Somewhat by accident, Bloomer, 26, found Priya Kalyan-Masih six months into her pregnancy. Kalyan-Masih is a doula, a professional childbirth companion who provides emotional support, physical comfort, and education to women before, during, and after pregnancy. Bloomer hadn’t realized Medi-Cal would cover the service until she visited an informational fair near her home in the High Desert region of Southern California.

Medi-Cal, California’s Medicaid program for low-income residents, started offering the benefit in January — but doulas have wrestled with the program’s bureaucratic requirements and what they say is insufficient pay.

“Priya really listened to me. Out of all my births, this was the most peaceful and stress-free,” said Bloomer, who is a student working part-time as an in-home caregiver and at a detox center. “The fact that I didn’t have to pay anything out-of-pocket was life-changing.”

Having Kalyan-Masih at her side was critical for Bloomer because her partner — now fiancé — was imprisoned a few weeks after she found out she was pregnant, which would have meant she’d have to navigate her pregnancy and delivery without him.

Across the country, doulas are being enlisted to combat rising maternal mortality rates. In 2021, the most recent year for which data is available, about 1,200 women in the U.S. died from pregnancy complications either during pregnancy or within six weeks afterward, about 60% more deaths than were reported two years earlier, according to the Centers for Disease Control and Prevention.

The numbers are starkest for Black women and their children. In 2021, Black women died at more than 2½ times the rate of white women.

Doulas are distinct from the medical team and act as advocates for birthing parents. A National Institutes of Health study published this year found that doula care was associated with reductions in cesarean sections, epidural use, length of labor, premature deliveries, and maternal stress.

During Bloomer’s pregnancy, Kalyan-Masih assisted with strategies such as mapping a birth plan and coaching Bloomer on breathing techniques to ease her anxiety.

Less than a year after Bloomer moved from Texas to be with her fiancé, Tim Smith, he was arrested for firearm possession while on probation for drug-related charges. That left Bloomer in Victorville, on the edge of the Mojave Desert, far from friends and family.

In Smith’s absence, Bloomer was grateful for Kalyan-Masih’s companionship and reminders to take care of herself, she said.

But what meant the most was Kalyan-Masih’s willingness to weave Smith into the birth without judgment, she said. Kalyan-Masih acted as his eyes and ears at the hospital in June, running around with Bloomer’s phone so Smith could meet his newborn daughter, Tiara, via FaceTime.

“It meant everything. I mean, I’m locked up and I saw the baby before Mia did,” Smith recalled, laughing. “Priya made everything possible. She held the phone. She was running around when the baby came out. She made it feel like I was there.”

Smith met Tiara in person when he was released a month later.

Kalyan-Masih’s presence also led to a noticeable difference in how medical staff treated her, Bloomer said.

During her previous deliveries, she felt the medical professionals had been pushy and dismissive. For example, when her son Thaddeus was born last year, she said, doctors pressured her to get an epidural against her wishes after Smith left the room to grab her lunch.

“When I had Priya in the room, they were more attentive to my needs and didn’t treat me like my opinion didn’t matter,” Bloomer said. “It wasn’t an argument or debate. It was just like, ‘OK, that’s what we’re doing.’”

Medi-Cal covers up to 11 doula visits before and after pregnancy, and support during labor and delivery — and patients can petition for extra postpartum visits. Doulas can also be paid by Medi-Cal for providing support during and after miscarriages or abortions.

“I always explain it as obstetricians and midwives are the ones catching babies, and doulas catch Mom,” said Kalyan-Masih, who is a medical doctor by training and a doula since January.

Kalyan-Masih is pleased with California’s investment in doula services but said it has been a challenge to maneuver Medi-Cal’s administrative requirements, like acquiring business licenses.

Samsarah Morgan, a doula and founder of the Oakland Better Birth Foundation, said the business license fees, in addition to Medi-Cal’s reimbursement rates, prevent some doulas from participating in the program.

The state pays doulas fixed rates per visit, adding up to $1,154 if patients schedule the standard number of nine visits before and after birth, in addition to labor and delivery. Doulas can make up to $2,078 through Medi-Cal if patients schedule additional postpartum visits. The $1,154 rate is more than twice what the state initially proposed in 2022, and Morgan said that she’s grateful for the increase — but that it’s still not enough.

In her own practice, most clients pay $2,500 to $3,500, typically out-of-pocket since, in her experience, many private insurance plans don’t cover doula services, she said.

“I want to work with clients who are on Medi-Cal, but I also need to pay my bills,” Morgan said.

Griselda Melgoza, a spokesperson for the Department of Health Care Services, which administers Medi-Cal, said the department pays doulas the same as other providers — including doctors, nurses, and physician assistants — for the same services. The department has proposed rate increases for doula services next year, which would vary by type of delivery. A doula who provides the standard nine visits and attends a vaginal delivery, for example, would be paid $2,180, 89% more than the current rate.

Preliminary data shows that 50 doula claims were processed statewide as of July 31 and that claims from that time frame are still coming in, Melgoza said. She added that the department is working to make the benefit more accessible. In November, for instance, it eliminated most referral requirements, removing a hurdle for patients.

Bloomer said she wishes she had been able to work with a doula during previous pregnancies, especially when she was carrying Lucas, her first child, at age 19.

At the time, she didn’t know what questions to ask or what to expect, including how to cope with postpartum depression.

“With a doula, I would have been more informed,” Bloomer said as 6-month-old Tiara babbled on her lap. “I would have felt more empowered. I would have had the kind of support that would have made me a better mom.”

This article is part of “Faces of Medi-Cal,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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

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

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Impulsado por los planes Medi-Cal del condado —que proporcionan seguro médico a los residentes con bajos ingresos— en colaboración con su Oficina de Educación y el Departamento de Salud Mental, el programa se basa en servicios de teleterapia proporcionados por Hazel Health, una de las empresas que han surgido para hacer frente a la escasez nacional de servicios de salud mental, algo que se agravó durante la pandemia de covid-19.

La teleterapia es uno de los cuatro proyectos del condado de Los Angeles que recibirán en conjunto hasta $83 millones del Programa de Incentivos de Salud Mental para Estudiantes del estado, uno de los componentes del “plan maestro” del gobernador demócrata para subsanar las deficiencias en el acceso de los jóvenes a los servicios de salud mental.

El contrato de Hazel Health en Los Angeles tiene como meta ayudar a las escuelas sobrecargadas a hacer frente al aumento de la demanda de estos servicios. Promete ser una iniciativa piloto para demostrar tanto la eficacia de la terapia virtual para los alumnos, como la capacidad de educadores y administradores para gestionar eficazmente un programa extenso y delicado en colaboración con una empresa con fines de lucro.

Para algunos educadores y familias los resultados iniciales son prometedores.

Anjelah Salazar, de 10 años, dijo que el especialista de Hazel la ha ayudado a sentirse mucho mejor. La estudiante de quinto grado empezó a sufrir ataques de pánico diarios al cambiar de escuela este año a la primaria Stanton de Glendora.

Su madre, Rosanna Chavira, contó que no sabía qué hacer —aunque es coordinadora clínica de una empresa que trata enfermedades mentales— y le preocupaba no poder pagar un terapeuta que aceptara su seguro. Cuando Chavira supo de Hazel, no lo dudó.

“El hecho de que sea gratis y de que un profesional le enseñe estrategias para sobrellevar distintas situaciones significa mucho”, dijo Chavira. “Ya se notan los resultados”.

Salazar dijo que hasta ahora tuvo cinco citas virtuales con su terapeuta. Una técnica de afrontamiento que aprecia especialmente es un ejercicio de tapping: todas las noches, antes de acostarse, se presiona con el dedo un poquito los ojos, las mejillas, el pecho y las rodillas. Con cada toque, dice: “Soy valiente”.

Christine Crone, madre de Brady, alumno de séptimo grado, afirmó que aún no ha comprobado si las sesiones son eficaces para su hijo, que estudia en Arroyo Seco Junior High en Santa Clarita, pero sí sabe que las disfruta.

“Normalmente le cuesta llegar a tiempo y estar preparado, pero con estas sesiones siempre deja lo que está haciendo y es puntual”, dijo Crone. “Dice que su terapeuta es agradable, divertido y que es fácil hablar con él”.

Jennifer Moya, consejera de salud mental en la escuela primaria Martha Baldwin de Alhambra, una ciudad al este de Los Angeles, dijo que a sus alumnos les gusta la flexibilidad de la teleterapia, que les permite reunirse con los terapeutas en cualquier momento entre las 7 de la mañana y las 7 de la tarde.

“Esta generación de niños ha crecido en la era digital”, señaló Moya, que se encarga de remitir a los alumnos a Hazel en su centro. “Les encanta que esto sea fácil”.

Pablo Isais, consejero de salud mental en la escuela primaria Granada’s Alhambra, dijo que los servicios también pueden ser una solución provisional mientras un estudiante espera una cita en persona, que puede tomar de seis a ocho semanas.

“Ser capaz de comunicarles que hay servicios disponibles a los que pueden acceder en la próxima semana es increíble”, dijo Moya.

Hasta ahora, sólo 607 estudiantes del condado de Los Angeles han participado en las sesiones desde que se ofrecieron por primera vez, en Compton, en diciembre de 2022, explicó Alicia Garoupa, jefa de servicios de bienestar y apoyo de la Oficina de Educación. Ella reconoció algunos problemas iniciales, pero aseguró que Hazel es “otra herramienta en nuestra caja de herramientas”.

El estado confía en las empresas con fines de lucro

La teleterapia desempeña un papel cada vez más importante en las escuelas del país, a medida que educadores y trabajadores sociales se enfrentan a la presión de abordar los crecientes problemas de salud mental. Según un informe de abril de Chalkbeat, 13 de los 20 distritos escolares más grandes del país, incluido Los Angeles Unified, la han incorporado desde que comenzó la pandemia.

El acuerdo del condado de Los Angeles con Hazel prevé el pago a la empresa de hasta $20 millones hasta finales de 2024. Además, Hazel puede facturar a los seguros de los estudiantes.

La empresa con sede en San Francisco, fundada en 2015, ha recaudado $112,5 millones de inversores y tiene contratos en 15 estados. Entre las empresas que buscan los dólares destinados para la salud mental de los jóvenes están otra startup de San Francisco, Daybreak Health, graduada de la prestigiosa incubadora tecnológica Y Combinator, junto con BeMe, Brightline y Kooth.

California eligió a Brightline y Kooth para una iniciativa estatal de $532 millones, en 2024, sobre servicios virtuales de comportamiento juvenil, otro componente importante del plan maestro de Newsom. Algunos programas estatales y locales se superponen, reconoció Naomi Allen, cofundadora y CEO de Brightline, pero dijo que la oferta de Brightline es más amplia que lo que Hazel hace en las escuelas, con servicios que incluyen desde sesiones de coaching para cuidadores hasta recursos de meditación.

“El estado financia el acceso gratuito a los servicios para todos los niños del estado, lo cual es un programa extraordinariamente ambicioso”, afirmó Allen.

Aún así, quedan muchos interrogantes sobre la eficacia de la teleterapia para estudiantes. Tampoco ha resultado ser una fuente de ingresos segura para las empresas: Brightline despidió al 20% de su plantilla la primavera pasada, la segunda ronda de despidos en seis meses.

Complemento, no solución

Chelsy Duffer-Dunbar, que en aquel momento trabajaba para Los Angeles Unified como trabajadora social psiquiátrica, declaró a KFF Health News en octubre que aún no había trabajado con Hazel, pero señaló que el condado exige que un miembro del personal permanezca a la vista del estudiante durante sus citas y le ayude si surgen problemas técnicos.

“Le sigue quitando tiempo al personal”, aseguró Duffer-Dunbar. “Mi día ya es muy estresante. No puedo imaginar tener una evaluación por amenaza y otra por suicidio en el trabajo y luego tener que buscar a alguien para que se siente en esta sesión de terapia con el niño o la niña y su iPad”.

Duffer-Dunbar añadió que quiere que el distrito dé prioridad a los terapeutas en persona que trabajan con la comunidad local, especialmente para los niños más pequeños que tienen problemas con la teleterapia.

Duffer-Dunbar ha dejado el distrito por recortes presupuestarios que la obligaban a desempeñar un trabajo más agobiante.

Hazel insistió en que la teleterapia no es una solución para todas las situaciones.

“Es una oportunidad para ampliar el acceso”, apuntó Andrew Post, jefe de innovación de la empresa.

Colaboración entre educación y salud

Fue necesaria una complicada colaboración entre los distritos escolares, las agencias del condado y los dos planes de Medi-Cal, L.A. Care Health Plan y Health Net, para poner en marcha el programa de terapia escolar. Las normas de financiación estatales se diseñaron para ayudar a las entidades a trabajar juntas.

“Este programa nos ha ayudado a acercarnos a los distritos escolares”, comentó Michael Brodsky, director de salud comunitaria de L.A. Care Health Plan. “Si podemos tratar a los niños cuando van a la escuela y derivarlos para que reciban tratamiento mientras están en la escuela, eso es bueno”.

Hazel ofrece principalmente sesiones de terapia individual de corta duración con trabajadores sociales clínicos u otros consejeros, el 40% de los cuales son bilingües. Son los más indicados para prestar apoyo temporal a quienes tienen necesidades leves o moderadas, como los estudiantes que luchan contra el estrés académico o empiezan en una escuela nueva, pero también pueden derivar a pacientes para que reciban atención a largo plazo.

El mayor distrito inscrito en el programa, Los Angeles Unified, cuenta con el 41% de los alumnos del condado, pero no todos los distritos están preparados para dar el salto. Cuatro de cada 10 distritos han optado por no ofrecer los servicios de Hazel, lo que Garoupa atribuye en parte a la preocupación por el intercambio de información sobre los estudiantes.

El contrato con Hazel termina en diciembre de 2024, pero Garoupa dijo que la Oficina de Educación y sus socios tienen la intención de mantener los servicios hasta junio de 2025. Cualquier prórroga posterior dependerá de los resultados.

Sonya Smith, colega de Garoupa, indicó que la Oficina de Educación evaluará la eficacia de Hazel a través de una encuesta anual, informes mensuales de impacto y reuniones semanales.

“El número de estudiantes que utilizan Hazel va a ser, obviamente, una medida clave”, añadió Smith. “La tasa de utilización de Hazel es del 3% al 8%. Evaluaremos si esas cifras se mantienen, si los estudiantes acceden a la atención en el momento oportuno y si alivia la carga del personal escolar y los proveedores comunitarios”.

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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Spearheaded by the county’s Medi-Cal plans — which provide health insurance to low-income residents — in collaboration with its Office of Education and Department of Mental Health, the LA school program relies on teletherapy services provided by Hazel Health, one of a clutch of companies that have sprung up to address a nationwide shortage of mental health services that grew much worse during the covid-19 pandemic.

The teletherapy effort is one of four LA County projects that will collectively receive up to $83 million from the state’s Student Behavioral Health Incentive Program, one component of the Democratic governor’s “master plan” to address gaps in youth mental health care access.

LA’s Hazel Health contract is aimed at helping overburdened schools cope with a surge in demand for mental health services. It promises to be a telling case study in both the efficacy of virtual therapy for students and the ability of educators and administrators to effectively manage a sprawling and sensitive program in partnership with a for-profit company.

For some Los Angeles County educators and families, the initial results are promising.

Anjelah Salazar, 10, said her Hazel clinician has helped her feel a lot better. After the fifth grader switched to a new school this year, Stanton Elementary in Glendora, she started having panic attacks every day.

Her mom, Rosanna Chavira, said she didn’t know what to do — even though she’s a clinical coordinator for a company that treats mental health conditions — and worried she wouldn’t be able to find an affordable therapist who accepted their insurance. Once Chavira learned about Hazel, she jumped at the opportunity.

“This being free and having a licensed professional teaching her coping skills, it just means the world,” Chavira said. “You can already see changes.”

Salazar said she’s met with her virtual therapist five times so far. One coping technique that she especially appreciates is a tapping exercise: Every night before bed, she taps her eyes, her cheeks, her chest, and her knees. With each tap, she recites the same affirmation: “I am brave.”

Christine Crone, parent of seventh grader Brady, said she has yet to see if the sessions have been effective for her son, who attends Arroyo Seco Junior High in Santa Clarita, but she knows he enjoys them.

“He struggles normally with being on time and prepared, but with these sessions, he always stops what he is doing and makes sure he is logged in on time,” Crone said. “He says that his therapist is nice, fun, and easy to talk to.”

Jennifer Moya, a mental health counselor at Martha Baldwin Elementary in Alhambra, a city east of Los Angeles, said her students like the flexibility of teletherapy, which allows them to meet with clinicians anytime between 7 a.m. and 7 p.m.

“This generation of kids has grown up digital,” said Moya, who is in charge of referring students to Hazel at her school. “They love that this is easy.”

Pablo Isais, a mental health counselor at Alhambra’s Granada Elementary School, said the services can also be a stopgap while a student waits for an in-person appointment, which can take six to eight weeks.

“To be able to let them know that there are services available that they can access within the next week is amazing,” Moya said.

Thus far, early in the rollout, only 607 Los Angeles County students have participated in Hazel sessions since they were first offered, in Compton, in December 2022, said Alicia Garoupa, chief of well-being and support services for the Office of Education. She acknowledged some bumps in the rollout but said Hazel is “another tool in our toolbox.”

State Relies on For-Profit Ventures

Teletherapy is playing an increasingly important role in schools across the nation as educators and social workers face pressure to address growing mental health issues. According to an April Chalkbeat report, 13 of the nation’s 20 largest school districts, including Los Angeles Unified, have added teletherapy since the pandemic began.

LA County’s deal with Hazel calls for the company to be paid up to $20 million through the end of 2024. In addition, Hazel can bill students’ insurance.

The San Francisco-based company, founded in 2015, has raised $112.5 million from investors and has contracts in 15 different states. Other companies chasing youth mental health dollars include another San Francisco startup, Daybreak Health, a graduate of the prestigious Y Combinator tech incubator, along with BeMe, Brightline, and Kooth.

California chose Brightline and Kooth for a 2024 $532 million statewide initiative on virtual youth behavioral services, another important component of Newsom’s master plan. There is some overlap between the state and local programs, Brightline co-founder and CEO Naomi Allen acknowledged, but she said the Brightline offering is broader than what Hazel is doing in schools, with services including everything from coaching sessions for caregivers to meditation resources.

“The state is funding free access to services for every child in the state, which is just a remarkably ambitious program,” said Allen.

Still, many questions remain about the efficacy of teletherapy for students. It’s also proving to be no surefire moneymaker for the companies thus far: Brightline laid off 20% of its staff last spring, the second round of layoffs in six months.

Supplement, Not Solution

Chelsy Duffer-Dunbar, who at the time worked for Los Angeles Unified as a psychiatric social worker, told KFF Health News in October that she hadn’t yet worked with Hazel, but noted that the county requires that a member of staff stay within eyesight of the student during their appointments and assist if tech issues arise.

“It is still taking up staff time,” Duffer-Dunbar said. “My day is already so stressful. I can’t imagine having a threat assessment and a suicide assessment at work and then trying to scramble around to find someone to sit in on this therapy session with the kiddo and their iPad.”

Duffer-Dunbar said she wants the district to prioritize in-person clinicians who are immersed in the local community, especially for younger kids who have trouble engaging with teletherapy.

Duffer-Dunbar has since left the district in response to budget cuts that forced her into a more burdensome role.

Hazel emphasized that teletherapy is not a one-size-fits-all solution.

“It’s an opportunity to expand access,” said Andrew Post, chief of innovation at the company.

Education and Health Care Working Together

It took a complicated collaboration between school districts, county agencies, and the two Medi-Cal plans, L.A. Care Health Plan and Health Net, to set up the school therapy program. The state funding rules were designed to push the entities to work together.

“This program has helped us get closer to school districts,” said Michael Brodsky, senior medical director for community health at L.A. Care Health Plan. “If we can catch kids while they’re at school and refer them to get treatment while they’re in school, that’s good.”

Hazel provides primarily short-term one-to-one therapy sessions with clinical social workers or other licensed counselors, 40% of whom are bilingual. They are best suited to provide temporary support to those with mild to moderate needs, such as students struggling with academic stress or starting at a new school, but they can also make referrals for long-term care.

The largest district enrolled in the program, Los Angeles Unified, accounts for 41% of the county’s students, but not all districts are ready to take the leap. Four in 10 districts have opted to not offer Hazel’s services, which Garoupa attributes partially to data-sharing concerns.

The contract with Hazel ends in December 2024, but Garoupa said the Office of Education and its partners intend to maintain services through June 2025. Any extension beyond that will depend on the results.

Sonya Smith, a colleague of Garoupa’s, said the Office of Education will be continuously evaluating Hazel’s effectiveness through an annual survey, monthly impact reports, and weekly meetings.

“The number of students that are using Hazel is obviously going to be a key metric,” Smith said. “Hazel’s historic utilization rate is 3% to 8%. We’ll be evaluating if those numbers hold up, if students are accessing care in a timely manner, and if it’s lightening the burden for school staff and community-based providers.”

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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Johnson, 58, said her ordeal started in September 2022, when she went for a CT scan of her abdomen after a bout of covid-19. Though Johnson warned the lab she was allergic to iodine, she believes the lab tech used it in an injection, triggering an allergic reaction. She spent the next three weeks in the hospital, feeling as if her body was on fire.

When she was discharged to her home at the base of the San Jacinto Mountains in Riverside County, Johnson said, her quality of life deteriorated and her frustration mounted as she waited for her Medi-Cal plan to get her assessed by a specialist. She could barely walk or stand, she could no longer cook for herself, and sometimes she couldn’t even lift her leg high enough to step into the tub.

“I would never wish this on anybody,” Johnson said while rocking back and forth on the couch to still the pain. “You don’t know if you should cry, or just say OK, I can make it through this. It messes with you mentally.”

Johnson said her primary care doctor told her he wasn’t sure what triggered the pain but suspects it was compounded by the lingering effects of covid. Johnson, who is diabetic, developed neuropathy, a type of nerve damage, possibly after the allergic reaction caused her blood sugar levels to skyrocket, her doctor told her.

He referred Johnson, who receives care through California’s Medicaid program for low-income people, to an endocrinologist in March. But Johnson said she was not offered timely appointments, and it took more than six months, four referrals, multiple complaints to her health plan, and a legal aid group’s help to finally snag a phone call with an endocrinologist in mid-September.

Access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The Inland Empire, where Johnson lives, has the second-lowest supply of specialists in the state, according to the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The state Department of Managed Health Care, which regulates most Medi-Cal health plans, requires plans to get patients in to see specialists within 15 business days, unless a longer waiting time would not harm the patient’s health. But the timeline often looks very different in reality.

“It’s hard to get a specialist to contract for Medi-Cal patients. Period,” said Amanda Simmons, executive vice president of Integrated Health Partners of Southern California, a nonprofit organization that represents community health clinics. “Specialists don’t want to do it because reimbursement rates are so low.”

Johnson said she made her first call in March to the endocrinologist assigned by her Medi-Cal insurer, Inland Empire Health Plan, and that the office offered her an appointment several months out. Over the next four months, she received three more referrals, but she said she got a similar response each time she called. When Johnson objected to the lengthy wait times, requesting earlier appointments, she was told there was no availability and that her condition wasn’t urgent.

“They told me it wasn’t important,” Johnson said. “And I asked, ‘How would you know? You’ve never seen me.’”

Esther Iverson, director of provider communications for the plan, declined to speak about Johnson’s case but said the plan makes every effort to meet the 15-day requirement. It can be challenging to meet the standard, she said, due to a lack of available physicians — especially for certain specialties, such as endocrinology and pain management.

She pointed to the nationwide physician shortage, which is more pronounced in rural areas, including parts of San Bernardino and Riverside counties, where the plan operates. She also noted that many physicians decided to leave the field or retire early due to burnout from the covid pandemic.

At the same time, she said, the plan’s enrollment ballooned to 1.6 million as eligibility expanded in recent years. Statewide, more than 15 million Californians are enrolled in Medi-Cal.

“The highest priority for us is timely access to quality care,” Iverson said.

During her quest, Johnson enlisted the help of Inland Counties Legal Services, which provides free legal representation to low-income residents. They called the plan multiple times to request earlier appointments but got mired in bureaucratic delays and waiting periods.

In one instance in August, after the insurer told Johnson it couldn’t meet the 15-day time frame, her legal representative, Mariane Gantino, filed an appeal, arguing that Johnson’s request was urgent. The insurer’s medical director responded within a few hours denying the claim, saying the plan concluded that her case was not urgent and that a delay would not cause a serious threat to her health.

“I’m so burned out after dealing with this for so long,” Johnson said in mid-September. “Why do they have the 15-day law if there aren’t going to be any consequences?”

A few days later, Johnson finally received the call she had been waiting for: an offer of a phone appointment with an endocrinologist, on Sept. 18. During the appointment, the doctor adjusted her diabetes and other medications but didn’t directly address her pain, she said.

“I’m in the same position,” Johnson said. “I’m still in pain. What’s next?”

Over the years, Johnson has worked a variety of jobs — from driving eighteen-wheelers cross-country to weaving hair — but her most consistent work was as a caregiver, including to her six children, 21 grandchildren, and three great-grandkids, with another great-grandchild on the way. Now, because of her extreme pain, the roles have been reversed. A daughter and granddaughter who live with her have become her full-time caregivers.

“I can’t do nothing. I can’t take care of my grandkids like I used to,” said Johnson, who sleeps most of the day and wakes up only when her pain medication wears off. “I was planning to take care of the new baby that’s coming. I probably can’t even hold her now.”

This article is part of “Faces of Medi-Cal,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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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This story can be republished for free (details).

The first bill, SB 326, is designed to transform the state’s Mental Health Services Act into the Behavioral Health Services Act, using an existing tax on millionaires to treat the most seriously mentally ill and to increase programs for substance use disorders. The second, AB 531, authorizes the state to issue $6.38 billion in bonds to build more housing for homeless people and treatment beds for those with the most severe needs.

Newsom will now ask voters to approve the changes on the March primary ballot.

“This reform will bring much needed accountability currently lacking at the local and state level, increased transparency and visibility into the whole mental health and addiction treatment system, and a modernized focus to address today’s crises,” Newsom said in a statement.

According to a June statewide study on homelessness by the University of California-San Francisco, more than 171,000 Californians experience homelessness daily, representing 30% of the nation’s homeless population. The majority of participants in the study reported high lifetime rates of mental health and substance use challenges; 82% reported a period in their life in which they experienced a serious mental health condition, and nearly two-thirds reported the use of illicit drugs or heavy drinking.

The mental health act was passed as Proposition 63 by voters in 2004 and levied a tax of 1% on income above $1 million, known as the “millionaire’s tax.” That money then flowed from the state to counties for use in five mental health areas, including community support, prevention, and facilities. Funding changes year to year, but the tax generated $3.3 billion in the 2022-23 fiscal year, according to the nonpartisan Legislative Analyst’s Office.

However, the program has been criticized over the years for falling short of its initial promise. Last year, the Los Angeles Times highlighted several reasons, including revenue swings, consistent underfunding of social and mental health programs, tension between state and county officials, and a shortage of mental health clinicians.

Newsom pledged that the newly renamed Behavioral Health Services Act would build 10,000 new beds and housing units for people experiencing homelessness who have behavioral health needs. It would also focus on diversifying the workforce and improving accountability — tracking outcomes in a more detailed way — so the government can understand what’s working and what’s not.

However, counties that administer this money at the local level have raised concerns. A letter from the California State Association of Counties and other organizations representing local government interests expressed fear that Newsom’s proposal would result in counties receiving significantly less funding for core services, little protection from fluctuation in funds, and less flexibility in spending.

The governor’s office emphasized that new requirements still provide flexibility.

Assembly member Jacqui Irwin (D-Thousand Oaks), who was the lead author of the bond bill and served for seven years as the chair of the body’s Military and Veterans Affairs Committee, is particularly proud of a provision that will reserve $1.07 billion for housing for veterans. California has the largest number of veterans experiencing homelessness — 31% of the nation’s homeless veteran population — according to a 2021 homelessness report by the U.S. Department of Housing and Urban Development.

“Getting veterans experiencing homelessness off the streets has long been a priority for California, but getting some of our most vulnerable veterans into needed treatment for behavioral health challenges will be transformative,” Irwin said.

Sen. Susan Talamantes Eggman (D-Stockton), who co-authored the bond bill and was the lead author of the other bill, said the bills are critical to the state’s continuum of care. “Together they will build out voluntary housing, reprioritize resources to those with the greatest needs, and provide a true safety net to prevent the many people falling through the cracks that we see today,” she said.

El primer proyecto de ley, el SB 326, está diseñado para transformar la Ley de Servicios de Salud Mental del estado en la Ley de Servicios de Salud Conductual, al utilizar un impuesto existente a los millonarios para tratar a los enfermos mentales más graves y aumentar los programas para los trastornos por consumo de drogas.

La segunda, la AB 531, autoriza al estado a emitir bonos por valor de $6,380 millones para construir más viviendas para personas sin hogar y camas para tratamiento para los más necesitados.

Newsom pedirá ahora a los votantes que aprueben los cambios en las boletas de las primarias de marzo.

“Esta reforma aportará la tan necesaria rendición de cuentas que actualmente falta a nivel local y estatal, una mayor transparencia y visibilidad en todo el sistema de salud mental y tratamiento de adicciones, y un enfoque modernizado para hacer frente a las crisis actuales”, dijo Newsom en un comunicado.

Según un estudio estatal sobre los sin techo realizado en junio por la Universidad de California-San Francisco, más de 171,000 californianos sufren diariamente la falta de vivienda, lo que representa el 30% de la población sin hogar del país.

La mayoría de los participantes en el estudio declaró haber padecido a lo largo de su vida problemas de salud mental y de consumo de drogas; el 82% dijo haber sufrido algún trastorno mental grave en algún momento de su vida, y casi dos tercios indicó haber usado drogas ilícitas o haber bebido en exceso.

La ley de salud mental fue aprobada como Proposición 63 por los votantes en 2004 e imponía un impuesto del 1% sobre los ingresos superiores a un millón de dólares, conocido como el “impuesto de los millonarios”. Ese dinero pasaba del estado a los condados para su uso en cinco áreas de salud mental, entre ellas el apoyo comunitario, la prevención y las instalaciones. La financiación cambia año a año, pero el impuesto generó $3,300 millones en el año fiscal 2022-23, según la Oficina del Analista Legislativo, que no es partidista.

Sin embargo, el programa ha sido criticado a lo largo de los años por no cumplir su promesa inicial. El año pasado, Los Angeles Times destacó varias razones, incluidos los cambios en los ingresos, la subfinanciación constante de los programas sociales y de salud mental, la tensión entre los funcionarios estatales y del condado, y la escasez de médicos de salud mental.

Newsom prometió que la recién rebautizada Ley de Servicios de Salud Mental construiría 10,000 nuevas camas y viviendas para personas sin hogar con necesidades de salud mental. También se centraría en diversificar la mano de obra y mejorar la rendición de cuentas —mediante un seguimiento más detallado de los resultados—, para que el gobierno pueda saber qué funciona y qué no.

Sin embargo, los condados que administran este dinero a nivel local han expresado su preocupación. En una carta de la Asociación de Condados del Estado de California y otras organizaciones que representan los intereses de los gobiernos locales, expresaron el temor de que la propuesta de Newsom diera lugar a que los condados recibieran muchos menos fondos para servicios básicos, poca protección frente a la fluctuación de los fondos y menos flexibilidad en el gasto.

La oficina del gobernador hizo hincapié en que los nuevos requisitos siguen siendo flexibles.

La asambleísta Jacqui Irwin (demócrata de Thousand Oaks), autora principal del proyecto de ley de bonos y presidenta durante siete años de la Comisión de Asuntos Militares y de Veteranos, está especialmente orgullosa de una disposición que reservará $1,070 millones a viviendas para veteranos. California tiene el mayor número de veteranos sin hogar —el 31% de la población de veteranos sin hogar del país—, según un informe de 2021 del Departamento de Vivienda y Desarrollo Urbano de Estados Unidos.

“Sacar de las calles a los veteranos sin hogar ha sido durante mucho tiempo una prioridad para California, pero conseguir que algunos de nuestros veteranos más vulnerables reciban el tratamiento necesario para los problemas de salud conductual será transformador”, dijo Irwin.

La senadora estatal Susan Talamantes Eggman (demócrata de Stockton), quien es coautora del proyecto de ley de bonos, y fue la autora principal del otro proyecto de ley, dijo que estas propuestas legislativas son fundamentales para la continuidad de la asistencia que provee el estado. “Juntos construirán viviendas, reasignarán los recursos a los más necesitados y proporcionarán una verdadera red de seguridad para evitar que muchas personas caigan en las fisuras que vemos hoy en día”, afirmó.

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Santa Clara Valley Medical Center, along with other units of county-owned Santa Clara Valley Healthcare, will also adopt procedures to ensure patients are informed of their eligibility for charity care, which nonprofit and public hospitals must provide.

“This is huge,” said Helen Tran, a senior attorney with Western Center on Law & Poverty, which joined another California-based legal group, the Consumer Law Center, in a lawsuit against the hospital. “It’s so important that the hospital is stepping up to take corrective action. That’s something we haven’t seen many hospitals do.”

Filed in 2019 and settled in June, the lawsuit alleged that Santa Clara Valley Medical Center billed patients and sent them to collections for charges they should not have been required to pay. Emily Hepner, one of the plaintiffs, was a full-time student, raising two children alone,and uninsured in 2014 when she needed urgent surgery, according to the lawsuit. The hospital never followed up after telling her she might be eligible for charity care and, nearly a year later, she received a $34,884 bill. The hospital later sued her for that amount plus attorney fees.

The Santa Clara settlement comes at a time of mounting scrutiny of charity care around the country. A number of nonprofit hospitals have been found skimping on their obligations to provide free and discounted care, and failing to inform patients about their eligibility as more Americans struggle with medical debt.

“Santa Clara Valley Healthcare prides itself on delivering quality healthcare for individuals and communities that face significant socioeconomic hurdles to receiving this basic benefit,” said Paul Lorenz, the system’s chief executive, in a press release. “These newly implemented outreach efforts, combined with our current programs, multilingual approaches, and recent state-initiated efforts, will allow us to better serve those most in need.” The health system and the county declined further comment.

The federal Affordable Care Act requires nonprofit hospitals to provide charity care, known officially as “financial assistance policies,” to maintain their tax-exempt status. California requires it of all acute care hospitals. California patients whose income is below 400% of the federal poverty level can be eligible, meaning a single person earning less than $58,320 can qualify for financial assistance. A family of three, like Hepner’s, could qualify today if the household makes less than $99,440. Factors such as a person’s assets and the amount of medical expenses can also be considered.

In 2020, Santa Clara County raised the eligibility threshold for discounts from 350% of the federal poverty guidelines to 650%, and patients can qualify for free care if they make below 400%.

Under the settlement, the county agreed to give former patients at SCVMC the opportunity to apply for financial assistance retroactively, seek refunds, and have court judgments corrected. The entire Santa Clara Valley Healthcare system, which includes SCVMC and two other hospitals, also now must inform patients in eight languages about its charity care program and discount payment options in a timely manner.

A 2019 KFF Health News investigation found that St. Joseph Medical Center in Takoma, Washington, for example, settled a similar lawsuit in 2019 and agreed to pay more than $22 million in refunds and debt forgiveness. Tax-exempt hospitals around the country sent $2.7 billion in bills over the course of a year to patients who probably qualified for free or discounted care, the investigation found.

Tran said it’s the first charity care settlement in California that provides restitution for a large group of patients since the Hospital Fair Pricing Act, which aims to protect patients from unaffordable hospital costs, took effect in 2007.

Emma Dinkelspiel, a senior attorney at Bay Area Legal Aid, said many hospitals obfuscate, making it difficult for patients to access financial aid.

“When you call in, they’ll tell you that charity care doesn’t exist and instead suggest payment plans,” Dinkelspiel said. “There are some hospital systems who maybe advertise with posters but don’t include information when they send out their debt collection letters.”

According to a December report by KFF Health News, 1 in 5 hospitals that were scrutinized didn’t post aid policies online.

In California, more than 4 million families could be income-eligible for free or discounted care, according to the 2022 American Community Survey.

Tran credits the county for addressing the issue and said private hospitals should follow their example.

“It’s really setting the bar for what hospitals are able to do,” Tran said. “We’re hoping that other hospitals throughout California will too.”

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Next spring, Los Angeles city voters will have a chance to put the brake on runaway salaries by capping hospital executives’ pay at $450,000 a year. The measure, proposed by a local union and approved by the City Council in June, will appear on the March 2024 ballot.

The vote will be the first fruit of a long-running campaign by the Service Employees International Union-United Healthcare Workers West, a California union with more than 100,000 members, to cap compensation. The advance has galvanized the union to collect signatures for similar efforts in San Diego, Chula Vista, and La Mesa.

Union officials say a cap is necessary given that hospital executives’ pay increases have outpaced those of hourly workers across the country, widening disparities, according to recent studies. Critics accuse the union of playing politics.

The California Hospital Association, which lobbies for the hospital industry, says the proposal would drive out talent and is meant to exert pressure on hospitals, referencing previous proposals the union has made over the past 10 years.

“This measure won’t do anything to reduce health care costs or improve the quality of care in the community,” said Jan Emerson-Shea, a spokesperson for the hospital association. “On the contrary, it will only make it more difficult to recruit qualified hospital leaders, including physicians and nurse leaders.”

If passed, policy and legal experts warn the cap could draw legal challenges and will likely be hard to implement. For one thing, the measure does not steer the funds that would be saved in cutting top salaries toward lower-wage staff or improving patient care.

Glenn Melnick, a health care economist at the University of Southern California, said he understands SEIU-UHW’s motive but questioned whether other policies could better improve health care delivery and lower costs.

“It may be helpful to this group because they’re in negotiations and putting pressure on hospitals and negotiating their contracts, but I think, in the long run, it’s not necessarily good for the health care workers and patients,” Melnick said.

According to a Lown Institute study, hospital executives at nonprofit hospitals across the country made on average eight times what was earned by workers without advanced degrees, such as medical records personnel and janitorial staff. Some of the highest-paid CEOs received 60 times the hourly pay of general workers.

The proposed city ordinance caps total executive compensation — which includes salary, health insurance, housing allowances, stocks, and bonuses — at any private health care facility, including hospitals and skilled nursing facilities. If approved, the cap would be enforced through civil lawsuits, and the city attorney’s office would get to be first in line to sue. The union estimates the policy change could affect at least 23 hospital executives, managers, and administrators, 13 of them CEOs, and said that’s likely an undercount.

Thomas Priselac, for example, CEO of Cedars-Sinai Medical Center, made $5.7 million in 2020, according to the Lown Institute researchers. Scott Reiner, CEO of the Adventist Health system, made $2.4 million that same year. And Rodney Hanners, CEO of USC’s Keck Medicine, made $1.4 million. According to the U.S. Census Bureau, the median household income in L.A. from 2017 to 2021 was $69,778, on average.

Yet the measure has holes. The motion targets only private health care facilities, excluding highly paid public hospital executives, such as Ronald Reagan UCLA Medical Center’s CEO, Johnese Spisso, who made $1.9 million in 2020, according to Lown Institute.

Ted Seto, a business law professor at Loyola Law School in L.A., said SEIU-UHW’s proposal is not only poorly written but filled with ambiguities. For example, it’s unclear whether an employee or a hospital would be on the hook for a $1,000-a-day fine. And because health benefits are included in total compensation, Seto said, it’s conceivable an administrator who earns $100,000 at a self-insured hospital could be diagnosed with cancer and wind up paying the hospital back for any portion of their treatment exceeding the $450,000 cap. SEIU-UHW says it can’t predict how the measure will be interpreted.

And it might not even be legal in some cases. Seto said L.A. likely wouldn’t have the power to enforce the cap for current executives because it can’t override existing employment contracts.

“I don’t think it’s silly to try to address the huge discrepancies between higher-paid and lower-paid people,” Seto said. “But I think that the approach that they’re taking here is really silly.”

Ivor Pine, a spokesperson for the city attorney’s office, said that the office could not comment on the legality but stated that the council is merely passing the issue to the ballot.

The cap has been proposed by SEIU at least five times in the past 10 years: in California in 2013, 2015, and 2016; in Oregon in 2014; and in Arizona in 2016. The hospital industry has opposed each initiative.

The Los Angeles Times reported in 2013 that the hospital association accused the union of threatening to launch ballot measures aimed at executive pay if the hospital association didn’t make it easier for 20,000 workers to organize. Months later, several media outlets reported that SEIU-UHW withdrew its ballot initiative on executive compensation after reaching a deal with the industry.

Renée Saldaña, a spokesperson for SEIU-UHW, rejected the idea that the current CEO cap is a negotiation tactic. “We’ve never shied away from the political process,” Saldaña said. “We see this as a way to give voters an opportunity to weigh in on important issues that affect them as well.”

The cap is going on the same ballot as another one of the union’s bills for a $25 minimum hourly wage for L.A. health care workers. The measure was approved by the City Council in 2022, but the hospital association challenged it, pushing it to the 2024 ballot for a referendum.

“We felt it was appropriate to have both of those conversations at the same time — the lowest-paid health care workers and the CEOs who are paying themselves millions of dollars while fighting tooth and nail to keep health care workers from making a $25 hourly minimum wage,” Saldaña said.

State lawmakers are also weighing the union’s bill in the legislature to adopt a statewide increase.

Datosha Williams, a member of SEIU-UHW and a Kaiser Permanente service representative in L.A., said the issue of executive compensation is important to her given the industry’s resistance to the $25 minimum wage for health workers.

Williams, who has worked at KP for 16 years, earns more than $25 an hour, but she said it’s still challenging, as a single mom, to raise a family on her income.

“We have members who are literally homeless,” Williams said. “People have told us that they decided to live out of their cars in west L.A. and get gym memberships to take showers to show up to work clean, just so they can afford to live on their own in California.”

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A poll commissioned by Public Health Advocates, a Davis-based health policy nonprofit, showed that more than two-thirds of California voters want behavioral health professionals to be part of the emergency response in non-life-threatening situations. Among seven types of situations potentially warranting emergency response, voters think law enforcement agencies are least equipped to respond to calls about mental health crises and people who are unhoused, according to the May 24 poll.

“Police response has become the oversized band-aid for something the band-aid was never designed to cover or heal,” said Ryan McClinton, who manages Public Health Advocates’ First Response Transformation Campaign.

His group and like-minded advocates in California are stepping up a campaign to overhaul the state’s 911 system so more mental health professionals and others with specialized training handle many emergencies, rather than the police.

Law enforcement officials agree that 911 response merits a more nuanced approach. But powerful police unions are against proposals that might reduce their control over 911 operations, and the budget and staff that go with them. Police representatives contacted said they favored alternatives that would supplement the current system rather than supplant it, and that would keep overall responsibility for 911 with police departments.

“Our 911 dispatchers do an amazing job and are the perfect people to handle those in crisis,” said Tim Davis, president of the Sacramento Police Officers Association, a union. “It is imperative that 911 remain under the direction of the police department, as the majority of the calls they receive are for police services.”

McClinton, however, said emergency response systems are outdated and in need of transformation. In many California counties, change is already underway. Forty-one of the state’s 58 counties have some form of mobile crisis services in which mental health workers go out and address crisis needs in the community, according to a survey conducted by the County Behavioral Health Directors Association of California.

Michelle Cabrera, executive director of CBHDA, said that by next year all California counties will have mobile crisis services up and running.

Established in 1968, 911 was designed for reporting fires. However, it quickly became an all-purpose system for routing a much broader set of calls to police.

Californians now make more than 25 million 911 calls annually. Nationally, as many as 15% are for behavioral health emergencies, according to a 2021 study in the journal Psychiatric Services.

Andrea Rivera, a legislative health advocate, said 911 centers today are inundated with calls that aren’t necessarily emergencies — an influx the system wasn’t built to handle.

“911 has become a catchall,” said Rivera, who works for the California Pan-Ethnic Health Network. “While it might be unfair to law enforcement, which doesn’t have the capacity or training, it’s particularly unfair for the community members that don’t feel like they have someone to turn to.”

Alternative approaches vary widely across the state. Santa Clara County, for example, has five mobile response teams that can respond to 911 calls, and can also be deployed by dispatchers at 988, the national Suicide & Crisis Lifeline.

Some teams are made up of clinicians and other trained professionals who can provide peer support. Some respond alongside police, while others arrive wearing plainclothes in a non-police vehicle.

Sandra Hernandez, a division director of Behavioral Health Services in Santa Clara County, said the program is in its infancy but has been effective so far. One surprising takeaway she noted was how much community members appreciated being able to ask for help without emergency vehicles arriving at their doorstep and alerting nosy neighbors to a moment of crisis.

Hernandez recalled one letter her team received from a grateful resident: “My neighbors didn’t even know. They thought I had company.”

Cities in Oregon, New Mexico, and Colorado have similar programs.

Advocates point to cases like that of Jaime Naranjo, a Sacramento County resident who was shot and killed by police last year at his home. Naranjo’s wife, Elisa Naranjo, said her husband was suicidal and had been experiencing delusions and carrying a machete when she called 911 for help.

Sacramento has a Mobile Crisis Support Team, but it’s not 24/7 and Elisa called 911 outside its hours of operation. The Sacramento County Sheriff’s Office said that when police arrived the deputy told Naranjo to drop the weapon, but he did not comply. That, the Sheriff’s Office said, is when Naranjo advanced on the deputy, who shot and killed him.

In California, proposed legislation would make alternative response a statewide requirement. State Sen. Aisha Wahab’s SB 402, which is championed by Public Health Advocates, would require 911 service centers to dispatch professionals other than armed police officers for calls related to mental health or homelessness.

This approach is akin to the role 988 was meant to fill, Wahab said, but low awareness of the 988 number has been a barrier to effectiveness.

Wahab introduced an alternative response program three years ago in Hayward, while on its City Council, and said its success inspired her to draft the legislation. She said the bill, whose fate won’t be decided until next year, is a priority for her but acknowledged it would be complicated to enact changes statewide.

Police union representatives said they supported the idea of alternative response in principle.

“Our members are not mental health professionals,” said Alexa Pratt, the communications director for the Association of Orange County Deputy Sheriffs. “We agree that law enforcement should not be the lead addressing mental health calls but should be there to assist in these programs.”

Tom Saggau, a San Jose Police Officers’ Association spokesperson, referenced a pilot program in San Jose of which police were initially skeptical, until they saw how sharing the burden of emergency call response eased their workload. The program has grown sixfold in eight years.

Saggau, who also represents the Los Angeles Police Protective League, a union, said Los Angeles has drafted a list of 28 types of calls that could be diverted to other initial responders and don’t require a police presence.

Still, police departments are protective of their control over 911 and associated personnel and funding.

Saggau criticized proposals to restructure 911 as outgrowths of the “defund the police” movement and voiced frustration that some advocates think supporting alternative response requires a redistribution of police budgets.

The push to defund the police, which gained international momentum after George Floyd’s murder in 2020, refers to reallocating funding away from police departments to other government agencies that support social services.

“It’s not an either-or,” Saggau said. “You can have a fully staffed, robust police department and you can also have a robust alternative response model.”

Wahab believes it’s critical to ensure all cities and counties have clinicians and other unarmed emergency responders on hand.

“It’s very simple,” Wahab said. “You save lives by having the appropriate response to a crisis.”

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The report from the county Department of Public Health, entitled “Medical Debt in LA County: Baseline Report and Action Plan,” said medical debt disproportionately affects the uninsured and underinsured, low-income residents, and Black and Latino populations. It said the consequences are alarming, noting that debt negatively impacts factors that determine future health outcomes, such as housing, employment, food security, and access to prescriptions and health care.

Naman Shah, the director of medical and dental affairs at the public health department and a co-author of the report, said he was particularly struck that medical debt affects approximately the same percentage of Angelenos as other public health concerns do, such as diabetes and asthma.

“We try to look at factors that affect people’s lives that are widespread, preventable, and impact not just our physical health but our mental and social health,” Shah said. “This makes medical debt one of the top public health problems.”

Medi-Cal, the state’s Medicaid program, has expanded coverage in recent years, notably to residents living in the county without legal permission. By 2024, approximately 92% of Californians under age 65 will be insured, the University of California-Berkeley Labor Center projected. Yet L.A. County’s study revealed that despite expanded insurance coverage through the Affordable Care Act and the covid-19 emergency, the prevalence of medical debt remained unchanged from 2017 to 2021.

Researchers cited an investigation by KFF Health News, “Diagnosis: Debt,” which discovered that more than 100 million of Americans, 41% of adults, are saddled with medical bills they cannot pay. That investigation drew largely on a nationwide poll designed to capture not just bills patients couldn’t afford, but other borrowing used to pay for health care as well.

By contrast, the county report analyzed an annual survey of Los Angeles County residents who reported having problems paying medical bills for themselves or anyone in their household in the prior 12 months.

The medical bills are often relatively small, but they can be burdensome for struggling households. In 2021, roughly 30% of adults with trouble paying medical debt owed less than $1,000. About half of those who took on credit card debt to pay off the bills or were unable to pay for necessities owed less than $2,000.

To alleviate the problem, the report recommends collecting and sharing data related to medical debt, enforcing fair billing and collection laws, and improving financial assistance programs where qualified patients can access free or discounted care. One idea is for the county to partner with debt relief organizations to buy up residents’ medical debt and retire it.

One such organization, the nonprofit RIP Medical Debt, buys medical debt for pennies on the dollar to provide rapid debt relief. Shah said the county could fund a program with RIP Medical Debt or one of its peers.

County supervisors are still being briefed on the report, said Becky Schlikerman, a spokesperson for the public health department.

Will Nicholas, the primary author of the report and director of the public health department’s Center for Health Impact Evaluation, noted that one of the biggest predictors of medical debt is a person’s health status. Those in poor health who have trouble paying medical bills are almost three times as likely to accumulate debt as their peers with excellent health, the report found.

“Just because someone happens to be sick and needs medical care, why should they suffer disproportionately from medical debt?" Nicholas said. “That seems like an injustice.”

While the uninsured bore the greatest burden, with about 26% facing medical debt, many insured patients also have debt. Nicholas said privately insured patients are financially vulnerable due to high out-of-pocket expenses, including copays and the share of bills not paid by insurance, which can be exorbitant for hospital stays and other services. Medi-Cal enrollees may accumulate debt by unknowingly accepting services not covered by the safety-net program, Nicholas said.

Shah said medical debt troubles him as a physician.

“I will say that it's incredibly concerning to me as someone who's taken an oath to do no harm that sick patients who are seeking health care to get better are being made sicker by the care they receive when they accrue medical debt,” Shah said.

California Healthline senior correspondent Bernard J. Wolfson contributed to this report.