Gov. Gavin Newsom in September vetoed legislation championed by the California Hospital Association that would have allowed all hospitals to apply for an extension of the deadline for up to five years. Instead, the Democratic governor signed a more narrowly tailored bill that allows small, rural, or “distressed” hospitals to get an extension of up to three years.

“It’s an expensive thing and a complicated thing for hospitals — independent hospitals in particular,” said Elizabeth Mahler, an associate chief medical officer for Alameda Health System, which serves Northern California’s East Bay and is undertaking a $25 million retrofit of its hospital in Alameda, on an island beside Oakland.

The debate over how seismically safe California hospitals should be dates to the 1971 Sylmar quake near Los Angeles, which prompted a law requiring new hospitals to be built to withstand an earthquake and continue operating. In 1994, after the magnitude 6.7 Northridge quake killed at least 57 people, lawmakers required existing facilities to be upgraded.

The two laws have left California hospitals with two sets of standards to meet. The first — which originally had a deadline of 2008 but was pushed to 2020 — required hospital buildings to stay standing after an earthquake. About 20 facilities have yet to meet that requirement for at least one of their buildings, although some have received extensions from the state.

Many more — 674 buildings, spread across 251 licensed hospitals — do not meet the second set of standards, which require hospital facilities to remain functional in the event of a major earthquake. That work is supposed to be done by 2030.

“The importance of it is hard to argue with,” said Jonathan Stewart, a professor at UCLA’s Samueli School of Engineering, citing a 2023 earthquake in Turkey that damaged or destroyed multiple hospitals. “There were a number of hospitals that were intact but not usable. That’s better than a collapsed structure. But still not what you need at a time of emergency like that.”

The influential hospital industry has unsuccessfully lobbied lawmakers for years to extend the 2030 deadline, though the state has granted various extensions to specific facilities. Newsom’s signature on one of the three bills addressing the issue this year represents a partial victory for the industry.

Hospital administrators have long complained about the steep cost of seismic retrofits.

“While hospitals are working to meet these requirements, many will simply not make the 2030 deadline and be forced by state law to close,” wrote Carmela Coyle, president and CEO of the California Hospital Association, in a letter to Newsom before he vetoed the CHA bill. A 2019 Rand Corp. study paid for by the CHA pinned the price of meeting the 2030 standards at between $34 billion and $143 billion statewide.

Labor unions representing nurses and other medical workers, however, say the hospitals have had plenty of time to get their buildings into compliance, and that most have the money to do so.

“They’ve had 30 years to do this,” Cathy Kennedy, a nurse in Roseville and one of the presidents of the California Nurses Association, said in an interview prior to the governor’s action. “We are kicking the can down the road year after year, and unfortunately, lives are going to be lost.”

In his veto message on the CHA bill, Newsom wrote that a blanket five-year extension wasn’t justified, and that any extension “should be limited in scope, granted only on a case-by-case basis to hospitals with demonstrated need and a clear path to compliance, and in combination with strong accountability and enforcement mechanisms.”

He also vetoed a bill directed specifically at helping several hospitals operated by Providence, a Catholic hospital chain.

But he signed a third bill, which allows small, rural, and “critical access” hospitals, and some others, to apply for a three-year extension, and directs the Department of Health Care Access and Information to offer them “technical assistance” in meeting the deadline.

The state designates 37 hospitals as providing “critical access,” while 56 are considered “small,” meaning they have fewer than 50 beds, 59 are considered “rural,” and 32 are “district” hospitals, meaning they are funded by special government entities called “health care districts.” They can seek a three-year extension as long as they submit a seismic compliance plan and identify milestones for implementing it.

Debi Stebbins, executive director of the Alameda Health Care District, which owns the Alameda Hospital buildings, said small hospitals face a big challenge. Even though Alameda is very close to San Francisco and Oakland, the tunnels, bridges, and ferries that connect it to the mainland could easily be shut in an emergency, making the island’s hospital a lifeline.

“It’s an unfunded mandate,” Stebbins said of the state’s 2030 deadline.

The Rand study estimated the average cost of a retrofit at more than $92 million per building, but the amount could vary greatly depending on whether it’s a building that houses hospital beds.

Small and rural hospitals can get some aid from the state via grants financed by the California Electronic Cigarette Excise Tax, but HCAI spokesperson Andrew DiLuccia said it would yield just $2-3 million total annually. He added that the Small and Rural Hospital Relief Program has also received a one-time infusion of $50 million from a tax on health insurers to help with the seismic work.

Labor unions and critics of the extensions often point to the large profits that some hospitals reap: A California Health Care Foundation report published in August found that California’s hospitals made $3.2 billion in profit during the first quarter of 2024. The study notes that there “continues to be wide variation in financial performance among hospitals, with the bottom quartile showing a net income margin of -5%, compared to +13% for the top quartile.”

Stebbins has had to help her district figure out a plan.

After Newsom vetoed a bill in 2022 that would have granted an extension on the seismic retrofit deadline specifically for Alameda Hospital, the hospital system and its partner health care district used parcel tax money to help back a loan.

The cost to retrofit will be about $25 million, and the system is also investing millions more into other projects, such as a new skilled nursing facility. The construction work is set to be completed in 2027.

“No one wants things crashing in an earthquake or anything else, but at the same time, it’s a burden,” Mahler, the Alameda Health System associate chief medical officer, said. “How do we make sure that they get what they need to stay open?”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

UC Health accused Anthem of not negotiating in good faith, while Anthem leaders retorted that UC Health had demanded too much and rebuffed the insurer’s request for administrative efficiencies. In fact, roughly 8 million Anthem members in California were at risk of losing in-network access to UC Health’s vast network of prestigious hospitals and medical facilities, which could have left them with much higher out-of-pocket expenses. While not all patients were made aware of the situation, Anthem notified some enrollees they would be reassigned to new primary care doctors if no deal were reached.

But even as the parties announced an eleventh-hour agreement on Feb. 5, industry analysts say the conflict has become part of a trend in which patients are increasingly caught in the crossfire of contract disputes. Amid negotiations over rising labor and equipment costs, it’s often patients who are ultimately saddled with higher bills as the health industry continues to consolidate.

“This type of contract dispute is a routine feature of the health care system,” said Kristof Stremikis, director of market analysis and insight at the California Health Care Foundation. “At the same time, from a patient’s perspective, it’s an unfortunate feature of our health care system because it creates uncertainty and anxiety.” (California Healthline is an editorially independent service of the California Health Care Foundation.)

Stremikis noted that as mergers occur in the health industry, patients are left with fewer choices. Any time there are disputes, disruptions are felt more widely. And such fights rarely result in lower costs for consumers long-term across California.

A KFF analysis found widespread evidence that consolidation of health providers leads to higher health care prices for private insurance. The same brief from 2020 found some evidence suggesting that large, consolidated insurance companies are able to obtain lower prices from providers, but that has not necessarily led to lower premiums for patients. And a 2022 report from the California Department of Health Care Access and Information found that health care costs have grown “at an unsustainable rate,” and noted that between 2010 and 2018 “health insurance premiums for job-based coverage increased more than twice the rate of growth for wages.” State regulators also found that health plans spent nearly $1.3 billion more on prescription drugs in 2022 than in 2021.

In trying to slow growth, California in 2022 set up an Office of Health Care Affordability, which has proposed a 3% spending growth target for the industry for 2025-2029. But enforcement will start in 2028 at the earliest, using spending data from 2026.

Cathy Jordan, 60, a social worker in Yuba City, California, has been a patient at UC Davis Health for two decades. Jordan was diagnosed at the end of 2021 with aggressive small cell carcinoma, a rare form of cancer. She has undergone surgery, chemotherapy, radiation, and other treatments since then, yet her cancer has returned twice.

“I don’t have the luxury of time — my cancer comes back fast,” Jordan said.

She is among the group of Anthem-insured patients at UC Health who were at risk of losing access to in-network care there, and when she got a notice from Anthem, she grew alarmed, she said.

Jordan’s oncologist, Rebecca Brooks, said in an interview prior to the agreement being reached that it would be “incredibly disruptive” for cancer patients to have to switch providers in the middle of their treatments.

“It’s a detriment to their care,” said Brooks, director of the gynecologic oncology division at UC Davis Health. “It’s going to disrupt treatment and cause worse outcomes.”

Jordan said she appreciates that UC Davis Health has a National Cancer Institute comprehensive cancer center designation; the only other cancer center of that caliber in Northern California not part of UC Health is at Stanford University, several hours away in Santa Clara County.

Jordan was worried that she and other UC Health patients would have to compete for treatment elsewhere. She was also uncomfortable with the idea of adjusting to a new setting and routine while undergoing intensive medical treatment.

“Someone needs to say, ‘We need to think about these patients.’ Someone needs to step up and say, ‘What’s going to be best for our patients?’” Jordan said. “This is my life.”

Stremikis said such concerns are ever more urgent as the health care industry consolidates. UC San Francisco recently announced it would acquire two struggling hospitals in San Francisco, and it is joining Adventist Health in making a new effort to purchase a bankrupt community hospital in Madera. And UC Irvine recently agreed to buy four hospitals in Southern California.

“There is consolidation vertically up and down the supply chain and horizontally,” he explained. “So when there are disputes between these large entities, it has a larger and larger impact because there are fewer choices for patients.”

While contract disputes between health care providers and insurers are nothing new, there is some evidence that they are increasing, at least in public view. FTI Consulting published data last year that found a steady increase in media coverage of rate negotiations between providers and insurers from 2022 to 2023. In addition to the fight with Anthem, UC Health narrowly avoided a break with Aetna last year by reaching an agreement in April. And regional hospital systems, including Sonoma Valley Hospital and Salinas Valley Health, have been at odds with Anthem within the last few months.

UC and Anthem have now agreed to extend the current contract to April 1 while terms of the new agreement are being finalized. UC Health spokesperson Heather Harper said the rate increases were below the inflation rate.

Anthem spokesperson Michael Bowman said the new contract would allow Anthem members to access care at UC Health for years to come.

“This underscores our mutual commitment to providing Anthem’s consumers and employers with access to high quality, affordable care at UC Health,” Bowman said in an email.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Asserting that the Food and Drug Administration has not moved quickly enough on dangerous food additives, state lawmakers last month passed the California Food Safety Act, which bans four ingredients found in popular snacks and packaged foods — including candy corn and other Halloween treats.

Consumer health advocates hope the ban, signed into law by Democratic Gov. Gavin Newsom on Oct. 7 and set to take effect in 2027, will lead confectioners and food producers to modify their recipes for products sold both in California and elsewhere around the country.

The law prohibits the manufacture and distribution of brominated vegetable oil, potassium bromate, propylparaben, and red dye No. 3, which are used in processed foods including variations of instant potatoes and store-brand sodas, as well as candies. The additives have been linked to increased risks of cancer and nervous system problems, according to the Environmental Working Group, which sponsored the legislation, and are already banned in many other countries.

Melanie Benesh, vice president of government affairs for the Environmental Working Group, celebrated the new law as “a very big deal” and the first of its type in the country.

Food manufacturers and their lobbyists opposed the legislation, rejecting the idea that the four additives are unhealthy and arguing that such assessments should be made by the FDA.

“We should rely on the scientific rigor of the FDA in terms of evaluating the safety of food ingredients and additives,” said Christopher Gindlesperger, a spokesperson for the National Confectioners Association.

But food safety advocates say the FDA has moved far too slowly in regulating food chemicals.

“It’s unacceptable that the U.S. is so far behind the rest of the world when it comes to food safety,” said state Assembly member Jesse Gabriel (D-Woodland Hills), who introduced the bill along with Assembly member Buffy Wicks (D-Oakland), in a statement.

A letter sent to lawmakers from the sponsors of AB 418 this year noted that many new additives put in food products are not reviewed by the FDA before reaching the market. A provision in federal law called “generally recognized as safe” allows the industry to designate the chemicals as safe enough to include in food, even without notifying the agency.

FDA spokesperson Enrico Dinges, referencing the Federal Food, Drug, and Cosmetic Act, noted in an email that “food and color additives must be approved for their intended conditions of use, and safety information must be available to establish a reasonable certainty of no harm before they are used in products on the market.”

He added that the agency regularly reviews new data on food chemicals, and it is working on a proposed rule to ban the use of brominated vegetable oil — one of the ingredients included in the new California law — as a food ingredient. Dinges said it was “not uncommon for a substance to be approved in one jurisdiction but not in another.” He noted some color additives are authorized for use in Europe and elsewhere but not allowed in the U.S.

California’s initiative made headlines this year as a “Skittles ban” that would wipe popular candies off California shelves. But Gabriel and other proponents of the bill said the intention is simply to require modifications in the ingredients, as has already happened in Europe.

One additive included in an original version of the bill — titanium dioxide, which is in Skittles and other candy — was removed from those products before the bill reached its final version. It has been labeled a carcinogen by the International Agency for Research on Cancer.

“I admire the California legislature for doing this,” said Joan Ifland, a researcher who studies food addiction and a fellow at the American College of Nutrition. She hopes state lawmakers go further in addressing food safety issues and the chemicals in processed food. “It should give courage to other legislators.”

Perhaps the most prominent ingredient on California’s banned list is red dye No. 3. It is allowed only in candied and cocktail cherries in the European Union but is widely used in the U.S.

A search of Food Scores, an online database maintained by the Environmental Working Group, generated more than 3,000 products that contain the chemical. The list includes items like frosted pretzels and scores of brand-name candies such as Peeps and Pez. It also includes items like fruit cocktail cups, protein drinks, and yogurts.

Peeps is already phasing out the ingredient — products will no longer contain red dye No. 3 after the 2024 Easter season, according to Keith Domalewski, director of marketing for its parent company, Just Born Quality Confections.

“Just Born has always evolved with new developments and consumer preferences,” Domalewski said in an emailed statement. “We have worked hard to develop new formulations to bring fans the colorful PEEPS they know and love.”

Pez representatives did not respond to a request for comment. The two major manufacturers of candy corn also did not comment.

The FDA banned some uses of the color additive in 1990, confirming it had been linked to increased risks of cancer, and prohibited its use in cosmetics and as a pigment in various foods. It said at the time it was taking steps to restrict the chemical — but never did.

Another of the newly banned ingredients, potassium bromate, has also been linked to cancer and is on California’s Proposition 65 list of ingredients that may pose increased cancer risks. It also has not been banned.

Food manufacturers and distribution groups did not indicate whether they would challenge California’s new law.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

A bill before the legislature would significantly increase the fees doctors pay to fund the medical board, which says it hasn’t had the budget to carry out its mission properly. It would also mandate new procedures for investigating complaints.

Patient advocates say the board, which oversees about 150,000 physicians and surgeons with active licenses in the state, is hamstrung by a lack of funding and clunky processes, and that its shortcomings pose a risk to the public by allowing bad doctors to continue practicing. The board opened only about 1,000 investigations out of nearly 10,000 complaints last year, according to its 2022 annual report.

But the California Medical Association, which represents physicians, is again fighting proposed increases in the fee, which was unchanged for more than a decade before being raised in 2021 after a contentious debate. Now lawmakers want to boost the license renewal fee to $1,289 every two years, up from $863 currently.

The doctors’ lobby largely defeated the 2021 efforts to strengthen the board, and critics say the group is trying to whittle away the board’s power by depriving it of funding.

The legislation, sponsored by Sen. Richard Roth, a Riverside Democrat, would also require board staff to interview patients or families before closing their complaints, create a unit to better facilitate communications, and improve efficiency by changing procedures and adjusting standards of evidence for investigations.

Another provision would allow patients and relatives to make a statement during the investigation about how a doctor’s negligence or misconduct affected them — similar to crime victims speaking during a sentencing hearing in criminal court.

The bill faces a pivotal vote in the state Assembly’s Appropriations Committee this month.

Most California licensing boards are funded through license fees. Currently, dentists pay $668 for a two-year license renewal, plus other permitting fees such as $325 for general anesthesia or $650 for oral surgery. Attorneys actively practicing in California pay $510 annually.

But the medical association insisted in a memo that it “cannot agree to a fee increase of nearly 50% that will primarily go toward building a multimillion-dollar reserve fund and future programs for the Medical Board.”

“If the bill is passed in its current form, it would have vast, negative impacts on the practice of medicine and health care delivery in California,” it added.

George Soares, a legislative advocate for the California Medical Association, told lawmakers last month that the association would be willing to accept a fee increase, but that $1,289 is too much — more than double the national average for state medical licenses. A July working paper from the National Bureau of Economic Research found that physicians’ annual earnings average $350,000 across the U.S.

The medical board supports the bill and says a fee hike is needed to cover operations, repay millions of dollars in loans, and establish a three-month reserve. Over the past two years, the Department of Consumer Affairs, which is responsible for the operations of the medical board and other licensing boards, has had to backfill the board’s $79 million budget, using a total of $18 million in loans from Bureau of Automotive Repair license fees to cover the gap.

“The simple reality is that the board is not able to pay its bills,” a spokesperson for the medical board read from a joint statement from Randy Hawkins, the vice president of the board, and Richard Thorp, a former president of the California Medical Association and current member of the board, at a committee hearing last month.

“We are physicians in private practice, and this fee increase will impact us personally, albeit at an increased cost of less than $20 per month,” the statement read. “We do not see this as a burden but rather as an investment into the organization that helps ensure that physicians have the confidence of the patients that we are privileged to treat.”

Roth points out that the medical board, which is composed of eight physicians and seven members of the public, has little control over staffing costs. Its 169 employees work for the state and are covered by labor agreements negotiated by statewide employee unions.

Consumer advocates say the opposition from the doctors’ lobby is part of a years-long effort to weaken the board and deprive it of adequate funding.

A report about the medical board’s operations conducted by a consulting firm that serves as the enforcement monitor for the board, Alexan RPM Inc., underscored the board’s financial challenges and recommended adopting automatic annual fee increases tied to the consumer price index, or something similar. Some lawmakers suggested the fees could be determined on a sliding scale based on doctors’ income.

Critics have complained for years that the medical board doesn’t hold doctors accountable often enough. Families that file complaints against doctors frequently go years without updates on the status of investigations, and often aren’t told why when their complaints are rejected.

“This is kind of the culmination of two things: patient advocacy trying to make changes and a few years of very recent, direct pushes by the legislature,” said Carmen Balber, the executive director of Consumer Watchdog, a consumer and patient advocacy organization.

The California Medical Association has already blunted some aspects of the bill, including securing the removal of a provision to add two more members of the public to the board, which would have made it a public-member majority instead of its current physician majority.

The association is also opposed to a provision currently in the bill that would lower the standard of proof for disciplining doctors in instances besides those in which they could lose their licenses.

Tracy Dominguez, a Bakersfield resident whose daughter, Demi, and grandson, Malakhi, died in 2019 from complications of severe preeclampsia, is among those advocating for reforms.

One of the physicians who treated Dominguez’s daughter prior to her death had already been accused by the medical board of gross negligence that led to the death of a young mother, according to medical board documents. Advocates at Consumer Watchdog allege his negligence had already caused death or permanent injury of other mothers and babies he treated, and that he was already banned from practicing in some hospitals at the time he treated Demi Dominguez but had been allowed to keep his license.

Tracy Dominguez said she hopes changing evidentiary standards and strengthening the medical board overall “will put dangerous doctors away.”

And a chance to provide a victim impact statement would be important for families hurt by medical neglect, she added. It would be “an opportunity for them to hear from the family, directly — to know that she was a person, not just a number.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

A paramedic for about 30 years, Susan Farren knew all was not well with first responders: Eight of her colleagues had died by suicide. Others had grappled with substance abuse or gone through painful divorces.

So, in 2018, Farren founded a nonprofit in Santa Rosa to train and support emergency personnel struggling with trauma and stress. Hundreds of firefighters, police officers, and other first responders have since availed themselves of the organization’s timely help.

“Nobody prepares you to walk into a house where four people have been murdered,” said Farren, executive director of First Responders Resiliency, Inc.

Firefighters, paramedics, and police often respond to the worst days of people’s lives — accidents, deaths, fires, and other distressing events. After the deadly mass shootings earlier this year in Monterey Park and Half Moon Bay, and countless others across the country, awareness of how such trauma affects first responders has grown.

But there is no national consensus on when and which emergency personnel should be provided workers’ compensation benefits.

“We wouldn’t think twice about taking care of a first responder who broke their leg, and we shouldn’t think twice about taking care of their mental health needs,” Karen Larsen, CEO of the Steinberg Institute, a nonprofit public policy institute, said in an email.

This year, there has been a push in California by first responders for laws that expand access to workers’ compensation for post-traumatic stress injuries among their ranks. But some business groups and local governments want to pump the breaks, citing worries about potential fraud or abuse of the workers’ compensation system.

The allegation that some people could take advantage of a more open workers’ compensation system should not deter California from providing immediate access to mental health treatment to those who need it, said Farren, who noted that many of the first responders she works with are denied workers’ compensation coverage or have to go through many steps to get it approved.

“That shouldn’t keep us from getting help to those who really need it. That help should be available often, and affordably, and it should be available immediately,” Farren said.

Perceptions about employers’ responsibility for alleviating work-related mental stress have changed over time, and that’s showing up in workers’ compensation. Each state has its own workers’ compensation laws, which provide benefits like disability pay and medical care to workers injured or sickened on the job.

More than half have enacted PTSD policies or policy changes since 2018, according to a 2021 report by Optum, a company that creates workers’ compensation programs. Coverage varies widely for post-traumatic stress injuries, which can be triggered by a single traumatic event or continued exposure to high stress and traumatic events.

In 2019, Gov. Gavin Newsom signed legislation into law to give California firefighters and police officers a stronger chance at earning workers’ compensation. The bill, SB 542, authored by state Sen. Henry Stern (D-Calabasas) changed state law so that post-traumatic stress “injury,” such as PTSD, is legally presumed to be work-related for those first responders.

It was a small step by lawmakers in a state where recognition of work-related injuries for workers’ compensation has typically been limited to physical illnesses such as heart disease and cancer. Previously, psychiatric conditions were handled differently, with employers and insurance companies long contending that psychological injuries can have many sources and might be too easy to blame on work.

Researchers at the Rand Corp. suggested in a 2021 report that further study is needed to evaluate the financial toll the 2019 law has had on employers — particularly counties and other municipalities that pay for police, firefighters, and other publicly employed first responders. Rand researchers estimated the added costs for local governments and the state to cover post-traumatic stress injuries could rise from $20 million to $116 million annually.

Firefighters and police in most cases now no longer have to prove that work was mostly responsible for their PTSD. But the law sunsets in 2025 and excludes many other first responders, including dispatchers, paramedics, and first responders at state hospitals.

This year, legislation by state Sen. John Laird (D-Santa Cruz), SB 623, co-sponsored by an advocacy group representing firefighters in the state — California Professional Firefighters — would extend PTSD workers’ compensation coverage until 2032 and open it up to state firefighters, additional law enforcement officers, public safety dispatchers, and other emergency response communication employees who work for public agencies. The Senate Labor, Public Employment and Retirement Committee unanimously approved the bill in April, and it is awaiting a vote by the Senate Appropriations Committee.

Business groups and local governments — many of which opposed the 2019 law — are lobbying against more expansion. In letters to lawmakers, groups including the California Chamber of Commerce, California Coalition on Workers’ Compensation, California Hospital Association, and California State Association of Counties warned that pending legislation could “open the door to abuse and fraud.”

“There is no evidence that workers are being inappropriately denied the care or benefits that they need,” Virginia Drake, a spokesperson for the California Coalition on Workers’ Compensation, told KFF Health News. The group represents employers, cities and counties, insurance brokers, and government agencies on issues of workers’ compensation.

Legislation that would extend benefits to more first responders would “put taxpayer funds at risk by tying the hands of public employers and forcing them to pay even the most questionable claims,” she added in a statement.

In addition, there does not seem to be consensus on which emergency personnel should get covered.

A measure by Assemblymember Freddie Rodriguez, a Democrat from Chino who worked as an emergency medical technician for three decades, has stalled. AB 597 would expand workers’ compensation coverage to paramedics and emergency medical technicians, but it didn’t get a hearing in the Assembly. Unions representing paramedics and EMTs in California did not return messages seeking comment.

“It’s a very stressful job,” said Rodriguez, who told KFF Health News that two of his paramedic friends had died by suicide. “It affects people differently.”

Clearing a path to speedy mental health recovery, particularly after traumatic incidents, “should be automatic,” he added.

It’s unclear if Newsom will back Laird’s bill extending coverage for groups of emergency responders, amid a projected $22.5 billion deficit. A spokesperson for his office, Omar Rodriguez, said the governor typically does not comment on pending legislation and “will evaluate the bills on their own merits if they reach his desk.”

Last year, the Democratic governor vetoed similar legislation, saying in a statement that it would be premature to shift coverage of PTSD before any studies had been conducted on how the current law has worked for those who are covered.

Broadening coverage, Newsom wrote, “could set a dangerous precedent that has the potential to destabilize the workers’ compensation system going forward.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Un hombre de 72 años de Los Angeles, consciente de que es negro, intenta que quienes lo atienden se sientan cómodos con él. “Es probable que mis acciones se juzguen y se apliquen a toda la raza, sobre todo si son negativas”, afirmó. “Y más si se perciben como agresivas”.

Muchos californianos negros afirman haber adaptado su aspecto o comportamiento —hasta el punto de minimizar las preguntas—, para reducir las posibilidades de discriminación y prejuicios en hospitales, clínicas y consultas médicas.

Entre las estrategias que dicen haber adoptado, el 32% presta especial atención a su forma de vestir; el 35% modifica su forma de hablar o su comportamiento para que los médicos se sientan cómodos. Y el 41% les dicen a sus médicos que son personas educadas, informadas y preparadas.

Estos comportamientos se recogen en una encuesta con 3,325 participantes como parte de un estudio de octubre titulado “Escuchando a los californianos negros: cómo el sistema sanitario socava su búsqueda de una buena salud”, financiado por la California Health Care Foundation. Parte de su objetivo fue llamar la atención sobre el esfuerzo que deben realizar los pacientes negros para obtener una atención médica de calidad.

“Si nos fijamos en la frecuencia con la que los californianos negros alteran su forma de hablar y de vestir para acudir a una visita médica, es una señal de que algo tiene que cambiar”, dijo Shakari Byerly, cuya empresa de investigación, Evitarus, dirigió el estudio.

Un tercio de los pacientes negros afirma que va a las consultas con un acompañante para que observe y abogue por ellos. Y, según el estudio, más de una cuarta parte evita la atención médica simplemente porque creen que no se les tratará bien.

“El sistema nos mira de forma diferente, no sólo en las consultas médicas”, señaló el doctor Michael LeNoir, que no participó en el estudio.

LeNoir, alergista y pediatra de Oakland que fundó, hace casi dos décadas, el African American Wellness Project para combatir las disparidades en salud, no encontró sorprendentes las respuestas, dado que muchos negros han aprendido a hacer esos ajustes de forma rutinaria. “Existe una discriminación generalizada”, dijo, “así que todos aprendemos nuestro papel”.

Existen abundantes pruebas de la desigualdad racial en la atención médica.

Un análisis del Urban Institute publicado en 2021, reveló que los pacientes negros tienen muchas más probabilidades de sufrir problemas relacionados con procedimientos quirúrgicos que los pacientes blancos no hispanos en el mismo hospital.

Un estudio publicado en noviembre por la Oficina Nacional de Investigación Económica descubrió que las madres y los bebés negros tenían peores resultados de salud que otros grupos en diferentes niveles de la atención de salud. Y otro trabajo publicado en enero, dirigido por investigadores del Instituto Oncológico Dana-Farber, evidenció que los pacientes afroamericanos e hispanos mayores con cáncer avanzado tienen menos probabilidades de recibir opioides para el dolor que los pacientes blancos no hispanos.

Gigi Crowder, directora ejecutiva de la National Alliance on Mental Illness, en el condado de Contra Costa, dijo que con frecuencia ve retrasos en los diagnósticos de salud mental en pacientes negros.

“Escucho historias sobre cuánto tarda la gente en recibir sus diagnósticos”, contó Crowder. “Muchos no reciben sus diagnósticos hasta seis o siete años después del inicio de su enfermedad”.

Casi un tercio de los encuestados en el estudio de la California Health Care Foundation —que analizó sólo a californianos negros, no a otros grupos étnicos o raciales— declararon haber sido tratados mal por un proveedor de salud debido a su raza o etnia. Una participante dijo que su médico le aconsejó simplemente que hiciera más ejercicio y adelgazara cuando ella le explicó que le faltaba el aire. Finalmente descubrió que tenía anemia y necesitó dos transfusiones de sangre.

“Siento que las voces negras no se escuchan. No se las toma tan en serio”, expresó la mujer a los investigadores. “En este caso, no se me escuchó, y acabó siendo un problema muy grave, de hecho potencialmente mortal”.

Personas con las que KHN habló, que no participaron de la encuesta, describieron experiencias similares.

Shaleta Smith, de 44 años y residente en el sur de California, acudió a una emergencia sangrando, una semana después de dar a luz a su tercera hija. Un médico quiso darle el alta, pero una enfermera llamó al obstetra de Smith para pedirle una segunda opinión. Resultó ser un problema grave que requerió una histerectomía.

“Casi me muero”, dijo Smith.

Años más tarde, en una experiencia no relacionada, su médico de cabecera insistió en que su persistente pérdida de voz y su fiebre recurrente eran síntomas de laringitis. Tras suplicar que la derivaran a un especialista, éste le diagnosticó un trastorno autoinmune.

Smith dijo que no tiene claro si el prejuicio fue un factor en esas interacciones con los médicos, pero siempre tiene que esforzarse para que se tomen en serio sus problemas de salud. Cuando visita a sus médicos, Smith les dice que trabaja en el campo de la medicina y la administración.

Los pacientes negros tienen que preocuparse por buscar médicos que los atiendan mejor.

Ovester Armstrong Jr. vive en Tracy, en el Valle Central, pero está dispuesto a conducir una hora hasta la zona de la Bahía para buscar proveedores que estén más acostumbrados a tratar a pacientes negros y de otras minorías.

“He tratado con médicos que no tienen experiencia en la atención a diferentes culturas, que no son conscientes de las diferencias culturales o incluso de nuestra vida social, del hecho de que nuestros menús son diferentes”, afirmó Armstrong.

Pero es posible que Amstrong no encuentre al médico que busca. Un estudio de la UCLA de 2021 reveló que la proporción de médicos estadounidenses negros es del 5,4%, lo que supone un aumento de sólo 4 puntos porcentuales en los últimos 120 años.

El proyecto de bienestar de LeNoir proporciona información a los pacientes para que puedan hacer preguntas informadas a sus médicos. Y el California Black Women’s Health Project está contratando “embajadoras” de salud para ayudar a las pacientes negras a navegar el sistema, según Raena Granberry, directora de salud materna y reproductiva de la organización.

Joyce Clarke, de 70 años, quien vive en el sur de California, lleva preguntas escritas cuando va al médico. “Los profesionales de la salud son ante todo personas, por lo que vienen con sus propios prejuicios, ya sean intencionados o no, y eso hace que una persona negra se mantenga en guardia”, afirmó Clarke.

Aunque el estudio arroja luz sobre la forma en que los pacientes negros interactúan con los profesionales médicos, Katherine Haynes, responsable de programas de la California Health Care Foundation, dijo que nuevas investigaciones podrían determinar si las experiencias de los pacientes mejoran.

“Las personas que proporcionan la atención —los médicos— necesitan información oportuna sobre cuál es la experiencia que viven los pacientes”, señaló Haynes.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

A 72-year-old in Los Angeles, mindful that he is a Black man, tries to put providers at ease around him. “My actions will probably be looked at and applied to the whole race, especially if my actions are negative,” he said. “And especially if they are perceived as aggressive.”

Many Black Californians report adjusting their appearance or behavior — even minimizing questions — all to reduce the chances of discrimination and bias in hospitals, clinics, and doctors’ offices. Of the strategies they describe taking, 32% pay special attention to how they dress; 35% modify their speech or behavior to put doctors at ease. And 41% of Black patients signal to providers that they are educated, knowledgeable, and prepared.

The ubiquity of these behaviors is captured in a survey of 3,325 people as part of an October study titled “Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health,” funded by the California Health Care Foundation. (KHN receives funding support from the California Health Care Foundation.) Part of its goal was to call attention to the effort Black patients must exert to get quality care from health providers.

“If you look at the frequency with which Black Californians are altering their speech and dress to go into a health care visit,” said Shakari Byerly, whose research firm, Evitarus, led the study, “that’s a signal that something needs to change.”

One-third of Black patients report bringing a companion into the exam room to observe and advocate for them. And, the study found, more than a quarter of Black Californians avoid medical care simply because they believe they will be treated unfairly.

“The system looks at us differently, not only in doctors’ offices,” said Dr. Michael LeNoir, who was not part of the survey.

LeNoir, an Oakland allergist and pediatrician who founded the African American Wellness Project nearly two decades ago to combat health disparities, found the responses unsurprising, given that many Black people have learned to make such adjustments routinely. “There is general discrimination,” he said, “so we all learn the role.”

There is ample evidence of racial inequality in health care. An analysis by the nonprofit Urban Institute published in 2021 found that Black patients are much more likely to suffer problems related to surgical procedures than white patients in the same hospital. A study published in November by the National Bureau of Economic Research found that Black mothers and babies had worse outcomes than other groups across many health measures. And a study published in January, led by Dana-Farber Cancer Institute investigators, found that older Black and Hispanic patients with advanced cancer are less likely to receive opioid medications for pain than white patients. (Hispanic people can be of any race or combination of races.)

Gigi Crowder, executive director of the Contra Costa County chapter of the National Alliance on Mental Illness, said she frequently sees delayed mental health diagnoses for Black patients.

“I hear so many stories about how long it takes for people to get their diagnoses,” Crowder said. “Many don’t get their diagnoses until six or seven years after the onset of their illness.”

Almost one-third of respondents in the California Health Care Foundation study — which looked only at Black Californians, not other ethnic or racial groups — reported having been treated poorly by a health care provider because of their race or ethnicity. One participant said her doctor advised her simply to exercise more and lose weight when she reported feeling short of breath. She eventually discovered she had anemia and needed two blood transfusions.

“I feel like Black voices aren’t as loud. They are not taken as seriously,” the woman told researchers. “In this case, I wasn’t listened to, and it ended up being a very serious, actually life-threatening problem.”

People KHN spoke with who weren’t part of the study described similar bad experiences.

Southern California resident Shaleta Smith, 44, went to the emergency room, bleeding, a week after giving birth to her third daughter. An ER doctor wanted to discharge her, but a diligent nurse called Smith’s obstetrician for a second opinion. It turned out to be a serious problem for which she needed a hysterectomy.

“I almost died,” Smith said.

Years later and in an unrelated experience, Smith said, her primary care doctor insisted her persistent loss of voice and recurring fever were symptoms of laryngitis. After she pleaded for a referral, a specialist diagnosed her with an autoimmune disorder.

Smith said it’s not clear to her whether bias was a factor in those interactions with doctors, but she strives to have her health concerns taken seriously. When Smith meets providers, she will slip in that she works in the medical field in administration.

Black patients also take on the additional legwork of finding doctors they think will be more responsive to them.

Ovester Armstrong Jr. lives in Tracy, in the Central Valley, but he’s willing to drive an hour to the Bay Area to seek out providers who may be more accustomed to treating Black and other minority patients.

“I have had experiences with doctors who are not experienced with care of different cultures — not aware of cultural differences or even the socialization of Black folks, the fact that our menus are different,” Armstrong said.

Once he gets there, he may still not find doctors who look like him. A 2021 UCLA study found that the proportion of U.S. physicians who are Black is 5.4%, an increase of only 4 percentage points over the past 120 years.

While health advocates and experts acknowledge that Black patients should not have to take on the burden of minimizing poor health care, helping them be proactive is part of their strategy for improving Black health.

LeNoir’s African American Wellness Project arms patients with information so they can ask their doctors informed questions. And the California Black Women’s Health Project is hiring health “ambassadors” to help Black patients navigate the system, said Raena Granberry, senior manager of maternal and reproductive health for the organization.

Southern California resident Joyce Clarke, who is in her 70s, takes along written questions when she sees a doctor to make sure her concerns are taken seriously. “Health professionals are people first, so they come with their own biases, whether intentional or unintentional, and it keeps a Black person’s guard up,” Clarke said.

While the study shed light on how Black patients interact with medical professionals, Katherine Haynes, a senior program officer with the California Health Care Foundation, said further research could track whether patient experiences improve.

“The people who are providing care — the clinicians — they need timely feedback on who’s experiencing what,” she said.

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

University of California Health is in the middle of a two-year process to renew contracts with affiliate hospitals and clinics that help the university deliver care in underserved parts of the state. Many of the agreements are with faith-based facilities, including prominent hospitals operated by Dignity Health, Providence, or Adventist Health. Such arrangements generate more than $20 million a year for the UC system and help the public university approach its goal of improving public health.

The current policy, adopted in 2021, states that UC physicians have the freedom to advise, refer, prescribe, or provide emergency care, covering cases in which moving a patient “would risk material deterioration to the patient’s condition.” But some UC doctors and faculty worry that physicians would be allowed to perform certain surgeries only in an emergency.

They want to add a clause stating that physicians have the right to perform procedures in a manner they deem advisable or necessary without waiting for the patient’s condition to get worse.

Others have gone so far as to urge the university to reject partnerships with hospitals that have ethical and religious directives against sterilization, abortion, some miscarriage management procedures, and some gender-affirming treatments. The Academic Senate, a faculty body that helps the university set academic policies, and other faculty councils urged the university’s president to avoid working with health care facilities because many have restrictions that “have the potential for discriminatory impact on patients.”

In response, university leaders have pledged publicly to ensure that doctors and trainees can provide whatever care they deem necessary at affiliated facilities but haven’t made changes to the policy language.

“We’ve made it clear that the treating provider is the one to decide if an emergency exists and when to act,” said Dr. Carrie Byington, executive vice president for University of California Health, at a fall meeting of the UC Board of Regents, the governing board of the university system.

UC Health has given itself until the end of this year to make contracts conform to its new policy. During the October board meeting, staffers estimated that one-third of the contracts had been evaluated. Administrators haven’t said whether the current policy thwarted any contracts.

Back in June 2021, the regents approved the policy governing how its doctors practice at outside hospitals and clinics with religious or ethical restrictions. Regent John Pérez made significant amendments to a staff proposal. At the time, it was celebrated as a win by those advocating for the university to push back on religious directives from affiliates.

Pérez noted at the time that his amendments were aimed at “making clear that it’s the regents’ expectation in policy that nothing that is not based on science or [the] best practice of medicine should limit the ability of our practitioners to practice medicine in the interest of the patients.”

But some doctors and faculty said Pérez’s proposal was then wordsmithed as it was converted from the regents’ vote into a formal policy months later. Some questioned whether the policy could be interpreted as restricting services unless there is an emergency, and said it does not go far enough to define an emergency.

“It sounds pretty good,” Dr. Tabetha Harken, director of the Complex Family Planning, Obstetrics & Gynecology division at the UC Irvine School of Medicine, testified before the board. “It passes the commonsense test, but in reality, this is just the federal minimum requirement of care.”

Pérez declined to comment to KHN.

At the regents’ meetings, concerned doctors offered examples of pregnancy and gender-affirming care they believe would be at risk in some hospitals.

One was tubal ligation or sterilization procedures immediately after birth to prevent future pregnancies that may put the woman at risk. It’s a simpler procedure if done postpartum because the uterus is larger than normal and it eliminates the need for additional surgery, said Dr. Jennifer Kerns, an associate professor at UC-San Francisco and director of the school’s Complex Family Planning Fellowship.

Dr. Mya Zapata of UCLA Health described cases of two patients who might not be able to get the same care at a religiously restricted hospital: a trans male who seeks out a hysterectomy based on a mental health referral for gender-affirming surgery, and a cisgender female who seeks out the same procedure for uterine fibroids.

In a hospital with restrictions, Zapata said, the cisgender patient would be able to get the surgery but the trans patient would not, despite both being considered nonemergency cases.

But it’s unclear if physicians are running into problems. UC Health leaders said there have been no formal complaints from university doctors or trainees practicing at affiliate medical centers about being blocked from providing care.

Critics said the lack of complaints may not reflect reality since physicians may find workarounds by transferring or referring patients elsewhere. One researcher, Lori Freedman, who works at UCSF, has spoken to dozens of doctors working at religious-affiliated hospitals across the country. Many have not filed complaints about care restrictions out of fear they’d put their job at risk, she said.

The debate stems from a partnership with Dignity Health, a Catholic-affiliated hospital system. In 2019, UCSF Medical Center leaders considered a controversial plan to create a formal affiliation with Dignity. Critics voiced opposition in heated public meetings, and the plan drew condemnation from dozens of reproductive justice advocates and the gay and transgender communities. UCSF ultimately backed off the plan.

When it became clear that UC medical centers across the state had similar affiliation contracts, faculty members raised additional concerns. Janet Napolitano, then president of the UC system, convened a working group to evaluate the consequences of ending all agreements with organizations that have religious restrictions. Ultimately, the group stressed the importance of maintaining partnerships to provide care to medically underserved populations.

“With 1 in 7 patients in the U.S. being cared for in a Catholic hospital,” the group wrote in its report, “UC’s isolating itself from major participants in the health care system would undermine our mission.”

Dignity Health, which merged in 2019 with Catholic Health Initiatives to form CommonSpirit Health, has already reached a new contract that adopts the updated UC policy. Chad Burns, a spokesperson for Dignity, said the hospital system values working with UC Health for its expertise in specialties, such as pediatric trauma, cancer, HIV, and mental health. He added that the updated agreement reflects “the shared values of UC and Dignity Health.”

Some UC doctors point out that they have not only public support, but legal standing to perform a variety of reproductive and contraceptive treatments. After California voters passed Proposition 1, the state constitution was officially changed in December to affirm that people have a right to choose to have an abortion or use contraceptives. Unlike health systems in other states, some faculty say UC Health can assert reproductive rights.

“We have a lot of latitude, being in California, to be able to make these decisions and stand in our power,” Kerns said. “I think it’s our responsibility to do so.”

Other doctors say the university system should prioritize public service. Dr. Tamera Hatfield, a maternal-fetal medicine specialist at UC-Irvine, testified at a regents’ meeting that she had never been asked to modify care for patients based on religious restrictions since her department formed an affiliation with Providence St. Joseph Hospital-Orange about a decade ago.

“Partnering with faith-based institutions dedicated to serving vulnerable populations affords opportunities to patients who are least able to navigate our complex health systems,” she said.

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

This spring, a Chevron worker testified that the company revoked health coverage for hundreds of members of the United Steelworkers Local 5 at the Richmond, California, refinery during a strike that ultimately lasted two months. Thousands of nurses at Stanford Health Care were told in April they would lose their health insurance if they did not return to work during their weeklong strike. More than 300 workers at Sequoia Hospital in Redwood City received a similar message after going on strike in mid-July as contract negotiations stalled.

Freezing health insurance benefits is a common tactic in a labor dispute because without them, workers might be more easily persuaded to concede to management’s demands. But California lawmakers are giving an edge to strikers.

Assembly member Jim Wood, a Democrat, is hoping a new California law he authored will dissuade employers from cutting off health benefits during labor disputes by allowing private-industry workers to maximize state subsidies for coverage purchased through Covered California, the state’s health insurance marketplace. The bill, which takes effect in July, was sponsored by the California Labor Federation, California Teamsters Public Affairs Council, and the Los Angeles County Federation of Labor.

“The goal of the legislation is to say, ‘No you can’t do this,’” Wood said. “Never try it again.”

According to Covered California spokesperson Kelly Green, eligible workers will have their premiums covered as if their incomes were just above the Medicaid eligibility level. The state would factor in the worker’s federal subsidy and cover the difference. For example, a single person making $54,360 a year may pay 8.5% of their income, or about $385 a month, on premiums under a middle-tier health plan. Under the new law for striking workers, that person selecting the same plan would pay nothing in premiums — as if that person made $20,385 a year — for the duration of the strike.

The federal government authorized an enhanced subsidy under the American Rescue Plan Act. The enhanced subsidy will continue through 2025 under the Inflation Reduction Act. The state’s share of the subsidy could increase once the federal boost ends.

One estimate that unions shared with the state suggested the law would cost California an average of $341 a month per worker — with strikes lasting one to two months. Labor groups estimate the bill will affect fewer than 5,000 workers a year. California has nearly 15 million workers in the private sector, and strikes are generally a tool of last resort in labor negotiations.

It’s not clear how businesses will respond. Chevron, Stanford Health Care, and Sequoia Hospital’s operator, Dignity Health, did not respond to requests for comment. The bill met no formal opposition from businesses or taxpayer groups. Covered California’s subsidies are footed by a mix of federal and state funds as part of the Affordable Care Act, so there’s no direct cost to businesses.

Last year, Gov. Gavin Newsom, a Democrat, signed the Public Employee Health Protection Act, which bars public employers from terminating health coverage during an authorized strike. The new law for the private industry is different: There’s no ban on — or financial penalty for — revoking health benefits during strikes.

Nationally, Democrats in the House and Senate have pushed for an outright ban on this practice, but neither bill has advanced out of committee.

When California workers lose their employer-sponsored health benefits, they may become eligible for the state’s Medicaid program, known as Medi-Cal, or qualify to purchase health insurance through Covered California. With the latter option, workers could receive a range of subsidies to help pay for their monthly premiums. Generally, the lower a household’s income, the bigger the subsidy.

But even when workers do qualify for Covered California, that insurance can be much more expensive than the plans they had through their job — sometimes consuming 30% to 40% of their income, proponents said. And striking workers may experience delays since coverage may not take effect until the following month.

“This is one of the drawbacks of having a health care system that is tied to employment,” said Laurel Lucia, health care program director at the University of California-Berkeley Labor Center. “We saw during the pandemic, when there were furloughs or layoffs, people lost job-based coverage when they needed it most.”

Striking Sequoia workers reached an agreement with Dignity Health and returned to the 208-bed facility before health coverage stopped on Aug. 1, but some said they might have stayed on the picket line longer if not for fear of losing their benefits.

“That was pretty scary,” said Mele Rosiles, a certified nursing assistant and a member of the union’s bargaining team who was pregnant at the time. “A majority of our workers felt threatened by this move from our employer to strip our family’s health insurance if we didn’t return to work.”

The California Association of Health Plans raised concerns over an early version of the bill that sought to establish a category for striking workers, but the industry group dropped its opposition once it was determined that Covered California could administer the change without it.

Covered California estimates it will spend about $1.4 million to launch this benefit. The agency said it will create application questions to screen for eligible workers and remind them to stop coverage once they go back to work.

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).