D.C. healthcare cuts set to impact thousands, hitting the undocumented hardest

N.S., an immigrant from Nigeria, has been a DC Health Care Alliance patient for the last 20 years.

She doesn’t qualify for Medicaid, she lacks the paperwork to work legally, and she can’t afford private insurance. So N.S., who asked to use an alias due to her immigration status, relies on the city-funded program to pay for the medication and regular blood tests she needs to live with a serious autoimmune condition. Alliance covers about 26,000 low-income residents like her, regardless of immigration status.

Now, that’s set to change: a package of staggered health-care rollbacks in this year’s budget mean all Alliance members over age 21 are expected to lose their coverage by October 2027. The first cuts go into effect next week and will impact around 2,700 people, according to the Office of the Deputy Mayor for Health and Human Services. 

“I’m really going out of my mind, just trying to understand — what am I supposed to do? How am I supposed to afford it? I can’t. I just can’t,” N.S. said. She particularly worries about being the sole caretaker for her son, who has autism.

In January, some Alliance members will be able to join the Healthy DC Plan, also known as the Basic Health Plan, which is primarily meant to serve people who are getting cut off from Medicaid. However, since this federally funded program only supports lawfully present residents, just a fraction of Alliance members will be eligible.

During budget talks, Deputy Mayor for the D.C. Health and Human Services Wayne Turnage characterized the plan to dismantle the decades-old health insurance program as a way to navigate grim revenue forecasts while managing surging healthcare costs. While Alliance enrollment increased by just 31% between 2011 and 2026, Alliance expenditures shot up by 384% during the same period.

“Due to a challenging fiscal environment, the changes to Medicaid and Alliance are both being made to reduce overall cost to the District,” Turnage’s office told The 51st. A fiscal impact statement from May forecast $48 million in savings in fiscal 2026 as a result of Alliance cuts. 

However, Councilmember Christina Henderson, who chairs the Council’s health committee, said that threats from Congress also played a role in the decision.

The day that all Alliance coverage for ages 21+ is supposed to end entirely — Oct. 1, 2027 — is the same day that, in the original House-passed version of the “Big, Beautiful Bill,” steep financial consequences would have gone into effect for states that provide health care to undocumented people. But this provision did not make it into the final version of that bill, which passed a few weeks before D.C. Council approved this year’s budget.

“I do feel like there were some decisions that were made by the Bowser administration on the front end, that were based on assumptions of what we thought was going to happen on the federal side,” said Henderson. “Not all of those things seemed to pan out.”

In the meantime, advocates are throwing themselves into a final push to enroll those who are still eligible: The last day anyone over 25 can register for Alliance is next Tuesday.

The first stage of a two year phase out will occur the following day, on Oct. 1, when the maximum income for Alliance patients will drop from 215% of the federal poverty level — about $34,000 a year, for a one-person household — to 138%, or about $22,000 per year. In October of 2026 the income limit is expected to drop to 19% of the federal poverty level before ending entirely for ages 21+ the next year.

Advocates also have their eye on a bigger goal: restoring Alliance funding and reversing a plan that experts say will inflict serious harm on patients who are forced to skip check-ups and go without life-saving medication. 

“They’re telling my patients, ‘I don’t care if you go blind. I don’t care if you die from diabetes. I don’t care if you die from untreated heart disease,’” said Dr. Kate Sugarman, a family doctor in Ward 1 who works extensively with immigrant patients. “No! It’s not acceptable.”

D.C. Council’s last-minute judgment calls

On a recent Sunday morning at Shrine of the Sacred Heart, while some parishioners had coffee or chatted after Spanish and Portuguese mass, others approached the bustling booths of healthcare organizations.

In the middle of the busy scene was Unite Here Local 25 organizer Amanda Gomez. Low wages and poor benefits make many of their members in the restaurant industry dependent on Alliance, Gomez said. 

“It’s a big slap in the face because, like, you already have your federal government saying to immigrants, you know, ‘you don’t belong here,’” Gomez said. “And now you have your city government saying, ‘And we’re not gonna support you.’”

Henderson said that while Congress backed off from its threat to defund states that provide health care to undocumented people, it happened too late to pivot.

When the D.C. Council received its budget draft from Mayor Muriel Bowser’s office — which happened two months later than normal this year — that provision was still included in the “Big, Beautiful Bill.” This was still the case when D.C. Council’s Committee on Health approved its recommended edits to the budget in late June. 

The Senate removed those penalties from the final version of the bill that Trump signed into law on July 4. But that happened so close to the final budget vote on July 28 that making major changes would have been particularly difficult, Henderson said.

The thought of D.C. leaders making sweeping policy decisions based on fears that never materialized infuriates Kate Coventry, deputy director of legislative strategy at the DC Fiscal Policy Institute.

“Why are we preemptively acting? Wait until they tell us we can’t have this insurance,” Coventry said. “People are going to die because of lack of health insurance, because of what Congress might do. Why are we obeying before we are told?”

Turnage, by contrast, made no mention of any direct pressure from Congress in prepared testimony to the Committee on Health in June (and wouldn’t comment on whether it played a role in the cuts). 

“The challenging nature of the city’s finances, combined with the unsustainable cost growth in both the Medicaid and Alliance programs, required saving actions that have no historical precedent in the District,” he said in June. “However, the strategies put forth were thoughtfully deliberated and crafted in a manner to minimize the loss of access to quality health care.”

Henderson suggested that there might still be ways to avoid fully eliminating Alliance, perhaps beginning with changes in the fiscal 2027 budget. But she noted that the District’s financial problems aren’t going away anytime soon, and neither is the threat of federal lawmakers who have proven themselves increasingly willing to force changes on a city that they don’t represent.

“Especially [with] D.C. not being a state, it is really hard for us to have the stability and consistency of some of these policies, particularly around health insurance, when we’re dealing with a president and a Congress that is constantly moving the goalposts on what they’re trying to do with federal policy,” Henderson said.

Health experts fear for patients

Maria Gómez, the founder of the community health organization Mary’s Center, fears returning to what D.C. was like before Alliance started in 2001.

“People had to, like, beg different clinics and beg hospitals to see them,” said Gómez. “So people went without dialysis. People went to prenatal care at the last minute, when they were about to deliver.”

Alliance was created in response to the closure of D.C. General Hospital, which was one of the only hospitals that would regularly treat people without insurance. Since then, the District’s rate of uninsured residents has dropped to one of the lowest in the country: just 2.7% in 2023, compared to a nationwide rate of 7.9%, according to U.S. census data.

As D.C.’s health-care options begin backsliding – with undocumented people likely relying on a limited number of federally qualified health centers, which offer a basic range of treatments on a sliding pay scale – Sugarman expects to see the effects firsthand. She referred to one Alliance patient she saw this month, whose diabetes requires multiple daily injections that are unaffordable without insurance, and whose heart disease, kidney disease and eye disease frequently send him to the hospital.

“I don’t know what’s going to happen to him,” she said. “It’s terrifying.”

Henderson noted that providers have a responsibility to help people who are actively having a health emergency, regardless of whether they have insurance. She expects that an upcoming supplemental budget will include more funding for “uncompensated care,” helping providers respond to an expected influx of people seeking emergency help.

“If you have an emergency situation, there are still avenues and places for you to be able to seek care,” Henderson said. “You know, they’re not going to turn you away.”

But health experts have major concerns about people having to wait until a crisis to get care. 

Sugarman recalled seeing a diabetic patient who, despite feeling fine, had extremely high blood sugar that was beginning to damage her eyes. Catching it in time saved her from potentially going blind.

“It all started because she went to the doctor for a checkup,” Sugarman said.

Preventative care doesn’t just safeguard people’s health. It also avoids costly and dangerous ER visits, where Emergency Medicaid coverage lasts only as long as the emergency itself.

Losing Alliance would leave few options for people like N.S., who said that without her medication, she would rapidly lose the ability to cook her son’s meals, go grocery shopping, or even get out of bed. Patients like her, who depend on Alliance for lifesaving medications, may suffer some of the greatest and most immediate harm.

“I expect many will have big problems affording them, and their health conditions may worsen, if they cannot afford to get medicines,” Dr. Nicole Lurie, a longtime volunteer physician at Bread for the City, said over email. “I expect many will end up in the hospital. Some people may even die.”

The fight for Alliance continues

Sugarman and other advocates are currently collecting letters from D.C. residents that they will use to push leaders to restore Alliance funding — or, at a minimum, delay cuts as much as possible while researching alternatives.

Coventry expects most of the DC Fiscal Policy Institute’s advocacy on this issue to focus either on next budget season, which begins in the spring, or on a supplemental budget, if the council adopts one. 

Even if Alliance doesn’t go away entirely, Henderson noted that sustaining the program would be a substantial task that would likely require “some programmatic changes” no matter what. Still, she argued that the reason the program exists at all is because D.C. leaders recognize the importance of providing people with medical insurance.

“I think we all value folks having access to health care, and we’re trying to figure out how to do that under the constraints that we currently are under,” she said.

Regardless of what officials do further down the line, people like N.S. are already in a world of questions with no obvious answers.

Next year, for instance, N.S. is scheduled to receive a dental implant for a cracked molar. But Alliance members are losing their dental insurance in January — leaving her staring down a $1,300 dental bill that she has no clear way of paying.

And that’s only the beginning. The thought of what happens if N.S. loses Alliance coverage altogether — if she’s asked to pay money she doesn’t have for the medicine that keeps her alive, or else wait to go to the hospital until her symptoms qualify as an “emergency” — gives her a simple message for D.C. leaders.

“Set your priorities right,” she said. “Choose life.”

What should I do now if I need Alliance insurance?

Apply for Alliance or check your enrollment status before Oct. 1 if you:

• Live in D.C.
• Will be 26 or older by Oct. 1
• Earn 138% of the federal poverty level or less (about $1,800 per month for an individual)
• Don’t have other insurance, or your Alliance coverage has lapsed or might lapse soon

Call the D.C. Health Care Ombudsman at (202) 724-7491 to check your status or learn how to apply. If you need help, contact Legal Aid DC.