Samantha Young, Author at KFF Health News

As Foundation for ‘Excited Delirium’ Diagnosis Cracks, Fallout Spreads

Renuka Rayasam and Markian Hawryluk and Samantha Young — Wed, 13 Dec 2023 10:00:00 +0000

When Angelo Quinto’s family learned that officials blamed his 2020 death on “excited delirium,” a term they had never heard before, they couldn’t believe it. To them, it was obvious the science behind the diagnosis wasn’t real.

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Gun Violence Is a Plague. Could Medicaid Help?

Samantha Young — Tue, 12 Dec 2023 14:17:46 +0000

To tackle America’s gun problem, a growing number of states are allowing Medicaid dollars to fund community-based violence programs intended to stop shootings. The idea is to boost resources for violence prevention programs, which have been overwhelmed in some cities by a spike in violent crime since the covid-19 pandemic.

An infusion of reliable funding, their advocates say, could allow these nonprofits to expand their reach to more residents most at risk of being shot — or of shooting someone. That’s the plan in Chicago, where Arne Duncan, the former U.S. education secretary, leads the violence prevention group Chicago CRED.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

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“We’re trying to build a public health infrastructure to combat gun violence,” Duncan told me. “Having Medicaid start to be a player in this space and create those opportunities could be a game changer.”

In 2020, many cities around the country confronted a rise in shootings and homicides after officials responding to the pandemic shut down schools, businesses and critical social services. That same year, police murdered George Floyd, a Black man in Minneapolis, sparking nationwide protests and calls to cut police funding. Americans, already armed to the hilt, rushed to buy more guns.

While the pandemic has receded, gun violence has surged in some cities. Gun ownership is at a historic high in the United States, which is estimated to have more guns than people. Programs that worked a few years ago in places like Oakland, Calif. — which had won acclaim for slashing its gun violence — can’t keep up.

Gun violence also brings a hefty price tag. Studies from the Government Accountability Office and Harvard Medical School have shown that the cost of caring for gunshot survivors ranges from $1 billion in initial treatments to $2.5 billion over 12 months. And it’s not only gunshot victims who need medical help.

“The patients that we see, there’s a lot of grief. Parents losing their children, grandparents losing their grandchildren. That impacts people’s health tremendously,” said Noha Aboelata, founding CEO of Roots Community Health Center in Oakland. “Entire neighborhoods have ongoing stress and trauma.”

Exactly how taxpayer dollars should be spent is up for debate, as I discovered in Oakland. Although there’s a growing call to spend money on violence prevention programs, some believe the answer is more police.

With gun-control legislation stalled in Congress, the Biden administration has opened up federal Medicaid dollars to violence prevention. President Biden announced the novel approach in April 2021, and now the money is starting to flow to interested states.

“These are concrete things that we can do that avoid the debates around the Second Amendment,” said Kyle Fischer, policy and advocacy director for The Health Alliance for Violence Intervention, which lobbied for the policy change.

But the process to unlock the funding has been lengthy, and it’s unclear how much money will ultimately be spent on these programs. Because Medicaid is a state-federal program intended to provide health care for low-income residents, states must also approve spending the money on violence prevention. So far, only California, Colorado, Connecticut, Illinois, Maryland, New York and Oregon have passed laws, Fischer said.

In Illinois, which two years ago became the first state to approve Medicaid reimbursement for violence prevention, Chicago CRED hopes to get approval for its program next spring.

Despite the long and often bureaucratic process, Medicaid dollars are incredibly attractive for community organizations that have historically relied on philanthropic donations and grants, which can vary year to year.

“Medicaid is reliable,” Fischer said. “If you’re doing the work, you’re qualified for it, and you are taking care of patients. You get reimbursed for the work that you do.”

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

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‘Everybody in This Community Has a Gun’: How Oakland Lost Its Grip on Gun Violence

Samantha Young — Tue, 28 Nov 2023 10:00:00 +0000

OAKLAND, Calif. — The red-tipped bullet pierces skin and melts into it, Javier Velasquez Lopez explains. The green-tipped bullet penetrates armored vests. And the hollow-tipped bullet expands as it tears through bodies.

At 19, Velasquez Lopez knows a lot about ammunition because many of his friends own guns, he said. They carry to defend themselves in East Oakland, where metal bars protect shop windows and churches stand behind tall, chain-link fences.

Some people even hide AR-15-style assault weapons down their pants legs, he said.

“It doesn’t feel safe. Wherever you’re at, you’re always anxious,” said Velasquez Lopez, who dreams of leaving the city where he was born. “You’re always wondering what’s going to happen.”

Last year, two gunmen in ski masks stormed his high school, killing a school district carpenter and injuring five other adults, including two students.

Oakland won acclaim just a few years ago as a national model for gun violence prevention, in part by bringing police and community groups together to target the small number of people suspected of driving the gun violence.

Then, in 2020, the covid-19 pandemic shut down schools, businesses, and critical social services nationwide, leaving many low-income people isolated and desperate — facing the loss of their jobs, homes, or both. The same year, police murdered George Floyd, a Black man in Minneapolis, which released pent-up fury over racial discrimination by law enforcement, education, and other institutions — sparking nationwide protests and calls to cut police funding.

In the midst of this racial reckoning and facing the threats of an unknown and deadly virus, Americans bought even more guns, forcing some cities, such as Raleigh, North Carolina; Chicago; New York City; and Oakland, to confront a new wave of violent crime.

“There was emotional damage. There was physical damage,” said James Jackson, CEO of Alameda Health System, whose Wilma Chan Highland Hospital Campus, a regional trauma center in Oakland, treated 502 gunshot victims last year, compared with 283 in 2019. “And I think some of this violence that we’re seeing is a manifestation of the damage that people experienced.”

Jackson is among a growing chorus of health experts who describe gun violence as a public health crisis that disproportionately affects Black and Hispanic residents in poor neighborhoods, the very people who disproportionately struggle with Type 2 diabetes and other preventable health conditions. Covid further eviscerated these communities, Jackson added.

While the pandemic has retreated, gun violence has not. Oaklanders, many of whom take pride in the ethnic diversity of their city, are overwhelmingly upset about the rise in violent crime — the shootings, thefts, and other street crimes. At town halls, City Council meetings, and protests, a broad cross-section of residents say they no longer feel safe.

Programs that worked a few years ago don’t seem to be making a dent now. City leaders are spending millions to hire more police officers and fund dozens of community initiatives, such as placing violence prevention teams at high schools to steer kids away from guns and crime.

Yet gun ownership in America is at a historic high, even in California, which gun control advocates say has the strictest gun laws in the country. More than 1 million Californians bought a gun during the first year of the pandemic, according to the latest data from the state attorney general.

As Alameda County District Attorney Pamela Price told an audience at a September town hall in East Oakland: “We are in a unique, crazy time where everybody in this community has a gun.”

The Streets of Oakland

Oakland’s flatlands southeast of downtown are the backdrop of most of the city’s shootings and murders.

The area stands in stark contrast to the extreme wealth of the millionaire homes that dot the Oakland Hills and the immaculate, flower-lined streets of downtown. The city’s revived waterfront, named after famed author and local hero Jack London, draws tourists to trendy restaurants.

On a Saturday night in August, Shawn Upshaw drove through the flatlands along International Boulevard, past the prostitutes who gather on nearly every corner for at least a mile, and into “hot spots,” where someone is shot nearly every weekend, he said.

“When I grew up, women and kids would get a pass. They wouldn’t get caught in the crossfire,” said Upshaw, 52, who was born and raised in Oakland. “But now women and kids get it, too.”

Upshaw works as a violence interrupter for the city’s Department of Violence Prevention, which coordinates with the police department and community organizations in a program called Ceasefire.

When there’s a shooting, the police department alerts Upshaw on his phone and he heads to the scene. He doesn’t wear a police uniform. He’s a civilian in street clothes: jeans and a black zip-up jacket. It makes him more approachable, he said, and he’s not there to place blame, but rather to offer help and services to survivors and bystanders.

The goal, he said, is to stop a retaliatory shooting by a rival gang or grieving family member.

Police also use crime data to approach people with gang affiliations or long criminal records who are likely to use a gun in a crime — or be shot. Community groups follow up with offers of job training, education, meals, and more.

“We tell them they’re on our radar and try to get them to recognize there are alternatives to street violence,” said Oakland Police Department Capt. Trevelyon Jones, head of Ceasefire. “We give them a safe way of backing out of a conflict while maintaining their street honor.”

Every Thursday at police headquarters, officers convene a “shooting review.” They team up with representatives from community groups to make house calls to victims and their relatives.

After the program launched in 2012, Oakland’s homicides plummeted and were down 39% in 2019, according to a report commissioned by the Oakland Police Department.

Then covid hit.

“You had primary care that became an issue. You had housing that became an issue. You had employment that became an issue,” said Maury Nation, an associate professor at Vanderbilt University. “It created a surplus of the people who fit that highest risk group, and that overwhelms something like Ceasefire.”

With ever-rising housing prices in Oakland and across California, homeless encampments have multiplied on sidewalks and under freeway bypasses. The city is also bracing for the loss of jobs and civic pride if the Oakland Athletics baseball team relocates after April 2024, following departures by the NBA’s Golden State Warriors in 2019 and the NFL’s Raiders in 2020.

“Housing, food insecurity, not having jobs that pay wages for folks, all can lead to violence and mental health issues,” said Sabrina Valadez-Rios, who works at the Freedom Community Clinic in Oakland and teaches a high school class for students who have experienced gun violence. Her father was fatally shot outside their Oakland home when she was a child. “We need to teach kids how to deal with trauma. Violence is not going to stop in Oakland.”

Shared with permission from The Trace.

Homicides in Oakland climbed to 123 people in 2021, police reports show, dipping slightly to 120 last year. Police have tallied 108 homicides as of Nov. 12 this year. Neither the police department nor the city provided statistics on how many of those killings involved firearms, despite repeated requests from KFF Health News.

Experts also blame the rise in killings in Oakland and other American cities on the prevalence of gun ownership in the U.S., which has more guns than people. For all the pandemic disruption worldwide, homicide rates didn’t go up in countries with strict gun laws, said Thomas Abt, director of the Center for the Study and Practice of Violence Reduction at the University of Maryland.

“We saw gun violence, homicides, shootings spike up all around the country. And interestingly, it did not happen internationally,” Abt said. “The pandemic did not lead to more violence in other nations.”

Unrest in Oakland

Oakland residents are angry. One by one, business owners, community organizers, church leaders, and teenagers have stood at town halls and City Council meetings this year with an alarming message: They no longer feel safe anywhere in their city — at any time.

“It’s not just a small number of people in the evening or nighttime. This is all hours, day and night,” said Noha Aboelata, founder of the Roots Community Health Center in Oakland. “Someone’s over here pushing a stroller and someone’s getting shot right next to them.”

One morning in early April, automatic gunfire erupted outside a Roots clinic. Patients and staff members dropped to the ground and took cover. After the shooting stopped, medical assistants and a doctor gave first aid to a man in his 20s who had been shot six times.

Everyone is blaming someone or something else for the bloodshed.

Business owners have had enough. In September, Target announced it would close nine stores in four states, including in Oakland because of organized retail theft; the famed Vietnamese restaurant Le Cheval shut its doors after 38 years, partly blaming car break-ins and other criminal activity for depressing its business; and more than 200 business owners staged an hours-long strike to protest the rise in crime.

The leadership of the local NAACP, the nation’s oldest civil rights organization, made headlines this summer when it said Oakland was seeing a “heyday” for criminals, and pointed to the area’s “failed leadership” and “movement to defund the police.”

“It feels like there’s a dark cloud over Oakland,” said Cynthia Adams, head of the local chapter, which has called on the city to hire 250 more police officers.

Price, a progressive elected last year, already faces a recall effort, in part because she rejects blanket enhanced sentences for gangs and weapons charges, and has declined to charge youths as adults.

The new mayor, Sheng Thao, was criticized for firing the police chief for misconduct and breaking a campaign promise to double funding at the city’s Department of Violence Prevention. In her first State of the City address last month, Thao described the surge in crime as “totally and completely unacceptable,” and acknowledged that Oaklanders are hurting and scared. She said the city has expanded police foot patrols and funded six new police academies, as well as boosted funding for violence prevention and affordable housing.

“Not a day goes by where I don’t wish I could just wave a magic wand and silence the gunfire,” Thao said.

Many in the community, including Valadez-Rios, advocate for broader investment in Oakland’s poorest neighborhoods over more law enforcement.

City councils, states, and the federal government are putting their faith in violence prevention programs, in some cases bankrolling them from nontraditional sources, such as the state-federal Medicaid health insurance program for low-income people.

Last month, California’s Democratic Gov. Gavin Newsom approved an 11% state tax on guns and ammunition, and $75 million of the revenue annually is expected to go to violence prevention programs.

Although these programs are growing in popularity, it is unclear how successful they are. In some cases, proven programs that involve law enforcement, such as Ceasefire, were cut back or shelved after George Floyd was murdered, said Abt, the Maryland researcher.

“The intense opposition to law enforcement means that the city was unwilling to use a portion of the tools that have been proven,” Abt said. “It’s good to work on preventing youth violence, but the vast majority of serious violence is perpetrated by adults.”

Not a day goes by where I don’t wish I could just wave a magic wand and silence the gunfire.
Oakland Mayor Sheng Thao

A Focus on Schools

Kentrell Killens, interim chief at the Oakland Department of Violence Prevention, acknowledges that young adults drive Oakland’s gun violence, not high school kids. But, he said, shootings on the streets affect children. Of the 171 homicides in 2019 and 2020, 4% of victims were 17 or under, while 59% were ages 18 to 34, according to the Oakland Police Department.

The number of children injured in nonfatal shootings is also worrisome, he said. Roughly 6% of victims and 14% of suspects in nonfatal shootings were 17 or younger in 2019 and 2020.

“We’ve seen the impact of violence on young people and how they have to make decisions around what roles they want to play,” said Killens, who spent a decade as a case manager working with schoolkids.

By being in the schools, “we can deal with the conflicts” that could spill into the community, he added.

At Fremont High School, Principal Nidya Baez has welcomed a three-person team to her campus to confront gun violence. One caseworker focuses on gun violence and another on sexual assaults and healthy relationships. The third is a social worker who connects students and their families to services.

They are part of a $2 million city pilot program created after the Oakland School Board eliminated school-based police in 2020 — about one month after George Floyd was killed and after a nine-year push by community activists to kick police out of schools.

“We’ve been at a lot of funerals, unfortunately, for gang-related stuff or targeting of kids, wrong-place-wrong-time kind of thing,” said Baez, whose father was shot and injured on his ice cream truck when she was a child.

When Francisco “Cisco” Cisneros, a violence interrupter from the nonprofit group Communities United for Restorative Youth Justice, arrived at Fremont in January, students were wary, he said. Many still are. Students are hard-wired not to share information — not to be a “snitch” — or open up about themselves or their home life, especially to an adult, Cisneros said. And they don’t want to talk to fellow students from another network, group, or gang.

“If we catch them at an early age, right now, we can change that mindset,” said Cisneros, who was born and raised in Oakland.

Cisneros pulls from his past to build a rapport with students. This summer, for example, when he overheard a student chatting on the phone to an uncle in jail, Cisneros asked about him. It turns out Cisneros and the boy’s uncle had grown up in the same neighborhood.

That was enough to begin a relationship between Cisneros and the student, “J,” who declined to be identified by his full name for fear of retribution. The 16-year-old credits Cisneros, whom he describes as “like a dad,” with keeping him engaged in school and employed with summer jobs — away from trouble. Still, he regularly worries about making a wrong move.

“You could do one thing and you could end up in a situation where your life is at risk,” J said in Cisneros’ office. “You go from being in school one day to being in a very bad, sticky situation.”

The program is underway in seven high schools, and Cisneros believes he has helped prevent a handful of conflicts from escalating into gun violence.

A Better Life

After his school counselor was shot at Rudsdale High School in September 2022, Velasquez Lopez heard that the man and other victims were treated at nearby Highland Hospital.

“Seeing him get hurt, he obviously needed medical attention,” Velasquez Lopez said. “That made it obvious I could help my community if I were to be a nurse to help people that live around my area.”

When a recruiter from the Alameda Health System came to campus to promote a six-week internship at Highland Hospital, Velasquez Lopez applied. It was, he said, a dramatic step for a student who had never cared about school or sought vocational training.

Over the summer, he volunteered in the emergency room, learned how to take a patient’s vitals, watched blood transfusions, and translated for Spanish-speaking patients.

Velasquez Lopez, who graduated this year, is now looking for ways to get a nursing degree. The cost of college is out of reach at the moment, but he knows he doesn’t want to stay in a city where you can easily buy a gun for $1,000 — or half that, if it’s been used in a crime.

Velasquez Lopez said he has bigger goals for himself.

Young people in East Oakland “always feel like we’re trapped in that community, and we can’t get out,” he said. “But I feel like we still have a chance to change our lives.”

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

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California prohíbe el controversial diagnóstico de “delirio excitado”

Samantha Young — Thu, 12 Oct 2023 21:00:00 +0000

SACRAMENTO, California — California es el primer estado en prohibir el diagnóstico de síndrome de “delirio excitado”. La decisión, dijo un activista de derechos humanos, representa un “momento decisivo” que hará que sea más difícil para la policía justificar el uso de fuerza excesiva.

El gobernador demócrata Gavin Newsom firmó un proyecto de ley el 8 de octubre para prohibir que los forenses, doctores, y examinadores médicos incluyeran el síndrome de “delirio excitado” (o agitado) en certificados de defunción o informes de autopsias.

Las autoridades no podrán utilizar el término para describir el comportamiento de una persona en sus informes, y en tribunales civiles no se permitirán testimonios que se refieran al síndrome. La ley entrará en vigencia en enero.

El término “delirio excitado” ha existido durante décadas, pero se ha estado utilizando cada vez más en los últimos 15 años para explicar casos de muerte súbita en personas bajo custodia policial que experimentan una gran agitación física y mental. El diagnóstico se ha citado como defensa legal en las muertes de George Floyd en 2020 en Minneapolis; Daniel Prude en Rochester, Nueva York; y Angelo Quinto en Antioch, California, entre otros.

“Este es un momento decisivo en California y en todo el país”, dijo Joanna Naples-Mitchell, abogada para la organización Physicians for Human Rights, con sede en Nueva York, y coautora de un informe de 2022 sobre el uso del diagnóstico.

“En una demanda de muerte por negligencia, la mención del síndrome de delirio agitado es un gran obstáculo para que la familia obtenga justicia si la víctima fue asesinada por la policía”, dijo Naples-Mitchell. “Ahora les resultará básicamente imposible dar testimonios sobre el síndrome en California”.

Aunque la nueva ley convierte a California en el primer estado que ya no reconoce el síndrome de “delirio excitado” como diagnóstico médico, varias asociaciones médicas nacionales ya lo habían desacreditado.

Desde 2020, tanto la Asociación Médica Estadounidense como la Asociación Americana de Psiquiatría han refutado la validez del síndrome como afección médica, señalando que el término se ha utilizado desproporcionadamente para hablar de hombres negros bajo custodia policial.

Este año, la Asociación Nacional de Examinadores Médicos rechazó el diagnóstico de delirio excitado como causa de muerte, y se espera que el Colegio Americano de Médicos de Emergencias vote este mes sobre el tema.

En 2009, la organización publicó un documento en el cual apoya el diagnóstico de “delirio excitado”, argumentando que las personas que están sufriendo una crisis mental, a menudo bajo los efectos de drogas o alcohol, pueden presentar una fuerza sobrehumana cuando la policía trata de controlarlos, y luego morir a causa de este síndrome.

En el caso de Quinto, su madre, Cassandra Quinto-Collins, había llamado a la policía de Antioch dos días antes de Navidad porque su hijo estaba pasando por una crisis de salud mental. Dijo que cuando llegaron, ella ya lo había tranquilizado, pero aún así la policía mantuvo a su hijo de 30 años en el suelo hasta que se desmayó.

En un video desgarrador tomado por Quinto-Collins, que se transmitió en todo el país después de su muerte, ella le preguntaba a la policía qué estaba pasando, mientras su hijo yacía en el suelo inconsciente, con las manos esposadas a la espalda. Angelo Quinto murió tres días después en el hospital.

La oficina forense del condado de Contra Costa, parte del departamento del sheriff, atribuyó la muerte de Quinto al “delirio excitado”. La familia Quinto presentó una demanda por muerte por negligencia contra el condado y busca cambiar la causa de muerte en su certificado de defunción.

Quinto-Collins también testificó a favor del proyecto de ley AB 360, presentado por el asambleísta estatal demócrata Mike Gipson. El proyecto fue aprobado por la legislatura con apoyo bipartidista. Ninguna organización se opuso formalmente a la medida, ni siquiera la Asociación de Jefes de Policía de California, cuyo director ejecutivo se negó a hacer comentarios.

“Hay mucho más trabajo por hacer, pero esto pone en evidencia la corrupción y las cosas que hemos permitido que sucedan ante nuestras narices”, dijo Robert Collins, el padrastro de Quinto. “El hecho de que California haya prohibido el diagnóstico es realmente revelador”.

Parte del problema con el diagnóstico de síndrome de “delirio excitado” es que el delirio es un síntoma de una afección subyacente, dicen los profesionales médicos. Por ejemplo, el delirio puede ser un síntoma de la vejez, de la hospitalización, de una cirugía importante, de la adicción, de medicamentos o de infecciones, dijo Sarah Slocum, psiquiatra de Exeter, New Hampshire, y coautora de una revisión sobre el delirio agitado publicada en 2022.

“No pondríamos ‘fiebre’ simplemente en un certificado de defunción”, dijo Slocum. “Por lo tanto, es difícil identificar ‘delirio agitado’ como causa de muerte cuando hay algo subyacente que lo impulsa”.

En California, algunas entidades ya habían restringido el uso del término, como el Departamento de Policía del Transporte Rápido de Bay Area, que prohíbe hablar de “delirio excitado” en sus informes escritos y en su manual.

Pero estos cambios confrontan décadas de condicionamiento entre las fuerzas del orden y el personal médico de emergencia, a quienes se les ha enseñado que el “delirio excitado” es real y se les ha capacitado sobre cómo actuar cuando sospechan que una persona lo padece.

“Tiene que haber un entrenamiento nuevo y sistemático”, dijo Abdul Nasser Rad, director de investigación y datos de Campaign Zero, un grupo sin fines de lucro enfocado en la reforma de la justicia penal que ayudó a redactar la ley de California. “Existe una verdadera preocupación sobre cómo se está capacitando a la policía y a los profesionales de emergencias sobre este tema”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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California Bans Controversial ‘Excited Delirium’ Diagnosis

Samantha Young — Thu, 12 Oct 2023 09:00:00 +0000

SACRAMENTO, Calif. — California is the first state to ban doctors and medical examiners from attributing deaths to the controversial diagnosis known as “excited delirium,” which a human rights activist hailed as a “watershed moment” that could make it harder for police to justify excessive force.

Democratic Gov. Gavin Newsom signed a bill Oct. 8 to prohibit coroners, medical examiners, physicians, or physician assistants from listing excited delirium on a person’s death certificate or in an autopsy report. Law enforcement won’t be allowed to use the term to describe a person’s behavior in any incident report, and testimony that refers to excited delirium won’t be allowed in civil court. The law takes effect in January.

The term excited delirium has been around for decades but has been used increasingly over the past 15 years to explain how a person experiencing severe agitation can die suddenly through no fault of the police. It was cited as a legal defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California, among others.

“This is a watershed moment in California and nationwide,” said Joanna Naples-Mitchell, a lawyer with the New York-based Physicians for Human Rights, who co-authored a 2022 report on the use of the diagnosis.

“In a wrongful death lawsuit, if excited delirium comes up, it’s a big hurdle for a family getting justice if their family member was actually killed by police,” Naples-Mitchell said. “So, now it will be basically impossible for them to offer testimony on excited delirium in California.”

Even though the new law makes California the first state to no longer recognize excited delirium as a medical diagnosis, several national medical associations already discredited it. Since 2020, the American Medical Association and the American Psychiatric Association have rejected excited delirium as a medical condition, noting the term has disproportionately applied to Black men in law enforcement custody. This year, the National Association of Medical Examiners rejected excited delirium as a cause of death, and the American College of Emergency Physicians is expected to vote this month on whether to formally disavow its 2009 position paper supporting excited delirium as a diagnosis. That white paper proposed individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die from the condition.

In the case of Quinto, his mother, Cassandra Quinto-Collins, had called Antioch police two days before Christmas because her son was experiencing a mental health crisis. She had subdued him by the time they arrived, she said, but officers held her 30-year-old son to the ground until he passed out.

In a harrowing home video taken by Quinto-Collins, which was broadcast nationally after his death, she asked police what happened as her son lay on the floor unconscious, hands behind his back in handcuffs. He died three days later in the hospital.

The Contra Costa County coroner’s office, part of the sheriff’s department, blamed Quinto’s death on excited delirium. The Quinto family has filed a wrongful death lawsuit against the county and is seeking to change the cause of death on his death certificate.

Quinto-Collins also testified in favor of the bill, AB 360, introduced by state Assembly member Mike Gipson, a Democrat. It sailed through the legislature with bipartisan support. No organization formally opposed the measure, including the California Police Chiefs Association, whose executive director declined to comment this week.

“There’s a lot more work to be done, but it is a unique window into some of the corruption, some of the things that we’ve allowed to happen under our noses,” said Robert Collins, Quinto’s stepfather. “I think it’s really telling that California is ending it.”

Part of the problem with an excited delirium diagnosis is that delirium is a symptom of an underlying condition, medical professionals say. For example, delirium can be caused by old age, hospitalization, a major surgery, substance use, medication, or infections, said Sarah Slocum, a psychiatrist in Exeter, New Hampshire, who co-authored a review of excited delirium published in 2022.

“You wouldn’t just put ‘fever’ on someone’s death certificate,” Slocum said. “So, it’s difficult to then just put ‘excited delirium’ on there as a cause of death when there is something that’s underlying and driving it.”

In California, some entities already had restricted the use of excited delirium, such as the Bay Area Rapid Transit Police Department, which prohibits the term in its written reports and policy manual.

But these changes confront decades of conditioning among law enforcement and emergency medical personnel who have been taught that excited delirium is real and trained how to handle someone suspected of having it.

“There needs to be a systematic retraining,” said Abdul Nasser Rad, managing director of research and data at Campaign Zero, a nonprofit group that focuses on criminal justice reform and helped draft the California law. “There’s real worry about just how officers are being trained, how EMS is being trained on the issue.”

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

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Feds Say Hospitals That Redistribute Medicaid Money Violate Law

Samantha Young — Wed, 16 Aug 2023 09:00:00 +0000

The Biden administration wants to crack down on private arrangements among some hospitals to reimburse themselves for taxes that help fund coverage for low-income people. It contends the practice violates federal law.

Federal regulators say these arrangements “appear designed to” redirect Medicaid dollars away from facilities that treat the poorest patients to those that “provide fewer, or even no, Medicaid-covered services,” according to a proposed enforcement plan released May 3 by the Centers for Medicare & Medicaid Services.

The practice is typically orchestrated by the lobbying groups that represent hospitals in state capitals — and is often kept secret. Not even federal regulators know how widespread it is, although programs operate in at least a few states, including California and Missouri. It’s also the subject of a Texas lawsuit that could block the federal government’s proposal.

“It does seem like these associations are finding a way to distribute the money in a really weird way,” said Joshua Gordon, the director of health policy for the Committee for a Responsible Federal Budget in Washington, D.C. “But without the transparency, we don’t exactly know what’s going on.”

Previous efforts to block these payback arrangements have gone nowhere in the face of opposition from the powerful health care industry and state health officials who fear that clamping down could result in less money for Medicaid, the joint state-federal health insurance program for low-income people. Several Medicaid experts predicted the latest proposal could meet the same fate, or face immediate court challenges if adopted.

The federal government’s sweeping and contentious proposal would require states to police hospitals, nursing homes, and other health care providers to ensure they made no private agreements to redistribute Medicaid dollars.

Public and private hospitals argue CMS has no jurisdiction to regulate private transactions and has overstepped its legal authority. Together with state health officials from around the country, they warn the move could strip billions of federal dollars from Medicaid and threaten safety-net coverage for 94 million low-income people. Texas alone could lose $6 billion a year, according to Texas Health and Human Services.

KFF Health News attempted to interview state health leaders and hospital association officials around the country, but they declined to comment or did not respond to repeated calls and emails.

The federal government’s proposal is part of a broader Medicaid financing package, and it resurrects a long-standing effort by administrations of both parties over the years to rein in Medicaid spending — which ballooned to $734 billion in 2021.

In this case, regulators are targeting what are known as provider taxes, which states are increasingly imposing on hospitals, nursing homes, and other health care providers to help states pay for their share of the Medicaid program. The more provider taxes states levy, the more money they can also get in federal funding.

These taxes are a critical source of revenue that all states except Alaska rely on for their Medicaid programs — and to get federal matching Medicaid dollars. They account for 17% of state Medicaid funding in 2018, according to a 2020 report by the Government Accountability Office, which called for more transparency in how the money is collected and spent.

In California, hospitals have redistributed provider tax funds since 2009. Here’s how it works: Hospitals with a significant share of low-income patients get more Medicaid funding back than they pay in the tax, so they donate a small portion of their Medicaid funding to a charity run by the leadership of the California Hospital Association, a statewide lobbying organization. The charity awards grants to the hospitals that treat a smaller share of low-income patients and don’t receive as much funding back as they paid in taxes.

For instance, Cedars-Sinai in Los Angeles, one of the country’s richest hospitals, paid nearly $172 million in provider taxes in 2022, eclipsing the $151 million it got back in Medicaid dollars. Then, it received nearly $28 million from the hospital association’s charity — earning about $6.9 million from the program, the hospital’s audited financial statements show.

Meanwhile, faith-based Adventist Health, which serves a larger share of poor people and operates roughly two dozen hospitals in California, Oregon, and Hawaii, paid $148 million in taxes in 2022 and reaped $401 million in Medicaid dollars through the program, according to its independently audited financial statements. It then contributed $3 million of that Medicaid money to the charity.

Federal law sets stringent rules for provider taxes: They must be broad-based and apply to all providers within a certain category, like hospitals; providers within a state must be taxed at the same rate; and taxes can’t be returned directly or indirectly to providers as part of a “hold harmless” agreement.

It’s that last clause that has spurred the feds to act.

Regulators say some health care providers, to gain the needed support within their ranks for the tax, are moving the tax money — and the federal revenue it draws to states — among themselves.

“We believe providers with relatively higher Medicaid volume agree to redistribute some of their Medicaid payments to ensure broad support for the tax program,” they wrote in their proposal.

These agreements “undermine the fiscal integrity” of the Medicaid program, they wrote.

It’s unclear how widespread such agreements are because hospitals don’t make them public. CMS said it has identified “instances” of Medicaid redistribution payments, but spokesperson Greg Myers declined to elaborate.

Jonathan Williams, vice president of government affairs at Sutter Health, which operates about 20 hospitals across Northern California, argued in a June 30 letter to the federal agency that these arrangements help hospitals expand “care networks and afford necessary incentives to ensure that providers can continue caring for Medicaid beneficiaries with unique and specific care needs.”

Missouri’s hospital association also runs a “pooling arrangement,” in which hospitals that get more Medicaid money than they paid in taxes can donate funds to the hospitals that didn’t.

“Missouri providers have had various private agreements to redistribute funds among themselves for decades, with the full knowledge and approval of CMS,” according to an unsigned and undated letter to the agency from the MO HealthNet Division, which runs the state’s Medicaid program.

In 2002, Missouri got federal approval for its redistribution program by pledging to use the funds for Medicaid services, whereas California has not received approval.

The federal government’s plan would require states to get health care providers to attest that they don’t participate in any arrangement that violates federal law. State officials described the proposal as an impractical administrative burden that could dissuade hospitals, nursing homes, and other providers from participating in Medicaid altogether. “Imposing additional requirements on providers that participate in Medicaid managed care networks would only serve to further dissuade network participation, which will have a negative impact on member access to care,” Mike Levine, the assistant secretary for MassHealth, Massachusetts’ Medicaid program, wrote to CMS on July 3.

Texas, which has long tangled with the federal agency over how it funds its Medicaid program, sued in federal court earlier this year after the agency declared in a separate letter to states that these types of arrangements aren’t allowed and must be reported. The letter was sent in February, before the agency issued its formal proposal.

In June, a federal judge handed Texas and its health care industry a victory, temporarily delaying the reporting requirement that regulators had outlined in their February letter. The judge agreed with Texas that the agency had exceeded its legal authority and couldn’t regulate private agreements.

State health officials and hospital leaders are pointing to the Texas court case as evidence that the agency’s May proposal to crack down on the redistribution of Medicaid funds is a “widely controversial interpretation” of the law, as the Tennessee Hospital Association put it in a July 3 letter to CMS.

Federal regulators have not said if or when they will implement their plan. The last time the agency issued a sweeping Medicaid financing proposal, it withdrew it almost a year later.

Mark McClellan, who served as head of the Centers for Medicare & Medicaid Services for two years during the George W. Bush administration, predicted states and Congress would push back hard if the new proposal moved forward.

“Medicaid is a huge component of state spending and keeps getting bigger,” McClellan said. “So, sudden CMS changes or clamping down is going to be disruptive for state coverage.”

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

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Industry Groups in California Vie for New Medicaid Money

Angela Hart and Samantha Young — Fri, 21 Jul 2023 09:00:00 +0000

SACRAMENTO, Calif. — California’s powerful health care industry just notched a historic win: The state is going to give it an $11.1 billion infusion to improve care for millions of low-income Medicaid patients.

But the intense jockeying over the money is only beginning.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Some providers worry they may be left out.

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

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

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

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

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

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

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

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

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

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

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

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Health Care Coalition Jockeys Over Medi-Cal Spending, Eyes Ballot Initiative

Angela Hart and Samantha Young — Wed, 31 May 2023 09:00:00 +0000

SACRAMENTO — Influential health care interests are jockeying over a potential infusion of $19.4 billion into Medi-Cal, California’s Medicaid program, while also angling for a 2024 ballot initiative to permanently lock in that funding, California Healthline has learned.

The Coalition to Protect Access to Care, which includes groups representing doctors, hospitals, insurance companies, and clinics, is lobbying Gov. Gavin Newsom and his fellow Democratic lawmakers on allocating proceeds from a tax on health insurance companies. The governor earlier this month proposed to spend nearly $820 million from renewing the Managed Care Organization, or MCO, tax to boost Medi-Cal reimbursement rates and divert $8.3 billion to the state general fund, leaving $10.3 billion up for grabs.

Each sector has its own idea of how that money should be spent, even as the health care industry presents a unified front, according to interviews with hospital leaders, health insurance executives, doctor groups, and community clinics. The coalition also wants to cement higher Medi-Cal funding into the state constitution, potentially through a ballot initiative in November 2024.

“We are actively exploring a plan to provide permanent and predictable funding, and stability, in the health care system,” said Dustin Corcoran, CEO of the California Medical Association, who confirmed talks with other industry groups and health care advocates about an initiative.

Medi-Cal, a massive safety-net program, has long failed to deliver timely, comprehensive health care and adequately meet the needs of 15.8 million low-income and disabled Californians who depend on it. Hospitals, clinics, and other health care providers say reimbursement rates fall short of the cost of their services.

“Health care has eluded patients for a long time,” Corcoran said. “This is absolutely a generational opportunity to improve Medi-Cal and ensure that patients can access care whenever they need it.”

California is among more than a dozen states that levy taxes on managed care organizations, a type of health plan, to draw in extra federal health care money for Medicaid. California adopted the tax back in 2005 and it has been renewed five times, according to state Department of Finance spokesperson H.D. Palmer. The last version, which expired in December, generated $2 billion annually.

However, the tax revenue has never been dedicated for new initiatives in Medi-Cal and Newsom wants to change that, such as by paying providers higher rates for primary care, mental health and addiction treatment, and maternity care.

While health groups and lawmakers agree on propping up Medi-Cal and raising reimbursement rates, various sectors of the health industry are positioning themselves to benefit from the portion still up for grabs. Hospitals say they are especially deserving of a large share of the $10.3 billion in revenue but have not indicated how they want the money distributed.

“It’s not that every other player isn’t important,” said Carmela Coyle, the president and CEO of the California Hospital Association, which is lobbying Newsom and lawmakers for a broad bailout even though not all hospitals need help. “But we did take the lion’s share of the hit during covid.”

Corcoran, of the California Medical Association, which represents doctors, contends that all providers who serve Medi-Cal patients should benefit, not just one type. “The tax has to deal with the entire ecosystem of health care,” he said. “You can’t just focus on a particular part of it.”

Insurers say they are still mulling over support of the tax, arguing it should benefit all Medi-Cal patients. In California, health insurance companies agreed to be taxed by the government, which brings in extra federal dollars to plug holes in Medi-Cal. Health insurers don’t get the money back directly. Instead, the money is spread across the entire health care system.

“We don’t just run around supporting new taxes. It’s not an easy decision,” said Charles Bacchi, the president and CEO of the California Association of Health Plans, which represents public and private insurers in the state. “For the health plans that have to add this tax to their premiums, it needs to be affordable for our customers.”

Newsom and lawmakers are hoping to agree on the tax by the June 15 budget deadline. However, negotiations on how to spend the money could continue well into summer and perhaps even next year.

Newsom wants to levy the tax through 2026 and spend the money over an eight- to 10-year period. But health providers and consumer advocates want it spent over roughly three years. The Newsom administration argues that stretching the money over 10 years protects against potential federal health care rule changes that could result in less revenue for California.

“We’ve spread those dollars out for a long period of time to provide sustainability and longer-term fiscal certainty to our providers,” Michelle Baass, director of the state Department of Health Care Services, which administers Medi-Cal, told lawmakers last week.

Health industry groups, community clinics, and patient advocates are pushing back, arguing there is always federal uncertainty. They say Medi-Cal, which has undergone major expansions, including to cover unauthorized immigrants, needs an infusion of money now.

“We should invest today because the need is so high,” said Francisco Silva, president and CEO of the California Primary Care Association, which represents community clinics that overwhelmingly serve low-income patients.

Anthony Wright, executive director of Health Access California, is prodding industry groups and the administration to come up with a deal addressing disparities by targeting all the money to improve patient care and promote more equitable access to doctors.

“Frankly, your experience in the Medi-Cal program is really different around the state — county by county, plan by plan,” Wright said, arguing investments must be made “in those areas where there are real problems.”

Doctors and insurance industry leaders are arguing to use the $10.3 billion for even higher Medi-Cal rates, and health plans say specifically there should be bigger rate increases for specialty care and loan forgiveness for doctors in underserved areas.

Community clinics, which offer one-stop care, want more payments that reimburse them each time a patient shows up for care rather than bundling them into one visit for one fee. And public hospitals are eyeing the revenue to offset their projected losses from caring for a disproportionate share of low-income people. The Newsom administration wants to raise Medi-Cal rates for hospital emergency room and outpatient visits, Baass told lawmakers.

If health interests can strike an agreement, it’s an opportunity for them to secure and direct billions in spending as they see fit. But the coalition could also splinter.

“It needs to be done in a way that’s fair to everybody,” said Democratic state Sen. John Laird of Santa Cruz, who sits on the budget committee. “The worry is that everybody wants a piece of it.”

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

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California Hospitals Seek a Broad Bailout, but They Don’t All Need It

Samantha Young and Angela Hart — Thu, 25 May 2023 09:00:00 +0000

SACRAMENTO, Calif. — One of the country’s richest hospitals, which caters to Hollywood elites, accepted nearly $28 million last year from an unusual source: a charity that siphons money from other California hospitals, many of which serve the state’s poorest residents.

Cedars-Sinai Health System in Los Angeles secured the grant under California’s recession-era financing scheme that allows wealthy hospitals to take valuable health care tax money from poorer ones. Hospitals across the state agreed in 2009 to the arrangement in order to tap billions more per year in taxpayer dollars to support the state’s Medicaid program, called Medi-Cal.

Now, some of those hospitals serving a greater share of Medi-Cal patients are in dire financial need and face cutbacks and potential closures. But instead of asking for help for only those at greatest risk, California’s powerful hospital industry is putting the squeeze on Gov. Gavin Newsom and fellow Democratic lawmakers for an unprecedented bailout. And they are doing it even as the state faces a nearly $32 billion budget deficit.

Hospitals argue that to avert a crisis, they need an emergency infusion of $1.5 billion. They also want a steady annual stream of new health care tax money despite already having their own dedicated tax intended to support struggling facilities that serve a large percentage of the state’s low-income people, such as Madera Community Hospital in the Central Valley, which closed earlier this year.

Ads by the California Hospital Association paint a scary picture: “1 in 5 Hospitals are at risk of closure.” Yet another warns, “Health care that millions rely on is at risk.” Those claims are being repeated by state lawmakers as they debate financial rescue for hospitals.

#OneInFive hospitals in California is at risk of closing. That would leave millions of patients without access to vital health care services. https://t.co/XH9e5Ozzqn pic.twitter.com/8YgqAD8cLy
— California Hospital Association (@CalHospitals) May 12, 2023

But a KFF Health News analysis of state data revealed that despite increased labor costs and inflation, many California hospitals have been profitable in recent years. The industry earned roughly $131 billion last year in patient revenue, a key indicator of profitability — $7.3 billion more than the previous year. After factoring in rising costs, the industry still turned a profit of about $207 million last year. State figures show the industry reaped $9.2 billion in patient revenue in 2021, partly a reflection of big swings in the stock market.

Leading health care finance experts and former state officials are urging Newsom and lawmakers to resist the industry’s fear tactics, saying that, even though hospitals are still reeling from the covid-19 pandemic, many have plush financial reserves.

“They are big fans of these giant bailouts, where the relatively rich hospitals benefit as well as the ones who really need it,” said Glenn Melnick, a health economist at the University of Southern California. “A big chunk of the hospitals, even if they’re losing money, don’t need taxpayer money to help them through this crisis.”

Melnick and others who have analyzed the financial state of California hospitals say a sliver of California’s 368 general hospitals are in crisis and that relief should be given only to those that can show they are in immediate peril. Many hospitals in underserved and rural communities are struggling financially, in part because they have failed to attract enough patients with private insurance. And the cost of providing care to lower-income patients who rely on Medi-Cal hasn’t kept pace with government reimbursement rates.

But low Medi-Cal rates aren’t necessarily a predictor of financial disaster, according to a report released Thursday by the California Health Care Foundation. (KFF Health News publishes California Healthline, which is an editorially independent service of the California Health Care Foundation.)

Health economists found that hospitals “with the lowest margins were no more dependent on Medi-Cal or Medicare than the average California hospital.” And many cash-strapped hospitals may be sitting on enormous wealth, an indication they don’t necessarily need more taxpayer money.

“Most of the facilities that have negative margins are a part of larger systems, which suggests that they have the underlying wealth of those systems to stabilize them,” said Kristof Stremikis, director of market analysis and insight for the foundation.

Carmela Coyle, the influential leader of the state hospital lobby, said California’s hospitals are in the worst crisis they’ve faced in recent history, largely because the state reimburses providers just 74 cents on the dollar to care for Medi-Cal patients.

“You have these underserved communities in the Central Valley, where a hospital comes in, they’re doing their best, and those underserved individuals are not reimbursed the same as everybody else,” Coyle told KFF Health News. “The real underlying issue here is government underfunding.”

But Coyle isn’t disclosing the full picture. Experts agree that reimbursement rates in Medi-Cal — money provided to doctors, clinics, and hospitals for taking care of low-income patients — are too low to cover the actual cost of care. Yet the state and federal government give billions in bonus and incentive payments that can actually result in higher reimbursements and even profits.

After Madera Community Hospital cut off services and shuttered, Coyle warned that it was a “canary in the coal mine” for other hospitals unable to make ends meet because of its high proportion of low-income patients and reliance on government payments. But the hospital actually made nearly $15 million from Medi-Cal in 2021, KFF Health News has gleaned from state hospital financial records.

The overarching problem, according to emails obtained by KFF Health News, was an inability to demand higher payments from commercial health insurance companies, as well as attract their patients — 70% of whom sought care outside Madera County.

The hospital “does not have the ability to negotiate competitive rates on its own,” according to an email last June to the California attorney general’s office from representatives of Trinity Health, a national Catholic health system, which backed off from acquiring the hospital.

The Madera hospital’s CEO, Karen Paolinelli, and other hospital leaders made another last-ditch effort to keep its doors open: They asked for an advance payment of their hospital tax revenue — money distributed through health insurance plans and the state. The payment they sought was from the Hospital Quality Assurance Fee, which allows hospitals to tax themselves to draw in federal money for Medi-Cal. Adopted in California in 2009 and later approved by voters through a ballot initiative, the tax brought in $8.4 billion last year.

“We did ask before we closed to get paid some of the provider money owed to us,” Paolinelli said. “But we were not successful.”

She said the hospital needed $5 million to remain open and couldn’t secure funding in time.

Under the hospital tax revenue, the money is spread across California hospitals, but the system is designed to protect the rich hospitals and essentially help them avoid industry taxes.

Hospitals with a greater share of low-income patients pay a higher tax than wealthier systems that don’t serve as many poor people. However, they benefit handsomely, ultimately increasing how much they are paid to care for Medi-Cal patients. Then those hospitals give up a portion of their tax money to a charity that funnels it to better-performing hospitals in exchange for their political support for the hospital tax.

“The winner hospitals contribute money to a fund that is used to distribute money to the loser hospitals,” said Elaine Batchlor, CEO of MLK Community Health, which is asking for financial help because roughly 70% of its patients are on Medi-Cal. “No hospital loses by being a part of it. If you were going to lose money, you’d be against it.”

The transactions are routed through the California Health Foundation and Trust, the charity operated by the leadership of the California Hospital Association.

For example, Cedars-Sinai paid nearly $172 million in taxes in 2022, eclipsing the $151 million it got back in additional Medi-Cal dollars. To make up for the loss, it secured the nearly $28 million in grant revenue — earning nearly $6.9 million from the program, its commissioned tax audit shows.

Cedars-Sinai spokesperson Duke Helfand acknowledged the benefit from the taxing scheme but said the health system effectively subsidizes Medi-Cal enrollees and incurs losses of more than $180 million annually serving those low-income patients. “Over the years, our teams at Cedars-Sinai have effectively managed our financial resources, enabling us to provide exceptional patient care,” Helfand said.

By comparison, the faith-based Adventist Health, which serves more poor people and operates roughly two dozen hospitals in California, Oregon, and Hawaii, paid $148 million in taxes in 2022 and reaped $401 million in additional Medi-Cal dollars through the program, according to its independent tax audit. It then contributed $3 million of that money to the charity.

These sorts of financing arrangements are under federal scrutiny. Officials with the Centers for Medicare & Medicaid Services have blasted “hold harmless” deals that can result in wealthier hospitals receiving enough money back that they ultimately wind up paying little or no tax at all.

“A health care-related tax cannot have a hold harmless provision that guarantees to return all or a portion of the tax back to the taxpayer,” Daniel Tsai, deputy administrator and director for the federal Medicaid agency, wrote in February.

Dave Regan, president of Service Employees International Union-United Healthcare Workers West, which represents hospital workers, has long lambasted California’s scheme as a ploy that lets wealthy hospitals siphon valuable health care dollars from smaller, rural hospitals that need more support for Medi-Cal patients.

“We believe the policies and practices of the hospital industry, in large part, contribute to the problems that Madera faced,” Regan said. “The hospital industry is richer than it’s ever been — and it’s being disingenuous, trying to get the public to fork over more money at a time when they have more money than they’ve ever had.”

California Hospital Association spokesperson David Simon defended the charity, saying it helps “hospitals provide health care services despite losses” from the tax.

Hospital leaders say exorbitant costs and inflation have created extreme financial woes. Last year, California’s hospitals paid at least $10 billion more for labor, supplies, and other expenses than the year before, according to state hospital finance data. And overall, they saw substantially smaller investment gains, reporting nearly $119 million in non-operating revenue compared with $6 billion the year before — a big blow to their financial cushion to ensure patient care.

The industry points out 200 hospitals had negative operating margins last year, yet KFF Health News found that, even before the pandemic, about 160 hospitals reported losing money in their operating budgets. Experts say the finding underscores the reality that hospitals operate on slim margins.

And, credit ratings agencies have recently upgraded the bonds of a number of hospitals and health systems, including Sutter Health in Northern California and Loma Linda University Medical Center in San Bernardino County.

“We just upgraded Sutter like two weeks ago, so it would be very hard-pressed, for me, to look at California and say California is looking bad,” said Kevin Holloran, a senior director at Fitch Ratings.

Some Democratic lawmakers agree that not all hospitals need a bailout. Instead, they favor targeted relief such as a $150 million loan program that Newsom signed into law earlier this month to help struggling hospitals.

“I’m not a big fan of writing everybody a check,” said Democratic Assemblymember Jim Wood, chair of the Health Committee, who says hospitals ought to be more transparent about their finances before state taxpayers give them any more money. “If you’re a hospital system that’s doing well, I don’t believe you should be getting any additional resources from the state.”

KFF Health News senior correspondent Bernard J. Wolfson contributed to this report.

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

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The Nation’s Health Secretary Has This Doctor on Call

Samantha Young — Tue, 02 May 2023 09:00:00 +0000

SACRAMENTO — Carolina Reyes, a Harvard-trained physician who specializes in high-risk pregnancies, got into medicine to help women obtain health care, especially underserved or marginalized people who face systemic racism. She’s seen progress, albeit slow, over three decades, yet the number of maternal deaths each year continues to rise.

Luckily, she’s got the ear of President Joe Biden’s health secretary.

Reyes, 64, is married to Health and Human Services Secretary Xavier Becerra, who is championing the administration’s initiative to require all states to provide Medicaid coverage to mothers for a year after giving birth. In March, the Centers for Disease Control and Prevention released data showing a 40% increase in U.S. maternal deaths from 2020 to 2021. The mortality rate among Black women was 2.6 times that of white women, no matter their economic status.

Over the years, Becerra has spoken highly of his wife’s expertise, but she downplays her influence, saying her husband of nearly 35 years “had it in him to begin with” to improve health care for women and to demand fewer pregnancy-related deaths. She, too, describes the nation’s high maternal mortality rate as unacceptable and preventable.

Reyes, a Latina who grew up as one of eight children in California’s agricultural heartland, now practices perinatology at the University of California-Davis. She is a member of a California Department of Public Health panel that reviews cases of maternal deaths and recommends improvements. And she chairs the board of the California Health Care Foundation, a nonprofit that works to increase health care access. (California Healthline is an editorially independent service of the California Health Care Foundation.)

Her work has been a blend of medicine and advocacy, and she worries recent federal court rulings will erode hard-fought victories regarding the safety of pregnant women and their babies. She discussed the nation’s maternal health crisis and health care disparities with California Healthline senior correspondent Samantha Young. The interview has been edited for length and clarity.

Q: When did you first realize there are disparities in the health care system?

When I was in high school in the Fresno Unified School District, we were under a consent decree to desegregate. And I was, at the time, student body president at Roosevelt High School. I was asked to be on this unified school district desegregation task force, where the district had to come up with a plan.

It was a time when I really had incredible exposure to how policies are made at a larger level, societal level, that really determine where people live, where they can seek health care, where they go to school. That experience had a tremendous impact on my life in terms of what I wanted to do in a career and how to give back.

Q: The U.S. has one of the best health care systems in the world, yet the maternal mortality rate is high compared with other developed countries. Why do think that is?

What we know by the CDC and maternal mortality review committees is that about 60% of maternal deaths are considered preventable. And that’s really been a lot of what I’ve tried to focus on: What can we do to reduce the severity of disease? Or what can we do within the role that we play in maternal health that can reduce that?

We know that there are societal issues absolutely that increase women’s risks and there are public health issues. But there’s a role that hospitals play in helping reduce that risk. Ten years ago, I was on the maternal mortality review committee for the state of California when we started reviewing cases of women who died within hospital systems to see, “Is there a role that we can play in a hospital system to reduce that risk?”

We recognized that sometimes there were conditions that were not recognized early enough so that there was a delay in the care. Sometimes there was a misdiagnosis. Or in some hospital systems, especially rural systems where there aren’t as many resources, sometimes there was the lack of specialists available. So, we’ve identified these risks and said, “We can do something about them.”

Q: You served on a federal panel 20 years ago that published a groundbreaking report identifying racism in health care. It seems as if we could be much further along.

The purpose of that committee was to really answer the question: Do patients receive a different level of care based on race? Looking back, we knew there was something there, but we really didn’t know. And it took months for the committee to come to that agreement, that there was a difference. I mean, that was honestly monumental, because we just didn’t have that level of consensus before. And so just to say “That treatment is unequal and it’s unacceptable” was really profound.

We thought that the 700-page report was going to be a time period where there was going to be tremendous movement, and I think I’ve learned over 20 years that change doesn’t happen quickly, especially when providers and health systems don’t see that they play a role. It’s like … “OK, so maybe it exists, but not for me.”

We all saw George Floyd and how he was treated. And during covid we saw a tremendous difference in who was dying, right? Underrepresented minorities — certainly much higher. It was that culmination that made us realize the elephant in the room. We can’t ignore that this does exist, that there is a difference in how people are treated, even in our health care system.

Q: When addressing racism in health care, you talk about diversifying not just the health care workforce, but also the boardrooms of hospitals and health systems. Why is that important?

At the board level, change is hard. But we all play a role because leadership really helps determine much of what’s carried out. So, to have a leadership that is understanding and representative of the communities they serve, I think it has been demonstrated that we do make a difference.

Q: As a health care provider, do you have a wish list of policies you’d like the government to take up?

There was tremendous effort around offering preventive health services as a part of what was covered under the Affordable Care Act. And individuals exhaled, finally thinking this is a tremendous win, especially for women in pregnancy. Because we fought for preventive health services to help them have access so they can prepare for their pregnancy. So, for women, this was huge. But now with the Texas federal court ruling that the U.S. Preventive Services Task Force didn’t have any authority, it is a tremendous step backward.

We have culturally, linguistically appropriate standards in place, but it’s a matter in terms of how they’re carried out by state and by individual hospital systems. My wish list is that we really do listen to our patients, speak to them in a language of their choice, and provide them written materials in the language of their choice. We don’t fully do that.

Q: You mentioned one Texas ruling on the ACA. What’s your take on the ruling by another Texas judge suspending the abortion pill? And the U.S. Supreme Court’s overturning of Roe v. Wade?

As a maternal-fetal medicine specialist who tries to help women plan for pregnancies, those rulings are a tremendous setback.

Q: And what about women of color? Will they find access to abortion services more difficult?

Oh, absolutely. When we speak of underrepresented minorities or those with less resources, they have less resources to then seek the appropriate care. Some women may have the opportunity to go to a different state or seek care elsewhere if their state doesn’t provide it. Many women just don’t have those resources to devote to them and don’t have a choice. So, we will see that disparity widen.

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

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This story can be republished for free (details).

Samantha Young, Author at KFF Health News

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