贝瑟尼·祖利克（Bethany Zulick）在一月份重返校园，准备成为一名高中英语教师。几年前，她曾在海外从事英语作为第二语言的教学工作，并且非常热爱这份工作。
Bethany Zulick went back to school in January to become a high school English teacher. Years ago, she taught English as a second language overseas and loved it.
“看到学生们学习新单词、或是他们的脸上露出理解的神情，那种感觉真是太令人兴奋了，”居住在米苏拉（Missoula）的祖利克说道。
"It's so exciting to me to watch someone learn a new word or have that spark of understanding," said Zulick, who lives in Missoula.
她原本认为，作为一名代课教师，自己能够赚取足够的收入来支撑重返校园的学费和生活开销——不过唯一的难题是医疗保险的费用。她担心自己因为过敏或需要预防性医疗护理而无法及时就医。
Zulick knew she could earn enough money as a substitute teacher to make going back to school financially viable — except for the cost of health insurance. She didn't want to risk being unable to see her doctor for her allergies or for preventive care.
蒙大拿州立大学（Montana State University）提供的医疗保险费用非常高，几乎与她的学费相当。不过后来她找到了一个解决办法：通过“医疗补助计划”（Medicaid）来覆盖这些费用，这样她就无需支付任何月度保费了。这个方案在最初几个月运作得相当顺利——她白天上课，晚上则通过在线课程继续学习。
The health insurance offered through Montana State University was too expensive, Zulick said, almost as much as her tuition. But then she found a solution that allowed her to make the leap: Medicaid. She wouldn't have to pay any monthly premiums.
然而到了六月份，州政府寄来了一封令她感到困惑至极的信件。她知道蒙大拿州确实在夏季推出了新的医疗补助计划相关要求，但原以为自己直到明年医疗保险续期时才需要证明自己符合这些要求。
It worked well for a few months, as Zulick taught by day and took online classes at night. But in June, the state sent a letter that she said left her "completely confused."
然而，这封来自蒙大拿州公共卫生与人类服务部（Montana Department of Public Health and Human Services）的信件中关于具体提交证明时间的说明却相互矛盾：信件中一方面表示她需要在明年春天（即下一次续期时）才需要证明自己符合要求；另一方面却又要求她在收到信件的当天（6月26日）起“30天内”就提交相关文件以证明自己的合规性。她不禁疑惑：这只是一封例行公事式的群发邮件，可以忽略不计吗？还是她的医疗保险真的因此处于危险之中？
She knew Montana was rolling out a system for Medicaid work requirements over the summer, but she thought she wouldn't have to prove she met the requirements until next year, when her Medicaid enrollment came up for renewal. Yet the letter from the Montana Department of Public Health and Human Services outlining the new requirements gave conflicting information on when Zulick would have to prove she was meeting them. First, it said at her next renewal, which would be sometime next spring.
所有州都必须在1月1日前实施这些新的规定，不过蒙大拿州、内布拉斯加州（Nebraska）和阿肯色州（Arkansas）这三个州已经率先开始了这一进程。
Lower down, it told her she would have to submit paperwork to prove compliance much earlier — "within 30 days" of the date on the letter, June 26.
医疗补助计划的支持者担心，这些州加快实施新规定的时间表会导致数千人失去医疗保障——因为他们对这些新规定感到困惑，尽管他们实际上符合该计划的申请资格；同时，蒙大拿州的现状可能预示着明年全国范围内将会发生类似的问题。
She wondered: Was it a boilerplate mass-mailing letter she could ignore, or was her insurance on the line?
州卫生部门官员表示他们已经做好了充分准备，并向州立法者承诺每月将处理大约5,000份申请。
All states must implement the new work requirements by Jan. 1, but three states — Montana, Nebraska and Arkansas — have already gotten started.
随着民众的困惑日益加深，以及可获得的帮助越来越少，蒙大拿州众议院议员SJ·豪厄尔收到了数十位选民的咨询电话，他们主要对类似祖利克（Zulick）所收到的那些通知感到困惑。
Medicaid advocates worry that the expedited timeline in those states will lead to thousands of people losing coverage because they're confused about the new rules, even if they are eligible for the program — and that Montana may offer a troubling preview of what will happen nationwide next year.
这位民主党议员在9月初的听证会上向卫生部门负责人询问了这些通知的具体内容，她说：“卫生部门发出的通知非常令人困惑，人们很难找到相关信息来了解实际情况。”
State health department officials maintain they are well prepared and told state lawmakers they plan to process roughly 5,000 enrollees monthly.
州卫生部门官员在听证会上向立法者表示，已经对发给申请者的通知进行了修改，使其内容更加清晰易懂。
Growing confusion and dwindling help State Rep. SJ Howell of the Montana House has gotten dozens of calls from confused constituents, specifically about letters like the one Zulick received.
在蒙大拿州，约有71,000人受到新规定的影响。医疗补助的费用由联邦政府和州政府共同承担，各州负责具体实施这一为低收入者或残疾人提供医疗保障的计划。
"The notices coming from the department are very, very confusing, and it's very hard to find help figuring out what's going on," said the Democratic legislator, who asked health department leaders about those letters at a hearing in early September. Letters being sent to enrollees have been updated to be clearer, state health officials told lawmakers at the hearing.
根据新的规定，申请者必须证明自己每月至少工作80小时、从事志愿服务或接受教育；否则，他们必须提供符合某些豁免条件的证明（例如身体虚弱或担任家庭成员的主要照顾者）。
In Montana, nearly 71,000 people are subject to the new rules.
蒙大拿州于7月开始逐步实施这些新规定，并给申请者提供了截至10月1日的缓冲期来遵守这些要求。
Medicaid costs are split between the federal and state governments, and states are responsible for administering the program, which provides health insurance for people with low incomes or disabilities.
批评者认为这段时间实在不够，因为该州尚未完成新计算机系统的建设，也未招聘到所需的员工。州卫生部门官员在9月9日的听证会上向立法者透露，原本计划招聘的59个职位中，目前只有约20个得到了填补。
Under the new work requirements, enrollees must document that they're working, volunteering, or studying 80 hours per month — or they must show that they qualify for one of a range of exemptions, such as being "medically frail" or being the primary caretaker for a family member. Montana began with a soft launch of the work requirements in July and gave enrollees until Oct. 1 to comply.
该州早在今年夏天就已经招聘了其中一半的工作人员，但官员们表示，由于人员流动（即员工离职或新员工入职），他们又失去了部分员工。
Critics contend that isn't enough time, because the state hasn't finished setting up new computer systems or hiring the staff it said it would need.
州卫生部门表示，最终他们将能够自动核实学生是否已注册公立大学。不过，这套计算机系统预计要到明年才能正式投入使用，因此像祖利克（Zulick）这样的学生仍需要自行查找并提交相关文件以证明自己的大学入学资格。
Of the 59 positions, only about 20 were filled, state health department officials told state lawmakers during the Sept. 9 hearing. The state had already hired over half of those workers earlier this summer, but officials said they lost staff to turnover.
然而，能够帮助居民完成这些繁琐行政手续的外部资源却非常有限。
State health officials have said they'll eventually be able to automatically verify that students are enrolled in public universities.
例如，非营利组织“Cover Montana”曾帮助蒙大拿州居民填写相关申请表格，但去年该组织失去了联邦政府的资助，其员工人数从18人锐减至仅剩两名兼职工作人员，他们只能通过电话热线提供帮助。
However, that computer system isn't expected to be up and running until next year, leaving students like Zulick to track down and submit the correct paperwork to prove their college enrollment.
虽然该州确实设立了热线服务，但联邦数据显示，蒙大拿州的居民在等待接通电话时所花费的时间远高于全国平均水平；许多来电者在与州政府工作人员取得联系之前就直接挂断了电话。
However, there are fewer outside resources to help residents with these bureaucratic tasks.
“我们担心州政府如果急于推进这项工作，可能会引发混乱，”蒙大拿州医疗保健基金会（Montana Healthcare Foundation）的首席执行官亚伦·沃恩汉姆（Aaron Wernham）说。该基金会致力于改善该州的医疗保健体系。
For example, Cover Montana, a nonprofit that helps Montanans fill out such paperwork, lost federal funding last year, going from a staff of 18 to two part-time employees working a phone line. The state does operate a helpline, but federal data shows that Montanans stay on hold much longer than the national average and that many callers hang up before they connect with a state employee.
“鉴于州政府对自己所采取的措施披露的信息如此有限，我更加担心会出现混乱，”沃恩汉姆补充道。
"We were worried about chaos that could be generated by the state rushing," said Aaron Wernham, CEO of the Montana Healthcare Foundation, a nonprofit aimed at improving health in the state.
沃恩汉姆还提到了2023年类似的情况：当时各州因疫情暂停了常规的医疗补助资格审核工作，随后不得不重新评估所有医疗补助受益人的资格。许多原本符合条件、本应继续享受医疗补助的蒙大拿州居民，因文件填写错误等原因而失去了补助资格——根据两年前的州政府数据，这类人数约为8.7万人。
"Given how little information the state has provided about what they are doing, I'm much more worried about chaos," Wernham added. Wernham pointed to a similar upheaval in 2023, when states undertook a massive process to redetermine the eligibility of all Medicaid enrollees, after regular eligibility checks were paused during the pandemic.
甚至那些本不需要提交申请、因为他们的医疗补助资格本应自动续期的弱势群体，也被从医疗补助名单中剔除，其中包括无家可归者。
Many Montanans who were financially eligible lost Medicaid coverage for technical reasons, such as incorrectly filling out paperwork — roughly 87,000, according to state data from two years ago.
关键规定：
Even vulnerable Montanans who didn't need to file paperwork, because their coverage should have been automatically renewed, were dropped from the Medicaid rolls, including people who were homeless.
蒙大拿州立法机构通过相关措施 2019年，蒙大拿州立法机构通过了一项法案，提出在医疗补助（Medicaid）项目中加入工作要求的条款；但直到现在，该州才获得联邦政府的批准，得以正式实施这些规定。
Long-sought requirements in the state The Montana Legislature passed a measure in 2019 expressing its desire to add work requirements to Medicaid, but the state didn't have permission from the federal government to move forward until now.
共和党人马特·雷吉尔（Matt Regier）表示：“对于依赖社会保障体系的人来说，工作要求能够促使他们承担更多责任。”
Having work requirements creates accountability for people who rely on the social safety net, said Montana Senate President Matt Regier, a Republican.
“在这种经济环境下，如果你是一个身体健康、有能力工作的成年人，你就真的应该站出来承担责任。”
"In an economy like this, if you're an able-bodied adult that's able to work, you really do need to step up," he said.
当被问及参保者对相关规定的困惑时，雷吉尔回应称：10月1日的截止日期为解决新系统中的问题提供了充足的时间。
Asked about confusion among enrollees about the rules, Regier responded that the Oct. 1 deadline offered more than enough time to work out the kinks in the new system.
祖利克（Zulick）的遭遇祖利克原本担心自己会错过这个截止日期，因为她于7月结婚后不再符合医疗补助的资格；不过她在6月收到通知时并不知道这一情况。
In the end, Zulick learned she didn't need to worry about that deadline, because she got married in July and no longer qualified for Medicaid, although she didn't know that would be the case when she got the June letter.
其他人的担忧然而，仍有人担心会失去医疗保障。例如希瑟·里尔（Heather Reel）——她在7月参加了在州议会大厦举行的抗议活动，反对蒙大拿州过早推行这些规定。
But others remain scared about losing coverage, including Heather Reel, who attended a rally at the state capitol in July to push back against Montana's early rollout. Reel relies on Medicaid for its mental health coverage.
里尔依赖医疗补助来支付她的心理健康治疗费用。她表示：“如果没有医疗补助，我将难以照顾患有自闭症且无法说话的 teenage 儿子。由于需要在快餐店工作并同时照顾儿子，我担心自己会过于忙碌，而无法按时上报自己的工作时间。”
Without it, she said, she would struggle to care for her teenage son, who has autism and is nonverbal. Between her shifts at a fast food restaurant and caring for her son, she's scared she'll be too busy to figure out how to report her work hours.
专家的观点为非营利组织“Commonwealth Fund”提供医疗补助分析的阿凯伊萨·科尔曼（Akeiisa Coleman）指出：“提前实施医疗补助工作要求的少数几个州，其实是在‘边飞行边建造飞机’（即边推进改革边完善相关机制）。”“蒙大拿州的做法可能会成为全国范围内类似改革的参考范例。”
Montana's rollout is a potential preview The handful of states that are implementing the Medicaid work requirements early are building the plane as they're taking off, said Akeiisa Coleman, who provides Medicaid analysis for The Commonwealth Fund, a nonprofit focused on making healthcare more equitable. "Montana is going to be an example for what we might see nationally as things roll out," she said.
她补充说：“虽然大多数其他州仍坚持将1月1日作为系统建设和测试的截止日期，但它们可能仍未完成所有必要的准备工作。”
Although most other states are sticking to the Jan. 1 deadline to build and test their Medicaid systems, they still might not have all the components in place, she said.
如果各州无法根据新规定自动续保或终止医保资格，州政府工作人员就必须逐案人工处理。这可能造成积压和更多混乱，进而导致更多人失去医保资格，科尔曼说。
If states can't automatically renew or deny coverage based on the new rules, state workers will have to do so manually, on a case-by-case basis. That could create backlogs and more disruption, leading more people to lose coverage, Coleman said.
州卫生部门发言人乔恩·埃贝尔特在一份声明中表示，蒙大拿州医疗补助办公室已为10月1日的政策变动做好准备。
Jon Ebelt, a spokesperson for the state's health department, said in a statement that Montana's Medicaid office is ready for the change on Oct. 1.
“我们致力于在满足相关要求的同时，确保符合条件的蒙大拿州居民继续享有医保，并会继续密切监测政策实施情况。”埃贝尔特说。
"We are committed to ensuring eligible Montanans maintain coverage while meeting requirements, and we will continue to monitor implementation closely," Ebelt said.
民主党籍州议员曾多次要求州卫生官员延长10月1日的期限，以便参保者遵守新规定，但州卫生部门领导层表示暂无此计划。
Democratic state lawmakers have repeatedly asked state health officials to extend the Oct. 1 deadline for enrollees to comply with the new rules, but state health department leadership said they have no plans to do so.
这则报道来自NPR与蒙大拿公共广播公司及KFF健康新闻合作的健康报道项目。
This story comes from NPR's health reporting partnership with Montana Public Radio and KFF Health News.