A KHN-Spotlight PA investigation found that Pennsylvania has allowed providers to continue operating despite repeated violations of state regulations and harm to clients.

This article was published on Friday, April 30, 2021 in Kaiser Health News.

By Aneri Pattani and Ed Mahon, Spotlight PA April 30, 2021

This investigation is a joint project of KHN, a national newsroom that produces in-depth journalism about health issues, and Spotlight PA, an independent, collaborative newsroom dedicated to producing investigative journalism for all of Pennsylvania.

When Ian Kalinowski was at work, his mom usually texted him. So when he saw her number show up as an incoming call around lunchtime one Tuesday, he figured it had to be important.

Now, more than seven years later, he remembers her screams, the shock and the questions she asked over and over again.

"Why are they saying this to me? Why are they lying to me?" Ian recalled his mom asking. "They're telling me Adam's dead. Why would they do this to me?"

Adam was Ian's older brother. Growing up, it seemed they spent every second together. Football, hockey and tag filled long days outside their Pittsburgh home. When Ian moved away for college, he and Adam turned to online poker to stay in touch. Adam served as best man at Ian's wedding, and Ian admired his brother's artistic streak. Adam could turn any piece of paper into an origami swan. His mom's home is still full of swans.

Adam's struggle with opioid and alcohol addiction was painful for Ian to watch. The problems began, it seemed to Ian, after Adam dropped out of college and used drugs to deal with his depression. Adam sought treatment, and he relied on methadone for many years, but his problems continued. When he was 32, he typically drank dozens of beers each day. On Feb. 3, 2014, he entered a treatment center run by Addiction Specialists Inc., according to a lawsuit later filed by his family against the facility. The center, in a Fayette County strip mall, was about an hour's drive south of Pittsburgh.

Less than 24 hours after Adam made it to the facility, he was dead, according to expert reports from doctors in the family's wrongful death lawsuit. Ian couldn't understand what went wrong, and neither could his mom, still in denial on the other end of the phone call.

What his family didn't know was that Addiction Specialists, often known as ASI, had a history of violating state rules. In a later federal investigation into the facility's billing and drug distribution practices, a grand jury concluded that a litany of problems occurred at the business many months before and after Adam's arrival.

In the wrongful death suit, a lawyer for the Kalinowski family alleged Adam wasn't evaluated by a physician when he arrived at ASI, didn't receive the medication or treatment he needed, became increasingly uneasy and anxious throughout the night and killed himself. An Allegheny County judge in December 2019 said the business, two of its owners — Rosalind and Sean Sugarmann — and an ASI physician were negligent in caring for Adam. The judge ordered them to pay over $1.6 million in damages, although Ian doubts they ever will.

ASI eventually shut down, two years after Adam died.

In recent interviews with KHN-Spotlight PA, the Sugarmanns denied responsibility for Adam's death and maintained that ASI was a good facility. Rosalind said it helped a lot of people in a rural area with a high drug-overdose rate.

Addiction treatment facilities in Pennsylvania, like ASI, are licensed and regulated by the state to ensure they follow certain rules and keep vulnerable people struggling with addiction safe. Oversight used to fall to the Department of Health. But in 2012, the state created the Department of Drug and Alcohol Programs, a $125 million agency set up to give substance use the attention lawmakers felt it deserved.

At the time of Adam's death in 2014, the department had taken few disciplinary actions against ASI. It had issued citations and required the company to submit plans to correct them. But the Sugarmanns told KHN-Spotlight PA that, at the time, they didn't fear the state would shut them down.

Perhaps for good reason.

A KHN-Spotlight PA investigation found that the department has allowed providers to continue operating despite repeated violations of state regulations and harm to clients. More than 80 interviews and a review of thousands of pages of state government and court records revealed that the department lacks resources and regulatory power, uses an inherently flawed oversight system that does little to ensure high-quality or effective care, and rarely takes strong disciplinary action against facilities when so many Pennsylvanians need services.

The department has no standard criteria for when it should force facilities to serve fewer patients and, as of early April, had revoked just one treatment provider's license in nearly a decade. It doesn't, as a regular practice, compare facilities to see if any stand out for an unusual number of violations or the most client deaths. And since state inspections focus heavily on records, they can be tricked with fraudulent paperwork, former employees in the treatment field said.

This leaves Pennsylvanians — who suffer one of the highest drug overdose death rates in the nation — in the dark about which treatment facilities have troubling track records.

Some advocates point out that overregulating or closing facilities could leave people suffering from addiction without options for care. But in the current system, state and judicial records show, some patients have received inadequate treatment or even died; certain facilities have fraudulently billed insurance companies; and owners rake in federal and state tax dollars, as well as private money from victims of the opioid crisis.

"Many of these rehab facilities are not properly run or supervised, and many are in it for the money," said Peter Friday, an attorney who represented Adam's family in their lawsuit. "These places have been unbridled."

Who Polices the Providers?

Even though the Department of Drug and Alcohol Programs provides the licenses that allow addiction treatment facilities to operate, Jennifer Smith, secretary of the department, said it has limited responsibility for them. Law enforcement agencies are often better positioned to take action against troubled providers, she said, and insurance companies that pay for services also offer oversight.

"It's not our job to really police the providers," Smith said in an interview. "Our function is to really try to enable them to meet the [state's] requirements, and by doing so, enabling them to provide quality services."

Yet, as the regulating body of these treatment facilities, the department collects some of the most critical information necessary to properly police them, including reports of client deaths and physical and sexual assaults.

Smith said most providers are trying to do good work. She said annual inspections ensure facilities meet safety standards, like having enough staff members and a building that's up to code. But inspections are not meant to evaluate quality of care, she said.

The KHN-Spotlight PA investigation found the department makes little of what it knows about troubling facilities accessible to the public. Its website shows if a facility currently has a provisional license — a designation indicating the provider failed to meet several state requirements and will be inspected more frequently until it resolves those concerns — but not whether it ever received such a sanction in the past, for what issues, nor how they were resolved.

The department does not post the reports it collects about deaths and assaults, which represent some of the most concerning events at treatment facilities.

When KHN-Spotlight PA filed a public records request for those reports, the department shared only incidents that it decided did not warrant investigation. It said it could not provide the total number of such events at specific facilities since it doesn't have aggregate data prior to September 2019, when it launched a new electronic reporting system. Even the available data from that new system provides an incomplete picture, as less than a quarter of treatment facilities had enrolled in the voluntary system as of March 2021.

Smith said people should pick facilities the same way they do primary care doctors, based on publicly available information, personal recommendations and discussions with insurers.

One of the main public resources the department offers is a website with reports from its facility inspections. Inspectors write these reports after a site visit, listing any violations of state regulations they found. But these reports provide a limited window into the daily reality for clients, as there's no indication of which violations are more severe than others, and many regulations focus on building conditions and completion of records. One regulation, for example, mandates the temperature at which refrigerated food must be maintained.

In response to each violation inspectors find, the facility submits a plan to address it. If the facility fails to provide a plan or follow through on it, the department has two primary options: force the facility to reduce the number of clients it serves or issue a provisional license. If the department wants to permanently revoke a facility's license, it must go through an administrative court process to get approval.

In nearly a decade before December 2020, the state issued provisional licenses to fewer than 80 facilities — less than 10% of providers— and forced only three to reduce their capacity, according to data from the department. In ASI's case, regulators said multiple times that the company failed to document that it provided required counseling and other services. A department spokesperson said it didn't force ASI to operate under provisional licenses before 2015 because the business submitted plans of correction the department found acceptable. Even if a facility has many violations, the department considers how cooperative it is in working to fix them, Smith said.

After a recent reorganization, the department formed a quality improvement unit with three employees, Smith said. The unit may work directly with treatment facilities but is meant to address broader prevention efforts and other addiction-related programs as well. The department is also working with a national company to provide an online platform where clients can leave reviews of facilities, starting in spring 2022.

But many employees and clients in the treatment field are skeptical of any long-term improvement. For years, they've seen troubled facilities make fixes, only to have the same deficiencies arise in later inspections.

The department's own records show the cycle can persist for years.

Years of Citations, Little Action

At SOAR Corp methadone clinic in Philadelphia, inspectors from the state Department of Health first issued citations for unqualified employees in 2009, before the Department of Drug and Alcohol Programs was created and took over inspections in 2012. Inspectors at the time also found one counselor who was responsible for 40 clients — above the state-mandated maximum of 35.

SOAR Corp responded by saying it had demoted an unqualified counselor, had hired another counselor to lower caseloads and would ensure future hires met the state's requirements.

But state records show that within a year of those 2009 citations, the facility was cited three more times for similar issues: hiring an unqualified project director, overloading counselor caseloads and lacking enough medical personnel. Year after year, state inspectors found the same problems. Yet the state approved SOAR to open additional locations in Lansdowne, Levittown and Warminster in 2010, 2016 and 2018, respectively.

In interviews with KHN-Spotlight PA, a dozen former employees and nearly a dozen current and former clients across multiple SOAR sites complained about poor hiring practices and chronic understaffing as just two symptoms of their much larger concerns. They believed the company relentlessly pursued profits by getting as many clients in the door as possible, with little care for the quality of treatment.

The Philadelphia location has received three provisional licenses from the state, in 2012, 2019 and 2020, putting it among the 10 most frequent recipients of this sanction over nearly the past decade.

The former counselors felt that expectations to maximize "billable hours" led to their burnout. And they saw high turnover among staffers. The former and current clients said they sometimes went weeks without therapy or were switched from one overwhelmed counselor to another every few months.

Nicole Tihansky was a client at SOAR's Levittown location for about a year until last fall. She said she waited more than a month before getting her first counseling session, and then was assigned about five counselors, one after the other.

"It makes you just want to get in and out of the session quickly, because you know you'll get another counselor in a month," she said.

Understaffing is a problem across the treatment industry, according to employees in the field. But former SOAR employees who have worked for multiple companies said SOAR stood out in their experiences for its high staff turnover and inadequate therapy.

"It's not about therapy or addressing the needs of clients," said Esther Kirshenbaum, a counselor who worked at the Philadelphia location from 2017 to 2019. "The attitude is to just get clients in here and make sure we get paid."

In a statement, SOAR CEO Richard Mangano said the company "makes every effort to comply with local, State, and Federal regulations."

KHN-Spotlight PA shared with SOAR a detailed list of more than a dozen allegations from their reporting, including violations of state regulations and putting profits over patient care. Mangano did not address them specifically.

"Soar Corp categorically denies any allegation or suggestion of wrongdoing. … Soar Corp has and will continue to work with DDAP to improve the important services it provides," Mangano wrote, referring to the Department of Drug and Alcohol Programs.

In its responses to state citations in recent years, SOAR explained that clients didn't show up to scheduled counseling sessions, and that services like drug tests and physician evaluations had been provided but simply not documented properly.

The Department of Drug and Alcohol Programs has never forced SOAR to decrease its capacity, nor have state officials initiated the administrative court process to permanently revoke its license.

Former clients and employees said state licensing inspections were announced ahead of time, causing a rush by SOAR employees in the days before a site visit to complete treatment plans, counseling notes and other required paperwork.

Nicholas Cucchiaro was a SOAR counselor from 2017 to 2018. He shared with KHN-Spotlight PA what he reported to the Department of Drug and Alcohol Programs and the Pennsylvania Office of Attorney General after he was fired. He told the agencies that a senior administrator at SOAR instructed him to make up counseling notes for clients who had gone weeks without an assigned therapist.

"These are notes from therapy sessions that never happened," he said, adding he knew it was wrong but feared losing his job if he didn't comply.

About a dozen other former employees and clients described to KHN-Spotlight PA their own experiences of similar practices, ranging from thrusting months' worth of forms upon clients in the days before an inspection to backdating their paperwork.

The Department of Drug and Alcohol Programs and the attorney general's office both agreed to look into the allegations, Cucchiaro said, but he didn't hear of any consequences for SOAR.

The attorney general's office told KHN-Spotlight PA that it reviewed "a small number" of complaints regarding SOAR and referred the matter to the Department of Drug and Alcohol Programs.

Smith, the department head, said that as a general matter it's difficult to prevent facilities from falsifying paperwork, because state regulations require advance notice of licensing inspections. But if the department receives a complaint, it can conduct unannounced inspections, she said, and other facilities have been cited for fraudulent paperwork.

Unannounced site visits were made in response to the complaints at SOAR, according to a department spokesperson, and citations were issued for violations that did not include fraudulent paperwork. SOAR's Philadelphia location received provisional licenses in 2019 and 2020, but as of mid-April all the company's sites were operating on full licenses after remedying the cited issues.

A Growing Industry

One significant limitation on the department's oversight is its inability to impose financial penalties on treatment facilities.

In contrast, the state's environmental protection and health departments can fine polluters and nursing homes for violations.

A 2017 report from the state auditor general's office urged lawmakers to allow the department to charge licensing fees and assess financial penalties, pointing to other states that do so. Smith told KHN-Spotlight PA that fining facilities would help weed out repeat violators.

A bill introduced in the Pennsylvania legislature to allow the department to generate licensing fees went nowhere two years ago. A similar measure was recently referred to the state Senate Health and Human Services Committee.

"I hope that it's considered quickly as ensuring drug treatment facilities are given appropriate oversight is of utmost importance," the bill's sponsor, state Sen. Judy Schwank (D-Berks), said in a statement. 

Meanwhile, with millions of dollars on the line, the treatment industry is growing in Pennsylvania. Over the past four years, the state has seen a net gain of about 40 facilities, the department said, bringing the total to more than 800 treatment providers. State budget documents suggest the industry's client capacity has grown by about 5,000 over a similar period.

The Department of Drug and Alcohol Programs employed 82 people, including two dozen who conduct facility inspections, as of April. That's about half the number of dog wardens employed by the state to inspect kennels.

Smith said there is "adequate staff to perform our current licensing responsibilities."

In December 2018 — the same year the department said it received complaints from former SOAR employees and clients — it approved the company to open a location in Warminster. Inspection surveys at the facility since have found it violated state rules by providing a certain medication without state approval and failing to provide the required hours of therapy to some patients.

A former SOAR supervisor who is still working in the treatment industry and asked not to be named doubts the state will ever take stronger action against the company.

"The state knows the demand for treatment and the demand for medication-assisted treatment," the former supervisor said. "If you took SOAR's license in Northeast Philadelphia and didn't give them a provisional, you could be displacing 500 clients."

The Need for Treatment

The urgency of the opioid crisis puts regulators in a tough position: If they shut down a facility, where will all the patients get treatment?

James McKay, a professor at the University of Pennsylvania's medical school who researches the efficacy of addiction treatments, said facilities that are committing insurance fraud or actively harming patients should be penalized. But the question becomes more complicated when judging how well a facility is serving its clients.

In Philadelphia, where there are many treatment programs, it might make sense to close one that has ineffective interventions, untrained counselors and many clients dropping out, McKay said.

"But if you're out in the middle of the state and there's only one treatment program in any reasonable distance, as long as they're not treating you badly, you're at least going to get some support and meet others in recovery," he said. "So much of this depends on what the other alternatives are."

In western Pennsylvania, an inpatient detox and rehab facility called Clear Day Treatment of Westmoreland has received multiple provisional licenses since it opened in 2018. State inspectors have noted at least six incidents that involved drugs on the premises and have cited the facility at least twice for understaffing, writing that the lack of sufficient staff fails to ensure "efficient and safe operation."

Despite these concerns, the facility is the only one in the county that provides detox services while allowing patients to stay on any of three medications for opioid use disorder. Many patients in the area need that service, said Colleen Hughes, executive director of the Westmoreland Drug and Alcohol Commission. (The commission is one of more than 40 agencies across the state that the Department of Drug and Alcohol Programs contracts with to coordinate substance use services locally.)

The commission determined in 2017 that a lack of residential rehabs in the county was one factor delaying people's treatment. Clear Day responded to a request for proposals to meet that need from companies that manage Medicaid-paid behavioral health for the state in that region. Clear Day has been awarded nearly $750,000 in state Medicaid funds left over from previous years to help with startup costs, according to Southwest Behavioral Health Management, one of the companies that put out the request.

Stephen Devlin, executive director of Clear Day, said in a statement that Southwest Behavioral Health Management closely monitored those funds, which helped the facility provide "much needed" addiction treatment services.

"State auditors have been diligent in ensuring that Clear Day addressed all deficiencies that have been identified during audits," Devlin wrote, "and, further, that Clear Day provides strong and effective treatment to the individuals in our care."

Hughes said her office has addressed the issues of understaffing and drugs on the premises with Clear Day through meetings and training sessions.

Smith, head of the Department of Drug and Alcohol Programs, said: "None of us want to see providers closing. We want them to be successful. We want them to be able to deliver the services for their benefit and for ours."

Waiting for Consequences

In Fayette County, ASI came under fire from state and federal authorities in 2015.

The FBI raided the facility that October. The following January, a federal grand jury indicted one of the owners, Rosalind Sugarmann, and an ASI doctor on multiple counts of illegally distributing a medication to treat opioid addiction.

Nearly three months later, a counselor employed by ASI overdosed while staying at the facility, an attorney for the state later said in an administrative court filing against ASI. Ultimately, a bankruptcy case forced the business to close.

In late 2016, Sugarmann pleaded guilty to illegal drug distribution and healthcare fraud. But that hasn't kept her and her family out of the recovery business. Less than a year after she was released from prison, Sugarmann — who has talked publicly about her own substance use decades ago — announced she was opening a recovery home.

"I'm not going to stop working with addicts ever. That's my calling in life," Sugarmann said in an interview with KHN-Spotlight PA. "Somebody helped me, and I help somebody else."

But two families said Sugarmann failed their loved ones.

There's Adam Kalinowski, who died at ASI in 2014, and there's 37-year-old James Pschirer, who died of an overdose in a recovery home Sugarmann's family operates. These homes offer peer support and often have curfews and rules designed to help people stay away from drugs after they've been discharged from inpatient treatment.

In Kalinowski's case, Sugarmann said ASI reported his death to everyone it was required to. There's no indication from department records that the state cited ASI in connection with his suicide.

(The Department of Drug and Alcohol Programs wouldn't comment on Kalinowski's case specifically but said it worked with the FBI to investigate problems at ASI.)

Neither Sugarmann nor her husband, Sean, mounted a defense against the Kalinowski family's lawsuit in court. In a recent interview with KHN-Spotlight PA, Sean Sugarmann placed the blame for Kalinowski's death elsewhere, saying that the facility was staffed correctly and that, given his eventual suicide, Kalinowski never should have been sent to ASI.

Kalinowski's family also sued UPMC Mercy, the Pittsburgh hospital where he was treated before going to ASI, and affiliated entities, but resolved the claims against them through a private settlement, according to a family attorney. UPMC denied responsibility for Kalinowski's death. In a pretrial court filing, an expert witness for UPMC directed blame at ASI, saying Kalinowski was well enough to be safely discharged to a residential treatment facility. That he wasn't evaluated by a doctor, nurse or professional counselor when he arrived at ASI was a concern, the expert wrote, and "perhaps this tragedy could have been avoided" if ASI had provided a higher level of care.

More recently, Rosalind Sugarmann has faced criticism for her involvement with recovery homes.

In February 2019, while still under federal supervision, Sugarmann announced on a blog that she was "back in commission!!" and would open a men's recovery home called The Second Act outside Pittsburgh.

A 2017 law gave the Department of Drug and Alcohol Programs new power to regulate recovery homes in addition to treatment facilities. The state missed a June 2020 deadline to implement the voluntary licensing process but plans to roll out the program this year.

James Pschirer turned to The Second Act for a place to stay in the fall of 2019. His mom, Andrea Zack, helped him with rent, writing out a $250 check to Sugarmann, according to a photocopy of the check the family provided.

Then, on Nov. 1, 2019, James died inside the home from a fentanyl and cocaine overdose, a photo of the death certificate provided by his family showed.

Andrea and James' sister, Amanda Pschirer, went to The Second Act to collect his clothes and personal items. Andrea kept the coins in his pockets, knowing he had touched them.

It wasn't until after James' death that his family found out about Sugarmann's criminal conviction, they said.

Amanda knows her brother chose to use drugs, but she thinks he could still be alive if he had stayed in another home with better oversight. And she's angry that nothing stopped Sugarmann from being involved with one.

"I am worried that someone else will die under her care," Amanda said.

In interviews, Rosalind and Sean Sugarmann downplayed their involvement with The Second Act. "My kids are involved in the recovery homes," Rosalind told KHN-Spotlight PA. "I'm not an owner there." The business is registered in their children's names, and Rosalind said she's lived in Los Angeles since early 2020.

Still, Sean Sugarmann acknowledged helping his adult children manage the business, and said in March he was living in the men's home at that time. One of his daughters referred questions about The Second Act to Sean. Rosalind promotes the business on social media accounts, encouraging people to move in. She told KHN-Spotlight PA, "I'm not gonna deny that I'm a consultant."

Sean said an overdose death "could have happened anywhere, and I think it happens everywhere."

Last fall, Amanda Pschirer reached out to state officials with concerns about recovery homes. But she said she didn't receive a response for four months. The department said a computer glitch with an online form, discovered in January, caused the delay in responding to her submission and about 260 others.

Ian Kalinowski, whose brother died at ASI seven years ago, has followed Rosalind's posts online and saw that she's still involved in the recovery business. He's outraged.

He and his family are still grieving Adam's loss. Ian wishes his young children had gotten to meet their uncle. He doubts the ASI defendants will ever provide the $1.6 million-plus that the judge said they owe.

Ian recognizes that ASI's leaders faced some consequences for problems at the business.

"But there have still been no repercussions for what happened to my brother," he said of the Sugarmanns.

He's not optimistic there ever will be.

Methodology: How We Investigated Pennsylvania's Addiction Treatment Industry and Found Weak Oversight of Providers

Pennsylvania is at the epicenter of the nation's opioid crisis, ranking among the top five states for overdose death rates and top 10 for number of adults suffering from substance use disorder in recent years, according to national data. And the addiction treatment industry there is growing.

Federal grants, state initiatives and Medicaid pump millions of taxpayer dollars into the field annually. The state has seen a net gain of about 40 licensed treatment facilities over the past four years, bringing the total to more than 800.

But an investigation by Spotlight PA and KHN found the Pennsylvania Department of Drug and Alcohol Programs — which licenses these facilities — provides weak oversight and lacks the resources and regulatory power to police them, allowing providers to continue operating despite repeated violations and harm to clients. The department has no standard criteria to determine when it should force facilities to serve fewer patients and, in nearly a decade, has revoked just one provider's license.

Spotlight PA, an independent, collaborative newsroom reporting on the Pennsylvania state government and statewide issues, began investigating the oversight of addiction treatment facilities shortly after its launch in late 2019. The newsroom later partnered with KHN, a national organization that produces in-depth journalism about health issues.

Our team began by scraping thousands of facility inspection reports from the Department of Drug and Alcohol Programs' website. We then analyzed them to find the most egregious citations: ones that mentioned a failure to report patient deaths and assault, that noted medication errors or that revealed unsafe staffing ratios.

We also requested from the department historical data about which facilities had received provisional licenses — designations indicating that facilities have failed to meet several state requirements and will be inspected more frequently until they resolve those concerns. The department didn't have an automated system to gather this data but agreed to compile it manually. It provided the information with the following caveat: "Due to incorrect data entered into the licensing database, the attached report may not include all provisional licenses since 2012. It is as close to accurate as we can determine base[d] on the available data."

Additionally, the team filed an open records request for reports of unusual incidents. These are certain serious events that the department requires facilities to report, including client deaths and incidents of physical and sexual abuse, among others. The department provided reports of only those incidents that it decided did not warrant investigation. It said it could not provide the total number of such events because it doesn't have facility-specific aggregate data prior to September 2019, when it launched a new electronic reporting system. Even available data from that new system provides an incomplete picture, as less than a quarter of treatment facilities had enrolled in the voluntary system as of March 2021.

Reporters also reviewed the department's administrative court history to see cases in which the state had initiated legal action against a facility.

To further inform our reporting, Spotlight PA launched a public callout for readers to send in tips and concerns about facilities.

Using a combination of these sources — facility inspection surveys, provisional license history, administrative court cases, limited reports of unusual incidents and tips from the public — we compiled a list of 34 facilities that appeared to have the most troubling track records.

From the short list of facilities, Spotlight PA and KHN reporters then reached out to current and former employees and clients at various locations. The interviews helped establish whether people's firsthand experiences matched the concerns that arose in the data.

Our reporters also reviewed the licensing applications that these facilities had submitted to the state, as well as lawsuits filed by clients and employees against the facilities. We interviewed former employees of the Department of Drug and Alcohol Programs to understand the oversight system and challenges within the agency.

The final story was based on interviews with more than 80 people and a review of thousands of pages of state government and court records.

Spotlight PA is powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media. The independent, nonpartisan newsroom is funded by foundations and readers like you who are committed to accountability journalism that gets results: spotlightpa.org/donate

Aneri Pattani: apattani@kff.org, @aneripattani

Doctors Without Jobs and Unmatched and Unemployed Doctors of America are tied to Progressives for Immigration Reform, an organization that the Southern Poverty Law Center has designated as an anti-immigrant group.

This article was published on Friday, April 30, 2021 in Kaiser Health News.

By Victoria Knight

In their last year of medical school, fourth-year students get matched to a hospital where they will serve their residency.

The annual rite of passage is called the National Resident Matching Program. To the students, it's simply the Match.

Except not every medical student is successful. While tens of thousands do land a residency slot every year, thousands others don't.

Those "unmatched" students are usually left scrambling to figure out their next steps, since newly graduated doctors who don't complete a residency program cannot receive their license to practice medicine.

At first glance, two new advocacy groups, Doctors Without Jobs and Unmatched and Unemployed Doctors of America, seem to be championing their cause, helping them find residency slots and lobbying Congress to create more medical residency positions. The groups also recently organized a protest in Washington, D.C., to draw attention to the scarcity of residencies.

But the organizations aren't merely support groups. They are tied to Progressives for Immigration Reform, an organization that the Southern Poverty Law Center has designated as an anti-immigrant group. PFIR is financed by an anti-immigrant foundation and its executive director has been affiliated with a network of anti-immigrant groups.

The two doctor groups want U.S.-trained and U.S. citizen doctors to get top priority in the Match over foreign-educated doctors. While both Doctors Without Jobs and Unmatched and Unemployed Doctors of America do not say they are anti-immigrant, their websites include messaging that implies foreign doctors are taking residency spots away from U.S. doctors.

However, newly unmatched medical students searching for a source of support aren't necessarily aware of the groups' anti-immigrant affiliations.

Haley Canoles, a fourth-year medical student who didn't match this year, was caught off guard when she learned of the organizations' deeper agenda.

"I had no idea. I just recently joined Twitter and started following groups that I thought could help me network to find a residency position," Canoles wrote in a private message on Twitter. "I absolutely do not stand for any anti-immigration agenda."

As the percentage of unmatched U.S. medical students increases each year and the number of residency positions remains mostly static, more could be drawn to a support group such as Doctors Without Jobs.

According to 2021 data from the National Resident Matching Program, the percentage of medical school graduates who don't match has increased. In 2021, 7.2% of students didn't match into residency programs, up from 5.7% in 2017.

Meanwhile, the percentage of non-U.S. citizens who attended foreign medical schools who didn't match has declined over the past five years to 45.2% in 2021, from 47.6% in 2017.

That makes advocates for international medical students worry that, if this trend continues, there could be increased resentment toward doctors educated abroad and xenophobic attitudes in the medical community.

"I obviously disagree with the idea that foreign medical graduates are taking spots from U.S. medical graduates," said Dr. William Pinsky, president and chief executive officer of the Educational Commission for Foreign Medical Graduates, which certifies international medical graduates before they enter the U.S. graduate medical education system. "What residency directors primarily look for is who is the best qualified, and sometimes foreign medical graduates fit that bill."

Kevin Lynn, executive director of PFIR, founded Doctors Without Jobs as an offshoot of the organization in 2018, after meeting an unmatched doctor outside a protest at the White House.

"I didn't even know this was a problem, and then we started looking at the data and realizing that thousands of medical students weren't getting into residency programs," said Lynn. "At the same time, the number of foreign doctors who graduate from foreign medical schools and get taxpayer-funded residencies is increasing."

PFIR endorses restricting immigration into the U.S., it says, to protect the American labor force and the environment. Its website also says it researches the "unintended consequences of mass migration."

In a 2020 report, the SPLC found that Lynn had been closely involved with members of prominent Washington anti-immigration hate groups, including the Federation for American Immigration Reform (FAIR) and the Center for Immigration Studies (CIS). Both organizations push for reducing the number of immigrants in the U.S., are designated as hate groups by the SPLC and were founded by Dr. John Tanton, whom the SPLC has tied to white nationalists, racists and eugenicists.

And in July 2020, at the height of the COVID pandemic, Lynn sent a letter to then-Senate Majority Leader Mitch McConnell asking him not to allow a bipartisan bill that would allocate unused green cards to foreign healthcare workers into the next COVID stimulus bill, and instead prioritize unmatched U.S. doctors. That effort was publicized in Breitbart News, a right-wing publication that shares the anti-immigrant view. The bill died in the Senate.

The SPLC also reported that Joe Guzzardi, a writer for Doctors Without Jobs, has previously written more than 700 blog posts for a white nationalist hate website.

According to recent nonprofit filings, from 2015 to 2019 PFIR received almost $2 million in funding from the anti-immigrant Colcom Foundation, which also provides significant funds to FAIR and CIS. Neither Doctors Without Jobs nor Unmatched and Unemployed Doctors of America have made any public financial disclosures, though Doctors Without Jobs accepts donations.

The modus operandi of these types of nativist groups is to take any policy problem area and say the solution is to restrict or eliminate immigration into the U.S., said Eddie Bejarano, a research analyst at SPLC who wrote the 2020 report. Doctors not receiving residency spots is just the latest issue that the anti-immigration movement has seized on.

"They're taking issues like this and saying that the solution is grounded in nativism, it's not about reform," said Bejarano. "It's out of the textbook for nativists, if they can prey on the fears for normal Americans, such as here, where doctors are just wanting a fair shot at a job and blaming it on immigrants."

Lynn's rhetoric doesn't contradict Bejarano's observation. "I believe we should be prioritizing Americans," Lynn said in an interview with KHN. "People say that is xenophobic, that is racist. These are attempts to quiet dissent. What I'm saying are uncomfortable truths."

Unmatched and Unemployed Doctors of America has a less direct connection to the anti-immigrant groups. It claims it is solely volunteer-run, independent of Doctors Without Jobs and doesn't receive any funding from the organization. But it does say on its website that it is affiliated with Doctors Without Jobs. The groups have worked together to organize a recent protest and feature each other on their respective websites and in promotional materials.

Leaders of Unmatched and Unemployed Doctors of America declined an interview but provided KHN with an emailed statement claiming nearly half its members are immigrants or are second-generation immigrants.

Doctors Without Jobs and Unmatched and Unemployed Doctors of America have increased their activity in the past couple of months. In January, members of the two groups traveled to Washington to protest outside the headquarters of the Association of American Medical Colleges, to bring attention to the issue of unmatched doctors. The AAMC runs the electronic system for submitting residency program applications.

The groups said they met with members of Congress to discuss reintroducing the Resident Physician Shortage Reduction Act, which would increase federally supported medical residency positions by 2,000 annually for seven years. The bill was introduced again in the House and Senate in March.

Doctors Without Jobs also recently released a video targeting the AAMC and saying that the organization is promoting a policy that "allows foreign medical students to take American students' residencies."

In an emailed statement, Karen Fisher, the AAMC's chief public policy officer, said that any unnecessary restrictions on immigration would only accelerate and worsen the existing physician shortage and that foreign-trained doctors often fill critical gaps in the healthcare workforce.

"The nation's teaching hospitals seek to recruit the most qualified candidates into their residency training programs," said Fisher. "A blanket preference for U.S. applicants runs counter to this goal and would severely restrict the pool of highly qualified individuals and prevent U.S. patients from receiving the best possible care from a diverse and dedicated group of aspiring physicians."

Victoria Knight: vknight@kff.org, @victoriaregisk

As the country emerges from over a year of lockdowns, percolating differences among residents about appropriate precautions have been heightened as people long to return to normalcy.

This article was published on Thursday, April 29, 2021 in Kaiser Health News.

By Judith Graham

Tensions were running high at PDX Commons, a cohousing community for adults 55 and older in Portland, Oregon. Several people wanted to keep visitors off-site until all 35 residents were vaccinated. Others wanted to open to family and friends for the first time in a year.

How do communities with dozens of members decide what to do during a public health crisis when members have varying tolerance for risk and different opinions about safe practices?

Cohousing communities have grappled with such questions throughout the coronavirus pandemic. These are groups of people committed to communal living who own homes in complexes with shared common areas, such as clubhouses, laundry facilities and gardens.

This past year, these communities have been a godsend for many residents, with ongoing virtual activities and a sense of camaraderie that has shielded them from the relentless loneliness and boredom that have traumatized so many older Americans.

"All you have to do is go out on your porch and someone will come and sit with you," said Elizabeth Magill, 60, who lives at Mosaic Commons in Berlin, Massachusetts, with her husband, Ken Porter, 70. "I can't imagine not being in a place like this during the pandemic."

But now, as the country emerges from over a year of lockdowns, percolating differences among residents about appropriate precautions have been heightened as people long to return to normalcy — and expand outside their "pod" of the community.

"You have this tension between personal freedom and respect for other members of the community," said William Aal, a Spokane, Washington, consultant who recently advised PDX Commons about strategies to improve communication.

There are 170 such communities across the country and an additional 140 under development, according to the Cohousing Association of the United States. About two dozen are for older adults; the others are intergenerational. On average, communities have about 30 units occupied by people who live alone, couples or families.

The pandemic upended their rituals, as in-person activities and communal dining — typically offered several times a week — were canceled and relationships sustained by regular contact began to fray.

"It's created all kinds of challenges for community living," said Mary King, an organizational consultant and a resident of Great Oak Cohousing in Ann Arbor, Michigan.

Disagreements have arisen over everything from when residents should wear masks (outside in common areas? should children be required to wear them?) to how laundry rooms should be used (sign-ups for one family at a time, with what kind of cleaning precautions before and after?) to whether visitors are welcomed, with what restrictions.

"Some people have felt at super-high risk and have wanted to take really strict precautions, while others have felt 'This is no big deal, it's going to blow over,'" said Karin Hoskin, a resident at Wild Sage Cohousing in Boulder, Colorado, and executive director at the national co-housing association.

Because residents are independent homeowners, some feel they should be able to do whatever they want. Yet cohousing communities see themselves as more than a collection of individual homeowners and typically adopt policies by consensus.

On the positive side, communities have adopted strategies to keep residents safe and connected during the pandemic. Great Oak Cohousing, an intergenerational community, created a buddy system for each resident, with one or two people who would check in regularly. King said one resident became seriously ill from COVID, and "a couple" of others had mild cases.

Communities have hosted outdoor parties or concerts, organized activities such as weekly poetry readings, formed walking or hiking clubs, planned communal takeout meals and arranged to have tech-savvy members help other residents schedule vaccine appointments.

The advent of vaccines has inspired an even more complicated round of conversations: Should common areas reopen as residents become fully vaccinated? What level of vaccination in the community provides enough protection? What about residents or visitors who decline to be vaccinated?

"We've talked about how we're not going to require vaccinations for somebody to participate in meals, because there are people who will not be vaccinated, whatever their reason is, and we need to be OK with that," Hoskin said of her Boulder community.

At PDX Commons in Portland, most residents have been eager to set aside strict policies adopted when the pandemic took hold last year. Unlike many other cohousing communities, PDX members live in the city, in a single, U-shaped building with shared entrances, with three floors of condominiums facing an inner courtyard.

A sleek two-bed, two-bath unit is currently on the market for $595,000, with homeowner association fees of about $550 a month. Social interaction is a selling point. This one, the listing says, is "in the center of the action."

Out of an abundance of caution, the PDX COVID committee decided early on that no family members or friends could come inside the building. A discussion of how to host visitors outside took four months to resolve, provoking frustration. Strict cleaning and sanitation protocols were seen as overbearing.

"We were lectured many times on washing hands, and it didn't feel very good," said Karen Jolly, 75, who moved her 95-year-old mother into her two-bedroom condo for much of last year rather than leave her alone in an independent living facility.

"The rules we created were too controlling, too restrictive, too much telling people what to do," said Dr. Karen Erde, 68, who sat on the emergency COVID committee, which was disbanded last summer after residents objected. They did work, however: PDX has not reported any COVID cases, Erde said.

Claire Westdahl, 75, couldn't tolerate being apart from three young grandchildren and moved from her PDX condo to a tiny home put up on her son's Portland property from May through October. She's since decided to sell her condo and move in permanently with her son's family.

"The lockdown forced people to make some really deep choices about what they valued and how they wanted to live," said Westdahl, a widow. "My deep choice is I'm here to be a grandma."

Like other seniors, she's deeply aware of time lost during the pandemic and doesn't want to wait even a few more months before reuniting with friends and family. "Turning 75 really changed my sense of time," she said. "I don't know how much I have left and what I have is precious and I'm not going to waste it."

That sense of urgency, shared by other PDX residents, fueled difficult discussions over when and how to open up the community in March as most residents became fully vaccinated but three younger members still hadn't gotten shots.

"We've protected older members who have some pretty significant risk factors and, now that those people have been vaccinated, it's a turnaround — they have to protect us," said Gretchen Brauer-Rieke, 64. Since we first spoke, she's received one shot of the Pfizer-BioNTech vaccine and expects to get the second in early May.

At a meeting in early April, Brauer-Rieke and several others proposed a compromise: Visitors would be allowed back into PDX if they wore masks, were met at the door by a member and escorted to a residence, and avoided common areas inside the building.

This new policy has been delayed, temporarily, as Multnomah County, which encompasses Portland, has moved into a "high-risk" COVID category. It isn't what everyone wanted, but it's something they can all live with.

And that, ultimately, is what cohousing is all about. "How do we deal with tensions in our community? We talk it through. We have workgroups. We compromise," said Janet Gillaspie, 65, a PDX co-founder. "And we think about what's best for the community as opposed to 'What do I need?'"

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

However, decisions on sending county jail inmates to state prison are based more on legal factors than vaccination status.

This article was published on Thursday, April 29, 2021 in Kaiser Health News.

By Bernard J. Wolfson

LOS ANGELES — The inmates huddled near the front or lingered on the bunk beds lining both sides of their narrow, crowded dorm at the Men's Central Jail, listening as Lt. Sheriff Dwight Miley and nurse practitioner Marissa Negrete offered them COVID vaccinations and answered their questions.

Those who wanted the vaccine should line up at the door, Miley and Negrete said. They'd be taken into a short, cramped hallway where medical workers waited with loaded syringes.

The shot wasn't mandatory, Miley said, but he encouraged them to get it by dangling a carrot that might seem odd to someone on the outside: Being vaccinated would help them get transferred more quickly to state prison.

"Who do you think they'll take first from here — those who've been vaccinated or those who haven't?" Miley asked the detainees. "Common sense says they'll choose those who've been vaccinated."

Many people who have been convicted and sentenced to long terms in state prison are eager to get there. But because of COVID, transfers from county jails to the state prison system have slowed significantly in the past year.

Jails and prisons have been virtual COVID petri dishes: The infection rate among the nation's prisoners is more than five times higher, and the mortality rate three times higher, than among the general population.

Among the Los Angeles County inmates who agreed to be vaccinated, a common incentive was that they believed — in line with Miley's urgings — it would get them to state prison sooner.

"I took the vaccine to go upstate quicker," said Anthony Contreras, 29, who has been in the jail for three years and was sentenced in February to a term of 15 years to life for attempted murder. Arturo Mendoza, 42, sentenced to six years in prison for illegal firearms possession, said he got the injection to avoid getting sick, but added: "I prefer to be upstate because the living is better."

However, being vaccinated will not necessarily get inmates to state prison faster, said Vanessa Nelson-Sloane, director and founder of Life Support Alliance, an advocacy group for life-term prison inmates. Decisions on sending county jail inmates to state prison are based more on legal factors than vaccination status, she said.

One reason L.A. County inmates want to expedite their transfer is that state prisons are once again open for family visits after a 13-month halt, while the jail is still closed to visitors.

Moreover, prisons offer numerous courses and vocational programs, and prisoners who enroll in them can get time shaved off their sentences, Nelson-Sloane said.

In the Los Angeles County Jail system — the biggest in the nation, with an average of over 15,000 inmates on a given day — 4,313 inmates have tested positive for COVID since the pandemic started. That's more than any jail system or individual prison in the United States, though not the highest per capita rate, according to UCLA's COVID-19 Behind Bars Data Project.

Men's Central Jail, the largest and oldest of the seven county-run detention facilities, has seen the highest number of those cases.

For the first couple of months this year, the jail administered the Moderna vaccine, which requires two shots about a month apart. That created added anxiety for certain inmates and logistical complexity for the medical team, since the jail has high turnover and many incarcerated people leave before receiving a second dose.

When the jail started getting bigger shipments of the Johnson & Johnson vaccine, which requires only one shot, the medical staff and many of the inmates were happy about it.

"Johnson & Johnson is our preferred vaccine," said Dr. Sean Henderson, chief medical officer of L.A. County's Correctional Health Services. "Given that they are often in my care for such a short period of time, and given the fact that it appears Johnson & Johnson has the same long-term efficacy in terms of keeping you from becoming ill or dying, Johnson & Johnson does make more sense for our patient population."

Several of the inmates said they had initially declined when they were offered the two-shot Moderna vaccine but changed their minds with the option of a single shot.

Of the 8,722 total vaccine doses given to inmates as of Friday, 17% were Johnson & Johnson, Henderson said. Fewer than 4% of the shots given nationwide have been Johnson & Johnson.

On April 13, federal health officials recommended suspending use of the single-shot vaccine over concerns about a possible link to a rare type of blood clot. For the next 10 days, the county's jails were giving only Moderna, but the Johnson & Johnson suspension was lifted Friday.

So far, just over 4,000 L.A. County Jail inmates have been fully vaccinated, Henderson said — about 26% of the jail system's average daily population. That compares with 60% in the California state prison system.

But county jails have much higher turnover rates than state prisons, and Henderson's team has not vaccinated as many of the short-term inmates as it would like.

Instead, the medical team has been targeting longer-term inmates, including those awaiting transfer to state prison and nonviolent prisoners who have been returned by state prisons to serve the rest of their sentences in county jail.

Despite the high risk of infection among incarcerated people, California granted vaccine access to them more slowly than to some other high-risk groups, including nursing home residents and seniors. Officials in the Golden State did not start vaccinating all jail and prison inmates, regardless of age or health status, until March 15.

Florida delayed even longer, blocking vaccine access to prisoners until the first week of April.

The crowded, unsanitary conditions in which inmates typically live make them highly susceptible to infection, and their high rate of chronic diseases puts them at greater risk of severe COVID illness. Jails and prisons are disproportionately populated by Latino and Black men, who have been hardest hit by the pandemic. In the L.A. County correctional system, 31% of prisoners are Black and 53% are Latino.

Now that jail officials have the green light to vaccinate all inmates who want to be vaccinated, they face another challenge: vaccine hesitancy.

Henderson said about half of L.A. County Jail inmates decline when asked if they want the vaccine, though some change their minds after repeated offers.

A survey published in December by the Centers for Disease Control and Prevention found that 55% of jail and prison inmates would hesitate or refuse to take the vaccine. Willingness to be vaccinated was lowest among Black prisoners and people ages 18 to 29. The most common reason for refusal was distrust of government and other institutions.

Andre Moore, a 33-year-old inmate in the Men's Central Jail who said he was wrongly convicted of sexual assault and sentenced in October 2019 to a long term in state prison, refused the vaccine because "I don't think anything the government does is good."

Living in a crowded dorm with inmates who are less meticulous about hygiene than he is, and where many don't wear masks, makes him worry about getting COVID. "But I'm way more nervous about the vaccine," Moore said.

Sharon Dolovich, a UCLA law professor who created the COVID-19 Behind Bars project, said corrections officials need to try to instill trust in the inmates. "With this population, you can't just go in and say, 'Here's the vaccination, take it,'" she said. "There's a lot of distrust and resentment and fatalism."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson