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More than two dozen people lined up outside a state public assistance office in Montana before it opened to ensure they didnt get cut off from Medicaid.

This story also ran on USA Today. It can be republished for free.

Callers in Missouri and Florida reported waiting on hold for more than two hours on hotlines to renew their Medicaid coverage.

The parents of a disabled man in Tennessee who had been on Medicaid for three decades fought with the state this summer to keep him enrolled as he lay dying from pneumonia in a hospital.

Seven months into what was predicted to be the biggest upheaval in the 58-year history of the government health insurance program for people with low incomes and disabilities, states have reviewed the eligibility of more than 28 million people and terminated coverage for over 10 million of them. Millions more are expected to lose Medicaid in the coming months.

The unprecedented enrollment drop comes after federal protections ended this spring that had prohibited states from removing people from Medicaid during the three pandemic years. Since March 2020, enrollment in Medicaid and the related Childrens Health Insurance Program had surged by more than 22 million to reach 94 million people.

The process of reviewing all recipients eligibility has been anything but smooth for many Medicaid enrollees. Some are losing coverage without understanding why. Some are struggling to prove theyre still eligible. Recipients and patient advocates say Medicaid officials sent mandatory renewal forms to outdated addresses, miscalculated income levels, and offered clumsy translations of the documents. Attempting to process the cases of tens of millions of people at the same time also has exacerbated long-standing weaknesses in the bureaucratic system. Some suspect particular states have used the confusing system to discourage enrollment.

Its not just bad, but worse than people can imagine, said Camille Richoux, health policy director for the nonprofit Arkansas Advocates for Children and Families. This unwinding has not been about determining who is eligible by all possible means, but how we can kick people off by all possible means.

To be sure, some of the Medicaid recipients who signed on to the program when the U.S. unemployment rate soared amid covid-19 lockdowns have since gotten health insurance through new jobs as unemployment dropped back to pre-pandemic lows.

And some of the disenrolled are signing up for Affordable Care Act marketplace plans. Centene CEO Sarah London, for example, told investors on Oct. 24 that the health care giant expected as many as 2.4 million of its 15 million Medicaid managed care members to lose coverage from the unwinding, but more than 1 million customers had joined its exchange plans since the same time last year.

Still, its anyones guess how many former Medicaid beneficiaries remain uninsured. States dont track what happens to everyone after theyre disenrolled. And the final tallies likely wont be known until 2025, after the unwinding finishes by next summer and federal officials survey Americans insurance status. Email Sign-Up

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Without Medicaid, Patients Miss Appointments

Trish Chastain, 35, of Springfield, Missouri, said her Medicaid coverage is scheduled to expire at the end of the year. Though her children are still covered, she no longer qualifies because her income is too high at $22 an hour. Chastains employer, a rehab center, offers health insurance but her share of the premium would be $260 a month. I cant afford that with my monthly budget, she said.

She said she did not know she might be eligible for a lower-cost plan on the Affordable Care Act marketplace. That still would mean new costs for her, though.

Gaps in coverage can jeopardize peoples access to health services or their financial security if they get medical bills for care they cannot postpone.

Any type of care that’s put off whether it’s asthma, whether it’s autism, whether it’s something as simple as an earache can just get worse if you wait, said Pam Shaw, a pediatrician in Kansas City, Kansas, who chairs the American Academy of Pediatrics state government affairs committee.

Doctors and representatives of community health centers around the country said they have seen an uptick in cancellations and no-shows among patients without coverage including children. Nationwide, states have already disenrolled at least 1.8 million children in the 20 states that provide the data by age. Children typically qualify more easily than adults, so child advocates believe many kids are being wrongly terminated based on their parents being deemed no longer eligible. Meanwhile, enrollment in CHIP, which has higher income eligibility levels than Medicaid, has shown only a tiny increase.

Kids accounted for varying shares of those disenrolled in each state, ranging from 68% in Texas to 16% in Massachusetts, according to KFF. In September, President Joe Bidens administration said most states were conducting eligibility checks incorrectly and inappropriately disenrolling eligible children or household members. It ordered states to reinstate coverage for some 500,000 people.

Varying Timetables, Varying Rates of Disenrollment

Idaho, one of a few states that completed the unwind in six months, said it disenrolled 121,000 people of the 153,000 recipients it reviewed as of September because it suspected they were no longer eligible with the end of the public health emergency. Of those kicked off, about 13,600 signed up for private coverage on the states ACA marketplace, said Pat Kelly, executive director of Your Health Idaho, the states exchange. What happened to the rest, state officials say they dont know.

California, by contrast, started terminating recipients only this summer and is automatically transferring coverage from Medicaid to marketplace plans for those eligible.

The Medicaid disenrollment rates of people reviewed so far vary dramatically by state, largely along a blue-red political divide, from a low of 10% in Illinois to a high of 65% in Texas.

I feel like Illinois is doing everything in their power to ensure that as few people lose coverage as possible, said Paula Campbell of the Illinois Primary Health Care Association, which represents dozens of community health centers.

Nationwide, about 71% of Medicaid enrollees terminated during the unwinding have been cut because of procedural issues, such as not responding to requests for information to verify their eligibility. Its unclear how many are actually still eligible.

State and local Medicaid officials say they have tried contacting enrollees in multiple ways including through letters, phone calls, emails, and texts to check their eligibility. Yet some Medicaid recipients lack consistent addresses or internet service, do not speak English, or are juggling more pressing needs.

The unwinding effort continues to be very challenging and a significant lift for all states, said Kate McEvoy, executive director of the National Association of Medicaid Directors.

People Are Not Getting Through

In many states, that has meant enrollees have faced long waits to get help with renewals. The worst phone waits were in Missouri, according to a KFF Health News review of letters the Centers for Medicare & Medicaid Services sent to states in August. In the letter to Missouris Medicaid program, CMS said it was concerned that the average wait time of 48 minutes and the 44% rate of Missourians abandoning those calls in May was impeding equitable access to assistance and patients ability to maintain coverage.

Some people are waiting on hold more than three hours, said Sunni Johnson, an enrollment worker at Affinia Healthcare, which runs community health centers in the St. Louis area. Thats a significant hurdle for a population in which many have limited cellphone minutes. On May 4, 2023, Jody White (left) and Grace Burke of Morton Comprehensive Health Services in Tulsa, Okahoma, examined a list of the health centers patients whose Medicaid eligibility was up for review that month. White had spent the morning calling patients on the list to make sure they were aware of the process and offer his assistance.(Bram Sable-Smith/KFF Health News)

In Florida, which has removed over 730,000 people from the program since April, enrollees earlier this year were waiting almost 2 hours on a Spanish-language call center, according to a report from UnidosUS, a civil rights advocacy group. The Spanish versions of the Medicaid application, renewal website, and other communications are also confusing, said Jared Nordlund, the Florida director for UnidosUS.

They can barely get the Spanish translations right, he said.

Miguel Nevarez, press secretary for Floridas Department of Children and Families, which is managing the states Medicaid redetermination process, criticized complaints about poor translations and long waits for the Spanish-language call center as a false narrative. He said, The data clearly shows Florida has executed a fair and effective plan for redeterminations.

In California, similarly jammed phone lines, crowded and understaffed county offices, and trouble downloading renewal applications electronically are all compounding peoples difficulty to renew their Medicaid, said Skyler Rosellini, a senior attorney in the Los Angeles office of the National Health Law Program. We do know, based on the cases were getting, that people are not getting through.

Jasmine McClain, a 31-year-old medical assistant, said she tried everything before Montana ended Medicaid coverage for her kids, ages 3 and 5, in early October. She tried submitting paperwork online and over fax to prove they still qualified. She spent hours on hold with the state hotline. After her kids coverage ended, she went to a state public assistance office in Missoula but couldnt get an appointment. One day in mid-October, roughly 30 people lined up outside the office starting as early as 6:40 a.m., before its doors opened.

After three weeks of her pleading for help while her kids were uninsured, the state restored her kids coverage. She said a supervisor told her the familys paperwork submitted online wasnt processed initially.

The phone call system was a mess. Callbacks were a week out to even talk to somebody, McClain said. It just was just a lot of hurdles that I had to get through.

Spokespeople for the Montana, Florida, and Missouri Medicaid programs all said their states had reduced call wait times.

Some Medicaid recipients are seeking help through the courts. In a 2020 class-action lawsuit against Tennessee that seeks to pause the Medicaid eligibility review, parents of recipients describe spending hours on the phone or online with the state Medicaid program, trying to ensure their childrens insurance coverage is not lost.

One of those parents, Donna Guyton, said in a court filing that Tennessees Medicaid program, called TennCare, sent a June letter revoking the coverage of her 37-year-old son, Patrick, who had been eligible for Medicaid because of disabilities since he was 6. As Guyton made calls and filed appeals to protect her sons insurance, he was hospitalized with pneumonia, then spent weeks there before dying in late July.

While Patrick was fighting for his life, TennCare was threatening to take away his health insurance coverage and the services he relied on, she said in a court filing. Though we should have been able to focus on Patricks care, our family was required to navigate a system that kept denying his eligibility and putting his health coverage at risk.

TennCare said in a court filing Patrick Guytons Medicaid coverage was never actually revoked the termination letter was sent to his family because of an error.

Phil Galewitz in Washington, D.C., wrote this article. Daniel Chang in Hollywood, Florida; Katheryn Houghton in Missoula, Montana; Brett Kelman in Nashville, Tennessee; Samantha Liss and Bram Sable-Smith in St. Louis; and Bernard J. Wolfson in Los Angeles contributed to this report. Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Katheryn Houghton: khoughton@kff.org, @K_Hought

Brett Kelman: bkelman@kff.org, @BrettKelman

Samantha Liss: samanthal@kff.org, @samanthann Related Topics California Insurance Medicaid Multimedia States Arkansas California Florida Idaho Illinois Massachusetts Missouri Montana Oklahoma Tennessee Texas Contact Us Submit a Story Tip

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This man survived Hiroshima bombing – and has a stark warning for us all

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This man survived Hiroshima bombing - and has a stark warning for us all

Toshiyuki Mimaki is exhausted when we meet him.

The 83-year-old sinks into his chair, closes his eyes, and asks us to keep it brief.

But then he starts talking, and his age seems to melt away with the power of his stories.

He is a survivor of Hiroshima’s atomic bomb, a lifelong advocate for nuclear disarmament and, as of last year, a Nobel Peace Prize winner.

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‘Why do these animals like war so much?’

But now, on the 80th anniversary of the bombing, he comes with more than just memories – he has a message, and it is stark.

“Right now is the most dangerous era,” he says.

“Russia might use it [a nuclear weapon], North Korea might use it, China might use it.

“And President Trump – he’s just a huge mess.

“We’ve been appealing and appealing, for a world without war or nuclear weapons – but they’re not listening.”

Read more:
The ‘destroyer of worlds’ who built the atomic bomb

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Trump issues nuclear sub order

‘I didn’t hear a sound’

Mr Mimaki was three years old when the US dropped an atomic bomb on the city of Hiroshima.

It was the first time a nuclear weapon had been used in war, and it’s remembered as one of the most horrific events in the history of conflict.

It’s estimated to have killed over 70,000 people on the spot, one in every five residents, unleashing a ground heat of around 4,000C, melting everything in its path and flattening two thirds of the city.

Horrifying stories trickled out slowly, of blackened corpses and skin hanging off the victims like rags.

“What I remember is that day I was playing outside and there was a flash,” Mr Mimaki recalls.

“We were 17km away from the hypocentre. I didn’t hear a bang, I didn’t hear a sound, but I thought it was lightening.

“Then it was afternoon and people started coming out in droves. Some with their hair all in mess, clothes ragged, some wearing shoes, some not wearing shoes, and asking for water.”

Hiroshima Survivor Toshiyuki Mimak, 83, speaks to Sky News
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Toshiyuki Mimaki

‘The city was no longer there’

For four days, his father did not return home from work in the city centre. He describes with emotion the journey taken by his mother, with him and his younger bother in tow, to try to find him.

There was only so far in they could travel, the destruction was simply too great.

“My father came home on the fourth day,” he says.

“He was in the basement [at his place of work]. He was changing into his work clothes. That’s how he survived.

“When he came up to ground level, the city of Hiroshima was no longer there.”

‘People are still suffering’

Three days later, the US would drop another atomic bomb on the city of Nagasaki, bringing about an unconditional Japanese surrender and the end of the Second World War.

By the end of 1945, the death toll from both cities would have risen to an estimated 210,000 and to this day it is not known exactly how many lost their lives in the following years to cancers and other side effects.

“It’s still happening, even now. People are still suffering from radiation, they are in the hospital,” Mr Mimaki says.

“It’s very easy to get cancer, I might even get cancer, that’s what I’m worried about now.”

-FILE PHOTO MARCH 1946 - This general view of the city of Hiroshima showing damage wrought by the atomic bomb was taken March 1946, six months after the bomb was dropped August 6, 1945. The 50th anniversary of the bombing of Hiroshima and the end of World War II is August 1995
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This image shows the city in March 1946, six months after the atomic bomb was dropped on 6 August 1945. Pic: Reuters

Tragically, many caught up in the bomb lived with the stigma for most of their lives. Misunderstandings about the impact of radiation meant they were often shunned and rejected for jobs or as a partner in marriage.

Many therefore tried to hide their status as Hibakusha (a person affected by the atomic bombs) and now, in older age, are finding it hard to claim the financial support they are entitled to.

And then there is the enormous psychological scars, the PTSD and the lifelong mental health problems. Many Hibakusha chose to never talk about what they saw that day and live with the guilt that they survived.

For Mr Mimaki, it’s there when he recounts a story of how he and another young girl about his age became sick with what he now believes was radiation poisoning.

“She died, and I survived,” he says with a heavy sigh and strain in his eyes.

He has subsequently dedicated his life to advocacy, and is co-chair of a group of atomic bomb survivors called Nihon Hidankyo. Its members were awarded the Nobel Peace Prize in 2024.

Pic: Reuters
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The city is marking 80 years since the blast. Pic: Reuters

‘Why do humans like war so much?’

But he doesn’t dwell much on any pride he might feel. He knows it’s not long until the bomb fades from living memory, and he deeply fears what that might mean in a world that looks more turbulent now than it has in decades.

Indeed, despite advocacy like his, there are still around 12,000 nuclear warheads in the world in the hands of nine countries.

“In the future, you never know when they might use it. Russia-Ukraine, Israel-Gaza, Israel-Iran – there is always a war going on somewhere,” he says.

“Why do these animals called humans like war so much?

“We keep saying it, we keep telling them, but it’s not getting through, for 80 years no-one has listened.

“We are Hibakusha, my message is we must never create Hibakusha again.”

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The chilling document that traces nuclear weapons back to Britain – and the threat we now face

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The chilling document that traces nuclear weapons back to Britain - and the threat we now face

Eighty years ago today, an American B-29 bomber dropped an atomic bomb on the Japanese city of Hiroshima.

It was the dawn of the atomic age, but the birth of the bomb can be traced beyond the deserts of New Mexico to Britain, five years earlier.

A copy of a hand-typed document, now in the Bodleian library in Oxford, is the first description of an atom bomb small enough to use as a weapon.

The Frisch-Peierls Memorandum was written by two nuclear physicists at the University of Birmingham in 1940.

Frisch-Peierls Memorandum
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The memorandum is the first description of an atom bomb small enough to use as a weapon

Otto Frisch and Rudolf Peierls don’t feature in the film Oppenheimer, but their paper is credited with jump-starting the Manhattan Project that ultimately built the bomb.

Both Jewish scientists who had both fled Nazi Germany, they built on the latest understanding of uranium fission and nuclear chain reactions, to propose a bomb made from enriched uranium that was compact enough to be carried by an aircraft.

The document, so secret at the time only one copy was made, makes for chilling reading.

The Frisch-Peirels Memorandum
Frisch-Peierls Memorandum

Not only does it detail how to build a bomb, but foretells the previously unimaginable power of its blast.

“Such an explosion would destroy life in a wide area,” they wrote.

“The size of this area is difficult to estimate, but it will probably cover the centre of a big city.”

Radioactive fallout would be inevitable “and even for days after the explosion any person entering the affected area will be killed”.

Both lethal properties of the bombs that would subsequently fall on Hiroshima and Nagasaki, killing around 100,000 instantly and more than 100,000 others in the years that followed – most of them civilians.

Read more:
Hiroshima survivor’s stark warning
The ‘destroyer of worlds’ who built the atomic bomb

The US dropped an atomic bomb on Hiroshima, Japan on 6 August 1945
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The atomic bomb was dropped by parachute and exploded 580m (1,900ft) above Hiroshima

‘The most terrifying weapons ever created’

Those bombs had the explosive power of around 16 and 20 kilotonnes of TNT respectively – a force great enough to end the Second World War.

But compared to nuclear weapons of today, they were tiny.

“What we would now term as low yield nuclear weapons,” said Alexandra Bell, president of the Bulletin of Atomic Scientists, which campaigns for nuclear disarmament.

“We’re talking about city destroyers…these really are the most terrifying weapons ever created.”

Five square miles of the city were flattened
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The atomic bomb flattened Hiroshima – but is much less powerful than modern nuclear weapons

Many of these “high yield” nuclear weapons are thermonuclear designs first tested in the 1950s.

They use the power of nuclear fission that destroyed Hiroshima to harness yet more energy by fusing other atoms together.

Codenamed “Mike”, the first test of a fusion bomb in 1952 yielded at least 500 times more energy than those dropped on Japan.

Impractically devastating, but proof of lethal principle.

Variants of the W76 thermonuclear warhead currently deployed by the US and UK are around 100Kt, six times more powerful than the Hiroshima bomb.

gfx still from Clarke explainer

Just one dropped on a city the size of London would result in more than a quarter of a million deaths.

The largest warhead in America’s current arsenal, the B83 has the explosive equivalent of 1.2 megatonnes (1.2 million tonnes of TNT) and would kill well over a million instantly.

gfx still from Clarke explainer

But modern intercontinental ballistic missiles (ICBMs) are designed to carry multiple warheads.

Russia’s Sarmat 2, for example, is thought to be capable of carrying 10 megatonnes of nuclear payload.

They’re designed to strike multiple targets at once, but if all were dropped on a city like London most of its population of nine million would be killed or injured.

gfx still from Clarke explainer

If that kind of power is incomprehensible, consider how many nuclear warheads there now are in the world.

Nine countries – the US, Russia, China, France, the UK, India, Pakistan, North Korea and Israel – have nuclear weapons.

Several others are interested in having them.

The US and Russia have around 4,000 nuclear warheads each – 90% of the global nuclear arsenal and more than enough to destroy civilisation.

map from Clarke explainer

According to analysis from the Stockholm International Peace Research Institute, China us thought to have around 600 warheads, but has indicated a desire to catch up.

Beijing is believed to be building up to 100 new warheads a year and the ICBMs to deliver them.

Five more nuclear powers, including the UK, plan to either increase or modernise their existing nuclear stockpiles.

The nuclear arms race that created this situation was one imagined by Frisch and Peierls in their 1940 memorandum.

Given the mass civilian casualties it would inevitably cause, the scientists questioned whether the bomb should ever be used by the Allies.

Chinese soldiers simulate nuclear combat
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Chinese soldiers simulate nuclear combat

They wrote, however: “If one works on the assumption that Germany is, or will be, in the possession of this weapon… the most effective reply would be a counter-threat with a similar bomb.”

What they didn’t believe was that the bomb they proposed, and went on to help build at Los Alamos, would ever be used.

Devastated by its use on Japan, Peierls disavowed the bomb and later campaigned for disarmament.

But that work is now as unfinished as ever.

Non-proliferation treaties helped reduce the expensive and excessive nuclear arsenals of Russia and the US, and prevent more countries from building nuclear bombs.

Russian air force crew member oversees an instrument panel on board a Tu-95 nuclear-capable strategic bomber
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A Russian airman on a nuclear-capable strategic bomber

‘Everything trending in the wrong direction’

But progress ground to a halt with the invasion of Ukraine, as nuclear tensions continued elsewhere.

“After all the extremely hard, tedious work that we did to reduce nuclear risks everything is now trending in the wrong direction,” said Alexandra Bell.

“The US and Russia refuse to talk to each other about strategic stability.

“China is building up its nuclear arsenal in an unprecedented fashion and the structures that were keeping non-proliferation in place stemming the spread of nuclear weapons are crumbling around us.”

A White House military aide carries the so-called nuclear football as U.S. President Donald Trump boards Marine One.
Pic: PA
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The US president is always in reach of the ‘nuclear football’ , a bag which contains the codes and procedures needed to authorise a nuclear attack

‘New risks increasing the threat’

The world may have come closer to nuclear conflict during the Cuban missile crisis of 1963, but the fragmented and febrile state of geopolitics now is more dangerous, she argues.

Conflict regularly flares between nuclear armed India and Pakistan; Donald Trump’s foreign policy has sparked fears that South Korea might pursue the bomb to counter North Korea’s nuclear threat; some states in the Middle East are eyeing a nuclear deterrent to either nuclear-wannabe Iran or nuclear armed Israel.

Add to the mix the military use of AI and stressors like climate change, and the view of the Bulletin of Atomic Scientists is the situation is more precarious than in 1963.

“It’s more dangerous, but in a different way,” said Alexandra Bell. “The confluence of all these new existential risks are increasing the threat worldwide.”

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Bill and Hillary Clinton subpoenaed in Jeffrey Epstein probe

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Bill and Hillary Clinton subpoenaed in Jeffrey Epstein probe

The US House Oversight Committee has issued subpoenas for depositions with former president Bill Clinton and former secretary of state Hillary Clinton relating to the sex trafficking investigation into Jeffrey Epstein.

The Republican-controlled committee also subpoenaed the Justice Department for files relating to the paedophile financier, as well as eight former top law enforcement officials.

Donald Trump has denied prior knowledge of Epstein‘s crimes, claiming he ended their relationship a long time ago.

Trump and Epstein at a party together in 1992. Pic: NBC News
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Mr Trump and Mr Epstein at a party together in 1992. Pic: NBC News

The US president has repeatedly tried to draw a line under the Justice Department’s decision not to release a full accounting of the investigation, but politicians from both major political parties, as well as many in Mr Trump’s political base, have refused to drop their interest in the Epstein files.

Epstein died in a New York jail cell in 2019 awaiting trial on sex trafficking charges, and since then, conspiracy theories have swirled about what information investigators gathered on him and who else may have been involved in his crimes.

Republicans on the House Oversight Committee initiated the subpoenas for the Clintons last month, as well as demanding all communications between former president Joe Biden’s Democrat administration and the Justice Department about Epstein.

The committee previously issued a subpoena for an interview with Epstein’s former girlfriend, Ghislaine Maxwell, who had been serving a prison sentence in Florida for luring teenage girls to be sexually abused by Epstein. She was recently transferred to another facility in Texas.

Mr Clinton was among those acquainted with Epstein before the criminal investigation against him in Florida became public two decades ago. He has never been accused of wrongdoing by any of the women who say Epstein abused them.

Mr Clinton previously said, through a spokesperson, that while he travelled on Epstein’s jet, he never visited his homes and had no knowledge of his crimes.

Read more:
All we know about Trump and Epstein’s ‘friendship’

This is a rare escalation

The subpoenaing of former president Bill Clinton is an escalation, both legally and politically.

Historically, it is rare for congressional oversight to demand deposition from former presidents of the United States.

Ghislaine Maxwell, Jeffrey Epstein’s former girlfriend and accomplice, had already been summonsed.

But the House Oversight Committee has now added Bill and Hillary Clinton, several former Attorneys General and former FBI directors to its list.

It signals bipartisan momentum – Democrats voting with Republicans for transparency.

The committee will now hear from several people with known ties to Epstein, his connection with Bill Clinton having been well-documented.

But the subpoenas set up a potential clash between Congress and the Department of Justice.

Donald Trump, the candidate, had vowed to release them. A government led by Mr Trump, the president, chose not to.

If Attorney General Pam Bondi still refuses to release the files, it will fuel claims of a constitutional crisis in the United States.

But another day of Epstein headlines demonstrates the enduring public interest in this case.

The subpoenas give the Justice Department until 19 August to hand over the requested records.

The committee is also asking the former officials to appear for depositions throughout August, September and October, concluding with Hillary Clinton on 9 October and Bill Clinton on 14 October.

Although several former presidents, including Mr Trump, have been issued congressional subpoenas, none has ever appeared before members under compulsion.

Last month, Mr Trump instructed Attorney General Pam Bondi to release information presented to the grand jury that indicted Maxwell for helping Epstein sexually abuse teenage girls.

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