Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.

This article was published on Thursday, October 22, 2020 in Kaiser Health News.

By Rachel Bluth

SACRAMENTO, Calif. — In an election year dominated by a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.

Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure could cost the state roughly $7.8 billion over about 30 years, according to an estimate from the nonpartisan state Legislative Analyst’s Office.

In 2004, voters approved Proposition 71, a $3 billion bond, to be repaid with interest over 30 years. The measure got the state agency up and running and was designed to seed research.

During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could reap millions in royalties from new treatments.

Yet most of those ambitions remain unfulfilled.

“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about how quickly research would yield cures. “You can’t rush this kind of work.”

So advocates are back after 16 years for more research money, and to increase the size of the state agency.

Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.

When the first bond measure was adopted in 2004, the George W. Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell: human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.

Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.

But advocates for Proposition 14 say the ability to do that research is still tenuous. In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut off those funds once again.

The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.

A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.

Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.

But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM board member who does not support the new bond measure. He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.

The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.

McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.

The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. “It undermines people’s trust in science,” Darnovsky said. “No one can promise cures, and nobody should.”

Robert Klein, a real estate developer who wrote both ballot measures, disagrees. He was inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.

“What are you going to do if this doesn’t pass? Tell those people we’re sorry, but we’re not going to do this?” Klein said. “The thought of other children needlessly dying is unbearable.”

Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.

“The promise was that it would pay for itself and it hasn’t,” Sheehy said. “We can’t really afford it, and this is the worst way to pay for it.”

Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money. Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to Weissman at Stanford for research.

That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion. Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.

“Gilead will make far more than that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.

Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks promising — and ultimately reap the profits.

Case in point: Fedratinib, one of the two FDA-approved drugs funded partly by CIRM, can cost about $20,000 for 120 capsules, according to GoodRx.

“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.

On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public. In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.

But in practice, the regulations have never really been tested.

Proposition 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits drug companies: Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.

The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.

And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.

Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.

“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said. “But at the end of the day, they’re only as good as people being able to access them affordably.”

Much like President Barack Obama, a President Biden could find his health policies initially sidelined by economic issues — in his case, caused by the pandemic.

This article was published on Thursday, October 22, 2020 in Kaiser Health News.

By Julie Rovner

If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.

Barring something truly unforeseen, it's fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.

Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He's also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.

But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he's promised, such as expanding the reach of the Affordable Care Act, creating a "public option" that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.

And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.

Still, no matter what the partisan makeup of Congress, "priority one is to get the COVID response going," said Len Nichols, a professor of health policy at George Mason University.

Biden's COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.

In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government's top infectious disease expert, who has been derided by President Donald Trump. "Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad," says Biden's website.

Biden's COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.

"If we've learned anything, it is that the health sector and the economy are not two separate spheres. They are connected," said Nichols. "I think health care and the economy are complementary and will be for the foreseeable future."

Assuming Biden gets beyond the pandemic and recession, he could move onto some of his bigger health promises, including expanding eligibility for Medicare, creating a "public option" health plan and boosting premium subsidies for the ACA.

Biden took heat throughout the primaries for his "moderate" approach to improving health insurance access and costs, compared with the "Medicare for All" plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn't mean his far less sweeping approach would be easy to get through Congress.

"There's a really big difference when you're running the government than when you're running for office," said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.

Many of Biden's proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.

"We pushed," Obama said in a recent interview on the podcast "Pod Save America," talking about the public option. "I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, 'I'm not voting for a public option.'"

Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option "are not well-defined, and there are many different theories of what it should be and where it should be fielded. There's no common vision about what it really means."

The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. "More than half these people have commercial insurance," he said. "What will happen to them?"

Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he's reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or "surprise" medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. "It would be a big statement," she said. "Whoever wins would then have the wind at their back."

But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats' preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.

As always, even when health is at the top of the agenda, it proves difficult to address.

Julie Rovner: jrovner@kff.org, @jrovner

In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus.

This article was published on Wednesday, October 21, 2020 in Kaiser Health News.

By Katheryn Houghton and Matt Volz

Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.

While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.

All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term.

In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.

Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.

His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.

Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.

“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”

An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)

“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”

Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.

Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.

In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.

Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.

Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.

One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.

Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”

Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.

Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.

Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.

Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.

The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.

Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.

Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.

People of color are disproportionately affected by the coronavirus. It is not merely because they're more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.

This article was published on Wednesday, October 21, 2020 in Kaiser Health News.

By April Dembosky, KQED

 In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah's Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.

The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.

"That night I had written down in a journal, letters to everyone I'm close to, the things I wanted them to know in case I died," she remembered.

Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.

Still, she wasn't sure if she should go to the hospital.

"As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life," said Monterroso, who is Latina. "So there was this weird, 'I don't want to go and use resources for nothing' feeling."

It took four friends to convince her she needed to call 911.

But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.

At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That's a false reading. Her cycling oxygen levels? The machine's wrong. The shooting pains in her leg? Probably just a cyst.

"The doctor came in and said, 'I don't think that much is happening here. I think we can send you home,'" Monterroso recalled.

Her experiences, she reasons,  are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they're more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.

"That is certainly part of it, but the other part is the lack of value people see in our lives," Monterroso wrote in a Twitter thread detailing her experience.

Research shows how doctors' unconscious bias affects the care people receive, with Latino and Black patients being less likely to receive pain medications or get referred for advanced care than white patients with the same complaints or symptoms, and more likely to die in childbirth from preventable complications.

In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend's cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla's accelerated heart rate? Her low oxygen levels? Why are her lips blue?

The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso's tone and her friends' tone.

"The implication was that we were insubordinate," Monterroso said.

She told the doctor she didn't want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.

"Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?" Monterroso recalled the doctor saying to her. "I only feel comfortable giving you that test if you say that you're fine getting breast cancer."

Monterroso thought to herself, "Swallow it up, Karla. You need to be well." And so she said to the doctor: "I'm fine getting breast cancer."

He never ordered the test.

Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.

"One of the nurses came in and she was like, 'I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,'" Monterroso said. "And I started bawling. Because that's all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It's really hard to be questioned in that way."

Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso's case, but said in a statement that it is "deeply committed to equity in access to health care" and "providing culturally-sensitive care for all we serve." After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.

She believes her experience is an example of why people of color are faring so badly in the pandemic.

"Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate," she said. "And if we are not advocating for ourselves, we can be treated as invisible."

Unconscious Bias in Health Care

Experts say this happens routinely, and regardless of a doctor's intentions or race. Monterroso's doctor was not white, for example.

Research shows that every doctor, every human being, has biases they're not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.

"Do I question a white man in a suit who's coming in looking like he's a professional when he asks for pain meds versus a Black man?" Salazar said, noting one of his own possible biases.

Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.

"There's just so much uncertainty," he said. "When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact."

Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it's not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso's is addressed, the intervention is usually weak.

"How do I tell my clinician, 'Well, the patient thinks you're racist?'" Salazar said. "It's a hard conversation: 'I gotta be careful, I don't want to say the race word because I'm going to push some buttons here.' So it just starts to become really complicated."

A Data-Based Approach

Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.

"It was viewed almost from a punishment standpoint. 'Doc, your patients of this persuasion don't like you and you've got to do something about it.' It's like, 'You're a bad doctor, and so your punishment is you have to go get training," said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)

Now, KP's approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.

KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.

"If you see a pattern evolving around a certain group and it's a persistent pattern, then that tells you there's something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you're not addressing," Copeland said. "Then the real work starts."

When doctors are presented with the data from their patients and the science on unconscious bias, they're less likely to resist it or deny it, Copeland said. At his health system, they've reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.

"Folks don't flinch about it," he said. "They're eager to learn more about it, particularly about how you mitigate it."

Still Unwell

It's been nearly six months since Monterroso first got sick, and she's still not feeling well.

Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.

She declined Alameda Hospital's invitation to speak to their staff about her experience, concluding it wasn't her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.

She acknowledges that Alameda Hospital is public, and it doesn't have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.

"Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that," she said. "And if I don't say what's happening, then people with much less resources are going to come into this experience, and they're going to die."

This story is part of a partnership that includes KQED, NPR and KHN.

April Dembosky, KQED: @adembosky