Category: From California Healthline.org

California’s new initiative to compel treatment for some of the state’s most severely mentally ill residents — many of whom are living on the streets — is falling short of its initial objectives. But with the program expanding from 11 counties to all 58 on Dec. 1, state officials are projecting confidence that they can reach their goal to help 2,000 adults by the end of the year.

In the first nine months of CARE court, 557 petitions were filed by first responders, families, or local health officials, all of whom can now request help for individuals who are ill. As of the end of June, 100 people had been placed in court-approved treatment plans, according to the latest data available.

“We’re pleased to see how many people have come through and how appropriate those referrals have been so far,” said Corrin Buchanan, a deputy secretary for the California Health and Human Services Agency, which oversees the program. “These are the right kinds of people we were hoping to serve.”

The Community Assistance, Recovery and Empowerment (CARE) Act — the first law of its kind in the nation — empowers civil court judges to order adults into monitored plans that include housing, social services, and treatment for addiction or mental illness. Until now, counties such as Los Angeles, San Diego, and San Francisco have been piloting the program, which Democratic Gov. Gavin Newsom has called a “paradigm shift” to prioritize the Californians who are sickest and most in need.

But officials in counties that have already launched the program said the low number of cases reflects the amount of time it takes — sometimes weeks or months — to find people and persuade them to enroll. And judges dismissed nearly 40% of petitions in the program’s first nine months, in part because of the program’s narrow criteria to target only those with untreated schizophrenia or other psychotic disorders.

State officials have estimated that between 7,000 and 12,000 people will be eligible for a CARE plan. The state has directed $358 million in one-time funding, and it projects it will spend $108 million a year on the program.

CARE court is one of a raft of changes Newsom has spearheaded to address rampant homelessness, including overhauling the public mental health system and funneling billions of dollars for counties to execute those changes on the ground. Recent moves include loosening conservatorship laws and passing Proposition 1, a voter-approved measure that gives the state more control over mental health funding previously managed by counties.

Local health representatives say they’re juggling the governor’s initiatives as he demands results to reduce homelessness.

While CARE court was meant to target people who cycle in and out of jails and hospitals and onto the streets, county officials said they’re encountering a substantial number of clients who already have housing and, in some cases, private health insurance.

Many family members have had their hopes dashed when they find that only a small number of people qualify for CARE court resources and that ultimately treatment is largely voluntary, county officials said. Unlike in a conservatorship, which hands all decision-making power over to the state or an adult guardian, counties can’t treat or medicate participants against their will. But counties can rack up steep court fines if a judge determines the county hasn’t provided help.

“There’s been a tremendous need for the management of expectations, especially with family members,” said Amber Irvine, program manager for San Diego County’s CARE court. She added that while she considers the program a success, “we need to, as a whole, adjust our expectations of what can be accomplished in a year with such a complicated program and such a complex population.”

San Diego County’s program has been among the most robust, with 221 petitions filed since it launched in October 2023, although a third of the county’s participants were already under conservatorship. Irvine said 76 of the state’s 100 CARE plan participants are from the county.

But it’s not easy. It takes county outreach workers there an average of 54 days of casual conversations, encounters in encampments, and distributing food or supplies — activities the state doesn’t typically reimburse for — to persuade someone to accept services. In some cases, that number stretches to more than four months, Irvine said.

She and others credit the state for funding CARE programs, which has enabled county staff to conduct intensive outreach. San Diego County boasts the state’s first CARE graduate, a participant who was able to exit conservatorship and leave a locked psychiatric facility.

Though Irvine thought the county was overprepared with 15 new hires, the staff was able to take on less than half the anticipated caseload. Other counties have had to shift personnel from understaffed departments to prepare for CARE court.

Staffing needs remain uncertain with the remaining counties set to launch CARE programs, said Jacqueline Wong-Hernandez, chief policy officer for the California State Association of Counties. In September, Newsom vetoed a bill that would have provided scholarships to mental health professionals if they agreed to work for CARE court, citing budget pressures.

Alameda County’s contractor has prepared for the Dec. 1 launch by hiring a team of more than a dozen, including a full-time nurse, case managers, employment coordinators, and a clinician to prescribe medications.

Officials there are identifying clients already known to cycle through crisis services, so they can file petitions on their behalf. And the county is figuring out how to tap state housing funds that allow clients to stabilize in short-term housing.

“It’s really a lot to set up,” said Kate Jones, who is helping to oversee the county’s rollout.

Mark Ghaly, who was the chief architect of the CARE program before leaving his post as California’s health secretary this fall, said he worked for many years at the county level and empathizes with counties struggling to implement multiple initiatives at the same time. He added that CARE court was never meant to be launched in a vacuum.

“We’re going to have to see this whole tapestry of efforts come together to really make the kind of dent that I know we can as a state,” Ghaly said.

State Sen. Tom Umberg, a Democrat who co-authored CARE court legislation, said that more health care providers need to be made aware of the program so they can help spot potential enrollees.

Still, one county representative worries that the public could conflate court-approved treatment plans for the severely mentally ill with solving homelessness. In 2023, California had an estimated homeless population of more than 180,000.

“The solution to homelessness in California is housing, and the more people are prevented from falling into homelessness in California, the fewer county behavioral health clients we will have,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.

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Public health, one of the more misunderstood concepts in the health world, is about the health of entire populations, rather than individuals. As a result, public health is closely tied to things like the environment, nutrition, and safety.

One commonality among many of President-elect Donald Trump’s picks to manage federal health agencies is their distrust of the nation’s public health system. With major concerns such as bird flu looming, that sentiment could translate into efforts to undermine those of public health workers.

To illuminate the importance and nuances of public health — and recognizing that public health is best explained at the local level — KFF Health News has partnered with Civic News Company to launch a project called Healthbeat.

In this special episode of KFF Health News’ “What the Health?”, chief Washington correspondent Julie Rovner is joined by KFF Health News public health correspondent and Healthbeat national reporter Amy Maxmen, Healthbeat editor-in-chief Charlene Pacenti, and Healthbeat New York City reporter Eliza Fawcett.

Among the takeaways from this week’s episode:

• The covid-19 pandemic revealed the need for a deeper understanding of public health — a data-driven field devoted to the health and well-being of populations. Some of the biggest public health issues of the moment include childhood vaccination rates, and long covid and post-traumatic stress disorder cases among health care workers.
• Bird flu is top of mind for many in public health. While the virus has been around for decades, its transmissibility to cattle is new, and that concerning characteristic emerged in the United States. The outbreak was not contained when it was first observed in a handful of states, and now the question is whether the virus mutates to enable human-to-human transmission — a trait that could make bird flu the next pandemic.
• Many in the public health community are wary of the possibility that Trump and his administration’s officials could gut funding and policies that support the nation’s health — and even non-health policies can hold consequences for health care. For instance, anti-immigration measures could drain the health workforce; many immigrants work as home health aides, nursing home staffers, and more.

Mentioned in this week’s podcast:

Click to open the Transcript

Transcript: Public Health and the Dairy Cow in the Room

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What The Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this special holiday episode — more on that in a minute — on Wednesday, Nov. 20, at 2:30 p.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. 

Today, I am thrilled to be joined here in our KFF studios by some of the staff of KFF Health News’ newest project, Healthbeat, which we’ve created with another nonprofit, Civic News Company, to cover public health in America. Here with us today, our Healthbeat editor-in-chief, Charlene Pacenti. 

Charlene Pacenti: Hello. 

Rovner: Amy Maxmen, KFF Health News public health correspondent and Healthbeat’s national reporter. 

Amy Maxmen: Hi. 

Rovner: And Eliza Fawcett, New York City reporter. 

Eliza Fawcett: Hi there. 

Rovner: Hello, everyone, and thank you so much for being here. Charlene, I want to start with you. What exactly is Healthbeat, and why do we need it? 

Pacenti: Now more than ever, I would say. Healthbeat was created in the wake of covid when it became very apparent that people needed a deeper understanding of what public health is, the kind of invisible shield that keeps us all safe. And we also needed more news coverage that centers reliable, science-based information so that people could make good decisions about the health of their families, themselves, and the people around them. So we thought part of that coverage should be rooted in communities. It’s been shown that no matter their politics or how they feel about the federal government, people do trust their local public health leaders. And we think that by elevating those voices on timely issues, we can start to win back people’s trust, not only in journalism but in science. 

Rovner: That sounds like a very uphill battle. 

Pacenti: Yes, as you mentioned, but we are part of Civic News Company, which you mentioned, whose model has been developed over the past 10 years covering schools with Chalkbeat. And so we’re trying to leverage the success they’ve had with the local plus national reporting. So for Healthbeat, we’re partnering with KFF Health News, which has a long tradition of excellent health reporting, to handle national coverage. And then we’ve opened two local bureaus to start. We’re in New York and Atlanta with a third location to come next year. 

Rovner: Cool. Amy, you’re our public health expert at the table. How is public health different from what we think of as regular health care or medical care in general? 

Maxmen: I am excited to answer that question, because I’m really into public health. So whereas you think about health care as what happens in a clinic. An individual is sick, and they’re treated within a hospital system. Public health really focuses on preventing illness and improving health at a population level through population-level interventions. So for example, infectious disease outbreaks are often a big component of public health, and that’s because they spread in communities. 

So even though a person is treated in a hospital — say if you have somebody who has measles, now the person’s treated for measles in a hospital — but public health officers actually go into communities. They figure out how the virus is spreading. They might go to schools or to hospitals or to a shopping mall, wherever that person was. Similarly, if a person is shot, they go to an emergency room and they get health care in that emergency department. But public health is going to look at the surrounding issues. How does gun violence affect the whole neighborhood? What does it mean to grow up with stress? Does it mean you can exercise as much if the neighborhood’s dangerous? So that’s sort of why also a big component of public health is about collecting a lot of data and analyzing that data. 

Rovner: I feel like people kind of misunderstand this a lot. They think of public health, they think of health care as something that’s between a health practitioner and you, the patient, whereas public health is bigger than that, and you are not the focus of public health, right? It’s everybody around you. 

Maxmen: Yeah, that’s the public part. Yeah, and it’s fun because it’s out there in the world. 

Rovner: But why do people — I feel like people really misunderstand that, and I feel like that’s the source of a lot of the frustration that people get with public health. It’s like, Well, that might not be good for me. 

Maxmen: Yeah, that’s the tricky thing because I think at its root, you have to believe in societal goods. You have to believe that having a cleaner neighborhood is good for everyone and not just because you have to take out your trash or not. I don’t know if that’s the best comparison. 

Rovner: Eliza, how’d you get into public health? 

Fawcett: I started as a reporter at the Hartford Courant during the start of the covid pandemic. I became really interested in covering health and also mental health during that time. And I grew up in New York, and it’s been really exciting to be the first New York reporter for Healthbeat, really getting into community health issues and understanding the sprawling New York City health department, which is one of the biggest in the country. And since I grew up in New York, it’s been really exciting to be doing this work. 

Rovner: Charlene, what kinds of stories is Healthbeat pursuing? 

Pacenti: Well, as you can imagine, public health is very broad, and we’re just getting started. We just officially launched Aug. 30, so we’ve just had the last of our reporters come aboard for right now. So we’re trying to narrow it down a little bit, and we’re kind of focusing on three key buckets for our coverage. One is infectious diseases, which Amy’s doing such a great job on bird flu right now, but also we’re looking at that locally, too. What are the flu numbers right now? We’re going into flu season. What are the covid numbers? How’s RSV [respiratory syncytial virus] ramping up? And those sorts of things, and the community’s preparedness to deal with outbreaks. 

Accountability is another really big thing that we’re focused on. What many people may not realize is that public health funding, even at the local level, comes from Washington. It’s coming from CDC [the Centers for Disease Control and Prevention]. It’s coming from HHS [the Department of Health and Human Services]. And so we’re looking at how those dollars flow down to the local communities and how they are spent, and also just officials who are in charge of public health policy. In Georgia already, we’ve seen some pretty good impact in our reporting just by showing up, frankly. Our first Atlanta reporter, Rebecca Grapevine, she got on the job the first week and realized that the Board of Public Health in Georgia had not held a public meeting in five months. So we wrote about that, and the story got a lot of attention. And by golly, in November they had a meeting. So that was really great. 

And then the third thing is really community. We really want to center our coverage on the people on the ground who are working on public health from many aspects. It can be social workers. It can be your local epidemiologist at the health department. It can be volunteers at a house of worship who has a ministry trying to help with homelessness or maternal mortality or any of those things. We’re really trying to be a platform and a voice for those people. At Civic News Company, we call people like that civic catalysts. They’re out there doing the work, and we really want to shine a light on them. 

Rovner: So Amy, obviously we’re going to talk about bird flu separately in a few minutes. What are the other public health, big national public health stories that you’re watching right now? 

Maxmen: I think we’ll keep an eye on vaccination rates. You can expect those to unfortunately drop. And I’m not talking about just the covid vaccine but childhood vaccination rates. It’s important to keep in mind the majority of adults, around 70%, still say that childhood vaccines are really important. But remember, going back to what’s public health, the power of vaccines is in herd immunity effect. So children are being protected with, say, a measles vaccine, but we want to have high rates above 90% of vaccinations so that teachers who are immunocompromised, children who are immunocompromised, infants too young to be vaccinated, so that they’re all protected, too. And what we’re going to see, if we see RFK [Robert F. Kennedy] Jr. as the head of HHS, there’s some rumors floating that Joseph Ladapo might have a role in the administration as well. 

Rovner: He’s the Florida surgeon general who we’ve talked about a lot on the podcast, who himself is kind of vaccine agnostic, if you will. 

Maxmen: Yeah. Exactly. And so we’re seeing a lot of signs that we’re going to hear a lot of terms like “choice” and “consent” when it comes to vaccines. And those sound like great words, but what it ultimately means is that we’ll see a loosening of mandates around having children be vaccinated before they go to public school, and that combined with misinformation. So we’ll probably see lower vaccine rates among children. So that’s something to watch because it means more outbreaks. Outbreaks are costly to contain in money and in lives lost. So that’s definitely one story. 

There’s certainly others besides even the bird flu, which I’ll talk about. I write a lot about occupational health, so there’s lots of health care workers who lost their lives in covid, but also I’ve covered how many are facing long covid and PTSD [post-traumatic stress disorder] because they weren’t very well protected when they were at work during the pandemic, during the peak of the pandemic. I’ve written about how farmworkers and construction workers and landscapers have had heat-related illness and injuries. There was a law that the Occupational Safety and Health Administration has been working on, but it will almost certainly stall under a Trump administration. So we’re not going to have national regulations on heat. So those are some of the other things I’ll be thinking about. 

Rovner: What are the big stories in New York, Eliza? 

Fawcett: Well, a lot of them are the same as what Amy mentioned, and we’re trying to see how the big changes coming down the pike with the second Trump administration will impact us locally. Obviously that is in big part about funding and whether CDC funding stays the same, is reduced, etc. Same for NIH [the National Institutes of Health] and other federal agencies that deal with health issues. The way that local health departments work, even really big ones like New York City, is that they do get a lot of money from the federal government, obviously. And so any small changes could have a really big impact on work on the ground, whether that’s making sure that kids can get vaccines. The Vaccines for Children Program is responsible for making sure that many, many, many children in the United States get vaccinated. 

Rovner: I’m, of course, so old that I covered the Vaccines for Children Program when it began in the 1990s. But yes, that is how most kids get vaccinated now, is through the federal government’s Vaccines for Children Program. One thing that obviously we are looking towards, the possibility with Republicans back in control of the Congress and the White House, is health care budget cuts. I assume New York is assuming that there will be less money in a Trump administration. 

Fawcett: Yeah, I think it’s a real concern for public health leadership in the city, and it’s been interesting to see what the response has been from city and state officials after the election. They’ve kind of made this point of saying that New Yorkers will be protected, whether that’s reproductive rights or vaccinations. And there’s this feeling of kind of pulling up the drawbridge, that New York has a pretty robust public health infrastructure. And so whatever happens on the federal level, we’ll be OK. But obviously things are a lot more complicated and intertwined than that. The city does get a lot of its funding from, or the New York City public health department does get a lot of its funding from the city and from the state but also from the federal government. And so if there are major changes there, that could have a big impact on the kinds of community-led programs that do good public health work in the city. 

And even on vaccinations, that’s an interesting question, too. Because while the CDC provides recommendations, they don’t actually provide mandates. That’s a states issue. If the CDC starts changing its messaging around vaccinations, particularly if RFK Jr. is running HHS, which is a big concern, that can still have a trickle-down impact on what New Yorkers think about getting vaccinated in general, which has already been a big concern for folks. So I think it’s been interesting to see this dynamic starting to play out in the city, where on the one hand, there’s this strong progressive leadership that is vowing to keep up the good fight. But we’ll see the extent to which they can really protect themselves from any large changes that are going to happen. 

Rovner: Let’s talk about bird flu, because it’s sort of the elephant or the dairy cow in the room. We’ve been watching all year, and I guess health authorities have been watching with some alarm as we’re seeing bird flu spreading in dairy cattle herds and then occasionally to people, to dairy workers, and now to some people who are apparently not dairy workers. What is your feeling about where we are with bird flu? And what has the Biden administration done about it? And what do you anticipate that the incoming Trump administration might do differently? 

Maxmen: Yeah, so I think the past, looking back on the past year with bird flu — the huge disappointment, appalling if you talk to researchers, sort of frustrating if you talk to public health officials — is we failed to contain it when the bird flu outbreak was confined to just a handful of states. That would be when it was smaller. It’s like putting out a fire when it’s small versus once there’s a huge forest fire. It’s harder to put out. So now it’s in at least 15 states, and the number might be higher because a lot of farms, maybe the majority of farms, haven’t tested at different periods during the year. There’s 52 cases among people in the U.S., mainly among farmworkers. But yeah, as you just mentioned from the case in California, there’s a few cases that have been mysterious, people who have no contact, no known contact with farm animals. 

These unknowns are actually kind of what’s as staggering as also the growth of the epidemic. We’ve sort of lost track of what’s going on. So what this means is, I’ve talked to so many experts at this point, and nobody thinks we’re going to eliminate this on dairy farms. And to be clear, bird flu has been around for 30 years. But the bird flu in cattle spreading among mammals, that’s new and that’s in the U.S. So what does this mean? This means best-case scenario, millions if not billions of dollars in losses for the dairy and poultry industry. It means farmworkers are going to continue to get the bird flu, which is not comfortable. And then it also means we just have this kind of ominous constant threat that maybe the virus will evolve in a way where it spreads between people easily. And that’s when you could get a pandemic. 

Rovner: That’s been the big fear about a pandemic. 

Maxmen: That’s the fear. 

Rovner: I mean but that was a fear even before the covid-19 pandemic. What everybody was afraid of was a bird flu pandemic, was an avian flu that mutated to pass from person to person. 

Maxmen: Exactly. It’s been on the — because humans don’t have a lot of experience with the bird flu. It’s novel. We may or may not have some partial immunity to it, so it could be very bad. So there’s a chance it will never mutate in a way that has it spread easily between people. But if it does, it could be horrible like on the scale of what we saw during covid. And so that’s why everyone I talked to, I guess the big question is: Why are we taking a gamble on this? But that’s what we’ve done this past year essentially — intentional, not intentional. I could get into — I’ve reported a lot on why this is, but that’s where we’re at. 

Rovner: Some of this, I know, comes back to the whole trust issue, which is that the CDC couldn’t get onto some of the dairy farms to test, because the dairy farmers didn’t trust the government. What has the Biden administration been able to accomplish in terms of dealing with the bird flu? 

Maxmen: Well, yeah, so on a local level, this is really left to local public health departments a lot of the time. So that’s really who’s doing the work here. Sometimes it’s state health departments, but on the ground we’re talking about veterinarians, farmers, and local health officials. I actually FOIA-ed [through the Freedom of Information Act] a lot of health departments and some agriculture departments to learn what’s even happening. The system of surveillance is a voluntary system, so when there’s mistrust or also just fears, right, so farmers would be afraid of, if they say they have the bird flu, of losing their entire milk market, which is a big one because then they lose the whole farm. So there’s a lot of concerns about their own privacy. 

So basically a lot of the cooperation has kind of fallen apart with that. What could the CDC do? I think there’s a lot of disappointment for the CDC and the USDA [Department of Agriculture] from the experts that I speak with, because although, yes, they can’t just storm onto farms, they haven’t actually been using the bully pulpit to say: This is what’s going wrong. We’re really concerned. This is how we can do it better. This is how we can get around some of these problems like farmers being afraid of losing their milk market or farmworkers being afraid of losing their job. 

They haven’t really been very open about the problems, and they also haven’t acted with urgency. So the response on the high level has seemed slow and uncoordinated. They’ll announce that they will be doing outreach to farmworkers, but then there will be months passed with no outreach. They’ll say that they’re going to be working on having other groups be able to test for the bird flu virus, but we still don’t see any group besides the CDC having that ability. So there’s a lot of people who are aggravated with the response under the Biden administration, and some of it’s not just because of leadership. There’s internal issues within the U.S. We have a voluntary system in a lot of ways, so for better or worse, this might be the way it is. 

Rovner: And what would you expect from an incoming Trump administration even? We obviously don’t know a lot about what to expect from an incoming Trump administration, but based on their handling of covid, what would you expect? 

Maxmen: Exactly. So based on their handling of covid, one is, I can say: Time-wise, OK, what’s on our side? The plus is as outbreaks continue, people often get better at figuring out what to do. So on the plus side, maybe farmers will start to have a little bit more trust that they’re not going to have huge losses and that therefore they’ll be a little bit more open. Maybe vets will get a better handle on how to control this. So that’s the plus side. The downside is also pretty huge. So during covid, the CDC basically stopped holding press briefings. So right now, at least there are press briefings. Here, I was critical of the CDC, but I might completely lose all contact with them under a Trump administration. 

Another one that’s quite big is there’s a study that showed that we’re missing a lot of cases among farmworkers, and I expect us to have more bird flu cases among people and miss more of them. And that’s bad because it’s bad for the people who have the bird flu, but also it means we might miss the moment if this starts to spread between people. If a person spreads it to their kids or other family members, we might miss those moments. And the reason why we’ll miss them — this happened during covid — is when there’s huge threats of deportations and when there’s just a lot of anti-immigrant rhetoric. I did a lot of reporting in the Central Valley around meatpacking plant workers and farmworkers. 

When there’s a lot of threats like this, people are maybe … There’s a lot of people in that community who are immigrants, and maybe some are undocumented. You also have people on temporary work visas whose visa is tied to their employers. Maybe they have family members who aren’t legally here, so they don’t want to risk even the threat of deportation by going to a clinic when they’re sick. They don’t want to complain if work conditions are really unsafe. If they’re given, say, no protection wall taking care of sick cattle, there’s no incentive to complain about the employer if you think you might actually be deported. So stigma tends to drive infectious diseases underground, and that’s sort of what we can expect. 

Rovner: And obviously immigration is one of those issues that we don’t cover generally as a health issue, but in New York, it is a health issue, right? 

Fawcett: Yeah, absolutely. I think that’s another thing that we’ll be looking at closely as this Trump administration gets going. Obviously, there are a lot of concerns among migrant communities in the city about mass deportations, which Trump has vowed to fulfill. And New York has a really large and fairly effective system for taking care of people regardless of immigration status or insurance, particularly through the municipal hospital system, NYC Health and Hospitals. And leadership there has said that migrants’ access to health care will be protected, but there is a lot that remains to be seen about how those communities will be impacted. 

Rovner: And Amy, which is the bigger threat out in the rest of the nation, the idea of people who could potentially spread misinformation about public health at the national level or the threat of not having enough money? 

Maxmen: Oh, I don’t like binaries. Having misinformation at a very high level is pretty terrifying. It’s pretty terrifying. And I think also, I always keep in mind big-picture stuff. As a reporter, if you’re constantly combating every new little piece of misinformation, it’s a bit exhausting. It’s great to fact-check what people say, the big picture. Speaking about RFK Jr., he’s endorsed a lot of conspiracy theories. And there’s studies showing that if you believe in multiple conspiracy theories, there’s a good chance you’re going to believe in another one. So to have a conspiratorial mindset at a high level of government or even in very influential positions, that’s pretty scary. Yeah. 

Fawcett: I think the other aspect to this conversation as well is just that, broadly speaking, the public health system is kind of beleaguered right now coming out of covid. A lot of the federal money that was there to support this work has dried up, and there are budget holes that need to be filled now, and people are burnt out. So I think that’s another aspect here. Will folks be ready to have any fight that needs to happen under another Trump administration? 

Rovner: Charlene, one of the things you said at the beginning is that one of the efforts here is to help rebuild trust in public health. Public health has been, I think, of everything, of all of the parts of American society where the public has lost trust, public health is way up towards the top. And also it’s way up towards the top in terms of the misinformation that’s been spread. So how do you combat those two things? It’s something that we talk about all the time on the podcast, and I don’t know how to fix it. 

Pacenti: It’s really tough. I think that one way that we really look at it is elevating local voices. To your point about immigrants and immigration status as a social determinant of health, we had a report just yesterday that came out in Georgia that laid out all the things that Amy and Eliza were just talking about in Georgia as well — the stigma, the not asking for help, because you fear about getting involved with the authorities in some negative way. But there are a lot of community organizations that are a safe space that do work to provide culturally sensitive care and speak the language and offer the help to people so that they’re not threatened. So I think by highlighting those resources, that’s one thing that we can do. 

And another one is just highlighting people who know what they’re talking about, scientific experts in the community, particularly local ones. One really exciting thing that we’re doing in New York is we’re kind of combining two of those concepts through a partnership with Your Local Epidemiologist. This is a newsletter that is run by Katelyn Jetelina, who back in 2020 started an email. She was teaching at the University of Texas. She’s an epidemiologist, and she was just writing an email to her students and her family and friends to explain the science behind what was going on with covid. And it has snowballed, and four years later, it’s really huge. So we have partnered with her to bring that concept to Healthbeat readers in New York. So every week we have our own epidemiologist. Her name is Marisa Donnelly, and she does an email newsletter every week that kind of breaks down what we call the community health forecast. And it’s all kinds of really great, science-driven information with nice little charts that just lays it all out for you. 

Rovner: It’s like the weather forecast, but for health? 

Pacenti: Exactly, exactly. So I think that’s one way. Just lay it out for people. Give them the rationale behind it, the science behind it, and I think that work like that over time, hopefully, will help regain some trust. 

Rovner: Well, I want to thank the panel. This has been really inspiring. I’m hoping that we can come back to you periodically to see how public health in general and Healthbeat in specific are doing. So thanks for joining us. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks this week to our producer, Taylor Cook, our editor, Emmarie Huetteman, and KFF Health News enterprise editor Kelly Johnson. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, at KFF.org, or you can still find me at X, @jrovner, and increasingly at Bluesky, @julierovner.bsky.social. Do you hang around on social media any place, Amy? 

Maxmen: You know I’ve just started. I’ve joined the Bluesky trend. I just sort of came over there. It’s kind of one of those moments where there’s a lot of journalists and health people and researchers, so yeah, I’ve— 

Rovner: Do you have a handle? 

Maxmen: My handle is amymaxmen.bsky.social. 

Rovner: Excellent. Charlene? 

Pacenti: I’m most active on LinkedIn, where all the health people are. 

Rovner: There you go. Eliza? 

Fawcett: I am also on Bluesky newly, under my name, elizafawcett, and still kind of lurking on Twitter. 

Rovner: There you go. We’ll be back in your feed next week. Until then, have a very happy holiday weekend and be healthy. 

---

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In mid-May, Mandi Rokx had a 3-month-old baby and a letter from a Florida agency warning that they both would be cut from Medicaid, the health insurance program for people with low incomes or disabilities.

Under a Florida law passed in 2021, Rokx was supposed to receive 12 months of continuous coverage after giving birth. But the letter from Florida’s Department of Children and Families said their coverage would end May 31.

The explanation: “You failed to complete or follow through with your Medicaid renewal.”

Rokx said she didn’t understand why the state was cutting coverage. She had provided everything it asked for, she said.

She worried about what losing Medicaid would mean for her daughter, Vernita. Initially after the coverage ended, Rokx said, she paid out-of-pocket for the infant’s checkups. She then turned to a free health fair put on once a month by a local nonprofit near her home in Melrose, Florida.

“I just hope she doesn’t get sick,” she said.

An unknown number of mothers in Florida have abruptly lost Medicaid coverage after giving birth, despite being eligible, according to an ongoing federal lawsuit filed against the state in August 2023. The issue is linked to the state’s computer eligibility system, run by Deloitte Consulting, according to trial testimony from state and Deloitte employees. It is yet one more example of problems states and beneficiaries have encountered with Medicaid management systems operated by Deloitte, a giant consulting firm.

As of July, Florida had awarded the global firm contracts valued at more than $100 million to modernize, operate, and maintain the state’s integrated eligibility system for Medicaid and other benefits.

Deloitte did not respond to requests for comment about its work in Florida.

In total, 25 states have awarded Deloitte eligibility system contracts, making the company the dominant player in this crucial slice of government business. These agreements, in which Deloitte commits to design, develop, or operate state-owned systems, are worth at least $6 billion, according to a KFF Health News analysis of state contracts.

The KFF investigation found that errors in Deloitte-run eligibility systems can cost millions and take years to fix while denying benefits like health insurance to eligible people.

In response to the investigation, Deloitte spokesperson Karen Walsh said the firm’s clients — state governments — “understand large system implementations are challenging due to the complexity of the programs they support and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.”

Senate Democrat John Fetterman of Pennsylvania, which is one of Deloitte’s state clients, sees it much differently. “Let’s call this what it is: a racket,” he said. “This isn’t an occasional glitch. It’s a pattern of systemic failure. And the worst part? We’re paying them billions to do it.”

In July, Kimber Taylor of Jacksonville and Lily Mezquita of Orlando testified in a federal courtroom in Florida that state officials removed them from Medicaid even though their pregnancies made them eligible. The class-action lawsuit alleges that Florida did not adequately explain to people with Medicaid the reason for cutting their health insurance, or explain to them that they could appeal the decision before losing coverage.

Florida has denied the allegations in court filings. But the trial revealed problems with the computer system the state uses to determine Medicaid eligibility and inform people that they are no longer eligible. Deloitte did not respond to questions about the trial, in which a judge’s decision is pending.

Although Deloitte is not a named defendant in the lawsuit, an employee was called to testify about the firm’s role in operating Florida’s eligibility system. Harikumar Kallumkal, a Deloitte managing director who is responsible for Florida’s system, said that a “defect” may have led to coverage losses for new mothers.

William Roberts, a state worker who reviews Medicaid eligibility decisions, also testified that the agency learned about a “glitch” that cut postpartum coverage for eligible new mothers in April 2023 — the same month Florida launched a Medicaid eligibility review process known as “unwinding,” which all states undertook after pandemic-era coverage protections ended in March of that year. Kallumkal testified that Deloitte fixed the problem by April or May 2024.

And yet Rokx’s coverage was cut May 31.

During the unwinding, Florida disenrolled nearly 2 million people, including kids, from Medicaid, according to the Centers for Medicare & Medicaid Services.

Patient advocates say flaws in Florida’s Deloitte-operated computer system prevented some of the state’s most vulnerable residents from getting care they were entitled to receive.

“Florida’s Medicaid officials knew from the start of the unwinding period that their system was not handling pregnancy and postpartum Medicaid correctly, and proceeded full steam ahead anyway,” said Lynn Hearn, an attorney with the Florida Health Justice Project, a nonprofit legal aid and advocacy group that together with the National Health Law Program represents the class-action plaintiffs. “To this day, we don’t know that the problems have been fully corrected. The mothers of this state deserve better from their government.”

Medicaid is the largest insurance payer for childbirths in Florida, covering nearly 98,000, or 44%, of all deliveries in 2022, according to the state health department. But it’s unclear how many mothers have been cut from the Medicaid coverage they were entitled to receive. Florida’s Department of Children and Families on Sept. 9 cashed a check from KFF Health News to cover the processing fee for records it requested about eligible mothers who were disenrolled. As of Nov. 22, the state had not released the records.

The state did provide an estimate during the trial, but that number was not made available by the state to KFF Health News. In a court filing, the plaintiffs cited the state’s estimate as showing that 19,802 women were removed from pregnancy coverage as of March 2024, one year after Florida began unwinding. It’s unclear how many of these women lost coverage incorrectly. The figure is probably a conservative estimate — it excludes anyone who was removed from coverage because of paperwork issues.

Mallory McManus, deputy chief of staff for the Department of Children and Families, told KFF Health News that after identifying the problem, agency workers “manually corrected cases until necessary system updates were in place.” She added that the department also reviewed the system to “ensure there were no gaps in coverage.”

McManus said that Floridians who were disenrolled from Medicaid “were properly noticed and provided with information on requesting an appeal.”

Rokx, Taylor, and Mezquita ultimately regained their Medicaid coverage after seeking help from the Florida Health Justice Project. Attorneys there have said they are often able to get coverage restored for eligible people by reaching out directly to the state agency’s general counsel — an avenue not known to most Floridians.

While the class-action lawsuit awaits a judgment, the problems revealed at trial echo those encountered in other states with Deloitte-run Medicaid eligibility systems, such as Arkansas, Colorado, Florida, Georgia, Kentucky, Michigan, Pennsylvania, Rhode Island, Tennessee, and Texas.

In Texas, according to a July report by the U.S. Government Accountability Office, “about 100,000 eligible individuals had been disenrolled due to eligibility system errors,” including denial of postpartum coverage for some eligible women.

The error-plagued systems and widespread denials of Medicaid for eligible people have caught the attention of lawmakers on congressional committees that oversee social programs. They blame state leaders who they say aren’t holding vendors like Deloitte accountable.

“As the errors compound, contractors are rewarded with more billing hours and higher payouts,” said Rep. Lloyd Doggett (D-Texas). “This is an alarming and unacceptable waste of taxpayer dollars.”

Sen. Ron Wyden (D-Ore.), chairman of the Senate Finance Committee, which oversees Medicaid, said that too many people “can’t even get in through the front door due to outdated and inaccurate eligibility systems.”

And Rep. Kathy Castor (D-Fla.) said that “there’s such a pattern of trying to discourage and inappropriately cutting families off of Medicaid in Florida.”

“It appears to be intentional,” she said, “and I think it clearly is.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Within days of Donald Trump’s election victory, health care entrepreneur Calley Means turned to social media to crowdsource advice.

“First 100 days,” said Means, a former consultant to Big Pharma who uses the social platform X to focus attention on chronic disease. “What should be done to reform the FDA?”

The question was more than rhetorical. Means is among a cadre of health business leaders and nonmainstream doctors who are influencing President Donald Trump’s focus on health policy.

Trump’s return to the White House has given Means and others in this space significant clout in shaping the nascent health policies of the new administration and its federal agencies. It’s also giving newfound momentum to “Make America Healthy Again,” or MAHA, a controversial movement that challenges prevailing thinking on public health and chronic disease.

Its followers couch their ideals in phrases like “health freedom” and “true health.” Their stated causes are as diverse as revamping certain agricultural subsidies, firing National Institutes of Health employees, rethinking childhood vaccination schedules, and banning marketing of ultra-processed foods to children on TV.

Public health leaders say the emerging Trump administration’s interest in elevating the sometimes unorthodox concepts could be catastrophic, eroding decades of scientific progress while spurring a rise in preventable disease. They worry the administration’s support could weaken trust in public health agencies.

Georges Benjamin, executive director of the American Public Health Association, said he welcomes broad intellectual scientific discussion but is concerned that Trump will parrot untested and unproven public health ideas he hears as if they are fact.

Experience has shown that people with unproven ideas will have his ear and his “very large bully pulpit,” he said. “Because he’s president, people will believe he won’t say things that aren’t true. This president, he will.”

But those in the MAHA camp have a very different take. They say they have been maligned as dangerous for questioning the status quo. The election has given them an enormous opportunity to shape politics and policies, and they say they won’t undermine public health. Instead, they say, they will restore trust in federal health agencies that lost public support during the pandemic.

“It may be a brilliant strategy by the right,” said Peter McCullough, a cardiologist who has come under fire for saying covid-19 vaccines are unsafe. He was describing some of the election-season messaging that mainstreamed their perspectives. “The right was saying we care about medical and environmental issues. The left was pursuing abortion rights and a negative campaign on Trump. But everyone should care about health. Health should be apolitical.”

The movement is largely anti-regulatory and anti-big government, whether concerning raw milk or drug approvals, although implementing changes would require more regulation. Many of its concepts cross over to include ideas that have also been championed by some on the far left.

Robert F. Kennedy Jr., an anti-vaccine activist Trump has nominated to run the Department of Health and Human Services, has called for firing hundreds of people at the National Institutes of Health, removing fluoride from water, boosting federal support for psychedelic therapy, and loosening restrictions on raw milk, consumption of which can expose consumers to foodborne illness. Its sale has prompted federal raids on farms for not complying with food safety regulations.

Means has called for top-down changes at the U.S. Department of Agriculture, which he says has been co-opted by the food industry.

Though he himself is not trained in science or medicine, he has said people had almost no chance of dying of covid-19 if they were “metabolically healthy,” referring to eating, sleeping, exercise, and stress management habits, and has said that about 85% of deaths and health care costs in the U.S. are tied to preventable foodborne metabolic conditions.

A co-founder of Truemed, a company that helps consumers use pretax savings and reimbursement programs on supplements, sleep aids, and exercise equipment, Means says he has had conversations behind closed doors with dozens of members of Congress. He said he also helped bring RFK Jr. and Trump together. RFK Jr. endorsed Trump in August after ending his independent presidential campaign.

“I had this vision for a year, actually. It sounds very woo-woo, but I was in a sweat tent with him in Austin at a campaign event six months before, and I just had this strong vision of him standing with Trump,” Means said recently on the Joe Rogan Experience podcast.

The former self-described never-Trumper said that, after Trump’s first assassination attempt, he felt it was a powerful moment. Means called RFK Jr. and worked with conservative political commentator Tucker Carlson to connect him to the former president. Trump and RFK Jr. then had weeks of conversations about topics such as child obesity and causes of infertility, Means said.

“I really felt, and he felt, like this could be a realignment of American politics,” Means said.

He is joined in the effort by his sister, Casey Means, a Stanford University-trained doctor and co-author with her brother of “Good Energy,” a book about improving metabolic health. The duo has blamed Big Pharma and the agriculture industry for increasing rates of obesity, depression, and chronic health conditions in the country. They have also raised questions about vaccines.

“Yeah, I bet that one vaccine probably isn’t causing autism, but what about the 20 that they are getting before 18 months,” Casey Means said in the Joe Rogan podcast episode with her brother.

The movement, which challenges what its adherents call “the cult of science,” gained significant traction during the pandemic, fueled by a backlash against vaccine and mask mandates that flourished during the Biden administration. Many of its supporters say they gained followers who believed they had been misled on the effectiveness of covid-19 vaccines.

In July 2022, Deborah Birx, covid-19 response coordinator in Trump’s first administration, said on Fox News that “we overplayed the vaccines,” although she noted that they do work.

Anthony Fauci, who advised Trump during the pandemic, in December 2020 called the vaccines a game changer that could diminish covid-19 the way the polio vaccine did for that disease.

Eventually, though, it became evident that the shots don’t necessarily prevent transmission and the effectiveness of the booster wanes with time, which some conservatives say led to disillusionment that has driven interest in the health freedom movement.

Federal health officials say the rollout of the covid vaccine was a turning point in the pandemic and that the shots lessen the severity of the disease by teaching the immune system to recognize and fight the virus that causes it.

Postelection, some Trump allies such as Elon Musk have called for Fauci to be prosecuted. Fauci declined to comment.

Joe Grogan, a former director of the White House’s Domestic Policy Council and assistant to Trump, said conservatives have been trying to articulate why government control of health care is troublesome.

“Two things have happened. The government went totally overboard and lied about many things during covid and showed no compassion about people’s needs outside of covid,” he said. “RFK Jr. came along and articulated very simply that government control of health care can’t be trusted, and we’re spending money, and it isn’t making anyone healthier. In some instances, it may be making people sicker.”

The MAHA movement capitalizes on many of the nonconventional health concepts that have been darlings of the left, such as promoting organic foods and food as medicine. But in an environment of polarized politics, the growing prominence of leaders who challenge what they call the cult of science could lead to more public confusion and division, some health analysts say.

Jeffrey Singer, a surgeon and senior fellow at the Cato Institute, a libertarian public policy research group, said in a statement that he agrees with RFK Jr.’s focus on reevaluating the public health system. But he said it comes with risks.

“I am concerned that many of RFK Jr.’s claims about vaccine safety, environmental toxins, and food additives lack evidence, have stoked public fears, and contributed to a decline in childhood vaccination rates,” he said.

Measles vaccination among kindergartners in the U.S. dropped to 92.7% in the 2023-24 school year from 95.2% in the 2019-20 school year, according to the Centers for Disease Control and Prevention. The agency said that has left about 280,000 kindergartners at risk.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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GEO Group, one of the nation’s largest private prison contractors, filed a federal lawsuit last month against California officials to strike down a state law allowing local public health officials to inspect immigration detention facilities.

The Florida-based company argued in a filing that California’s law, signed by Gov. Gavin Newsom in August, is unconstitutional because it steps on the federal government’s authority to manage detention centers. By extension, GEO claimed intergovernmental immunity as a contractor.

“This case involves the latest in a string of attempts by the State of California to ban federal immigration enforcement in the state, or so significantly burden such efforts as to drive federal agencies and contractors involved in that constitutionally mandated national security function from California,” according to the lawsuit filed in the U.S District Court for the Eastern District of California.

GEO spokesperson Christopher Ferreira did not respond to requests for comment. The lawsuit names Newsom, state Attorney General Rob Bonta, and Kern County health officer Kristopher Lyon as defendants. All three declined to comment. A first hearing is scheduled for February.

GEO Group could expand its grip on immigration detention facilities now that former President Donald Trump won a second term. Trump has promised a mass deportation of immigrants living in the U.S. without authorization, and investors sense Trump’s policies will create a boon for private prison companies such as GEO. GEO’s stock skyrocketed, increasing 75%, after Trump’s victory.

People and groups associated with the private prison giant spent roughly $5.6 million on lobbying and donations this past election cycle, much of it going to conservative political action committees, including $1 million to Make America Great Again Inc., according to OpenSecrets, a nonprofit that tracks campaign finance and lobbying data.

César García Hernández, an immigration law professor at Ohio State University’s Moritz College of Law, said a judge will most likely block implementation of the California law while litigation is pending. In March, a federal judge blocked Washington state from enforcing most of a law to increase oversight and improve living conditions at that state’s only private immigration detention facility.

“GEO has been rather successful in turning to the courts in order to block access to its facilities,” García Hernández said. “The private prison company is trying to insulate itself by taking cover under the fact that it is operating this facility under contract with the federal government.”

California’s bill grants local public health officers, who routinely inspect county jails and state prisons, the ability to inspect private detention facilities, including all six federal immigration centers in California. Detainees have complained of health threats ranging from covid-19, mumps, and chickenpox outbreaks to contaminated water, moldy food, and air ducts spewing black dust.

State lawmakers have attempted to regulate immigration facilities with mixed results.

In 2019, Newsom, a Democrat, signed a measure banning private prisons and detention facilities from operating in California. But a federal court later declared the law unconstitutional, saying it interfered with federal functions.

In 2021, California lawmakers passed a bill requiring private detention centers to comply with state and local public health orders and worker safety and health regulations. That measure was adopted at the height of the covid-19 pandemic, as the virus tore through detention facilities where people were packed into dorms with little or no protection from airborne viruses.

Under the new law, public health officers will determine whether the facilities are complying with environmental rules, such as ensuring proper ventilation, and offering basic mental and physical health care, emergency treatment, and safely prepared food. Unlike public correctional facilities, which are inspected every year, health officers will inspect private detention centers as they deem necessary.

Supporters say public health officers are well positioned to inspect these facilities because they understand how to make confined spaces safer for large populations.

But GEO argued that California health codes and regulations aren’t always consistent with federal standards.

The lawsuit pointed out, for instance, that California requires detainees at risk of self-harm or suicide to be transferred to a mental health facility. But Immigration and Customs Enforcement rules grant detention centers more discretion, allowing them to transfer a detainee to a mental health facility or keep them in suicide-resistant isolation at the detention center through monitoring every 15 minutes. GEO also warned in its complaint that implementing the law could cost up to $500,000.

Immigrant advocates say the federal government has done a poor job ensuring health and safety. In a paper published in June, researchers showed that immigration officials and a private auditor conducted inspections infrequently — at least once every three years — and provided limited public information about deficiencies and if or how they were addressed.

In response, detainees have filed suits alleging crowded and unsanitary conditions; denial of adequate mental and medical health care; medical neglect; and wrongful death by suicide.

“Why shouldn’t they let an inspector go inside the facilities if they are abiding by the standards,” said Jose Ruben Hernandez Gomez, who was detained for 16 months and released in April 2023. “If they have nothing to hide, they shouldn’t be filing a lawsuit.”

Hernandez Gomez went on a hunger strike for 21 days after filing dozens of grievances alleging abusive treatment and poor sanitation.

Last month, eight members of California’s congressional delegation urged the Department of Homeland Security to end its contracts with two GEO-operated immigration centers, Golden State Annex and Mesa Verde ICE Processing Center, where multiple hunger and labor strikes were held this year. Strikers demanded an end to inadequate medical and mental health services, poor living conditions, and solitary confinement.

Advocates fear GEO’s legal victories could be dangerous for the health of immigrants.

After Washington state’s Department of Health was denied access to the Northwest ICE Processing Center, the state’s only immigration center, two people died in the facility, including one in October.

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Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators. The Centers for Medicare & Medicaid Services, which oversees the ACA, credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.

Now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?

“They really have this tightrope to walk,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “The more you tighten it up to prevent fraud, the more barriers there are that could inhibit enrollment among those who need the coverage.”

CMS said in July that some types of policy changes — those in which the agent is not “affiliated” with the existing plan — will face more requirements, such as a three-way call with the consumer, broker, and a healthcare.gov call center representative.

In August, the agency barred two of about a dozen private sector online-enrollment platforms from connecting with healthcare.gov over concerns related to improper switching.

And CMS has suspended 850 agents suspected of being involved in unauthorized plan-switching from accessing the ACA marketplace.

Still, the clampdown could add complexity to enrollment and slow the process. For example, a consumer might have to wait in a queue for a three-way call, or scramble to find a new agent because the one they previously worked with had been suspended.

Given that phone lines with healthcare.gov staff already get busy — especially during mid-December — agents and policy analysts advise consumers not to dally this year.

“Hit the ground running,” said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.

Meanwhile, reports are emerging that some rogue entities are already figuring out workarounds that could undermine some of the anti-fraud protections CMS put in place, Nolan said.

“Bottom line is: Fraud and abuse is still happening,” Nolan said.

Brokers assist the majority of people actively enrolling in ACA plans and are paid a monthly commission by insurers for their efforts. Consumers can compare plans or enroll themselves online through federal or state marketplace websites. They can also seek help from people called assisters or navigators — certified helpers who are not paid commissions. Under a “find local help” button on the federal and state ACA websites, consumers can search for nearby brokers or navigators.

CMS says it has “ramped up support operations” at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, and it expects “minimal wait times,” said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight.

Wu said those three-way calls are necessary only when an agent or a broker not already associated with a consumer’s enrollment wants to change that consumer’s enrollment or end that consumer’s coverage. It does not apply to people seeking coverage for the first time.

Organizations paid by the government to offer navigator services have a dedicated phone line to the federal marketplace, and callers are not currently experiencing long waits, said Xonjenese Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment across the state through its Covering Florida navigator program.

Navigators can assist with the three-way calls if a consumer’s situation requires it.

“Because we have our quick line in, there’s no increased wait time,” Jacobs said.

The problem of unauthorized switches has been around for a while but took off during last year’s open enrollment season.

Brokers generally blamed much of the problem on the ease with which rogue agents can access ACA information in the federal marketplace, needing only a person’s name, date of birth, and state of residence. Though federal regulators have worked to tighten that access with the three-way call requirement, they stopped short of instituting what some agent groups say is needed: two-factor authentication, which could involve a code accessed by a consumer through a smartphone.

Unauthorized switches can lead to a host of problems for consumers, from higher deductibles to landing in new networks that do not include their preferred physicians or hospitals. Some people have received tax bills when unauthorized policies came with premium credits for which they did not qualify.

Unauthorized switches posed a political liability for the Biden administration, a blemish on two years of record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats demanded more oversight and punishment of rogue agents, while Republicans said fraud attempts were fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire, will be decided by Congress next year as the Trump administration takes power. But the premiums and subsidies that come with 2025 plans that people are enrolling in now will remain in effect for the entire year.

The actions taken this year to thwart the unauthorized enrollments apply to the federal marketplace, used by 31 states. The remaining states and the District of Columbia run their own websites, with many having in place additional layers of security.

For its part, CMS says its efforts are working, pointing to the 30% drop in complaint casework. The agency also noted a 90% drop in the number of times an agent’s name was replaced by another’s, which it says indicates that it is tougher for rival agents to steal clients to gain the monthly commissions that insurers pay.

Still, the move to suspend 850 agents has drawn pushback from agent groups that initially brought the problem to federal regulators’ attention. They say some of those accused were suspended before getting a chance to respond to the allegations.

“There will be a certain number of agents and brokers who are going to be suspended without due process,” said Nolan, with the health agents’ group. She said that it has called for increased protections against unauthorized switching and that two-factor authentication, like that used in some state marketplaces or in the financial sector, would be more effective than what’s been done.

“We now have to jump through so many hoops that I’m not sure we’re going to survive,” she said of agents in general. “They are just throwing things against the wall to see what sticks when they could just do two-factor.”

The agency did not respond to questions asking for details about how the 850 agents suspended since July were selected, the states where they were located, or how many had their suspensions reversed after supplying additional information.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Los cambios no autorizados en los planes médicos de la Ley de Cuidado de Salud a Bajo Precio (ACA) parecen haberse reducido en las últimas semanas: reguladores federales informaron que hay menos quejas de los consumidores.

Los Centros de Servicios de Medicare y Medicaid (CMS), que supervisan ACA, atribuyen esta reducción a las medidas adoptadas para prevenir problemas de inscripción y cambios de planes, que ya habían generado más de 274,000 quejas hasta agosto.

Ahora, el período anual de inscripción abierta de ACA, que comenzó el 1 de noviembre, plantea una prueba en el mundo real: ¿lograrán estos cambios frenar el fraude perpretado por agentes o corredores deshonestos sin ralentizar demasiado el proceso de inscripción o reducir el número total de inscripciones para la cobertura de 2025?

“Realmente tienen que caminar por una cuerda floja”, dijo Sabrina Corlette, codirectora del Centro de Reformas de Seguros de Salud de la Universidad de Georgetown. “Cuanto más se endurecen las medidas para prevenir el fraude, más barreras podrían existir que inhiban la inscripción de quienes necesitan la cobertura”.

En julio, los CMS anunciaron que ciertos tipos de cambios de póliza, particularmente aquellos en los que el agente no está “afiliado” al plan existente, enfrentarán requisitos adicionales, como una llamada tripartita con el consumidor, el corredor y un representante del centro de llamadas de cuidadodesalud.gov.

En agosto, la agencia prohibió a dos de unas doce plataformas privadas de inscripción en línea conectarse con cuidadodesalud.gov debido a preocupaciones relacionadas con cambios indebidos de planes. Además, los CMS suspendieron a 850 agentes sospechosos de participar en cambios no autorizados de planes dentro de los mercados de seguros de salud de ACA.

Sin embargo, estas medidas podrían agregar complejidad al proceso de inscripción y hacerlos más lento. Por ejemplo, un consumidor podría tener que esperar en “fila” para realizar una llamada tripartita o buscar un nuevo agente porque el anterior fue suspendido.

“Empiecen rápido”, recomendó Ronnell Nolan, presidenta y directora ejecutiva de Health Agents for America, una organización profesional de corredores de seguros.

Mientras tanto, algunos reportes sugieren que entidades deshonestas ya están encontrando formas de eludir las protecciones contra el fraude implementadas por CMS.

“La realidad es que el fraude y el abuso aún están ocurriendo”, dijo Nolan.

Los corredores ayudan a la mayoría de las personas que se inscriben activamente en planes de ACA y reciben una comisión mensual de las aseguradoras por sus esfuerzos.

Los consumidores pueden comparar planes o inscribirse ellos mismos en línea a través de los sitios web del mercado federal o estatal. También pueden buscar ayuda de asistentes, a veces llamadas navegadores, quienes están certificados pero no reciben comisiones.

Bajo “encuentren ayuda local” en el sitio federal y en los de los mercados estatales, los consumidores prueben encontrar a corredores o navegadores locales.

Los CMS afirman que han “ampliado las operaciones de apoyo” en sus centros de llamadas del mercado federal cuidadodesalud.gov, los cuales están abiertos las 24 horas del día, anticipando una mayor demanda de llamadas tripartitas.

Según Jeff Wu, subdirector de políticas del Centro de Información y Supervisión de Seguros para Consumidores de los CMS, se esperan “tiempos de espera mínimos”.

Wu aclaró que estas llamadas tripartitas solo son necesarias cuando un agente o corredor que no está asociado con la inscripción de un consumidor desea modificarla o finalizar su cobertura. No aplican para personas que buscan cobertura por primera vez.

Los navegadores, que cuentan con una línea telefónica directa al mercado federal, pueden asistir en estas llamadas tripartitas si es necesario.

El problema de los cambios no autorizados no es nuevo, pero se intensificó durante la temporada de inscripción abierta del año pasado.

Los corredores culpan en gran parte de este problema a la facilidad con la que agentes deshonestos pueden acceder a la información de ACA en el mercado federal, necesitando solo el nombre, la fecha de nacimiento y el estado en donde vive la persona. Aunque los reguladores han trabajado para limitar este acceso, no han implementado lo que algunos grupos de agentes consideran necesario: la autenticación en dos pasos, que podría requerir un código que los consumidores recibirían en su teléfono móvil.

Estos cambios no autorizados pueden causar una serie de problemas para los consumidores, desde deducibles más altos hasta la inclusión en redes que no incluyen a sus médicos o hospitales preferidos. Algunas personas han recibido facturas de impuestos cuando pólizas no autorizadas venían con créditos para pagar las primas para los cuales no calificaban.

Los cambios no autorizados plantearon una responsabilidad política para la administración Biden, una mancha en dos años de inscripciones récord en ACA.

La práctica generó críticas de legisladores de ambos partidos; los demócratas exigieron más supervisión y castigo a los agentes deshonestos, mientras que los republicanos dijeron que los intentos de fraude fueron alimentados por las medidas de la administración Biden que permitieron subsidios de primas más generosos y períodos de inscripción especiales.

El destino de esos subsidios mejorados, que expirarán, lo decidirá el Congreso el próximo año cuando la administración Trump tome el poder. Pero las primas y los subsidios que vienen con los planes 2025 en los que las personas se están inscribiendo ahora permanecerán vigentes durante todo el año.

Las medidas adoptadas este año para frustrar las inscripciones no autorizadas se aplican al mercado federal, utilizado por 31 estados. Los estados restantes y el Distrito de Columbia tienen sus propios sitios web, y muchos de ellos cuentan con capas de seguridad adicionales.

A pesar de la controversia, los CMS dicen que sus esfuerzos están funcionando, destacando una disminución del 30% en las quejas.

La agencia también informó una reducción del 90% en el número de veces que el nombre de un agente fue reemplazado por otro, lo que indica que ahora es más difícil para los agentes rivales robar clientes para obtener las comisiones mensuales.

No obstante, algunos grupos de agentes critican que algunos de los 850 agentes suspendidos no tuvieron oportunidad de responder a las acusaciones antes de ser sancionados. “Habrá agentes y corredores suspendidos sin un debido proceso”, dijo Nolan. Según estos grupos, implementar la autenticación en dos pasos sería más efectivo que las medidas actuales. “Estamos saltando tantos obstáculos que no estoy segura de que vayamos a sobrevivir”, concluyó Nolan.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

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ATLANTA — Lloyd Mills was tired of being stuck in a small, drab hospital room. On a rainy mid-September morning, a small TV attached to a mostly blank white wall played silently. There was nothing in the space to cheer it up — no cards, no flowers.

In February, the 32-year-old with autism, cerebral palsy, and kidney disease was brought to Grady Memorial Hospital from the group home where he had been living because he was having auditory hallucinations and suicidal thoughts, he said.

“Being here is not helping me, mentally, physically, emotionally,” Mills said.

He wanted to return to a group home or some other community setting where he could receive the care he needs without being confined. It’s his legal right. But it took the state agency overseeing his care more than eight months to get that done — and that placement would be short-lived.

Nearly 15 years ago, the U.S. Department of Justice sued Georgia for unnecessarily segregating people with developmental disabilities and mental illness. The state settled the case and agreed to a massive overhaul of the services it offers to that population. Despite hundreds of millions of dollars in investments and some notable improvements, the state’s system of caring for people with developmental disabilities and mental illness still has holes. The gaps often leave people like Mills sequestered in institutional settings and without the proper community supports.

Advocates said those failures continue to violate the rights of Georgians who have been historically marginalized and put their health at risk. “It’s an emergency,” said Susan Walker Goico, director of Atlanta Legal Aid Society’s Disability Integration Project. “Anytime somebody has to live in a segregated setting when they don’t want to, it’s terrible.”

The Americans with Disabilities Act, as clarified in a 1999 U.S. Supreme Court decision, says Mills and other people with disabilities have been legally entitled to receive care at home and in other community settings instead of being unnecessarily confined to places like hospitals and nursing homes.

That decision in Olmstead v. L.C. became the foundation for the lawsuit the Department of Justice levied against Georgia in 2010 that sought to force the state to fix its system.

Later that year, state officials agreed to stop putting people in state hospitals solely because they have developmental disabilities. They also agreed to use Medicaid to pay for people to receive care in the community, and to establish crisis response and housing services for those with mental illness.

The state agreed to make the fixes within five years. Nearly a decade and a half later, it’s still not finished.

Even critics acknowledge Georgia has made considerable improvements in the services it provides for people with developmental disabilities and mental illness. Since the start of the settlement, the state has invested nearly $521 million in community services. And, in late September, a federal judge released the state from many parts of its Olmstead settlement.

However, the DOJ, patient advocates, and even state officials acknowledge more work remains. They say there are many reasons it’s taking so long: the scale of the undertaking, loss of momentum over time, a workforce shortage that has limited appropriate community placements, and a lack of political will.

“The longer it continues, the more you sort of say, ‘Are we serious about solving this problem?’” said Geron Gadd, a senior attorney with the National Health Law Program.

The main challenges won’t be easy to solve without appropriate attention, investments, and commitment from lawmakers, advocates said. In a recent court filing, the state admitted it needs to remove more people with developmental disabilities from psychiatric hospitals, improve case management for people with mental illness, and provide more housing with mental health supports.

That final goal is the “bedrock” of Georgia’s mental health and developmental disability system, Goico said. “You have to have a place to live in order to get your services and to stay out of institutions.”

But people with developmental disabilities and mental illness regularly can’t find appropriate community placements, so they cycle in and out of hospitals and nursing homes, Goico and other observers noted.

In 2010, Georgia launched a housing voucher program for people with mental illness who are chronically homeless, incarcerated, or continually in and out of emergency rooms.

The state agreed to create the capacity to offer vouchers to 9,000 people by July 2015. Currently, only about 2,300 are in the program. Even so, state lawmakers declined to fund additional waivers in next year’s budget, saying they were waiting for an update on Georgia’s compliance with the DOJ settlement.

A legal settlement may dictate that states do certain things, but “the state legislature has to still vote to allocate funds,” said David Goldfarb, former director of long-term supports and services policy at the Arc of the United States, a disability rights organization.

The settlement has resulted in a huge transformation of Georgia’s service system, even though “it’s taking them quite a time to get there,” said Jennifer Mathis, a deputy assistant attorney general with the DOJ’s civil rights division.

For people with developmental disabilities, like Mills, that prolonged arrival means more time confined to hospitals and nursing homes.

Mills said he has had dozens of hospital stays, though none as long as his eight-month stint. “Sometimes it would go from two weeks to a month,” he said in September. “It’s stressful.”

Kevin Tanner, head of Georgia’s Department of Behavioral Health and Developmental Disabilities, noted that the number of people stuck in hospitals had been as high as 30 a day. It’s “down to the teens now,” he said, due in part to the recent opening of two homes for people with developmental disabilities in crisis, with eight beds to serve people statewide.

“No system’s perfect,” Tanner said.

Other states have struggled to achieve compliance. Virginia and North Carolina have been under similar federal oversight since 2012.

But some states have shown it’s possible to make fixes. Delaware entered an Olmstead settlement with the DOJ in 2011 and exited federal oversight five years later. Oregon settled a case in 2015 and achieved compliance in 2022.

In Georgia, a shortage of housing for people with developmental disabilities and mental illness has been exacerbated by the shuttering of home and community service providers in recent years, said Lisa Reisman, owner of Complete Care at Home, which offers home medical care to older adults and people with disabilities.

Many service providers blamed the shortage of home and community services on Georgia’s low Medicaid reimbursement rates, which have made it hard for providers to keep workers. Years of low rates “decimated the infrastructure,” said Ryan Whitmire, president of Developmental Disabilities Ministries of Georgia.

Reisman said she has had to turn down placement requests from the state because she couldn’t accommodate them. In those situations, she said, a state official said service providers would sometimes drop off clients at ERs because they “were out of money and they didn’t know where to put them.”

Service providers, including Whitmire, said nurses and other caregivers often leave for higher-paying jobs in fast food or retail.

This year, state lawmakers appropriated more than $106 million to increase Medicaid rates for mental health and developmental disability service providers. Some of those rates hadn’t been raised since 2008.

State lawmakers also recently passed a bill that would require a study every four years of rates it pays providers — though it would still be up to lawmakers to increase payments.

Not only was Lloyd Mills’ extended time in the hospital hard mentally and physically, it also made him lose his Medicaid coverage, said his representatives from the Georgia Advocacy Office, a nonprofit that represents people with disabilities.

Because he was in a hospital, he was unable to spend his monthly Supplemental Security Income payments, which accumulated until he had too much money to keep his health coverage.

In late October, eight months after his hospital stay began, the state moved him to a group home in Macon, about 85 miles southeast of Atlanta. In the days before his move, Mills said he was ready to start his next chapter.

“I’m just ready to live my life, and I don’t plan on ever coming back here again,” he said.

But his stay was short. In mid-November, after just a few weeks of living at the group home, Mills ended up back in a hospital. His advocates worry he won’t be heading to a community placement anytime soon.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

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Relating to Relatives of Lonely Dementia Patients

I was sent the article by Judith Graham on older adults with dementia living alone (“Going It Alone: Millions of Aging Americans Are Facing Dementia by Themselves,” Oct. 15). I appreciate this article. My mom lives alone with dementia. My son lives next door and checks on her, and my daughter comes when she is able to vacuum floors and to scrub the kitchen and bathroom. I handle the bills, clean and change her clothes, wash her clothes, search for mail, and bring in groceries. She refused to allow the home health aide in, which complicates the care schedule. Neighbors watch out for her, including police at the station across the street. It is complex and complicated for caregivers. Applying for Medicaid is a nightmare, as is searching for memory care facilities. The thought of actually moving her is heartbreaking and so stressful. Again: Thank you for sharing that others with dementia are living on their own.

— Gail Daniels, Washington, D.C.

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On the social platform X, a reader drew on her own experience:

Having cared for my mom toward the end of her journey with dementia, this is terrifying.

For many elders, there is no family to cushion the insults of dementia and cognitive decline.https://t.co/LTZ76Ojgwg

— Shava Nerad – @shava23@bluesky 🌻 (@shava23) October 19, 2024

— Shava Nerad, Arlington, Massachusetts

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Bonding — To the Letter

Thanks a million! I read your article “Going It Alone: Historic Numbers of Americans Live by Themselves as They Age” (Sept. 17) in the Las Vegas Review-Journal and related to it on a major level. As a senior living alone, I am experiencing some of the same “social isolation” expressed by your interviewees. Since I love to write, I thought it would be interesting to involve some of the persons mentioned in a nationwide pen pal association. This would place very little demand on their budget (other than postage and stationery), on their time, and with little or no travel involved.

It is breathtakingly exhilarating to receive a letter from a friend or relative, a package from anywhere, and experience the reward of sitting down and reading good news from afar.

I appreciate our advances in technology and I use it rather sparingly. However, I come from a generation that writes in cursive, knows the five elements of letter writing, and understands what a return address is and where it’s positioned on an envelope.

— Gloria Rankin, Las Vegas

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A specialist in health economics and policy tweeted praise:

—  Paul Hughes-Cromwick (Pooge), Ann Arbor, Michigan

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On X, a group of interdisciplinary faculty representing Johns Hopkins University shared KFF Health News’ coverage about racial bias in the development and use of pulse oximeters:

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A Slap on the Wrist for Pulse Oximeters

Between 1983 and 1988, I had four sons at Stanford Hospital. I was friends with Eben Kermit, who was a bioengineer. He was developing the original pulse oximeter on babies in the neonatal intensive care unit (“Systemic Sickness: FDA’s Promised Guidance on Pulse Oximeters Unlikely To End Decades of Racial Bias,” Oct. 7). He tested only white babies. That is because white parents could come to the NICU in the daytime, which is when Eben was at work in the NICU. Black parents could come only at night because their work wouldn’t give them time off to care for a very sick baby. Since no one was there to sign consent forms, at night, with the Black parents, no Black children were included. Discrimination against Black parents by their employers is continuing to cascade through the Black community through the exclusion of Black people from the development of medical technology.

— Zoe Joyner Danielson, a toxicology biologist, Woodland, California

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This X post came from a consulting and training firm that focuses on health equity issues:

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What’s All This Fuss About Fluoride?

No one seems to address the fact that not everyone drinks water from public water systems (“Does Fluoride Cause Cancer, IQ Loss, and More? Fact-Checking Robert F. Kennedy Jr.’s Claims,” Nov. 18). I see many people buying bottled water by the trunkful, or have a water fountain at home with 5-gallon bottles of purified drinking water, or have reverse osmosis water filtration systems installed at their sink.

So even if RFK Jr. removes fluoride from public water systems, I can’t see that there would be a drastic increase in dental issues. Also, when you get your teeth cleaned at the dentist, they give you a fluoride treatment (unless you opt out). So on this issue of removing fluoride, would this be a drastic issue knowing that many now are not getting fluoridated water?

— Suzann Lebda, Sun Lakes, Arizona

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Hitting the Paywall

Why does your newsletter link to articles with paywalls? As an example:

The Oct. 18 aggregation “Former Medicare Chief Warns About Medicare Advantage Pay Rates” links to Stat News, where the article cannot be read without a subscription. If you are doing this as a means to provide subscribers to them, too bad.

In any case, this practice does not represent your organization well since it supports the trend that only those who can afford it get to be informed. I hope you reconsider this practice.

The financial barriers to accessing important information are hurting us as individuals and as a society. It is expensive for most people to have access to a mainstream publication, but it gets cost-prohibitive to have access to multiple points of view, to learn, reason, and make up our own minds. In most cases, the only alternative available is to get “bites of information” from the “free” social media. The results are as one would expect: We become less aware of what is really going on as we are guided into silos of ignorance.

Thank you.

— Carl Loben, Bellevue, Washington

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On X, a technology journalist in Spain shared the article about pregnant people being asked by their providers to pay out-of-pocket fees earlier than expected:

— José María López, Badalona, Spain

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A New Generation of Health Plans Overdue

The recent article “Pay First, Deliver Later: Some Women Are Being Asked To Prepay for Their Baby” (Nov. 15) effectively highlights the emotional and financial uncertainty facing providers and patients. I commend the author for capturing how this uncertainty, rooted in empathy and fairness, must be better understood and addressed.

I write to draw attention to market trends and federal legislation aimed at alleviating this issue. Until recently, health plans considered the out-of-pocket experience as definitionally out-of-scope, leaving patients, and providers, to manage this growing uncertainty on their own.

The evidence shows that it is possible to build a more pragmatic and empathic out-of-pocket experience into a health plan, improving care accessibility and affordability without removing patient responsibility. This approach has been proven, across thousands of employer health plans, to feel better and financially benefit everyone — patients, providers, and plans (employers/insurers).

On Oct. 15, 2024, the Medicare Prescription Payment Plan launched, offering nearly 54 million Americans the option to have their insurer pay their out-of-pocket expenses upfront at the point of service giving members time to review and repay the balance — without interest or fees. If the patient in the article had a health plan with this capability, her OB-GYN would have been paid, on her behalf, by her insurer. She would have received a simple monthly statement to repay in full or over time from the comfort of her home. Everyone benefits and it is a better member experience.

This new, bipartisan, commonsense improvement to one of health care’s most acute pain points is rapidly expanding as employers and insurers realize there is significant actuarial value, provider savings, and member behavior change caused by improving a person’s ability to pay for care.

Brian Whorley, Columbia, Missouri

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An associate professor in the health care leadership program at Rockhurst University’s Helzberg School of Management also shared the article on X:

— Jim Dockins, Kansas City, Missouri

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On Hospital Gatekeepers and Tolls

In regards to the article “Pay First, Deliver Later: Some Women Are Being Asked To Prepay for Their Baby” (Nov. 15): Back in 1992, the hospital where my son was going to be delivered required that the projected copay be paid to them one month before the delivery date or my wife would not be admitted (a Catholic hospital, very charitable).

My wife was born at the same hospital in 1963; at that time, my father-in-law was informed by the hospital that he could not take her home until the bill was paid in full. He contacted a friend who was an attorney who told him to let the hospital know that would be considered kidnapping and that he would be calling the police if they didn’t release her.

— Andrew McGovern, Great River, New York

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Taken Advantage Of?

I belong to a Blue Cross Blue Shield Medicare Advantage plan and, for the past several years, it has offered a home assessment with a reward of $25. I have participated in the program in the past but declined this year since I didn’t think there was much value to the program. I am a retired registered nurse, and I felt that the nurse who did my assessment did not do an especially thorough job, and any questions I asked of her, she could not answer. The nurse was also from out of state.

After reading your article on “The Medicare Advantage Influence Machine” (Sept. 30), the reasons for the assessment seem to be more than improving the beneficiary’s health and well-being, which is what I believed. I am relatively healthy and active, so it would not appear that BCBS found any new diagnoses that it could bill Medicare for, but I assume that that is not the case with other seniors.

— Bruce Gilman, Millis, Massachusetts

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An economist in Florida had this to say on social media:

— Luke Neumann, St. Petersburg, Florida

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In Defense of Deloitte

On March 12, 2024, in good faith and with respect for KFF Health News, Deloitte’s health and human services practice leader provided a 90-minute interview with two reporters for a story they said was about “problems with Deloitte’s eligibility systems across the country.”

We agreed to the interview because we had heard from several of our state clients that they, too, had been contacted, and that the questions being raised showed a misunderstanding of integrated eligibility systems, the technology that sustains them, and the complexity of the health and human services programs they support.

The eligibility systems are owned by the states, not Deloitte; they are uniquely built for each state (in some cases, by other vendors decades ago); and we work at the direction of our clients to maintain and enhance these systems to comply with state-specific policies, rules, and processes, and evolving federal regulations.

Two stories subsequently ran: “Medicaid for Millions in America Hinges on Deloitte-Run Systems Plagued by Errors” (June 24) and “Errors in Deloitte-Run Medicaid Systems Can Cost Millions and Take Years To Fix” (Sept. 5).

Many of the issues reported as “widespread” are isolated to specific situations or involve sensitive data that cannot be refuted by Deloitte due to client confidentiality obligations. That said, there are many reasons why someone may lose coverage or no longer be eligible for a benefit they once received.

Not every “issue” a constituent faces is the result of a system “error,” and challenges with individual cases in individual systems are not due to some fundamental problem in the way Deloitte supports state Medicaid programs.

On the issue of contract changes, Deloitte rejected the claim in March that our state clients send us a “change request … when a fix is needed.” We said that was inaccurate and explained that when there are policy or rule changes — or a global pandemic — that require modifications to a state’s technology, change orders are not only necessary but appropriate.

They do not represent errors in a system that need to be fixed.

Throughout the unwinding of the covid-19 public health emergency — as technologies evolved and policies changed — Deloitte worked closely with states to minimize challenges for those going through the Medicaid redetermination process. The innovations and human-centered design processes we helped our clients implement enhanced the digital experience for their constituents and made it easier for caseworkers, staff, and community partners to support the 34 million people in their care.

Our clients understand that large system implementations are challenging due to the complexity of the programs they support, and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.

That is why so many states continue to select Deloitte to help them maintain their mission-critical systems, and why industry analysts like Forrester and Gartner consistently rank Deloitte as a leader in system integration and business transformation.

— Karen L. Walsh, Government & Public Services, Deloitte Consulting LLP, Harrisburg, Pennsylvania

[Editor’s note: KFF Health News stands by its reporting on Deloitte and the state eligibility determination systems that Deloitte supports.]

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An assistant professor at Harvard voiced her opinion on X:

— Adrianna McIntyre, Boston

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Far Less Than Meets the Eye

I read your article about the new $2,000 limit for out-of-pocket payments for Medicare Part D (“Medicare Drug Plans Are Getting Better Next Year. Some Will Also Cost More,” Oct. 21). As someone with very high drug costs, I was very excited about this change. However, once I researched the different drug plans available for me and my husband, I realized that the money we spend on drugs that are prescribed by a doctor but not covered by our plan will not count toward the $2,000 limit. Therefore, our cost for necessary drugs will continue to be exorbitant.

I think that there are many seniors who will be very disappointed once they realize this.

— Pia Stampe, Eureka, California

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In sharing the article on X, a Florida attorney simply shared their contact information:

“Medicare Drug Plans Are Getting Better Next Year. Some Will Also Cost More:”https://t.co/9uEjVxTSGb 
Grady H. Williams, Jr., LL.M., Attorneys at Law P.A.
1543 Kingsley Avenue, Building 5
Orange Park, FL 32073
Tel: 904-264-8800 • Fax: 904-264-0155

— Grady H. Williams (@floridaelder) November 9, 2024

— Grady H. Williams, Orange Park, Florida

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Shedding Light on Fluorescence in Dental Care

Congratulations on a highly impactful publication (“Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn,” Nov. 1). The facts presented are harrowing for a retired practitioner with multiple specialties who tried a lifetime to preserve teeth and promote human health.

As you might know, oral biofilm is the biggest enemy of oral health and even general health. Dental clinicians have not been able to visualize and identify the presence of pathogenic oral microbiome until recently. Pathogenic oral bacteria are among the significant generators of hard and soft tissue deterioration, such as tooth decay, gum diseases, and even infection of dental implants. The most trusted and used diagnosis procedure is still the X-ray.

X-rays can identify only established diseases. Unfortunately, radiologic diagnosis is still the most trusted diagnostic tool used and taught in dental education.

Microbiology, the microbiome science, utilizes fluorescence as its major identification procedure. Some of the most aggressive oral bacteria, generators of caries, gum diseases, etc., generate so-called porphyrins, which, once excited by a specific wavelength, emit light at a different wavelength. Highly reliable and simple-to-use technologies have been created recently to support direct visualization and point-of-care identification of this pathogenic bacteria through the above-described procedure. These devices support the diagnostic process and help the dental clinician by guiding the treatment execution and identifying when the treatment goal has been achieved. Dental treatment protocols utilizing “Fluorescence-Enhanced Theragnosis” have become reliable and less invasive.

The high loss of human lives in the ICUs during the pandemic due to ventilator-associated pneumonia could have been dramatically reduced using the above protocol.

Wound-care science has already implemented fluorescence and is undergoing a tremendous protocol change. Tumor surgery celebrates fluorescence-guided surgery as a milestone in its development.

Academic dental education is due for an urgent renewal. We must open the doors and facilitate science translation to benefit humankind!

— Liviu Steier, Needham, Massachusetts

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A reader who manages a website predicting the collapse of the American health care system commented on X:

https://t.co/JTFn1h12rc 🙄😠👎Technically, American dentistry was once ranked as the best in the world. Unfortunately, It has a history of mismanagement and negligence. It’s a “reputational good” that’s been flooded with scams. Now it’s payback time. It’s demonstrating the…

— Francis Anthony Toto (@francisatoto) November 2, 2024

— Francis Anthony Toto, San Diego

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