Last year, he said, in a single involving bogus “medicated” creams and unnecessary urine tests, a Beverly Hills couple was charged with defrauding 27 health insurers out of $40 million.

“That’s just the tip of the iceberg,” said Poizner, a Silicon Valley businessman. “Then there’s all of the fraud that never gets reported.”

Poizner held the office from 2007 to 2011 as a Republican but now is running as an unaffiliated candidate, and has made fighting fraud a centerpiece of his health care agenda.

He argues that the health industry may be forfeiting billions of dollars because the state insurance department’s fraud division is understaffed: 57 investigator jobs, or 24 percent, are unfilled.

Ultimately, that inflates health care costs and puts patients in harm’s way, he said.

“These vacancy rates are critical to fill,” Poizner said. “The less health care fraud there is, the better the quality of the health care system.”

Poizner is sounding a very different note from his Democratic opponent, state Sen. Ricardo Lara, who says reducing health care costs requires a broad transformation of health care, not just chasing criminals.

Lara, who co-authored the last year, said he believes health care costs will drop if people have coverage instead of postponing care until it is most urgent and expensive.

“If we can get everyone comprehensive primary care, that’s a good way to start,” Lara said.

The insurance commissioner oversees car, property and some health insurance plans. Rooting out illegal activity is part of the job.

But in a state dominated by liberal politicians, many challenging the very structure of the U.S. health care system, Poizner’s nuts-and-bolts focus stands out as traditional and politically pragmatic. Some political observers see his platform as a safe way to secure votes, or as one put it, “an old standby.”

Walter Zelman, professor of health science at California State University-Los Angeles, said focusing on other areas of health care, such as how doctors and hospitals get paid, would make a much bigger dent in cutting health care costs. But they’re less popular to implement, he said.

“To talk about fraud and abuse … that doesn’t really threaten anybody,” Zelman said. “It’s more maybe of a good campaign issue than it is an actual way of reducing costs.”

Democratic strategist Steve Maviglio agreed. “Who’s against combating fraud? I mean that’s the safest bet you can take, and that’s the one that’s in everybody’s platform, Republican or Democrat,” he said.

When candidates don’t have a comprehensive solution to health care issues, Maviglio added, “that’s their go-to talking point.”

Poizner said fraud is worth chasing because it poses a threat to patients, often involving unnecessary surgeries or prescriptions. And the costs are “all passed on, every dollar, to consumers, in the form of higher rates,” he said.

Vacancies in the department’s fraud unit have gone up and down over the years. In 2013, 1.5 percent of positions were unfilled, but in 2016, almost 30 percent were vacant.

When Poizner was insurance commissioner, the vacancy rate hovered between 12 percent and 23 percent.

The current insurance commissioner, Dave Jones, said one reason the rate is high now is because he has created more positions.

“It’s a challenge for any law enforcement agency to fill positions,” Jones said, pointing to the relatively low pay his department offers compared with other state offices.

The starting yearly salary for a fraud investigator — who are sworn police officers —ranges from $54,280 to $88,000, Jones said, so his department is “hemorrhaging” those employees to higher-paying jobs at the state Department of Corrections and Rehabilitation and the attorney general’s office.

“There’s no question that we have more work than we have resources available to do,” Jones said.

To make the most of the manpower, his department prioritizes the biggest scams, he said, such as those that inflict the most patient harm.

In case, for instance, the insurance department joined whistleblowers in a lawsuit alleging that drug manufacturer Bristol-Myers Squibb paid doctors to prescribe their products, such as cholesterol and diabetes drugs. The company settled for $30 million.

California’s other health insurance regulator, the Department of Managed Health Care, oversees the vast majority of commercial health insurance plans in the state. But it has only three employees who look into fraud. On occasion, the Department of Insurance collaborates with them to root out criminal billing.

Poizner said he would fight to lure more people to insurance department jobs by lobbying for more state money to raise investigators’ wages.

Lara said he also wants the department’s fraud unit to be fully staffed, but “you can’t fix health care costs just from fighting fraud alone.” Instead, he said, he would try to prevent insurers from gouging consumers on premiums and look into reducing prescription drug costs.

A fraud investigator with the insurance department said his team could always use more help.

Vladislav Mikulich, a detective sergeant who supervises about a dozen investigators at the department’s southern fraud division, which covers the Los Angeles area, said health care scammers are savvy white-collar criminals that hide their illegal activities in “fantastic ways.”

He said he knows there’s much more fraud than his team can investigate, partly because of what they hear from informants.

“Every one of them could talk my ear off for the next month about the things that they have done in the past, or things they are currently seeing,” Mikulich said.

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Low-income people with diabetes are better able to afford their medications and manage their disease in states that expanded Medicaid under the Affordable Care Act, a new study suggests.

The , released Monday afternoon, found a roughly 40 percent increase in the number of prescriptions filled for diabetes drugs in Medicaid programs of the 30 states (including Washington, D.C.) that expanded eligibility in 2014 and 2015, compared with prior years.

By contrast, states that didn’t embrace the Medicaid expansion saw no notable increase.

“Gaining Medicaid insurance would have significantly reduced out-of-pocket spending for insulin for previously uninsured patients, thereby facilitating uptake of the medication,” the Health Affairs study said.

Diabetes, characterized by abnormally high blood sugar, is a chronic disease that requires expensive and ongoing medical care.  in the U.S. have diabetes or prediabetes, making the disease one of the country’s most formidable health challenges.

“In the long run, preventing diabetic complications not only saves lives, but it improves public health and saves public money,” said Dr. Michael Bush, an endocrinologist in Beverly Hills, Calif., and president of the California chapter of the American Association of Clinical Endocrinologists.

Bush and other experts said the Health Affairs study shows that the Medicaid expansion can help patients manage their health and also limit unnecessary spending. An analysis by the Centers for Disease Control and Prevention cited by the study shows that each diabetic patient who is treated for the condition can lead to a $6,394 reduction in health care costs (in 2017 dollars) because of fewer hospital admissions.

In California, roughly 3.9 million people gained coverage when the state expanded eligibility for Medi-Cal, the state’s version of the federal Medicaid program. In all, about 13.5 million people — more than one-third of Californians — are enrolled in Medi-Cal.

By 2016, people had enrolled in Medicaid nationwide as a result of the expansion, according to the Kaiser Family Foundation. The foundation estimates that who live in non-participating states would have qualified for Medicaid had their states chosen to expand. (Kaiser Health News is an editorially independent program of the foundation.)

“It’s not particularly surprising that extending Medicaid opened up this door for lots of other people to be able to fill prescriptions and be able to take advantage of managing a chronic disease like diabetes,” said Flojaune Cofer, director of state policy and research at Public Health Advocates, a nonprofit organization based in Davis, Calif., that seeks to eliminate health inequalities in California.

But Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Medicaid expansion may not mean good news for everyone.

Medicaid pays a fraction of a drug’s list price, which leads pharmaceutical companies , he said. That, in turn, could drive up everyone’s premium costs or lead those with private insurance to pay more out-of-pocket.

“You have to look at not just the immediate effects of a policy, but all of the effects of a policy,” Cannon said. “As prices rise, fewer people will be able to afford diabetic medications.”

Last year, nearly 900,000 Californians with Medi-Cal were known to have diabetes, according to state figures.

One of them is James Warden, 62, a retired rancher near Fresno, Calif., who said he was forced to stop working because of a back injury several years ago.

Warden enrolled in Medi-Cal in 2016 and was diagnosed with diabetes last year after a urinary condition landed him in the hospital, he said. Without the coverage, he said, he wouldn’t have the insulin his body needs.

“Medi-Cal saved me,” he said. “I wouldn’t have the money to be able to pay, or go to the doctor or anything.”

The researchers found that people in groups with a higher prevalence of diabetes before the ACA became law, such as those ages 55–59, showed larger increases in filling their diabetes prescriptions after the Medicaid expansions.

The price of insulin, a staple medication for many diabetes patients, rose almost 200 percent from 2002 to 2013, according to the study.

And nearly 40 percent of insulin users who responded to the American Diabetes Association’s 2018 reported that they had faced a price increase in the past year. As a result of the price hikes, many said, they took less of the medication, missed doses or switched to a cheaper drug.

In states that didn’t expand Medicaid after 2014, such as Texas and Florida, the number of diabetes prescriptions filled remained relatively flat, the study found. In these states, low-income and uninsured diabetics must rely on a “patchwork of options” to get insulin and other medications to treat their disease, according to the American Diabetes Association. Patients may need to seek help through drug company patient assistance programs or charities, the group said.

The study also showed a surge in filled prescriptions for newer, pricier diabetes drugs that have fewer side effects and control diabetes more effectively. And there was an increase in prescriptions for metformin, a generic drug that is often used as a first line of treatment for new Type 2 diabetes patients.

The rise in metformin prescriptions suggests the federal health law also led to more people being diagnosed with the disease, the authors said.

The study, conducted by University of Southern California pharmaceutical and health economists, was based on an analysis of filled prescriptions before and after the state Medicaid expansions began in 2014. The number of states that expanded Medicaid has since grown to

The prescriptions analyzed cover the period from 2008 to 2015. About 15 percent of retail pharmacies did not share their information, and the data did not include prescriptions filled by health clinics or via mail-order, which could have led to underestimates of the total effect, the authors said.

Bush, the Beverly Hills endocrinologist, acknowledged that providing diabetes drugs to Medicaid patients is costly to taxpayers. But he said it’s money well spent.

“This is clearly a disease where if you take care of it now, you can prevent complications that occur later,” he said.

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El estudio, publicado en , encontró un aumento de aproximadamente 40% en el número de recetas médicas para medicamentos contra la diabetes en los programas de Medicaid de los 30 estados (incluyendo a Washington, DC) que ampliaron la elegibilidad en 2014 y 2015, en comparación con años anteriores.

Por el contrario, los estados que rechazaron la expansión de Medicaid no vieron un aumento notable.

“Obtener un seguro de Medicaid habría reducido significativamente los gastos de bolsillo de insulina para pacientes que anteriormente no tenían seguro, lo que facilitaría la aceptación del medicamento”, dijo el estudio de Health Affairs.

La diabetes, que se caracteriza por niveles anormalmente altos de azúcar en la sangre, es una enfermedad crónica que requiere atención médica costosa y continua. Más de en el país tienen diabetes o prediabetes, convirtiendo a la enfermedad en uno de los desafíos de salud más grandes.

“A la larga, prevenir las complicaciones de la diabetes no solo salva vidas, sino que mejora la salud pública, y ahorra dinero público”, dijo el doctor Michael Bush, endocrinólogo en Beverly Hills, California, y presidente de la sección de California de la Asociación Estadounidense de Endocrinólogos Clínicos.

Bush y otros expertos dijeron que el estudio de Health Affairs muestra que la expansión de Medicaid puede ayudar a los pacientes a controlar su salud y también a limitar los gastos innecesarios. Un análisis de los Centros para el Control y Prevención de Enfermedades (CDC) citado por el estudio muestra que cada paciente con diabetes que recibe tratamiento para la afección puede llevar a una reducción de $6,394 en los costos de atención médica debido a la menor cantidad de internaciones.

En California, aproximadamente 3.9 millones de personas obtuvieron cobertura cuando el estado amplió la elegibilidad para Medi-Cal, la versión estatal del programa federal de Medicaid. En total, alrededor de 13.5 millones de personas, más de un tercio de los californianos, están inscriptos en Medi-Cal.

Para 2016, alrededor de 12 millones de personas se habían inscrito en Medicaid a nivel nacional como resultado de la expansión, según la Kaiser Family Foundation. La fundación estima que más de 2 millones de personas que viven en estados no participantes habrían calificado para Medicaid si sus estados hubieran elegido la expansión.

“No es particularmente sorprendente que la expansión de Medicaid abriera la puerta para que muchas más personas pudieran obtener recetas y manejar una enfermedad crónica como la diabetes”, dijo Flojaune Cofer, directora de política estatal e investigación en Public Health Advocates, una organización sin fines de lucro con sede en Davis, California, que busca eliminar las desigualdades de salud en California.

Pero Michael Cannon, director de estudios de políticas de salud en el libertario Instituto Cato, dijo que la expansión de Medicaid podría no significar buenas noticias para todos.

Medicaid paga una fracción del precio de lista de un medicamento, lo que lleva a las compañías farmacéuticas a , dijo. Eso, a su vez, podría aumentar los costos de las primas o los gastos de bolsillo para los que tiene un seguro privado.

“Hay que mirar no solo los efectos inmediatos de una política, sino todos sus efectos”, dijo Cannon. “A medida que suban los precios, menos personas podrán pagar los medicamentos para la diabetes”.

El año pasado, casi 900,000 californianos con Medi-Cal tenían diabetes, de acuerdo con cifras estatales.

Uno de ellos es James Warden, de 62 años, un ranchero retirado cerca de Fresno, California, quien dijo que tuvo que dejar de trabajar hace unos años, por una lesión en la espalda.

Warden se inscribió en Medi-Cal en 2016 y fue diagnosticado con diabetes el año pasado luego que tuviera que ir al hospital por una condición urinaria, contó. Sin la cobertura, dijo, no tendría la insulina que su cuerpo necesita.

“Medi-Cal me salvó”, dijo. “No tendría el dinero para poder pagar, o ir al médico o cualquier cosa”.

Los investigadores descubrieron que las personas en grupos con una mayor prevalencia de diabetes antes de que ACA se convirtiera en ley, como las que tienen entre 55 y 59 años, mostraron mayores aumentos en la reposición de sus medicamentos para la diabetes luego de las expansiones de Medicaid.

El precio de la insulina, un medicamento básico para muchos pacientes con diabetes, aumentó casi un 200% entre 2002 y 2013, según el estudio.

Y casi el 40% de los usuarios de insulina que respondieron a la de la American Diabetes Association (ADA) en 2018 informaron que se habían enfrentado a un aumento de precios en el último año. Como resultado, muchos dijeron que tomaban menos medicamento, salteaban dosis o cambiaban a uno más barato.

En los estados que no ampliaron Medicaid después de 2014, como Texas y Florida, el número de recetas de diabetes permaneció relativamente estable, encontró el estudio. En estos estados, las personas con diabetes de bajos ingresos y los que no tienen seguro deben confiar en un “mosaico de opciones” para obtener insulina y otros medicamentos para tratar su enfermedad, según la ADA. Los pacientes pueden necesitar buscar ayuda a través de programas de asistencia a pacientes de compañías farmacéuticas o de la caridad, dijo el grupo.

El estudio también mostró un aumento en las recetas de medicamentos para la diabetes más nuevos y costosos que tienen menos efectos secundarios y la controlan de manera más efectiva. Y hubo un aumento en las recetas de metformina, un medicamento genérico que a menudo se usa como primera línea de tratamiento para los pacientes recién diagnosticados con diabetes tipo 2.

El aumento de las recetas de metformina sugiere que la ley federal de salud también provocó que más personas fueran diagnosticadas, dijeron los autores.

El estudio, realizado por economistas farmacéuticos y de salud de la Universidad del Sur de California, se basó en un análisis de recetas antes y después que comenzaran las expansiones estatales de Medicaid, en 2014. La cantidad de estados que expandió Medicaid ha crecido a .

Las recetas analizadas cubren el período comprendido entre 2008 y 2015. Alrededor del 15% de las farmacias minoristas no compartió su información, y los datos no incluían las recetas de clínicas de salud o recibidas por correo, lo que podría haber llevado a subestimar el efecto total, dijeron los autores.

Bush, el endocrinólogo de Beverly Hills, reconoció que proporcionar medicamentos para la diabetes a pacientes de Medicaid es costoso para los contribuyentes. Pero dijo que es dinero bien gastado.

“Es claramente una enfermedad en la que, si usted se ocupa de ella ahora, puede prevenir complicaciones que ocurren más adelante”, dijo.

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The state marketplace, Covered California, said the rate increase for 2019 would have been closer to 5 percent if the federal penalty for going without health coverage had not been repealed in last year’s Republican tax bill.

The average increase in California is smaller than the double-digit hikes expected around the nation, due largely to a healthier mix of enrollees and more competition in its marketplace. Still, health insurance prices keep growing faster than wages and general inflation as a result of rising medical costs overall, squeezing many middle-class families who are struggling to pay their household bills.

The 8.7 percent increase in California ends two consecutive years of double-digit rate increases for the state marketplace.

“It’s not great that health care costs are still increasing that much, but the individual market is not sticking out like a sore thumb like it has in other years,” said Kathy Hempstead, senior adviser at the Robert Wood Johnson Foundation. “It’s falling back to earth.”

The future may be less bright. An estimated 262,000 Californians, or about 10 percent of individual policyholders in and outside the exchange, are expected to drop their coverage next year because the ACA fines were eliminated, according to the state. Peter Lee, executive director of Covered California, warned that the exodus of healthier consumers will drive up insurance costs beyond 2019 — not just for individual policyholders but for California employers and their workers.

“We are paying, in essence, a surcharge for federal policies that are making coverage more expensive than it should be,” Lee said in an interview. “There will be more of the uninsured and more uncompensated costs passed along to all of us.”

Critics of the Affordable Care Act say it has failed to contain medical costs and left consumers and taxpayers with heavy tabs . Nearly 90 percent of Covered California’s 1.4 million enrollees qualify for federal subsidies to help them afford coverage.

Foiled in its attempt to repeal Obamacare outright, the Trump administration has taken to rolling back key parts of the law and has slashed federal marketing dollars intended to boost enrollment. Instead, the administration backs cheaper alternatives, such as short-term coverage or association health plans, which don’t comply fully with ACA rules and tend to offer skimpier benefits with fewer consumer protections.

Taken together, those moves are likely to draw healthier, less expensive customers out of the ACA exchanges and leave sicker ones behind.

Nationally, 2019 premiums for silver plans — the second-cheapest and most popular plans offered — are expected to jump by 15 percent, on average, according to an of 10 states and the District of Columbia by the Avalere consulting firm. across the country, however. Decreases are expected in Minnesota while insurers in Maryland are seeking increases.

In California, exchange officials emphasized, consumers who shop around could pay the same rate as this year, or even a little less.

Christy McConville of Arcadia already spends about $1,800 a month on a Blue Shield plan for her family of four, opting for “platinum” coverage, the most expensive type. Her family doesn’t qualify for federal subsidies in Covered California.

She’s worried about further increases and doesn’t want to switch plans and risk losing access to the doctors she trusts. “We’re getting right up to the limit,” McConville said.

Amanda Malachesky, a nutrition coach in the Northern California town of Petrolia, said the elimination of the penalty for being uninsured makes dropping coverage more palatable. Her family of four pays almost $400 a month for a highly subsidized Anthem Blue Cross plan that has a $5,000 deductible.

“I’ve wanted to opt out of the insurance model forever just because they provide so little value for the exorbitant amount of money that we pay,” said Malachesky, who recently paid several hundred dollars out-of-pocket for a mammogram. “I’m probably going to disenroll … and not give any more money to these big bad insurance companies.”

Covered California is aiming to stem any enrollment losses by spending more than $100 million on advertising and outreach in the coming year. In contrast, the Trump administration spent only $10 million last year for advertising the federal exchange across the 34 states that use it.

Also, California lawmakers are looking at ways to fortify the state exchange. State legislators are considering bills that would limit the sale of short-term insurance and prevent people from joining association health plans that don’t have robust consumer protections.

However, California hasn’t pursued an insurance mandate and penalty at the state level, which both health plans and consumer advocates support. New Jersey and Vermont have enacted such measures.

Lee said it’s up to lawmakers to decide whether a state mandate makes sense.

David Panush, a Sacramento health care consultant and a former Covered California official, said some lawmakers may be reluctant to push the idea, even in deep-blue California.

“The individual mandate has always been the least popular piece of the Affordable Care Act,” he said.

Despite the constant uncertainty surrounding the health law, many insurers nationally are posting profits from their ACA business and some plans are looking to expand further on the exchanges.

In California, the same 11 insurers are returning, led by Kaiser Permanente and Blue Shield of California. Together, those two insurers control two-thirds of exchange enrollment. (Kaiser Health News, which publishes California Healthline, is not affiliated with Kaiser Permanente.)

The Covered California rate increases are fairly uniform across the state. Premiums are climbing 9 percent across most of Southern California as well as in San Francisco. Monterey, San Benito and Santa Cruz counties faced the highest increase at 16 percent, on average.

The rates are subject to state regulatory review but are unlikely to change significantly. Open enrollment on the exchange starts Oct. 15.

The ACA’s expansion of coverage has dramatically cut the number of uninsured Californians. The proportion of Californians lacking health insurance fell to 6.8 percent at the end of last year, down from 17 percent in 2013, federal data show.

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Becerra’s pledge came in response to from the administration Thursday that it would not defend key parts of the Affordable Care Act in court. The administration instead called on federal courts to scuttle the health law’s protection for people with preexisting medical conditions and its requirement that people buy health coverage.

Becerra accused the administration of going “AWOL.” It “has decided to abandon the hundreds of millions of people who depend on” the law, he said in an interview with Kaiser Health News.

“It’s, simply put, an attack on the health care that millions of Americans have come to count on, and California, being the most successful state in implementing the Affordable Care Act, stands to lose perhaps more than anyone else.”

About 1.5 million Californians buy coverage through the state’s ACA exchange, Covered California, and nearly 4 million have joined Medicaid as a result of the program’s expansion under the law.

The state has been at the forefront in resisting many Trump Administration policies, including on health care and immigration.

“This is not a new experience for us under this new Trump era of having to defend Californians,” Becerra said. In the case of health care, “fortunately we have who are prepared to do it with us. ”

At issue is a lawsuit filed by 20 Republican state attorneys general on Feb. 26, which charged that Congress’ changes to the law in last year’s tax bill rendered the entire ACA unconstitutional. In the tax law, Congress repealed the penalty for people who fail to have health insurance starting in 2019.

Becerra is leading an effort by Democratic attorney generals from others states and the District of Columbia to defend the ACA against that lawsuit. In May, the court allowed them to “intervene” in the case.

The Trump administration filed a brief in the case on Thursday, arguing that without the tax to encourage healthy people to sign up, the parts of the law guaranteeing coverage to people with previous health conditions — without charging them higher rates — should be struck down as well.

In to House Speaker Paul Ryan explaining the administration’s decision, U.S. Attorney General Jeff Sessions cited the Justice Department’s “longstanding tradition” of defending the constitutionality of federal laws “if reasonable arguments can be made in their defense.”

But in this case, he wrote, he could not find those arguments to defend the constitutionality of the provisions and “concluded that this is a rare case where the proper course is to forgo defense.”

The administration called on the court to declare the provisions that guarantee coverage to be invalid beginning on January 1, 2019, when the mandate penalty goes away.

Because the lawsuit could easily go all the way to the U.S. Supreme Court, a process that could take years, the protections for people with preexisting conditions are likely to stay in place during that period.

Lieutenant Governor Gavin Newsom, the Democratic front-runner in the race for California’s next governor, breathed the same fire as Becerra against the federal government on Friday.

“Trump and his cronies can’t unilaterally roll back preexisting protections for millions of Californians,” Newsom said. “California will fight like hell to protect our families and their healthcare.”

A spokesman for his opponent in the race, Republican gubernatorial candidate John Cox, declined to comment.

If the court ultimately declared the provisions targeted by the Trump Administration unconstitutional, California would be temporarily cushioned from the effects because there are laws already on the books should the ACA – or its provisions – go away.

For instance, existing rules would protect people with pre-existing conditions for twelve months if the ACA were struck down.

During that time, “policymakers in California would look really hard at being able to try to do something so we don’t lose those gains,” said Deborah Kelch, director of the Insure the Uninsured Project in Sacramento.

“It’s hard to look at California and imagine just folding it up and starting over.”

Some critics of the administration’s decision said California should go forward with enacting its own mandate for individual coverage, as a few other states have done. No one has pushed that issue forward in the Legislature.

Since he took office in January 2017, Becerra has emerged filing more than 30 lawsuits on health care and other issues.

In California’s primary election Tuesday, Becerra, a Democrat, with 45 percent of the vote. He will face retired judge Steven Bailey, a Republican, in the November general election.

Bailey’s spokesman Corey Uhden said Friday that he wouldn’t comment on the constitutionality of the ACA provisions. However, he said, Bailey opposes the individual mandate and wants less government regulation of health insurance.

Alex Leeds Matthews contributed to this report.

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The results of Tuesday’s primary have set up general-election contests between candidates — for governor, attorney general, insurance commissioner and some congressional seats — with sharply differing views on government’s role in health care.

The outcome in the Golden State could help shape the fate of the Affordable Care Act and influence whether Republicans in Washington take another shot at dismantling the landmark law.

“For the Affordable Care Act, California is a bellwether state,” said David Blumenthal, president of the Commonwealth Fund, a New York-based health policy research organization. If California voters don’t elect more Democrats to Congress, it will be harder for the party to gain legislative control and “the Affordable Care Act will continue, as it has been, to be under attack from an empowered Republican majority,” he said.

Despite being targeted for voting last year to repeal the ACA and cut Medicaid funding, several Republican incumbents performed well at the polls in California.

“California was supposed to lead the blue wave, but that’s not what we saw” in the primary, said Ivy Cargile, an assistant professor of political science at California State University-Bakersfield.

In the California governor’s race, Democratic front-runner Gavin Newsom quickly sought to cast the November contest as a referendum on Trump and his effort to undo much of President Barack Obama’s legacy, particularly on health care.

endorsing Republican candidate John Cox, a multimillionaire real estate investor, helped propel the political outsider to the general election.

“It looks like voters will have a real choice — between a governor who will stand up to Donald Trump and a foot soldier in his war on California,” Newsom said Tuesday night to supporters in San Francisco.

California has embraced the federal health law enthusiastically and stands to lose more than any other state if the ACA is gutted. About 1.5 million Californians buy coverage through the state’s Obamacare exchange, Covered California, and nearly 4 million have joined Medicaid as a result of the program’s expansion under the law.

Newsom, a former San Francisco mayor and the current lieutenant governor, has the coverage gains made under the ACA. He has vowed to go even further by pursuing a state-run, single-payer system for all Californians.

Newsom won the primary with 33 percent of the vote and Cox placed second with 26 percent. Some mail-in votes and provisional ballots .

Cox has slammed Newsom and fellow Democrats for imposing government controls on health care that he says make coverage too expensive for families. He said he isn’t interested in defending the Affordable Care Act and that, if the law is scrapped, millions of Californians can go into high-risk insurance pools — an idea that predates the health law.

Andrew Busch, a government professor at Claremont McKenna College, said the political divide over health care has grown even wider this year as single-payer has gained support from mainstream Democrats in California.

“I’d say the Republican candidates are pretty much where the Republicans have been, but the Democratic candidates have shifted to the left, so the choice is starker than it has been,” Busch said.

Heading into Tuesday’s primary, it wasn’t clear that California voters would face such drastically different choices on the November ballot. Under the state’s primary system, the top two vote-getters, regardless of party affiliation, advance to the general election. That left many experts predicting single-party matchups across the state.

But that scenario also didn’t pan out in the race for attorney general, a position that has played a key role in California’s resistance politics since Trump was elected. Democratic incumbent Xavier Becerra, who has become a national leader against Trump’s agenda, will face off against Republican Steven Bailey in the fall.

Becerra has filed on health care and other issues since taking office in January 2017.

Bailey, a criminal attorney and former judge, has blamed the Affordable Care Act for driving up health care costs, and he favors less industry regulation. He also has criticized Becerra for fixating too much on Trump.

“Just because a tweet comes out of Washington, it doesn’t require a lawsuit to be filed the next day,” Bailey said.

Health care could also play a role in several of California’s congressional races. Democrats are trying to win back control of the House, in part to better block Republican efforts to roll back the ACA.

“The actions of the Trump administration, the elimination of the individual mandate and its impact on markets will become more of an issue,” said Chris Jennings, a former health care adviser in the Obama administration. “The conservative caucus has been forcefully advocating for another aggressive return to the repeal effort.”

nationally is in a district of California’s San Joaquin Valley where Republican incumbent Jeff Denham drew several Democratic opponents after voting to repeal the health law last year — as did .

Denham led a crowded primary field with 38 percent of the vote Tuesday. Democrat Josh Harder is holding on to second place with nearly 16 percent, just ahead of a Republican challenger. until late-arriving ballots are counted.

Harder said the Republicans’ repeal-and-replace effort on health care was a major reason he decided to run. He made it a centerpiece of his campaign and ran ads criticizing Denham for voting to take away coverage from thousands of his constituents. About 40 percent of residents in this Modesto-area district are enrolled in Medicaid, the government insurance program for the poor and disabled.

Denham has defended his repeal vote, saying that patients’ access to doctors has only gotten worse since coverage was expanded under the ACA. In a statement last year, Denham said, “coverage does not necessarily equal care and families must resort to overflowing emergency rooms to be seen.”

But Dan Schnur, a Republican political strategist who teaches at the University of Southern California and the University of California-Berkeley, said health care has gone from a negative to a positive for Democratic candidates, who have spent the past several elections defending Obamacare.

“As a result, they’re doing everything they can to emphasize the health care debate rather than run away from it,” he said.

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But medical insurance? Not so much. The commissioner’s direct control over health insurers is limited, because the California Department of Insurance — headed by the commissioner — regulates only a of the market.

Still, the job carries the power of the bully pulpit, amplifying the commissioner’s voice on matters of regional, statewide and national importance.

The incumbent, Dave Jones, has used that bullhorn frequently to chastise health insurers, to roll back the Affordable Care Act and interject his voice on subjects ranging from prescription drug prices to to .

The four candidates vying in the June 5 primary to replace Jones — who is running for attorney general — will no doubt follow his lead in making use of the soapbox the commissioner’s office provides. Three of the four are ardent supporters of a statewide single-payer system and would use the office to promote it.

One of them, Democratic state Sen. , said one of his biggest priorities is “to ensure that everyone gets health care.” He is a strong proponent of government-run health care for all Californians and author of the now-dormant legislation, , which would create such a system.

, a San Francisco teacher-librarian who is the Peace and Freedom Party’s candidate, said she’s running because the commissioner’s office is “part of the political movement … for single-payer health care and socialism.” She added: “Insurance doesn’t serve a productive role in society.”

, a Los Angeles pulmonologist and a Democrat, said that as a medical practitioner, he regularly sees the financial challenges people face with the high cost of care. As a result, he said, he is best placed to find a “real solution which includes health care for all, not health care for most.”

, a Silicon Valley businessman, strongly opposes the idea of government-run health care and said the candidates who are advocating it “probably should be running for a different post.” He said he would push to eliminate fraud and wasteful health spending and create a system that rewards doctors and hospitals for the quality of their care rather than the volume of their services.

Poizner, who served as insurance commissioner from 2007 to 2011 as a Republican and is running now under no party banner, leads the field with 20.7 percent of voter preferences, according to a by Probolsky Research.

Lara is in second place with 13.7 percent, followed by Mahmood with 6.3 percent, and Hrizi with 5.9 percent, the poll found. However, more than half of respondents were undecided or declined to state their preference. The candidates who finish first and second in the primary will face off in the general election Nov. 6.

The commissioner’s authority over the health insurance industry has been eroded significantly in recent years, largely because of California’s bifurcated system of regulation. Regulatory discretion has to the Department of Managed Health Care (DMHC), which now oversees not only HMOs but also some PPOs, which were previously the domain of the commissioner.

This dual system often has allowed insurers to drive a wedge between the two agencies and essentially choose their regulators. Blue Shield of California, for example, one of the state’s biggest insurers, voted with its feet and is now mostly regulated by the DMHC.

The insurance commissioner has primary regulatory authority over health plans that cover of Californians enrolled in commercial health plans, according to the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.) Throw in the state’s nearly 13 million managed-care Medi-Cal plans, and the commissioner’s share drops to around 5 percent.

Despite this limitation, the Department of Insurance has statutory powers it can — and does — exercise. It pursues fraud, fines insurers that break the law and investigates consumer complaints about coverage. It also oversees the state’s 360,000 licensed insurance agents, with the power to investigate them, arrest them and turn them over for prosecution.

The department can also require health plans to comply with certain coverage requirements. Jones, for example, has issued rules to ensure plans have a robust , and provide equal access to care for the .

The commissioner also plays a role in examining merger proposals.

One power the insurance commissioner does not have, which Jones has often lamented, is the authority to prevent insurers from imposing large premium hikes — a matter of significant public concern as rates have soared in recent years. The DMHC doesn’t have that power, either.

The commissioner does examine proposed rate increases, and on occasion Jones has persuaded insurers to of them.

Lara proposes rolling the two regulators into one, under the insurance commissioner, and granting the newly combined agency the power to reject what it deems to be unreasonable rate hikes by insurers. That would help “bring prices down on behalf of consumers,” Lara said.

to allow the insurance commissioner to reject health insurance rate increases failed in 2014, as did a state bill in 2012.

In previous years, candidates talked a lot more about keeping premiums down, but this year much of the campaign rhetoric has focused on the idea of universal health care, said Stephen Shivinsky, a former Blue Shield executive who is now consulting for health insurers.

“Trump’s election changed everything,” Shivinsky said. Federal attempts to repeal the Affordable Care Act reignited questions about how health care is delivered, and “that really brought about the debate on single-payer,” he said.

Garry South, a longtime California campaign strategist, said he’s not surprised the Democratic candidates are talking up their support for universal health care, especially single-payer.

“If you’re going to run as a Democrat, you have to be for single-payer,” South said. Not doing so “would be like running for governor of California and opposing gun control.”

Poizner, the apparent front-runner, not only opposes government-run health care but also thinks it is way beyond the purview of the job he’s seeking. His goals for health care are relatively modest, including a study of how the money in California’s $400 billion health care system is spent, with an eye toward trimming the fat.

“As insurance commissioner, I want to focus on what I can get done,” he said.

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In late March, California’s Board of Pharmacy barred the distribution of medications — including lidocaine and other local anesthetics — from a Texas factory belonging to the company, . The decision came after the pharmacy board had issued a cease-and-desist order against the plant in February, citing “an immediate threat to the public health or safety.”

In December, the Food and Drug Administration issued a damning inspection report on PharMEDium’s Tennessee plant that led the company to voluntarily cease production there.

There are two kinds of compounding pharmacies: ones that mix custom prescriptions for individual patients, from chemotherapy cocktails to thyroid drugs, and those like PharMEDium, which mass-produce ready-to-use IV bags, prefilled syringes and other sterile medical solutions for hospitals, surgery centers and other health care facilities.

PharMEDium, one of the nation’s largest compounding pharmacy companies, is owned by and supplies medications to about 77 percent of hospitals nationwide.

Before the crackdown on PharMEDium, hospitals already were facing of the injectable opioid painkillers Dilaudid, morphine and fentanyl, which started with manufacturing delays at pharmaceutical giant Pfizer. The shutdown at PharMEDium’s Tennessee plant, which makes those drugs, has intensified the shortage nationally.

Doctors, determined to spare their patients pain, consequently have turned to second-choice pain drugs and increased their use of local anesthetics such as lidocaine. But now, even those local anesthetics — , and — are in short supply due to manufacturing problems and back orders, according to doctors and federal regulators.

Shortages of both types of painkillers have hit California health care providers especially hard. They must contend with the state crackdown on PharMEDium’s Texas plant, which produces local anesthetics, and federal scrutiny of the Tennessee plant, which produces the injectable opioids. Some California hospitals have abandoned the company altogether.

“We’re having to be very creative,” said Dr. Aimee Moulin, an emergency doctor at the University of California-Davis Health System who is president of the California chapter of the American College of Emergency Physicians.

“There are times when we’re not able to achieve that amount of anesthesia that we would like,” Moulin said. When that happens, she often turns to a second-choice drug that might not be as effective.

Dr. Rita Agarwal, who practices at Stanford University’s Lucile Packard Children’s Hospital, said the facility has a sufficient supply of local anesthetics to cope with the injectable opioid shortages. But if that changes, doctors may have to cancel elective surgeries, she said.

“If we can’t provide patients with adequate pain relief, then it’s sort of barbaric to do the surgery,” said Agarwal, who is also a professor of anesthesiology at Stanford.

In the meantime, her team is using more drugs like Demerol or remifentanil, which are not ideal in many cases because they have side effects or are short-acting.

“It’s unbelievably frustrating,” Agarwal said. “The solutions are [being] snatched away from us.”

California’s concern about PharMEDium dates to at least 2016, when the state warned the company about drugs “lacking in quality or strength” and fined it for failing to notify state officials about a product recall, according to public records obtained by California Healthline.

Then, the California Board of Pharmacy’s temporary , issued Feb. 27, faulted PharMEDium’s Sugar Land, Texas, plant for 14 violations, including flawed expiration dating and improper labeling. Virginia Herold, the board’s executive officer, called the action an “extraordinary authority” that it doesn’t use frequently.

In late March, the board decided not to renew the plant’s license. The agency is not aware of any patient harm that may be related to the plant’s failures, Herold said.

PharMEDium spokeswoman Lauren Esposito said the company is committed to resolving the matter.

“We look forward to renewing our California licenses and resuming shipment of our products into the state of California as soon as the board feels that its observations have been satisfactorily addressed,” she said.

California’s crackdown could make waves economically and symbolically, because of the size of its market and the message it sends to other states, said Dave Thomas, a principal with LDT Health Solutions, a consulting firm for compounding pharmacies.

“This can get pretty hairy for PharMEDium pretty fast,” he said.

At the federal level, the FDA’s December report on PharMEDium’s Memphis, Tenn., plant listed .

The report said the plant, which supplies injectable opioids to hospitals around the country, wasn’t doing enough to ensure medications were sterile before shipping them.

The FDA also reprimanded the company for poor employee training and failure to report and thoroughly investigate a case in which a patient became unconscious after receiving an injection of morphine produced by PharMEDium.

In the industry’s defense, said Thomas, the consultant, FDA inspectors can be inconsistent and deficiencies cited at compounding plants can depend on the person writing the report.

Government officials have stepped up scrutiny of compounding pharmacies since 2012, when contaminated drugs from the New England Compounding Center led to a national meningitis outbreak that and sickened 793 patients. The incident led to an eight-year prison sentence for the compounder’s supervising pharmacist, and that created new requirements for the pharmacies.

PharMEDium doesn’t know when the Memphis plant will start production again, Esposito said.

“We are actively working to address the items noted by FDA during the inspection and will resume … activities when we have determined our own readiness,” she said.

Because the Memphis plant is still offline, shortages of injectable opioids have worsened, according to a large California medical system.

“It’s been a struggle” to maintain an adequate stock of the medications since the plant stopped producing, said Donald Kaplan, a pharmacy director at Kaiser Permanente in Southern California. (California Healthline is produced by Kaiser Health News, which is not affiliated with Kaiser Permanente.)

Opioid supplies have dwindled so dramatically that Kaiser is shipping medications from one hospital to others that are in short supply, sometimes multiple times per week, he said.

In recent years, some hospitals have sought alternatives to PharMEDium because of quality problems, according to the California Hospital Association.

That’s the case with Mayers Memorial Hospital District in Shasta County, whose chief clinical officer Keith Earnest said it hasn’t used PharMEDium’s products in five years.

“I am glad they are finally no longer allowed to ship to California,” he said. “It has been a long time coming.”

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The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable , Dilaudid and — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.

As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit , which works with health care providers to promote patient safety.

In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.

In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.

The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.

In a to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”

In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.

The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.

Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.

Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.

Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.

Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.

“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”

Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.

“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”

During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.

The shortage of the three medications, which is , became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.

A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.

That followed by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.

Other liquid-opioid manufacturers, including and , are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.

At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.

“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency .

When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.

The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.

, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.

The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.

“We essentially have to ration to patients that are most vulnerable,” Shah said.

Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.

Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.

Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.

“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.

Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.

“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.

Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.

Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.

When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.

“But they didn’t,” he said.

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The health insurers debuted their bubbly superhero Tuesday in front of California’s stately Capitol building. The heart, who wore black booties and white, Michael Jackson-esque gloves, had no name. No matter. S/he bopped. S/he waved at school children. S/he flashed the thumbs-up. S/he made the Capitol feel a bit like Disneyland.

Passers-by couldn’t help but giggle at the insurance industry’s mute mascot. And they certainly seemed to have no clue that the anthropomorphized heart was merely the latest PR stunt in an ongoing feud between two health system titans: health insurers and drugmakers.

“It’s very cute. I don’t know exactly what’s going on. … What is happening here exactly?” asked Christine Danho, 25, an administrative assistant who stopped to snap a picture.

In recent years, the two deep-pocketed industries have pointed fingers at each other over the rising cost of prescription drugs, each side accusing the other of who need life-saving medicines.

The which bankrolled the event, introduced its heart “hero” and “high-priced drug nemesis” with fighting words for drugmakers.

“Pharma has made a practice of swarming the State Capitol with their minions working to keep drug prices sky high,” the lobbying group’s press release proclaimed.

True, drugmaker Pfizer shelled out $732,454 in 2017 to lobby California policymakers on health care, and the California Life Sciences Association, comprised largely of pharmaceutical companies, spent $522,323, according to the California Secretary of State.

But among the top five spenders in health care lobbying last year? The health plan association itself, which doled out about $1.2 million.

Drugmakers called the health plans out on their own tactics.

“Like a broken record, the insurers continue to blame everyone else for high health care costs when their policies are making lifesaving medicines increasingly more expensive for patients,” said Priscilla VanderVeer, a vice president with Pharmaceutical Researchers and Manufacturers of America (PhRMA).

VanderVeer’s colleague, Nicole Kasabian Evans, was a spokeswoman for the health plans not so long ago, but now she helps run PhRMA’s public relations strategy in California. And she had no qualms about criticizing her former employer’s media strategy.

“Honestly, are they generating any real news out of this event?” Kasabian Evans asked. It’s nothing more than “someone in a costume hand[ing] out tchotchkes,” she declared.

The health plan group said it timed the event to coincide with , and highlighted three heart disease medications on a poster board whose prices have spiked in recent years.

During the first hour of the event, the heart looked lonely, hoping for a little attention. But as the sun warmed the air and an unrelated rally brought people to the Capitol steps, onlookers cozied up to the health plans’ cherry red mascot for photo-ops or grabbed free heart-shaped stress balls.

Eric Wang, visiting from Los Angeles for a meeting with legislators, said opposing groups need to “work together to figure out a way to make our health care system affordable.”

But it’s unlikely the feud between drugmakers and health insurers will dissipate anytime soon. The federal government is only taking small steps to control drug prices, which means the debate over drug prices will continue to flare in state houses around the country.

“That’s where the fight has shifted,” said Steve Pearson, an expert on medical costs with  the . “There’s going to be a lot more money from both industries.”

Lila Cervantes, who was at the Capitol  advocating for higher education funding, posed for a picture with the heart, but she admitted later that she didn’t know much about the war between health insurers and drugmakers.

“There’s probably a lot of right and a lot of wrong on both sides,” Cervantes said. “We gotta’ sometimes take the politics out of it and … do what’s best for the people.”

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