Doctors, hospitals, and health insurers for weeks issued dire warnings to Republican lawmakers that millions of people would lose health coverage and hospitals would close if they cut Medicaid funding to help pay for President Donald Trump’s big tax and spending bill.

But Republicans ignored those pleas, made even deeper cuts, and sent the legislation on July 3 to the White House, where Trump signed it the next day.

The law’s passage marked a rare political loss for some of the health industry’s biggest players. When unified, doctors, hospitals, and insurers have stood among the most powerful lobbying forces in Washington and have a long track record of blocking or forcing changes to legislation that could hurt them financially.

But health industry lobbyists are catching their breath and assessing the damage after Trump’s massive bill raced through Congress in less than two months with only Republican votes.

Several lobbyists offered various reasons for being unable to stave off big cuts to Medicaid, a $900 billion state-federal health insurance program that covers an estimated 72 million low-income and disabled people nationally and accounts for 19% of all spending on hospital care, about $283 billion a year, according to the latest data. But nearly all agreed that GOP lawmakers were more worried about angering Trump than facing backlash from local hospitals and constituents back home.

“Members were more scared of Trump issuing a primary challenge than disappointing local voters who may find their hospital has to close or their insurance premium may go up,” said Bob Kocher, a partner with venture capital firm Venrock who served in the Obama administration, referring to election primaries leading into the midterms.

Consider what happened to Sen. Thom Tillis (R-N.C.). After he took to the Senate floor to announce his opposition to the bill because of its cuts to Medicaid, Trump threatened to support a challenger to run against Tillis next year. Shortly thereafter, Tillis announced his retirement from politics.

But other factors were at work.

The health industry’s warnings to lawmakers may have been dismissed because hospitals, health centers, and other health care provider groups are seen by Republicans as strong backers of the Affordable Care Act, the law known as Obamacare that’s considered Democrats’ biggest domestic achievement in decades.

The ACA expanded government health insurance coverage to millions of people previously not eligible. And no Republicans voted for it.

“Hospitals’ support of the ACA has frustrated Republicans, and as a result there is less a reservoir of goodwill to hospitals than in the past,” Kocher said.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said her lobbying team spent extra time on Capitol Hill with lawmakers and their staffers, raising concerns about how the legislation would imperil health care coverage.

“There was almost an overriding sense on the part of Republicans in Congress to deliver a major victory for President Trump,” she said. Her group represents health plans that provide coverage in about 40 states. “That superseded some of their concerns, reluctance, and hesitation.”

Connolly said she repeatedly heard from GOP lawmakers that the focus was on delivering on Trump’s campaign promise to extend his 2017 tax cuts.

She said the concerns of some moderate members helped lead to one concession: a $50 billion fund to help rural hospitals and other health providers.

The money, she said, may have made it easier for some lawmakers to support a bill that, in total, cuts more than $1 trillion from Medicaid over a decade.

Another twist: Many new lawmakers were clearly still learning about Medicaid, she said.

Republicans also seemed eager to reduce the scope of Medicaid and Affordable Care Act marketplace coverage after enrollment in both programs soared to record levels during the pandemic and the Biden administration, she said. Trump’s law requires states to verify eligibility for Medicaid at least every six months and ends auto-enrollment into marketplace plans — steps health policy experts says will reverse some of those gains.

Charles “Chip” Kahn, a longtime health lobbyist and CEO of the Federation of American Hospitals, which represents for-profit hospitals, said the industry’s message was heard on Capitol Hill. But because the bill dealt with so many other issues, including tax cuts, border security, and energy, lawmakers had to decide whether potential health coverage losses were more important.

It was very different than in 2017, when Republicans tried to repeal Obamacare but failed. Trump’s 2025 measure, Kahn said, isn’t a health reform bill or a health bill.

It “left us with an outcome that was unfortunate.”

There were some successes, however, Kahn said.

Industry lobbying did prevent the federal government from reducing its share of spending for states that expanded Medicaid under the ACA. Hospitals and other Medicaid advocates also persuaded Congress not to cap the program’s open-ended federal funding to states. Both measures would have tallied billions more in additional Medicaid funding cuts.

The new law doesn’t change eligibility rules for Medicaid or change its benefits. But it does stipulate that states require most Medicaid enrollees who gained coverage via the ACA’s expansion to document that they work or volunteer 80 hours a month, a provision the Congressional Budget Office predicts will lead to about 5 million people losing coverage by 2034.

The law also limits states’ use of a decades-old system of taxing health providers to leverage extra federal Medicaid funding. This was another loss for the hospital industry, which has supported the practice because it led to higher payments from Medicaid.

Medicaid generally pays lower fees for care than private insurance and Medicare, the program for people 65 and older as well as those with disabilities. But due to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Kahn credits the Paragon Health Institute, a conservative think tank, and its CEO Brian Blase for pushing the argument that provider taxes amounted to legalized “money laundering.” Blase advised Trump on health policy in his first term.

One hospital executive who asked for his name to be withheld to avoid professional retribution said the message — that some facilities had used this play to increase their profits — resonated with GOP lawmakers. “They thought some hospitals were doing fine financially and did not want to reward them,” he said.

Still, Kahn, who is retiring at the end of the year, said he was pleased the Senate delayed implementation of the provider tax cuts until 2028. That will give the health industry a chance to revise the law, he speculated, possibly after the 2026 midterm election changes the balance of power in Congress.

In rural northeastern Louisiana, Todd Eppler, CEO of Desoto Regional Medical Center, had hoped Congress would pass the initial House version of the bill, which didn’t include cuts to provider-tax funding. But he said any impact on his hospital in Mansfield, located in House Speaker Mike Johnson’s district, will be offset by the $50 billion rural health fund.

“I am happy where we ended up,” Eppler said. “I think they listened to rural hospitals.”

Hospitals have argued for decades that any cuts in federal funding to Medicaid or Medicare would harm patients and lead to service reductions. Because hospitals are usually one of the largest employers in a congressional district, the industry often also warns of potential job losses. Such arguments typically give lawmakers pause.

But this time around, that message had little traction.

One health industry lobbyist, who asked not to be identified to speak candidly without risking professional repercussions, said there was a sense on Capitol Hill that hospitals could withstand the funding cuts.

But there’s also a belief that trade groups including the American Hospital Association, the largest hospital industry lobbying organization, could have been more effective. “There is lot of concern that AHA statements were too soft, too little, and too late,” he said.

AHA helped lead a coalition of hospital organizations that spent millions of dollars on television advertising against the GOP bill. Its president and CEO, Rick Pollack, said in a statement before the House voted on the legislation that the cuts to Medicaid would be a “devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities.”

Pollack said in a statement to KFF Health News that the appeal of tax cuts drove Republican lawmakers to pass the law.

“Hospitals and health systems have tirelessly advocated to protect coverage and access for millions of people,” he said. “We will continue to raise these critical issues to mitigate the effects of these proposals.”

The nation’s largest trade group for doctors, the American Medical Association, also opposed the funding cuts to Medicaid and other federal health programs. Its president, Bobby Mukkamala, said in a July 1 statement that the changes “will shift costs to the states and specifically to physicians and hospitals to provide uncompensated care at a time when rural hospitals and physician practices are struggling to keep their doors open.”

But the AMA was also focused on securing higher Medicare fees for doctors. The law ultimately included a one-time 2.5% Medicare pay bump for doctors in 2026. This wasn’t a victory because it left out the House version’s permanent payment fix that would have tied doctor pay to the medical inflation rate. Mukkamala noted the temporary lift but described it as falling “far short of what is needed to preserve access to care for America’s seniors.”

Joe Dunn, chief policy officer at the National Association of Community Health Centers, said his organization worked relentlessly this year to prevent deeper Medicaid cuts that would financially hurt nonprofit clinics. Health center administrators visited Washington in February, made thousands of phone calls, and sent emails to members of Congress.

One payoff was that the health centers were exempted from the law’s requirement that providers charge some Medicaid enrollees up to $35 copayments for services.

But at the end of the day, Dunn said, many GOP House and Senate members simply wanted to finish the bill. “They went in a direction that satisfied the president’s timelines and goals,” he said.

Chief Washington correspondent Julie Rovner contributed to this report.

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Nearly two-thirds of adults oppose President Donald Trump’s “One Big Beautiful Bill” approved in May by the House of Representatives, according to a KFF poll released Tuesday.

And even Trump’s most ardent supporters like the legislation a lot less when they learn how it would cut federal spending on health programs, the poll shows.

The KFF poll found that about 61% of Republicans and Republican-leaning independents — and 72% of the subset who identify with Trump’s “Make American Great Again” movement — support the bill, which would extend many of Trump’s 2017 tax cuts while reducing spending on domestic programs, including cutting billions from Medicaid.

But when pollsters told survey respondents about the bill’s consequences for health care, opposition grew, including among MAGA supporters.

For example, after being told that the bill would decrease funding for local hospitals and increase the number of people without health insurance, support among those who back MAGA dropped more than 20 percentage points — resulting in less than half the group still backing the bill.

Ashley Kirzinger, KFF’s director of survey methodology and associate director of its Public Opinion and Survey Research program, said it’s no surprise polling shows that party affiliation affects how most of the public views the bill.

“But the poll shows that support, even among MAGA supporters, drops drastically once the public hears more about how the bill could impact local hospitals and reduce Medicaid coverage,” she said.

“This shows how the partisan lens wears slightly when the public learns more about how the legislation could affect them and their families.”

KFF is a health policy research, polling, and news organization that includes KFF Health News.

House Speaker Mike Johnson, a Louisiana Republican who won passage of the legislation in the chamber he controls by a single vote on May 22, has insisted the bill would not “cut Medicaid.” The nonpartisan Congressional Budget Office, which calculates the effects of legislation on the nation’s deficits and debt, says the measure would reduce federal spending on Medicaid by $793 billion over 10 years, resulting in nearly 8 million more people becoming uninsured.

The bill is encountering strident opposition from the health industry, most notably hospitals that expect to see large cuts in funding as a result of millions of people losing Medicaid coverage. The House-passed legislation would increase the frequency of eligibility checks and require that most nondisabled adults regularly prove they are working, studying, or volunteering at least 80 hours a month to keep their coverage.

“This is common sense,” Johnson said May 25 on the CBS News program “Face the Nation.” “And when the American people understand what we are doing here, they applaud it.”

Critics say the bill marks the latest attempt by Republicans to roll back the Affordable Care Act.

As the Senate moves toward a possible vote on its version of the legislation before Independence Day, the KFF poll shows Medicaid and the ACA are more popular than ever.

About 83% of adults support Medicaid, including large majorities of Democrats (93%), independents (83%), and Republicans (74%). That’s up from 77% in January, with the poll finding the biggest jump in favorability among Republicans.

Medicaid and the related Children’s Health Insurance Program cover about 78 million people who are disabled or have low incomes.

About two-thirds of adults hold favorable views of the ACA, the most since the law’s enactment in 2010, as recorded in KFF polls. The law has only been consistently popular with a majority of adults since about 2021.

Views of the ACA remain split along partisan lines, with most Republicans (63%) holding unfavorable views and most Democrats (94%) and independents (71%) viewing it favorably.

The poll found other indications that the public may not understand key provisions of the GOP bill, including its work requirements.

The poll finds two-thirds of the public — including the vast majority of Republicans (88%) and MAGA supporters (93%) and half (51%) of Democrats — initially support requiring nearly all adults on Medicaid to prove they are working or looking for work, in school, or doing community service, with exceptions such as for caregivers and people with disabilities.

However, attitudes toward this provision shifted dramatically when respondents were presented with more information.

For example, when told most adults with Medicaid are already working or unable to work, and that those individuals could lose coverage due to the challenge of documenting it, about half of supporters changed their view, resulting in nearly two-thirds of adults opposing Medicaid work requirements and about a third supporting them.

The poll of 1,321 adults was conducted online and by telephone June 4-8 and has a margin of error of plus or minus 3 percentage points.

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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Millions would lose Medicaid coverage. Millions would be left without health insurance. Signing up for health plans on the Affordable Care Act marketplaces would be harder and more expensive.

President Donald Trump’s domestic policy legislation, the One Big Beautiful Bill Act that cleared the House in May and now moves to the Senate, could also be called Obamacare Repeal Lite, its critics say. In addition to causing millions of Americans to lose their coverage under Medicaid, the health program for low-income and disabled people, the measure includes the most substantial rollback of the ACA since Trump’s Republican allies tried to pass legislation in 2017 that would have largely repealed President Barack Obama’s signature domestic accomplishment.

One difference today is that Republicans aren’t describing their legislation as a repeal of the ACA, after the 2017 effort cost them control of the House the following year. Instead, they say the bill would merely reduce “waste, fraud, and abuse” in Medicaid and other government health programs.

“In a way, this is their ACA repeal wish list without advertising it as Obamacare repeal,” said Philip Rocco, an associate professor of political science at Marquette University in Milwaukee and co-author of the book “Obamacare Wars: Federalism, State Politics, and the Affordable Care Act.”

The GOP, Rocco said, learned eight years ago that the “headline of Obamacare repeal is really bad politics.”

Democrats have tried to frame Trump’s One Big Beautiful Bill Act as an assault on Americans’ health care, just as they did with the 2017 legislation.

“They are essentially repealing parts of the Affordable Care Act,” Rep. Frank Pallone Jr. (D-N.J.) said as the House debated the measure in May. “This bill will destroy the health care system of this country.”

Nearly two-thirds of adults have a favorable view of the ACA, according to polling by KFF, a national health information nonprofit that includes KFF Health News.

In contrast, about half of people polled also say there are major problems with waste, fraud, and abuse in government health programs, including Medicaid, KFF found.

“We are not cutting Medicaid,” House Speaker Mike Johnson said May 25 on CNN’s “State of the Union,” describing the bill’s changes as affecting only immigrants living in the U.S. without authorization and “able-bodied workers” whom he claimed are on Medicaid but don’t work.

The program is “intended for the most vulnerable populations of Americans, which is pregnant women and young single mothers, the disabled, the elderly,” he said. “They are protected in what we’re doing because we’re preserving the resources for those who need it most.”

The 2025 legislation wouldn’t cut as deeply into health programs as the failed 2017 bill, which would have led to about 32 million Americans losing insurance coverage, the Congressional Budget Office estimated at the time. By contrast, the One Big Beautiful Bill Act, with provisions that affect Medicaid and ACA enrollees, would leave nearly 9 million more people without health insurance by 2034, according to the CBO.

That number rises to nearly 14 million if Congress doesn’t extend premium subsidies for Obamacare plans that were enhanced during the pandemic to help more people buy insurance on government marketplaces, the CBO says. Without congressional action, the more generous subsidies will expire at the end of the year and most ACA enrollees will see their premiums rise sharply.

The increased financial assistance led to a record 24 million people enrolled in ACA marketplace plans this year, and health insurance experts predict a large reduction without the enhanced subsidies.

Loss of those enhanced subsidies, coupled with other changes set in the House bill, will mean “the ACA will still be there, but it will be devastating for the program,” said Katie Keith, founding director of the Center for Health Policy and the Law at Georgetown University.

Republicans argue that ACA subsidies are a separate issue from the One Big Beautiful Bill Act and accuse Democrats of conflating them.

The House-passed bill also makes a number of ACA changes, including shortening by a month the annual open enrollment period and eliminating policies from Joe Biden’s presidency that allowed many low-income people to sign up year-round.

New paperwork hurdles the House bill creates are also expected to result in people dropping or losing ACA coverage, according to the CBO.

For example, the bill would end most automatic reenrollment, which was used by more than 10 million people this year. Instead, most ACA enrollees would need to provide updated information, including on income and immigration status, to the federal and state ACA marketplaces every year, starting in August, well before open enrollment.

Studies show that additional administrative hurdles lead to people dropping coverage, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“Not only do people drop out of the process, but it tends to be healthier, younger, lower-income folks who drop out,” she said. “That’s dumb because they go uninsured. Also, it is bad for the insurance market.”

Supporters of the provision say it’s necessary to combat fraudulent enrollment by ensuring that ACA beneficiaries still want coverage every year or that they are not being enrolled without their permission by rogue sales agents. Most of the Medicaid coverage reductions in the bill, the CBO says, are due to new work requirements and directives for the 21 million adults added to the program since 2014 under an expansion authorized by the ACA.

One new requirement is that those beneficiaries prove their eligibility every six months, instead of once a year, the norm in most states.

That would add costs for states and probably lead to people who are still eligible falling off Medicaid, said Oregon Medicaid Director Emma Sandoe. Oregon has one of the most liberal continuous eligibility policies, allowing anyone age 6 or older to stay on for up to two years without reapplying.

Such policies help ensure people don’t fall off for paperwork reasons and reduce administrative burden for the state, Sandoe said. Requiring more frequent eligibility checks would “limit the ability of folks to get care and receive health services, and that is our primary goal,” Sandoe said.

The 2017 repeal effort was aimed at fulfilling Trump’s promises from his first presidential campaign. That’s not the case now. The health policy provisions of the House bill instead would help to offset the cost of extending about $4 trillion in tax cuts that skew toward wealthier Americans.

The Medicaid changes in the bill would reduce federal spending on the program by about $700 billion over 10 years. CBO has not yet issued an estimate of how much the ACA provisions would save.

Timothy McBride, a health economist at Washington University in St. Louis, said Republican efforts to make it harder for what they term “able-bodied” adults to get Medicaid is code for scaling back Obamacare.

The ACA’s Medicaid expansion has been adopted by 40 states and Washington, D.C. The House bill’s work requirement and added eligibility checks are intended to drive off Medicaid enrollees who Republicans believe never should have been on the program, McBride said. Congress approved the ACA in 2010 with no Republican votes.

Most adult Medicaid enrollees under 65 are already working, studies show. Imposing requirements that people prove they’re working, or that they’re exempt from having to work, to stay on Medicaid will lead to some people losing coverage simply because they don’t fill out paperwork, researchers say.

Manatt Health estimates that about 30% of people added to Medicaid through the ACA expansion would lose coverage, or about 7 million people, said Jocelyn Guyer, senior managing director of the consulting firm.

The bill also would make it harder for people enrolled under Medicaid expansions to get care, because it requires states to charge copayments of up to $35 for some specialist services for those with incomes above the federal poverty level, which is $15,650 for an individual in 2025.

Today, copayments are rare in Medicaid, and when states charge them, they’re typically nominal, usually under $10. Studies show cost sharing in Medicaid leads to worse access to care among beneficiaries.

Christopher Pope, a senior fellow with the conservative Manhattan Institute, acknowledged that some people will lose coverage but rejected the notion that the GOP bill amounts to a full-on assault on the ACA.

He questioned the coverage reductions forecast by the CBO, saying the agency often struggles to accurately predict how states will react to changes in law. He said that some states may make it easy for enrollees to satisfy new work requirements, reducing coverage losses.

By comparison, Pope said, the ACA repeal effort from Trump’s first term a decade ago would have ended the entire Medicaid expansion. “This bill does nothing to stop the top features of Obamacare,” Pope said.

But McBride said that while the number of people losing health insurance under the GOP bill is predicted to be less than the 2017 estimates, it would still eliminate about half the ACA’s coverage gains, which brought the U.S. uninsured rate to historical lows. “It would take us backwards,” he said.

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

President Donald Trump’s signature budget legislation would punish 14 states that offer health coverage to people in the U.S. without authorization.

The states, most of them Democratic-led, provide insurance to some low-income immigrants — often children — regardless of their legal status. Advocates argue the policy is both humane and ultimately cost-saving.

But the federal legislation, which Republicans have titled the “One Big Beautiful Bill,” would slash federal Medicaid reimbursements to those states by billions of dollars a year in total unless they roll back the benefits.

The bill narrowly passed the House on Thursday and next moves to the Senate. While enacting much of Trump’s domestic agenda, including big tax cuts largely benefiting wealthier Americans, the legislation also makes substantial spending cuts to Medicaid that congressional budget scorekeepers say will leave millions of low-income people without health insurance.

The cuts, if approved by the Senate, would pose a tricky political and economic hurdle for the states and Washington, D.C., which use their own funds to provide health insurance to some people in the U.S. without authorization.

Those states would see their federal reimbursement for people covered under the Affordable Care Act’s Medicaid expansion cut by 10 percentage points. The cuts would cost California, the state with the most to lose, as much as $3 billion a year, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

Together, the 15 affected places cover about 1.9 million immigrants without legal status, according to KFF. The penalty might also apply to other states that cover lawfully residing immigrants, KFF says.

Two of the states — Utah and Illinois — have “trigger” laws that call for their Medicaid expansions to terminate if the feds reduce their funding match. That means unless those states either repeal their trigger laws or stop covering people without legal immigration status, many more low-income Americans could be left uninsured.

The remaining states and Washington, D.C., would have to come up with millions or billions more dollars every year, starting in the 2027 fiscal year, to make up for reductions in their federal Medicaid reimbursements, if they keep covering people in the U.S. without authorization.

Behind California, New York stands to lose the most federal funding — about $1.6 billion annually, according to KFF.

California state Sen. Scott Wiener, a Democrat who chairs the Senate budget committee, said Trump’s legislation has sown chaos as state legislators work to pass their own budget by June 15.

“We need to stand our ground,” he said. “California has made a decision that we want universal health care and that we are going to ensure that everyone has access to health care, and that we’re not going to have millions of undocumented people getting their primary care in emergency rooms.”

California Gov. Gavin Newsom, a Democrat, said in a statement that Trump’s bill would devastate health care in his state.

“Millions will lose coverage, hospitals will close, and safety nets could collapse under the weight,” Newsom said.

In his May 14 budget proposal, Newsom called on lawmakers to cut some benefits for immigrants without legal status, citing ballooning costs in the state’s Medicaid program. If Congress cuts Medicaid expansion funding, the state would be in no position to backfill, the governor said.

Newsom questioned whether Congress has the authority to penalize states for how they spend their own money and said his state would consider challenging the move in court.

Utah state Rep. Jim Dunnigan, a Republican who helped spearhead a bill to cover children in his state regardless of their immigration status, said Utah needs to maintain its Medicaid expansion that began in 2020.

“We cannot afford, monetary-wise or policy-wise, to see our federal expansion funding cut,” he said. Dunnigan wouldn’t say whether he thinks the state should end its immigrant coverage if the Republican penalty provision becomes law.

Utah’s program covers about 2,000 children, the maximum allowed under its law. Adult immigrants without legal status are not eligible. Utah’s Medicaid expansion covers about 75,000 adults, who must be citizens or lawfully present immigrants.

Matt Slonaker, executive director of the Utah Health Policy Project, a consumer advocacy organization, said the federal House bill leaves the state in a difficult position.

“There are no great alternatives, politically,” he said. “It’s a prisoner’s dilemma — a move in either direction does not make much sense.”

Slonaker said one likely scenario is that state lawmakers eliminate their trigger law then find a way to make up the loss of federal expansion funding.

Utah has funded its share of the cost of Medicaid expansion with sales and hospital taxes.

“This is a very hard political decision that Congress would put the state of Utah in,” Slonaker said.

In Illinois, the GOP penalty would have even larger consequences. That’s because it could lead to 770,000 adults’ losing the health coverage they gained under the state’s Medicaid expansion.

Stephanie Altman, director of health care justice at the Shriver Center on Poverty Law, a Chicago-based advocacy group, said it’s possible her Democratic-led state would end its trigger law before allowing its Medicaid expansion to terminate. She said the state might also sidestep the penalty by asking counties to fund coverage for immigrants. “It would be a hard situation, obviously,” she said.

Altman said the House bill appeared written to penalize Democratic-controlled states because they more commonly provide immigrants coverage without regard for their legal status.

She said the provision shows Republicans’ “hostility against immigrants” and that “they do not want them coming here and receiving public coverage.”

U.S. House Speaker Mike Johnson said this month that state programs that provide public coverage to people regardless of immigration status serve as “an open doormat,” inviting more people to cross the border without authorization. He said efforts to end such programs have support in public polling.

A Reuters-Ipsos poll conducted May 16-18 found that 47% of Americans approve of Trump’s immigration policies and 45% disapprove. The poll found that Trump’s overall approval rating has sunk 5 percentage points since he returned to office in January, to 42%, with 52% of Americans disapproving of his performance.

The Affordable Care Act, widely known as Obamacare, enabled states to expand Medicaid to adults with incomes of up to 138% of the federal poverty level, or $21,597 for an individual this year. Forty states and Washington, D.C., expanded, helping reduce the national uninsured rate to a historic low.

The federal government now pays 90% of the costs for people added to Medicaid under the Obamacare expansion.

In states that cover health care for immigrants in the U.S. without authorization, the Republican bill would reduce the federal government’s contribution from 90% to 80% of the cost of coverage for anyone added to Medicaid under the ACA expansion.

By law, federal Medicaid funds cannot be used to cover people who are in the country without authorization, except for pregnancy and emergency services.

The other states that use their own money to cover people regardless of immigration status are Colorado, Connecticut, Maine, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, Vermont, and Washington, according to KFF.

Ryan Long, director of congressional relations at Paragon Health Institute, an influential conservative policy group, said that even if they use their own money for immigrant coverage, states still depend on federal funds to “support systems that facilitate enrollment of illegal aliens.”

Long said the concern that states with trigger laws could see their Medicaid expansion end is a “red herring” because states have the option to remove their triggers, as Michigan did in 2023.

The penalty for covering people in the country without authorization is one of several ways the House bill cuts federal Medicaid spending.

The legislation would shift more Medicaid costs to states by requiring them to verify whether adults covered by the program are working. States would also have to recertify Medicaid expansion enrollees’ eligibility every six months, rather than once a year or less, as most states currently do.

The bill would also freeze states’ practice of taxing hospitals, nursing homes, managed-care plans, and other health care companies to fund their share of Medicaid costs.

The Congressional Budget Office said in a May 11 preliminary estimate that, under the House-passed bill, about 8.6 million more people would be without health insurance in 2034. That number will rise to nearly 14 million, the CBO estimates, after the Trump administration finishes new ACA regulations and if the Republican-led Congress, as expected, declines to extend enhanced premium subsidies for commercial insurance plans sold through Obamacare marketplaces.

The enhanced subsidies, a priority of former President Joe Biden, eliminated monthly premiums altogether for some people buying Obamacare plans. They are set to expire at the end of the year.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

It has been nearly eight years since Sen. John McCain’s middle-of-the-night thumbs-down vote torpedoed Republican efforts to repeal the Affordable Care Act and make drastic cuts to Medicaid.

With Donald Trump back in the White House and the GOP back in control of Congress, Republicans again have their eyes on Medicaid, the government health program for those with low incomes or disabilities. A GOP proposal unveiled this week would require many enrollees to prove they are working, volunteering, or studying, and to shoulder more of the costs of their care. It would also curtail taxes levied on providers that help states draw down billions in additional federal money.

Changes are needed, conservative lawmakers say, because the program is broken and costs too much. Medicaid’s annual price tag has soared from about $590 billion in 2017 to nearly $900 billion today.

If this script sounds familiar, it’s because Republicans made the same proposals and arguments in 2017, when they last had narrow control of Congress and Trump in the White House.

But while the 2025 Medicaid debate on Capitol Hill feels like a 2017 replay, the GOP’s latest effort toward a massive transformation could be more of a long shot, several health policy experts say. In the past eight years, Medicaid enrollment has surged to a record high, with the covid-19 pandemic driving numbers up and nine more states expanding the program to cover more low-income Americans, including six controlled by Republicans.

More enrollees, particularly in red states, means more constituents who rely on Medicaid to cover their health costs — making it harder for lawmakers to approve cuts.

“More red states have more skin in the game,” said Christine Eibner, a senior economist at Rand Corp., a nonprofit research organization.

More than three-quarters of the public opposes major cuts to Medicaid, including 55% of Republicans, according to a recent poll from KFF, a health information nonprofit that includes KFF Health News.

With the expansion of coverage to more Americans, Medicaid has grown more popular and important, said Krista Drobac, a health policy consultant who formerly worked for the National Governors Association. “Cutting it is not as politically palatable, even though Congress has moved further to the right.”

After months of saying little beyond citing a need to cut “waste, fraud, and abuse,” Republicans on the House Energy and Commerce Committee released legislation May 11 outlining their plans.

The bill does not include some of the most controversial proposals the GOP considered, such as eliminating the extra federal funding that allowed states to dramatically expand the program. Nonetheless, the changes it does propose amount to hundreds of billions of dollars in Medicaid spending cuts and could cause at least 8.6 million Americans to lose their health coverage, according to a preliminary estimate by the Congressional Budget Office released by the committee’s Democrats.

Some of the proposals are more targeted, such as a new financial penalty on states such as California that use their own money to cover people living in the country without legal permission.

Others would have widespread implications. In addition to requiring low-income people to prove their eligibility every six months, the GOP proposal would mandate that nondisabled enrollees younger than 65, with some exceptions, show that they work, volunteer, or attend school at least 80 hours per month.

A work requirement is an easier sell politically because it is not seen as cutting benefits, Billy Wynne, a Colorado-based health consultant, said in an interview before the legislation was unveiled.

But unlike in 2017, when the GOP also proposed implementing work requirements, such a policy is no longer just a theory: Arkansas’ program, which was suspended by a federal judge in 2019 after less than a year, left 18,000 people without coverage — with no indication the policy led to more people working. And Georgia’s program has been plagued by administrative burdens and cost overruns.

In fact, most Medicaid enrollees are already employed — just 8% of those who would be required to work are not already doing so, according to KFF.

Awareness about Medicaid and its beneficiaries has improved since 2017, Wynne said. “These are working families, and they vote.”

During a marathon House committee debate on the legislation that started Tuesday afternoon and continued through Wednesday morning, Rep. Jake Auchincloss of Massachusetts, a Democrat, voiced concern that burdensome new paperwork requirements would lead to many low-income people dropping or losing their coverage.

“These aren’t work requirements,” he said. “They’re paperwork requirements.”

Another complication for the GOP’s current effort is that the focus is not fixing the health system, as it was with the past push to repeal Obamacare. This time, Republicans’ main goal is offsetting the cost of extending $4 trillion in tax cuts passed under Trump in 2017 — separately from the repeal effort — that will otherwise expire at the end of this year.

Enrollment in Medicaid and its related Children’s Health Insurance Program swelled to over 93 million during the pandemic, a record high. Enrollment had fallen below 79 million as of December, but that was still about 5 million more people than were covered during the repeal debate in the summer of 2017.

Medicaid and CHIP cover more than 1 in 5 Americans, as well as 40% of children, 41% of births, and long-term care for 62% of nursing home residents.

Congressional Republicans for decades have sought to rein in Medicaid costs by capping federal spending but have faced resistance from Democrats, states, and the health industry.

The 2010 Affordable Care Act provided billions in federal Medicaid funding that enabled 40 states and the District of Columbia to expand the program to over 21 million nondisabled adults. But the law passed with no Republican votes, leaving Medicaid expansion open to partisan squabbling.

The new GOP proposal would require Medicaid enrollees making poverty-level wages or higher to pay copayments of as much as $35 per health care service.

Medicaid usually doesn’t require copays, and advocates for low-income people say any out-of-pocket charge at the doctor’s office could discourage them from seeking care.

Republican members of Congress face more pressure to avoid coverage cuts for their constituents, with many now representing expansion states, including key Senate leaders from South Dakota (Majority Leader John Thune) and Idaho (Finance Committee Chairman Michael Crapo).

There’s also pressure coming from an unusual source: Trump voters.

Last fall, Trump attracted more low-income voters than usual for a GOP presidential candidate.

Those voters are more likely to depend on Medicaid for health coverage. Matt Salo, a Washington, D.C.-based health consultant who was formerly executive director of the National Association of Medicaid Directors, said Trump voters have been telling Republicans at town hall meetings that they did not vote for benefit cuts.

“MAGA voters and people on Medicaid and their family members overlap in ways that have never been true before,” Salo said, referring to Trump’s “Make America Great Again” movement.

Republicans also face unfavorable odds of curtailing a long-standing practice by nearly every state — known as provider taxes — through which states pay some of their share of Medicaid costs by taxing hospitals, nursing homes, and other providers. Those funds then help states collect more matching dollars from the federal government.

For decades, Republicans have sought to limit Medicaid provider taxes, and their latest proposal would effectively freeze the taxes at current rates, squeezing state programs as costs continue to rise. Since 2017, such taxes have become more commonplace, and some states now rely on the funding for nearly a third of their Medicaid budgets.

Conservative groups and some GOP lawmakers have begun referring to these taxes as “money-laundering” schemes, even though they are legal and the taxes are approved by the federal government before states implement them.

One thing that hasn’t changed since 2017 is the strong defense of Medicaid from Democrats, hospital executives, and consumer groups, who argue the GOP’s plan will leave more people uninsured or unable to pay their bills, and force hospitals to close, worsening access to care.

Yet the Trump White House is better staffed to work with Congress than it was in 2017, and more members of the party, whether out of fear or loyalty, are likely to side with the president. So far this year, the Republican caucus has had just enough votes to confirm Trump’s Cabinet and pass a budget framework to tee up legislation to extend his tax cuts.

While the House GOP’s plan would amount to major changes for Medicaid, its legislation left out some of the more ground-shifting ideas like capping federal funding per enrollee or nixing extra expansion funding altogether — and it still needs to earn the approval of Senate Republicans.

Medicaid’s chief backers could end up breathing a sigh of relief, just as they did in summer 2017.

KFF Health News’ Julie Rovner contributed to this report.

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

Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.

Donald Trump’s return to the White House — along with a GOP-controlled Senate and House of Representatives — is expected to change that.

Republicans in Washington say they plan to use funding cuts and regulatory changes to dramatically shrink Medicaid, the nearly $900-billion-a-year government health insurance program that, along with the related Children’s Health Insurance Program, serves about 79 million mostly low-income or disabled Americans.

The proposals include rolling back the Affordable Care Act’s expansion of Medicaid, which over the last 11 years added about 20 million low-income adults to its rolls. Trump has said he wants to drastically cut government spending, which may be necessary for Republicans to extend 2017 tax cuts that expire at the end of this year.

Trump made little mention of Medicaid during the 2024 campaign. The first Trump administration approved work requirements in several states, though only Arkansas implemented theirs before a federal judge said it violated the law. The first Trump administration also sought to block grant funding to states.

House Budget Committee Chair Jodey Arrington (R-Texas) told KFF Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. “Without them, we will watch this country sadly enter into fiscal collapse.”

Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.

“You need wholesale reform on the health care front, which can include undoing a lot of the damage being done by the ACA and Obamacare,” Roy said. “Frankly, we could end up providing better service if we do it the right way.”

Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.

“Medicaid is an obvious target for huge cuts,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “An existential fight about Medicaid’s future likely lies ahead.”

Medicaid, which turns 60 in July, is nearing the end of a disruptive period, after covid pandemic-era coverage protections expired in 2023 and all enrollees had to prove they still qualified. More than 25 million people lost coverage over the 18 months after the “unwinding” began, though it has not notably increased the number of people without insurance, according to the latest census data.

The unwinding’s disruptions could pale in comparison to what happens in the next four years, said Matt Salo, former executive director and founder of the National Association of Medicaid Directors. “What we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates,” he said.

But Salo said any efforts to shrink the program will face pushback.

“A lot of powerful entities — state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good — wants to see Medicaid work efficiently and be adequately funded,” he said. “And they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model.”

The GOP is looking at several tactics to reduce the size of Medicaid:

• Shifting to block grants. Switching to annual block grants could lower federal funding for states to operate the program while giving states more discretion over how to spend the money. Currently, the government matches a certain percentage of state spending each year with no cap. Republican presidents since Ronald Reagan have sought to block-grant Medicaid with no success. Arrington said he favors ending the open-ended federal funding to states and replacing it with a set annual amount based on how many people each state has in the program.
• Cutting ACA Medicaid funding. The ACA provided financing to cover, through Medicaid, Americans with incomes up to 138% of the federal poverty level, or $20,783 for an individual last year. The federal government pays 90% of the cost for adults covered through the law’s Medicaid expansion, which 40 states and Washington, D.C., have adopted. The GOP may try to lower that funding to the same match rate the feds pay states for everyone else in the program, which averages about 60%. “We should absolutely note that we are subsidizing the healthy, able-bodied Medicaid expansion population at a higher rate than we do the poorest and sickest among us, which was the original intent of the program,” Arrington said. “That’s not right.”
• Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state’s population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate — all but two are Democratic-run states, including New York and California. The GOP may seek to cut the base rate to 40% or less.
• Adding work requirements. During the first Trump term, federal courts ruled that Medicaid law doesn’t allow coverage to be conditioned on enrollees’ working or seeking jobs. But the GOP may try again. “If we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself,” Rep. Tom McClintock (R-Calif.) told KFF Health News. Because most Medicaid enrollees already work, go to school, or serve as caregivers, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
• Placing enrollment hurdles. About 10 states offer some populations what’s called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy’s been shown to prevent enrollees from falling out of the program for short periods because of hardships or paperwork problems, which can lead to surprise medical bills and debt. The Trump administration could seek to repeal waivers that allow states to grant multiyear continuous eligibility, which would require people in those states to reapply for coverage annually.

If the GOP’s plans to shrink Medicaid are realized, Democrats and health experts say, low-income people forced to buy private insurance would face challenges paying monthly premiums and the large copayments and deductibles common to commercial plans that typically don’t exist in Medicaid.

The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has issued reports saying the billions in extra money states took to expand Medicaid under the ACA has been a boon to private insurers that manage the program and relatively wealthier people it says shouldn’t be enrolled.

Josh Archambault, a senior fellow with the conservative Cicero Institute, said he hopes the Trump administration holds states accountable for overpaying providers and enrolling people in Medicaid who are not eligible. Conservatives have cited CMS reports saying states improperly pay Medicaid providers billions of dollars a year, though the federal government notes that is mostly due to lack of documentation.

He said the GOP will look to scale back Medicaid to its “traditional” populations of children, pregnant women, and people with disabilities. “We need to rebalance the program that most people think is underperforming,” he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, according to polls.

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With Donald Trump’s return to the White House and Republicans taking full control of Congress in 2025, the Affordable Care Act’s Medicaid expansion is back on the chopping block.

More than 3 million adults in nine states would be at immediate risk of losing their health coverage should the GOP reduce the extra federal Medicaid funding that’s enabled states to widen eligibility, according to KFF, a health information nonprofit that includes KFF Health News, and the Georgetown University Center for Children and Families. That’s because the states have trigger laws that would swiftly end their Medicaid expansions if federal funding falls.

The states are Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia.

The 2010 Affordable Care Act encouraged states to expand Medicaid programs to cover more low-income Americans who didn’t get health insurance through their jobs. Forty states and the District of Columbia agreed, extending health insurance since 2014 to an estimated 21 million people and helping drive the U.S. uninsured rate to record lows.

In exchange, the federal government pays 90% of the cost to cover the expanded population. That’s far higher than the federal match for other Medicaid beneficiaries, which averages about 57% nationwide.

Conservative policy groups, which generally have opposed the ACA, say the program costs too much and covers too many people. Democrats say the Medicaid expansion has saved lives and helped communities by widening coverage to people who could not afford private insurance.

If Congress cuts federal funding, Medicaid expansion would be at risk in all states that have opted into it — even those without trigger laws — because state legislatures would be forced to make up the difference, said Renuka Tipirneni, an associate professor at the University of Michigan’s School of Public Health.

Decisions to keep or roll back the expansion “would depend on the politics at the state level,” Tipirneni said.

For instance, Michigan approved a trigger as part of its Medicaid expansion in 2013, when it was controlled by a Republican governor and legislature. Last year, with the government controlled by Democrats, the state eliminated its funding trigger.

Six of the nine states with trigger laws — Arizona, Arkansas, Indiana, Montana, North Carolina, and Utah — went for Trump in the 2024 election.

Most of the nine states’ triggers kick in if federal funding falls below the 90% threshold. Arizona’s trigger would eliminate its expansion if funding falls below 80%.

Montana’s law rolls back expansion below 90% funding but allows it to continue if lawmakers identify additional funding. Under state law, Montana lawmakers must reauthorize its Medicaid expansion in 2025 or the expansion will end.

Across the states with triggers, between 3.1 million and 3.7 million people would swiftly lose their coverage, researchers at KFF and the Georgetown center estimate. The difference depends on how states treat people who were added to Medicaid before the ACA expansion; they may continue to qualify even if the expansion ends.

Three other states — Iowa, Idaho, and New Mexico— have laws that require their governments to mitigate the financial impact of losing federal Medicaid expansion funding but would not automatically end expansions. With those three states included, about 4.3 million Medicaid expansion enrollees would be at risk of losing coverage, according to KFF.

The ACA allowed Medicaid expansions to adults with incomes up to 138% of the federal poverty level, or about $20,783 for an individual in 2024.

Nearly a quarter of the 81 million people enrolled in Medicaid nationally are in the program due to expansions.

“With a reduction in the expansion match rate, it is likely that all states would need to evaluate whether to continue expansion coverage because it would require a significant increase in state spending,” said Robin Rudowitz, vice president and director of the Program on Medicaid and the Uninsured at KFF. “If states drop coverage, it is likely that there would be an increase in the number of uninsured, and that would limit access to care across red and blue states that have adopted expansion.”

States rarely cut eligibility for social programs such as Medicaid once it’s been granted.

The triggers make it politically easier for state lawmakers to end Medicaid expansion because they would not have to take any new action to cut coverage, said Edwin Park, a research professor at the Georgetown University Center for Children and Families.

To see the impact of trigger laws, consider what happened after the Supreme Court in 2022 struck down Roe v. Wade and, with it, the constitutional right to an abortion. Conservative lawmakers in 13 states had crafted trigger laws that would automatically implement bans in the event a national right to abortion were struck down. Those state laws resulted in restrictions taking effect immediately after the court ruling, or shortly thereafter.

States adopted triggers as part of Medicaid expansion to win over lawmakers skeptical of putting state dollars on the hook for a federal program unpopular with most Republicans.

It’s unclear what Trump and congressional Republicans will do with Medicaid after he takes office in January, but one indicator could be a recent recommendation from the Paragon Health Institute, a leading conservative policy organization led by former Trump health adviser Brian Blase.

Paragon has proposed that starting in 2026 the federal government would phase down the 90% federal match for expansion until 2034, when it would reach parity with each state’s federal match for its traditional enrollees. Under that plan, states could still get ACA Medicaid expansion funding but restrict coverage to enrollees with incomes up to the federal poverty level. Currently, to receive expansion funding, states must offer coverage to everyone up to 138% of the poverty level.

Daniel Derksen, director of the Center for Rural Health at the University of Arizona, said it’s unlikely Arizona would move to eliminate its trigger and make up for lost federal funds. “It would be a tough sell right now as it would put a big strain on the budget,” he said.

Medicaid has been in the crosshairs of Republicans in Washington before. Republican congressional leaders in 2017 proposed legislation to cut federal expansion funding, a move that would have shifted billions in costs to states. That plan, part of a strategy to repeal Obamacare, ultimately failed.

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Nearly a year after the Biden administration gave Florida the green light to become the first state to import lower-cost prescription drugs from Canada — a longtime goal of politicians across the political spectrum, including President-elect Donald Trump — the program has yet to begin.

Florida Gov. Ron DeSantis hailed the FDA’s approval of his plan in January, calling it a victory over the drug industry, which opposes importation on the grounds that it would lead to a surge in counterfeit medications.

A Florida health official familiar with the importation program told KFF Health News there was no planned date yet for the state to begin importing drugs. The official asked not to be identified because they weren’t authorized to speak publicly about the program.

Florida applied to create an importation program in November 2020, just months after the Trump administration gave states the option. DeSantis, a Republican, complained publicly for years about the pace of the federal approval process under the Biden administration and in 2022 filed suit against the FDA for what he called a “reckless delay.”

Trump touted his administration’s move to bring medicines over the border in a preelection interview published last month by AARP, the advocacy group for older Americans, which supports allowing Americans to buy drugs from Canada. He vowed to “continue my efforts to protect Americans from unaffordable drug prices” in a second term.

It’s not clear whether his second administration will or can do more to help Florida and other states set up programs, because it’s ultimately up to the states to act. Colorado is the only other state that has an importation plan pending with the FDA.

FDA spokesperson Cherie Duvall-Jones said she could not answer whether Florida had submitted documents the agency requires before the state can start importing medicines. She referred all questions to the state.

After this article was published — and 14 weeks after KFF Health News first contacted Florida officials for comment — Alecia Collins, deputy chief of staff for the Florida Agency for Health Care Administration, said the state is “awaiting feedback from the FDA on the last of the [pharmaceutical] labels so we can move forward with the next steps for launching the program.” The FDA did not immediately respond to a follow-up request for comment.DeSantis press secretary Jeremy Redfern said he had been “slammed” since the first week of November and could not answer questions.

Drug companies typically sell medications for far less in Canada than in the United States, as a result of Canadian government price controls. But because of safety and efficacy concerns, federal law prohibits consumers from buying drugs from outside U.S. borders except in rare cases.

Politicians ranging from conservatives such as DeSantis to liberals such as Sen. Bernie Sanders of Vermont have long pushed for importing lower-cost prescription drugs from Canada.

In 2000, Congress passed a law allowing states to import prescription drugs from north of the border, with the caveat that it could go forward only if the secretary of the Department of Health and Human Services affirmed it was safe. That didn’t happen until 2020, when Trump’s HHS secretary, Alex Azar, made such a declaration.

Since 2022, Azar has been chairman of the board at LifeScience Logistics, a Dallas-based company that Florida is paying millions of dollars to set up its drug importation program, including warehousing its medicines.

Azar on Nov. 13 refused to answer questions from KFF Health News about drug importation, saying he wasn’t authorized to speak on the matter.

Florida’s program would not directly assist consumers at the pharmacy. It’s instead aimed at lowering costs for the state Medicaid program and for the corrections and health departments.

Matthew Baxter, a senior director at Ontario-based Methapharm Specialty Pharmaceuticals, which has contracted with LifeScience to export drugs, would not say whether Methapharm has sent any medicines over the border.

The pharmaceutical industry and the Canadian government oppose U.S. drug importation. Drug companies say importation would increase the risk of counterfeit drugs appearing on U.S. pharmacy shelves, while the government in Ottawa has warned it won’t allow medicines to be exported if Canadians could experience shortages as a result.

Florida’s predicted savings would also be relatively minor. DeSantis estimated the program would save state agencies up to $180 million in its first year. Florida’s annual Medicaid budget tops $30 billion.

Florida identified 14 drugs, including for cancer and AIDS, that it would attempt to import from Canada for its state agencies.

Camm Epstein, a health policy analyst in Saratoga Springs, New York, said drug importation is a seemingly simple concept that resonates with the public, which is why DeSantis and others have turned to the idea as a response to rising drug prices. “It riles up the crowd,” he said. “Who doesn’t want to pay lower drug costs?”

But bringing drugs over the border is complicated because of the FDA’s many requirements, including finding companies to work with — a Canadian exporter and a U.S. importer — and following a process that ensures the drugs are authentic, Epstein said.

“This was, at best, a boondoggle,” he said.

Florida has spent tens of millions of dollars to stand up its drug importation program. The state has already paid LifeScience Logistics $50 million to set up a warehouse to store the medicines. DeSantis noted the costs in his 2022 lawsuit against the FDA.

“Plaintiffs have paid their retained importer and distributor over $24 million thus far — and increasing at the rate of $1.2 million every month — even though not a single prescription pill has been imported, relabeled, or distributed, solely because of the FDA’s idleness,” the state said in its suit.

Florida’s delay may be due to operational challenges, Epstein said. “Predictably, even if they turned on the spigot there would be no flow, because Canada was not going to permit for the supply,” he said.

Colorado and Florida are among at least nine states that have passed laws allowing for Canadian drug importation. Colorado’s 2022 application to the FDA is still pending. In December 2023, Colorado officials released a report noting the state was unable to find a drugmaker willing to sell it medicines from Canada.

[Update: This article was revised at 1 p.m. ET on Nov. 22, 2024, to add a comment from a Florida Agency for Health Care Administration spokesperson.]

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

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert 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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