The single largest cut in Gov. Gavin Newsom’s latest budget proposal threatens to undo a multibillion-dollar deal he made with health care industry leaders last year to shore up the state’s expansive public insurance program with a new tax. 

Newsom wants to take $6.7 billion that had been earmarked for increased Medi-Cal payments to health care providers and instead use it to help plug the ballooning state deficit. Providers last year agreed to be taxed to generate that money with the stipulation that it be invested in Medi-Cal, the state’s insurance program for lower-income households.

Newsom said his budget proposal preserves core services for programs like Medi-Cal and emphasized that his administration has expanded services “like no other state in U.S. history has ever expanded.”

“We are maintaining that,” Newsom said during a recent budget presentation.

Groups representing doctors, hospitals and patients warn the cut would weaken an already overburdened health care system that serves one-third of the state’s population. Industry groups have gathered signatures to place a measure on the November ballot that would overrule any cuts made in the state budget and to prevent Newsom and future governors from repurposing Medi-Cal funds.

“We are deeply disappointed that the governor’s proposal jeopardizes access to health care for millions of Californians,” the Coalition to Protect Access to Care, the group supporting the ballot measure, said in a statement.

The coalition is the same group that brokered last year’s deal — known as the Managed Care Organization, or MCO, tax — and is primarily supported by the California Medical Association, California Hospital Association, ambulance operators, Planned Parenthood Affiliates of California and health insurers. 

Under the original deal, the health insurance plans serving Medi-Cal patients would get taxed in order for the state to claim a dollar-for-dollar matching amount of money from the federal government. The promise was that the money generated — upwards of $35 billion for the state over four years — would be invested in the Medi-Cal system to increase reimbursement rates and attract doctors and other providers who otherwise say they don’t get paid enough. 

Instead, Newsom’s new proposal increases the tax on health plans, uses the new money to alleviate the deficit, and cancels planned Medi-Cal rate increases for emergency room doctors, specialists and certain other providers. Increased payments that started in January for primary care, obstetrics and mental health would not be touched.

“This is mind-boggling for the public, but really the story is about equality,” said John Baackes, chief executive of L.A. Care Health Plan, the largest publicly operated health plan in the country. 

For the past decade, California lawmakers have steadily restored Medi-Cal services cut during the Great Recession, added new ones, and expanded eligibility to include all low-income Californians regardless of citizenship. Today Medi-Cal covers things like dental exams, hearing aids, doula services and acupuncture. It is one of the most comprehensive public insurance plans in the country.

Expanding Medi-Cal access

L.A. Care serves more than 3 million Medi-Cal members in Southern California. Between January and March, more than 164,000 new members were enrolled when California granted Medi-Cal to working-age, undocumented immigrants. But increasing enrollment and benefits without providing more incentives to providers has strained the health system to a breaking point, Baackes said.

“Nobody is saying that the state doesn’t have a (budget) problem. We know they have a problem, but the cost that’s going to be paid by the people who benefit from the Medi-Cal program is very difficult for the providers to accept,” Baackes said.

In recent budget hearings, representatives from the Newsom administration said they were trying to protect Medi-Cal’s core services while balancing a $27.6 billion deficit.

“These decisions and proposals are difficult and not put forward lightly,” said Michelle Baass, director of the Department of Health Care Services, which oversees Medi-Cal, during a recent Assembly budget hearing.

At that hearing, lawmakers who approved the tax deal last year accused the administration of not being honest about how the money would be used. 

“I’m just wondering if any of the discussions we’ve had about the shortages, the closures, the issues that we have on the ground, the workforce shortages, if any of those things came into thought as you were trying to preserve core services, which is important, but if you don’t have providers to go to, what have we done?” said Assemblymember Akilah Weber, a Democrat and obstetrician from La Mesa, in the hearing. 

Looking to California’s November election

Jarrod DePriest, president of Maxim Healthcare Services, said he was shocked to learn the “dollars meant to protect Medi-Cal” could be diverted. DePriest’s company provides home health services, such as nurses for people who would otherwise be confined in a hospital. A majority of its clients are children with complex health needs like cerebral palsy or severe respiratory problems, DePriest said. 

Between 2018 and 2024, the number of nurses his company employs dropped by half because Medi-Cal reimbursement rates haven’t kept up with salaries and inflation, DePriest said. Consequently his company serves nearly 10,000 fewer patients.

“Down the road things will get worse and worse,” DePriest said.

His group and others, like air ambulance operators, were not included in the original Medi-Cal rate deal and are fighting for some of the tax revenue — but it’s unlikely with the current deficit. The proposed cuts signal to them that the state is unwilling to invest in Medi-Cal, which is exactly what ballot measure proponents hoped to avoid.

Dustin Corcoran, president of the California Medical Association and leader of the ballot coalition, said providers will only accept more Medi-Cal patients if they are confident the state will fund the program permanently.

“Medi-Cal has been underfunded for so long, one of the things we were trying to accomplish was the predictability and stability of rates,” Corcoran said. “You can’t have providers in situations where they don’t believe in consistency in the rates, and they have to choose between bankruptcy and patient abandonment. That shouldn’t be a choice that a provider ever has to make.”

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

In just the first few months of 2024, four California hospitals have closed or announced plans to close their maternity wards.

The closures are part of an accelerating trend unfolding across the state, creating maternity care deserts and decreasing access to prenatal care. In the past three years, 29 hospitals stopped delivering babies, according to a CalMatters investigation on maternity ward closures. Nearly 50 obstetrics departments have closed over the past decade.

Now, California lawmakers are trying to slow the trend. 

Assemblymember Akilah Weber and Sen. Dave Cortese are pursuing legislation to increase transparency around planned maternity ward closures, potentially giving counties and the state time to intervene. 

Weber, a Democrat from La Mesa, wants hospitals to notify the state a year in advance if labor and delivery services are at risk of ending. The measure would also require the state to conduct a community impact report when a hospital indicates that it may lose maternity care. 

Cortese, a Democrat from Campbell, wants to increase the public notification requirement of an impending closure from 90 days to 120 days and require the hospital to conduct an analysis of how a closure could increase costs for the county health system, where the next closest maternity wards are located and who is most likely to be affected. 

Cortese’s bill would also require increased notification for planned closures of inpatient psychiatric services.

“We cannot continue to just discuss these issues and not implement policies to prevent or mitigate the harms and the continued disparities,” Weber said during an Assembly Health Committee hearing Tuesday. 

Groups representing doctors and reproductive health advocates support the measure. Cortese’s bill is supported by nurses and consumer health advocates.

Why Are Maternity Wards Closing?

Ryan Spencer, a lobbyist for the regional chapter of American College of Obstetricians and Gynecologists who testified in support of Weber’s measure, said there are often situations during birth where “every minute can be the difference between life and death.”

“What if you are a patient like this and literally had nowhere to go who had to drive hours upon hours to get care? We have to find a way to end this crisis,” Spencer said during his testimony.

Maternity wards are closing for a number of reasons, according to hospital administrators. They cite labor shortages, increasing costs, low reimbursements and declining birth rates. 

The California Hospital Association opposes Cortese’s bill and has registered “concerns” about Weber’s. The group argues that neither bill will address the underlying reasons for maternity ward closures and may cause hospitals to terminate services sooner as employees leave and patients look elsewhere for care, said Kirsten Barlow, vice president of policy with the hospital association during a Senate hearing earlier this month.

Current law requires hospitals to notify the public 90 days before a proposed service cut, but doesn’t require additional notification to be given to the state. Weber said that 90 days is “clearly not sufficient for the state to be able to intervene.”

Maternity Care Deserts Emerge

CalMatters found that 12 counties have no hospital delivering babies, including Madera County where the sudden closure of the county’s only hospital in 2022 spurred a flurry of emergency legislation supporting distressed hospitals. 

Madera Community Hospital now is on track to reopen, but without a maternity ward. The company reopening the hospital, American Advanced Management, has indicated that low insurance reimbursement rates factored into its decision to open without labor and delivery.  

“Reopening maternity would be like reopening two hospitals at the same time,” Matthew Beehler, chief strategy officer at American Advanced Management, previously told CalMatters. 

Still, the bill authors and advocates are adamant that access to maternity care is a necessity. National studies indicate that rates of preterm birth increase and women receive less prenatal care when labor and delivery units shut down, particularly in rural areas. CalMatters found that maternity closures in California disproportionately impact low-income and Latino communities.

“This is really a very simple bill. It doesn’t do much. It creates a public hearing opportunity at the local level to deal with issues that are…absolutely vital to the survival of our constituents,” Cortese said during a Senate Health Committee hearing on his measure.

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters. 

This article was supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

Perla Lopez hands a stack of papers to Baudeilio, a 44-year-old undocumented immigrant and day laborer. She has just helped him apply for Medi-Cal at the benefits center at St. John’s Community Health’s in South Los Angeles. 

“If you see anything you don’t understand from the county, come back here,” Lopez tells Baudeilio in Spanish.

The application takes less than 20 minutes. The paperwork, though brief, marks a major milestone in California’s decades-long expansion of health care for undocumented immigrants. 

Beginning Jan. 1, for the first time, undocumented immigrants of all ages will qualify for Medi-Cal, the state’s health insurance program for extremely low-income people. It makes California the only state to fund comprehensive health care for undocumented immigrants.

Baudeilio, who has been denied coverage before and asked that his last name not be published to protect him from immigration authorities, will join more than 700,000 undocumented immigrants between the ages of 26 and 49 who will become eligible for Medi-Cal as part of the state’s final expansion of the program — the realization of a long-awaited dream for Californians without legal status.

“This is the culmination of literally decades of work, and it’s huge,” said Sarah Darr, policy director for the California Immigrant Policy Center. “It’s huge because of all the work and effort and advocacy that went into making this possible, and it’s also huge because of the impact that it’s going to have.”

Gov. Gavin Newsom and the state’s Democratic-led Legislature have committed more than $4 billion to the Medi-Cal expansion annually. Newsom’s 2022 budget made the latest expansion possible, and though the state is now headed into a $68 billion deficit, advocates say the positive impact Medi-Cal will have on individual health is priceless.

The change resonates deeply with Lopez, who is herself undocumented.

Last year, when the state expanded Medi-Cal to older immigrants over 50, Lopez’s mother was finally able to get medication and blood testing equipment for her diabetes. This year, surrounded by tinsel and other Christmas decorations in the brightly lit office, Lopez is happy she gets to deliver good news to undocumented patients. 

“It really touches me,” said Lopez, who is eligible to work through the Deferred Action for Childhood Arrivals program. “It’s a stressor we take away from them…For people with health issues, Medi-Cal really makes a difference.”

The clinic where Lopez works estimates about 13,000 of its patients will become eligible for Medi-Cal in the new year. They’re part of the largest group in California’s ambitious plan to close the insurance gap. Los Angeles County alone accounts for roughly half of the enrollees who are expected to qualify for Medi-Cal.

“It’s an exciting moment for our patients as well as for us,” said Annie Uraga, benefits counselor coordinator at St. John’s Community Health. “They’re ready. Many of them are in need or waiting for specialist visits.”

California’s Health Insurance Expansion

The final expansion comes nine years after then-Gov. Jerry Brown signed the law making undocumented children eligible for state insurance in 2015, and is due to the efforts of advocates trekking to the Capitol to plead their case.

“When we talk to people who are impacted by this, the difference it makes in their lives is something that truly numbers and words cannot even describe,” Darr with the California Immigrant Policy Center said. “In many cases people have lived for decades without any kind of health care whatsoever.”

Full-scope Medi-Cal, which offers access to primary and preventive care, specialists, pharmaceuticals, and other wraparound services, will change lives, Darr said. California does not share immigration information with federal authorities, and enrolling in Medi-Cal will not threaten chances to pursue legal residency, something known as the public charge rule.

The California Immigrant Policy Center along with consumer advocacy group Health Access California have been the leading force in the campaign to eliminate citizenship requirements for Medi-Cal. The work was not easy even in left-leaning California. Many moderate Democrats voted against the legislation or refrained from weighing in on the debate in the early days, Darr said, but slowly, public opinion and political will shifted.

About 66% of California adults supported health coverage for undocumented immigrants in March 2021, up from 54% in 2015, according to a survey by the Public Policy Institute of California. 

Former Republican President Donald Trump lambasted California’s expansion for young adults in 2020, and claimed California and other states would “bankrupt our nation by providing free taxpayer-funded healthcare to millions of illegal aliens.” Elected California Republicans, though less harsh in their condemnation of the state’s immigration policies in recent years, have accused Newsom of overloading the state’s budget and Medi-Cal system. 

“Medi-Cal is already strained by serving 14.6 million Californians — more than a third of the state’s population. Adding 764,000 more individuals to the system will certainly exacerbate current provider access problems,” the Senate Republican Caucus said in a January 2022 budget analysis.

Newsom, for his part, has played a critical role in propelling the movement forward, said Rachel Linn Gish, communications director for Health Access California. Newsom, who took office in 2019, campaigned on the promise of establishing universal health care in California, and advocates have spent the duration of his governorship pushing him to keep that promise.

“You cannot talk about coverage for all if you’re not talking about coverage for everyone regardless of their immigration status,” Linn Gish said. “Gov. Newsom made it a major platform of his from day one, and I think it’s hard to untie those two things.”

Still, Newsom has faced pressure to do more for undocumented immigrants and to do it faster. Advocates and some legislators lobbied Newsom to roll out this last expansion sooner, in part because of the disproportionate toll COVID-19 took on essential workers, many of whom are undocumented.

This expansion is projected to cost more than $835 million in the next six months and $2.6 billion every year thereafter. Previous expansions, which opened the door to more than 1.1 million undocumented enrollees, cost the state approximately $1.6 billion annually, according to past Legislative Analysis Office reports. The total $4 billion price tag, though significant, represents a fraction of Medi-Cal’s expansive $37 billion budget.

Still, many undocumented Californians will remain ineligible for health insurance. Roughly half a million immigrants make too much money to qualify for Medi-Cal but still can’t afford private insurance. Advocates want to expand Covered California to include that population, but the state’s ballooning deficit makes that unlikely in the near future.

Health Disparities Among Undocumented

Undocumented immigrants often avoid medical care, making it difficult to compare their health to other Californians. Some studies indicate they experience higher rates of chronic conditions like heart disease, asthma and high blood pressure. Immigrants without legal status in California are also more likely to suffer from mental distress and self-report poor health.

Dr. Efrain Talamantes, chief operating officer at AltaMed in Los Angeles, the largest federally qualified health center in California, said he frequently sees young, undocumented individuals who feel healthy but “already are having the end damage of chronic conditions that have not been detected.”

The change will allow Talamantes and others who serve those communities to give patients affordable, high-level care. Although California offers many undocumented immigrants emergency Medi-Cal and some counties fund their own programs, services can be disjointed with monthslong wait times. 

“When these patients now receive Medi-Cal and are part of a managed care health care plan with us, then we’re responsible for their entire care from primary and specialty to hospital care,” Talamantes said.

Miriam Pozuelos is one such person. The Los Angeles-area mother said the expansion lifts a huge financial burden from her family. She and her husband pay out-of-pocket for any medical services, and often go without. Both have already applied to full-scope Medi-Cal for January.

“When me and my family heard about this expansion, we were just really hoping that it would actually come true and that we can start getting the care that we need and not be worried about ‘I have to pay this enormous bill,’” Pozuelos said in Spanish.

Back at the St. John’s Community Health benefits center, Lopez helps another undocumented immigrant renew his emergency Medi-Cal, which will automatically roll over to full-scope next month. Wilder, 41, who requested his last name be withheld to protect him from immigration authorities, said he needs two root canals totaling $8,000. He has searched for months for a cheaper option without success, Wilder said. He also needs medication for high blood pressure but can’t always afford it. 

The Medi-Cal expansion means he’ll finally be able to take care of his health, he said. 

“It’s nice seeing them leaving happy and smiling,” Lopez said. “Even if it takes us three hours, they leave with a sense of relief that they can see the doctor.”

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters. 

Health coverage is supported by the California Health Care Foundation, which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

Ashley Hooks always planned to retire at Lakewood Regional Medical Center, where she has been a nurse for 12 years. But now, Hooks said, staffing issues are so bad and burnout so severe that she’s rethinking how she wants to spend the rest of her career. 

Since the COVID-19 pandemic began, the number of nurses at the hospital dropped from just below 500 to 330 according to her union’s roster, said Hooks, who is 53.

“It wasn’t even this difficult during the height of the COVID pandemic,” she said. 

Hooks’ stress reflects pressure many California nurses are under because of steep understaffing that she and others say is driving many professionals out of the industry.

According to the Hospital Association of Southern California, nursing vacancy rates among local hospitals exceed 30%. Prior to the pandemic the average vacancy rate was 6%.

“Within the last year and a half or so, it’s really gotten worse,” Hooks said.

Now the Legislature is looking at several ideas to address the nursing shortage by bringing more early-career nurses into the field. But so far, the groups with most to gain — or lose — are at odds over how to solve the staffing problems afflicting California’s health care workforce. 

Labor organizations and hospitals want nursing schools to prioritize certain applicants for admission, such as people who already have experience in the industry.

“We don’t have enough nurses entering the system as opportunities are opening up for them to leave the system,” said Peter Sidhu, a nurse and executive vice president of United Nurses Associations of California/Union of Health Care Professionals. 

But the schools say that won’t help them graduate more nurses. They need more faculty and more hands-on training opportunities to increase class sizes. 

Hospitals and unions say they don’t have much time to waste. Estimates show California faces a shortage of about 36,000 licensed nurses, according to the UC San Francisco Health Workforce Research Center on Long-Term Care. 

Preliminary data from a statewide survey conducted in 2022 shows nurses cut back on the number of hours worked per week since 2020, and nearly half the workforce reports symptoms of burnout, said Joanne Spetz, director of the Institute for Health Policy Studies at UC San Francisco, who has studied nursing workforce issues for more than a decade.

More nurses, even those as young as 35, are thinking about leaving the profession entirely or retiring within the next two years, and half of the workforce had at least one patient die of COVID-19, Spetz said. 

“There is a lot of trauma in the nursing workforce,” Spetz said. “The numbers are not good.”

Union-Backed bills for Nursing Shortage

Labor advocates say the nursing shortage creates a vicious cycle. The nurses on shift wind up doing more work. They get burned out and flee the industry, worsening the problem. 

Service Employees International Union (SEIU) and the United Nurses Associations of California/Union of Health Care Professionals turned their attention to the state’s community college system, where graduates can earn degrees to become nursing assistants, licensed vocational nurses or registered nurses. Both groups say community colleges offer the most affordable and efficient way to earn a nursing degree.

One of their ideas aims to help high school students get into nursing schools faster. Another would give entry-level workers the chance to move into more skilled and higher paid positions like nursing.

Sidhu’s union is sponsoring a bill that would create a pilot program for high school students who take extra classes to have preferential admission into a community college nursing program.

A second measure, which is co-sponsored by SEIU and the California Hospital Association, would require community colleges to set aside 15% of enrollment slots for health care workers looking to further their education with a more advanced degree. They say helping current workers get higher-paying jobs within health care will help with retention. 

“When we talk to our hospital members, workforce issues are the number one thing that keep them up at night,” said Jan Emerson-Shea, spokesperson for the California Hospitals Association. “We also hear from employees that they’ve tried getting into community college programs, but because they’re so impacted, it can take them three, four or five years to get into the program.”

California Colleges Skeptical of Union Bills

But community college and some university nursing school leaders contend neither bill will boost the number of graduates. Nursing programs are full, they say, and the proposals do nothing to expand the number of admission slots.

“These bills come up and I wonder who on earth would propose something like this to impact the community colleges without getting our input,” said Tammy Vant Hul, south region president of the California Organization of Associate Degree Nursing Program Directors. 

Vant Hul is also dean of nursing at Riverside City College, the second largest community college nursing program in the state. High school students would not have completed enough prerequisites to apply directly to a nursing program, much less be guaranteed admission, Vant Hul said, and existing health care workers already get additional points during the admissions process. 

The problem isn’t generating career interest in nursing; it’s creating more spots, program leaders say.

Karen Bradley, president of the California Association of Colleges of Nursing, said nursing programs have an overabundance of competitive applicants.

“We have not had a dip at all in enrollment in my program. I have a waiting list,” said Bradley, who is also dean of California Baptist University’s nursing program. “Every dean is going to tell you that they have a waiting list or enough qualified applicants that they turn away students.”

About 14,000 new students enrolled in nursing programs during the 2020-21 school year, according to the Board of Registered Nursing’s annual school report. That’s about 1,000 fewer students than the previous two years due to smaller class sizes, but schools across the state received more than 55,000 applications, a 10-year record.

The bills’ sponsors say they have spoken with the California Community Colleges Chancellor’s Office, which has not taken a position on any of the workforce bills.

Separate from the bills, United Nurses Associations of California/Union of Health Care Professionals lobbied for a $300 million investment over five years to double the state’s nursing school capacity. It was included in the state budget Gov. Gavin Newsom signed earlier this summer.

The details of how the money will be spent have not been decided, Sidhu said, but it could be used to increase faculty salaries and overcome other factors that limit class sizes.

More Room Needed for California Nurse Trainees  

Representatives for nursing programs say the money will be helpful, but they’re worried about other bottlenecks that they say prevent them from enrolling more students.

Lack of nursing faculty caps class sizes, for instance, with potential educators instead choosing to make more money working in health care. They also say hospitals are not offering enough opportunities for their students to get hands-on training.

“As we move forward with the nursing shortage, clinical placements are an issue. So many hospitals kind of downsized their willingness to bring on students during the pandemic, and those spots never came back,”  said Linda Zorn, legislative chair for the California Organization of Associate Degree Nursing and executive director of economic and workforce development for Butte-Glenn Community College District.

A third proposal in the Legislature attempts to clear that hurdle by guaranteeing clinical placement spots for community college students. A mix of opponents are fighting the bill, including hospitals, four-year universities and some community college advocates who say it will take spots away from other students and overwhelm nursing staff.

“Some hospitals aren’t big enough. They can’t take on hundreds of students. They have 25 beds,” said Sarah Bridge, senior legislative advocate for the Association of Health Care Districts, which represents primarily small, rural hospitals in the state.

During the 2020-21 school year, the most commonly cited reason by nursing schools for decreasing class sizes was “unable to secure clinical placements,” according to the Board of Registered Nursing’s annual school report, in part due to workforce challenges resulting from the pandemic. The report states that more than 15,000 students were impacted by restricted training spots compared to roughly 2,200 students during the 2018-19 school year.

Bridge said many small and rural hospitals also are teetering on the edge of a financial crisis. It costs about $7,000 to train one student, not including the salary cost of nurses who supervise students. Multiply that by the number of student trainees accepted and some hospitals can’t foot the bill, Bridge said.

Zorn said nursing schools know they have to be sensitive to how many students get sent to any one hospital, which is part of the reason many are skeptical of the bill. The number of student training spots recently has been limited by the profession’s thinly stretched workforce. 

“It can close down the rural hospitals if you don’t have the correct staffing,” Zorn said.

Leaders from four-year degree programs also say the proposal would displace their nursing students in favor of community college students.

The bill sponsors say the intent of the legislation is to create more training capacity, not to displace existing students, as some critics have claimed, said Eric Robles, legislative director for United Nurses Associations of California/Union of Health Care Professionals. 

“If hospitals are getting bailouts, I would sure hope everybody believes our nurse workforce needs a bailout too,” Robles said. “And that bailout can come through strengthening the pipeline, growing the workforce and maintaining the workforce.”

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

Premiums for health insurance sold through the state marketplace will increase by nearly 10% next year, the highest rate hike since 2018, Covered California officials have announced.

The projected 9.6% hike is the result of a “complicated time for health care,” Covered California Executive Director Jessica Altman said during a media briefing, but many Californians will be shielded from the increases as a result of federal and state financial assistance. 

About 90% of enrollees qualify for some type of federal or state financial aid and 20% will see no change in their monthly premium, officials said. About 1.6 million Californians turn to the marketplace for health insurance, which offers plans that cost as little as $10 a month.

The rate increase, however, represents the return of a troubling trend: runaway health care costs, experts said.

“We’re seeing even larger increases in the private market. It’s worrisome,” said Anthony Wright, executive director of Health Access California, a consumer advocate group. “Individual consumers need health coverage and they need help now.”

During the COVID-19 pandemic, an influx of $3 billion from the federal government helped dampen the effect of rising health care costs in California. Covered California premium increases held below 2% between 2020 and 2022. 

The federal government extended assistance for two more years, but the 2024 increase reflects post-pandemic inflationary pressures, such as higher drug costs, more people going to see the doctor, labor shortages and wage costs, Altman said.

The rate hikes vary by region, with more than one-third of enrollees potentially experiencing a double-digit increase, according to state data. Those who live in Mono, Inyo and Imperial counties may see the largest price increase at 15.8% compared to last year. Those same counties also experienced the largest increase last year.

“We’re glad that Covered California has federal and state subsidies to provide immediate help now, but we do need policy makers to double down on containing the costs of health care long-term,” Wright said. “This is a clarion call for the overall cost of health care going forward.”

Covered California Waives Deductibles for Many

Last week, the Covered California board voted to implement a plan that will make coverage more affordable for about 650,000 enrollees by eliminating their deductibles for the coming year. 

The vote capped a drawn-out budget battle between Gov. Gavin Newsom, legislators and health care consumer advocates who have criticized Newsom for repeatedly moving money intended for health care subsidies into the state’s general fund.

Under the plan, deductibles will be eliminated for individuals earning as much as $33,975 annually and families earning up to $69,375 annually. Previously, people with those plans paid deductibles of up to $5,400. The new plan also significantly reduces out-of-pocket copays for doctor visits and prescription drugs.

“Despite the rate increase, Californians who enroll in health care coverage through Covered California will benefit from the greatest level of financial support ever offered…as we head into 2024,” Altman said.

‘Hefty’ Health Insurance Increase

Christine Eibner, a senior economist with the RAND Corporation, a research and policy think tank, called the state’s projected premium increase “hefty.”

“There will be some sliver of people who will have to pay the full cost,” Eibner said. “A lot of people are protected so maybe they don’t care, but who is paying? Ultimately it’s the taxpayer.”

A significant number of people who are no longer eligible for Medi-Cal, the state’s public insurance program for very low-income individuals, also are expected to enroll in Covered California, which could drive future cost increases. 

“That population is relatively expensive,” Eibner said. “People who are lower income have more health care issues, and bringing them into the market may lead to higher premiums.”

The state paused checking people for Medi-Cal eligibility during the federal COVID-19 public health emergency, but about 225,000 Californians have been kicked off since the state resumed monthly reviews this year. Covered California’s enrollment period runs from November through the end of January. 

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

California is preparing to close dozens of state-run COVID-19 testing and treatment sites ahead of the planned end of the state of emergency in February. 

Sites that are operating under 50% capacity are scheduled to close before the end of January. Forty-four OptumServe sites were to be shuttered this week, and 48 mobile “mini-buses” will begin closing in two weeks, according to the California Department of Public Health.

OptumServe, a health care operations company, runs 123 testing and treatment sites along with four vaccination clinics through state contracts. 

The health care giant has at least four contracts, under its former name Logistics Health, with the state totalling $1.05 billion to provide testing and vaccination services though it has been criticized in the past for its bumpy rollout. Another branch of the company signed an additional $47 million contract to design a data management system for COVID-19 test results.

“A final plan for demobilizing the remaining sites is being prepared, but we have not set a completion date,” an unidentified department spokesperson said in a statement. The state health department would only answer emailed questions and did not attribute the statement to a person.

The state of emergency, which has provided extra funding and staffing flexibilities at medical facilities, is slated to end on the last day of February.

The closures come just one week after Gov. Gavin Newsom released his January budget proposal, which moves $614 million in unspent COVID-19 response funds to the state’s general fund and drastically reduced the amount of pandemic money for the upcoming year. 

Last year’s budget included $1.8 billion for COVID-19 emergency response and the state’s long-term strategy, while the proposed budget for the upcoming fiscal year is only $176.6 million. The cutbacks come as the state faces a projected $22.5 billion deficit, according to Newsom’s proposal. State Health and Human Services Secretary Dr. Mark Ghaly said in a budget call with reporters that the bulk of the proposed decrease comes from fewer state testing responsibilities, but he emphasized that the spending reductions are not “a statement about moving on from COVID in California.”

“We will continue to seek opportunities to support public health,” Ghaly said. “We learned a lot through this COVID response, and we need to make sure we don’t lose those gains.”

Demand for molecular COVID-19 testing has plummeted statewide since last January, when the omicron variant pushed hospitals to the brink of collapse. At the time, more than 800,000 PCR test results were reported for a single day and more than 15,000 people were hospitalized with COVID-19 at the peak of the surge. In comparison, less than 30,000 test results and 4,600 hospitalizations were reported on the final day of December (the most recent day with finalized tallies, according to state data).

Across the state, county health departments are preparing for the closures and absorbing the costs into their own budgets.

In Los Angeles County, OptumServe will stop operating four sites, but the county will contract with another vendor to keep the doors open, a county health services spokesperson said via email. 

“It is important to underscore that the change will be seamless,” the health services communications office told CalMatters in an unsigned statement. “Community residents seeking a testing site will not experience any disruption to the existing services.”

During a media briefing last week, L.A. County Public Health Director Barbara Ferrer said the county was committed to ensuring there are “ample” testing and vaccination options.

In other areas of the state, health departments are unable to run the sites alone. All five OptumServe sites in Fresno County will close by Jan. 31. Only one of the sites is currently operating above 50% capacity, public health spokesperson Michelle Rivera said. The mobile test-to-treat buses will stop services the first week of February.

Community members will still have options, Rivera said. The county health department is continuing to work with community-based organizations, UCSF-Fresno and Fresno State’s nursing school to keep offering testing, treatment and vaccination services throughout the area. The Fresno County Board of Supervisors also approved funding for a rural mobile health program to deliver health care to farmworker and other rural communities.

Fresno County has been hit particularly hard by the latest post-holiday wave of COVID-19 as well as concurrent flu and respiratory syncytial virus surges, issuing emergency do-not-transport orders to EMTs for the sixth time since the start of the pandemic to combat overflowing emergency departments. Do-not-transport orders, also known as assess-and-refer, require ambulance personnel to determine whether a patient requires emergency transportation or if they are stable enough to be referred to a non-emergency medical facility like primary care.

In Santa Clara County, state-run sites are also slated for closure in the coming weeks, emergency operations spokesperson Roger Ross said. The county will, however, continue to run three mass vaccination sites and has already begun folding COVID-19 response into the health department’s normal operations.

“Public health recently created a COVID Prevention and Control Program as part of our standard operations. Most of the work now resides here,” Ross said. “Unfortunately, it appears we will be dealing with COVID for the long haul.”

In Orange County, where COVID-19 health orders have at times drawn public ire, testing and vaccination strategies will largely move to “the open marketplace where individuals will self-manage COVID-19” through primary care and other community resources, the health department announced last month in a news release. County-run vaccine sites, which were serving about 200 patients per week, were closed in December, although the health department continues to offer vaccinations for vulnerable populations like unhoused individuals, said Obinna Oleribe, deputy chief of Orange County public health services.

The federal government requires health insurance plans to cover eight over-the-counter COVID-19 tests per person per month, including FDA-approved at-home PCR tests. Every household can also order four free rapid tests from the federal government. When used appropriately, at-home tests of all kinds are considered highly accurate, although data shows PCR tests are more reliable. 

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

Living on the streets of California is a deadly affair. The life expectancy of an unsheltered person is 50, according to national estimates, nearly 30 years less than that of the average Californian.

As homelessness spirals out of control throughout the state, so too do deaths on the street, but it’s those whose lives are the most fragile who are least likely to get medical care.

Now, the state Medi-Cal agency is endeavoring to improve health care access for people experiencing homelessness. Through a series of incentives and regulatory changes, the Health Care Services Department is encouraging Medi-Cal insurers to fund and partner with organizations that bring primary care into encampments.

They’re known as street medicine teams. There are at least 25 in California.

“Oh crap. This is where she was, and they just swept that,” said Brett Feldman on a Friday morning in November, looking at a green tent, crumpled and abandoned on Skid Row in Los Angeles. Feldman, a physician assistant, is searching for a female patient in her 40s with severe and unmanaged asthma. She cycles predictably in and out of the hospital, and Feldman knows she’s due for another hospitalization soon.

The road is streaked with water from a cleaning truck, and sanitation workers in fluorescent vests sweep up debris. Parking enforcement and police cruisers line the section of road where a homeless encampment once stood. Nearly 5,000 people live in the half-mile block infamous for the hypervisibility it affords the state’s unrelenting homeless crisis.

Burdened by disproportionate rates of addiction, mental health disorders and chronic disease, people experiencing homelessness are some of the state’s neediest patients, but few receive anything more than emergency services. Barriers like lack of transportation and cumbersome insurance rules keep most from getting regular health care. Instead, they drift through the emergency room during a crisis, racking up high costs to the system and deteriorating physically in the interim. 

Delivering health care this way is costly and not particularly effective for the patient or the system. More than half of the state’s $133-billion Medi-Cal budget is spent on the top 5% of high-needs users, according to the California Department of Health Care Services. 

“Where we have been falling short, especially with this population, is their reality is so different from ours that we haven’t been building reality-based systems for them,” Feldman said. “They have Medi-Cal. They’re eligible for all these benefits, but they can’t access these benefits.”

The state’s efforts to bridge the gap between eligibility and access is supported in part through CalAIM, a multi-year plan to revamp the state’s low-income health insurance program. Grants to hire staff or invest in billing or data collection software  offer some stability to teams that have historically been volunteer- or charity-operated. The department also issued a rule change in November allowing street medicine teams to tap into and manage homeless patients’ Medi-Cal benefits, meaning providers can be reimbursed for their work. 

“One of our core principles of CalAIM is breaking down the walls of health care and meeting people where they are,” said Jacey Cooper, director of the state’s Medi-Cal program. “We really feel like street medicine helps us do that.”

Street Medicine Brings Health Care to Homeless

Several months ago, Feldman’s Skid Row patient suffered a brain injury from lack of oxygen during an asthma attack. She’s now confined to a wheelchair and reliant on a friend for basic needs like finding food and using the toilet. 

Newer asthma medications might be able to help end her hospitalization cycle, but until recently only her assigned primary care doctor, whom she has never seen, was allowed to refer her to a specialist for assessment under Byzantine Medi-Cal rules. Feldman had been trying to get her a primary care appointment for more than a year, to no avail.

Under the new rules, however, Feldman could have referred the asthmatic patient directly to the lung specialist she needed or gotten prior authorization for the medication since it was recommended during a hospital stay. Instead, without adequate medical care to address her condition, her life has been irrevocably altered.

Statistically, she’ll be lucky to live longer than a few more years.

“She used to be a staple down here. She knew everybody,” Feldman said. “Now, she can’t walk, is confined to her tent. She’s lonely because she’s used to being part of the Skid Row community. She had a very full life despite being unhoused.”

Feldman, co-founder and director of the street medicine program at the University of Southern California’s Keck School of Medicine, said the goal of street medicine is to give some autonomy back to people who usually have very little power left in their lives.

Each day he and a team of providers scour the county streets diagnosing chronic and acute conditions, treating mental illness and substance use, delivering medicine, drawing blood for tests and following up with patients who request a visit. Community health workers hand out food and hygiene supplies and help them navigate hurdles as they try to obtain housing and social services.

“We know that people who are experiencing homelessness have higher mortality, have higher ER utilization, have higher length of stay when they get admitted,” Cooper said. “We really see this as part of a comprehensive approach to ensuring that we have a true continuum of care for people experiencing homelessness.”

The traditional health care system thrives off efficiency: The more patients move through an office, the more the provider gets paid, resulting in brief appointments and little sympathy for circumstances that make patients late. But that setup doesn’t work for unsheltered people who run the risk of getting their belongings stolen if they leave their camp — or who would rather find something to eat than take care of what may seem like a minor malady.

Less than 30% of unhoused people with Medi-Cal have ever seen their primary care provider, according to a state legislative analysis of a street medicine bill vetoed by Gov. Gavin Newsom in 2021. The measure passed the legislature with broad support but was opposed by the state Health Care Services Department for potential duplication of services. In the veto, Newsom directed the department to work with street medicine teams to fill any gaps left out by CalAIM — one such gap was adjusting billing codes that prevented street medicine reimbursement.

“When you’re focused on those very basic needs, like food, safety, shelter, how are you then able to focus on, you know, managing your diabetes or your blood pressure or some of these risk factors that can lead to more serious downstream effects?” said Dr. Kyle Patton, medical director of the street medicine program at Shasta Community Health Center in Redding.

On a Monday in September, Patton and Anna Cummings, a case worker, trekked through a wooded area on the north edge of town to meet Amber Schmitt, 47, a patient with an infected leg. The ground is muddy from a storm the night before. Schmitt is paying a friend $700 a month to stay in his apartment, but hidden among the trees and rolling hills is her abandoned encampment, along with dozens of others. Schmitt gets $1,000 a month from Social Security, but it’s not enough to afford a security deposit or rent in the area, she said.

The gash on Schmitt’s right shin is mottled and inflamed. She said she scraped it on a fallen branch. Patton cleaned and dressed it for her previously, but she had no choice but to reuse bandages after running out. Now she can barely walk from the pain.

“This is a silver-based dressing, which will kill bacteria in wounds,” Patton tells Schmitt after rinsing the area with a saline wash. “We’ll get you some more dressing too. And then you’ve got some skin breakdown and maceration between your toes. I don’t like the look of that.”

He gives her a fungal cream and a bottle of antibiotics. Schmitt is a leukemia survivor and has had a hip replacement on the same injured leg. Her medical history makes her prone to infections and poor circulation in her extremities, Patton said.

“There’s people that would maybe make the argument that … they have health insurance here in California, they should just utilize the system as is. The reality is because of certain factors within the context of their homelessness, they’re not able to do that,” Patton said.

Although they qualify for comprehensive health coverage under Medi-Cal, the program wasn’t necessarily designed with homeless people in mind. For example, Medi-Cal will pay for transportation to and from a doctor’s appointment, but it requires the patient to provide a fixed address and give several week’s notice to the driver, something most people experiencing homelessness aren’t able to arrange. 

Link Between Homelessness and Health

Health data on homeless people are sparse, with no state agency and only a handful of counties tracking the information, but it’s clear that most of their deaths are preventable. 

In Alameda and Marin counties, half result from acute or chronic health conditions like cardiovascular disease, cancer or respiratory failure. In Orange County, these make up a quarter of deaths among the unhoused. In Los Angeles County, heart disease is the second-leading cause of death among people experiencing homelessness, second only to overdoses.

Even overdose deaths are considered preventable — yet in San Francisco, overdoses cause 82% of deaths among the unsheltered.

“We commonly see conditions that you would see in a typical population, but they’re just not addressed; so out-of-control high blood pressure, uncontrolled diabetes…also substance use in terms of opioids, we see a whole lot more than in the general population,” said Dr. Absalon Galat, medical director for LA County’s Department of Health Services’ Housing for Health division. 

Galat’s team started its foray into street medicine in an effort to dole out COVID-19 vaccines, but team members quickly found they needed to do more. The county used COVID-19 relief funds to purchase mobile clinics, and CalAIM funding has helped them hire 60 staff members.

In September, the county’s fleet of mobile clinics, complete with fully outfitted exam rooms, began visiting areas where services are sparse. Smaller teams of clinicians and case workers roam encampments to follow-up with patients, treat minor issues and bring patients to the mobile clinic. There’s some disagreement among street medicine providers about whether mobile clinics remove enough barriers because they still require patients to travel to a set location, but Galat said his goal is to improve access, whether it’s by wheel or foot.

“People are dying every day,” Galat said. “So we have to try with what we know best in the medical field right now to limit people who are dying.”

The connection between homelessness and health is inextricable, said Dr. Michelle Schneidermann, director of the People-Centered Care team at the California Health Care Foundation, a statewide health policy think tank.

“Either one can lead to the other. A catastrophic health incident or a series of conditions can lead to someone not being able to work, leading to poverty,” Schneidermann said. “We see this all the time, health conditions precipitating homelessness, and the other way around.”

Take Danny Doran, 56, who visited LA County’s mobile clinic at Whittier Narrows Park on a recent Thursday to pick up insulin. He spent his career as a plumber and owned a home in Bishop. Three years ago he fell into a diabetic coma and was hospitalized for months. A friend Doran trusted to pay his bills while he was hospitalized emptied his bank account and disappeared — Doran has been homeless ever since. Several weeks ago he was beaten and robbed by another homeless man, who left him with a fracture in his skull and a tremor in his hands.

“I guess I’m a little bit naive,” Doran said. “We’re all humans and we’re prone to mistakes, you know? So I hate for anyone to have their money stolen like mine was and end up like me on the streets.”

At the mobile clinic, Doran said the doctor on staff agreed to be his primary care physician. His previous primary care doctor stopped accepting Medi-Cal insurance, and Doran hasn’t had regular access to insulin ever since.

“The doc here, she truly has compassion for her patients. I’m glad our paths crossed,” Doran said.

Schneidermann, who is overseeing a study on street medicine programs across California, said CalAIM, which also pays for housing services, is an opportunity for the state to address its most pernicious problem.

“Until we can end our crisis of homelessness…we have to find a way to deliver care for people on the streets,” Schneidermann said.

New Programs Popping Up

Prior to CalAIM and the Health Care Services Department’s rule changes, street medicine programs operated outside of traditional health care, funded by philanthropies or the rare health organization willing to lose money. Now, the department’s changes offer some hope for stability, Feldman said. 

Noting that these programs were birthed out of the pandemic, Feldman said they “might not exist in a few years if they’re not supported, but they have all these patients that rely on them.”

A year ago only 25 programs existed across the state, primarily concentrated in urban areas, Feldman said. But ever since CalAIM launched at the beginning of 2022, he’s run into more organizations looking to begin services. CalAIM requires Medi-Cal insurers to coordinate patients’ physical, behavioral, dental and developmental care as well as social services — something many street medicine teams already do. The goal is to make the “system hustle behind the scenes rather than making the patient hustle,” California Health Care Foundations’ Schneidermann said.

One such program is run by Anthony Menacho in Sacramento. Unlike USC, Shasta Community Health or LA County’s teams that are staffed full time, Menacho’s street medicine band is composed entirely of volunteers. They visit six camps every other weekend. 

The work was funded initially by a $100,000 grant from Health Net, the largest Medi-Cal provider in the state, but Menacho, who trained as a physician assistant with Feldman at USC, wants to be able to do the work full time and hire more clinicians. He’s working to secure money through CalAIM and the Department of Health Care Services. 

“We don’t have the academic resources or people behind us to be able to put in a department or infrastructure on the drop of the dime,” Menacho said. “We run on grants, but that’s not true sustainability. We can’t do it ourselves. It has to be a coordinated effort and I think that’s what CalAIM is trying to do.”

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

Hundreds waiting hours for a monkeypox vaccine only to be turned away. Residents taking to social media to detail struggles getting diagnosed and treated. State and local leaders demanding federal action. Emergency orders declared.

At face value, these details paint the picture of a country and state in crisis, struggling to apply lessons learned from the past two and a half years of COVID-19 response. However, scientists, public health leaders, and physicians who spoke with CalMatters said infrastructure and resources augmented during the COVID-19 pandemic have, in fact, aided the monkeypox response.

Still, it has its faults.

“What we learned from COVID is that speed is everything. When we look at the response of monkeypox later on, we’ll see speed is the main thing we take issue with,” said Dr. Peter Chin-Hong, infectious disease specialist at UC San Francisco and member of the state’s scientific advisory committee for monkeypox.

California has the second-highest number of monkeypox cases in the country, with more than 1,300 infected residents, according to the latest state data. Gay and bisexual men have been disproportionately impacted, making up 96% of cases. Some experts say we’re already past the point of controlling monkeypox, which was first reported in California in late May.

The culprit? Too little testing and treatment and too few vaccinations — all of it layered with too much red tape at both the federal and state level. It’s a familiar refrain and one that has frustrated state and local leaders.

A cadre of California lawmakers asked the U.S. Department of Health and Human Services to allow the state to reallocate some of the $1.5 billion in COVID-19 response funds to monkeypox. Others submitted a $38.5 million emergency state budget request for monkeypox resources, and the California Department of Public Health sent a letter to the Centers for Disease Control and Prevention requesting 600,000 to 800,000 vaccines — that’s more than half of the total available doses for the entire country.

California is expected to receive 72,000 doses of the JYNNEOS vaccine used for monkeypox, with an additional 43,000 sent straight to Los Angeles County. Those doses represent “a drop in the bucket” of what’s needed, state epidemiologist Dr. Erica Pan told county health officers in a meeting last week.

During a Senate oversight hearing held Tuesday, Sen. Scott Wiener, a San Francisco Democrat, said “severe public health failures” at the federal level led to the current outbreak. 

“We need to turn this around,” Wiener said. “We need to continue to push hard to make sure that our state, federal, state and local public health authorities are directing the resources where they’re needed most and rapidly expanding support for vaccination, testing and treatment to slow and hopefully stop this spread.”

Lessons Learned

Despite continued resource challenges, public health systems are better prepared to respond to monkeypox than they were to COVID-19. In the early days of the pandemic, hospitals didn’t even have a way to quickly report how many COVID-19 patients were hospitalized or in intensive care.

“(Monkeypox) is a serious concern, but public health is far more prepared now than we have ever been,” said Sarah Bosse, Madera County public health director. 

Madera County has not reported any monkeypox cases, but neighboring Fresno County has seven cases. Bosse said her department is already in talks with the state on how to redirect COVID-19 contact tracers to monkeypox response and how to scale up vaccination clinics. 

“The state has been very proactive in identifying counties that need additional support,” Bosse said. 

In comparison, in 2020, 11 counties declared local emergencies for COVID-19 before Gov. Gavin Newsom declared a statewide emergency, freeing up staff and fiscal resources. This time, only San Francisco beat the state to the punch, a signal that state officials are closely in tune with local needs. 

“To someone like me who has been doing this for 30 years, this actually moved very fast,” said Dr. Timothy Brewer, an infectious disease specialist at UC Los Angeles, who recalled it was three years between when the first case of AIDS was described in Los Angeles and identification of the HIV virus. It took an additional three years before the first treatment was developed.

Comparing monkeypox to the HIV/AIDS epidemic and COVID-19 pandemic — both of which activists and state leaders have done — isn’t exactly apples-to-apples. What researchers knew about each disease at the onset of their respective outbreaks and available treatments varied widely. 

“What’s frustrating is that unlike COVID, which was a brand new virus that we had never seen before…with monkeypox we do know about it. It’s been around almost 70 years,” Wiener said. “We actually have a vaccine and an effective treatment. You would think that would be a recipe for very quickly controlling an outbreak.”

However, the influx of attention and money on the state’s chronically underfunded public health resources during the past two years has helped agencies ramp up for monkeypox much more quickly than they did with COVID-19.

For example, six months after the first confirmed COVID-19 case in California, the state was still rationing test kits and struggling to process a backlog of results. In comparison, one month after the first monkeypox case in the U.S., the Centers for Disease Control and Prevention onboarded five commercial laboratories, making monkeypox testing widely available at hospitals and doctors’ offices. In the same time period, the California Department of Public Health doubled its weekly testing capacity from 1,000 to 2,000 tests with an average turnaround time of three days, far shorter than the 12 days reported for early COVID-19 tests. 

The state also had to build data reporting systems for contact tracing, testing and vaccinations from scratch in 2020. County health officials say they’re now using those same systems for monkeypox. By Aug. 15, the state plans to launch a monkeypox vaccine appointment portal through the MyTurn website developed for COVID-19.

“We have weekly calls with (the state health department) and everyone is saying we need funding resources for this,” said Tulare County Public Health Director Karen Elliott. “I think that’s one of the reasons (the state health department) wanted the state of emergency. It cuts a lot of red tape.”

Some of that red tape stems from reallocating money earmarked for COVID-19 to monkeypox, which requires both federal and state approval. Public health funding is notoriously categorical, representing a history of crisis allocation rather than continuous investment in safety-net systems and disease prevention. This severely limits the flexibility needed to respond to an outbreak.

“We have a specific budget for tobacco prevention, a specific budget for obesity prevention,” Madera’s public health director Bosse said. “We have 78 (funding streams) for one department that all have to be tracked separately.”

The state allocated $12.3 billion to pandemic response in the past two years. Some counties have money left over or have staff hired to run COVID-19 clinics and conduct contact tracing, but haven’t been able to use them for monkeypox, which Elliott says they’ll need as cases increase in Tulare County. 

The Legislature also approved $300 million in ongoing public health funding for local health departments in June, the first significant state investment since 2008. Typically that money would take several months to make its way to county health agencies, but the state of emergency has helped them get the money now, county officials said.

Still, county officials emphasize that spending flexibility is needed in public health. Riverside County Public Health Director Kimberly Saruwatari said the employees responding to monkeypox are working “outside of their grant requirements” and local departments won’t be able to sustain that spending. San Diego County Public Health Director Elizabeth Hernandez testified during Tuesday’s hearing that her department is spending $90,000 per week on monkeypox response and has incurred more than $400,000 in expenses. 

Shortfalls Remain

Even with a more coordinated statewide response, bureaucratic delays and shortages at the federal level threaten to upend local efforts to control the spread. The CDC recommends doctors only test a small subset of the population that suspects they are a close contact of someone with monkeypox or are symptomatic. Also, the antiviral treatment for severe cases is considered experimental and requires hours of paperwork for each patient along with an ethics review, rendering most clinics unable to give it to patients. Meanwhile, vaccines remain far too scarce.

UCSF’s Dr. Chin-Hong said limitations on who can get tested mean cases are diagnosed far too late.

As of Aug. 2, the state health department had received 6,682 monkeypox test results, with the positivity rate around 19%. Generally, a positivity rate higher than 5% means not enough testing is being conducted. 

“In an outbreak setting you want to test as many people as possible. You know you’re successful if you have a lot of negative tests,” Chin-Hong said.

The earlier a case is diagnosed, the easier it is to conduct contact tracing, which becomes critical in the face of vaccine shortages. That, however, continues to be an obstacle.

The Mercury News reported that San Francisco’s health department has largely abandoned contact tracing as a primary containment strategy — citing difficulties in getting patients to divulge sexual partners — and is instead telling people to “self-refer partners.” Monkeypox is not a sexually transmitted disease but has been spreading through sexual networks due to the close skin-to-skin contact needed for transmission. In comparison, contact tracing for COVID-19 quickly became infeasible in part because the ease of airborne transmission made it impossible for many people to pinpoint where they became infected.

Epidemiologists say monkeypox could feasibly be contained given its long incubation period of two to three weeks, but it requires public health departments to have ample employees to do the work of getting a detailed history from patients and calling every known contact.

“We don’t have enough money for robust contact tracing given the number of cases,” Chin-Hong said. “That leaves people to do their own contact tracing. They need to get tested.”

Elliot, Tulare County’s public health director, said most counties will have trouble scaling up contact tracing without state support. Her staff has three communicable disease investigators who work to find close contacts of each case and two public health nurses that are in daily contact with positive patients to monitor their symptoms.

“We have two cases but we’d be ignorant to think we won’t have more,” she said. “Eventually, we won’t have the bandwidth for this anymore.”

Los Angeles County Health Officer Dr. Muntu Davis said his department has “insufficient resources for contact tracing” and has requested help from the state. Confirmed monkeypox cases in Los Angeles County doubled in the past 10 days to 647 infections, Davis told legislators at Tuesday’s hearing.

With lackluster testing and contact tracing resources, Chin-Hong said the primary strategy for monkeypox containment becomes  “vaccinate like crazy” for the most at-risk population: gay, bisexual and transgender men.

Yet again, that strategy comes with severe limitations.

“I want to be clear, the state of emergency and emergency budget request? Neither will solve our most basic need, which is for more vaccine. We can’t distribute a vaccine that we don’t have,” said Kat DeBurgh, executive director of the Health Officers Association of California.

Officials continue to stress that risk remains low for the general public, and some say the political discourse has caused unwarranted panic.

Monkeypox won’t infect as many people as COVID-19 due to its mode of transmission and has not caused any deaths in the United States, although it can cause painful lesions on the skin. Twenty-seven patients, representing 3% of all cases, are hospitalized in California primarily for pain management, according to State Health Officer Dr. Tomás Aragón. 

In comparison, more than 4,300 COVID-19 patients are currently hospitalized and 93,056 Californians have died since the beginning of the pandemic.

“This is a self-limiting, non-fatal disease,” Solano County Public Health Director Dr. Bela Matyas said. “Here we are redeploying from COVID to monkeypox. COVID kills. Monkeypox doesn’t. And I think it’s fair to ask where the logic is in that kind of decision-making.”

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

Deondray Moore sat in a plastic folding chair, rolled up his sleeve and got his first COVID-19 shot in the parking lot of Center of Hope Community Church in Oakland a week ago. He was the last in his family to get vaccinated after putting it off for more than a year, and only acquiesced because he wants to be in the delivery room when his son is born this summer. 

“My mom has been trying to get me vaccinated forever, since the (vaccines) came out,” Moore said. “My partner got it quick, and her kids got it as fast as they could. She wasn’t playing around. She was like ‘Don’t miss out on the baby.’”

The 35-year-old Oakland native, an African American, knows multiple people who have contracted COVID-19 and died. Moore wears a mask and doesn’t go out much. But he’s suspicious of the vaccine and the way it was developed. “I just don’t trust the government,” he said. 

African Americans, who have a litany of historical reasons to mistrust public health officials and doctors, have the lowest vaccination rate in the state, at 55%.

COVID-19 has become deadlier for Black Californians since the widespread availability of vaccinations, and vaccine hesitancy could be among the reasons why. Other races, which have higher vaccination rates, have seen death rates rise, but not as dramatically.

A CalMatters analysis shows since last summer, the rate of Black Californians dying from COVID-19 has increased tenfold — from one death per 100,000 people last July to 10.4 deaths this week. That surpasses Latinos and all races except Pacific Islanders, who are dying at the rate of 14.7 per 100,000, according to state data.

And while statewide deaths from COVID have declined in the past week, they have continued to rise for African Americans. 

So far, 5,544 Black people have died from the virus in California.

Dr. Kim Rhoads, an associate professor of epidemiology at University of California, San Francisco, said she isn’t surprised by the growing death rate among African Americans. “Disparities aren’t new. They aren’t new to COVID,” said Rhoads, who helped organize the community clinic where Moore got his shot.

For some Black residents, the disparity grew worse after vaccines became widely available last summer, according to a study from UC Santa Cruz and UC San Francisco researchers. 

Middle-aged Blacks make up a growing, disproportionate share of the Californians who died, while the proportion shrank for Latinos and others: In March 2021, Black people aged 40-64, who make up roughly 5% of all middle-aged Californians, accounted for 6% of COVID-19 deaths in that age group. But a few months later, their numbers skyrocketed, accounting for 21% by last July, according to the study.

In contrast, middle-aged Latinos accounted for 66% of all COVID-19 deaths at the beginning of March 2021, but then last July shrank to 30%, mirroring their proportion of all middle-aged Californians. 

Lead researcher Alicia Riley said preliminary data through November shows continuing disparities.

So why did the vaccines apparently help Latinos but not Black Californians? It’s possible that those who are most at risk of dying from the disease aren’t getting vaccinated. Younger African Americans also may not have been included in early vaccination campaigns or may have felt they weren’t at risk of severe illness or death.

“What’s puzzling to me is that they have a really different story in terms of who’s dying,” said Riley, a UCSC assistant professor of global and community health. “Are the people who were at risk of dying in the Latino community actually being reached with vaccination, whereas somehow that’s not happening for Black Californians as effectively?”

Experts say myriad other factors could also be driving the trend, including poverty, lack of insurance, distrust of the health care system and higher rates of health complications like diabetes or heart disease.

The increased share of deaths for Black Californians is a powerful sign of “who was left behind when everyone else was kind of moving on out of the pandemic,” Riley said.

The study did not find significant differences for other age groups, although state data suggests Black children fare worse than other races, too. 

Black children in California are the second most likely to die from the virus among Californians younger than 18, with 1.2 deaths per 100,000 Black children. Pacific Islanders are twice as likely to die from COVID as Black children, while all other races have less than one COVID-19 death per 100,000 children. 

The drivers for African American deaths are likely deeper than vaccination disparities. 

Rhoads, who studies death disparities in Black cancer patients, said pre-existing health complications also aren’t entirely to blame. Structural factors like poor quality health care also likely contribute to higher death rates, she said. For instance, medical devices like the pulse oximeter, which is used to determine whether a patient needs supplemental oxygen, don’t work well on dark skin.

“If we just say comorbidities, then we’re blaming the victim number one and we’re washing our hands of any responsibility,” Rhoads said.

Vaccine Campaigns Successful for Some

Substantial gains have been made among Latinos, according to Riley’s study. After bearing the brunt in the early stages, Latinos’ death rate dropped from nearly 25 deaths per 100,000 people in January 2021 to 1 death per 100,000 in July. Over the last month, the California Department of Public Health estimates 7.2 Latinos died of COVID per 100,000 people, lower than the statewide  rate of 8 per 100,000.

Around June 2021 the percentage of fully vaccinated Latinos outstripped Blacks and Native Americans, leaving Blacks in last place. Only 57% of Latinos are fully vaccinated, but some hard hit agricultural areas like Imperial County were quick to accept the vaccine — and it has made a difference.

Eduardo Garcia, senior policy manager for the Latino Community Foundation, said high death rates among Latinos early in the pandemic galvanized local groups and clinics to dole out vaccines and combat misinformation.

“Over 34,000 California Latinos have died since the beginning of the pandemic,” Garcia said. “It touched people close to home. I think that also created an impulse for people to get information from reliable sources and get the vaccine.” 

Rhoads said refocusing COVID-19 vaccination messaging on preventing deaths rather than infections is important for equity, particularly since getting her community to trust the vaccine has been harder. 

“It’s about a historical relationship between Black people and public health and health care,” Rhoads said. “Instead of saying lack of trust, I’m saying there’s no relationship there, so there should be no expectation of trust.”

That trust was further shaken last spring when the Food and Drug Administration warned of rare but severe side effects associated with the Johnson and Johnson vaccine. Rhoads said the number of people seeking vaccinations at her clinic dropped precipitously.

To help bridge the gap, Rhoads founded Umoja Health, a collective of community and faith-based organizations in the Bay Area, to make COVID-19 testing and vaccination easy and accessible for African Americans. They bring pop-up clinic supplies to churches, schools and neighborhoods where they know vaccination rates are low. It takes patience and continued effort, Rhoads said. 

At Castlemont High School in Oakland, where the clinic frequently sets up shop, it was several weeks before many Black students trusted them enough to get the vaccine.

“The Latino students came immediately,” she said. “But as we’ve been there over time, we’re starting to see more and more of the African American students come through, and then we started to see people bringing their parents.”

‘Back to Normal’ Threatens Blacks and Pacific Islanders

Gov. Gavin Newsom’s recent announcement that California would be moving into a new phase of the pandemic worries advocates and community health organizers like Rhoads. 

The new state action plan acknowledges continuing disparities when it comes to COVID-19 deaths and highlights money in Newsom’s budget that includes $819 million to expand Medi-Cal to undocumented individuals next year, $1.7 billion to invest in a more diverse health care workforce over five years and $65 million to fund the creation of an office of community partnerships and strategic communication. 

But the plan offers little in terms of immediate action to fix disparities, and includes no specific programs to help Black communities. 

The state health department on Thursday announced new $27 million contracts would be awarded to more than 100 community-based health organizations to shore up vaccination efforts in underserved communities, including African American ones.

However, community advocates worry that rhetoric used by Newsom like “turning the page” on the pandemic will ultimately prevent groups that have never caught up from moving forward.

“We still have growing death rates and case rates. How can we move forward in the pandemic when we’re still suffering?” said Karla Thomas, policy director for the UCLA Native Hawaiian and Pacific Islander COVID-19 Data Policy Lab.

Throughout the pandemic, Pacific Islanders have been hit the hardest by COVID-19. Their mortality rate is nearly twice that of the statewide rate and nearly six times higher than the lowest rate of 2.5 deaths per 100,000 people among those who identify as multi-racial.

While data suggests that Pacific Islanders are nearly 100% vaccinated, Thomas said there is reason to believe that the state’s numbers are inaccurate. At times that number has creeped above 100%. From a personal experience, Thomas said she is one of only two people in her 50-person Samoan church in San Bernardino that she knows is vaccinated. It’s not uncommon for there to be more than two funerals a month in her community. 

“I’m really concerned that we’re not taking an equitable approach to mitigate the pandemic among (Native Hawaiian and Pacific Islander) communities and other communities of color,” Thomas said. She criticized the lifting of the state’s mask mandate on Feb. 15 and the governor’s endemic plan.

Rhoads echoed Thomas’ sentiments.

The pandemic “is not over. It’s not for people who aren’t vaccinated, who don’t have regular health care,” she said.

Last week Rhoads and more than 35 organizations sent a letter to the state health department in part criticizing the state’s inconsistent and confusing messaging on masking. The health department’s initial criteria for lifting the indoor mask mandate included vaccination and infection rates that were unmet when the mandate expired.

Rhoads said instances like this erode public trust in government and scientific organizations, particularly among groups that placed little faith in the institutions to begin with. 

In response, the department agreed to schedule a meeting between Rhoads and State Public Health Officer Dr. Tomas Aragon. 

In a separate response to CalMatters, the state health department said vaccine equity was the “north star” of its efforts to reach marginalized communities, and that it would continue to partner with community organizations, ethnic media, translators and faith-based groups. 

“This work is ongoing, and closing the equity gap across all California communities remains a priority to the state’s vaccination efforts,” the department said in a statement.

‘Nothing to Be Afraid Of’

In Oakland at the Umoja clinic last week, George Dowell, a 40-year-old African American, said he was getting his second vaccination dose because he didn’t “want to be left behind” as more and more businesses require proof of vaccination for entry.

Dowell is among the age group experiencing higher death rates in Riley’s study. He spent the past year watching vaccinated friends and family carefully for side effects before deciding to get the shot himself.

Social media and misinformation played a role in Dowell’s hesitation. “I was listening to certain people, social media, instead of listening to myself and doing what’s right,” Dowell said. 

Three weeks ago, he decided it was time. He found the Umoja clinic while driving around the neighborhood and got his first Pfizer shot. Dowell wanted to show his school-aged nieces and nephews that “there was nothing to be afraid of” as they became eligible for the vaccine.

Dowell’s 27-year-old son is also unvaccinated, and Dowell said he promised he would call to let him know how he feels after this second shot.

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

Labor advocates are calling it “Striketober.”

As weary health care workers across California enter the 19th month of the pandemic, thousands are walking off the job and onto the picket line, demanding more staffing.

The strikes and rallies threaten to cripple hospital operations that have been inundated by the COVID-19 Delta surge as well as patients seeking long-delayed care. 

More than two dozen hospitals across the state — including some Kaiser Permanente and Sutter Health facilities and USC Keck Medicine — have experienced strikes by engineers, janitorial staff, respiratory therapists, nurses, midwives, physical therapists and technicians over the past four months.

This week, nearly a third of all California hospitals reported “critical staffing shortages” to the federal government, with more predicting shortages in the coming week. Hospitals are unable to meet the state’s required staff-to-patient ratios for nurses or schedule adequate numbers of other critical personnel.

In the Central Valley, the region hit hardest by the Delta surge, National Guard medics have been deployed since September to assist area hospitals.

The reason for the shortages? Record patient volumes at the same time that many workers have been driven away from the bedside by burnout, early retirement and the seemingly unending stress of the pandemic.

SEIU-United Healthcare Workers West estimates that about 10% of its members — close to 10,000 people — have retired, left the profession, or taken extended leaves of absence during the pandemic. 

“What’s really important is that 10% doesn’t turn into 15%, does not turn into 20%. There’s not enough temporary staff out there to fix what’s going on,” said Dave Regan, president of SEIU-UHW.

The shortages are an untenable scenario, unions say — one that has persisted for many years brought to a boiling point by the pandemic. 

Since the pandemic began, union grievances with hospitals are increasingly about inadequate staffing, although bargaining over pay remains a key issue.

Money matters when it comes to holding onto workers, they say, especially because temporary staff brought on for pandemic response often make more than regular employees. In some instances, traveling nurses have been paid $10,000 per week at California hospitals with severe staffing needs.

“You’re paying exorbitant amounts for travelers while the existing workforce makes exactly the same amount (as before the pandemic),” Regan said.

Striking to ‘Stop the Bleeding’

Early in the pandemic, Gov. Gavin Newsom announced efforts to expand the health care workforce through a volunteer health corps. Although tens of thousands signed up, most people didn’t have the necessary medical skills, and only 14 volunteers worked out.

The California Department of Public Health also signed a $500 million contract to help hospitals pay for emergency health care workers like traveling nurses. That contract expired in June.

Unions say those efforts are a Band-aid on a larger problem. Instead, they say policymakers should get hospitals to try harder to retain their current employees. 

“Right now, hospitals, the health industry, the state of California, you need to do a lot more so that it doesn’t get worse,” Regan said. “We’re doing very little as a state to support this workforce that has been under a really unique set of pressures.” 

In an early attempt to stop the churn, SEIU-UHW sponsored a bill that would have provided hazard pay retention bonuses to health workers. Opposed by the hospital association. the bill stalled before it was voted upon by the Assembly and did not make it to the Senate.

Assemblymember Al Muratsuchi, a Democrat from Torrance who introduced the bill, said the hospitals’ claims that they couldn’t afford hazard pay were unfounded since they received billions in federal pandemic funds, some “specifically earmarked for hazard pay and bonuses for frontline workers.”

“The state made a decision that they were not going to provide financial incentives to recognize and retain healthcare workers, and we think that’s shortsighted,” Regan said. 

Over the summer, hundreds of nurses at hospitals, including USC’s Keck Medicine, San Francisco’s Chinese Hospital and Riverside Community Hospital, staged strikes over inadequate staffing and safety concerns.

Now more than 700 hospital engineers employed by Kaiser Permanente facilities in Northern California have been striking for four weeks, demanding higher wages.

In Antioch, more than 350 workers at Sutter Delta ended a week-long strike over inadequate staffing Friday but have yet to reach a contract agreement with their employer.

In the Victor Valley and Roseville, hundreds of workers staged recent rallies and vigils to highlight what they’re calling a “worker crisis.” Advocates say their upcoming schedules are packed with pickets planned in solidarity with other unions. 

And perhaps the strongest flexing of union muscle has come in Southern California, where members of the United Nurses Associations of California/Union of Health Care Professionals, or UNAC/UHCP, voted overwhelmingly to approve a strike against Kaiser Permanente if negotiations remain at a standstill. Should a strike materialize in the coming weeks, more than 24,000 members would walk out of the health care giant’s medical centers and clinics in more than a dozen cities.

Although the dollars and cents of bargaining vary from union to union, the common thread is clear: They want employers to “stop the bleeding” of health care workers fleeing the profession and invest more in recruiting and retaining staff.

The union found 72% of its members — which includes nurses, occupational and physical therapists, midwives and other medical staff — were struggling with anxiety and burnout, and between 42-45% reported depression and insomnia. About 74% said staffing was a primary concern.

How Hospitals Are Responding to Shortages

Hospitals say it is not as easy as hiring more employees. With so many people leaving the workforce, there aren’t enough candidates to fill the gap. Even support staff like janitors, cafeteria workers, clerks and assistants are in short supply. 

“There is no question there is a shortage of health care workforce. We have far fewer people in the workforce today than we did when the pandemic started,” said Jan Emerson-Shea, spokesperson for the California Hospital Association.

Many hospitals have offered employees shift bonuses, child care subsidies and temporary housing to keep them from spreading the virus to family members while keeping them at patients’ bedside. But it hasn’t been enough. 

“I don’t know that it’s anybody’s first choice, but we are in a situation where we have to rely on the travelers (traveling nurses),” Emerson-Shea said. “Hospitals would much rather have their permanent staff, but in this situation, with as long as it has been and the workforce dynamics so complex, we need both.”

The state hospital association has asked state Health and Human Services Secretary Dr. Mark Ghaly to assist hospitals with workforce concerns in part by reinstating funding for traveling workers and making it easier for hospitals to get exemptions from the state’s strict nurse-to-patient ratios. In a written response, Ghaly said the state would continue helping designated surge hospitals pay for extra staff and was working to expedite nursing ratio waivers for heavily impacted regions. 

“There’s no resolution yet, but the conversations are occurring, which is important because we are not through the pandemic,” Emerson-Shea said. 

Like many industries, hospitals rely on historic averages to predict the need for employees. The average number of patients in a given time period determines how many employees will be scheduled each day. The problem, workers say, is that using the average means frequently they are working with minimal staff.

“There needs to be a massive paradigm shift of how hospitals treat clinicians, and that’s less just-in-time staffing and less just-in-time supplies,” said Gerard Brogan, director of nursing practice at the California Nurses Association and National Nurses United. 

Peter Sidhu, a former intensive care nurse at the Kaiser Woodland Hills Medical Center, said the union has filed staffing grievances each year for the past seven years. During the pandemic, the strain has gotten worse. Woodland Hills Medical Center is one of the facilities that may be affected by a strike.

“Between the first surge and second surge, we had several months where there was zero planning. There were no new grad programs, there was no new hiring,” Sidhu said. 

“So going into that second surge, which was really bad here in California, we knew we were in trouble,” Sidhu said. With adequate staffing prior to the pandemic and efforts to increase staff levels in between surges, workers would not have burned out so rapidly, he contends. 

Bargaining over salaries and benefits between Kaiser and Alliance of Health Care Unions, which includes the Southern California group UNAC/UHCP, stalled at the end of September after five months. The strike authorization is the first of its kind for UNAC/UHCP in the past 26 years, and members say long-standing staffing issues and burnout contributed to employee dissatisfaction.

“The vote to authorize a strike by union members is disappointing, especially because our members and communities are continuing to face the challenges of the ongoing pandemic,” Arlene Peasnall, Kaiser’s senior vice president of human resources, said in a statement. “In the event of any kind of work stoppage, our facilities will be staffed by our physicians along with trained and experienced managers and contingency staff.”

‘Burnout Can Only Be Getting Worse’

In a recent study by the UC San Francisco Health Workforce Research Center on Long-Term Care, the number of nurses aged 55 to 64 planning on quitting or retiring in the next two years jumped nearly 14% between 2018 and 2020, setting up the field for a five-year shortage. 

Joanne Spetz, the center’s associate director of research and lead study author, said new graduates before the pandemic sometimes struggled to find employment while employers frequently complained about not being able to find enough experienced nurses to hire. But the overall number of nurses in the workforce was enough then.

Now, with nurses reducing their hours or quitting, the state is in a more tenuous position. About 7% fewer nurses reported working full-time in 2020 compared to 2018, and sharp declines in employment were seen among nurses 55 years and older, according to the study. 

“We’re looking at having a shortage in the short term,” she said. “The wild card is, with the pandemic lasting this long, burnout can only be getting worse. What if we have a bunch of 30 to 35 year-old nurses who say ‘screw this,’ then we’re losing a lot of years of working life from these nurses.”

Sidhu is one of those experienced nurses who found himself reeling from the dual forces of COVID-19’s brutal emotional toll and short staffing. 

He had volunteered to work with the first COVID-19 patient that arrived at his ICU in March 2020. That first patient quickly turned into dozens each day, with many dying. 

“One day you walk in and your unit is full, and two days later you walk in and a large portion of those patients have passed away. You’re double-stacking body bags,” Sidhu said. 

He struggled with anxiety, anger and insomnia before his shifts, knowing there would be more patients than nurses could care for, and that they would have no time for breaks. He said he was told that under the state’s temporary emergency waiver of nurse-to-patient ratios he would have to take on more patients. 

A year into the pandemic, Sidhu called it quits and now works as the union’s treasurer. Of the eight members in his original ICU nursing team, only two remain working, he said.

“I’m 42, and I was planning on working at the bedside until I turn 60,” Sidhu said. “And then after COVID, I said ‘I am done.’ I was super-done.”

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.