The Biden administration finalized nursing home staffing rules Monday that will require thousands of them to hire more nurses and aides — while giving them years to do so.

The new rules from the Centers for Medicare & Medicaid Services are the most substantial changes to federal oversight of the nation’s roughly 15,000 nursing homes in more than three decades. But they are less stringent than what patient advocates said was needed to provide high-quality care.

Spurred by disproportionate deaths from covid-19 in long-term care facilities, the rules aim to address perennially sparse staffing that can be a root cause of missed diagnoses, severe bedsores, and frequent falls.

“For residents, this will mean more staff, which means fewer ER visits potentially, more independence,” Vice President Kamala Harris said while meeting with nursing home workers in La Crosse, Wisconsin. “For families, it’s going to mean peace of mind in terms of your loved one being taken care of.”

When the regulations are fully enacted, 4 in 5 homes will need to augment their payrolls, CMS estimated. But the new standards are likely to require slight if any improvements for many of the 1.2 million residents in facilities that are already quite close to or meet the minimum levels.

“Historically, this is a big deal, and we’re glad we have now established a floor,” Blanca Castro, California’s long-term care ombudsman, said in an interview. “From here we can go upward, recognizing there will be a lot of complaints about where we are going to get more people to fill these positions.”

The rules primarily address staffing levels for three types of nursing home workers. Registered nurses, or RNs, are the most skilled and responsible for guiding overall care and setting treatment plans. Licensed practical nurses, sometimes called licensed vocational nurses, work under the direction of RNs and perform routine medical care such as taking vital signs. Certified nursing assistants are supposed to be the most plentiful and help residents with daily activities like going to the bathroom, getting dressed, and eating.

While the industry has increased wages by 27% since February 2020, homes say they are still struggling to compete against better-paying work for nurses at hospitals and at retail shops and restaurants for aides. On average, nursing home RNs earn $40 an hour, licensed practical nurses make $31 an hour, and nursing assistants are paid $19 an hour, according to the most recent data from the Bureau of Labor Statistics.

CMS estimated the rules will ultimately cost $6 billion annually, but the plan omits any more payments from Medicare or Medicaid, the public insurers that cover most residents’ stays — meaning additional wages would have to come out of owners’ pockets or existing facility budgets.

The American Health Care Association, which represents the nursing home industry, called the regulation “an unreasonable standard” that “creates an impossible task for providers” amid a persistent worker shortage nationwide.

“This unfunded mandate doesn’t magically solve the nursing crisis,” the association’s CEO, Mark Parkinson, said in a statement. Parkinson said the industry will keep pressing Congress to overturn the regulation.

Richard Mollot, executive director of the Long Term Care Community Coalition, a New York City-based advocacy nonprofit, said “it is hard to call this a win for nursing home residents and families” given that the minimum levels were below what studies have found to be ideal.

The plan was welcomed by labor unions that represent nurses — and whom President Joe Biden is counting on for support in his reelection campaign. Service Employees International Union President Mary Kay Henry called it a “long-overdue sea change.” This political bond was underscored by the administration’s decision to have Harris announce the rule with SEIU members in Wisconsin, a swing state.

The new rules supplant the vague federal mandate that has been in place since the 1980s requiring nursing homes to have “sufficient” staffing to meet residents’ needs. In practice, inspectors rarely categorized inadequate staffing as a serious infraction resulting in possible penalties, federal records show.

Starting in two years, most homes must provide an average of at least 3.48 hours of daily care per resident. About 6 in 10 nursing homes are already operating at that level, a KFF analysis found.

The rules give homes breathing room before they must comply with more specific requirements. Within three years, most nursing homes will need to provide daily RN care of at least 0.55 hours per resident and 2.45 hours from aides.

CMS also mandated that within two years an RN must be on duty at all times in case of a patient crisis on weekends or overnight. Currently, CMS requires at least eight consecutive hours of RN presence each day and a licensed nurse of any level on duty around the clock. An inspector general report found that nearly a thousand nursing homes didn’t meet those basic requirements.

Nursing homes in rural areas will have longer to staff up. Within three years, they must meet the overall staffing numbers and the round-the-clock RN requirement. CMS’ rule said rural homes have four years to achieve the RN and nurse aide thresholds, although there was some confusion within CMS, as its press materials said rural homes would have five years.

Under the new rules, the average nursing home, which has around 100 residents, would need to have at least two RNs working each day, and at least 10 or 11 nurse aides, the administration said. Homes could meet the overall requirements through two more workers, who could be RNs, vocational nurses, or aides.

Homes can get a hardship exemption from the minimums if they are in regions with low populations of nurses or aides and demonstrate good-faith efforts to recruit.

Democrats praised the rules, though some said the administration did not go nearly far enough. Rep. Lloyd Doggett (D-Texas), the ranking member of the House Ways and Means Health Subcommittee, said the changes were “modest improvements” but that “much more is needed to ensure sufficient care and resident safety.” A Republican senator from Nebraska, Deb Fischer, said the rule would “devastate nursing homes across the country and worsen the staffing shortages we are already facing.”

Advocates for nursing home residents have been pressing CMS for years to adopt a higher standard than what it ultimately settled on. A CMS-commissioned study in 2001 found that the quality of care improved with increases of staff up to a level of 4.1 hours per resident per day — nearly a fifth higher than what CMS will require. The consultants CMS hired in preparing its new rules did not incorporate the earlier findings in their evaluation of options.

CMS said the levels it endorsed were more financially feasible for homes, but that assertion didn’t quiet the ongoing battle about how many people are willing to work in homes at current wages and how financially strained homes owners actually are.

“If states do not increase Medicaid payments to nursing homes, facilities are going to close,” said John Bowblis, an economics professor and research fellow with the Scripps Gerontology Center at Miami University. “There aren’t enough workers and there are shortages everywhere. When you have a 3% to 4% unemployment rate, where are you going to get people to work in nursing homes?”

Researchers, however, have been skeptical that all nursing homes are as broke as the industry claims or as their books show. A study published in March by the National Bureau of Economic Research estimated that 63% of profits were secretly siphoned to owners through inflated rents and other fees paid to other companies owned by the nursing homes’ investors.

Charlene Harrington, a professor emeritus at the nursing school of the University of California-San Francisco, said: “In their unchecked quest for profits, the nursing home industry has created its own problems by not paying adequate wages and benefits and setting heavy nursing workloads that cause neglect and harm to residents and create an unsatisfactory and stressful work environment.”

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

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Two months after a cyberattack on a UnitedHealth Group subsidiary halted payments to some doctors, medical providers say they’re still grappling with the fallout, even though UnitedHealth told shareholders on Tuesday that business is largely back to normal.

“We are still desperately struggling,” said Emily Benson, a therapist in Edina, Minnesota, who runs her own practice, Beginnings & Beyond. “This was way more devastating than covid ever was.”

Change Healthcare, a business unit of the Minnesota-based insurance giant UnitedHealth Group, controls a digital network so vast it processes nearly 1 in 3 U.S. patient records each year. The network is a critical conduit for shuttling information between most of the nation’s insurance companies and medical providers, who submit claims through it to get paid for treating patients.

For Benson, the cyberattack continues to significantly disrupt her business and her ability to pay her seven other clinicians.

Before the hack brought down the system, an insurance company would process a provider’s claim, then send a type of receipt known as an “electronic remittance,” which details the amount the provider was paid and whether the claim was denied. Without it, providers don’t know if they were paid correctly or how much to bill patients. 

Now, instead of automatically handling those receipts digitally, some insurers must send forms in the mail. The forms require manual entry, which Benson said is a time-consuming process because it requires her to match up service dates and details to divvy up pay among her clinicians. And from at least one insurer, she said, she has yet to receive any remittances.  

“I’m holding on to my sanity by a thread,” Benson said.

The situation is so dire, Alex Shteynshlyuger, a urologist who owns a practice in New York City, said he had to transfer money from his personal accounts to pay his office bills.  

“Look, I am freaking out,” Shteynshlyuger said. “Everyone is freaking out. We are like monkeys in a cage. We can’t really do anything about it.”

Roughly 30% of his claims were routed through Change’s platform. Except for Medicare and certain Blue Cross plans, he said, he has been unable to submit claims or receive payment from any insurers.

The company is encouraging struggling providers to reach out to the company directly via its website, said Tyler Mason, vice president of communications for UnitedHealth Group.

“I don’t think we’ve had a single provider that hasn’t been helped that’s contacted us.” As part of that help, Mason said, UnitedHealth has sent providers $7 billion so far.

Ever since the February cyberattack forced UnitedHealth to disconnect its Change platform, the company has been working “day and night to restore services” and has made “substantial progress,” UnitedHealth CEO Andrew Witty told shareholders April 16. 

“We see a fairly normal claims receipts and payments flow going on at this point,” Chief Financial Officer John Rex said during the shareholder call. “But we’ll really want to be careful on that because we know there are certain care providers out there that may have been left out of it.”

Rex said the company expects full operations to resume next year.

The company reported that the hacking has already cost it $870 million and that leaders expect the final tally to total at least $1 billion this year. To put that in perspective, the company reported $99.8 billion in revenue for the first quarter of 2024, an 8.6% increase over that period last year.

Meanwhile, the House Energy and Commerce Health Subcommittee held a hearing April 16 seeking answers on the severity and damage the cyberattack caused to the nation’s health system.

Subcommittee chair Brett Guthrie (R-Ky.) said a provider in his hometown is still grappling with the fallout from the attack and losing staff because they can’t make payroll. Providers “still haven’t been made whole,” Guthrie said.

Rep. Frank Pallone Jr. (D-N.J.) voiced concern that a “single point of failure” reverberated around the country, disrupting patients’ access and providers’ financial stability.

Lawmakers expressed frustration that UnitedHealth failed to send a representative to the Capitol to answer their questions. The committee had sent Witty a list of detailed questions ahead of the hearing but was still awaiting answers.

As providers wait, too, they are trying to cover the gaps. To pay her practice’s bills, Benson said, she had to take out a nearly $40,000 loan — from a division of UnitedHealth.

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

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For the past year, police Detective Tim Lillard has spent most of his waking hours unofficially investigating his wife’s death.

The question has never been exactly how Ann Picha-Lillard died on Nov. 19, 2022: She succumbed to respiratory failure after an infection put too much strain on her weakened lungs. She was 65.

For Tim Lillard, the question has been why.

Lillard had been in the hospital with his wife every day for a month. Nurses in the intensive care unit had told him they were short-staffed, and were constantly rushing from one patient to the next.

Lillard tried to pitch in where he could: brushing Ann’s shoulder-length blonde hair or flagging down help when her tracheostomy tube gurgled — a sign of possible respiratory distress.

So the day he walked into the ICU and saw staff members huddled in Ann’s room, he knew it was serious. He called the couple’s adult children: “It’s Mom,” he told them. “Come now.”

All he could do then was sit on Ann’s bed and hold her hand, watching as staff members performed chest compressions, desperately trying to save her life.

A minute ticked by. Then another. Lillard’s not sure how long the CPR continued — long enough for the couple’s son to arrive and take a seat on the other side of Ann’s bed, holding her other hand.

Finally, the intensive care doctor called it and the team stopped CPR. Time of death: 12:37 p.m.

Lillard didn’t know what to do in a world without Ann. They had been married almost 25 years. “We were best friends,” he said.

Just days before her death, nurses had told Lillard that Ann could be discharged to a rehabilitation center as soon as the end of the week. Then, suddenly, she was gone. Lillard didn’t understand what had happened.

Lillard said he now believes that overwhelmed, understaffed nurses hadn’t been able to respond in time as Ann’s condition deteriorated. And he has made it his mission to fight for change, joining some nursing unions in a push for mandatory ratios that would limit the number of patients in a nurse’s care. “I without a doubt believe 100% Ann would still be here today if they had staffing levels, mandatory staffing levels, especially in ICU,” Lillard said.

Last year, Oregon became the second state after California to pass hospital-wide nurse ratios that limit the number of patients in a nurse’s care. Michigan, Maine, and Pennsylvania are now weighing similar legislation.

But supporters of mandatory ratios are going up against a powerful hospital industry spending millions of dollars to kill those efforts. And hospitals and health systems say any staffing ratio regulations, however well-intentioned, would only put patients in greater danger.

Putting Patients at Risk

By next year, the United States could have as many as 450,000 fewer nurses than it needs, according to one estimate. The hospital industry blames covid-19 burnout, an aging workforce, a large patient population, and an insufficient pipeline of new nurses entering the field.

But nursing unions say that’s not the full story. There are now 4.7 million registered nurses in the country, more than ever before.

The problem, the unions say, is a hospital industry that’s been intentionally understaffing their units for years in order to cut costs and bolster profits. The unions say there isn’t a shortage of nurses but a shortage of nurses willing to work in those conditions.

The nurse staffing crisis is now affecting patient care. The number of Michigan nurses who say they know of a patient who has died because of understaffing has nearly doubled in recent years, according to a Michigan Nurses Association survey last year.

Just months before Ann Picha-Lillard’s death, nurses and doctors at the health system where she died had asked the Michigan attorney general to investigate staffing cuts they believed were leading to dangerous conditions, including patient deaths, according to The Detroit News.

But Lillard didn’t know any of that when he drove his wife to the hospital in October 2022. She had been feeling short of breath for a few weeks after she and Lillard had mild covid infections. They were both vaccinated, but Ann was immunocompromised. She suffered from rheumatoid arthritis, a condition that had also caused scarring in her lungs.

To be safe, doctors at DMC Huron Valley-Sinai Hospital wanted to keep Ann for observation. After a few days in the facility, she developed pneumonia. Doctors told the couple that Ann needed to be intubated. Ann was terrified but Lillard begged her to listen to the doctors. Tearfully, she agreed.

With Ann on a ventilator in the ICU, it seemed clear to Lillard that nurses were understaffed and overwhelmed. One nurse told him they had been especially short-staffed lately, Lillard said.

“The alarms would go off for the medications, they’d come into the room, shut off the alarm when they get low, run to the medication room, come back, set them down, go to the next room, shut off alarms,” Lillard recalled. “And that was going on all the time.”

Lillard felt bad for the nurses, he said. “But obviously, also for my wife. That’s why I tried doing as much as I could when I was there. I would comb her hair, clean her, just keep an eye on things. But I had no idea what was really going on.”

Finally, Ann’s health seemed to be stabilizing. A nurse told Lillard they’d be able to discharge Ann, possibly by the end of that week.

By Nov. 17, Ann was no longer sedated and she cried when she saw Lillard and her daughter. Still unable to speak, she tried to mouth words to her husband “but we couldn’t understand what she was saying,” Lillard said.

The next day, Lillard went home feeling hopeful, counting down the days until Ann could leave the hospital.

Less than 24 hours later, Ann died.

Lillard couldn’t wrap his head around how things went downhill so fast. Ann’s underlying lung condition, the infection, and her weakened state could have proved fatal in the best of circumstances. But Lillard wanted to understand how Ann had gone from nearly discharged to dying, seemingly overnight.

He turned his dining room table into a makeshift office and started with what he knew. The day Ann died, he remembered her medical team telling him that her heart rate had spiked and she had developed another infection the night before. Lillard said he interviewed two DMC Huron Valley-Sinai nurse administrators, and had his own doctor look through Ann’s charts and test results from the hospital. “Everybody kept telling me: sepsis, sepsis, sepsis,” he said.

Sepsis is when an infection triggers an extreme reaction in the body that can cause rapid organ failure. It’s one of the leading causes of death in U.S. hospitals. Some experts say up to 80% of sepsis deaths are preventable, while others say the percentage is far lower.

Lives can be saved when sepsis is caught and treated fast, which requires careful attention to small changes in vital signs. One study found that for every additional patient a nurse had to care for, the mortality rate from sepsis increased by 12%.

Lillard became convinced that had there been more nurses working in the ICU, someone could have caught what was happening to Ann.

“They just didn’t have the time,” he said.

DMC Huron Valley-Sinai’s director of communications and media relations, Brian Taylor, declined a request for comment about the 2022 staffing complaint to the Michigan attorney general.

Following the Money

When Lillard asked the hospital for copies of Ann’s medical records, DMC Huron Valley-Sinai told him he’d have to request them from its parent company in Texas.

Like so many hospitals in recent years, the Lillards’ local health system had been absorbed by a series of other corporations. In 2011, the Detroit Medical Center health system was bought for $1.5 billion by Vanguard Health Systems, which was backed by the private equity company Blackstone Group.

Two years after that, in 2013, Vanguard itself was acquired by Tenet Healthcare, a for-profit company based in Dallas that, according to its website, operates 480 ambulatory surgery centers and surgical hospitals, 52 hospitals, and approximately 160 additional outpatient centers.

As health care executives face increasing pressure from investors, nursing unions say hospitals have been intentionally understaffing nurses to reduce labor costs and increase revenue. Also, insurance reimbursements incentivize keeping nurse staffing levels low. “Hospitals are not directly reimbursed for nursing services in the same way that a physician bills for their services,” said Karen Lasater, an associate professor of nursing in the Center for Health Outcomes and Policy Research at the University of Pennsylvania. “And because hospitals don’t perceive nursing as a service line, but rather a cost center, they think about nursing as: How can we reduce this to the lowest denominator possible?” she said.

Lasater is a proponent of mandatory nurse ratios. “The nursing shortage is not a pipeline problem, but a leaky bucket problem,” she said. “And the solutions to this crisis need to address the root cause of the issue, which is why nurses are saying they’re leaving employment. And it’s rooted in unsafe staffing. It’s not safe for the patients, but it’s also not safe for nurses.”

A Battle Between Hospitals and Unions

In November, almost one year after Ann’s death, Lillard told a room of lawmakers at the Michigan State Capitol that he believes the Safe Patient Care Act could save lives. The health policy committee in the Michigan House was holding a hearing on the proposed act, which would limit the amount of mandatory overtime a nurse can be forced to work, and require hospitals to make their staffing levels available to the public.

Most significantly, the bills would require hospitals to have mandatory, minimum nurse-to-patient ratios. For example: one nurse for every patient in the ICU; one for every three patients in the emergency room; a nurse for triage; and one nurse for every four postpartum birthing patients and well-baby care.

Efforts to pass mandatory ratio laws failed in Washington and Minnesota last year after facing opposition from the hospital industry. In Minnesota, the Minnesota Nurses Association accused the Mayo Clinic of using “blackmail tactics”: Mayo had told lawmakers it would pull billions of dollars in investment from the state if mandatory ratio legislation passed. Soon afterward, lawmakers removed nurse ratios from the legislation.

While Lillard waited for his turn to speak to Michigan lawmakers about the Safe Patient Care Act in November, members of the Michigan Nurses Association, which says it represents some 13,000 nurses, told lawmakers that its units were dangerously understaffed. They said critical care nurses were sometimes caring for up to 11 patients at a time.

“Last year I coded someone in an ICU for 10 minutes, all alone, because there was no one to help me,” said the nurses association president and registered nurse Jamie Brown, reading from another nurse’s letter.

“I have been left as the only specially trained nurse to take care of eight babies on the unit: eight fragile newborns,” said Carolyn Clemens, a registered nurse from the Grand Blanc area of Michigan.

Nikia Parker said she has left full-time emergency room nursing, a job she believes is her calling. After her friend died in the hospital where she worked, she was left wondering whether understaffing may have contributed to his death.

“If the Safe Patient Care Act passed, and we have ratios, I’m one of those nurses who would return to the bedside full time,” Parker told lawmakers. “And so many of my co-workers who have left would join me.”

But not all nurses agree that mandatory ratios are a good idea. 

While the American Nurses Association supports enforceable ratios as an “essential approach,” that organization’s Michigan chapter does not, saying there may not be enough nurses in the state to satisfy the requirements of the Safe Patient Care Act.

For some lawmakers, the risk of collateral damage seems too high. State Rep. Graham Filler said he worries that mandating ratios could backfire.

“We’re going to severely hamper health care in the state of Michigan. I’m talking closed wards because you can’t meet the ratio in a bill. The inability for a hospital to treat an emergent patient. So it feels kind of to me like a gamble we’re taking,” said Filler, a Republican.

Michigan hospitals are already struggling to fill some 8,400 open positions, according to the Michigan Health & Hospital Association. That association says that complying with the Safe Patient Care Act would require hiring 13,000 nurses.

Every major health system in the state signed a letter opposing mandatory ratios, saying it would force them to close as many as 5,100 beds.

Lillard watched the debate play out in the hearing. “That’s a scare tactic, in my opinion, where the hospitals say we’re going to have to start closing stuff down,” he said.

He doesn’t think legislation on mandatory ratios — which are still awaiting a vote in the Michigan House’s health policy committee — are a “magic bullet” for such a complex, national problem. But he believes they could help.

“The only way these hospitals and the administrations are gonna make any changes, and even start moving towards making it better, is if they’re forced to,” Lillard said.

Seated in the center of the hearing room in Lansing, next to a framed photo of Ann, Lillard’s hands shook as he recounted those final minutes in the ICU.

“Please take action so that no other person or other family endures this loss,” he said. “You can make a difference in saving lives.”

Grief is one thing, Lillard said, but it’s another thing to be haunted by doubts, to worry that your loved one’s care was compromised before they ever walked through the hospital doors. What he wants most, he said, is to prevent any other family from having to wonder, “What if?”

This article is from a partnership that includes Michigan Public, NPR, and KFF Health News.

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

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SAN FRANCISCO — Chinese Hospital, located in the heart of this city’s legendary Chinatown, struggles with many of the same financial and demographic challenges that plague small independent hospitals in underserved areas across the country.

Many of its patients are aging Chinese speakers with limited incomes who are reliant on Medicare and Medi-Cal, which pay less than commercial insurance and often don’t fully cover provider costs. And due to an arcane federal rule, Chinese Hospital receives a lower rate of reimbursement than many other hospitals that treat a large number of low-income patients. Add the high cost of labor and supplies in this post-pandemic world, and it’s not hard to see why the hospital lost $20 million over the past two years and tapped a nearly $10.4 million loan from the state’s distressed hospital loan fund.

Yet the 88-bed hospital has strong ties to the University of California-San Francisco and the city’s public health department. And it gets support from businesses, charities, and the surrounding community. For Jian Zhang, 58, the hospital’s CEO since 2017, fundraising is like breathing.

“I feel like it’s a full-time job for me,” said Zhang, who arrived in San Francisco from Guangzhou, China, as an international student in 1990, earned a nursing doctorate from the University of San Francisco, and has remained in the Bay Area.

Revenue from fundraising and other services have provided a big boost, helping the hospital significantly offset what it lost on patient care in 2022, according to the hospital and state data. By contrast, Madera Community Hospital and Beverly Hospital were far less able to do so. Those hospitals, which also serve low-income populations with many patients on government health care programs, filed for bankruptcy last year.

Chinese Hospital has its roots in a medicinal dispensary, founded in 1899 to provide health care for Chinese immigrants who were effectively excluded from mainstream medical facilities. The hospital itself opened in 1925, and a second building was added next door in 1979. In 2016, a new building replaced the original hospital.

Today, Chinese Hospital includes those two buildings plus five outpatient clinics offering Eastern and Western medicine, spread out across San Francisco and neighboring San Mateo County. Through partnerships, Chinese Hospital has been able to offer specialty services to its patients, including eye surgery, palliative care, and a stroke center. And $10 million in grants it received from the state last year will help build a subacute unit, which is for fragile patients who still need nursing and monitoring following a hospital stay.

In an interview with KFF Health News senior correspondent Bernard J. Wolfson, Zhang discussed the challenges facing small independent hospitals, including Chinese Hospital, and offered her vision for its future. The following Q&A has been edited for length and clarity:

Q: What are some of the main challenges your hospital faces?

We are facing all the challenges other hospitals are facing, especially the covid pandemic and its associated negative impact — the physician shortage and workforce shortage, the labor cost increases. But as a small community hospital, we don’t have a lot of reserve money. It’s hard to make ends meet.

That is a huge challenge because of the low reimbursement rate. We serve more than 80% Medicare and Medi-Cal patients.

Q: What are some specific challenges of serving a largely Chinese population?

In this market, with the workforce shortage, and especially after the pandemic, it’s even harder to recruit bilingual physicians, and other bilingual staff.

And culturally, Chinese patients, when they are sick, need to drink soup for healing or eat certain other foods for healing. You can’t be providing sandwiches and salads. They won’t eat that. So our kitchen has to provide Chinese food, has to boil soup, and then we have to cook different food for our patients who are non-Chinese.

Q: Are you concerned about the state’s budget shortfall?

Absolutely. We all were expecting that Medi-Cal would increase rates. We have been pushing that for many years. But if it’s not going to happen, a lot of our programs we probably won’t be able to do. I am very concerned about it.

Q: Chinese Hospital has its own health plan, and you said 40% to 50% of your patients are members of it. How has that helped?

It’s like Kaiser Permanente. You have your own members, and you manage them. You want your patients to be in outpatient. So you take care of them, keep them healthy, so they don’t need to come to the hospital for acute care. That’s how you save money.

Q: And I imagine that getting fixed monthly payments — capitation payments — for a large proportion of your patients also helps?

Definitely, capitation payments help. Especially during the pandemic. Think about it. If you didn’t have capitation payments, when procedures were canceled, you didn’t have income.

Q: What else has helped you weather the storm?

We have partnerships with San Francisco’s Department of Public Health and UCSF. During the pandemic, we took overflow patients from the city, so we didn’t have to lay off a lot of people. We signed a contract with the city to open up the second floor of our hospital to take overflow patients from Zuckerberg San Francisco General hospital.

Q: You also have strong fundraising activity.

We do have strong community support. The hospital is not just a hospital to me. It’s really part of our history. In the past, it was the only place [Chinese people] could go. Wherever I went, to a conference, for example, somebody would raise their hand and say, “Oh, I was born at Chinese Hospital” or “My grandfather was born at Chinese Hospital.” It is really, really deeply rooted in the community.

Q: What’s your vision for the future of the hospital?

Chinese Hospital is very important to the community, and I want to see it survive and thrive. But it definitely needs support from the government and from the community. Moving forward, we will continue to build on collaborations and partnerships.

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

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

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The Host Mary Agnes Carey KFF Health News @maryagnescarey Read Mary Agnes' stories.

Lawmakers in Washington this week held the first congressional hearing on the Change Healthcare cyberattack, a breach that sent shock waves through the health care system as payments for care ground to a halt and left some providers in financial trouble. Republicans and Democrats alike zeroed in on how big health care conglomerations — like Change’s parent company, UnitedHealth Group — are leaving patients vulnerable.

And nearly 1 in 4 adults who lost Medicaid coverage in the past year are now uninsured, according to a new KFF survey probing the effects of what’s known as the “unwinding” of enrollments in the government insurance program for low-income people since pandemic-era protections expired.

This week’s panelists are Mary Agnes Carey of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

Panelists Jessie Hellmann CQ Roll Call @jessiehellmann Read Jessie's stories. Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• Though the Change Healthcare hearing on Capitol Hill illuminated bipartisan agreement on the perils of vertical integration in health care, lawmakers did not agree on possible solutions. Addressing consolidation, however, could remedy issues in health care beyond cybersecurity.
• The KFF survey on the unwinding found that nearly half of those who lost coverage signed back up for Medicaid weeks or months later, a signal that those enrollees should never have been dropped in the first place. Even a temporary loss in health coverage can have serious, lingering consequences.
• Republicans in Arizona are grappling with the fallout from the state’s newly reinstated, Civil War-era abortion law — echoing recent problems for Alabama Republicans after a state Supreme Court ruling upended access to in vitro fertilization there. Softened stances from conservative hard-liners like Senate candidate Kari Lake point to the potential negative consequences for the party in a critical election year.
• And the Centers for Disease Control and Prevention released new information about the current measles outbreak, revealing that many of those sickened are children, as well as adults who are unvaccinated or whose vaccination status is unknown.

Also this week, Julie Rovner, KFF Health News’ chief Washington correspondent, interviews Caroline Pearson of the Peterson Health Technology Institute.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Mary Agnes Carey: KFF Health News’ “When Rogue Brokers Switch People’s ACA Policies, Tax Surprises Can Follow,” by Julie Appleby. 

Jessie Hellmann: Tampa Bay Times’ “Vulnerable Florida Patients Scramble After Abrupt Medicaid Termination,” by Teghan Simonton. 

Sarah Karlin-Smith: Stat’s “Grocers Are Pushing Legislation They Claim Would Enhance Food Safety. Advocates Say It Would Gut FDA Rules,” by Nicholas Florko. 

Lauren Weber: The New York Times’ “Chinese Company Under Congressional Scrutiny Makes Key U.S. Drugs,” by Christina Jewett. 

Also mentioned on this week’s podcast:

• KFF Health News’ “Nearly 1 in 4 Adults Dumped From Medicaid Are Now Uninsured, Survey Finds,” by Phil Galewitz.
• The New York Times’ “Under Pressure From Trump, Arizona Republicans Weigh Response to 1864 Abortion Ban,” by Chris Cameron.

Click to open the transcript Transcript: Too Big To Fail? Now It’s ‘Too Big To Hack’

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Mary Agnes Carey: Hello and welcome back to “What the Health?” I’m Mary Agnes Carey of KFF Health News filling in this week for your usual host, Julie Rovner. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 18, at 10 a.m. Eastern. As always, news happens fast and things might’ve changed by the time you hear this. So here we go. We’re joined today via video conference by Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Carey: Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Hey, there.

Carey: And Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Carey: Later in this episode we’ll have Julie’s interview with Caroline Pearson of the Peterson Health Technology Institute. That’s a new nonprofit designed to assess the costs and benefits of new digital health technologies. But first, this week’s news.

Congress jumped in into the Change Healthcare cyberattack story this week with the House Energy and Commerce Committee holding a hearing into the historic theft of medical data that shut down operations at hospitals and pharmacies.

Some of these medical providers are still experiencing revenue losses due to unpaid claims. Representatives of UnitedHealth Group, which owns Change Healthcare, were not present at this hearing, but they promised to testify at a future date. Jessie, you covered the hearing. Start us out. What happened?

Hellmann: There was a lot of frustration from members about how this attack happened and the circumstances that led to us being in this situation. There’s a lot of frustration just about the size of UnitedHealth Group. They’re a massive health care company, one of the biggest in the United States, and there were just a lot of complaints about the vertical integration that just made this cyberattack so much more widespread that there weren’t really many policy solutions that were talked about.

It was like an airing of grievances. So I think we’re still pretty early on in terms of Congress trying to figure out how to respond to these kinds of things and preventing them from happening again. And it already seems like there’s some disagreement from Democrats and Republicans about how to respond to this. Democrats like Sen. Ron Wyden are talking about how there’s really no mandatory cybersecurity requirements for hospitals and other health care sector industries to meet, and he thinks that should change.

And Republicans are talking about how they don’t think that there should be a top-down mandate where we’re requiring health care providers meet cybersecurity requirements. So at this point, it seems like there are some more debate that needs to happen on this, and it’s not very clear how Congress will respond.

Carey: Lauren, jump in.

Weber: Yeah. I just wanted to say, I mean, just to take a step back, we talk about these cyberattacks on hospitals or health care, they can have really serious consequences. There was a study I think that came out that said mortality risks rose by 21%, which is a wild stat when you think about the fact that a lot more hospitals have been held ransom in the last few years, a significantly larger number, to real outcome risks. And the other concern is you have patients’ personal data being leaked.

I just did a story with Dan Diamond and my co-worker Dan Keating about the over $2 billion in Medicare fraud over catheters. I mean, those numbers probably got leaked in some sort of hack or ransomware attack like you’re seeing here. And so on top of obviously the vertical integration of UnitedHealthcare, I think these conversations around the real threat of ransomware attacks really are quite something, and the fact that there are not a lot of solutions is concerning for health care as a whole.

Karlin-Smith: The thing that struck me about the vertical integration component of this and how it made the attack so much worse, is that there are other health policy issues that Congress has been looking at or other parts of the government have been concerned about in health care, where vertical integration is seen as a key problem. So a space I’ve covered a lot lately is the pharmacy benefit managers and some of their role in drug pricing, but I know there’s other concerns around the gobbling up of primary care, other just smaller medical practices and vertical integration.

So I think there’s an interesting hook, I guess, for policymakers and lawmakers to think about if they take on that topic. Do they solve actually multiple problems potentially in the health policy space, not just cybersecurity?

Carey: And might these thoughts be part of the Senate finance hearing? Jessie, you mentioned a moment ago that Ron Wyden, the chair of that committee, is having a hearing. Can you give us any window into that?

Hellmann: Yeah. He was speaking at the American Hospital Association conference this week and he said there was going to be a hearing. It sounds like it’s going to be with UnitedHealth Group CEO Andrew Witty. I don’t think there’s been a date set for that, but reports have indicated it’ll be this month.

And it’ll be the first time that he’s really been questioned publicly about this attack and how it happened and the impact of it. So, I don’t imagine they’ll go very easy on him, especially. … It just seems like lawmakers are getting more and more frustrated as we learn more about this or grappling with the long-term effects of it.

Carey: True, and it’s certainly a very, very expensive thing for UnitedHealth Group. The company on Tuesday reported an $872 million charge for “unfavorable cyberattack effects” in the first quarter. But UnitedHealth didn’t reveal how much or if it had paid ransom to the hackers. So maybe we’ll get more there. Let’s go ahead and move on to Medicaid, specifically Medicaid unwinding and what’s happening there.

This is the process where states are reassessing Medicaid eligibility for millions of Americans who enrolled during the pandemic and dropping those who don’t qualify or perhaps didn’t complete the renewal procedures. The full Medicaid unwinding process won’t be completed until later this year. Recently released data from my KFF colleagues who study the Medicaid program found that nearly a quarter of adults disenrolled from Medicaid in the past year say they are now insured.

The KFF survey details how tens of millions of Americans have struggled to retain coverage in the government insurance program for low-income people after the pandemic-era protections expired last spring. While 23% of those surveyed report being uninsured, an additional 28% found coverage through an employer, Medicare, the Affordable Care Act’s [Health] Insurance Marketplace, or health care for members of the military, the KFF survey found.

So, my question for all of you is were you surprised at these findings? We’ve all been keeping our eyes on the unwinding issue for months. It’s been a topic of discussion many times here on “What the Health?” What’s your take so far?

Weber: I can’t say based on what we all know that it’s surprising. I mean, I think what’s concerning and what we only will see as this continues to play out is what the effect of that loss of coverage is. I think we won’t know for some time because it’ll take research a while to catch up. I mean, we have the anecdotal reports, but I mean, people losing coverage even temporarily can be devastating in terms of their medical outcomes.

I want to point to some of the data from that survey I believe from KFF is the impact on children has been particularly unfortunate. Nearly 5 million children, I believe, have lost Medicaid coverage so far. I think 2 million of them are in three states, Texas, Georgia, and Florida, which have not expanded Medicaid under the Affordable Care Act. And that’s a lot of kids not having access to potentially health care they desperately need, and remains to be seen what the outcomes of that are.

Carey: People might think that the reenrollment certification process is fairly straightforward, right? What are some of the problems that Medicaid beneficiaries are facing as they try to prove that they’re eligible for coverage? Can we unpack that a little bit?

Karlin-Smith: Some of it it just seems like the states don’t actually have enough people and staff to help everybody in an efficient way, and that every state process is different. So that’s been a big barrier.

Weber: There’s also, I mean, the mailing issue is always an issue. This has always been a Medicaid problem. People send mail to old addresses, outdated addresses. Even The New York Times even spoke to someone who they had updated their address, but they still didn’t get their renewal packet at the right place and it impacted their child’s ability to see several specialists.

We all deal with logistical problems when it comes to mail. I know I certainly have missed some mail in the past. But when it comes to your actual health care, especially health care for your children, it’s pretty wild that we rely on this antiquated of a system and this amount of red tape for some of these people’s access.

Karlin-Smith: I was going to say there are reports even of the way the state’s software and processes were going. That they were triggering one child in a family to be kicked off and not the other child. So clearly, again, the systems the states are using to kick people off have their own problems that are improperly booting people who shouldn’t be booted.

Carey: Sure. Jess, did you have any sense of whether, and they don’t have to, but would lawmakers try to jump in as this unwinding unfolds to try to remedy some of these issues that are happening with state systems or on the federal government side? Or is that something you think they’re just going to let it play out and see what happens?

Hellmann: I think if they were going to jump in, they probably would’ve done it already. This process has been playing out for several months now, and it seems like the Biden administration has been pushing states to get a handle on the process and make sure people shouldn’t be losing coverage if they’re still eligible. But it seems like that’s going to continue happening. The survey said that nearly half of the people who lost coverage ended up signing up again weeks or months later, which indicates they probably shouldn’t have been kicked off in the first place.

I was reading stories about how people didn’t find out that they were kicked off until they tried to schedule a medical appointment or their providers told them, “Your coverage isn’t active anymore.” So it just shows that there’s this really big disconnect between people and their states sometimes. It can be hard to reach people.

Carey: Sure. Well, we’ll continue to watch this as I’m sure you all will. But right now I would like to move to a topic that was discussed on last week’s podcast. This is about the Arizona Supreme Court’s ruling that an abortion ban originally passed in 1864 — that’s before the end of the Civil War and decades before Arizona even became a state — that that law could be enforced. And in some other states, including Florida, voters will likely have the chance in November to decide whether to include abortion rights in their state constitutions.

So to that point, Arizona Republicans are trying to figure out how to respond to a planned ballot measure this fall that would enshrine abortion rights. And we have some news on this. On Thursday, Republican lawmakers in the Statehouse blocked an effort to repeal the ban in the state legislature, but then a handful of Republicans in the state Senate sided with Democrats and allowed them to introduce a bill to repeal it.

What does this split among Republican members of the Arizona Legislature mean for the overall GOP’s efforts, not only in this state but nationwide, to take some of the momentum from Democrats on the abortion issue?

Weber: I think what we’re seeing here is what we saw a little bit, obviously, in Alabama with the IVF fallout. You’re seeing Democrats capitalizing on the moment to some extent with their electorate and saying, “Look, Republicans are not on your side. Vote for us, et cetera. We’ll have this ballot measure. We’ll see what the turnout is.”

And as we’ve talked about on this podcast several times, I mean, I think it remains to be seen, especially in a presidential year in which we have two candidates who are historically somewhat unpopular it seems with their parties, how abortion ballot measures across the country could play out in terms of turnout for one party or another, when folks are apathetic about the election as a whole.

So I think there’s a lot of movement and a lot of scurrying in Arizona, which obviously would be an influential state in that presidential election to see how that could influence politics one way or another.

Carey: And they’ve got these additional pressures, right? You’ve got former President Trump, who’s the presumptive GOP nominee, saying that Arizona Republican lawmakers should “act immediately” to repeal this law. You’ve got GOP Senate candidate Kari Lake from Arizona also calling for the overturning of the 1864 law. And we do have voters in about a dozen states that could decide the fate of abortion rights in November with all of these constitutional amendments on the ballot in what is absolutely a pivotal election year.

And that’s including in a lot of battleground states that are key to deciding the presidential race and which party controls Congress. I also think it’s interesting to note, ever since the Supreme Court overturned Roe v. Wade in June of 2022, every ballot measure that has sought to preserve or expand abortion access has been successful, while those that have sought to restrict abortion access have failed, even in states that skew conservative. Is the same thing going to happen this fall? Get out your crystal balls.

Weber: I mean, I think there’s a reason that [Sen.] Josh Hawley is out there not exactly thrilled about an abortion ballot in his state in his election year. I mean, I think if we talk about you see Kari Lake, you see Donald Trump, I think they see the writing on the wall. As we’ve discussed that there’s concerns that these abortion ballots, which have been popular, which have driven turnout, could result in negative downstream consequences for them getting elected.

So it still remains to be seen. It’s very early. But yes, I think there’s a reason you have Kari Lake, Donald Trump, and Josh Hawley all saying those things.

Karlin-Smith: No, I think it’s interesting. I’ve just been thinking about this is you could think about these politicians as being opportunistic and just changing their views because …

Carey: No way!

Karlin-Smith: … they see the tide going in their favor. But on the other hand, I guess maybe in some ways this is how a democracy is supposed to work, that people see how their citizens are feeling and represent them. You can get a little bit cynical watching this in Washington, seeing everybody shift their tune as they realize the popular opinion is not with them.

Carey: Sure. And I think another thing to watch as we go forward is there’ll be a lot of twists and turns in the wording of these amendments on ballots, some of which opponents may say is done intentionally to confuse people. I see people nodding their heads. Anybody want to jump in?

Hellmann: I think The New York Times story this week about the proposed ballot measure on abortion right[s] in Arizona really laid that out. They got access to this presentation that was done by Republican operatives framing these competing abortion ballot measures that they were thinking of [proposing], or putting out there, as being intentionally misleading to people. So that’s definitely part of the strategy that is not very surprising and that they’ve admitted privately.

Carey: Well, we’ll see how that plays out. That’s another fascinating angle that we’ll all be watching. So I’d like to shift gears just a little bit. I want to chat about a new ruling from the U.S. Equal Employment Opportunity Commission that says abortion-related accommodations are included under the Pregnant Workers Fairness Act that was released earlier this week. What are these accommodations?

Karlin-Smith: These are essentially accommodations to ensure people can have unpaid leave for pregnancy-related issues without losing their job. And it’s particularly important for people that do not get covered by FMLA [Family and Medical Leave Act], which protects people who work for larger employers, which actually that was what shocked me about all of this, that there are some people that don’t get the FMLA protections.

Carey: Because they’re too small, right? It’s like 15 and under, you don’t hit that.

Karlin-Smith: Fifty, I think.

Carey: Fifty. Beg your pardon. If you’re a smaller employer, as an employee, you may not be eligible. That’s the takeaway.

Karlin-Smith: Correct. Yeah. There’s controversy over whether abortion should qualify under these protections, although of course, again, you have to remember, abortion care also essentially encompasses things like care for miscarriages and so forth. I think sometimes people create these arbitrary lines between abortion/miscarriage, and it’s all sort of one and the same. I think it becomes really hard to tease that out based on if you’re thinking about pregnancy and the complications that arise with that.

Weber: Just to chime in, I mean too just on the pregnancy protections, I mean, the reason rules like this were protected because back in March, EEOC [Equal Employment Opportunity Commission], they settled an over-$200,000 lawsuit with Walgreens, which essentially did not allow a pregnant woman to go seek emergency medical care when she started spotting and later that day she miscarried. I mean, these are situations that seem hard to believe, but happen every day here in the U.S. So that kind of protection would theoretically, hopefully protect someone in that kind of situation.

Carey: Right, and we should talk to your point, Lauren. I hit on the abortion perspective there with the first question, but this is also talking about things like letting people have water, letting them have a chair, letting them sit down. These are deemed as reasonable accommodations, and some people may still oppose them on religious grounds if it deals with care for an abortion, but we will leave that there and turn to another topic we have talked a lot about: measles.

According to the Centers for Disease Control and Prevention, also known as the CDC, eight more measles cases have been reported, bringing that total to 121 so far this year. Forty-seven percent of those cases are in children ages 5 and younger. And for 82% of individuals who’ve been diagnosed with measles, their vaccination status is either unvaccinated or unknown. And the cases noted this week were in California, Illinois, and Ohio.

Lauren, I know you’ve written a lot about public health officials and their tracking of these kind of things. How are they trying to contain this outbreak?

Weber: Well, it depends on what state you’re in for the answer to that, MAC.

Carey: There you go.

Weber: I would say that in general, what we’re seeing here with this explosion of measles is really the ramifications of the misinformation and anti-vaccine rhetoric whipped up by covid coming to bear. We’ve had the highest rate, according to CDC data from I think it was the 2022-2023 school year, of parents requesting exemptions for their children. In kindergarten, we’re seeing more measles cases, which again is a vaccine-preventable disease.

Most public health officials, the vast majority, are advocating for vaccination, public awareness, bringing up those vaccination numbers, making sure we track down cases. But then you see others in Florida, most notably the surgeon general in the third-most-populous state, not following public health guidance when it comes to measles.

And the concern is, as we move forward, what will happen as you have more measles cases potentially show up in a Florida or in another very red state where a public health official may choose to take a different tack? We’ll see how that continues to play out this year.

Carey: I know, Lauren, you’ve written extensively about this, and others feel free to jump in, but I mean, you’re talking about public health departments that have really been hit: funding cuts, staff reductions. And that’s going to impact their ability to track and contain measles and other highly contagious diseases.

Weber: I mean, I think also we have to talk about the fact that public health as a whole has been incredibly politicized. Anytime you say the word “public health” it usually has a somewhat negative reaction in a post-covid world. I mean, we live with covid, but after the pandemic began. And you are seeing even though health departments did get a boost of funds from covid money and some of the money that passed through the CDC, those funds are going to drop off soon. So you’re even going to see a reduction in workforce from the growth they had to combat those cuts they’d faced for years.

You’re going to have, again, that boom-bust cycle when it comes to public health. And when you have that boom-bust cycle, that means that you don’t have enough public health workers to properly track a measles outbreak or monitor any other water outbreak or other public health issue that we all just live our lives and don’t think about every day. And so it is concerning when you see what is a vaccine-preventable disease and, as many experts have told me, not something we should be seeing in 2024 in America coming up this frequently in children.

And again, let’s just point out that measles can have deadly effects. It can also have very serious health effects. It is not a fun thing for any child or any person to endure. And so a lot of public health experts are just really, frankly, discouraged that message has been lost in some corners of this country.

Carey: All right. Well, that’s the news for this week. Now we’re going to play Julie’s interview with Caroline Pearson and then we’ll come back for our extra credits.

Julie Rovner: I am pleased to welcome to the podcast Caroline Pearson, executive director of the Peterson Health Technology Institute. If that organization sounds familiar, it’s because we talked about the Institute’s first public project a couple of weeks ago. Caroline, thanks for joining us.

Caroline Pearson: I’m so excited to be here, Julie. Thanks so much.

Rovner: So let’s start with what the Peterson Health Technology Institute is and what it does.

Pearson: Wonderful. Well, we are an independent, nonprofit evaluator of digital health tools. So we are trying to figure out what works and what doesn’t in the space of health technology.

Rovner: And there is an awful lot of that to choose from, right?

Pearson: There is indeed, and it’s really hard to sort the wheat from the chaff. And so we hope to be helpful.

Rovner: So for those who don’t remember or weren’t listening a couple of weeks ago, remind us what your first assessment was about and what you found.

Pearson: We conducted an assessment of digital diabetes tools to support adults with Type 2 diabetes, and they rely on noncontinuous glucometers. Those are the ones that you prick your finger with. And then they support the patients with diabetes by encouraging them to take their blood glucose on a regular basis, to make a variety of behavior and lifestyle changes, and really to help with self-management between their clinician visits.

Rovner: All of which sounds cool. What did you find?

Pearson: Well, diabetes is obviously a huge and growing issue in this country, and it really does rely on patients to manage so much on their own. And so it makes sense that these tools were created to be helpful to patients. And if we can help them manage better, in theory, we can help them be healthier. But unfortunately, while many of these tools have been around 10, some of them 15 years at this point, we found very little evidence that they’re having meaningful clinical benefits for patients across the board.

And so we found that really patients weren’t seeing significant improvements in their hemoglobin A1C that were sufficient to change their prognosis or their health spending — and unfortunately, were paying a lot of money both through health plans and through physicians for these digital solutions. And so on net, they’re increasing costs and not delivering a lot of health benefits.

Rovner: And I keep saying this, that every time somebody looks at something that didn’t work, that’s a success, not a failure, right?

Pearson: Well, I’m so excited that we’re just having a serious conversation about evidence. We’ve been excited about health technology. Obviously covid was a huge boom. But as we’re innovating, we need to be measuring and taking a step back and making sure that the tools that we’re using are delivering the value that we want. And if they’re not, we keep innovating. We push forward. But it’s important to bring that real evidence-based framework to this industry.

Rovner: So what are you doing next and how do you decide which specific technology to assess? As you mentioned, there’s an awful lot out there.

Pearson: Well, there’s many to choose from. Our next one is going to be looking at virtual solutions to help with musculoskeletal problems. So these are really, like, virtual physical therapy apps that people can do at home on their own and much more convenient and can really help with access. And then after that, we’ve got hypertension coming up, and mental health for anxiety and depression before the end of the year.

And I think the theme that you’ll see across all four of those is these are really big clinical areas, things that affect a lot of patients and create a lot of health care spending. And places where we’ve seen really a lot of technology investment, and we think there’s some opportunity for evaluation of that investment.

Rovner: So technology assessment has a more controversial history than I think many people realize. I am old enough to remember the congressional Office of Technology Assessment, which was summarily canceled when Republicans took over Congress after the 1994 elections. Why is this subject so touchy and how are you going to avoid falling into the trap of being perceived as unbalanced?

Pearson: Well, first and foremost, we are, I think, the only entity that we know of that really doesn’t have a stake in the game. We’re a philanthropy and we simply want to make health care more effective and more efficient. So we really have the ability to be truly independent, whereas many of the entities in this space are pay-to-play or have some investment interest. I don’t know why it’s been so hard. I really can’t explain. Many people remind me about the OTA and that it did exist once.

Rovner: It was very popular when it existed. They did a lot of good work.

Pearson: It did. It did. Well, I guess no one even needs to vote for my institute. So we’re going to keep doing this good work because we think it’s important and we hope to really drive impact both for patients and those who are purchasing these technologies, but also for folks who are developing these technologies and investing in them. I think everyone wants to be able to figure out what’s really working and put their investment and their energy behind that.

Rovner: Well, absolutely. We will be watching. Caroline Pearson, thank you so much for joining us.

Pearson: Thank you, Julie. Great to be here.

Carey: All right, we’re back. And it’s time for our extra-credit segment. That’s when we each recommend a story that we read this week and think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Lauren, why don’t you start us off with your extra credit?

Weber: I’ll fangirl another former KFF Health News colleague, Christina Jewett, who’s at The New York Times, who basically taught me everything I know. So shoutout on this podcast.

Carey: She’s awesome. I can verify.

Weber: She wrote, as always, a great dive called “Chinese Company Under Congressional Scrutiny Makes Key U.S. Drugs.” It basically gets into how this company, WuXi, I believe is how you say it, but I could be wrong, is behind pretty much, I believe it was a 1 in 4, one-fourth of the drugs used in the U.S. OK, that’s a lot of the drugs used in the U.S., but it is under congressional scrutiny as potentially having too deep of interest from China.

And so there are talks of limiting its access to U.S. companies and limiting its contracts and so on, which could be very devastating to many of the drugs it’s involved with, which include those that treat cystic fibrosis, leukemia, a wide variety of things. Again, if you cover a quarter of the drugs in the U.S., you’re covering a lot of things that are very important. And what Christina did so deftly is there’s all been this talk about this company, it’s all been in the ether, but she went and found out actually what kind of drugs that would impact if there was some sort of ban. And it’s definitely something to be watching when we think about biotech interests abroad and just in general access to the U.S.’s drug supply and our access as patients to its availability.

Carey: Jessie, can you share your extra credit, please?

Hellmann: My story is from the Tampa Bay Times. It’s called “Vulnerable Florida Patients Scramble After Abrupt Medicaid Termination.” It focuses on people who receive the home- and community-based services. Some people in Florida have been finding that they were disenrolled during this redetermination process, and a lot of these people are people who would probably never lose eligibility if not for procedural reasons.

There are people that need a lot of intense care in their homes and they rely on this program for that care. And advocates in Florida have been sending up red flags about what’s going on there. And the state has said in their defense that they’ve reached out to these families and didn’t get any paperwork back.

But I think it’s important to note that these are families and these are individuals who have a lot going on and they’re caring for their loved ones. And it might be easier for them to fall through the cracks, and there are really serious consequences to that.

Carey: Sarah?

Karlin-Smith: I took a look at a Stat story by Nick Florko, “Grocers Are Pushing Legislation They Claim Would Enhance Food Safety. Advocates Say It Would Gut FDA Rules.” And my favorite thing about this story is it focuses on a bill with a title called Food Traceability Enhancement Act, which would make you think, I think, for many people, that the idea is to, again, increase food safety.

And actually it appears to be an effort by food, grocery store lobbyists and so forth to gut FDA safety rules that are set to go into effect in 2026 that would help better control, contain, prevent food outbreaks. So it’s raising alarm, particularly by one of the former FDA heads of the food program, who basically worries it’s going to, again, set back big efforts to better protect all of us who consume food.

Carey: Good reminder. You always got to watch those bill titles. The details may not reflect the title. My extra credit this week is from my KFF Health News colleague Julie Appleby. The headline is “When Rogue Brokers Switch People’s ACA Policies, Tax Surprises Can Follow.” Julie broke that story about ACA enrollees being switched into plans that they didn’t select. That’s a tactic that earned commissions for some dishonest insurance agents, but it’s caused headaches for people who are now on the hook to pay more in taxes for health coverage they didn’t even know that they had.

So that’s our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review. That helps others find us too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me on X @maryagnescarey. Lauren, where are you these days?

Weber: Still only can find me on X. I’m @LaurenWeberHP, the HP is for health policy

Carey: Jessie.

Hellmann: Also still on X @jessiehellmann.

Carey: And Sarah?

Karlin-Smith: I’m at X on @SarahKarlin and the trying to get more into Blue Sky at @sarahkarlin-smith.

Carey: Julie will be back in your feed next week. Until then, be healthy.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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Carrie Lester looks forward to the phone call every Thursday from her doctors’ medical assistant, who asks how she’s doing and if she needs prescription refills. The assistant counsels her on dealing with anxiety and her other health issues.

Lester credits the chats for keeping her out of the hospital and reducing the need for clinic visits to manage chronic conditions including depression, fibromyalgia, and hypertension.

“Just knowing someone is going to check on me is comforting,” said Lester, 73, who lives with her dogs, Sophie and Dolly, in Independence, Kansas.

At least two-thirds of Medicare enrollees have two or more chronic health conditions, federal data shows. That makes them eligible for a federal program that, since 2015, has rewarded doctors for doing more to manage their health outside office visits.

But while early research found the service, called Chronic Care Management, reduced emergency room and in-patient hospital visits and lowered total health spending, uptake has been sluggish.

Federal data from 2019 shows just 4% of potentially eligible enrollees participated in the program, a figure that appears to have held steady through 2023, according to a Mathematica analysis. About 12,000 physicians billed Medicare under the CCM mantle in 2021, according to the latest Medicare data analyzed by KFF Health News. (The Medicare data includes doctors who have annually billed CCM at least a dozen times.)

By comparison, federal data shows about 1 million providers participate in Medicare.

Even as the strategy has largely failed to live up to its potential, thousands of physicians have boosted their annual pay by participating, and auxiliary for-profit businesses have sprung up to help doctors take advantage of the program. The federal data showed about 4,500 physicians received at least $100,000 each in CCM pay in 2021.

Through the CCM program, Medicare pays to develop a patient care plan, coordinate treatment with specialists, and regularly check in with beneficiaries. Medicare pays doctors a monthly average of $62 per patient, for 20 minutes of work with each, according to companies in the business.

Without the program, providers often have little incentive to spend time coordinating care because they can’t bill Medicare for such services.

Health policy experts say a host of factors limit participation in the program. Chief among them is that it requires both doctors and patients to opt in. Doctors may not have the capacity to regularly monitor patients outside office visits. Some also worry about meeting the strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly copayment if they don’t have a supplemental policy.

“This program had potential to have a big impact,” said Kenneth Thorpe, an Emory University health policy expert on chronic diseases. “But I knew it was never going to work from the start because it was put together wrong.”

He said most doctors’ offices are not set up for monitoring patients at home. “This is very time-intensive and not something physicians are used to doing or have time to do,” Thorpe said.

For patients, the CCM program is intended to expand the type of care offered in traditional, fee-for-service Medicare to match benefits that — at least in theory — they may get through Medicare Advantage, which is administered by private insurers.

But the CCM program is open to both Medicare and Medicare Advantage beneficiaries.

The program was also intended to boost pay to primary care doctors and other physicians who are paid significantly less by Medicare than specialists, said Mark Miller, a former executive director of the Medicare Payment Advisory Commission, which advises Congress. He’s currently an executive vice president of Arnold Ventures, a philanthropic organization focused on health policy. (The organization has also provided funding for KFF Health News.)

Despite the allure of extra money, some physicians have been put off by the program’s upfront costs.

“It may seem like easy money for a physician practice, but it is not,” said Namirah Jamshed, a physician at UT Southwestern Medical Center in Dallas.

Jamshed said the CCM program was cumbersome to implement because her practice was not used to documenting time spent with patients outside the office, a challenge that included finding a way to integrate the data into electronic health records. Another challenge was hiring staff to handle patient calls before her practice started getting reimbursed by the program.

Only about 10% of the practice’s Medicare patients are enrolled in CCM, she said.

Jamshed said her practice has been approached by private companies looking to do the work, but the practice demurred out of concerns about sharing patients’ health information and the cost of retaining the companies. Those companies can take more than half of what Medicare pays doctors for their CCM work.

Physician Jennifer Bacani McKenney, who runs a family medicine practice in Fredonia, Kansas, with her father — where Carrie Lester is a patient — said the CCM program has worked well.

She said having a system to keep in touch with patients at least once a month has reduced their use of emergency rooms — including for some who were prone to visits for nonemergency reasons, such as running out of medication or even feeling lonely. The CCM funding enables the practice’s medical assistant to call patients regularly to check in, something it could not afford before.

For a small practice, having a staffer who can generate extra revenue makes a big difference, McKenney said.

While she estimates about 90% of their patients would qualify for the program, only about 20% are enrolled. One reason is that not everyone needs or wants the calls, she said.

While the program has captured interest among internists and family medicine doctors, it has also paid out hundreds of thousands of dollars to specialists, such as those in cardiology, urology, and gastroenterology, the KFF Health News analysis found. Primary care doctors are often seen as the ones who coordinate patient care, making the payments to specialists notable.

A federally funded study by Mathematica in 2017 found the CCM program saves Medicare $74 per patient per month, or $888 per patient per year — due mostly to a decreased need for hospital care.

The study quoted providers who were unhappy with attempts to outsource CCM work. “Third-party companies out there turn this into a racket,” the study cited one physician as saying, noting companies employ nurses who don’t know patients.

Nancy McCall, a Mathematica researcher who co-authored the 2017 study, said doctors are not the only resistance point. “Patients may not want to be bothered or asked if they are exercising or losing weight or watching their salt intake,” she said.

Still, some physician groups say it’s convenient to outsource the program.

UnityPoint Health, a large integrated health system based in Iowa, tried doing chronic care management on its own, but found it administratively burdensome, said Dawn Welling, the UnityPoint Clinic’s chief nursing officer.

For the past year, it has contracted with a Miami-based company, HealthSnap, to enroll patients, have its nurses make check-in calls each month, and help with billing. HealthSnap helps manage care for over 16,000 of UnityHealth’s Medicare patients — a small fraction of its Medicare patients, which includes those enrolled in Medicare Advantage.

Some doctors were anxious about sharing patient records and viewed the program as a sign they weren’t doing enough for patients, Welling said. But she said the program has been helpful, particularly to many enrollees who are isolated and need help changing their diet and other behaviors to improve health.

“These are patients who call the clinic regularly and have needs, but not always clinical needs,” Welling said.

Samson Magid, CEO of HealthSnap, said more doctors have started participating in the CCM program since Medicare increased pay in 2022 for 20 minutes of work, to $62 from $41, and added billing codes for additional time.

To help ensure patients pick up the phone, caller ID shows HealthSnap calls as coming from their doctor’s office, not from wherever the company’s nurse might be located. The company also hires nurses from different regions so they may speak with dialects similar to those of the patients they work with, Magid said.

He said some enrollees have been in the program for three years and many could stay enrolled for life — which means they can bill patients and Medicare long-term.

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

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A pair of heart devices linked to hundreds of injuries and at least 14 deaths has received the FDA’s most serious recall, the agency announced Monday.

Related Article Patients Facing Death Are Opting for a Lifesaving Heart Device — But at What Risk?

The HeartMate 3 is considered the safest mechanical heart pump of its kind, but a federal database contains more than 4,500 reports in which the medical device may have caused or contributed to a patient’s death.

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The recall comes years after surgeons say they first noticed problems with the HeartMate II and HeartMate 3, manufactured by Thoratec Corp., a subsidiary of Abbott Laboratories. The devices are not currently being removed from the market. In an emailed response, Abbott said it had communicated the risk to customers this year.

The delayed action raises questions for some safety advocates about how and when issues with approved medical devices should be reported. The heart devices in question have been associated with thousands of reports of patients’ injuries and deaths, as described in a KFF Health News investigation late last year.

“Why doesn’t the public know?” said Sanket Dhruva, a cardiologist and an expert in medical device safety and regulation at the University of California-San Francisco. Though some surgeons may have been aware of issues, others, particularly those who do not implant the device frequently, may have been in the dark. “And their patients are suffering adverse events,” he said.

The recall involves a pair of mechanical pumps that help the heart pump blood when it can’t do so on its own. The devices, small enough to fit in the palm of a hand, are implanted in patients with end-stage heart failure who are waiting for a transplant or as a permanent solution when a transplant is not an option. The recall affects nearly 14,000 devices.

Amanda Hils, an FDA press officer, said the agency is working with Abbott to investigate the reported injuries and deaths and determine if further action is needed.

“To date, the number of deaths reported appears consistent with the adverse events observed in the initial clinical trial,” Hils said in an email.

According to the FDA’s recall notice, the devices can cause buildup of “biological material” that reduces their ability to help the heart circulate blood and keep patients alive. The buildup accumulates gradually and can appear two years or more after a device is implanted in a patient’s chest.

Doctors were advised to watch out for “low-flow alarms” on the devices and, if they do diagnose the obstruction, to either monitor the patient or perform surgery to implant a stent, release the blockage, or replace the pump. “Rates of outflow obstruction are low,” Abbott spokesperson Justin Paquette said in an email, adding that patients whose devices are functioning normally “have no reason for concern.”

A review of the FDA device database shows at least 130 reports related to HeartMate II or 3 that mention the complication reported by regulators. The earliest such report filed with the FDA dates to at least 2020, according to a KFF Health News review of the database.

Monday’s alert is the second Class 1 recall of a HeartMate device this year.

In January, Abbott issued an urgent “correction letter” to hospitals about a separate issue in which the HeartMate 3 unintentionally starts and stops due to the pump’s communication system, which cardiologists use to assess patients’ status. The FDA alerted the public in March.

In February, Abbott issued another urgent letter to hospitals about the blockage problem, asking them to inform physicians, complete and return an acknowledgment form, and pay attention to low-flow alarms on the device’s monitor that may indicate an obstruction. The company said in the letter that it is working on “a design solution” to prevent the blockages.

A study published in 2022 in the Journal of Thoracic and Cardiovascular Surgery reported the obstruction in about 3% of cases, though the incidence rate was higher the longer a patient had the device.

The only other Class 1 recall issued for the HeartMate 3 was in May 2018, when the company issued corrective action notices to hospitals and physicians warning that the graft line that carries blood from the pump to the aorta could twist and stop blood flow.

The FDA recall notice issued Monday includes additional guidance for physicians to diagnose the blockage using an algorithm to detect obstructions and, if needed, a CT angiogram to verify the cause.

At present, the HeartMate 3, which was first approved by the FDA in 2017, is the only medical option for many patients with end-stage heart failure and who do not qualify for a transplant. The HeartMate 3 has supplanted the HeartMate II, which received FDA approval in 2008.

If the new recall leads to the device being removed from the market, end-stage heart failure patients could have no options, said Francis Pagani, a cardiothoracic surgeon at the University of Michigan who also oversees a proprietary database of HeartMate II and HeartMate 3 implants.

If that happens, “we are in trouble,” Pagani said. “It would be devastating to the patients to not have this option. It’s not a perfect option — no pump ever is — but this is as good as it’s ever been.”

It’s not known precisely how many patients have received a HeartMate II or HeartMate 3 implant. That information is proprietary. The FDA recall notices show worldwide distribution of more than 22,000 HeartMate 3 devices and more than 2,200 of the HeartMate II.

The blockage complication may have gone unreported to the public for so long partly because physicians are not required to report adverse events to federal regulators, said Madris Kinard, a former FDA medical device official and founder of Device Events, a company that makes FDA device data more user-friendly for hospitals, law firms, and investors.

Only device manufacturers, device importers, and hospitals are required by law to report device-related injuries, deaths, and significant malfunctions to the FDA.

“If this is something physicians were aware of, but they weren’t mandated to report to the FDA,” Kinard said, “at what point does that communication between those two groups need to happen?”

Dhruva, the cardiologist, said he is looking for transparency from Abbott about what the company is doing to address the problem so he can have more thorough conversations with patients considering a HeartMate device.

“We’re going to expect to have some data saying, ‘Hey we created this fix, and this fix works, and it doesn’t cause a new problem.’ That’s what I want to know,” he said. “There’s just a ton more that I feel in the dark about, to be honest, and I’m sure that patients and their families do as well.”

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

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More than $4.3 billion in opioid settlement money has landed in the hands of city, county and state officials to date — with billions more on the way. But instead of using the cash to add desperately needed treatment, recovery and prevention services, some places are using it to replace existing funding.

Local officials say they’re trying to stretch tight budgets, especially in rural areas. But critics say it’s a lost opportunity to bolster responses to an ongoing addiction crisis and save lives.

“To think that replacing what you’re already spending with settlement funds is going to make things better — it’s not,” said Robert Kent, former general counsel for the Office of National Drug Control Policy. “Certainly, the spirit of the settlements wasn’t to keep doing what you’re doing. It was to do more.”

The debate is playing out in Scott County, Ind. The rural community made headlines in 2015 after intravenous drug use led to a massive HIV outbreak and then-Gov. Mike Pence (R) legalized syringe service programs. (The county has since shuttered its syringe program.) 

In 2022, the county received more than $570,000 in opioid settlement funds. It spent about 45 percent of that on salaries for its health director and emergency medical services staff, according to reports it filed with the state. The money usually budgeted for those salaries was freed to buy an ambulance and create a rainy-day fund for the health department.

In public meetings, Scott County leaders said they hoped to reimburse the departments for resources they dedicated to the HIV outbreak years ago. 

Their conversations echo the struggles of other rural counties, which have tight budgets in part because for years they poured money into combating the opioid crisis. Now they want to recoup some of those expenses.

But many families affected by addiction, recovery advocates, and legal and public health experts say that misses the point, that the settlements were aimed at helping the nation make progress against the overdose epidemic.

Thirteen states and Washington, D.C., have restricted substituting opioid settlement funds for existing government spending, according to state guides created by OpioidSettlementTracker.com and the public health organization Vital Strategies. A national set of principles created by Johns Hopkins University also advises against the practice, known as supplantation.

But it’s happening anyway. 

County commissioners in Blair County, Pa., used about $320,000 of settlement funds for a drug court that has been operating with other sources of money for more than two decades, according to a report the county filed with a state council overseeing settlement funds.

In New York, some lawmakers and treatment advocates say the governor’s proposed budget substitutes millions of opioid settlement dollars for a portion of the state addiction agency’s normal funding.

Given the complexities of state and local budgets, it’s often difficult to spot supplantation. But one place to start is identifying how much opioid settlement money your community has received so far. Use our searchable database to find out. Then ask elected officials how they’re spending those dollars. In many places, dedicated citizens are the only watchdogs for this money.

If you discover anything interesting, shoot me a note.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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

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SACRAMENTO, Calif. — Nearly a half-million health workers who stand to benefit from California’s nation-leading $25 minimum wage law could be in for a rude awakening if hospitals and other health care providers follow through on potential cuts to hours and benefits.

A medical industry challenge to a new minimum wage ordinance in one Southern California city suggests layoffs and reductions in hours and benefits, including cuts to premium pay and vacation time, could be one result of a state law set to begin phasing in in June. However, some experts are skeptical of that possibility.

The California Hospital Association brought a partly successful legal challenge to Inglewood’s $25 minimum wage ordinance, which barred employers from taking those sorts of steps to offset their higher costs.

“Layoffs, reductions in premium pay rates, reductions in non-wage benefits, reductions in hours, and increased charges are consequences of an employer having less money to spend—which will necessarily be the case given the significant increase in spending on wages due to the minimum wage,” the association said in its lawsuit. Additional examples include reducing health coverage and charging for parking or work-related equipment.

Inglewood voters approved the ordinance in November 2022, nearly a year before California legislators enacted a $25 minimum wage for health workers. Those statewide higher wages are to be phased in starting in June under California’s first-in-the-nation law, but Gov. Gavin Newsom has since said they are too expensive as the state faces a deficit estimated between $38 billion and $73 billion. It’s unclear if lawmakers will agree to a delay or take other steps to reduce the cost.

U.S. District Judge Dale S. Fischer agreed with the hospital industry in a March 11 tentative ruling when he shot down the portion of Inglewood’s ordinance banning layoffs and clawbacks by employers, while allowing the rest of the ordinance to remain in effect. He gave the sides time to object to his preliminary decision, though none did.

The California Hospital Association represents more than 400 hospitals and was a key backer of the state’s carefully crafted compromise law, which notably contains none of the employee safeguards included in the Inglewood ordinance.

Spokesperson Jan Emerson-Shea said the association doesn’t know how providers will react once the state law takes effect. “We don’t have any insights,” she said.

“The challenge for any health care organization is figuring out how to pay for the higher wages,” said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco. “Since labor costs are the largest part of any health care organization’s costs, it’s hard to figure out how to reduce spending without looking at labor costs.”

Providers can try to increase revenues by bargaining for higher reimbursements from commercial insurers, she said. Public hospitals, nursing homes, and community clinics get most of their money through Medi-Cal, the state’s Medicaid program.

Providers could reduce the services they offer, pare back charity care, and cut or delay capital investments, Spetz said. In the long term, she expects some combination of spending cuts and revenue increases.

Both the state law and local ordinance cover far more than doctors and nurses, with a definition of health worker that includes janitors, housekeepers, groundskeepers, security guards, food service workers, laundry workers, and clerical staff.

The most recent estimate by the Health Care Program at the University of California-Berkeley Labor Center is that as many as 426,000 health workers would make an average of $6,400 extra in the law’s first year, a 19% average pay bump mainly benefiting lower-income workers of color and women. State finance officials project that well over 500,000 workers will benefit.

Researchers didn’t include layoffs and other potential staffing and benefit reductions when they projected the state law’s costs and benefits, said Laurel Lucia, the program’s director. But she pointed to initial projections by hospitals, doctors, and business and taxpayer groups that the wage hike would cost $8 billion annually, thereby imperiling services and resulting in higher premiums and higher costs for state and local governments.

“It seems like a contradiction to say this law’s going to cost billions of dollars while at the same time saying it’s going to reduce workers’ total compensation,” said Lucia, who projects a far lower price tag.

She added that state finance officials had anticipated that Medi-Cal reimbursements would reflect the increased labor costs, while Medicare would eventually at least partially compensate for the higher labor costs.

Michael Reich, chair of the Center on Wage and Employment Dynamics at UC Berkeley’s Institute for Research on Labor and Employment, and affiliated economist Justin Wiltshire recently argued that California’s new $20 minimum wage law for fast-food workers won’t result in mass layoffs and price increases, as some have predicted.

Health care is much different than fast food, Reich acknowledged, but he argued for much the same positive result.

“A higher minimum wage will make it easier and cheaper for hospitals to recruit and retain these workers. The cost savings, and the productivity benefits of more experienced workers, could offset much of the labor cost increase,” Reich said.

The hospital association filed its lawsuit against Inglewood’s ordinance in July, while it was still opposing early versions of the statewide minimum wage legislation. Among many other provisions, the statewide law put on hold an initiative to cap hospital executives’ salaries in Los Angeles.

The hospital association’s legal challenge referenced in part layoffs and reduced working hours imposed by Centinela Hospital Medical Center after Inglewood’s ordinance took effect.

But Centinela said the reduction was entirely unrelated to the ordinance and that all staff were offered alternate positions, which many accepted.

“Centinela Hospital also has since added many more jobs in new clinical positions above minimum wage scale,” the hospital said in a statement.

Service Employees International Union-United Healthcare Workers West, the prime backer of both the local ordinance and the statewide law, sued the hospital in April 2023 alleging that it cut workers’ hours to offset the higher minimum wage. The case is still pending.

The union did not respond to repeated requests for comment.

In a court filing, however, the union and city of Inglewood said similar employer restrictions in previous minimum wage laws have survived.

The ordinance “merely sets the backdrop for collective bargaining negotiations,” and does not bar employers from locking out employees or hiring replacement workers during a strike. Employers can still lay off workers or reduce their hours, they said, so long as they don’t do so to fund the higher minimum wage.

But Fischer agreed with the hospital association that layoffs and reductions in employees’ total compensation packages are “obvious responses by an employer to rising compensation costs.”

Restricting employers’ options would violate federal labor relations rules, he said.

“The minimum wage an employer has to pay its employees will invariably affect the total amount of compensation it is able or willing to pay,” he wrote “This will then invariably affect the number of employees it can retain and the number of hours those employees will be scheduled to work.”

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

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

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LITTLE ROCK, Ark. — Sixth-grade boys were lining up to be measured in the Mann Arts and Science Magnet Middle School library. As they took off their shoes and emptied their pockets, they joked about being the tallest.

“It’s an advantage,” said one. “You can play basketball,” said another. “A taller dude can get more girls!” a third student offered.

Everyone laughed. What they didn’t joke about was their weight.

Anndrea Veasley, the school’s registered nurse, had them stand one by one. One boy, Christopher, slumped as she measured his height. “Chin up slightly,” she said. Then Veasley asked him to stand backward on a scale so he didn’t see the numbers. She silently noted his height as just shy of 4 feet, 7 inches, and his weight as 115.6 pounds.

His parents later would be among thousands to receive a letter beginning, “Many children in Arkansas have health problems caused by their weight.” The letter includes each student’s measurements as well as their calculated body mass index, an indicator of body fat. The BMI number categorizes each child as “underweight,” “normal,” “overweight,” or “obese.” Christopher’s BMI of 25.1 put him in the range of obesity.

In 2003, Arkansas became the first state to send home BMI reports about all students as part of a broader anti-obesity initiative. But in the 20 years since, the state’s childhood obesity rates have risen to nearly 24% from 21%, reflecting a similar, albeit higher, trajectory than national rates. During the pandemic, the state obesity rate hit a high of more than 26%.

Still, at least 23 states followed Arkansas’ lead and required height and weight assessments of students. Some have since scaled back their efforts after parents raised concerns.

One school district in Wyoming used to include a child’s BMI score in report cards, a practice it has since stopped. Ohio allows districts to opt in, and last year just two of 611 school districts reported BMI information to the state. And Massachusetts stopped sending letters home. Even Arkansas changed its rules to allow parents to opt out.

Multiple studies have shown that these reports, or “fat letters” as they’re sometimes mockingly called, have had no effect on weight loss. And some nutritionists, psychologists, and parents have criticized the letters, saying they can lead to weight stigma and eating disorders.

BMI as a tool has come under scrutiny, too, because it does not consider differences across racial and ethnic groups, sex, gender, and age. In 2023, the American Medical Association called the BMI “imperfect” and suggested it be used alongside other tools such as visceral fat measurements, body composition, and genetic factors.

All that highlights a question: What purpose do BMI school measurements and letters serve? Nearly 20% of American children were classified as obese just before the pandemic — up from only 5% some 50 years ago — and lockdowns made the problem worse. It’s unclear what sorts of interventions might reverse the trend.

Joe Thompson, a pediatrician who helped create Arkansas’ program and now leads the Arkansas Center for Health Improvement, said BMI letters are meant to be a screening tool, not a diagnostic test, to make parents aware if their child is at risk of developing serious health issues, such as heart disease, diabetes, and respiratory problems.

Sharing this information with them is critical, he said, given that many don’t see it as a problem because obesity is so prevalent. Arkansas is also a rural state, so many families don’t have easy access to pediatricians, he said.

Thompson said he’s heard from many parents who have acted on the letters. “To this day, they are still our strongest advocates,” he said.

The program also led to new efforts to reduce obesity. Some school districts in Arkansas have instituted “movement breaks,” while others have added vegetable gardens, cooking classes, and walking trails. One district sought funding for bicycles. The state does not study whether these efforts are working.

Researchers say the BMI data also serves an important purpose in illuminating population-level trends, even if it isn’t helpful to individuals.

Parents are generally supportive of weighing children in school, and the letters have helped increase their awareness of obesity, research shows. At the same time, few parents followed up with a health care provider or made changes to their child’s diet or physical activity after getting a BMI letter, several other studies have found.

In what is considered the gold-standard study of BMI letters, published in 2020, researchers in California found that the letters home had no effect on students’ weight. Hannah Thompson, a University of California-Berkeley assistant professor who co-authored the study, said most parents didn’t even remember getting the letters. “It’s such a tiny-touch behavioral intervention,” she said.

Arkansas now measures all public school students in even grades annually — except for 12th graders because by that stage, the pediatrician Joe Thompson said, the students are “beyond the opportunities for schools to have an impact.” The change also came after many boys in one school wore leg weights under their jeans as a prank, he said.

Kimberly Collins, 50, remembers being confused by the BMI letters sent to her from the Little Rock School District stating that all her children were considered overweight, and that one daughter was classified as obese.

“It offended me as a mama,” she said. “It made me feel like I wasn’t doing my job.”

She didn’t think her children looked overweight and the family pediatrician had never brought it up as a concern.

Hannah Thompson, the researcher from California, said that’s the biggest problem with BMI letters: Parents don’t know what to do with the information. Without support to help change behavior, she said, the letters don’t do much.

“You find out your child is asthmatic, and you can get an inhaler, right?” she said. “You find out that your child is overweight and where do you even go from there? What do you do?”

Kevin Gee, a professor at the University of California-Davis, who has studied BMI letters, said the mailings miss cultural nuances. In some communities, for example, people prefer their children to be heavier, associating it with comfort and happiness. Or some eat foods that they know aren’t very nutritious but are an important way of expressing love and traditions.

“There’s a lot of rich contextual pieces that we know influences rates of obesity,” Gee said. “And so how do we balance that information?”

Collins’ daughter, now 15, said that as she’s grown older she increasingly feels uncomfortable about her weight. People stare at her and sometimes make comments. (Collins’ mother asked that her daughter’s name not be published because of her age and the sensitive nature of the subject.)

“On my birthday, I went to get my allergy shots and one of the nurses told me, ‘You are getting chubbier,’” she said. “That didn’t make me feel the best.”

Collins said it pains her to see her soft-spoken daughter cover herself with her arms as if she’s trying to hide. The teenager has also begun sneaking food and avoids the mirror by refusing to turn on the bathroom light, Collins said. The girl signed up for tennis but stopped after other children made fun of her, her mother said.

Looking back, Collins said, while she wishes she had paid more attention to the BMI letters, she also would have liked practical suggestions on what to do. Collins said she had already been following the short list of recommended healthy practices, including feeding her children fruits and vegetables and limiting screen time. She isn’t sure what else she could have done.

Now everyone has an opinion on her daughter’s weight, Collins said. One person told her to put a lock on the fridge. Another told her to buy vegan snacks. Her mother bought them a scale.

“It’s a total uphill climb,” Collins said with a sigh.

This article was produced as a part of a project for the Spencer Education Journalism Fellowship.

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

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