Los Angeles' strict 'no shot, no school' measles vaccine mandate for students in 1977 eradicated the virus there and influenced the rest of the country.  

The “no shots, no school” warning was a novel threat at the time. Since the 1920s — and smallpox — no major city in the United States had locked the unvaccinated out of school.

The threat — voiced most audibly by Dr. Shirley Fannin, whom the Los Angeles Times described as “the energetic, no-nonsense physician” in charge of communicable disease control — brought results. About 40,000 county schoolkids were excluded — sent home or forced to sit in the school auditorium all day. Within a week most had been vaccinated. The epidemic, which had killed two children, caused brain damage in five and left scores hospitalized with pneumonia, fizzled out.

By demonstrating that the public would acquiesce with rigorous enforcement of school vaccine mandates, the L.A. school system had a powerful influence on the country. President Jimmy Carter launched a national initiative to get measles and other recommended vaccines to all American children. Federal health officials twisted arms, shaming reluctant states, one by one, into tightening their vaccination rules. By 1981, 95% of U.S. schoolchildren had received the recommended vaccines. Over the next two decades, the U.S. nearly eliminated diseases like polio, rubella, measles and tetanus.

The Los Angeles Unified School District announced in September that it would exclude schoolkids 12 and older from campus on Jan. 10 unless they were vaccinated against covid-19. On Friday, however, the district decided to suspend the enforcement until next fall, according to school board member Jackie Goldberg. About 28,000 kids — roughly 14% — had yet to show proof of vaccination, she said. To provide those children with teachers for online learning would have deprived vaccinated kids at some schools of proper instruction, and “that wouldn’t have been fair.”

Goldberg, who grew up in the Inglewood section of Los Angeles, is troubled by vaccine hesitancy. She remembers the 1977 measles outbreak: “We were terrified. Kids were dying,” she said. At the time, many Angelenos had no health care, and the county’s free vaccination clinics were seen more as a gift than as what some consider them today — an imposition.

Before then, vaccination rates were low in Los Angeles for two reasons: Lower-income people couldn’t afford or get access to vaccines, and many people were indifferent to the risks of measles, considering the disease a normal part of childhood since most children suffered no permanent effects. Some people were opposed to vaccines in general, but “they were thought to be kooks, and there were so few of them,” said Dr. Peter Krause, a Yale University epidemiologist who worked on an outbreak of measles at the UCLA campus in 1977. Well into the 1990s, only about 0.5% of children in California were exempted from the vaccine requirements because their parents opposed or mistrusted vaccination.

What was different then? No social media, of course. And partisan politics played no role in vaccination rates. Dr. James Cherry, 91, who has taught in UCLA’s pediatric infectious diseases department since 1973, can’t recall meeting any anti-vaccine Republicans during the 1977 pandemic. He finds it remarkable to hear Govs. Greg Abbott of Texas and Ron DeSantis of Florida fighting mandates aimed at stopping a virus that has killed more than 790,000 Americans.

“The thing just blows the mind,” he told me. “Measles was bad, bad for a lot of reasons, but covid is a hell of a lot worse. And we could prevent virtually all deaths by vaccination.”

Today, the clever use of social media by anti-vaccine activists has revealed the vulnerability of the vaccination effort. Public health departments are understaffed and overwhelmed by work and attacks of vitriol and violence. And fighting endemic infectious diseases has never been easy.

But now, the politics seem even messier than the disease, let alone the vaccines. Battles over covid vaccination mandates could ripple outward to threaten vaccine mandates long in place for diseases that are still deadly at worst, and costly nuisances at best.

Refusing mask and vaccine mandates has become integral to many Americans’ identity, creating a base to which GOP politicians have responded.

Sen. Richard Pan (D-Sacramento), who fought for state laws to close loopholes that people opposed to vaccines used to avoid vaccinations against childhood diseases, is still hopeful reality will win out. But the process may look less like public consensus than an angry majority turning on anti-science rebels.

“People are going to get frustrated, tired of the persistence of these diseases, and there will be more general public pressure for mandates,” he said. “The question is, ‘How many people will die in the process?’”

Building Healthy Online Communities, or BHOC, an organization in the San Francisco Bay Area focused on HIV and STD prevention, has launched an effort to boost niceness on apps designed for men who have sex with men.

This article was published December 10, 2021, by Kaiser Health News.

By David Tuller

Editor’s note: This article contains references to racial and ethnic slurs.

Corey Baker, a gay man in Columbus, Ohio, has seen many dating app profiles that include phrases like “Blacks — don’t apply.” Sometimes when he declines invitations, he said, men lash out with insults like “you’re an ugly Black person anyway.” And some of his friends have been slammed with the N-word in similar situations.

Many of these events occurred “when I didn’t think I was attractive or deserving of love,” he said. And they took an emotional toll. “If you’re experiencing a wall of people saying they’re not attracted to you, I think that does impact your mental health,” said Baker, who is 35 and a school librarian.

The notion of kinder, gentler rejections on hookup sites might seem like an oxymoron. Yet experts in sexual health — as well as users of gay meeting apps, like Baker — say the harshness of much online behavior can exacerbate low self-esteem and feelings of depression or anxiety. That toxic combination can also lead to impulsive and potentially unsafe sexual choices.

In response, Building Healthy Online Communities, or BHOC, an organization in the San Francisco Bay Area focused on HIV and STD prevention, has launched an effort to boost niceness on apps designed for men who have sex with men. “People in the LGBTQ community face discrimination externally, but we also have to acknowledge that there is discrimination within the community,” said BHOC director Jen Hecht.

Through surveys and focus groups, BHOC asked more than 5,000 users of nine gay apps how the sites could support better online behavior related to race, appearance, HIV status, age, disability, gender identity and other factors. It also sought advice on technical improvements the apps could make, such as offering users greater flexibility in conducting searches for contacts.

“If I can filter out people who wrote ‘no fats, no fems, no black people,’ I don’t even have to deal with seeing it,” wrote one respondent quoted in BHOC’s report on the data gathered from app users. Representatives for some of the participating apps said they welcomed the collaboration. “We’ve had a non-bullying policy since day one,” said David Lesage, marketing and social media director for Adam4Adam.

Mean online behavior is, of course, not limited to apps for men. When asked last month by email whether meeting sites that cater to the general population should also be trying to address the issue, Evan Bonnstetter, Tinder’s director of product policy, responded that the company was “unable to participate in this opportunity.” (Bonnstetter has since left Tinder.) Bumble, another site popular with heterosexuals, did not respond to a request for comment.

Gay and bisexual men, like other groups that face discrimination, have higher rates of depression, substance misuse and related mental health concerns. But John Pachankis, an associate professor at the Yale School of Public Health who studies gay men’s health, said his research has identified aggressiveness within the gay community as a major problem.

“I was initially quite surprised that gay men were consistently noting their treatment at the hands of other gay men as being a predominant stressor,” Pachankis said. Apps, he added, “are a site of a lot of potential rejection in a short amount of time in a way that is particularly anonymous and efficient and can be really detrimental.”

In one study, Pachankis and his colleagues simulated a gay app environment in which some research participants were exposed to dismissive comments and others to approving comments. (The comments were all computer-generated.)

In subsequent responses on questionnaires, the men exposed to the dismissive comments reported greater emotional distress and expressed more skepticism about the benefits of condoms. They were also more likely to choose riskier options in a card-playing game.

Given that the app environment is the source of stress, Pachankis said, it makes sense for BHOC and other public health organizations to try to influence it

Some respondents quoted in the BHOC report dismissed the initiative as silly or unwarranted. “If someone does not meet the preferences specified by the user for being ‘fat,’ ‘too old,’ or not the right ‘race,’ then too bad,” wrote one. “I find this overreach in striving to be PC as offensive and ridiculous.”

But most respondents recognized that apps could support better online behavior and reduce unnecessary pain, Hecht said.

“It’s a society-wide problem, and I do agree that gay men’s dating apps are not going to single-handedly address it, but that doesn’t mean they can’t play a role,” she said. “To the extent that the users get to control and customize, that will increase their positive experiences on the apps and decrease the likelihood that they’ll have these negative experiences.”

One popular recommendation from respondents was to allow all users, and not just paying customers, to block anyone they feel is being abusive. Another was to allow users to restrict who can see profile fields with potentially sensitive information, such as HIV status or gender identity. Respondents also believed apps could help diminish the pain of rejection by providing neutral, pre-written messages for users to send, such as “sorry, it’s not a match.”

Grindr, one of the participating apps, does not include standard rejection statements but is exploring this option to help users on both sides of what is inevitably a “high-intensity moment,” said Jack Harrison-Quintana, the company’s director of equality.

“It’s very easy to feel very rejected because you are getting rejected,” Harrison-Quintana said. “People experience a lot of hurt from things that are said to them online, and that is what we are trying to address.”

Jehangeer Ali Syed, an international development consultant in Washington, D.C., said he has been disturbed by being treated as an “exotic element” in online exchanges. Although he is not from the Middle East, some men “sexually objectify me as an ‘Arab stallion,'” said the 36-year-old Pakistani. “I have been called a ‘sand-[N-word],’” he added.

This sort of encounter, he said, “makes you doubt yourself, makes you feel insecure and makes you question if I’m doing anything wrong.”

BHOC noted in its report that many respondents were unaware of existing app features that could help them customize and control their experiences. The report called for apps to expand their educational efforts about these possibilities.

That suggestion resonated with Grindr’s Harrison-Quintana. Grindr already includes some of the options recommended in the report, he said, but it could do a better job of communicating with customers. “It’s not just about implementing features, it’s also about maybe letting users know those features are available to them,” he said.

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

Senator Joe Manchin of West Virginia opposes adding dental and other benefits for Medicare beneficiaries. He says it will cost the federal government too much.

This article was published December 10, 2021, by Kaiser Health News.

By Phil Galewitz

Sharon Marchio misses having teeth for eating, speaking and smiling.

For the past few years, after the last of her teeth were extracted, she’s used dentures. “My dentist calls them my floating teeth because no matter how much adhesive you use, if you eat something hot or warm, they loosen up and it is a pain,” said Marchio, 73, of Clarksburg, West Virginia.

Marchio believes that losing her teeth was merely part of getting older. It’s quite common in West Virginia, where a quarter of people 65 and older have no natural teeth, the highest rate of any state in the country, according to federal data.

Like half of Medicare enrollees nationally, Marchio has no dental insurance. Worries about the costs led her to skip regular cleanings and exams, crucial steps for preventing infections and tooth loss.

Medicare doesn’t cover most dental care, but consumer advocates had hoped that would change this year after Democrats took control of the White House and Congress. President Joe Biden and progressives, led by Sen. Bernie Sanders, sought to add the benefit to a major domestic spending package, the Build Back Better Act, that Democrats are seeking to pass.

But those chances are looking slim because at least one Democratic senator — Joe Manchin of, yes, West Virginia — opposes adding dental and other benefits for Medicare beneficiaries. He says it will cost the federal government too much.

In a Senate split evenly between Republicans and Democrats, losing Manchin's vote would likely sink the proposal, which is unlikely to get any Republican votes.

Last month, the House passed the roughly $2 trillion package of Democrats’ domestic priorities that include health measures, free preschool, affordable housing programs and initiatives to fight climate change. It added hearing services coverage to Medicare but no dental benefit. The package is expected to undergo revisions in the Senate, and Democratic leaders hope a vote will happen in the chamber before the end of the year.

In West Virginia, one of the most heavily Republican states in the country, oral health advocates and progressives say it’s disappointing that Manchin would stand in the way of adding dental coverage for Medicare recipients — particularly given the state’s poor oral health record.

“It is unfortunate that our senator — who I respect and agree with on a lot of things — is going to draw the line on this issue,” said Fotinos Panagakos, associate dean for research at the West Virginia University School of Dentistry and a member of the Santa Fe Group, a think tank made up of scholars, industry executives and former government officials pushing for a Medicare dental benefit. “It would be a huge benefit.”

West Virginia has the third-highest share of people 65 and older, behind only Florida and Maine. Panagakos said that nearly 300,000 West Virginia Medicare recipients would gain dental benefits under the bill. Yet, Manchin’s efforts aren’t likely to cost him politically. He is not up for reelection until 2024.

“What political price do you pay when four other Republicans vote ‘no’ against everything?” Ryan Frankenberry, state director of the progressive Working Families Party in West Virginia, said, referring to the state’s three House members and Sen. Shelley Moore Capito, who all oppose the bill. “It’s a difficult argument to blame one person for not passing the benefit when every other Republican vote went against it.”

Manchin’s opposition, Frankenberry said, stems from the need to respond to the political pressures of representing an increasingly conservative state — and arguments from conservative commentators that Medicare is becoming insolvent and increasing the federal deficit.

Manchin, who did not respond to requests for an interview, has raised concerns about adding new Medicare spending when the Medicare Part A hospital trust fund is slated to become insolvent in 2026 if Congress takes no action. But that fund would not cover the proposed dental benefit; it would become part of Medicare Part B, which covers outpatient services such as doctor visits.

Manchin has also suggested that new social programs being advanced by the Democrats in the Build Back Better Act should be means-tested — in essence, offering the coverage only to people with lower incomes.

Dentists are concerned that Medicare — like Medicaid — would pay less than what they normally charge, said Richard Stevens, executive director of the West Virginia Dental Association.

The American Dental Association has also called for limiting any new Medicare dental benefit through means testing. ADA officials say a means test would ensure the benefit is helping those who really need it and save money for the Medicare program.

But critics say the ADA’s position is an effort by the powerful dental lobby to kill the benefit — because it knows Congress has little appetite to turn to means testing in Medicare. The program remains popular largely because everyone 65 and older is entitled to all its benefits.

“On the surface, their position sounds altruistic,” said Michael Alfano, who is a former dean of the New York University College of Dentistry and helped found the Santa Fe Group. “But there is no interest in Congress to make it a means-tested benefit.”

While adding a Medicare benefit would increase demand for dental services, it would also reduce what are considered dentists’ most lucrative patients, those who pay out-of-pocket and don’t benefit from insurer-discounted fees, Alfano said. “In my mind, the ADA did not have public interest at heart — they put the financial returns of dentists at the top of the ledger when developing this approach,” he said.

Alfano said there is still hope for an eleventh-hour change in the bill. “It’s not dead, but I would be lying if I said I was not disappointed,” he said.

West Virginia seniors have other options for getting dental coverage.

Many get some benefits when they enroll in private Medicare Advantage plans. And in January, West Virginia added an adult dental benefit to Medicaid, the federal-state health insurance program for people with low incomes, giving enrollees an annual maximum benefit of $1,000. Previously, West Virginia was one of about a dozen states that either provided no adult dental benefit to Medicaid recipients or only covered emergencies.

Through September, about 53,000 of the nearly 390,000 adult enrollees in West Virginia’s Medicaid program had used the benefit.

Stevens of the West Virginia Dental Association said he could not explain why so few Medicaid enrollees had used the benefit, though he noted that the $1,000 maximum might not be enough to persuade some to seek care. “For people with more serious oral health conditions, $1,000 does not go very far,” Stevens said. “It’s hardly worth the time for the patient and not worth the time for the dentist.”

Craig Glover, CEO of FamilyCare Health Centers in Charleston, West Virginia, said a Medicare benefit would help the many older patients who come to his dental clinic. He said some patients don’t return for needed follow-up care because of concerns about costs.

Without dental coverage, older adults in West Virginia rely on community health centers — which offer a sliding fee scale based on income — and free health clinics for care. But they can still face higher costs than they can afford or long waits for care.

The dental appointments at the Susan Dew Hoff Memorial Clinic in West Milford, where Marchio has been treated, are booked several months in advance, said office manager Gail Marsh.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Montana nonprofit hospitals receive millions of dollars in tax exemptions as charities each year in exchange for giving back to their communities. A KHN review found that some of Montana's richest medical centers are falling behind most state and national hospitals.

This article was published on December 9, 2021, by Kaiser Health News.

By Katheryn Houghton

Overall, Montana's nearly 50 nonprofit hospitals directed, on average, roughly 8% of their total annual expenses toward community benefits, such as covering the treatment costs of people who can't afford care. That's according to a KHN analysis of the hospitals' IRS filings ending in 2019, which provide a snapshot of hospitals' financial picture from before the pandemic. The national average as of 2018 was 10%, according to the American Hospital Association.

Hospitals self-report how much they give in community benefits, and their reporting processes are opaque. Even so, KHN's analysis found that some of Montana's wealthiest hospitals were spending well below the state and national averages.

Billings Clinic, the state's largest provider, spent roughly 5% of its operating costs on community benefits, while St. Peter's Health in Helena and Benefis Health System in Great Falls each reported less than 2%. By contrast, St. Luke Hospital in Ronan reported 22%.

Federal law doesn't dictate how much nonprofit hospitals must spend on such benefits, and the definition of what counts is vague. How nonprofits record their giving varies, and hospitals say that makes it an unfair measuring stick. However, it's what hospitals themselves report to the IRS.

Montana nonprofit hospitals face little to no oversight of their community benefit spending ― as is the case for much of the nation's nonprofit health systems. That can allow nonprofit hospitals to act more like businesses than charities. Meanwhile, hospitals tend to be among the biggest economic engines in their communities, giving large salaries to their executives while Americans are stuck with at least $141 billion in medical bills they can't afford.

"There are millions of Americans that do not have health insurance, and they need health care," said Gerard Anderson, a health policy professor at Johns Hopkins University who studies hospital giving. "Hospitals are places that have been given tax advantages to help."

Sued for Medical Debt at Benefis

Last year, Taruha Kirkaldie, 33, of Havre got a letter from a debt collector — she was being sued over a nearly $19,000 Benefis Health bill.

Kirkaldie didn't have health insurance in 2018 when a cut on her hand turned into a serious staph infection. She needed to travel to Great Falls for intravenous antibiotics and surgery. She said a hospital staffer helped her apply for Medicaid, the federal-state insurance program for those with low incomes, but her family of five made about $50,000 a year, too much to qualify.

Kirkaldie recalled being told that she wouldn't qualify for the hospital's aid program either because she owned a home in Harlem, Montana, that wasn't her primary residence.

Now Kirkaldie pays about $350 a month to pay off her hospital debt. "We still live paycheck to paycheck," Kirkaldie said.

Benefis Health reported making $49.6 million more than it spent in 2019. Of the $21.5 million it put toward community benefits, $1.4 million went to financial aid. By contrast, Bozeman Deaconess Hospital, a smaller hospital, spent $4.8 million on its financial aid.

Still, Benefis spends more on community benefits than it gets in tax breaks, spokesperson Kaci Husted said. The biggest chunk, according to the IRS filing, was nearly $17 million the hospital absorbed to offer services such as palliative care. The hospital also spent roughly $106,000 for health professional education.

Husted said she couldn't provide details about Kirkaldie's case but added that all the hospital's standard billing notices say patients can apply for financial assistance. She said its denial rate was low but didn't provide specifics. Husted attributed the hospital's limited financial aid to a lack of applications. "Perhaps, at times, people just don't want to go through the work of completing the application," Husted said.

She said a big part of the hospital's financial assistance effort is helping people sign up for public health coverage and that few need financial aid now that many patients qualify for Medicaid as a result of the expansion of the state's program in 2016.

That doesn't help people who don't qualify, like Kirkaldie.

What Counts as a Community Benefit

Montana hospitals use local needs assessments to help them decide how to spend their community benefit money.

Billings' regional assessments found residents needed better access to healthy foods. Melissa Henderson, a manager for Healthy by Designs, a community health coalition, said Billings Clinic, St. Vincent Healthcare and the local health department pay for its two full-time employees, who organize a farmers market and advocate for creating bike paths, among other things.

She said it's powerful to have the area's largest employers advocating for improvements like bike lanes even when no money is given.

"What I see is the hospitals are really doing their best to have an impact on their community," Henderson said.

In the Billings Clinic tax documents that KHN examined, the hospital reported making $73.9 million above its operating costs from July 2018 through June 2019. In that report, the hospital said it doesn't have the resources to address every community need, including the lack of transportation to health care facilities. However, it paid for rides to help patients who otherwise struggled to get to appointments until 2018. It stopped after it instead backed a successful initiative to increase taxes to bolster local transportation programs, among other services.

Mike Larson, executive director of Billings' nonprofit Adult Resource Alliance, said he saw the need for medical rides increase after the hospital stopped picking up patients. Larson said that his ride program for older adults had trouble meeting demand, despite receiving some of the new tax proceeds, and that his biggest concern was whether the partnership with the city would have enough staffers and vehicles to keep up.

Larson said Billings Clinic's business model causes it to act like a for-profit. "They're very cautious in terms of how they approach community support," he said.

The clinic's transportation service was difficult to offer, hospital spokesperson Zach Benoit said, because many patients needed special assistance such as mechanical lift systems to put wheelchairs into a vehicle. The hospital is considering getting an ambulance, but Benoit said that would be costly and require special staffing.

JJ Carmody, Billings Clinic's director of reimbursement, said the health system spent more than $36 million in 2019 on community benefits, including $12.7 million on financial aid and $3.6 million on programs to train health professionals.

"That's significant, and I also believe that's fair," Carmody said. "That's a large portion of our profit that's dedicated to community benefit."

In 2019, Billings Clinic paid its then-CEO Dr. Randall Gibb more than $1.2 million, according to the tax filing.

‘Very Little Motivation to Change'

Hospitals, industry watchdogs and policymakers alike debate what should count as a charitable benefit. And when questioned, hospitals often point to different categories that change the picture of how they perform.

St. Peter's Health reported spending $3.1 million on community benefits from July 2018 through June 2019. That's compared with the estimated $10 million it received in tax exemptions in 2016, according to a state audit presented to lawmakers last year.

Nate Coburn, the hospital's chief financial officer, said benefits would be much higher if the hospital counted services that bring in less money than they cost, such as running a behavioral health unit. The hospital used to count them: A 2016 tax document shows it spent more than $16 million on community benefits. Coburn said St. Peter's is considering correcting its forms to add those numbers.

Montana leaders have known hospitals have a transparency problem. The state audit estimated hospitals combined had $146 million in tax exemptions in 2016. That's money that didn't go toward local tax bases that help fund schools and repair roads.

In exchange, the audit said, hospitals reported spending $257 million on community benefits. But that number came with a huge caveat: The audit found hospitals report benefits vaguely and inconsistently, making it hard to determine if they can justify their charity status.

Opaque hospital filings are an issue nationwide. Some states have created minimum community benefit standards, with Oregon among the latest. There, health systems rely on a formula that sets a minimum for how much charity care hospitals give. But such hard lines are rare.

"There's really no enforcement, with very little motivation to change things," said Dr. Vikas Saini, president of the Lown Institute health care think tank in Massachusetts.

Rich Rasmussen, president of the Montana Hospital Association, said hospitals are working with his organization to come up with more consistent ways to count benefits and plan to share those results online next year. But, he added, tax reports don't capture everything hospitals offer.

"We have hospitals that are still showing incredible outcomes in their quality, and that's a benefit to the community," Rasmussen said. "If we can avoid somebody being readmitted, if we can ensure that somebody can be discharged home, those are pieces that you can tell in the narrative of what you're doing outside of what you might fill out."

But hospital pricing experts, including Anderson, said the tax reports can paint hospitals in too good a light for accomplishing goals any business should have. One example, Anderson said, is counting the cost of staff training as a community benefit.

"Walmart trains their employees, for-profit hospitals train their employees, so it makes no sense to me why a nonprofit hospital should be able to call this ‘community benefit,'" Anderson said.

Montana policymakers have voiced frustration, doubting whether all hospitals pay their fair share. But little has changed.

The state audit recommended that lawmakers define how hospitals report their spending, but no such laws made it out of the legislative session this year. A bill proposed by Republican state Sen. Bob Keenan would have required the state's largest hospitals to jointly hand over $4.3 million for the state to decide how it's spent on community benefits. Hospital lobbyists called the move a "sick tax" and argued it was the wrong time to burden the systems fighting the pandemic. The bill died in committee.

Many of Montana's large hospitals did well financially after the state's expansion of Medicaid, which now provides heavily subsidized health insurance to about 1 in 10 Montanans. And while hospitals have been strained while caring for covid patients, they have also received millions of dollars in federal relief. Nationally, many wealthy hospitals got richer during the pandemic.

The audit recommended the Montana Department of Public Health and Human Services define charity care and create a review process to ensure hospital policies match industry standards. Department spokesperson Jon Ebelt said that the pandemic delayed that work but that it plans to resume it in the coming months.

Saini, of the Lown Institute, said hospitals that are putting a lot toward community benefits have an interest in wanting more transparency — but they're too busy caring for patients to lobby for change. So holding hospitals accountable will likely have to come from political pressure, he said.

"I don't think all of it is just this data issue," Saini said. "There are some hospitals that do more, full stop."