Being able to make a living off that degree? That’s a different question — and the answer is affecting the supply of physical therapists across the nation: The cost of getting trained is out of proportion to the pay.

“There’s definitely a shortage of PTs. The jobs are there,” said Lee, a student at California State University-Sacramento who is on track to receive his degree in May. “But you may be starting out at $80,000 while carrying up to $200,000 in student debt. It’s a lot to consider.”

As many patients seeking an appointment can attest, the nationwide shortage of PTs is real. According to survey data collected by the American Physical Therapy Association, the job vacancy rate for therapists in outpatient settings last year was 17%.

Wait times are generally long across the nation, as patients tell of waiting weeks or even months for appointments while dealing with ongoing pain or post-surgical rehab. But the crunch is particularly acute in rural areas and places with a high cost of living, like California, which has a lower ratio of therapists to residents — just 57 per 100,000, compared with the national ratio of 72 per 100,000, according to the association.

The reasons are multifold. The industry hasn’t recovered from the mass defection of physical therapists who fled as practices closed during the pandemic. In 2021 alone, more than 22,000 PTs — almost a tenth of the workforce — left their jobs, according to a report by the health data analytics firm Definitive Healthcare.

And just as baby boomers age into a period of heavy use of physical therapy, and covid-delayed procedures like knee and hip replacements are finally scheduled, the economics of physical therapy are shifting. Medicare, whose members make up a significant percentage of many PT practices’ clients, has cut reimbursement rates for four years straight, and the encroachment of private equity firms — with their bottom-line orientation — means many practices aren’t staffing adequately.

According to APTA, 10 companies, including publicly held and private equity-backed firms, now control 20% of the physical therapy market. “What used to be small practices are often being bought up by larger corporate entities, and those corporate entities push productivity and become less satisfying places to work,” said James Gordon, chair of the Division of Biokinesiology and Physical Therapy at the University of Southern California.

There’s a shortage of physical therapists in all settings, including hospitals, clinics, and nursing homes, and it’s likely to continue for the foreseeable future, said Justin Moore, chief executive of the physical therapy association. “Not only do we have to catch up on those shortages, but there are great indicators of increasing demand for physical therapy,” he said.

The association is trying to reduce turnover among therapists, and is lobbying Congress to stop cutting Medicare reimbursement rates. The Centers for Medicare & Medicaid Services plans a 3.4% reduction for 2024 to a key metric that governs pay for physical therapy and other health care services. According to the association, that would bring the cuts to a total of 9% over four years.

Several universities, meanwhile, have ramped up their programs — some by offering virtual classes, a new approach for such a hands-on field — to boost the number of graduates in the coming years.

“But programs can’t just grow overnight,” said Sharon Gorman, interim chair of the physical therapy program at Oakland-based Samuel Merritt University, which focuses on training health care professionals. “Our doctoral accreditation process is very thorough. I have to prove I have the space, the equipment, the clinical sites, the faculty to show that I’m not just trying to take in more tuition dollars.”

All of this also comes at a time when the cost of obtaining a physical therapy doctorate, which typically takes three years of graduate work and is required to practice, is skyrocketing. Student debt has become a major issue, and salaries often aren’t enough to keep therapists in the field.

According to the APTA’s most recent published data, median annual wages range from $88,000 to $101,500. The association said wages either met or fell behind the rate of inflation between 2016 and 2021 in most regions.

A project underway at the University of Iowa aims to give PT students more transparency about tuition and other costs across programs. According to an association report from 2020, at least 80% of recent physical therapy graduates carried educational debt averaging roughly $142,000.

Gordon said USC, in Los Angeles’ urban core, has three PT clinics and 66 therapists on campus, several of whom graduated from the school’s program. “But even with that, it’s a challenge,” he said. “It’s not just hard to find people, but people don’t stay, and the most obvious reason is that they don’t get paid enough relative to the cost of living in this area.”

Fewer therapists plus growing demand equals long waits. When Susan Jones, a Davis, California, resident, experienced pain in her back and neck after slipping on a wet floor in early 2020, she went to her doctor and was referred for physical therapy. About two months later, she said, she finally got an appointment at an outpatient clinic.

“It was almost like the referral got lost. I was going back and forth, asking, ‘What’s going on?’” said Jones, 57. Once scheduled, her first appointment felt rushed, she said, with the therapist saying he could not identify an issue despite her ongoing pain. After one more session, Jones paid out-of-pocket to see a chiropractor. She said she’d be hesitant to try for a physical therapy referral in the future, in part because of the wait.

Universities and PT programs graduate about 12,000 therapists a year, Moore said, and representatives of several schools told KFF Health News they’re studying whether and how to expand. In 2018, USC added a hybrid model in which students learn mostly online, then travel to campus twice a semester for about a week at a time for hands-on instruction and practice.

That bumped USC’s capacity from 100 students a year to 150, and Gordon said many of the hybrid students’ professional skills are indistinguishable from those of students on campus full time.

Natalia Barajas received her PT doctorate from USC last year and was recently hired at a clinic in nearby Norwalk, with a salary of $95,000, a signing bonus, and the opportunity to earn more in incentives.

She’s also managing a lot of debt. Three years of tuition for the USC physical therapy program comes to more than $211,000, and Barajas said she owes $170,000 in student loans.

“If it were about money alone, I probably would have shifted to something else a while ago,” Barajas said. “I’m OK with my salary. I chose to do this. But it might not be the perfect situation for everybody.”

But Milam was haunted by a family history of cancer, including his mother’s death from stomach cancer at 54. So, at age 37, he told his physician in San Francisco that he wanted to take every precaution against being diagnosed too late to live a full life. As it happened, his doctor said there was a new test to try.

The blood test, Galleri, returned a DNA signal for colon cancer. After a colonoscopy confirmed it was stage 3, Milam underwent eight hours of surgery, followed by radiation and chemotherapy. Today, he said, he is cancer-free.

“That test saved my life, and that’s a fact,” said Milam, speaking with California Healthline from his tour bus in July.

Galleri, priced at $949, is the first of a wave of so-called multi-cancer early-detection (MCED) tests, which analyze DNA fragments in the blood for abnormalities associated with cancer. Grail, the Menlo Park-based biotech company that created Galleri, says it checks more than a million specific DNA sites for cancer signals and can identify more than 50 types of cancer, including cervical, colon, breast, and prostate. More than a dozen prospective rivals are developing their own cancer-screening products.

The medical community, however, has yet to come to a consensus on the value of MCED tests. The notion of broadly screening seemingly healthy people has raised alarms among those who already lament the American medical system’s penchant for overtesting and, often, overtreating patients based on test results. Some note the controversy around prostate-specific antigen tests for prostate cancer as an example.

“A screening test has to be magnificent, mathematically, for it to be beneficial,” said Jerome Hoffman, a professor emeritus at UCLA’s Department of Medicine and a longtime critic of overtesting and overdiagnosis. “The biggest threat on the horizon is overdiagnosis — finding things that don’t matter but that we intervene on anyway.”

Many experts say it isn’t yet clear whether the tests do more good than harm — and having one already commercially available troubles them.

“You interview a hundred people and tell them there’s a test that could detect 20 or 30 or 50 cancers with a single blood sample, and a whole lot of them are going to say, ‘I want that,’” said Philip Castle, cancer prevention director at the National Cancer Institute. “But this is a brave new world. We don’t know anything about these tests, truly.”

Milam’s journey began in San Francisco when he was having blood drawn to check for covid-19 antibodies. He told his doctor, Jordan Shlain, about his fear of developing life-threatening cancer, and about his family’s history with the disease.

Shlain, founder of the San Francisco-based concierge practice Private Medical, told Milam about Galleri.

“Our practice had done a 12- to 18-month review of the science. We grilled the people at Grail,” said Shlain. “The short version is, new test, promising results, and we know that genetics and genomics have transformed the way cancer is treated. You have to be skeptical if you’re a scientist, but this is also a tension between policymakers and primary care doctors. I take care of individuals, not populations.”

Shlain said he doesn’t recommend the test for all patients; it would depend on their histories and risk factors. On the other hand, he said, “You can’t prevent cancer, but you can prevent it from killing you by catching it early. That’s just a truism.”

Milam, who continues to both perform and run Cookies (the company has been the subject of recent lawsuits), has become an evangelist for the test. He has often discussed his experience with his more than 2 million Instagram followers, and he wonders why more doctors don’t prescribe Galleri as they would standard screenings. Shlain said even some doctors in his practice are reluctant, despite Private Medical’s deep dive into the research.

Grail’s path has not been smooth. The company was originally a spinoff of San Diego gene-sequencing pioneer Illumina, and after the firm raised venture funding and proved its technology, Illumina bought it back last year for $7.1 billion. But because Illumina dominates the market for the sequencers needed in MCED testing, the Federal Trade Commission has sued to unwind the deal on antitrust grounds.

Grail also acknowledged in June that about 400 of its customers were mistakenly told they might have cancer — not because of an error with the test, but because incorrect form letters were inadvertently sent out by a vendor.

Josh Ofman, Grail’s president, said the company is lobbying Congress “along with many constituent groups” to authorize Medicare to cover the cost of MCED tests, which could unlock billions of federal dollars in potential revenue. Grail recommends annual screening, but it’s generally not covered by insurers.

Said Castle, speaking of MCED tests in general, “I can’t remember seeing anything [in laboratory tests] that compares with the potential market of this. This is the kind of money being thrown around that we usually reserve for pharma.”

Grail used an exemption for laboratory-developed tests to begin marketing Galleri without FDA approval two years ago, a move that raised eyebrows in the medical community because that process is typically used for tests with no commercial value. Another MCED blood test, by Exact Sciences, is following the same path to market and is expected to be available soon.

“I’m going to guess that we’ll see more and more of that because companies are eager to start selling,” said Barnett Kramer, a former director of cancer prevention at the NCI and a member of the Lisa Schwartz Foundation for Truth in Medicine. “But that sometimes comes before the actual proof of a benefit — and I think that’s the case here.”

Detailed studies on the net benefit of MCED tests could take 10 to 15 years, Castle said. The FDA doesn’t have to wait for a large-scale federal study to be completed, but it could still be years before the agency approves any MCED test.

The aim of a longer, large-scale study is to better understand both the benefits and risks associated with early-cancer screening. Among other considerations: Many types of the disease lack treatments, and not all cancers grow significantly or ever become a problem. Skeptics of MCED tests worry about patients being diagnosed and treated — sometimes intrusively and with potential dangers — based on a finding that isn’t a true threat.

“It’s not enough to say you find cancer,” Castle said. “The question is, can we find cancer and save lives? We also want to know about the harms associated with this — false negatives and false positives — and whether the test works equally well in all populations.”

Ofman said Galleri has been the subject of multiple small-scale tests, including a study led by University of Oxford researchers that found a 76% positive predictive value — the probability that a patient with an abnormal test result actually has cancer. The study was supported by the United Kingdom’s National Health Service, which has undertaken a randomized clinical trial of the test that will ultimately involve 140,000 adults. Early results are expected next year.

Currently, established tests screen for only a handful of cancers — and those generally identify cancer in its later stages, when less can be done to intervene. According to NCI research, 73% of people who die of cancer had cancers that weren’t detected by the standard tests in use.

“You have more treatment options for cancers that are found early, sometimes including ones that are curative,” Ofman said. “And even with stage 3 or 4 cancers, treatments when the cancers are found asymptomatically get better outcomes.”

But with more than 100,000 Galleri tests already sold, Kramer, with the Foundation for Truth in Medicine, is among those concerned that the marketing of the product is running ahead of evidence in its favor.

“The weight of ethical burden shifts to the person who is trying to get the healthy person to take the test,” Kramer said. “The best-case scenario here is that the test might actually reduce the risk of dying from the second-most common cause of death in the adult population, and if it did that with a low risk of overdiagnosis, that would be a major win. But we’re a long way from being able to say that.”

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“I told him we could probably eat the same apples for the next 20 years and be OK, but we wouldn’t be OK if he didn’t continue his potential groundbreaking work,” Milken, 76, said. “Then we funded him.”

Driven by a family history of disease and his own experience with prostate cancer, Milken, the onetime junk-bond wizard whose spectacular downfall on securities charges led to a 22-month prison term in the 1990s, has spent the last three decades trying to advance medical science so that people “can find cures to life-threatening diseases within their own lifetimes.”

In “Faster Cures,” a book that is part memoir and part medical history, the financier-turned-philanthropist argues for applying business principles to foster quicker medical breakthroughs: more collaboration and information-sharing among researchers, a more streamlined path through government regulations, and more public and private funding to keep the best and brightest working in the field. The book was written with Geoffrey Evans Moore, a longtime associate of Milken’s.

Milken, whose net worth is estimated at $6 billion, has donated $1.2 billion to medical research and public health causes and raised another $1 billion for them from donors, according to a spokesperson. Much of that money is distributed through the Santa Monica-based Milken Institute, which funds organizations around the world that support research and education.

This interview has been edited for length and clarity.

Q: Was it difficult to write about your father’s death from cancer and your own diagnosis of advanced prostate cancer in 1993, which was thought at the time to be terminal?

Life-threatening diseases are not separated by wealth or anything else. One in 2 men are going to get diagnosed with cancer in their lifetime; for women, it’s 1 in 3. In the hospital room or in surgery, we’re all equal. That’s why I wanted to personalize it because my family is no different. In the 1970s, science could not move fast enough to save my father’s life.

Q: Is the U.S. too slow in reaching cures?

A train today in Europe or Asia can travel at 200 miles an hour, but the average train in the U.S. travels at the same speed as 100 years ago because you can’t put faster trains on tracks that aren’t more modern. Science is this train that’s moving fast, but the tracks are 20th-century tracks. As science moves quickly — sequencing your genome and your microbiome, for example — many of the ways we deal with our health system still relate to what it was in the 1900s, not in this century.

Q: What are those outdated practices?

One is collaboration. Thirty years ago, after my diagnosis, I attended a prostate cancer conference at MD Anderson Cancer Center in Houston, and I noticed that no one from Memorial Sloan Kettering [in New York City] was presenting, and they were the other recognized top experts in the field. When I asked why, I was told by MD Anderson’s people that they felt Sloan Kettering was a competitor. I said, “They’re not a competitor to patients.” We’ve done a huge amount of work in that area to get researchers and scientists sharing information and working together.

Q: Are cancer patients getting into clinical trials at earlier stages?

Yes, but there’s another element here relating to health equity. The demographics of America have changed considerably. Sixty years ago, 75% of everyone living in the U.S. who was not born here came from Europe. Today, more than 70% of everybody living here who wasn’t born here came from Latin America or Asia, but our clinical trials are still largely Caucasian. We’re not including people who will someday make up the majority of people in this country.

Q: You also spend a lot of time writing about prevention, especially as it pertains to diet. Why?

If you went to medical school in China 30 or 40 years ago, you wouldn’t have even studied diabetes because it was so rare there. Today, because of changes in the food chain and what they’re eating — meat-based and fat-based diets — China has the most people with diabetes of any country in the world. That’s what thousands of McDonald’s and KFC and other franchises will do. We also know that eating certain foods can slow the growth of certain kinds of cancers, or that changing your diet can accelerate the growth. The CEO of one of the largest medical research companies in the world told me, “The next great drug is going to be prevention.”

Q: But isn’t the medical industry oriented toward selling treatment and not prevention?

When we proposed the idea to the medical community in the ’90s that you are what you eat, they said, “Prove it.” And we didn’t sequence the genome until 2003, so prior to that the evidence was mostly anecdotal, but there was plenty of it. The notion is mainstream today, but teaching doctors that nutrition makes a difference is still a minor, minor part of medical school. It should be at the forefront. We often refer to the produce section of the grocery store as the pharmacy of the 21st century.

Q: Your financial theories revolved around finding lower-graded bonds that produced great returns — essentially, identifying an undervalued segment of the market. Is there an undervalued equivalent in medicine or science?

It’s about the democratization of capital. In medicine and science, access to financial capital serves as a multiplier effect, but the largest asset is human capital. I’ve spent considerable time trying to identify the future Ted Turners or [telecommunications giant] John Malones of the world of medicine, then convincing them to go into research and funding them.

Q: How do you provide financing to the most talented people in the field?

That includes private and public funding. In 1998, we organized a march on Washington, and a few months later President Clinton signed into law a massive increase in the NIH [National Institutes of Health] budget. Since then, there’s been an incremental half a trillion dollars invested into the NIH, and that has made all the difference for so many organizations working on specific diseases or types of cancer.

Q: Why do you fund medical research?

My interest in medicine and science started when I was 8 years old. It accelerated in the ’70s when my wife’s mother was diagnosed with breast cancer and my father’s melanoma returned. That began a search for medical solutions that I brought into my existing philanthropy in 1982. Who a person is and what they believe in — there has always been a lot of misinformation out there, and it’s only going to get worse with artificial intelligence chat. It’s not just related to me. But I think the thousands of companies that we financed, and the millions of jobs created, are evidence that the ideas I put forth are today in the mainstream. All of the facts are there for one to see.

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 law, modeled after legislation in the United Kingdom, will ban websites from profiling users in California under age 18, tracking their locations, or nudging them to provide personal information. It will also require online services to automatically put privacy settings at their highest levels on sites that kids access when the law goes into effect next year.

Passed with unanimous bipartisan support, the measure presents a road map for federal lawmakers to stop social media companies from targeting kids. But the tech industry’s response, including a recent lawsuit that describes the law as having global ramifications, demonstrates how hard its powerful lobby will work to undermine or dilute regulation.

“Big Tech isn’t afraid to throw its weight around, that’s for sure,” said Jordan Cunningham, a Republican former California Assembly member who co-authored the bill. “That’s true in D.C. and Sacramento alike.”

Gov. Gavin Newsom last year signed the law, which imposes strict guardrails on online services that children use. Its greatest reach, some privacy experts believe, lies in the requirement that online services must consider what’s best and safest for kids from the very start — meaning that companies will have to design their websites based on privacy rules to protect users.

“The privacy piece is truly noteworthy,” said Jennifer King, a privacy and data policy fellow at the Stanford University Institute for Human-Centered Artificial Intelligence. “It basically says, ‘You can’t collect data on kids under 18, and you have to consider that in the design of your product.’”

That’s precisely the sort of regulation online services want to avoid. Three months after Newsom signed the bill, the deep-pocketed tech industry responded with a federal lawsuit in December to block the law from taking effect on July 1, 2024.

One of the industry’s most powerful trade associations, NetChoice, argues, in part, that the law violates free speech provisions of the U.S. Constitution. Members of the association include giants like Google, Meta (which owns Facebook and Instagram), TikTok, and Twitter.

Biden, in his State of the Union address on Feb. 7, asked Congress “to pass bipartisan legislation to stop Big Tech from collecting personal data on kids and teenagers online” and to prevent targeted advertising to children.

“We must finally hold social media companies accountable for the experiment they are running on our children for profit,” Biden said.

Multiple studies have found that targeted ads and pushes toward certain online content can be harmful to kids’ well-being, and a 2021 report found that Facebook’s own research indicated nearly a third of teenage girls felt worse about their bodies after using Instagram.

In California, Cunningham and Democrat Buffy Wicks overcame the fierce opposition of an industry that wields immense power in Sacramento by appealing to their colleagues not just as lawmakers but also as parents. The measure drew strong support from the international 5Rights Foundation, which pushed for its passage after it helped create the U.K. law, and from Facebook whistleblower Frances Haugen, whose testimony before Congress in 2021 sparked renewed scrutiny of the social media giant’s privacy practices.

“There is a lot of common ground for all of us, Democrats and Republicans, to come together and say, ‘OK, what’s really going on with our kids when they’re online?’” said Wicks, who has two young children. “Politically, this bill could serve as a model, especially in its bipartisan nature.”

Last year, the pair crafted an aggressive strategy to fend off the industry, authoring two bills that sought to hold social media companies accountable in different ways. Big Tech successfully blocked one bill, which would have permitted state prosecutors to sue companies that knowingly addict minors.

“We knew they had to oppose a bill that imposes liability, costs, and damages,” said Cunningham, a father of four who served in the Assembly for six years before declining to run for reelection last fall.

That left lawmakers room to approve the other measure, AB 2273, known as the California Age-Appropriate Design Code, with little pushback. The measure forbids online services from designing features on their websites that are harmful to children.

And its requirement that online services build safeguards into their sites, such as the default privacy settings for children, represents “an existential threat” to a tech industry that derives massive profit from its ability to mine and monitor user data regardless of one’s age, Cunningham said.

In its lawsuit, filed in the U.S. District Court for the Northern District of California in San Jose, NetChoice posits the case as one of unfair restriction on free speech guarantees. The association also claims all users will have to turn over far more personal data for online services to verify who is younger than 18.

Wicks called that assertion “fearmongering,” noting that many sites already use algorithms that assess age with uncanny precision, and said she is “cautiously optimistic” the law will withstand a legal challenge because it focuses on product safety and not free speech. California Attorney General Rob Bonta spokesperson Joanne Adams told KHN that Bonta’s office would defend “this important children’s safety law in court.”

Newsom also weighed in last month after the industry filed a motion on Feb. 17 to block the law from taking effect this summer while the NetChoice lawsuit is pending. In his statement, the father of four said that no other state is doing more than California to protect kids.

In fact, some lawmakers want to go further. In February, state Sen. Nancy Skinner introduced a bill that would bar social media companies from using algorithms or other technical features that direct content to children and could prompt them to purchase fentanyl, inflict harm on themselves or others, engage in dangerous diets, or take their own lives.

NetChoice association counsel Chris Marchese said the industry supports national regulation rather than state action. “We just don’t support a patchwork of state laws, some of which will be very different from others,” Marchese said.

Critics of the industry say that’s because Big Tech wants an industry-friendly law from legislators in D.C. In 2022, five of the tech industry’s biggest companies together spent nearly $69 million lobbying the federal government, according to public filings. That’s more than either the pharmaceutical or oil and gas industries spent, Bloomberg News reported.

This year, lawmakers have proposed bills to strip federal protections for online services that don’t do more to protect kids, but it’s unclear if they will fare better than past efforts. At a hearing in February, Senate Judiciary Committee Chairman Dick Durbin (D-Ill.) accused Facebook, Snapchat, and other social media companies of “doing everything they can to keep our kids’ eyes glued to the screens.”

If Congress does pass federal rules, California leaders hope they won’t override or weaken laws adopted in their state.

“We can see that this is tech’s next pivot, [but] we’ve got to get this right,” Cunningham said. “In 20 years, people in public health will look back and say, ‘Man, we just let these companies conduct the biggest social experiment ever on children. How did they get away with that?’”

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The problem, Dorio told California lawmakers last year, was the hospital had the right to override the family’s wishes because the patient had not completed an advance directive or designated a power of attorney. The hospital chose to listen to the family, but under state law, his family’s wishes held no weight.

That’s no longer the case. As of Jan. 1, California joined 45 other states and the District of Columbia with next-of-kin laws that designate a surrogate to make decisions on a patient’s behalf — even if that person wasn’t specifically authorized by the patient before the medical situation arose. The list includes spouses or domestic partners, siblings, adult children and grandchildren, parents, and an adult relative or close friend — in many cases, the people who brought in the patient for care in the first place.

“Hospitals and HMOs could usurp the rights of the families to make critical medical decisions under the law that was in place at the time — including decisions on pulling the plug,” Dorio, a geriatrics specialist in Santa Clarita and member of the California Senior Legislature, told KHN. “We knew we needed a law like most other states have.”

According to data analyzed by Penn Medicine researchers, only about a third of U.S. adults have either an advance directive, with which they detail instructions about medical care, or a medical power of attorney, which authorizes someone else to make those decisions.

The idea behind the next-of-kin law, proponents say, is to empower representatives to advocate for patients rather than allow a hospital to make medical decisions, which can be influenced by cost, bed space, or insurance pressures.

“This law takes the pressure off the hospitals, who are being asked to render care, save lives, deal with Medicare, deal with insurance — any number of things all at once,” said Michele Mann, a Valencia attorney who specializes in estate planning, including advance directives.

Patient medical rights have evolved through the years, but it is something of a mystery why the state took so long to put a next-of-kin statute on the books. When the California Senior Legislature, which sponsors and lobbies for laws aimed at helping the state’s older population, approached the state’s Office of the Legislative Counsel for help with the bill, Dorio said, some staff attorneys expressed surprise that such a law wasn’t already in place.

Patients without an advance directive or power of attorney have long been able to designate a surrogate, even if it’s simply by verbally declaring so while at the hospital – but that relies upon the patient being conscious.

If patients arrive at a hospital or medical center incapacitated or later become so, providers must make a good-faith effort to find a person authorized to make medical decisions, according to a California statute in effect since 2005. The steps include going through the patient’s belongings and reaching out to anyone the hospital “reasonably believes has the authority” to make decisions via directive or power of attorney. The hospital must show it has contacted the secretary of state to ask whether the patient had an advance directive.

With the new law in place, health care providers still must check for a patient’s advance directive or power of attorney. But once officials have determined that none exists, they can turn to the next-of-kin list, all of whom are legally authorized to speak for the patient.

“It’s groundbreaking,” said Mann, who makes decisions for her sister, a patient with multiple sclerosis in a long-term care facility. “With the next-of-kin list, often the person who brought the patient in is a family member or close friend with a clear understanding of the patient’s wishes. In those cases, the hospital’s search is over — a legally authorized representative is standing there.”

AB 2338, introduced by Assembly member Mike Gipson, added a section to the probate code, and it resembles the way most states handle the division of a person’s assets after death. When people in California die without a will, their assets and property are distributed in a fixed, descending order of priority: spouse first, then children, parents, siblings, etc. Now, a person’s medical decisions will be decided in the same way — but not necessarily in the same order.

California gives hospitals and health care providers the discretion to decide which family member or close friend can make medical decisions — a provision inserted into the bill after the influential California Hospital Association and other medical groups opposed a set hierarchy.

Some experts question how effective the new law will be, since hospitals retain the power to pick the patient’s representative, especially if there are conflicting opinions among family members.

“Although I have no reason to believe they would abuse the power, the hospitals get to decide who would be a good decision-maker,” said Alexander Capron, a medical law and ethics expert and professor emeritus at the University of Southern California.

Lois Richardson, a vice president and legal counsel for the hospital association, said a strict order of surrogates often doesn’t reflect what a patient would want. “The concern has always been that having a strict statutory hierarchy, in many, many cases, does not reflect real family relationships,” Richardson said.

The hospital lobby dropped its opposition after Gipson agreed to give the industry flexibility, and the measure passed through the legislature with virtually no opposition.

Ideally, people should have an advance directive to ensure their wishes are followed, Gipson said. But for seniors, those who live alone, and anyone without a stated directive, the law opens the field of people who may be able to advocate on their behalf — including a close friend who might just as well be family.

“At least this way, you have someone who knows what you want making those decisions,” Gipson said, “rather than leaving it up to a hospital.”

El año pasado, Dorio le explicó a legisladores estatales que el problema era que el hospital tenía derecho a invalidar los deseos de la familia porque el paciente no había hecho un documento de directiva avanzada, ni había designado a alguien con poder notarial. El hospital optó por escuchar a la familia, pero según la ley del estado, los deseos de la familia no tenían peso.

Eso ya no es así. Desde el 1 de enero, California se sumó a otros 45 estados y al Distrito de Columbia con leyes que permiten a una persona tomar decisiones en nombre de un paciente, incluso si no estaba autorizada por el paciente antes de que ocurriera la situación médica.

La lista incluye cónyuges o parejas de hecho, hermanos, hijos y nietos adultos, padres y un pariente adulto o amigo íntimo; y en muchos casos, a las personas que llevaron al paciente para que lo atendieran en un primer momento.

“Los hospitales y las HMO podían usurpar los derechos de las familias y tomar decisiones médicas críticas en virtud de la ley vigente en aquel momento, incluidas las decisiones de desconectar al paciente”, explicó a KHN Dorio, especialista en geriatría de Santa Clarita y miembro de la organización no partidista California Senior Legislature. “Sabíamos que necesitábamos una ley como la que tienen la mayoría de los otros estados”.

Según datos analizados por investigadores de Penn Medicine, solo un tercio de los adultos estadounidenses tiene o bien instrucciones previas, que detallan lo que quieren sobre su atención médica, o bien un poder médico, que autoriza a otra persona a tomar esas decisiones.

Según sus partidarios, la finalidad detrás de la ley de parentesco es darles facultad a los representantes para que aboguen por los pacientes en lugar de permitir que un hospital tome las decisiones médicas, que pueden estar influenciadas por el costo, las camas disponibles o las presiones de los seguros.

“Esta ley libera de presión a los hospitales, a los que se pide que presten asistencia, salven vidas, se ocupen de Medicare, de los seguros… de muchas cosas a la vez”, afirmó Michele Mann, abogada de Valencia, California, especializada en planificación patrimonial, incluidas las directivas avanzadas.

Los derechos médicos de los pacientes han evolucionado a lo largo de los años, pero es un misterio por qué el estado ha tardado tanto tiempo en aprobar una ley de parentesco. Cuando la California Senior Legislature, que patrocina y promueve leyes destinadas a ayudar a la población de edad avanzada, pidió ayuda a la Oficina del Asesor Legislativo del Estado con el proyecto de ley algunos abogados se sorprendieron de ya no hubiera una ley vigente, dijo Dorio.

Los pacientes que no disponen de un documento de directivas avanzadas o de un poder notarial pueden designar a un sustituto, aunque solo sea declarándolo verbalmente en el hospital, pero, obviamente, es necesario que el paciente esté consciente.

Si un paciente llega a un hospital o centro médico incapacitado o lo está posteriormente, los proveedores deben hacer un esfuerzo de buena fe para encontrar a una persona autorizada a tomar decisiones médicas, según una ley de California en vigor desde 2005.

Los pasos incluyen revisar las pertenencias del paciente y ponerse en contacto con cualquier persona que el hospital “crea razonablemente que tiene autoridad” para tomar decisiones a través de directivas o de un poder notarial. El hospital debe demostrar que se ha puesto en contacto con el secretario de estado para preguntar si el paciente tenía instrucciones anticipadas.

Con la nueva ley vigente, los proveedores de atención médica deben comprobar si el paciente tiene directivas avanzadas o un poder notarial. Pero una vez que los funcionarios han determinado que no existe ninguno, pueden recurrir a la lista de parientes más próximos, todos los cuales están legalmente autorizados a hablar en nombre del paciente.

“Es innovador”, afirmó Mann, que toma decisiones por su hermana, que tiene esclerosis múltiple y vive en un centro de cuidados de largo plazo. “Con la lista de parientes cercanos, a menudo la persona que trae al paciente es un familiar o un amigo íntimo que conoce claramente los deseos del paciente. En esos casos, se acabó la búsqueda del hospital: hay un representante legalmente autorizado”.

El proyecto de ley AB 2338, presentado por el asambleísta Mike Gipson, agregó una sección al código de sucesiones, y se asemeja a la forma en que la mayoría de los estados maneja la división de los bienes de una persona después de su muerte.

En California, cuando una persona muere sin dejar testamento, sus bienes y propiedades se distribuyen siguiendo un orden de prioridad fijo y descendiente: primero el cónyuge, después los hijos, los padres, los hermanos, etc. Ahora, las decisiones médicas de una persona se decidirán de la misma manera, pero no necesariamente en el mismo orden.

California otorga a los hospitales y a los proveedores médicos la discreción de decidir qué familiar o amigo íntimo puede tomar decisiones médicas, una disposición introducida en el proyecto de ley después de que la influyente Asociación de Hospitales de California y otros grupos médicos se opusieran a una jerarquía pre establecida.

Algunos expertos se preguntan hasta qué punto será eficaz la nueva ley, ya que los hospitales conservan la facultad de elegir al representante del paciente, sobre todo si hay opiniones encontradas entre los miembros de la familia.

“Aunque no tengo motivos para creer que vayan a abusar del poder, los hospitales pueden decidir quién sería una buena persona para tomar decisiones”, dijo Alexander Capron, experto en derecho médico y ética, y profesor emérito de la Universidad del Sur de California.

Lois Richardson, vicepresidenta y asesora jurídica de la asociación de hospitales, dijo que un orden estricto de sustitutos a menudo no refleja lo que un paciente desearía. “La preocupación siempre ha sido que, en muchos casos, una jerarquía estatutaria estricta no refleja las relaciones familiares reales”, agregó.

El cabildeo de los hospitales abandonó su oposición después de que Gipson accediera a dar flexibilidad al sector, y la medida se aprobó en la legislatura prácticamente sin oposición.

Lo ideal sería que las personas dispusieran de un documento de directivas avanzadas para garantizar el cumplimiento de sus deseos, según Gipson. Pero para las personas mayores, las que viven solas y cualquiera que no tenga este documento, la ley abre el abanico de personas que pueden actuar en su nombre, incluido un amigo íntimo que bien podría ser de familia.

“Al menos así, tienes a alguien que sabe lo que quieres tomando esas decisiones”, indicó Gipson, “en lugar de dejarlo en manos de un hospital”.

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“I had a few guys that I sort of immediately knew I should check in on,” said Hastings, the Los Angeles Rams’ sports psychologist and mental health clinician. “A couple of spouses and significant others, too.”

Hastings’ familiarity with the Rams’ personnel, and with which players might be emotionally traumatized after watching Hamlin’s shocking medical emergency, was the product of her having spent six seasons with the club — getting to know the athletes, meeting rookies when they first arrive, and making herself a regular presence at the Rams’ facility.

Across the NFL, no such continuity of care exists. The league is working its way toward the kind of mental health support for its players, coaches, and staff in which a range of counseling is standard and readily accessible.

It was just over three years ago, in 2019, that the NFL implemented a formal program to manage its employees’ mental health needs. That came as part of a new collective bargaining agreement, after the NFL Players Association pushed hard for its creation. Among other things, the agreement mandates that each team have a licensed behavioral health clinician on staff.

But individual franchises still have great latitude in implementing that directive. Some have full-time sports psychologists; others employ clinicians part time, while a few contract with outside providers and make them available to players, Hastings said. And clinicians aren’t required to have any sports background, which some sports psychologists see as a critical flaw.

“This is a very specialized area,” said Sam Maniar, a psychologist who consults for the Cleveland Browns and formerly worked as the team’s full-time clinician. “The environment of athletics, and especially at the highest level, is something that does require specialization, and not every clinician being brought into the NFL has that.”

Hastings was a sprinter and hurdler in her undergraduate years at Notre Dame, has deep professional experience with athletes, and is listed in the U.S. Olympic & Paralympic Committee’s registry for sports psychology and mental training. She keeps her private practice a short drive from the Rams’ training facility in Agoura Hills, northwest of Los Angeles, and though technically a part-time employee, Hastings said she is at the facility three or four times a week “and basically on call 24/7 during the season.”

In that capacity, Hastings has worked to forge a foundation of trust with elite athletes who often think of a sports psychologist only in terms of getting them primed to compete.

“It’s often the case that a player comes in for something performance-related, and that opens up the door for conversations in other areas of mental health,” she said. “The relationship deepens.”

That kind of ingrained presence with teams is crucial, clinicians say, particularly as some athletes have begun to speak more openly about the mental and emotional challenges they face and have indirectly encouraged their peers to be more open to getting help.

Tennis sensation Naomi Osaka, Olympic gold medalists Simone Biles and Michael Phelps, NBA stars Kevin Love and DeMar DeRozan all have publicly discussed their mental health challenges over the past decade, and several have led campaigns to raise awareness. “I credit them for discussing their struggles and the great benefits they received by accessing some care that was available to them,” said Maniar, who runs an athletic performance center in Ohio and works with college and high school football teams beyond his relationship with the Browns.

The NFL is a difficult arena for such conversations. Players in the league are accustomed to working through all manner of pain and injury practically as a job condition, and for much of the league’s existence, its athletes essentially were trained to show no vulnerability.

The implementation of a leaguewide program, though an important milestone, hasn’t radically accelerated the pace of change. “I think the NFL is still a dinosaur in that respect,” Green Bay Packers quarterback Aaron Rodgers told The New York Times two seasons ago. “There’s a stigma around talking about feelings, struggles, and dealing with stress. There’s a lot of vernacular that seems to tag it as weakness.”

The players union has become more aggressive in addressing the issue. “NFL players are often seen as the pinnacle of masculinity, and because caring about our own mental well-being and seeking support has not historically been associated with masculinity, too many of us do not prioritize that aspect of our health,” union president JC Tretter, an eight-year NFL veteran, wrote in a 2021 blog post to players, urging them to make use of the resources available.

Hamlin’s highly unusual emergency, in which he required on-field CPR before being transported to a hospital from the Cincinnati stadium where the Bills and Bengals were playing, “really created anxiety in some players, and it triggered others,” Hastings said. In addition to contacting several players individually, she sent out a message across the Rams organization reminding the athletes, coaches, and staff she was available to talk.

“A lot of them were receptive,” Hastings said. “The elephant in the room is mortality. The players know they can be hurt, and they’ve all dealt with injuries, but this included an element over which they had no control.”

Players from the Bills and the Cincinnati Bengals stood in stunned silence as Hamlin lay on the field. Days later, Buffalo players still struggled to articulate their feelings. “The scene replays over and over in your head,” quarterback Josh Allen said during a news conference, fighting back tears. “It’s hard to describe how I felt and how my teammates felt in that moment. It’s something we’ll never forget.”

Hamlin’s subsequent progress, including his release from hospital care to convalesce at home, “will help alleviate some of the trauma the players have been undergoing,” said Dr. Joshua Norman, an Ohio State University sports psychiatrist who often works with athletes on processing emotions. “But even though they try to compartmentalize things, these players have witnessed a serious injury. Some of them will have a strong reaction.”

Dr. Claudia Reardon, a University of Wisconsin psychiatrist, said the term “vicarious trauma” applies in this case. “The original traumatic event didn’t happen to you personally, but it is experienced as traumatic to have witnessed it or learned about it,” Reardon said. Reactions range from fear and helplessness to nightmares and flashbacks, she said, and some athletes will try to avoid “people, places, or things that remind them of the trauma they witnessed.”

“I wouldn’t be surprised to see a few players retire early,” Maniar said. “And a big concern is a player going out there and playing hesitantly or in fear. That is a sure way to get hurt in a sport like football, and this is a league where the contracts are not guaranteed. You’ve heard the saying ‘NFL means not for long.’ The players feel that pressure.”

The NFL’s best chance to make big strides in its mental health coverage, clinicians say, may derive from the simple fact that it is continually drafting and developing new talent. “The younger generation is just more sophisticated about mental health, period,” said Norman. “They come to a college campus often already having established some connection with their mental health needs, through counseling or other means. They’re more open to the idea of dealing with their mental health.”

Within franchise complexes, the work goes on. Both Hastings and Maniar were hired by their NFL teams years before the league made a clinician mandatory, and both made sure they kept an office away from the practice facility for those players who weren’t comfortable seeing them at work. But lately, Hastings said, that, too, is changing.

“Players are talking about these kinds of issues with each other more often, and they’re doing so very publicly,” she said. “In many ways, we’ve been building out our mental health protocol since I was brought on in 2017.” In the NFL, it is proving a slow turn.

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She soon discovered how far a clerical error can reach — even across a continent — and how frustrating it can be to fix.

During a college break in 2013, Elliott, then 22, began to feel faint and feverish while visiting her parents in Venice, Florida, about an hour south of Tampa. Her mother, a nurse, drove her to a facility that locals knew simply as Venice Hospital.

In the emergency department, Elliott was diagnosed with a kidney infection and held overnight before being discharged with a prescription for antibiotics, a common treatment for the illness.

“My hospital bill was about $100, which I remember because that was a lot of money for me as an undergrad,” said Elliott, now 31.

She recovered and eventually moved to California to teach preschool. Venice Regional Medical Center was bought by Community Health Systems, based in Franklin, Tennessee, in 2014 and eventually renamed ShorePoint Health Venice.

The kidney infection and overnight stay in the ER would have been little more than a memory for Elliott.

Then another bill came.

The Patients: Grace E. Elliott, 31, a preschool teacher living with her husband in San Francisco, and Grace A. Elliott, 81, a retiree in Venice, Florida.

Medical Services: For Grace E., an emergency department visit and overnight stay, plus antibiotics to treat a kidney infection in 2013. For Grace A., a shoulder replacement and rehabilitation services in 2021.

Service Provider: Venice Regional Medical Center, later renamed ShorePoint Health Venice.

Total Bill: $1,170, the patient’s responsibility for shoulder replacement services, after adjustments and payments of $13,210.21 by a health plan with no connection to Elliott. The initial charges were $123,854.14.

What Gives: This is a case of mistaken identity, a billing mystery that started at a hospital registration desk and didn’t end until months after the file had been handed over to a collection agency.

Early this year, Grace E. Elliott’s mother opened a bill from ShorePoint Health Venice that was addressed to her daughter and sought more than $1,000 for recent hospital services, Elliott said. She “immediately knew something was wrong.”

Months of sleuthing eventually revealed that the bill was meant for Grace Ann Elliott, a much older woman who underwent a shoulder replacement procedure and rehabilitation services at the Venice hospital last year.

Experts said that accessing the wrong patient’s file because of a name mix-up is a common error — but one for which safeguards, like checking a patient’s photo identification, usually exist.

The hospital had treated at least two Grace Elliotts. When Grace A. Elliott showed up for her shoulder replacement, a hospital employee pulled up Grace E. Elliott’s account by mistake.

“This is the kind of thing that can definitely happen,” said Shannon Hartsfield, a Florida attorney who specializes in health care privacy violations. (Hartsfield does not represent anyone involved in this case.) “All kinds of human errors happen. A worker can pull up the names, click the wrong button, and then not check [the current patient’s] date of birth to confirm.”

It was a seemingly obvious error: The younger Elliott was billed for a procedure she didn’t have by a hospital she had not visited in years. But it took her nearly a year of hours-long phone calls to undo the damage.

At first, worried that she had been the victim of identity theft, Grace E. Elliott contacted ShorePoint Health Venice and was bounced from one department to another. At one point, a billing employee disclosed to Elliott the birthdate the hospital had on file for the patient who had the shoulder replacement — it was not hers. Elliott then sent the hospital a copy of her ID.

It took weeks for an administrator at ShorePoint’s corporate office in Florida to admit the hospital’s error and promise to correct it.

In August, though, Grace E. Elliott received a notice that the corporate office had sold the debt to a collection agency called Medical Data Systems. Even though the hospital had acknowledged its error, the agency was coming after Grace E. Elliott for the balance due for Grace A. Elliott’s shoulder surgery.

“I thought, ‘Well, I’ll just work with them directly,’” Grace E. Elliott said.

Her appeal was denied. Medical Data Systems said in its denial letter that it had contacted the hospital and confirmed the name and address on file. The agency also included a copy of Grace A. Elliott’s expired driver license to Grace E. — along with several pages of the older woman’s medical information — in support of its conclusion.

“A collection agency, as a business associate of a hospital, has an obligation to ensure that the wrong patient’s information is not shared,” Hartsfield said.

In an email to KHN, Cheryl Spanier, a vice president of the collection agency, wrote that “MDS follows all state and federal rules and regulations.” Spanier declined to comment on Elliott’s case, saying she needed the written consent of both the health system and the patient to do so.

Elliott’s second appeal was also denied. She was told to contact the hospital to clear up the issue. But because the health system had long since sold the debt, Elliott said, she got no traction in trying to get ShorePoint Health Venice to help her. The hospital closed in September.

Resolution: In mid-November, shortly after a reporter contacted ShorePoint Health, which operates other hospitals and facilities in Florida, Grace E. Elliott received a call from Stanley Padfield, the Venice hospital’s outgoing privacy officer and director of health information management. “He said, ‘It’s taken care of,’” Elliott said, adding that she was relieved but skeptical. “I’ve heard that over and over.”

Elliott said Padfield told her that she had become listed as Grace A. Elliott’s guarantor, meaning she was legally responsible for the debt of a woman she had never met.

Elliott soon received a letter from Padfield stating that ShorePoint Health had removed her information from Grace A. Elliott’s account and confirmed that she had not been reported to any credit agencies. The letter said her information had been removed from the collection agency’s database and acknowledged that the hospital’s fix initially “was not appropriately communicated” to collections.

Padfield said the error started with a “registration clerk,” who he said had “received additional privacy education as a result of this incident.”

Devyn Brazelton, marketing coordinator for ShorePoint Health, told KHN the hospital believes the error was “an isolated incident.”

Using the date of birth provided by a hospital worker, Elliott was able to contact Grace A. Elliott and explain the mix-up.

“I’m a little upset right now,” Grace A. Elliott told KHN on the day she learned about the billing error and disclosure of her medical information.

The Takeaway: Grace E. Elliott said that when she asked Padfield, the Venice hospital’s outgoing privacy officer, whether she could have done something to fight such an obvious case of mistaken identity, he replied, “Probably not.”

This, experts said, is the dark secret of identity issues: Once a mistake has been entered into a database, it can be remarkably difficult to fix. And such incorrect information can live for generations.

For patients, that means it’s crucial to review the information on patient portals — the online medical profiles many providers use to manage things like scheduling appointments, organizing medical records, and answering patient questions.

One downside of electronic medical records is that errors spread easily and repeat frequently. It is important to challenge and correct errors in medical records early and forcefully, with every bit of documentation available. That is true whether the problem is an incorrect name, a medication no longer (or never) taken, or an inaccurate diagnosis.

The process of amending a record can be “very involved,” Hartsfield said. “But with patients able now to see more and more of their medical records, they are going to want those amendments, and health systems and their related entities need to get prepared for that.”

Grace A. Elliott told KHN that she had received a call from ShorePoint Health in the previous few months indicating that she owed money for her shoulder replacement.

She asked for a copy of the bill, she told KHN. Months after she asked, it still hadn’t arrived.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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Bonta, the first Filipino American to serve as the state’s top prosecutor, asked 30 hospital CEOs in August for a list of the commercial software programs their facilities use to support clinical decisions, schedule operating rooms, and guide billing practices. In exchange, he offered them confidentiality. His goal, Bonta told KHN, is to identify algorithms that may direct more attention and resources to white patients than to minorities, widening racial disparities in health care access, quality, and outcomes.

“Unequal access to our health care system needs to be combated and reversed, not carried forward and propagated, and algorithms have the power to do either,” Bonta said.

It’s too early to know what Bonta will find, and his office will not name the hospitals involved. The California Hospital Association said in a statement that such bias “has absolutely no place in medical treatment provided to any patient in any care setting” and declined to comment further.

Advocates have high hopes for what Bonta will find — and for the next four years. “We expect to see a lot more from him in this full term,” said Ron Coleman Baeza, managing director of policy for the California Pan-Ethnic Health Network. “There is much more work to do.”

Last year, Gov. Gavin Newsom appointed Bonta as attorney general after Xavier Becerra left the position to join the Biden administration as secretary of the U.S. Department of Health and Human Services. In the Nov. 8 election, which won him his first full term, Bonta faced Republican challenger Nathan Hochman, a former federal prosecutor who campaigned on prosecuting violent criminals and pulling the deadly synthetic opioid fentanyl off the streets. In contrast, Bonta advocated for gun control and decriminalizing lower-level drug offenses, and in January advised law enforcement officials not to prosecute women for murder when a fetus dies, even if their drug use contributed to the death.

In unofficial results, Bonta had about 59% of the statewide vote, compared with 41% for Hochman.

Bonta, formerly a state legislator representing the East Bay, will be eligible to run for a second full term, which could allow him to serve for nearly 10 years.

His wife, Democratic state Assembly member Mia Bonta, was among the public officials who discussed their abortion experiences after a leaked draft of a U.S. Supreme Court opinion that was published in May revealed the justices would likely repeal Roe v. Wade. After they did, the attorney general threatened legal action against local jurisdictions that tried to adopt abortion bans.

Bonta called health care a right for all Californians and said he wanted to help people of color and low-income communities get more access to doctors and treatments, as well as better care. “It’s something I’ve been actively working on as an elected official my entire career, and even before that,” said Bonta, whose father helped organize health clinics for Central Valley farmworkers.

But health equity remains an elusive goal, even as it has become a catchphrase among advocates, researchers, politicians, and health care executives. And as with most aspects of the state’s mammoth health care system, progress comes slowly.

The Newsom administration, for example, will require managed-care plans that sign new Medicaid contracts to hire a chief equity officer and pledge to reduce health disparities, including in pediatric and maternal care. The state’s Medicaid program, known as Medi-Cal, serves nearly 15 million people — most of whom are people of color. But those changes won’t come until 2024, at the earliest.

State lawmakers are also trying to minimize racial discrimination through legislation. In 2019, for example, they passed a law that mandates implicit bias training for health care providers serving pregnant women. Black women are three times as likely to die from having a baby as white women.

In recent years, researchers started warning that racial discrimination was baked into the diagnostic algorithms that doctors use to guide their treatment decisions. One model predicted a lower rate of success for vaginal births among Black and Hispanic women who previously had a cesarean delivery than among white women, but failed to take into account patients’ marital status and insurance type, both of which can affect the success rate of a vaginal birth. Another, used by urologists, assigned Black patients coming into emergency rooms with “flank pain” a lower likelihood of having kidney stones than non-Black patients — even though the software’s developers failed to explain why.

Some researchers likened such medical algorithms to risk assessment tools used in the criminal justice system, which can lead to higher bail amounts and longer prison sentences for Black defendants. “If the underlying data reflect racist social structures, then their use in predictive tools cements racism into practice and policy,” they wrote in the New England Journal of Medicine in 2020.

Bonta is seeking the hospital industry’s cooperation in his algorithm investigation by framing racial and ethnic disparities as injustices that require intervention. He said he believes that his inquiry is the first of its kind and that it falls under the California Department of Justice’s responsibility to protect civil rights and consumers. “We have a lot of depth,” he said of his 4,500-employee agency.

Coleman Baeza and other advocates for health care consumers said the attorney general should also monitor nonprofit hospital mergers to ensure that health care facilities don’t reduce beds in underserved communities and crack down on predatory medical lending, particularly in dental care.

“They violate existing consumer protections, and that falls squarely within the AG’s jurisdiction,” said Linda Nguy, a senior policy advocate for the Western Center on Law and Poverty.

Nguy urged Bonta to go after underperforming health plans when they fail to contract with enough providers so patients can get timely appointments, even though the California Department of Managed Health Care is the state’s main health insurance regulator.

“During covid, the health plans were essentially given a pause on reporting of their timely access. But that pause is over, and the plans have to meet these requirements,” Nguy said. “He can ask for that utilization data.”

Bonta remains circumspect on a particular issue related to race.

His office has been facilitating California’s reparations task force, which issued a nearly 500-page preliminary report this year that noted that Black Californians had shorter life expectancies and poorer health outcomes than other groups. In surveys of hospitals across the country, Black patients with heart disease “receive older, cheaper, and more conservative treatments” than white patients, the report said.

The task force could recommend cash compensation for Black Californians who can establish ties to enslaved ancestors, but Bonta hasn’t endorsed that plan. The final report is due in July.

“If we can move the needle, then we should,” Bonta said. “There are a whole set of different possible solutions, pathways to get there.”

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It’s little surprise, then, that voters will face not one but two ballot propositions this fall aimed at capturing California’s sports betting market. Although neither appears to have strong public support, gambling addiction experts are worried about one far more than the other.

Proposition 26, supported by some of the state’s largest tribal casino owners, would permit sports betting, but only within existing brick-and-mortar establishments that already offer gambling and at horse-racing venues. By contrast, Proposition 27, designed and funded by such national corporate gambling sites as DraftKings, FanDuel, and BetMGM, would legalize online sports betting, essentially opening the door for people to bet on games — and the athletes and plays within them — whether they’re sitting in the bleachers or on a couch.

Each measure would likely increase instances of problem gambling and gambling addiction, but mental health experts say the sheer ease of online betting — on scores, player point totals, the number of penalties in a game, and almost everything else connected to a sporting event — increases the chance for trouble.

“You don’t get addicted to full-season fantasy football; you get addicted to in-game betting,” said Dr. Timothy Fong, a psychiatrist and co-director of the UCLA Gambling Studies Program. “Instead of one bet on the Rams-Chargers game, I now can make an infinite amount right from my phone.”

Sports betting is already legal in some form in 36 states and Washington, D.C., and calls to gambling hotlines spiked in Michigan, Connecticut, New York, and other states after they allowed that form of gambling. The National Problem Gambling Helpline Network reported a 45% increase in year-over-year inquiries in 2021, when 11 states went live with some new form of sports betting.

Although gambling addiction doesn’t involve the ingestion of drugs or chemicals, it does involve the stimulation of regions of the brain the same way that other addictive disorders do. The American Psychiatric Association classifies gambling as such, placing it in the same category as tobacco, alcohol, cocaine, cannabis, and opioids. Research shows that mesolimbic dopamine, which provides the brain feelings of reward and pleasure, is released in larger quantities in pathological gamblers than in people in control groups. Gamblers get hooked on that reward.

For many states, the lure is obvious: tax revenue. In 2020, Pennsylvania collected $38.7 million from gambling — three-quarters of it generated by mobile sports betting. California’s nonpartisan Legislative Analyst’s Office estimates the state will collect hundreds of millions in tax dollars each year, but likely not more than $500 million annually, if Proposition 27 passes. The office pegged state revenue from Proposition 26 at tens of millions of dollars a year. Some of that money would come from taxing 10% of sports bets at racetracks, and some could come from tribal casinos, which would need to renegotiate compacts with the state.

For weeks, Californians have been bombarded by competing ads in what’s become the nation’s most expensive ballot-initiative fight, at $400 million and counting. The fight may have turned voters off. A recent poll by the UC-Berkeley Institute of Governmental Studies found 42% of likely voters opposed to Proposition 26, compared with 31% in support. Support for Proposition 27 was even smaller, with 53% of likely voters opposed and only 27% in favor.

Both ballot measures offer limited new resources to help people with gambling problems or addictions, and neither requires the state to improve tracking or treatment.

The authors of Proposition 26 included a provision to direct 10% of the sports betting revenue from horse-racing tracks to the state Department of Public Health, with some of that money set aside “to prevent and treat problem gambling,” according to material furnished to KHN by supporters of the initiative. But racetracks have been in decline for decades, and their share of sports betting would be the smallest slice of the pie. Additionally, the amount that could be generated from tribal casinos is uncertain because it would depend on whether new compacts require additional payments and direct money to treatment programs.

Kathy Fairbanks, a spokesperson for the Vote Yes on Proposition 26 campaign, noted that tribes already contribute roughly $65 million a year to the state Gambling Control Commission, which funds the Office of Problem Gambling. “Prior to tribes getting casino gambling in California 20-plus years ago, there was no dedicated funding for problem gambling,” Fairbanks said. California has had racetrack wagering since the 1930s, and the lottery started in 1985.

Proposition 27 would require participating companies to pay 10% of gross gambling revenues to the state. Of that, 85% would be designated for homeless and mental health programs, including those for problem gambling.

Nathan Click, a spokesperson for the Yes on 27 campaign, said the initiative would enact “the strongest problem gaming safeguards for online sports betting in the country” and would require each authorized gambling platform’s employees to be trained on how to spot problem gambling.

But psychologists say that online betting is immediate, accessible, and nearly effortless. Anyone with a phone, tablet, or computer can get started with a credit card. And there’s virtually no limit on the bets that can be placed on a single game, even while the game is being played.

“People don’t become addicted to Mega Millions,” Fong said. “They become addicted to scratchers, with more bets per minute.”

One way the gambling industry entices people to keep playing is through promotional credits that essentially allow them to begin betting without spending their own money. Rick Benson, founder of Algamus Gambling Treatment Services, said “free play” offers are not just common in casinos but are also heavily marketed by websites and on social media, potentially luring new gamblers into thinking they have nothing to lose.

That makes Proposition 27 a bigger concern. Researchers at McGill University and the Oregon Research Institute found that online gaming is a gateway to behavioral disorders, including problem gambling, marked by continued gambling despite negative consequences in a person’s life, or full addiction, which is uncontrollable. Gambling can lead to ruinous results, such as bankruptcy, mental health and family issues, and substance use.

Because Proposition 26 restricts betting to casinos and racetracks, it could moderate the activity. “Studies have shown that gambling participation is in some ways tied to access,” said Robert Jacobson, executive director of the California Council on Problem Gambling. “The rates of participation go up once people are within 50 to 60 miles of a casino.”

Still, how Proposition 26 would affect gambling prevalence isn’t clear because the provision also clears the way for tribal casinos to add Las Vegas-style games, such as roulette and craps.

It’s also not understood how big of a problem gambling addiction is in California, mostly because the state’s Office of Problem Gambling has not updated its data since 2006. In August, a state audit declared that the office, which has an annual budget of roughly $8.5 million, “has not effectively evaluated its programs.” The office doesn’t know how many California residents are experiencing or have recently experienced gambling-related issues.

Addiction researchers, however, believe the problem has remained consistent, with about 4% of residents experiencing either problem gambling or gambling addiction. That equates to about 1.6 million Californians who may have a gambling issue, although the number could be much higher because fewer than 1 in 10 people with gambling disorders seek treatment.

The two initiatives would amend the constitution so the legislature could create new sports betting laws. State agencies would then have to come up with regulations for implementing sports betting, which, the experts say, could be gamed by gambling interests.

“The votes,” Jacobson said, “are only the front end of the activity.”

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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