Azar made the historic declaration in September 2020, just two months before his boss, former President Donald Trump, lost reelection.

Now, Azar’s involved in the business of making importation happen. He is chairman of the board of LifeScience Logistics, a Dallas-based company that Florida is paying as much as $39 million to help manage its Canadian drug importation program, not including the cost of drugs.

LifeScience officials confirmed Azar’s position but didn’t respond to questions about how much he is paid or whether he’s involved in the Florida work. Azar didn’t return messages left with his employers or sent to a personal email address.

The revolving door between government and private sector jobs is well documented. It’s common for top U.S. officials in both parties to leave government service for what are often far better-paid jobs or board seats at companies in the industries they formerly regulated.

About 57% of presidential Cabinet-level officials later served on corporate boards of directors, according to a 2019 study by researchers at Boston and Harvard universities in The Journal of Politics, which examined 84 Cabinet members who served from 1992 to 2014.

“In general, we favor Cabinet secretaries not going into industries which they once regulated, because the possibility of conflicts of interest are unavoidable,” said Robert Weissman, president of Public Citizen, a government watchdog group.

He called Azar’s case atypical because his approval of drug importation was opposed by the pharmaceutical industry, in which Azar was formerly employed. Drugmakers argue the policy puts patients at risk of consuming counterfeit medicines. Azar joined the LifeScience board in January 2022, one year after the end of Trump’s term and about a year after Florida contracted with LifeScience in late 2020.

Katie Hernandez, a spokesperson for LifeScience Logistics, said in a statement that the company, which manages nearly 6 million square feet of warehouse storage across 11 states, signed its deal with Florida before Azar joined the board.

Ivana Katic, assistant professor of organizational behavior at the Yale School of Management, said that Azar’s position at LifeScience “can appear as a conflict of interest” because his policy decision as HHS secretary later benefited him professionally.

Azar was a deputy secretary at HHS during the George W. Bush administration before joining pharmaceutical giant Eli Lilly and Co. as a top executive in 2007, remaining there until months before joining the Trump administration.

Weissman, who supports drug importation, said he doubts Azar had any personal benefit in mind before his decision. Florida Gov. Ron DeSantis had pushed Trump to authorize importation from Canada, and the former president had said he supported importation before Azar certified it was safe.

Canadian drug importation has been the subject of decades of debate. While the U.S. does not regulate most drug costs, Canada does, generally resulting in lower prices than across the border.

In 2018, Azar called importation a “gimmick” because Canada’s pharmaceutical market isn’t large enough to meet U.S. demand. Indeed, the Canadian government has repeatedly warned the U.S. against importation, promising to block any plan that poses a risk of causing shortages in Canada.

The country has implemented regulations “to prohibit certain drugs intended for the Canadian market from being sold for consumption outside of Canada if that sale could cause, or worsen, a drug shortage in Canada,” Health Canada, which regulates drug safety, said in a Jan. 8 statement after the FDA’s approval of Florida’s plan. “This includes all drugs that are eligible for bulk importation to the U.S., including those identified in Florida’s bulk importation plan, or any other US state’s future importation programs.”

Under its contract with Florida, LifeScience Logistics must buy drugs from Canadian suppliers, contract with a lab to verify their authenticity, store the medicines, and ship them to state agencies for distribution. LifeScience built a 100,000-square-foot facility in Lakeland, Florida, to warehouse drugs imported from Canada.

President Joe Biden supported drug importation during his 2020 campaign, but after the election his administration moved slowly to advance the process. Colorado has an importation application pending with the FDA, while several other states have passed laws allowing for importation. DeSantis has accused the Biden administration of slow-walking a decision, and his administration filed a lawsuit over the FDA’s delay.

Florida’s importation plan will save the state up to $180 million in the first year of the program, the state said. The importation program wouldn’t aid consumers directly. It’s instead aimed at helping state agencies, including its prisons, health department, and Medicaid program, obtain lower-cost drugs for HIV and AIDS, diabetes, and other conditions.

Florida’s plan still faces many hurdles. On top of Canada’s reluctance to participate in U.S. importation programs, some drug manufacturers have deals with Canadian wholesalers preventing them from exporting medicines, and the FDA decision is likely to face a legal challenge by drugmakers.

The drug industry’s major lobbying group, the Pharmaceutical Research and Manufacturers of America, or PhRMA, previously sued to stop Azar’s importation decision. It’s expected to file suit to block Florida’s program as well.

A PhRMA spokesperson declined to comment on Azar’s role.

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Azar spent about a decade with pharmaceutical giant Eli Lilly and Co. before coming to the nation’s capital to lead HHS in the Trump administration. But in September 2020, just a couple of months before former president Donald Trump lost reelection, Azar certified the safety of drugs imported from Canada — a policy opposed by the U.S. drug industry. 

Now Azar chairs the board of a company trying to make prescription drug imports happen. In January 2022, a year after leaving his Cabinet post, Azar became chairman of the board of LifeScience Logistics, the firm managing Florida’s Canadian importation program, which just won approval from the Food and Drug Administration.

Florida Gov. Ron DeSantis’s (R) government is paying the Dallas-based company as much as $39 million to buy drugs from Canadian suppliers, contract with a lab to verify their authenticity, store the medicines and distribute them to state agencies. 

Officials at LifeScience, which manages nearly 6 million square feet of warehouse storage across 11 states, confirmed Azar’s position but didn’t respond to questions about how much he’s paid or whether he’s involved in the Florida work. Azar didn’t return messages left for him with employers, including the University of Miami, where he teaches part-time, or sent to a personal email address.

Robert Weissman, president of Public Citizen, a government-watchdog group, called Azar’s journey through the revolving door atypical. That’s because HHS’s certification of drug imports from Canada was opposed by the U.S. pharmaceutical industry, where Azar had once worked. Drugmakers argue that the policy puts patients at risk of consuming counterfeit medicines.  

DeSantis had pushed Trump to authorize importation from Canada, and the former president had said he supported importation before Azar certified it was safe.

Azar’s position with LifeScience “can appear as a conflict of interest,” said Ivana Katic, assistant professor of organizational behavior at the Yale School of Management, because Azar’s HHS policy decision later benefited him professionally.

Last week, the FDA announced that it would approve Florida’s first-in-the-nation import plan. 

Top U.S. officials in both parties, of course, commonly leave government service for what are often better-paid jobs or board seats at companies in the industries they formerly regulated.

About 57 percent of presidential Cabinet-level officials later served on corporate boards of directors, according to a 2019 study by researchers at Boston and Harvard universities in the Journal of Politics, which examined 84 Cabinet members who served from 1992 to 2014. 

“In general, we favor Cabinet secretaries not going into industries which they once regulated, because the possibility of conflicts of interest are unavoidable,” Weissman said.

Canadian drug importation has been the subject of decades of debate, and before signing off on it, Azar was a skeptic. In 2018, he called importation a “gimmick,” saying Canada’s pharmaceutical market wasn’t large enough to meet U.S. demand. 

Indeed, the Canadian government has repeatedly warned the United States it would block any scheme that poses a risk of causing shortages in Canada.

The country has implemented regulations “to prohibit certain drugs intended for the Canadian market from being sold for consumption outside of Canada if that sale could cause, or worsen, a drug shortage in Canada,” Health Canada, the national agency responsible for drug safety, said in a Jan. 8 statement after the FDA’s approval of Florida’s plan.

President Biden supported drug importation during his 2020 campaign, but after the election his administration moved slowly to advance the process. DeSantis has accused the Biden administration of slow-walking a decision and his government filed a lawsuit over the FDA’s delay.

Florida’s plan — aimed at helping the state health department and other agencies, including prisons and its Medicaid program, obtain lower-cost medicines — still faces many hurdles. On top of Canada’s reluctance to participate in U.S. importation programs, some drug manufacturers have deals with Canadian wholesalers preventing them from exporting medicines.

The drug industry’s major lobbying group, the Pharmaceutical Research and Manufacturers of America, or PhRMA, previously sued to stop Azar’s importation decision. It’s expected to file suit to block Florida’s program as well. A PhRMA spokesperson declined to comment on Azar’s role.

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The survey sheds light on why millions of beneficiaries nationwide were dropped from the federal-state health insurance program for “procedural reasons.” KFF Health News obtained the survey, which Utah’s Medicaid program paid more than $20,000 to conduct, through a public records request.

Like many states, Utah terminated Medicaid coverage for a large share of enrollees whose eligibility was reevaluated in 2023, following a three-year pause during the coronavirus pandemic. And, as in most states, an overwhelming number of those disenrollments were executed for procedural reasons such as missing paperwork, rather than determinations that people were no longer eligible for coverage.

Nationally, more than 13.3 million people were cut from Medicaid in 2023, according to KFF, and procedural issues were cited in just over 70% of cases. In Utah, such issues accounted for 94% of disenrollments — the second-highest rate among states.

It’s been unclear what led to those procedural terminations in Utah and other states. But the Utah survey of more than 1,000 disenrolled Medicaid beneficiaries, conducted in October, found that 57% of people who left the program in 2023 never tried to renew their coverage.

“It is frustrating to see that 57% of respondents did not attempt to renew and that over 50% of those former members reported paperwork or other challenges as the reason they did not attempt to renew coverage,” said Matt Slonaker, executive director of the Utah Health Policy Project, an advocacy group.

Many of them found insurance elsewhere — 39% through an employer and 15% through the Affordable Care Act marketplaces, according to the survey.

But 30% became uninsured, and many people reported obstacles in reapplying for Medicaid, which covers people with low incomes and disabilities.

Nineteen percent said they never received renewal documents from the Utah Medicaid enrollment agency, the Department of Workforce Services. Fourteen percent said they didn’t get around to the paperwork, 13% said it was too difficult, and 7% said they didn’t have the necessary documents to prove their eligibility.

The online survey, which had a margin of error of plus or minus 3%, found that many disenrolled people had trouble getting questions answered by the state Medicaid agency. While 39% of those polled said they were able to resolve their issue the same day or the next day, 12% waited more than two weeks, and 21% said they were still waiting for their question, complaint, or problem to be resolved.

About half of those disenrolled described the renewal process as difficult. Just a quarter found it to be easy.

“Too many people, overrepresented by children, will be newly uninsured as a result of the unwinding, and much needs to be done to develop and execute ‘chase’ strategies to find and assist these people with getting covered,” Slonaker said.

Jennifer Strohecker, Utah’s Medicaid director, said the state is using feedback from the survey to improve its consumer engagement. It’s renewing more beneficiaries using databases to verify their income and residency, she said, and is assisting with enrollment at laundromats and Department of Motor Vehicles offices.

The state’s strong economy and low unemployment rate may help explain the high percentage of people terminated from Medicaid, she said. And about 35% who were disenrolled are returning to the program, said Kevin Burt, a deputy director of the Utah Department of Workforce Services.

But health experts worry that any disruption of insurance coverage can leave people vulnerable to losing access to care or responsible for large medical bills.

In August 2023, the Centers for Medicare & Medicaid Services sent letters to states expressing concern over high procedural disenrollment rates. CMS said the procedural disenrollment rate was too high in more than half of states and urged them to reduce it.

The Biden administration has expressed alarm in particular about losses of coverage among children, who accounted for about 46% of enrollment in Medicaid and the related Children’s Health Insurance Program in August, according to KFF. Almost 90 million people were enrolled in the two programs that month — up about 20 million from before the covid-19 pandemic.

Medicaid beneficiaries typically must have their eligibility reviewed every year to renew their coverage. But in March 2020, after the pandemic hit, the federal government froze eligibility checks as part of the public health emergency. That prevented people from losing coverage.

Since last spring, when Congress ended the emergency, states began to once again review beneficiaries’ eligibility — and terminated coverage for millions. This “unwinding” is scheduled to continue through May, though some states have already completed their process.

Utah has dropped roughly 150,000 of about 500,000 Medicaid beneficiaries since April.

Utah officials confirmed this week that the state’s Medicaid unwinding is under audit by the Department of Health and Human Services’ Office of Inspector General, which can levy fines and other penalties on states that it finds broke the law.

Strohecker said she believes Utah is one of a handful of states facing such an examination. The state is also facing an audit by the HHS Office of Civil Rights, possibly due to the high proportion of Black, Hispanic, and Pacific Islander beneficiaries who lost coverage. That agency is also able to issue fines.

Lindsey Browning, a policy analyst for the National Association of Medicaid Directors, said she is aware of about a dozen states facing these audits, which she said are routine when there are big changes in Medicaid policy.

Both HHS agencies refused to confirm or comment on the audits.

UnidosUS, the nation’s largest Hispanic civil rights and advocacy group, has called on states to more aggressively protect eligible people from losing Medicaid coverage.

“People of all races and ethnicities are losing their health care, but Latinos and members of other historically marginalized communities are suffering disproportionate harm, as are children,” said Stan Dorn, health policy director of UnidosUS.

Stephanie Burdick, a Medicaid enrollee and consumer advocate on Utah’s Medicaid advisory board, said the survey points to serious shortcomings in the state’s unwinding.

“It’s a huge communication failure,” she said when asked why more than half of those dropped made no effort to renew their coverage. Many Medicaid enrollees, she said, didn’t know they had to reapply.

“A lot of people thought it was like the federal stimulus checks and was just a one-time benefit,” she said.

Utah fully expanded Medicaid in 2020 under the Affordable Care Act, raising eligibility to cover more working people with low incomes. As a result, tens of thousands of people who enrolled during the pandemic had never been through the process of renewing their coverage.

The Utah survey found that former Medicaid recipients rated the state’s program as 7 on a scale of 1 to 10. And nearly 80% said they would reenroll in the program if they could.

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A survey conducted for state officials in Utah, obtained by KFF Health News, holds some clues.

Like many states, Utah terminated Medicaid coverage for a large share of enrollees whose eligibility was reevaluated in 2023, following a three-year pause during the coronavirus pandemic. And like most states, an overwhelming share of those disenrollments were made for procedural reasons, such as missing paperwork.

More than 13.3 million people were disenrolled from Medicaid in 2023, according to KFF, and just over 70 percent of disenrollments were for procedural reasons.

It’s been unclear what led to those procedural terminations in Utah and other states. But the Utah survey of more than 1,000 disenrolled Medicaid beneficiaries, conducted in October, found that 57 percent of people who left the program in 2023 never tried to renew their coverage.

The good news is that many of them found insurance elsewhere — 39 percent through an employer, and 15 percent through the Affordable Care Act marketplaces, according to the survey.

The bad news is that 30 percent became uninsured, and many people reported obstacles in reapplying for Medicaid, which covers low-income and disabled people.

Nineteen percent said they never received renewal documents from the Utah Medicaid enrollment agency, the Department of Workforce Services. Fourteen percent said they didn’t get around to the paperwork, 13 percent said it was too difficult, and 7 percent said they didn’t have the necessary documents to prove their eligibility.

The survey found that many disenrolled people who asked why had trouble getting questions answered by the state Medicaid agency. While 39 percent polled said they were able to resolve their issue the same day or the next day, 12 percent waited over two weeks and 21 percent said their question or complaint was never resolved.

Half of those disenrolled described the renewal process as difficult. Just a quarter found it to be easy.

The online survey had a margin of error of plus-or-minus 3 percent. 

Medicaid beneficiaries typically must have their eligibility reviewed every year to renew their coverage. But in March 2020, after the pandemic hit, the federal government froze eligibility checks as part of the public health emergency. That kept anyone from being dropped.

Since the spring, when Congress ended the emergency, states have begun once again reviewing eligibility for Medicaid beneficiaries — and terminating coverage for millions. The “unwinding” is scheduled to continue through May of this year, though some states have already completed it.

Utah has dropped about 150,000 of about 500,000 Medicaid beneficiaries since April.

Stephanie Burdick, a Medicaid enrollee and consumer advocate on Utah’s Medicaid advisory board, said the state’s survey results point to serious shortcomings in Utah’s unwinding.

“It’s a huge communication failure,” she said when asked why more than half of those dropped made no effort to renew their coverage. Many Medicaid enrollees, she said, didn’t know they had to reapply. 

“A lot of people thought it was like the federal stimulus checks and was just a one-time benefit,” she said.

Jennifer Strohecker, Utah’s Medicaid director, said the state is using feedback from the survey to improve its consumer engagement. It’s renewing more beneficiaries using databases to verify their income and residency, she said, and is assisting with enrollment at laundromats and Department of Motor Vehicles offices.

The state’s strong economy and low unemployment rate may help explain the high percentage of people terminated from Medicaid, she said. And about 35 percent who were disenrolled are returning to the program, said Kevin Burt, deputy director of the Utah Department of Workforce Services.

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Eleven states and Washington, D.C., together provide full health insurance coverage to more than 1 million low-income immigrants regardless of their legal status, according to state data compiled by KFF Health News. Most aren’t authorized to live in the U.S., state officials say.

Enrollment in these programs could nearly double by 2025 as at least seven states initiate or expand coverage. In January, Republican-controlled Utah will start covering children regardless of immigration status, while New York and California will widen eligibility to cover more adults.

“These are kids, and we have a heart,” said Utah state Rep. Jim Dunnigan, a Republican who initially opposed his state’s plan to cover children lacking legal status but relented after compromises including a cap on enrollment.

There are more than 10 million people living in the U.S. without authorization, according to estimates by the Pew Research Center. Immigrant advocates and academic experts point to two factors behind state leaders’ rising interest in providing health care to this population: The pandemic highlighted the importance of insurance coverage to control the spread of infectious diseases; and some states are focusing on people without legal status to further drive down the country’s record-low uninsured rate.

States have also expanded coverage in response to pleas from hospitals, lawmakers say, to reduce the financial burden of treating uninsured patients.

All states pay hospitals to provide emergency services to some unauthorized residents in emergency rooms, a program known as Emergency Medicaid. About a dozen states have extended coverage for only prenatal care for such people. Full state-provided health insurance coverage is much less common, but increasing.

An estimated half of the people living in the U.S. without authorization are uninsured, according to a KFF-Los Angeles Times survey. That’s more than five times the uninsured rate for U.S. citizens. Immigrants lacking authorization are ineligible for federal health programs. But states can use their own money to provide coverage through Medicaid, the state-federal insurance program for low-income people.

California was the first state to begin covering immigrants regardless of their legal status, starting with children in 2016.

“This is a real reflection of the conflict we have in the country and how states are realizing we cannot ignore immigrant communities simply because of their immigration status,” said Adriana Cadena, director of the advocacy group Protecting Immigrant Families. Many of the millions of people without permanent legal residency have been in the United States for decades and have no path to citizenship, she said.

These state extensions of health coverage come against a backdrop of rising hostility toward migrants among Republicans. The U.S. Border Patrol apprehended nearly 1.5 million people in fiscal year 2023 after they crossed the southern border, a record. GOP presidential candidates have portrayed the border as in crisis under Biden, and dangers of illegal immigration, like increasing crime, as the nation’s top domestic concern.

Simon Hankinson, a senior research fellow specializing in immigration issues with the conservative Heritage Foundation, said states would regret expanding coverage to immigrants lacking permanent legal residency because of the cost. Illinois, he noted, recently paused enrollment in its program over financial concerns.

“We need to share resources with people who contribute to society and not have people take benefits for those who have not contributed, as I don’t see how the math would work in the long run,” Hankinson said. “Otherwise, you create an incentive for people to come and get free stuff.”

Most adults lacking authorization work, accounting for about 5% of the U.S. labor force, according to the Pew Research Center. The state with the most unauthorized residents with state-provided health insurance is California, which currently covers about 655,000 immigrants without regard for their legal status. In January, it will expand coverage to people ages 26-49 regardless of their immigration status, benefiting an estimated 700,000 additional Californians.

Connecticut, Maine, Massachusetts, New York, Rhode Island, Vermont, Washington, D.C., and Washington state also provide full coverage to some people living in the U.S. without authorization. New York and Washington state are expanding eligibility next year.

Oregon, Colorado, and New Jersey in recent years began covering more than 100,000 people in total regardless of legal status. Minnesota will follow in 2025, covering an estimated 40,000 people.

While states are expanding coverage to people living in the U.S. potentially without authorization, some are imposing enrollment limits to control spending.

The cost of Utah’s program is capped at $4.5 million a year, limiting enrollment to about 2,000 children. Premiums will vary based on income but cost no more than $300 a year, with preventive services covered in full.

“The pandemic highlighted the need to have coverage for everybody,” said Ciriac Alvarez Valle, senior policy analyst for Voices for Utah Children, an advocacy group. “It will make a huge impact on the lives of these kids.”

Without coverage, many children use emergency rooms for primary care and have little ability to afford drugs, specialists, or hospital care, she said. “I am not sure if this will open the door to adults having coverage, but it is a good step forward,” Alvarez Valle said.

Colorado also limits enrollment for subsidized coverage in its program, capping it at 10,000 people in 2023 and 11,000 in 2024. The 2024 discounted slots were booked up within two days of enrollment beginning in November.

Adriana Miranda was able to secure coverage both years.

“You feel so much more at ease knowing that you’re not going to owe so much to the hospitals,” said Miranda, 46, who is enrolled in a private plan through OmniSalud, a program similar to the state’s Obamacare marketplace in which low-income Coloradans without legal residency can shop for plans with discounted premiums.

Miranda left Mexico in 1999 to follow her two brothers to the United States. She now works at Lamar Unidos, a nonprofit immigrant rights group.

Before she had health insurance, she struggled to pay for care for her diabetes and racked up thousands of dollars of debt following foot surgery, she said. Under the state program, she doesn’t pay a monthly premium due to her low income, with a $40 copay for specialist visits.

“I was really happy, right? Because I was able to get it. But I know a lot of people who also have a lot of need couldn’t get it,” she said.

OmniSalud covers only a small fraction of the more than 200,000 people living in Colorado without authorization, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. But starting in 2025, all low-income children will be able to be covered by the state’s Medicaid or the related Children’s Health Insurance Program regardless of immigration status.

“There is a growing acknowledgement that people regardless of their immigration status are part of the community and should have access to health care in a regular, reliable manner,” Fox said. “If they don’t, it adds costs and trauma to the health systems and communities.”

KFF Health News senior audio producer Zach Dyer contributed to this report.

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Once estados y Washington, DC, ofrecen cobertura completa de salud a más de un millón de inmigrantes de bajos ingresos, independientemente de su estatus migratorio, según datos estatales recopilados por KFF Health News. La mayoría son indocumentados, según funcionarios estatales.

La inscripción en estos programas podría llegar a duplicarse para 2025, ya que al menos siete estados están iniciando o ampliando la cobertura. En enero, Utah, controlado por los republicanos, comenzará a cubrir a los niños independientemente de su estatus migratorio. Nueva York y California ampliarán la elegibilidad para cubrir a más adultos.

“Estos son niños, y tenemos corazón”, dijo el republicano Jim Dunnigan, representante estatal de Utah, que al principio se oponía al plan de cubrir a niños indocumentados, pero cedió después de compromisos, incluyendo un límite en la inscripción.

Según estimaciones del Pew Research Center, hay más de 10 millones de personas viviendo en el país sin papeles.

Defensores de inmigrantes y académicos señalan dos factores que aumentaron el interés de líderes estatales en proporcionar atención médica a esta población: la pandemia destacó la importancia de la cobertura de salud para controlar la propagación de enfermedades infecciosas, y algunos estados se centran en personas sin estatus legal para reducir aún más la tasa récord de personas sin seguro en el país.

Según legisladores, los estados también han ampliado la cobertura en respuesta a las súplicas de los hospitales para reducir la carga financiera del tratamiento de pacientes sin seguro.

Todos los estados pagan a los hospitales por brindar servicios de emergencia a algunos residentes sin papeles, un programa conocido como Medicaid de Emergencia. Alrededor de una docena de estados han extendido la cobertura solo para cuidado prenatal para este grupo. La cobertura completa proporcionada por el estado es mucho menos común, pero está aumentando.

Según una encuesta de KFF-Los Angeles Times, se estima que la mitad de las personas que viven en el país sin un estatus legal no tienen seguro, más de cinco veces la tasa de personas sin cobertura entre los ciudadanos estadounidenses.

Los inmigrantes sin papeles no son elegibles para los programas federales de salud, pero los estados pueden usar su propio dinero para proporcionar cobertura a través de Medicaid, el programa de seguro estatal-federal para personas con bajos ingresos.

California fue el primer estado en comenzar a cubrir a inmigrantes sin considerar su estatus legal, comenzando con niños en 2016.

“Esto es un verdadero reflejo del conflicto que tenemos en el país y de cómo los estados se dan cuenta de que no podemos ignorar a las comunidades de inmigrantes simplemente por su estatus migratorio”, dijo Adriana Cadena, directora del grupo de defensa Protecting Immigrant Families.

Muchas de las millones de personas sin residencia permanente han estado en los Estados Unidos durante décadas y no tienen un camino hacia la ciudadanía, agregó.

Estas ampliaciones estatales de la cobertura se producen en medio de una creciente hostilidad hacia los migrantes entre los republicanos.

La Patrulla Fronteriza detuvo a casi 1.5 millones de personas en el año fiscal 2023 después de cruzar la frontera con México, una cifra récord. Los candidatos presidenciales republicanos han retratado la frontera como una crisis bajo Biden, y a los peligros de la inmigración ilegal, entre ellos el supuesto aumento de la criminalidad, como la principal preocupación nacional.

Simon Hankinson, investigador especializado en temas de inmigración en la conservadora Heritage Foundation, dijo que los estados lamentarán expandir la cobertura a inmigrantes indocumentados por al costo. Puso como ejemplo a Illinois, que recientemente puso una pausa en la inscripción en su programa debido a preocupaciones financieras.

“Necesitamos compartir recursos con personas que contribuyen a la sociedad y no permitir que las personas obtengan beneficios para las que no han contribuido, ya que no veo cómo las matemáticas funcionarían a largo plazo”, dijo Hankinson. “De lo contrario, estarías creando un incentivo para que las personas vengan y obtengan cosas gratis”.

La mayoría de los adultos sin papeles trabajan, representan aproximadamente el 5% de la fuerza laboral nacional, según el Pew Research Center. California es el estado con más indocumentados con seguro médico estatal, que actualmente cubre a unos 655,000 inmigrantes sin tener en cuenta su estatus migratorio. En enero, ampliará la cobertura a personas de 26 a 49 años, en este grupo, beneficiando a unos 700,000 californianos adicionales.

Connecticut, Maine, Massachusetts, Nueva York, Rhode Island, Vermont, Washington, DC, y el estado de Washington también ofrecen cobertura completa a algunas personas que viven en el país sin documentos. Nueva York y el estado de Washington ampliarán la elegibilidad el próximo año.

Oregon, Colorado y Nueva Jersey comenzaron a cubrir a más de 100,000 personas en total en los últimos años, independientemente de su estatus legal. Minnesota seguirá en 2025, cubriendo a unas 40,000.

Aunque algunos estados están expandiendo la cobertura de salud, están imponiendo límites en la inscripción para controlar el gasto.

El costo del programa de Utah tiene un tope de $4.5 millones al año, limitando la inscripción a alrededor de 2,000 niños. Las primas variarán según los ingresos, pero no costarán más de $300 al año, con servicios preventivos cubiertos por completo.

“La pandemia destacó la necesidad de tener cobertura para todos”, dijo Ciriac Alvarez Valle, analista de políticas senior de Voices for Utah Children, un grupo de defensa. “Tendrá un gran impacto en la vida de estos niños”.

Sin cobertura, muchos niños usan las salas de emergencia para atención primaria y las familias no pueden pagar medicamentos, especialistas o internaciones, dijo. “No estoy segura de si esto abrirá la puerta para que los adultos tengan cobertura, pero es un buen paso adelante”, agregó Alvarez Valle.

Colorado también limita la inscripción para la cobertura subsidiada en su programa, estableciendo un límite de 10,000 personas en 2023, y 11,000 en 2024. Los espacios disponibles para 2024 se llenaron en dos días desde el inicio de la inscripción en noviembre.

Adriana Miranda pudo obtener cobertura los dos años.

“Te sientes mucho más tranquila sabiendo que no le debes tanto a los hospitales”, dijo Miranda, de 46 años, que está inscrita en un plan privado a través de OmniSalud, un programa estatal similar al mercado de seguros del Obamacare en el que los residentes de bajos ingresos de Colorado sin residencia legal pueden buscar planes con primas con descuento.

Miranda dejó México en 1999 para seguir a sus dos hermanos a Estados Unidos. Ahora trabaja en Lamar Unidos, una organización sin fines de lucro que trabaja por los derechos de los inmigrantes.

Antes de tener seguro médico, luchaba para pagar por la atención de su diabetes y acumuló miles de dólares en deudas después de una cirugía de pie, contó. Bajo el programa estatal, no paga una prima mensual debido a sus bajos ingresos, con un copago de $40 para visitas a especialistas.

“Estaba realmente feliz, ¿verdad? Porque pude obtenerlo. Pero sé que muchas personas que también tienen muchas necesidades no lo obtuvieron”, dijo. OmniSalud cubre solo a una pequeña fracción de las más de 200,000 personas que viven en Colorado sin papeles, dijo Adam Fox, subdirector de la Iniciativa de Salud del Consumidor de Colorado.

Pero a partir de 2025, todos los niños en familias de bajos ingresos podrán estar cubiertos por el Medicaid estatal o el Programa de Seguro de Salud Infantil (CHIP), independientemente de su estatus migratorio.

“Hay un reconocimiento creciente de que las personas, más allá de su estatus migratorio, son parte de la comunidad y deben tener acceso a atención médica de manera regular y confiable”, dijo Fox. “Si no lo hacen, agrega costos y trauma a los sistemas de salud y a las comunidades”.

Zach Dyer, productor de audio senior de KFF Health News, colaboró con este informe.

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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El informe del 1 de diciembre, preparado para la legislatura estatal por el Departamento de Política y Financiamiento de Atención Médica del estado, indica que los funcionarios estatales se acercaron a 23 fabricantes de medicamentos en el último año para proponer un programa de importación. Solo cuatro accedieron a discutir la propuesta, y ninguno mostró interés en participar.

“En general, los desafíos que persisten están fuera de la autoridad estatal y dependen de la acción de la FDA y/o de los fabricantes de medicamentos”, dice el informe.

Legisladores de ambos partidos, a nivel estatal y nacional, han buscado durante décadas legalizar la importación de medicamentos desde Canadá.

Desde 2020, cuando la administración del presidente Donald Trump abrió la puerta a la importación de medicamentos canadienses con regulaciones emitidas pocas semanas antes de perder la reelección, solo algunos estados han presentado solicitudes a la Administración de Alimentos y Medicamentos (FDA) para crear programas de importación.

La FDA aún no ha tomado decisiones al respecto. Colorado presentó su solicitud en diciembre de 2022. Florida, que presentó la solicitud en 2020, ha estado esperando casi tres años por una decisión de la administración Biden sobre su plan de importación, impulsado por el gobernador Ron DeSantis, ahora candidato presidencial republicano.

Cherie Duvall-Jones, vocera de la FDA, dijo que la entidad federal no ha actuado sobre las solicitudes de importación de los estados porque no ha determinado si ahorrarían dinero significativo para los consumidores sin plantear riesgos para la salud pública.

Los consumidores estadounidenses pagan algunos de los precios más altos del mundo por medicamentos de marca. Los medicamentos suelen ser más baratos en Canadá, donde el gobierno controla los precios.

Bajo el gobierno de Trump, el gobierno federal declaró que la importación de medicamentos desde Canadá se podía hacer de manera segura, cumpliendo por primera vez con una condición establecida en una ley de 2003.

Pero los funcionarios de Colorado mencionaron otro inconveniente: la regla no tuvo en cuenta que los estados tendrían que negociar directamente con las farmacéuticas, que se oponen a vender sus medicamentos de marca en Estados Unidos a precios canadienses.

“Como la Regla Final federal no contempló la necesidad de este paso de negociación, hemos instado a la FDA a emitir más guías sobre cómo los estados pueden poner en práctica el programa teniendo esto en cuenta, pero hasta la fecha, no se ha emitido ninguna orientación”, dice el informe de Colorado.

A diferencia de lo que hizo con muchas otras políticas de salud de la administración Trump, Biden no ha revocado ni revisado la regla de importación. Pero su administración tampoco ha mostrado mucho apoyo a la idea. El secretario del Departamento de Salud y Servicios Humanos (HHS), Xavier Becerra, dijo a KFF Health News en diciembre pasado que no se comprometería a que la FDA resolviera alguna solicitud estatal en 2023.

El presidente ha sugerido repetidamente que durante su mandato los estadounidenses podrían importar medicamentos de Canadá. Durante su campaña de 2020, Biden dijo que permitiría la importación de medicamentos certificados como seguros por el gobierno. En 2021, ordenó a la FDA trabajar con los estados para importar medicamentos recetados desde Canadá. En un discurso de 2022 sobre cómo planeaba reducir los precios de los medicamentos, citó estimaciones de Colorado sobre cuánto podrían ahorrar las personas en el estado a través de la importación.

Los funcionarios de la FDA respondieron a la solicitud de Colorado en marzo pidiendo más información y una lista más pequeña de medicamentos a los que apuntar, para demostrar que la importación podría ahorrar dinero. La solicitud inicial de Colorado enumeraba 112 medicamentos de alto costo. El estado estima que los residentes y empleadores podrían ahorrar un promedio de 65% en los costos de esos medicamentos, incluidos fármacos para la diabetes, el asma y el cáncer.

Colorado dijo que planea presentar una solicitud actualizada a principios del próximo año. Para entonces, es posible que la FDA haya tomado una decisión sobre la solicitud de Florida.

Las propuestas de importación de Colorado y Florida son diferentes. El programa de Colorado tiene como objetivo ayudar directamente a los consumidores a obtener medicamentos más baratos. El plan de Florida busca reducir el gasto en medicamentos en programas gubernamentales como Medicaid, el sistema penitenciario y las instalaciones dirigidas por el Departamento de Niños y Familias del estado.

La industria farmacéutica ha argumentado que la administración Trump no certificó adecuadamente que los medicamentos importados de Canadá serían seguros, poniendo en peligro la salud de los estadounidenses. El gobierno de Canadá también ha expresado preocupación de que las importaciones de Estados Unidos generen escasez y precios más altos en su país.

“Los fabricantes de medicamentos harán cualquier cosa para proteger a su gallina de los huevos de oro que son los consumidores y pacientes estadounidenses que pagan los precios más altos por medicamentos en el mundo”, dijo la senadora estatal de Colorado, Sonya Jaquez Lewis, demócrata, farmacéutica y defensora líder de la importación de medicamentos.

Jaquez Lewis dijo que la Casa Blanca y el Congreso deberían obligar a los fabricantes de medicamentos a negociar con los estados para iniciar programas de importación.

En su respuesta inicial a la solicitud de Colorado, la FDA enumeró varios tipos de información que aún necesitaba, incluidos planes sobre etiquetado y elegibilidad de medicamentos, según una carta de marzo de la FDA al estado. Otro problema, dijo la FDA: el estado planeaba importar medicamentos a través de la frontera en Buffalo, Nueva York. La FDA dijo que el único puerto de entrada permitido para medicamentos está en Detroit.

Los funcionarios de Colorado le dijeron a la FDA en marzo que, sin la aprobación federal de su solicitud, estaban teniendo dificultades para obtener compromisos de los fabricantes de medicamentos para obtenerlos.

“Se ha dejado claro que los posibles socios estarán más interesados en comprometerse una vez que nuestro programa haya sido aprobado por la FDA”, escribió Kim Bimestefer, directora ejecutiva del Departamento de Política y Financiamiento de la Atención Médica de Colorado, a la FDA.

“Aunque entendemos que el marco regulatorio no permite una aprobación provisional, sabemos que mostrar progreso hacia un programa aprobado ayudará en nuestras negociaciones con los fabricantes de medicamentos”, agregó.

Otro inconveniente es que la regla de la FDA no permite a los estados comprar medicamentos directamente a distribuidores secundarios. En cambio, deben comprarlos directamente a los fabricantes, dijo Marc Williams, vocero de la agencia de Colorado.

Esto ha resultado difícil porque los fabricantes de medicamentos han prohibido la exportación de productos destinados a la venta en Canadá a los Estados Unidos, dijo Williams.

“Sin su permiso y un acuerdo de suministro directo con un fabricante, Colorado no puede comprar e importar estos medicamentos a precios más bajos que ahorrarían dinero a las personas”, dijo.

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The Dec. 1 report, prepared for the state legislature by Colorado’s Department of Health Care Policy & Financing, says that state officials approached 23 drugmakers in the last year about an importation program. Only four agreed even to discuss the proposal; none expressed interest in participating.

“Generally, the challenges that remain are outside state authority and rely on action by FDA and/or drug manufacturers,” the report reads.

Lawmakers in both parties, at the state and national level, have sought for decades to legalize importing drugs from Canada. Since 2020, when President Donald Trump’s administration opened the door to Canadian drug imports with regulations issued just weeks before he lost reelection, only a few states have filed applications with the Food and Drug Administration to create importation programs.

The FDA hasn’t yet ruled on any of them. Colorado filed its application in December 2022. Florida, which applied in 2020, has been waiting nearly three years for a decision from the Biden administration on its importation plan, pushed by Gov. Ron DeSantis, now a Republican presidential candidate.

FDA spokesperson Cherie Duvall-Jones said the FDA has not acted on states’ importation applications because it has not determined whether they would save significant money for consumers without posing risks to public health.

U.S. consumers pay some of the highest prices in the world for brand-name pharmaceuticals. Drugs are generally less expensive in Canada, where the government controls prices.

Under Trump, the federal government declared that importing drugs from Canada could be done safely — satisfying for the first time a condition spelled out in a 2003 law.

But Colorado officials cited another catch: The rule didn’t take into account that states would have to negotiate directly with drug manufacturers, which oppose selling their brand-name drugs in the United States at Canadian prices.

“As the federal Final Rule did not contemplate the need for this negotiation step, we have urged FDA to release further guidance regarding how states can operationalize the program with this in mind, but to date, no guidance has been released,” the Colorado report said.

Unlike many other Trump administration health policies, Biden hasn’t revoked or revised the importation rule. But his administration hasn’t shown much support for the idea, either. Health and Human Services Secretary Xavier Becerra told KFF Health News last December that he wouldn’t commit to the FDA ruling on any state application in 2023.

The president has repeatedly suggested that under his watch Americans would be able to import drugs from Canada.

During his 2020 campaign, Biden said he’d allow for the importation of drugs the government certified as safe. In 2021, he ordered the FDA to work with states to import prescription drugs from Canada. In a 2022 speech about how he planned to reduce drug prices, he cited Colorado estimates of how much people in the state could save through importation.

FDA officials responded to Colorado’s application in March by asking for more information and a smaller list of drugs to target, to prove that importation could save money. Colorado’s initial application listed 112 high-cost drugs. The state estimates residents and employers could save an average of 65% on the costs of those medicines, including drugs for diabetes, asthma, and cancer.

Colorado said it plans to submit an updated application early next year. By then, it’s possible the FDA will have ruled on Florida’s application.

The Colorado and Florida importation proposals differ. Colorado’s program is intended to directly help consumers obtain cheaper medicines. Florida’s plan aims to cut spending on drugs in government programs such as Medicaid, the prison system, and facilities run by the state Department of Children and Families.

The drug industry has argued the Trump administration didn’t properly certify that drugs imported from Canada would be safe, jeopardizing Americans’ health. Canada’s government, too, has expressed concern that U.S. imports would lead to shortages and higher prices in its country.

Drug manufacturers “will do anything to protect their golden goose that is United States consumers and patients who pay the largest amount for drugs in the world,” said Colorado state Sen. Sonya Jaquez Lewis, a Democrat, pharmacist, and leading advocate for drug importation.

The White House and Congress, she said, should force drugmakers to negotiate with states to start importation programs.

In its initial response to Colorado’s application, the FDA listed several types of information it still needed, including plans on labeling and drug eligibility, according to a March letter from the FDA to the state. Another problem, the FDA said: The state planned to import medicines across the U.S. border in Buffalo, New York. The FDA said the only port of entry it allows for medicines is in Detroit.

Colorado officials told the FDA in March that without federal approval of its application, it was having difficulty securing commitments from drug manufacturers to obtain medicines.

“It has been made clear that potential partners will be more interested in committing to participate once our program has been approved by the FDA,” Kim Bimestefer, executive director of the Colorado Department of Health Care Policy & Financing, wrote to the FDA.

“While we understand the regulatory framework does not permit for a provisional approval, we know that showing progress towards an approved program will aid in our negotiations with drug manufacturers,” she added.

Another complication is that the FDA’s rule doesn’t allow states to buy drugs directly from secondary drug wholesalers. Instead, they must purchase medicines directly from manufacturers, said Marc Williams, a spokesperson for the Colorado agency.

That’s proven challenging because drug manufacturers have prohibited the export of products intended for sale in Canada to the U.S., Williams said.

“Without their permission and a supply agreement directly with a manufacturer, Colorado is unable to buy and import these lower-priced drugs that would save people money,” he said.

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But officials in Denver say they’ve been stymied by opposition from drugmakers — as well as the Biden administration’s inaction on the policy. That’s according to a Dec. 1 report we obtained that was prepared for the state legislature by the Colorado agency working on the importation plan.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

Colorado filed an application with the Food and Drug Administration in December 2022 to set up an importation program, becoming among the first states to try to take advantage of the Trump rule. But federal regulators under Biden have yet to green light it. 

• “Generally, the challenges that remain are outside state authority and rely on action by FDA and/or drug manufacturers,” the Colorado Department of Health Care Policy & Financing report reads.

The report says Colorado officials reached out to 23 drug companies in the past year; they either declined to discuss the program, said they would not participate or did not respond at all.

Lawmakers in both parties have sought for decades to legalize importation of drugs from Canada. Florida has been waiting nearly three years for a decision from the Biden administration on its importation plan, pushed by Gov. Ron DeSantis, now a GOP presidential candidate.

U.S. consumers pay some of the highest prices in the world for brand-name pharmaceuticals. Drugs are generally less expensive in Canada, where the government controls prices.

Under President Donald Trump, the federal government declared that importing drugs from Canada could be done safely — satisfying for the first time a condition spelled out in a 2003 law. The Trump administration finalized its importation rules in September 2020 just as voters were about to head to the polls.

But Colorado officials say there was at least one more catch: The rule didn’t take into account that states would have to negotiate directly with drug manufacturers, which oppose selling their brand-name drugs in the United States at Canada’s significantly lower prices.

“As the federal Final Rule did not contemplate the need for this negotiation step, we have urged FDA to release further guidance regarding how states can operationalize the program with this in mind, but to date, no guidance has been released,” the Colorado report said.

Biden reversed a lot of what Trump did on health care — but not the importation rule. However, his administration hasn’t shown much support for the idea. Health and Human Services Secretary Xavier Becerra told KFF Health News last December that he wouldn’t commit to the FDA ruling on any state application in 2023.  

The president has repeatedly suggested that under his watch, Americans would be able to import drugs from Canada. 

During his 2020 campaign, Biden said he’d allow it if the government certified the drugs as safe. In 2021, he ordered the FDA to work with states to import prescription drugs from Canada. In a 2022 speech about how he was going to reduce drug prices, he cited Colorado estimates of how much people in the state could save through importation.

FDA officials responded to Colorado’s importation application in March 2023 by asking for more information, including a smaller list of drugs to target to prove that importation can save money. Colorado’s initial application included 112 high-cost drugs. The state estimates that it could save residents and employers an average of 65 percent on the costs of those medicines, including drugs for diabetes, asthma and cancer.

Colorado said it plans to submit an updated application in early 2024. By then, it’s possible the FDA will have ruled on Florida’s application.

The drug industry, wary that a government-organized importation program could eat into its profits, opposes the idea and has argued that importation would circumvent U.S. safety controls. 

“They will do anything to protect their golden goose that is United States’ consumers and patients who pay the largest amount for drugs in the world,” said Colorado state Sen. Sonya Jaquez Lewis (D), a pharmacist and a leading advocate for drug importation.

The White House and Congress, she said, should force drugmakers to negotiate with states to start importation programs.

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Utah has dropped more than 130,000 out of about 500,000 Medicaid beneficiaries since April, after the federal government lifted a pandemic-era requirement that states keep people enrolled in the insurance program for low-income people. Since then, every state has started what’s called an “unwinding” to reassess whether people in Medicaid are still eligible and drop those no longer qualified — including people who fail to respond to government inquiries.

Utah’s survey sheds light on the fate of the 11 million people cut from the program nationwide so far. While officials predicted some of them would wind up uninsured, little information is yet available about how many obtained coverage elsewhere. States have renewed Medicaid coverage for more than 20 million people, according to KFF’s unwinding tracker.

The Utah survey, said Arielle Kane, director of Medicaid initiatives at the advocacy group Families USA, “does, unfortunately, give us a window, in a bad way, as Utah is a state with very low unemployment — so in a state with higher unemployment it may be worse.”

On top of the pandemic throwing millions of Americans out of work and onto Medicaid rolls, in 2020 Utah began expanding its program under the Affordable Care Act, raising eligibility to cover more working people with low incomes. As a result, tens of thousands who enrolled three years ago had never been through the process of renewing their coverage.

Utah’s Medicaid director, Jennifer Strohecker, announced the results of the survey of disenrolled people on Nov. 14. “This is really challenging for us and concerning to us as we consider what this means on the population,” she said.

Advocates for expanded U.S. insurance coverage fear many people left uninsured by the unwinding are children, as they make up more than 40% of Medicaid enrollees.

The survey had 1,003 respondents and a margin of error of plus or minus 3%, said Kolbi Young, a spokesperson for the Medicaid agency. The agency declined to make the full survey results available, saying they’re still under review.

Nationwide, there are other signs that many people dropped from Medicaid are winding up uninsured. Epic Research, a division of the electronic medical records company, published a study Nov. 17 showing that uninsured emergency room visits increased substantially this summer, after the unwinding began.

The researchers examined ER records from nearly 1,300 hospitals. They found that the self-pay rate among patients increased from 6.1% in March to 8.5% in August — the highest rate observed since the first weeks of the pandemic.

Even before the pandemic, it was typical for many people who lost Medicaid coverage to go without insurance for a time, said Robin Rudowitz, a Medicaid policy researcher and vice president at KFF. “We do know from earlier research that following a disenrollment from Medicaid, two-thirds of people had a period of uninsurance over the course of the following year,” she said.

So Utah’s survey results — showing about a third of disenrolled people lack insurance — is “not outlandish, but it is very concerning,” said Emily Zheutlin, a health policy analyst with the Utah Health Policy Project and a member of the state’s Medicaid advisory board.

She said people in the state have had difficulty renewing their Medicaid coverage, with long wait times on calls to the state Medicaid agency. Many people also don’t know they need to reverify their eligibility, she said.

Without health coverage, people may delay seeking needed care or be left with unaffordable bills when they get it.

Rachel Craig, government affairs manager for the Association for Utah Community Health, which represents community health centers, had feared up to half of those disenrolled from Medicaid would be uninsured.

“This is better than expected, though it’s still a big number,” she said.

But she said the state’s survey could be skewed because people with insurance may be more likely to respond than people who are uninsured.

KFF Health News data journalist Hannah Recht contributed to this report.

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