MIAMI — Josefina Muralles works a part-time overnight shift as a receptionist at a Miami Beach condominium so that during the day she can care for her three kids, her aging mother, and her brother, who is paralyzed.

She helps her mother feed, bathe, and give medicine to her adult brother, Rodrigo Muralles, who has epilepsy and became disabled after contracting covid-19 in 2020.

“He lives because we feed him and take care of his personal needs,” said Josefina Muralles, 41. “He doesn’t say, ‘I need this or that.’ He has forgotten everything.”

Though her husband works full time, the arrangement means their household income is just above the federal poverty line — too high to qualify for Florida’s Medicaid program but low enough to make Muralles and her husband eligible for subsidized health insurance through the Affordable Care Act marketplace, also known as Obamacare.

Next year, Muralles said, she and her husband may not be able to afford that health insurance coverage, which has paid for her prescription blood thinners, cholesterol medication, and two surgeries, including one to treat a genetic disorder.

Extra subsidies put in place during the pandemic — which reduced the premiums Muralles and her husband paid by more than half, to $30 a month — are in place only through Dec. 31. Without enhanced subsidies, Affordable Care Act insurance premiums would rise by more than 75% on average, with bills for people in some states more than doubling, according to estimates from KFF, a health information nonprofit that includes KFF Health News.

Florida and Texas would be hit especially hard, as they have more people enrolled in the marketplace than other states. Some of their congressional districts alone, especially in South Florida, have more people signed up for Obamacare than entire states.

Like many of the more than 24 million Americans enrolled in the insurance marketplace this year, Muralles was unaware that the enhanced subsidies are slated to expire. She said she cannot afford a premium hike because inflation has already eaten into her household’s budget.

“The rent is going up,” she said. “The water bill is going up.”

Low-income enrollees like the Muralles couple would see the biggest percentage increases in premiums if enhanced subsidies expire.

Middle-income enrollees who earn more than four times the federal poverty line would no longer be eligible for subsidies at all. Those middle-income enrollees (who earn at least $62,600 for a single person in 2025) are disproportionately older, self-employed, and living in rural areas.

Julio Fuentes, president of the Florida State Hispanic Chamber of Commerce, said many of his organization’s members are small business owners who rely on Obamacare for health coverage.

“It’s either this or nothing,” he said.

The Congressional Budget Office estimated that letting the enhanced subsidies expire would, by 2034, increase the number of people without health insurance by 4.2 million. In tandem with changes to Medicaid in the House of Representatives’ reconciliation bill and the Trump administration’s proposed rules for the marketplace, including toughening income verification and shortening enrollment periods, it would increase the number of uninsured people by 16 million over that time period.

A study by the Urban Institute, a nonprofit think tank, found that Hispanic and Black people would see greater coverage losses than other groups if the extra subsidies lapse.

Fuentes noted that about 5 million Hispanics are enrolled in the ACA marketplace, and that Donald Trump won the Hispanic vote in Florida in 2024. He hopes the president and congressional Republicans see extending the enhanced subsidies as a way to hold on to those voters.

“This is probably a good way, or a good start, to possibly grow that base even more,” he said.

Enrollment in the marketplace has grown faster since 2020 in the states won by Trump in 2024. A recent KFF survey found that 45% of Americans who buy their own health insurance identify as or lean Republican, including 3 in 10 who identify as Make America Great Again supporters. Smaller shares identify as Democrats or Democratic-leaning independents (35%) or do not lean toward either party (20%).

Kush Desai, a White House spokesperson, said the rules proposed by the Trump administration, combined with the provisions in the House-passed budget bill, would “strengthen the ACA marketplace.” He noted that the CBO projects the legislation would reduce premiums for some plans about 12% on average by 2034 — but out-of-pocket costs would rise or remain the same for most subsidized ACA consumers.

“Democrats know Americans broadly support ending waste, fraud, and abuse, as The One, Big, Beautiful Bill does, which is why they are desperately trying to change the conversation,” Desai said.

But Lauren Aronson, executive director of Keep Americans Covered, a group in Washington, D.C., representing health insurers, hospitals, physicians, and patient advocates, said it is critical to raise awareness about the likely impact of losing the enhanced subsidies, which are also known as advanced premium tax credits. She is encouraged that Democrats have proposed legislation to extend the enhanced tax credits, and that some Republican senators have voiced support.

What worries Aronson most is that the Republican-controlled Congress is more focused on extending tax cuts than enhanced subsidies, she said. The current bill extending the 2017 tax cuts would increase the federal deficit by about $2.4 trillion over the next decade, according to the CBO, while making the enhanced subsidies permanent would increase the deficit by $358 billion over roughly the same period.

“Congress is moving forward on a tax reconciliation package that purports to benefit working families,” Aronson said. “But if you don’t take care of the tax credits, working families will be left holding the bag.”

Brian Blase, president of Paragon Health Institute, a conservative health policy think tank, said the enhanced subsidies were supposed to be a temporary measure during the covid-19 pandemic to help people at risk of losing coverage.

Instead, he said, the enhanced subsidies facilitated fraud because enrollees did not need to verify their income eligibility to receive zero-premium plans if they reported incomes at or near the federal poverty level.

The enhanced subsidies also worsen health inflation, discourage employers from offering health insurance benefits, and crowd out alternative models, such as short-term insurance and Farm Bureau plans, Blase said.

“Permitting these subsidies to expire would just be going back to Obamacare as it was written,” Blase said. “That is a more efficient program than the program that we have now.”

New rules for the marketplace proposed by the Trump administration in March are already designed to address fraud, said Anna Howard, a policy expert with the American Cancer Society Cancer Action Network, which advocates for increased health insurance coverage. Howard said extending the enhanced tax credits would help ensure that people who are legitimately eligible for coverage can get it.

“We don’t want to see over 5 million people be kicked off their health insurance coverage out of fears of fraud when the policies being proposed don’t necessarily address fraud,” she said.

Without affordable premiums, many consumers will turn to short-term health plans, health care cost-sharing ministries, and other forms of coverage that do not have the benefits or protections of the health law, she said.

“These are plans that don’t provide coverage for prescription drugs, or they have lifetime and annual limits,” she said. “For a cancer patient, those plans don’t work.”

Though the enhanced subsidies do not expire until the end of the year, the Blue Cross Blue Shield Association would prefer Congress to act by fall to avoid confusion during open enrollment, said David Merritt, a senior vice president. Insurers are preparing rates to meet state deadlines. By October, consumers will receive 60-day plan renewal notices with their 2026 premiums.

Without enhanced subsidies, Merritt said, competition in the marketplace will wither, leading to fewer coverage options and higher prices, especially in states that have not expanded Medicaid eligibility and where Obamacare enrollment spiked during the past four years, like Florida and Texas. “Voters and patients are really going to see the impact,” he said.

Republican and Democratic representatives for some of the Florida congressional districts with the highest numbers of people in the marketplace did not respond to repeated interview requests.

Muralles, of North Miami, Florida, said she wants her representatives to work in the interest of constituents like herself, who need health insurance coverage to care for their families.

“Now is the time to prove to us that they are with us,” Muralles said. “When everybody’s healthy, everybody goes to work, everybody can pay taxes, everybody can have a better life.”

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

It’s a holy grail of health care: forcing the industry to reveal prices negotiated between health plans and hospitals — information that had long been treated as a trade secret. And among the flurry of executive orders President Donald Trump signed during his first five weeks back in office was a promise to “Make America Healthy Again” by giving patients accurate health care prices.

The goal is to force hospitals and health insurance companies to make it easier for consumers to compare the actual prices of medical procedures and prescription drugs. Trump gave his administration until the end of May to come up with a standard and a mechanism to make sure the health care industry complies.

But Trump’s 2025 order is also a symbol of how little progress the country has made since he issued a similar directive nearly six years ago. Consumers find it only partially useful, and the quality of the information is spotty.

A ‘Bold’ First Step That Fizzled

The 2019 order was “pretty bold,” said Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News. “They basically went at the providers and the plans and said, ‘All this data you think is confidential we’re not going to make confidential anymore.’”

What followed was, to consumer advocacy groups, a disappointment. Hospitals and insurers posted on websites voluminous, complex, and confusing data about their prices. The information has been a challenge for even experts in health care pricing to navigate, let alone consumers. Some members of Congress filed legislation to put the force of law behind price transparency requirements; those bills died. And President Joe Biden’s administration was criticized for not more stringently enforcing the regulations, with one consumer advocacy group even buying a Super Bowl ad featuring the rapper Fat Joe alleging that “hospitals and insurers hide their prices.”

Trump’s new order, signed in February, said that hospitals and health plans “were not adequately held to account when their price transparency data was incomplete or not even posted at all.”

The Government Accountability Office reported in October that the Centers for Medicare & Medicaid Services didn’t know whether prices reported by the health care industry were correct or complete. But CMS, which regulates hospitals, now plans to “systematically monitor compliance” and help institutions understand the requirements, said Catherine Howden, an agency spokesperson.

Howden did not answer questions about whether CMS staffers overseeing price transparency compliance have been fired as part of the Trump administration’s wide-ranging effort to cut the federal workforce.

‘Zombie’ Rates and Other Inconsistencies

Meanwhile, independent researchers have found numerous problems with the quality of price data both hospitals and health insurers do share with consumers.

A recent report from the Peterson-KFF Health System Tracker found that data reported by four health insurers in New York City often included prices that they say they pay hospitals for services that those health providers don’t — or can’t — provide. These are called “ghost” or “zombie” rates. For example, the health plans reported dentists, optometrists, and audiologists receiving payments for knee replacements, gastrointestinal exams, and other procedures unrelated to their specialties.

In other cases, the data included different prices for the same service paid for by the same insurer at the same hospital. UnitedHealthcare, for example, reported paying New York-Presbyterian/Weill Cornell Medical Center three rates — $47,000, $64,000, and $70,000 — to treat a heart attack.

Or, the insurers reported paying the same price for vastly different services. Aetna, for example, said it paid exactly $6,292 to Mount Sinai Beth Israel hospital for the treatment of respiratory infections, heart attacks, cancers of the digestive tract, kidney and urinary tract infections, and psychosis.

Neither UnitedHealthcare nor Aetna addressed the discrepancies in the data. Cole Manbeck, a spokesperson for UnitedHealthcare, said the insurer has met price transparency requirements and urged members “to use our cost-estimator tools for exact costs based on their specific health plan.” Aetna spokesperson Shelly Bendit referred questions to AHIP, a lobbying and trade association for insurers.

Health insurers have “strongly supported” price transparency, said Chris Bond, a spokesperson for AHIP. The group will work with the Trump administration to provide transparency “in a way that is meaningful for the end user, while also promoting a competitive private market,” Bond said.

What’s a Consumer To Do?

Estimates and total prices aren’t very useful for consumers, who are mainly interested in what they’ll ultimately have to pay out-of-pocket, said David Cutler, a professor of applied economics at Harvard University. That can vary by health plan, depending on deductibles, copayments, and other fees.

“Most of the price transparency information doesn’t have that,” he said.

It also doesn’t give consumers information about the quality of care, Cutler added, which can lead to an old bias. “It’s kind of like wine when you go to the restaurant,” he said. “People assume that the more expensive wine is better.”

Cutler said he’s skeptical that price transparency will lower costs for patients. But he said it may offer insight to hospitals and health plans about what their competitors are charging and paying for services — knowledge that could inadvertently lead to price increases if hospitals that receive a lower rate than a competitor demand higher reimbursement from health plans.

Trump’s recent executive order notes that the top quarter of the most expensive health service prices have dropped by 6.3% a year since his 2019 order.

However, the same research referenced in the executive order showed that the bottom quarter of services got more expensive, at a rate of about 3.4% per year, according to the analysis by Turquoise Health, a health care price data firm that examined rates at more than 200 hospitals in the 10 largest U.S. markets.

Some patients say that with research and persistence, they’ve been able to make price transparency work for them.

Theresa Schmotzer, 50, of Goodyear, Arizona, said she used hospital price data to save nearly $3,000 on outpatient surgery to have a fibroid removed last year.

Schmotzer, who has health insurance, said the hospital first told her she would owe $3,700 for the procedure and wanted the payment upfront. But she was skeptical.

She said her health insurer was unable to quote a price for the procedure or specify how much she would owe. The morning of the surgery, Schmotzer said, she found a spreadsheet online at PatientRightsAdvocate.org that included different prices paid by insurers, including hers. The reported price for the procedure was closer to $700, she said.

Schmotzer said she took a printout of the spreadsheet to the hospital and presented it during preadmission. She paid her $300 deductible and told the hospital to bill her for the rest.

A few months later, she said, the bill arrived in the mail for the remaining $400, which she paid.

When people go for surgery and aren’t clear upfront what the cost will be, it stokes fear, she said. “Because they’re going in blind.”

Next Steps

Hospitals say they want to work with federal regulators and comply with reporting requirements, said Ariel Levin, director of coverage policy for the American Hospital Association, which represents about 5,000 institutions. Levin said consumers should be given the price of services and “a more comprehensive estimate” that represents an entire episode of care and the amount they’ll owe out-of-pocket, based on their health plan.

CMS has developed rules since Trump’s 2019 order to make price information reported by hospitals and health plans easier to understand, and the agency has fined more than a dozen hospitals for failing to comply.

Federal rules allow hospitals to report an estimate, a price range, or a historical rate for their services, while health plans can adjust prices based on factors like the severity of the case, the length of treatment, and a patient’s age.

KFF’s Claxton said that such flexibility doesn’t allow for “apples-to-apples comparisons” and that the data must be reliable before researchers can use it to better understand health care costs. “It doesn’t seem to be that yet,” he said.

Much remains to be done before price transparency lives up to expectations that it will increase competition and lower costs, said Katie Martin, chief executive of the Health Care Cost Institute, a nonprofit research group.

Price transparency alone is not a silver bullet, Martin said. It’s “a critical first step” for employers, lawmakers, regulators, and others to better understand how money flows through the health care system and how to make it more efficient, she said. “It’s not the whole thing.”

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

HAVANA, Fla. — For a rural community, this town of 1,750 people has been more fortunate than most. A family doctor has practiced here for the last 30 years.

But that ended in December when Mark Newberry retired. To attract a new doctor, Havana leaders took out want ads in local newspapers, posted notices on social media, and sweetened the pot with a rent-free medical office equipped with an X-ray, an ultrasound machine, and a bone density scanner — all owned by the town.

Local leaders hope the recruitment campaign will help attract candidates amid a nationwide shortage of doctors.

“This is important for our community,” said Kendrah Wilkerson, Havana’s town manager, “in the same way that parks are important and good future planning is important.”

According to a Florida Department of Health report, doctor shortages affect all or part of nearly every county, but less populous counties, such as Gadsden, where Havana is located, have the fewest physicians per 10,000 residents.

Florida’s doctor shortage is expected to grow in the next decade, with one study projecting a statewide need of 18,000 physicians — including 6,000 primary care doctors — by 2035.

“This is a huge, huge issue,” said Matthew Smeltzer, a managing partner of Capstone Recruiting Advisors, a company that helps hospitals, physician practices, and other employers find and hire doctors. “It probably hits small towns the hardest, just because most people would prefer to live in a midsize or large community.”

In this challenging environment, Havana leaders are hoping that want ads and rent-free perks will make their small town stand out and persuade a doctor to practice here.

Wilkerson describes the community, just south of the Georgia border, as an ideal place to raise a family. Its country roads are lined with farms, pastures, and churches. Main Street downtown features antique stores, gift shops, a general store, and restaurants.

“Everything you would imagine a Hallmark movie to be is kind of where we live,” Wilkerson said. “It’s people who still care and look out for each other, and neighbors are actually friends.”

Offering generous incentives was how town leaders got Newberry to practice in Havana in 1993. The town gave Newberry an initial deal similar to the one it’s offering now, and later began providing him about $15,000 a year in financial support.

Newberry, who served about 2,000 patients, declined to be interviewed. “I’m just retiring!” he said in an email, adding that “the town has chosen unconventional ways” of recruiting a doctor.

By subsidizing office space and the use of medical equipment to attract a doctor, Havana is looking out for the needs of its residents, Wilkerson said.

Without a town doctor, some of Newberry’s former patients now have to travel to Tallahassee, about a 30-minute drive southeast of Havana. Others are seeing doctors in Quincy, about a 20-minute drive west.

“Our hope is that they’ll come back when we find us a new doctor,” Havana Mayor Eddie Bass said.

Susan Freiden, a former town manager who retired in 2006, said having a local doctor is also important to meet the needs of the town’s low-income residents, many of whom are older adults. “Not everybody can get to Tallahassee to get a doctor,” she said. “Not everybody has transportation.”

But it remains to be seen whether rent-free office space and equipment are enough to attract a doctor to Havana. The town’s recruitment campaign has drawn a lot of interest from nurse practitioners, but few primary care physicians have applied for the position.

Town leaders say they’re holding out hope of finding a family physician, who can practice and prescribe medications independently.

“We would really, you know, prefer to have a true doctor that can handle it all for us,” Bass said.

Smeltzer, the physician headhunter, said primary care physicians are in especially low supply. And though in his experience Florida, North Carolina, Tennessee, and Texas are among the places doctors want to live and work, it often takes something extra to persuade them to work in a small town, he said.

“If someone wants to practice in a small town, they’re more likely to go to where they have ties, whether it’s themselves or their spouse or significant other,” he said.

The challenge for a community of Havana’s size, Smeltzer said, is that “there may literally be nobody from that town that went to med school. Or, if there is, maybe it’s one. But were they a primary care physician?”

Still, there is a silver lining. Smeltzer said young physicians are placing a high value on work-life balance and meaningful relationships with their patients — qualities that may give an edge to a small-town, independent practice.

“We hear quality of life and work-life balance far more in the last three to five years than we ever heard before,” he said, “and that’s almost in lockstep with compensation in terms of what they’re focusing on.”

Freiden, the former Havana town manager, said those are the same values Newberry had when he started to practice here. She even became one of his patients.

“He was just perfect,” she said, “because he wasn’t all about the money, if you can imagine that. He was kind of a different kind of physician.”

Fortunately for Havana, the town recently received interest from a family medicine doctor who grew up here, went to medical school, and expects to finish a three-year residency at Tallahassee Memorial HealthCare in June.

Camron Browning, a 2003 graduate of Northside Havana High School, told the seven-member Town Council in a December interview that he was focusing on family medicine and that, during his residency, he has seen thousands of patients, delivered babies, and gained experience as a hospitalist.

“My goal,” he said, “was to be able to come home and serve my hometown.”

Smeltzer said Havana’s incentives could be attractive to new doctors, such as Browning, who would face daunting startup costs to establish an independent practice.

After the December interview, the Council voted unanimously to begin contract negotiations with Browning, who said he would plan to be ready to see patients as soon as possible after completing his residency.

“I’m here to stay,” Browning told the Council. “This was always my dream.”

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

As a part-time customer service representative, Jolene Dybas earns less than $15,000 a year, which is below the federal poverty level and too low for her to be eligible for subsidized health insurance on the Obamacare marketplace.

Dybas, 53, also does not qualify for Medicaid in her home state of Alabama because she does not meet the program requirements. She instead falls into a coverage gap and faces hundreds of dollars a month in out-of-pocket payments, she said, to manage multiple chronic health conditions.

“I feel like I’m living in a state that doesn’t care for me,” said Dybas, a resident of Saraland, a suburb of Mobile.

Alabama is one of 10 states that have refused to adopt the Affordable Care Act’s expansion of Medicaid, the government health insurance program for people who are low-income or disabled.

But lawmakers in Alabama and some other Southern states are reconsidering their opposition in light of strong public support for Medicaid expansion and pleas from powerful sectors of the health care industry, especially hospitals.

Expansions are under consideration by Republican legislative leaders in Georgia and Mississippi, in addition to Alabama, raising the prospect that more than 600,000 low-income, uninsured people in those three states could gain coverage, according to KFF data.

Since a 2012 Supreme Court ruling rendered the ACA’s Medicaid expansion optional, it has remained a divisive issue along party lines in some states. Political opposition has softened, in part because North Carolina’s Republican-controlled legislature voted last year to expand the program. Already, more than 346,000 residents of the Tar Heel State have gained coverage.

And lawmakers in nearby states are taking notice.

“There has certainly been a lot of discussion of late about Medicaid expansion,” said Georgia House Speaker Jon Burns, a Republican, in a speech to the state chamber of commerce shortly after the legislative session began on Jan. 8.

“Expanding access to care for lower-income working families through a private option — in a fiscally responsible way that lowers premiums — is something we will continue to gather facts on in the House,” Burns said.

In addition to Georgia, state House speakers in Alabama and Mississippi have indicated a new willingness to consider coverage expansion. All three states have experienced a large number of hospital closures, particularly in rural areas.

Medicaid expansion has become “politically safer to consider,” said Frank Knapp, president of South Carolina’s Small Business Chamber of Commerce. In his state, Republican lawmakers are weighing whether to appoint a committee to study expansion.

It’s the kind of momentum some health policy analysts view as a favorable shift in the political discourse about expanding access to care. And it comes as a new crop of conservative leaders grapple with their states’ persistently high rates of poor, uninsured adults.

An additional incentive: Under President Joe Biden’s 2021 American Rescue Plan Act, the federal government pays newly expanded states an additional 5 percentage points in the matching rate for their regular Medicaid population for two years, which would more than offset the cost of expansion for that period.

But even as new discussions take place in legislatures that once froze out any talk of Medicaid expansion, considerable obstacles remain. Republican Mississippi Gov. Tate Reeves, for example, still opposes expansion. And several nonexpansion states appear to have little to no momentum.

“A lot of things need to come together in any given state to make things move,” said Robin Rudowitz, director of the Program on Medicaid and the Uninsured at KFF.

Under Medicaid expansion, adults earning up to 138% of the federal poverty level, or about $35,600 for a family of three, qualify for coverage.

Expansion has reduced uninsured rates in rural areas, improved access to care for low-income people, and lowered uncompensated care costs for hospitals and clinics, according to KFF analyses of studies from 2014 to 2021. In states that have refused to expand Medicaid, all of those challenges remain acute.

Alabama’s legislative session began Feb. 6. Republican House Speaker Nathaniel Ledbetter has suggested that he’s open to debating options for increased coverage. So many hospitals are in “dire straits,” he said at a Montgomery Area Chamber of Commerce meeting in January. “We’ve got to have the conversation.”

Expansion could make as many as 174,000 uninsured people in Alabama eligible for coverage, according to KFF data. Still, Ledbetter prefers a public-private partnership model, and has looked at Arkansas’ program, which uses federal and state money to pay for commercial insurance plans on the Obamacare marketplace for people who would be eligible for Medicaid under expansion.

In Alabama, lawmakers have introduced a plan that would levy a state tax on gaming revenue and could help fund health insurance coverage for adults with annual incomes up to 138% of the federal poverty level.

Robyn Hyden, executive director of advocacy group Alabama Arise, which supports Medicaid expansion, has seen progress on efforts to increase coverage. “The devil’s going to be in the details,” she said.

Mississippi’s new House speaker, Jason White, a Republican, has said he wants to protect hospitals and keep residents from seeking regular care through the emergency room. More than 120,000 uninsured people in Mississippi would become newly eligible for Medicaid under expansion, according to KFF data.

White told KFF Health News in a written statement that improving access to health care is a priority for business leaders, community officials, and voters.

“The desire to keep Mississippians in the workforce and out of the emergency room transcends any political party and is a vital component to a healthy workforce and a healthy economy,” he said. State legislators are determined to work with Reeves on the issue, he said.

Burns, the Georgia House speaker, has said that he’s open to a proposal for an Arkansas-style plan. Republican Gov. Brian Kemp said he would reserve comment until after the legislative process, according to spokesperson Carter Chapman.

He emphasized Kemp’s commitment to his recently launched plan requiring low-income adults to work, volunteer, or receive schooling or vocational training for 80 hours a month in exchange for Medicaid coverage. As of mid-January, the cumulative enrollment was right around 3,000. Expansion could make at least 359,000 uninsured people in Georgia newly eligible for Medicaid, according to KFF data.

In South Carolina, Republican lawmakers are considering legislation that would allow them to form a committee to study expansion. State Sen. Tom Davis, a Republican from Beaufort who sponsored the bill and previously opposed expanding Medicaid, said he’s not endorsing or opposing Medicaid expansion at this time.

“We need to have a debate,” Davis said during a committee meeting in January.

The state legislature would likely have to work with Gov. Henry McMaster, a Republican, who, according to spokesperson Brandon Charochak, remains opposed to Medicaid expansion.

North Carolina started enrolling residents under its expansion Dec. 1. They included Patrick Dunnagan, 38, of Raleigh. The former outdoor guide said he hasn’t been able to work for years because of kidney disease and chronic pain.

He has relied on financial support from his family and said his medical debt stands at more than $5,000. Medicaid coverage will provide financial security.

Dunnagan said people with chronic health conditions in nonexpansion states “are accumulating medical debt and not getting the care they need.”

Bills proposed in Texas’ legislature didn’t get a vote last year. And the state doesn’t allow voter-initiated referendums, which have been a route to expansion in some Republican-led states. An estimated 1.2 million uninsured people would be eligible for coverage — more than in any other state still holding out — if Texas expanded.

Republican lawmakers in Tennessee and Florida have said they won’t allow Medicaid expansion. In Florida, advocates have launched a petition drive for a ballot initiative, but the earliest it could go to voters is 2026.

In Kansas, Gov. Laura Kelly, a Democrat, is once again pressing her state’s Republican-controlled legislature to adopt Medicaid expansion, calling it a “commonsense proposal” that would lower health care costs for all consumers and protect rural hospitals. But the state’s House speaker remains opposed to Medicaid expansion.

Advocates believe it’s only a matter of time before Medicaid expansion happens nationwide as opposition eases and people continue to suffer the consequences of being uninsured.

For Dybas in Alabama, the prospect of gaining coverage is enough to make her consider relocating. In Minnesota, where she once lived, “I wouldn’t have this problem,” Dybas said.

Perhaps, as in Arkansas, conservatives will adopt models that rely more heavily on commercial insurance.

But many holdout states in the South — where death rates for heart disease, cancer, and diabetes are mostly worse than in other states — see growing disparities between the health of their citizens and those of neighboring states that have expanded, said Lucy Dagneau, a senior director for the American Cancer Society’s advocacy arm, the Cancer Action Network. The group lobbies state legislatures for expanded insurance coverage.

“There will be a tipping point for all these states,” she said.

KFF Health News South Carolina correspondent Lauren Sausser and senior correspondent Renuka Rayasam contributed to this report.

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