Through a data network connecting its records system with other providers, the health center receives not just X-ray and lab results but real-time alerts when hospitals on the network admit or discharge its patients who have diabetes or asthma, enabling care teams to troubleshoot and significantly drive down emergency room visits.

But Christine Park, the community health center’s chief medical officer, said that even with those achievements, data sharing is far from seamless: The hospitals visited by the center’s patients aren’t all on the same network, and it’s often necessary to exchange records via fax.

“You know the patient went there, and you know there’s got to be a note,” Park said, “but you keep bumping up against that glass door.”

Despite and of effort invested in improving health care data sharing, , Americans’ medical records often remain siloed, leading to duplicate testing, increased costs, and wasted time for patients and care teams. And as the Trump administration and lawmakers from several states aim to bolster health data sharing, they face financial and operational hurdles that have stymied previous efforts.

Further complicating these efforts is whether providers and other stakeholders — facing the prospect of reduced Medicaid revenue after the passage of President Donald Trump’s major tax-and-spending law this summer — will invest the time and money needed to improve data sharing. And in some states, lawmakers and privacy advocates have heightened concerns about information sharing because of instances in which patient data has been used by and agencies.

In July, the Trump administration launched a voluntary, tech-focused initiative aimed at modernizing health data sharing and giving patients better access to their information. The announced that over 60 technology and health care companies had pledged to “kill the clipboard.” Health data networks and digital health records systems agreed to follow common information-sharing rules, providers pledged to share data through these networks, and tech companies agreed to enable patients to pull their data from these networks or apps.

applauded the focus on patient access, while skeptics questioned whether the voluntary plan would sufficiently motivate health care providers to participate.

“There’s not really a carrot here,” said venture capitalist Bob Kocher, who was a health official in the Obama administration.

Previous initiatives have run into data sharing’s bleak economics for providers: It requires investment and carries risks given privacy and security issues, and the financial return is often limited.

are paid primarily for the volume of services they render, limiting the incentive to share data and reduce unnecessary care, despite years of and to move toward a system that rewards providers financially for improving health outcomes. And health systems, Kocher said, can lose patients to business rivals when they share data.

In a statement, Amy Gleason, a strategic adviser to CMS, acknowledged that data sharing requires investment and that “some providers face financial pressures.” She added that CMS uses all available levers to encourage health care providers to share data, including testing new payment models. New federal initiatives are also aimed at enforcing regulations and at .

The federal government has long tried to streamline the sharing of health records. After the passage of the 2009 Health Information Technology for Economic and Clinical Health Act — or HITECH Act — during the Obama administration, federal subsidies were used successfully to push most hospitals and doctors to and to get most states to establish or enable a type of data network known as a health information exchange.

Subsequent administrations worked to make these systems more interoperable. The first Trump administration required providers to promptly share electronic records with patients and other providers, and the Biden administration to connect national, state-level, and other types of data networks.

But hospitals with fewer resources struggle with sharing data, and federal health IT efforts have historically left out many behavioral health and long-term care providers, said Julia Adler-Milstein, a professor of medicine at the University of California-San Francisco. especially those who treat underserved patients, find accessing information on health record systems other than their own difficult. Patients, too, struggle to consolidate their records.

States have forged ahead with medical data sharing in myriad ways, some using monetary incentives or, less frequently, penalties to get providers to share data with their exchanges.

Melissa Kotrys, chief executive of Contexture, the state-designated health information exchange in Arizona and Colorado, said most hospitals in both states connect to the exchange. To encourage participation, annual Medicaid incentives to providers that join and achieve specific milestones, while Colorado offers incentives to rural providers.

For many years, New York state — which requires hospitals, nursing homes, and other providers regulated by the state to join a regional network — with federal support. The state continues to fund the platform that connects them, also with the U.S. government’s support. in the state participate.

This year, lawmakers in at least seven states introduced bills largely aimed at enhancing digital record sharing and bolstering privacy protections, according to Alan Katz, a policy leader at Civitas Networks for Health, a national group representing health information exchanges. Some of these bills, , propose expanding the capabilities of already robust, existing exchanges.

In California, Democratic state Sen. Caroline Menjivar that would lay groundwork for the state to better enforce its that health care organizations share health and social services data in real time.

Supporters say the state needs more enforcement authority to ensure compliance and to support priorities such as better integrating health care and social services.

“I wouldn’t say this is the last step by any means, but it’s a necessary next step,” said Timi Leslie, executive director of Connecting for Better Health, the nonprofit that sponsored the bill, SB 660.

Amid the Trump administration’s restrictive stance on and are sharing patient data with deportation officials, the bill would exempt data on gender-affirming care and immigration status, as well as other sensitive information, from being shared.

The California Hospital Association opposes the bill, saying to the state Assembly that it would impose enforcement and costs on hospitals at a time when they face federal and state cuts.

Claudia Williams, a former health information exchange leader, said she doubts the bill can drive meaningful data sharing without providing ongoing funding for incentives and infrastructure.

In a statement, Menjivar said the state had already granted to hospitals and other organizations to help them meet the mandate’s requirements and has . The bill passed both chambers and is on its way to the governor for approval.

There’s broad agreement amid the numerous federal and state efforts to improve health record sharing that the endpoint should be data being at the right place at the right time, said UCSF’s Adler-Milstein. “But the actual process of getting an entire health care system’s IT, incentives, and policies to align behind that is extremely hard.”

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The law, , requires state-regulated health plans offered by large employers to cover infertility diagnosis and treatment, including IVF. will qualify for coverage under the law. Advocates have praised the law as “,” especially in making and aspiring single parents eligible, though cost concerns .

People who had been planning fertility care based on the original timeline are now “left in a holding pattern facing more uncertainty, financial strain, and emotional distress,” Alise Powell, a director at Resolve: The National Infertility Association, said in a statement.

During IVF, a patient’s eggs are retrieved, combined with sperm in a lab, and then transferred to a person’s uterus. A single cycle can , out of reach for many. The California law requires insurers to cover up to three egg retrievals and an unlimited number of embryo transfers.

Not everyone’s coverage would be affected by the delay. Even if the law took effect July 1, it wouldn’t require IVF coverage to start until the month an employer’s contract renews with its insurer. Rachel Arrezola, a spokesperson for the California Department of Managed Health Care, said most of the employers subject to the law renew their contracts in January, so their employees would not be affected by a delay.

She declined to provide data on the percentage of eligible contracts that renew in July or later, which would mean those enrollees wouldn’t get IVF coverage until at least a full year from now, in July 2026 or later.

The proposed new implementation date comes amid heightened national attention on fertility coverage. California is now with an IVF mandate, and in February, President Donald Trump seeking policy recommendations to expand IVF access.

It’s the second time Newsom has asked lawmakers to delay the law. When the Democratic governor signed the bill in September, he asked the legislature to consider delaying implementation by six months. The reason, Newsom said then, was to allow time to reconcile differences between the bill and a by state regulators to include IVF and other fertility services as an essential health benefit, which would require the marketplace and other individual and small-group plans to provide the coverage.

Newsom spokesperson Elana Ross said the state needs more time to provide guidance to insurers on specific services not addressed in the law to ensure adequate and uniform coverage. Arrezola said embryo storage and donor eggs and sperm were examples of services requiring more guidance.

State Sen. Caroline Menjivar, a Democrat who authored the original IVF mandate, acknowledged a delay could frustrate people yearning to expand their families, but requested patience “a little longer so we can roll this out right.”

Sean Tipton, a lobbyist for the American Society for Reproductive Medicine, contended that the few remaining questions on the mandate did not warrant a long delay.

Lawmakers to advance the delay to a vote by both houses of the legislature, likely before the end of June. If a delay is approved and signed by the governor, the law would immediately be paused. If this does not happen before July 1, Arrezola said, the Department of Managed Health Care would enforce the mandate as it exists. All plans were required to submit compliance filings to the agency by March. Arrezola was unable to explain what would happen to IVF patients whose coverage had already begun if the delay passes after July 1.

The California Association of Health Plans, which opposed the mandate, declined to comment on where implementation efforts stand, although the group agrees that insurers need more guidance, spokesperson Mary Ellen Grant said.

Kaiser Permanente, the state’s largest insurer, has already sent employers information they can provide to their employees about the new benefit, company spokesperson Kathleen Chambers said. She added that eligible members whose plans renew on or after July 1 would have IVF coverage if implementation of the law is not delayed.

Employers and some fertility care providers appear to be grappling over the uncertainty of the law’s start date. Amy Donovan, a lawyer at insurance brokerage and consulting firm Keenan & Associates, said the firm has fielded many questions from employers about the possibility of delay. Reproductive Science Center and Shady Grove Fertility, major clinics serving different areas of California, posted on their websites that the IVF mandate had been delayed until January 2026, which is not yet the case. They did not respond to requests for comment.

Some infertility patients confused over whether and when they will be covered have run out of patience. Ana Rios and her wife, who live in the Central Valley, had been trying to have a baby for six years, dipping into savings for each failed treatment. Although she was “freaking thrilled” to learn about the new law last fall, Rios could not get clarity from her employer or health plan on whether she was eligible for the coverage and when it would go into effect, she said. The couple decided to go to Mexico to pursue cheaper treatment options.

“You think you finally have a helping hand,” Rios said of learning about the law and then, later, the requested delay. “You reach out, and they take it back.”

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“When we first found out IVF was our only option, it just felt so overwhelming,” said Freschi, who has insurance through the California marketplace. “No one sets aside 20, 30 grand to grow your family.”

The Freschis are far from alone in requiring medical assistance to have children: About 13% of women and 11% of men in the U.S. , while others are in a same-sex relationship, single, or want to preserve their eggs or sperm before undergoing various medical treatments.

And, like the Freschis, do not have health insurance that pays for IVF.

During his campaign, President Donald Trump vowed that the government or require insurers to cover it. In February, he signed an seeking policy recommendations on expanding IVF access, dubbing himself the “” a few weeks later.

Whether the administration’s efforts will change policy remains unknown, but state-level attempts to mandate fertility coverage reveal the gauntlet of budgetary and political hurdles that such initiatives face — obstacles that have led to millions of people being left out.

“There are economic opponents, and there are ideological opponents,” said Sean Tipton, a lobbyist for the American Society for Reproductive Medicine. “It is a tough lineup of opponents. And that’s very consistent from state to state.”

have passed legislation requiring insurers to cover at least some fertility care, and 15 of those require coverage for IVF. The laws vary widely, though, when it comes to who and what gets covered, largely because of debates over cost. Fertility services can range from diagnostic testing and ovulation-enhancing drugs to IVF, widely considered the most effective but also the most expensive treatment, during which one or more lab-fertilized eggs are transferred to a uterus.

It’s mostly those footing the bill amid rising and that have voiced opposition. State insurance mandates “factor in significantly” when it comes to whether employers continue to provide coverage at all because of financial concerns, according to Chris Bond, a spokesperson for AHIP, which represents health insurers, who also said employers “want to have flexibility with how these benefits are structured.”

States cite concerns about higher premiums and the budget impact of having to cover government workers. In the past few years, infertility coverage bills in , , and , for example, failed largely over cost.

IVF advocates, however, from a decade ago showing that fertility care in states with mandates has accounted for of total premium costs, a figure similar to . And advocates often argue that building a family is a , though fertility care is wealthy, white women. Covering IVF for the Medicaid population, which includes more than 70 million Americans, rarely into legislative proposals.

The California Example

California is a case study in how many of these conversations play out. Cost concerns sank IVF legislation in the state for before lawmakers approved a mandate last year. goes into effect July 1 and requires large employers with state-regulated health insurance to cover infertility diagnosis and treatment, including IVF. State employees will get coverage in 2027.

California’s mandate is considered one of the most comprehensive and inclusive in the country, said Barbara Collura, president of Resolve: The National Infertility Association, making same-sex couples and single parents eligible for coverage. But it still leaves out most of the state’s insured population, including those covered by Medicaid, the Affordable Care Act marketplace, and self-insured companies, which account for of workers and are federally regulated.

Mimi Demissew, executive director of Our Family Coalition, an LGBTQ+ rights nonprofit that co-sponsored SB 729, said her group envisioned the broadest possible mandate, which would have included people covered by small employers, the marketplace, and other privately purchased plans. “We dreamed big,” she said. “But the pushback and the whittling down was because of the budget.”

Gov. Gavin Newsom’s finance department over concerns about the state’s budget and higher premiums. And groups representing the cited costs in their opposition, with the California Chamber of Commerce “one of the most formidable expenses a business experiences,” per a legislative analysis.

The law going into effect this year is estimated to cover around 9 million people, 5 million fewer than originally proposed. Annual premiums, whose cost is typically shared by employers and employees, are projected to increase for people with state-regulated health insurance by approximately $40 per person covered in the first year.

Mandates Vary Widely by State

More than 10 states — including California — have what fertility experts call , which requires some insurers to cover IVF with minimal restrictions. But even in those states, large swaths of the population miss out.

In Massachusetts, which has one of the country’s oldest, broadest mandates for infertility coverage, including IVF, of women were eligible as of 2019.

Those covered by these mandates, however, are grateful. Luisa Lopez, a nonprofit executive, credited the three IVF cycles that New York’s mandate covered with allowing her and her husband to have a baby after 10 years of trying.

“I feel very lucky to live in a state that prioritized this,” Lopez said. Still, she said, she was on the hook for thousands of dollars in copays and other costs.

In states with narrow mandates, coverage is elusive. With , only state employees have qualified for IVF coverage through Utah’s mandate, for example. Joseph Letourneau, a University of Utah fertility specialist who successfully lobbied for fertility preservation coverage for Medicaid patients and state employees with cancer, said he couldn’t recall ideological opposition to fertility coverage but that some legislators were concerned about raising costs.

Oklahoma and Kentucky limit coverage requirements to patients who wish to preserve their fertility because of specific medical conditions.

Pushback Beyond Costs

Some opponents of IVF coverage say life begins at the moment of conception and have expressed concerns about the disposal of embryos during the IVF process.

Chieko Noguchi, a spokesperson for the U.S. Conference of Catholic Bishops, said the Catholic Church teaches that IVF is morally wrong because it “involves the death or freezing of embryonic children and treats human beings like products that can be bought and ordered.”

In Republican-controlled-Georgia, some advocates say the proposal of abortion restrictions has distracted from efforts to mandate fertility coverage. SisterSong, a reproductive justice nonprofit, supports two bills that would require private insurers and Medicaid to cover IVF in Georgia. But, the organization’s director of maternal health and birth equity initiatives, Leah Jones, acknowledged a steep uphill battle given the costs and anti-abortion legislation that some could criminalize IVF. Having to fight just for the legality of IVF, she said, detracts from expanding access.

“We’re always on the defense,” Jones said.

Several states, , or have that would protect access to IVF after Alabama’s state Supreme Court ruled that embryos created through IVF , leading to . Zemmie Fleck, executive director of Georgia Right to Life, said the Georgia anti-abortion bill would not make IVF illegal.

This over protecting versus restricting or even prohibiting IVF has raised questions about how his executive order will play out. Letourneau of Utah said some of his patients have asked if the order will cover their treatment costs.

The White House did not respond to requests for comment.

An Uncertain Road Ahead

While a provide IVF coverage as a health benefit, most patients are left to find ways to pay on their own. Some have turned to loans — IVF financing startups such as and have raised millions in venture funding.

The Freschis have applied for grants, , and have put their upcoming cycle on a credit card.

“It’s so scary,” said Freschi, describing worries about potential unexpected IVF costs. “It just feels like you’re constantly walking around with a weight on you.”

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Pahlka’s 2023 book, “,” outlines her views on why the government so often fails to achieve its policy goals in the digital age. In it, she argues that “archaeological” layers of policies, regulations, and processes center the bureaucracy, not the public.

As a deputy chief technology officer under President Barack Obama, Pahlka helped launch the , a unit within the White House that paired top technology talent with federal agencies to make government services more efficient and user-friendly. It was the predecessor to Elon Musk’s “Department of Government Efficiency,” or DOGE. On Feb. 25, from the renamed service, saying they would not “carry out or legitimize DOGE’s actions.”

Pahlka believes bolstering the government’s tech chops and relying less on contractors could save taxpayer dollars. However, as the administration looks to slash spending, she worries that DOGE’s “very indiscriminate” approach to date could wind up harming people who rely on public benefits such as Medicaid.

ºÚÁϳԹÏÍø News spoke to Pahlka, now a senior fellow at the nonpartisan Niskanen Center, about what she sees as “irresponsible transformation” and how best to fast-track government reform. This interview, conducted in mid-February, has been edited for length and clarity.

Q: You’ve made a career of bringing Silicon Valley talent into the public sector to improve the delivery of government services. What have you learned from mixing tech with government?

A: It’s really easy to look from the outside of government and say, “That’s crazy it works that way. I’m going to go in and fix it.” And when you get in, it’s that way for a reason, and you gain so much more empathy and sympathy for people in public service. You realize that people who you thought were obstructionists actually are just trying to do their jobs.

Civil servants deserve respect. We’re just not transforming government fast enough.

Q: What are the key changes you think would speed things up?

A: One, you have to be able to hire the right people and fire the wrong ones.

You also have to be able to reduce procedural bloat. When the unemployment insurance crisis hit, every state’s labor commissioner got called in front of the legislature and yelled at for the backlog. Rob Asaro-Angelo in New Jersey brought boxes and boxes of paper — 7,119 pages of active regs. And when they kept yelling, he kept pointing them to them and saying, “You can’t be scalable with 7,119 pages of regulations.”

The third pillar is investment in digital and data infrastructure.

And the fourth is closing the loop between policy and implementation. In California, you get thousands of bills introduced every year in the legislature. We don’t need that many. We need legislators to follow up on bills that have already been passed, see if they’re working, tweak them if they’re not. They need to go into agencies and say, “If this is hard for you to do, what mandates and constraints can we remove so you can make this a priority?”

Q: Civic technologists pushed through layers of bureaucracy in California to boost participation in the Supplemental Nutrition Assistance Program. How did that process unfold?

A: When we started working on California’s SNAP application, it was 212 questions. It started from, “What are all the policies that we need to comply with?” Instead of, “How would this be easy for someone to use?”

I think it can always be helpful to have fresh eyes on something. If those eyes have experience in consumer technology, they’re going to see through that lens of, “How do we deliver something that is easy for people to use?”

Q: House Republicans are to safety net programs such as SNAP and Medicaid, and restricting eligibility. In recent years, organizations including Code for America hundreds of millions in private funding to modernize social safety net programs and make them more accessible. How optimistic do you feel that these efforts will progress over the next four years?

A: Let me say what I hope for: I hope that the states now get that when we don’t transform fast enough in a responsible way, you are inviting irresponsible transformation. I hope this gives governors and mayors all over the country a kick in the butt to say, “Whatever we have done so far, it has been insufficient. We really need to work on the capacity of our state to deliver in a modern era.”

Q: What do you mean by irresponsible transformation?

A: Maybe there is good stuff that DOGE is doing now that I don’t know about or good stuff that they will do in the future. I don’t have a crystal ball. But I do see that there is a huge difference between without Congress’ permission and making an IT system work better.

Q: To that point, seems to have shifted from modernizing government systems to, ostensibly, rooting out fraud, waste, and abuse. What do you make of that change?

A: I think the thesis that better technology could reduce waste, fraud, and abuse is sound, but you want to see both better use of technology to ensure that taxpayer dollars aren’t wasted, and that people who need their benefits are going to get them. You need a North Star that includes both of those things.

Q: And you’re not seeing that in DOGE?

A: They have not expressed great care for what damage can happen to people who rely on benefits. I’m just seeing large, very indiscriminate cuts.

They have signaled that government needs its own internal tech capacity and that it’s shocking how reliant on contractors our government is. I would agree with that.

We have a very dysfunctional government technology contracting ecosystem. There’s this set of big firms that we’ve outsourced our technology to that get to charge taxpayers a shocking amount of money to implement changes.

Q: Thousands of federal workers are now being pushed out. In light of your view that we outsource too much, what are your feelings on that?

A: We’ve overrelied on the idea that we should bring people in from the outside and underinvested in helping career civil servants to do transformation work themselves.

When I wrote my book, the biggest hero was Yadira Sánchez, who I think now has been at the Centers for Medicare & Medicaid Services for 25 years. She’s a leader who really pushes for the kinds of decisions that are going to make a service for doctors that’s going to be usable. She gets pushback and comes back and says, “If you make that decision, we are going to alienate doctors. They’re going to stop taking Medicare patients. And we’ve got to do it this different way.”

We need more of her, and we need to empower lots of people like that.

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Then, Kim learned to go further. Through a training program, she gained the know-how and confidence to provide emotional support. She learned evidence-based mental health such as asking open-ended questions. She also discovered that some things she was already doing, such as listening attentively and restating what she hears, are core to communicating empathy — a of a successful relationship between a client and their mental health provider.

“It was very refreshing to see that it’s named and to realize those are skills,” she said.

, where Kim works, is a part of a fledgling movement trying to address a dire shortage of therapists by training community health workers and other nonlicensed professionals who have trusted relationships with their communities to add mental health counseling to their roles. This approach, already implemented abroad and some common mental health conditions, is called lay counseling.

The Oakland, California-based community health center serves mostly low-income Asian immigrants who speak limited English. As a community health worker, Kim now also practices lay counseling under a licensed therapist’s supervision. She does not have a license, but as a Korean immigrant and strong-arm robbery survivor, she shares lived experiences with many of the people she serves, enabling her to build trust.

Research suggests Asian Americans see mental health providers than people of other races, and up to half of some subgroups accessing mental health care. Figures like these may be only the tip of the iceberg, as Asian Americans can be reluctant even to seek help. Cultural stigma against mental illness and feeling like one’s problems pale in comparison to the trauma faced by earlier generations are among the reasons, said Connie Tan, senior research analyst at , a think tank.

Asian Health Services introduced lay counseling during the covid-19 pandemic. Violence against Asian Americans , and therapists fluent in any of the 14 languages spoken by the communities the health center cares for were in short supply. of people in the U.S. identify as Asian, Native Hawaiian, or Pacific Islander, but these groups account for only .

Concerned that people were falling through the cracks, the health center in 2021 launched a grant-funded initiative to support victims of violence. In addition to lay counseling and therapy by licensed providers, available in several languages, the program, known as the , provides services such as helping clients access crime victim funds.

The program has sent 43 community health workers, case managers, and other employees to a lay counseling training program, said Ben Wang, the health center’s director of special initiatives. Trainees learn through formal instruction, observing teachers providing counseling, and practicing counseling with one another, along with feedback from instructors.

Thu Nguyen, a domestic violence survivor, was struggling with anxiety and self-blame. “My inside talk eats me up,” she explained. Worried that sharing with family members would burden them, she was unsure where else to turn for support after meeting with a therapist she didn’t click with. Through the program, Nguyen was assigned to Kim, who connected her to a compatible therapist.

Nguyen also leaned on Kim for emotional support. When she confided feeling guilty and inadequate as a single mother, Kim responded without judgment and affirmed Nguyen’s dedication.

“She validates my feeling,” said Nguyen, a Vietnamese immigrant. “She would say, ‘I understand that it’s hard. You’re doing the best.’”

Asian Americans can struggle to find therapists , speak their language, or come from similar communities. Licensed therapists typically must complete an advanced degree, pass professional exams, and work at least two years under supervision. Requirements vary by state and by type of license. It has that the process ensures high-quality care.

Lay counseling proponents contend this path is costly and time-consuming, limiting the field’s diversity and exacerbating the therapist shortage. They also point to . Lay counseling has been implemented in several countries, where mounting evidence symptoms of depression, anxiety, and a few other mental health conditions.

“The idea that someone without a license could not [communicate empathy] skillfully is ridiculous,” said Elizabeth Morrison, a psychologist and co-founder of , which has trained 420 people, including Kim, to add lay counseling to their roles since launching two years ago. Trainees hail from a variety of jobs, including faith leaders and first responders.

The 65-hour primarily virtual course such as supporting people who have experienced trauma, counseling methods such as cognitive behavioral therapy and motivational interviewing, first-line strategies for treating depression and anxiety, and setting boundaries. The course does not teach how to diagnose mental health conditions. Instead, trainees learn to affirm strengths, acknowledge feelings, avoid giving advice, and otherwise listen empathically.

Asian Health Services staff members who provide lay counseling receive ongoing support and guidance after the training from a program manager and a licensed therapist, Wang said.

Raquel Halfond, a senior director at the , said she believes it’s important for lay counselors to receive training and to practice under the supervision of a licensed mental health professional, but the group has no formal model or standards for the use of lay counselors.

The course not only upskills but also recognizes what many trainees that may not be acknowledged as counseling. “It’s like this invisible, unpaid work, and people chalk it up as someone being nice,” Morrison said.

Lay counseling is still nascent, and it often takes years for a new field to become established — and for insurers to get on board. Morrison and Laura Bond, a research fellow at Harvard Medical School’s , another lay counseling training initiative, said they are not aware of any organizations that can bill public or private insurers for lay counseling.

In an email, Leah Myers, a spokesperson for the California Department of Health Care Services, which oversees Medi-Cal, the state’s Medicaid program, acknowledged there is no billing code for lay counseling or certification for lay counselors. She said Medi-Cal reimburses certain nonlicensed providers for services that “may include what would be considered ‘lay counseling’-like activities” but would need more details to make a determination.

The Community Healing Unit’s , from the state of California to support victims of hate crimes, ends in 2026. The program has served over 300 people and is developing a survey to gather feedback, Wang said.

Nguyen knew Kim wasn’t a licensed therapist but didn’t care, she said; she appreciated that Kim, a fellow Asian woman, made her feel safe to process her feelings. Kim was also easily accessible through biweekly check-ins, and responded promptly if Nguyen called at other times.

Now, Nguyen said, telling herself “you’re doing good” comes more easily.

Supplemental support comes from the through .

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As a relative newcomer to Los Angeles, the recruiter, now 31, knew few Black people who could recommend doctors who had treated them with respect. She combed review sites, including Google reviews and Healthgrades, but couldn’t find how nearby physicians and hospitals might treat a Black woman like her.

“It’s hard to tell if it’s a fellow Black person who’s giving the review,” Caldwell said.

Consumer ratings sites rarely identify patient experiences by race or ethnicity and hospitals are under no obligation to reveal the racial and ethnic breakdowns of their patient satisfaction scores. Yet that information could be instrumental in holding maternity care providers and hospitals accountable for treating patients inequitably and could empower expectant mothers like Caldwell in finding quality obstetric care.

“You can’t change what you don’t see,” said Kimberly Seals Allers, founder of allowing Black and brown women to find and leave reviews of maternity care providers. She’s one of a few entrepreneurs developing new tools for collecting feedback from mothers of color.

A steady drip of new research over the past several years has spotlighted racial discrimination by maternity care providers and in one of the country’s most vexing health disparities: Black women experience the worst birthing outcomes, a gap not explained by income or education, according to a . In 2021, they were as likely to die of pregnancy-related causes as white women.

Mothers of color, especially Black women, report that they do in fact experience discrimination. They are to say that their care providers ignored them, scolded them, or pressured them into treatments they didn’t want. The extent to which discrimination is reported by survey, but one recently published report by the Centers for Disease Control and Prevention found roughly 30% of Black, Hispanic, and multiracial women , compared with 20% of women overall.

It’s unclear how many hospitals track survey responses by race, and, even if they do, they rarely reveal that information. And the federal government requires generic reporting on how patients say they were treated, making it difficult to pin down and address incidents of bias in maternity care.

Funding and Regulations Lag

Currently, the results of the industry’s standard patient experience survey, known as the Hospital Consumer Assessment of Healthcare Providers and Systems, are made publicly available by the federal government to help patients compare hospitals. They incentivize hospitals to improve care and are included in the rankings of many hospital ratings sites, such as U.S. News & World Report’s Best Hospitals. But it doesn’t ask about or discrimination and has , .

These flaws can also make the survey inadequate for improving birth equity. “We know it’s insufficient,” said Amanda P. Williams, an OB-GYN and clinical innovation adviser to the nonprofit California Maternal Quality Care Collaborative. Hospitals, she said, could fill in the gaps by collecting feedback from and breaking the results out by race and other demographic information; they could also talk to patients through forums such as town halls or focus groups.

Joy Lewis, senior vice president for health equity strategies at the American Hospital Association, said many hospitals do this work, both generally and in obstetrics.

However, Williams believes it isn’t happening enough in maternity care.

She said there are some pockets where people are doing these activities but that they are not yet widespread. At a national conference of 200 hospital executives this year, Williams said, only a few raised their hands when asked if they break out their maternity outcomes data. “If your overall C-section rate is fine, you might think everything’s hunky-dory,” she said. “But if you see that your Black people are having 50% higher C-section rates than your white and Asian patients, there’s very important work to be done.”

Then there are barriers to participation. Studies have found many in the Black community .

Fearing retaliation and being seen as an “angry Black woman,” Ta-She-Ra Manning, a maternal health program coordinator in Fresno, California, said she didn’t provide any critical feedback when her OB-GYN dismissed her concerns about unusual symptoms during her 2021 pregnancy.

Meanwhile, new funding to measure disparities has been slow in coming. President Biden’s 2023 budget to develop a supplemental survey aimed at reducing maternal health disparities, among other steps. But Congress did not fund the item. Instead, in the Department of Health and Human Services is developing it with its own funding and estimates the work will take less than five years, according to a statement from Caren Ginsberg, who directs the agency’s surveys.

Still, the public likely won’t see changes anytime soon. After a survey’s measures are created, it can take several years for the results to be publicly reported or tied to payment, said Carol Sakala, senior director for maternal health at the National Partnership for Women & Families, an advocacy organization.

“This molasses level of movement contrasts acutely with all the things hitting the news about people not getting the right care and attention and respect,” Sakala said.

Amid growing interest in health equity, traditional ratings sites are grappling with how much to share with the public. For its , U.S. News & World Report recently started assessing whether hospitals tracked racial disparities in maternity outcomes measures, but it withholds actual results. Healthgrades is taking time to think through how to collect and display sensitive information publicly, said spokesperson Sarah Javors in a statement.

Black Innovators Fight for Better Data

Some Black women are trying to fill the void by creating new feedback mechanisms that could be more trusted by the community. Allers said she created Irth after a traumatic birth experience as a Black mother at a highly rated hospital left her feeling failed by mainstream ratings. On the app, verified users answer questions, from whether they felt respected by their doctor to if they experienced certain types of mistreatment such as dismissal of pain. Irth currently has 10,000 reviews of hospitals, OB-GYNs, and pediatricians nationally, according to Allers.

“Our data is for the community,” said Allers. “They know their feedback has value to another mom or family.”

Irth also offers analysis of the reviews to hospitals and leads campaigns to collect more reviews for them. But Allers said many hospitals have expressed little interest.

Karen Scott, an OB-GYN who created , a scientifically validated survey that measures racism in Black birthing experiences, said she has met hospital leaders who don’t think their providers could mistreat patients or who worry that documenting responses could carry legal risk.

The American Hospital Association’s Lewis declined to comment specifically on Irth and PREM-OB but acknowledged the Black community’s long-standing mistrust of health care providers. She said hospitals want to hear more from patients in historically marginalized groups.

Early signs of progress are emerging in parts of the country.

California hospitals will likely report disparities in birth outcomes and patient satisfaction measures. Hospitals are expected to start posting by race and other demographics on their websites in 2026, though the state hasn’t finalized the measures that will be required, said Andrew DiLuccia, a spokesperson for the state’s health data agency. At least two states, and , have disclosed rates of C-sections among low-risk patients by race for individual hospitals.

Scott founded Birthing Cultural Rigor to increase uptake of her survey. The firm has to recruit respondents in select counties in Georgia, Michigan, Ohio, and Tennessee. Scott said results will be used to train local health professionals on how to reduce racism in maternity care.

Separately, Irth will collect and analyze reviews for three hospitals or health systems in California, said Allers. One of them, MemorialCare Miller Children’s and Women’s Hospital Long Beach, will work with Irth to better understand the impact of birth equity efforts such as implicit bias training.

“We’ll get to see if what we’re doing is actually working,” said Sharilyn Kelly, executive director of the hospital’s perinatal services.

Caldwell, the recruiter, eventually found a doctor she trusted and went on to have a smooth pregnancy and delivery. Her son is now 8 months old. But with so little information available on how she might be treated, she said, she felt anxious until she met her doctor, when “a lot of that stress and anxiety melted away.”

Digital strategy & audience engagement editor Chaseedaw Giles contributed to this report.

[Editor’s note: California Healthline is an editorially independent service of the California Health Care Foundation, which has contributed funding to PREM-OB and the birth equity nonprofit Narrative Nation, which developed Irth.]

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April Valentine, a 31-year-old Black mother, died while giving birth in Inglewood, California, on Jan. 10. Her family has raised questions of improper care: Why didn’t nurses investigate numbness and swelling in her leg, symptoms she reported at least 10 times over the course of 15 hours? Why did it take nearly 20 hours for her doctor to see her after she arrived at the hospital already in labor?

Valentine’s family wants the state to investigate how she died and whether systemic or interpersonal racism could have played a role. have amplified their demands. “I think she would have been treated differently if she was white,” said Valentine’s cousin Mykesha Mack, who filed a complaint.

The of death was a blood clot that formed in her leg and traveled to her lung — a . The state has issued a to Centinela Hospital for risking the health and safety of Valentine, and an inspection report suggests it her risk for blood clots, take precautions, and alert her physician. Centinela announced last month that it would on Oct. 25.

Even so, the odds of finding discrimination and getting justice remain stacked against her family.

The statuses of the state’s investigations aren’t clear, and a federal investigation is pending. The hospital and Valentine’s OB-GYN deny allegations of improper care and reject assertions by some family members that Valentine’s care team, which was largely Black, could have harbored bias toward her. But a ºÚÁϳԹÏÍø News analysis shows state authorities are ill-equipped to investigate discrimination complaints and often avoid fining hospitals that violate regulations. That highlights a big gap in the state’s ability to hold doctors and hospitals accountable when it comes to reducing bias in maternal care.

Aiming to reduce stark health disparities, in 2019, California became the first state to for maternity care providers. But the state hasn’t penalized physicians and hospitals that treat patients inequitably, as it hasn’t found discrimination in the incidents brought to their attention. Neither of the agencies overseeing health care facilities and physicians — the California Department of Public Health and Medical Board of California — has found discrimination, despite hundreds of complaints going back a decade, the ºÚÁϳԹÏÍø News analysis found.

In the unlikely event that regulators find discrimination, they usually prefer corrective actions for violations, such as improvement plans, as opposed to penalties. Karen Smith, a physician who led the Department of Public Health from 2015 to 2019, said the agency wants hospitals to provide high-quality care, not to shut them down. So when one violates a regulation, the agency typically tries to help it remedy the problem, depending on the severity. The medical board has for avoiding meaningful penalties, even for grossly negligent doctors.

California’s rate of maternal deaths is in the country, but is as high for Black women as for women of other races. , including systemic racism and provider bias, implicit or not, are thought to contribute to this disparity. Valentine’s is high-profile death of a Black mother whose family said her care providers dismissed her.

Some advocates believe these cases keep happening because the state’s oversight of hospitals and doctors is too lax. “There’s no accountability,” said Linda Jones, a co-founder of Black Women Birthing Justice, a nonprofit organization seeking birth equity. “Why should they do anything different?”

A Mother’s Pleas Are Dismissed

Valentine, who worked with at-risk youth and styled hair on the side, was acutely aware of the risks Black mothers face, so she diligently and sought a and , her family said.

Valentine’s sister Kesiah Cordova said she accompanied the first-time mother to a late-afternoon visit on Jan. 9 with her OB-GYN, Gwen Allen, who told them Valentine was dilated and that she would meet them at the hospital. Valentine went to Centinela Hospital Medical Center, owned by , one of the country’s largest for-profit health systems.

Cordova and Valentine’s partner, Nigha Robertson, were both with her throughout her stay. They said she got to the hospital around 8:30 p.m. While being admitted, Valentine was asked several questions by staff that made her feel uncomfortable, including if she knew who her baby’s father was and what type of housing her baby would live in, they said. Robertson said he doubts white mothers are asked these questions as often. Centinela responded in a statement that every patient is asked these questions to identify any nonmedical factors that could affect their health, so it can provide any necessary resources. Nurses then forbade her doula from attending her delivery, despite the hospital’s approval a month earlier, Robertson and Cordova added. The hospital said it welcomes doulas.

After receiving an epidural five hours later, Valentine reported leg numbness and, later, swelling, they said. Cordova and Robertson estimated that they witnessed Valentine ask nurses to examine her leg and call her doctor at least 10 times. Each time, they said, the nurses declined, saying her symptoms were normal.

“Every time they came to check on her, she would say, ‘Hey, can you look at my leg?’” said Cordova. “The nurse didn’t even lift up the blanket to check.”

Cordova and Robertson said nurses repeatedly told them they couldn’t call Valentine’s OB-GYN because she would get upset. They said Allen did not visit her until 4 p.m. the next day and did not address her concerns.

Two hours later, Cordova and Robertson said, Valentine coughed and vomited. A nurse told them this was normal. Then Valentine stopped breathing. Robertson and Cordova said the nurse in the room froze, so Robertson stepped in and gave Valentine CPR for about five minutes until additional staff, then Allen, arrived. They said her providers did not try to revive her before she was wheeled away. Centinela refuted these allegations but said it could not comment further.

Aniya was delivered via emergency cesarean section from her mother’s body.

No Track Record of Finding Discrimination

The state’s public health department and medical board would not comment on the details of Valentine’s case.

The California Department of Public Health is “deeply saddened” by what happened to Valentine and her family and takes “every action within its legal authority to safeguard patients,” including thoroughly investigating complaints, said spokesperson Ali Bay in a statement.

Asked how it evaluates the possibility of discrimination, the public health department sidestepped and said its role is to determine if any federal or state regulations were violated, and later added that hospitals must follow regulations that allow patients to exercise their rights without regard to race. It provided ºÚÁϳԹÏÍø News a copy of a letter dated Feb. 23 from Mark Ghaly, secretary of the California Health and Human Services Agency, to the Los Angeles County Board of Supervisors. Ghaly declined to be interviewed.

In the letter, he said the state would review medical records, interview medical staff, and assess the hospital’s policies and procedures in its investigation.

But the public health department’s track record shows it hasn’t substantiated a discrimination complaint yet. Statewide, the department has not found any violations of regulations protecting patients against discrimination since 2007, Bay said. She said the department found over 650 complaints that mention racism, discrimination, or both in all available records since 2007. It receives an average of around and reported incidents across all facility types every year.

The medical board also hasn’t substantiated discrimination complaints against physicians. Since 2014, it has not found that a physician discriminated against a patient in any of the over 240 complaints it has closed, said Aaron Bone, the board’s chief of legislation and public affairs. He cautioned against drawing conclusions from a small sample; the agency received approximately 10,000 complaints of all types in 2020 alone.

Both agencies’ figures have limitations. The medical board tracks only discrimination resulting in a doctor’s refusal to treat. And neither agency knows exactly how many discrimination complaints were race-based.

The exact reasons for their limited track records are unclear, but some experts point to the high burden of proof for substantiating these cases.

Abbi Coursolle, a senior attorney at the National Health Law Program, said anti-discrimination laws and regulations can be . They are intended to protect people from intentional discrimination and policies or actions that disproportionately harm them. But people can unconsciously harbor biases, or there could be alternative explanations for ignoring a patient, such as a provider being busy, which can make discrimination hard to substantiate.

Racism “is complicated and hard to isolate, but the law hasn’t quite caught up to that,” she said.

State agencies, she added, can interpret the law so narrowly that people can’t take advantage of these protections.

The California agencies said they do their best within their legal authority. The medical board blamed current law, which, it said, requires “clear and convincing evidence” to discipline a physician, and it can be challenging to substantiate cases if the allegations aren’t documented or aren’t corroborated by witnesses. There may not always be sufficient evidence to find a violation, said Bay, of the public health department.

Smith, the former public health department director, said discrimination by a facility is typically hard to find unless investigators identify a pattern, but that type of research can be labor-intensive and hampered by underreporting of complaints.

So far, the public health department has imposed a $75,000 fine for risking Valentine’s health and safety. In his letter, Ghaly said the state could revoke or suspend the hospital’s license if it finds Centinela violated state or federal regulations. It could also refer the case to other agencies. The federal Department of Health and Human Services’ Office for Civil Rights acknowledged it is investigating Valentine’s case but declined to comment.

Centinela’s fine is the exception, not the rule. Last year, roughly 100 fines were levied against hospitals statewide out of nearly 12,000 complaints and incidents closed, according to a state database. The department cautioned that the data contains many redundant complaints and noted that not all violations require issuing fines. It declined to provide aggregated data on corrective actions, such as improvement plans, and nonfinancial penalties, such as license suspensions.

on improve hospital care, illustrating how regulators’ hands may be tied.

‘Thoughts and Prayers’

The state public health department conducted an inspection of Centinela in February. It found the hospital an unnamed labor and delivery patient’s risk for clotting and failed to notify her physician when she reported “leg heaviness” and when her vital signs were abnormal. Though the inspection, by the Los Angeles Times, does not name Valentine, it describes the account her partner and family shared, including the date she was admitted to the hospital.

In its report, the department deemed the situation “immediate jeopardy,” meaning the hospital’s failure to meet requirements caused or could have caused death or serious injury. But regulators removed that label after the hospital submitted an improvement plan. Among other measures, it promised to reeducate nurses on how to prevent blood clots.

The report found Centinela made similar missteps with other patients, potentially increasing their risk for developing blood clots in deep veins, typically in the leg, which, when untreated, can travel to the lungs. Known as a pulmonary embolism, this condition is one of the of pregnancy-related deaths in the United States, and is if discovered early, according to the Centers for Disease Control and Prevention. It was also the official cause of Valentine’s death, stated the Los Angeles County medical examiner’s website.

Centinela said it immediately addressed the inspection’s findings. Sue Lowe, a Centinela spokesperson, said it was the hospital, not the state, that decided to close its maternity and newborn units, “to create capacity for services of greatest benefit and need for patients.”

Robertson, Valentine’s partner, said he felt the report validated his account.

“They killed her,” said Robertson, who has retained an attorney. For him, justice would mean a punishment severe enough to ensure Valentine’s situation never happens again, but he wants Centinela to remain in business since it’s the only hospital in Inglewood.

Lowe said the hospital could not discuss specifics due to patient privacy laws but extended the hospital’s “thoughts and prayers” to Valentine’s family. She added, “We express our deepest condolences.”

Before the results of the state’s inspection report and the county’s autopsy report were publicized, Centinela implied the death was unpreventable. “Despite the highest standards of care,” said Lowe, “there are certain medically complex and emergent situations that cannot be overcome.” Centinela declined to comment on the autopsy results.

Lowe defended the hospital’s track record, noting it has won national and . She said it had gone a decade without a maternal death in labor and delivery before Valentine’s. She also said the unit was appropriately staffed.

In 2020, the hospital registered 1.8 times the number of complaints and incidents as the state average. So far this year, it’s 9.5 times as many. Lowe responded that the state hasn’t substantiated many of these and that, in some recent years, the hospital had fewer total violations than the state average for hospitals of its size.

The hospital, Lowe said, maintains “robust policies prohibiting discrimination” and requires diversity and implicit bias training for staff. “Our staff reflects the community that we serve,” she added.

Allen, the OB-GYN, directed questions to her attorney, Ludlow B. Creary II, who said his client could not comment on the case, citing patient privacy protections. But he urged against drawing conclusions without both sides of the story and a medical expert’s assessment of whether Allen caused Valentine’s death. Allen, like the community she has served for 20 years, is Black, he added.

Doctors Oppose More Oversight

Mack, Valentine’s cousin, said Valentine’s providers being largely Black did not sway her view that they could have discriminated against her. She said she hopes the state evaluates whether interpersonal or systemic racism, or both, contributed to Valentine’s death. Did her clinicians dismiss her complaints due to bias, and did the hospital, located in a minority neighborhood, provide lower-quality care?

Both types of racism can be hard to see. The numbers, however, show they exist. Studies suggest Black mothers are more likely than white ones to by clinicians and to deliver at hospitals with .

The public health department discrimination and systemic racism could have contributed to a maternal death in a quality improvement process known as the California Pregnancy-Associated Mortality Review. But this committee lacks authority to discipline hospitals or clinicians.

Attempts to reform laws often face resistance. Last year, the medical board to lower the burden of proof for disciplining physicians from “clear and convincing” to a standard equivalent to “more likely than not,” followed by . A bill including this request the California State Senate and is pending in the Assembly.

The California Medical Association, which represents physicians, , unless amended. “Clear and convincing” is the standard for disciplining professional license-holders in California, spokesperson Shannan Velayas said.

In Inglewood, a world away from bureaucrats and lobbyists, Robertson grieves and struggles as a single father. His job in crime scene and disaster cleanup can require long and unpredictable hours. He was recently called in to work at 2 in the morning, leaving him scrambling to get ahold of Aniya’s godmother to come watch her.

“It’s overwhelming, just all this juggling,” he said.

In periods of calm, father and daughter bond over picture books Valentine bought and go to the park with their dog. Robertson said Aniya, now over 6 months old and sitting up, is deeply loved.

Still, there’s a void that will only grow as Aniya gets older. He can’t style her hair the way Valentine would have and worries that he won’t be able to support her as a mother would when Aniya becomes a young woman.

“I don’t want nobody else to have to go through this hurt and pain,” Robertson said.

When told the state rarely finds discrimination, he paused, recognizing a gap in accountability. He said, “The government pick and choose which situations that they press the issue on.”

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In September, American Medical Response, the largest U.S. provider of ambulance services, announced it had “” to end nonemergency transports in Los Angeles County and blamed the state for having one of the lowest Medicaid reimbursement rates in the country. “What’s more,” the company, which sold for in 2017 to , said, “we are not subsidized by taxpayer funds like public agencies, and almost 80% of our patients pay nothing or below cost for our services.”

The company, which also cited high operational costs, said its nonemergency division in that area was on track to lose $3.5 million in 2022.

The California Department of Health Care Services, which administers the state’s Medicaid program for low-income people, known as Medi-Cal, did not contest that the base rate hasn’t increased since 1999, but said that reimbursements have increased through add-on payments for and .

In its initial announcement, AMR mentioned the phaseout of nonemergency services only in L.A. County. However, the company told KHN that it would stop servicing five hospitals in Orange County in addition to seven hospitals in L.A. County.

Jason Sorrick, vice president of government affairs at KKR-owned Global Medical Response, which is now AMR’s parent company, said AMR would exit over the next six months and shift vehicles and as many of the 170 crew members as possible to its core emergency services.

AMR’s pullout equates to a loss of 28,000 nonemergency transports a year and could create a predicament for the hospitals that contracted with the company. L.A. County said it does not track the total number of nonemergency rides provided by ambulances in the county, while Orange County wasn’t immediately able to share its figure.

Although ambulances are typically associated with 911 calls, many are used to transport frail or vulnerable patients between health care facilities. A patient may need to go to a rehabilitation facility after hip surgery, or someone who attempted suicide may need to be moved from an emergency room to a psychiatric facility. Such transfers, known as interfacility transports, enable hospitals to free up beds and maintain patient access.

There isn’t consensus on what the impact of AMR’s pullout will be. The state told KHN that it will review and address access issues on a “targeted basis” if it becomes aware of any. Patient advocates said it’s too early to draw conclusions about the effect on patients, particularly those covered by Medi-Cal. The California Ambulance Association flagged concerns that companies are already stretched thin by staffing and vehicle shortages.

Though the two counties and the insurers that serve their Medi-Cal populations did not express immediate concern about AMR’s decision, some hospitals may have trouble dealing with the loss.

“Halting these services will undoubtedly impact hospitals’ ability to efficiently manage” the flow of patients from arrival to discharge, said Adam Blackstone, senior vice president of communications for the Hospital Association of Southern California.

AMR said its pullout will primarily affect Providence, a Catholic health system operating in several states, including California. It did not respond to a request for comment.

AMR now also attributes its exit to avoiding a labor dispute. Sorrick said that because of Medi-Cal’s rates, AMR could not staff both emergency and nonemergency ambulances and raise wages for unionized emergency staffers who were threatening to strike. So it shuttered its lower-priority nonemergency division, which wasn’t unionized. It planned to use the savings to increase wages for emergency staff members.

Michael Diaz, an EMT and president of the International Association of EMTs and Paramedics Local 77, which represents 350 EMTs and paramedics for AMR emergency services in L.A. County, confirmed that AMR’s announcement came the day before the union planned to march in protest for higher wages.

Diaz, whose national union had joined the industry in lobbying the California legislature for higher rates, said AMR’s announcement could also have been politically motivated. “They’re sending a message,” he said.

So far, it’s unclear whether elected officials have noticed the pullout. Leaders of legislative budget committees declined to comment or did not respond to inquiries.

Medi-Cal spending on all medical transportation services totaled about $975 million in fiscal year 2021-22, according to data from the Department of Health Care Services.

The department said Medi-Cal’s insurers are ultimately responsible for maintaining an adequate network of medical transportation providers and noted that the insurers are allowed to pay above the base rate. The ambulance industry said it’s uncommon for insurers to pay more.

Jimmy Pierson, president of the California Ambulance Association, said other ambulance companies usually pick up the slack when one exits a market. But he warned that competitors may not be able to cover all of AMR’s nonemergency ambulance rides this time, given unprecedented labor and supply shortages — including — and rising Medi-Cal enrollment and inflation. A recent national survey found that EMTs turned over at an .

“How are you going to find 170 employees in a labor shortage?” Pierson asked. “How will you find those ambulances?”

Ambulance companies said that hiring and retention have been battered by low wages, burnout, and lasting effects of EMT school closures during the pandemic — and that low Medi-Cal reimbursements make paying EMTs competitive salaries difficult.

A few other companies in the state have already shut down or scaled back services, Pierson added. In 2016, AMR in Tulare County, a region in the Central Valley with shares of residents on Medi-Cal.

Sorrick said AMR believes enough companies provide nonemergency transports to absorb the volume.

Chad Druten, president of the Los Angeles County Ambulance Association, said the county has approximately 1,200 licensed private ambulances operated by , most of which are small to medium-sized and focus on nonemergency transports. A few large companies, including AMR, cover emergency calls.

Melissa Harris, who owns AmbuServe Ambulance Service in L.A. County, said she plans to compete for small portions of AMR’s contracts, focusing on the ones with fewer Medi-Cal patients. Harris said she loses money on every Medi-Cal-covered transport and can’t easily buy and staff new ambulances. If she wins any contracts, she will likely have to “trade” away her existing contracts that serve the highest portions of Medi-Cal patients.

The consequences of that, Harris said, would hit underserved patients the hardest.

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En abril de 2020, su padre, un jardinero jubilado, murió de insuficiencia cardíaca y pulmonar. González hizo el duelo solo. Su trabajo como médico en formación le exponía a un alto riesgo de contraer el virus, y no quería contagiar a su familia. El estrés económico también se apoderó de él al tener que hacer frente a los elevados costos del entierro.

Ahora, González reclama una mejor remuneración y prestaciones para los residentes que trabajan horarios agotadores en los hospitales públicos del condado de Los Angeles por lo que, según él, reciben menos de $18 la hora, mientras atienden a los pacientes más vulnerables del condado.

“Se están aprovechando de nuestro altruismo”, dijo González. Ahora es jefe de residentes de medicina familiar en Harbor-UCLA y presidente del Comité de Internos y Residentes (CIR), un sindicato nacional que representa a los médicos en prácticas y que forma parte del Sindicato Internacional de Empleados de Servicios (SEIU).

“Necesitamos que se reconozcan los sacrificios que hemos hecho”, señaló.

Los residentes son médicos recién recibidos, que han terminado la carrera de medicina, y deben pasar de tres a siete años de formación en hospitales universitarios antes de poder ejercer de forma independiente.

Bajo la supervisión de un médico profesor, los residentes examinan, diagnostican y tratan a los pacientes. Algunos buscan formación adicional en especialidades médicas como “fellows” (práctica de especialización).

Estos médicos en formación se están agrupando en California, y otros estados, para exigir mayores salarios y mejores beneficios y condiciones de trabajo, luego de la enorme presión vivida durante la pandemia.

Así, se suman a enfermeras y enfermeros, auxiliares de enfermería y otros trabajadores de salud que se están sindicalizando y amenazan con ir a la huelga, ya que la , el y la falta de uniformidad en el suministro de y les han llevado al límite.

Más de 1,300 residentes sindicalizados y otros médicos en formación de tres hospitales públicos del condado de Los Angeles, incluido el Harbor-UCLA, votarán el 30 de mayo si se declaran en huelga para pedir un aumento de salarios y de gastos de alojamiento, tras un mes de bloqueo de las negociaciones con el condado.

Desde marzo, los residentes de , la y el se han sindicado.

“Los residentes siempre han trabajado horarios de locos, pero el estrés de la pandemia les afectó mucho”, explicó , director de la Facultad de Relaciones Industriales y Laborales de la Universidad de Cornell.

La Asociación de Escuelas de Medicina de Estados Unidos, un grupo que representa a los hospitales universitarios y a las facultades de medicina, no abordó directamente la tendencia a la sindicalización de los residentes, pero la jefa de atención sanitaria de la organización, la doctora Janis Orlowski, comunicó a través de un vocero que una residencia es un aprendizaje laboral, y que la función principal de un residente es formarse.

Los residentes cobran como aprendices mientras estudian, se forman y trabajan, dijo Orlowski, y la asociación trabaja para garantizar que reciban una formación y un apoyo eficaces.

David Simon, vocero de la Asociación de Hospitales de California, no quiso hacer comentarios. Pero remitió a publicado en JAMA Network Open, en septiembre, en el que se mostraba que los residentes de cirugía en programas sindicados no reportaban menores tasas de agotamiento que los de los programas no sindicados.

Según el sindicato nacional, hasta el momento ningún nuevo grupo sindical ha alcanzado ningún acuerdo. Pero algunos de los más antiguos han conseguido mejoras en los , y las . El año pasado, un sindicato de residentes de la consiguió subvenciones para la vivienda y permisos parentales pagos.

Con más de 20,000 miembros, el CIR/SEIU representa a en Estados Unidos. Su directora ejecutiva, Susan Naranjo, dijo que antes de la pandemia se organizaba un nuevo grupo sindical cada año, y que en el último año y medio se han unido ocho.

Las condiciones de trabajo de los residentes ya habían sido objeto de escrutinio mucho antes de la pandemia.

El salario medio de los residentes en Estados Unidos en 2021 , según MedScape, un sitio web de noticias para médicos, y los residentes pueden trabajar .

Aunque una encuesta cuyos resultados se publicaron encontró que el 43% de los residentes se sentían compensados adecuadamente, los que se están sindicalizando dicen que los salarios son demasiado bajos, especialmente teniendo en cuenta la carga de trabajo de los residentes, su deuda de préstamos estudiantiles y el aumento del costo de vida.

La tasa salarial afecta de manera desproporcionada a los residentes de comunidades de bajos ingresos y de color, afirmó González, porque tienen menos ayuda financiera de la familia para subvencionar su educación médica y para pagar otros gastos.

Sin embargo, al tener poco control sobre el lugar en el que se forman —a los graduados de escuelas de medicina se les asigna su residencia mediante un algoritmo—, individualmente, los residentes tienen un poder de negociación limitado con los hospitales.

Para los residentes sindicalizados que buscan ser escuchados, los aumentos salariales y los beneficios, como los estipendios de vivienda, son a menudo la prioridad, dijo Naranjo.

Los pacientes merecen médicos que no estén agotados y preocupados por el estrés financiero, dijo la , “fellow” de endocrinología en el Centro Médico de la Universidad de Vermont. A Amin le sorprendió que la institución se negara a reconocer al sindicato de residentes, teniendo en cuenta los sacrificios personales que hicieron durante la pandemia.

Si un hospital no reconoce voluntariamente a un sindicato, el CIR puede solicitar que la Junta Nacional de Relaciones Laborales administre una elección. El sindicato nacional lo hizo en abril, y con una mayoría de votos certificada, la sección de Vermont puede ahora comenzar la negociación colectiva, señaló Naranjo.

Annie Mackin, vocera del centro médico, declaró en un correo electrónico que está orgullosa de sus residentes por haber prestado una atención excepcional durante la pandemia y respeta su decisión de afiliarse a un sindicato. Mackin no quiso referirse a las preocupaciones de los residentes sobre las condiciones de trabajo.

, profesora de políticas de salud en la Universidad George Washington, cree que los Centros de Servicios de Medicare y Medicaid (CMS) también tienen cierta responsabilidad en las condiciones de trabajo de los residentes. Dado que la agencia paga a los hospitales universitarios para que formen a los residentes, debería responsabilizar a los centros de cómo los tratan, dijo.

Y el Consejo de Acreditación para la Educación Médica de Postgrado, que establece las normas laborales y educativas para los programas de residencia, se está moviendo en la dirección correcta con nuevos requisitos como la licencia familiar pagada, agregó, pero necesita hacer más.

Está por verse hasta dónde llegarán estos sindicatos para conseguir sus objetivos.

Las huelgas son poco frecuentes entre los médicos. La última huelga del CIR fue , la realizaron residentes en Nueva York.

Naranjo aseguró que una huelga sería el último recurso para sus miembros en el condado de Los Angeles, pero culpó al condado de retrasar y cancelar continuamente las sesiones de negociación. Entre sus demandas, el sindicato pide que el condado iguale el aumento salarial concedido a los miembros del SEIU 721, un sindicato que representa a otros empleados del condado, y que se conceda un subsidio de vivienda de $10,000.

Las encuestas realizadas a los miembros del sindicato han revelado que la mayoría de los médicos residentes del condado de Los Angeles dicen trabajar 80 horas a la semana, según Naranjo.

Una vocera del Departamento de Servicios de Salud del condado de Los Angeles, Coral Itzcalli, agradeció a su “heroica” fuerza de trabajo de primera línea por proporcionar “la mejor atención de su clase” y reconoció la importante carga que la pandemia ha supuesto para sus vidas personales y profesionales. Dijo que el Consejo de Acreditación para la Educación Médica de Postgrado establece los límites de horas y que la mayoría de los médicos en formación dicen trabajar “significativamente menos” de 80 horas a la semana.

Jesús Ruiz, vocero de la Oficina Ejecutiva del condado de Los Angeles, que gestiona las negociaciones laborales, indicó por correo electrónico que el condado espera llegar a un “contrato justo y fiscalmente responsable” con el sindicato.

Se espera que los resultados de la votación sobre la huelga se anuncien el 31 de mayo, según comunicó el sindicato.

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In the early weeks of the pandemic, Dr. , then a second-year resident of family medicine at Harbor-UCLA Medical Center, ran on fumes, working as many as 80 hours a week in the ICU. He was constantly petrified that he would catch the covid-19 virus and guilt-ridden for not having enough time to help his ailing father.

In April 2020, his father, a retired landscaper, died of heart and lung failure. González mourned alone. His job as a doctor-in-training put him at high risk of catching the virus, and he didn’t want to inadvertently spread it to his family. Financial stress also set in as he confronted steep burial costs.

Now, González is calling for better pay and benefits for residents who work grueling schedules at Los Angeles County’s public hospitals for what he said amounts to less than $18 an hour — while caring for the county’s most vulnerable patients.

“They’re preying on our altruism,” González said of the hospitals. He is now chief resident of family medicine at Harbor-UCLA and president of the Committee of Interns and Residents, a national union that represents physician trainees and that is part of the Service Employees International Union.

“We need acknowledgment of the sacrifices we’ve made,” he said.

Residents are newly minted physicians who have finished medical school and must spend three to seven years training at established teaching hospitals before they can practice independently. Under the supervision of a teaching physician, residents examine, diagnose, and treat patients. Some seek additional training in medical specialties as “fellows.”

These trainees are banding together in California and other states to demand higher wages and better benefits and working conditions amid intensifying burnout during the pandemic. They join nurses, nursing assistants, and other health care workers who are unionizing and threatening to strike as , the , and inconsistent supplies of and have pushed them to the brink.

More than 1,300 unionized residents and other trainees at three L.A. County public hospitals, including Harbor-UCLA, will vote May 30 on whether to strike for a bump in their salaries and housing stipends, after a months-long negotiation deadlock with the county. Since March, residents at , , and the have unionized.

“Residents were always working crazy hours, then the stress of the pandemic hit them really hard,” said , a director at Cornell University’s School of Industrial and Labor Relations.

The Association of American Medical Colleges, a group that represents teaching hospitals and medical schools, did not address the unionization trend among residents directly, but the organization’s chief health care officer, Dr. Janis Orlowski, said through a spokesperson that a residency is a working apprenticeship and that a resident’s primary role is to be trained.

Residents are paid as trainees while they are studying, training, and working, Orlowski said, and the association works to ensure that they receive effective training and support.

David Simon, a spokesperson for the California Hospital Association, declined to comment. But he forwarded published in JAMA Network Open in September showing that surgery residents in unionized programs did not report lower rates of burnout than those in nonunionized programs.

So far, none of the new chapters have negotiated their first contracts, the national union said. But some of the longer-standing ones have won improvements in . Last year, a resident union at the secured housing subsidies and paid parental leave through its first contract.

With more than 20,000 members, CIR represents about in the U.S. Executive Director Susan Naranjo said that before the pandemic one new chapter organized each year and that eight have joined in the past year and a half.

Residents’ working conditions had come under scrutiny long before the pandemic.

The average resident salary in the U.S. in 2021 , according to Medscape, a physician news site, and residents can work . Although one survey whose results were released last year 43% of residents felt they were adequately compensated, those who are unionizing say wages are too low, especially given residents’ workload, their student loan debt, and the rising cost of living.

The pay rate disproportionately affects residents from low-income communities and communities of color, González said, because they have less financial assistance from family to subsidize their medical education and to pay for other costs.

But with little control over where they train — medical school graduates are matched to their residency by an algorithm — individual residents have limited negotiating power with hospitals.

For unionizing residents seeking a seat at the table, wage increases and benefits like housing stipends are often at the top of their lists, Naranjo said.

Patients deserve doctors who aren’t exhausted and preoccupied by financial stress, said , an endocrinology fellow at the University of Vermont Medical Center. She was surprised when the institution declined to recognize the residents’ union, she said, considering the personal sacrifices they had made to provide care during the pandemic.

If a hospital does not voluntarily recognize a union, CIR can request that the National Labor Relations Board administer an election. The national union did so in April, and with a certified majority vote, the Vermont chapter can now begin collective bargaining, Naranjo said.

Annie Mackin, a spokesperson for the medical center, said in an email that it is proud of its residents for delivering exceptional care throughout the pandemic and respects their decision to join a union. Mackin declined to address residents’ workplace concerns.

, an associate professor of health policy at George Washington University, believes that the federal Centers for Medicare & Medicaid Services also bears some responsibility for residents’ working conditions. Because the agency pays teaching hospitals to train residents, it should hold the facilities accountable for how they treat them, she said. And the Accreditation Council for Graduate Medical Education, which sets work and educational standards for residency programs, is moving in the right direction with new requirements like paid family leave, she added, but needs to do more.

How far these unions will go to achieve their goals is an open question.

Strikes are rare among doctors. The last CIR strike wasÌýÌýby residents in New York.

Naranjo said a strike would be the last resort for its L.A. County members but blamed the county for continuously delaying and canceling bargaining sessions. Among its demands, the union is calling for the county to match the wage increase granted to members of SEIU 721, a union that represents other county employees, and for a $10,000 housing allowance.

The union’s member surveys have found that most L.A. County residents report working 80 hours a week, Naranjo said.

A spokesperson for L.A. County’s Department of Health Services, Coral Itzcalli, thanked its “heroic” front-line workforce for providing “best-in-class care” and acknowledged the significant toll that the pandemic has taken on their personal and professional lives. She said limits on hours are set by the Accreditation Council for Graduate Medical Education and that most trainees report working “significantly less” than 80 hours a week.

Jesus Ruiz, a spokesperson for the L.A. County Chief Executive Office, which manages labor negotiations for the county, said via email that the county hopes to reach a “fair and fiscally responsible contract” with the union.

Results of the strike vote are expected to be announced May 31, the union said.

This story was produced by , which publishes , an editorially independent service of the .

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