California lawmakers have approved a controversial no-bid statewide Medi-Cal contract for HMO giant Kaiser Permanente over the objection of county governments and competing health plans. But key details — including how many new patients KP will enroll — are still unclear.

On June 30, with little fanfare, Gov. Gavin Newsom signed the bill that codifies the deal, despite concerns first reported by KHN that KP was getting preferential treatment from the state that would allow it to continue enrolling a healthier pool of Medi-Cal patients, leaving other health plans with a disproportionate share of the program’s sickest and costliest patients. Medi-Cal, California’s version of Medicaid, the government-funded health insurance program for people with low incomes, covers nearly 14.6 million Californians, 84% of whom are in managed-care plans.

Now that the debate is over, opponents of the KP deal are looking ahead.

“We look forward to working with the state on implementing the statewide contract, and we will continue to advocate the value and importance of local plans in providing care to their communities,” said Linnea Koopmans, CEO of Local Health Plans of California, which spearheaded the opposition.

Kaiser Permanente is a huge player in California’s health insurance market, covering nearly a quarter of all Golden State residents. But its slightly less than 900,000 Medi-Cal enrollees are only about 7% of that program’s total managed-care membership.

Kaiser Permanente has long been allowed to limit its Medi-Cal membership by accepting only people who have been KP members in the recent past — primarily in employer-based or Affordable Care Act plans — and their immediate family members.

Under the new law, the number of Kaiser Permanente enrollees in the program “would be permitted to grow by 25%” over the five-year life of the contract, starting from its level on Jan. 1, 2024, when the contract takes effect, said Katharine Weir-Ebster, a spokesperson for the Department of Health Care Services, which runs Medi-Cal. But that 25% figure is not in the text of the law — and the precise magnitude of the intended enrollment increase for KP remains unclear.

Currently, most of KP’s Medi-Cal members are covered through subcontracts with local, publicly governed health plans around the state. Under the new law, those members would be covered directly by Kaiser Permanente under its statewide contract. Proponents say the change will increase efficiency, reduce confusion for consumers, and make Kaiser Permanente more accountable to the state.

Opponents have argued that having a national behemoth compete with local plans — especially in places such as Orange, Ventura, San Mateo, and Sonoma counties, where county-operated plans have been the sole Medi-Cal option — could weaken community control over health care and compromise the safety net system that serves California’s most vulnerable residents.

The new law commits KP to increasing its footprint in Medi-Cal by accepting certain categories of new enrollees, including current and former foster care youths, kids who have received services from another child welfare agency, seniors who are eligible both for Medi-Cal and Medicare, and enrollees who fail to choose a health plan and are assigned one by default.

Nearly half of Medi-Cal enrollees in counties with more than one health plan are assigned by default, Weir-Ebster said. The law, however, doesn’t specify how many default enrollees Kaiser Permanente will accept, saying only that the number will be based on KP’s “projected capacity” in each county or region.

Another significant source of enrollment growth for Kaiser Permanente will be patients — and their family members — transferring out of KP commercial plans in counties where KP will be a Medi-Cal option for the first time.

Some prominent consumer advocacy groups argue that any increase in Kaiser Permanente’s Medi-Cal population is a positive development, especially since the HMO gets high marks for the quality of its care.

“We think that system is something that more Medi-Cal members should have access to, and this bill is a step in that direction,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network, which advocates for equity in health care.

Kaycee Velarde, head of Medi-Cal contracting for KP, said via email that the deal will give more people “access to our high-quality Medi-Cal managed care plan” and allow for better collaboration with the state “to improve quality for a broader number of Medi-Cal enrollees.”

But exactly how the new arrangement will work remains unclear.

The specifics — including the enrollment growth figure — are expected to be enshrined in a memorandum of understanding separate from the contract. That has raised some eyebrows, since MOUs are not typically binding in the same way contracts are. Nor is it clear when the details will come.

“Our expectation is that the Department of Health Care Services is developing the MOU,” Velarde said. The department doesn’t have an estimate of when a draft will be issued, Weir-Ebster said.

Many skeptics of the deal remain concerned about its impact on the safety-net population. The law says Kaiser Permanente will provide the “highest need” specialty services to non-KP members in certain areas of the state. But it does not specify which services or where they will be provided. Those details, expected to be in the MOU, have not yet been decided, Weir-Ebster said.

Leslie Conner, CEO of Santa Cruz Community Health, which runs three clinics in Santa Cruz County, said access to specialty care is a challenge for patients. “That’s going to be a remaining problem that I hope Kaiser would work with the community to address,” she said. “If we don’t all figure it out together, there’s going to be winners and losers, and, honestly, the losers are always the low-income people.”

Lawmakers did make a small number of changes to the original bill intended to address opponents’ concerns. One of them, aimed at local health plans’ fear of having a sicker pool of Medi-Cal enrollees, says all Medi-Cal managed-care plans should be paid in “an actuarially sound manner” in line with the medical risk of their enrollees.

Another one directs the state to assess, before the contract begins, whether KP is adequately complying with behavioral health coverage requirements. The health care giant has come under fire in recent years for providing inadequate mental health services, and the state Department of Managed Health Care is investigating the HMO’s mental health program after a sharp increase in complaints, said Rachel Arrezola, a department spokesperson.

Sal Rosselli, president of the National Union of Healthcare Workers, which has waged a pitched battle against KP over mental health care, said the provision in the new law to assess compliance is insufficient. The union had wanted KP to undergo an annual certification process that would have barred it from enrolling new Medi-Cal enrollees in any year it wasn’t certified.

“Can you imagine any health plan would be granted such a large expansion of its Medi-Cal contract if it couldn’t provide therapy for cancer or cardiac care?” Rosselli said.

Ultimately, KP’s contract creates more choice for the Medi-Cal population, said Linda Nguy, a lobbyist with the Western Center on Law & Poverty. But the group, which advocates for people with low incomes, pledged to keep an eye on how the new law is rolled out.

“We will be monitoring it and certainly raising issues as things come up,” Nguy said.

California counties, health insurance plans, community clinics, and a major national health care labor union are lining up against a controversial deal to grant HMO giant Kaiser Permanente a no-bid statewide Medi-Cal contract as the bill heads for its first legislative hearing Tuesday.

The deal, hammered out earlier this year in closed-door talks between Kaiser Permanente and Gov. Gavin Newsom’s office and first reported by KHN, would allow KP to operate Medi-Cal plans in at least 32 counties without having to bid for the contracts. Medi-Cal’s other eight commercial health plans must compete for their contracts.

Medi-Cal is California’s version of Medicaid, the federal-state program that provides health coverage to low-income people.

Opponents of the KP proposal say they were blindsided by it after having spent months planning for big changes happening in Medi-Cal, which serves more than 14 million Californians. They say the deal would largely allow KP to continue picking the enrollees it wants, and they fear that would give it a healthier and less expensive patient population than other health plans.

Currently, the state allows KP to limit its Medi-Cal membership by accepting only those who have been its members in the recent past, primarily in employer-based or Affordable Care Act plans, and their immediate family members.

“A closed system that excludes vulnerable populations is inequitable,” the heads of 10 county boards said in a letter to Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee, which will consider the proposal. They questioned whether Kaiser Permanente would be assigned patients with “more complex physical, behavioral, and socio-economic needs versus giving the existing safety net system and local plans, who do not exclude populations, a disproportionate share of complex and costly patients.”

Kaiser Permanente said in an emailed statement that, under the terms of the deal, it would take more Medi-Cal patients with high needs and would collaborate with counties and other health plans on patient care.

Michelle Baass, director of the Department of Health Care Services, which runs Medi-Cal, told KHN in early February that the deal would “ensure that more low-income patients have access to Kaiser’s high quality services” and “lead to better health care for more Medi-Cal enrollees.”

The deal must win state legislative and federal approval. Opposition to the bill that would codify it, AB 2724, is being spearheaded by Local Health Plans of California, which represents the 16 local, publicly governed Medi-Cal plans that cover most of the 12 million Medi-Cal beneficiaries in managed care. The proposal would make many of them direct competitors of Kaiser Permanente, and they could lose hundreds of thousands of enrollees and millions of dollars in Medi-Cal revenue.

Among them are some of the state’s largest Medi-Cal health plans, including L.A. Care, by far the biggest, with 2.4 million members; and the Inland Empire Health Plan, with about 1.5 million members in San Bernardino and Riverside counties.

In addition, the boards of supervisors of 16 counties had registered their opposition as of April 15, as had the California State Association of Counties, at least two community clinic groups, and the National Union of Healthcare Workers, which represents thousands of KP clinicians.

The other commercial Medi-Cal plans are lying low as they bid for the state’s Medi-Cal business. The two largest, Health Net and Anthem Blue Cross, declined to comment.

The public health plans and many of the counties said the proposal was sprung on them after they spent months preparing for major Medi-Cal shifts — for example, a more demanding contract with the state, scheduled to take effect in 2024, and an ambitious $6 billion project to provide enrollees with nontraditional services, such as food assistance, home modifications, and help with housing.

Some medical providers are also critical of the proposal.

Leslie Conner, CEO of Santa Cruz Community Health, which operates three clinics in Santa Cruz County, said her group is building a $19 million primary care clinic based on estimates — available at the time the plan was drawn up — of the number of uninsured residents and Medi-Cal members who don’t have a doctor.

“It’s just not helpful to have to recalculate when Kaiser comes in taking more primary care lives,” Conner said. “We didn’t get a chance to talk through that with the state or with Kaiser.”

Conner said that KP, which currently doesn’t have Medi-Cal members in Santa Cruz County, has generously collaborated with Santa Cruz Community Health in the past and that she expects that to continue.

“I’m more disturbed by the state doing this negotiation with a private company,” she said. “That’s just wrong.”

Kaiser Permanente said in its emailed statement that the Department of Health Care Services approached it with the proposal and that it agreed to collaborate “because we recognize, fundamentally, the benefits to the enrollees.” The proposal, it said, “meets the fundamental objectives the state has for Medi-Cal: to improve quality, reduce complexity and improve patient outcomes.”

KP, which covers 9.4 million Californians, the vast majority in its commercial plans, has 912,000 Medi-Cal enrollees. Most of them are through subcontracts with other Medi-Cal health plans in 17 counties, and the rest are in the five counties where KP already contracts directly with the state.

Kaiser Permanente calls its current enrollment-limiting arrangement continuity of care, but critics say it leaves other health plans at a disadvantage — and they worry about it becoming enshrined in state law. In addition to leaving them with a disproportionate share of sicker, costlier patients, they say, it could saddle them with lower quality ratings from the state.

But KP said its mix of sick and healthy Medi-Cal patients is “comparable to other Medi-Cal managed care plans.” It added that the proposal calls on it to increase the number of its Medi-Cal enrollees, including those from “more vulnerable populations.”

Under the proposal, KP has committed to increasing its Medi-Cal membership 25% over the five years of the contract. It would accomplish this partly by taking previous KP enrollees in counties where it currently doesn’t have Medi-Cal members, according to an 11-page document released in March by the Department of Health Care Services. KP would also take, for the first time, a limited number of the enrollees who don’t choose a plan when they sign up for Medi-Cal. And it would enroll children in foster care and the typically complex, expensive patients who are eligible for both Medi-Cal and Medicare.

As of April 15, many details were not yet in the bill language, which will be fleshed out and debated over the next several months.

For instance, the bill makes no mention of the 25% enrollment growth target. And although the Department of Health Care Services document says KP’s direct contract would cover 32 counties, the bill leaves that number open.

“The state clearly has to disclose a lot more information and detail about how this will work,” said Edwin Park, a California-based research professor with Georgetown University’s Center for Children and Families.

Felicia Matlosz, a spokesperson for the bill’s author, Assembly member Joaquin Arambula (D-Fresno), said his office is “working to reconcile the language” with the state’s proposal.

Arguably, the health plans that would be most affected by this proposal are those that are the sole Medi-Cal plan in their counties, known as county organized health systems, or COHS.

They were created by the boards of their counties and operate in partnership with the counties, their safety-net health facilities, and private-sector medical providers. In the 40 years since they were established in California, they have been the only state-contracted Medi-Cal plan in their counties.

“It’s the end of the model,” said Stephanie Sonnenshine, CEO of the Central California Alliance for Health, a county organized health system for Santa Cruz, Monterey, and Merced counties. “It’s a significant policy change that hasn’t been vetted as a policy change.”

KHN correspondent Rachel Bluth contributed to this report.

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The new Medicaid drug program debuted this January, with a private company in charge. But it was woefully unprepared, and thousands of low-income Californians were left without critical medications for weeks, some waiting on hold for hours when they called to get help.

What happened in the two years between the contract award and the start of the program is a case study in what can go wrong when government outsources core functions to the private sector.

California awarded the Medi-Cal Rx program to a unit of Magellan Health, a company with expertise in pharmacy benefits and mental health. But Magellan was then gobbled up by industry giant Centene, worth roughly $50 billion, which was looking to expand its mental health portfolio. 

Centene was already a big player in state Medicaid drug programs — but one with a questionable record. The company was accused by six states of overbilling their Medicaid programs for prescription drugs and pharmacy services and settled to the tune of $264.4 million. Three other states made similar allegations and have settled with the company, but the amounts have not been disclosed. Centene, in resolving the civil actions, denied any wrongdoing.

KHN has learned California health officials also are investigating Centene.

Handing Over Control

In his 2019 inauguration speech, Newsom vowed to use California’s “market power and our moral power to demand fairer prices” from the “drug companies that gouge Californians with sky-high prices.”

Drug spending by the state for its Medicaid, prison, state hospital, and other programs had been climbing 20% a year since 2012, so the first-term Democrat issued an executive order requiring California to make its own generic drugs and forge partnerships with counties and other states to buy drugs in bulk. He also directed the state to buy prescription drugs for Californians enrolled in Medi-Cal, the state’s Medicaid program, which covers roughly 14 million people.

Newsom no longer wanted to allow the state’s two dozen Medi-Cal managed-care health plans to provide prescription drug coverage to their enrollees, arguing the state would get a better deal from drug companies by harnessing its purchasing power.

That December, California awarded a competitive $302 million contract to Magellan Medicaid Administration, a subsidiary of Magellan Health, to make sure Medi-Cal enrollees get the medications that California would buy in bulk. Magellan provides pharmacy services to public health plans in 28 states and the District of Columbia.

Even though Magellan’s biggest money maker is mental health insurance, it met a key requirement of the state’s call for bids: It didn’t provide health insurance to any Medicaid enrollees in California.

Magellan was supposed to take over the drug program in April 2021. But on Jan. 4 of that year, Centene — which was seeking a greater role in the lucrative behavioral health market — announced plans to buy Magellan. 

St. Louis-based Centene, however, is one of the largest Medi-Cal insurers in the state, a factor that would have disqualified it from bidding for the original contract. Centene provides health coverage for about 1.7 million low-income Californians in 26 counties through its subsidiaries Health Net and California Health & Wellness. It earned 11% of its revenue from California businesses in 2019, according to its 2021 annual report to the U.S. Securities and Exchange Commission.

But the state bent over backward to make it work, delaying implementation of the program while Magellan set up firewalls, sectioned off its business operations from Centene, and paid for a third-party monitor.

State regulators reviewed the merger in a 30-minute public hearing in October 2021. They didn’t mention Centene’s legal settlements with other states.

The state Department of Managed Health Care approved the merger Dec. 30. Two days later, the state launched its new prescription drug program with Magellan at the controls.

Centene’s Legal Troubles

In the past 10 months, Centene has settled with nine states over accusations that it and its pharmacy business, Envolve, overbilled their Medicaid programs for prescription drugs and services: It settled with Arkansas, Illinois, Kansas, Mississippi, New Hampshire, and Ohio, according to news releases from attorneys general in those states. The three other states have not been identified by Centene or the states themselves.

The company has set aside $1.25 billion for those settlements and future lawsuits, according to its 2021 report to the SEC.

Centene, which has denied wrongdoing in public statements, did not respond to multiple requests by KHN for interviews, nor did it respond to emailed questions. Magellan also did not respond to interview requests.

From the start, other California health insurers opposed the state takeover of the Medi-Cal drug program, partly because it took away a line of business. They were even more furious when the state allowed one of their biggest competitors to seize the reins — especially given its legal entanglements.

The state Department of Health Care Services, which administers Medi-Cal, acknowledged to KHN in March that it’s investigating the company but declined to provide specifics. The state is investigating Centene’s role in providing pharmacy benefits before the state took the job from managed-care insurers.

“DHCS takes all allegations of fraud, waste, and abuse seriously and investigates allegations when warranted,” department spokesperson Anthony Cava said in a statement.

A Sale in the Offing?

When Medi-Cal Rx debuted Jan. 1, thousands of Californians couldn’t refill critical — sometimes lifesaving — medications for days or weeks. Doctors, pharmacists, and patients calling for help often languished on hold for as many as eight hours.

Magellan blamed the problems on staff shortages during the covid-19 omicron surge and missing patient data from insurance plans. State health officials went to great lengths to fix the problems and appeared before legislative committees to provide lawmakers with assurances that the contractor wouldn’t be paid in full.

But Medi-Cal patients still face uncertainty.

Not long after Magellan took over California’s Medi-Cal drug program, reports surfaced in Axios and other publications that Centene might sell Magellan’s pharmacy business.

Centene officials have not confirmed a sale. But it would align with the company’s recent moves to restructure its pharmacy operations in the face of state investigations — such as seeking an outside company to begin managing its drug spending.

“Once you tell a PBM they actually have to behave, that’s when there’s no more money in it. It’s time to go,” said Antonio Ciaccia, president of drug-pricing watchdog 3 Axis Advisors, referring to businesses known as pharmacy benefit managers.

Yet another ownership change in California’s drug program could bring more disruption to the state’s most vulnerable residents, some of whom are still having trouble getting their drugs and specialty medical supplies after Magellan’s rocky takeover.

“I don’t know what kind of instability that creates internally when there’s a change of this magnitude,” said Linnea Koopmans, CEO of Local Health Plans of California, which represents the state’s publicly run Medicaid insurers that compete against Centene. “It’s just an open question.”

Koopmans and other Centene critics acknowledge that California has long relied on private insurance plans to offer medical and prescription drug coverage to Medi-Cal enrollees and that the state shouldn’t be surprised by ownership changes that come with consolidation in the health care industry. For example, Centene has a history of taking over California contracts after an acquisition — it did so when it purchased Health Net in 2016.

But consumer advocates say the Centene fiasco makes it clear that the state must improve oversight of corporate mergers if it chooses to hand over responsibility for public programs.

“In an ideal world, this is all backroom machinations that people don’t notice — until they do, until there is a problem,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. “It just increases the need to make sure that that oversight is there, that accountability is there.”

SACRAMENTO — Gov. Gavin Newsom’s administration has negotiated a secret deal to give Kaiser Permanente a special Medicaid contract that would allow the health care behemoth to expand its reach in California and largely continue selecting the enrollees it wants, which other health plans say leaves them with a disproportionate share of the program’s sickest and costliest patients. 

The deal, hammered out behind closed doors between Kaiser Permanente and senior officials in Newsom’s office, could complicate a long-planned and expensive transformation of Medi-Cal, the state’s Medicaid program, which covers roughly 14 million low-income Californians. 

It has infuriated executives of other managed-care insurance plans in Medi-Cal, who say they stand to lose hundreds of thousands of patients and millions of dollars a year. The deal allows KP to limit enrollment primarily to its previous enrollees, except in the case of foster kids and people who are eligible for both Medicare and Medi-Cal.  

“It has caused a massive amount of frenzy,” said Jarrod McNaughton, CEO of the Inland Empire Health Plan, which covers about 1.5 million Medi-Cal enrollees in Riverside and San Bernardino counties. “All of us are doing our best to implement the most transformational Medi-Cal initiative in state history, and to put all this together without a public process is very disconcerting.” 

Linnea Koopmans, CEO of the Local Health Plans of California, echoed McNaughton’s concerns.

Insurance plans got wind of the backroom talks when broad outlines of the deal were leaked days before the state briefed their executives Thursday.

Dr. Bechara Choucair, Kaiser Permanente’s chief health officer, argued in a prepared written response on behalf of KP that because it operates both as a health insurer and a health care provider, KP should be treated differently than other commercial health plans that participate in Medi-Cal. Doing business directly with the state will eliminate complexity and improve the quality of care for the Medi-Cal patients it serves, he said. 

“We are not seeking to turn a profit off Medi-Cal enrollment,” Choucair said. “Kaiser Permanente participates in Medi-Cal because it is part of our mission to improve the health of the communities we serve. We participate in Medi-Cal despite incurring losses every year.” 

His statement cited nearly $1.8 billion in losses in the program in 2020 and said KP had donated $402 million to help care for uninsured people that year.

Kaiser Permanente, the state’s largest managed-care organization, is one of Newsom’s most generous supporters and close political allies. 

The new, five-year contract, confirmed to KHN by administration officials and expected to be announced publicly Friday, will take effect in 2024 pending approval from the legislature — and will make KP the only insurer with a statewide Medi-Cal contract. It allows KP to solidify its position before California’s other commercial Medi-Cal plans participate in a statewide bidding process — and after those plans have spent many months and considerable resources developing their bidding strategies.

Other health plans fear the contract could also muddle a massive and expensive initiative called CalAIM that aims to provide social services to the state’s most vulnerable patients, including home-delivered meals, housing aid for homeless people, and mold removal from homes. Under its new contract, KP must provide some of those services. But some executives at other health plans say KP will not have to enroll a large number of sick patients who need such services because of how it limits enrollment.

Critics of the deal noted Newsom’s close relationship with KP, which has given nearly $100 million in charitable funding and grant money to boost Newsom’s efforts against homelessness, covid response, and wildfire relief since 2019, according to state records and KP news releases. The health care giant was also one of two hospital systems awarded a no-bid contract from the state to run a field hospital in Los Angeles during the early days of the covid pandemic, and it got a special agreement from the Newsom administration to help vaccinate Californians last year.

Jim DeBoo, Newsom’s executive secretary, used to lobby for KP before joining the administration. Toby Douglas, a former director of the state Department of Health Care Services, which runs Medi-Cal, is now Kaiser Permanente’s vice president for national Medicaid.  

Partnering with CA Governor Gavin Newsom, Kaiser Permanente increases its commitment to addressing homelessness https://t.co/ncYzG8nWdt

— Paul Erskine (@Paul_Erskine) January 17, 2020

Still, many critics agree that Kaiser Permanente is a linchpin of the state’s health care system, with its strong focus on preventive care and high marks for quality of care. Many of the public insurance plans upset by the deal subcontract with KP for patient care and acknowledge that their overall quality scores will likely decline when KP goes its own way.

Michelle Baass, director of the state Department of Health Care Services, said Medi-Cal had risked losing KP’s “high quality” and “clinical expertise” altogether had it been required to accept all enrollees, as the other health plans must. But she said KP will have to comply with all other conditions that other plans must meet, including tightened requirements on access, quality, consumer satisfaction, and health equity. 

The state will also have greater oversight over patient care, she said.  

“This proposal is a way to help ensure Kaiser treats more low-income patients, and that more low-income patients have access to Kaiser’s high-quality services,” Baass said. 

Though Kaiser Permanente has 9 million enrollees, close to a quarter of all Californians, only about 900,000 of them are Medi-Cal members. 

Under the current system, 12 of the 24 other managed care insurance plans that participate in Medi-Cal subcontract with KP to care for a subset of their patients, keeping a small slice of the Medi-Cal dollars earmarked for those patients. Under the new contract, KP can take those patients away and keep all of the money.

In its subcontracts, and in counties where it enrolls patients directly, KP accepts only people who are recent Kaiser Permanente members and, in some cases, their family members. It is the only health plan that can limit its Medi-Cal enrollment in this way. 

The new contract allows KP to continue this practice, but it also requires Kaiser Permanente to take on more foster children and complex, expensive patients who are eligible for both Medi-Cal and Medicare. It allows KP to expand its geographic reach in Medi-Cal to do so. 

Baass said the state expects KP’s Medi-Cal enrollment to increase 25% over the life of the contract. 

KP defended the practice of limiting enrollment primarily to its previous members, arguing that it provides “continuity of care when members transition into and out of Medi-Cal.” 

The state has long pushed for a larger KP footprint in Medi-Cal, citing its high quality ratings, its strong integrated network, and its huge role on the broader health care landscape.

“Kaiser Permanente historically has not played a very big role in Medi-Cal, and the state has long recognized that we would benefit from having them more engaged because they get better health outcomes and focus on prevention,” said Daniel Zingale, a former Newsom administration official and health insurance regulator who now advises a lobbying firm that has Kaiser Permanente as a client. 

But by accepting primarily people who have been KP members in the recent past, the health system has been able to limit its share of high-need, expensive patients, say rival health plan executives and former state health officials.

The executives fear the deal could saddle them with even more of these patients in the future, including homeless people and those with mental illnesses — and make it harder to provide adequate care for them. Many of those patients will join Medi-Cal for the first time under the CalAIM initiative, and KP will not be required to accept many of them.

“Awarding a no-bid Medi-Cal contract to a statewide commercial plan with a track record of ‘cherry picking’ members and offering only limited behavioral health and community support benefits not only conflicts with the intent and goals of CalAIM but undermines publicly organized health care,” according to an internal document prepared by the Inland Empire Health Plan. 

The plan said it stands to lose the roughly 144,000 Medi-Cal members it delegates to KP and about $10 million in annual revenue. L.A. Care, the nation’s largest Medicaid health plan, with 2.4 million enrollees in Los Angeles County, will lose its 244,000 KP members, based on data shared by the plan. 

The state had been scheduled on Wednesday to release final details and instructions for the commercial plans that are submitting bids for new contracts starting in 2024. But it delayed the release a week to make the KP deal public beforehand.

Baass said the state agreed to exempt KP from the bidding process because the standardized contract expected to result from it would have required the insurer to accept all enrollees, which Kaiser Permanente does not have the capacity to do. 

“It’s not surprising to me that the state will go to extraordinary means to make sure that Kaiser is in the mix, given it has been in the vanguard of our health care delivery system,” Zingale said.

Having a direct statewide Medi-Cal contract will greatly reduce the administrative workload for KP, which will now deal with only one agency on reporting and oversight, rather than the 12 public plans it currently subcontracts with. 

And the new contract will give it an even closer relationship with Newsom and state health officials.

In 2020, KP gave $25 million to one of Newsom’s key initiatives, a state homelessness fund to move people off the streets and into hotel rooms, according to a KHN analysis of charitable payments filed with the California Fair Political Practices Commission. The same year, it donated $9.75 million to a state covid relief fund.

In summer 2020, when local and state public health departments struggled to contain covid spread, the health care giant pledged $63 million in grant funding to help contract-tracing efforts.

KP’s influence extends beyond its massive charitable giving. Its CEO, Greg Adams, landed an appointment on the governor’s economic recovery task force early in the pandemic, and Newsom has showcased KP hospitals at vaccine media events throughout the state. 

Thank you @GavinNewsom @CHHSAgency @MayorOfLA @LAPublicHealth @HildaSolis for joining KP CEO Greg Adams, @NancyGinMD and @KP_LAMC physicians & staff during this historic moment. We appreciate your leadership as we work together to end this devastating #pandemic. #COVID19 pic.twitter.com/E9nHdrPpTd

— Kaiser Permanente Southern California (@KPSCALnews) December 14, 2020

“In California and across the U.S., the campaign contributions and the organizing, the lobbying, all of that stuff is important,” said Andrew Kelly, an assistant professor of health policy at California State University-East Bay. “But there’s a different type of power that comes from your ability to have this privileged position within public programs.”

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They were among the state’s most frail residents: nearly 9,400 mothers, fathers, grandparents, aunts and uncles whom Californians entrusted to a nursing home’s care. An additional 56,275 confirmed covid cases among nursing home residents weren’t fatal.

“The number of covid infections and deaths that happened in skilled nursing facilities in California is truly appalling,” Jim Wood, a Democrat who chairs the state Assembly Health Committee, said at a recent hearing he convened on nursing homes. “I expect better from us.”

Covid-19’s unrelenting spread exposed deep, systemic problems with the quality of care — or lack thereof — at nursing homes across the country. In the nation’s most populous state, the industry’s track record during the pandemic is spurring leaders to radically rethink how it pays and oversees them.

Gov. Gavin Newsom’s administration is drafting a proposal to tie state funding more directly to performance: Among the state’s roughly 1,200 skilled nursing facilities, those that meet new quality standards would get a larger share of state funding than those that don’t.

But exactly how the Golden State would measure quality care and allocate the roughly $5.45 billion a year that nursing homes collectively receive is far from settled — and promises to spark one of 2022’s biggest health care fights. When the legislature debates those details as part of state budget negotiations, the nursing home industry vows to oppose any proposal tying Medicaid payments to quality metrics such as staffing levels, pay and turnover.

In fact, the industry plans to argue it needs more money to deliver better results — and it wields substantial power in the Capitol.

In the past decade, it has spent at least $10 million to influence lawmakers and has given one or more political donations to Newsom and at least 105 current members of the 120-member legislature, according to a KHN analysis of campaign finance records.

But patient advocates and family members who lost loved ones in nursing facilities during the pandemic are mobilizing a counterattack to convince lawmakers that now is the time to overhaul the system.

“There are a lot of problems people have complained about for a long time,” said Charlene Harrington, a professor emerita of social and behavioral sciences at the University of California-San Francisco and an expert on nursing homes. “This is an opportunity to correct those problems.”

At least 140,790 covid deaths have been reported in U.S. nursing homes, according to the latest data from the Centers for Disease Control and Prevention. Older adults have a heightened risk of dying of covid, and the coronavirus spreads more easily in institutional settings such as nursing homes and assisted living facilities.

That’s one reason Craig Cornett, CEO of the California Association of Health Facilities, thinks blaming nursing homes for high covid infection rates, especially early in the pandemic, is unfair. Not only are their residents naturally at higher risk than the rest of the public, he said, but the facilities were forced to accept hospital transfer patients who had not been tested for the virus, they couldn’t get adequate supplies of personal protective equipment, and they suffered as staff members got covid in the community and then brought it into work.

Cornett also pointed to federal statistics that show California has among the lowest nursing home covid death rates in the country and one of the highest staff vaccination rates.

But multiple studies in California and elsewhere have found that nursing homes with fewer nursing staff members experienced significantly higher covid infection and death rates. That devastating outcome is bolstering a two-decades-long argument by patient advocates that nursing homes must hire more workers.

“Some of these problems that we saw in the pandemic could have been avoided if nursing homes had adequate staffing,” said Harrington, who co-authored a December 2020 study for the California Health Care Foundation that showed nursing homes with lower staffing levels earlier that year had twice the covid case rates than those with higher staffing levels. (California Healthline is an editorially independent publication of the foundation.)

Some lawmakers and patient advocates suggest that the best way to improve care is to boost staffing, and that the best way to achieve that is to alter the complicated formulas that determine the daily rate nursing homes are paid by Medicaid, the government insurance program that covers about two-thirds of nursing home residents.

Currently, Medicaid reimburses a portion of what nursing homes spend on staff, administrative and other expenses, paying them a higher proportion for staff costs than administrative costs. Facilities can receive bonus payments for meeting quality standards — although the bonuses are limited and have been criticized for not boosting performance at facilities that need it most.

The California Department of Health Care Services, which administers the state’s Medicaid program, called Medi-Cal, is drafting a plan that would do away with the bonus payments and integrate quality measures into the daily Medi-Cal payment rates nursing homes receive. The department is considering multiple ways to measure quality, spokesperson Anthony Cava said in a statement: Nursing homes that offer more staff education and training could receive higher per diem rates, as could those that have more staff and less staff turnover.

That’s a non-starter for the nursing home industry, which doesn’t consider staffing to be an appropriate measure of how well residents do. Rather, Cornett, whose lobbying group represents more than 800 nursing homes, said facilities should be graded on the number of patient falls and infections, as well as patients’ abilities to perform daily activities.

“We want more staff and want to pay our staff,” Cornett said. “But we need the state to change the system so we can get more money into the staffing line. And that’s going to require a higher amount of money.”

Nursing homes warn that a heavy focus on staffing misses other critical costs of running a facility safely. Even under the current reimbursement system, they say, facilities are scraping by.

“Not all of the costs in a facility are for staff. Skilled nursing facilities, like other healthcare providers, have a variety of costs including medical supplies, consulting, real estate, taxes, administrative services, overhead and many others,” said Mark Johnson, an attorney for Brius Healthcare, one of the largest nursing chains in California.

Whether lawmakers will be sympathetic to the industry’s plea for more money is questionable. They are increasingly demanding transparency about how skilled nursing facilities make and spend their money. Like hospitals and other health care providers, nursing facilities have received billions of dollars in federal covid relief funding to help offset the costs of hiring temporary workers, testing and protective gear. It isn’t lost on lawmakers that this $12 billion industry is attracting a growing number of private investors who are buying ownership shares in their facilities.

“That tells me there’s money out there, there’s profit out there,” said Wood, who also sits on the budget subcommittee that will review the administration’s proposal. “Private equity is not going to go into facilities if they don’t have a chance to make a pretty significant return.”

There’s a lot at stake for the roughly 400,000 residents of nursing homes in the state — and for the industry, which is a big spender and a powerful force in Sacramento.

The California Association of Health Facilities has given just over $2 million in contributions and spent $5.67 million lobbying lawmakers in the past 10 years, from Jan. 1, 2011, through Sept. 30, 2021, according to records filed with the California secretary of state’s office. And Cornett, its CEO, is a veteran of the state Capitol who worked as the top budget aide to four former Assembly speakers and two Senate leaders.

During that time frame, 50 of California’s largest individual and corporate nursing home owners and operators have given a combined $2.6 million directly to lawmakers, the Republican and Democratic state political parties and ballot measures. That figure is likely an undercount because it is difficult to identify everyone with an ownership stake in a nursing home or chain. Facilities are often partially owned by real estate investors, venture capital firms and other business interests not listed on government records.

Cornett downplayed his industry’s influence and said trial lawyers are the players with deep pockets and are funding the patient advocates, an allegation those groups dispute.

But a 2018 report by the California State Auditor found that the three largest private operators — Brius Healthcare, Plum Healthcare Group and Longwood Management Corp. — are highly profitable. Their combined 2006 net income of $10 million grew to between $35 million and $54 million by 2015, the most recent year the state auditor analyzed.

Patient advocates say those profits negate the industry’s argument for needing more taxpayer dollars.

“To some extent, the state is being bamboozled with this idea that the money that they’re paying now is not enough to do the job that we’ve asked them to do,” said Tony Chicotel, an attorney with California Advocates for Nursing Home Reform. “The bottom line is it goes to profit.”

Methodology

KHN analyzed campaign finance records filed with the California secretary of state’s office from Jan. 1, 2011, through Sept. 30, 2021.

We downloaded contributions made by the California Association of Health Facilities, the organization that represents the industry in Sacramento.

To determine how much nursing homes have contributed directly to political campaigns, we identified 50 of California’s largest individual and corporate skilled nursing home owners using data published by the Centers for Medicare & Medicaid Services. We connected those owners to nursing home chains and management companies that run nursing homes.

We then searched each entity and individual on the secretary of state’s website to see if they made any political contributions. We did not include money they gave to the California Association of Health Facilities to ensure we did not double-count contributions.

To track lobbying, we created a spreadsheet of expenses reported on lobbying disclosure forms from Jan. 1, 2011, through Sept. 30, 2021, also available on the secretary of state’s website, by the California Association of Health Facilities. None of the nursing home companies we identified spent any money directly lobbying lawmakers. Instead, they gave money to the association.

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

He pledged to lead California’s single-payer movement, a high-stakes liberal dream that would eliminate private health insurance and slash how much providers are paid. The tough rhetoric continued after he was elected, when Newsom told insurers to “do their damn job” to improve mental health treatment or face fines, and he vowed to cut the health care industry’s soaring revenues.

“We’ve got to get serious about reducing health care costs,” the first-term Democrat said in January 2020 as he unveiled his proposal to establish an Office of Health Care Affordability that would do the unthinkable in a system powered by profits: set caps on health care spending and require doctors and hospitals to work for less money. “We mean business.”

Industry leaders were rattled. But rather than mobilize a full-throttle defense to sink Newsom’s effort to regulate them, they have used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.

When Newsom ultimately drafted legislation for the office, he took an idea health care executives had pitched and made it his own: Instead of capping prices or cutting revenues, he would allow industry spending to grow — but with limits.

Political infighting killed the legislation this year, but it is expected to come back in January and spark one of next year’s blockbuster health care battles.

“They’re fearful of what might happen to them, and they’re trying to protect their interests because they’re threatened,” David Panush, a veteran Sacramento health policy consultant, said about health care industry players. They know “there’s blood in the water and the sharks are coming.”

If Newsom’s plan to rein in health care spending succeeds, it could provide him some political cover as he campaigns for reelection next year, giving him a major health care win even as he sidesteps progressive demands such as creating a single-payer system.

But it could also cement the power of an industry that continues to wield immense influence — negotiating behind the scenes to protect its massive revenues and secure exemptions and side deals in exchange for its support.

“Every time we try to do something to reduce health care costs, it meets with huge opposition,” said state Assembly member Jim Wood (D-Santa Rosa), head of the Assembly Health Committee who is working closely with the Newsom administration on this proposal.

Industry power players have only pushed back harder as lawmakers have tried to take them on, Wood said. “Anybody or anything that disrupts the status quo is met with huge resistance and huge resources to fight it,” he said.

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When Newsom took office in 2019, he knew public sentiment was turning against the health care industry. On average, health care costs were around $11,600 per person that year, up from $4,600 in 1999, according to federal data. In California, hospitals account for the biggest share of spending, nearly one-third, while 20% of health care dollars goes to doctors.

California consumers are demanding action, with 82% of state residents saying it’s “extremely” or “very” important for the governor and legislature to make health care more affordable, according to a 2021 poll from the California Health Care Foundation.

Much of Newsom’s tough talk on industry spending came early in his term. “We’re going to create specific cost targets for all sectors to achieve, and we are going to assess penalties if they don’t achieve those targets,” Newsom said in January 2020. “If that didn’t wake up members of the system, I don’t know what will.”

Newsom’s wake-up call came on the heels of tense legislative debates on bills that would have empowered the state to set health care prices and created a single-payer system. The measures gained surprising momentum but ultimately buckled under opposition from health care giants.

Then the covid-19 crisis hit and propelled the recall effort to oust him from office — and the wake-up call was met with a slap of the snooze button. The governor and his health industry allies nestled closer. Just as he needed them to be the state’s front line of defense, they needed him to keep hospitals from overflowing, to secure protective gear and to push vaccinations.

Health care titans became regular fixtures in Newsom’s orbit. His calendars, obtained by KHN, show that doctors, hospitals and health insurance leaders have routinely received access to the governor.

Carmela Coyle, head of the California Hospital Association, stood beside Newsom at the state emergency operations center in the early days of the covid crisis, and Paul Markovich, CEO of Blue Shield of California, obtained a lucrative no-bid state vaccination contract to implement Newsom’s vaccination effort.

The coziness of the industry’s relationship with Newsom burst into public view in late 2020 when he was photographed dining at the ritzy French Laundry restaurant with Dustin Corcoran and Janus Norman, the CEO and top lobbyist, respectively, of the state doctors’ lobby, the California Medical Association.

“There is no possible way we could have come out of this covid crisis where the health care industry was given so much power without influence coming along with that,” said Carmen Balber, executive director of the advocacy group Consumer Watchdog.

Newsom did not respond to questions about the industry’s influence, but spokesperson Alex Stack said his proposal to regulate health care spending “is a priority for this administration, and we look forward to continuing to work on this issue to get it done.”

Doctors and Blue Shield have given Newsom millions of dollars to support his political career over many years, including a $20 million donation in September 2020 from Blue Shield for his homelessness initiatives.

The recall effort earlier this year only solidified Newsom’s relationship with health care executives. Industry groups wrote checks to the California Democratic Party, which fought to keep Newsom in office. It received $1 million each from Blue Shield and the hospital lobby and $875,000 from the doctors’ lobby, according to state campaign finance records.

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Though Newsom vowed to go after the industry, he hasn’t aggressively taken it on, and health care executives and lobbyists continue to wield their influence as they shape the debate over the Office of Health Care Affordability.

That could put Newsom in a political bind as he runs for reelection — first in the June 2022 primary and then the November general election — because he will face intense opposing political pressure from liberal Democrats who want him to keep his campaign promise and adopt single-payer.

Health and political experts say Newsom can help alleviate that pressure by adopting a strict law going after spiraling health care spending.

“This issue isn’t going away — it does need to be addressed,” acknowledged Corcoran. The push to control costs “should be uncomfortable for everybody, but not horribly so.”

But it won’t be easy. After powerful industry leaders joined forces with organized labor and consumer advocates to propose a plan to the governor, they jammed negotiations with their demands, splintering the coalition and killing the effort this year.

Coyle, with the hospital association, had left the coalition early out of concern that hospitals were the primary target, and approached the Newsom administration independently. She is also asking Newsom to relax stringent earthquake safety standards for hospitals.

Corcoran wants to exempt “small” doctor practices — which he defines as practices with up to 100 doctors — from regulation, arguing that restrictive government cost controls could put them out of business, leading to increased industry consolidation and higher prices.

“The goal posts were constantly shifting,” said Yasmin Peled, a lobbyist for the advocacy group Health Access California, which was involved in negotiations. “The asks were constantly changing.”

Before negotiations completely broke down, Newsom embraced the idea floated by Coyle: The state should control growth, not impose revenue cuts. And it should not focus only on hospitals, but apply to all health care sectors, including doctors and insurers. (The pharmaceutical industry would not be subject to the cost control provisions of the measure because of restrictions in federal law, according to Wood’s office.)

With battle lines drawn, industry groups are poised for a major fight next year as Newsom and state Democratic lawmakers muscle through legislation. Their primary goal will be to protect their interests, said Mark Peterson, a professor of public policy, political science and law at UCLA.

“There’s no question this industry has power. The real question is what they do with it,” Peterson said. “They’re getting wins, and important ones.”

And the leaders of California’s single-payer movement will want their due.

Publicly, union leaders say they’re standing beside Newsom because he has displayed political courage during the covid-19 pandemic by taking actions such as imposing the nation’s first statewide stay-at-home order. But behind the scenes, they are aggressively pressuring him to follow through on his 2018 campaign pledge to establish a government-run, single-payer health care system.

“I expect him to lead on California accomplishing single-payer and being an example for the rest of the country,” said Sal Rosselli, president of the National Union of Healthcare Workers, which is urging Newsom to get federal permission to fund such a system.

Another union, the California Nurses Association, is pushing Newsom to back state legislation early next year to do away with private health insurance and create a single-payer system. But “first, everyone needs to get out and vote no on this recall,” said Stephanie Roberson, the union’s lead lobbyist.

“This is about life or death for us. It’s not only about single-payer. It’s about infection control. It’s about Democratic and working-class values,” she said. “We lose if Republicans take over.”

Together, the unions have made hundreds of thousands of dollars in political contributions, funded anti-recall ads and phone-banked to defend Newsom. The latest polling indicates Newsom will survive Tuesday’s recall election, which has become a battle between Democratic ideals and Republican angst over government coronavirus mandates. The Democratic Party closed ranks around the governor early and kept well-known Democratic contenders off the ballot, leaving liberal voters with little choice other than Newsom.

“This is a crucial moment for Newsom, and for his supporters who are lining up behind him,” said Mark Peterson, a professor of public policy, political science and law at UCLA who specializes in the politics of health care. “They’re helping him stay in office, but that comes with an expectation for some action.”

But it’s not clear that Newsom — who will face competing demands to pay back other supporters pushing for stronger action on homelessness, climate change and public safety — could deliver such a massive shift.

Reorganizing the health system under a single-payer financing model would be tremendously expensive — around $400 billion a year — and difficult to achieve politically, largely because it would require tax increases.

The concept already faces fierce opposition from some of Newsom’s strongest supporters, including insurer Blue Shield of California and the California Medical Association, which represents doctors.

No state has a single-payer system. Vermont tried to implement one, but its former governor, a Democrat, abandoned his plan in 2014 partly because of opposition to tax increases. California would not only need to raise taxes, but would also likely have to seek voter approval to change the state constitution, and get permission from the federal government to use money allocated for Medicare and Medicaid to help fund the new system.

The last big push for single-payer in California ended in 2017 because it did not adequately address financing and other challenges. Leading up to the 2018 gubernatorial election, Newsom campaigned on single-payer health care, telling supporters “you have my firm and absolute commitment as your next governor that I will lead the effort to get it done,” and “single-payer is the way to go.”

In office, though, Newsom has distanced himself from that promise as he has expanded the existing health system, which relies on a mix of public and private insurance company payers. For instance, he and Democratic lawmakers imposed a health insurance mandate on Californians and expanded public coverage for low-income people, both of which enrich health insurers.

Newsom has, however, convened a commission to study single-payer and in late May wrote to President Joe Biden, asking him to work with Congress to pass legislation giving states freedom and financing to establish single-payer systems. “California’s spirit of innovation is stifled by federal limits,” Newsom wrote.

Newsom’s recall campaign, asked about his stance on single-payer, referred questions to his administration. The governor’s office said in prepared comments that Newsom remains committed to the idea.

“Governor Newsom has consistently said that single-payer health care is where we need to be,” spokesperson Alex Stack wrote. “It’s just a question of how we get there.”

Stack also highlighted a new initiative that will build up the state’s public health insurance program, Medi-Cal, saying it “paves a path toward a single-payer principled system.”

Activists say Newsom has let them down on single-payer but are standing behind him because he represents their best shot at obtaining it. However, some say they’re not willing to wait long. If Newsom doesn’t embrace single-payer soon, liberal activists say, they will look for a Democratic alternative when he comes up for reelection next year.

“Newsom is an establishment candidate, and we as Democrats aren’t shy about ripping the endorsement out from under someone who doesn’t share our values,” said Brandon Harami, Bay Area vice chair of the state Democratic Party’s Progressive Caucus, who opposes the recall. “Newsom has been completely silent on single-payer. A lot of us are really gunning to see some action on his part.”

State Assembly member Ash Kalra (D-San Jose), who also opposes the recall, will reintroduce his single-payer bill, AB 1400, in January after he paused it earlier this year to work on a financing plan. Its chief sponsor is the California Nurses Association.

Using lessons learned from the failed 2017 attempt to pass single-payer legislation, the nurses union is deploying activists to pressure state and local lawmakers into supporting the bill. Resolutions have been approved or are pending in multiple cities.

“This is an opportunity for California to lead the way on health care,” Los Angeles City Council member Mike Bonin said before an 11-0 vote backing Kalra’s single-payer bill in late August.

Kalra argued that support from Los Angeles shows his bill is gaining momentum. He is also preparing a new strategy to take on doctors, hospitals, health insurers and other health industry players that oppose single-payer: highlighting their profits.

“They are the No. 1 obstacle to this passing,” Kalra said. “They’re going to do whatever they can to discredit me and this movement, but I’m going to turn the mirror around on them and ask why we should continue to pay for wild profits.”

An industry coalition called Californians Against the Costly Disruption of Our Health Care was instrumental in killing the 2017 single-payer bill and is already lobbying against Kalra’s measure. The group again argues that single-payer would push people off Medicare and private employer plans and result in less choice in health insurance.

Single-payer would “force these millions of Californians who like their health care into a single new, untested government program with no guarantee they could keep their doctor,” coalition spokesperson Ned Wigglesworth said in a statement.

Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand health care access, is on Newsom’s single-payer commission. He said it will work through “tension” in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.

“We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism,” Ross said. “I’m not ruling out any bold stroke on single-payer; I would just want to know how we get it done.”

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But among the allies rushing to Newsom’s defense are doctors, nurses, dentists and other health care interests who credit those pandemic measures for protecting them as front-line workers and saving the lives of countless Californians.

Their unions and trade associations have written checks totaling more than $4.8 million as of 10 a.m. Friday to keep the first-term Democrat in office, according to a KHN analysis of campaign finance filings with the California secretary of state’s office.

Even before covid-19, Newsom had been a steadfast health care advocate and ally, adopting policies that expanded health benefits and coverage to hundreds of thousands of Californians — and lined the pockets of the industry in the process.

“He’s done so much so broadly within the health care sector in California to the benefit of patients and providers of all sorts,” said Andrew Kelly, an assistant professor in the Department of Health Sciences at California State University-East Bay. “That is good for the health care business, as well as our community — improving access to care and outcomes.”

Californians will decide Sept. 14 whether to recall Newsom on a ballot that also asks them to pick his replacement from a list of 46 candidates. If more than 50% of voters choose “yes” to recall Newsom, the candidate who wins the most votes will replace him.

The recall election offers Republicans in blue California — where Democrats hold all statewide offices and control the legislature — their best shot at winning the governor’s office. The GOP candidates with the highest name recognition are businessman John Cox, conservative talk show host Larry Elder, former San Diego Mayor Kevin Faulconer, reality TV star and former Olympian Caitlyn Jenner, suburban Sacramento state Assembly member Kevin Kiley and former congressman Doug Ose.

A poll released Tuesday by the University of California-Berkeley Institute of Governmental Studies found that 47% of likely voters said they favor recalling Newsom, compared with 50% who said they oppose recalling the governor.

Newsom’s supporters have given more than $40 million to fight the recall, compared with nearly $12 million by recall backers, which includes $5 million from Cox for his own campaign.

The health care contributions to fight the recall make up a fraction of the total, but they’re far-reaching: Health care worker unions, dentists, physicians, pharmacists, insurance companies, at least one hospital and others have made big contributions to independent campaign committees created by Newsom’s supporters that can accept unlimited donations.

The health care group that has given the most — $2.25 million — is the union representing California’s nursing home workers and in-home caregivers, Service Employees International Union 2015. Other contributions included $150,000 from the Union of American Physicians and Dentists (whose members include doctors and dentists employed by the state and some counties) and $500,000 from the California Dental Association. These groups either declined telephone interviews or did not respond to requests for comment.

In an emailed statement, SEIU 2015 did not address its sizable contributions but said it intended to mobilize “our mostly black, brown and immigrant caregivers who have been on the front lines of this pandemic to make their voices heard as we go door-to-door, over the phone and online encouraging a vote against the recall.”

An emailed statement from the California Dental Association said its political action committee “puts a great deal of consideration into supporting candidates who are interested in solving the challenges experienced by the dental profession and their patients.”

Republican candidates haven’t received any big donations — defined by the California Fair Political Practices Commission as $1,000 or more — from organized health care groups, which gubernatorial hopeful Kiley said shows just how cozy the governor is with the industry.

“You have vested interests that do whatever it takes to get the governor to do what they want,” said Kiley, one of two Assembly members who sued Newsom last year for using his emergency powers during a pandemic. “He’s taking money from all of them.”

The diverse field of health care interests defending Newsom aren’t always on the same side politically. In fact, they’re often at odds.

But if you’re in health care or public health, the prospect of Newsom being booted from office is worrisome, especially if you want the state to continue combating the pandemic, said Mark Peterson, a professor of public policy and political science at UCLA.

“I don’t think anyone who would be replacing the governor in the recall would be anywhere near as aggressive and might actually put in reverse the public health actions that have been taken,” Peterson said.

Sal Rosselli, president of the National Union of Healthcare Workers, which represents nurses, drug rehab counselors, pharmacists and others, said his union’s 15,000 members are grateful for Newsom’s leadership in the pandemic — citing his first-in-the-nation statewide stay-at-home order, his directive to hospitals last winter to test workers for covid, and other workplace orders that protected essential workers.

“These are all examples of real leadership,” Rosselli said.

In January, the union created a ballot committee to urge Californians not to sign the recall petition — chipping in just over $100,000 of its own money and collecting $10,000 apiece from state Senate leader Toni Atkins and Assembly Speaker Anthony Rendon, among others, to help pay for political ads praising Newsom’s leadership during the pandemic.

Nathan Click, a Newsom campaign spokesperson, did not address the money Newsom has received from the health care industry, but said Californians have a clear choice for governor.

“On one side, you have a governor who has expanded health care for Californians and fought to lower health care costs for families,” Click said via email. “On the other side are a bunch of Trump lackeys who want to repeal Obamacare and take away health care from those who need it most.”

When Newsom campaigned for governor in 2018, he called for a government-backed, single-payer health system at a time when the Trump administration and many Republican lawmakers were trying to dismantle the Affordable Care Act.

He hasn’t delivered on his single-payer pledge, citing insurmountable federal hurdles. But he has signed legislation and advocated for policies that insured more Californians or boosted their benefits, policies that also enrich insurers and providers by bringing them more patients.

For instance, low-income undocumented immigrants ages 19 to 25 became eligible for full benefits under Medi-Cal, California’s Medicaid program for poor residents, last year. Next year, people 50 and older will become eligible regardless of their immigration status.

For the more than 13 million Californians already in the program, Newsom and legislators agreed last year to restore dental, vision and other optional health care benefits that had been cut during the Great Recession. And they boosted the rates the program pays physicians and dentists.

Qualified Californians can also tap into state subsidies to reduce the cost of health insurance premiums sold through Covered California, a benefit approved by Newsom in 2019.

The recall has handed the unions an opportunity to pressure Newsom to act on his single-payer pledge, arguing that the pandemic has laid bare deadly disparities in health care. For example, Latinos in California not only were exposed to covid at much higher rates but also died at 1.5 times the rate of white Californians, according to researchers at Stanford University.

“We trust that Gavin Newsom is the person to lead” on single-payer, said Rosselli, who has known Newsom since he got into politics nearly 20 years ago. “To make California the first state in the nation as an example for the rest of the country on ending these inequities in health care.”

Methodology

Gov. Gavin Newsom is facing a recall election Sept. 14. To find out which health care interests are contributing for and against the recall effort, KHN analyzed campaign finance reports filed with the California secretary of state’s office through 10 a.m. Friday, July 30. Each candidate and campaign committee participating in the recall is required to report how much money they’ve raised and spent. Any donation of $1,000 or more must be reported within 24 hours.

We downloaded and analyzed campaign records from two committees created to support the recall, committees run by the leading Republican candidates, and five committees created to oppose the recall.

That’s the verdict of state lawmakers and patient advocates who have been working for years to reform the Medical Board of California.

But an attempt this year to give the board more money and power to investigate complaints of fraud, gross negligence, sexual misconduct and other misbehavior is under attack from one of the most politically potent forces in California’s Capitol: doctors themselves.

And so far, it seems, the doctors are winning.

The California Medical Association (CMA), whose top lobbyist sat next to Gov. Gavin Newsom at the infamous French Laundry dinner last fall, swooped in to slash a proposed hike on physicians’ licensing fees even though the board, which relies on those fees, is teetering on insolvency. It also beat back a proposal to put more non-physician members of the public on the board, which would have diminished the influence of the doctors who represent a majority.

“The strength and the power of the CMA is that they are able to deflect and obstruct the beneficial and necessary legislation to protect the consumer and to ensure the success of the medical board,” said former state Sen. Jerry Hill, who four years ago lost his push to overhaul the board. “That’s what I found, and that’s what I see occurring this year.”

This year’s bill was approved by the state Senate after it was amended under pressure from the doctors’ group. The measure is now before the state Assembly, where it remains a target of the California Medical Association. As currently written, SB 806 would authorize a smaller licensing fee increase, restore the board’s authority to recoup investigative costs from doctors who have been disciplined and create an independent monitor to evaluate the board’s complaint and disciplinary processes.

The mission of the medical board, composed of eight physicians and seven members of the public, is to license and discipline doctors. But critics say the board has allowed some doctors who have committed wrongdoing to keep their licenses, despite reports of egregious behavior, while families complain they’ve been left in the dark for years.

The board received 10,868 complaints in the 2019-20 fiscal year. During that period, it initiated 1,956 investigations, revoked 35 physician licenses, put 170 doctors on probation and reprimanded 108 doctors, according to the board’s 2019-2020 Annual Report. An additional 96 physicians surrendered their licenses.

In his independent review of cases that came before the panel last year, board member Eserick “TJ” Watkins told lawmakers the board had settled 84% of complaints, with a bias toward allowing doctors to continue to practice without real rehabilitation.

“This board’s value is we protect the doctors, and we’ll go over and above in order to do so,” said Watkins, one of the board’s members representing the public.

Earlier this year, the board’s executive director told lawmakers the board is taking longer to investigate complex cases than it did six years ago, in part because of more complaints and vacancies among the board’s support staff. In fiscal year 2019-20, those cases took an average of 548 days from start to end, he said, compared with 310 in fiscal year 2013-14.

Patients and their families who have testified at legislative hearings describe an unresponsive and uncommunicative board that usually allows doctors accused of negligence or malpractice to continue to practice.

“I thought there would be a lot of integrity and thoroughness to the investigation process, and I didn’t get a sense that the medical board really looked at the matter,” said Alka Airy, who in 2019 filed a complaint of unprofessional conduct and potential negligence against the University of California-San Francisco’s Lung Transplant Program after her sister, Shilpa Airy, died the year before.

According to the complaint, doctors who treated Shilpa Airy between 2015 and 2018 failed to evaluate how her lung failure affected her heart or refer her to a cardiologist. She died of end-stage heart failure while waiting for a lung transplant. Airy said the board closed the complaint without taking action. The board declined to comment.

By comparison, when Alka Airy filed a complaint with the California Board of Registered Nursing, she said, she was interviewed by an investigator who requested additional records beyond what the doctors or hospital may have provided. Airy said she is still waiting to learn the outcome of the case.

A UCSF spokesperson said its clinicians have fully cooperated with all investigators and could not comment on pending investigations.

“I think my experience was very similar to thousands of other folks who sent in complaints to the medical board,” Airy said. “It’s not a transparent process. So much happens behind closed doors.”

Board spokesperson Carlos Villatoro said the board bases its disciplinary decisions “on the facts and circumstances of each case” to determine whether revoking a physician’s license is necessary.

“The board does not have the authority to punish a licensee by imposing a level of discipline that goes beyond what is necessary to protect the public,” Villatoro said via email.

Advocates for patients and even some board members believe that tipping the board’s balance of power to public members could regain some of the public’s trust. But that provision was removed from this year’s bill after the California Medical Association argued the panel — like other comparable state boards — needed the expertise of people in the profession it regulates.

Dr. Howard Krauss, himself a former trustee of the CMA, has been on the board for eight years. In that time, he said, he’s never witnessed a decision that pitted physicians on the board against public members.

“The optics of having a board with one more public member than a physician might be of benefit,” Krauss said at an emergency hearing this month.

Critics say the board also lacks the resources and the ability to pursue timely investigations, hamstrung by a legislature beholden to the CMA, whose 50,000 pediatricians, surgeons and other physicians are influential members of every lawmaker’s district.

The California Medical Association is one of the most prolific campaign contributors in Sacramento and has given to Newsom and all but one of the 119 lawmakers currently serving in the state legislature.

In addition to making campaign contributions directly to lawmakers, the association spent $18.6 million between Jan. 1, 2011, and March 30, 2021, lobbying lawmakers and state agencies on a variety of issues, from flavored tobacco to medical malpractice caps, according to records filed with the California secretary of state’s office. It employs its own lobbyists and hires outside lobbying firms.

The group routinely scores access to the state’s top leaders. Among the movers and shakers at the French Laundry dinner party in Napa Valley in November were the association’s top lobbyist, Janus Norman, and CEO, Dustin Corcoran.

CMA spokesperson Anthony York said the organization is “like any other group in the Capitol” that advocates for its members. He said the $367 increase in licensing fees that lawmakers initially proposed — from $783 to $1,150 — would have been too big a burden on doctors who fought to stay open during the pandemic.

Family medicine physicians in California earned an average annual wage of $220,240 as of the first quarter of this year, according to the state Employment Development Department. “A lot of physician practices are struggling to keep their doors open,” York said. “Now is not the time for a fee increase.”

After state Sen. Richard Roth (D-Riverside) introduced the legislature’s must-pass bill to reauthorize the medical board in May, the CMA issued an “action alert” to its members, urging doctors to call, text and email their senators to voice their opposition. Eight days later, it declared a partial victory when Roth amended his bill to lower the fee increase to $863 and eliminate a requirement that the board be controlled by public members, a provision that had been backed by Senate leader Toni Atkins.

“While the bill is not perfect,” the association wrote on its website, the removal of those provisions “was a major victory.”

Despite repeated requests from the medical board, lawmakers haven’t approved a licensing fee increase in 16 years, even though the fees are the board’s primary source of income. The CMA agreed to the last fee increase in 2005 as part of a deal that also took away the board’s ability to recover legal and investigative costs for cases in which doctors had been disciplined.

York said the association remains opposed to the provision that would restore the board’s ability to recoup investigative costs and has concerns about the role of the independent monitor.

In its report to the legislature, the medical board projected it would be insolvent by the end of 2021-22 without an increase in licensing fees.

Doctors “just don’t want to pay for it,” said Bridget Gramme, an attorney at the Center for Public Interest Law at the University of San Diego School of Law. “What is the money going for? It’s going for a stronger discipline system, which they don’t want.”

Roth, who chairs the Senate Business, Professions and Economic Development Committee, said the CMA’s influence wasn’t the reason he amended the bill to reduce the fee increase. Rather, he said the board hadn’t justified the large fee increase — even though he included it in the original version of the bill — and could make do with a modest fee increase combined with better money management.

“Everybody had an opportunity to voice their perspective,” Roth said, pointing out that the bill still includes provisions that doctors oppose. “The goal is to make sure that we have a medical board that is functioning effectively and efficiently, that the enforcement process does the right thing at the right time for the right reasons, and that we squeeze every bit of operational efficiency that we can afford.”

As he watches from afar, Hill, the former legislator, said he doesn’t think the California Medical Association will give up until it kills every provision it opposes.

“This whole thing is part of CMA’s playbook. It’s how they operate,” Hill said. “They hire just about every available lobbyist in Sacramento to remove the rest of what was in the bill.”

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At least 30 tech and health care companies have received lucrative, no-bid government contracts, or helped fund and carry out critical public health activities during the state’s battle against the coronavirus, a KHN analysis has found. The vast majority are Newsom supporters and donors who have contributed more than $113 million to his political campaigns and charitable causes, or to fund his policy initiatives, since his first run for statewide office in 2010.

For instance, the San Francisco-based software company Salesforce — whose CEO, Marc Benioff, is a repeat donor and is so tight with the governor that Newsom named him the godfather of his first child — helped create My Turn, California’s centralized vaccine clearinghouse, which has been unpopular among Californians seeking shots and has so far cost the state $93 million.

Verily Life Sciences, a sister company of Google, another deep-pocketed Newsom donor, received a no-bid contract in March 2020 to expand covid testing — a $72 million venture that the state later retreated on. And after Newsom handed another no-bid testing contract — now valued at $600 million — to OptumServe, its parent company, national insurance giant UnitedHealth Group dropped $100,000 into a campaign account he can tap to fight the recall effort against him.

Newsom’s unprecedented reliance on private companies — including health and technology start-ups — has come at the expense of California’s overtaxed and underfunded public health system. Current and former public health officials say Newsom has entrusted the essential work of government to private-sector health and tech allies, hurting the ability of the state and local health departments to respond to the coronavirus pandemic and prepare for future threats.

“This outsourcing is weakening us. The lack of investment in our public health system is weakening us,” said Flojaune Cofer, a former state Department of Public Health epidemiologist and senior director of policy for Public Health Advocates, which has lobbied unsuccessfully for years for more state public health dollars.

“These are companies that are profit-driven, with shareholders. They’re not accountable to the public,” Cofer said. “We can’t rely on them helicoptering in. What if next time it’s not in the interest of the business or it’s not profitable?”

Kathleen Kelly Janus, Newsom’s senior adviser on social innovation, said the governor is “very proud of our innovative public-private partnerships,” which have provided “critical support for Californians in need during this pandemic.”

State Health and Human Services Secretary Dr. Mark Ghaly echoed the praise, saying private-sector companies have filled “important” roles during an unprecedented public health crisis.

The state’s contract with OptumServe has helped dramatically lower covid test turnaround times after a troubled start. Another subsidiary of UnitedHealth Group, OptumInsight, received $41 million to help California rescue its outdated infectious disease reporting and monitoring system last year after it crashed.

“Not only are we much better equipped on all of these things than we were at the beginning, but we are also seeing some success,” Ghaly said, “whether it’s on the vaccination front, which has really picked up and put us in a place of success, or just being able to do testing at a broad scale. So, I feel like we’re in a reasonable position to continue to deal with covid.”

The federal government finances most public health activities in California and significantly boosted funding during the pandemic, but local health departments also rely on state and local money to keep their communities safe.

In his first year as governor, the year before the pandemic, Newsom denied a budget request from California’s 61 local public health departments to provide $50 million in state money per year to help rebuild core public health infrastructure — which had been decimated by decades of budget cuts — despite warnings from his own public health agency that the state wasn’t prepared for what was coming.

After the pandemic struck, Newsom and state lawmakers turned away another budget request to support the local health departments driving California’s pandemic response, this time for $150 million in additional annual infrastructure funding. Facing deficits at the time, the state couldn’t afford it, Newsom said, and federal help was on the way.

Yet covid cases continued to mount, and resources dwindled. Bare-bones staffing meant that some local health departments had to abandon fundamental public health functions, such as contact tracing, communicable disease testing and enforcement of public health orders.

“As the pandemic rages on and without additional resources, some pandemic activities previously funded with federal CARES Act resources simply cannot be sustained,” a coalition of public health officials warned in a late December letter to Newsom and legislative leaders.

Newsom has long promoted tech and private companies as a way to improve government, and has leaned on the private sector throughout his political career, dating to his time as San Francisco mayor from 2004 to 2011, when he called on corporations to contribute to his homelessness initiatives.

And since becoming governor in January 2019, he has regularly held private meetings with health and tech executives, his calendars show, including Facebook CEO Mark Zuckerberg, Google CEO Sundar Pichai and Apple CEO Tim Cook.

“We’re right next door to Silicon Valley, of course, so technology is our friend,” Newsom wrote in his 2013 book, “Citizenville,” arguing that “government needs to adapt to this new technological age.”

With California’s core public health infrastructure already gutted, Newsom funneled taxpayer money to tech and health companies during the pandemic or allowed them to help design and fund certain public health activities.

Other industries have jumped into covid response, including telecommunications and entertainment, but not to the degree of the health and technology sectors.

“It’s not the ideal situation,” said Daniel Zingale, who has steered consequential health policy decisions under three California governors, including Newsom. “What is best for Google is not necessarily best for the people of California.”

Among the corporate titans that have received government contracts to conduct core public health functions is Google’s sister company Verily.

Google and its executives have given more than $10 million to Newsom’s gubernatorial campaigns and special causes since 2010, according to state records. It has infiltrated the state’s pandemic response: The company, along with Apple, helped build a smartphone alert system called CA Notify to assist state and local health officials with contact tracing, a venture Newsom hailed as an innovative, “data-driven” approach to reducing community spread. Google, Apple and Facebook are sharing tracking data with the state to help chart the spread of covid. Google — as well as Facebook, Snapchat, TikTok, Twitter and other platforms — also contributed millions of dollars in free advertising to California, in Newsom’s name, for public health messaging.

Other companies that have received lucrative contracts to help carry out the state’s covid plans include health insurance company Blue Shield of California, which received a $15 million no-bid contract to oversee vaccine allocation and distribution, and the private consulting firm McKinsey & Co., which has received $48 million in government contracts to boost vaccinations and testing and work on genomic sequencing to help track and monitor covid variants. Together, they have given Newsom more than $20 million in campaign and charitable donations since 2010.

Private companies have also helped finance government programs and core public health functions during the pandemic — at times bypassing local public health departments — under the guise of making charitable or governmental contributions, known as “behested payments,” in Newsom’s name. They have helped fund vaccination clinics, hosted public service announcements on their platforms, and paid for hotel rooms to safely shelter and quarantine homeless people.

Facebook and the Chan Zuckerberg Initiative, the philanthropic organization started by Facebook founder Mark Zuckerberg and his wife, Priscilla Chan, have been among the most generous, and have given $36.5 million to Newsom, either directly or to causes and policy initiatives on his behalf. Much of that money was spent on pandemic response efforts championed by Newsom, such as hotel rooms and child care for front-line health care workers; computers and internet access for kids learning at home; and social services for incarcerated people leaving prison because of covid outbreaks.

Facebook said it is also partnering with the state to deploy pop-up vaccination clinics in hard-hit areas like the Central Valley, Inland Empire and South Los Angeles.

In prepared statements, Google and Facebook said they threw themselves into the pandemic response because they wanted to help struggling workers and businesses in their home state, and to respond to the needs of vulnerable communities.

Venture capitalist Dr. Bob Kocher, a Newsom ally who was one of the governor’s earliest pandemic advisers, said private-sector involvement helped California tremendously.

“We’re doing really well. We got almost 20 million people vaccinated and our test positivity rate is at an all-time low,” Kocher said. “Our public health system was set up to handle small-scale outbreaks like E. coli or hepatitis. Things work better when you build coalitions that go beyond government.”

Public health leaders acknowledge that private-sector participation during an emergency can help the state respond quickly and on a large scale. But by outsourcing so much work to the private sector, they say, California has also undercut its already struggling public health system — and missed an opportunity to invest in it.

Take Verily. Newsom tapped the company to help expand testing to underserved populations, but the state chose to end its relationship with the company in January after county health departments rejected the partnership, in part because testing was not adequately reaching Black and Latino neighborhoods. In addition to requiring that residents have a car and Gmail account, Verily was seen by many local health officials as an outsider that didn’t understand the communities.

It takes years of shoe leather public health work to build trusted relationships within communities, said Dr. Noha Aboelata, founder and CEO of the Roots Community Health Center in the predominantly Black and Latino neighborhood of East Oakland.

“I think what’s not fine is when these corporations are claiming to be the center of equity, when in fact it can manifest as the opposite,” she said. “We’re in a neighborhood where people walk to our clinic, which is why when Verily testing first started and they were drive-up and you needed a Gmail account, most of our community wasn’t able to take advantage of it.”

To fill the gap, the clinic worked with Alameda County to offer old-fashioned walk-up appointments. “We’re very focused on disparities, and we’re definitely seeing the folks who are most at risk,” Aboelata said.

The state took a similar approach to vaccination. Instead of giving local health departments the funding and power to manage their own vaccination programs with community partners, it looked to the private sector again. Among the companies that received a vaccination contract is Color Health Inc., awarded $10 million to run 10 vaccine clinics across the state, among other covid-related work. Since partnering with California, Color has seen its valuation soar to $1.5 billion — helping it achieve “unicorn” start-up status.

As the state’s Silicon Valley partners rake in money, staffing at local health departments has suffered, in part because they don’t have enough funding to hire or replace workers. “It is our biggest commodity and it’s our No. 1 need,” said Kat DeBurgh, executive director of the Health Officers Association of California.

With inadequate staffing to address the pandemic, the state is falling further behind on other basic public health duties, such as updating data systems and technology — many county health departments still rely on fax machines to report lab results — and combating record-setting levels of sexually transmitted diseases such as syphilis.

“We’ve put so many resources into law enforcement and private tech companies instead of public health,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “This is having a devastating impact.”

Dr. Karen Smith, former director of the state Department of Public Health, left the state in July 2019 and now is a consultant with Google Health, one of Big Tech’s forays into the business of health care.

She believes Silicon Valley can improve the state’s crumbling public health infrastructure, especially when it comes to collecting and sharing data, but it can’t be done without substantial investment from the state. “Who the heck still uses fax? Public health doesn’t have the kind of money that tech companies have,” said Smith, who said she wasn’t speaking on behalf of Google.

Without adequate funding to rebuild its infrastructure and hire permanent workers, Smith and others fear California isn’t prepared to ride out the remainder of this pandemic — let alone manage the next public health crisis.

Statewide public health advocacy groups have formed a coalition called “California Can’t Wait” to pressure state lawmakers and Newsom to put more money into the state budget for local public health departments. They’re asking for $200 million annually. Newsom will unveil his latest state budget proposal by mid-May.

“We’re in one of those change-or-die moments,” Capitol health care veteran Zingale said. “Newsom has been at the vanguard of the nation in marshaling the help of our robust technological private sector, and we’re thankful for their contributions, but change is better than charity. I don’t want to show ingratitude, but we should keep our eyes on building a better system.”

KHN data editor Elizabeth Lucas and California politics correspondent Samantha Young contributed to this report.

Methodology: How KHN compiled data about political spending and the role of technology and health care companies in California’s covid response.

Private-sector companies from Silicon Valley and the health care industry have participated in California’s public health response to covid-19 in a variety of ways, big and small. Some have received multimillion-dollar contracts from the state of California to perform testing, vaccination and other activities. Others have donated money and resources to the effort, such as free public health advertising time.

KHN identified the companies that received pandemic-related contracts or work from the state by filing Public Records Act requests with state agencies; searching other sources, including California’s “Released COVID-19 Response Contracts” page; and contacting state agencies and companies directly.

We then searched the California Fair Political Practices Commission website for tech and health care companies that didn’t receive contracts but played a role in the state’s pandemic response by donating money and resources. Through what are known as “behested payments,” these companies donated to charitable causes or Gov. Gavin Newsom’s policy initiatives on his behalf. These contributions included money to help fund and design state public health initiatives such as quarantine hotel rooms.

Based on those searches, we found at least 30 health or technology companies that have participated in the state’s pandemic response: Google and its sister company Verily Life Sciences; Salesforce; Facebook; Apple; McKinsey & Co.; OptumServe and OptumInsight — subsidiaries of national health care company UnitedHealth Group; Netflix; Pandora; Spotify; Zoom Video Communications Inc.; electric car manufacturer BYD; Bloom Energy; Color Health Inc.; DoorDash; Twitter; Amazon; Accenture; Skedulo; Primary.Health; Pfizer; HP Inc.; Microsoft; Snapchat; Blue Shield of California; Kaiser Permanente; Lenovo Inc.; YouTube; and TikTok. The Chan Zuckerberg Initiative, the philanthropic organization started by Facebook founder Mark Zuckerberg and his wife, Priscilla Chan, also participated.

We then searched the California secretary of state’s website to determine which of those companies, and their executives, gave direct political contributions to Newsom’s personal campaign accounts and a ballot measure account run by the governor called “Newsom’s Ballot Measure Committee” during his five campaigns for statewide office since 2010, plus the ongoing recall effort against him.

We found that at least 24 of the tech or health companies that participated in the state’s pandemic response, or their executives, gave direct political contributions to Newsom, made behested payments in his name or both.

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

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