KALISPELL, Mont. — On a cold February morning at the Flathead Warming Center, Tashya Evans waited for help with her Medicaid application as others at the shelter got ready for the day in this northwestern Montana city.

Evans said she lost Medicaid coverage in September because she hadn’t received paperwork after moving from Great Falls, Montana. She has had to forgo the blood pressure medication she can no longer pay for since losing coverage. She has also had to put off needed dental work.

“The teeth broke off. My gums hurt. There’s some times where I’m not feeling good, I don’t want to eat,” she said.

Evans is one of about 130,000 Montanans who have lost Medicaid coverage as the state reevaluates everyone’s eligibility following a pause in disenrollments during the covid-19 pandemic. About two-thirds of those who were kicked off state Medicaid rolls lost coverage for technical reasons, such as incorrectly filling out paperwork. That’s one of the highest procedural disenrollment rates in the nation, according to a KFF analysis.

Even unsheltered people like Evans are losing their coverage, despite state officials saying they would automatically renew people who should still qualify by using Social Security and disability data.

As other guests filtered out of the shelter that February morning, Evans sat down in a spare office with an application counselor from Greater Valley Health Clinic, which serves much of the homeless population here, and recounted her struggle to reenroll.

She said that she had asked for help at the state public assistance office, but that the staff didn’t have time to answer her questions about which forms she needed to fill out or to walk her through the paperwork. She tried the state’s help line, but couldn’t get through.

“You just get to the point where you’re like, ‘I’m frustrated right now. I just have other things that are more important, and let’s not deal with it,’” she said.

Evans has a job and spends her free time finding a place to sleep since she doesn’t have housing. Waiting on the phone most of the day isn’t feasible.

There’s no public data on how many unhoused people in Montana or nationwide have lost Medicaid, but homeless service providers and experts say it’s a big problem.

Those assisting unsheltered people who have lost coverage say they spend much of their time helping people contact the Montana Medicaid office. Sorting through paperwork mistakes is also a headache, said Crystal Baker, a case manager at HRDC, a homeless shelter in Bozeman.

“We’re getting mail that’s like, ‘Oh, this needs to be turned in by this date,’ and that’s already two weeks past. So, now we have to start the process all over again,” she said. “Now, they have to wait two to three months without insurance.”

Montana health officials told NPR and KFF Health News in a statement that they provided training to help homeless service agencies prepare their clients for redetermination.

Federal health officials have warned Montana and some other conservative states against disenrolling high rates of people for technicalities, also known as procedural disenrollment. They also warned states about unreasonable barriers to accessing help, such as long hold times on help lines. The Centers for Medicare & Medicaid Services said if states don’t reduce the rate of procedural disenrollments, the agency could force them to halt their redetermination process altogether. So far, CMS hasn’t taken that step.

Charlie Brereton, the director of the Montana health department, resisted calls from Democratic state lawmakers to pause the redetermination process. Redetermination ended in January, four months ahead of the federal deadline.

“I’m confident in our redetermination process,” Brereton told lawmakers in December. “I do believe that many of the Medicaid members who’ve been disenrolled were disenrolled correctly.

Health industry observers say that both liberal-leaning and conservative-leaning states are kicking homeless people off their rolls and that the redetermination process has been chaotic everywhere. Because of the barriers that unsheltered people face, it’s easy for them to fall through the cracks.

Margot Kushel, a physician and a homeless researcher at the University of California-San Francisco, said it may not seem like a big deal to fill out paperwork. But, she said, “put yourself in the position of an elder experiencing homelessness,” especially those without access to a computer, phone, or car.

If they still qualify, people can usually get their Medicaid coverage renewed — eventually — and it may reimburse patients retroactively for care received while they were unenrolled.

Kushel said being without Medicaid for any period can be particularly dangerous for people who are homeless. This population tends to have high rates of chronic health conditions.

“Being out of your asthma medicine for three days can be life-threatening. If you have high blood pressure and you suddenly stop your medicine, your blood pressure shoots up, and your risk of having a heart attack goes way up,” she said.

When people don’t understand why they’re losing coverage or how to get it back, that erodes their trust in the medical system, Kushel said.

Evans, the homeless woman, was able to get help with her application and is likely to regain coverage.

Agencies that serve unhoused people said it could take years to get everyone who lost coverage back on Medicaid. They worry that those who go without coverage will resort to using the emergency room rather than managing their health conditions proactively.

Baker, the case manager at the Bozeman shelter, set up several callbacks from the state Medicaid office for one client. The state needed to interview him to make sure he still qualified, but the state never called.

“He waited all day long. By the fifth time, it was so stressful for him, he just gave up,” she said.

That client ended up leaving the Bozeman area before Baker could convince him it was worth trying to regain Medicaid.

Baker worries his poor health will catch up with him before he decides to try again.

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

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

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SACRAMENTO, Calif. — California state lawmakers this year are continuing their progressive tilt on health policy with dozens of proposals including a ban on a Froot Loops ingredient and free condoms for high schoolers.

As states increasingly fracture along partisan lines, California Democrats are stamping their supermajority on legislation that they will consider until they adjourn at the end of August. But the cost of these proposals will be a major factor given the enormity of the state’s deficit, currently estimated at between $38 billion and $73 billion.

Health Coverage

Lawmakers are again considering whether to create a government-run, single-payer health care system for all Californians. AB 2200 is Democratic Assembly member Ash Kalra’s second such attempt, after a similar bill failed in 2022. The price tag would be enormous, though proponents say there would also be related savings. The high potential cost left Assembly Speaker Robert Rivas and others skeptical it could become law while the state faces a deficit.

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AB 4 would require Covered California, the state’s health insurance exchange, to offer health insurance policies to people who are otherwise not able to obtain coverage because of their immigration status, to the extent it can under federal law. That could eventually lead to subsidized insurance premiums similar to those offered in Colorado and Washington.

Medical Debt

Health care providers and collection agencies would be barred from sharing patients’ medical debt with credit reporting agencies under SB 1061. The bill would also prohibit credit reporting agencies from accepting, storing, or sharing any such information without consumer consent. Last year, the Biden administration announced plans to develop federal rules barring unpaid medical bills from affecting patients’ credit scores. California would be the third state to remove medical bills from consumer credit reports.

Medi-Cal

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The Medi-Cal program, which provides health care for low-income people, would be required to cover medically supportive food and nutrition starting July 1, 2026, under AB 1975. The bill builds on an existing but limited pilot program. The legislation says Californians of color could benefit from adequate food and nutrition to combat largely preventable chronic health conditions, and it’s one of 14 measures sought by the California Legislative Black Caucus as part of reparations for racial injustice.

More than 1.6 million California residents, disproportionately Latinos, have been kicked off Medi-Cal since the state resumed annual eligibility checks that were halted during the covid-19 pandemic. AB 2956 would have the state seek federal approval to slow those disenrollments by taking steps such as letting people 19 and older keep their coverage automatically for 12 months.

Violence Prevention

An increase in attacks on health workers is prompting lawmakers to consider boosting criminal penalties. In California, simple assault against workers inside an ER is considered the same as simple assault against almost anyone else, and carries a maximum punishment of a $1,000 fine and six months in jail. In contrast, simple assault against emergency medical workers in the field, such as an EMT responding to a 911 call, carries maximum penalties of a $2,000 fine and a year in jail. AB 977 would set the same maximum penalties for assaulting emergency health care workers on the job, whether they are in the field or an ER.

California could toughen penalties for interfering with reproductive health care services. Posting personal information or photographs of a patient or provider would be a felony if one of them is injured as a result. AB 2099 also boosts penalties for intimidation or obstruction.

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Under SB 53, gun owners would have to lock up their weapons in state-approved safes or lockboxes where they would be inaccessible to anyone but the owner or another lawfully authorized user. Democratic Sen. Anthony Portantino, the bill’s author, says that would make it tougher for anyone, including children, to use guns to harm themselves or others or use the weapons to commit crimes. Critics say it would make it harder to access the weapon when it’s needed, such as to counter a home invasion. Relatedly, AB 2621 and AB 2917 address gun violence restraining orders.

Substance Use

The spike in drug overdoses has prompted several responses: AB 3073 would require the state’s public health department to partner with local public health agencies, wastewater treatment facilities, and others to pilot wastewater testing for traces of dangerous drugs in an effort to pinpoint drug hot spots and identify new drugs. AB 1976 would require workplace first-aid kits to include naloxone nasal spray, which can reverse opioid overdoses. And senators have proposed at least nine bills aimed at curbing overdose deaths, particularly from the deadly synthetic opioid fentanyl.

Youth Welfare

Under AB 2229, backed by a “Know Your Period” campaign, school districts’ sex education curricula would have to include menstrual health. There was no registered opposition.

Public schools would have to make free condoms available to all pupils in grades nine to 12 under SB 954, which would help prevent unwanted pregnancies and sexually transmitted infections, according to the author, Democratic Sen. Caroline Menjivar. Democratic Gov. Gavin Newsom vetoed a similar bill last year.

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Reality show star Paris Hilton is backing a bipartisan bill to require more reporting on the treatment of youth in state-licensed short-term residential therapeutic programs. SB 1043 would require the state Department of Social Services to post information on the use of restraints and seclusion rooms on a public dashboard.

California would expand its regulation of hemp products, which have become increasingly popular among youths as a way to bypass the state’s adults-only restrictions on legal cannabis. AB 2223 would build on a 2021 law that Assembly member Cecilia Aguiar-Curry said in hindsight didn’t go far enough.

Public schools would, under AB 2316, generally be barred from providing food containing red dye 40, titanium dioxide, and other potentially harmful substances, which are currently used in products including Froot Loops and Flamin’ Hot Cheetos. It’s Democratic Assembly member Jesse Gabriel’s follow-up to his legislation last year that attempted to ban a chemical used in Skittles.

Women’s Health

AB 2515 would ban the sale of menstrual products with intentionally added PFAS, also known as “forever chemicals.” PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, have been linked to serious health problems. Newsom vetoed a previous attempt.

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Public grade schools and community colleges would, under AB 2901, have to provide 14 weeks of paid leave for pregnancies, miscarriages, childbirth, termination of pregnancies, or recovery. Newsom vetoed a similar bill in 2019.

AB 2319 would improve enforcement of a 2019 law aimed at reducing the disproportionate rate of maternal mortality among Black women and other pregnant women of color.

Social Media

Social media companies could face substantial penalties if they don’t do enough to protect children, under AB 3172. The measure would allow financial damages of up to $1 million for each child under age 18 who proves in court they were harmed, or three times the amount of the child’s actual damages. The industry opposes the bill, calling it harmful censorship.

Cyberbullies could face civil liabilities up to $75,000 under SB 1504, and those damages could be sought by anyone. Under current law, damages are capped at $7,500 and may be pursued only by the state attorney general.

Wellness

Bosses could be fined for repeatedly contacting employees after working hours under AB 2751, a “right to disconnect” bill patterned after similar restrictions in 13 countries. The bill’s author, Democratic Assembly member Matt Haney, said despite the advent of smartphones that “have blurred the boundaries between work and home life,” employees shouldn’t be expected to work around the clock. The measure is opposed by the California Chamber of Commerce.

Finally, Democrat Anthony Rendon, a long-serving state Assembly speaker, is spending his last year in the chamber leading a first-in-the-nation Select Committee on Happiness and Public Policy Outcomes. The committee isn’t planning any legislation but intends to issue a report after lawmakers adjourn in August.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Biden-Harris Administration Takes Action to Increase Access to Care

HHS Celebrates Earth Day 2024 with Fact Sheet of Accomplishments

HHS is marking Earth Day by introducing new programming to help the health sector reduce its significant carbon footprint

HIPAA privacy protections for reproductive health care

Earth Day observance

ONC Releases Common Agreement Version 2.0

MANTI, Utah — Garrett Clark estimates he has spent about six years in the Sanpete County Jail, a plain concrete building perched on a dusty hill just outside this small, rural town where he grew up.

He blames his addiction. He started using in middle school, and by the time he was an adult he was addicted to meth and heroin. At various points, he’s done time alongside his mom, his dad, his sister, and his younger brother.

“That’s all I’ve known my whole life,” said Clark, 31, in December.

Clark was at the jail to pick up his sister, who had just been released. The siblings think this time will be different. They are both sober. Shantel Clark, 33, finished earning her high school diploma during her four-month stay at the jail. They have a place to live where no one is using drugs.

And they have Cheryl Swapp, the county sheriff’s new community health worker, on their side.

“She saved my life probably, for sure,” Garrett Clark said.

Swapp meets with every person booked into the county jail soon after they arrive and helps them create a plan for the day they get out.

She makes sure everyone has a state ID card, a birth certificate, and a Social Security card so they can qualify for government benefits, apply to jobs, and get to treatment and probation appointments. She helps nearly everyone enroll in Medicaid and apply for housing benefits and food stamps. If they need medication to stay off drugs, she lines that up. If they need a place to stay, she finds them a bed.

Then Swapp coordinates with the jail captain to have people released directly to the treatment facility. Nobody leaves the jail without a ride and a drawstring backpack filled with items like toothpaste, a blanket, and a personalized list of job openings.

“A missing puzzle piece,” Sgt. Gretchen Nunley, who runs educational and addiction recovery programming for the jail, called Swapp.

Swapp also assesses the addiction history of everyone held by the county. More than half arrive at the jail addicted to something.

Nationally, 63% of people booked into local jails struggle with a substance use disorder — at least six times the rate of the general population, according to the federal Substance Abuse and Mental Health Services Administration. The incidence of mental illness in jails is more than twice the rate in the general population, federal data shows. At least 4.9 million people are arrested and jailed every year, according to an analysis of 2017 data by the Prison Policy Initiative, a nonprofit organization that documents the harm of mass incarceration. Of those incarcerated, 25% are booked two or more times, the analysis found. And among those arrested twice, more than half had a substance use disorder and a quarter had a mental illness.

“We don’t lock people up for being diabetic or epileptic,” said David Mahoney, a retired sheriff in Dane County, Wisconsin, who served as president of the National Sheriffs’ Association in 2020-21. “The question every community needs to ask is: ‘Are we doing our responsibility to each other for locking people up for a diagnosed medical condition?’”

The idea that county sheriffs might owe it to society to offer medical and mental health treatment to people in their jails is part of a broader shift in thinking among law enforcement officials that Mahoney said he has observed during the past decade.

“Don’t we have a moral and ethical responsibility as community members to address the reasons people are coming into the criminal justice system?” asked Mahoney, who has 41 years of experience in law enforcement.

Swapp previously worked as a teacher’s aide for those she calls the “behavior kids” — children who had trouble self-regulating in class. She feels her work at the jail is a way to change things for the parents of those kids. And it appears to be working.

Since the Sanpete County Sheriff’s Office hired Swapp last year, recidivism has dropped sharply. In the 18 months before she began her work, 599 of the people booked into Sanpete County Jail had been there before. In the 18 months after she started, that number dropped to 237.

In most places, people are released from county jails with no health care coverage, no job, nowhere to live, and no plan to stay off drugs or treat their mental illness. Research shows that people newly released from incarceration face a risk of overdose that is 10 times as high as that of the general public.

Sanpete wasn’t any different.

“For seven to eight years of me being here, we’d just release people and cross our fingers,” said Jared Hill, the clinical director for Sanpete County and a counselor at the jail.

Nunley, the programming sergeant, remembers watching people released from jail walk the mile to town with nothing but the clothes they’d worn on the day they were arrested — it was known as the “walk of shame.” Swapp hates that phrase. She said no one has made the trip on foot since she started in July 2022.

Swapp’s work was initially funded by a grant from the U.S. Health Resources and Services Administration, but it has proved so popular that commissioners in Sanpete County voted to use a portion of its opioid settlement money to cover the position in the future.

Swapp doesn’t have formal medical or social work training. She is certified by the state of Utah as a community health worker, a job that has become more common nationwide. There were about 67,000 people working as community health workers in 2022, according to the U.S. Bureau of Labor Statistics.

Evidence is mounting that the model of training people to help their neighbors connect to government and health care services is sound, said Aditi Vasan, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania who has reviewed the research on the relatively new role.

The day before Swapp coordinated Shantel Clark’s release, she sat with Robert Draper, a man in his 50s with long white hair and bright-blue eyes. Draper has been in and out of jail for decades. He was sober for a year and had been taking care of his ill mother. She kept getting worse. Then his daughter and her child came to help. It was all a little too much.

“I thought, if I can just go and get high, I can deal with this shit,” said Draper. “But after you’ve been using for 40 years, it’s kinda easy to slip back in.”

He didn’t blame his probation officer for throwing him back in jail when he tested positive for drugs, he said. But he thinks jail time is an overreaction to a relapse. Draper sent a note to Swapp through the jail staff asking to see her. He was hoping she could help him get out so he could be with his mom, who had just been sent to hospice. He had missed his father’s death years ago because he was in jail at the time.

Swapp listened to Draper’s story without interruptions or questions. Then she asked if she could run through her list with him so she would know what he needed.

“Do you have your Social Security card?”

“My card?” Draper shrugged. “I know my number.”

“Your birth certificate, you have it?”

“Yeah, I don’t know where it is.”

“Driver’s license?”

“No.”

“Was it revoked?”

“A long, long time ago,” Draper said. “DUI from 22 years ago. Paid for and everything.”

“Are you interested in getting it back?”

“Yeah!”

Swapp has some version of this conversation with every person she meets in the jail. She also runs through their history of addiction and asks them what they most need to get back on their feet.

She told Draper she would try to get him into intensive outpatient therapy. That would involve four to five classes a week and a lot of driving. He’d need his license back. She didn’t make promises but said she would talk to his probation officer and the judge. He sighed and thanked her.

“I’m your biggest fan here,” Swapp said. “I want you to succeed. I want you to be with your mom, too.”

The federal grant that funded the launch of Sanpete’s community health worker program is held by the regional health care services organization Intermountain Health. Intermountain took the idea to the county and has provided Swapp with support and training. Intermountain staff also administer the $1 million, three-year grant, which includes efforts to increase addiction recovery services in the area.

A similarly funded program in Kentucky called First Day Forward took the community health worker model a step further, using “peer support specialists” — people who have experienced the issues they are trying to help others navigate. Spokespeople from HRSA pointed to four programs, including the ones in Utah and Kentucky, that are using their grant money for people facing or serving time in local jails.

Back in Utah, Sanpete’s new jail captain, Jeff Nielsen, said people in small-town law enforcement weren’t so far removed from those serving time.

“We know these people,” Nielsen said. He has known Robert Draper since middle school. “They are friends, neighbors, sometimes family. We’d rather help than lock them up and throw away the key. We’d rather help give them a good life.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For Tim Lillard, the question has been why.

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

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

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

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

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

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

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

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

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

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

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

Putting Patients at Risk

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

But nursing unions say that’s not the full story. There are now 4.7 million registered nurses in the country, more than ever before, with an estimated 130,000 nurses having entered the field from 2020 to 2022.

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

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

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

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

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

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

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

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

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

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

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

Less than 24 hours later, Ann died.

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

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

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

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

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

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

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

Following the Money

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

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

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

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

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

A Battle Between Hospitals and Unions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q: What else has helped you weather the storm?

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

Q: You also have strong fundraising activity.

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

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

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

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

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

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SACRAMENTO, Calif. — Gov. Gavin Newsom’s administration has compromised on long-sought rules that would protect indoor workers from extreme heat, saying tens of thousands of prison and jail employees — and prisoners — would have to wait for relief.

The deal comes a month after the administration unexpectedly rejected sweeping heat standards for workers in sweltering warehouses, steamy kitchens, and other dangerously hot job sites. The rules had been years in the making, and a state worker safety board voted to adopt them March 21. But in a controversial move, the administration upended the process by saying the cost to cool state prisons was unclear — and likely very expensive.

So the Democratic administration said the rules can proceed but must exempt tens of thousands of workers at 33 state prisons, conservation camps, and local jails, “in recognition of the unique implementation challenges,” said Eric Berg, of California’s Division of Occupational Safety and Health, at a Thursday hearing. A separate regulation will be drafted for correctional facilities, which could take a year, if not longer.

It’s unclear if the standards will become law in time to protect millions of other workers from summer’s intensifying heat. The compromise rules must go through a 15-day public comment period, and legal reviews within 100 days, which could push implementation well into summer. But that can’t even happen until the original regulation is rejected by the Office of Administrative Law, which has until next month.

“Summer is arriving, and many workers, unfortunately, are going to suffer heat conditions,” said Tim Shadix, legal director at the Warehouse Worker Resource Center. “Some will likely get really sick, potentially even die from heat illness, while we continue to wait for the standard.”

Berg told members of the Occupational Safety and Health Standards Board on April 18 that Cal/OSHA would try to accelerate the timeline and get protections in place for summer.

California has had heat standards on the books for outdoor workers since 2005, and rules for indoor workplaces have been in the works since 2016. The proposed standards would require work sites to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear protective clothing or are exposed to radiant heat, such as furnaces. Buildings could be cooled with air conditioning, fans, misters, and other methods.

The rules allow workarounds for businesses that can’t cool their workplaces sufficiently, such as laundries or restaurant kitchens.

Because the rules would have a sweeping economic impact, state law requires Newsom’s Department of Finance to sign off on the financial projections, which it refused to do last month when it was unclear how much the regulations would cost state prisons. The California Department of Corrections and Rehabilitation said implementing the standards in its prisons and other facilities could cost billions, but the board’s economic analysis pegged the cost at less than $1 million a year.

Department of Finance spokesperson H.D. Palmer couldn’t promise that the compromise rules would be signed off on, but “given that the earlier correctional estimates were the issue before, not having them in the revised package would appear to address that issue,” he said.

Business and agricultural groups complained repeatedly during the rulemaking process that complying with the rules would burden businesses financially. At the April 18 hearing, they highlighted the administration’s lack of transparency and questioned why one sector should be given an exemption over another.

“The massive state costs that are of concern, specifically around prisons in the billions of dollars, are also costs that California employers will bear,” said Robert Moutrie, a senior policy advocate at the California Chamber of Commerce.

Labor advocates asked board members not to exempt prisons, saying corrections workers need protection from heat, too.

“It’s a huge concern that prison workplaces all over are being excluded from the heat standard, leaving out not just guards, but also nurses, janitors, and the other prison workers across California unprotected from heat,” said AnaStacia Nicol Wright, an attorney with Worksafe, a workplace safety advocacy nonprofit. “California needs to prioritize the safety and well-being of their workers, regardless of whether they work in corrections, a farm, or a sugar refinery.”

Prisons will continue to provide cooling stations in air-conditioned areas, and make water stations, fans, portable cooling units, and ice more available to workers, according to the California Department of Corrections and Rehabilitation. Prison housing units, which house roughly 93,000 inmates as of April 17, all can be cooled, usually with evaporative coolers and fans. The department has 58,135 staff members, spokesperson Terri Hardy said.

Only Minnesota and Oregon have adopted heat rules for indoor workers. Legislation has stalled in Congress, and even though the Biden administration has initiated the long process of establishing national heat standards for outdoor and indoor work, they may take years to finalize.

Seven workers died in California from indoor heat between 2010 and 2017. Heat stress can lead to heat exhaustion, heatstroke, cardiac arrest, and kidney failure. In 2021, the Centers for Disease Control and Prevention reported, 1,600 heat-related deaths occurred nationally, which is likely an undercount because health care providers are not required to report them. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

“These are not overly cumbersome things to implement, and they are easy ways to keep people safe and healthy,” said Jessica Early, patient advocacy coordinator at the National Union of Healthcare Workers. “Now is the urgent time to make our workplaces safer and more resilient in the face of rising temperatures.”

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

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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Marking the one-year anniversary of President Biden’s Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers

A team of Montana researchers is playing a key role in the development of a more effective vaccine against tuberculosis, an infectious disease that has killed more people than any other.

The BCG (Bacille Calmette-Guérin) vaccine, created in 1921, remains the sole TB vaccine. While it is 40% to 80% effective in young children, its efficacy is very low in adolescents and adults, leading to a worldwide push to create a more powerful vaccine.

One effort is underway at the University of Montana Center for Translational Medicine. The center specializes in improving and creating vaccines by adding what are called novel adjuvants. An adjuvant is a substance included in the vaccine, such as fat molecules or aluminum salts, that enhances the immune response, and novel adjuvants are those that have not yet been used in humans. Scientists are finding that adjuvants make for stronger, more precise, and more durable immunity than antigens, which create antibodies, would alone.

Eliciting specific responses from the immune system and deepening and broadening the response with adjuvants is known as precision vaccination. “It’s not one-size-fits-all,” said Ofer Levy, a professor of pediatrics at Harvard University and the head of the Precision Vaccines Program at Boston Children’s Hospital. “A vaccine might work differently in a newborn versus an older adult and a middle-aged person.”

The ultimate precision vaccine, said Levy, would be lifelong protection from a disease with one jab. “A single-shot protection against influenza or a single-shot protection against covid, that would be the holy grail,” Levy said.

Jay Evans, the director of the University of Montana center and the chief scientific and strategy officer and a co-founder of Inimmune, a privately held biotechnology company in Missoula, said his team has been working on a TB vaccine for 15 years. The private-public partnership is developing vaccines and trying to improve existing vaccines, and he said it’s still five years off before the TB vaccine might be distributed widely.

It has not gone unnoticed at the center that this state-of-the-art vaccine research and production is located in a state that passed one of the nation’s most extreme anti-vaccination laws during the pandemic in 2021. The law prohibits businesses and governments from discriminating against people who aren’t vaccinated against covid-19 or other diseases, effectively banning both public and private employers from requiring workers to get vaccinated against covid or any other disease. A federal judge later ruled that the law cannot be enforced in health care settings, such as hospitals and doctors’ offices.

In mid-March, the Bill & Melinda Gates Medical Research Institute announced it had begun the third and final phase of clinical trials for the new vaccine in seven countries. The trials should take about five years to complete. Research and production are being done in several places, including at a manufacturing facility in Hamilton owned by GSK, a giant pharmaceutical company.

Known as the forgotten pandemic, TB kills up to 1.6 million people a year, mostly in impoverished areas in Asia and Africa, despite its being both preventable and treatable. The U.S. has seen an increase in tuberculosis over the past decade, especially with the influx of migrants, and the number of cases rose by 16% from 2022 to 2023. Tuberculosis is the leading cause of death among people living with HIV, whose risk of contracting a TB infection is 20 times as great as people without HIV.

“TB is a complex pathogen that has been with human beings for ages,” said Alemnew Dagnew, who heads the program for the new vaccine for the Gates Medical Research Institute. “Because it has been with human beings for many years, it has evolved and has a mechanism to escape the immune system. And the immunology of TB is not fully understood.”

The University of Montana Center for Translational Medicine and Inimmune together have 80 employees who specialize in researching a range of adjuvants to understand the specifics of immune responses to different substances. “You have to tailor it like tools in a toolbox towards the pathogen you are vaccinating against,” Evans said. “We have a whole library of adjuvant molecules and formulations.”

Vaccines are made more precise largely by using adjuvants. There are three basic types of natural adjuvants: aluminum salts; squalene, which is made from shark liver; and some kinds of saponins, which are fat molecules. It’s not fully understood how they stimulate the immune system. The center in Missoula has also created and patented a synthetic adjuvant, UM-1098, that drives a specific type of immune response and will be added to new vaccines.

One of the most promising molecules being used to juice up the immune system response to vaccines is a saponin molecule from the bark of the quillay tree, gathered in Chile from trees at least 10 years old. Such molecules were used by Novavax in its covid vaccine and by GSK in its widely used shingles vaccine, Shingrix. These molecules are also a key component in the new tuberculosis vaccine, known as the M72 vaccine.

But there is room for improvement.

“The vaccine shows 50% efficacy, which doesn’t sound like much, but basically there is no effective vaccine currently, so 50% is better than what’s out there,” Evans said. “We’re looking to take what we learned from that vaccine development with additional adjuvants to try and make it even better and move 50% to 80% or more.”

By contrast, measles vaccines are 95% effective.

According to Medscape, around 15 vaccine candidates are being developed to replace the BCG vaccine, and three of them are in phase 3 clinical trials.

One approach Evans’ center is researching to improve the new vaccine’s efficacy is taking a piece of the bacterium that causes TB, synthesizing it, and combining it with the adjuvant QS-21, made from the quillay tree. “It stimulates the immune system in a way that is specific to TB and it drives an immune response that is even closer to what we get from natural infections,” Evans said.

The University of Montana center is researching the treatment of several problems not commonly thought of as treatable with vaccines. They are entering the first phase of clinical trials for a vaccine for allergies, for instance, and first-phase trials for a cancer vaccine. And later this year, clinical trials will begin for vaccines to block the effects of opioids like heroin and fentanyl. The University of Montana received the largest grant in its history, $33 million, for anti-opioid vaccine research. It works by creating an antibody that binds with the drug in the bloodstream, which keeps it from entering the brain and creating the high.

For now, though, the eyes of health care experts around the world are on the trials for the new TB vaccines, which, if they are successful, could help save countless lives in the world’s poorest places.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Heiress Paris Hilton is on a mission to shine a light on the “troubled teen industry,” a largely unregulated multibillion-dollar industry that is gaining public scrutiny for alleged abuse of vulnerable youths.

Hilton told state lawmakers in Sacramento on Monday she was subjected to abuse disguised as therapy decades ago when she was housed in residential facilities for teenagers struggling with substance abuse, mental illness and problematic behavior. 

She testified at the state Capitol in support of a bill ordering disclosure of the use of restraints or seclusion rooms in disciplining minors at residential facilities.

“When I close my eyes at night, I still have nightmares about solitary confinement 20 years later,” said Hilton, 43, at a news conference before the hearing. “The sounds of my peers screaming as they were physically restrained by numerous staff members and injected with sedatives will also never leave me.”

Having already won regulation in several other states, Hilton made clear that she wants federal oversight of the mental and behavioral health facilities — even as the reality star bumps up against the reality of this contentious Congress.

“If you are abusing children, I will find out,” Hilton said. “I will find you and I will come with my huge spotlight and shine it on wherever you are.”

Hilton visited D.C. last year to advocate the federal Stop Institutional Child Abuse Act, which would establish best practices and transparency in youth residential care programs.

But the proposal is stalled in Congress, and similar federal efforts have failed for more than a decade.

After the 2020 release of the documentary “This is Paris,” in which Hilton details abuses that she said she faced while attending Provo Canyon School in Provo, Utah, she has testified at state capitols, supporting successful bills in Missouri, Montana, Oregon and Utah.

Now, fresh off the Coachella slide with pal Kesha, Hilton is eyeing the most populous state.

There is no formal opposition to the bipartisan bill, which passed unanimously out of the state Senate’s Human Services Committee. It still has multiple steps before passage, including consideration by the full membership of both houses of the legislature.

The National Association of Therapeutic Schools and Programs, the nation’s largest such member organization, told KFF Health News that it supports the California bill as well as federal proposals.

Republican state Sen. Shannon Grove of Bakersfield, the bill’s lead author, said the goal is to protect young people housed in short-term residential therapeutic programs. Her legislation would require the California Department of Social Services — which licenses the facilities — to produce a public dashboard by 2026 on the use of restraints and seclusion rooms as well as serious injuries or deaths associated with them.

“There are complaints of broken arms, slammed hands in doors,” Grove said, noting that the facilities typically house vulnerable populations, including foster youths. “There’s no data to show what happened and what caused that. And so, the goal is to go after the data.”

Grove certainly found an ally in Hilton and her 16.4 million followers on the social platform X.

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On a narrow street lined with row houses and an auto body shop in the Kensington neighborhood of North Philadelphia, Marsella Elie climbs a home’s front steps and knocks hard on the door.

A middle-aged man appears with a wary look on his face.

“Hello, sir, how are you doing today?” asked Elie, wearing a royal-blue jacket embroidered with the city government’s Liberty Bell logo. “My name is Marsella. I’m working with the city. You heard about the overdoses that are going around in the neighborhood, right?”

The man gives a cautious nod.

Elie gestures to the pamphlets she’s holding about drug overdoses and addiction treatment programs. She holds up a box of Narcan, a brand of naloxone, which can reverse an opioid overdose.

“What we’re trying to do is get this in everybody’s household. Have you ever heard of this before?” Elie asked before handing the man a tote bag filled with more pamphlets, fentanyl test strips, and the box of Narcan.

Elie and other part-time city workers and volunteers are part of a large-scale, citywide door-to-door campaign in Philadelphia that aims to equip homes with naloxone and other drug overdose prevention supplies.

City officials hope that this proactive approach will normalize naloxone as an everyday item in the medicine cabinet, and prevent people from dying of overdoses, especially Black residents.

In Philadelphia in 2022, a record 1,413 people died from drug overdoses, according to city data. Among Black residents, deaths were up 20% from the year before, with many happening in private homes.

“The best thing we can do to make these things more accessible is to just give them to people,” said Keli McLoyd, deputy director of the city’s Opioid Response Unit, speaking about the tote bag with naloxone and other supplies. “We’re not asking you if you’re using drugs. The goal here is really to build sort of a collective responsibility. As Black and brown folks, as we saw during the covid epidemic, nobody’s coming to save us. For us, this is a tool that we can use to save ourselves.”

The canvassing initiative aims to take prevention supplies directly to people who might not otherwise seek it out themselves, and to spread awareness about overdoses beyond Kensington, the epicenter of the city’s addiction epidemic. Canvassers plan to knock on more than 100,000 doors in Philadelphia’s “hot spots” — ZIP codes with escalating rates of opioid overdoses, many in minority communities.

Widening racial disparities in overdose deaths are among the long-term consequences of the war on drugs, McLoyd said. Policies from that national anti-drug campaign led to decades of aggressive police tactics, racial profiling, and lengthy prison sentences, disproportionately affecting people of color and their communities.

Research shows that Black Americans still account for a disproportionate number of drug arrests and child protective services.

“Because of that, it’s very clear why Black or brown people might be hesitant to raise their hand and say, ‘I’m a person who uses drugs, I need those resources,’” McLoyd said.

Other communities have distributed naloxone and other supplies, albeit on a smaller scale than Philadelphia.

What Philadelphia is doing could become a model for other densely populated places, said Daliah Heller, vice president of drug use initiatives at Vital Strategies, a public health organization working with local governments in seven states to address the opioid epidemic.

“There’s something intensely personal about a human engagement,” Heller said. “And somebody knocking at your door to talk about drug use and overdose risk and that there’s something that can be done, I think is really powerful.”

Over the years, naloxone has become more accessible than ever before, Heller pointed out. It can now be ordered online and through the mail, it’s available in specialized vending machines, and some drugstores now sell Narcan nasal spray over the counter.

But tens of thousands of Americans are still dying from opioid overdoses every year. That means prevention efforts and messaging about the crisis are still not reaching some people, Heller said. And to her, reaching people means meeting them where they are. “That means physically, that means in terms of what they know about something, what their perception is of something, and their beliefs,” she said. “We need to think like that when we think about naloxone distribution.”

The Philadelphia canvassing project is funded in part by the city’s share of settlement payouts from national lawsuits against opioid manufacturers and distributors. The city is set to receive about $200 million over roughly 18 years from settlements with AmerisourceBergen, Cardinal Health, McKesson, and Johnson & Johnson.

The initiative is staffed by many of the same people who initially started canvassing as part of the 2020 census count.

Not everyone answers the door for the canvassers. Some aren’t home when they come around. In those cases, workers hang a flyer on the door handle that offers information about overdose risks and contacts for further resources. The teams of canvassers, often with language interpreters, later make a second sweep through a neighborhood to reach people they missed the first time.

On a recent Thursday, Philadelphia canvassers were knocking on doors in the Franklinville and Hunting Park neighborhoods. In this ZIP code, about 85 people died of drug overdoses in 2022, according to city data. That’s fewer than the 193 people who died of overdoses in Kensington in 2022, but much higher than the few deaths seen in the city’s most affluent neighborhoods.

The canvassers approached a resident, Katherine Camacho, on the sidewalk, as she came out of her garage. Camacho told the teams she was aware of the overdose problem in her community and then eagerly accepted a box of Narcan.

“I will carry this with me, because, like I said, sometimes you’re in the street driving somewhere and you could save a life,” Camacho told them. “And if you don’t have these things, it’s harder to do so, right?”

Camacho said she’s seen how the opioid crisis has caused suffering in her neighborhood and across the city. As for Philadelphia’s canvassing effort, she said she believes that “God is putting these people to help.”

As she headed into her house carrying the box of Narcan, Camacho said she wanted to do her part to help, too.

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

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