During her time in the Florida Legislature, Cruz had supported a new law allowing the use of treated wastewater in local water systems. But many Tampa residents were staunchly opposed to a plan by their water utility to do just that, and Cruz was forced to backtrack, with her spokesperson asserting she had never favored the type of complete water reuse known as “toilet to tap.” She lost anyway, and the water plan has been canceled.

Tampa’s showdown may be a harbinger of things to come as climate change and drought cause water shortages in many parts of the country. With few alternatives for expanding supply, cities and states are rapidly adding recycled water to their portfolios and expanding the ways in which it can be used. Researchers say it’s safe — and that it’s essential to move past the 20th century notion that wastewater must stay flushed.

“There is no reason to only use water once,” said Peter Fiske, director of the National Alliance for Water Innovation at the Lawrence Berkeley National Laboratory. “We’ve got to be more clever with the water we’ve got.”

But proponents are still fighting an uphill battle to overcome the “yuck” factor. A recent study found that reused water is not only safe but that it’s actually cleaner than conventionally sourced water — yet acceptance is “hindered by perceptions of poor water quality and potential health threats.”

Several projects were canceled in California in the 1990s because of such worries. In San Gabriel, Miller Brewing Company opposed a water reclamation project when people started joking about “beer aged in porcelain.”

“You have to have a lot of education in a community to say why [recycled water] is needed” and what experts are doing to ensure the safety of the water, said Noelle George, the Texas managing director for the trade association WateReuse.

Many forms of water reuse have long been routine. Water from yard sprinklers, for example, soaks into the groundwater. Or, if it is processed in a treatment plant, it goes into a river or lake, where it’s used again. Municipalities and others often treat a form of wastewater known as gray water to use for irrigation.

But in the world of water reuse, the gold standard is known as direct potable reuse — cleaning wastewater, including sewage, to drinking water standards.

With DPR systems, the water from showers, sinks, and toilets first goes to a conventional treatment plant, where it is disinfected with chemicals and aeration. Then it gets a second scrubbing in a multistage process that first uses a bioreactor to break down nitrogen compounds, then employs microfiltration to clean out particles and reverse osmosis to remove viruses, bacteria, and salts. Finally, hydrogen peroxide is added and the water goes through an ultraviolet light processing, which is supposed to kill any contaminants that are left.

Experts say the water that emerges at the end of this process is so clean it has no taste, and that minerals must be added to give the water flavor. It’s also free of a little-known health hazard; chlorine, often used to disinfect conventional water, can react with organic material in the water to create chloroform, exposure to which can cause negative health effects.

Big Spring, Texas, is the only place in the country with a DPR municipal water system, in which all wastewater is treated and sent back to the tap. Another notable DPR system is the Changi Water Reclamation Plant in Singapore, which cleans 237 million gallons each day.

In Tampa, intense opposition focused on the high cost of the water treatment and the possible presence of pharmaceuticals, hormones, and so-called forever chemicals, known as PFAS.

“We have never thought that it was necessary to drink wastewater,” said Gary Gibbons, the vice chair of the Tampa Bay Sierra Club, in September 2022. He said the project, which the city referred to by the acronym PURE, would result in contaminants in the drinking water and the groundwater aquifer.

Experts reject these concerns as uninformed and say properly treated wastewater is safer than a lot of conventional drinking water sources.

“I would almost rather have an advanced treatment plant of the type used for potable water recycling than water that comes from a river that has several cities and farms and industries upstream that are discharging into it,” said David L. Sedlak, an expert on potable reuse at the University of California-Berkeley.

With higher temperatures and long-term pressure on water sources including aquifers and mountain snowpacks, a lot more water reuse is coming.

In Texas, the state permits DPR plants on a case-by-case basis, and the city of El Paso is building one that’s slated to be online by 2026. Colorado last year began allowing DPR. In California, regulations spelling out the approach to DPR should be ready by the end of this year, with some cities setting goals of recycling all water by 2035. Florida and Arizona are also moving to expand direct potable reuse.

There’s also a lot of activity around what’s known as indirect potable reuse. Orange County, California, has the world’s largest IPR facility, which cleans 130 million gallons of water a day to irrigation standards, passes it through advanced purification, and finally injects it into groundwater, which serves as an environmental buffer. The water is then piped to all municipal users.

San Francisco is pioneering another approach. Since 2015, the San Francisco Public Utilities Commission, which operates the dams, reservoirs, and aqueducts that deliver water from the Sierra Nevada to the city, has required all buildings over 100,000 square feet be equipped for recycling gray water. The downtown Salesforce Tower has its own recycling plant: Sinks, laundry machines, and showers drain into the basement recycling system, and the water is then reused for flushing toilets and irrigation, saving about 30,000 gallons a day.

“We don’t need to flush toilets with drinking water,” said Fiske, noting that toilets make up about 30% of all water use.

San Francisco water officials are studying the feasibility and safety of cleaning all wastewater to potable standards at the building level. The headquarters of the water utility has a blackwater system called the Living Machine that uses engineered wetlands in the sidewalks around the building to treat wastewater, cutting water use by two-thirds. (Blackwater systems recycle water from toilets; gray water systems reuse water from all other drains.)

Some experts see a day when buildings will not have to be hooked up to external sewer and water systems at all, with advanced recycling systems augmented by rainwater. For the moment, though, educational campaigns are still needed to bring recycled water into the mainstream.

Epic Cleantec, which created a recycling system for a new San Francisco apartment tower, thought beer might help. The company last year teamed up with a local brewery to produce beer from recycled water. The Epic OneWater Brew by Devil’s Canyon Brewing isn’t sold; rather, it’s a demonstration product, given away and served at events.

While people might not want to drink recycled water, they will usually try the beer.

“We made beer out of recycled water, because we’re trying to change the conversation,” said Aaron Tartakovsky, CEO of Epic Cleantec. “We’re fundamentally trying to help people rethink how our communities handle water.”

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

USE OUR CONTENT

This story can be republished for free (details).

But in at least one California county, history is repeating itself. And across the country, many local leaders are finding themselves in similar positions: choosing between paying bills due today or investing in the fight against an ongoing crisis.

Mendocino County in rural Northern California has reported the highest rate of overdose deaths in the state. Its board of supervisors decided to use more than $63,000 of opioid settlement funds — about 6.5% of all the settlement cash the county has received in the first two years of distribution— to help fill a budget shortfall of about $6 million. Specifically, the money has been allotted to cover employee health insurance premiums, wage increases, and cost-of-living adjustments. County officials plan to use that amount as a recurring source of payment, since opioid settlements are scheduled to arrive annually till 2038.

The board also used retirement reserves and delayed repair projects and equipment purchases to plug the gap.

“We have to balance our budget by law,” said Glenn McGourty, chair of the board of supervisors. “You find money where you can.”

Vice Chair Mo Mulheren added that health insurance deficits were caused, in part, by the overprescribing of opioids and the costs of addiction treatment for county employees or their family members. Now the settlement dollars can make the county “whole again,” she said.

But many people with substance use disorders and their loved ones want the money to be used to make their communities whole again in a different way — by supporting people in recovery and preventing opioid-related deaths. More than 100,000 Americans died of drug overdoses last year.

The settlement funds are the result of thousands of lawsuits filed against a host of health care companies, including Johnson & Johnson, McKesson, CVS Health, and Walmart, for aggressively promoting and distributing painkillers. The money should remediate the effects of that corporate behavior, say attorneys general, treatment providers, and those directly affected by the crisis.

In Mendocino County, McGourty said, “we certainly expend a lot of money on substance abuse.” But tourism and tax revenues, which were boosted at the height of the pandemic as Bay Area residents escaped to the rural county, have recently decreased. Meanwhile, costs for the sheriff’s office, jail, and behavioral health programs often run over budget, partly due to the opioid epidemic, he said.

The story is all too familiar to Matthew Myers, former president of the Campaign for Tobacco-Free Kids, which monitors how states spend money from the tobacco master settlement agreement of 1998.

Back then, states won more than $240 billion to be distributed over the first 25 years and continued annual payments for as long as the companies are selling cigarettes. In theory, the money was to be used to help people stop smoking, but there were no legal restrictions on how it was spent. In a 2007 report, the Government Accountability Office reported states had allocated $16.8 billion, or 30% of the money they’d received, to health care and $12.8 billion, or 23%, to budget shortfalls.

“Almost from the beginning, a significant number of states used the tobacco settlement money for anything but tobacco,” Myers said. “What’s most concerning, though, is that over time the track record of the states has gotten worse.”

People who made the original agreements left office, budget needs arose — especially during recessions — and oversight from the public and nonprofit organizations waned. Tobacco settlement money flowed to transportation departments to fill potholes, support corporate tax breaks, and even subsidize tobacco farmers. Today, less than 3% of the annual payouts is used for smoking cessation or prevention.

It’s a sobering statistic that many attorneys general kept in mind when negotiating the opioid settlements. To avoid the same scenarios, they set restrictions: At least 85% of the money has to be spent on opioid remediation, with a menu of suggested strategies.

Some states are stricter than others. In California, for example, 70% of the settlement funds funnel into an abatement account from which the state doles it out to counties and cities. All money from that account must be spent on future opioid remediation efforts, with at least half for creating treatment infrastructure, diverting people from the criminal justice system, preventing youth addiction, or other activities the state identified as high-impact. The state Department of Health Care Services has issued written guidance, held webinars, and offered customized assistance to local governments to ensure the money is used appropriately.

“We really want to make sure that all of this funding is for opioid remediation,” said Marlies Perez, who oversees opioid settlement funding at the department.

If her team finds examples of misspending, they can take local governments to court.

But there’s a caveat: The department has authority only over money that comes from the abatement fund and an additional 15% the state receives directly. The final 15% of the state’s settlement money goes straight to local governments and can be used for anything the localities define as opioid-related.

That’s why Mendocino County was able to use $63,000 to plug its budget hole and plan to spend a chunk of future funds similarly. (It has received roughly $780,000 more through the state abatement fund, which must be spent on opioid remediation.)

Even if that use of funds is legal, some people question whether it is appropriate.

Jacqueline Williams is executive director of the Ford Street Project, a nonprofit that runs a food bank, homeless shelter, and Mendocino County’s only adult residential addiction treatment program. “It’s disheartening that the need is so great,” she said, yet some of the settlement money is not going directly to the crisis.

She has asked the county for $4 million to build a 24-bed sober living facility, where clients — many of whom are homeless — can stay after completing residential treatment. “The hardest thing is when somebody asks for help if you don’t have a bed,” said Williams, who hasn’t received a final response to her request.

Jenine Miller, Mendocino County’s behavioral health director, said the county is using revenue from a local sales tax increase to build a psychiatric hospital, crisis respite facilities, and mobile response teams, but there is still a need for more residential treatment for addiction specifically.

“I can never say I have enough funds to do everything we need to do,” she said.

Miller signed off on a report the county is required to file with administrators of the settlement, saying it spent $63,000 on purposes that do not qualify as opioid remediation. She told KFF Health News that she understands the county’s need to recuperate costs to its health insurance plan, “but the largest amount of the money needs to be in our community doing prevention, early intervention, and treatment.”

Mulheren, the vice chair of the board of supervisors, said if the county has savings in future years, it may be able to put some of the recurring $63,000 toward addiction initiatives. The county recently switched from being self-insured to a group health insurance plan for its roughly 900 employees.

“We’re trying to constantly figure out how we can save money, especially when it comes to the health insurance premiums.” Mulheren said.

But Myers, of the Campaign for Tobacco-Free Kids, said his experience with the tobacco settlement suggests the first few years of spending set the tone for the future.

“If states don’t start spending money for the designated purpose effectively and build it into the DNA of the budget process, the risks down the road only grow,” he said.

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

USE OUR CONTENT

This story can be republished for free (details).

After emergency surgery to remove the mass, along with her ovaries, uterus, fallopian tubes, and appendix, Hughes said, she saw an Instagram post in which a woman with uterine cancer linked her condition to chemical hair straighteners.

“I almost fell over,” she said from her home in Smyrna, Georgia.

When Hughes was about 4, her mother began applying a chemical straightener, or relaxer, to her hair every six to eight weeks. “It burned, and it smelled awful,” Hughes recalled. “But it was just part of our routine to ‘deal with my hair.’”

The routine continued until she went to college and met other Black women who wore their hair naturally. Soon, Hughes quit relaxers.

Social and economic pressures have long compelled Black girls and women to straighten their hair to conform to Eurocentric beauty standards. But chemical straighteners are stinky and costly and sometimes cause painful scalp burns. Mounting evidence now shows they could be a health hazard.

Relaxers can contain carcinogens, like formaldehyde-releasing agents, phthalates, and other endocrine-disrupting compounds, according to National Institutes of Health studies. The compounds can mimic the body’s hormones and have been linked to breast, uterine, and ovarian cancers, studies show.

African American women’s often frequent and lifelong application of chemical relaxers to their hair and scalp might explain why hormone-related cancers kill disproportionately more Black than white women, say researchers and cancer doctors.

“What’s in these products is harmful,” said Tamarra James-Todd, an epidemiology professor at the Harvard T.H. Chan School of Public Health, who has studied straightening products for the past 20 years.

She believes manufacturers, policymakers, and physicians should warn consumers that relaxers might cause cancer and other health problems.

But regulators have been slow to act, physicians have been reluctant to take up the cause, and racism continues to dictate fashion standards that make it tough for women to quit relaxers, products so addictive they’re known as “creamy crack.”

Michelle Obama straightened her hair when Barack served as president because she believed Americans were “not ready” to see her in braids, the former first lady said after leaving the White House. The U.S. military still prohibited popular Black hairstyles like dreadlocks and twists while the nation’s first Black president was in office.

California in 2019 became the first of nearly two dozen states to ban race-based hair discrimination. Last year, the U.S. House of Representatives passed similar legislation, known as the CROWN Act, for Creating a Respectful and Open World for Natural Hair. But the bill failed in the Senate.

The need for legislation underscores the challenges Black girls and women face at school and in the workplace.

“You have to pick your struggles,” said Atlanta-based surgical oncologist Ryland Gore. She informs her breast cancer patients about the increased cancer risk from relaxers. Despite her knowledge, however, Gore continues to use chemical straighteners on her own hair, as she has since she was about 7 years old.

“Your hair tells a story,” she said.

In conversations with patients, Gore sometimes also talks about how African American women once wove messages into their braids about the route to take on the Underground Railroad as they sought freedom from slavery.

“It’s just a deep discussion,” one that touches on culture, history, and research into current hairstyling practices, she said. “The data is out there. So patients should be warned, and then they can make a decision.”

The first hint of a connection between hair products and health issues surfaced in the 1990s. Doctors began seeing signs of sexual maturation in Black babies and young girls who developed breasts and pubic hair after using shampoo containing estrogen or placental extract. When the girls stopped using the shampoo, the hair and breast development receded, according to a study published in the journal Clinical Pediatrics in 1998.

Since then, James-Todd and other researchers have linked chemicals in hair products to a variety of health issues more prevalent among Black women — from early puberty to preterm birth, obesity, and diabetes.

In recent years, researchers have focused on a possible connection between ingredients in chemical relaxers and hormone-related cancers, like the one Hughes developed, which tend to be more aggressive and deadly in Black women.

A 2017 study found white women who used chemical relaxers were nearly twice as likely to develop breast cancer as those who did not use them. Because the vast majority of the Black study participants used relaxers, researchers could not effectively test the association in Black women, said lead author Adana Llanos, an associate professor of epidemiology at Columbia University’s Mailman School of Public Health.

Researchers did test it in 2020.

The so-called Sister Study, a landmark National Institute of Environmental Health Sciences investigation into the causes of breast cancer and related diseases, followed 50,000 U.S. women whose sisters had been diagnosed with breast cancer and who were cancer-free when they enrolled. Regardless of race, women who reported using relaxers in the prior year were 18% more likely to be diagnosed with breast cancer. Those who used relaxers at least every five to eight weeks had a 31% higher breast cancer risk.

Nearly 75% of the Black sisters used relaxers in the prior year, compared with only 3% of the non-Hispanic white sisters. Three-quarters of Black women also self-reported using the straighteners as adolescents, and frequent use of chemical straighteners during adolescence raised the risk of pre-menopausal breast cancer, a 2021 NIH-funded study in the International Journal of Cancer found.

Another 2021 analysis of the Sister Study data showed sisters who self-reported that they frequently used relaxers or pressing products doubled their ovarian cancer risk. In 2022, another study found frequent use more than doubled uterine cancer risk.

After researchers discovered the link with uterine cancer, some called for policy changes and other measures to reduce exposure to chemical relaxers.

“It is time to intervene,” Llanos and her colleagues wrote in a Journal of the National Cancer Institute editorial accompanying the uterine cancer analysis. While acknowledging the need for more research, they issued a “call for action.”

No one can say that using permanent hair straighteners will give you cancer, Llanos said in an interview. “That’s not how cancer works,” she said, noting that some smokers never develop lung cancer, despite tobacco use being a known risk factor.

The body of research linking hair straighteners and cancer is more limited, said Llanos, who quit using chemical relaxers 15 years ago. But, she asked rhetorically, “Do we need to do the research for 50 more years to know that chemical relaxers are harmful?”

Charlotte Gamble, a gynecological oncologist whose Washington, D.C., practice includes Black women with uterine and ovarian cancer, said she and her colleagues see the uterine cancer study findings as worthy of further exploration — but not yet worthy of discussion with patients.

“The jury’s out for me personally,” she said. “There’s so much more data that’s needed.”

Meanwhile, James-Todd and other researchers believe they have built a solid body of evidence.

“There are enough things we do know to begin taking action, developing interventions, providing useful information to clinicians and patients and the general public,” said Traci Bethea, an assistant professor in the Office of Minority Health and Health Disparities Research at Georgetown University.

Responsibility for regulating personal-care products, including chemical hair straighteners and hair dyes — which also have been linked to hormone-related cancers — lies with the Food and Drug Administration. But the FDA does not subject personal-care products to the same approval process it uses for food and drugs. The FDA restricts only 11 categories of chemicals used in cosmetics, while concerns about health effects have prompted the European Union to restrict the use of at least 2,400 substances.

In March, Reps. Ayanna Pressley (D-Mass.) and Shontel Brown (D-Ohio) asked the FDA to investigate the potential health threat posed by chemical relaxers. An FDA representative said the agency would look into it.

Natural hairstyles are enjoying a resurgence among Black girls and women, but many continue to rely on the creamy crack, said Dede Teteh, an assistant professor of public health at Chapman University.

She had her first straightening perm at 8 and has struggled to withdraw from relaxers as an adult, said Teteh, who now wears locs. Not long ago, she considered chemically straightening her hair for an academic job interview because she didn’t want her hair to “be a hindrance” when she appeared before white professors.

Teteh led “The Cost of Beauty,” a hair-health research project published in 2017. She and her team interviewed 91 Black women in Southern California. Some became “combative” at the idea of quitting relaxers and claimed “everything can cause cancer.”

Their reactions speak to the challenges Black women face in America, Teteh said.

“It’s not that people do not want to hear the information related to their health,” she said. “But they want people to share the information in a way that it’s really empathetic to the plight of being Black here in the United States.”

Kara Nelson of KFF Health News contributed to this report.

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

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

USE OUR CONTENT

This story can be republished for free (details).

The deal comes as a federal bankruptcy court in Fresno weighs whether to force Madera to sell off its assets to satisfy creditors. The biggest creditor is Fresno’s St. Agnes Medical Center, which walked away from a deal to take over Madera and effectively forced it into bankruptcy. The hospital closed in January.

“I can confirm the [Madera Community Hospital] board accepted a letter of intent with a suitor,” Riley Walter, the hospital’s lead bankruptcy lawyer, told the Bee in an email. The paper identified the suitor as Adventist, a faith-based nonprofit health system that operates in California, Oregon, and Hawaii and recently took over another troubled hospital, in Bakersfield.

A lot still must happen for the Madera hospital to reopen. Madera County supervisors are considering whether to spend $500,000 to keep the hospital’s skeletal operations running after the bankruptcy court this week declined to authorize any spending beyond Aug. 4. The hospital has also applied for an $80 million loan from the state’s new distressed hospital fund, but it’s not clear how much it will receive.

Analysts said it would take many months to hire staff and resume operations at the hospital, the only one in the rural and majority-Hispanic agricultural county of Madera.

Rural hospitals across California and much of the country are struggling in the face of low reimbursements for low-income patients served by Medicaid, skyrocketing costs during the pandemic, and chronic staffing troubles. Madera also suffered from bad contracts with private insurers and management missteps, according to an article reported jointly by KFF Health News and The Fresno Bee.

Experts warn that reopening will be costly, and that any plan must address the underlying problems that caused Madera to go bankrupt in the first place.

Staffers said they were devastated when St. Agnes walked away from a deal to save the hospital last December. California Attorney General Rob Bonta blasted St. Agnes and its parent, Trinity Health, for trying to “extract every dollar possible” in the bankruptcy after walking away from the deal with no notice and little explanation. St. Agnes blamed the decision on complex circumstances and additional conditions imposed by Bonta, but he had agreed to most demands, experts said.

More details on the Adventist deal are expected by Aug. 1, when the Board of Supervisors will vote on whether to authorize the $500,000 to keep things running and the bankruptcy court will hold another hearing.

Madera Community Hospital board officials declined to comment to the Bee. The Adventist CEO could not immediately be reached, the newspaper reported.

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

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

USE OUR CONTENT

This story can be republished for free (details).

The state’s health insurance exchange will zero out some patients’ hospital deductibles, up to $5,400; lower the copay of primary care visits from $50 to $35; and reduce the cost for generic drugs from $19 to $15. Some enrollees will also see their annual out-of-pocket spending capped at $6,100, down from $7,500.

Covered California CEO Jessica Altman argues these are tangible reductions — savings on deductibles and copays on top of subsidies to lower monthly premiums — that will affect hundreds of thousands of people and entice them to use their coverage.

“Deductibles uniquely detract people from seeking care, so that’s a significant focus,” Altman told KFF Health News. “California is really grappling with affordability and thinking about, ‘What does affordability really mean?’ Many people simply do not have $5,000 sitting in their bank account in case they need it for health care.”

Additional reductions in patients’ out-of-pocket costs — on top of existing federal health insurance subsidies to reduce monthly premiums — will take effect in January for people renewing or purchasing coverage during Covered California’s next enrollment period, which begins in the fall. The state could go further in helping reduce patients’ costs in subsequent years with future budget increases, Altman said.

Still, those savings may be offset by higher costs elsewhere. Covered California announced July 25 that inflation and other factors are driving up annual premium rates on participating health plans by an average of nearly 10% next year, the largest average increase since 2018.

California started fining those without health coverage in the tax year 2020, establishing its own “individual mandate.” In that first year, the state raised $403 million in penalty revenue, according to the state Franchise Tax Board. It has continued to levy fines, paid for largely by low- or middle-income earners, the very people the new subsidies are intended to help.

Legislative leaders had pushed Newsom, a fellow Democrat, to funnel the tax revenue into lowering health care costs for low- and middle-income people purchasing coverage via Covered California — many of whom reported skipping or delaying care due to high out-of-pocket costs.

The governor for years resisted pleas to put penalty money into Covered California subsidies, arguing that the state couldn’t afford it and needed the money given looming economic downturns and the potential loss of federal premium subsidies — which could be threatened by a change in federal leadership.

But under ongoing pressure, Newsom relented in June and agreed to begin spending some of the money to boost state subsidies. According to the state Department of Finance, California is expected to plow $83 million next year and $165 million annually in subsequent years to expand financial assistance — roughly half the revenue it raises annually — into reducing Covered California patients’ costs. The remainder of the money will be set aside in a special health care fund that could be tapped later.

The budget deal also allows the Newsom administration to borrow up to $600 million in penalty revenue for the state general fund, which it must pay back. Penalty revenues are projected to bring in $362 million this year with an additional $366 million projected next year, according to Finance Department spokesperson H.D. Palmer.

Covered California board members approved the new plan design last week. They say the cost-sharing subsidies will lower out-of-pocket spending for nearly 700,000 people out of roughly 1.6 million enrolled in Covered California.

The boost in funding, which represents the state’s most significant effort to slash patients’ costs in Covered California, will largely benefit lower-income Californians who earn below 250% of the federal poverty level, which is $33,975 for an individual and $69,375 for a family of four for 2023, according to the exchange.

“Bringing down deductibles goes a long way to help middle-class California families struggling with increasing costs of living,” said Senate President Pro Tempore Toni Atkins, who rallied fellow Democrats to block a plan by Newsom and his administration to keep the revenue for the state general fund, which can be used for any purpose.

Atkins added, “We will continue our work to lower the costs even more in the years to come.”

Newsom spokesperson Brandon Richards defended the governor’s health care record, saying Newsom is committed to ensuring Californians can access health care. In addition to boosting assistance in Covered California, Richards said, the governor has expanded public health insurance coverage to immigrants lacking legal status and is increasing how much doctors, hospitals, and other providers get paid to see Medicaid patients.

Originally required by the federal Affordable Care Act, the so-called individual mandate to hold health coverage or pay a tax penalty was gutted by Republicans in 2017, eliminating the fine nationally. Newsom reinstated it for California when he took office in 2019 — a key component of his ambitious health care platform.

California is one of at least five states, along with Massachusetts, New Jersey, Rhode Island, and Vermont, as well as the District of Columbia that have their own health coverage mandate, though not all levy a tax penalty for remaining uninsured. Among them, California is most aggressively trying to lower health care costs and achieve universal coverage, said Larry Levitt, executive vice president for health policy at KFF.

“Even though they may disagree on the big picture of health care reform and single-payer, California Democrats have managed to come together and unify around these incremental steps to improve the current system,” Levitt said. “Step by step, they have put in place the pieces to get as close to universal coverage as they possibly can.”

Democratic leaders in the state have faced political blowback for not using the penalty revenue for health care, details first reported by KFF Health News, even though Newsom and other Democrats vowed to spend the money to make health care more affordable in Covered California.

Advocates say the deal represents a win for low- and middle-income people.

“We’re excited that this money is protected for health care, and ultimately is set aside for future affordability assistance,” said Diana Douglas, chief lobbyist with the consumer advocacy group Health Access California.

Advocates want the state to tap those health care dollars to get more people covered, such as lowering health care costs for immigrants living in the state without legal permission.

A bill this year by Assembly member Joaquin Arambula, a Fresno Democrat, would require Covered California to establish a separate health insurance marketplace so that immigrants who lack legal status and earn too much to qualify for Medi-Cal, California’s version of Medicaid, can purchase comprehensive coverage that is nearly identical to plans sold on Covered California. Currently, immigrants without legal residency are not allowed on the exchange. Other states, such as Washington and Colorado, have set up similar online marketplaces.

“We’re working hard to create a system that has equal benefits and affordability assistance for everyone,” Arambula said.

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

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

USE OUR CONTENT

This story can be republished for free (details).

The U.S. Department of Justice and the states’ attorneys general say Francis Lagattuta, a physician, and his Lags Medical Centers performed — and billed for — medically unnecessary tests and procedures on thousands of patients over more than five years. It was “a brazen scheme to defraud Medicare and Medicaid of millions of dollars by inflicting unnecessary and painful procedures on patients whom they were supposed to be relieving of pain,” Phillip Talbert, U.S. attorney for the Eastern District of California, said in a statement this month.

The federal Medicare program suspended reimbursements to Lags Medical in June 2020, and Medi-Cal, California’s Medicaid program, followed in May 2021. Lags Medical shut down the same day the state suspended reimbursements. The company, based in Lompoc, California, had more than 30 pain clinics, most of them in the Central Valley and the Central Coast.

A KFF Health News review last year found the abrupt closure left more than 20,000 California patients — mostly working-class people on government-funded insurance — struggling to obtain their medical records or continue receiving pain prescriptions, which often included opioids.

Lagattuta and Lags Medical did not admit liability under the settlement. Lagattuta denied the governments’ claims, saying in a statement he was “pleased” to announce the settlement of a “long-standing billing dispute.” As part of the agreement, Lagattuta will be barred for at least five years from receiving Medicare and Medicaid reimbursements.

“Since the Centers have been closed for a couple of years, it made sense for Dr. Lagattuta to settle the dispute and continue to move forward with his other business interests and practice,” Malcolm Segal, an attorney for Lagattuta and the centers, said in the statement.

According to state officials, the federal government will receive the bulk of the money, about $8.5 million. California will receive about $2.7 million, and an additional $130,000 will go to Oregon. The settlement amount is based in part on Lagattuta’s and Lags Medical’s “ability to pay.” It does not cover the governments’ full losses, which the U.S. attorney’s office in Sacramento said are not public record.

A nearly four-year investigation by federal officials and the California Department of Justice found that from March 2016 through August 2021, Lagattuta and his company submitted reimbursement claims for unneeded skin biopsies, spinal cord stimulation procedures, urine drug tests, and other tests and procedures. Lagattuta began requiring all his clinics to perform various medical procedures on every patient, the officials said, no matter if they were needed or requested by patients’ medical providers. Patients who refused were told they would have their pain medication reduced and could suffer adverse medical consequences.

U.S. and California investigators piggybacked on a federal claim filed in late 2018 by a whistleblower, Steven Capeder, Lags Medical’s former operations and marketing director, who will receive more than $2 million of the settlement.

As part of the settlement, Lagattuta and his company acknowledged that in mid-2016 he began requiring his providers to do at least two to three skin biopsies on Medicare patients each day and told providers to quit if they wouldn’t comply. Such biopsies are used to measure small-fiber neuropathy, which causes burning pain with numbness and tingling in the feet and lower extremities.

According to the settlement, a monthly report in early 2018 set a goal of performing 250 biopsies a week. Lagattuta created a separate team that was required to order at least 150 biopsies weekly, often overruling providers. And the company’s chief executive officer in late 2019 texted Lagattuta to report a particularly high number of biopsies, illustrating the text with emojis of a money bag and a smiley face.

Authorities said Lagattuta violated regulations requiring that skin biopsy results be interpreted by a trained pathologist or neurologist. Instead, they say, Lagattuta had the biopsies read by a family member who had no formal medical training and by a former clinic executive’s spouse, who was trained as a respiratory therapist.

Lags Medical clinics performed more than 22,000 biopsies on Medi-Cal patients from 2016 through 2019.

The settlement also alleges Lagattuta encouraged unsuitable patients to undergo spinal cord stimulation. It describes the procedure as “an invasive surgery of last resort,” in which implants placed near the spinal cord apply low-voltage electrical pulses to nerve fibers.

Lagattuta paid a psychiatrist $3,000 each month to falsely certify that every Lags Medical candidate for the procedure had no psychological or substance use disorders that would negatively affect the outcome, according to the settlement. For instance, the settlement says the psychiatrist overruled a Lags Medical social worker to OK the procedure for a young woman who had bipolar disorder with hallucinations that included hearing a man’s voice ordering her out of bed.

He also issued blanket orders for every patient to have urine drug testing, a policy the company’s CEO said “should be a big money maker.”

KFF Health News found that from 2017 through 2019 nearly 60,000 of the most extensive urine drug tests were billed to Medicare and Medi-Cal under Lagattuta’s provider number. Medicare reimbursed Lagattuta $5.4 million for those tests.

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

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

USE OUR CONTENT

This story can be republished for free (details).

Now, with the nonprofit Madera, California, hospital bankrupt and shuttered, St. Agnes looms as a dark knight, pushing to liquidate the hospital to get a loan it made to Madera paid back — even if that means dashing the hopes of the community activists, political leaders, and health care officials that the hospital can still reopen.

A pivotal moment in the case could come July 25, when a bankruptcy judge in Fresno will hear arguments on whether the Madera hospital should be allowed to spend its dwindling cash reserves on things such as building maintenance, security, utilities, and the salaries of its three top executives.

The hospital wants to run a skeletal operation while it seeks a buyer and develops a reopening plan. But the federal bankruptcy court in Fresno has authorized it to spend money only through July 29. If the judge doesn’t think the hospital has a viable plan, he may refuse an extension, which would likely mean liquidation.

Problems like Madera’s are common among other small, financially challenged hospitals in California and nationwide. They typically have low patient volumes and rely disproportionately on payments from Medicaid and Medicare, which constrains revenue and makes it difficult to attract talent or invest in cutting-edge equipment. Add to the mix a crushing surge in expenses stemming from the covid-19 pandemic, and dozens of such facilities are struggling to survive. Two others, both in California, have filed for bankruptcy this year.

Yet Madera had problems that were all of its own making. The hospital made money on patients insured by Medi-Cal, the state safety-net insurance program that pays notoriously low rates, according to financial data filed with state regulators. But it lost money on its commercially insured patients due to low volume and bad deals with insurance providers. It also failed to seek covid relief funds in a timely manner. A state hospital bailout fund came too late.

Plus, Madera had no backup plan when St. Agnes and its parent company, the hospital chain Trinity Health, walked away from a proposed merger with the troubled hospital late last year, giving virtually no notice and scant explanation. Their move shocked and infuriated officials, former employees, and community advocates in Madera and Sacramento.

In a brief December press release, St. Agnes and Trinity blamed their decision on “complex circumstances” and “additional conditions” imposed by state Attorney General Rob Bonta. But industry experts said Bonta had agreed to most of what St. Agnes asked for and were baffled as to why they walked away from the deal.

The spectacle of St. Agnes and Trinity now pushing in court for the liquidation of tiny Madera has drawn Bonta’s ire.

“For Trinity, it was always about profit, not the health of the Madera community,” Bonta told KFF Health News in a statement. “They are now attempting to use their position as Madera’s biggest creditor to extract every dollar possible, instead of keeping the community’s interests at heart.”

Bonta said his office had “offered maximum flexibility to Trinity in recognition of Madera’s financial circumstances.”

An agricultural area of 2,150 square miles and home to nearly 160,000 people, Madera County is 60% Hispanic, and more than one-fifth of its residents live below the poverty line, according to census data.

A Community Left in the Lurch

Jennifer Lara, a former Madera Community Hospital nursing assistant, said she and colleagues had been looking forward to positive change after the anticipated merger with St. Agnes. “We were floored when we found out the hospital was closing,” she said. “We didn’t think anything other than the hospital continuing on was going to happen.”

St. Agnes and Trinity declined to comment. The longtime CEO of St. Agnes, Nancy Hollingsworth, retired in May amid a reorganization that made the hospital part of a regional group based in Idaho. It’s unclear whether her departure was related to the collapse of the Madera deal. Hollingsworth could not be reached for comment.

St. Agnes’ considerable leverage in the bankruptcy case is the result of a $15.4 million loan it extended to Madera during merger talks last year. Madera has since repaid $8 million, leaving a debt of over $7 million, which still makes St. Agnes its largest creditor.

St. Agnes, one of 88 hospitals belonging to Trinity, a multistate, Catholic, nonprofit health system headquartered in Livonia, Michigan, argued in a recent bankruptcy court filing that Madera still has made no significant progress finding a buyer, more than four months after filing for Chapter 11 bankruptcy protection on March 10, and should not be allowed to continue spending money “without a serious path forward to either sell or mothball the hospital.”

The hospital has been talking to three potential partners, “one of whom is late to the game,” said Riley Walter, Madera’s bankruptcy lawyer.

Mohammad Ashraf, a cardiologist and member of the executive committee of Madera’s medical staff, said the first two entities in question, whom he declined to identify, are management service organizations, not hospital groups. “They don’t want to spend any money to buy it. They just want to run it,” he said.

Without a convincing strategy for the future of Madera Community Hospital, the end of the bankruptcy case could come quickly.

Ranjit S. Rajpal, a Madera cardiologist for over 40 years, said the closure of the hospital is bad news for patients who need time-sensitive care, such as for heart attacks, strokes, or other traumas, and who now must travel greater distances to get it.

And the closure will exacerbate existing health inequities for people who face challenges getting care because of immigration status, language barriers, lack of transportation, or other socioeconomic factors, he said. “Those disparities will be compounded as time goes by.”

Community leaders and the hospital’s leadership hold out hope for reopening. The hospital has applied for $80 million from California’s new, $300 million loan fund for distressed hospitals. Hospital leaders must produce a reopening plan by July 31, but even if it does, it’s unlikely to get the full requested amount: Sixteen hospitals have already applied for loans totaling over $385 million, said Joe DeAnda, spokesperson for the California State Treasurer’s Office.

“They’re not going to give a quarter of their total fund to one hospital that doesn’t even have a partner,” said Glenn Melnick, a health economist at the University of Southern California who authored an analysis commissioned by the AG’s office of the proposed St. Agnes-Madera merger. “Eighteen months ago, the ask would have been a lot smaller.”

Even if Madera Community Hospital finds a viable partner and gets the funding it needs, reopening would be daunting and expensive. The hospital would need to hire hundreds of nurses, technicians, and other staffers in a tight and expensive health care labor market and find a way to avoid the financial problems that landed it in bankruptcy.

“Some things an acute care hospital offers are profitable, and others are not,” said Jay Varney, Madera County’s administrative officer, whose role is akin to a CEO. “It doesn’t make much sense to have it reopen like it was and have it go bankrupt again.”

‘Running Out of Time’

Reopening the facility with all the services it provided before is not the only option. Baldwin Moy, an attorney for California Rural Legal Assistance, a community advocacy group, said he and colleagues have been arguing for the court to allow Madera additional time either to find a buyer or for the county “to put together a package that can reopen the emergency room with some stripped-down clinical operation.” But, Moy said, they are “running out of time.”

Karen Paolinelli, the hospital’s CEO, said the current suitors are interested in reopening it as an acute care facility that “may or may not have all services that were previously offered by Madera Hospital on day one.”

If the hospital can hold out for a few more months, it says, it can collect $23.5 million owed by the state for “provider fees,” and possibly an additional $10 million from the Federal Emergency Management Agency. Those payments would more than cover the hospital’s entire debt of $30 million. But the amount and timing of payments are unclear.

Paolinelli, voicing a common industry complaint, said the hospital has a disproportionately high number of Medi-Cal patients and Medi-Cal rates do not cover the cost of providing care. But state data shows that Madera received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients. Madera also lost about $6.8 million on commercially insured patients in 2021, the state data shows. Commercial insurance payments covered only 59.5% of what it cost to care for those patients. That compares with a statewide average of 156%, according to Melnick.

Paolinelli said Madera tried to negotiate better rates with commercial health plans but “does not have much leverage with the payors.” She added that many residents of Madera who get commercial insurance through their employers choose Kaiser Permanente, whose nearest acute care hospital is in Fresno, 20 miles away.

State Democratic Sen. Anna Caballero, whose district includes parts of Madera, Merced, and Fresno counties, said that if Madera Community Hospital were to successfully reopen, more people with commercial insurance would have to choose it over other hospitals outside the county, which they had not been doing frequently.

“The county and the city may need to say, ‘If you need hospitalization, you need to go to Madera, and there will be no copay, but if you go out of the county, there’s a copay you have to pay,’” Caballero said.

But with no clear path to reopening yet in sight, Caballero said, that discussion is premature.

Melissa Montalvo covers Latino communities for The Fresno Bee as part of the Central Valley News Collaborative, a partnership that includes The Fresno Bee, Vida en el Valle, Valley Public Radio, and Radio Bilingüe. This article is part of the Central Valley News Collaborative, which is supported by the Central Valley Community Foundation with technology and training support from Microsoft Corp.

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

USE OUR CONTENT

This story can be republished for free (details).

But the intense jockeying over the money is only beginning.

Top state health officials say they plan to plow most of the money into higher payments for doctors, hospitals, and other health care providers who serve Californians covered by Medi-Cal, the state’s Medicaid program. But the framework, hammered out this summer as part of state budget negotiations, lacks critical details, which has set off a lobbying frenzy among health industry groups seeking a cut.

Even as they battle for their share, industry leaders are quietly plotting a November 2024 ballot initiative to lock in the Medi-Cal payment increases, which they argue are needed to sustain the safety-net program that covers nearly 16 million Californians — a staggering 40% of the state’s population.

“We are addressing decades of systemic underfunding in Medicaid that has exacerbated inequity and health care provider deserts, where patients are often forced to get their care in emergency departments,” said Dustin Corcoran, the CEO of the influential California Medical Association, which represents doctors.

Corcoran also leads the coalition negotiating with Gov. Gavin Newsom and fellow Democratic lawmakers in Sacramento over how the money — a combination of state and federal funding to be doled out over six years — will be spent.

“Even with this historic deal, there are still parts of the health care system that are going to struggle to provide the care that patients need,” Corcoran said. “The coalition is dedicated to ensuring long-term stability and predictability in reimbursement rates in California.”

California has among the lowest Medicaid reimbursement rates in the country, which is often cited as a key reason many low-income patients can’t get care and often face excruciating wait times, especially for primary care, obstetric, and mental health appointments, said Kathryn Phillips, the associate director for improving access to care at the California Health Care Foundation. (KFF Health News publishes California Healthline, which is an editorially independent service of the California Health Care Foundation.)

“That’s where the state is struggling the most,” she said. “Low rates are why a physician may not accept Medi-Cal patients, or only accept a low number of patients.”

This deal funds the largest increase in base Medi-Cal reimbursement rates in at least 25 years, said Jennifer Kent, a former director of the state Medicaid agency.

The money will come from the managed care organization tax, which has been levied since 2005 on health insurers that do business in California. Revenue from the tax, which allows the state to secure billions in federal health care dollars it wouldn’t otherwise receive, has previously been funneled into the state general fund, which can be used for anything state leaders want.

Under the deal, and for the first time, Newsom and the legislature have agreed to use the money to improve care for poor Californians. Of the $19.4 billion projected to be raised by the tax between 2023 and 2026, $11.1 billion will go directly to Medi-Cal and $8.3 billion to the general fund to offset state spending on Medi-Cal, according to state Department of Finance spokesperson H.D. Palmer.

The new funding will start flowing next year, with $820 million earmarked for initial rate increases in primary care, obstetric care, and mental health care, Palmer said.

From 2025 through 2029, the state plans to allocate nearly $2.7 billion a year, according to the department. State and industry officials said they plan to direct some of the money to expand medical residency programs for doctors serving low-income people, fund new beds for psychiatric patients, and increase the workforce of other providers such as nurses, mental health therapists, and community health workers.

But the bulk will go to rate increases for primary care and an array of providers and services, including hospitals and long-term care facilities, abortion care, and emergency services. Higher rates for specialists, such as psychiatrists and dentists, are also desperately needed.

Although Newsom and state health officials have promised to direct the money to health care providers, they haven’t specified which ones will get increases — and there’s no guarantee the money won’t be diverted to another program. Medi-Cal, a massive and ballooning program with a budget of $152 billion this fiscal year, is under tremendous pressure. The state continues to expand the program to more people and offers a growing list of expensive services, despite the threat of budget deficits.

“There has to be more guardrails,” said Assembly member Vince Fong (R-Bakersfield) during a June legislative debate. “This should not be seen as a revenue grab.”

Mark Ghaly, Newsom’s health and human services secretary, acknowledged that even though some providers and treatments may be left out initially, the payment boosts represent a critical step toward better access.

“The core providers in Medicaid will benefit,” Ghaly told KFF Health News. “There’s always going to be someone out there with a question and a concern, and I hope that as we learn about them and we hear them, we address them.”

Ghaly said the tax will bring some Medicaid rates in California from the bottom in the country to the top. While he acknowledged concerns that the money might be diverted in future years, he said Newsom is committed to spending it on Medi-Cal. “Who knows about the uncertainty of the future?” he said. “But we have basically done as much as you can to hard-wire these changes into the way we design Medicaid. The man with the pen — the governor of California — is committed to this.”

Even though the tax deal isn’t big enough to fix all the problems in Medi-Cal, it will improve patient care, said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents private and public insurers.

“There’s a lot more work to do hammering out the rate increases and where they should go,” Bacchi said. “We have to make sure that the funding actually survives the budget process next year.”

Some providers worry they may be left out.

“We’ve argued hard for optometrists to be included,” said Kristine Schultz, executive director of the California Optometric Association, noting that optometrists can’t afford to treat poor patients because of low rates. For example, optometrists get about $39, on average, to conduct an eye exam on a new Medi-Cal patient, while Medicare reimburses $158, she said.

As a result, she said, patients “are not able to get in for months.”

Ann Rivello, a therapist in San Mateo County specializing in trauma, also cited low rates — and complicated medical billing demands — as the reasons she doesn’t accept Medi-Cal patients.

“I’ve been practicing over 20 years and I do not accept Medi-Cal even though it’s within my values,” she said.

Detailed rates for most health care treatments for Medi-Cal patients are not publicly available because they are negotiated privately by insurance companies and vary by geography and health insurance plan. And the state has a slew of bonus payments it uses to supplement base Medi-Cal rates, further obfuscating how much health care providers receive.

While Medi-Cal rates vary widely, on average, California reimburses 76% of Medicare rates, Phillips said. Next year, the state plans to raise that base payment rate to 87.5% of Medicare in three target areas — primary care, obstetrics, and mental health.

As health care providers battle for their slice of the tax revenue, they say they want to avoid the same lobbying fight each time the state renews the tax, which happens every few years. One option they are considering: a ballot initiative next year that would lock the Medi-Cal funding into the state constitution.

Bacchi declined to take a position on the concept but said insurers are “taking a look at it.” He argues that California “needs to make a long-term commitment to the Medi-Cal program.”

John Baackes, the CEO of L.A. Care, the largest Medi-Cal insurer, supports the idea. He argues that a permanent increase in Medi-Cal rates would help address the disparities between Medi-Cal and private insurance coverage.

“The pandemic showed us that inequality is a life-and-death matter, because if you look at the people who got sick the most and died, they were people of color,” he said. “If we continue to ignore that, we’re idiots.”

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

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

USE OUR CONTENT

This story can be republished for free (details).

Lockdowns made people feel isolated, depressed, and anxious, leading some to increase their alcohol intake. Alcohol sales rose during the pandemic, with especially large jumps in the consumption of spirits.

While this led to a rise in all sorts of alcohol-related deaths, the number of Californians dying from alcoholic liver disease spiked dramatically, with 14,209 deaths between 2020 and 2022, according to provisional data from the Centers for Disease Control and Prevention.

Alcoholic liver disease is the most common cause of alcohol-induced deaths nationally. In California, the death rate from the disease during the last three years was 25% higher than in the three years before the pandemic. The rate peaked at 13.2 deaths per 100,000 residents in 2021, nearly double the rate from two decades ago.

The disease is usually caused by years of excessive drinking, though it can sometimes occur after a short period of heavy alcohol use. There are often no symptoms until late in the disease, when weakness, confusion, and jaundice can occur.

Many who increased their drinking during the pandemic were already on the verge of developing severe alcoholic liver disease, said Jovan Julien, a postdoctoral researcher at Harvard Medical School. The extra alcohol sped up the process, killing them earlier than they would have otherwise died, said Julien, who co-wrote a modeling study during the pandemic that predicted many of the trends that occurred.

Even before the pandemic, lifestyle and dietary changes were contributing to more deaths from alcoholic liver disease, despite little change in alcohol sales, said Brian Lee, a hepatologist and liver transplant specialist with Keck School of Medicine of the University of Southern California.

Lee and other researchers found a connection between alcoholic liver disease and metabolic syndrome, a condition often characterized by excess body fat around the waist. Metabolic syndrome — often caused by poor diet and an inactive lifestyle — has risen across the country.

“Having metabolic syndrome, which is associated with obesity, high blood pressure, and diabetes, more than doubles your risk of having advanced liver disease at the same level of drinking,” Lee said.

The Californians alcoholic liver disease most often kills are those between 55 and 74 years old. They make up about a quarter of the state’s adults but more than half the deaths from alcoholic liver disease.

However, death rates among Californians 25 to 44 roughly doubled during the last decade. About 2,650 Californians in that age group died of the disease during the last three years, compared with 1,270 deaths from 2010 through 2012.

“People are drinking at earlier levels,” Lee said. “People are developing obesity at younger ages.”

The highest death rates from alcoholic liver disease occur in rural eastern and Northern California. In Humboldt County, for instance, the death rate from alcoholic liver disease is more than double the statewide rate.

Jeremy Campbell, executive director of Waterfront Recovery Services in Eureka, said Humboldt County and other rural areas often don’t have the resources and facilities to address high rates of alcohol use disorder. His facility provides high-intensity residential services and uses medication to get people through detox.

“The two other inpatient treatment facilities in Eureka are also at capacity,” he said. “This is just a situation that there's just not enough treatment.”

Campbell also pointed to the demographics of Humboldt County, which has a much higher proportion of white and Native American residents than the rest of the state. Alcoholic liver disease death rates in California are highest among Native American and white residents.

Death rates rose more among Native American, Latino, Asian, and Black Californians during the last decade than among non-Latino white Californians, CDC data shows. Part of that is due to disparities in insurance coverage and access to care, said Lee. In addition, Lee said, rates of metabolic syndrome have increased more quickly among nonwhites than among whites. Racial health disparities also manifest in differing survival rates for Black and white patients after liver transplants, he added.

The trend is expected to continue. Julien projects a temporary dip in deaths because many people who would have died of the disease in 2022 or 2023 instead died sooner, after a boost in drinking during the pandemic, but that deaths will rise later as bad habits developed during the pandemic begin to take a long-term toll.

“As people increased their consumption during covid-19, we have more folks who have now initiated alcohol use disorder,” Julien said.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

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

USE OUR CONTENT

This story can be republished for free (details).

About three weeks before his May move, Tennison called the agency that administers Medi-Cal in Contra Costa County, where Walnut Creek is located, to inform them he’d be moving to San Joaquin County.

Little did he suspect his transfer would get tangled in red tape, disrupt his care, and saddle him with two bills totaling nearly $1,700 after he was removed from his old plan without notice before his new one in Stockton took effect.

Medi-Cal members who move counties are often bumped temporarily from managed care insurance plans into traditional Medi-Cal, also known as “fee for service,” in which the state pays providers directly for each service rendered. But managed care practitioners who don’t participate in traditional Medi-Cal have no way to get paid when they see such patients, and they sometimes bill them directly — even though that’s prohibited.

Medi-Cal is a statewide program, but it is administered by the counties, which have separate government bureaucracies and different approaches to care: Some have just one county-operated Medi-Cal plan. Others have only commercial health plans, which are paid by the state to manage the care of Medi-Cal patients. Many have one of each.

Traveling from Walnut Creek to Stockton takes a little more than an hour by car, but as far as Tennison is concerned, the two cities might as well be on opposite sides of the planet.

Tennison, 63, needed a smooth health care transition. With severe chronic pain in his back, shoulders, and neck, he requires regular physical therapy and monitoring by an orthopedist, as well as multiple pain medications. He also has carpal tunnel syndrome and Type 2 diabetes.

Because of miscommunication and confusion surrounding his move, several physical therapy appointments he’d made for June 2022 were canceled, and he had to wait nearly two months for new ones.

“To me the whole issue is the confusion,” Tennison said. “Right hand and left hand, nobody talks to each other, and nobody talked to me.”

The first hint of trouble came when he called Contra Costa County Employment & Human Services in late April 2022 to report his upcoming move and was told the new county had to initiate the transfer — only to hear from a worker at San Joaquin’s Human Services Agency that it was the other way around.

They were both wrong: Medi-Cal members who move can inform either county.

Tennison persuaded a Medi-Cal worker in San Joaquin County to initiate the transfer. He also filed a notice of his move online, which Medi-Cal workers in Contra Costa processed and flagged for a June 2 transfer date, said Marla Stuart, director of the county’s Employment & Human Services Department.

They set that date, Stuart said, because they believed Tennison might have some medical appointments in May under his Contra Costa Anthem Blue Cross plan.

Medi-Cal workers in San Joaquin County, however, set a move date of May 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for most of May, according to Stuart.

“If anybody had called me to verify any of this, I definitely would have told them May 5 was the wrong date,” said Tennison, who moved to Stockton on May 17.

“There were good intentions all around,” said Stuart. “It’s unfortunate what happened.”

Being cut from Anthem left Tennison with fee-for-service Medi-Cal, a rapidly shrinking part of the program.

He discovered it only in mid-July, when he called the Office of the Ombudsman for managed care Medi-Cal to complain about two bills he’d received — one for $886.92 from his orthopedic surgeon and another for $795 from his physical therapist.

He had seen both providers in May, when he thought he was still covered by Anthem. But he wasn’t, and they billed him directly, despite signed agreements and a state law that prohibit billing patients for services covered by Medi-Cal.

The bills caught Tennison by surprise, because the ombudsman had told him in early June that he had still been on Anthem through May, he said.

“To me, that’s how insurance works: One insurance ends, the other begins,” he said.

When Medi-Cal patients are between health plans and temporarily in fee for service, it theoretically ensures they have ongoing access to health care. But in practice, that’s not always the case.

“Because the state is pushing most Medi-Cal members into managed care, fewer providers are accepting fee for service,” said Hillary Hansen, an attorney with Legal Services of Northern California who is handling Tennison’s case.

The prohibition against billing Medi-Cal patients is spottily enforced, Hansen said. And although the patients are not legally required to pay, she said, their credit rating can suffer if they don’t. Michael Bowman, a spokesperson for Anthem, said the company regularly communicates with its providers to ensure compliance with the terms of their contracts and Medi-Cal rules.

Hansen is not confident Tennison’s bills will be paid anytime soon. After legal aid lawyers sent a letter to state officials about improper Medi-Cal billing, and later met with them about it, the officials instructed them to have their clients submit reimbursement claims.

But the reimbursement rules require that patients have already paid the bills, and Medi-Cal beneficiaries typically can’t afford that, Hansen said.

Tennison submitted his reimbursement form in May and is waiting to hear back. “Getting medical care should not be this difficult,” he said. “Here it is a year later, and I’m still trying to work this out.”

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

USE OUR CONTENT

This story can be republished for free (details).