Tagged California

Childbirth In The Age Of Addiction: New Mom Worries About Maintaining Sobriety

When she was in her early 20s, Nicole Veum says, she made a lot of mistakes.

“I was really sad and I didn’t want to feel my feelings,” she said. “I turned to the most natural way I could find to cover that all up and I started using drugs: prescription pills, heroin for a little bit of time.”

Veum’s family got her into treatment. She’d been sober for nine years when she and her husband, Ben, decided to have a baby. Motherhood was something she wanted to feel.

If she needed an epidural during labor, Veum told her doctor, she didn’t want any fentanyl in it. She didn’t want to feel high.

“I remembered seeing other friends,” she said. “They’d used it, and they were feeling good and stuff. I didn’t want that to be a part of my story.”

An epidural is a form of regional anesthesia given via an injection of drugs into the space around the spinal cord. It is typically a mix of two types of medication: a numbing agent, usually from the lidocaine family, and a painkiller, usually fentanyl.

The amount of fentanyl in the mix is limited, and little passes into the bloodstream, anesthesiologists say. But if a woman doesn’t want the fentanyl, it’s easy to formulate an epidural solution without it. Doctors either use a substitute medication or boost the concentration of the numbing agent.

“There’s no medical reason why someone should be forced to be exposed to opioids if they don’t want to,” said Dr. Kelly Pfeifer, a family physician and addiction expert who now works as director of high-value care at the California Health Care Foundation. (Kaiser Health News produces California Healthline, an editorially independent publication of the California Health Care Foundation.)

Pfeifer said there’s another situation to be aware of: pregnant women who are taking methadone or suboxone to manage opioid addiction. During labor, anesthesiologists often prescribe narcotics to help manage pain, but some of those commonly used — like Nubain — can immediately reverse the effects of methadone or suboxone.

“Suddenly, you’re in the middle of labor — which is already painful — and now you’re in the middle of the worst withdrawal of your life,” Pfeifer said.

Adrian Veum plays at home. Nicole Veum says she’s loving being his mom, and feels “reborn.”(Adam Grossberg/KQED)

For Veum, one of the worst wildfires in California’s recorded history is what interrupted her birth plan. She and her husband live in Santa Rosa, Calif., and she was in active labor when devastating fires ignited nearby on Oct. 8, 2017. What are now known as the “Wine Country Wildfires” burned more than 5,000 homes and killed 44 people.

“There was a ton of smoke in the hospital,” Veum said. “Like you could visibly see it outside — and smell it.”

Nurses told her everybody had to evacuate. Veum was transferred to another hospital, 5 miles away. And the special instructions for her epidural got lost in the chaos.

“Then, when they went to change the drug, I saw the tube said ‘Fentanyl’ on it,” she recalled. “And by that point I was starting to feel ‘the itchies’” — one of the familiar physical signs she would experience when starting to get high.

Most women without a history of addiction wouldn’t experience these sensations when given opioid anesthesia, said Dr. Jennifer Lucero, chief of obstetric anesthesiology at the University of California-San Francisco Medical Center. Anytime a woman who is not in recovery asks for an epidural without fentanyl (usually out of the mom’s concern for the baby), Lucero explains why it’s there.

The fentanyl allows the anesthesiologist to balance out the numbing agent in the solution, she said, so women don’t have as much pain from the contractions but can still feel the pressure and are able to move their legs a bit or shift in bed during labor.

Once she explains the trade-offs, and assures women that the opioid will have no effect on their fetus, most of her patients opt to keep fentanyl in the epidural solution.

But doctors have been trying to cut down on administering opioids in other ways during labor and delivery, namely in what they prescribe for pain after the birth.

For years, women who had a normal, vaginal birth were sent home with a 30-day supply of Norco, Percocet or another opioid, Lucero said.

“Some people would think they’re supposed to take them all,” Lucero said, while other women “would not use it, and it would just be sitting in the bathroom cabinet.”

While most people who get a bottle of pills when leaving the hospital won’t develop dependence or an addiction, some will. When a patient is prescribed opioids for short-term pain, the risk of chronic use starts to increase as early as the third day of the prescription, according to a report published last year by the Centers for Disease Control and Prevention. A study out this year suggests that every week of opioid use increases the risk of misuse.

As recently as 2017, postpartum women were routinely being prescribed three- to five-day supplies of opioids — even after an uncomplicated vaginal delivery. A study published that year of 164,720 Pennsylvania women on Medicaid who gave birth vaginally found that 12 percent of them filled an opioid prescription after they gave birth — even though most did not have a clear medical need for a painkiller, such as vaginal tearing or an episiotomy.

Now obstetricians are issuing new guidelines to patients, Lucero said, and they’re trying to prescribe limited amounts of opioids, and only post-surgically, to women who have had a cesarean section.

Nicole Veum ended up being one of those women. After she was transferred to the second hospital during the wildfire evacuation, she spent another 12 hours in the early stages of labor, but she wasn’t progressing. She agreed to a C-section.

After the birth of her son, doctors sent her home with a bottle of Percocet — another opioid. They told her that if she was worried about being able to maintain her sobriety, she could have her husband or a friend hold on to the bottle and control the dosage.

Pfeifer, the physician and addiction specialist, said that in a situation like that, sending Veum home with just a few Percocet pills, or even suggesting she take only ibuprofen, would have been fine.

“Any parent will tell you there’s nothing more stressful than the first week of being a parent and having a baby and being in sleep deprivation,” Pfeifer said. “And here you have a little bottle of Vicodin that you used to turn to, to make you feel better when you’re stressed.”

First the fires. Then the fentanyl in her epidural. Then the Percocet. It was Veum’s first test in seeing how her sobriety and motherhood would line up. She called a friend who was also in recovery. They talked it all through, and Veum was fine.

“I was OK. I was OK with it. It was just something that happened,” she said as her baby, Adrian, now a year old, plays with a new toy.

Veum is 32 now. She’s returned to school this fall to work toward her college degree, after a 14-year break. And she is loving being a mom.

“A lot of people, metaphorically, felt it as a baby coming out of the ash — the life coming from the ashes,” she said about her child born in the midst of the 2017 wildfires.

“And I feel that,” Veum said. “I feel like it was a big time for our community — and me personally — to be reborn in some way.”

This story is part of a partnership that includes KQEDNPR and Kaiser Health News.


KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

An Underused Strategy For Surge In STDs: Treat Patients’ Partners Without A Doctor Visit

If patients return to Dr. Crystal Bowe soon after taking medication for a sexually transmitted infection, she usually knows the reason: Their partners have re-infected them.

“While you tell people not to have sex until both folks are treated, they just don’t wait,” she said. “So they are passing the infection back and forth.”

That’s when Bowe, who practices on both sides of the North and South Carolina border, does something doctors are often reluctant to do: She prescribes the partners antibiotics without meeting them.

Federal health officials have recommended this practice, known as expedited partner therapy, for chlamydia and gonorrhea since 2006. It allows doctors to prescribe medication to their patients’ partners without examining them. The idea is to prevent the kind of reinfections described by Bowe — and stop the transmission of STDs to others.

However, many physicians aren’t taking the federal government’s advice because of entrenched ethical and legal concerns.

“Health care providers have a long tradition of being hesitant to prescribe to people they haven’t seen,” said Edward Hook, professor at the University of Alabama’s medical school in Birmingham. “There is a certain skepticism.”

A nationwide surge of sexually transmitted diseases in recent years, however, has created a sense of urgency for doctors to embrace the practice. STD rates have hit an all-time high, according to the Centers for Diseases Control and Prevention. In 2017, the rate of reported gonorrhea cases increased nearly 19 percent from a year earlier to 555,608. The rate of chlamydia cases rose almost 7 percent to 1.7 million.

“STDs are everywhere,” said Dr. Cornelius Jamison, a lecturer at the University of Michigan Medical School. “We have to figure out how to … prevent the spread of these infections. And it’s necessary to be able to treat multiple people at once.”

A majority of states allow expedited partner therapy. Two states — South Carolina and Kentucky — prohibit it, and six others plus Puerto Rico lack clear guidance for physicians.

A 2014 study showed that patients were as much as 29 percent less likely to be re-infected when their physicians prescribed medication to their partners. The study also showed that partners who got those prescriptions were more likely to take the drugs than ones who were simply referred to a doctor.

Yet only about half of providers reported ever having prescribed drugs to the partners of patients with chlamydia, and only 10 percent said they always did so, according to a different study. Chlamydia rates were higher in states with no law explicitly allowing partner prescriptions, research published earlier this year showed.

Because of increasing antibiotic resistance to gonorrhea, the CDC no longer recommends oral antibiotics alone for the infection. But if patients’ partners can’t go in for the recommended treatment, which includes an injection, the CDC said that oral antibiotics by themselves are better than no treatment at all.

“Increasing resistance plus increasing disease rates is a recipe for disaster,” said David Harvey, executive director of the National Coalition of STD Directors. The partner treatment is important for “combating the rising rates of gonorrhea in the U.S. before it’s too late.”

The CDC recommendations are primarily for heterosexual partners because there is less data on the effectiveness of partner treatment in men who sleep with men, and because of concern about HIV risk.

Bowe said that even though she writes STD prescriptions for her patients’ partners, she still worries about possible drug allergies or side effects.

“I don’t know their medical conditions,” she said. “I may contribute to a problem down the road that I’m going to be held liable for.”

Physician Crystal Bowe, who practices in North and South Carolina, said she occasionally writes prescriptions for her patients’ partners but worries about possible drug allergies or side effects. “I don’t know their medical conditions,” she says. “I may contribute to a problem down the road that I’m going to be held liable for.” (Courtesy of Crystal Bowe)

In many cases, doctors and patients simply do not know about partner therapy. Ulysses Rico, who lives in Coachella, Calif., said he contracted gonorrhea several years ago and was treated by his doctor. He didn’t know at the time that he could have requested medicine for his girlfriend. She was reluctant to go to her doctor and instead got the required antibiotics through a friend who worked at a hospital.

“It would have been so much easier to handle the situation for both of us at the [same] moment,” Rico said.

Several medical associations support partner treatment. But they acknowledge the ethical issues, saying it should be used only if the partners are unable or unwilling to come in for care.

Federal officials are trying to raise awareness of the practice by training doctors and other medical professionals, said Laura Bachmann, chief medical officer of the CDC’s office of STD prevention. The agency posts a map with details about the practice in each state.

Over the past several years, advocates have won battles state-by-state to get partner treatment approved, but implementation is challenging and varies widely, said Harvey, whose National Coalition of STD Directors is a member organization that works to eliminate sexually transmitted diseases.

The fact that some states don’t allow it, or haven’t set clear guidelines for physicians, also creates confusion — and disparities across state lines.

The Planned Parenthood affiliate that serves Indiana and Kentucky sees this firsthand, said clinical services director Emilie Theis. In Indiana, providers can legally write prescriptions for their patients’ partners, but they are prohibited from doing so in Kentucky, even though the clinics are only a short drive apart, she noted. A similar dynamic is at play along the South Carolina-North Carolina border, where Bowe practices.

California started allowing partner treatment for chlamydia in 2001 and for gonorrhea in 2007. The state gives medication to certain safety-net clinics, a program it expanded three years ago. However, “it has been an incredibly difficult sell” because many medical providers think “it’s a little bit outside of the traditional practice of medicine,” said Heidi Bauer, chief of the STD control branch of California’s public health department.

At APLA Health, which runs several health clinics in the Los Angeles area, nurse practitioner Karla Taborga occasionally gives antibiotics to patients for their partners. But she tries to get the partners into the clinic first, because she worries they might also be at risk for other sexually transmitted infections.

“If we are just treating for chlamydia, we could be missing gonorrhea, syphilis or, God forbid, HIV,” Taborga said. But if prescribing the drugs without seeing the patients is the only way to treat them, she said, “it’s better than nothing.”

Edith Torres, a Los Angeles resident, said she pressured her then-husband to go to the doctor after he gave her chlamydia several years ago: She refused to have sex with him until he did. Torres said she wanted him to hear directly from the doctor about the risks of STDs and how they are transmitted.

If he had taken the medication without a doctor visit, he wouldn’t have learned those things, she said. “I was scared, and I didn’t want to get it again.”


KHN’s coverage in California is supported in part by Blue Shield of California Foundation.

Podcast: KHN’s ‘What The Health?’ Split Decision On Health Care

Voters on Election Day gave control of the U.S. House to the Democrats but kept the U.S. Senate Republican. That will mean Republicans will no longer be able to pursue partisan changes to the Affordable Care Act or Medicare. But it also may mean that not much else will get done that does not have broad bipartisan support.

Then the day after the election, the Trump administration issued rules aimed at pleasing its anti-abortion backers. One would make it easier for employers to exclude birth control as a benefit in their insurance plans. The other would require health plans on the ACA exchanges that offer abortion as a covered service to bill consumers separately for that coverage.

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

Among the takeaways from this week’s podcast:

  • The Trump administration’s new contraception coverage rule comes after an earlier, stricter regulation was blocked by federal courts.
  • The insurance bills that the Trump administration is now requiring marketplace plans to send to customers for abortion coverage will be for such a small amount of money that they could become a nuisance and may persuade insurers to give up on the benefit.
  • House Democrats, when they take control in January, say they want to move legislation that will allow Medicare to negotiate drug prices. But fiscal experts say that may not have a big impact on costs unless federal officials are willing to limit the number of drugs that Medicare covers.
  • It appears that both Democrats and Republicans in Congress are interested in doing something to protect consumers from surprise medical bills. The issue, however, may fall to the back of the line given all the more pressing issues that Congress will face.
  • One of the big winners Tuesday was Medicaid. Three states approved expanding their programs, and in several other states new governors are interested in advancing legislation that would expand Medicaid.

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

Julie Rovner: Kaiser Health News’ “Hello? It’s I, Robot, And Have I Got An Insurance Plan For You!” by Barbara Feder Ostrov

Margot Sanger-Katz: Stat News’ “Life Span Has Little to Do With Genes, Analysis of Large Ancestry Database Shows,” by Sharon Begley

Joanne Kenen: The Washington Post’s “How Science Fared in the Midterm Elections,” by Ben Guarino and Sarah Kaplan

Rebecca Adams: The New Yorker’s “Why Doctors Hate Their Computers,” by Atul Gawande

To hear all our podcasts, click here.

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

Measure To Cap Dialysis Profits Pummeled After Record Spending By Industry

Record-breaking spending by the dialysis industry helped doom a controversial California ballot measure to cap its profits.

The industry, led by DaVita and Fresenius Medical Care, spent nearly $111 million to defeat Proposition 8, which voters trounced, 62 to 38 percent, and appeared to approve in just two of 58 counties. The measure also faced strong opposition from medical organizations, including doctor and hospital associations, which argued it would limit access to dialysis treatment and thus endanger patients.

The opposition presented a powerful message that “if you can’t get dialysis, you will die,” said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. “If you didn’t know that, the commercials made it clear.”

Despite arguments about the outsize profits of dialysis companies, Kominski said the “Yes on 8” case wasn’t as clear. The measure, sponsored by the Service Employees International Union-United Healthcare Workers West, sought to cap dialysis clinic profits at 115 percent of the costs of patient care. Revenues above that amount would have been rebated primarily to insurance companies. Medicare and other government programs, which pay significantly lower prices for dialysis, wouldn’t have received rebates.

The union raised nearly $18 million — a large sum for most initiatives but about 16 percent of what the opposition mustered.

The proposition also was poorly written and difficult for voters to understand, said Erin Trish, associate director of health policy at the USC Schaeffer Center for Health Policy and Economics. Trish said she wasn’t surprised by the landslide defeat given the widespread ads against the initiative about the potential harms to patients. “The message came through loud and clear,”  she said.

Trish said health care industry groups genuinely viewed Proposition 8 as a poor initiative — but they also didn’t want to see rate regulation. “This is not what most of these associations want to open the door to,” Trish said.

Generally speaking, said Jessica Levinson, a professor at Loyola Law School, voters’ default on initiatives is “no.” In addition, money spent against an initiative is usually more effective than money spent for it. Levinson said people weren’t 100 percent sure what they were voting on with Proposition 8. All of those factors made passage “an uphill battle,” she said.

Kathy Fairbanks, a spokeswoman for the opposition, credited the electorate for properly sorting out the facts. “Voters did their homework and saw who lined up on both sides,” Fairbanks said. “All the leaders of the medical community were against Proposition 8 because of the negative impact it would have had on patients and access to dialysis.”

Proponents of the measure argued that highly profitable dialysis companies don’t invest enough in patient care and that they need to hire more staff and improve clinic safety. Opponents said passage would have forced clinics to cut their hours or close altogether, resulting in more emergency room visits by dialysis patients.

SEIU-UHW said the opponents tried to “scare and mislead” voters. It vowed to continue targeting profitable dialysis companies with another measure on the 2020 ballot, as well as through legislation.

“We exposed problems within the dialysis industry and we put a spotlight on a sector that has operated in the shadow for far too long,” said Sean Wherley, spokesman for the “Yes” campaign. “But we are not finished yet. … The need is still there to hold this industry accountable.

He added that the union is proud to have put a spotlight on “the inflated charges that drive up health care costs for all California.”

Critics say that SEIU-UHW, which represents more than 95,000 workers in California, uses state and local ballot initiatives as a way to pressure legislators and gain bargaining power. They’ve sponsored measures on such topics as hospital and clinic funding, access to affordable insurance and training for in-home caregivers.

The union maintains its goal is simply to improve health care.

Two other Bay Area initiatives sponsored by SEIU, aiming to limit hospital pricing, also were defeated Tuesday, indicating that the ballot box may not be the best place to address concerns about costs in the health care industry.

“This is too complicated to do by ballot proposition,” Trish said.

Dialysis patients participated heavily in both the pro and con sides of the initiative, appearing in dramatic television ads and presenting their personal stories on social media.

Lili Hernandez, 27, who began treatment four years ago, showed up to her appointments at a DaVita clinic in Hollywood with “Yes on Prop. 8” placards even as  the clinic posted “No” signage, she said.

Hernandez supported the initiative because she believes the corporations should be held accountable, she said. “They take advantage of how much money they can charge, but don’t give the best service,” she said. “Too many people are at risk of infection and neglect.”

She woke up Wednesday feeling defeated. “I was awake last night, checked results online, had my cry and went to sleep,” she said, adding that she thinks people were confused about the initiative and believed the “false ads.”

Meanwhile, DeWayne Cox, a dialysis patient from Los Angeles, expressed relief. “This means that voters got the message, they understood,” he said.

Cox, 56, said he comes from a union family and believes in unions, but this was a “terrible” move by SEIU because it could lead to cutbacks in services. “Not only was this scary for me, but they made me angry,” he said, noting concerns about potential cutbacks in services. “If their motive was truly to help patients, they would have written a better, more precise measure.”

The measure became the most expensive race in California this year. Industry giants DaVita and Fresenius Medical Care, which operate nearly three-quarters of the chronic dialysis clinics in California, were responsible for more than 90 percent of the contributions in opposition to the measure

The California Medical Association, the California Hospital Association and the California chapter of the American College of Emergency Physicians all opposed Proposition 8. “Our concern was the impact on patient care,” said hospital association spokeswoman Jan Emerson-Shea. “If dialysis clinics were forced to close and patients needed care, we are the only place within the health care system that is open 24/7.”

Municipal ballot initiatives sponsored by SEIU-UHW targeted Stanford Health Care in Livermore and Palo Alto by attempting to cap prices at 115 percent of the “reasonable” cost of care. Under the initiatives, hospitals and other medical providers would have been required to pay back any charges above the cap each year to private commercial insurers. The initiatives failed dramatically, losing 77 to 23 percent in Palo Alto and in Livermore, 82 to 17 percent.

Voters did approve three statewide health care initiatives Tuesday, however:

  • Proposition 2 won 61 to 39 percent, allowing the state to issue $2 billion in bonds for housing for homeless people in need of mental health services. Bond money will be distributed to counties and repaid with proceeds from the Mental Health Services Act, which levies a 1 percent tax on personal incomes of $1 million and above.
  • Proposition 4, which won by the same margin, allows the state to distribute $1.5 billion in bonds to help the state’s 13 children’s hospitals’ pay for construction and equipment. It was the third time in 14 years that voters had agreed to subsidize the hospitals.
  • Proposition 11, passing with  59 percent of the vote, requires private ambulance employees to remain on call during their breaks — just as firefighters, policemen and other public emergency workers do.

Samantha Young and Harriet Rowan contributed to this report.


KHN’s coverage of these topics is supported by
California Health Care Foundation
and
Blue Shield of California Foundation

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

California’s Top Lawyer Sees Election Win As Mandate To Sustain Trump Resistance

California Attorney General Xavier Becerra has cemented his role as one of the nation’s top defenders of the Affordable Care Act, filing multiple lawsuits in the past two years to uphold key protections of the law and often clashing with the Trump administration.

Voters this week gave Becerra a clear mandate to continue that work, he said.

“Californians had a chance to register their opinion on the work that I’ve done,” Becerra told California Healthline on Wednesday, the day after voters overwhelmingly elected him to the state’s top law enforcement job — 61 percent to 39 percent over Republican Steven Bailey.

“My sense is there’s a pretty clear signal.”

Becerra has filed 44 legal challenges against the Trump administration in less than two years on cases involving immigration, birth control, health care, transgender rights, net neutrality, climate change and other issues.

Four of the lawsuits involve former President Barack Obama’s signature achievement, the 2010 federal health care law, which Trump and fellow Republicans have sought to dismantle. In one key case, Becerra is leading more than a dozen other Democratic attorneys general against a Texas-led GOP lawsuit challenging the law’s constitutionality.

“We’re defending health care protections and rights not just for the 40 million Californians, but for the 320 million Americans in the country, because the Trump administration elected to back out of their role in defending a federal statute,” Becerra said. “We stepped in and are now the lead state defending the Affordable Care Act. That’s a big undertaking.”

Democratic Gov. Jerry Brown appointed Becerra to the top post at the state Department of Justice in December 2016 after Kamala Harris was elected to the U.S. Senate. So, Tuesday’s election was the first time that the 60-year-old Democrat, who previously served in Congress, won a statewide office.

Bailey had criticized Becerra for fighting Washington instead of focusing on California issues — not an argument that resonated with voters in a state that prides itself as the head of Trump resistance.

Becerra said he has sought to spotlight health care at the state Justice Department, creating a new “strike force” of attorneys who have expertise in health care issues.

Becerra, the son of Mexican immigrants, said he also is ready to defend California should state lawmakers decide to extend health care coverage to unauthorized immigrant adults (children already are eligible). That could spur a legal challenge and would not likely be supported by the Trump administration.

The state’s estimated 1.8 million unauthorized immigrants make up nearly 60 percent of the state’s remaining uninsured residents. Covering them is key to Democratic leaders’ goal of insuring all Californians.

Aside from tangling with Trump, Becerra also has taken on both the hospital and pharmaceutical industries.

This year, he filed a lawsuit against Sutter Health, the largest hospital system in Northern California, for anti-competitive practices, and he is investigating pharmaceutical manufacturers and the three largest opioid distributors over unlawful practices. In 2017, Becerra joined a federal lawsuit that charges six makers of generic drugs with an illegal conspiracy to increase prices for an antibiotic and a diabetes medication. All three cases are pending.

In the Sutter Health lawsuit, Becerra said evidence will show that the hospital chain overcharged for services. While he has made anti-competitiveness a priority, he would not say whether he planned similar lawsuits against other hospitals. But he didn’t rule it out.

“We’re going to be vigilant to make sure that everyone follows the law and does what they’re supposed to,” Becerra said. “If we find that there are people who are acting anti-competitively or overpricing or trying to take advantage of California health care consumers, we’ll be prepared to act.”

All of the investigations and litigation, he said, are slow-moving. He compared the process to a football game in which most of the plays yield small gains, with an endgame in sight.

“We’re looking to score some touchdowns,” he said.


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

California Dreamin’? With Newsom’s Win, Single-Payer Unlikely To Follow Anytime Soon

Californians on Tuesday elected a governor who campaigned for a complete overhaul of how people get their health coverage — but they shouldn’t hold their breath.

Rather, as Gov.-elect Gavin Newsom and the Democratic-controlled legislature take steps to provide more people with health insurance, they’ll likely approach it piecemeal over several years.

Newsom himself is already tempering expectations about California’s move to a single-payer system, saying it will take more than the will of one person to realize.

“I’m not going to hesitate to be bold on this issue, and I also want to set expectations,” Newsom told reporters last week at a campaign stop in Sacramento. “It’s a multiyear process.”

The Democratic lieutenant governor easily routed Republican John Cox in the governor’s race Tuesday, with Newsom vowing to stand up to President Donald Trump and restore the “California Dream” by addressing affordable housing, health care and income inequality in the nation’s most populous state.

Newsom’s views are in stark contrast to Cox’s, who maintained that government should largely stay out of health care. The free-market businessman said single-payer would send health care costs soaring while diminishing quality, and warned that it “is a sure way to destroy the California economy.”

Like many Democrats, Newsom has described health care as a right and vowed to defend the Affordable Care Act as governor. He also criticized the legislature last year when it held up a single-payer bill that would have created one government-run public insurance program for all Californians.

He won the endorsement from the politically powerful California Nurses Association for vigorously advocating single-payer. Going slow on single-payer could test his relationship with the union, which launched a brutal attack against the Democratic state Assembly speaker when he shelved the measure last year.

It could also upset progressive Democrats and donors who are counting on action.

“This is the governor who has the best shot to get this done,” said Stephanie Roberson, the union’s director of government relations. “It takes political will and courage, and I’m going to cash in on what he said to my association.”

Now Newsom’s attitude is cautious — many say realistic — even in a state that aims to set national trends and relishes its role at the forefront of the resistance to the Trump administration.

Last week, Newsom called single-payer the most “effective and efficient” strategy to achieve universal coverage, but he questioned whether it could be achieved at the state level, given the Trump administration’s opposition to the concept.

Trump’s top Medicare and Medicaid official, Seema Verma, last summer firmly rejected the idea that the federal government would grant the essential exemptions from federal rules to try single-payer, which she called “unaffordable” and “something that’s not going to work.” The exemptions, or waivers, are necessary because the state relies heavily on federal health care dollars that would be needed to pay single-payer costs.

Undaunted, the California Nurses Association said it intends to bring another single-payer bill before the legislature next year and has launched a national campaign to pass single-payer in other states and convince Congress of its merits.

But it’s unlikely that a single-payer bill will make it to Newsom’s desk next year, in part due to the price tag: A single-payer system could cost an estimated $400 billion annually. Lawmakers earlier this year directed a council to study the feasibility of a publicly funded health insurance plan, and its findings aren’t due until 2021 — giving the new governor and lawmakers time to punt on the issue.

Still, Democrats who head the key legislative health committees see Newsom as a partner who will be more engaged on health care than fellow Democrat Gov. Jerry Brown has been these past eight years.

“Health care has not been one of the issues that he’s been particularly focused on,” Assemblyman Jim Wood, chairman of the Assembly Health Committee, said of Brown. “I think we’ve missed some opportunities to really move forward on some policies that would be good for all Californians.”

Brown this year blocked measures that would have expanded health care coverage to some low-income unauthorized immigrants — not because he philosophically opposed the idea, lawmakers say, but because it would have required new state spending.

He also raised cost concerns about bills that would have provided state-funded tax credits and subsidies to people who buy coverage through Covered California, the state’s insurance exchange.

With a new governor, those proposals are back on the table. Newsom was, after all, the San Francisco mayor who signed off on the nation’s first universal health care program for city residents without insurance, including undocumented immigrants. And, as he has reminded reporters, he did it during a recession.

“It’s a question of what do you value, what you prioritize,” he said last week when asked how the state could afford both universal health care and his call for universal preschool.

Newsom’s campaign did not respond to questions about how he would expand coverage absent single-payer. But, earlier this year, his spokesman told California Healthline that proposals to give coverage to undocumented immigrants and earmarking state dollars to help consumers buy insurance coverage were “two major parts” of his plan to deliver health coverage to all state residents. The state’s estimated 1.8 million unauthorized immigrants, for example, make up roughly 59 percent of the state’s remaining uninsured residents, according to Covered California.

The Democratic-dominated legislature would have to approve these moves.

“We’re going to be looking at a variety of ways that we might be able to get everyone covered,” Wood said. But, he added, “it will be significantly expensive to do that.”

Wood and state Sen. Richard Pan, chair of the Senate Health Committee, said lawmakers should look at the structural issues in health care — how prices for services and pharmaceuticals are regulated and how efficiencies, improved access and curbs on costly care of chronic diseases might be achieved.

“I think it’s clear the health care landscape is a focal point for the California legislature,” said Erin Trish, associate director of health policy at University of Southern California’s Schaeffer Center. “They don’t have to push for a single-payer system to push for expanded coverage.”

Expanding health care coverage would require more state spending, but that wouldn’t necessarily mean a hit to the state economy, experts said.

After California implemented the Affordable Care Act (albeit with significant federal assistance), the state’s economy continued to grow and the number of uninsured residents fell to 7.2 percent in 2017, according to the U.S. Census Bureau.

“We’ve expanded coverage and our economy has continued to flourish,” said Dr. Andrew Bindman, a primary care physician who is also a professor at the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco, who helped draft the federal health care law. “These things are achievable, and I think California is a model of that.”

Pan, the chair of the Senate Health Committee, said he looks forward to engaging Newsom, someone who proved he could move beyond rhetoric by signing the San Francisco measure that offered more city residents health coverage.

“Hopefully, we have an opportunity to get something done,” Pan said.


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

Hello? It’s I, Robot, And Have I Got An Insurance Plan For You!

“Anna” will not stop calling. She really, really wants to sell you health insurance.

What a lot of consumers really, really want is to smack Anna upside her robocalling head.

As health insurance open-enrollment season gets underway in California and nationwide, automated phone calls offering Affordable Care Act or other health plans are spiking — and driving many consumers to the brink. California residents may have it worst, because its open-enrollment period is twice as long as in other parts of the country.

“It’s at epidemic levels at this time of year,” said Aaron Foss, founder of Nomorobo, who estimates his spam call-blocking service, based in Long Island, N.Y., headed off more than 850,000 health-related robocalls in October alone — nearly five times their interceptions for September, Foss said.

Nomorobo tracked about 820 different robocall pitches for health insurance in the last week of October. More than 100 of them were from the robot Anna.

Almost all of these calls are illegal, according to rules published by the Federal Trade Commission in 2009. Many offer skimpy health plans that don’t cover what you might need, insurance regulators and consumer advocates say. Others, they say, are downright fraudulent, with unscrupulous insurance “brokers” taking payment and promising insurance that never comes through.

Alice Cave, 62, a retired data analyst from Alexandria, Va., who spends winters in Tucson, said she’s gotten so many of these calls that she typically won’t answer her phone unless she recognizes the number. On Monday, expecting a call from a California reporter, she answered her cellphone.

It was “Anne.” (Anna’s robot cousin? Other relatives include “Jordan,” “Allison” and “Mandy,” though variants on Anna remain most prevalent.)

“She was saying, ‘I really need to talk to you — we’ve got deals on health insurance.’ I thought, ‘God, what a crock,’” Cave said. “If it’s too good to be true, it probably is. Anything that comes in on the phone, I’m going to be skeptical. Why would they offer me this deal? I already have great insurance. It’s crazy.”

Some fed-up consumers try to stymie robocallers, with amusing results. Twitter user Jon Heise in June confounded his robot by insisting, after whatever it said, that he was a “meat popsicle.” Eventually, it hung up.

It’s not all fun and games. In California, the Department of Insurance is investigating health insurance robocalls, said Janice Rocco, deputy commissioner for health policy and reform. In late August, the agency filed a court order against Health Plan Intermediaries Holdings LLC, accusing the Florida company of deceptive and misleading practices in selling “Obamacare” plans that didn’t comply with the health law. The company could face fines of up to $10,000 per violation, Rocco said.

In this case, the company’s robocalls featured “Anne,” according to the court order. In its legal response, the company did not admit to the agency’s allegations and denied responsibility. A hearing date has not yet been set, Rocco said. (Arkansas’ insurance commissioner issued a cease and desist order against the company in 2016.)

Under federal law, calls using prerecorded messages are legal only for such things as doctor appointment reminders, flight cancellations, credit card fraud alerts and political candidates. Calls to sell products and services are not.

In a typical robocall sales pitch, a friendly female voice comes on the line. Sometimes the call appears to originate from major insurers like Blue Cross Blue Shield or Aetna or from a local number a caller might suppose is a school or neighbor.

Often, the voice will ask the consumer to dial “1” to enroll or “2” to opt out of future calls. Both options can be a trap, experts say.

“If you pick up, you become a lead that’s sent to health insurance agents or brokers,” Nomorobo’s Foss said. And option 2 doesn’t put you on a do-not-call list; it merely lets the spammers know they’ve hit a working number, he added.

A reporter from Kaiser Health News connected with one of the insurance brokers behind one of these robocalls by pressing the dreaded “1.”

A man identifying himself as “Ray Khan” said he’s a licensed insurance broker and provided a National Insurance Producer Registry number. The reporter was unable to locate Khan in that national registry with that number, which was not assigned to anyone.

Khan asked for the reporter’s Social Security number and other personal information. He said he did not have an office and that enrollment needed to be done over the phone. He referred the caller to a website that does not provide information about plans offered but is a platform for consumers to be contacted by brokers.

“It’s a legitimate company. We work for different insurance carriers,” Khan said. “You have to trust someone if you want to do it.”

That’s exactly what you shouldn’t do — trust folks who call you out of the blue, according to the Department of Insurance’s Rocco. “Someone selling a comprehensive medical plan is not going to be reaching you via a robocall,” Rocco said.

Most of what’s sold through these automated calls are so-called skinny plans that don’t comply with Affordable Care Act requirements, or are short-term insurance plans, which typically offer coverage for only a few months and often don’t cover preexisting conditions or prescription drugs. Such plans have been outlawed in California, starting Jan. 1.

Despite state and federal crackdowns — some involving multimillion-dollar fines — robocalls aren’t going away anytime soon. So the best thing for consumers to do when they receive one is to just hang up or, like Virginia resident Cave, not respond to unfamiliar numbers, advises the Federal Communications Commission.

Instead, check out the federal Obamacare exchange, healthcare.gov, or your state’s marketplace.


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

Quick: What’s The Difference Between Medicare-For-All and Single-Payer?

MODESTO, Calif. — Betsy Foster and Doug Dillon are devotees of Josh Harder. The Democratic upstart is attempting to topple Republican incumbent Jeff Denham in this conflicted, semi-rural district that is home to conservative agricultural interests, a growing Latino population and liberal San Francisco Bay Area refugees.

To Foster’s and Dillon’s delight, Harder supports a “Medicare-for-all” health care system that would cover all Americans.

Foster, a 54-year-old campaign volunteer from Berkeley, believes Medicare-for-all is similar to what’s offered in Canada, where the government provides health insurance to everybody.

Dillon, a 57-year-old almond farmer from Modesto, says Foster’s description sounds like a single-payer system.

“It all means many different things to many different people,” Foster said from behind a volunteer table inside the warehouse Harder uses as his campaign headquarters. “It’s all so complicated.”

Across the country, catchphrases such as “Medicare-for-all,” “single-payer,” “public option” and “universal health care” are sweeping state and federal political races as Democrats tap into voter anger about GOP efforts to kill the Affordable Care Act and erode protections for people with preexisting conditions.

Republicans, including President Donald Trump, describe such proposals as “socialist” schemes that will cost taxpayers too much. They say their party is committed to providing affordable and accessible health insurance, which includes coverage for preexisting conditions, but with less government involvement.

Voters have become casualties as candidates toss around these catchphrases — sometimes vaguely and inaccurately. The sound bites often come across as “quick answers without a lot of detail,” said Gerard Anderson, a professor of public health at the Johns Hopkins University Bloomberg School Public Health.

“It’s quite understandable people don’t understand the terms,” Anderson added.

For example, U.S. Sen. Bernie Sanders (I-Vt.) advocates a single-payer national health care program that he calls Medicare-for-all, an idea that caught fire during his 2016 presidential bid.

But Sanders’ labels are misleading, health experts agree, because Medicare isn’t actually a single-payer system. Medicare allows private insurance companies to manage care in the program, which means the government is not the only payer of claims.

What Sanders wants is a federally run program charged with providing health coverage to everyone. Private insurance companies wouldn’t participate.

In other words: single-payer, with the federal government at the helm.

Absent federal action, Democratic gubernatorial candidates Gavin Newsom in California, Jay Gonzales in Massachusetts and Andrew Gillum in Florida are pushing for state-run single-payer.

To complicate matters, some Democrats are simply calling for universal coverage, a vague philosophical idea subject to interpretation. Universal health care could mean a single-payer system, Medicare-for-all or building upon what exists today — a combination of public and private programs in which everyone has access to health care.

Others call for a “public option,” a government plan open to everyone, including Democratic House candidates Antonio Delgado in New York and Cindy Axne in Iowa. Delgado wants the public option to be Medicare, but Axne proposes Medicare or Medicaid.

Are you confused yet?

Sacramento-area voter Sarah Grace, who describes herself as politically independent, said the dialogue is over her head.

“I was a health care professional for so long, and I don’t even know,” said Grace, 42, who worked as a paramedic for 16 years and now owns a holistic healing business. “That’s telling.”

In fact, most voters approached for this article declined to be interviewed, saying they didn’t understand the issue. “I just don’t know enough,” Paul Her of Sacramento said candidly.

“You get all this conflicting information,” said Her, 32, a medical instrument technician who was touring the state Capitol with two uncles visiting from Thailand. “Half the time, I’m just confused.”

Paul Her, 32, a medical instrument technician from Sacramento, says he’s “just confused” by the conflicting health care pitches he hears from politicians. (Samantha Young/KHN)

The confusion is all the more striking in a state where the expansion of coverage has dominated the political debate on and off for more than a decade. Although the issue clearly resonates with voters, the details of what might be done about it remain fuzzy.

A late-October poll by the Public Policy Institute of California shows the majority of Californians, nearly 60 percent, believe it is the responsibility of the federal government to make sure all Americans have health coverage. Other state and national surveys reveal that health care is one of the top concerns on voters’ minds this midterm election.

Democrats have seized on the issue, pounding GOP incumbents for voting last year to repeal the Affordable Care Act and attempting to water down protections for people with preexisting medical conditions in the process. A Texas lawsuit brought by 18 Republican state attorneys general and two GOP governors could decimate protections for preexisting conditions under the ACA — or kill the law itself.

Republicans say the current health care system is broken, and they have criticized the rising premiums that have hit many Americans under the ACA.

Whether the Democratic focus on health care translates into votes remains to be seen in the party’s drive to flip 23 seats to gain control of the House.

The Denham-Harder race is one of the most watched in the country, rated too close to call by most political analysts. Harder has aired blistering ads against Denham for his vote last year against the ACA, and he sought to distinguish himself from the incumbent by calling for Medicare-for-all — an issue he hopes will play well in a district where an estimated 146,000 people would lose coverage if the 2010 health law is overturned.

Yet Harder is not clinging to the Medicare-for-all label and said Democrats may need to talk more broadly about getting everyone health care coverage.

“I think there’s a spectrum of options that we can talk about,” Harder said. “I think the reality is we’ve got to keep all options open as we’re thinking towards what the next 50 years of American health care should look like.”

To some voters, what politicians call their plans is irrelevant. They just want reasonably priced coverage for everyone.

John Byron, a 73-year-old retired grandfather from Modesto, wants a government-run health care system that doesn’t include private insurance companies. What politicians call the program is irrelevant to him, he says. (Samantha Young/KHN)

Sitting with his newspaper on the porch of a local coffee shop in Modesto, John Byron said he wants private health insurance companies out of the picture.

The 73-year-old retired grandfather said he has seen too many families struggle with their medical bills and believes a government-run system is the only way.

“I think it’s the most effective and affordable,” he said.

Linda Wahler of Santa Cruz, who drove to this Central Valley city to knock on doors for the Harder campaign, also thinks the government should play a larger role in providing coverage.

But unlike Byron, Wahler, 68, wants politicians to minimize confusion by better defining their health care pitches.

“I think we could use some more education in what it all means,” she said.


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

Ad Check: What Happens If California Limits Dialysis Center Profits?

California voters are being bombarded with ads in what is the most expensive ballot measure campaign this year. They are being asked to decide Tuesday whether the state should limit the profit of kidney dialysis centers to 15 percent over the cost of patient care, with revenue above that rebated primarily to insurers.

What exactly would happen if voters approve Proposition 8 is still vague, and the $127 million raised to persuade voters hasn’t made it any clearer.

Both sides are making bold statements. But even the Legislative Analyst’s Office, nonpartisan officials who advise the state Legislature, said Prop 8 could result in a “net positive impact in the low tens of millions of dollars to net negative impact in the tens of millions of dollars.” In other words: No one knows.

Here’s what both sides had to say and what they base it on.

Against Proposition 8

The dialysis companies, mostly DaVita and Fresenius Medical Care, have contributed more than $110 million to fight Prop 8, more than six times what the “Yes on 8” campaign has raised. Their ads feature concerned health care professionals and dialysis patients warning voters of the terrible effects Prop 8 would have on dialysis patients and taxpayers in California.

This ad is just one in a series in heavy rotation on TV stations across the state. Like most of the “No on 8” advertisements, it prominently cites the Berkeley Research Group when claiming Prop 8 “would force many dialysis clinics to shut down, and threaten the care that patients need to survive.”

The narrator of the ad goes on to say “studies show Prop 8 will increase health care costs by hundreds of millions of dollars,” again citing the Berkeley Research Group.

The Berkeley Research Group is a large international consulting firm hired by the “No on 8” committee to analyze the proposition’s economic impact. It was paid more than $200,000 by the committee, according to campaign finance reports filed with the California secretary of state.

The consulting firm — which is not affiliated with the University of California — based its analysis on financial data from dialysis clinics around the state, including self-reported totals for direct patient care, quality improvements and “non-allowable” costs. Non-allowable costs, which might include some management staff positions and corporate overhead costs, will be ironed out through a public rule-making process if Prop 8 is passed.

The researchers used their own interpretation of non-allowable costs, took that to calculate how many clinics would surpass the 15 percent margin, and then applied the reimbursements that Prop 8 would require to conclude that “most clinics will migrate to having negative operating margins.” The analysis estimated that Prop 8 would increase health care costs for taxpayers by between $12 million and $2.6 billion annually.

Whether that happens depends on how clinics could adjust their operations to decrease their expenses that are not considered allowable patient care costs.

There is nothing unusual about relying on consultants to supply ammunition for a political campaign. “The effort to marshal research to support an advocacy campaign is not at all uncommon,” said Edward Walker, a sociology professor at UCLA specializing in political lobbying by businesses. He also pointed out that the advocacy campaigns often try to distance themselves from the research they pay for.

The Berkeley Research Group report leaves no room for uncertainty. “It is certain that Prop 8 will result in the closure of numerous clinics and the withdrawal of dialysis services from hundreds of thousands of patients,” the report said.

For Proposition 8

The Yes committee is funded almost exclusively by the Service Employees International Union-United Healthcare Workers West. The union has long fought to organize workers at dialysis clinics. Rather than focus on Prop 8’s possible effects, the “Yes” ads criticize the dialysis industry in general. The labor union has contributed more than $17 million to the “Yes on 8” committee, the largest amount SEIU has ever shelled out.

This ad starts out dramatically: “$150,000 a year,” the narrator intones. “That’s how much big dialysis corporations charge some patients, a 350 percent markup over the cost of care.” The ad doesn’t cite a source, but the figure roughly matches what industry financial analysts say private health insurance pays for dialysis.

Dialysis companies argue that the low reimbursement rate from Medicare — which covers about 90 percent of patients — is the reason they are forced to charge more for the 10 percent who are covered by private insurance. Those private insurance payments allow them to remain profitable. SEIU argues that high rates for private insurance contributes to higher overall health care costs and points out that the dialysis companies have a higher profit margin than hospitals in the state.

DaVita, a for-profit company that runs half of all dialysis clinics in California and is the biggest contributor to the “No on 8” campaign, reported profits of $1.8 billion on revenue of $10.9 billion last year, almost all of which came from its dialysis business.

The “Yes on 8” ad also cites an investigation by ProPublica, a nonprofit news organization, which found that the U.S. has one of the highest fatality rates for dialysis in the industrialized world. The narrator says, “Dialysis corporations make a killing, driving up insurance rates while patients report blood stains and cockroaches in their clinics,” while a quote from the ProPublica article is flashed on the screen. It says: “dangerous conditions, inadequate care, higher-than-expected mortality rates.”

While the ProPublica report did find troubling conditions in dialysis clinics around the country, the allegation of cockroaches was from a different report. ProPublica’s investigation examined records from more than 1,500 clinics in a number of states, including California, and it noted filthy or unsafe conditions in almost half of the units. But it doesn’t say the problem is any better or worse in California.

The “Yes on 8” committee’s communications approach is part of an ongoing campaign to challenge the power and profits of large dialysis companies, and organize their workers.

“This is in part a proxy battle between the labor unions and the dialysis centers,” Walker said. “It’s a way to increase the pressure and the leverage.”


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

Billions In ‘Questionable Payments’ Went To California’s Medicaid Insurers And Providers

California’s Medicaid program made at least $4 billion in questionable payments to health insurers and medical providers over a four-year period because as many as 453,000 people were ineligible for the public benefits, according to a state audit released Tuesday.

In one case, the state paid a managed-care plan $383,635 to care for a person in Los Angeles County who had been dead for more than four years, according to California State Auditor Elaine Howle.

She said she found “pervasive discrepancies” in Medicaid enrollment in which state and county records didn’t match up from 2014 to 2017, leading to other errors that persisted for years. The bulk of the questionable payments, or $3 billion, went to health plans that contract with the state to care for 80 percent of enrollees in California’s Medicaid program, known as Medi-Cal.

The program for low-income residents is the nation’s largest and funded by both the federal and state governments. The state findings echo similar problems cited by federal officials and come at a time when the Trump administration has applied extra scrutiny to California’s spending on Medicaid.

In the report, the state auditor said it’s critical for the state to have accurate information on eligibility “because it pays managed care plans a monthly premium for an increasing number of Medi-Cal beneficiaries regardless of whether beneficiaries receive services.”

(Story continues below.)

California paid a managed-care plan $383,635 to care for a person in Los Angeles County who had been dead for more than four years.

California’s Medicaid program has 13.2 million enrollees, covering about 1 in 3 residents. It has an annual budget of $107 billion, counting federal and state funds. Nearly 11 million of those enrollees are in managed care plans, in which insurers are paid a monthly fee per enrollee to coordinate care.

The state’s Medicaid enrollment soared by more than 50 percent since 2013 due to the rollout of the Affordable Care Act and the expansion of Medicaid. Enrollment grew from 8.6 million in December 2013 to more than 13 million in December 2017, according to the audit report.

In the case of the dead patient, a family member had notified the county of the enrollee’s death in April 2014. However, the person’s name remained active in the state system, and California officials assigned the patient to a managed-care plan in November of that year.

From then on, the state kept making monthly payments of about $8,300 to the health plan until August 2018, shortly after the auditor alerted officials of the error. Auditors didn’t identify the health plan.

There also were costly mistakes in cases in which Medi-Cal pays doctors and hospitals directly for patient care – a program known as “fee for service.”

For instance, the state auditor found that Medi-Cal paid roughly $1 million in claims for a female patient in Los Angeles County from June 2016 to December 2017 even though the county office had determined in 2016 that she was ineligible.

In a written response to the auditor, the California Department of Health Care Services said it agreed with the findings and vowed to implement the auditor’s recommendations. However, the agency warned it may not meet the auditor’s timeline, which called for the main problems to be addressed by June 2019.

In a statement to California Healthline, the agency said it is implementing a quality control process and “where appropriate, DHCS will recover erroneous payments.”

Early on in 2014, as the ACA rolled out, the state struggled to clear a massive backlog of Medi-Cal applications, which reached about 900,000 at one point. There were widespread computer glitches and consumer complaints amid the increased workload at the county and state level.

In addition to questionable payments for care of ineligible enrollees, Howle and her audit team also discovered some patients who may have been denied benefits improperly. The state auditor identified more than 54,000 people who were deemed eligible by county officials but were not enrolled at the state level. As a result, those people may have had trouble getting medical care.

In February, a federal watchdog estimated that California had signed up 450,000 people under Medicaid expansion who may not have been eligible for coverage.

The inspector general at the U.S. Department of Health and Human Services said California made $1.15 billion in questionable payments during the six-month period it reviewed, from Oct. 1, 2014, to March 31, 2015.

In August, Seema Verma, administrator of the U.S. Centers for Medicare and Medicaid Services, told a U.S. Senate committee that she was closely tracking California to ensure the state “returns a significant amount of funding owed to the federal government related to the state’s Medicaid expansion.”

Verma expressed concern that states had overpaid managed-care plans during the initial years of Medicaid expansion, resulting in “significant profits for insurance companies.” By year’s end, she said she expects the federal government to recoup about $9.5 billion from California’s Medicaid program, covering overpayments from 2014 to 2016.

Tony Cava, a spokesman for Medi-Cal, said the state has already returned about $6.9 billion to the federal government and expects more than $2 billion more to be sent back by December.


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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