About 119,300 California men took paid family leave for bonding in the state’s fiscal year that ended at the end of June, up by 19%, or nearly 20,000, from 2020, according to California’s Employment Development Department. The number of women taking state leave for bonding has held relatively steady at roughly 150,000 since 2019.

Not only are a new generation of fathers more likely to embrace taking time off to build a connection with their children, but more employers have normalized leaves for their male workers. Those attitudes, experts said, were strengthened during the pandemic, when many men worked from home as their children learned remotely or played nearby.

“If you have a male co-worker who takes paternity leave, you’re more likely to take paternity leave,” said Maya Rossin-Slater, associate professor of health policy at Stanford University.

Moreover, research shows that when fathers take leave, mothers tend to have better health outcomes, with fewer hospitalizations for health complications and better mental health results, Rossin-Slater said. The effects on children, however, have yet to be adequately studied, she said.

Kevin Zapata, a 41-year-old Los Angeles-area marketing professional, became one of those fathers who took paid leave to bond with his baby when his daughter was born earlier this year. He said family leave gave him the time to adjust to life with a new child while helping his wife recover from giving birth.

“Men are starting to realize that it makes a difference to be there,” Zapata said. “It doesn’t hurt to be the one changing diapers, to be the one feeding the baby, to be the one helping mom out.”

California generally provides up to eight weeks of paid family leave. New parents can receive 60% to 70% of their pay, depending on income. The average benefit in fiscal year 2022 was $806 a week. People giving birth can also receive up to 12 weeks of paid disability leave. The application form for paid leave asks new parents to select their gender.

Outside California, residents of most states have access by law only to 12 weeks of unpaid, job-protected leave. At least a dozen other states have approved paid family leave programs.

In at least some of those states, the number of men taking family leave is exploding. In New York, the number nearly doubled from 2018 to 2022. In New Jersey, it more than tripled from 2014 to 2021.

In 2005, during the early days of paid family leave in California, 83% of claims were filed by women and 17% by men. Since then, most of the growth in claims for leave has occurred among new fathers.

California’s data does not capture everyone who takes paid time off to care for a child. A growing number of employers now offer paid leave to workers as a benefit, outside the state’s program. That means a worker who receives a company’s paid leave benefit would not be eligible for the state program.

Some of the state’s wealthiest counties, including Marin, Orange, and San Diego, include or are near several large employers with generous paid family leave programs and have relatively low rates of men taking part in the state’s paid leave program. The counties with the highest rates of leave claims filed by men per 100 births in early 2023 were in the Central Coast: Monterey, San Benito, Santa Barbara, and Santa Cruz.

Nathaniel Miller, a 40-year-old digital media strategist in the Sacramento area, took paid leave earlier this year to be with his newborn son. His employer, the University of California, offers 100% income replacement for eligible earnings during bonding.

Miller said paid leave allowed his family time to find child care. Miller and his wife are maximizing their son’s time with a parent by taking leave at separate times.

“At first, it was like, I’m not strong enough to hold him,” Miller said in September, while on paid leave. “Now my body’s getting more accustomed to holding him a lot and rocking him for naps. He’s getting more used to sleeping with me as opposed to going down for naps with mom.”

It’s unclear whether California’s trend will continue. The number of men taking leave peaked between July 2021 and June 2022 before tapering out last year.

Jenya Cassidy, director of the nonprofit California Work & Family Coalition, said California’s current benefits are too low to support many low-income families. A worker earning $3,000 a month would get about $416 a week in paid family leave benefits.

“It’s eight weeks paid at 60% of your gross income,” Zapata said. “It takes a hit on us. That’s why a lot of people around my age delay having families or don’t even bother to family-plan because they know of the struggle that it can cause financially.”

Still, a new law signed last year will allow paid leave to replace up to 90% of wages for low-income workers and up to 70% for others. The new rates take effect in 2025.

Nationwide, differences remain, both in terms of paid leave availability and in terms of men’s attitudes toward taking leave. About 33% of men and 45% of women took paid bonding leave during the last decade after the birth of their first child, census figures show. Including unpaid leave, sick days, and vacation time, about 67% of first-time fathers took bonding leave after 2015, compared with 96% of first-time mothers. Women tend to take more weeks of leave.

Still, eight states have enacted paid family leave measures in the last six years. Advocates continue to push for federal paid family leave. President Joe Biden has repeatedly proposed funding paid family leave. Then-President Donald Trump endorsed a paid family leave measure in 2020 that would have let new parents collect on future child tax credits.

“We would like as much as possible for California to be a model,” Cassidy said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

Heat was the underlying or contributing cause of about 1,670 deaths nationwide in 2022, for a rate of about 5 deaths per million residents, according to provisional data from the CDC. That’s the highest heat-related death rate in at least two decades. Data from this year, which has been exceptionally hot in much of the country, is not yet available. The next-highest death rate was logged in 2021.

Heat-related illness ranges from heat exhaustion, which causes heavy sweating and a rapid pulse, to heatstroke, which causes confusion, loss of consciousness, high fever, and in many of the severest cases even death. Heat-related illness can occur alongside and exacerbate other health conditions.

The simplest explanation for the increase is that it is getting hotter. The last eight years were the hottest on record, according to NASA figures dating to the late 1800s.

But factors other than climate change also play a role.

Substance abuse, especially misuse of methamphetamines, has emerged as a major factor in heat-related illness. Methamphetamines can cause body temperature to increase to dangerous levels, and the combination of meth abuse, heat, and homelessness can be fatal.

About 140 death certificates in California listed both heat-related illness and drug overdose as causes from 2018 through 2022, according to CDC data. That’s about 25% of all deaths in which heat-related illness was an underlying or contributing factor.

Homelessness has risen in the past few years, including in several hot Western states like California, and unsheltered homeless people are particularly vulnerable during heat waves. Homeless people represented about 13% of California hospitalizations involving a primary diagnosis of heat-related illness from 2017 through 2021, state data shows. California’s 172,000 unhoused residents make up fewer than half a percent of the state’s population, federal data shows.

“With any environmental crisis, people experiencing homelessness experience it first, they experience it worst, and they experience it longest,” said Katie League, behavioral health manager for the National Health Care for the Homeless Council.

The elderly are also particularly vulnerable to heat-related illness. Their bodies often don’t adjust as well as younger people’s to temperature change, and they often have chronic health conditions exacerbated by heat. The numbers of elderly residents in California and across America have risen sharply as baby boomers have aged.

The climate trends are worrying. Heat waves are starting earlier and lasting longer, said the Public Health Institute’s Paul English, director of Tracking California, which makes environmental health data accessible.

He pointed to the recent heat wave in Phoenix, which saw a record 31 consecutive days with temperatures of at least 110 degrees. “This just means no break for the human body to recuperate,” he said. Heat-related illness had led to about 2,810 emergency room visits in Arizona this year as of July 29, up more than 25% from the same point in 2022, state data shows.

And the numbers tell only part of the story: Heat-related illness is often underdiagnosed. A 2021 Los Angeles Times investigation found that the true number of excess deaths and hospitalizations during a heat wave is often much higher than the official count.

“This is an underestimate of what’s happening,” English said.

California’s Riverside County, home of the desert resort of Palm Springs, has been hit especially hard by heat illness, with a hospitalization rate about 75% higher than the statewide rate.

“We have a large population that lives in the desert,” said Wendy Hetherington, branch chief of epidemiology and program evaluation for the Riverside University Health System. “It’s an older population, too. We also do have a lot of the farm-working community that works outside year-round.”

In California, hospitalizations involving a diagnosis of heat-related illness spiked from 2017 through 2021, rising to levels not seen since the state’s infamous 2006 heat wave, according to the most recent data from the state Department of Health Care Access and Information. Hospitalization data for 2022 is not yet available. Emergency room visits for heat-related illness have also trended higher, in California and nationwide.

Advocates and experts called for more cooling centers, more affordable housing, and better workplace safety rules to help get vulnerable populations out of the rising heat.

A recent scientific study found the human body does not function optimally when outside temperatures rise to 104 degrees or higher. Temperatures that high often cause the body to burn more calories while simultaneously raising heart rates.

“The problem,” English said, “is we’re reaching the human limit of adapting to temperature.”

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

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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Lockdowns made people feel isolated, depressed, and anxious, leading some to increase their alcohol intake. Alcohol sales rose during the pandemic, with especially large jumps in consumption of spirits.

While this led to a rise in all sorts of alcohol-related deaths, the number of Californians dying from alcoholic liver disease spiked dramatically, with 14,209 deaths between 2020 and 2022, according to provisional data from the Centers for Disease Control and Prevention.

Alcoholic liver disease is the most common cause of alcohol-induced deaths nationally. In California, the death rate from the disease during the last three years was 25% higher than in the three years before the pandemic. The rate peaked at 13.2 deaths per 100,000 residents in 2021, nearly double the rate from two decades ago.

The disease is usually caused by years of excessive drinking, though it can sometimes occur after a short period of heavy alcohol abuse. There are often no symptoms until late in the disease, when weakness, confusion, and jaundice can occur.

Many who increased their drinking during the pandemic were already on the verge of developing severe alcoholic liver disease, said Jovan Julien, a postdoctoral researcher at Harvard Medical School. The extra alcohol sped up the process, killing them earlier than they would have otherwise died, said Julien, who co-wrote a modeling study during the pandemic that predicted many of the trends that occurred.

Even before the pandemic, lifestyle and dietary changes were contributing to more deaths from alcoholic liver disease, despite little change in alcohol sales, said Brian Lee, a hepatologist and liver transplant specialist with Keck School of Medicine of the University of Southern California.

Lee and other researchers found a connection between alcoholic liver disease and metabolic syndrome, a condition often characterized by excess body fat around the waist. Metabolic syndrome — often caused by poor diet and an inactive lifestyle — has risen across the country.

“Having metabolic syndrome, which is associated with obesity, high blood pressure, and diabetes, more than doubles your risk of having advanced liver disease at the same level of drinking,” Lee said.

The Californians alcoholic liver disease most often kills are those between 55 and 74 years old. They make up about a quarter of the state’s adults but more than half of the deaths from alcoholic liver disease.

However, death rates among Californians 25 to 44 roughly doubled during the last decade. About 2,650 Californians in that age group died from the disease during the last three years, compared with 1,270 deaths from 2010 through 2012.

“People are drinking at earlier levels,” Lee said. “People are developing obesity at younger ages.”

The highest death rates from alcoholic liver disease occur in rural eastern and Northern California. In Humboldt County, for instance, the death rate from alcoholic liver disease is more than double the statewide rate.

Jeremy Campbell, executive director of Waterfront Recovery Services in Eureka, said Humboldt County and other rural areas often don’t have the resources and facilities to address high rates of alcohol use disorder. His facility provides high-intensity residential services and uses medication to get people through detox.

“The two other inpatient treatment facilities in Eureka are also at capacity,” he said. “This is just a situation that there’s just not enough treatment.”

Campbell also pointed to the demographics of Humboldt County, which has a much higher proportion of white and Native American residents than the rest of the state. Alcoholic liver disease death rates in California are highest among Native American and white residents.

Death rates rose more among Native American, Latino, Asian, and Black Californians during the last decade than among non-Latino white Californians, CDC data shows. Part of that is due to disparities in insurance coverage and access to care, said Lee. In addition, Lee said, rates of metabolic syndrome have increased more quickly among nonwhites than among whites. Racial health disparities also manifest in differing survival rates for Black and white patients after liver transplants, he added.

The trend is expected to continue. Julien projects a temporary dip in deaths because many people who would have died from the disease in 2022 or 2023 instead died sooner, after a boost in drinking during the pandemic, but that deaths will rise later as bad habits developed during the pandemic begin to take a long-term toll.

“As people increased their consumption during covid-19, we have more folks who have now initiated alcohol use disorder,” Julien said.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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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All that means young Californians aren’t having as much sex.

The number of young adults going without sex was rising even before covid made dating harder and riskier. In 2011, about 22% of Californians ages 18 to 30 reported having no sexual partners in the prior 12 months. That crept up to 29% in 2019, and it jumped to 38% in 2021, according to the latest figures from UCLA’s California Health Interview Survey.

Other age groups in California also reported an increase in abstinence, but the trend was not nearly as pronounced.

“Everything happens later,” said San Diego State University psychology professor Jean Twenge, author of “Generations: The Real Differences Between Gen Z, Millennials, Gen X, Boomers, and Silents—and What They Mean for America’s Future.” She said the numbers reflect how young adults increasingly delay major life events, such as moving out of their parents’ homes and forging long-term romantic relationships.

Singles saw the most dramatic change.

It has long been the case that single people are more likely to report having no sex than married or cohabiting people. But as young adults delay marriage, the gap has widened.

Young adults may be putting off long-term relationships “due to their increasingly economically precarious status or stress related to completing education and looking for jobs,” said Lei Lei, a sociology professor at Rutgers who recently co-authored a paper that examined why fewer young adults are having sex. “They are busy with other domains of life.” Researchers also noted that hundreds of thousands of young adults identify as asexual.

Rising computer use may play a role in the trend. Young adults increasingly form relationships through playing video games with people they do not physically meet, Lei said. These distant relationships sometimes interfere with the formation of sexual relationships.

A Pew Research Center report from 2015 found equal numbers of men and women played video games but that young adult men were more than three times as likely as young adult women to identify as serious “gamers.”

Young adults also have access to endless amounts of free pornography online, a departure from the porn magazines, videotapes, and DVDs many of their parents bought. Much of the most popular online porn features violence or coercion, which gives some young adults a flawed perspective on sex and turns others off it entirely, said Debby Herbenick, director of the Center for Sexual Health Promotion at Indiana University Bloomington’s School of Public Health.

“Those kinds of behaviors are really, really normalized among young people,” she said, referring to rough sex.

Sex also has a correlation with income. Young adults who make less money were more likely to go without sex than peers making more.

Much recent discourse about lack of sex among young adults has revolved around so-called incels, young men who contend — often in vile, misogynistic terms — that dating apps like Tinder make it easier for women to find conventionally attractive, wealthy, or otherwise high-status men and ignore everyone else.

Erin Tillman, a certified sex educator and executive director of the nonprofit Sex-Positive Los Angeles, said it makes her sad when she hears men blame women for not wanting to have sex with them. She said those men could likely change their perspective and find intimacy.

“They hold the cards in terms of making themselves better,” she said.

The sexless trend has the potential to lower rates of unplanned pregnancy. And it could also reduce the spread of sexually transmitted infections, though that has not yet happened.

Herbenick does worry about young adults who want sex but aren’t having it. “It can feel really lonely if you feel like people are rejecting you or wouldn’t be interested in you,” she said.

But Tillman remains optimistic, noting the latest group of young adults, like every new generation, is finding its way and approaching sex differently than their parents.

“I’m not worried, because people are just basically finding different ways to connect with each other,” Tillman said.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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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Deaths attributed to malnutrition more than doubled, from about 650 in 2018 to roughly 1,400 in 2022, according to preliminary death certificate data from the California Department of Public Health. The same trend occurred nationwide, with malnutrition deaths more than doubling, from about 9,300 deaths in 2018 to roughly 20,500 in 2022, according to the U.S. Centers for Disease Control and Prevention.

Malnutrition is particularly common among older people, especially those who are ill, low-income, homebound, or without reliable access to healthy food or medical services. It can result from not eating enough but also from poor eating habits that lead to nutritional deficiencies. The majority of deaths in California from malnutrition last year occurred in residents 85 and older.

Several experts said covid lockdowns likely cut off access to healthy food. Because the oldest people were the most likely to die from covid, officials encouraged them to limit their exposure to others who might have the disease.

“People who may have been reliant on public transportation or reliant on others to get to the grocery store — suddenly they’re nervous to take the bus,” said Lindsay Clarke, senior vice president of health education and advocacy at the Alliance for Aging Research, a nonprofit group in Washington, D.C. “That family member or friend who would have come to pick them up and take them to the grocery store is worried about having them in their car.”

Pandemic lockdowns also hindered safety net programs that feed seniors. For example, many adult day care centers closed, eliminating places for seniors to go during the day as an alternative to nursing care. Dr. Louise Aronson, a geriatrician and professor at the University of California-San Francisco, said seniors who used the programs “may rely on the food they get there as their best meal of the day.”

Malnutrition deaths rose in 2022 even as lockdowns faded. Experts said the persistence of the trend could be due to some of the oldest residents continuing to isolate.

Covid remains a serious danger for that demographic. About 5,400 Californians 85 and older died from covid last year, making it the fifth leading cause of death for that age group — responsible for more than twice as many deaths as diabetes, preliminary state data show.

“For a lot of people who are older adults and people with disabilities, it’s not really over,” said Trinh Phan, who works from California for the nonprofit Justice in Aging. Phan said many older Californians are afraid of covid, asking themselves, “Do I actually want to risk that for myself given my own risk factors?”

While the number of California malnutrition deaths jumped during the pandemic, it had been increasing for years. Some of that increase may be due to the overall aging of the population, experts said.

About 678,000 Californians are 85 or older, a number that increased by roughly 59% from 2000 to 2021, census data show.

Californians 85 or older accounted for almost three in five malnutrition deaths in the state last year. Those 95 or older make up almost one in five malnutrition deaths, even though only about one in 700 Californians fall within that age group.

“Biologically we do eat less as we grow older,” Aronson said. “You’re just literally less hungry.”

In addition, particularly old people have slower metabolism and digestion than younger people. “When you’re eating less food overall, it’s hard to get all the nutrients you need,” she said.

More factors beyond pandemic lockdowns and an aging population may be causing the steep rise in reported malnutrition among older people. The rate of malnutrition deaths per 100,000 residents in California among those 85 or older rose precipitously around 2013, jumping fivefold by 2019 and from there doubling during the pandemic.

Complicating the picture is how often malnutrition appears in conjunction with other illnesses. Older adults are more vulnerable to diseases — such as heart failure, cancer, Alzheimer’s, and depression — that can reduce their appetites and lead to malnutrition as a secondary cause of death.

Malnutrition was a contributing cause in 5,600 deaths in California on top of the 1,400 deaths for which it was the primary, underlying cause, provisional CDC data show. The number of deaths for which malnutrition was a secondary cause of death rose by about 1,700, or 43%, from 2018 through 2022.

“You might be admitted with diabetes but at the same time you’re also malnourished, and so the malnourishment adds to your problems,” said Paul Brown, a professor at the University of California-Merced who has co-presented papers on malnutrition in California at an American Public Health Association conference.

There is also an increased push to recognize malnutrition. Two of the nation’s leading nutrition science organizations released updated guidelines in 2012 to better standardize diagnosis.

The highest malnutrition death rates among older Californians from 2020 through 2022 were in rural or semirural counties: Lake, Merced, Butte, Tuolumne, and Sutter.

Brown said older residents living in rural counties often live in “food deserts,” which are areas that lack access to healthy food.

Among large, urban counties, Sacramento had the highest rate of malnutrition deaths among those 65 or older from 2020 through 2022. County spokesperson Macy Obernuefemann said the public health agency helps control and manage chronic diseases often accompanied by malnutrition and that several programs help seniors get the food they need.

Several programs in California seek to lower malnutrition among older people. The state’s network of 33 Area Agencies on Aging often offer healthy meals to older adults, according to Sara Eisenberg, a spokesperson for the California Department of Aging. Organizations such as Meals on Wheels do so as well. The agencies also regularly try to make sure seniors are enrolled in CalFresh, the state’s food assistance program for eligible low-income residents, Eisenberg said.

CalFresh benefits increased in late 2021 by 27%, helping many seniors afford food. A bill in the legislature, SB 600, would increase the minimum CalFresh benefits from $23 a month to $50. There’s also a push to expand CalFresh benefits to more undocumented immigrants, many of whom face food insecurity.

“I think that there has been really positive movement,” Phan said.

However, enhanced CalFresh benefits that gave millions of people more money during the pandemic expired in late March.

Population trends suggest malnutrition will continue to be a problem. The number of Californians 85 and older, the group most prone to malnutrition, is projected to grow by about 420,000, or 54%, from 2020 to 2030, according to state Department of Finance projections.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

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The recent upsurge in at-home deaths started in 2020, the first year of the pandemic, and the rate has continued to climb, outlasting the rigid lockdowns at hospitals and nursing homes that might help explain the initial shift. Nearly 40% of deaths in California during the first 10 months of 2022 took place at home, up from about 36% for all of 2019, according to death certificate data from the California Department of Public Health. By comparison, U.S. Centers for Disease Control and Prevention data shows that about 26% of Californians died at home in 1999, the earliest year for which data on at-home deaths is accessible in the agency’s public database.

The trend is amplified among California residents with serious chronic conditions. About 55% of Californians who died from cancer did so at home during the first 10 months of 2022, compared with 50% in 2019 and 44% in 1999. About 43% of Californians who died from Alzheimer’s in the first 10 months of 2022 did so at home, compared with 34% in 2019 and nearly 16% in 1999.

Nationwide, the share of deaths occurring at home also jumped in 2020, to 33%, then rose to nearly 34% in 2021. Nationwide data for 2022 is not yet available.

Covid’s early, deadly sweep across California does not in itself explain the increase in at-home death rates; the vast majority of people who have died from covid died in a hospital or nursing home. Instead, medical experts said, the surge — at least initially — appears to coincide with sweeping policy changes in hospitals and nursing homes as caregivers struggled to contain a virus both virulent and little understood.

The sweeping bans on in-person visitation in hospitals and nursing homes, even to the bedsides of dying patients, created an agonizing situation for families. Many chose to move a loved one back home. “It was devastating to have Mom in a nursing home and dying, and the only way you can see Mom is through the window,” said Barbara Karnes, a registered nurse who has written extensively about end-of-life care.

At the same time, fears of covid exposure led many people to avoid hospitals in the first years of the pandemic, in some cases neglecting treatment for other serious conditions. That, too, is thought to have contributed to the rise in at-home deaths.

Those who specialize in end-of-life care say it is no surprise the trend has continued even as visitation policies have eased. They said more people simply want to die in a comfortable, familiar place, even if it means not fighting for every second of life with medical interventions.

“Whenever I ask, ‘Where do you want to be when you breathe your last breath? Or when your heart beats its last beat?’ no one ever says, ‘Oh, I want to be in the ICU,’ or ‘Oh, I want to be in the hospital,’ or ‘I want to be in a skilled nursing facility.’ They all say, ‘I want to be at home,’” said John Tastad, coordinator for the advance care planning program at Sharp HealthCare in San Diego.

Meanwhile, the physicians who specialize in the diseases that tend to kill Americans, such as cancer and heart disease, have become more accepting of discussing home hospice as an option if the treatment alternatives likely mean painful sacrifices in quality of life.

“There’s been a little bit of a culture change where maybe oncologists, pulmonologists, congestive heart failure physicians are referring patients to palliative care earlier to help with symptom management, advanced care planning,” said Dr. Pouria Kashkouli, associate medical director for hospice at UC Davis Health.

The trends have created a booming industry. In 2021, the California Department of Health Care Access and Information listed 1,692 licensed hospice agencies in its tracking database, a leap from the 175 agencies it listed in 2002.

That much growth — and the money behind it — has sometimes led to problems. A 2020 investigation by the Los Angeles Times found that fraud and quality-of-care issues were common in California’s hospice industry, a conclusion bolstered by a subsequent state audit. Gov. Gavin Newsom signed a bill in 2021 that placed a temporary moratorium on most new hospice licenses and sought to rein in questionable kickbacks to doctors and agencies.

When done correctly, though, home hospice can be a comfort to families and patients. Hospice typically lasts anywhere from a few days to a few months, and while services vary, many agencies provide regular visits from nurses, health aides, social workers, and spiritual advisers.

Most people using hospice are insured through the federal Medicare program. The amount Medicare pays varies by region but is usually around $200 to $300 a day, said Dr. Kai Romero, chief medical officer at the nonprofit Hospice by the Bay.

To find quality end-of-life care, Andrea Sankar, a professor at Wayne State University and author of “Dying at Home: A Family Guide for Caregiving,” recommends seeking out nonprofit providers and having a list of questions prepared: How often will nurses visit in person? In what circumstances do patients have access to a physician? What help will be available for a crisis in the middle of the night?

While hospice providers offer crucial guidance and support, families need to be prepared to shoulder the bulk of the caregiving. “It really takes a pretty evolved family system to be able to rally to meet all of the needs,” said Tastad at Sharp HealthCare.

Several end-of-life experts said they expect the proportion of Californians choosing to die at home to keep climbing, citing a variety of factors: Medical advances will make it easier for patients to receive pain management and other palliative care at home; telemedicine will make it easier for patients to consult doctors from home; and two powerful forces in American health care — insurance companies and the federal government — increasingly see dying at home as an affordable alternative to lengthy hospital stays.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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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More than 20 states, including California, are investigating or have investigated Centene’s Medicaid pharmacy billing. The company has agreed to pay settlements to 14 of those states, with the total reaching about $613 million. The latest was in Oregon, which announced a $17 million settlement from Centene on Dec. 6. Centene told KHN in October that it was working to settle with Georgia and other states that it didn’t identify. It has denied wrongdoing in all the investigations.

Centene’s political giving has been purposeful: The company earns billions of dollars from governments and then uses its profits to back the campaigns of the officials who oversee those government contracts. The company has developed this sophisticated, multipronged strategy as it pursues even more state government-funded contracts and defends against sweeping accusations that it overbilled many of those very governments.

Among the tactics the company has used: Executives and their family members made political contributions in their own names. For instance, from 2015 through 2021, Centene’s then-CEO Michael Neidorff and his wife, Noémi, wrote at least $380,000 in personal checks to state candidates, with more than 60% going to California Gov. Gavin Newsom, a Democrat who governs a state where the insurer generated 11% of its revenue in 2019.

Centene didn’t respond to specific questions about its political giving. But company spokesperson Suzy DePrizio said in a statement that the company follows all local, state, and federal laws and records all contributions from its political action committee. She said Centene’s contributions “are intended to serve as support to those who advocate for sound public policy healthcare decisions, which is evident by our nearly equal support of candidates from both parties.”

KHN senior correspondent Samantha Young recently teamed up with senior editor Andy Miller and contributor Rebecca Grapevine to dig into Centene’s political giving. Read more about their findings here, which were published before Oregon announced its settlement with Centene.

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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According to new data from the U.S. Census Bureau, working from home for some portion of the week has become the new normal for a large segment of Californians. The data shows high-income employees with college degrees are more likely to have access to this hybrid work model, while lower-income employees stay the course with on-site responsibilities and daily commutes.

At a basic level, that means low-wage workers will continue to shoulder greater risks of infection and serious illness as new covid variants sweep through job sites, alongside seasonal waves of flu and other respiratory viruses. Multiple studies have found that covid took its greatest toll in low-income neighborhoods, whose workers were deemed essential during early pandemic lockdowns — the farmworkers, grocery clerks, warehouse packers, and other service employees who continued to report to work in person.

In addition, researchers say the shift will ripple across the broader economy in ways big and small, as more employees have the flexibility to live farther from a job site and as workplace traditions like lunch outings and bar nights fade or evolve.

The U.S. Census Bureau interviewed roughly 260,000 Americans from June through October, including about 20,000 Californians, as part of a wide-ranging questionnaire called the Household Pulse Survey. Surveyors asked dozens of questions about pandemic-era lifestyle changes, including some about working from home.

The survey found that nearly 20% of California adults lived in households in which at least one person had telecommuted or worked from home five days or more in the previous week. About 33% of California adults lived in households in which someone had worked from home at least one day the previous week.

Nationwide, the survey found that almost 30% of adults lived in households in which at least one person worked from home for some portion of the previous week. About 16% lived in households in which someone worked from home at least five days the previous week.

The results mark a notable shift from previous Census Bureau surveys that asked about working from home, though in different terms. In 2019, before the pandemic, about 6.3% of employed Californians and 5.7% of employed Americans said they “usually worked from home.”

Researchers who specialize in workforce issues said the findings mirror their own and are indicative of a cultural upheaval that will outlive the pandemic.

Jose Maria Barrero is an academic economist and a co-founder of WFH Research, which is documenting the shift toward working from home. Before the pandemic, about 5% of workdays in the U.S. were conducted from home, according to his group’s analyses. In contrast, its surveys this year show that about 30% of working days in the U.S. are now work-from-home days.

The 2022 survey by the Census Bureau revealed disparities in the kinds of families that are adapting to hybrid work, mostly centered around income.

About 64% of California adults in households with annual incomes of $150,000 or higher said at least one household member had worked from home some portion of the week. Nearly 40% of adults in those high-earning households said a household member had worked from home five days a week or more.

By comparison, just 15% of California adults in households with annual incomes of less than $50,000 said a household member had worked from home at least part of the week.

“It’s very hard for you to work remotely if you are a barista in a coffee shop or you’re working in a manufacturing plant,” Barrero said. “The sorts of jobs that people with low education tend to do are jobs that require them to be physically present.”

Racial disparities also exist. Nearly 45% of California adults who identify as Asian and 40% who identify as white lived in households in which someone worked from home some portion of the week, compared with 26% of Black adults and 21% of Latino adults.

The connection between income and hybrid work played out nationally, as well. States with greater portions of high-income residents tended to have more workers who reported telecommuting.

For example, fewer than 20% of adults in Alabama, Arkansas, Kentucky, Louisiana, Mississippi, and West Virginia lived in households in which at least one member had worked from home the prior week. The median household income in each of those states last year was between $48,000 and $56,000.

By comparison, 35% or more of adults in Colorado, Maryland, Massachusetts, Minnesota, New Jersey, Oregon, Utah, Virginia, and Washington lived in households in which at least one member had worked from home. The median household income in each of those states last year was between $71,000 and $91,000.

The disparities also clustered along educational lines. About 56% of California adults with a bachelor’s degree lived in households in which someone worked from home at least one day during the prior week, compared with 17% of California adults with only a high school degree.

The gaps will have consequences.

Andra Ghent, an economist at the University of Utah who studies work-from-home patterns, said tens of millions of Americans are settling into “hybrid” arrangements, in which they work from home a few days a week and occasionally go into the office. Before the home-work option, she said, many didn’t want to live too far from the urban core, concerned that commutes would become unmanageable. But with routine daily commutes out of the picture, many will move to the suburbs or exurbs, where they will have more space, she said.

On the one hand, commuting less, particularly by car, is often good for the health of the environment, Ghent noted. “But if people move to places where the usual mode of transit is cars instead of something that’s more pedestrian- or cyclist-friendly or more likely to use public transit, that’s not such a good thing,” Ghent said. “It sort of increases our urban sprawl, which we know is not good for sustainability.”

When higher-income people move away, cities lose a valuable source of tax revenue. That could exacerbate challenges in urban areas, as resources for social programs and infrastructure shrink. To avoid that fate, cities will need to make themselves attractive places to live, not just work, Barrero said.

“What you don’t want to be is a city of basically office towers, and everybody at the end of the day leaves, and there’s nothing to do in evenings and on weekends,” he said. “Because that means that basically all of the people can be remote or hybrid.”

The migration to telecommuting also allows employers to look to other states or even other countries for hires. Tobias Sytsma, an associate economist at the Rand Corp., recently authored a report detailing how U.S. companies may increasingly “offshore” remote work to employees abroad.

In addition, higher-income workers could see their wages rise or fall, depending on where they live, Sytsma said. High-paid workers in San Francisco will compete for remote jobs with lower-paid workers in places like Fresno, California, or Boise, Idaho.

“So we should start to see these wages fall in cities like San Francisco and New York and Seattle, where they’re already really high,” Sytsma said, “and we’ll probably start to see them rise in more rural areas.”

Barrero said employers recognize that many people have found they prefer working from home — and that it gives companies leverage to ask workers to accept less money in exchange.

He said his research also indicates that today’s work models — for both at-home and on-site employees — are likely to endure for months and years.

“We’ve had in our survey a question asking people, ‘Is this the long-term plan that your employer has, or are you still waiting to implement part of the plan?’” Barrero said. “And consistently we get more than 80% of people saying that they’re already following the long-term plan.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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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Given the collective immunity people have garnered through a combination of mass vaccination and protections built from earlier infections, Californians overall were far less likely to die from covid in 2022, when the omicron variant dominated, than during the first two years of the pandemic, when other variants were largely at play, amplifying a national trend.

Still, each week, the virus is killing hundreds of Californians, hitting hardest among the unvaccinated. The virus remained among the state’s leading causes of death in July, trailing heart disease, cancer, stroke, and Alzheimer’s disease but outpacing diabetes, accidental death, and a host of other debilitating diseases. In the first seven months of the year, about 13,500 California residents died of covid, according to preliminary death certificate data from the state Department of Public Health. By comparison, the virus killed about 31,400 people in 2020 and almost 44,000 in 2021.

From April 2020 through December 2021, covid killed an average of 3,600 people a month, making it the third-leading cause of death in the state cumulatively for that time period, behind heart disease and cancer. From December 2020 through February 2021, it briefly overtook heart disease as the leading cause of death, taking the lives of more than 38,300 Californians in just three months. During its most recent peak, in January 2022, covid took about 5,900 lives.

Covid fell out of the top 10 causes of death for a brief period in the spring only to reenter this summer as the omicron variant continued to mutate. In July, even with more than 70% of Californians fully vaccinated, covid was the fifth-leading cause of death, cutting short more than 1,000 lives, state data show.

Clearly vaccinations made a difference. Covid death rates fell in recent months as covid shots and prior infections afforded much of the population significant protection against severe illness, said Dr. Timothy Brewer, a professor of medicine and epidemiology at UCLA. Brewer said the omicron variant, while more transmissible than earlier strains, appears to be a milder version of the virus.

Research into that question is ongoing, but preliminary data suggests omicron is less likely to cause serious disease and death, according to the Centers for Disease Control and Prevention, which also notes that the severity of symptoms can be affected by vaccination status, age, and other health conditions.

The decline in deaths was particularly striking among California’s Latino population.

In 2020 and 2021, Latino residents accounted for 47% of covid deaths in California — about 35,400 deaths — although they make up 40% of the state’s population. By comparison, Latinos accounted for 34% of covid deaths from January through July 2022, according to state data. That translates to about 4,600 deaths.

Conversely, the proportion of covid deaths involving white residents increased from 32% in the first two years of the pandemic to 44% in the first seven months of 2022. That equates to 24,400 deaths involving white residents in 2020-21 and about 6,000 deaths in the first seven months of 2022. White people make up about 35% of the state’s population.

Researchers point to several factors in the shift. During the first two years of the pandemic, large numbers of the workers deemed essential, who continued to report to job sites in person, were Latino, while white residents were more likely to be employed in occupations that allowed them to work from home, U.S. Census Bureau surveys show.

“They just got exposed more,” said Dr. George Rutherford, a professor of epidemiology and biostatistics at the University of California-San Francisco. “They’re doing essential jobs and had to leave the house and go to work.”

An imbalance in remote work remains, census data shows, but today the large majority of both Latino and white workers in California are reporting to work in person.

Seciah Aquino, deputy director of the Latino Coalition for a Healthy California, said efforts to make sure that testing, treatment, and vaccinations were available to underserved communities of color also had an impact. And because Latino communities were hit so hard during the pandemic, she said, many California Latinos are still wearing masks. “They are still making sure that they’re staying home if they’re sick,” she said. “They’re still abiding by those policies even if the greater narrative is changing.”

Age is also a key factor in the demographic shifts, Brewer said.

Californians age 75 and older made up 53% of covid deaths through July in 2022, up from 46% in 2020 and 2021. Only about 6% of the state’s residents are 75 and older. And white Californians 75 and older outnumber Latinos in that age group about 3 to 1.

In the initial vaccination rollout, California prioritized seniors, first responders, and other essential workers, and for several months in 2021 older residents were much more likely to be vaccinated than younger Californians.

“Now, the vaccination rates have caught up pretty much with everybody except for kids, people under 18,” Brewer said. “You’re seeing it go back to what we saw before, which is that age remains the most important risk factor for death.”

More than 86% of Californians age 65 and older have completed their primary covid shot series. But the protection afforded by vaccines wanes over time, and since many seniors got their shots early, enough time passed between their second shot and the omicron wave of early 2022 to leave them vulnerable. About one-third of Californians 65 and older had not received a booster by early 2022, when the omicron wave peaked, and about one-quarter still haven’t received a booster.

Geographic shifts in covid prevalence have occurred throughout the pandemic: Outbreaks hit one area while another is spared, and then another community serves as the epicenter a few months later.

Residents of the San Francisco-Oakland metro area accounted for 7.8% of the state’s deaths in 2022, through early September, up from 5.4% in 2020-21. The area is home to about 12% of the state’s residents. The Sacramento metro area has also accounted for a higher share of covid deaths this year: 6% in 2022 versus 4.5% in 2020-21.

At the same time, Los Angeles-Long Beach-Anaheim metro residents made up 42% of covid deaths in 2022, down slightly from 43% in 2020-21. The area is home to about 33% of the state’s residents. A similar dip happened in the nearby Riverside-San Bernardino metro area.

Again, age could be a factor in the geographic shifts. A higher proportion of residents in San Francisco and Sacramento are 75 and older than in Los Angeles and Riverside, census data show.

It’s unclear whether this shift will last. As the Los Angeles Times reported, covid deaths grew at a faster pace in July in L.A. County than they did in the Bay Area.

The data also shows that vaccination remains one of the strongest deterrents to death from covid. From January through July, unvaccinated Californians died at roughly five times the rate as vaccinated Californians. But the gap has narrowed. From April through December 2021, California’s unvaccinated residents died, on average, at around 10 times the rate of vaccinated Californians.

Brewer said the gap lessened because the omicron variant was more likely than earlier variants to “break through” and cause infection in vaccinated Californians. The omicron variant, while less deadly, also infected many more people than earlier variants.

This trend, too, may prove short-lived: The next generation of covid booster shots are rolling out across the state.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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).

In 1991, California’s coroners officially classified 133 deaths of children ages 9 and younger as homicides. By 2011, that figure had fallen to 81.

In 2020, it stood at 40.

Adjusted for population changes, the state’s child homicide rate — the number of homicides per 100,000 children ages 0 to 9 — dropped about 50% from 2011 to 2020 and is down about 70% from three decades earlier, according to data from the U.S. Centers for Disease Control and Prevention and the California Department of Public Health.

Nationwide, the child homicide rate fell 14% over the past decade and 28% from three decades earlier.

Most child homicides involve newborns, infants, and young toddlers. Deanne Tilton Durfee, executive director of the Los Angeles County Inter-Agency Council on Child Abuse and Neglect, noted that “safe surrender” laws came online in California and many other states around 2001. Enacted in response to a spate of infant abandonments, these laws allow parents to confidentially surrender an infant 3 days old or younger without fear of prosecution.

More than 1,000 California infants have been safely surrendered since the law went into effect, according to the California Department of Social Services. The number of infants found recklessly abandoned statewide fell from an average of 18 a year from 2001 through 2005 to an average of two a year from 2015 through 2019. And the number of abandoned babies who died went from 52 in 2001-05 to zero in 2015-19.

“Safe surrender has clearly made a difference,” Tilton Durfee said. “We show an absolute correlation between the declining number of child homicides and the rising number of safe surrenders. I mean, it’s not equal, it’s not exact, but clearly since we started, we saw the number of child homicides by abandonment decline.”

Better access to family planning services may also play a role in the decline of child homicides as people give birth to fewer unwanted babies. The birth rate — births per 1,000 women — in California and nationwide has plummeted over the past three decades, and women are, on average, waiting until they are older and more mature to give birth. Although fathers or boyfriends kill children significantly more often than mothers, Tilton Durfee said data collected in Los Angeles County shows a correlation between the age of the mother and child homicides: Older mothers kill children less often.

Some child welfare experts pointed to studies that show an association between declining child homicide rates and increased access to abortion.

Although news coverage is painfully rife with stories of child victims who fell through the cracks of overwhelmed social service agencies, experts interviewed by KHN said that the social safety net is stronger overall in California now than it was in earlier decades and that early intervention with at-risk families has made a difference.

Various agencies — law enforcement, social services, hospitals, nonprofit community groups — seek to prevent child homicides. Child safety advocates said many California counties have worked in recent years to improve communication among those groups so they know when a child may be at risk for homicide.

“They are more apt to do something with what they know and involve each other,” said Dr. Michael Durfee, who helped start the nation’s first multiagency “child death review team” in Los Angeles County in 1978.

Organizations like First 5 California and state agencies like the Department of Social Services have also started several home-visitation programs for parents of newborns. “I think home visitation has made a big difference,” said Tilton Durfee. She said the programs provide “some eyes and ears and support inside the home to see how safe the child is or to help the stressed parent.”

Other advocates credited advances in early diagnoses and support services for children with disabilities, who historically have been more likely than other children to be victimized.

“We’re screening, and so now we’re starting to identify those things and make changes early on,” said Sheila Boxley, president and CEO of the statewide Child Abuse Prevention Center.

The decline in California’s child homicide rates held true across race and ethnicity — but didn’t erase disturbing disparities. The rate of homicides involving young Black children from 2011 through 2020 was more than three times as high as the rate for white and Hispanic children and about seven times as high as the rate for Asian children.

Tilton Durfee blamed long-standing systemic racism. She said the factors often at play in families in which a young child is killed — unemployment, substance misuse, mental illness, domestic violence — are statistically more likely in the African American community.

Determining when a child’s death is a homicide is often difficult. Several datasets try to capture the extent of the problem. The death certificate data used for this story is based on coroners’ cause-of-death determinations.

Kimberly Gin, the Sacramento County coroner and president of the California State Coroners Association, said coroners have used the same standard for decades when determining whether a death is the result of homicide. A homicide occurs as a result of a willful act “committed by another person to cause fear, harm, or death,” according to the National Association of Medical Examiners.

“Some are easy: If a child is shot, it’s a homicide,” Gin said. “The drug overdoses or if it looks like it may be an accident — sometimes it isn’t as clear.”

A separate dataset from the California Department of Justice collects information directly from law enforcement agencies about deaths designated by those agencies as homicides, including the age of victims. For most age groups, the information reported by law enforcement investigators matches a coroner’s final cause-of-death determination. But when the victims are very young, records show broader discrepancies between the initial assessment by law enforcement agencies and the coroner’s final determination.

The state DOJ dataset consistently shows more California homicides for children ages 0 to 9 than the death certificate data does: 13 more homicides in 2020, for instance. However, like the death certificate data, it shows a significant decline in the child homicide rate: a 70% decline since 1991 and a 28% decline since 2011.

The decline in child homicides continued during the first year of the pandemic, even as homicides surged for many other age groups, according to both death certificate and state DOJ figures. Preliminary figures show further declines in 2021, but Gin, the Sacramento County coroner, called those numbers “iffy” because investigations into child deaths from last year may be ongoing.

Tilton Durfee supports several measures that she says would keep the child homicide rate falling. She called for improvements to mental health care for parents of newborns. She said more programs are needed to prepare pregnant parents for the challenges they will face. She expressed support for pending legislation that would reestablish a state child death review council to identify trends and disparities in child deaths. And she said insurance companies and public agencies should start covering the costs of home visits to support new parents.

“We are very shy of having the level of home visitation that could make the dent that is possible,” she said, “particularly with these young children.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

USE OUR CONTENT

This story can be republished for free (details).