PAHO Director warns of intensifying climate threats to health in the Americas at global conference in Brazil

Cristina Mitchell

29 Jul 2025

And presto: You’ve got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.

The Trump administration and congressional Republicans have just checked that achievement off their list.

They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of new regulations released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.

Among the many provisions, there’s this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.

Wait. What?

I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It’s an echo of the federal immigration raids in Los Angeles and elsewhere.

“It’s creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. “For those who believe health care is a human right, this is like excluding that population from something that should be a given.”

In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.

It’s not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.

The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And “Dreamers” will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.

The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.

Supporters of the policy changes enshrined in the CMS rule and budget law think it’s high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.

“It’s about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program,” says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.

But Blase doesn’t have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.

Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. “If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered,” she says.

Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California’s 1.9 million enrollees. That’s because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.

Covered California data shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.

Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.

The covid-era enhanced tax credits, which have more than doubled ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets by an average of 66% at Covered California and more than 75% nationally.

And an analysis by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.

Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.

“Who are the people who are going to decide to go through hours and hours of onerous paperwork?” says Morse Gasteier. “They’re people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks.”

California and 20 other states this month challenged some of that red tape in a federal lawsuit to stop provisions of the CMS rule that erect “unreasonable barriers to coverage.” California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.

“The Trump administration claims that their final rule will prevent fraud,” Bonta said. “It’s obvious what this is really about. It’s yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act.”

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

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.

USE OUR CONTENT

This story can be republished for free (details).

PAHO/WHO convenes journalists to reshape how road safety is covered in Latin America

Cristina Mitchell

28 Jul 2025

WHO urges action on hepatitis, announcing hepatitis D as carcinogenic

Cristina Mitchell

28 Jul 2025

View the full post Sandals Resorts awarded CARPHA’s highest health and safety honour on NOW Grenada.

• Trying to explain a scene from “The Lion King” to my mom. 
• Missing my mom when she went back to Ohio after a long visit with me and my baby in New York. 
• Describing to a friend how many New Yorkers volunteer to help me carry the baby’s stroller up and down the subway stairs, and how diverse the range of people who help me is, and how it makes me appreciate the no-nonsense communal spirit of this city, where people take care of each other without even breaking their stride.
• Thinking about what an emotional movie “Inside Out” is — I wasn’t thinking about what actually happens in the movie, I was thinking about how the movie made me cry, and I cried.

From these incidents, you might conclude, rightly, that children’s movies are my Achilles’ heel. What might be less obvious is that I’m crying more these days because I recently tapered off antidepressants after nearly 10 years. Escitalopram (the generic version of Lexapro) had long helped improve my mental health with minimal side effects — apart from stopping up my tear ducts. Now I’m in the process of discovering what my mind is like without the assistance of medication.

Read the rest…

Santo Domingo — From the age of 60 onwards, the upward curve that increases the probability of a cerebrovascular accident ( CVA ) begins. However, in recent years, episodes have been observed in patients between 15 and 48 years of age.

This is according to Dr. José Joaquín Puello, a professor of medicine in the field of neurosurgery, who received a tribute this Saturday for his career during the National Symposium on Comprehensive Stroke Management, organized by the Cruz Jiminián Catheterization, Arrhythmia, and Pacemaker Unit.

During his speech, Puello highlighted that approximately 16 to 20 million people worldwide suffer a stroke each year, a figure that is on the rise, with the estimate being that it will reach 77 million by 2030.

In the case of the Dominican Republic, he stated that the prevalence is 183 patients per 100,000 inhabitants, which leads to an estimate that between 20,000 and 22,000 cases occur each year, with a high mortality rate.

“Of every 183 patients with their first stroke , 90 die. We’re talking about an epidemic,” he said.

A stroke, also known as an ictus, is the second cause of death in the country, but it is also the first cause of disability. 

Receive a weekly summary of the most important news stories for the Dominican diaspora and the United States in your inbox.

It occurs when there is an interruption in blood flow to the brain, and can be of two types: 

• Ischemic stroke occurs in 85% of cases when a clot blocks the flow of blood and nutrients, also known as a cerebral infarction.
• Hemorrhagic stroke, commonly known as a stroke, occurs in 15% of cases and occurs after a rupture of blood vessels.

Luis Eduardo Aybar, director of the Sanitary City, also expressed concern about comorbidities that increase risk factors. He cited these as high blood pressure, diabetes, a sedentary lifestyle, smoking, and a high-fat diet.

“We are facing a true pandemic. Strokes are becoming the number one most important public health disorder ,” he added.

The doctor indicated that he had observed an increase in cognitive disorders after coronavirus infections in 2020, where 38% of patients who were hospitalized with Covid continue to present after-effects to this day, as well as an increase in kidney diseases that keep hemodialysis units full.

1.9 million neurons die every minute

Emergency physician Abilquis Escoto explained the “ABCs of stroke ,” stating that for every minute a patient goes without treatment, they lose 1.9 million neurons.

“For every hour, the brain ages 3.6 years,” he added.

Escoto cited as serious the fact that between 30 and 40% of patients do not recognize the symptoms of a stroke (dizziness, double vision, loss of balance, distorted face), meaning that in the last three months, 90% of patients admitted to the Cruz Jiminián Unit arrive outside the response window.

Similarly, he compared local data with other countries, highlighting that in Europe, between 20 and 35% of patients receive acute treatment for strokes. At the same time, in the Dominican Republic, the figure barely reaches between 2% and 5%.

“Fifty percent of strokes are prevented when blood pressure is kept under control,” he warned.

High cost of treatment

Dr. Minelly Rodríguez, in her talk titled “The Reality of Stroke in the Dominican Republic,” commented that the cost of treating a patient for a first stroke can reach 700,000 pesos, including the Intensive Care Unit (ICU), treatment, and subsequent rehabilitation, representing a burden on the health system of up to 54 billion pesos each year.

The first warning signs will be a patient whose speech is slurred, whose mouth is twisted, or whose half of the body is dead.

Rodríguez urged patients not to stay home, as Dominicans typically self-medicate or drink a tea recommended by a family member or neighbor, and when it comes to stroke, every second counts.

Among the limitations for optimal care, he stated: 

• Shortage in specialized stroke units.
• Limited timely access to thrombolysis or thrombectomy, treatments used to dissolve or remove blood clots in the brain, exceeding the 4.5-hour window after the event occurs.
• Patients living in rural areas and remote provinces are unable to reach the hospital in time because most stroke centers are located in Santo Domingo and Santiago.
• There is a need to improve health insurance coverage for acute and post-stroke care.

Primary care

For his part, Minister of Public Health Víctor Atallah commented that since last year, the focus has been on prevention and primary care to detect patients before a stroke occurs.

To this end, “More Health and Hope” campaigns are being held in various provinces across the country, offering consultations and medical imaging. Improvements have been made to the Hearts Strategy for patients with hypertension and diabetes, and clinical protocols for managing these chronic non-communicable diseases have been strengthened.

“There’s no time for a stroke; we have to get to work,” he said, referring to the window of action that lasts just 4.5 hours after a patient begins to show symptoms of a stroke.

Stroke Prevention
To prevent a stroke, it is crucial to recognize the warning signs and respond promptly. Control your blood pressure, blood sugar, and cholesterol levels. Eat a healthy diet, exercise regularly, and get plenty of sleep. Avoid excessive tobacco and alcohol use, and keep stress under control. If you experience any symptoms, seek immediate attention: with stroke, time is brain.