Tagged California

California’s Top Lawyer Cements His Role As Health Care Defender-In-Chief

SACRAMENTO, Calif. — Xavier Becerra, the political savvy Democratic attorney general of California, has sued the Trump administration 45 times in the past two years, often with much fanfare.

In winning a legal challenge Sunday against new government rules limiting birth control, he once against cemented himself as a national figure leading a fight against the administration across a range of issues — especially health care.

The 12 other states and the District of Columbia that had joined Becerra’s lawsuit also gained a last-minute reprieve from the federal regulations that would have taken effect Monday. They would have allowed most employers to refuse to provide insurance coverage for workers’ birth control by raising a religious or moral objection.

Those rules were also halted for the rest of the country on Monday when a Pennsylvania judge granted a nationwide injunction in a similar lawsuit.

The contraception case is one of several fronts where Becerra has led state coalitions to defend the Affordable Care Act in lawsuits in Texas, California and Washington, D.C.

“The Trump administration is trying to chip away at those protections,” said Andrew Kelly, an assistant professor at the Department of Health Sciences at California State University-East Bay. “It’s left to states like California and Attorney General Becerra in taking a lead in confronting these efforts.”

Becerra is perhaps best known for leading the opposition to the Texas v. U.S. lawsuit. In that suit, the Texas attorney general argued that the Affordable Care Act should be rendered unconstitutional because Congress eliminated the tax penalty on the uninsured. A federal judge last month sided with Texas, ruling that the federal health care law is unconstitutional.

Becerra, who said he helped write the health care law, said he felt compelled to step in when the Trump administration decided not to defend the law. Sixteen states and the District of Columbia joined that lawsuit, which is now on appeal.

The multistate strategy is one that attorneys general have used often in the past few decades when they don’t agree with policies coming out of Washington, legal and political experts say. And it’s not unique to one political party.

Republican attorneys general, for example, sued the Obama administration to block the expansion of Medicaid in their states. When George W. Bush was president, the state of Massachusetts led Democratic states in an effort to force the Environmental Protection Agency to regulate greenhouse gas emissions from cars.

The legal tit for tat is what Nicholas Bagley, a professor at the University of Michigan Law School, described as a disconcerting “militarization” of the state attorneys general offices to press an agenda in the courts.

“At a time of polarized politics, there’s every incentive to pull whatever levers are available to you to try to advance your goals,” Bagley said. “Over time, the state attorneys general have come to the view that the courts are an important forum to have these fights over important questions.”

The behavior of the attorneys general also comes in response to an administration that is using its executive authority to push initiatives that it can’t get Congress to approve.

President Donald Trump is left “to try to use either the regulatory process or executive order to accomplish his goals,” said Gerald Kominski, a professor of health policy at UCLA. “Anyone who opposes those goals has to proceed through the legal process to challenge them.”

Becerra, the first Latino to serve as California attorney general, has sued the Trump administration on a wide range of issues: health care, immigration, the Muslim travel ban, citizenship questions on the census, the border wall, climate change and clean-water rules.

When the former congressman was sworn in to his second term last week, he declared that he had “been a little busy keeping the dysfunction and insanity in Washington, D.C., from affecting California,” and defending the state from the “overreach of the federal government.” And he doesn’t have any plans to let up.

“Whether it’s the criminals on our streets or the con man in the boardrooms or the highest office of the land,” Becerra said, “we’ve got your back.”

But Becerra’s record has been mixed.

The victory in court Sunday was limited. Oakland-based U.S. District Judge Haywood Gilliam Jr. blocked the rules from taking effect in the District of Columbia and the 13 states that challenged them, but he refused to stop them from taking effect in the rest of the country. That national reprieve came a day later in a Pennsylvania court, with U.S. District Judge Wendy Beetlestone describing the harm to women as “actual and imminent.”

If the administration appeals, as expected, Pennsylvania, along with California and its legal coalition would move ahead with their cases to permanently throw out the rules, arguing that the Affordable Care Act guaranteed women no-cost contraception as part of their preventive health care, a provision that they say has benefited more than 62 million women since 2012, when the regulations went into effect.

The Trump rules, California argued in legal filings, would “transform contraceptive coverage from a legal entitlement to an essentially gratuitous benefit wholly subject to an employer’s discretion.” In its proposed regulations, the U.S. Department of Health and Human Services described the exemption as narrow and one that would affect a fraction of women — no more than 127,000.

That’s a number Becerra disputes.

In claiming victory on the birth control lawsuit, Becerra said Sunday that his coalition will continue to advocate for women’s access to reproductive health care.

How much more will Becerra fight during the next four years? Addressing the crowd who gathered this month to see him sworn in to a second term, he conveyed a simple response:

“The sky is the limit.”


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

California’s Top Lawyer Cements His Role As Health Care Defender-In-Chief

SACRAMENTO, Calif. — Xavier Becerra, the political savvy Democratic attorney general of California, has sued the Trump administration 45 times in the past two years, often with much fanfare.

In winning a legal challenge Sunday against new government rules limiting birth control, he once against cemented himself as a national figure leading a fight against the administration across a range of issues — especially health care.

The 12 other states and the District of Columbia that had joined Becerra’s lawsuit also gained a last-minute reprieve from the federal regulations that would have taken effect Monday. They would have allowed most employers to refuse to provide insurance coverage for workers’ birth control by raising a religious or moral objection.

Those rules were also halted for the rest of the country on Monday when a Pennsylvania judge granted a nationwide injunction in a similar lawsuit.

The contraception case is one of several fronts where Becerra has led state coalitions to defend the Affordable Care Act in lawsuits in Texas, California and Washington, D.C.

“The Trump administration is trying to chip away at those protections,” said Andrew Kelly, an assistant professor at the Department of Health Sciences at California State University-East Bay. “It’s left to states like California and Attorney General Becerra in taking a lead in confronting these efforts.”

Becerra is perhaps best known for leading the opposition to the Texas v. U.S. lawsuit. In that suit, the Texas attorney general argued that the Affordable Care Act should be rendered unconstitutional because Congress eliminated the tax penalty on the uninsured. A federal judge last month sided with Texas, ruling that the federal health care law is unconstitutional.

Becerra, who said he helped write the health care law, said he felt compelled to step in when the Trump administration decided not to defend the law. Sixteen states and the District of Columbia joined that lawsuit, which is now on appeal.

The multistate strategy is one that attorneys general have used often in the past few decades when they don’t agree with policies coming out of Washington, legal and political experts say. And it’s not unique to one political party.

Republican attorneys general, for example, sued the Obama administration to block the expansion of Medicaid in their states. When George W. Bush was president, the state of Massachusetts led Democratic states in an effort to force the Environmental Protection Agency to regulate greenhouse gas emissions from cars.

The legal tit for tat is what Nicholas Bagley, a professor at the University of Michigan Law School, described as a disconcerting “militarization” of the state attorneys general offices to press an agenda in the courts.

“At a time of polarized politics, there’s every incentive to pull whatever levers are available to you to try to advance your goals,” Bagley said. “Over time, the state attorneys general have come to the view that the courts are an important forum to have these fights over important questions.”

The behavior of the attorneys general also comes in response to an administration that is using its executive authority to push initiatives that it can’t get Congress to approve.

President Donald Trump is left “to try to use either the regulatory process or executive order to accomplish his goals,” said Gerald Kominski, a professor of health policy at UCLA. “Anyone who opposes those goals has to proceed through the legal process to challenge them.”

Becerra, the first Latino to serve as California attorney general, has sued the Trump administration on a wide range of issues: health care, immigration, the Muslim travel ban, citizenship questions on the census, the border wall, climate change and clean-water rules.

When the former congressman was sworn in to his second term last week, he declared that he had “been a little busy keeping the dysfunction and insanity in Washington, D.C., from affecting California,” and defending the state from the “overreach of the federal government.” And he doesn’t have any plans to let up.

“Whether it’s the criminals on our streets or the con man in the boardrooms or the highest office of the land,” Becerra said, “we’ve got your back.”

But Becerra’s record has been mixed.

The victory in court Sunday was limited. Oakland-based U.S. District Judge Haywood Gilliam Jr. blocked the rules from taking effect in the District of Columbia and the 13 states that challenged them, but he refused to stop them from taking effect in the rest of the country. That national reprieve came a day later in a Pennsylvania court, with U.S. District Judge Wendy Beetlestone describing the harm to women as “actual and imminent.”

If the administration appeals, as expected, Pennsylvania, along with California and its legal coalition would move ahead with their cases to permanently throw out the rules, arguing that the Affordable Care Act guaranteed women no-cost contraception as part of their preventive health care, a provision that they say has benefited more than 62 million women since 2012, when the regulations went into effect.

The Trump rules, California argued in legal filings, would “transform contraceptive coverage from a legal entitlement to an essentially gratuitous benefit wholly subject to an employer’s discretion.” In its proposed regulations, the U.S. Department of Health and Human Services described the exemption as narrow and one that would affect a fraction of women — no more than 127,000.

That’s a number Becerra disputes.

In claiming victory on the birth control lawsuit, Becerra said Sunday that his coalition will continue to advocate for women’s access to reproductive health care.

How much more will Becerra fight during the next four years? Addressing the crowd who gathered this month to see him sworn in to a second term, he conveyed a simple response:

“The sky is the limit.”


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Providers Walk ‘Fine Line’ Between Informing And Scaring Immigrant Patients

While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.

“We are walking a fine line,” said Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics. “Until there is confirmation this indeed is going to be the policy, we don’t want to add to the angst and the concern.”

However, if immigrants do come to a clinic wondering whether using Medicaid can affect their legal status, trained staff members will answer their questions, she said.

Other providers prefer to prepare their patients proactively in case the proposal is adopted. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via their patient newsletter and host workshops where patients can speak to legal experts in several Asian languages.

“We can’t just sit back and watch,” said CEO Sherry Hirota. “We allocate resources to this because that’s part of our job as a community health center — to be there not only when they’re covered, but to be there always,” even when that coverage is in jeopardy, she said.

The proposed “public charge” rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants’ use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people.

Currently, people are considered public charges if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care.

Should the rule go into effect, it could force patients to choose between health care and their chance at a green card, McCollum Plese said. “And most people will probably not take the services,” she said.

The rule would not be retroactive, meaning it wouldn’t take into account past use of public benefits like Medicaid, according to legal experts.

But health centers and medical providers know that if they tell patients about it now, they risk scaring some of them into premature decisions about their benefits, including dropping coverage.

Some immigrant patients already are skipping medical appointments out of fear stoked by the proposed rule, providers and advocates report.

“For now, our focus has been on correcting misinformation, not necessarily raising awareness among those who haven’t heard about the potential changes,” said Erin Pak, CEO of KHEIR Center, a clinic group with three locations in Los Angeles. “This is a proposal that thrives on fear and misunderstanding, so we wanted to be thoughtful about how and when to engage patients on the issue, given that nothing has passed into law.”

The Department of Homeland Security is reviewing more than 200,000 comments from the public before it issues a final rule. It’s possible the department won’t adopt the rule at all, legal experts say.

At KHEIR Center, the patient population is predominantly Korean immigrants, a group that is highly aware of the proposed public charge rule because of the coverage it has received in Korean-language media, according to Kirby Van Amburgh, the center’s director of external affairs.

Other groups served by the clinic, such as Latino and Bengali immigrants, have asked few questions, she said.

Trained staff address patients’ questions one-on-one, and hand out a fact sheet when needed.

Last month, L.A. Care health plan, which covers more than 2 million Medicaid enrollees in Los Angeles County, hosted a public charge webinar for about 180 providers. David Kane, an attorney at Neighborhood Legal Services of Los Angeles, led the webinar and urged doctors to tell concerned patients that nothing has changed yet, and that most immigrants would not be affected.

He also explained that if the federal government adopts the rule, it would not be effective immediately. There would most likely be a 60-day grace period before the changes take effect, Kane said. After that, implementation could be further delayed in court.

John Baackes, CEO of L.A. Care, who has been critical of the public charge proposal, said his organization offered the webinar because of the estimated 170,000 legal immigrants on his plan who could potentially be affected.

“I think we’ve got to let people know what could come, and try to give them more accurate information so that they don’t act imprudently,” he said. To do that, “we have to stay current.”


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Providers Walk ‘Fine Line’ Between Informing And Scaring Immigrant Patients

While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.

“We are walking a fine line,” said Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics. “Until there is confirmation this indeed is going to be the policy, we don’t want to add to the angst and the concern.”

However, if immigrants do come to a clinic wondering whether using Medicaid can affect their legal status, trained staff members will answer their questions, she said.

Other providers prefer to prepare their patients proactively in case the proposal is adopted. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via their patient newsletter and host workshops where patients can speak to legal experts in several Asian languages.

“We can’t just sit back and watch,” said CEO Sherry Hirota. “We allocate resources to this because that’s part of our job as a community health center — to be there not only when they’re covered, but to be there always,” even when that coverage is in jeopardy, she said.

The proposed “public charge” rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants’ use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people.

Currently, people are considered public charges if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care.

Should the rule go into effect, it could force patients to choose between health care and their chance at a green card, McCollum Plese said. “And most people will probably not take the services,” she said.

The rule would not be retroactive, meaning it wouldn’t take into account past use of public benefits like Medicaid, according to legal experts.

But health centers and medical providers know that if they tell patients about it now, they risk scaring some of them into premature decisions about their benefits, including dropping coverage.

Some immigrant patients already are skipping medical appointments out of fear stoked by the proposed rule, providers and advocates report.

“For now, our focus has been on correcting misinformation, not necessarily raising awareness among those who haven’t heard about the potential changes,” said Erin Pak, CEO of KHEIR Center, a clinic group with three locations in Los Angeles. “This is a proposal that thrives on fear and misunderstanding, so we wanted to be thoughtful about how and when to engage patients on the issue, given that nothing has passed into law.”

The Department of Homeland Security is reviewing more than 200,000 comments from the public before it issues a final rule. It’s possible the department won’t adopt the rule at all, legal experts say.

At KHEIR Center, the patient population is predominantly Korean immigrants, a group that is highly aware of the proposed public charge rule because of the coverage it has received in Korean-language media, according to Kirby Van Amburgh, the center’s director of external affairs.

Other groups served by the clinic, such as Latino and Bengali immigrants, have asked few questions, she said.

Trained staff address patients’ questions one-on-one, and hand out a fact sheet when needed.

Last month, L.A. Care health plan, which covers more than 2 million Medicaid enrollees in Los Angeles County, hosted a public charge webinar for about 180 providers. David Kane, an attorney at Neighborhood Legal Services of Los Angeles, led the webinar and urged doctors to tell concerned patients that nothing has changed yet, and that most immigrants would not be affected.

He also explained that if the federal government adopts the rule, it would not be effective immediately. There would most likely be a 60-day grace period before the changes take effect, Kane said. After that, implementation could be further delayed in court.

John Baackes, CEO of L.A. Care, who has been critical of the public charge proposal, said his organization offered the webinar because of the estimated 170,000 legal immigrants on his plan who could potentially be affected.

“I think we’ve got to let people know what could come, and try to give them more accurate information so that they don’t act imprudently,” he said. To do that, “we have to stay current.”


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Newsom Diverges Sharply From Washington With Health Care Budget

SACRAMENTO, Calif. — Gov. Gavin Newsom on Thursday unveiled his first state budget, one that leads California down a very different health care path than the one Washington has forged.

The progressive blueprint embraces a state health insurance mandate, beefed-up insurance subsidies, coverage for undocumented immigrants and six months of paid parental leave — not unexpected from a Democrat who campaigned on expanding health care and criticized President Donald Trump and congressional Republicans for eroding the Affordable Care Act.

The new governor declared his $209 billion state budget proposal, of which health care accounts for nearly 30 percent, “a reflection of our values.”

Newsom’s 2019-20 budget plan is just the starting point. He must negotiate with the legislature on a final budget by June 15 — so some of these proposals are certain to change or be eliminated.

“These are first-in-the-nation, new steps to provide new help for people to afford access and coverage,” said Anthony Wright, executive director of Health Access California. “That’s a good thing.”

Lee Ohanian, a senior fellow at the conservative Hoover Institution and an economics professor at the University of California-Los Angeles, countered that California would need to cut costs if it wants pay for Newsom’s initiatives.

“Newsom has a long list of very expensive things he would like to do,” Ohanian said. “He’s going to have to take money from something else.”

While the Democratic legislature is generally supportive of expanding health care coverage, there are both political and financial obstacles to the sweeping proposals that Newsom has laid out.

The governor’s plan to create subsidies for middle-class Californians, for example, relies on lawmakers approving a financial penalty on the uninsured, which was an unpopular provision in the Affordable Care Act. Newsom estimated the penalty would raise roughly $500 million a year.

The estimated subsidies would be modest. For an individual who earns between 250 and 400 percent of the federal poverty level — or between about $30,350 and $48,560 — the subsidies would average about $10 a month, said Newsom cabinet secretary Ana Matosantos. Although these Californians already qualify for a federal tax credit under the Affordable Care Act, many still can’t afford their insurance.

For individuals who make between 400 and 600 percent of the federal poverty level — or between about $48,560 and $72,840 — and therefore don’t qualify for federal tax credits, the state subsidy would come to about $70 a month on average, depending on location and premium costs, Matosantos said.

“It will certainly be a help to some people,” but doesn’t do a lot to address overall affordability, said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Congress eliminated the federal tax penalty for uninsured people, effective this year, as part of its 2017 tax bill. In response, New Jersey, Vermont and the District of Columbia have passed their own mandates in an effort to keep healthy enrollees from dumping coverage. A third state, Massachusetts, already had a state mandate.

Newsom argued during his budget briefing that, unlike the federal tax penalty, the California penalty would not be considered a tax and would only need a simple majority to win legislative approval.

“California does not need to go in the direction of the rest of the country,” he said.

Whether lawmakers will embrace the penalty is unclear, even though Democrats have supermajorities in both houses. California voters last year recalled a Democratic state senator who voted for a gas tax increase.

Assembly Health Committee Chair Jim Wood acknowledged the vote could be “a difficult one.”  The Healdsburg Democrat, who is carrying a bill to create state-based subsidies, said he is hopeful his colleagues will consider all the governor’s health care proposals as a revenue-neutral package.

For example, the executive order that Newsom signed earlier this week that directs state agencies to work together to negotiate prescription drug prices could save the state hundreds of millions of dollars, Wood said. Those savings, along with the revenue from the health insurance penalty, could help pay for subsidies, or for coverage under Medi-Cal for unauthorized immigrant young adults, he said.

“It’s kind of a three-dimensional chess game right now in trying to put all these things together,” Wood said.

Lawmakers last year considered extending full Medi-Cal benefits to both young adults and seniors who are in the country illegally. But the proposals were dropped during budget negotiations, in part because former Gov. Jerry Brown balked at the cost.

Medi-Cal is California’s version of the federal Medicaid program.

Newsom’s budget includes $260 million to pay for Medi-Cal for undocumented immigrant adults ages 19 to 25. California already covers all kids up to age 19, regardless of their immigration status. Newsom described the expansion as the right thing to do from both a moral and a financial standpoint.

U.S. Sen. Bill Cassidy (R-La.) on Tuesday announced he would introduce legislation in Congress prohibiting California from using federal dollars to provide Medi-Cal to undocumented immigrants. However, Newsom’s budget would use state dollars to pay for the expansion, just as state funds pay for undocumented children’s coverage. Cassidy’s spokesman did not return an email seeking comment.

Among the health-related proposals that still need more vetting is Newsom’s plan to expand the state’s paid parental leave program from six weeks to six months.

Details were scarce, and the governor said a task force is studying how to pay for it — whether through increased taxes on employers or using general fund dollars. That too could be a sticking point among lawmakers.

“I am a big proponent of parents spending time with newborn children,” said Assemblyman Jay Obernolte, the ranking Republican on the Assembly Budget Committee. “However, I am absolutely opposed to forcing employers to do that.”

Newsom’s budget also includes several other health-related initiatives, including:

  • $25 million to improve the detection and treatment of early psychosis, which includes symptoms such as hallucinations and disorganized thoughts and behaviors.
  • $10 million to provide clean water, including bottled or hauled water, to communities during emergencies.
  • $100 million for programs that coordinate health and social services and help provide housing for people with mental illness.
  • $60 million to increase developmental screenings for children at 9, 18 and 30 months of age.
  • $342.3 million to restore recent cuts in the In-Home Supportive Services program, which provides in-home care and transportation to low-income older people or those with disabilities.


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Podcast: KHN’s ‘What The Health?’ New Year, New Health Proposals

The new Democratic majority in the House of Representatives took its first steps on health care — voting to intervene in the appeal of a Texas-led lawsuit that found the Affordable Care Act unconstitutional in December. And around the country, Democratic governors and mayors unveiled new initiatives aimed at making health care cheaper and more accessible.

In Washington, the partial shutdown of the government has left most health agencies untouched but shuttered major parts of the Food and Drug Administration and the Indian Health Service.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Much of the attention on the impact of the federal judge’s decision in Texas to invalidate the ACA has centered on how it affects people with preexisting medical conditions. But the ruling is much more far-reaching and could affect broad swaths of health care in the country.
  • The partial government shutdown has had only a small impact on the Department of Health and Human Services, which already received its funding. But the FDA, which is funded through the Agriculture Department’s appropriations bill, is affected. Officials there say they are trying to keep up with high-risk food inspections and may bring some employees back to work.
  • The FDA receives a substantial part of its budget through the fees paid by pharmaceutical companies for review of their products. But during the shutdown, the agency is not allowed to accept more fees, so it will run out of money for drug application reviews in about a month, officials said.
  • Recent efforts by some Democratic state and local officials highlight the intraparty debate over health care. New California Gov. Gavin Newsom has proposed expanding insurance premium subsidies to people making up to 600 percent of the federal poverty level (about $72,800 for an individual) — up from the law’s current 400 percent (about $48,500) — while Washington Gov. Jay Inslee wants to set up a government-run plan that would be an option for people buying their own insurance. And in New York City, Mayor Bill de Blasio wants to offer coverage to people who are in the country illegally.
  • The latest government enrollment figures show that more than 11 million people signed up for coverage offered in the ACA marketplaces. That is down a bit from prior years, but still more than industry watchers predicted given the tax penalty for not having coverage expired this year.
  • The small slippage in enrollment in the past two years, following changes made by the Trump administration and a Republican-led Congress, may signal challenges in the future, especially in small markets where getting competition has been tough.

Also this week, Julie Rovner interviews KHN senior correspondent Jordan Rau, who investigated and wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a skiing accident that required repeat surgeries — and bills for the patient, although she did nothing wrong. You can read the story here, and its update here.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Rewire.News’ “There’s Almost No Data About What Happens When Catholic Hospitals Deny Reproductive Care,” by Amy Littlefield

Rebecca Adams: The Washington Post Magazine’s “Life, Death and Insulin,” by Tiffany Stanley

Margot Sanger-Katz: Vox.com’s “A $20,243 Bike Crash: Zuckerberg Hospital’s Aggressive Tactics Leave Patients With Big Bills,” by Sarah Kliff

Anna Edney: The Washington Post’s “The FDA Is Still Letting Doctors Implant Untested Devices Into Our Bodies,” by Jeanne Lenzer and Shannon Brownlee

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Newsom Comes Out Swinging On Day One For Single-Payer, Immigrant Coverage

SACRAMENTO, Calif. — Within hours of assuming office Monday, Gov. Gavin Newsom issued a defiant challenge to the Trump administration with sweeping plans to expand health coverage to more Californians, pushing for a single-payer system and insurance for undocumented young adult immigrants.

He also called for new state-funded subsidies to help people afford health insurance, coupled with a requirement that all Californians have health insurance. And he signed an executive order that directs state agencies to work together to negotiate prescription drug prices.

Newsom revealed his proposals on Facebook Live, following a combative inaugural speech earlier in the day in which he vowed to stand up to a “corrupt” administration in Washington and lead California along a progressive path.

“Every person should have access to quality, affordable health care,” Newsom said in his inaugural speech. “Far-away judges and politicians may try to turn back our progress. But we will never waver in our pursuit of guaranteed health care for all Californians.”

Newsom had campaigned for a single-payer system, and he said Monday that he remained committed to it. In a letter to President Donald Trump and congressional leaders, Newsom called on the federal government to allow California and other states to create a single-payer payer program.

U.S. Rep. Ro Khanna (D-Calif.), who is working with Newsom, said Congress needs to pass a bill that gives states permission to create their own health care programs and still receive federal funding.

While that request seems like a long shot in the Republican-controlled Senate, Khanna said he and other Democratic lawmakers want to start hearings in the Democratic-controlled House of Representatives — in preparation for when there is a Democrat in the White House.

“Realistically, we’re looking at 2021 before this could become law,” Khanna said.

Newsom’s out-of-the-gate move on single-payer reflects a clear shift from his predecessor, Democratic Gov. Jerry Brown, who had described the ambitious proposal — which could cost an estimated $400 billion annually — as financially impossible.

Newsom’s announcement also gives momentum to advocates of single-payer both in California and nationally.

“This is a necessary first step in getting this program together,” said Stephanie Roberson, director of government relations at the California Nurses Association, a group that has been among the most outspoken advocates for single-payer in the state. “This is definitely a campaign promise that has come to fruition for us.”

As a candidate, Newsom had also backed expanding health care to young adults who are in the country illegally — a Democratic plan that died in budget negotiations last year when Brown balked at the estimated cost: $140 million for the first year.

Newsom said his budget, scheduled to be released Thursday, will set aside state funding to expand Medi-Cal, California’s version of the federal Medicaid program for low-income people, to eligible adults up to age 26. That would make California the first state to provide full Medicaid benefits to unauthorized immigrant adults.

In 2016, California opened Medi-Cal to all kids up to age 19, regardless of their immigration status. Since then, more than 250,000 children have enrolled.

Immigration and health care advocates estimate that more than 100,000 young adults aged 19 to 25 could enroll if Newsom’s proposal is adopted by the state legislature.

“The truth is we need every single adult to be covered. That’s the best way to make sure people thrive,” said Almas Sayeed, with the California Immigrant Policy Center. “But we’re thrilled that he is picking up a part of this campaign — and this early on.”

Immigrants in the country illegally make up almost 60 percent of California’s roughly 3 million uninsured residents.

Newsom also wants California to become the first state to offer subsidies to middle-class families who struggle to buy health insurance. Under the Affordable Care Act, people who earn more than 400 percent of the federal poverty level — about $48,500 a year for an individual or about $100,000 for a family of four — don’t qualify for federal financial assistance to help them purchase their own policies. Newsom’s plan would provide state subsidies to individuals earning up to $72,840 and families of four earning up to $150,600.

To pay for those subsidies, for which the new governor did not put a price tag, Newsom said he will ask the Democratic-controlled legislature to impose a health coverage requirement on Californians — and a penalty for those who don’t comply.

The federal tax penalty for uninsured people under the Affordable Care Act went away on Jan. 1, a provision of the Republican tax bill of 2017.

A state mandate to have insurance may be the most controversial piece of Newsom’s proposals, said Larry Levitt, a senior vice president at the Kaiser Family Foundation. “There would be real concerns raised of whether coverage is affordable enough to require people to get it,” he said. “Pairing the expansion in subsidies for people in the middle class with the individual mandate may make the mandate more palatable.” (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

In other moves that don’t require legislative approval, Newsom signed an executive order creating the new position of California surgeon general, who he said would promote preventive care and highlight health disparities across California.

The new governor also signed an order directing state agencies to collaborate on purchasing prescription drugs.

Currently, state agencies negotiate individually with drug companies for prisons or veterans, for example.

There are various ways the state could consolidate prescription drug purchasing, and some would require federal approval, said Erin Trish, associate director of the USC Schaeffer Center for Health Policy & Economics. A consolidated negotiator could achieve lower prices, but that could require limiting the number of covered drugs, Trish said. “You have to be willing to exclude coverage of drugs to have meaningful bargaining leverage to change prices,” she added.

This and Newsom’s other first-day proposals underscore that California has a governor who intends to focus on health care, Trish and other policy experts said.

“This is an issue that he cares about, that California cares about, that he has experience on and strong opinions on,” she said. “This is the Newsom administration putting the stake in the ground, saying we are going to take on health care.”


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

End Of Tax Penalty Could Fall Hardest On Previously Uninsured Californians

The elimination of the Affordable Care Act tax penalty on people who don’t have health insurance could roll back recent coverage gains for Hispanics, young people, the healthy and the poor, according to a new study.

The study, published Monday in the journal Health Affairs, stems from a 2017 survey in which researchers at Harvard University Medical School and Massachusetts General Hospital asked more than 3,000 Californians who had bought individual health care plans: “Would you have purchased health insurance coverage this year if there was no penalty?”

Nineteen percent said they would not have, and a disproportionately large number of those were in population groups most likely to be uninsured before the law took effect.

“Especially for lower-income consumers who are potentially eligible for subsidies, it’s really important to try to understand how eliminating the penalty might affect their choices,” said Vicki Fung, lead author of the study and an assistant professor of medicine at Harvard Medical School.

The federal penalty for not having health coverage disappeared Jan. 1, following the decision by the Republican-controlled Congress to reduce it to zero in the 2017 tax reform package. While it was in effect, the penalty potentially cost a taxpayer thousands of dollars a year — though the ACA allowed numerous exemptions from coverage based on financial hardship and other personal circumstances.

The researchers behind the Health Affairs study estimated that if the people who said they would drop insurance in the absence of a penalty had not been enrolled in a health plan, premiums would have been 4 to 7 percent higher that year. Covered California, the state’s Obamacare exchange, said last summer that the elimination of the penalty added nearly 4 percentage points to its average 2019 premium.

The study concluded that other states could be harder hit than California by the elimination of the penalty. Premium increases of the magnitude they estimated for the Golden State are unlikely to destabilize its individual insurance market, they said.

Covered California has spent hundreds of millions of dollars promoting its health plans to consumers — more than the federal government spends for the 39 states that use the federal healthcare.gov exchange.

Still, the loss of coverage caused by ending the tax penalty could fall heavily on many Californians, the study suggests.

About 31 percent of Hispanics responding to the survey said they would not buy health insurance if it were not required, compared with 13 percent of whites, Fung said. (Hispanics can be of any race.)

About 22 percent of people without chronic conditions said they would not have bought insurance if there were no penalty, compared with 12 percent of those with two or more chronic illnesses, according to the study. And more than twice as many men aged 18 to 30 said they would have dropped coverage than among those 51 and older.

The percentage of health plan enrollees who said they would skip coverage in the absence of the penalty was also higher among those with lower income and education levels.

The study’s findings largely echo what other policy analysts have found. But most of their studies have involved statistical models, rather than direct surveys of consumers, Fung said.

A University of California-Berkeley study released in November projected that between 150,000 and 450,000 fewer Californians would enroll in coverage in 2020 without the penalty. An analysis by the Congressional Budget Office estimated that repealing the penalty would induce 4 million people nationally to forgo coverage this year, and 13 million in 2027.

About 1.3 million Californians bought health insurance through Covered California in 2018. A vast majority of them qualified for federal tax credits that lower their premiums, and about 44 percent also got subsidies to reduce what they pay out-of-pocket when they seek care.

The Health Affairs study “really underscores the need for state policies to protect the gains we’ve made and to continue progress toward universal coverage, such as state-level individual mandates and subsidies to buy coverage,” said Laurel Lucia, director of the health care program at the UC-Berkeley Labor Center and one of the authors of the UC-Berkeley study.

Legislative proposals last year to create state-based financial aid for purchasing insurance failed, but their proponents have renewed hope for some of their ideas under California’s new Democratic governor, Gavin Newsom.


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

No-Go On Drunken Driving: States Deploy Breathalyzers In Cars To Limit Road Deaths

On Jan. 1, California joined the majority of states that have laws requiring drivers with drunken-driving convictions to install breathalyzers in vehicles they own or operate.

Researchers, public health advocates and political leaders believe these laws are helping reduce alcohol-related road deaths.

The gadgets, known as ignition interlock devices, are mounted on the steering wheel of a vehicle and prevent it from starting if the driver’s blood-alcohol reading is above a predetermined level.

In California, the breathalyzers are mandatory only for repeat offenders. Five other states — Georgia, Indiana, Massachusetts, Montana and Ohio — have similar laws. Thirty-two states and D.C. require the devices even for first-time offenders.

The advent of such laws across the United States in the past 15 years has been accompanied by some good news: Deaths involving drunken driving are only about half of what they were in the early 1980s, though they have ticked back up in recent years. The long-term decline is largely attributable to greater public awareness, stricter seat belt enforcement and the establishment in 2000 of a nationwide legal blood-alcohol threshold of 0.08 percent — far below the 0.15 percent standard commonly used before then.

State Sen. Jerry Hill (D-San Mateo), the author of the California law, said breathalyzers in cars will make roads safer than under the current law, which generally relies on license restrictions and suspensions.

“We’ve seen people on a suspended license continue to drive and continue to cause destruction,” said Hill, who lost his best friend to drunken driving in the 1980s.

There is some evidence that the breathalyzers have an impact. Nationally, from 2006 to 2016, ignition-locking breathalyzers prevented 2.3 million attempts to drive by people with a blood-alcohol level at or above 0.08 percent — the legal threshold for driving under the influence — according to a 2017 report by the advocacy group Mothers Against Drunk Driving.

Emma McGinty, an associate professor at the Johns Hopkins Bloomberg School of Public Health, found that laws requiring interlocks for all DUI offenders were associated with a 7 percent drop in the rate of fatal crashes caused by drunken drivers. Another study found that laws covering all offenders were associated with 15 percent fewer alcohol-related fatalities compared with states that have less stringent laws.

Federal data show that in some states the number of alcohol-related deaths was lower a few years after the implementation of ignition interlock laws. But the declines could have been caused by multiple factors. In other states, crash deaths were higher. And in some, the number has bounced up and down.

New Mexico was the first state to implement an interlock law that applied to all offenders, including first-timers. The state saw a significant drop in DUI-related deaths about three years after its law took effect in 2005. The biggest dip came seven years after the law took effect, but then the number started to creep up again.

Texas, which enacted an all-offender law in 2015, has seen drunken-driving fatalities rise since then — but that meshes with the national increase recorded in 2016 and 2017. Some researchers think the strength of the economy can influence fatality statistics. “One thing that is often speculated is that as the economy gets better, people drive more,” McGinty said. “By virtue of having more people on the road, [we’re] likely to see an uptick in crashes.”

Oregon enacted its interlock law in 2008, when the state recorded 137 DUI-related fatalities. Two years later, the number of alcohol-involved crash deaths had dropped by almost half, to 70. But by 2015, it had spiked back up to 154 deaths.

The new California law builds on a pilot program in four counties — Alameda, Los Angeles, Sacramento and Tulare — which have required interlock devices in the vehicles of all DUI offenders since 2010.

The statewide law requires installation of an interlock device for one year after the second DUI offense, and for six months after a first offense if somebody is injured. After a first DUI with no injury, the driver can choose to avoid license restrictions by installing a device in his car for six months.

Installation of the breathalyzers runs from $70 to $150, and they cost another $60 to $80 a month to maintain. But the law provides for a sliding scale based on people’s income, so low-income drivers would end up paying only a small percentage of the total cost.

Advocates of interlock laws say they would rather see a statewide California law targeting all DUI offenders, not just repeat offenders. McGinty’s research shows a much smaller decline in alcohol-related fatal crash rates associated with repeat-offender laws.

But even as is, “the law will make a difference,” said Frank Harris, director of state government affairs at Mothers Against Drunk Driving. “If a person gets a DUI, the next day they can get an ignition interlock device and drive, go to work, go to their kid’s soccer games. The trade-off for society is that those folks are driving sober.”


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Sweetgreen Makes Healthful Fast Food — But Can You Afford It?

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Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.Credit Jason Henry for The New York Times

Healthful, fast and affordable food is the holy grail of the public health and nutrition community. A popular restaurant chain shows just how much of a challenge that is.

It began when three Georgetown University students were frustrated that they could not find a healthy fast-food restaurant near their campus. With money raised from family and friends, they started their own, renting a small storefront on M Street in Georgetown. The result was Sweetgreen, a restaurant that offered organic salads, wraps and frozen yogurt. Pretty soon, the daily line of lunchtime customers stretched out the door and around the corner.

Ten years later, the line is still there, but Sweetgreen has grown into a nationwide salad chain, with more than 40 locations. Sweetgreen is part of a small but growing breed of farm-to-table fast-food chains – like Chopt Creative Salad Company on the East Coast and Tender Greens in California – that are giving fast-food restaurants a plant-based makeover. Their mission: to fix fast food, which has long been fattening and heavily processed.

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At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.Credit Jason Henry for The New York Times

Sweetgreen’s owners say their goal is to offer customers foods made with nutritious, sustainable and locally grown ingredients. The company has decentralized its food sourcing and production. Fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site. They don’t sell soda or use refined sugar.
Sweetgreen expects to open another 20 stores in major cities around the country this year, and eventually to expand to places where experts say healthy, delicious fast food is needed most — low-income neighborhoods.

But while the chain has proven there is a big appetite for more healthful fast food, the goal of taking this concept to poor areas may be a distant reality. The company and other chains like it operate almost exclusively in affluent communities, far from the low-income food deserts where obesity is rampant and farmers’ markets and healthy food stores are scarce. And with salads that typically cost between $9 and $14, some question whether a healthful fast-food chain like Sweetgreen can ever be affordable for average Americans.

Maegan George, a Columbia University student who lives near a Sweetgreen, calculated that for the price of one Sweetgreen salad, she could buy the same ingredients in bulk at a local market and make several similar salads at home.

“I’m a first-generation student and I’m on full financial aid,” she said. “Sweetgreen is delicious and I enjoy it. But there’s no way I could afford to eat there on a regular basis.”

Jackie Hajdenberg, another Columbia student, wrote about the restaurant for the campus newspaper, The Spectator, earlier this year, lamenting that on a per calorie basis, a salad at Sweetgreen was three times the price of a Big Mac at McDonald’s.

“Sweetgreen has not only made it easier for people to make healthy decisions – it has also illustrated the unequal socioeconomic landscape of the world in which we live,” she wrote.

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Salad options at Sweetgreen change often, depending on what is available at local farms.

Salad options at Sweetgreen change often, depending on what is available at local farms.Credit Jason Henry for The New York Times

Sweetgreen says it prices its food so that it can compensate its suppliers and employees fairly, and that it expects nutritious fast food to become more affordable as the healthy food movement grows. Nicolas Jammet, a co-founder of Sweetgreen, said the company wants to serve lower-income customers, and has long-term plans to expand to low-income communities.

To get there, he said, the company will have to overcome hurdles involving its supply chain, the minimum wage and greater nutrition awareness and education among the public. For the past six years the company has been running a nutrition education program in schools that teaches children about healthier eating and locally grown food.

“It’s a long-term goal for us to be part of this larger systematic change that needs to happen,” he said. “But there are so many parts of this problem that need to be addressed.”

Mr. Jammet notes that the company was among the first to show that fast-food chains don’t need profits from soda and sugary drinks to succeed. He believes chains like Sweetgreen have caused a ripple effect throughout the fast-food industry.

In January, for example, Chick-fil-A unveiled a new kale, broccolini and nut “superfood” salad, responding to customer demands for “new tastes and healthier ways to eat in our restaurants.” McDonald’s is experimenting with kale salads, and Wendy’s is testing a spinach, chicken and quinoa salad.

“Companies like McDonald’s have more power to change the way that people eat than we do,” Mr. Jammet said. “We don’t see these companies as the enemy. We just have to force change on them.”

Public health experts say that such changes cannot come soon enough. A University of Toronto study recently showed that people have a higher risk of developing diabetes if they live in “food swamps” – an area with three or more fast-food restaurants and no healthy dining options.

Another study published in JAMA in June found that the percentage of Americans eating an unhealthy diet — high in sugar, refined grains, soft drinks and processed foods and low in fruits and vegetables — was on the decline, but the improvements in diet were much smaller for lower-income Americans.

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Customers wait in line at Sweetgreen in Berkeley, Calif.

Customers wait in line at Sweetgreen in Berkeley, Calif.Credit Jason Henry for The New York Times

Overall about twice as many people from poor households have poor diets compared to those at higher income levels.
Why is traditional fast food so cheap? One reason is the underlying infrastructure of the industry. Many of the ingredients, like the soy that’s turned into oil for deep fryers, or the the corn that’s fed to animals and used to make high-fructose corn syrup, begin with crops that are heavily subsidized by the government. To make their food economical, many traditional fast-food chains mass-produce their food in large factories, often stripping it of fiber and other nutrients that decrease its shelf life, while adding salt, sugar and other flavorings and preservatives.

Then they freeze and ship the processed components, like burger patties, bread, pickles and sauce, to their restaurants. There they are reheated and assembled, often with minimal effort, ensuring that a Big Mac in Seattle looks and tastes the same as a Big Mac in Charlotte, N.C.

By comparison, every Sweetgreen location has a chalkboard that lists the farms where its organic arugula, peaches, yogurt or blueberries are produced. As a result, the menus vary by location and by season. In Boston, Sweetgreen stores use New England Hubbard squash. In Los Angeles, the menu features a different variety of squash grown locally in California.

Those differences mean fresher, more nutritious ingredients, but ultimately costlier food for customers — one of the obstacles that Sweetgreen and other chains like it will have to overcome if they hope to make their food more accessible to all income brackets.
Marion Nestle, a professor of nutrition, food studies and public health at New York University and the author of “Food Politics,’’ says restaurants like Sweetgreen offer an encouraging, but imperfect, model for making fast food more healthful.

“What’s not to like?” she asks. “The cost, maybe, but for people who can afford it the quality is worth it. Next step: Moving the concept into low-income areas.”

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