A California bill awaiting its first hearing would subject drug industry intermediaries known as pharmacy benefit managers, or PBMs, to licensing by the state Department of Insurance. And it would require them to pass along 100% of the rebates they get from drug companies to the health plans and insurers that hire them to oversee prescription drug benefits.

But the proposal, which would impose some of the toughest PBM regulations in the nation, faces at least one major hurdle: Newsom. He vetoed a similar measure last year, unconvinced it would lower consumer costs. He signaled his intent to offer an alternative but has yet to reveal it.

Any fight over PBM reform promises to be a pricey one. Interest groups on both sides spent at least $7 million combined lobbying California lawmakers and the Newsom administration on health care last year, according to records filed with the secretary of state.

“This bill directly threatens the profitability of PBMs going forward,” said Ge Bai, a health policy professor at Johns Hopkins University who has tracked similar bills in other states. “These bills are really the result of an interindustry dog fight, and these are ridiculously fierce fights because PBMs control revenue for pharmacies, as well as for manufacturers.”

The country’s top three PBMs —CVS Caremark, affiliated with Aetna; UnitedHealth Group’s Optum Rx; and Express Scripts, owned by Cigna — control roughly 80% of prescriptions in the United States, according to the Federal Trade Commission. In theory, they leverage their buying power to extract steep discounts from drug manufacturers and pass savings along to insurance companies and employers who provide health coverage.

But as prescription drug prices continue to spiral and federal efforts to control them stall, state lawmakers are focusing on PBMs, which help insurers decide which drugs their plans cover and how much patients will pay out-of-pocket to get them. However, they have been stymied by the drug industry’s secretive ecosystem of rebates, reimbursements, and obscure fees, thwarting efforts to lower drug costs.

In addition to California, PBM proposals have been introduced this legislative session in Arkansas, Iowa, and at least 20 other states as of Feb. 10, according to the National Academy for State Health Policy. All 50 states and Washington, D.C., have some sort of PBM regulation on the books.

And although President Donald Trump has criticized PBMs and vowed to “knock out the middleman,” his recent actions undoing moves to lower prescription drug prices have left some health care experts skeptical that meaningful reform will come from Washington, D.C.

Meanwhile, state data shows California health plan drug costs have grown by more than 50% since 2017. California insurers spent 11% more on pharmaceuticals in 2023 than in 2022, with specialty and brand-name drugs driving the increase.

Both Newsom and bill author Sen. Scott Wiener (D-San Francisco) have said PBMs play a role in high drug prices. While Wiener wants to ban some of their practices outright, Newsom has so far taken a more measured approach, calling for more disclosure and pointing to his plan for the state to manufacture its own generic drugs, which has yet to get off the ground.

In vetoing Wiener’s 2024 bill, which passed in a near-unanimous bipartisan vote, Newsom said he was unconvinced that licensing PBMs would improve affordability for patients and instead directed his administration to “propose a legislative approach” to gather more data from PBMs. In a statement, Newsom spokesperson Elana Ross noted that “Big Pharma backed the vetoed bill” and said the Democratic governor, in partnership with the legislature, will take action to address PBMs this year. She declined to elaborate.

In his January budget proposal, Newsom said his administration was “exploring approaches to increase transparency” in the entire drug supply chain, not just PBMs.

Industry representatives say they’re being unfairly targeted with transparency laws and regulations and blame pharmaceutical companies for setting high drug prices.

“The PBM is taking the risk on price variation, and it allows the client to have certainty on what they’re going to be paying,” said Bill Head, an assistant vice president of state affairs for the Pharmaceutical Care Management Association, which represents PBMs. “We’re hired because it works. It saves money at the end of the day.”

He said PBMs pass on more than 95% of the rebates they receive from drugmakers — a number health policy researchers say is hard to verify.

Consumer advocates say drugmakers simply raise their prices to maintain profits and PBMs charge insurers far more for many medicines than pharmacies are paid to actually dispense them, a practice known as spread pricing.

A January report by the Federal Trade Commission found the three biggest PBMs appeared to steer the most profitable prescriptions away from competitors and to their affiliated pharmacies, which they reimbursed at markups exceeding 1,000% for some drugs, including some used to treat cancer, multiple sclerosis, and serious lung conditions. Over a six-year period, the analysis found, those PBMs and their affiliated pharmacies made roughly $8.7 billion in additional revenue by marking up prices on a sample of 51 specialty drugs.

Wiener’s latest bill, SB 41, would ban such markups, as well as spread pricing, and bar PBMs from receiving performance bonuses based on drug rebates. Similar provisions were stripped out of last year’s bill in the final days before its passage.

“These are practices that only PBMs are engaging in and they’re causing harm, reducing consumer choice, increasing drug costs, and it’s time to address them,” Wiener said. “I’m not going to let that idea just evaporate because of one veto.”

Clint Hopkins, who has co-owned Pucci’s Pharmacy in Sacramento since 2016, said he often deals with complaints from frustrated patients who don’t understand drug pricing schemes and restrictions set by pharmacy benefit managers.

He’s had to turn away customers whose drugs can cost him hundreds of dollars in losses each time they’re filled and says spread pricing is helping drive independent pharmacies out of business.

“I’m not asking to be paid more. I am asking to be paid fairly — at cost or above.”

Under current law, California requires PBMs to disclose some information about drug rebates, and other information, to its clients. That data is often labeled as proprietary to the companies, leaving an incomplete picture of the supply chain, said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy.

PBM representatives say pharmacies, insurers, and other actors in the supply chain should have to disclose information about their profits and practices, too.

“You want to look under the hood?” Head said. “We’re open to that, but let’s look under everybody’s hood.”

Bai said lawmakers are likely going after PBMs because insurers are one portion of the supply chain that they have the power to regulate. But she warned such legislation could cost consumers more if drugmakers and pharmacies remain unchecked. A better approach, Bai suggested, would be to bar PBMs entirely from managing benefits for generic drugs, one of their biggest revenue sources.

“In health care, there’s no saint and there’s no villain. Everybody’s trying to make money,” Bai said. “These fights will bring no benefit to patients unless we go to the root.”

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

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

USE OUR CONTENT

This story can be republished for free (details).

In 2013, California regulators fined the insurer $4 million for failing to reduce wait times, giving patients inaccurate information, and improperly tracking appointment data. And in 2023, KP agreed to pay $50 million, the largest penalty ever levied by the state’s Department of Managed Health Care, for failing to provide timely care, maintain a sufficient number of mental health providers, and oversee its providers effectively.

Now, Kaiser Permanente is back in the hot seat as mental health workers in Southern California wage a strike that’s in its fourth month. KP therapists and union representatives accuse the HMO giant of saddling workers with excessive caseloads and often forcing patients to wait twice as long as the state allows for follow-up appointments. They say that the staff is burned out and that this work environment makes it hard to recruit clinicians, exacerbating the staffing problem.

KP rebuffs these claims, saying the union is parading out old problems, seeking to create “an inaccurate and outdated perception” of KP’s care. They say the union’s pay demands are “in direct contrast to our commitment to providing quality, affordable care.”

Kaiser Permanente — the largest commercial health plan in California, with about 9 million members — is far from alone in struggling to provide adequate mental health care. A pandemic-induced shortage of health care workers has created obstacles for all health plans in recent years, on top of a preexisting scarcity. Moreover, many therapists decline to contract with insurers. And lingering bias in the health care system against mental health services — and patients — may also be at play.

Federal and state laws require health plans to provide mental health care on par with medical care. But many people who have sought therapy can vouch that those measures, known as mental health parity laws, do not seem to be followed consistently. You can spend hours or even days calling every therapist allegedly in your insurance company’s network and come away empty-handed.

Secret-shopper surveys of 4,300 randomly selected outpatient providers listed as accepting new patients showed that “an alarming proportion” of them were unresponsive or unreachable, according to a federal government report issued last month. And while that was true for medical providers, it was consistently worse for mental health and substance abuse care, according to the report.

In California, state regulators have been conducting behavioral health care investigations of the insurance companies they regulate to help identify the extent and causes of delays in care.

So far, the DMHC has investigated nine health plans (not including KP) and found dozens of violations related to appointment availability, timely access, quality of care, and patient appeals, department spokesperson Rachel Arrezola says. The agency also has identified numerous “barriers” that do not necessarily break the law but may make it more difficult for patients to get care, she says.

Mark Peterson, a professor at UCLA’s Luskin School of Public Affairs, notes that the open-ended nature of therapy can conflict with health plans’ focus on their bottom lines. “It may be once a week, it may be more than once a week and go on for years,” Peterson says.

For insurers, he says, the question is, “How do you put an appropriate limit on that?”

And the unwillingness of many therapists to accept insurance companies’ payment rates, or to abide by their restrictions, often leads them to decline participation in health plan networks and charge higher rates. That, Peterson says, makes therapy financially inaccessible for a lot of people seeking it.

Even if you have some coverage for therapy outside your health plan network, your insurer will pay only a percentage of the rate that it recognizes as legitimate. “If your therapist is charging $300 an hour, and your insurance company only recognizes $150 an hour, and they only pay 50% of what they recognize, now you’ve got a quarter coverage of your therapy,” Peterson says.

Since Kaiser Permanente is a closed system and patients don’t get reimbursed for care outside the network, access problems for its patients can be “highly pronounced,” Peterson adds.

In California, KP has accounted for over $54 million of the $55.7 million in mental-health-related fines the DMHC has levied on insurers in the past two decades. That includes the $50 million fine imposed in 2023, which was part of a settlement in which KP agreed to fix deficiencies the department found and to invest an additional $150 million in projects intended to enhance access to mental health care, not just for KP members, around California.

Officials at the National Union of Healthcare Workers, which represents some 2,400 KP mental health workers in the ongoing Southern California contract talks, say the HMO could easily invest enough to become a paragon of high-quality mental health care if it wanted to.

Greg Tegenkamp, the lead union negotiator, says KP could “lead the way to do the right thing.”

Kaiser Permanente says it already is doing the right thing, even as it acknowledges past shortcomings. In a recent statement, it said it has invested over $1 billion in new treatment spaces and more mental health providers since 2020.

“We’ve grown our workforce and increased our network of skilled therapists so that any Kaiser Permanente member who needs an appointment is able to get timely, high-quality, clinically appropriate care,” the company says.

In addition to higher wages and lower patient loads, workers want more time to complete follow-up tasks outside sessions and the reinstatement of a pension that was eliminated for those hired in Southern California after 2014.

Kaiser Permanente says that it already pays its mental health workers in Southern California about 18% above the market rate and that the current proposal would raise pay even more. KP recently raised its proposed wage increase by a modest amount, according to union officials.

KP refutes reports from workers about long wait times for patients seeking mental health appointments. It says the average wait time is 48 hours for urgent appointments and six business days for nonurgent ones, “which is better than the state’s requirement” of no more than 10 days.

But workers say KP patients still face long delays for follow-up appointments.

“It’s really hard for our patients to get regular, frequent appointments,” says Kassaundra Gutierrez-Thompson, a KP therapist in Southern California who is on strike. Gutierrez-Thompson says she’s seen it from both sides, since she is also a patient who sees a KP psychiatrist for depression and recently faced a big rescheduling delay after one of her appointments was canceled without notice.

As a provider, Gutierrez-Thompson says, she and her colleagues are expected to see patients “back-to-back-to-back.” She says some of her colleagues developed urinary tract infections when they couldn’t get to the bathroom. One even started wearing adult diapers, she says.

“The working conditions are like a factory,” Gutierrez-Thompson says. “We do such human work, but they would love for us to be robots with no needs and just see patients all day.”

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

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

USE OUR CONTENT

This story can be republished for free (details).

In a 60-page report sent Monday to the legislature, the California Department of Housing and Community Development recommended lawmakers set a maximum safe indoor air temperature of 82 degrees Fahrenheit for the Golden State’s estimated 14.6 million residential dwelling units.

“This is a big deal,” said C.J. Gabbe, an associate professor of environmental studies at Santa Clara University. “We’re seeing more and more concerns about the increase in heat-related morbidity and mortality in California, which is leading to these kinds of maximum indoor temperature guidelines.”

If the housing proposal is adopted, California could have the most comprehensive requirements in the nation, Gabbe said. Some local jurisdictions, including Phoenix, Dallas, and New Orleans, have set their own standards, and the city and county of Los Angeles are exploring their own protections.

Last year was the planet’s warmest on record, and extreme weather is becoming more frequent and severe, according to the National Oceanic and Atmospheric Administration. Even though most heat deaths and illnesses are preventable, about 1,220 people in the United States are killed by extreme heat every year, according to the Centers for Disease Control and Prevention. Heat stress can cause heatstroke, cardiac arrest, and kidney failure, and it’s especially harmful to the very young and the elderly.

State law protects renters in the winter by requiring all rental residential dwelling units to include functioning heating equipment that can keep the indoor temperature at a minimum of 70 degrees, but there is no similar standard giving renters the right to cooling.

The release of this report is a key milestone, but it’s just the first step of a long road, vulnerable to legislative politics and an influential housing industry that has successfully delayed similar proposals in the past. In 2022, state lawmakers directed the housing department to issue cooling recommendations after proposed legislation stalled when landlords, real estate agents, and builders raised concerns such a standard would be cost-prohibitive.

Those concerns remain. Many California rental units are older homes, sometimes 90 to 100 years old, and installing air conditioning would require expensive changes, including upgrading the electrical system, said Daniel Yukelson, CEO of the Apartment Association of Greater Los Angeles.

“These types of government mandates, absent some kind of financing or significant tax breaks, would really put a lot of smaller owners out of business,” said Yukelson, who added that he’s concerned it would lead to housing getting bought by large corporations that would spike rent prices.

The report recommends lawmakers provide incentive programs for owners to retrofit residential units so the cost isn’t passed along to renters. It also suggested a variety of strategies that could be deployed to keep homes cool: central air conditioning, window units, window shading, fans, and evaporative room coolers.

For new construction, housing officials suggested new standards incorporating designs to keep indoor temperatures from topping 82 degrees, such as cool roofs and cool walls designed to reflect sunlight, or landscaping to provide shade.

Whether the legislature will take up the housing department’s recommendations is unclear. Spokespeople for Democratic Assembly Speaker Robert Rivas and Sen. Henry Stern, Democrats who co-authored the 2022 cooling standard bill, declined to comment.

Californians largely stand behind the idea, according to a 2023 poll from the University of California-Berkeley Institute of Governmental Studies and co-sponsored by the Los Angeles Times. Sixty-seven percent of voters said they supported the concept of the state establishing cooling standards for residential properties.

As temperatures rise and heat waves become longer and more intense, the report cautions, deaths in California could rise to 11,300 a year by 2050. And deaths from all causes “may be up to 10% higher on hot nights compared with nights without elevated temperatures,” according to a February presentation by the Los Angeles County Department of Public Health.

That’s because it can be particularly dangerous when people can’t cool off at night during extended heat waves, said David Konisky, a professor of environmental policy at Indiana University.

“When you can’t count on evening cooling off and allowing the body to readjust,” he said, “that’s when things get really dangerous for people’s health.”

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

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

USE OUR CONTENT

This story can be republished for free (details).

For Taylor Farms, a major global purveyor of packaged salads and cut vegetables, that’s made it a logical place to pioneer a novel type of health care for its workforce, one that could have broad utility in the smartphone era: cross-border medical consultations through an app.

The company is among the first customers of a startup called MiSalud, which connects Spanish-speaking Taylor Farms employees to physicians and mental health therapists in Mexico. Providers aren’t licensed in the U.S. and can’t prescribe medications but instead serve as health coaches who can dispense advice and work with a U.S.-based doctor if needed.

Amy Taylor, who has led the company’s wellness initiative since 2014 and is the daughter-in-law of company founder Bruce Taylor, said about 5,600 of Taylor Farms’ 6,400 employees who work where MiSalud is currently available have signed up for the app, and 2,300 have used the app at least once. The service is free for employees and up to three family members.

Amy Taylor said the company hopes the app, which is part of a broader wellness program, can help employees stay healthier while keeping health care and other labor costs in check. She plans a full evaluation once the program has been in place for two years.

The health of farmworkers is a major concern for the state’s agricultural economy. A 2022 study led by researchers from the University of California-Merced evaluated the health of more than 1,200 farmworkers and found that 37% of men and 47% of women reported having at least one chronic condition, including common conditions such as diabetes, high blood pressure, and anxiety.

Taylor said her company’s employees, ranging from fieldworkers and drivers to retail packaging and office staff, mirror the study’s findings. She said predominant health concerns among workers include obesity, high blood pressure, diabetes, and mental health.

“These are the people who are feeding America healthy food,” Taylor said of the company’s employees. “They should also be healthy.”

MiSalud — or “My Health” — was the inspiration of Bismarck Lepe, a serial entrepreneur and Stanford graduate, who hails from a migrant farmworker family. Until age 6, when his family settled in Oxnard, California, they would travel between Mexico, California, and Washington state to harvest fruit. He saw that family and friends often delayed health care until they could return to Mexico because the U.S. system was too difficult to navigate, and insurance coverage too expensive or hard to find.

“My mother still prefers to get her health care in Mexico,” Lepe said. “It’s easier for her.”

Lepe and co-founders Wendy Johansson and Cindy Blanco Ochoa launched MiSalud Health in 2021 with $5 million from a venture capital fund backed by Melinda French Gates’ Pivotal Ventures, which focuses on social-impact investing. It has since added Samsung Next and Ulu Ventures as investors.

MiSalud started out by offering consultations with Mexican physicians for individuals who downloaded the app, Johansson said. But people keen enough to find the app, download it, and sign up for the program themselves weren’t ultimately those who needed it most, and in 2023 the company pivoted to offering its service to companies as an employee benefit. (Individuals can still use it too.)

Besides Taylor Farms, the company counts the California city of Lynwood among about a dozen other clients, according to Johansson. MiSalud touted that nearly 40% of employees served by its platform say that without the app they would either have ignored their health concerns or waited until they could travel to Mexico to see a doctor.

Paul Brown, a UC-Merced professor of health economics who contributed to the university’s farmworker health study, warned that telehealth consultations aren’t adequate substitutes for in-person care by a primary care physician or a specialist. However, “to the extent that these types of programs can kind of link people into more standard care, that’s good,” he added.

Brown said MiSalud’s approach could be more effective if policies changed to allow Mexican doctors to more easily treat patients in the U.S. A California program begun in 2002 allows Mexican doctors to travel to the Salinas Valley and other heavily Latino communities and treat patients, but cross-border telemedicine, even between states, remains limited.

Even so, Taylor Farms employees say the app has been helpful. Rosa “Rosita” Flores, a line supervisor with the company’s retail operations, said she decided to give MiSalud a try after co-workers raved about it.

A recent company wellness fair, partly sponsored by MiSalud, had alerted her to the importance of monitoring her blood sugar and blood pressure levels, so she booked an appointment on the app to discuss it. “The app is very easy to use,” she said in Spanish. When she had to cancel a video chat after her daughter got sick, the health coaches followed up by text.

Proponents of cross-border medicine say the approach helps bridge linguistic and cultural barriers in health care. Almost half of all U.S. immigrants — about two-thirds of whom are native Spanish speakers — have limited proficiency in English, and research has repeatedly shown that language barriers often discourage people from seeking care.

For example, Alfredo Alvarez, a MiSalud health coach who is a licensed physician in Mexico, pointed to belief in el mal de ojo, or the “evil eye” — the idea that a jealous or envious glance by someone can cause harm, especially to children. An American doctor might be dismissive of the notion, but he understands.

“This isn’t uncommon here,” he said of Mexico. “It’s a belief in traditional medicine.”

It’s not that Alvarez encourages his socios, or members, to pass an egg over the child or make the child wear a special bracelet — traditional ways of diagnosing and treating el mal de ojo. Rather, he acknowledges their traditions and steers them to evidence-based medicine.

MiSalud’s coaches can try to break stereotypes as well. For example, Alvarez said, a Mexican reverence for machismo can translate to the idea that “men don’t do doctor visits.” Meanwhile, he said, women may overlook their health in prioritizing other family members’ needs.

Coaches also try to remove the stigma around seeking mental health treatment. “A lot of our socios have been extremely uncomfortable with or wary of mental health professionals,” said Rubén Benavides Crespo, a MiSalud mental health coach who is a licensed psychologist in Mexico.

The app tries to break through by making it easy to book counseling appointments and asking questions such as whether someone has trouble sleeping, rather than invoking more worrisome or potentially stigmatizing terms like anxiety or depression.

MiSalud representatives say the app saw a 50% increase in requests for mental health support following the November presidential election. A more common request, however, is grief counseling, often following the loss of a loved one.

“Loss requires adaptation,” Benavides said.

For Sam Chaidez, director of operations for a Taylor Farms location in Gonzales, MiSalud is a welcome addition for weight management. The son of fieldworkers, Chaidez graduated from UC-Davis and returned to the Salinas Valley to work for the company in 2007.

In 2019, Chaidez, a new parent at the time, began to understand his risk for diabetes and other health problems because of Taylor Farms’ wellness program. Through diet and exercise and, more recently, coaching by MiSalud, Chaidez has shed 150 pounds.

Chaidez encourages co-workers to walk with him at lunch, and he credits MiSalud coaches for helping him keep the weight off and stay healthy. “It’s been a great help,” he said.

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

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

USE OUR CONTENT

This story can be republished for free (details).

• Click here to watch Allen on CBS News Chicago
• Read Allen’s “What RFK Jr. Might Face in His Nomination Hearings This Week”

KFF Health News editor-at-large for public health Céline Gounder discussed why the CIA has “low confidence” in its assessment of the origins of the covid-19 virus on CBS News 24/7 on Jan. 27.

• Click here to watch Gounder on CBS News 24/7

KFF Health News senior correspondent Noam N. Levey discussed the Consumer Financial Protection Bureau’s final rule to remove medical debt from consumer credit reports on PBS’ “PBS News Weekend” on Jan. 25.

• Click here to watch Levey on “PBS News Weekend”
• Read the KFF Health News series “Diagnosis: Debt”

KFF Health News contributor Sue O’Connell discussed Montana’s mental health facilities on Billings’ KTVQ on Jan. 24.

• Click here to watch O’Connell on KTVQ
• Read O’Connell’s “Montana Eyes $30M Revamp of Mental Health, Developmental Disability Facilities,” co-reported with Mike Dennison

KFF Health News senior correspondent Renuka Rayasam discussed bird flu in Georgia on WUGA’s “The Georgia Health Report” on Jan. 24.

• Click here to hear Rayasam on “The Georgia Health Report”
• Read Amy Maxmen’s “How America Lost Control of the Bird Flu, Setting the Stage for Another Pandemic”

KFF Health News chief Washington correspondent Julie Rovner discussed the nomination of Robert F. Kennedy Jr. for secretary of Health and Human Services on CBS News on Jan. 22.

• Click here to watch Rovner on CBS News

KFF Health News correspondent Molly Castle Work discussed mental health specialists’ role in the Los Angeles wildfire response on America’s Heroes Group on Jan. 22.

• Click here to hear Work on America’s Heroes Group
• Read Work’s “Amid Wildfire Trauma, L.A. County Dispatches Mental Health Workers to Evacuees”

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

USE OUR CONTENT

This story can be republished for free (details).

His administration rescinded a long-standing policy not to arrest people without legal status at or near sensitive locations, including hospitals. That has left different states offering starkly different guidelines to hospitals, community clinics, and other health facilities for interacting with immigrant patients.

• California is advising health care providers to avoid including patients’ immigration status in bills and medical records and telling them that, while they should not physically obstruct immigration agents, they are under no obligation to assist with an arrest. The guidance from Democratic Attorney General Rob Bonta also encourages facilities to post information about patients’ right to remain silent and provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.”
• Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization. Still, patients can refuse to answer questions about their immigration status without losing access to care.

Some health care providers fear immigration authorities will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. They point to examples from Trump’s first term, when agents arrested a child during an ambulance transfer, a young man leaving the hospital, and a woman waiting for emergency surgery.

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

On Tuesday, Trump directed the U.S. Department of Justice to investigate state and local officials who don’t cooperate with immigration enforcement.

But no matter the guidelines that states issue, hospitals around the U.S. stress one thing: Patients won’t be turned away for care because of their immigration status.

“None of this changes the care patients receive,” said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

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

USE OUR CONTENT

This story can be republished for free (details).

But the state’s progress in extending health coverage to all residents could come to an abrupt halt as the second Trump administration takes power alongside a Republican Congress whose leadership has long been hostile to the Affordable Care Act, the 2010 federal law also known as Obamacare.

Top of mind for Covered California officials is the looming expiration of the additional federal subsidies for health insurance approved by Congress in 2021 as part of a covid pandemic relief package. That resulted in lower premiums for people around the country — especially middle-class households — who buy health insurance through the exchanges established by the Affordable Care Act.

“Whether there will be action to extend the enhanced subsidies — that’s a big impact that we are closely tracking,” said Covered California Executive Director Jessica Altman, who noted the program had about 1.5 million enrollees prior to enhanced subsidies.

Republicans have criticized the cost of the subsidies, and it’s not clear they’ll renew them.

Without an extension, researchers at the University of California-Berkeley Labor Center estimate, Covered California premiums for subsidized enrollees would soar by an average of $967 a year beginning in 2026, and an estimated 69,000 Californians would lose their insurance.

California took its own steps last year to make coverage more affordable, eliminating deductibles and reducing other out-of-pocket costs on all mid-tier policies known as “silver” plans.

However, the state’s health care spending is likely to face fresh pressure if Republicans in Washington follow through on long-standing designs to cut funding for Medicaid, the health insurance program for low-income Americans, known in California as Medi-Cal. In addition to bolstering Covered California, the state has also aggressively pushed to expand Medi-Cal, including to immigrants living in the U.S. without authorization, and now spends $161 billion a year on that program, about half paid by the federal government.

About 144,000 of Covered California’s 1.8 million enrollees as of Dec. 14 are first-time buyers, and nearly 90% of all enrollees qualify for financial help. Covered California has extended the enrollment period to March 8 for residents in Los Angeles and Ventura counties due to wildfires, and has also issued extensions related to the bird flu and an earthquake in Northern California.

Low-income residents pay little or nothing for monthly premiums, while for those earning more, premiums are capped at a percentage of household income. With the enhanced federal subsidies, no one is required to spend more than 8.5% of their income on premiums, provided they stick to a silver plan. Such plans, however, can have smaller provider networks and significant out-of-pocket costs.

According to Covered California, the average monthly premium is $136 for those who receive subsidies, two-thirds of whom pay $10 or less a month. But people with higher incomes can end up paying significantly more. For example, a family of four making $200,000 in the Los Angeles area would pay well over $1,000 a month for a silver plan, according to a calculator for estimating costs.

While federal and state subsidies have significantly boosted the amount of assistance available, the underlying cost of insurance has continued to go up. Covered California premiums are up by 7.9% on average for 2025, but the extra subsidies shield most enrollees from the increase.

“You end up with people’s out-of-pocket spending probably being lower than we’ve seen,” said Dylan Roby, a professor of health, society, and behavior at the University of California-Irvine. “That doesn’t necessarily mean that premiums are going down. It just means that the state or federal government is paying a larger share of premiums on behalf of enrollees than before.”

Neither Trump nor incoming congressional leaders have given clear signals about how they view the future of the subsidies, but both have a history of seeking to repeal and weaken the Affordable Care Act. House Speaker Mike Johnson has vowed “massive reform” of the health care law, though without offering specifics.

Experts including Roby say Republicans could extend the subsidies to avoid an outcry from consumers, health insurers, hospitals, and others who have benefited from them. Enrollment in marketplace plans is especially high in Republican-controlled states that have not expanded Medicaid, because it offers low-income people a way to access affordable health insurance.

“I don’t think Republican House members are that inclined to make all of their constituents’ health insurance premiums go up,” Roby said. “I’m kind of optimistic that [the subsidies] will be renewed.”

But uncertainty over the future of the subsidies, even if they eventually get renewed, could affect the cost of marketplace plans, said Rachel Linn Gish, communications director for Health Access California, a consumer advocacy coalition. That’s because insurers are already starting to plan their rates for next year and will likely price in the risk of nonrenewal, she said.

“We are going to be fighting for the next year to try to save those enhanced subsidies and subsequently all of the other frameworks and financing of the Affordable Care Act,” Linn Gish said. “Because if any of that gets rolled back, people will lose health care coverage.”

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

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

USE OUR CONTENT

This story can be republished for free (details).

Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization.

Donald Trump returned to the White House declaring a national emergency at the U.S.-Mexico border, suspending refugee admissions, and challenging birthright citizenship, or the policy of giving U.S. citizenship to anyone born in the U.S. As he begins carrying out the “largest deportation operation” in the nation’s history, states have offered starkly different guidelines to hospitals, community clinics, and other health facilities for immigrant patients.

Trump has also rescinded a long-standing policy not to arrest people without legal status at or near sensitive locations, including schools, churches, and hospitals. A proposal to formalize such protections died in Congress in 2023.

But no matter the guidelines that states issue, hospitals around the U.S. say patients won’t be turned away for care because of their immigration status. “None of this changes the care patients receive,” said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

During Trump’s first term, immigration agents arrested people receiving emergency care in hospitals and a child during an ambulance transfer. Immigration officers in Texas arrested a woman awaiting brain surgery in a hospital in Fort Worth. In Portland, Oregon, officers arrested a young man leaving a hospital, and in San Bernardino, California, a woman drove herself to the hospital to give birth after her husband was arrested at a gas station.

An estimated 11 million immigrants live in the United States without authorization, with the largest numbers in California, Texas, Florida, New York, New Jersey, and Illinois, according to Pew Research Center.

Half of immigrant adults likely without authorization are uninsured, compared with fewer than 1 in 10 citizens, according to the 2023 KFF-Los Angeles Times Survey of Immigrants, the largest nongovernmental survey of immigrants in the U.S. to date. While some states are highlighting health care expenses incurred by immigrants, a KFF brief noted that immigrants contribute more to the system through health insurance premiums and taxes than they use. Immigrants also have lower health care costs than citizens.

Some health care providers fear Immigration and Customs Enforcement agents will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. On Trump’s first day, the Republican president issued an executive order aimed at ending birthright citizenship for children born to a parent without legal authorization or on a visa, which could leave them ineligible for federal health and social programs. The order was immediately challenged by states and a civil rights group.

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need, who may not be able to get treatment for an ear infection or surgery,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

A recent survey conducted by the Im/migrant Well-Being Research Center at the University of South Florida found that 66% of noncitizens reported increased hesitation in seeking care after Florida Gov. Ron DeSantis signed a law in 2023 requiring hospitals that accept Medicaid to ask about a patient’s legal status. That’s compared with just 27% for citizens.

“That really was alarming to me to see how this law made people hesitant to go to the doctor, even in an emergency,” said Liz Ventura Molina, a co-author of the survey and report.

In signing the law, DeSantis touted it as “the most ambitious anti-illegal immigration” legislation in the nation. This month, the Republican governor called for a special session of the state legislature to help support Trump’s immigration agenda.

Jackson Health System, a public safety net provider in Miami, said in a statement that quarterly reports to the state don’t contain individual patient information. “We do adhere to all required cooperation with law enforcement agencies, including ICE, as part of any criminal investigations, understanding that privacy laws mandate we only release private patient information through a court-ordered warrant.”

In August, Texas Gov. Greg Abbott, a Republican, issued an executive order similar to Florida’s law to record health care costs incurred by immigrants without legal authorization. All hospitals that receive funding from Medicaid or the Children’s Health Insurance Program are expected to begin reporting the data to Texas Health and Human Services in March.

Even cities controlled by Democrats are walking a fine line. New York City Mayor Eric Adams met in December with Trump’s incoming “border czar,” Tom Homan, and pledged to remove immigrants who have been convicted of a major felony and lack legal status to remain in the country.

At the same time, Adams proposed an awareness campaign to let immigrants and asylum-seekers know they are safe to use the city’s hospital systems.

Some states are going further by advising health facilities to do all they can to protect immigrant patients.

In December, California Attorney General Rob Bonta released a 42-page document recommending providers avoid including patients’ immigration status in bills and medical records. The guidance also emphasized that while providers should not physically obstruct immigration agents, they are under no obligation to assist with an arrest.

According to the document, health care facilities should post information about patients’ right to remain silent and are encouraged to provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.” If feasible, it says, the facility should designate an immigrant-affairs liaison to help train staff and provide nonlegal advice to families.

“We cannot let the Trump deportation machine create a culture of fear and mistrust that prevents immigrants from accessing vital public services,” said Bonta, a Democrat.

On Tuesday, the Trump administration directed the Department of Justice to investigate state and local officials who don’t cooperate with immigration enforcement. During Trump’s first term, California limited cooperation with federal authorities, citing public safety and community trust concerns. The department, then under Jeff Sessions, sued to block the law but the state won in federal court, arguing that states have the authority to decide whether local resources are used to enforce federal law. The Trump administration appealed, but the Supreme Court turned down the petition.

Under California law, state-run health care facilities are required to adopt policies to limit their participation in immigration enforcement, and private entities are encouraged to follow similar protocols. David Simon, a spokesperson for the California Hospital Association, which represents more than 400 hospitals, said members have incorporated such policies, ensuring patient privacy.

“Hospitals don’t call ICE about patients,” Simon said.

California is bracing for a new round of clashes with Trump. Gov. Gavin Newsom and fellow Democratic state leaders have agreed to set aside $50 million for litigation and grants to nonprofit immigrant groups.

Lawmakers in New Jersey are considering legislation to limit health care facilities from asking about a patient’s immigration status. The bill would also require the state attorney general to establish policies for hospitals and health care facilities for ensuring patient access.

In New York City, hospital administrators are directing staff to seek guidance from an “immigration liaison” if immigration authorities show up, and to take photos and videos of any enforcement actions if they can’t reach them first. They are also discouraging staff from actively helping a person hide from ICE. In Massachusetts, some clinics and hospitals are training staff on how to read ICE warrants and plan to require ICE agents to identify themselves and present a warrant if they want to enter a private area.

“You can’t be scrambling in the moment,” said Altaf Saadi, a neurologist who co-directs a clinic for asylum-seekers at the Massachusetts General Hospital. “We have to prepare for these worst-case scenarios, and we hope that they don’t happen, but we do need to be prepared.”

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

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

USE OUR CONTENT

This story can be republished for free (details).

He pulled to the side of the road and cried at the sight of residents trying to save their homes.

“I could see people standing on the roof, watering it, trying to protect it from the fire, and they just looked so hopeless,” said Ramirez, a community outreach worker with the Pasadena Public Health Department.

That evening, the 49-year-old volunteered for a 14-hour shift at the city’s evacuation center, as did colleagues who had also been activated for emergency medical duty. Running on adrenaline and little sleep after finding shelter for homeless people all day, Ramirez spent the night circulating among more than a thousand evacuees, offering wellness checks, companionship, and hope to those who looked distressed.

Local health departments, such as Ramirez’s, have become a key part of governments’ response to wildfires, floods, and other extreme weather events, which scientists say are becoming more intense and frequent due to climate change. The emotional toll of fleeing and possibly losing a home can help cause or exacerbate mental health conditions such as anxiety, depression, post-traumatic stress disorder, suicidal ideation, and substance use, according to health and climate experts.

Wildfires have become a recurring experience for many Angelenos, making it difficult for people to feel safe in their home or able to go about daily living, said Lisa Wong, director of the Los Angeles County Department of Mental Health. However, with each extreme weather event, the county has improved its support for evacuees, she said.

For instance, Wong said the county deployed a team of mental health workers trained to comfort evacuees without retraumatizing them, including by avoiding asking questions likely to bring up painful memories. The department has also learned to better track people’s health needs and redirect those who may find massive evacuation settings uncomfortable to other shelters or interim housing, Wong said. In those first days, the biggest goal is often to reduce people’s anxiety by providing them with information.

“We’ve learned that right when a crisis happens, people don’t necessarily want to talk about mental health,” said Wong, who staffed the evacuation site Jan. 8 with nine colleagues.

Instead, she and her team deliver a message of support: “This is really bad right now, but you’re not going to do this alone. We have a whole system set up for recovery too. Once you get past the initial shock of what happened — initial housing needs, medication needs, all those things — then there’s this whole pathway to recovery that we set up.”

The convention center in downtown Pasadena, which normally hosts home shows, comic cons, and trade shows, was transformed into an evacuation site with hundreds of cots. It was one of at least 13 shelters opened to serve more than 200,000 residents under evacuation orders.

The January wildfires have burned an estimated 64 square miles — an area larger than the city of Paris — and destroyed at least 12,300 buildings since they started Jan. 7. AccuWeather estimates the region will likely face more than $250 billion in economic losses from the blazes, surpassing the estimates from the state’s record-breaking 2020 wildfire season.

Lisa Patel, executive director of the Medical Society Consortium on Climate and Health, said she’s most concerned about low-income residents, who are less likely to access mental health support.

“There was a mental health crisis even before the pandemic,” said Patel, who is also a clinical associate professor of pediatrics at Stanford School of Medicine, referring to the covid-19 pandemic. “The pandemic made it worse. Now you lace in all of this climate change and these disasters into a health care system that isn’t set up to care for the people that already have mental health illness.”

Early research suggests exposure to large amounts of wildfire smoke can damage the brain and increase the risk of developing anxiety, she added.

At the Pasadena Convention Center, Elaine Santiago sat on a cot in a hallway as volunteers pulled wagons loaded with soup, sandwiches, bottled water, and other necessities.

Santiago said she drew comfort from being at the Pasadena evacuation center, knowing that she wasn’t alone in the tragedy.

“It sort of gives me a sense of peace at times,” Santiago said. “Maybe that’s weird. We’re all experiencing this together.”

She had been celebrating her 78th birthday with family when she fled her home in the small city of Sierra Madre, east of Pasadena. As she watched flames whip around her neighborhood, she, along with children and grandkids, scrambled to secure their dogs in crates and grabbed important documents before they left.

The widower had leaned on her husband in past emergencies, and now she felt lost.

“I did feel helpless,” Santiago said. “I figured I’m the head of the household; I should know what to do. But I didn’t know.”

Donny McCullough, who sat on a neighboring green cot draped in a Red Cross blanket, had fled his Pasadena home with his family early on the morning of Jan. 8. Without power at home, the 68-year-old stayed up listening for updates on a battery-powered radio. His eyes remained red from smoke irritation hours later.

“I had my wife and two daughters, and I was trying not to show fear, so I quietly, inside, was like, ‘Oh my God,’” said McCullough, a music producer and writer. “I’m driving away, looking at the house, wondering if it’s going to be the last time I’m going to see it.”

He saved his master recording from a seven-year music project, but he left behind his studio with all his other work from a four-decade career in music.

Not all evacuees arrived with family. Some came searching for loved ones. That’s one of the hardest parts of his shift, Ramirez said. The community outreach worker helped walk people around the building, cot by cot.

A week in, at least two dozen people had been killed in the wildfires.

The work takes a toll on disaster relief workers too. Ramirez said many feared losing their homes in the fires and some already had. He attends therapy weekly, which he said helps him manage his emotions.

At the evacuation center, Ramirez described being on autopilot.

“Some of us react differently. I tend to go into fight mode,” Ramirez said. “I react. I run towards the fire. I run towards personal service. Then once that passes, that’s when my trauma catches up with me.”

Need help? Los Angeles County residents in need of support can call the county’s mental health helpline at 1-800-854-7771. The national Suicide & Crisis Lifeline, 988, is also available for those who’d like to speak with someone confidentially, free of charge.

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

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

USE OUR CONTENT

This story can be republished for free (details).

• Click here to hear Hart on “Central Valley Daily”
• Click here to hear Hart on “Forum”
• Read Hart and Christine Mai-Duc’s “Health Care Is Newsom’s Biggest Unfinished Project. Trump Complicates That Task.”

KFF Health News chief Washington correspondent Julie Rovner discussed health policy on WAMC/Northeast Public Radio’s “The Roundtable” on Jan. 13.

• Click here to hear Rovner on “The Roundtable”

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

USE OUR CONTENT

This story can be republished for free (details).