SACRAMENTO, Calif. — Should Gavin Newsom survive the Republican-driven attempt to oust him from office, the Democratic governor will face the prospect of paying back supporters who coalesced behind him.
And the leaders of California's single-payer movement will want their due.
Publicly, union leaders say they're standing beside Newsom because he has displayed political courage during the COVID-19 pandemic by taking actions such as imposing the nation's first statewide stay-at-home order. But behind the scenes, they are aggressively pressuring him to follow through on his 2018 campaign pledge to establish a government-run, single-payer healthcare system.
"I expect him to lead on California accomplishing single-payer and being an example for the rest of the country," said Sal Rosselli, president of the National Union of Healthcare Workers, which is urging Newsom to get federal permission to fund such a system.
Another union, the California Nurses Association, is pushing Newsom to back state legislation early next year to do away with private health insurance and create a single-payer system. But "first, everyone needs to get out and vote no on this recall," said Stephanie Roberson, the union's lead lobbyist.
"This is about life or death for us. It's not only about single-payer. It's about infection control. It's about Democratic and working-class values," she said. "We lose if Republicans take over."
Together, the unions have made hundreds of thousands of dollars in political contributions, funded anti-recall ads and phone-banked to defend Newsom. The latest polling indicates Newsom will survive Tuesday's recall election, which has become a battle between Democratic ideals and Republican angst over government coronavirus mandates. The Democratic Party closed ranks around the governor early and kept well-known Democratic contenders off the ballot, leaving liberal voters with little choice other than Newsom.
"This is a crucial moment for Newsom, and for his supporters who are lining up behind him," said Mark Peterson, a professor of public policy, political science and law at UCLA who specializes in the politics of healthcare. "They're helping him stay in office, but that comes with an expectation for some action."
But it's not clear that Newsom — who will face competing demands to pay back other supporters pushing for stronger action on homelessness, climate change and public safety — could deliver such a massive shift.
Reorganizing the health system under a single-payer financing model would be tremendously expensive — around $400 billion a year — and difficult to achieve politically, largely because it would require tax increases.
No state has a single-payer system. Vermont tried to implement one, but its former governor, a Democrat, abandoned his plan in 2014 partly because of opposition to tax increases. California would not only need to raise taxes, but would also likely have to seek voter approval to change the state constitution, and get permission from the federal government to use money allocated for Medicare and Medicaid to help fund the new system.
The last big push for single-payer in California ended in 2017 because it did not adequately address financing and other challenges. Leading up to the 2018 gubernatorial election, Newsom campaigned on single-payer healthcare, telling supporters "you have my firm and absolute commitment as your next governor that I will lead the effort to get it done," and "single-payer is the way to go."
In office, though, Newsom has distanced himself from that promise as he has expanded the existing health system, which relies on a mix of public and private insurance company payers. For instance, he and Democratic lawmakers imposed a health insurance mandate on Californians and expanded public coverage for low-income people, both of which enrich health insurers.
Newsom has, however, convened a commission to study single-payer and in late May wrote to President Joe Biden, asking him to work with Congress to pass legislation giving states freedom and financing to establish single-payer systems. "California's spirit of innovation is stifled by federal limits," Newsom wrote.
Newsom's recall campaign, asked about his stance on single-payer, referred questions to his administration. The governor's office said in prepared comments that Newsom remains committed to the idea.
"Governor Newsom has consistently said that single-payer healthcare is where we need to be," spokesperson Alex Stack wrote. "It's just a question of how we get there."
Stack also highlighted a new initiative that will build up the state's public health insurance program, Medi-Cal, saying it "paves a path toward a single-payer principled system."
Activists say Newsom has let them down on single-payer but are standing behind him because he represents their best shot at obtaining it. However, some say they're not willing to wait long. If Newsom doesn't embrace single-payer soon, liberal activists say, they will look for a Democratic alternative when he comes up for reelection next year.
"Newsom is an establishment candidate, and we as Democrats aren't shy about ripping the endorsement out from under someone who doesn't share our values," said Brandon Harami, Bay Area vice chair of the state Democratic Party's Progressive Caucus, who opposes the recall. "Newsom has been completely silent on single-payer. A lot of us are really gunning to see some action on his part."
State Assembly member Ash Kalra (D-San Jose), who also opposes the recall, will reintroduce his single-payer bill, AB 1400, in January after he paused it earlier this year to work on a financing plan. Its chief sponsor is the California Nurses Association.
Using lessons learned from the failed 2017 attempt to pass single-payer legislation, the nurses union is deploying activists to pressure state and local lawmakers into supporting the bill. Resolutions have been approved or are pending in multiple cities.
"This is an opportunity for California to lead the way on healthcare," Los Angeles City Council member Mike Bonin said before an 11-0 vote backing Kalra's single-payer bill in late August.
Kalra argued that support from Los Angeles shows his bill is gaining momentum. He is also preparing a new strategy to take on doctors, hospitals, health insurers and other health industry players that oppose single-payer: highlighting their profits.
"They are the No. 1 obstacle to this passing," Kalra said. "They're going to do whatever they can to discredit me and this movement, but I'm going to turn the mirror around on them and ask why we should continue to pay for wild profits."
An industry coalition called Californians Against the Costly Disruption of Our Healthcare was instrumental in killing the 2017 single-payer bill and is already lobbying against Kalra's measure. The group again argues that single-payer would push people off Medicare and private employer plans and result in less choice in health insurance.
Single-payer would "force these millions of Californians who like their healthcare into a single new, untested government program with no guarantee they could keep their doctor," coalition spokesperson Ned Wigglesworth said in a statement.
Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand healthcare access, is on Newsom's single-payer commission. He said it will work through "tension" in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.
"We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism," Ross said. "I'm not ruling out any bold stroke on single-payer; I would just want to know how we get it done."
Rapid at-home COVID tests are flying off store shelves across the nation and are largely sold out online as the delta variant complicates a return to school, work and travel routines.
But at $10 or $15 a test, the price is still far too high for regular use by anyone but the wealthy. A family with two school-age children might need to spend $500 or more a month to try to keep their family — and others — safe.
For Americans looking for swift answers, the cheapest over-the-counter COVID test is the Abbott Laboratories BinaxNOW two-pack for $23.99. Close behind are Quidel's QuickVue tests, at $15 a pop. Yet supplies are dwindling. After a surge in demand, CVS is limiting the number of tests people can buy, and Amazon and Walgreen's website were sold out as of Friday afternoon.
President Joe Biden said Thursday he would invoke the Defense Production Act to make 280 million rapid COVID tests available. The administration struck a deal with Walmart, Amazon and Kroger for them to sell tests for "up to 35 percent less" than current retail prices for three months. For those on Medicaid, the at-home tests will be fully covered, Biden said.
An increased supply should help to lower prices. As schools open and much of the country languishes without pandemic-related restrictions, epidemiologists say widespread rapid-test screening — along with vaccination and mask-wearing — is critical to controlling the delta variant's spread. Yet shortages, little competition and sticky high prices mean routine rapid testing remains out of reach for most Americans, even if prices drop 35%.
Consumers elsewhere have much cheaper — or free — options. In Germany, grocery stores are selling rapid COVID tests for under $1 per test. In India, they're about $3.50. The United Kingdom provides 14 tests per person free of charge. Canada is doling out free rapid tests to businesses.
Michael Mina, assistant professor of epidemiology at Harvard University, lauded Biden's announcement on Twitter while saying he "had some reservations" about its scale and noted that 280 million tests represent "less than one test per person over the course of a year."
Rep. Kim Schrier (D-Wash.) for months has advocated for rapid testing at a lower cost. "In an ideal world, a test would either be free or cost less than a dollar so that people could take one a few times a week to every day," she said in the days before Biden's announcement.
Biden's initiative "is a great start" for broader rapid testing, Schrier said Friday. "But there is a lot more to be done, and that must be done quickly, to use this really important tool to combat this virus."
A nationwide survey released in February by the Harvard T.H. Chan School of Public Health and Hart Research found that 79% of adults would regularly test themselves at home if rapid tests cost a dollar. But only a third would do so if the cost was $25.
Billions in taxpayer dollars have been invested in these products. Abbott Laboratories, for instance, cashed in on hundreds of millions in federal contracts and gave its shareholders fat payouts last year, increasing its quarterly dividend by 25%. Even so, according to a New York Times investigation, as demand for rapid tests cratered in early summer, Abbott destroyed its supplies and laid off workers who had been making them.
More than a year ago, Abbott said the company would sell its BinaxNOW in bulk for $5 a test to healthcare providers, but that option is not available over the counter to the public. Even with the anticipated price decrease, a two-pack will be more than $15. Abbott did not comment further.
Schrier said in spring that test prices were high because "big companies are buying up all the supplies." Also, "their profit is far higher making 1,000 $30 tests than 30,000 $1 tests" — in other words, they can make the same amount of money for many fewer tests.
In March, the Biden administration allocated $10 billion as part of the American Rescue Plan Act to perform COVID testing in schools, leaving the rollout largely to states. This followed $760 million spent by the Trump administration to buy 150 million of Abbott's rapid-response antigen tests, many of which went to schools. The rollout has been mixed, with states like Missouri mired in logistical challenges.
In late August, Schrier wrote a letter asking four federal agencies to update their distribution plans. She also urged the government to increase spending on rapid testing, saying "time is of the essence" as children returned to school.
Antigen tests can give real-time information to people exposed to COVID, said Dr. Dara Kass, an associate professor of emergency medicine at Columbia University Medical Center. Waiting for lab results from polymerase chain reaction (PCR) tests can take days, and many states — particularly in the hard-hit South — are seeing appointments fill up days in advance. At-home collection kits for PCR tests can cost over $100.
Rapid tests take under 15 minutes to detect COVID by pinpointing proteins, called antigens. The tests are similar to a pregnancy test, with one or two lines displayed, depending on the result.
The Centers for Disease Control and Prevention recommends that fully vaccinated people exposed to COVID wear a mask indoors for two weeks and get tested three to five days after exposure. The unvaccinated should quarantine for 14 days. But that leaves gray area for those vaccinated people hoping to attend classes or go about their lives, Kass said.
"Rapid tests give information," she added, "that allows somebody to engage in society safely." People can follow up with a PCR test, which is more sensitive, for confirmation of a diagnosis.
In Massachusetts, for example, a "Test and Stay" strategy for students exposed to COVID allows them to remain in school: Students take BinaxNOW tests five days in a row following close contact with an infected person.
More than 30 antigen tests have been developed in the U.S. — though just six companies have FDA authorization for over-the-counter use. No rapid COVID tests have full FDA approval. Two rapid molecular options, made by Lucira Health and Cue Health, also have emergency use authorization (EUA).
"Unfortunately, many submissions are incomplete or contain insufficient information for FDA to determine that they meet the statutory criteria," FDA spokesperson James McKinney said.
"As long as these tests are regulated as medical devices, the FDA has to regulate them not as critical public health tools, but as medical tools, with all of the onerous clinical trials that slow everything down 100-fold," Mina said on Twitter.
With only a handful of rapid tests on the market, it is harder for companies that have not yet received FDA authorization to catch up and, in turn, drive the prices down, said Michael Greeley, co-founder and general partner at Flare Capital Partners, a venture capital firm focused on healthcare technology. "If we're talking about people testing their kids every day going to school," he added, "for many families, the current costs are a real burden."
Broad adoption of rapid testing seems premature, he said, even with a mass purchase of tests by the U.S. government: "We can't even get people to floss, so the idea that people are now going to start rapid testing as their standard operating procedure is a flawed assumption."
Regardless, companies can't keep up with demand.
Ellume said it saw a 900% spike in the use of its tests over the past month. Its at-home rapid test costs up to $38.99. On Walmart's website, it was listed for $26.10 Friday but was out of stock.
The Australian manufacturer received $232 million from the U.S. Defense Department in February to scale up production, after the FDA authorized its at-home use late last year. But the federal Healthcare Enhancement Act, which furnished the funding, does not impose pricing restrictions. Ellume said it will begin production at a Frederick, Maryland, plant this fall. For now, it is shipping tests from Australia.
This summer, Lucira Health stopped selling its about $50 molecular rapid test online to focus on larger clients, including San Francisco's Chase Center, home to the Golden State Warriors, and the Olympics, Dan George, Lucira's chief financial officer, said during a recent earnings call.
The company is still losing money as it ramps up production but hopes to return to selling directly on its website and Amazon later this year.
SACRAMENTO, Calif. — Gov. Gavin Newsom's COVID-19 rules have been a lightning rod in California's recall election.
But there's a lot more at stake for Californians' healthcare than mask and vaccine mandates.
Newsom, a first-term Democrat, argues that their fundamental ability to get health insurance and medical treatments is on the line.
Republicans are seeking to "take away healthcare access for those who need it," according to his statement in the voter guide sent to Californians ahead of Tuesday's recall election.
Exactly where all the leading Republican recall candidates stand on healthcare is unclear. Other than vowing to undo state worker vaccine mandates and mask requirements in schools, none have released comprehensive healthcare agendas. Nor has Kevin Paffrath, the best-known Democrat in the race, who wants to keep existing vaccine and mask mandates.
Outside of his pandemic measures, Newsom has, in conjunction with the legislature, funded state subsidies to help low- and middle-income Californians buy health insurance; imposed a state tax penalty on uninsured people; and extended eligibility for Medi-Cal, the state's Medicaid program for low-income people, to undocumented immigrants ages 19 to 26. This year, he signed legislation to further expand eligibility to unauthorized immigrants ages 50 and up. Republicans opposed all those initiatives.
Voters, who have been mailed ballots, have two choices to make: First, should Newsom be removed? Second, who among the 46 replacement candidates should replace him? A Public Policy Institute of California poll released Sept. 1 showed that 58% of likely voters want to keep Newsom in office.
To see where the leading recall candidates stand on healthcare, KHN combed through their speeches and writings, and scoured media coverage. Republicans John Cox and Kevin Kiley and Democrat Paffrath also consented to interviews. Republicans Larry Elder and Kevin Faulconer did not respond to repeated requests for interviews.
Larry Elder
Elder, 69, a conservative talk radio host, is far ahead of other candidates in polls. Elder believes healthcare is a "commodity," not a right, and wants government out of health insurance.
He opposes Obamacare — even some of the most popular provisions of the 2010 law embraced by other Republicans, such as allowing children to stay on their parents' health insurance until age 26 and guaranteeing coverage for people with preexisting medical conditions.
"Forcing an insurance company to cover people with pre-existing conditions completely destroys the concept of insurance," Elder wrote in a 2017 opinion piece on his website.
In a 2010 opinion piece on creators.com, he wrote that he would end Medicaid, the state-federal health insurance program for low-income people, and phase out Medicare, the federal insurance program for older Americans and some people with disabilities. (As governor, he would not have the authority to do either.)
Instead, he wants people to rely primarily on high-deductible health plans and pay their hefty out-of-pocket costs with money they have saved in tax-free accounts.
Elder told CalMatters he doesn't think taxpayers should spend money on "healthcare for illegal aliens" but also recently told CNN he has no plans to limit their eligibility for Medi-Cal, saying it's "not even close to anything on my agenda."
Elder calls himself "pro-life" but has said he doesn't foresee abortion access changing in California. Still, anti-abortion activist Lila Rose tweeted that Elder had promised her he would cut abortion funding and veto legislation that made abortion more accessible.
Kevin Faulconer
In campaign stops and debates, the mayor of San Diego from 2014 to 2020 has cast himself as a moderate, experienced leader who worked with Democrats to clear the city's streets and provide shelters for homeless people.
Faulconer, 54, often refers to San Diego's success at decreasing homelessness as one of his greatest achievements in office. But that success came only after a 2017 hepatitis A outbreak killed 20 people and sickened nearly 600 others, most of whom were homeless. Faulconer and the city council were criticized for not intervening sooner to open more restrooms and hand-washing stations, despite warnings from health officials.
The city's 12% reduction in the number of people sleeping on the streets from 2019 to 2020 resulted largely from efforts to curb the spread of COVID by placing people in shelters.
A fiscal conservative, Faulconer is moderate on healthcare. He supports abortion rights and two years ago vowed not to restrict them.
If elected governor, Faulconer said, he would push to expand California's paid parental leave program to 12 weeks at full pay. Currently, new parents get up to 70% of their income for up to eight weeks.
John Cox
Cox, 66, has centered his campaign — as he did his unsuccessful 2018 gubernatorial bid against Newsom — on his business credentials. The lawyer and accountant thinks the solution to California's healthcare troubles lies in the free market, for example by letting patients know the cost of care ahead of time so they can shop for a better deal.
"I understand that healthcare is expensive, and families can't afford it very well," Cox said in an interview with KHN. But that's because "there's not enough price discrimination, not enough consumer orientation, not enough consumer choice."
Healthcare is expensive partly because doctors and hospitals can charge whatever they want, and patients overutilize care because they don't have to pay the full price, he said.
He favors health savings accounts with some government assistance for low-income people, which he said would make consumers more discriminating and keep healthcare prices in check. But he doesn't want to take profit completely out of healthcare.
"I certainly want companies to make money from providing healthcare," Cox said. "Because I think that's what gives them an incentive to innovate."
Kevin Kiley
Kiley, 36, a state Assembly member representing a suburban Sacramento district, often speaks out against government interference in people's lives. The former teacher and attorney believes government rules about insurance coverage, doctor-patient relationships and independent contracting have contributed to higher health costs.
Like Elder and Cox, he wants more transparency and consumer choice in healthcare.
"I'm not sure it's necessary to be continually specifying what every single plan needs to entail," Kiley said in an interview with KHN. "I don't know that legislators are always in the best position to be weighing in."
Rather than provide health benefits to undocumented immigrants, Kiley said, lawmakers should scrutinize Medi-Cal, which covers about one-third of Californians but is failing to provide basic preventive care, including childhood vaccines, to some of its neediest patients.
Kiley downplayed the coverage gains made under Obamacare that have reduced the state's uninsured rate from about 17% in 2013 to about 7%, saying a reduction was inevitable because of state and federal requirements to get health insurance or be penalized.
He has authored legislation, which did not pass, to increase funding for K-12 student mental health, which he says has only become more urgent in the pandemic.
Kevin Paffrath
Paffrath, 29, made his fortune giving financial advice on YouTube and renovating houses in Southern California.
If elected, Paffrath said, he would create 80 emergency facilities across the state to connect homeless people with doctors and substance use and mental health treatment. And he would require schools to offer better mental health education.
He also wants to create vocational programs for interested students ages 16 and up. With better job training and higher salaries, Medi-Cal rolls would naturally shrink, he argues.
"It's not Californians' fault that one-third of Californians are on Medi-Cal," Paffrath said in an interview with KHN. "It's our schools'."
Paffrath supports the Affordable Care Act and said he is willing to consider questions such as whether California should adopt a single-payer health system or manufacture generic prescription drugs.
Paffrath said he's most interested in cutting health insurance red tape, which creates bureaucratic hurdles for patients, makes doctors spend more time on paperwork than patient care, and discourages new providers from entering the field.
Hospital discharge day for Phoua Yang was more like a pep rally.
On her way rolling out of TriStar Centennial Medical Center in Nashville, Tennessee, she teared up as streamers and confetti rained down on her. Nurses chanted her name as they wheeled her out of the hospital for the first time since she arrived in February with COVID-19, barely able to breathe.
The 38-year-old mother is living proof of the power of ECMO — a method of oxygenating a patient's blood outside the body, then pumping it back in. Her story helps explain why a shortage of trained staff members who can run the machines that perform this extracorporeal membrane oxygenation has become such a pinch point as COVID hospitalizations surge.
"One hundred forty-six days is a long time," Yang said of the time she spent on the ECMO machine. "It's been like a forever journey with me."
For nearly five months, Yang had blood pumping out a hole in her neck and running through the rolling ECMO cart by her bed.
ECMO is the highest level of life support — beyond a ventilator, which pumps oxygen via a tube through the windpipe, down into the lungs. The ECMO process, in contrast, basically functions as a heart and lungs outside the body.
The process, more often used before the pandemic for organ transplant candidates, is not a treatment. But it buys time for the lungs of COVID patients to heal. Often they've been on a ventilator for a while. Even when it's working well, a ventilator can have its own side effects after prolonged use — including nerve damage or damage to the lung itself through excessive air pressure.
Doctors often describe ECMO as a way to let the lungs "rest" — especially useful when even ventilation isn't fully oxygenating a patient's blood.
Many more people could benefit from ECMO than are receiving it, which has made for a messy triaging of treatment that could escalate in the coming weeks as the delta variant surges across the South and in rural communities with low vaccination rates.
The ECMO logjam primarily stems from just how many people it takes to care for each patient. A one-on-one nurse is required, 24 hours a day. The staff shortages that many hospitals in hot zones are facing compound the problem.
Yang said she sometimes had four or five clinical staff members helping her when she needed to take a daily walk through the hospital halls to keep her muscles working. ECMO is unusual as life support, because patients can be conscious and mobile, unlike patients on ventilators who often are sedated. This presents its own challenges, however. For Yang, one person's job was just to make sure no hoses kinked as she moved, since the machine was literally keeping her alive.
Of all the patients treated in an intensive care unit, those on ECMO require the most attention, said nurse Kristin Nguyen, who works in the ICU at Vanderbilt University Medical Center.
"It's very labor-intensive," she said one morning, after a one-on-one shift with an ECMO patient who had already been in the ICU three weeks.
The Extracorporeal Life Support Organization said the average ECMO patient with COVID spends two weeks on the machine, though many physicians say their patients average a month or more.
"These patients take so long to recover, and they're eating up our hospital beds because they come in and they stay," Nguyen said. "And that's where we're getting in such a bind."
Barriers to using ECMO are not merely that there aren't enough machines to go around or the high cost — estimated at $5,000 a day or significantly more, depending on the hospital.
"There are plenty of ECMO machines — it's people who know how to run it," said Dr. Robert Bartlett, a retired surgeon at the University of Michigan who helped pioneer the technology.
Every children's hospital has ECMO, where it's regularly used on newborns who are having trouble with their lungs. But Bartlett said that, before the pandemic, there was no point in training teams elsewhere to use ECMO when they might use the technology only a few times a year.
It's a fairly high-risk intervention with little room for error. And it requires a round-the-clock team.
"We really don't think it should be that every little hospital has ECMO," Bartlett said.
Bartlett said his research team is working to make it so ECMO can be offered outside an ICU — and possibly even send patients home with a wearable device. But that's years away.
Only the largest medical centers offer ECMO currently, and that has meant most hospitals in the South have been left waiting to transfer patients to a major medical center during the recent pandemic surge. But there's no formal way to make those transfers happen. And the larger hospitals have their own COVID patients eligible for ECMO who would be willing to try it.
"We have to make tough choices. That's really what it comes down to — how sick are you, and what's the availability?" said Dr. Harshit Rao, chief clinical officer overseeing ICU doctors with physician services firm Envision. He works with ICUs in Dallas and Houston.
There is no formal process for prioritizing patients, though a national nonprofit has started a registry. And there's limited data on which factors make some COVID patients more likely to benefit from ECMO than others.
ECMO has been used in the United States throughout the pandemic. But there wasn't as much of a shortage early on when the people dying of COVID tended to be older. ECMO is rarely used for anyone elderly or with health conditions that would keep them from seeing much benefit.
Even before the pandemic, there was intense debate about whether ECMO was just an expensive "bridge to nowhere" for most patients. Currently, the survival rate for COVID patients on ECMO is roughly 50% — a figure that has been dropping as more families of sicker patients have been pushing for life support.
But the calculation is different for the younger people who make up this summer's wave of largely unvaccinated COVID patients in ICUs. So there's more demand for ECMO.
"I think it's 100% directed at the fact that they're younger patients," said Dr. Mani Daneshmand, who leads the transplant and ECMO programs at Emory University Hospital.
Even as big as Emory is, the Atlanta hospital is turning down multiple requests a day to transfer COVID patients who need ECMO, Daneshmand said. And calls are coming in from all over the Southeast.
"When you have a 30-year-old or 40-year-old or someone who has just become a parent, you're going to call. We've gotten calls for 18-year-olds," he said. "There are a lot of people who are very young who are needing a lot of support, and a lot of them are dying."
Even for younger people, who tend to have better chances on ECMO, many are debilitated afterward.
Laura Lyons was a comedian with a day job in New York City before the pandemic. Though just 31 when she came down with COVID, she nearly died. ECMO, she said, saved her life. But she may never be the same.
"I was running around New York City a year and a half ago, and now I'm in a wheelchair," she said. "My doctors have told me I'll be on oxygen forever, and I'm just choosing not to accept that. I just don't see my life attached to a cord."
Lyons now lives at her parents' house in central Massachusetts and spends most days doing physical therapy. Her struggle to regain her strength continues, but she's alive.
Since it's kind of the wild West to even get someone an ECMO bed, some families have made their desperation public, as their loved one waits on a ventilator.
As soon as Toby Plumlee's wife was put on a ventilator in August, he started pressing her doctors about ECMO. She was in a northern Georgia community hospital, and the family searched for help at bigger hospitals — looking 500 miles in every direction.
"But the more you research, the more you read, the more you talk to the hospital, the more you start to see what a shortage it really is," he said. "You get to the point, the only thing you can do is pray for your loved one — that they're going to survive."
Plumlee said his wife made it to sixth in line at a hospital 200 miles away — TriStar Centennial Medical Center, where Phoua Yang was finishing her 146-day ECMO marathon.
Yang left with a miracle. Plumlee and their children were left in mourning. His wife died before ever getting ECMO — a few days after turning 40.
This story was produced as part of NPR's partnership with Kaiser Health News and Nashville Public Radio.
Healthcare — and how much it costs — is scary. But you're not alone with this stuff, and knowledge is power. "An Arm and a Leg" is a podcast about these issues, and its second season is co-produced by KHN.
Charity care is one tiny provision in the giant Affordable Care Act, and it can make a big difference for patients who face huge bills. How did it get into the law? One Republican senator made sure the ACA required nonprofit hospitals to act more like charities — and less like loan sharks — but he still voted against the whole bill.
The national requirement to offer charity care emerged from the Obama White House's failed courtship of GOP Sen. Chuck Grassley of Iowa. In this episode, we hear how that political tango almost tanked the ACA — and how the battle over the ACA "broke America." Featured are David Axelrod, a former adviser to President Barack Obama; longtime health policy reporter and KHN chief Washington correspondent Julie Rovner; and a top Grassley aide.
This is the second in a four-part series that looks at the (slow, uneven) development of legal protections for consumers (aka patients, aka people who just don't want to die and aren't Bill Gates) against outrageous medical bills and draconian collection practices.
Catch up on the first episode, before or after listening to this one. It's about how a legendary lawyer — the guy who beat Big Tobacco in the 1990s — tried to sue nonprofit hospitals into acting more like charities and less like loan sharks. (He lost, but it wasn't a total dead end; that's where this episode picks up.)
As students head to college this fall, hundreds of schools are requiring employees and students to be vaccinated against COVID, wear masks on campus or both.
But at some schools, partisan politics have bolstered efforts to stymie public health protections.
Events at the University of South Carolina, in a deeply conservative state, demonstrate the limits of political pressure in some cases, even though "South Carolina is a red state and its voters generally eschew mandates," said Jeffrey Stensland, a spokesperson for the school.
As the fall semester approached, Richard Creswick, an astrophysics professor at the University of South Carolina, was looking forward to returning to the classroom and teaching in person. He felt it would be fairly safe. His graduate-level classes generally had fewer than a dozen students enrolled, and the school had announced it would require everyone on campus to wear masks indoors unless they were in their dorm rooms, offices or dining facilities. For Creswick, 69, that was important because he did not want his working on campus to add to the COVID risk for his wife, Vickie Eslinger, 73, who has been undergoing treatment for breast cancer.
But state Attorney General Alan Wilson weighed in early in August, sending a letter to the school's interim president, Harris Pastides, that a budget provision passed by the state legislature prohibited the university from imposing a mask mandate. Pastides, who previously served as dean of the university's school of public health, rescinded the mask mandate, although he encouraged people to still use them.
"We were very upset," Creswick said.
After the university revoked its mask mandate, within days Wilson sent out a campaign fundraising letter touting his intervention in public health measures and stating, "The fight over vaccines and masks has never been about science or health. It's about expanding the government's control over our daily lives."
Creswick and Eslinger, who felt strongly that the mask mandate was indeed about health, filed a lawsuit, arguing that the legislative provision cited by the attorney general did not prohibit a universal mask mandate. The state Supreme Court took up the case on an expedited basis and on Aug. 20 ruled 6-0 in their favor.
The school immediately reinstated its mask mandate and other colleges in the state followed suit.
After the court ruling, Creswick said he heard from professors at several other South Carolina colleges. "They're calling me a hero," he said, sounding bemused.
The attorney general's office didn't respond to a request for comment.
The Centers for Disease Control and Prevention recommends that everyone at colleges and universities wear masks indoors, even if they are fully vaccinated, in locales with substantial or high transmission of the coronavirus. Most of the country meets that standard at this point. The CDC also recommends that colleges offer and promote COVID vaccines.
To be sure, many colleges and universities already require students to mask up or be vaccinated.
As of Aug. 26, the Chronicle of Higher Education had tallied 805 campuses that require at least some employees or students to be vaccinated. Most schools grant exemptions from the vaccine mandate, often for religious or medical reasons. And hundreds of colleges are requiring students and staff members to wear masks on campus this fall, according to a running tally by University Business.
Still, 12 conservative-leaning states prohibit vaccine mandates at higher education institutions, according to an analysis by the National Academy for State Health Policy. The rules vary, and some apply only to public institutions. The group is in the process of analyzing mask mandate bans that apply to colleges and universities.
At Indiana University, a group of students challenged the school's vaccine mandate on the grounds it violated their constitutional right to "bodily integrity, autonomy and medical choice." The U.S. Court of Appeals for the 7th Circuit refused to block the school's policy. The court reasoned the universities can decide what they need to do to keep students safe in communal settings. The students then appealed to U.S. Supreme Court Justice Amy Coney Barrett, who refused without explanation to block the mandate.
Red states with Republican leadership are hardly the only ones where colleges and universities are facing restrictions on their ability to put public health protections in place. But for teachers, whose professions are rooted in encouraging the pursuit of learning and knowledge, prohibitions that fly in the face of science and jeopardize public health can be tough to swallow.
"It's completely demoralizing to realize that our health and safety has been trumped by politics," said Becky Hawbaker, an assistant professor in the College of Education at the University of Northern Iowa in Cedar Falls, Iowa, who is president of United Faculty, the union representing 600 faculty members at the school. "It seems like you know a train wreck is coming and you're sounding the alarm, and no one seems to listen."
At the University of Georgia in Athens in August, a professor who made masks mandatory in his classroom because of his advanced age and health conditions promptly resigned when a student refused to don a mask. Georgia's university system does not mandate masks or vaccines.
In May, Iowa Gov. Kim Reynolds, a Republican, signed a law prohibiting mask mandates at K-12 schools, and within city and county governments. A few days later, the Iowa Board of Regents, which oversees the University of Northern Iowa, the University of Iowa and Iowa State University, lifted emergency rules that had been in place the previous year requiring indoor masking and physical distancing at the colleges.
The University of Northern Iowa held classes in person throughout the past school year, without major problems, using those mask and distancing requirements, Hawbaker said. But with the rise of the delta variant and the increase in COVID cases in the community, now is not the time to remove safety restrictions, the union asserts.
So far, more than 200 people have signed an August letter sent by the union to the Board of Regents requesting mask and vaccine mandates on campus, and classroom changes to allow physical distancing, Hawbaker said.
"Both the Board and our universities recommend and encourage individuals to wear a mask or other face covering while on campus, and anyone who wishes to wear a mask may do so," Josh Lehman, a spokesperson for the board, wrote in an email. The board also supports students and staffers getting COVID vaccines, which are available on campus.
At Clemson University in Clemson, South Carolina, associate professor Kimberly Paul planned a protest with other faculty members in August to push for a mask mandate. After the state Supreme Court ruled in favor of Creswick, Clemson announced a mask mandate until Oct. 8. That stretch covers the period of greatest COVID risk, according to the school's modeling.
Paul and her colleagues want a mask mandate for the entire semester, after which the need can be reevaluated, she said.
"I'm a biologist, and this hits close to home," she said.
With workplace vaccine mandates in the offing, opponents are turning to a tried-and-true recourse for avoiding a COVID-19 shot: the claim that vaccination interferes with religious beliefs.
This article was published on Thursday, September 9, 2021 in Kaiser Health News.
In Northern California, the pastor of a megachurch hands out religious exemption forms to the faithful. A New Mexico state senator will "help you articulate a religious exemption" by pointing to the decades-old use of aborted fetal cells in the development of some vaccines. And a Texas-based evangelist offers exemption letters to anyone — for a suggested "donation" starting at $25.
With workplace vaccine mandates in the offing, opponents are turning to a tried-and-true recourse for avoiding a COVID-19 shot: the claim that vaccination interferes with religious beliefs.
No major denomination opposes vaccination. Even the Christian Science Church, whose adherents rely largely on prayer rather than medicine, does not impose an official policy. It counsels "respect for public health authorities and conscientious obedience to the laws of the land, including those requiring vaccination."
And if a person claims their privately held religious beliefs forbid vaccination, that defense is unlikely to hold up in court if challenged, legal experts say. Although individual clergy members have mounted the anti-vaccine bandwagon, they have no obvious justification in religious texts for their positions. Many seem willing to cater to people who reject vaccination for another reason.
Still, the U.S. Equal Employment Opportunity Commission (EEOC) grants broad leeway to what constitutes a sincerely held religious belief. As a result, some experts predict most employers and administrators won't want to challenge such objections from their employees.
"I have a feeling that not a lot of people are going to want to fight on this topic," said Dr. John Swartzberg, an expert on infectious diseases and professor at the University of California-Berkeley.
The Food and Drug Administration's full approval of the Pfizer-BioNTech vaccine on Aug. 23 could bring the matter to a head. Many government agencies, healthcare providers, colleges and the military had been awaiting the move before enforcing mandates.
California, which abolished nonmedical exemptions for childhood vaccination in 2015, has led the way on COVID vaccine mandates. Democratic Gov. Gavin Newsom's July 26 order for state employees and healthcare workers to be fully vaccinated or submit to weekly testing was the first of its kind, as was a similar declaration Aug. 11 for all teachers and staff at both public and private schools. The 23-campus California State University system joined UC in requiring vaccination of all students and staff, and companies like Google, Facebook and Twitter have announced mandatory proof of employee vaccination for those who return to their offices.
The University of California is requiring proof of vaccination for all staffers and students across its 10 campuses, a decision that potentially affects half a million people. But like many other businesses, it makes room for those who wish to request an exemption "on medical, disability or religious grounds," adding that it is required by law to do so.
Nothing in history suggests that a large number of students or staff members will seek such an out — but then, no previous vaccine conversation has been as overtly politicized as the one around COVID.
"This country is going to mandates. It just is. Every other alternative has been tried," said Dr. Monica Gandhi, an infectious diseases expert at UC-San Francisco. "That phrase, 'religious exemption,' is very big. But it's going to be quite hard in the current climate — in a mass health crisis, with a vaccine in place that works — to just let any such religious claims go."
Indeed, while pop-up anti-vaccine churches have long offered reluctant parents ways to exempt their kids from shots, these days churches, internet-based religious businesses and others seem to be offering COVID vaccination exemptions wholesale.
Dr. Gregg Schmedes, a Republican state senator and otolaryngologist in New Mexico, used an Aug. 19 Facebook post to direct healthcare workers "with a religious belief that abortion is immoral" to a site that attempts to catalog the use of cells from aborted fetuses to test or produce various COVID vaccines. One U.S.-distributed vaccine, the Johnson & Johnson product, is made using a cell culture that partly originated in retinal cells from a fetus aborted in 1985.
Yet the Vatican has deemed it "morally acceptable" to get a COVID vaccination. In fact, Pope Francis declared it "the moral choice because it is about your life but also the lives of others." In an increasing number of dioceses — Chicago, Philadelphia, Los Angeles and New York, among others — bishops have instructed priests and deacons not to sign any letter that lends the church's imprimatur to a request for religious exemption.
Schmedes did not respond to questions posed by KHN via email.
In the Sacramento-area city of Rocklin, meanwhile, a church that openly defied Newsom's COVID shutdown orders last year has handed out hundreds of exemption letters. Greg Fairrington, pastor of Destiny Christian Church, told attendees at a church service, "Nobody should be able to mandate that you have to take a vaccine or you lose your job. That's just not right, here in America."
EEOC guidelines suggest that employers make a "reasonable accommodation" to those with a sincerely held religious objection to a workplace rule. That might mean moving an unvaccinated employee to an isolated part of the office, or from a forward-facing position to one that involves less interpersonal contact. But the employer isn't required to do anything that results in an undue hardship or more than a "de minimis" cost.
As for the objection itself, the commission's advice is vague. Employers "should ordinarily assume that an employee's request for religious accommodation is based on a sincerely held religious belief," the EEOC says. Employers have the right to ask for supporting documentation, but employees' religious beliefs don't have to hew to any specific or organized faith.
The distinction between religion and ideology is blurring among those seeking exemptions. In Turlock, California, a preschool teacher was provided an exemption letter by her pastor, who offered the documents to those who felt taking a vaccine was "morally compromising." Asked by KHN via direct message why she sought the exemption, the woman said she didn't feel comfortable being vaccinated because of "what's in the vaccine," then added, "I personally am over 'COVID' and the control the government is trying to implement on us!" Like other exemption seekers, even those who have posted in Facebook anti-vaccine groups, she feared having other people know she sought an exemption.
A surgical technician working at Dignity Health, which has ordered its employees to be fully vaccinated by Nov. 1, said she was awaiting a response from the company's human resources department on her request for a religious exemption. She freely explained her reasons for applying by referencing two Bible passages and listing vaccine ingredients she said are "harmful to the human body." But she didn't want anyone to know she applied for the religious exemption.
A state's right to require vaccination has been settled law since a 1905 Supreme Court ruling that upheld compulsory smallpox vaccination in Massachusetts. Legal experts say that right has been upheld repeatedly, including in a 1990 Supreme Court decision that religiously motivated actions aren't insulated from laws, unless a law singles out religion for disfavored treatment. In August, Supreme Court Justice Amy Coney Barrett declined, without comment, a challenge to Indiana University's rule that all students, staff and faculty be vaccinated.
"Under current law it is clear that no religious exemption is required," Erwin Chemerinsky, dean of UC-Berkeley's law school, told KHN. Clearly, that is not preventing people from seeking one.
A Colorado health clinic incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes.
This article was published on Wednesday, September 8, 2021 in Kaiser Health News.
COMMERCE CITY, Colo. — In her 19 years of living with cerebral palsy, scoliosis and other ailments, Cynthia Enriquez De Santiago has endured about 60 surgeries and her heart has flatlined at least four times.
But the most unusual doctor's referral of her life came last year: Go see an attorney.
Enriquez De Santiago sought help at a Colorado health clinic that takes a novel approach to improving the health of its patients: It incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes. And the state's Medicaid program helps fund the initiative.
Although Medicaid traditionally doesn't fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs. Every day in Commerce City, four lawyers join the physicians, psychiatrists and social workers at Salud Family Health Centers' clinic in this suburb north of Denver, as part of Salud's philosophy that mending legal ills is as important for health as diet and exercise.
The goal: Reduce toxic stress and keep families intact, on the premise that it will serve their health for years to come, said Marc Scanlon, the attorney who directs the program.
Mostly, that has meant helping people with unemployment benefit claims and Social Security Disability Insurance denials. But it also regularly entails helping patients — many of whom speak only Spanish after having arrived here from Mexico or Central America — with immigration hearings.
The program is among at least 450 existing medical-legal partnerships across the nation that typically serve impoverished people and migrants. The vast majority don't rely on Medicaid dollars, which are used only in fewer than 10 states, according to the National Center for Medical-Legal Partnership.
The role of these sorts of medical-legal partnerships has grown over the past year as millions of people in the U.S. have faced lost income and the threat of losing their homes during the COVID-19 pandemic. Some partnerships have helped patients secure unemployment checks, while others have fought some of the evictions that weren't already barred by state or federal moratoriums.
"All the issues that people are struggling with in the pandemic are all the same issues that medical-legal partnerships have been trying to work with forever," said Vicki Girard, a law professor and co-director of the Georgetown University Health Justice Alliance in Washington, D.C.
In Montana, Kallie Dale-Ramos helped persuade a primary care association, the state's legal aid organization and six community health centers operating in cities across Montana to pool $20,000 to help hire an attorney, who can split time among the clinics to help patients affected by the pandemic.
Since the start of 2020, that investment has helped more than 130 patients seek unemployment claims — and potentially stave off financial ruin.
One woman had been waiting for unemployment assistance since applying in March 2020, and only recently received her first check, said Dale-Ramos. Without legal help along the way, the woman "would have just been like, 'I can't do this anymore,'" Dale-Ramos said.
This sort of legal-medical partnership is centered on the notion that doctors can do only so much to keep their patients healthy.
Proponents See Lasting Impact
Advocates for such programs cite the example of a child suffering from asthma caused by mold in a dilapidated apartment. While a doctor couldn't force a landlord to clean up the property or break the lease, a letter from a lawyer might be persuasive, said Dr. Tillman Farley, Salud's chief medical officer.
"Some of these impacts carry out for decades," Farley said. "And once you get into effects like that, then you're really talking generational changes in health outcomes."
Beyond common sense, evidence from emerging research suggests the approach can work. Patients at Veterans Affairs clinics in Connecticut and New York, for example, saw their mental health improve significantly within three months of consulting a clinic attorney, according to a 2017 study in Health Affairs.
And at Colorado's partnership, a survey of patients from 2015 to 2020 found statistically significant drops in stress and poor physical health, as well as fewer missed medical appointments among its 69 respondents, said Dr. Angela Sauaia, a professor at the Colorado School of Public Health who led the research.
The possible reasons for missing fewer doctor appointments after getting the legal help, Sauaia said, included patients having more income, being less depressed and having an improved immigration status that made them less fearful to venture into public.
Medical-legal partnerships should be considered part of healthcare, Sauaia believes. "You should be referring to them the same way a provider would be referring a patient to a specialty, such as endocrinology or surgery."
The biggest challenge for these programs is securing stable funding. Many are funded with a small amount of seed money, or by grants that run only a year or two.
Medicaid, established in 1965, is a nationwide healthcare program for people who have low incomes or are disabled. It's jointly funded by the federal government and each state, and traditionally has covered medical costs such as physician visits and hospital stays.
In recent years, though, some states have increasingly sought to use Medicaid dollars to fund initiatives such as using social workers or offering legal assistance to address the social determinants of health. That includes North Carolina, which is using a federal waiver and hundreds of millions of dollars in a highly scrutinized effort to transform its Medicaid program. Among its strategies is more legal aid for patients.
Some Critics See Overreach by Medicaid Plans
The nationwide shift has prompted some health policy experts to question whether Medicaid is beginning to run too far afield of its purpose.
"Everybody agrees that social factors play a very large role in health outcomes; the question is what to do about it," said James Capretta, a resident fellow of the American Enterprise Institute who was an associate director of the Office of Management and Budget during the George W. Bush administration.
"Medicaid is already an immense program with lots of financial challenges," Capretta noted. "The program was not built for Medicaid to pay for too many services beyond the more direct services that are related to a medical condition or a disability."
The small-scale use of waivers and supplemental Medicaid dollars to fund programs aimed at the social factors of poor health — such as housing for people with severe mental illness — works in some places, said Matt Salo, executive director of the National Association of Medicaid Directors. But for Medicaid to provide widespread funding for such social service programs would be unsustainable, and shouldn't happen, he said.
"It is not — and should not be — Medicaid's responsibility to figure out how to pay for it," he said.
Some advocates for legal assistance programs and health policy experts worry about a potential public backlash based on misperceptions about how the little-known medical-legal partnerships use Medicaid. For one, the programs generally aren't reimbursed for services in the same way traditional Medicaid programs are, said Sara Rosenbaum, a health law and policy professor at George Washington University. Medicaid is more of "an indirect funder," she said.
A 2019 Manatt Health Strategies report on funding for medical-legal partnerships said "the time is ripe" for these partnerships to explore the little-used avenues available in Medicaid.
The states that administer the Medicaid programs and the managed care organizations that contract with them have some discretion to fund non-clinical services that improve access or outcomes for social determinants of health, according to the report.
States also can write the medical-leaderships programs into a larger federal waiver application for experimental, pilot or demonstration projects that promote Medicaid's objectives.
"The dollars are minimal," said Ellen Lawton, former director of the National Center for Medical-Legal Partnership, and a senior fellow at HealthBegins, a consulting firm. "And I think what we're seeing is that — appropriately — the Medicaid programs are pacing themselves. They're looking to see what works — what works in our state, what works in our region, what works with the populations that we're focused on."
States have been creative in funding these sorts of legal assistance programs. Colorado officials said they amended their Medicaid spending plan to provide grants to two such partnerships. Other states have sought federal waivers allowing them to support those programs. The Department of Veterans Affairs also offers the services of medical-legal partnerships funded by outside organizations.
Scanlon, the attorney at the Salud clinic, is part of a nonprofit organization called Medical Legal Partnership Colorado that operates under a joint agreement with the clinic. Colorado's Medicaid program approved a $300,000 grant to the partnership that was renewed this year to pay for three attorneys' salaries.
Authorizing the funding took little convincing, said Michelle Miller, chief nursing officer for the state's Medicaid program. "When we were asked to approve funding for this, I jumped at it," Miller said.
One Woman's Story
For Cynthia Enriquez De Santiago, the 19-year-old patient from Salud's Commerce City clinic, legal advice made all the difference in her medical care.
In addition to her cerebral palsy, the teen is blind and has difficulty speaking; she needs round-the-clock care, including help eating and using the bathroom. Her doctor at the clinic put Rafaela De Santiago, Cynthia's mother, in touch with an attorney who could help her continue to be her daughter's legal guardian after the teen turned 18 last year.
The timing of that legal help proved critical: Several months after seeing the attorney, Enriquez De Santiago was rushed to a hospital. For no obvious reason, she had become hypothermic; her blood pressure dropped and her blood-oxygen levels cratered.
"The doctors were telling me I had to be ready for the worst," the teen's mother said through a Spanish-to-English interpreter.
Because she was Enriquez De Santiago's legal guardian, her mother was able to sign off on follow-up tests after that emergency to quickly get to the root of the medical problem and help prevent it from happening again.
Without guardianship, "it would have been really, really hard, because I wouldn't know where to begin the process," Rafaela De Santiago said.
The indictment alleges that SpineFrontier, Chin and Humad paid surgeons between $250 and $1,000 per hour in sham consulting fees for work they did not perform.
This article was published on Wednesday, September 8, 2021 in Kaiser Health News.
A Florida orthopedic surgeon and designer of costly spinal surgery implants was arrested Tuesday and charged with paying millions of dollars in kickbacks and bribes to surgeons who agreed to use his company's devices.
Dr. Kingsley R. Chin, 57, of Fort Lauderdale, Florida, is the founder, chief executive officer and owner of SpineFrontier, a device company based in Malden, Massachusetts. He and the company's chief financial officer, Aditya Humad, 36, of Cambridge, Massachusetts, were each indicted on one count of conspiring to violate federal anti-kickback laws, six counts of violating the kickback statute and one count of conspiracy to commit money laundering, officials said.
The indictment alleges that SpineFrontier, Chin and Humad paid surgeons between $250 and $1,000 per hour in sham consulting fees for work they did not perform. In exchange, the surgeons agreed to use SpineFrontier's products in operations paid for by federal healthcare programs such as Medicare and Medicaid. Surgeons accepted between $32,625 and $978,000 in improper payments, according to the indictment.
"Kickback arrangements pollute federal healthcare programs and take advantage of patient needs for financial gains," said Nathaniel Mendell, acting U.S. attorney for the District of Massachusetts.
"Medical device manufacturers must play by the rules, and we will keep pursuing those who fail to do so, regardless of how their corruption is disguised."
Chin and SpineFrontier were the subjects of a KHN investigation published in June that found that manufacturers of hardware for spinal implants, artificial knees and hip joints had paid more than $3.1 billion to orthopedic and neurosurgeons from August 2013 through 2019. These surgeons collected more than half a billion dollars in industry consulting fees, federal payment records show.
Chin, a self-styled "doctorpreneur," formed SpineFrontier about a decade after completing his training at Harvard Medical School.
Chin has patented dozens of pieces of spine surgery hardware, such as doughnut-shaped plastic cages, titanium screws and other products that generated some $100 million in sales for SpineFrontier, according to government officials. In 2018, SpineFrontier valued Chin's ownership of the company at $75 million, though its current worth is unclear. He maintains a medical practice in Hollywood, Florida. Neither Chin nor Humad could be reached for comment Tuesday.
Seth Orkand, a Boston attorney who represents Humad, said his client "denies all charges, and looks forward to his day in court."
The Department of Justice filed a civil lawsuit against Chin and SpineFrontier in March 2020, accusing the company of illegally funneling more than $8 million to nearly three dozen spine surgeons through the "sham" consulting fees. Chin and SpineFrontier have yet to file a response to that suit.
However, at least six surgeons have admitted wrongdoing in the civil case and paid a total of $3.3 million in penalties. Another, Dr. Jason Montone, 45, of Lawson, Missouri, pleaded guilty to criminal kickback charges and is set to be sentenced early next year. Federal law prohibits doctors from accepting anything of value from a device-maker for agreeing to use its products, though most offenders don't face criminal prosecution.
The grand jury indictment lists seven surgeons as having received bribes totaling $2,747,463 to serve as "sham consultants." One doctor, identified only as "surgeon 7," received $978,831, according to the indictment. Many of the illicit payments were made through a Fort Lauderdale company controlled by Chin and Humad, according to the indictment.
The SpineFrontier executives set up the separate company partly to evade requirements for device companies to report payments to surgeons to the government, according to the indictment. Some surgeons were told they could bill for more consulting hours if they used more expensive SpineFrontier products, officials said.
Conspiring to violate the kickback laws can bring a sentence of up to five years in prison, while violating the kickback laws can result in a sentence of up to 10 years, officials said.
"Kickbacks paid to surgeons as sham medical consultants, as alleged in this case, cheat patients and taxpayers alike," said Phillip Coyne, special agent in charge of the U.S. Department of Health and Human Services Office of Inspector General.
"Working with our law enforcement partners, we will continue to investigate kickback schemes that threaten the integrity of our federal healthcare system, no matter how those schemes are disguised."
OAKLAND, Calif. — Living unmedicated with schizophrenia and bipolar disorder, Eugenia Hunter has a hard time recalling how long she's been staying in the tent she calls home at the bustling intersection of San Pablo Avenue and Martin Luther King Jr. Way in Oakland's hip Uptown neighborhood. Craft coffee shops and weed dispensaries are plentiful here and one-bedroom apartments push $3,000 per month.
"At least the rats aren't all over me in here," the 59-year-old Oakland native said on a bright August afternoon, stretching her arm to grab the zipper to her front door. It was hot inside and the stench of wildfire smoke hung in the air. Still, after sleeping on a nearby bench for the better part of a year, she felt safer here, Hunter explained as she rolled a joint she'd use to ease the pain from also living with what she said is untreated pancreatic cancer.
Hunter has been hospitalized repeatedly, including once last summer after she overdosed on alcohol and lay unconscious on a sidewalk until someone stopped to help. But she is reluctant to see a doctor or use Medi-Cal, California's health insurance program for low-income and disabled people, largely because it would force her to leave her tent.
"My stuff keeps on getting taken when I'm not around and, besides, I'm waiting until I got a place to live to start taking my medication again," Hunter said, tearing up. "I can't get anything right out here."
Hunter's long and complex list of ailments, combined with her mistrust of the healthcare system, make her an incredibly difficult and expensive patient to treat. But she is exactly the kind of person California intends to prioritize under an ambitious experiment to move Medi-Cal beyond traditional doctor visits and hospital stays into the realm of social services. Under the program, vulnerable patients like Hunter will be assigned a personal care manager to coordinate their healthcare treatments and daily needs like paying bills and buying groceries. And they will receive services that aren't typically covered by health insurance plans, such as getting security deposits paid, receiving deliveries of fruits and vegetables, and having toxic mold removed from homes to reduce asthma flare-ups.
Over the next five years, California is plowing nearly $6 billion in state and federal money into the plan, which will target just a sliver of the 14 million low-income Californians enrolled in Medi-Cal: homeless people or those at risk of losing their homes; heavy users of hospital emergency rooms; children and seniors with complicated physical and mental health conditions; and people in — or at risk of landing in — expensive institutions like jails, nursing homes or mental health crisis centers.
Gov. Gavin Newsom is trumpeting the first-in-the-nation initiative as the centerpiece of his ambitious healthcare agenda — and vows it will help fix the mental health and addiction crisis on the streets and get people into housing, all while saving taxpayer money. His top healthcare advisers have even cast it as an antidote to California's worsening homelessness crisis.
But the first-term Democrat, who faces a Sept. 14 recall election, is making a risky bet. California does not have the evidence to prove this approach will work statewide, nor the workforce or infrastructure to make it happen on such a large scale.
Critics also fear the program will do nothing to improve care for the millions of other Medi-Cal enrollees who won't get help from this initiative. Medi-Cal has been slammed for failing to provide basic services, including vaccinations for kids, timely appointments for rural residents and adequate mental health treatment for Californians in crisis. Yet the managed-care insurance companies responsible for most enrollees' health will nonetheless be given massive new power as they implement this experiment. The insurers will decide which services to offer and which high-needs patients to target, likely creating disparities across regions and further contributing to an unequal system of care in California.
"This will leave a lot of people behind," said Linda Nguy, a policy advocate at the Western Center on Law & Poverty.
"We haven't seen health plans excel in even providing basic preventative services to healthy people," she said. "I mean, do your basic job first. How can they be expected to successfully take on these additional responsibilities for people with very high health needs?"
This revolution in Medi-Cal's scope and mission is taking place alongside a parallel initiative to hold insurance companies more accountable for providing quality healthcare. State health officials are forcing Medi-Cal managed-care plans to reapply and meet stricter standards if they want to continue doing business in the program. Together, these initiatives will fundamentally reinvent the biggest Medicaid program in the country, which serves about one-third of the state population at a cost of $124 billion this fiscal year.
If California's experiment succeeds, other states will likely follow, national Medicaid experts say. But if the richest state in the country can't pull off better health outcomes and cost savings, the movement to put health insurers into the business of social work will falter.
When Newsom signed the "California Advancing and Innovating Medi-Cal" initiative into law in late July — "CalAIM" for short — he celebrated it as a "once-in-a-generation opportunity to completely transform the Medicaid system in California." He declined an interview request.
Beginning next year, public and private managed healthcare plans will pick high-need Medi-Cal enrollees to receive nontraditional services from among 14 broad categories, including housing and food benefits, addiction care and home repairs.
The approach is known as "whole person care," and insurers will be required to assign patients a personal care manager to help them navigate the system. Insurers will receive incentive payments to offer new services and boost provider networks and, over time, the program will expand to more people and services. For instance, members of Native American tribes will eventually be eligible to receive treatment for substance misuse from natural healers, and inmates will be enrolled in Medi-Cal automatically upon release.
The insurers — currently 25 are participating — will focus most intensely on developing housing programs to combat the state's worsening homelessness epidemic. The state was home to at least 162,000 homeless people in 2020, a 6.8% increase since Newsom took office in 2019.
Jacey Cooper, the state's Medicaid director, said all Medi-Cal members will eventually be eligible for housing services. Initially, though, they will be available only to the costliest patients. State Medi-Cal expenditure data shows that 1% of Medi-Cal enrollees, many of the homeless patients who frequently land in hospitals, account for a staggering 21% of overall spending. And 5% account for 44% of the budget.
"You really need to focus on your top 1% to 5% of utilizers — that's your most vulnerable," Cooper said. "If you generally focus on that group, you will be able to yield better health outcomes for those individuals and, ultimately, cost savings."
State officials do not have a savings estimate for the program, nor a projection of how many people will be enrolled.
The plan, Cooper said, builds on more than 25 successful regional experiments underway since 2016. From Los Angeles to rural Shasta, big and small counties have provided vulnerable Medi-Cal patients with different services based on their communities' needs, from job placement services to providing a safe place for a homeless person to get sober.
Cooper highlighted interim data from the experiments that showed patients hospitalized due to mental illness were more likely to receive follow-up care, obtain treatment for substance abuse, avoid hospitalizations and emergency department visits, and see improvements in chronic diseases like diabetes.
She argued that data — even though it is not comprehensive — is enough to prove the initiative will work on a statewide scale.
However, studies of similar programs elsewhere have yielded mixed results. New York provided housing services to high-cost Medicaid enrollees with chronic diseases and mental health and substance use disorders and found major reductions in hospital admissions and emergency department visits between 2012 and 2017, and saw a 15% reduction in Medicaid spending.
In Camden, New Jersey, an early test of the "whole person care" approach provided expensive Medicaid patients with intensive care coordination, but not nontraditional services. A study concluded in 2020 that it hadn't lowered hospital readmissions — and thus didn't save healthcare dollars.
"We found we just couldn't help people with housing as quickly as they needed help," said Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers. "Many of these clients have bad credit, they may have a record, and they're still using. Those are huge challenges."
California may find success where the coalition hadn't because it will offer social services, she said, which the coalition has also started doing.
But it will take time. California will have five years to prove to the federal government it can save money and improve healthcare quality. Insurers will be required to track health outcomes and savings, and can boost services over time or drop programs that don't work.
So far, the regional experiments have failed to serve low-income Black and Latino residents, according to the interim assessments conducted by Nadereh Pourat, director of the UCLA Center for Health Policy Research. She concluded that they have primarily benefited white, English-speaking, middle-aged men.
Consider Eugenia Hunter, who is African American, and whose many untreated mental and physical illnesses, intertwined with her addictions, mean it will take a herculean effort — and cost — to get her off the street.
Hunter has been homeless for at least three years. Or maybe it's five; her mental illness clouds her memory, and she erupts in anger when pressed for details. She eases her frustration sometimes with sleep, sometimes by smoking crystal meth.
A stack of unopened health insurance letters sat beside Hunter one evening in late August. Her eyes were glassy when she struggled to remember when she received a cancer diagnosis — if she ever did at all.
Health insurers will not be required to offer social services to patients like Hunter because federal law requires nontraditional Medicaid services to be optional. But California is enticing insurers with bigger payouts and higher state rankings.
"We are asking the plans and providers to stretch. We're asking them to reform," Cooper said.
The state is urging insurers to start with the roughly 130,500 Medi-Cal patients already enrolled in the local experiments. To prepare, they are cobbling together networks of nonprofits and social service organizations to provide food, housing and other services — much as they do with doctors and hospitals contracted to deliver medical care.
Services will vary by insurer and region. The Inland Empire Health Plan, for example, will offer some patients home repairs that reduce asthma triggers, such as mold removal and installing air filters. But Partnership HealthPlan of California will not offer those benefits in its wildfire-prone Northern California region because it doesn't have an adequate network of organizations equipped to provide those services.
In interviews with nearly all of California's Medi-Cal managed-care plans, executives said they support the dual goals of helping patients get healthier while saving money, but "it is a lot to take on," said Richard Sanchez, CEO of CalOptima, which serves Orange County and will start modestly, primarily with housing services. "The last thing I want to do is make promises that we can do all these things and not come through."
Nearly all the health plans will offer housing services right away, focusing on three categories of aid: helping enrollees secure housing and rent subsidies; providing temporary rent and security deposit payments; and helping tenants stay housed, like intervening with a landlord if a patient misses rent.
Partnership HealthPlan, which serves 616,000 Medi-Cal patients in 14 Northern California counties, will prioritize its most at-risk enrollees with housing services, food deliveries and a "homemaker" benefit to help them cook dinner, do laundry and pay bills.
"It's a great deal of money for a small number of members and, frankly, there's no guarantee it's going to work," said Dr. Robert Moore, the plan's chief medical officer. "We are building something extraordinarily ambitious quickly, without the infrastructure in place to make it successful."
Even if offering new services costs more money than it saves, it's a worthwhile investment, said John Baackes, CEO of L.A. Care Health Plan, the largest Medi-Cal plan, which serves more than 2 million patients in Los Angeles County.
"When somebody has congestive heart failure, their diet should be structured around alleviating that chronic condition," he said, explaining his plan to offer patients healthful food. "What are we going to do — let them eat ramen noodles for the rest of their lives?"
In Alameda County, two plans are available to serve Hunter. The Alameda Alliance for Health, a public insurer established by the county, and Anthem Blue Cross, a private insurance company, will expand housing services.
"People like Eugenia Hunter are exactly who we want to serve, and we're prepared to go out and help her," said Scott Coffin, CEO of the Alameda Alliance, who is also on a local street medicine team.
But they'd have to find her first — chaos and homeless encampment sweeps force her to move her tent frequently. And then they'd have to win her trust.
In one moment, Hunter angrily described how health plans have tried to enroll her in services, but she declined, mistrustful of their motives. In the next moment, fighting back voices in her head, she said she desperately wants care.
"Someone is going to help me?" she asked. "All I want to do is pay my rent and succeed."