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When Jessica Staten’s kidney stones wouldn’t pass, she said, her doctor suggested a procedure to “blow ’em up.” She went to have it done last November at St. Joseph Medical Center in Bellingham, Washington, one of nine hospitals that the Catholic health system PeaceHealth operates in the Pacific Northwest and Alaska.

“I was probably there a total of 3½ hours, and everything went well,” said Staten, who works as an accountant and has health insurance. What came next shocked her: PeaceHealth sent a bill for $5,313.63 and, she said, told her she didn’t qualify for help to lower the cost. Staten said she asked about financial assistance but was told she earned slightly too much.

PeaceHealth aims to “carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way,” according to a 2022 tax filing.

For Staten, suffering lingered long after receiving care from the health system with the only hospital in town.

To pay off her medical bill, Staten ultimately took on more debt, using her condo as collateral to secure a line of credit of more than $5,000, according to records reviewed by California Healthline. She said the line of credit had an 11.2% interest rate. That was cheaper than a payment plan the hospital offered through a third party, which Staten said she was told would have charged about 12.5% interest.

“It’s all about the money,” said Staten, who has lived in Bellingham for more than 30 years. “That’s the way they think now at the hospital.”

PeaceHealth spokesperson Victoria Wilson said the hospital offers patients interest-free 12-month payment plans. For some patients, the monthly obligation is unaffordable. PeaceHealth also now offers longer-term plans with a 9% interest rate “in alignment with current regulations,” she said, declining to elaborate further.

“Each patient who comes to us seeking care is experiencing a vulnerable moment in their life and needs healing,” Wilson said in an emailed statement. “We hold each healing opportunity sacred, so financial healing is closely aligned with our Mission.”

The “Ethical and Religious Directives for Catholic Health Care Services,” issued by the U.S. Conference of Catholic Bishops, outlines social responsibility principles for Catholic health facilities. One states that “a just health care system will be concerned both with promoting equity of care — to assure that the right of each person to basic health care is respected — and with promoting the good health of all in the community.”

As of 2023, there were just over 600 Catholic general hospitals nationally and roughly 100 more managed by Catholic chains that place some religious limits on care, a California Healthline investigation revealed.

Catholic nuns established many hospitals in the name of service. But modern-day practices at such facilities demonstrate how they adhere to the directives and church teaching in one way — prohibiting or limiting procedures that the church deems immoral, such as abortion and what it calls “assisted suicide” — while neglecting social responsibility standards, patients and clinicians said.

“It does show the lack of control or influence that the faith organization has over the actual company,” said Shane Alderson, chair of the Baker County Board of Commissioners in Oregon. The local Catholic hospital owned by Trinity Health — Saint Alphonsus Medical Center-Baker City — last year shut down its obstetrics department. Its intensive care unit is also closed, Alderson said. “You get the feeling when you go to a Catholic hospital that the care and the vision is a lot more defined by the faith,” he said, adding: “It’s not really. It’s corporate.”

Sister Mary Haddad, president of the Catholic Health Association, said in a written statement that Catholic health systems “remain true to our origins and the missions on which we were founded through our ongoing commitment to serving those most in need.” In addition to patient care, she said, this includes investing in programs to address societal problems such as homelessness and food insecurity.

Health systems like CommonSpirit Health, Ascension, PeaceHealth, Trinity Health, and Providence St. Joseph pay their chief executives millions of dollars a year — payouts that kept pace during the covid-19 pandemic emergency, according to each company’s tax filings.

CommonSpirit Health’s then-CEO Lloyd Dean earned roughly $28 million in 2022; he was among nearly three dozen executives who pulled down more than $1 million that fiscal year, according to the health system’s tax filings.

Elsewhere, Rod Hochman, CEO of Providence St. Joseph Health, earned $12.1 million. Ascension CEO Joseph Impicciche was paid $9.1 million, according to corporate tax filings.

Spokespeople for Providence and Ascension said CEO compensation levels are market-competitive; CommonSpirit spokesperson Felicity Simmons said that Dean, who retired in July 2022, like other retiring executives “received standard deferred compensation benefits consistent with their many years of service.” (CommonSpirit’s 2021 tax filing showed Dean earned $35.5 million that year.)

To maintain their tax-exempt status, all nonprofit hospitals are required to spend on community benefits, but federal law doesn’t specify how much or which services qualify.

Several large nonprofit Catholic health systems spend far less on community benefits such as free or discounted care to eligible patients and community health improvement services than the estimated value of the millions they secure in tax breaks, according to research by the nonpartisan Lown Institute.

Based on 2021 data, the think tank found that five of the 10 health systems with the greatest “fair share deficits” are Catholic: Providence, CommonSpirit Health, Trinity Health, Ascension, and Bon Secours Mercy Health’s deficits were between $488 million and $1 billion.

Research by Community Catalyst, a consumer advocacy group, found that Catholic hospitals treat fewer Medicaid patients than other nonprofit hospitals, something at odds with their mission of prioritizing health care needs of the poor and underprivileged. And like other hospitals nationwide, many large Catholic health systems allow aggressive tactics against patients for unpaid medical bills such as using third-party collections, filing lawsuits, placing liens, garnishing wages, reporting bad debt to credit bureaus, or restricting care to people who owe, a KFF Health News investigation found.

Catholic bishops are “quite zealous for making sure that the reproductive and end-of-life care components of the ERDs are followed,” said Patricia Gabow, a physician who led a Denver safety net health system for two decades and has written about the evolution of Catholic health care in the U.S. She said “they should be as zealous” on enforcing the directives outlining Catholic health care’s social responsibilities.

Among those directives is this: “Catholic health care should distinguish itself by service to and advocacy for those people whose social condition puts them at the margins of our society and makes them particularly vulnerable to discrimination” including “the poor; the uninsured and the underinsured”; and “children and the unborn.” The U.S. Conference of Catholic Bishops declined to comment for this article, referring questions to the Catholic Health Association.

PeaceHealth’s first hospital was founded in the 1890s by nuns from New Jersey who ventured to the West to care for loggers, millworkers, fishers, and their families in the country’s remote frontier. Seven nuns and a cook staffed St. Joseph Hospital in Whatcom County, Washington, where Bellingham is located. St. Joseph is the Catholic patron saint of families, workers, and the dying.

Now no nuns serve on St. Joseph Medical Center’s or PeaceHealth’s leadership teams; two are on the health system’s 11-person board of directors. PeaceHealth CEO Liz Dunne earned $3.6 million in the fiscal year that ended June 30, 2023, tax filings show, and the Lown Institute estimates the health system spent $108.7 million less on community investments than the value of its tax exemptions. PeaceHealth declined to comment on executive compensation or the Lown Institute’s findings.

In 2023, the health system was forced to refund up to $13.4 million to more than 15,000 low-income patients after the Washington attorney general’s office found it billed patients who should have received financial help.

Catholic health systems “set a standard for themselves which is higher” than other U.S. hospitals, Gabow said. “Do they reach what they set for themselves? And there’s a fair amount of data to say probably not.”

Shutting Down Maternity Care

For more than a century, a Catholic hospital now named Saint Alphonsus Medical Center has provided care in Baker City, Oregon, a 10,000-person town less than 100 miles from the Idaho border.

The hospital was founded in 1897 by nuns from Philadelphia. They treated 115 patients in the first year, “many of whom were loggers, ranchers, and gold miners,” according to a document detailing its history. Patients “received complete health coverage” for $1 a month.

Like many of its peers across the nation, the small rural hospital would become part of larger Catholic health systems. In 2010 it settled in as part of Trinity Health, the nation’s fourth-largest hospital system by number of beds, according to federal data. Trinity Health operates 101 hospitals, plus other care sites, in 27 states. CEO Michael Slubowski’s most recently reported salary was $5.3 million in the company’s 2023 fiscal year, when Trinity had an operating margin of -2%, according to financial statements and tax filings. Operating margins are a measure of a hospital’s financial health.

Trinity Health spokesperson Melissa Lander said Slubowski’s compensation is based on factors including experience and performance, and pay “must be market competitive to attract and sustain talented people.”

Baker City was given a jolt in 2023. Blaming staffing shortages and a decline in births, hospital executives announced that Saint Alphonsus would close its obstetrics unit, the only one in the county. The move caused an uproar locally and pushback by Oregon’s two Democratic senators.

“What they were doing is essentially getting rid of the unit that made no money and cost a lot,” said Cathie Roach, a nurse who worked in Saint Alphonsus Medical Center’s obstetrics unit for roughly a decade before retiring last year.

Roach said the staffing shortages were “pretty much of their making.” Hospital management rotated nurses among departments in ways that made some feel “really uncomfortable,” and the hospital didn’t consider alternative ways of staffing the OB unit, she said.

For months, she said, nurses were getting hints that executives might close the birth center and began looking for jobs elsewhere. “Out here if you want to be an OB nurse and this is the only hospital, and they start talking about closing,” she said, “then, time to get out.”

Hospital leaders said its obstetric deliveries had “declined at a record rate.” However, birth data from the Oregon Health Authority tells a different story.

Births at the Baker City hospital declined to 103 in 2015, a nearly 30% drop from 2013, before rebounding. Annual births were in the 120s or 130s until the covid-19 pandemic took hold, when they fell 25% from 2019 to 2020. Still, from 2020 to 2022, between 100 and 112 babies were delivered each year.

Saint Alphonsus Health System and Trinity Health declined to comment.

Now the closest hospital where a person can give birth is over 40 miles away. In the winter in eastern Oregon, roads to get there are often closed.

In 2023, 54% of Baker County resident births were paid for by Medicaid, the health coverage program for people with low incomes, according to Oregon Health Authority statistics. That’s a higher share than Medicaid-covered births statewide.

“They really lost their charity,” Roach said, “when the old nuns disappeared.”

The Reach of Market Power

The actions of Catholic health systems can have an outsize impact because of their reach, fueled by mergers in recent years: Four of the 10 largest U.S. hospital chains by number of beds are Catholic, according to federal data from the Agency for Healthcare Research and Quality.

Haddad noted that that power has worked for the good of vulnerable populations.

The association and most of the Catholic health systems criticized the Lown Institute report on community benefit spending as flawed for excluding several categories reported to the IRS, including uncompensated care costs and spending on health professional education. Haddad called the research an effort “to disparage the work of Catholic health care by publishing misleading and biased reports that cherry-pick data.”

The Lown Institute considers five categories of community investments, including financial assistance for patients, community health services, and health services such as free clinics and addiction treatment.

Ascension spokesperson Sean Fitzpatrick called the report an “exercise in misinformation”; Trinity Health’s Lander said it “gives inaccurate and, unfortunately, misleading conclusions.” Bon Secours Mercy Health spokesperson Maureen Richmond said that the report “utilizes flawed high-level assumptions and incomplete data” and that the health system’s community benefit spending in 2021 exceeded the value of its tax exemptions by more than $274 million — while Lown calculated that its benefit fell short of tax exemptions by $488 million. Providence spokesperson Melissa Tizon said Lown’s methodology “falls short.”

The CHA and multiple health systems declined to answer questions about whether certain business practices raised by this story were consistent with the mission of Catholic health care.

Years ago, Catholic hospital mergers were motivated primarily by ministry, said Lawrence Singer, a retired associate professor who was affiliated with Loyola University Chicago School of Law. But things have changed.

“It really isn’t ‘save the ministry’ any longer,” he said. “It’s really business that’s driving a lot of this now.”

Consolidation raises market power, and several studies have found that it leads to higher prices for patients while the quality of care remains steady or declines.

The Federal Trade Commission has blocked certain deals it predicts could reduce competition. Historically the agency has targeted transactions in which hospitals operate in the same market, according to antitrust law experts. State regulators have broader authority than the federal government, but most states can’t reject proposed mergers without going to court, according to researchers at the University of California Law-San Francisco.

Some of the largest Catholic health systems, including CommonSpirit Health, Providence St. Joseph Health, and Trinity Health, achieved their size due to a different strategy: combining companies with little to no geographic overlap. Such “cross-market mergers” are traditionally harder for the FTC to block, according to health care antitrust experts.

When hospitals in the same market try to merge, “in some ways it’s a lot easier to quantify what’s going on” and the potential harm to competition, said Kevin Hahm, an antitrust attorney at Hunton Andrews Kurth and a former FTC official who investigated health care transactions.

But deals involving hospitals in different regions are increasingly drawing scrutiny. Researchers at the University of California-Berkeley, UC Law-San Francisco, and the University of Auckland found that health systems that acquired hospitals more than 50 miles away increased prices by 12.9% after six years compared with hospitals not involved in mergers or acquisitions.

“The new frontier,” said Thomas Greaney, one of that merger study’s authors, “is whether we’ll go after what we’ve called system power.”

‘We’re a Captive Audience’

Bellingham is one of the nation’s least competitive hospital markets: In 2021, it was the fifth most concentrated in the U.S. and had the highest health care prices of metro areas in Washington, according to the nonprofit Health Care Cost Institute.

The nuns who established PeaceHealth’s first hospital would open or operate others throughout the 20th century. PeaceHealth also acquired hospitals through mergers, including Southwest Medical Center in Vancouver and United General Hospital in Sedro-Woolley.

“PeaceHealth is the leader in all three of its markets, with decided market share leads in its Northwest and Oregon markets,” credit ratings firm Fitch Ratings reported in March. PeaceHealth declined to answer questions about whether a desire to charge higher prices drives market decisions.

Its hospitals stand out for what they’re paid. Rand Corp. researchers told California Healthline that commercial health plans in 2022 paid PeaceHealth’s Washington hospitals 314% of what Medicare would have paid for the same services. Those are the highest-priced rates among health systems in the state, according to Rand’s analysis. PeaceHealth declined to comment.

Staten’s medical bill from PeaceHealth is gone: She used the home equity line of credit to pay it off. Now she’s paying more on her mortgage every month.

She said she can’t afford to have another experience like her kidney stone surgery, which she was told involved a laser to break the stones into smaller pieces.

“It’s not like you’ve got three hospitals to choose from,” Staten said. “We’re a captive audience.”

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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Missoula is one of Montana’s largest cities but is surrounded by rural mountain communities where cattle ranching is king. Despite the latitude and altitude, in recent years this region has experienced punishing summer heat waves.

It has been difficult for residents to adapt to the warming climate and new seasonal swings. Many don’t have air conditioning and are unprepared for the new pattern of daytime temperatures hovering in the 90s — for days or even weeks on end. Dehydration, heat exhaustion, heatstroke, and abnormalities in heart rate and blood pressure are among the many health complications that can develop from excessive exposure to high temperatures.

It can happen anywhere and to anyone, said Missoula firefighter Andrew Drobeck. He remembers a recent 911 call. The temperature that day had risen to over 90 degrees and a worker at a local dollar store had fainted. “She’s sensitive to the heat. Their AC wasn’t working super good,” Drobeck said. “I guess they only get a 15-minute break.”

Drobeck said many of the heat calls his department receives are from seniors who struggle to stay cool inside their older homes. Montana’s population is among the oldest in the country. About 1 in 4 residents are over 60. Those over 65 are especially vulnerable to heat-related illness, according to the Centers for Disease Control and Prevention. As people age, their bodies don’t acclimate to heat as well as they did when they were younger, including not producing as much sweat.

In July, a heat dome that settled over much of the western U.S. baked the region and shattered two types of temperature records: daily highs, and number of consecutive days over 90 degrees. Although the Northwest, including western Montana, is typically cooler, the region experienced record-breaking heat this summer.

Emergency responders like Drobeck have noticed. Drobeck says 911 calls during heat waves have ticked up over the last few summers. But Missoula County officials wanted to know more: They wanted better data on the residents who were calling and the communities that had been hardest hit by the heat. So the county teamed up with researchers at the University of Montana to comb through the data and create a map of 911 calls during heat waves.

The team paired call data from 2020 with census data to see who lived in the areas generating high rates of emergency calls when it was hot. The analysis found that for every 1 degree Celsius increase in the average daily temperature, 911 calls increased by 1%, according to researcher Christina Barsky, who co-authored the study.

Though that may sound like a small increase, Barsky explained that a 5-degree jump in the daily average temperature can prompt hundreds of additional calls to 911 over the course of a month. Those call loads can be taxing on ambulance crews and local hospitals.

The Missoula study also found that some of the highest rates of emergency calls during extreme heat events came from rural areas, outside Missoula’s urban core. That shows that rural communities are struggling with heat, even if they get less media attention, Barsky said. “What about those people, right? What about those places that are experiencing heat at a rate that we’ve never been prepared for?” she said.

Barsky’s work showed that communities with more residents over 65 tend to generate more 911 calls during heat waves. That could be one reason so many 911 calls are coming from rural residents in Missoula County: Barsky said people living in Montana’s countryside and its small towns tend to be older and more vulnerable to serious heat-related illness.

And aging in rural communities can pose extra problems during heat waves. Even if it cools off at night, an older person living without air conditioning might not be able to cope with hours of high temperatures inside their home during the day. It’s not uncommon for rural residents to have to drive an hour or more to reach a library that might have air conditioning, a community center with a cooling-off room, or medical care. Such isolation and scattered resources are not unique to Montana. “I grew up in the Upper Peninsula of Michigan,” Barsky said. “There are no air-conditioned spaces in at least 50 miles. The hospital is 100 miles away.”

Heat research like the Missoula study has focused mostly on large cities, which are often hotter than outlying areas, due to the “heat island” effect. This phenomenon explains why cities tend to get hotter during the day and cool off less at night: It’s because pavement, buildings, and other structures absorb and retain heat. Urban residents may experience higher temperatures during the day and get less relief at night.

By contrast, researchers are only just beginning to investigate and understand the impacts of heat waves in rural areas. The impacts of extreme heat on rural communities have largely been ignored, said Elizabeth Doran, an environmental engineering professor at the University of Vermont. Doran is leading an ongoing study in Vermont that is revealing that towns as small as 5,000 people can stay hotter at night than surrounding rural areas due to heat radiating off hot pavement. “If we as a society are only focused on large urban centers, we’re missing a huge portion of the population and our strategies are going to be limiting in how effective they can be,” Doran said.

Brock Slabach, with the National Rural Health Association, agrees that rural residents desperately need help adapting to extreme heat. They need support installing air conditioning or getting to air-conditioned places to cool off during the day. Many rural residents have mobility issues or don’t drive much due to age or disability. And because they often have to travel farther to access health care services, extra delays in care during a heat-related emergency could lead to more severe health outcomes. “It’s not unreasonable at all to suggest that people will be harmed from not having access to those kinds of services,” he said.

Helping rural populations adapt will be a challenge. People in rural places need help where they live, inside their homes, said Adriane Beck, director of Missoula County’s Office of Emergency Management. Starting a cooling center in a small community may help people living in town, but it’s unrealistic to expect people to drive an hour or more to cool off. Beck said the Missoula County Disaster and Emergency Services Department plans to use data from the 911 study to better understand why people are calling in the first place.

In the coming years, the department plans to talk directly with people living in rural communities about what they need to adapt to rising temperatures. “It might be as simple as knocking on their door and saying, ‘Would you benefit from an air conditioner? How can we connect you with resources to make that happen?’” Beck said.

But that won’t be possible for every rural household because there simply isn’t enough money at the county and state level to pay for that many air-conditioning units, Missoula County officials said. That’s why the county wants to plan ahead for heat waves and have specific protocols for contacting and assisting vulnerable rural residents.

“Ideally we’d be in a situation where maybe we have community paramedics that can be deployed into those areas when we know that these events are going to happen so they can check on them and avoid that hospital admission,” Beck explained. She added that preventing heat-related hospitalizations among rural residents can ultimately save lives.

This article is from a partnership that includes MTPR, NPR, and KFF Health News.

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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SAN FRANCISCO — Andrew Douglass shoved his clothes and belongings into plastic trash bags as five police officers surrounded his encampment — a drab gray tent overflowing along a bustling sidewalk in the gritty Tenderloin neighborhood, where homeless people lie sprawled on public sidewalks, sometimes in drug overdoses.

Officers gave him a choice: Go to a shelter or get arrested and cited for sleeping outside.

Douglass was trying to figure out what to do as he dismantled his tent. If he accepted temporary shelter, he’d risk missing an important appointment with his street medicine case manager, who was due to meet him at his tent in the morning to help him secure a low-income housing unit with wraparound services — and he worried about losing his medications, ID, and other vital documents again in another homeless sweep.

Douglass, who didn’t have a working cellphone, knew if he moved from where he’d slept for months, his case manager might not be able to find him. “I’m so close to getting housing. I need to be here tomorrow morning so I can try and get inside,” he said, trying to reason with officers as he was handcuffed and arrested for illegal lodging.

California, the epicenter of the U.S. homelessness crisis, is cracking down on people living outside like never before, taking an aggressive new stance to dismantling and clearing homeless encampments in the wake of a watershed U.S. Supreme Court ruling in late June that makes it easier for government agencies to fine and arrest people for living on streets and sidewalks, in broken-down vehicles, or within public parks — even if there is no shelter or housing available. From San Francisco to Los Angeles, communities are launching cleanup operations, ratcheting up enforcement of existing anticamping laws, and, in some places, passing new laws to try to prevent people from living outdoors.

On the ground, health care experts and homeless service providers say the law enforcement crackdown is undercutting taxpayer investments in evidence-based treatment and housing services that are being deployed by cities and states around the nation as politicians look to the health care system to aggressively move people off the streets.

The sweeps — which have taken off under Democratic Gov. Gavin Newsom, who issued an executive order in late July requiring state agencies to remove encampments and encouraging local governments to do the same — have unleashed chaos for homeless people and are breaking crucial connections with health care providers, social service agencies, and housing navigators trying to help them get healthy and off the streets.

Newsom’s hard-line stance is undermining his signature Medicaid initiative, known as CalAIM, which dedicates $12 billion over five years in part to helping homeless people receive health care, housing, and social services. The experimental program, meant to stabilize the most vulnerable and keep low-income patients out of costly institutional care in hospitals, jails, and nursing homes, for instance, launched in early 2022 with backing from the Biden administration, and provides state and national health care funding to street medicine teams, hospitals, health insurance companies, community clinics, and other organizations to serve homeless people.

It comes as Newsom announced this month that his health secretary, Mark Ghaly, who has spearheaded the state’s infusion of social services for homeless people into the health care system, would be stepping down.

Encampment clearings are also upheaving long-standing federal health policies that provide billions of dollars each year to street medicine providers, case management teams, and front-line community clinic workers, including through the national “Health Care for the Homeless” program, which is also aimed at helping homeless people get healthy and navigate a path to permanent housing.

Newsom has been emphatic that streets are not a home and that it’s unsafe to let people live outside amid public health hazards like rats, drug needles, and piles of trash. The second-term governor, who has threatened to withhold homelessness funding from communities that fail to show enough progress, argues that his policies are helping get people long-term housing and services.

“There are simply no more excuses,” Newsom said in July.

Health care providers and homelessness experts say the result is a slow-moving health care catastrophe instigated by the very Democratic politicians touting the need for care and services around California, home to more homeless people than any other state in the nation.

No place is going as hard as San Francisco, a fiercely liberal city that has long embraced its reputation as a place where homeless people could find refuge and robust services.

Now, case managers, housing navigators, and street medicine teams say vulnerable people are growing sicker amid the crackdown and that many of their patients have simply disappeared. Others have lost medications and critical documents like birth certificates and Social Security cards, setting back efforts to stabilize people with housing, mental health services, and addiction treatment. Front-line providers here say the city has become a glaring example of homelessness policy gone wrong.

“All the sweeps and arrests are doing is moving people to the next sidewalk and disrupting their continuity of care. It’s a huge waste of resources,” said Shannon Heuklom, a primary care provider and an expert in street medicine for the San Francisco Community Health Center, with a clinic nestled in the heart of the Tenderloin.

“Some portion of folks may end up in a shelter, but for the most part the city is just moving them all around and making them more unwell, making their mental health worse, making their physical health worse,” she said.

Disrupted Care

In the Tenderloin, Douglass was frantic. Police told him and his wife, Jasmine Byron, and another partner, Christina Richardson, that they could avoid arrest if they went into a massive congregate shelter. But they’d have to sacrifice most of their stuff, taking just two bags each. They’d already lost lifesaving medications, including for epilepsy, in a previous camp clearing. And Douglass had finally replaced his ID and asthma medication; he didn’t want more stuff thrown away amid the chaos.

On this early August morning, Douglass opted to stay with his belongings. The trio are part of about 70 homeless arrests in San Francisco since the city’s mayor, London Breed, ratcheted up cleanup operations in the beginning of August following the Supreme Court’s decision in late June, according to San Francisco Police Department spokesperson Evan Sernoffsky.

“We’re here to enforce the law,” said Lt. Wayman Young, one of the five officers. “We get a lot of complaints: People can’t use the sidewalk; there’s a lot of garbage.”

As the three were separated and cuffed, a woman driving by stuck her hands out her window and clapped, cheering the sidewalk arrest and yelled “Thank you!” A passerby in a wheelchair averted the tense standoff by rolling into a traffic lane, dodging vehicles as he looked for a vacant section of sidewalk to use.

Douglass missed his housing appointment the morning after his arrest, confirmed his street medicine case manager, Justin Jackson from the San Francisco Community Health Center. Amid his tossed belongings were his ID card, which is required to get into housing, so he was back in line at the clinic the next day filling out a Department of Motor Vehicles voucher form to replace it for free.

Because Douglass is homeless and on Medi-Cal, California’s version of Medicaid, he is eligible for CalAIM services that assist homeless patients with finding a permanent place to live, as well as helping to cover security deposits and utility bills. CalAIM also offers eviction prevention support, and next year California is expected to add a new Medi-Cal benefit providing up to six months of free rent or temporary housing.

But with his documents thrown away, his eligibility for housing was delayed.

Front-line workers are now spending immense time and resources helping people replace valuables like medications, Social Security cards, and birth certificates lost due to sweeps. They notice patients are skipping routine health care and spot an uptick in drug use, anxiety, and depression.

“This is just making homelessness worse,” said Evelyn Peña, a CalAIM care manager at the Mission Neighborhood Health Center in San Francisco.

Taylor Cuffaro, a nurse practitioner and street medicine provider with the San Francisco Community Health Center, trudged the streets of the Tenderloin with Eli Benway, a licensed clinical social worker who provides talk therapy and other behavioral health treatment on the street, searching for patients on a bright August afternoon.

Some needed help managing chronic diseases and mental health conditions. Others were due for antipsychotic injectables that last longer than pill medications. Some needed refills of HIV medications.

“Health insurance companies aren’t just going to give you more medication,” Cuffaro said. “That’s not how it works, so people really are at risk of dying faster.”

Part of what’s being squandered is trust, which is vital for getting people off the streets. “These sweeps are just making our job impossible,” Cuffaro said, searching unsuccessfully for a patient in an alley.

Politics of Homelessness

The statewide crackdown is playing out despite a growing body of evidence showing that providing robust health care, along with social services and intensive case management, can effectively move homeless people off the streets and improve health, while also saving taxpayer and health care spending on costly institutional care.

Democrats are embracing a get-tough approach as public patience wears thin over the intractable crisis. Newsom’s stance is not entirely new: During his tenure as San Francisco mayor, from 2004 to 2011, he spearheaded controversial homelessness ideas, including an ordinance known as sit/lie, which made it illegal to sit or lie on public sidewalks.

Newsom and local leaders, including Breed, say they must balance ensuring public safety and clean streets with a humane approach to clearing camps, while trying to get people indoors. Breed administration officials argue that while some homeless people do accept shelter, many are opting to stay on the streets while declining treatment.

“People won’t accept shelter, and they won’t follow up on their medical care or behavioral health treatment or any of that, often because they need to stay and monitor their belongings, some of which are totally soiled and becoming a health hazard,” said David Nakanishi, a clinical social worker who heads the Breed administration’s Healthy Streets Operation Center, which spearheads the sweeps.

In Los Angeles, meanwhile, street medicine provider Brett Feldman is losing his patients amid the sweeps. “It really undermines our housing efforts,” he said.

A city report released in May found that clearing camps and enforcing anticamping laws that ban people from sleeping, sitting, or keeping belongings on sidewalks in certain sensitive areas, including school zones, parks, or freeway underpasses, is not effectively helping people into housing. After spending roughly $3 million enforcing anticamping laws from 2021 to 2023, the report found, the city placed just two people into permanent housing and 81% of encampment sites have been repopulated.

In one central Los Angeles district where law enforcement is not aggressively enforcing anticamping laws, street homelessness fell roughly 38% in a one-year period from 2023 to 2024, said Indu Subaiya, interim CEO for the nonprofit Healthcare in Action, which has been housing and treating patients there.

“We’re starting to actually see results and reductions in unsheltered homelessness,” Subaiya said. “However, in Southern California counties aggressively enforcing Newsom’s executive order and clearing encampments, we’re seeing our patients and their medical conditions set back profoundly.”

Once Douglass was released, he was back in the Tenderloin hunting for housing and popping his tent up the street from his previous hangout.

“Every time I try to get my documents to get housing, I get knocked backwards,” he said. “I guess the city thinks we all need to be in handcuffs.”

By the next morning, the encampment had grown twice in size.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.

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When Vice President Kamala Harris walked across the debate stage Tuesday night to shake the hand of former President Donald Trump, it was the first time the two had met in person. But that was the rare collegial moment in a face-off otherwise marked by false and sometimes bizarre statements by the former president.

The debate was hosted by ABC with moderators David Muir and Linsey Davis, who occasionally fact-checked Trump. He complained on the Fox News show “Fox & Friends” on Wednesday morning that it was a “three-to-one” contest.

The two presidential candidates covered a wide range of issues — from job and inflation numbers to abortion and immigration — in exchanges marked by personal attacks. As our PolitiFact partners noted, Harris often directly addressed Trump while answering the moderators’ questions. Trump mostly stared straight ahead. In response to Trump’s claims about the Biden administration’s record on crime, Harris cited Trump’s criminal conviction in New York and other indictments.

The moderators questioned Trump about whether he would attempt to dismantle the Affordable Care Act, also known as Obamacare — the health insurance program he pledged and failed to repeal and replace during his previous administration.

He said, if president, he would “only change it if we come up with something that’s better and less expensive.” He went on to say, “There are concepts and options we have to do that, and you’ll be hearing about it in the not-too-distant future.”

Trump has promised an Obamacare replacement since he was on the campaign trail in 2015. He claimed during the debate that he “saved” the ACA by issuing regulations aimed at lowering insurance premiums.

Harris’ previous support for “Medicare for All,” a proposal to replace private health insurance with a government-run health system, drew questions from the moderators and attacks by Trump.

Abortion was a clear flash point. Harris called state restrictions on the procedure enacted since 2022 “Trump abortion bans” and said it was immoral to take away a woman’s ability to make decisions about her own body. She also pledged to sign any bill that would reinstate the protections outlined in Roe v. Wade, which the Supreme Court overturned in 2022.

Trump said that as president he would never face the question of signing a national abortion ban because the issue is now being settled in states. “I’m not signing a ban,” he said. “There’s no reason to sign a ban.”

Trump also resurfaced claims — repeatedly judged false by PolitiFact and other fact-checking organizations — that Democrats support abortions up to the moment of birth and the “execution” of babies after birth. ABC’s Davis flagged Trump’s statement, saying that willfully terminating a newborn’s life is illegal in every state. In addition, the majority of Democrats support abortion access up to fetal viability, when the fetus is able to survive outside the womb, typically around 24 weeks of pregnancy.

Harris brought up Project 2025, a policy blueprint created by the conservative Heritage Foundation from which Trump has sought to distance himself.

Moments after the debate ended, pop superstar Taylor Swift posted on Instagram that she would be voting for Harris “because she fights for the rights and causes I believe need a warrior to champion them.” Swift’s post featured a photo of her with her cat and was signed “Childless Cat Lady” — a reference to comments made by JD Vance, the Republican vice presidential candidate.

Our PolitiFact partners fact-checked the debate in real time on a live blog, with more coverage here, as Harris and Trump clashed on the economy, immigration, and abortion.

Excerpts detailing specific health-related claims follow.

Trump: “But the governor before, he said, ‘The baby will be born, and we will decide what to do with the baby.’”

False.

Trump initially referenced a West Virginia governor. He meant Virginia, and corrected himself later in the debate.

Former Virginia Gov. Ralph Northam, a Democrat and a physician, never said he would sanction the execution of newborns. What he did say during a 2019 radio interview is that in rare, late-pregnancy cases when fetuses are nonviable, doctors deliver the baby, keep it comfortable, resuscitate it if the family wishes, and then have a “discussion” with the mother.

The issue is that Northam declined to say what that discussion would entail. Trump puts words in the then-governor’s mouth, saying doctors would urge the mother to let them forcibly kill the newborn, which is a felony in Virginia (and all other states) punishable by a long prison sentence or death.

Trump: “Every legal scholar, every Democrat, every Republican, liberal, conservative, they all wanted [abortion] to be brought back to the states where the people could vote.”

False. 

The 1973 Roe v. Wade decision inspired legions of supporters and opponents. Before the U.S. Supreme Court overturned it in 2022, numerous legal scholars wrote briefs urging the court to uphold the ruling.

Some legal scholars who favor abortion rights have criticized the 1973 ruling’s legal underpinnings, saying that different constitutional arguments, based on equal protection, would have provided a stronger case. But legal experts, including some who held this view, said those scholars would not have advocated for overturning Roe on this basis.

Trump: On the Affordable Care Act, “I saved it.”

False. 

During 2016, Trump campaigned on repealing and replacing the Affordable Care Act. While president, he sought to repeal the measure — and failed.

But his administration pursued various policies that hindered its reach and effectiveness, including cutting millions of dollars in advertising and outreach funding. He cut subsidies to insurance companies that offered coverage on the exchanges. He also took regulatory steps to permit less expensive and less comprehensive health coverage — for example, short-term health plans that didn’t comply with the ACA.

During the Trump administration, ACA enrollment declined, and the number of uninsured Americans rose by 2.3 million from 2016 to 2019, including 726,000 children, according to the U.S. Census Bureau.

Trump: Harris “wants everybody to be on government insurance” for health care.

This is misleading.

Harris once co-sponsored a bill to expand Medicare to Americans of all ages, but she does not currently support this proposal.

In April 2019, Harris became one of 14 original co-sponsors of the Medicare for All Act of 2019 sponsored by Sen. Bernie Sanders (I-Vt.). The legislation would have established a national health insurance program administered by the federal Department of Health and Human Services.

The bill would have created an automatic, federally run health insurance program for all Americans, which would mirror the socialized medicine systems in such countries as the United Kingdom.

Harris backed the bill when she was preparing to run in the 2020 presidential primaries and many candidates believed that Democratic base voters wanted the most liberal positions possible.

However, Medicare for All failed to advance to a vote in the Senate. After her 2020 candidacy ended, Harris focused instead on bolstering the ACA as opposed to pushing for Medicare for All.

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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Cuando la vicepresidenta Kamala Harris cruzó el escenario del debate el martes 10 por la noche para darle la mano al ex presidente Donald Trump, fue la primera vez que los dos se conocían en persona. Fue un breve y raro momento de cordialidad en un enfrentamiento marcado por declaraciones falsas y, a veces, bizarras del ex presidente.

La cadena ABC organizó el debate, moderado por David Muir y Linsey Davis, quienes ocasionalmente revisaron las afirmaciones de Trump. A la mañana siguiente, en el programa “Fox & Friends” de Fox News, Trump dijo que había sido un “debate de tres contra uno”.

Los dos candidatos presidenciales abordaron una amplia gama de temas, desde cifras de empleo e inflación hasta el aborto y la inmigración, en intercambios marcados por ataques personales.

Como señaló PolitiFact, Harris a menudo se dirigía directamente a Trump mientras respondía a las preguntas de los moderadores. Trump en su mayoría miraba al frente. En respuesta a las afirmaciones de Trump sobre el historial del gobierno de Biden en materia de crimen, Harris mencionó la condena penal de Trump en Nueva York, y otras acusaciones.

Los moderadores le preguntaron a Trump sobre si intentaría desmantelar la Ley de Cuidado de Salud a Bajo Precio (ACA, también conocida como Obamacare), el programa de seguro médico que prometió derogar y reemplazar durante su administración, algo que no logró.

Dijo que, si volviera a ser presidente, “solo lo cambiaría si encontráramos algo que fuera mejor y menos costoso”. Y agregó: “Hay conceptos y opciones para hacerlo, y los escucharán en un futuro no muy lejano”.

Trump ha estado prometiendo que reemplazaría el Obamacare desde su campaña de 2015. Durante el debate afirmó que “salvó” a ACA al emitir regulaciones destinadas a reducir las primas de los seguros.

El anterior apoyo de Harris al “Medicare para Todos”, una propuesta para reemplazar el seguro de salud privado por un sistema de salud administrado por el gobierno, generó preguntas de los moderadores y ataques por parte de Trump.

El aborto fue un claro punto de conflicto. Harris definió a las restricciones estatales impuestas al procedimiento, promulgadas desde 2022, como “las prohibiciones de Trump al aborto”, y dijo que era inmoral quitarle a una mujer la capacidad de tomar decisiones sobre su propio cuerpo. También prometió firmar cualquier ley que restableciera las protecciones descritas en Roe vs. Wade, que la Corte Suprema revocó en 2022.

Trump dijo que, como presidente, nunca enfrentaría la cuestión de firmar una prohibición nacional del aborto porque el tema ahora se está resolviendo en los estados. “No voy a firmar una prohibición”, dijo. “No hay razón para firmar una prohibición”.

Trump también sacó de nuevo a la luz afirmaciones, repetidamente consideradas falsas por PolitiFact y otras organizaciones de verificación de datos, de que los demócratas apoyan los abortos hasta el momento del nacimiento y la “ejecución” de bebés después del nacimiento.

Momentos después de terminar el debate, la super estrella del pop Taylor Swift publicó en Instagram que votaría por Harris “porque lucha por los derechos y causas que creo que necesitan a un guerrero que las defienda”. La publicación de Swift incluyó una foto de ella con su gato y estaba firmada como “Childless Cat Lady” (“Dama de gatos sin hijos”), una referencia a los comentarios de JD Vance, el candidato republicano a la vicepresidencia.

PolitiFact verificó lo dicho en el debate en tiempo real en un blog en vivo, mientras Harris y Trump chocaban sobre economía, inmigración y aborto.

A continuación, extractos que detallan afirmaciones específicas relacionadas con la salud:

Trump: “Pero el gobernador antes, dijo: ‘El bebé nacerá, y decidiremos qué hacer con el bebé’”.

Falso.

Trump inicialmente mencionó a “un gobernador de West Virginia”. Se refería a Virginia y se corrigió más tarde en el debate.

El ex gobernador de Virginia, Ralph Northam, demócrata y médico, nunca dijo que sancionaría la ejecución de recién nacidos. Lo que dijo en una entrevista de radio en 2019 es que, en raros casos de embarazo avanzado cuando los fetos no son viables, los médicos entregan al bebé, lo mantienen cómodo, lo reaniman si la familia lo desea y luego tienen una “discusión” con la madre.

El problema es que Northam se negó a decir en qué consistiría esa discusión. Trump pone palabras en la boca del entonces gobernador, diciendo que los médicos instarían a la madre a que permitiera que mataran al bebé, lo cual es un delito grave en Virginia (y en todos los demás estados) castigado con una larga condena de prisión o la pena de muerte.

Trump: “Todos los estudiosos del derecho, todos los demócratas, todos los republicanos, liberales, conservadores, todos querían que [el aborto] volviera a los estados donde la gente pudiera votar”.

Falso.

La decisión Roe vs. Wade de 1973 inspiró legiones de partidarios y opositores. Antes de que la Corte Suprema de Estados Unidos la anulara en 2022, numerosos estudiosos del derecho escribieron informes instando a la corte a mantener el fallo.

Algunos académicos que apoyan el derecho al aborto han criticado los fundamentos legales de la decisión de 1973, diciendo que otros argumentos constitucionales, basados en la protección igualitaria, habrían proporcionado un caso más sólido. Pero los expertos legales, incluidos algunos que sostenían esta opinión, dijeron que esos académicos nunca habrían abogado por anular Roe sobre esta base.

Trump: Sobre la Ley de Cuidado de Salud a Bajo Precio, “Yo la salvé”.

Falso.

Durante 2016, Trump hizo campaña para derogar y reemplazar ACA. Mientras fue presidente, intentó derogarla y fracasó.

Pero su administración impulsó varias políticas que obstaculizaron su alcance y efectividad, incluido el recorte de millones de dólares en publicidad y financiación de divulgación. Cortó los subsidios a las compañías de seguros que ofrecían cobertura en los intercambios. También tomó medidas regulatorias para permitir planes de salud menos costosos y menos completos, por ejemplo, planes de salud de corto plazo que no cumplían con los requerimientos de ACA.

Durante la administración Trump, la inscripción en ACA bajó y el número de estadounidenses sin seguro aumentó en 2.3 millones de 2016 a 2019, incluidos 726,000 niños, según la Oficina del Censo.

Trump: Harris “quiere que todos estén en un seguro gubernamental” para la atención médica.

Esto es engañoso.

Harris una vez copatrocinó un proyecto de ley para expandir Medicare a estadounidenses de todas las edades, pero actualmente no apoya esta propuesta.

En abril de 2019, Harris se convirtió en uno de los 14 copatrocinadores originales de la Ley Medicare para Todos de 2019 patrocinada por el senador Bernie Sanders (independiente de Vermont). La legislación habría establecido un programa nacional de seguro de salud administrado por el Departamento de Salud y Servicios Humanos (HHS) federal.

El proyecto de ley habría creado un programa de seguro de salud federal automático para todos los estadounidenses, que reflejaría los sistemas de medicina socializada en países como el Reino Unido.

Harris respaldó el proyecto de ley cuando se preparaba para postularse en las primarias presidenciales de 2020 y muchos candidatos creían que los votantes de la base demócrata querían las posiciones más liberales posibles.

Sin embargo, Medicare para Todos no logró avanzar a una votación en el Senado. Después de que su candidatura en 2020 terminara, Harris se centró en fortalecer ACA en lugar de impulsar Medicare para Todos.

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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PITTSBURGH — A false alarm that a gunman was roaming one Catholic high school and then another in March 2023 touched off frightening evacuations and a robust police response in the city. It also prompted the diocese to rethink what constitutes a model learning environment.

Months after hundreds of students were met by SWAT teams, the Catholic Diocese of Pittsburgh began forming its own armed police force.

Wendell Hissrich, a former safety director for the city and career FBI unit chief, was hired that year to form a department to safeguard 39 Catholic schools as well as dozens of churches in the region. Hissrich has since added 15 officers and four supervisors, including many formerly retired officers and state troopers, who now oversee school campuses fitted with Stop the Bleed kits, cameras, and defibrillators.

When religious leaders first asked for advice after what are known as “swatting” incidents, the veteran lawman said he didn’t hesitate to deliver blunt advice: “You need to put armed officers in the schools.”

But he added that the officers had to view schools as a special assignment: “I want them to be role models. I want them to be good fits within the school. I’m looking for someone to know how to deal with kids and with parents — and, most importantly, knows how to de-escalate a situation.”

Gun violence is a leading cause of death for young people in America, and the possibility of shootings has influenced costly decision-making in school systems as administrators juggle fear, duty, and dizzying statistics in efforts to keep schools safe from gun harm. In the first week of September, the risks were made tragically clear again, this time in Georgia, as a teenager stands accused of shooting his way through his high school and killing two students and two teachers.

Still, scant research supports the creation of school police forces to deter gun violence — and what data exists can raise as many questions as answers. Data shows over half of U.S. firearm deaths are, in fact, suicides — a sobering statistic from the federal Centers for Disease Control and Prevention that reflects a range of ills. Gun violence grew during the covid-19 pandemic and studies found that Black children were 100 times as likely as white children to experience firearm assaults. Research on racial bias in policing overall in the U.S. as well as studies on biased school discipline have prompted calls for caution. And an oft-cited U.S. Secret Service review of 67 thwarted plots at schools supports reasons to examine parental responsibility as well as police intervention as effective ways to stop firearm harm.

The Secret Service threat assessment, published in 2021, analyzed plots from 2006 to 2018 and found students who planned school violence had guns readily at home. It also found that school districts that contracted sworn law officers, who work as full- or part-time school resource officers, had some advantage. The officers proved pivotal in about a third of the 67 foiled plots by current or former students.

“Most schools are not going to face a mass shooting. Even though there are more of them — and that’s horrible — it is still a small number,” said Mo Canady, executive director of the National Association of School Resource Officers. “But administrators can’t really allow themselves to think that way.

“They have to think, ‘It could happen here, and how do I prevent it?’”

About a 20-minute drive north of Pittsburgh, a top public school system in the region decided the risk was too great. North Allegheny Superintendent Brendan Hyland last year recommended retooling what had been a two-person school resource officer team — staffed since 2018 by local police — into a 13-person internal department with officers stationed at each of the district’s 12 buildings.

Several school district board members voiced unease about armed officers in the hallways. “I wish we were not in the position in our country where we have to even consider an armed police department,” board member Leslie Britton Dozier, a lawyer and a mother, said during a public planning meeting.

Within weeks, all voted for Hyland’s request, estimated to cost $1 million a year.

Hyland said the aim is to help 1,200 staff members and 8,500 students “with the right people who are the right fit to go into those buildings.” He oversaw the launch of a police unit in a smaller school district, just east of Pittsburgh, in 2018.

Hyland said North Allegheny had not focused on any single news report or threat in its decision, but he and others had thought through how to set a standard of vigilance. North Allegheny does not have or want metal detectors, devices that some districts have seen as necessary. But a trained police unit willing to learn every entrance, stairway, and cafeteria and who could develop trust among students and staffers seemed reasonable, he said.

“I’m not Edison. I’m not inventing something,” Hyland said. “We don’t want to be the district that has to be reactive. I don’t want to be that guy who is asked: ‘Why did you allow this to happen?’”

Since 2020, the role of police in educational settings has been hotly debated. The video-recorded death of George Floyd, a Black man in Minneapolis who was murdered by a white police officer during an arrest, prompted national outrage and demonstrations against police brutality and racial bias.

Some school districts, notably in large cities such as Los Angeles and Washington, D.C., reacted to concerns by reducing or removing their school resource officers. Examples of unfair or biased treatment by school resource officers drove some of the decisions. This year, however, there has been apparent rethinking of the risks in and near school property and, in some instances in California, Colorado, and Virginia, parents are calling for a return of officers.

The 1999 bombing plot and shooting attack of Columbine High School and a massacre in 2012 at Sandy Hook Elementary School are often raised by school and police officials as reasons to prepare for the worst. But the value of having police in schools also came under sharp review after a blistering federal review of the mass shooting in 2022 at Robb Elementary School in Uvalde, Texas.

The federal Department of Justice this year produced a 600-page report that laid out multiple failures by the school police chief, including his attempt to try to negotiate with the killer, who had already shot into a classroom, and waiting for his officers to search for keys to unlock the rooms. Besides the teenage shooter, 19 children and two teachers died. Seventeen other people were injured.

The DOJ report was based on hundreds of interviews and a review of 14,000 pieces of data and documentation. This summer, the former chief was indicted by a grand jury for his role in “abandoning and endangering” survivors and for failing to identify an active shooter attack. Another school police officer was charged for his role in placing the murdered students in “imminent danger” of death.

There have also been increased judicial efforts to pursue enforcement of firearm storage laws and to hold accountable adults who own firearms used by their children in shootings. For the first time this year, the parents of a teenager in Michigan who fatally shot four students in 2021 were convicted of involuntary manslaughter for not securing a newly purchased gun at home.

In recent days, Colin Gray, the father of the teenage shooting suspect at Apalachee High School in Georgia, was charged with second-degree murder — the most severe charges yet against a parent whose child had access to firearms at home. The 14-year-old, Colt Gray, who was apprehended by school resource officers on the scene, according to initial media reports, also faces murder charges.

Hissrich, the Pittsburgh diocese’s safety and security director, said he and his city have a hard-earned appreciation for the practice and preparation needed to contain, if not thwart, gun violence. In January 2018, Hissrich, then the city’s safety officer, met with Jewish groups to consider a deliberate approach to safeguarding facilities. Officers cooperated and were trained on lockdown and rescue exercises, he said.

Ten months later, on Oct. 27, 2018, a lone gunman entered the Tree of Life synagogue and, within minutes, killed 11 people who had been preparing for morning study and prayer. Law enforcement deployed quickly, trapping and capturing the shooter and rescuing others caught inside. The coordinated response was praised by witnesses at the trial where the killer was convicted in 2023 on federal charges and sentenced to die for the worst antisemitic attack in U.S. history.

“I knew what had been done for the Jewish community as far as safety training and what the officers knew. Officers practiced months before,” Hissrich said. He believes schools need the same kind of plans and precautions. “To put officers in the school without training,” he said, “would be a mistake.”

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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The proportion of Americans without health insurance remained stable in 2023, the Census Bureau reported Tuesday, close to the record low the Biden administration achieved in 2022 through expansions of public programs, including the Affordable Care Act.

About 8% of Americans were uninsured, a statistically insignificant increase of just 0.1 percentage point from a year earlier. But because of the Census survey’s methodology, the findings likely don’t capture the experience of tens of millions of Americans purged from Medicaid rolls after pandemic-era protections expired in spring 2023.

Enrollment in Medicaid, the government health program for people with low incomes and disabilities, reached its highest level in April 2023. That was just before what’s called the “unwinding,” the process states have used to disenroll people from the program after the federal government lifted a prohibition on culling enrollment.

It isn’t yet clear what effect the unwinding has had on insurance coverage, but the Census Bureau will release additional data on Thursday from a different survey that may refine the numbers.

“We are likely at a turning point,” said Leighton Ku, director of the Center for Health Policy Research at George Washington University. “We are about to change to a new season where things will be a little worse off from Medicaid unwinding.”

The Medicaid unwinding has been completed in most states, and more than 25 million people have been disenrolled, according to KFF, a health information nonprofit that includes California Healthline. The Census report, based on surveys conducted early this year, counts people as uninsured only if they lacked insurance for all of 2023. So, for example, a person who was on Medicaid in April 2023 before the unwinding began then lost coverage and never regained it would nonetheless be counted as insured for the entire year.

Many people purged from Medicaid were successfully reenrolled in or obtained other insurance, such as Affordable Care Act marketplace or job-based coverage. Others remained uninsured.

Advocates have feared the unwinding would trigger a rise in the uninsured rate as people struggled to find alternative coverage.

But states, private health insurers, and advocates launched intense efforts to contact enrollees by phone, email, and social media to ensure they did not experience gaps in coverage.

Still, because of the way the Census Bureau reports the uninsured rate, the full impact of the unwinding won’t be known until the 2026 report.

Beyond Medicaid, several other factors boosted the number of Americans with health insurance last year, including a strong economy and near-record-low unemployment. Most Americans obtain insurance through their jobs, according to the Census, meaning that higher employment typically results in broader health coverage.

Another key factor: enhanced federal subsidies that since 2021 helped lower the cost of private coverage through Obamacare. Sign-ups on Affordable Care Act marketplaces hit a record high of 20.8 million in 2024, according to a Treasury report released Tuesday.

But that extra financial assistance is slated to expire at the end of 2025, setting up a flashpoint for whichever party controls power in Washington after the November elections. Democrats want to extend the subsidies introduced during the pandemic, while many Republicans wish to let them end.

Before Congress passed the ACA in 2010, the uninsured rate had been in double digits for decades. The rate fell steadily under President Barack Obama but reversed under President Donald Trump, only to come down again under President Joe Biden.

In addition to expanding subsidies, the Biden administration increased advertising and the number of counselors who help people sign up for plans during the open enrollment season, which Trump greatly curtailed.

Also contributing to the reduction in the number of uninsured Americans are state efforts to expand coverage to mostly low-income residents. North Carolina, for example, expanded Medicaid eligibility in December 2023, resulting in more than 500,000 additional enrollees.

Decades of research shows that expanded health coverage helps people individually and the public overall. Health insurance pays for routine care and can protect people from financial calamity because of severe injuries or illness.

People who are uninsured are more likely to delay or avoid getting health care, which can lead to relatively minor problems becoming more severe and costly to treat. Having more people covered also means more patients can pay their bills, which can improve the financial condition of hospitals and other providers.

The health insurance data released annually by the Census Bureau is considered the most accurate picture of health coverage in the United States. The state-level uninsured data it plans to release Thursday, based on a larger survey, counts people as uninsured if they say they don’t have coverage at the time they’re contacted. Thus, it likely will provide more insight into the effects of the unwinding.

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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Suspicions that U.S. consumers’ personal information could be accessed from India led regulators to abruptly bar two large private sector enrollment websites from accessing the Affordable Care Act marketplace in August.

New details about the suspensions come in legal filings made late Friday stemming from an effort by the two to regain access to the Obamacare marketplace before the upcoming ACA open enrollment period, which starts Nov. 1.

The Centers for Medicare & Medicaid Services wrote in a Sept. 2 letter to the companies that they were suspended after the agency identified “a serious lapse in the security posture” that could have led to marketplace data, including consumers’ personal information, being accessed from overseas.

The letter, included in the court filings, also noted that regulators will audit the two companies because they have “reasonable suspicion” that they are players in a separate problem: signing people up for Obamacare coverage — or changing their policies — without the consumers’ permission.

Whether those legal issues will be resolved before the upcoming enrollment period is an open question. Currently, the concerns raised about the companies remain allegations, with none of the legal challenges or the audit close to a ruling or conclusion.

Still, the larger issue of fraudulent ACA enrollment by rogue insurance agents seeking commissions will continue to pose a headache for regulators, with more than 200,000 complaints filed by consumers in the first six months of 2024. And it has become a political problem for the Biden administration. GOP lawmakers blamed the schemes partly on Biden-backed expanded Obamacare premium subsidies.

President Joe Biden has claimed record-breaking enrollment under the ACA as one of his administration’s major accomplishments, and regulators are looking to thwart deceptive enrollment schemes without slowing legitimate sign-ups. In recent weeks they’ve removed at least 200 agents’ access to the federal ACA marketplace, and in July began requiring, in many circumstances, that brokers participate in three-way calls with their clients and the healthcare.gov help center before changes can be finalized.

The CMS letter now adds another layer. It is the first time this year the agency has called out a company over questionable enrollments, saying it suspects “the Speridian Companies” might have “directed its employees and other agents to change Marketplace enrollees’ coverage and enroll insured and uninsured consumers without the enrollees’ consent.”

California-based Speridian Global Holdings owns the companies in question, which include enrollment platform Benefitalign and TrueCoverage, doing business as the Inshura enrollment site. It has a data center in India.

The now-suspended Benefitalign site handled at least 1.2 million applications for ACA coverage during the last open enrollment period, according to court documents, which would rank it among the largest of the private enrollment sites allowed to integrate with healthcare.gov, the federal marketplace.

Previously, CMS had said publicly only that it suspended the websites for “anomalous activity.”

The suspended companies deny any wrongdoing related to enrollment schemes. Spokesperson Catherine Riedel declined comment beyond their court filings.

In late August they filed a complaint against CMS over the suspensions in U.S. District Court for the District of Columbia, seeking a restraining order. They added to that complaint on Sept. 6, calling CMS’ suspension action “lawless.”

On Aug. 8, CMS suspended the two websites from accessing healthcare.gov information.

It did so, according to the Sept. 2 letter, over concerns that some consumer information “is processed and/or stored” in India, citing “suspicions” that the data is “being accessed from outside of the United States.”

That’s a problem, the letter says, because marketplace data must stay in the U.S. to “eliminate the possibility that foreign powers might obtain access.” Additionally, websites approved by CMS to integrate with the federal marketplace cannot transmit data outside of the U.S. or allow access from outside the country, under the terms of agreements such companies sign to get CMS approval to operate.

CMS did not spell out what consumer information might have been included, but ACA applications can contain information including a person’s name, date of birth, address, and detailed household income information.

Speridian companies were suspended, then reinstated, from the marketplace in prior years over other concerns, including problems with false Social Security Numbers submitted with some TrueCoverage ACA applications in 2018, and for a 2023 effort by Benefitalign to access the federal marketplace’s “software testing environment” from India, according to the CMS letter.

In seeking a restraining order against CMS, the companies argue that the agency’s action to suspend them now is arbitrary and capricious and violates its own regulations as well as the due process clause of the Constitution.

The filing calls the Sept. 2 CMS letter explaining the reasons for the suspensions “a post hoc justification” that includes a litany of “‘concerns,’ suspicions,’ ‘allegations.’” The filing also asserts “these intimations of violations are made without evidence of any actual violation.”

The court documents say the suspensions will prevent the companies from participating in the upcoming open enrollment period, harming them and “the thousands of brokers” and “millions of consumers who count on brokers” using those websites to sign up for ACA coverage.

The suspension remains in place, the CMS letter says, partly because its concerns have not been allayed by information provided by the companies, but also while the audit is conducted.

CMS has “reasonable suspicion, based on credible evidence it has considered,” that the companies were involved in enrolling consumers or changing their coverage without specific permission, the letter stated, noting that such allegations are included in a civil lawsuit filed by private sector lawyers in U.S. District Court for the Southern District of Florida.

The firms have previously said the allegations in the civil lawsuit are without merit.

Brokers who have used the suspended websites in the past have other options to enroll clients, including several other websites currently approved to integrate with the federal Obamacare marketplace. Consumers can also go directly to the federal or state ACA websites and enroll themselves or get assistance from call centers associated with those marketplaces.

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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The term “health equity” means different things to different people. It’s about access to medical care — but not only access to medical care. It’s about race, ethnicity, and gender; income, wealth, and class; and even geography — but not only those things. And it’s about how historical and institutional racism, manifested in things like over-policing and contaminated drinking water, can inflict health problems years and even generations later.

In a live taping on Sept. 6 at the Texas Tribune Festival, special guests Carol Alvarado, the Texas state Senate’s Democratic leader, and Ann Barnes, president and CEO of the Episcopal Health Foundation, along with KFF Health News’ Southern bureau chief Sabriya Rice and Midwest correspondent Cara Anthony, joined KFF Health News’ chief Washington correspondent, Julie Rovner, to discuss all that health equity encompasses and how current inequities can most effectively be addressed.

Anthony also previewed “Silence in Sikeston,” a four-part podcast and documentary debuting this month exploring how a history of lynching and racism continues to negatively affect the health of one rural community in Missouri.

Also mentioned on this week’s podcast, from KFF Health News’ “Systemic Sickness” project:

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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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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