Walgreens has announced it will stop dispensing the abortion pill mifepristone in 21 states where Republican attorneys general threatened legal action against the company, which is the nation’s second-largest pharmacy chain.

KHN senior correspondent Sarah Varney joined PBS NewsHour co-anchor Amna Nawaz in a report on the move and its ramifications for women in those states, many of which have outlawed or severely restricted abortion. In four — Alaska, Iowa, Kansas, and Montana — Walgreens could legally sell the pills but has said it will not. 

Other pharmacies such as CVS, Rite Aid, Costco, Walmart, and Kroger also face legal action.

To otherwise obtain the medication, Varney said, women could seek “a telehealth appointment with someone outside of the state” or “you could order from an online pharmacy.” 

But, she noted, the move by Walgreens restricts access to the drug for “women in what is typically a very time-sensitive situation.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The U.S. Department of Health and Human Services (HHS) joins the disability community in mourning the loss of Judy Heumann, who passed away over the weekend.

Just off the historic U.S. Route 66 in eastern New Mexico, a 10-bed hospital has for decades provided emergency care for a steady flow of people injured in car crashes and ranching accidents.

It also has served as a close-to-home option for the occasional overnight patient, usually older residents with pneumonia or heart trouble. It’s the only hospital for the more than 4,500 people living on a swath of 3,000 square miles of high plains and lakes east of Albuquerque.

“We want to be the facility that saves lives,” said Christina Campos, administrator of Guadalupe County Hospital in Santa Rosa. Its leaders have no desire to grow or be a big, profitable business, she said.

But even with a tax levy to help support the medical outpost, the facility lost more than $1 million in the past six months, Campos said: “For years, we’ve been anticipating kind of our own demise, praying that a program would come along and make us sustainable.”

Guadalupe is one of the nation’s first to start the process of converting into a Rural Emergency Hospital. The designation was created as part of the first new federal payment program launched by the Centers for Medicare & Medicaid Services for rural providers in 25 years. And though it is not expected to be a permanent solution to pressures facing rural America, policymakers and hospital operators alike hope it will slow the financial hemorrhage that continues to shutter those communities’ hospitals.

More than 140 rural hospitals have closed nationwide since 2010, and health policy watchers aren’t sure how many of the more than 1,700 rural facilities eligible for the new designation will apply. CMS officials said late last month that seven have already filed applications. Dr. Lee Fleisher, director of the Center for Clinical Standards and Quality at CMS, said how long it will take to review the applications will vary. The agency declined to provide the names or locations of hospitals seeking the designation.

Facilities that convert will get a 5% increase in Medicare payments as well as an average annual facility fee payment of about $3.2 million in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds that closed after the law passed on Dec. 27, 2020, are eligible to apply for the new payment model if they reopen.

The new program “strikes me as the first time we are saying, you know, maybe we can just take the beds away,” said Dr. Paula Chatterjee, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine. Outpatient and emergency visits already make up about 66% of Medicare payments for rural hospitals that are eligible to convert, according to Chatterjee’s recent research.

Still, she found that many would likely need to scale up some outpatient services, such as telehealth and substance use care. Even then the payment model might not be able to shift the “foundational pressures” of declining, aging, and sicker populations that are making it hard to deliver care in rural America, she said.

“This feels like rearranging deck chairs on the Titanic,” Chatterjee said.

More than 50 hospitals and other organizations have expressed interest in the rural emergency designation, said Janice Walters, chief operating officer of programs for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to facilities interested in converting.

Most hospitals “are still trying to figure out, ‘Is the math going to work?’” Walters said.

Those showing immediate interest are very small, with three or fewer patients staying overnight any given day, and, generally, they long ago gave up maternity care to save on expenses. The federal law will need to be amended to help larger rural hospitals with more overnight stays, said Brock Slabach, chief operations officer for the National Rural Health Association.

“It’s enough for now,” Slabach said. “But is it going to be enough for the long term? I don’t think so.” Top priorities for the group include adding the ability for hospitals to participate in a federal drug discount program and allowing for longer patient stays.

At Stillwater Medical in Oklahoma, Chief Administrative Officer Steven Taylor said the switch already makes sense for two of the system’s smaller hospitals that “have struggled financially.” The small regional health system’s outpost in Perry, which rarely has more than two inpatients a day, has already filed an application, and its facility in Blackwell will likely do so soon, he said.

Keeping emergency services “is the most important thing” for the small communities, he said. The new model requires a 24-hour emergency department and a clinician on call. It also caps the average length of patient stays at 24 hours — which Taylor said is not a problem. One patient may need to be watched for 12 hours for chest pain while another, with pneumonia, may need to stay for 36 hours, but that will average out to less than 24 hours for the year, he said.

Plus, he said, anybody who needs more intense care can be transferred to their regional hospital in Stillwater. Oklahoma, like other states, is working to update state laws for licensing or regulations to ensure hospitals can be credentialed with the rural emergency designation quickly.

John Henderson, president and chief executive of the Texas Organization of Rural & Community Hospitals, agreed with other speakers at the National Rural Health Association’s February policy conference in Washington, D.C. The new rule “could be a relief valve” for very small rural hospitals, he said. A two-bed facility in Crosbyton confirmed for Henderson earlier that day that it was the first in Texas to be approved for the new payment mechanism.

Henderson said he knew of several more of the state’s 158 rural hospitals that are applying or have already applied, and others are considering it: “These are the folks that are just hanging on.”

Dr. Denise Brown, CEO of virtual care provider Fident, spoke up from the front row during Henderson’s presentation. Her company uses telehealth so doctors and other clinicians can work virtually with multiple hospitals in different states. Brown said she was concerned that hospitals that convert won’t have enough ambulances available to transport or a place to send sicker patients, especially if they aren’t part of a larger health system.

Heads began to nod throughout the crowded room. Many rural hospitals needed every bed they had during the worst of the covid-19 pandemic, and to give up those beds now seems counterintuitive.

Those same rural hospitals often find that larger facilities refuse to take their patients who need specialized care, Brown said.

“How do I know that I can guarantee somebody a bed?” Brown said, adding that she prefers rural hospitals keep patients longer. How would she explain to concerned family members that their loved one was “two or three hours from home”?

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Midwest KHN correspondent Bram Sable-Smith discussed the Eli Lilly news on insulin prices on “PBS NewsHour” and insulin prices on Slate’s “What Next” on March 1.

• Click here to watch Sable-Smith on “PBS NewsHour”
• Click here to hear Sable-Smith on “What Next”
• Read Sable-Smith and Samantha Young’s “Eli Lilly Slashed Insulin Prices. This Starts a Race to the Bottom.“
• Read Sable-Smith’s “Armed With Hashtags, These Activists Made Insulin Prices a Presidential Talking Point“

KHN contributor Andy Miller discussed Georgia’s legislative wrap-up including Medicaid work requirements on Georgia Public Broadcasting’s “Lawmakers” on Feb. 28. He also discussed health care for foster children on WUGA’s “The Georgia Health Report” on Feb. 3.

• Click here to hear Miller on “Lawmakers”
• Read Miller’s “Path Cleared for Georgia to Launch Work Requirements for Medicaid“
• Click here to hear Miller on “The Georgia Health Report”
• Read Miller’s “Unmet Needs: Critics Cite Failures in Health Care for Vulnerable Foster Children“

Senior KHN correspondent Julie Appleby discussed how the end of the public health emergency will affect costs for covid-19 vaccines, treatments, and masks on KMOX’s “Health Matters” on Feb. 25.

• Click here to hear Appleby on “Health Matters”
• Read Appleby’s “Era of ‘Free’ Covid Vaccines, Test Kits, and Treatments Is Ending. Who Will Pay the Tab Now?“

KHN correspondent Cara Anthony discussed the youngest victims of gun violence and those who dig their graves on America’s Heroes Group on Feb. 25.

• Click here to hear Anthony on “America’s Heroes Group”
• Read Anthony’s “When Gun Violence Ends Young Lives, These Men Prepare the Graves“

KHN contributor Eric Berger discussed distracted driving laws and why Missouri still doesn’t have one on St. Louis Public Radio’s “St. Louis on the Air” on Feb 24.

• Click here to hear Berger on “St. Louis on the Air”
• Read Berger’s “Why Two States Remain Holdouts on Distracted Driving Laws“

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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MIAMI, FL – En retrospectiva, debería haber reconocido las señales de alarma, dijo Nikki Ruston.

El consultorio de Miami donde programó lo que se conoce como levantamiento (lifting) de glúteos brasileño había cerrado y transferido sus registros a un centro diferente, explicó. El precio que le ofrecieron, y que pagó por adelantado, aumentó el día de la intervención, y no conoció a su cirujano hasta poco antes de recibir anestesia general.

“Estaba lista para irme”, afirmó Ruston, de 44 años, de Lake Alfred, en Florida Central. “Pero ya había pagado todo”.

Pocos días después de la intervención, que fue en julio, Ruston fue hospitalizada por una infección, pérdida de sangre y náuseas, según consta en su historial médico.

“Busqué lo más barato, eso es lo que hice”, recordó Ruston recientemente. “Busqué el precio más bajo y lo encontré en Instagram”.

A personas como Ruston se las atrae para que vayan a centros de cirugía en consultorios del sur de Florida. Ocurre a través de marketing en redes sociales que muestran al levantamiento de glúteos brasileño, y a otras cirugías cosméticas, como engañosamente indoloras, seguras y asequibles, según investigadores, defensores de pacientes y asociaciones de cirujanos.

A diferencia de los centros de cirugía ambulatoria y de los hospitales, en donde un paciente puede pasar la noche en observación después del tratamiento, los centros de cirugía en consultorios ofrecen procedimientos que no suelen requerir hospitalización, y están regulados como una extensión de la consulta privada de un médico.

Pero estos centros suelen ser propiedad de corporaciones que ofrecen precios reducidos contratando a cirujanos a los que se incentiva para que atiendan al mayor número posible de pacientes al día, en el menor tiempo posible, según reguladores estatales y médicos que son críticos de estos centros.

Ruston dijo que ahora vive con un dolor constante, pero a otras pacientes un levantamiento de glúteos brasileño les ha costado la vida. Después de una serie de muertes, y a falta de normas nacionales, los reguladores de Florida fueron los primeros en promulgar normas en 2019 destinadas a hacer que los procedimientos sean más seguros. Más de tres años después, los datos muestran que todavía ocurren muertes.

Los defensores de los pacientes y algunos cirujanos —incluidos los que realizan el procedimiento ellos mismos— anticipan que el problema empeorará. Las restricciones de emergencia impuestas por la junta médica del estado en junio expiraron en septiembre, y el modelo de negocio popularizado en Miami se ha extendido a otras ciudades.

“Estamos viendo entidades con una fuerte huella en la cirugía estética de alto volumen y bajo costo, con sede en el sur de Florida, que han aparecido en otras partes del país”, señaló el doctor Bob Basu, vicepresidente de la Sociedad Americana de Cirujanos Plásticos y médico en Houston, Texas.

Durante un levantamiento de glúteos brasileño, se extrae grasa mediante liposucción de otras zonas del cuerpo, como el torso, la espalda o los muslos, y se inyecta en los glúteos. En 2021 se realizaron en todo el país más de 61,000 procedimientos de aumento de glúteos, tanto levantamientos como implantes, lo que supone un alza del 37% respecto al año anterior, según datos de la Aesthetic Society, un grupo de cirujanos plásticos.

Como ocurre con toda cirugía, pueden surgir complicaciones. El forense del condado de Miami-Dade ha documentado casi tres docenas de muertes de pacientes de cirugía estética desde 2009, de los cuales 26 fueron consecuencia de un levantamiento de glúteos brasileño. En cada caso, el paciente murió de una embolia pulmonar grasa, es decir, la obstrucción de vasos sanguíneos por grasa que entró a través de las venas en los músculos de los glúteos e impidió que la sangre fluyera a los pulmones.

Ningún sistema nacional de informes o códigos de aseguradoras hacen un seguimiento de los resultados y los datos demográficos de los pacientes que se realizan un levantamiento de glúteos brasileño.

A nivel mundial, a cerca de un 3% de los cirujanos se les ha muerto un paciente como resultado del procedimiento, según un informe de 2017 de un grupo de trabajo de la Fundación para la Educación e Investigación de la Cirugía Estética.

Expertos médicos dijeron que el problema surge, en parte, al tener a asistentes médicos y a enfermeras realizando partes clave del levantamiento de glúteos en lugar de a médicos. También es la consecuencia de un modelo de negocio motivado por los beneficios, no por la seguridad, que incentiva a los cirujanos a superar el número de operaciones estipulado en sus contratos.

En mayo, después de que muriera el quinto paciente en varios meses por complicaciones en el condado de Miami-Dade, el doctor Kevin Cairns propuso una norma estatal de emergencia para limitar el número de operaciones de levantamiento de glúteos que un cirujano pudiera realizar al día.

“Estaba harto de leer sobre mujeres que morían y de ver casos que llegaban a la junta”, explicó Cairns, médico y ex miembro de la Junta de Medicina de Florida.

Algunos médicos realizaban hasta siete cirugías, según expedientes disciplinarios contra cirujanos abiertos por el Departamento de Salud de Florida. La norma de emergencia las limitaba a no más de tres, y exigía el uso de una ecografía para ayudar a los cirujanos a reducir el riesgo de coágulo de grasa pulmonar.

Pero un grupo de médicos que realizan operaciones de levantamiento de glúteos brasileño en el sur de Florida, respondió formando la organización Surgeons for Safety. Argumentaron que los nuevos requisitos empeorarían la situación. Los médicos calificados tendrían que hacer menos procedimientos, dijeron, lo que llevaría a los pacientes a acudir a profesionales médicos peligrosos que no siguen las reglas.

Desde entonces, el grupo ha donado más de $350,000 al Partido Republicano del estado, a candidatos republicanos y a comités de acción política republicanos, según datos de contribuciones a campañas del Departamento de Estado de Florida.

Surgeons for Safety declinó las repetidas solicitudes de entrevista de KHN. Aunque el presidente del grupo, el doctor Constantino Mendieta, escribió en un editorial, en agosto, que estaba de acuerdo en que no todos han seguido los estándares de cuidado, calificó de “arbitrarios” los límites impuestos a los cirujanos. La norma sienta “un precedente histórico de controlar a los cirujanos”, declaró durante una reunión con la junta médica de Florida.

En enero, la senadora republicana por Florida, Ileana García, presentó un proyecto de ley ante la legislatura estatal que propone que no haya límite en la cantidad de levantamiento de glúteos brasileños que un cirujano pueda realizar en un día. En cambio, requiere que los centros de cirugía en consultorios, en donde se realizan los procedimientos, cuenten con un médico por paciente, y prohíbe que los cirujanos trabajen en más de una persona a la vez.

El proyecto de ley también permitiría a los cirujanos delegar algunas partes del procedimiento a otros médicos bajo su supervisión directa, y el cirujano debe usar un ultrasonido.

La legislatura de Florida se vuelve a reunir el 7 de marzo.

Se pide precaución a los consumidores que estén pensando en someterse a procedimientos estéticos. Al igual que Ruston, muchas personas basan sus expectativas en las fotos del antes y el después, y en los videos de marketing publicados en plataformas de redes sociales como Facebook, Snapchat e Instagram.

“Eso es muy peligroso”, afirmó Basu, de la Sociedad Americana de Cirujanos Plásticos. “Se entusiasman con un precio bajo y se olvidan de hacer los deberes”, añadió.

El precio promedio de un levantamiento de glúteos en 2021 fue de $4,000, según datos de la Aesthetic Society. Pero eso es solo por los honorarios del médico y no cubre la anestesia, los costos de la sala de operaciones, las recetas y otros gastos. Un levantamiento de glúteos brasileño “seguro”, realizado en un centro acreditado y con los cuidados postoperatorios adecuados, cuesta entre $12,000 y $18,000, según un artículo reciente en el sitio web de la Sociedad Americana de Cirujanos Plásticos.

Aunque Florida requiere una licencia médica para realizar una liposucción en pacientes que están bajo anestesia general, es común que profesionales médicos de nivel medio, como los asistentes médicos y las enfermeras, realicen el procedimiento en un consultorio, según el doctor Mark Mofid, coautor del estudio, de 2017, del grupo de trabajo de la Fundación para la Educación e Investigación de la Cirugía Estética.

Al depender de personal que no tiene la misma capacitación especializada y recibe menos paga, los cirujanos que trabajan en consultorios pueden completar más levantamientos de glúteos por día y cobrar un precio más bajo.

“Los hacen todos a la vez, en tres o cuatro salas distintas, y los atiende un solo cirujano”, explicó Mofid, cirujano plástico en San Diego, quien agregó que él no realiza más de un levantamiento de glúteos brasileño al día. “El cirujano no es quien está sobre el caso real, son sus asistentes”.

Basu dijo que los pacientes deben preguntar si su médico puede realizar el mismo procedimiento en un hospital o un centro de cirugía ambulatoria, donde hay reglas más estrictas que en los consultorios, en términos de quién puede realizar levantamiento de glúteos y cómo deben hacerse.

Se les recuerda a las personas en busca de gangas que la cirugía estética puede tener otros riesgos graves más allá de los mortales coágulos de grasa, como infecciones y perforación de órganos, además de problemas en los riñones, el corazón y los pulmones.

A la cirugía de Ruston la realizó un cirujano plástico certificado que dijo haber encontrado en Instagram. En un principio se le presupuestó $4,995, que dijo haber pagado en su totalidad antes de la cirugía. Pero cuando llegó a Miami, contó que la clínica agregó cargos por liposucción, y por prendas y dispositivos posquirúrgicos.

“Terminé pagando unos $8,000 “, dijo Ruston. Pocos días después de regresar a Lake Alfred, Ruston empezó a sentirse mareada y débil, y llamó al 911.

Los paramédicos la llevaron a la sala de emergencias, donde le diagnosticaron anemia por pérdida de sangre e infecciones sanguíneas y abdominales, según su historia clínica.

“Si pudiera volver atrás en el tiempo”, concluyó, “no me lo habría hecho”.

Chaseedaw Giles, de KHN, colaboró con este informe.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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MIAMI — In hindsight, Nikki Ruston said, she should have recognized the red flags.

The office in Miami where she scheduled what’s known as a Brazilian butt lift had closed and transferred her records to a different facility, she said. The price she was quoted — and paid upfront — increased the day of the procedure, and she said she did not meet her surgeon until she was about to be placed under general anesthesia.

“I was ready to walk out,” said Ruston, 44, of Lake Alfred in Central Florida. “But I had paid everything.”

A few days after the July procedure, Ruston was hospitalized due to infection, blood loss, and nausea, her medical records show.

“I went cheap. That’s what I did,” Ruston recalled recently. “I looked for the lowest price, and I found him on Instagram.”

People like Ruston are commonly lured to office-based surgery centers in South Florida through social media marketing that makes Brazilian butt lifts and other cosmetic surgery look deceptively painless, safe, and affordable, say researchers, patient advocates, and surgeon groups.

Unlike ambulatory surgery centers and hospitals, where a patient might stay overnight for observation after treatment, office-based surgery centers offer procedures that don’t typically require an inpatient stay and are regulated as an extension of a doctor’s private practice.

But such surgical offices are often owned by corporations that can offer discount prices by contracting with surgeons who are incentivized to work on as many patients per day as possible, in as little time as possible, according to state regulators and physicians critical of the facilities.

Ruston said she now lives with constant pain, but for other patients a Brazilian butt lift cost them their lives. After a rash of deaths, and in the absence of national standards, Florida regulators were the first in the nation to enact rules in 2019 meant to make the procedures safer. More than three years later, data shows deaths still occur.

Patient advocates and some surgeons — including those who perform the procedure themselves — anticipate the problem will only get worse. Emergency restrictions imposed by the state’s medical board in June expired in September, and the corporate business model popularized in Miami is spreading to other cities.

“We’re seeing entities that have a strong footprint in low-cost, high-volume cosmetic surgery, based in South Florida, manifesting in other parts of the country,” said Dr. Bob Basu, a vice president of the American Society of Plastic Surgeons and a practicing physician in Houston.

During a Brazilian butt lift, fat is taken via liposuction from other areas of the body — such as the torso, back, or thighs — and injected into the buttocks. More than 61,000 buttock augmentation procedures, both butt lifts and implants, were performed nationwide in 2021, a 37% increase from the previous year, according to data from the Aesthetic Society, a trade group of plastic surgeons.

As with all surgery, complications can occur. Miami-Dade County’s medical examiner has documented nearly three dozen cosmetic surgery patient deaths since 2009, of which 26 resulted from a Brazilian butt lift. In each case, the person died from a pulmonary fat embolism, when fat entered the bloodstream through veins in the gluteal muscles and stopped blood from flowing to the lungs.

No national reporting system nor insurance code tracks outcomes and patient demographics for a Brazilian butt lift. About 3% of surgeons worldwide had a patient die as a result of the procedure, according to a 2017 report from an Aesthetic Surgery Education and Research Foundation task force.

Medical experts said the problem is driven, in part, by having medical professionals like physician assistants and nurse practitioners perform key parts of the butt lift instead of doctors. It’s also driven by a business model that is motivated by profit, not safety, and incentivizes surgeons to exceed the number of surgeries outlined in their contracts.

In May, after a fifth patient in as many months died of complications in Miami-Dade County, Dr. Kevin Cairns proposed the state’s emergency rule to limit the number of butt lifts a surgeon could perform each day.

“I was getting sick of reading about women dying and seeing cases come before the board,” said Cairns, a physician and former member of the Florida Board of Medicine.

Some doctors performed as many as seven, according to disciplinary cases against surgeons prosecuted by the Florida Department of Health. The emergency rule limited them to no more than three, and required the use of an ultrasound to help surgeons lower the risk of a pulmonary fat clot.

But a group of physicians who perform Brazilian butt lifts in South Florida clapped back and formed Surgeons for Safety. They argued the new requirements would make the situation worse. Qualified doctors would have to do fewer procedures, they said, thus driving patients to dangerous medical professionals who don’t follow rules.

The group has since donated more than $350,000 to the state’s Republican Party, Republican candidates, and Republican political action committees, according to campaign contribution data from the Florida Department of State.

Surgeons for Safety declined KHN’s repeated interview requests. Although the group’s president, Dr. Constantino Mendieta, wrote in an August editorial that he agreed not all surgeons have followed the standard of care, he called the limits put on surgeons “arbitrary.” The rule sets “a historic precedent of controlling surgeons,” he said during a meeting with Florida’s medical board.

In January, Florida state Sen. Ileana Garcia, a Republican, filed a draft bill with the state legislature that proposes no limit on the number of Brazilian butt lifts a surgeon can perform in a day. Instead, it requires office surgery centers where the procedures are performed to staff one physician per patient and prohibits surgeons from working on more than one person at a time.

The bill would also allow surgeons to delegate some parts of the procedure to other clinicians under their direct supervision, and the surgeon must use an ultrasound.

Florida’s legislature convenes on March 7.

Consumers considering cosmetic procedures are urged to be cautious. Like Ruston, many people base their expectations on before-and-after photos and marketing videos posted on social media platforms such as Facebook, Snapchat, and Instagram.

“That’s very dangerous,” said Basu, of the American Society of Plastic Surgeons. “They’re excited about a low price and they forget about doing their homework,” he said.

The average price of a buttocks augmentation in 2021 was $4,000, according to data from the Aesthetic Society. But that’s only for the physician’s fee and does not cover anesthesia, operating room fees, prescriptions, or other expenses. A “safe” Brazilian butt lift, performed in an accredited facility and with proper aftercare, costs between $12,000 and $18,000, according to a recent article on the American Society of Plastic Surgeons’ website.

Although Florida requires a physician’s license to perform liposuction on patients who are under general anesthesia, it’s common in the medical field for midlevel medical practitioners, such as physician assistants and nurse practitioners, to do the procedure in office settings, according to Dr. Mark Mofid, who co-authored the 2017 Aesthetic Surgery Education and Research Foundation task force study.

By relying on staffers who don’t have the same specialty training and get paid less, office-based surgeons can complete more butt lifts per day and charge a lower price.

“They’re doing all of them simultaneously in three or four different rooms, and it’s being staffed by one surgeon,” said Mofid, a plastic surgeon in San Diego, who added that he does not perform more than one Brazilian butt lift in a day. “The surgeon isn’t doing the actual case. It’s assistants.”

Basu said patients should ask whether their doctor holds privileges to perform the same procedure at a hospital or ambulatory surgery center, which have stricter rules than office surgery centers in terms of who can perform butt lifts and how they should be done.

People in search of bargains are reminded that cosmetic surgery can have other serious risks beyond the deadly fat clots, such as infection and organ puncture, plus problems with the kidneys, heart, and lungs.

Ruston’s surgery was performed by a board-certified plastic surgeon she said she found on Instagram. She was originally quoted $4,995, which she said she paid in full before surgery. But when she arrived in Miami, she said, the clinic tacked on fees for liposuction and for post-surgical garments and devices.

“I ended up having to pay, like, $8,000,” Ruston said. A few days after Ruston returned home to Lake Alfred, she said, she started to feel dizzy and weak and called 911.

Paramedics took her to an emergency room, where doctors diagnosed her with anemia due to blood loss, and blood and abdominal infections, her medical records show.

“If I could go back in time,” she said, “I wouldn’t have had it done.”

KHN’s Chaseedaw Giles contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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PHILIPSBURG, Mont. — On a recent day in this 19th-century mining town turned tourist hot spot, students made their way into the Granite High School lobby and past a new filtered water bottle fill station.

Water samples taken from the drinking fountain the station replaced had a lead concentration of 10 parts per billion — twice Montana’s legal limit for schools of 5 parts per billion for the toxic metal.

Thomas Gates, the principal and superintendent of the small Philipsburg School District, worries the new faucets, sinks, and filters the district installed for roughly 30 water sources are temporary fixes. The high school, built in 1912, is likely laced with aged pipes and other infrastructure, like so much of this historic town.

“If we change faucets or whatever, lead is still getting pushed in,” Gates said.

The school in Philipsburg is one of hundreds in Montana grappling with how to remove lead from their water after state officials mandated schools test for it. So far, 74% of schools that submitted samples found at least one faucet or drinking fountain with high lead levels. Many of those schools are still trying to trace the source of the problem and find the money for long-term fixes.

In his Feb. 7 State of the Union address, President Joe Biden said the infrastructure bill he championed in 2021 will help fund the replacement of lead pipes that serve “400,000 schools and child care centers, so every child in America can drink clean water.”

However, as of mid-February, states were still waiting to hear how much infrastructure money they’ll receive, and when. And schools are trying to figure out how to respond to toxic levels of lead now. The federal government hasn’t required schools and child care centers to test for lead, though it has awarded grants to states for voluntary testing.

During the past decade, nationwide unease has been stirred by news of unsafe drinking water in places like Flint, Michigan. Politicians have promised to increase checks in schools where kids — who are especially vulnerable to lead poisoning — drink water daily. Lead poisoning slows children’s development, causing learning, speech, and behavioral challenges. The metal can cause organ and nervous system damage.

A new report by advocacy group Environment America Research & Policy Center showed that most states fall short in providing oversight for lead in schools. And the testing that has happened to this point shows widespread contamination from rural towns to major cities.

At least 19 states require schools to test for lead in drinking water. A 2022 law in Colorado requires child care providers and schools that serve any kids from preschool through fifth grade to test their drinking water by May 31 and, if needed, make repairs. Meanwhile, California leaders, who mandated lead testing in schools in 2017, are considering requiring districts to install filters on water sources with high levels of lead.

As states boost scrutiny, schools are left with complicated and expensive fixes.

As it passed the infrastructure bill, Congress set aside $15 billion to replace lead pipes, and $200 million for lead testing and remediation in schools.

White House spokesperson Abdullah Hasan didn’t provide the source of the 400,000 figure Biden cited as the number of schools and child care centers slated for pipe replacement. Several clean-water advocacy organizations didn’t know where the number came from, either.

Part of the issue is that no one knows how many lead pipes are funneling drinking water into schools.

The Environmental Protection Agency estimates between 6 million and 10 million lead service lines are in use nationwide. Those are the small pipes that connect water mains to plumbing systems in buildings. Other organizations say there could be as many as 13 million.

But the problem goes beyond those pipes, said John Rumpler, senior director for the Clean Water for America Campaign at Environment America.

Typically lead pipes connected to public water systems are too small to serve larger schools. Water contamination in those buildings is more likely to come from old faucets, fountains, and internal plumbing.

“Lead is contaminating schools’ drinking water” when there aren’t lead pipes connecting to a municipal water source, Rumpler said. Because of their complex plumbing systems, schools have “more places along the way where lead can be in contact with water.”

Montana has collected more data on lead-contaminated school water than most other states. But gaps remain. Of the state’s 591 schools, 149 haven’t submitted samples to the state, despite an initial 2021 deadline.

Jon Ebelt, spokesperson with the Montana Department of Public Health and Human Services, said the state made its deadline flexible due to the covid-19 pandemic and is working with schools that need to finish testing.

Greg Montgomery, who runs Montana’s lead monitoring program, said sometimes testing stalled when school districts ran into staff turnover. Some smaller districts have one custodian to make sure testing happens. Larger districts may have maintenance teams for the work, but also have a lot more ground to cover.

Outside Burley McWilliams’ Missoula County Public Schools office, about 75 miles northwest of Philipsburg, sit dozens of water samples in small plastic bottles for a second round of lead testing. Director of operations and maintenance for the district of roughly 10,000 students, McWilliams said lead has become a weekly topic of discussion with his schools’ principals, who have heard concerns from parents and employees.

Several of the district’s schools had drinking fountains and classroom sinks blocked off with bags taped over faucets, signs of the work left to do.

The district spent an estimated $30,000 on initial fixes for key water sources by replacing parts like faucets and sinks. The school received federal covid money to buy water bottle stations to replace some old infrastructure. But if the new parts don’t fix the problem, the district will likely need to replace pipes — which isn’t in the budget.

The state initially set aside $40,000 for schools’ lead mitigation, which McWilliams said translated to about $1,000 for his district.

“That’s the one frustration that I had with this process: There’s no additional funding for it,” McWilliams said. He hopes state or federal dollars come through soon. He expects the latest round of testing to be done in March.

Montgomery said Feb. 14 that he expects to hear “any day now” what federal funding the state will receive to help reimburse schools for lead mitigation.

Back in Philipsburg, Chris Cornelius, the schools’ head custodian, has a handwritten list on his desk of all the water sources with high lead levels. The sink in the corner of his office has a new sign saying in bold letters that “the water is not safe to drink.”

According to state data, half the 55 faucets in the high school building had lead concentrations high enough to need to be fixed, replaced, or shut off.

Cornelius worked to fix problem spots: new sinks in the gym locker rooms, new faucets and inlet pipes on every fixture that tested high, water bottle fill stations with built-in filtration systems like the one in the school’s lobby.

Samples from many fixtures tested safe. But some got worse, meaning in parts of the building, the source of the problem goes deeper.

Cornelius was preparing to test a third time. He plans to run the water 12 to 14 hours before the test and remove faucet filters that seem to catch grime coming from below. He hopes that will lessen the concentration enough to pass the state’s thresholds.

The EPA recommends collecting water samples for testing at least eight hours after the fixtures were last used, which “maximizes the likelihood that the highest concentrations of lead will be found.”

If the water sources’ lead concentrations come back high again, Cornelius doesn’t know what else to do.

“I have exhausted possibilities at this point,” Cornelius said. “My last step is to put up more signs or shut it off.”

KHN correspondent Rachana Pradhan contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The Host Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

With Medicare and Social Security apparently off the table for federal budget cuts, the focus has turned to Medicaid, the federal-state health program for those with low incomes. President Joe Biden has made it clear he wants to protect the program, along with the Affordable Care Act, but Republicans will likely propose cuts to both when they present a proposed budget in the next several weeks.

Meanwhile, confusion over abortion restrictions continues, particularly at the FDA. One lawsuit in Texas calls for a federal judge to temporarily halt distribution of the abortion pill mifepristone. A separate suit, though, asks a different federal judge to temporarily make the drug easier to get, by removing some of the FDA’s safety restrictions.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rachel Cohrs of STAT News, and Lauren Weber of The Washington Post.

Panelists Rachel Cohrs Stat News @rachelcohrs Read Rachel's stories Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories

Among the takeaways from this week’s episode:

• States are working to review Medicaid eligibility for millions of people as pandemic-era coverage rules lapse at the end of March, amid fears that many Americans kicked off Medicaid who are eligible for free or near-free coverage under the ACA won’t know their options and will go uninsured.
• Biden promised this week to stop Republicans from “gutting” Medicaid and the ACA. But not all Republicans are on board with cuts to Medicaid. Between the party’s narrow majority in the House and the fact that Medicaid pays for nursing homes for many seniors, cutting the program is a politically dicey move.
• A national group that pushed the use of ivermectin to treat covid-19 is now hyping the drug as a treatment for flu and RSV — despite a lack of clinical evidence to support their claims that it is effective against any of those illnesses. Nonetheless, there is a movement of people, many of them doctors, who believe ivermectin works.
• In reproductive health news, a federal judge recently ruled that a Texas law cannot be used to prosecute groups that help women travel out of state to obtain abortions. And the abortion issue has highlighted the role of attorneys general around the country — politicizing a formerly nonpartisan state post. –And Eli Lilly announced plans to cut the price of some insulin products and cap out-of-pocket costs, though their reasons may not be completely altruistic: An expert pointed out that a change to Medicaid rebates next year means drugmakers soon will have to pay the government every time a patient fills a prescription for insulin, meaning Eli Lilly’s plan could save the company money.

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

Julie Rovner: The New York Times’ “A Drug Company Exploited a Safety Requirement to Make Money,” by Rebecca Robbins.

Alice Miranda Ollstein: The New York Times’ “Alone and Exploited, Migrant Children Work Brutal Jobs Across the U.S.,” by Hannah Dreier.

Rachel Cohrs: STAT News’ “Nonprofit Hospitals Are Failing Americans. Their Boards May Be a Reason Why,” by Sanjay Kishore and Suhas Gondi.

Lauren Weber: KHN and CBS News’ “This Dental Device Was Sold to Fix Patients’ Jaws. Lawsuits Claim It Wrecked Their Teeth,” by Brett Kelman and Anna Werner.

Also mentioned in this week’s podcast:

• Politico’s “Why One State’s Plan to Unwind a Covid-Era Medicaid Rule Is Raising Red Flags,” by Megan Messerly.
• The Washington Post’s “Doctors Who Touted Ivermectin as Covid Fix Now Pushing It for Flu, RSV,” by Lauren Weber.
• NPR’s “To Safeguard Healthy Twins in Utero, She Had to ‘Escape’ Texas for Abortion Procedure,” by Selena Simmons-Duffin.
• The Daily Beast’s “Tennessee Abortion Ban a ‘Nightmare’ for Woman With Doomed Pregnancy,” by Michael Daly.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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When drugmaker Eli Lilly announced Wednesday it will slash the list price for some of its insulin products following years of criticism from lawmakers and activists that the price of the lifesaving hormone had become unaffordable, the news raised questions about what will happen to other efforts to provide low-cost insulin.

Civica, a nonprofit drugmaker based in Utah, for example, has said it plans to begin selling biosimilar insulin for roughly $30 per vial by 2024 — $5 more than the new price of Eli Lilly’s generic insulin.

In December, billionaire entrepreneur Mark Cuban said his new company, the Mark Cuban Cost Plus Drug Co., planned to sell low-cost insulin. And California is poised to launch an ambitious program to manufacture its own brand of the hormone, as well as generics of other high-priced prescription drugs.

Drug pricing experts welcomed the Eli Lilly news, predicting the move won’t undercut those efforts. And these other initiatives to bring lower-cost insulin to market, in turn, would put pressure on Eli Lilly to keep its prices down. Together these will help, not hamper, what could become a race to the bottom on insulin prices.

“The more competition, the more stable this solution will be so that five to 10 years from now the prices won’t go up again,” said Dr. Vincent Rajkumar, a Mayo Clinic oncologist who has been a critic of high drug costs.

The pressure could cause further ripples. Following Eli Lilly’s news, Sen. Bernie Sanders (I-Vt.) sent letters to the two other major insulin makers, Sanofi and Novo Nordisk, calling on them to follow suit.

People with diabetes, especially those with Type 1 who need the drug to survive, will benefit. Yet even while some of Eli Lilly’s persistent critics praised the move, they noted work remains to make insulin widely affordable.

“Additional competition and other accountability moves are still incredibly necessary because the companies can raise their list price again at any time,” said Elizabeth Pfiester, founder of T1International, a nonprofit that advocates for people with diabetes. “That’s why the government also needs to regulate insulin manufacturers to hold them accountable.”

Cuban’s company did not respond to requests for comment on how the Eli Lilly cuts might affect its efforts. But Civica’s plan remains unchanged following the news, said spokesperson Debbi Ford.

“From the beginning, we have said we are not entering medicine markets for market share,” Ford said. “We are participating for market impact.”

Democratic California Gov. Gavin Newsom tweeted Wednesday that “sky high prices for insulin have put it out of reach for too many” and his state will manufacture its “OWN insulin and ensure all who need access to this medicine” can afford it.

“Now, Eli Lilly is lowering their cost,” Newsom wrote. “Let’s keep it up.”

Last year, California lawmakers approved $100 million for the state to contract for cheaper insulin and make the lifesaving drug, cutting out drugmakers and go-between companies that add to the price consumers pay. Newsom has said that California’s insulin would be available “at a cheaper price, close to at cost.” Officials haven’t said when the state’s insulin will be available, though, or exactly how much it will cost.

“California’s goal was to get competition into the market however they can manage it,” said Robin Feldman, a professor at the University of California College of the Law-San Francisco who studies the insulin market. “If California’s entry results in bringing prices down from other manufacturers, that will be a good thing.”

Eli Lilly’s price cuts apply to what it described as its “most commonly prescribed” insulins, but Feldman noted those are older insulin products. Although California officials haven’t released details about which insulin products would be included in its program, Feldman said she expects the state will offer a variety to cover the market.

“It’s not aimed at any one company or any one drug,” she said. “It’s aimed at making affordable insulin available to market and putting pressure on other companies.”

Washington and Maine are also exploring ways to bring cheap insulin to consumers, and large insurance companies pledged millions in an agreement with Civica to manufacture cheaper insulin.

The cadre of newcomers aim to break open the insulin market because three pharmaceutical companies — Eli Lilly and Co., Sanofi, and Novo Nordisk — have long dominated the U.S. insulin supply and allowed their prices to escalate. The price of one of Eli Lilly’s products, for example, rose from $21 to $255 per vial between 1996 and 2016.

St. Louis University law professor Dr. Michael Sinha said Eli Lilly may have seen a threat from the discount insulin initiatives.

“This might be a response to some of those initiatives and the looming threat of really steep losses in terms of market share,” Sinha said.

University of California-San Diego pharmaceutical professor Inmaculada Hernández offered another possible reason for the price cut: changes to how drugs are paid for by Medicaid.

Beginning in 2024, Hernández said, drugmakers could be on the hook to pay fees, known as rebates, to Medicaid for drugs like insulin that have had steep price hikes. By lowering the list price of insulin, Eli Lilly could avoid those costs, Hernández said.

Hernández said that understanding the incentives behind Eli Lilly’s decision to cut list prices could help lower the price of other drugs that patients have trouble affording. If the makers of those other drugs also slash their list prices ahead of 2024, it could show the effectiveness of the new federal policy. If they don’t, it might underscore the importance of factors unique to insulin like public pressure by politicians and activists or market competition from initiatives like California’s.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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BUTTE, Mont. — Jennifer Mitchell remembered getting a call nearly two years ago that her 69-year-old husband, Bill, had crashed his car and had been committed to the Montana State Hospital, the state-run psychiatric hospital for adults about 20 miles from their home in Butte.

Physicians thought Bill Mitchell had dementia and could be a danger to himself or others, according to medical records. But once he was admitted, his wife really began to worry. She couldn’t visit him because of covid-19 restrictions, and she couldn’t get details about the care or the medicine he was receiving.

“I tried to get an idea of what he was taking, not taking. I could not get answers,” Jennifer said.

When Bill was discharged after 60 days, Jennifer discovered he had been taken off some of his congestive heart failure medications. A month later, he went into cardiac arrest and was moved to hospice care. He died on July 30, 2021, a day after his 70th birthday.

The psychiatric hospital in southwestern Montana has been under scrutiny since the federal Centers for Medicare & Medicaid Services decertified it in April 2022 following investigations into patient deaths and assaults. Federal officials found in the investigations that the hospital had failed to meet Medicare’s “basic health and safety requirements.”

Mitchell said that she was infuriated by the lack of transparency around her husband’s care and that she hoped decertification would force a change for the better. But it’s had the opposite effect. When federal oversight and funding of the Montana State Hospital was removed, so too was the ability of the public to learn details surrounding patient deaths and injuries.

Between April’s decertification and the end of December, five Montana State Hospital patients have experienced severe injuries requiring immediate medical care or hospitalization, and there have been eight substantiated abuse and neglect reports, Montana Department of Public Health and Human Services spokesperson Jon Ebelt said.

Six patients died in that period, though Ebelt declined to say how many deaths were investigated or if any deaths were deemed preventable.

The circumstances surrounding all those incidents are not publicly known. That’s because, unlike federal investigations, state-level investigations are not public record.

The state health department denied a public records request for all investigations into Montana State Hospital patient deaths, injuries, and assaults since losing federal certification. Ebelt cited a Montana law that says any records about providing treatment to the seriously mentally ill are confidential and privileged.

States vary widely in what information about abuse and neglect at state-run medical facilities is made public, said David Hutt, deputy executive director for legal services for the National Disability Rights Network.

Hutt noted that the lack of transparency at the Montana State Hospital is unique because it lost federal certification and oversight, which is extremely rare.

State-hired contractors have produced public reports highlighting improvements at the Montana State Hospital, such as a reduction in falls among geriatric patients. But those reports don’t disclose information related to patient deaths, severe injuries, or substantiated abuse and neglect cases, which had led to decertification in the first place.

The lack of information frustrates some lawmakers as they consider state health officials’ and Republican Gov. Greg Gianforte’s request for a $300 million appropriation to overhaul the state’s mental health system and a nearly $20 million request for capital improvements and CMS recertification efforts at the state hospital.

“We’ve stabilized MSH since that decertification with a change in leadership and with no significant increase in deaths, serious injuries, or substantiated abuse or neglect allegations,” state health department Director Charlie Brereton told state senators during his recent confirmation hearing.

Brereton, who declined to be interviewed for this article, did not mention at his hearing whether there had been more recent patient injuries and deaths, or substantiated reports of abuse and neglect.

State Democratic Rep. Mary Caferro, who serves on committees considering funding requests and other legislation to reform the state hospital, likened the current level of oversight at the state hospital to the fox watching the henhouse.

“The legislature, when we have good information, thorough information, we make better policy that’s in the best interest of the people we represent,” Caferro said.

Mental health experts agree with Caferro.

“We should know the answers to whether people in the hospital are safe,” said Ben Miller, a clinical psychologist and former president of Well Being Trust, a national foundation focused on mental health care.

A bill that passed through the Montana Senate and is before the House would automatically send all abuse and neglect reports at the state hospital to Disability Rights Montana within five days of an incident. The nonprofit is the federally designated advocacy and watchdog organization for people with disabilities in the state. It recently released a report detailing how some patients were discharged to homeless shelters.

Bernie Franks-Ongoy, the organization’s executive director, said that Disability Rights Montana hopes to be able to share general information from the reports with lawmakers and the public, but noted that state law significantly limits what can be made public. Caferro said she’ll seek to amend the bill to make redacted versions of the reports available to lawmakers and the public.

The Montana Mental Disabilities Board of Visitors also has regular access to the facility and patient records, but its last inspection of the state hospital was in 2019 and the next inspection isn’t expected until next year.

Some lawmakers call the oversight adequate.

“I don’t worry so much about the administration at the hospital hiding anything because they really do have the light shown on them constantly with DRM and the Board of Visitors,” said Republican Rep. Bob Keenan, who chairs the committee considering funding requests for the state hospital and the state’s mental health system.

Keenan and Gianforte blame the current conditions at the facility and loss of CMS certification at the state hospital on prior Democratic administrations. Federal officials noted serious deficiencies at the Montana State Hospital in 2017, but federal officials later deemed those issues resolved.

If lawmakers approve the mental health funding requests, the administration plans to open two lower-level mental health facilities in the coming years to reduce demand at the state hospital. However, the hospital would remain a key fixture of Montana’s mental health system, according to state health officials. Mental health advocates and many lawmakers agree the state hospital should be saved.

Jennifer Mitchell, the woman whose husband died shortly after his discharge from the state hospital, thinks the hospital is beyond repair and worries more patients will die at the facility. She reflected on how hospital officials frequently changed her husband’s medication in response to his depression and refusal to eat, and said she believes her husband would still be alive today if he hadn’t been committed there.

“There were just so many little mistakes or little things that could have been different, and it would have been a totally different outcome,” she said.

This story is part of a partnership that includes Montana Public Radio, NPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Newborns. Former inmates. College students. Expectant moms. People with disabilities. Foster kids. Homeless people. Single dads.

Your neighbor. Your co-worker.

You.

California’s Medicaid program, called Medi-Cal, serves a whopping 15.4 million people, offering care from cradle to grave: Half of all births are covered by Medi-Cal, as are more than half of all stays in nursing homes.

Everything about Medi-Cal is massive, from its upcoming fiscal year budget of $139 billion to the expansive list of benefits and services it offers. The way the program works — or doesn’t — could spell life or death for many enrollees.

“It’s critical, from the single pregnant mom, to the extremely frail elderly population that needs a nursing home,” said Jennifer Kent, former director of the state Department of Health Care Services, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many people would either be dead or would be severely compromised.”

In a new series, California Healthline will shed light on Medi-Cal’s successes and failures through the experiences of its enrollees. They include Stephanie Lammers, who can’t get her troubling abdominal symptoms checked at a clinic 50 miles from her small Calaveras County town because the transportation Medi-Cal is supposed to provide isn’t trustworthy; Carolina Morga Tapia, a Fresno woman who credits Medi-Cal with helping her have five healthy children; and Lucas Moreno Ramirez, a Los Angeles County man with stage 4 lung cancer who had to fight to keep his treatment going.

Medi-Cal is at a critical juncture as it attempts to serve the needs of a diverse patient population with a dizzying array of medical needs — from childhood vaccinations and cancer screenings to state-of-the-art care for rare genetic disorders. Roughly half of enrollees are Hispanic, and, next year, California will become the first state to expand eligibility to all immigrants who qualify, regardless of their legal status.

Medi-Cal is also undertaking several new initiatives that aim to save taxpayer money and improve quality. State officials are demanding that the 23 health insurers that serve most Medi-Cal patients provide better care — or face significant penalties, including potential expulsion from the program.

The state is also adding innovative social services that fall outside the traditional realm of medicine, including helping some enrollees pay for rent and buy groceries.

“People are watching California,” said Cindy Mann, who served as federal Medicaid director under former President Barack Obama. “What the state is doing is ambitious and very aggressive. It makes a significant mark on health care and health policy, not just because of the size and breadth of its program, but by being very comprehensive.”

But only a sliver of enrollees will get the new social services, even as many patients struggle to obtain basic care or get in to see their doctors. In reality, the type of care you get in Medi-Cal depends on where you live and which insurer provides your benefits.

That means the program is working for some, but failing for many others.

If you are in Medi-Cal, we would like to hear from you, whether you live in a big city or a rural region, regardless of your age, race, or ethnicity, and whatever your medical, dental, or mental health condition. Have you had difficulty seeing the right doctor for what ails you, even to the point of putting your life at risk? Or did Medi-Cal provide good care, perhaps sparing you serious harm or disability? Either way, please consider sharing your experience with us.

Here are snapshots of patients who have used the program at a critical time in their life.

‘I Just Don’t Go to the Doctor Anymore’

When Stephanie Lammers leans over to put on her shoes, it feels as if she’s squishing something inside her abdomen, she said.

Lammers, 53, has been suffering from frequent bouts of nausea, pain, and bloating for six months.

Her gastroenterologist wants to perform diagnostic procedures, including a colonoscopy and, if anything shows up, a biopsy. But Lammers, who lives in a motel with her boyfriend and teenage daughter in the Gold Rush town of San Andreas, doesn’t have a working car and can’t readily get to the clinic — which is 50 miles away.

For Lammers, like many Medi-Cal enrollees who live in rural areas, lack of transportation is a major impediment to obtaining care. The problem is particularly acute for patients who need to see specialists.

Lammers’ dermatologist and eye doctor are over an hour away from San Andreas, the county seat of Calaveras County, about 125 miles northeast of San Francisco. She isn’t seeing a neurologist, despite a series of mini-strokes and stress-related seizures. And she hasn’t been to a podiatrist in two years, even though her toes are twisted over one another and hang down, causing her to trip. She’s often in excruciating pain when she walks.

Medi-Cal is supposed to provide free transportation to enrollees who can’t otherwise get to their appointments.

But Lammers, whose health plan is California Health & Wellness, owned by Centene, the nation’s largest commercial Medicaid insurer, stopped using its ride service nearly a year ago, after she missed dozens of appointments because drivers just didn’t show up, she said. She was getting threatening letters from doctors’ offices over the no-shows.

Once she had to hitchhike more than 30 miles home from a counseling appointment. On other occasions, Lammers said, she did not receive the reimbursement she was owed for arranging her own rides.

“I just don’t go to the doctor anymore,” Lammers said. “If I go to the doctor, my boyfriend has to take the day off work, and if he takes the day off work, we have no money.”

During the last three months of 2022, Lammers canceled five appointments she had scheduled for the diagnostic abdominal procedures because her boyfriend had to work each time and couldn’t take her. She finally stopped rescheduling.

California Health & Wellness contracts with Modivcare, a Denver-based medical transportation company that is no stranger to patient complaints and lawsuits.

Before she gave up on the ride service, Lammers said, she would call California Health & Wellness to try to resolve the issue, only to be told that Modivcare was a separate company. “I’m like, ‘If you guys hired them and put them in charge of transportation, who oversees their screw-ups?’”

Courtney Schwyzer, a member of a legal aid team representing Lammers on various Medi-Cal matters, said the failure of medical ride services is a systemic problem. In late February, Schwyzer and her fellow attorneys filed a petition in court that she hopes will force the state Department of Health Care Services to address the problem.

California Health & Wellness spokesperson Darrel Ng said the company monitors the quality of its contractors, but a shortage of transportation providers in rural areas “has created unique challenges.”

Modivcare provides more than 4 million rides for Medi-Cal recipients annually, and more than 99% are without complaint, said Melody Lai, a company spokesperson.

Lammers, who is unemployed and trying to start a custom craft business called Stuff by Steph, said doctors have warned her that if she doesn’t reduce her stress level, it could shorten her life. But arranging medical care is the most stressful thing in her life right now, so she doesn’t try anymore.

“In order to keep from dying, I have to not go to the doctor,” she said.

‘It’s a Blessing’

Medi-Cal helped save the life of Carolina Morga Tapia, a 30-year-old, full-time mother of five who lives with her family amid almond groves in an agricultural enclave of Fresno.

Nine years ago, a bacterial infection triggered premature labor during the 25th week of her second pregnancy, and Morga Tapia almost died. She spiked a fever, bled profusely, and needed immediate transfusions and emergency surgery. After several days in critical care, she fully recovered.

But the doctors could not stop the premature birth, and her baby came out weighing just 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and she died four days later, on Sept. 13, 2013 — a Friday.

In each of her subsequent pregnancies, Medi-Cal paid for Morga Tapia to get shots of synthetic progesterone, intended to prevent another preterm birth. Those shots — one a week for about 20 weeks — can cost an average of more than $10,000 per pregnancy.

Morga Tapia and Nuñez, a construction worker, signed up for Medi-Cal when she was pregnant with her first child more than a decade ago. They’ve been on the same Anthem Blue Cross Medi-Cal plan ever since.

“It saves a lot of money, and it’s a blessing to have that extra help.”

Morga Tapia

The plan paid for prenatal care through all six of Morga Tapia’s pregnancies, and it has provided all the medical and dental care the family needs, she said.

“Without Medi-Cal, we would have to be paying for all of our children,” said Morga Tapia. “It saves a lot of money, and it’s a blessing to have that extra help.”

Her children, four girls and a boy, range in age from 1 to 10. They all go to the same children’s clinic and see the same pediatrician.

The kids, all in good health, get routine checkups, vaccinations, and other preventive care, Morga Tapia said. She gets appointment reminders via text and cards in the mail notifying her when it’s time for the kids’ vaccinations and wellness checks, as well as her Pap smears, she said.

Her family’s experience contrasts sharply with the state’s assessment of their health plan, according to a report on quality of care in Medi-Cal issued late last year. The report, which evaluated Medi-Cal health plans on pediatric care, women’s health, and chronic disease management, put Anthem Blue Cross in the lowest tier, and below par on multiple measures in numerous counties, including Fresno.

Another state report, released in late January, detailed how quickly insurers provide appointments for their patients, and put Anthem Blue Cross’ Medi-Cal plan near the bottom of the heap.

Anthem Blue Cross spokesperson Michael Bowman said in a statement that the period covered in the reports coincided with the covid-19 pandemic, “when our safety net providers dealt with significant challenges with workforce and appointment availability.”

Morga Tapia doesn’t give the insurer low marks. “It’s different for everybody. I have a good healthy family, and what Medi-Cal covers is really fortunate for us,” she said.

‘I Don’t Want to Die Yet’

In late 2021, doctors gave Lucas Moreno Ramirez a few months to live.

Struggling with diabetes and late-stage lung cancer, Moreno Ramirez suffered debilitating pain as he hacked and labored for breath. His doctors recommended that he stop treatment and start hospice care.

He felt as if they were giving up on him.

“They said they’re going to give me opioids for my pain and help me have a comfortable death,” said Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I told them I don’t believe in that. I don’t want to die yet.”

A former landscaper and factory worker, Moreno Ramirez learned he had to be his own advocate, fighting for the care he believed he deserved from Medi-Cal.

He said his Christian faith gave him strength, and over the next few months, Moreno Ramirez pushed the program and his doctors to keep battling his cancer, using a different treatment with fewer side effects than chemotherapy.

“I believe in prayer,” he said. “But I believe in science and medication, too.”

Moreno Ramirez is one of the roughly 1.6 million Californians enrolled in both Medicare, which covers people who are 65 and older or have disabilities, and Medi-Cal, which kicks in to cover the costs and benefits that Medicare doesn’t.

He also relies on his Medi-Cal insurer to help him navigate the byzantine system. L.A. Care, the largest Medi-Cal plan with nearly 2.6 million members, connected him with a care manager who worked with him to identify a different treatment called Tagrisso and advocated for him to get it. 

Even with the new medication, Moreno Ramirez’s coughing fits returned last year, and his symptoms grew so painful he suspected the cancer was growing. He asked to see his pulmonologist but was told the first appointment would be in June 2023. So he switched doctors and scored an appointment nearly six months sooner.

“My old doctor didn’t help me. I didn’t trust him,” Moreno Ramirez said. “He was always too busy for me. I told my doctors, ‘Give me a chance.’”

Having taken his care into his own hands, he says he’s not in pain, his cough has subsided, and he feels hopeful for the future. “Now I feel good,” he said.

He has also sought more attention for his diabetes and received a continuous glucose monitor to measure his blood sugar. It’s better controlled now than it has been in decades, he said.

“You have to stand up for yourself and advocate,” said Joann Pacelo, the care manager who helped Moreno Ramirez change doctors, get quicker referrals to specialists, and get approved for in-home nursing visits.

“A lot of times it’s difficult with Medi-Cal because the doctors are busy and the reimbursements are so low, but no one should be denied the care they deserve.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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PERRY, Iowa — Fran Ruhl’s family received a startling letter from the Iowa Department of Human Services four weeks after she died in January 2022.

“Dear FAMILY OF FRANCES RUHL,” the letter began. “We have been informed of the death of the above person, and we wish to express our sincere condolences.”

The letter got right to the point: Iowa’s Medicaid program had spent $226,611.35 for Ruhl’s health care, and the government was entitled to recoup that money from her estate, including nearly any assets she owned or had a share in. If a spouse or disabled child survived Ruhl, the collection could be delayed until after their death, but the money would still be owed.

The notice said the family had 30 days to respond.

“I said, ‘What is this letter for? What is this?’” said Ruhl’s daughter, Jen Coghlan.

It seemed bogus, but it was real. Federal law requires all states to have “estate recovery programs,” which seek reimbursements for spending under Medicaid, the joint federal and state health insurance program for people with low incomes or disabilities. The recovery efforts collect more than $700 million a year, according to a 2021 report from the Medicaid and CHIP Payment and Access Commission, or MACPAC, an agency that advises Congress.

States have leeway to decide whom to bill and what type of assets to target. Some states collect very little. For example, Hawaii’s Medicaid estate recovery program collected just $31,000 in 2019, according to the federal report.

Iowa, whose population is about twice Hawaii’s, recovered more than $26 million that year, the report said.

Iowa uses a private contractor to recoup money spent on Medicaid coverage for any participant who was 55 or older or was a resident of a long-term care facility when they died. Even if an Iowan used few health services, the government can bill their estate for what Medicaid spent on premiums for coverage from private insurers known as managed-care organizations.

Supporters say the clawback efforts help ensure people with significant wealth don’t take advantage of Medicaid, a program that spends more than $700 billion a year nationally.

Critics say families with resources, including lawyers, often find ways to shield their assets years ahead of time — leaving other families to bear the brunt of estate recoveries. For many, the family home is the most valuable asset, and heirs wind up selling it to settle the Medicaid bill.

For the Ruhl family, that would be an 832-square-foot, steel-sided house that Fran Ruhl and her husband, Henry, bought in 1964. It’s in a modest neighborhood in Perry, a central Iowa town of 8,000 people. The county tax assessor estimates it’s worth $81,470.

Henry Ruhl, 83, wanted to leave the house to Coghlan, but since his wife was a joint owner, the Medicaid recovery program could claim half the value after his death.

Fran Ruhl, a retired child care worker, was diagnosed with Lewy body dementia, a debilitating brain disorder. Instead of placing her in a nursing home, the family cared for her at home. A case manager from the Area Agency on Aging suggested in 2014 they look into the state’s “Elderly Waiver” program to help pay expenses that weren’t covered by Medicare and Tricare, the military insurance Henry Ruhl earned during his Iowa National Guard career.

Coghlan still has paperwork the family filled out. The form said the application was for people who wanted to get “Title 19 or Medicaid,” but then listed “other programs within the Medical Assistance Program,” including Elderly Waiver, which the form explained “helps keep people at home and not in a nursing home.”

Coghlan said the family didn’t realize the program was an offshoot of Medicaid, and the paperwork in her file did not clearly explain the government might seek reimbursement for properly paid benefits.

Some of the Medicaid money went to Coghlan for helping care for her mother. She paid income taxes on those wages, and she said she likely would have declined to accept the money if she’d known the government would try to scoop it back after her mother died.

Iowa Medicaid Director Elizabeth Matney said that in recent years the state added clearer notices about the estate recovery program on forms people fill out when they apply for coverage.

“We do not like families or members being caught off guard,” she said in an interview. “I have a lot of sympathy for those people.”

Matney said her agency has considered changes to the estate recovery program, and she would not object if the federal government limited the practice. Iowa’s Medicaid estate collections topped $30 million in fiscal year 2022, but that represented a sliver of Medicaid spending in Iowa, which is over $6 billion a year. And more than half the money recouped goes back to the federal government, she said.

Matney noted families can apply for “hardship exemptions” to reduce or delay recovery of money from estates. For example, she said, “if doing any type of estate recovery would deny a family of basic necessities, like food, clothing, shelter, or medical care, we think about that.”

Sumo Group, a private company that runs Iowa’s estate recovery program, reported that 40 hardship requests were granted in fiscal 2022, and 15 were denied. The Des Moines company reported collecting money from 3,893 estates that year. Its director, Ben Chatman, declined to comment to KHN. Sumo Group is a subcontractor of a national company, Health Management Systems, which oversees Medicaid estate recoveries in several states. The national company declined to identify which states it serves or discuss its methods. Iowa pays the companies 11% of the proceeds from their estate recovery collections.

The 2021 federal advisory report urged Congress to bar states from collecting from families with meager assets, and to let states opt out of the effort altogether. “The program mainly recovers from estates of modest size, suggesting that individuals with greater means find ways to circumvent estate recovery and raising concerns about equity,” the report said.

U.S. Rep. Jan Schakowsky introduced a bill in 2022 that would end the programs.

The Illinois Democrat said many families are caught unawares by Medicaid estate recovery notices. Their loved ones qualified for Medicaid participation, not realizing it would wind up costing their families later. “It’s really a devastating outcome in many cases,” she said.

Schakowsky noted some states have tried to avoid the practice. West Virginia sued the federal government in an attempt to overturn the requirement that it collect against Medicaid recipients’ estates. That challenge failed.

Schakowsky’s bill had no Republican co-sponsors and did not make it out of committee. But she hopes the proposal can move ahead, since every member of Congress has constituents who could be affected: “I think this is the beginning of a very worthy and doable fight.”

States can limit their collection practices. For example, Massachusetts implemented changes in 2021 to exempt estates of $25,000 or less. That alone was expected to slash by half the number of targeted estates.

Massachusetts also made other changes, including allowing heirs to keep at least $50,000 of their inheritance if their incomes are less than 400% of the 2022 federal poverty level, or about $54,000 for a single person.

Prior to the changes, Massachusetts reported more than $83 million in Medicaid estate recoveries in 2019, more than any other state, according to the MACPAC report.

Supporters of estate recovery programs say they provide an important safeguard against misuse of Medicaid.

Mark Warshawsky, an economist for the conservative American Enterprise Institute, argues that other states should follow Iowa’s lead in aggressively recouping money from estates.

Warshawsky said many other states exclude assets that should be fair game for recovery, including tax-exempt retirement accounts, such as 401(k)s. Those accounts make up the bulk of many seniors’ assets, he said, and people should tap the balances to pay for health care before leaning on Medicaid.

Warshawsky said Medicaid is intended as a safety net for Americans who have little money. “It’s the absolute essence of the program,” he said. “Medicaid is welfare.”

People should not be able to shelter their wealth to qualify, he said. Instead, they should be encouraged to save for the possibility they’ll need long-term care, or to buy insurance to help cover the costs. Such insurance can be expensive and contain caveats that leave consumers unprotected, so most people decline to buy it. Warshawsky said that’s probably because people figure Medicaid will bail them out if need be.

Eric Einhart, a New York lawyer and board member of the National Academy of Elder Law Attorneys, said Medicaid is the only major government program that seeks reimbursement from estates for properly paid benefits.

Medicare, the giant federal health program for seniors, covers virtually everyone 65 or older, no matter how much money they have. It does not seek repayments from estates.

“There’s a discrimination against what I call ‘the wrong type of disease,’” Einhart said. Medicare could spend hundreds of thousands of dollars on hospital treatment for a person with serious heart problems or cancer, and no government representatives would try to recoup the money from the person’s estate. But people with other conditions, such as dementia, often need extended nursing home care, which Medicare won’t cover. Many such patients wind up on Medicaid, and their estates are billed.

On a recent afternoon, Henry Ruhl and his daughter sat at his kitchen table in Iowa, going over the paperwork and wondering how it would all turn out.

The family found some comfort in learning that the bill for Fran Ruhl’s Medicaid expenses will be deferred as long as her husband is alive. He won’t be kicked out of his house. And he knows his wife’s half of their assets won’t add up to anything near the $226,611.35 the government says it spent on her care.

“You can’t get — how do you say it?” he asked.

“Blood from a turnip,” his daughter replied.

“That’s right,” he said with a chuckle. “Blood from a turnip.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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A federal judge said this week that she will begin fining California potentially tens of thousands of dollars daily after more than 200 prison inmates killed themselves during eight years in which state corrections officials failed to complete court-ordered suicide prevention measures.

Addressing a chronic tragedy that has plagued the state for decades, Chief U.S. District Judge Kimberly Mueller said she will start the fines April 1 — $1,000 a day for each of 15 unmet safeguards until all the state’s 34 adult prisons are in full compliance.

At the same time, she will impose fines for the state’s failure to hire enough mental health professionals. And she set a hearing for August to collect more than $1.7 million in fines that have accumulated since 2017 under a previous order punishing delays in transferring inmates to state mental hospitals.

“The court is at a critical crossroads,” Mueller wrote weeks ahead of her order, which was made public Tuesday. She said inmates with serious mental disorders make up more than one-third of California’s prison population of about 96,000 and they have “waited far too long for constitutionally adequate mental health care.”

State officials said they will review the judge’s orders. California Department of Corrections and Rehabilitation spokesperson Vicky Waters said in a statement that “suicide prevention is a very important issue for us.”

In court filings, state officials objected to Mueller’s setting “an unworkable, all but impossible standard.” They pointed to lower suicide rates each of the last two years, after two decades of California consistently exceeding the national suicide rate for state prison systems. The 15 suicides in 2021 were the fewest in two decades and half the annual average over that period. Attorneys representing inmates say there were 19 deaths by suicide last year, though the official report isn’t out yet.

Those recent lower suicide rates are “significant improvements and absolute evidence of success,” Paul Mello, an attorney representing the state, told Mueller at a Feb. 10 hearing. A court-appointed suicide prevention expert, Lindsay Hayes, said the reasons for the sudden drop are unclear and the effect of the coronavirus pandemic will need to be analyzed.

Suicides in California prisons have long been seen as a key indicator that the prison system isn’t providing adequate mental health care. Mueller’s predecessor ruled in the class-action lawsuit 27 years ago that California was providing unconstitutionally poor mental health care to inmates. Yet federal judges have struggled to force improvements despite repeated orders in the case.

This time, Mueller is acting after Hayes found that the department still is failing to meet the standards despite an order dating to 2015. The safeguards include things like suicide prevention training, suicide risk evaluations, suicide-resistant cells, and checking on vulnerable inmates every 30 minutes, and often more frequently, to make sure they aren’t harming themselves.

“They’re very standard for prisons and jails around the country, and they’re not doing them,” said Michael Bien, one of the attorneys representing inmates.

Among those who corrections officials say killed themselves is 31-year-old John Pantoja. He died by hanging in June, using a ligature torn from a bedsheet, according to the Sacramento County coroner.

Pantoja was a funny, loving, caring, healthy, athletic young man until he went into California’s juvenile justice system at age 16, his sister and father told KHN in an interview Tuesday.

He emerged a changed man five years later, they said.

“He came out with his mental state just totally depleted,” with multiple mental health diagnoses, including schizophrenia, and exhibiting mood swings consistent with bipolar disorder, Elizabeth Pantoja said. “Prior to going in, we didn’t see those signs. … That was opposite of how we knew him.”

Within a few months of his release from juvenile lockup, he engaged in a robbery and shootout with Chula Vista police in 2012. His defense at the time was that he had been attempting “suicide by cop,” enticing an officer to kill him. Once in prison, Amado Pantoja said, John heard voices he blamed on the mental health medications he was prescribed. Amado and Elizabeth said John seemed to be looking forward to a birthday visit from his family and a 2026 parole hearing based on his young age at the time of his crime.

His mental health really deteriorated in the last five years, when he was repeatedly put in solitary confinement and cut off from family visits during the pandemic, they said. More recently, the television he treated like a form of therapy had been broken, although his family was sending him a new one, and he’d seen medical workers with complaints of chronic pain.

He died the next day with a half-dozen drugs in his system, including medications for depression, pain, and seizures.

In a report of prisoner suicides between January 2020 and April 2022, Hayes frequently detailed missed opportunities to prevent deaths:

• An inmate at a Sacramento County maximum security prison killed himself with punctures to his neck on Christmas Eve 2020, hours after he was seen drinking liquid cleanser in his cell. Correctional officers said he also “had been acting irrationally, stressed out, pacing back and forth, crying, distressed after a series of telephone calls with his family.” A crisis counselor talked to him at his cell door because he refused to come out, but he denied he intended to kill himself. The counselor asked no further questions, citing a lack of privacy, and the inmate killed himself several hours later.
• An inmate at the state prison in Tehachapi was found hanging from a ventilation grate by a sheet in his cell on Jan. 5, 2020. He had a years-long history of cutting his wrists and other self-destructive behavior, including repeatedly in the two days before his death. A counselor decided hours before his suicide that he wasn’t serious. But a subsequent review found his self-harm — along with his “bizarre statements and increased paranoid delusions” — should have been enough warning. He left behind a note indicating he feared other inmates were plotting his murder.
• A prisoner was found hanging by a sheet in his cell in the substance abuse treatment facility in Corcoran the day before Thanksgiving 2021. His 11 years in prison were spent mostly in mental health programs for repeatedly cutting himself and hallucinations of voices saying people were trying to kill him. A medical chart entry that he’d been seen by a counselor the day he died “was falsified by the clinician.” A department review found “a concerning pattern” of mental health providers saying they would offer him interventions but never providing them.

Mueller, who had signaled for weeks that she would impose daily fines, said during the February hearing that they were needed to “ensure that the recommendations are implemented” after the state missed repeated deadlines to comply with nearly half the court-ordered safeguards.

“The court finds further delay in the defendants’ full implementation of the required suicide prevention measures is unacceptable,” Mueller wrote in her latest order.

Mueller also ordered fines for each unfilled position exceeding a 10% vacancy rate in the required number of mental health professionals needed to care for inmates with serious mental disorders. Those fines will be based on the maximum salary for each job, including some that top out at or near $300,000 per year, and Mueller said she would schedule a hearing to find the state in contempt and order payment if the fines accumulate for three consecutive months.

The state has been out of compliance on filling the vacancies for more than four years, Mueller said, noting that more than 400 positions are vacant statewide.

Mueller imposed $1,000-a-day fines in 2017 in an attempt to end a chronic backlog in sending inmates to state mental facilities. She has never collected the money — but now she has set the August hearing to do so.

Under her current order, the fines will similarly keep accumulating as long as Hayes determines the state isn’t complying. Once his review is complete — a process that previously has taken many months — Mueller said she would schedule a hearing on the payment of fines.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).