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?”

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Then, Kim learned to go further. Through a training program, she gained the know-how and confidence to provide emotional support. She learned evidence-based mental health counseling skills such as asking open-ended questions. She also discovered that some things she was already doing, such as listening attentively and restating what she hears, are core to communicating empathy — a vital component of a successful relationship between a client and their mental health provider.

“It was very refreshing to see that it’s named and to realize those are skills,” she said.

Asian Health Services, where Kim works, is a part of a fledgling movement trying to address a dire shortage of therapists by training community health workers and other nonlicensed professionals who have trusted relationships with their communities to add mental health counseling to their roles. This approach, already implemented abroad and proven to help address some common mental health conditions, is called lay counseling.

The Oakland, California-based community health center serves mostly low-income Asian immigrants who speak limited English. As a community health worker, Kim now also practices lay counseling under a licensed therapist’s supervision. She does not have a license, but as a Korean immigrant and strong-arm robbery survivor, she shares lived experiences with many of the people she serves, enabling her to build trust.

Research suggests Asian Americans see mental health providers at lower rates than people of other races, and up to half of some subgroups report difficulty accessing mental health care. Figures like these may be only the tip of the iceberg, as Asian Americans can be reluctant even to seek help. Cultural stigma against mental illness and feeling like one’s problems pale in comparison to the trauma faced by earlier generations are among the reasons, said Connie Tan, senior research analyst at AAPI Data, a think tank.

Asian Health Services introduced lay counseling during the covid-19 pandemic. Violence against Asian Americans was spiking, and therapists fluent in any of the 14 languages spoken by the communities the health center cares for were in short supply. Six percent of people in the U.S. identify as Asian, Native Hawaiian, or Pacific Islander, but these groups account for only 3% of psychologists.

Concerned that people were falling through the cracks, the health center in 2021 launched a grant-funded initiative to support victims of violence. In addition to lay counseling and therapy by licensed providers, available in several languages, the program, known as the Community Healing Unit, provides services such as helping clients access crime victim funds.

The program has sent 43 community health workers, case managers, and other employees to a lay counseling training program, said Ben Wang, the health center’s director of special initiatives. Trainees learn through formal instruction, observing teachers providing counseling, and practicing counseling with one another, along with feedback from instructors.

Thu Nguyen, a domestic violence survivor, was struggling with anxiety and self-blame. “My inside talk eats me up,” she explained. Worried that sharing with family members would burden them, she was unsure where else to turn for support after meeting with a therapist she didn’t click with. Through the program, Nguyen was assigned to Kim, who connected her to a compatible therapist.

Nguyen also leaned on Kim for emotional support. When she confided feeling guilty and inadequate as a single mother, Kim responded without judgment and affirmed Nguyen’s dedication.

“She validates my feeling,” said Nguyen, a Vietnamese immigrant. “She would say, ‘I understand that it’s hard. You’re doing the best.’”

Asian Americans can struggle to find therapists who understand their culture, speak their language, or come from similar communities. Licensed therapists typically must complete an advanced degree, pass professional exams, and work at least two years under supervision. Requirements vary by state and by type of license. It has long been held that the process ensures high-quality care.

Lay counseling proponents contend this path is costly and time-consuming, limiting the field’s diversity and exacerbating the therapist shortage. They also point to favorable research. Lay counseling has been implemented in several countries, where mounting evidence has shown it can improve symptoms of depression, anxiety, and a few other mental health conditions.

“The idea that someone without a license could not [communicate empathy] skillfully is ridiculous,” said Elizabeth Morrison, a psychologist and co-founder of Lay Counselor Academy, which has trained 420 people, including Kim, to add lay counseling to their roles since launching two years ago. Trainees hail from a variety of jobs, including faith leaders and first responders.

The 65-hour primarily virtual course teaches topics such as supporting people who have experienced trauma, counseling methods such as cognitive behavioral therapy and motivational interviewing, first-line strategies for treating depression and anxiety, and setting boundaries. The course does not teach how to diagnose mental health conditions. Instead, trainees learn to affirm strengths, acknowledge feelings, avoid giving advice, and otherwise listen empathically.

Asian Health Services staff members who provide lay counseling receive ongoing support and guidance after the training from a program manager and a licensed therapist, Wang said.

Raquel Halfond, a senior director at the American Psychological Association, said she believes it’s important for lay counselors to receive training and to practice under the supervision of a licensed mental health professional, but the group has no formal model or standards for the use of lay counselors.

The course not only upskills but also recognizes what many trainees already do or have learned that may not be acknowledged as counseling. “It’s like this invisible, unpaid work, and people chalk it up as someone being nice,” Morrison said.

Lay counseling is still nascent, and it often takes years for a new field to become established — and for insurers to get on board. Morrison and Laura Bond, a research fellow at Harvard Medical School’s Mental Health For All Lab, another lay counseling training initiative, said they are not aware of any organizations that can bill public or private insurers for lay counseling.

In an email, Leah Myers, a spokesperson for the California Department of Health Care Services, which oversees Medi-Cal, the state’s Medicaid program, acknowledged there is no billing code for lay counseling or certification for lay counselors. She said Medi-Cal reimburses certain nonlicensed providers for services that “may include what would be considered ‘lay counseling’-like activities” but would need more details to make a determination.

The Community Healing Unit’s largest grant, from the state of California to support victims of hate crimes, ends in 2026. The program has served over 300 people and is developing a survey to gather feedback, Wang said.

Nguyen knew Kim wasn’t a licensed therapist but didn’t care, she said; she appreciated that Kim, a fellow Asian woman, made her feel safe to process her feelings. Kim was also easily accessible through biweekly check-ins, and responded promptly if Nguyen called at other times.

Now, Nguyen said, telling herself “you’re doing good” comes more easily.

Supplemental support comes from the Asian American Journalists Association-Los Angeles through The California Endowment.

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

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Voters are being asked whether California should increase accountability in the 340B drug discount program, which provides money for community clinics, safety net hospitals and other nonprofit health-care providers.

The program requires pharmaceutical companies to give drug discounts to these clinics and nonprofit entities, which can bank revenue by charging higher reimbursement rates.

Advocates pushing the measure, Proposition 34, say some entities are using the drug discount program as a slush fund, plowing money into housing and homelessness initiatives that don’t meet basic patient safety standards. Researchers and advocates have called for greater oversight.

“There are 340B entities that are misusing these public dollars,” said Nathan Click, a spokesperson for the pro-Proposition 34 campaign. “The whole point of this program is to use this money to get more low-income people health-care services.”

The initiative wouldn’t bar 340B providers from using health-care funds for housing or homelessness programs. Instead, it targets providers that spend more than $100 million on purposes other than direct patient care over 10 years. It would mandate that 98 percentof 340B revenues go to direct patient care. It also targets 340B providers with health insurer contracts and pharmacy licenses and those serving low-income Medicaid or Medicare patients that have been dinged with at least 500 high-severity housing violations for substandard or unsafe conditions.

That has placed a bull’s eye on the Los Angeles-based AIDS Healthcare Foundation, a nonprofit that provides direct patient care via clinics and pharmacies in California and other states, including Illinois, Texas and New York. It also owns housing for low-income and homeless people.

A Los Angeles Times investigation found that many residents of AIDS Healthcare Foundation properties are living in deplorable, unhealthy conditions.

Michael Weinstein, the foundation’s president, disputes those claims and argues that Proposition 34 proponents, including real estate interests, are going after him for another ballot initiative that seeks to implement rent control in more communities across California.

“It’s a revenge initiative,” Weinstein said, arguing that the deep-pocketed California Apartment Association is targeting his foundation — and its health and housing operations — because it has backed ballot measures pushing rent control across California. “This is a two-pronged attack against us to defeat rent control.”

Weinstein is locked in a feud with the apartment association, the chief sponsor of the initiative, which has contributed handsomely to pass Proposition 34. Opponents argue that the initiative is “a wolf in sheep’s clothing.”

Weinstein acknowledged to KFF Health News that his nonprofit uses money from 340B drug discounts to support its housing initiatives but argued they are helping treat and house some of the most vulnerable people, who would otherwise be homeless.

The apartment association declined several requests for comment. But Proposition 34 backers say they aren’t going after rent control — or Weinstein and his nonprofit.

Supporters argue that “rising health care costs are squeezing millions of Californians” and say that the initiative would “give California patients and taxpayers much needed relief, and lowers state drug costs, while saving California taxpayers billions.”

If the initiative passes and 340B providers do not spend 98 percent of the revenue on direct patient care, they could lose their license to practice health care and their nonprofit status.

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Yet his doctor, Noha Aboelata, believed the patient was sicker than the device showed. So she sent him for a lab test, which confirmed her suspicion that he needed supplemental oxygen at home.

Months later, in December 2020, Aboelata thought back to her patient as she read a New England Journal of Medicine article showing that pulse oximeters were three times as likely to miss dangerously low blood oxygen levels in Black patients as in white ones. At a time when Black Americans were dying of covid at high rates and hospitals struggled to find beds and oxygen for those needing them, the finding exposed one of the most blatant examples of institutional racism in American health care.

“I was like, ‘Were there other patients I missed?” said Aboelata, a family physician and the CEO of Oakland-based Roots Community Health. As she shared the article with colleagues, “there was so much anger and frustration because we had every reason to believe we could rely on this device, and it was systematically not working in the population that we served.”

State attorneys general and U.S. senators have pressed the FDA to take steps to eliminate pulse oximetry’s racial bias, which has caused delays in treatment and worse health outcomes, and more recently has raised concern about the reliability of hospital AI tools that draw on reams of data from the devices.

Aboelata’s clinic has sued producers and stores that sell oximeters, demanding they pull the devices or add safety warnings to the labels. Many of her patients rely on home oxygen, which requires accurate readings for Medicare to cover.

But getting rid of the devices, central to care for heart and lung diseases, sleep apnea, and other conditions, isn’t an option.

Since the 1990s, the convenient fingertip clamps have come to stand in for many uses of arterial blood gas readings, which are the gold standard for determining oxygen levels but dangerous if not done carefully. Makers of oximeters will sell around $3 billion of them this year because they are used in nearly every hospital, clinic, and long-term care facility. During the pandemic, hundreds of thousands of Americans bought them for home use.

One of them was Walter Wilson, a 70-year-old businessman in San Jose who has had two kidney transplants since 2000. Wilson contracted covid last December but delayed visiting a doctor because his home pulse oximetry readings were in the normal range.

“I’m a dark-complected Black guy. I was very sick. Had the oximeter picked that up I would have gotten to the hospital sooner,” he said.

Wilson ended up back on dialysis after several years of good health. Now he’s looking to join a class action lawsuit against the device manufacturers.

“They’ve known for years that people with darker skin get bad readings,” he said, “but they tested them on healthy white people.”

After years of little action on the issue, the FDA in 2021 sent a safety warning to doctors about oximeters. It has also funded research to improve the devices and promised to issue new guidelines for how to make them.

But as the FDA polishes draft guidelines it had hoped to publish by Oct. 1, clinicians and scientists are unsure what to expect. The agency has indicated it will recommend that manufacturers test new oximeters on more people, including a large percentage with dark-pigmented skin.

Because of industry pushback, however, the guidance isn’t expected to ask device makers to test oximeters under real-world conditions, said Michael Lipnick, a University of California-San Francisco anesthesiologist and researcher.

Hospitalized people are often dehydrated, with restricted blood flow to their extremities. This condition, known as low perfusion — essentially, poor circulation — is particularly common with cardiovascular disease, which is more prevalent in Black patients.

Pigmentation and poor perfusion “work together to degrade pulse oximetry performance,” said Philip Bickler, who directs the Hypoxia Research Lab at UCSF. “During covid, Black patients showed up sicker because of all the barriers those patients face in accessing health care. They’re showing up on death’s door, and their perfusion is lower.”

The FDA guidance isn’t expected to require manufacturers to measure how well their devices perform in patients with poor perfusion. All this means that the FDA’s efforts could lead to devices that work in healthy dark-skinned adults but do “not fix the problem,” said Hugh Cassiere, who chairs a panel for the FDA’s Medical Devices Advisory Committee, at its February meeting.

A History of Inaction

Although some recent industry-sponsored studies have shown that certain devices work across skin tones, research dating to the 1980s has found discrepancies in pulse oximetry. In 2005, Bickler and other scientists at the Hypoxia Lab published evidence that three leading devices consistently failed to detect hypoxemia in darkly pigmented patients — especially those who were severely oxygen-depleted. Noting that these readings could be crucial to directing treatment, the authors called for oximeters to carry warnings.

The FDA’s response was modest. Its regulatory pathway for pulse oximeters clears them for sale as long as they show “substantial equivalence” to devices already on the market. In a 2007 draft guidance document, the FDA suggested that tests of new oximeters could “include a sufficient number of subjects with dark skin pigmentation, e.g., 30%.” However, the final guidance, issued in 2013, recommended “at least 2 darkly pigmented subjects or 15% of your subject pool, whichever is larger.” The studies were required to have only 10 subjects. And the agency did not define “dark-pigmented.”

Testing the devices involves fitting patients with masks that control the gases they breathe, while simultaneously taking pulse oximetry readings and samples of arterial blood that are fed into a highly accurate measuring device, invented by the Hypoxia Lab’s late founder, John Severinghaus.

Bickler, who evinces the bemused skepticism of a seasoned car mechanic when discussing the scores of devices his lab has tested, said “you can’t always trust what the manufacturers say.”

Their data, he said, ranges from “completely inaccurate” to “obtained under absolutely ideal conditions, nothing like a real-world performance.”

During the pandemic, a medical charity approached the lab about donating thousands of oximeters to poor countries. The oximeters it had chosen “weren’t very good,” he said. After that, the lab set up its own ratings page, a kind of Consumer Reports for pulse oximeters.

According to its tests, some expensive devices don’t work; a few of the $35 gadgets are more effective than competitors costing $350. Over a third of the marketed devices the lab has tested don’t meet current FDA standards, according to the site.

To investigate whether real-world tests of oximeters are feasible, the FDA funded a UCSF study that has recruited about 200 intensive care unit patients. The data from the study is being prepared to undergo peer review for publication, Bickler said.

He said the lab did not warm the hands of patients in the study, which is the customary practice of manufacturers when they test their devices. Warming assures better circulation in the finger the device is attached to.

“It affects the signal-to-noise ratio,” Bickler said. “Remember when car radios had AM stations, and you’d get a lot of static? That’s what poor perfusion does — it causes noise, or static that can obscure a clear signal from the device.”

Hypoxia Lab scientists — and doctors in the real world — don’t warm patients’ hands. But “the industry people can’t agree on how to handle it,” he said.

Masimo, a company that says it has the most accurate pulse oximeters on the market, would happily comply with any FDA guidance, Daniel Cantillon, Masimo’s chief medical officer, said in an interview.

How Much To Fix the Problem?

The very best devices, according to the Hypoxia Lab, cost $6,000 or more. That points to another problem.

With better accuracy, “you are going to reduce patient access to devices for a large proportion of the world that simply can’t afford them,” Lipnick said.

Even if the FDA can’t please everyone, its anticipated call for more people with darker skin in oximetry tests will “assure there’s real diversity in the development and testing of those devices before they come to market,” Lipnick said. “That bar has been too low for decades.”

It is difficult to assess harm to individuals from faulty oximeter readings, because these errors are often one factor in a chain of events. But studies at Johns Hopkins University and elsewhere indicated that patients whose oxygen depletion wasn’t noticed — possibly thousands of them — had delayed treatment and worse outcomes.

Already, Aboelata said, a few manufacturers — Zewa Medical Technology, Veridian Healthcare, and Gurin Products — have responded to the Roots Community Health lawsuit by including warnings about their devices’ limitations.

There’s not much she and other clinicians can do in daily practice, she said, other than establish a baseline reading with each new patient and be on the lookout for notable drops. Hospitals have other tools to check oxygen levels, but correct readings are critical for outpatient care, she said. In 2022, Connecticut enacted a law banning insurers from denying home oxygen or other services based solely on pulse oximetry readings.

But “adapting around the crappy device isn’t the solution,” said Theodore Iwashyna, the Johns Hopkins Bloomberg School of Public Health professor who co-authored the New England Journal of Medicine article. “A less crappy device is the solution.”

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Providence St. Joseph Hospital, in the small Northern California coastal city of Eureka, refused to provide the care she required because doctors could detect fetal “heart tones,” Nusslock said at a news conference Monday. California Attorney General Rob Bonta filed a lawsuit against the Catholic hospital detailing Nusslock’s dangerous experience and alleging the hospital violated multiple state laws when it discharged Nusslock — with an offer of a bucket and towels — to go elsewhere for what he described as standard medical care.

Bonta also filed a motion for a preliminary injunction in Humboldt County Superior Court, asking that it require Providence to treat anyone with an emergency medical condition. “The need for immediate relief is about to intensify,” the motion said. That’s because Mad River Community Hospital, where Nusslock ultimately got care 12 miles up the road, is slated to close its birth center this month.

Providence will be the only hospital within about 85 miles to offer labor and delivery, according to a KFF Health News analysis. When care is more than an hour away, academic researchers typically define the area as a hospital desert.

“It begs the question, what happens next time someone in Anna’s situation shows up at Providence? There will be no Mad River for them to go to,” Bonta said at a news conference. “With a dire lack of services, even here in California, and an influx of patients from states with abortion bans, we need hospitals to follow the law.”

The case illustrates how even in California, where the right to an abortion is enshrined in state law, there’s a glaring loophole. Catholic hospitals, which restrict reproductive health care because they follow the church’s “Ethical and Religious Directives,” are aggressively expanding nationally by acquiring secular hospitals. In swaths of the country, including parts of Northern California, they are the only choice. At the same time, maternity wards are closing rapidly, leaving more patients to contend with religious directives instead of accepted medical standards.

California’s lawsuit also comes amid uncertainty that emerged after the Supreme Court in 2022 overturned the constitutional right to an abortion: whether federal law requires hospitals to provide abortions as emergency medical care even in states that have banned the procedure. The high court punted on the question this summer. The Biden administration reaffirmed its policy that the Emergency Medical Treatment and Labor Act requires hospitals to stabilize or treat any patient who shows up at an emergency room. Texas is suing the administration over the policy.

The issue is also playing out in the presidential election. During the Oct. 1 vice presidential debate, Democratic Minnesota Gov. Tim Walz noted a Georgia woman who died because a hospital delayed care. Sen. JD Vance (R-Ohio) answered, in part, by asking Walz if he wanted to force Catholic hospitals to perform abortions against their religious beliefs, saying that “Kamala Harris has supported suing Catholic nuns.”

With federal protections in limbo, Bonta said California must rely on its state laws to protect patients. Specifically, Bonta, who is widely expected to run for governor, alleges that Providence violated a California law mandating that hospitals provide care “necessary to relieve or eliminate the emergency medical condition.”

Nusslock’s case isn’t an isolated incident, the lawsuit said. “One to two women per year receive abortion care at Mad River, after being refused care at Providence Hospital,” the lawsuit said. "These individuals, like Anna Nusslock, had all been discharged from Providence Hospital with instructions to go somewhere else." Bonta said his office is investigating how widespread cases are in California, where Catholic hospitals represent 15% of hospital beds.

In an Oct. 1 letter to employees that was obtained by KFF Health News, Providence Northern California Service Area Chief Executive Garry Olney said the hospital is “heartbroken” about Nusslock’s experience, which “did not meet our high standards for safe, quality, compassionate care.” He added the hospital is revisiting its training, education, and escalation processes to ensure it doesn’t happen again.

Providence spokesperson Bryan Kawasaki said its 51 hospitals abide by applicable federal and state laws, including EMTALA. Kawasaki declined to comment specifically on Nusslock’s case.

More women are running into barriers to obtaining care as Catholic health systems have gained market power, a KFF Health News investigation found. Four of the 10 largest hospital chains by number of beds are Catholic, according to federal data from the Agency for Healthcare Research and Quality.

Many Americans don’t have a choice — ambulances may take patients to a Catholic-run health system without giving them a say. Non-Catholic hospitals could be out of their insurance networks or too far to reach in an emergency. In the U.S, nearly 800,000 people have only Catholic or Catholic-affiliated birth hospitals within an hour’s drive, including pockets of Northern California.

Pregnant women who must drive farther to a delivery facility are at higher risk of harm to themselves or their fetus, research shows.

“It's really concerning, especially in a state like California, where people expect to have comprehensive access to care,” said Debra Stulberg, a family medicine physician at the University of Chicago. “The growth of Catholic hospitals, especially in this post-Dobbs era, continues to constrain the quality of care people get.”

The directives guiding care at Catholic-based health systems are issued by the U.S. Conference of Catholic Bishops. They state that abortions are “intrinsically evil” and “never permitted.”

The document does offer this guidance as an exception: Treatments that could cure “a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”

“The church, I would say, helps Catholic hospitals to apply some of our deepest beliefs and moral principles to very, very complex situations,” said John Brehany, executive vice president of The National Catholic Bioethics Center, an ethics authority for Catholic health institutions. “And one of those beliefs is that you can never directly intend to end the life of a developing human being."

Brehany wouldn’t comment on Nusslock’s case but gave the example that if a woman needed cancer treatment, the church would allow her to proceed with the treatment even if it “results in the death of an unborn child.” He added that some situations are “more debatable” than others.

As Catholic-based systems have consolidated and acquired more medical facilities, their care denials have been compounded by other hospitals closing their labor and delivery wards at alarming rates across the country. In California, 56 hospitals have shuttered their maternity wards in the past 12 years, according to an investigation by CalMatters. Nationwide, at least 267 hospitals closed labor and delivery units between 2011 and 2021, representing about 5% of the country’s hospitals, according to Chartis, a health analytics and consulting firm.

With each closure, patients could lose options for abortion care, contraceptives, tubal ligations, and gender-affirming care, said Mona Shah, senior policy and strategy director with Community Catalyst, a national health equity organization.

Nusslock’s 12-mile trip for care at Mad River cost her, according to the lawsuit and her public statement. She had passed an “apple-sized blood clot” and was hemorrhaging in “blinding pain,” she said, by the time she reached the operating room. In the lawsuit, Nusslock said her doctor told her later that her test results showed she most likely had an infection.

It’s a trip Bonta described as “patient dumping” and one Nusslock should never have made.

Seven months later, Nusslock said, she has trouble sleeping, recalling how Providence sent her away.

“I’ll never forget looking at my doctor, tears streaming down my face, my heart shattered into a million pieces, and just pleading with her, ‘Don’t let me die,’” she said.

KFF Health News data editor Holly K. Hacker contributed to this article.

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.

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“The politics of abortion and reproductive health can get voters to participate at higher rates,” said David McCuan, a political science professor at Sonoma State University. “Republicans have to moderate their stance if they’re going to be in the battle.”

After all, polls show most voters support restoring abortion rights overturned in 2022 by the Supreme Court. Aggressive ads are going up in competitive districts where Democrats see an opportunity to take control of the House by engaging voters who might not vote straight-ticket — or at all.

In New York, Democrat Josh Riley blasted Republican incumbent Marcus J. Molinaro in a 30-second ad for voting against abortion rights 13 times. Next door in New Jersey, Democratic hopeful Sue Altman called out Republican opponent Tom Kean Jr. for a “secret antiabortion agenda.” And in California, Democrat Will Rollins denounced Republican rival “Ken Calvert and MAGA extremists” for backing a national abortion ban.

Meanwhile, in March, shortly after her primary, Rep. Michelle Steel (R-Calif.) removed her support for a blanket abortion ban — the Life at Conception Act — saying it could create confusion because the bill could threaten in vitro fertilization. Following news reports about her reversal, the Orange County-area Republican released an ad in which she shared that she had used IVF and reiterated her support for the procedure.

On the campaign trail, Steel has said she supports exceptions to abortion bans in cases of rape, incest, and in which the mother’s health or life is at risk, a departure from bills she previously supported.

“What we all need to do is to make sure we look at her record, and that record is contrary to what she’s putting out there in her ads,” Steel’s Democratic challenger, Derek Tran, told me.

The Steel and Calvert campaigns told KFF Health News that their candidates oppose a national abortion ban. Calvert, who last backed a 20-week abortion ban in 2017, issued a statement saying the issue is best left to states.

Tim Rosales, a political strategist who has represented Republican candidates, said incumbents shouldn’t get heat for changing their minds over time.

Meanwhile, Rolling Stone reported in March that Rep. Don Bacon (R-Neb.) had deleted antiabortion endorsements from his website. Arizona Republican incumbent Rep. David Schweikert said he opposed a state abortion ban, even though he had co-sponsored a national ban six times.

And vice-presidential candidate JD Vance removed his antiabortion stance from his website the month former president Donald Trump selected him as his running mate.

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Five decades later, with 14 states banning abortion in almost all circumstances, the University of California-San Francisco breast cancer surgeon has once again taken up the fight for women’s reproductive rights. Since 2021, when Texas prohibited most abortions, she has boycotted the San Antonio Breast Cancer Symposium — a conference she had regularly attended, and frequently headlined, for 34 years.

“People are passing laws that are legislating what should be a medical decision,” she said. “And I am objecting in whatever way I can.”

Esserman and other physicians have urged their colleagues and medical societies to move all professional meetings out of states that criminalize abortion. Short of a move, they have called for boycotts of the events.

In November, Esserman expects 300 health providers and researchers to meet in San Francisco for an alternative breast cancer conference.

The effort to move annual conferences — which pump substantial revenue into local communities and attract many of the nation’s 1.1 million physicians and other medical professionals looking to network, satisfy continuing education requirements, and learn about the latest developments in their fields — has led to some notable relocations.

The American College of Obstetricians and Gynecologists moved its 2023 annual meeting and an estimated 4,000 participants from New Orleans to Maryland in response to Louisiana’s abortion ban. An estimated 3,600 health care professionals attended the American Association of Immunologists’ conference in Chicago this year, after the group moved the meeting from its planned Phoenix location in response to Arizona’s restrictive abortion law.

“In addition to causing great physical and psychological harm to patients,” the association said in a statement, abortion bans “threaten irreparable damage to the private and trusted relationship between medical professionals and their patients.”

Yet even doctors who agree about reproductive rights disagree about how to express dissent. Some argue it’s more important than ever to visit states where abortion has been outlawed, to learn about the issues surfacing because of the laws, and to help people organize against them.

“We cannot support penalizing communities that are already harmed by this legislation,” said obstetrician and gynecologist Jamila Perritt, president and CEO of Physicians for Reproductive Health. “As opposed to withdrawing support, what we’re calling for is actually flooding those folks with support.”

Physicians for Reproductive Health has been providing security for doctors targeted by anti-abortion activists, Perritt said, and training doctors to teach abortion care in abortion-restricting states and to testify to state legislatures about the need for abortion access.

“There is a lot to be gained by coming to these states, supporting us, seeing the reality, and bringing these conversations into your conference space so that you can better understand our reality, rather than just boycotting that state completely, which is not helpful,” said Bhavik Kumar, chief medical officer for Planned Parenthood of Greater Ohio and a medical director for Planned Parenthood Gulf Coast in Texas and Louisiana.

Since the Supreme Court’s 2022 decision to overturn Roe and eliminate a federal constitutional right to abortion, all but nine states and Washington, D.C., have imposed abortion restrictions, according to the Guttmacher Institute.

The San Antonio Breast Cancer Symposium continues to be held in Texas, where abortion is banned in almost all instances, and boycott calls do not appear to have slowed turnout. In fact, the number of in-person attendees increased from just under 8,000 in 2019 to 8,220 last year, organizers said.

Breast oncologist Virginia Kaklamani, a University of Texas Health Science Center-San Antonio professor of medicine who co-directs the San Antonio symposium, plans to stay in Texas. She doesn’t believe in boycotts, though she does share boycott proponents’ concerns. Despite exceptions, such as the American Association of Pro-Life Obstetricians and Gynecologists, doctors have by and large spoken against abortion restrictions.

“I think the way to handle it is to talk to our elected officials, to go out and vote. Moving meetings from one place to another is not going to help,” Kaklamani said. “You stay and you fight for your patients.”

Esserman recognizes that boycott calls have not had significant impact, but she feels compelled to keep applying pressure anyway.

She can’t help but think about a patient who recently came to her San Francisco practice nine weeks pregnant and with an aggressive breast cancer. If she were to continue the pregnancy, she would be ineligible for the most effective treatment. “Where I live, she has a choice,” Esserman said. In some states, she would have no choice but to carry the pregnancy to term.

Cary Gross, a Yale School of Medicine professor who co-authored a JAMA Internal Medicine opinion piece last year advocating boycotts, cited three arguments: expressing the profession’s values, acting as an ethical consumer, and protecting the health of attendees. Women physicians of childbearing age have voiced fears about traveling to anti-abortion states, especially while pregnant.

“The legislators passing these laws are probably not going to change their stance,” Gross said. “But for the general population, the more you can do to alert people, to remind people there’s another way, you have to make your voice heard.”

Still, Gross, Esserman, and others pushing for boycotts can point to no evidence that their efforts have changed hearts and minds, let alone laws.

Instead of moving the American Society of Hematology’s 2022 meeting out of New Orleans after Louisiana imposed a trigger law to ban abortion, Jane Winter, the society’s president at the time, met with Louisiana’s then-governor, John Bel Edwards, and told him about women whose survival might depend on getting an abortion. They talked about her 22-year-old patient who had Hodgkin lymphoma and learned she was pregnant just before a planned stem cell transplant.

“Gov. Edwards was visibly moved by our clinical cases and shared that lawmakers had not considered the impact of abortion restrictions on the care of our patients,” Winters wrote in a column for The Hematologist.

Last year, the hematologists held their meeting in San Diego, and they will meet again in California, which has no post-Roe abortion restrictions, in December.

In an email, Winter said her conversation with Edwards changed nothing concrete, as far as she knows. But she added, “I do believe that telling the stories of specific individuals – in my case, those of my patients – is one way to begin to change minds.”

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Proposition 36, on the November ballot, would unwind portions of a 2014 initiative, known as Proposition 47, that reduced most shoplifting and drug possession offenses to misdemeanors that rarely carried jail time.

Critics say that has allowed criminality to flourish and given those suffering from addiction little incentive to break the cycle. The law also has become a political weapon for former President Donald Trump and other Republican politicians who have tried to tie it to Vice President Kamala Harris to paint her as soft on crime. As California attorney general she took no position on the issue.

Much of the Proposition 36 debate has focused on the increased penalties for shoplifting, but the drug policy changes are even more dramatic. In addition to boosting penalties for some drug crimes, the measure would create a new “treatment-mandated felony” that could be imposed on people who illegally possess what are called “hard” drugs, including fentanyl, heroin, cocaine, and methamphetamine, and have two or more prior convictions for certain crimes.

Those who admit to the new felony would be required to complete drug or mental health treatment, job training, or other programs intended to “break the cycle of addiction and homelessness.” Those who complete the treatment program would have their charges dismissed, while failure could bring three years in prison.

The measure has opponents, including Gov. Gavin Newsom, warning about renewing a “war on drugs” that once helped swell California’s prison population.

Supporters counter that stricter penalties are necessary as overdose deaths from fentanyl crowd morgues. They also point to studies showing that more than 75% of people experiencing chronic homelessness struggle with substance abuse or a severe mental illness.

“We crafted this not to move people into any kind of custody setting, but to incentivize them into treatment,” said Greg Totten, chief executive officer at the California District Attorneys Association and a spokesperson for the initiative’s supporters.

Totten and others cast the measure as a way to revive drug courts, which they say waned in effectiveness after Proposition 47 removed the stick from what had been a carrot-and-stick approach.

Drug courts are led by a judge with a specialized caseload, use a collaborative approach to promote rehabilitation, and have been found to be effective in California and nationwide. Participants in California had “significantly lower rates of recidivism,” according to a study in 2006 commissioned by the Judicial Council of California: 29% were rearrested compared with 41% of a group who didn’t receive treatment.

The Center for Justice Innovation, a nationwide research and reform group that grew out of the New York state court system, found that drug court caseloads dropped across California after Proposition 47.

Still, advocates who favor decriminalization challenge the idea that the approach is effective and say coerced treatment violates people’s rights. Meanwhile, Lenore Anderson, a co-author of Proposition 47, said “we cannot pretend that this sort of feel-good idea that we’re going to arrest and incarcerate out of it is going to work. It never has.”

Proposition 47 led to an increase in property crime, but there is no evidence that changes in drug arrests sparked any increases in crime, found a recent study by the nonprofit, nonpartisan Public Policy Institute of California.

The latest reform effort leaves many questions, said Darren Urada of the University of California-Los Angeles Integrated Substance Abuse Programs. He was the principal investigator on UCLA’s evaluation of an earlier attempt to promote treatment.

“When policies are properly implemented, treatment obtained through courts can help people. However, there are a lot of details here that are not clear, and therefore a lot of opportunities for this to go poorly,” Urada said.

For instance, the ballot measure doesn’t say what would happen to someone who enters treatment but relapses, as is common; how long they would have to complete the program; or what would constitute completion for someone in long-term treatment for mental illness or substance abuse.

Those details were deliberately left vague so that local experts like community corrections partnerships, which are already established under existing law, could decide what works best in their jurisdictions, Totten said.

Totten expects a range of approaches including diversion programs and inpatient and outpatient treatment, and that judges would be guided by the recommendations of treatment professionals.

“I’m hopeful that that will help people who are really struggling with addiction, living on the streets, who engage in petty theft and other crimes in order to support their habit — that it will be a doorway into treatment for them,” said Anna Lembke, a Stanford University addiction expert.

The November ballot measure also would allow judges to send drug dealers to state prisons instead of county jails and boost penalties for possessing fentanyl. It would make it easier to charge someone with murder if they provide illegal drugs that kill someone.

The changes could increase California’s prison population, currently about 90,000, and its county jail and community supervision population, currently around 250,000, each by “a few thousand people,” projects the state’s nonpartisan Legislative Analyst’s Office. Opponents of the measure project that the increase would be far higher: 65,000 people, most for drug offenses and most of them people of color.

Newsom, one of the initiative’s most outspoken critics, argues that the November ballot measure lacks any funding; would reduce the $800 million in Proposition 47 savings, much of which has gone to treatment and diversion programs; and would only aggravate an existing lack of treatment alternatives.

“Prop. 36 takes us back to the 1980s,” Newsom, a Democrat, said in August as he signed a package of 10 property crime bills that he and legislative leaders tout as an alternative to the broader ballot measure.

Yet, illustrating the contentiousness of the debate, the ballot measure has been endorsed by some Democratic leaders, including San Francisco Mayor London Breed, San Diego Mayor Todd Gloria, and San Jose Mayor Matt Mahan, who often highlight its treatment requirement.

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Democratic challenger Will Rollins also called out his rival, Rep. Ken Calvert, and “MAGA extremists” in an ad last week for their backing of a bill that could criminalize medical practitioners who provide abortions.

A few blocks from state Route 14 in Lancaster, about 70 miles north of downtown Los Angeles, Rep. Mike Garcia’s Democratic opponent, George Whitesides, planted two billboards promising to protect reproductive health care, a jab at the Republican congressman, who has voted to cut taxpayer funding of abortions for service members and other Americans.

As Election Day approaches, Democratic hopefuls are doing all they can to tie Republican opponents in contested congressional districts to their anti-abortion records. Aggressive ads are going up in California, Arizona, Nebraska, New Jersey, New York, and Oregon, as Democrats see an opportunity to take control of the House by engaging voters who might not vote straight-ticket — or at all. Republicans currently control the House by a slim margin.

“What we all need to do is to make sure we look at her record, and that record is contrary to what she’s putting out there in her ads,” Tran said in an interview about Steel. “We’re making sure that we educate and remind the voters of who she really is.”

Democrats are also linking Republican incumbents to former President Donald Trump, who has taken credit for the 2022 Supreme Court decision overturning Roe v. Wade. Democrats are warning voters that more restrictions could come. During the Sept. 10 presidential debate, Trump dodged a question about whether he would veto a national abortion ban if elected.

A majority of voters support restoring a federal right to abortion, according to a recent KFF poll. And 1 in 14 voters say abortion is the most important issue in determining their choice. Those voters have the potential to make a difference in the close races, said David McCuan, a political science professor at Sonoma State University.

“The politics of abortion and reproductive health can get voters to participate at higher rates,” McCuan said. “It’s going to be a defining issue.”

Democrats are hoping the issue plays to their favor in California. Voters two years ago codified abortion rights into state law. In May, Planned Parenthood Affiliates of California launched a seven-figure campaign targeting seven Republican seats and Democrat Katie Porter’s open seat.

As a result, political analysts say, Republicans have shied away from their votes on abortion and some incumbents — such as Steel, Garcia, and Central Valley U.S. Rep. David Valadao — have moderated their stances to appeal to voters.

Steel, like Garcia and Valadao, has said she supports exceptions to abortion bans in cases of rape, incest, or threats to the life of the mother. All three co-sponsored a bill amounting to a blanket abortion ban in the previous Congress. Garcia and Valadao left their names off the bill last year, but Steel signed on again as a co-sponsor — briefly.

She withdrew her support after she won her March primary, explaining that it could create confusion because the three-page bill could threaten in vitro fertilization. In a September campaign ad, Steel shared that she had used IVF to have children and reiterated her support for the procedure. Steel spokesperson Lance Trover said she opposes a national abortion ban.

None of the Republican incumbents who represent a California “toss-up” district, as determined by the nonpartisan Cook Political Report, granted KFF Health News an interview. Those who did respond said they do not support a national abortion ban.

Rep. John Duarte added that he opposes a ban because he’s “pro-choice,” and Calvert said “the issue is best decided with the states and their voters directly.” Both voted for a bill to limit medication abortion and supported a measure that would have authorized prison time for medical providers who don’t resuscitate babies born after an attempted abortion.

Tim Rosales, a political strategist who has represented Republican candidates, said these incumbents shouldn’t get heat for changing their minds over time, noting that Democratic former Presidents Bill Clinton and Barack Obama reversed their positions on same-sex marriage.

“There has to be some allowance for evolution on a variety of issues,” Rosales said.

Ben Petersen, a spokesperson for the National Republican Congressional Committee, said Democrats who have called out Republicans for inconsistencies want to move the conversation away from other topics, such as the “disastrous cost of living crisis hurting women and families caused by their one-party control of Sacramento.”

This political dance is playing out on the national stage, especially in battleground races where Republicans find themselves on defense in states where abortion is on the ballot. Roughly two dozen races are considered toss-ups.

In a March post on the social platform X, Republican Nebraska Rep. Don Bacon wrote, “I’ve always defended the life of the mother,” after his Democratic rival, Tony Vargas, called him out for supporting a national abortion ban, which makes no exceptions for cases in which the mother’s life is at risk. That same month, Rolling Stone reported that the Omaha-area congressman had deleted some anti-abortion endorsements from his website. Nebraskans will vote this November on competing abortion ballot measures.

In Arizona, where voters will also be asked whether to enshrine abortion rights into the state constitution, Republican incumbent David Schweikert this year did not support a national abortion ban, which he had co-sponsored at least six times from 2012 to 2021. In April, he wrote on X that he opposed an abortion ban in Arizona, calling on the state legislature to “address this issue immediately.”

On the airwaves, on their websites, and on the campaign trail, Republican candidates are pivoting to convince voters that they have voted to protect women. For example, Steel this month released an ad titled “Champion,” in which the Orange County sheriff says Steel has “worked tirelessly to protect victims of domestic violence and sexual abuse.”

Trover, the Steel spokesperson, said she voted two years ago to reauthorize the Violence Against Women Act. That vote was on a larger $1.5 trillion government spending bill, which included the measure.

The year before, Steel voted against reauthorizing the act.

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The bill, by Sen. Monique Limón (D-Santa Barbara) and backed by Democratic Attorney General Rob Bonta, will block health care providers, as well as any contracted collection agency, from sharing a patient’s medical debt with credit reporting agencies. At least eight states have banned medical bills from consumer credit reports in the past two years. In June, the Biden administration proposed similar federal protections, but it’s unclear when the rules will be enacted — or, if former President Donald Trump is elected again, if they will be at all.

“Nobody chooses to get sick, and then your credit gets ruined,” said Chi Chi Wu, a senior attorney with the National Consumer Law Center. “That’s why we encourage states to keep adopting laws. In case something goes wrong at the federal level, the states could protect their own consumers.”

When California’s new law goes into effect in January, it will extend these protections to credit reports used for employment and tenant screening, Wu said. This is in addition to the proposed federal ban on reporting to credit agencies that inform credit card companies and mortgage lenders.

California lawmakers noted that medical debt — unlike other kinds of debt — isn’t an accurate reflection of credit risk, and its inclusion can depress credit scores and make it hard for people to get a job, rent an apartment, or secure a car loan.

But California lawmakers have left a glaring loophole. Patients who pay hospital bills using medical credit cards or medical specialty loans — which can come with interest rates as high as 36% — won’t get that debt taken off their credit report, as residents of Colorado, Minnesota, and New York do. It’s a concession the financial industry won through late-in-the-game “hostile” amendments, which “influential entities opposed to the measure prevailed” in including, Limón said. In a 2022 KFF poll on medical debt, 15% of adults said they had used a medical credit card.

Kelly Parsons-O’Brien, legislative chair of the California Association of Collectors, which represents collection agencies, said the exemptions were essential because medical credit card holders can buy nonmedical items and medical loans can be refinanced with nonmedical debt, making it “impossible” for creditors to know what’s actually a medical charge.

“More consumers will get into situations where they cannot afford to pay, and lenders will be operating in the dark,” Parsons-O’Brien said.

The three largest U.S. credit agencies — Equifax, Experian, and TransUnion — said they would stop listing some medical debt, including paid-off debts and those less than $500, but millions of patients were left with bigger medical bills on their credit reports. The Consumer Financial Protection Bureau reported in April that 15 million Americans still had medical bills on their credit reports.

About 4 in 10 Californians report carrying some type of medical debt, which disproportionately affects low-income, Black, and Latino patients, according to the California Health Care Foundation.

Dozens of states have enacted legislation to protect consumers from surprise billing and medical debt, according to the National Conference of State Legislatures. Newsom, a Democrat, also signed legislation on Tuesday banning hospitals from using liens on all real property owned by Californians who typically earn less than 400% of the federal poverty level. It expands current state law that protects a patient’s home from debt collectors.

A KFF Health News analysis found that credit reporting is the most common collection tactic used by hospitals to get patients to pay their bills. A credit score ban might make it more difficult for hospitals to collect.

When Sacramento resident Sonia Hayden and her boyfriend applied for a home loan last year, she discovered her credit score had dropped about a hundred points. It had been downgraded because of an approximately $200 emergency room charge after a car accident years ago.

The 44-year-old said her insurance covered tens of thousands of dollars in medical bills but that the hospital miscoded the $200 charge and she never received a bill for it. That, she said, should also have been charged to insurance.

Hayden tried unsuccessfully for over a year to resolve the issue with her health insurer. It’s still on her credit report. She was eventually able to get a home loan, but her interest rates were higher because of her credit score.

“Medical bills, they’re not on purpose, you know?” said Hayden, who testified in support of the legislation. “It was already a super traumatic accident. I almost died. And then to have this super stressful medical bill — nobody’s asking for that. It shouldn’t affect your credit.”

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.

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