-implementation-strategies/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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Trump’s Medicaid Work Mandate Debuting in Nebraska to Much Dismay

Schmeeka Simpson of Omaha works as a patient navigator for the American Civil Liberties Union and an administrative assistant at Nebraskans for Peace, plus picks up shifts at a Dunkin’ shop.

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

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

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

Even though she works three jobs, Schmeeka Simpson worries about losing her health coverage when Nebraska becomes the first state to require certain Medicaid enrollees to work, train, or go to school under a new federal mandate. (Schmeeka Simpson)

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

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

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

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

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

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

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

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

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

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

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

Nebraska’s Plan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

National Mandate

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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On a recent Monday, Sandy Guzman, a community health worker in rural Oregon, drove to visit a patient in her 60s in a small city called The Dalles.

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

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

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

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

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

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

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

These workers have been on the job since the 1960s, particularly in rural and low-income areas. Today, their numbers are growing. The Bureau of Labor Statistics reports about 65,000 of them, which the National Association of Community Health Workers says is probably an underestimate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The widower now lives comfortably in a mobile home park.

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

The New Old Age is produced through a partnership with The New York Times.

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

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