Tagged Trump Administration

KHN’s ‘What The Health?’: Trump Takes Credit Where It Isn’t Due

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The final debate for Democratic presidential candidates before the Feb. 3 Iowa caucuses did not delve as deeply into health care as some earlier debates. But it did include discussion of several health issues that have received relatively little attention, including prescription drug prices and long-term care.

Meanwhile, President Donald Trump is claiming credit for having “saved” federal protections for preexisting health conditions, perhaps the most popular piece of the Affordable Care Act, even as his own administration is in court trying to have the entire health law declared unconstitutional.

And Kansas may soon become the latest state to expand the Medicaid program under the ACA, as the Democratic governor and GOP Senate majority leader strike a deal.

This week’s panelists are Julie Rovner from Kaiser Health News, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Shefali Luthra of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Some advocates have complained that the Democratic presidential candidates are not discussing threats to abortion rights during the debates. But, generally, candidates look to talk about issues that differentiate them from their primary opponents, and all of the Democrats on stage are supportive of a woman’s right to an abortion.
  • Trump’s claim this week that he was protecting the right of consumers with medical problems to get health coverage was widely derided by ACA supporters. But his contention goes to the heart of the administration’s effort to buttress its health care initiatives ahead of the campaign.
  • At the same time, the Trump administration has set a requirement for plans sold on Obamacare marketplaces to bill consumers separately for the portion of the plan that covers abortion, generally a minuscule amount. That could confuse customers and create billing headaches for insurers and prompt some to discontinue the coverage.
  • Recent action by the Supreme Court may signal some changes coming in its view of abortion rights, now that the court has a stronger conservative majority. The justices refused to take an appeals court decision upholding a Kentucky law that requires doctors to show women seeking an abortion an ultrasound image of the fetus and describe the procedure to them.

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

Julie Rovner: The Deductible’s “Seven for the Twenties: A Futurist Looks at the Next Decade,” by Jeff Goldsmith

Alice Miranda Ollstein: The Wall Street Journal’s “Plan to Revamp Medicaid-Eligibility Checks Draws Criticism,” by Stephanie Armour

Tami Luhby: Vox.com’s “Everybody Covered,” by Dylan Scott, Ezra Klein and Tara Golshan

Shefali Luthra: Kaiser Health News’ “High-Deductible Plans Jeopardize Financial Health Of Patients And Rural Hospitals,” by Markian Hawryluk

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Trump’s Claim That He ‘Saved’ Preex Conditions ‘Part Fantasy, Part Delusion’

President Donald Trump attempted to take credit for one of the most popular elements of the Affordable Care Act: Its protection for people who have preexisting medical conditions.

“I was the person who saved Pre-Existing Conditions in your healthcare,” Trump tweeted Monday.

The protection for people with medical problems has been a rallying cry for Democrats, and they used the issue to help propel their widespread election victories in 2018.

Trump repeatedly has sought to align himself with this issue — in May, for instance, claiming he would “always protect patients with preexisting conditions.” We rated that claim False. His reelection campaign has made similar claims, which experts debunked.

Trump’s recent claim that he “saved” that guarantee of coverage adds a new twist, though. We contacted the White House to find out the basis for this statement.

Judd Deere, a White House spokesman, told us, “President Trump has repeatedly stated his commitment to protect individuals with preexisting conditions and his track record shows that he has consistently done what is necessary to improve care for the vulnerable.” Deere also pointed us to a range of other policy initiatives — such as efforts on kidney health, approving generic drugs and loosening restrictions on short-term health plans.

But none of those addressed the basis of Trump’s tweet.

The health policy experts we consulted, however, were unambiguous: The president’s claim has no factual basis and flies in the face of his ongoing policy efforts.

“I feel like we’re being gas-lit,” said Linda Blumberg, a health economist at the Urban Institute. “You can’t tell me you’re the savior of people with preexisting conditions when every single thing you’ve said or done is the opposite of that.” (Gaslighting means manipulating the telling of events in such a way it leads people to question their recollections.)

This skepticism persisted across the political spectrum.

“That’s a rather extended version of aspirational rhetoric short of any evidence,” said Tom Miller, a resident fellow at the conservative American Enterprise Institute.

The Preexisting Condition Protection

Under the Affordable Care Act, or ACA, health insurance plans cannot charge people higher prices because they have a medical condition. This protection has been intact since the law took effect, under then-President Barack Obama.

As a 2016 candidate, Trump promised to repeal and replace the health law. That came to a head in 2017, when the law came within one vote in the Senate of being undone.

“That tweet is part fantasy, part delusion, part politics and all lie,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill. “The president is lying about preexisting conditions. He supported, and continues to support, efforts to repeal the ACA that would take those consumer protections away.”

After that effort, Blumberg said, the president boasted that he had dismantled Obamacare — which is not only untrue, but, she added, confused many consumers.

Since then, the president has maintained his desire to undo the ACA and replace it with something new.

Neither his administration nor congressional Republicans have yet offered a replacement plan. None of the bills they have endorsed would maintain the guarantees of coverage for people with medical problems.

“By supporting repeal of the ACA, they’re supporting repeal of protecting preexisting condition prohibitions,” Robert Berenson, another analyst at the Urban Institute, previously told us.

Texas V. Azar

Meanwhile, the Trump administration’s work elsewhere could undo the protection.

A group of Republican-led states are suing to have the entire ACA dismantled. Their argument stems from a law Trump signed: the Tax Cuts and Jobs Act of 2017.

That law gutted the individual mandate — the ACA’s requirement that everyone have coverage or pay a penalty — by reducing the penalty to $0.

In this case, known as Texas v. Azar, the Republican states are arguing that the individual mandate was central to the ACA and that, without it, the entire law must be taken down. That would include the protections for people with preexisting conditions.

The administration has declined to defend the law in court, a move legal analysts have called almost unprecedented. The case is widely expected to go to the Supreme Court. Since the White House has unveiled no replacement, striking the law would leave a policy vacuum, allowing health plans to revert to discriminating against people with medical issues.

Miller argued that the still-pending court case and previous repeal efforts don’t necessarily mean there’s any imminent threat of the president gutting the ACA’s preexisting condition protections.

“For pure public opinion purposes, you want to say you’re protecting against preexisting condition protections,” Miller said. “Does he know how to do it? No. Is he doing anything trying to change it? Not really.”

But others noted that the administration’s stance is firmly against maintaining the ACA’s prohibitions.

“The Democrats have correctly said the Trump administration has in fact opposed protections for preexisting conditions by endorsing the lawsuit,” Berenson said.

Our Ruling

Trump tweeted that he “was the person who saved Pre-Existing Conditions in your healthcare.”

The president had nothing to do with the ban on health insurance plans discriminating against people with preexisting conditions. This consumer protection is a core part of the health care law that became law during the Obama presidency. Trump has expressly supported the repeal of this law without offering a replacement that would keep the protection intact.

And to this day, his administration is arguing in court that the law — including this provision — should be undone.

The president’s tweet is not only untrue, but it misrepresents his administration’s efforts to repeal the health care law without offering any replacement that might maintain its core protections. We rate this claim Pants on Fire.

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Team Trump Says Administration’s Action On Health Care ‘Is Working.’ Is It?

With the 2020 election months away, President Donald Trump’s reelection campaign is touting his health care record as a key reason voters should grant him another term.

Those talking points were distilled in a Dec. 31 social media post from Team Trump, the campaign’s official Twitter account, and again in a post on Monday from the president’s account. It represents messaging the president will likely repeat, especially as polls consistently show health care is a top concern for voters.

The December tweet advanced five specific achievements.

Trump reiterated those claims Monday, arguing that he was “the person who saved Pre-Existing Conditions in your Healthcare,” while “winning the fight to rid you of the … Individual Mandate.”

But a closer examination of the list of achievements suggests the claims are not as straightforward as the 260-odd characters would suggest. Let’s take a look at the big picture.

Access And Affordability

According to Team Trump, the specifics behind these claims include a range of actions, from steps designed to increase organ transplantation and access to HIV medication to loosening regulations around short-term limited-duration health care plans and association health plans as well as “more participation” in ACA insurance markets.

Critics dismissed this perspective.

“That tweet is so far inconsistent with the direction of their policy push,” said Linda Blumberg, a health policy analyst at the Urban Institute, a think tank. “It’s just astounding to me.”

The administration has attempted to or successfully undermined coverage, argued Blumberg and other policy analysts, pointing to the Affordable Care Act repeal effort, which the president championed and continues to prioritize, along with changes made to the individual marketplace, where people buy insurance.

Plus, the critics said, the administration has encouraged state-based experiments with Medicaid, the government health plan for low-income people. In particular, they pointed to the administration’s approval of some state plans to implement work requirements that, research suggests, would limit the program’s reach by introducing new layers of bureaucracy. These work requirements are controversial and the subject of legal challenges.

“Those policies haven’t always succeeded, but it is rather misleading, if not comical, for an administration that has pursued multiple policies that would reduce access to health care to claim that it has expanded such access,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill.

In fact, the number of Americans without health insurance has crept up under the Trump administration, according to data collected by the federal Centers for Disease Control and Prevention. Before Trump took office, the uninsured rate had been dropping since 2010, when the ACA took effect.

As for health care costs: Growth has slowed, but costs are still going up, said Robert Berenson, a health policy analyst at the Urban Institute who studies hospital pricing.

That’s largely because the price of hospital and doctor care continues to increase, he said, which makes health care more expensive.

There is one area in which prices appear to have dipped: In the 2019 and 2020 health insurance years, the rate of ACA premium increases slowed and, in some cases, declined, Blumberg said.

But context matters. In 2018, marketplace premiums rose dramatically. Experts attribute those increases to a general climate of uncertainty stemming from efforts to repeal the ACA, the elimination of the tax penalty for people who don’t have insurance coverage, and a White House decision to halt government subsidies to insurance companies that offered marketplace plans. Those payments were meant to make up for discounts that plans were required to give low-income customers.

What happened in 2019 and 2020 represented a course correction by insurers, in spite of administrative policy, marketplace analysts said. People who do not qualify for subsidies still faced very high rates.

“We would have been in a different place to begin with had they not caused all the disruption,” Blumberg said.

The administration argues otherwise.

“We are reporting that for the third year in a row enrollment in the Federal Exchange remained stable,” said Centers for Medicare & Medicaid Services Administrator Seema Verma in a Dec. 20 statement marking the end of 2020 open enrollment. “Far from undermining the Affordable Care Act — as some hysterical and inaccurate claims would have it — the Trump Administration is making the very best of what remains a failed experiment.”

Separately, the White House loosened regulations on other forms of coverage, such as short-term and association health plans, which are not required to comply with ACA regulations and carry lower premiums.

Health and Human Services Secretary Alex Azar described these plans as providing “a much more affordable option for millions of the forgotten men and women left out by the current system.” Conservatives say they also appeal to consumers who may not be interested in such a robust set of benefits.

“Giving people more choices of affordable options is better for consumers than giving them a take-it-or-leave-it plan that may cost too much and cover everything,” said Doug Badger, a visiting fellow at the Heritage Foundation, who previously worked in the George W. Bush administration.

Plus, he said, the Trump plans don’t get rid of marketplace plans for people who want them. They can still get the benefits of ACA regulations, if they choose.

“None of the Trump administration regulations took away the availability of coverage for people with preexisting conditions,” Badger said.

Others argued that these short-term plans — which can deny people coverage based on preexisting conditions — are a net loss. The lower premiums, they point out, are possible largely because they cover far less than an ACA plan would. Consumers drawn in by the low prices may be surprised later to learn how few of their health needs are covered.

“That’s not generally a positive for consumers. It’s not a positive for the markets,” Blumberg said.

The Individual Mandate And Preexisting Conditions

In its New Year’s Eve tweet, the Trump campaign also highlighted repealing the individual mandate — which required all Americans to have insurance or pay a penalty — and the still-intact protection for people with preexisting medical conditions to get coverage without a higher price.

Technically, though, the individual mandate is still on the books. What no longer exists — through the Tax Cuts and Jobs Act of 2017 — is the penalty for not having coverage, rendering the mandate more or less meaningless.

Axing the penalty opened the door to a legal challenge to the ACA. A group of Republican state attorneys general and governors are suing to have the whole ACA overturned, arguing that the individual mandate’s penalty was central to the Supreme Court’s 2012 decision upholding the law. Without it, they say, the entire law — including protections for people with preexisting conditions and other popular provisions — must be thrown out. The Department of Justice has chosen not to defend the law, and experts predict the case will eventually reach the Supreme Court.

The White House hasn’t revealed any replacement or contingency plan in the event the ACA is struck down.

“Not only did President Trump have nothing to do with covering preexisting conditions, he and congressional Republicans tried in 2017 to pass legislation repealing the ACA that would have eroded those consumer protections,” Oberlander said.

Generic Drugs And The Drug-Pricing Debate

The point touting a “record number of generic drugs approved” is true and fits into a larger policy concern — escalating prescription drug prices — which voters have called one of their top health care issues.

How much relief this push means for consumers at the pharmacy counter is still unknown.

According to research published this fall, most of the new generics greenlighted because of the administration’s efforts are for drugs that already have competition. For consumers, the problem of high drug prices is most acute when brands don’t have two or more generic alternatives. In that category, the number of approvals for generics didn’t increase.

Plus, the approval of new generics doesn’t translate to consumer access. Last February, a KHN review of FDA data suggested that nearly half of the newly approved drugs weren’t for sale in the United States — meaning they weren’t helping lower prices. This November, an analysis in The Wall Street Journal reiterated those findings.

Generics manufacturers may not sell their new drugs for a host of reasons, including, some experts have suggested, anti-competitive behavior and patent lawsuits by bigger pharmaceutical companies.

“Approval doesn’t mean launched or available on the market,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. Addressing the other pipeline issues, she said, would take “a lot” of policy legwork.

On the pharmaceutical subject, Team Trump argued that a number of administrative actions have brought down prices. But evidence supporting their position is scant.

“They want to take credit … on having a prescription drug bill that purportedly does something but it hasn’t passed,” Berenson said. The administration’s proposed rule changes and regulations have been similarly lackluster, he said.

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! In things I’ve learned today that I can’t stop thinking about: We apparently carry fat in our tongues? And you can lose it like any other fat on your body. This feels like something I should have known as a human, and yet I somehow managed 30-plus years without this information. Anyway, now that everyone is thinking too much about their tongues, let’s head to the news.

Democrats have asked the Supreme Court to expedite the case on the constitutionality of the health law, pushing for a ruling on the case during this term. This might seem paradoxical — as the lower courts have ruled against the ACA — but, as you Breeze readers know, the move is politically savvy. The health law is more popular than ever, and Democrats have been owning that advantage. If they can keep the Republicans’ attack on the legislation in the front of voters’ minds heading into the 2020 elections, there could be a repeat of the blue-wave midterms.

SCOTUS gave the Trump administration and Republicans until today to respond. (As of press time, they haven’t yet.)

The New York Times: Democrats Ask Supreme Court for Quick Decision on Obamacare

In a pretty harsh reality check, a new study this week found that a popular idea for cutting health spending doesn’t pan out when you look at the data. The strategy is based on identifying the hardest-to-treat, most expensive patients and better coordinating their care. But, despite the hype, the method didn’t cut hospital readmissions for those patients. The study highlights once again what we all know: Health care is complicated. And hyped-up promises to cut costs that sound too good to be true too often are.

Kudos to the evangelists of the method, though, for acknowledging it doesn’t work. “We could have coasted on the publicity we were getting,” said Dr. Jeffrey Brenner, a family physician in New Jersey who founded the program that was studied. “It’s my life’s work. So, of course, you’re upset and sad.”

The New York Times: These Patients Are Hard to Treat

The administrative costs of running a single-payer system in Canada come in at $551 per person per year. That seems like a lot, right? That’s what I thought, too, until I saw the total for Americans, which is *drum roll* $2,497 per year.

Los Angeles Times: U.S. Health System Costs Four Times More to Run Than Canada’s

California Gov. Gavin Newsom has proposed that California get into the drug-selling business — generic drugs, that is. The theory behind it is to increase competition and drive down prices. But despite generics accounting for 90% of the prescriptions filled in the country, they aren’t really the problem when talking high drug prices. It’s uncommon for those types of meds to only have one player in the marketplace, so pricing already tends to be competitive. For the average person, Newsom’s plan wouldn’t make much of a dent.

Los Angeles Times: Q&A: What You Need to Know About Gov. Newsom’s Drug Plan for California

But a strategy some people are hoping would make a difference is the VA model. The troubled federal agency might not have many bright spots these days, but patients who get prescriptions through Veterans Affairs are less likely than other insured Americans to skip doses and less likely to delay filling prescriptions because they were unable to afford them. What’s more, the program seems to curb racial disparities in accessing meds.

Stat: The VA Approach to Buying Drugs Means Patients Are Less Likely to Skip Medications Due to Cost

Mark your calendar: The annual J.P. Morgan Healthcare Conference runs through next week, and, as it nears, Stat looks back at the past 20 years of the event and how it has shaped the health care world. What emerges is a story of heroes and villains, booms and busts, sensational scandals, drinks and deals, flaring tempers and foolish predictions, and far more drama than anyone could expect from health care industry executives.

Stat: The Ghosts of JPMs Past: How 20 Years of Deals Have Shaped Health Care

In the latest sign that red-state resistance against Medicaid expansion is fading, Kansas Democratic Gov. Laura Kelly fulfilled a campaign promise by reaching a deal with Kansas Senate Republican Leader Jim Denning after a years-long impasse between the state’s two parties. Denning is eyeing a tough reelection race for next year — which could make the decision all the more notable.

The Wichita Eagle: Kansas Governor Kelly, Senate GOP Leader Reach Medicaid Deal

In a rare glimpse of good news, cancer death rates plummeted dramatically over a one-year period in the largest drop ever seen in national cancer statistics dating to 1930. The reason? Advancements in lung cancer treatments.

The Associated Press: Cancer Group Finds Biggest One-Year Drop in U.S. Death Rate

The back-and-forth over whether baby powder can be linked to ovarian cancer is the debate that launched 1,000 lawsuits (plus a couple of thousand more). A big study, however, tries to put the matter to rest. Research — that was deemed “overall reassuring” — now shows there is no strong connection between the two.

The Associated Press: Big Study Finds No Strong Sign Linking Baby Powder & Cancer

In the never-ending finger-pointing game that signals a reckoning in the opioid crisis, major drugstore chains like CVS and Walgreens are saying, “Nuh-uh, not our fault!” Instead, they say, doctors are to blame. Who are pharmacists to question doctors’ orders? The counter-argument, of course, is that when you’re filling prescriptions that equate to thousands of pain pills per person in a town you’re serving, it might be expected that someone would raise a red flag. Just maybe.

Experts say that by bringing up the doctors and providers, the drugstore chains could also be trying to complicate the case further, in hopes of mitigating some damage to themselves.

The Washington Post: Major Drugstore Chains Sue Doctors in Sprawling Federal Opioid Case

In the miscellaneous file for the week:

— You’ve heard of ambulance-chasing lawyers, but what about ambulance-chasing doctors? It’s becoming a growing practice for doctors to promise plaintiffs in personal-injury cases free upfront care with the hope of cashing in when the settlement comes. While the strategy is legal and doesn’t technically violate any ethical rules, it still seems a little off — and can also leave patients with big bills if their lawsuits don’t go as planned.

The Wall Street Journal: Who Wins in a Personal-Injury Lawsuit? It Can Be the Doctor

— Public health experts are warily watching the development of a pneumonia-like illness in China, with echoes of the SARS outbreak not distant enough not to draw comparison and concern.

The New York Times: China Identifies New Virus Causing Pneumonia-Like Illness

— As we continue to watch suicide rates skyrocket, experts scramble to figure out what can be done to halt the disturbing rise. Now, research suggests hope could come from an interesting strategy: raising the minimum wage by just $1.

NPR: For Suicide Prevention, Try Raising the Minimum Wage, Research Suggests

— A truism that has emerged for me over my decade-plus in journalism is that where there’s a catastrophe or disaster, there is someone who stands to gain something. In this case, it’s the windfall that will come to hospitals if the flu season is as bad as predicted.

Bloomberg: Record 2019-2020 Flu Season May Be Good for Hospitals

On that cheerful note, that’s it from me. Have a great weekend!

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KHN’s ‘What The Health?’: Democrats Roll Dice On SCOTUS And The ACA

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Democratic state attorneys general are asking the Supreme Court to intervene this term in a case that could invalidate the entire Affordable Care Act. In December, a federal appeals court panel ruled that the “individual mandate” provision of the health law is unconstitutional now that Congress has reduced the penalty for not having insurance to zero. But it sent the case back to the lower-court judge to determine how much else of the law can remain in light of that finding.

Democrats want the high court to rule on the case now, which would be unusual but not unprecedented.

Meanwhile, Republicans on Capitol Hill are asking the Supreme Court to use a Louisiana abortion case already on this year’s docket to overturn the landmark abortion rights case, Roe v. Wade. The Louisiana law — requiring doctors who perform abortions to have admitting privileges at nearby hospitals — is similar to a Texas law struck down by the court in 2016. But the court has added anti-abortion justices since then.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Paige Winfield Cunningham of The Washington Post

Among the takeaways from this week’s podcast:

  • The Democratic push to get the Supreme Court to quickly review the latest ACA challenge could have political benefits for the party in the campaign season. Democrats are eager to be seen as protecting new health care benefits. And if President Donald Trump is elected next fall, the high court could well become more conservative as several liberal-leaning justices may leave the court in the next few years.
  • Some advocates for a “Medicare for All” health care system are convinced that if the Supreme Court were to strike down the ACA, the resulting vacuum would make a government-run program more attractive to Americans.
  • Amid increasing efforts by states to restrict abortions and a more conservative majority on the Supreme Court, abortion may become a more potent voting issue for Democrats. It has long motivated Republican voters, but Democrats have been less driven by that single issue.
  • The much-publicized administration rules to cut back on flavored vaping products include a lesser-known provision allowing companies to go through a Food and Drug Administration process to prove their products have a net health benefit: helping adults quit smoking.
  • States continue to seek Trump administration approval for work requirements for their Medicaid programs, but if Democrats win the presidency in 2020, those approvals are likely to be reversed. Meanwhile, most of the state plans are tied up in court.

Also this week, Rovner interviews NPR’s Richard Harris, who reported the latest KHN-NPR “Bill of the Month” installment about a very expensive laboratory bill for a New York woman who had a cold. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: Stat News’ “Washington Took a Decade to Approve an Obscure Drug-Pricing Bill. That’s a Bad Omen for More Ambitious Reforms,” by Nicholas Florko

Joanne Kenen: The New Yorker’s “A World Without Pain,” by Ariel Levy

Stephanie Armour: The New York Times’ “In the U.S., an Angioplasty Costs $32,000. Elsewhere? Maybe $6,400,” by Margot Sanger-Katz

Paige Winfield Cunningham: KHN’s “Reduce Health Costs By Nurturing The Sickest? A Much-Touted Idea Disappoints,” by Dan Gorenstein and Leslie Walker. You can hear the episode of Dan’s podcast, “Tradeoffs,” about this study here.

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Fecal Bacteria In California’s Waterways Increases With Homeless Crisis

President Donald Trump, a self-described germophobe, has made no secret of his disgust with California’s growing homeless problem, which he has called a “disgrace” and “inappropriate” and equated to “living in hell.”

“We should all work together to clean up these hazardous waste and homeless sites before the whole city rots away,” Trump tweeted about San Francisco on Oct. 26. “Very bad and dangerous conditions, also severely impacting the Pacific Ocean and water supply.”

San Francisco officials were quick to dispute Trump’s claims. But some of California’s most prized rivers, beaches and streams are indeed contaminated with levels of fecal bacteria that exceed state limits, threatening kayakers, swimmers — and the state’s reputation as a bastion of environmental protection.

The presence of fecal bacteria in water is usually the result of problems with sewer systems and septic tanks. But water quality officials agree that the source of at least some of the fecal bacteria is California’s growing homeless population, most of whom don’t have reliable access to toilets.

“I’ve carried 5-gallon buckets that were unambiguously being used as toilets,” said David Gibson, executive officer of the San Diego Regional Water Quality Control Board, describing his experience cleaning up homeless encampments. “They were taking it to the San Diego River, dumping it there, and rinsing it out there.”

Fecal contamination of waterways is a widespread problem and becoming more urgent in states with large homeless populations. In Seattle, homeless people living in RVs are accused of dumping raw sewage straight into storm drains, which flows directly to local waterways. In Oregon, workers cleaning up homeless camps along the Willamette River in Eugene routinely find feces and needles.

California has the largest homeless population in the nation, estimated at more than 151,000 people in 2019, according to the U.S. Department of Housing and Urban Development. About 72% of the state’s homeless slept outside or in cars rather than in shelters or temporary housing.

The Trump administration has fixated on California’s homeless population in particular as a potent source of pollution.

In addition to Trump’s tweets, the U.S. Environmental Protection Agency sent a letter to California Gov. Gavin Newsom on Sept. 26 alleging that the state’s lack of urgency on homelessness threatens public health by polluting nearby water with untreated human waste. It then issued a notice to San Francisco accusing it of violating the federal Clean Water Act.

Jared Blumenfeld, secretary of the California Environmental Protection Agency, responded by accusing the federal EPA of retreating on clean water protection, and called the administration’s focus on the environmental impact of homelessness “sensationalized” and “misguided.”

But concerns extend beyond the Trump administration. A record number of Californians — about 1 in 4 — believe homelessness and housing is the top issue facing the state today, up from 1% in 1999, according to the Public Policy Institute of California.

When it comes to water, scientists look for E. coli and other bacteria to determine levels of fecal contamination. While E. coli is present in both human and animal feces, human fecal contamination is particularly dangerous because it can transmit diseases that affect people, including hepatitis A and cholera.

Most people are not at risk of getting sick unless they drink the water, or if pathogens enter open cuts or sores, said Richard Ambrose, a professor in the department of environmental health sciences at UCLA. Homeless people face the highest risk because they are more likely to wash or wade in the water and have less access to toilets and showers, he said.

In the city of Vernon, a homeless encampment is hidden under a bridge that crosses the Los Angeles River. (Anna Almendrala/KHN)

In the city of San Francisco, Trump’s favorite punching bag on the issue, fecal pollution on the streets gets swept into the storm drains after it rains and is routed to the same treatment plants as toilet water, which means Trump’s claims about the city’s water were inaccurate, officials say.

But that isn’t the case for most of the state’s cities and sewage systems. In San Diego, the state’s second-most populous county, dozens of homeless encampments line the 52-mile-long San Diego River, which flows into the Pacific Ocean. Officials have for decades recorded high levels of fecal bacteria in the river that exceed state standards, Gibson said.

Last year, the regional water board ordered San Diego County, several cities and municipal agencies to determine the source of the contamination. In addition to investigating the condition of leaky sewage infrastructure, which fails when it rains, the order requires municipalities to evaluate how homeless people living on riverbanks, in parking lots, trailers and RVs may be contributing to the problem, Gibson said.

Farther north, in Sacramento, regulators have been measuring elevated fecal bacteria levels in the lower American River for more than three years. Located near downtown Sacramento, it is a popular destination for water sports, even as hundreds of homeless people camp nearby.

Some recreational areas, including Tiscornia Beach, where families picnic, BBQ and wade in the river, had E. coli levels so high in the past year that they hit the upper limits of what the water board’s laboratories could measure — more than seven times higher than the state standard, said Adam Laputz, assistant executive officer of the Central Valley Regional Water Quality Control Board.

The board is conducting a three-year DNA analysis to determine whether the bacteria comes from people, birds or dogs, he said. “That source could be from a sewage collection that’s leaky, or it could be from leaky septic systems,” in addition to homeless encampments, he said.

If the source is human, the water board will embark on a new study to determine whether the source is an infrastructure failure or individuals.

In the San Francisco Bay Area and Southern California, which have the largest homeless populations in the state, some cities conduct routine water monitoring. But the regional water boards, which make key water quality decisions for their regions and take enforcement actions when necessary, aren’t testing to determine if and how homeless encampments affect water quality.

Contamination from homeless camps is so easy to observe — and smell — that there is no “need to monitor to know there’s a problem,” said Thomas Mumley, executive officer of the San Francisco Bay Regional Water Quality Control Board, which stretches from Napa County to Santa Clara County.

If there are no bathrooms in or near a homeless encampment, “we can assume there’s a discharge of waste” where there shouldn’t be, he said.

Bay Area regulators are working with some cities that are conducting pilot projects, such as offering free RV dump stations and providing sanitation services for encampments.

The board could one day require municipalities to adopt such projects or face fines, Mumley said.

“We’re cautious about using that authority,” he said. “We want public dollars going toward solutions, not just paying penalties.”

The Central Coast Water Board has already issued an order to the city of Salinas to map homeless encampments and focus more resources on their sanitation needs.

Large plastic tarps protect dilapidated camping tents on one side of the Atwater Village bike path, which runs alongside the Los Angeles River. (Anna Almendrala/KHN)

In Los Angeles, hundreds of homeless people camp within the Los Angeles River channel itself and thousands live nearby.

Along a stretch of the river that runs through Atwater Village north of downtown, one man, who called himself P. Dogg and said he had been homeless for three years, said that he bathes in the river when the water is “clear, not murky.”

Asked if he’s ever gotten sick from bathing in the river, he answered proudly: “Never once.”

While local testing of the Los Angeles River, San Gabriel River and the Ventura River Estuary wasn’t designed to measure the effects of homelessness, results suggest there have been significant impacts in some areas due to homeless encampments, said Renee Purdy, executive officer of the Los Angeles Regional Water Quality Control Board.

Purdy is working with area communities that have installed portable toilets and organized trash cleanups with money initially budgeted for water infrastructure maintenance.

“The long-term solution is really to address the societal issue of homelessness,” she said.

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California Public Health States