While Congress debates whether to put more money into free testing, California is leaning on programs it already had in place: special state-based coverage for uninsured Californians, school testing, and free tests offered by clinics, counties, and other groups. Absent free options, people without health insurance could pay as much as depending on where they get tested.

At the same time, demand for community testing — from residents with and without insurance — has dropped precipitously.

On a recent Thursday, only three people could be found getting tested at seven testing sites in Sacramento County. Staffers at these locations — from the formerly bustling mass-testing site at the state fairgrounds to a tiny kiosk in a church parking lot — said hardly anyone shows up anymore even though testing is still important for monitoring and reducing the spread of covid-19. They mostly see regulars who come in for routine testing required by their employer or school.

Dr. Olivia Kasirye, the public health officer for Sacramento County, said the county sends specimens to a state lab at no cost to the county, which has helped keep free testing services up and running. California is quietly , but the state says it will shift testing to a network of commercial labs. State officials told KHN there will be no changes for patients.

“I think we can maintain services” for now, but the future is uncertain, Kasirye said.

Since the beginning of the pandemic, the federal government had reimbursed providers for testing, treating, and vaccinating uninsured people for covid-19. But the stopped accepting reimbursement claims for tests and treatments March 22, and for vaccinations April 5, saying the money had run out. The government had been reimbursing providers per test.

Since then, states and counties have been watching their case rates and coffers to see whether they can keep testing uninsured residents.

In Alabama, Dr. Scott Harris, the state health officer, said offering free testing to people five days a week through county health departments is “probably not something we’re going to be able to sustain much longer,” especially in pockets of the state with large uninsured populations.

“We’re going to have zero services for those people,” Harris said. “And no ability to incentivize providers to see them.”

Congress returns from recess in late April but may not renew the program. Lawmakers previously considered extending it but chose not to include money for it in a that’s been pending since early April.

The Covid-19 Uninsured Group

Health care advocates say California has been able to continue free testing for the uninsured, including for residents without legal documentation, because of how it used a separate pot of federal funding. Although also leveraged pandemic support, advocates believe California expanded benefits the most.

In August 2020, California created an insurance program with pandemic relief money to cover covid-related treatments, testing, and vaccines for uninsured people or those whose insurance plans don’t cover those services. The Covid-19 Uninsured Group essentially acts as Medicaid for covid, but with no income requirements. That’s different from traditional Medi-Cal, California’s Medicaid program, which is for low-income people.

Coverage will end when the federal public health emergency does. On April 13, the U.S. Department of Health and Human Services renewed the emergency declaration for 90 days, extending it to .

The state program is a clever way to use federal dollars, said David Kane, a senior attorney at the Western Center on Law & Poverty. But he noted there are drawbacks. People must be enrolled before they can obtain services, and they can’t enroll themselves. Only certain health care providers, mostly hospitals and clinics, can sign people up.

“The program was never designed to exist in isolation,” Kane said, “but now it does.”

About 291,000 people were enrolled in the program as of April 4, according to Anthony Cava, a spokesperson for the state Department of Health Care Services, which administers Medi-Cal. An estimated Californians, or around 9.5% of people younger than 65, are uninsured.

Kane suggested that people find a qualified provider by the Department of Health Care Services or by calling the and get enrolled as soon as possible, especially if they are used to walking up to a testing site and paying nothing.

The challenge is getting people to sign up before they get sick or need a test, Kane said, and keeping the program going with the added patient load.

Screening Students

Another major source of free testing in California is public schools.

California distributed more than to schools before students left for spring break. The schools in turn handed out the rapid tests to families so they can screen students before sending them back to campus. The state had a similar program for the winter holidays.

The winter testing was “incredibly effective,” according to Primary Health, the company running the program for the state. About voluntarily reported their results back to a sampling of schools, according to the company.

In addition, the state is paying Primary Health to operate more than 7,000 free testing sites — most of which are in schools — by using leftover federal covid relief money disbursed to states at the beginning of the pandemic.

How long that funding will last isn’t clear.

“It seems like the federal government is stepping back and saying this portion of health care is going back to health care as we know it,” said Abigail Stoddard, Primary Health’s general manager of government and public programs.

Stoddard’s conversations with schools outside California are changing. Instead of conducting surveillance testing to determine whether the virus is circulating on campus, as California is doing, many are moving toward testing only kids with symptoms, she said.

For example, Primary Health operates , where schools are applying for grants to fund testing and will decide whether tests will be for sick students, healthy ones, or just staffers.

Local Free Testing

Free testing is still available in California through some hospitals, community clinics, local health departments, and private companies working with the state, although how long those options will remain is unclear.

In Sacramento County, the loss of federal funding for testing uninsured people has gone mostly unnoticed so far. “Our hope is that we have enough services and resources in the community that the additional coverage going away will not have a huge impact,” Kasirye said.

The county health department still offers free community testing to uninsured people .

But they may get harder to find. The testing company Curative used to offer free lab-run PCR and rapid antigen tests around the state, but now that the federal funding has run out, it offers only PCR tests to the uninsured for free. The company has also reduced the number of its sites, from 283 on April 14 to 135 on April 19.

In some states, Curative has either stopped testing uninsured people — or is charging them $99 to $135 per test.

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

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Newsom, a self-described feminist and the father of four young children, has long advocated family-friendly health and economic policies. Flush with a projected budget surplus of $75.7 billion, state politicians have come up with myriad legislative and budget proposals to make poorer families healthier and wealthier.

They include ending sales taxes on ; adding benefits such as doulas and early childhood trauma screenings to Medi-Cal, the state’s Medicaid program; allowing pregnant women to retain Medi-Cal coverage for a year after giving birth; and a pilot program to provide a universal basic income to low-income new parents.

“COVID-19 laid inequity bare for all to see,” Assembly member Wendy Carrillo (D-Los Angeles) said in a written statement. She is the co-author of Senate Bill 65, led by Sen. Nancy Skinner (D-Berkeley), which would pour hundreds of millions of dollars into family and health care programs annually, focusing on minority groups that Carrillo said were “pushed out of the social safety net by the prior White House.”

Newsom and the Democratic-controlled legislature are unified on major health care and social safety-net expansions, which would direct billions in health benefits and cash assistance to the state’s most vulnerable residents and low-income parents. Legislative Democrats for years have pushed a progressive agenda to help struggling parents and families, featuring proposals like those to permanently end taxes on menstrual products and diapers — .

“We don’t need to balance the budget on half of the population that has a uterus,” said Assembly member Cristina Garcia (D-Bell Gardens), who has to the “pink tax” on diapers and menstrual products.

Skinner, chair of the Senate budget committee, is among the powerful lawmakers who’ve put forward legislation to make childbirth safer and parenthood more affordable. Her bill, which cleared the Senate and was up for consideration this week in the state Assembly, has several features that would dramatically expand maternal health care (transgender men also get pregnant and give birth).

Before the pandemic, Medi-Cal covered mothers only up to 60 days after their pregnancies ended unless their income fell below a certain line or they had a mental health diagnosis. Skinner’s bill, part of a to improve birth outcomes, would expand full Medi-Cal coverage to 12 months after the end of a pregnancy. Other would intensify state reporting and reviews of fetal and pregnancy-related deaths and severe maternal morbidity, expand housing benefits for families that have a pregnant member, and increase training programs for midwives.

Newsom’s $268 billion budget blueprint includes about $200 million a year to fully implement the expansion of Medi-Cal coverage for new mothers, with matching dollars from the federal government until those funds expire in 2027. If the expansion were not renewed, the state would revert to previous Medi-Cal qualifications.

in California in 2017, the last year for which data could be found.

“Not all postpartum issues end at 60 days, and when patients lose insurance, we can’t address them in the usual way,” said Dr. Yen Truong, an OB-GYN who works with the American College of Obstetricians and Gynecologists on legislative issues in California.

About half of pregnancy-related deaths occur during the pregnancy or on the day of delivery, but about 12% take place after giving birth, according to the Centers for Disease Control and Prevention.

The U.S. had 17.4 early maternal deaths per 100,000 live births in 2018, according to the most recent CDC data with state figures. California’s rate, , was among the lowest in the nation, but the state collects data on maternal deaths in a way that could result in underestimates.

California’s overall numbers also obscure stark racial disparities. Statewide, Black infants averaged , compared with an average of three deaths among white babies. Data from 2013 from showed Black women had pregnancy-related deaths at rates more than four times as high as the overall rate in the state’s largest county.

“Given our state’s wealth and medical advancements, this is unacceptable,” Skinner, vice chair of the Legislative Women’s Caucus, said in a news release.

Democrats also appear unified on another aspect of Skinner’s bill: a pilot program to test a universal basic income program for struggling families. The bill would give $1,000 a month to low-income expectant and new parents with kids under 2 years old in counties that decide to participate. Newsom has also proposed for pilot programs for universal basic income.

These issues could play well, especially among women, and improve Newsom’s standing going into a recall election later this year, said Rose Kapolczynski, a longtime campaign consultant to former U.S. Sen. Barbara Boxer who has worked on reproductive health care issues in Sacramento.

Indefinitely rescinding sales taxes on diapers and menstrual products — the taxes have been — is a particular no-brainer because of its bipartisan appeal, she said.

“It’s hard for Republicans to attack something that is a tax cut, and sales taxes are regressive, so progressives would like it,” Kapolczynski said.

As for Medi-Cal expansions, Kapolczynski said that even though it wouldn’t affect most Californians, the pandemic has made health care even more important to voters. “The budget surplus is allowing many things that were called impossible to be possible, and that includes health care bills,” she said.

Investing in California’s young families could help close the racial gap in maternal and infant mortality, said Nourbese Flint, executive director of the Black Women for Wellness Action Project, which endorsed Skinner’s bill.

Flint is especially excited about the possibility of covering doulas through Medi-Cal. Doulas, trained as emotional and physical supports for women in pregnancy and postpartum, have been linked to and . If doulas saved Medi-Cal money by reducing cesarean births, that could enable the state to renegotiate payments for labor and delivery, according to an . Under Newsom’s proposed budget, Medi-Cal coverage of doulas would cost about .

California’s would become the first Medicaid program to include “full spectrum” doula coverage, meaning it would include care for women who have abortions, miscarriages and stillbirths, said Amy Chen, a senior attorney at the National Health Law Program.

“California has always led the country and been a little bit in front of where our federal government is when it comes to covering folks,” Flint said.

California Healthline correspondent Angela Hart contributed to this report.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

With Republicans now controlling both chambers of the Montana legislature and the governor’s office, a lawmaker is reviving an effort to both broaden and increase the frequency of eligibility checks to search for welfare fraud, waste and abuse. Proponents say it’s about what’s fair — weeding out people who don’t qualify, protecting safety nets for those who do, and saving the state millions. But advocates for low-income people who rely on such services and some policy analysts say such changes would unfairly drop eligible people who need the aid.

“We’re not looking to do anything mean. We’re taking the emotion out of it,” state Sen. , a Republican, said during a on his bill, the Provide for the Welfare Fraud Prevention Act. “If you don’t qualify, then you shouldn’t be participating in that program.”

The , and measures underway in and , are similar to earlier efforts undertaken to cut costs in states such as Illinois and Michigan. But this year’s bills come even as Congress states more Medicaid dollars if they ensure people have continuous coverage through the pandemic because of its economic shock waves.

The Montana would create a system potentially run by third-party vendors that would mine a large swath of data to see if someone, for example, has assets like a boat, has won the lottery or has filed for benefits in another state. The vendor could earn a bonus for flagging more cases than the state projected. State employees would have the final say in cutting someone from Medicaid, the Children’s Health Insurance Program, food stamps or other aid programs.

The state estimates the measure could save Montana’s treasury between $1.4 million and $2.3 million each year over the next four years by dropping more than 1,500 people on Medicaid and 277 children covered by CHIP.

This isn’t Smith’s first effort to create such a law. He sponsored a similar in 2015 that was vetoed by the state’s then-governor, Democrat Steve Bullock. In the , Bullock said the measure duplicated steps the state already took and unfairly stigmatized Montanans who are poor. Opponents of Smith’s latest proposal have repeated those concerns. Smith didn’t respond to several requests for an interview.

But this time, the potential legislation has a clearer path. The state has a new governor, Greg Gianforte, a Republican who called for heightened Medicaid eligibility checks throughout his 2020 campaign.

During Montana’s first hearing for the renewed effort, of Opportunities Solutions Project was the sole person to testify in support of the bill.

“I’ve seen this play out in state after state,” Centorino said. “Turns out, the less you look for welfare, fraud and waste, the less you find.”

Opportunity Solutions Project, the lobbying wing of the Foundation for Government Accountability, a right-leaning think tank, has backed that followed FGA model legislation. The organizations have also been in trying to link food assistance to work requirements and block states from expanding Medicaid.

Opportunity Solutions Project’s attempts to influence laws at the federal level, too, appear to be growing. The nonprofit spent $25,500 lobbying the federal government in 2017 and $420,000 last year, the Center for Responsive Politics.

Opponents of the Montana bill have said the focus on welfare recipients is misplaced. Nationally, most Medicaid payments deemed improper last year were tied to states not collecting information that federal standards already call for, not necessarily for covering ineligible enrollees, according to a U.S. Department of Health and Human Services .

, a University of Baltimore law professor, said the potential bonus Montana would pay a company finding more savings than expected is especially concerning.

“The goal should not be to create some bounty hunter system to find alleged cheats that don’t exist,” Gilman said. “This is built on an unfounded mistrust of poor people and undermines public support for social programs.”

If states do move to undertake broad data searches, she said, they need to start with a pilot program to test for errors in its design. Gilman called Michigan the ultimate cautionary tale. The state, which had used a new computer program to spot cheaters, ended up mired in lawsuits after it thousands with unemployment fraud between 2013 and 2015.

The Trump administration and federal agencies encouraged states to increase eligibility checks. According to a KFF analysis, as of January 2019 were conducting checks more often than during annual renewals, with some doing so quarterly. (KHN is an editorially independent program of KFF.)

, co-director of KFF’s Program on Medicaid and the Uninsured, said Medicaid and CHIP across the nation from late 2017 through 2019. Rudowitz said it’s hard to untangle all the reasons the enrollment declines occurred, but increased verification efforts that add to administrative hurdles create barriers to coverage.

, with the left-leaning Center on Budget and Policy Priorities, said people may not realize they’re still eligible when notified that their benefits are in question or may not even receive the notice. She said a search for benefits filed in a separate state may flag aid that can cross states, such as food stamps, and such searches can pull up property someone no longer owns. Frequent wage checks may not take into account inconsistent jobs. The onus would fall to the aid recipient to prove they are still eligible in each scenario, she said.

One state that Opportunity Solutions Project points to as a success is Illinois, which in 2012 hired a company to identify Medicaid recipients who might not be eligible. Wagner, who was an associate director with the Illinois Department of Human Services at the time of the change, said Illinois is unique because the state knew it had a backlog of status checks. Within a year, Illinois had canceled benefits for nearly 150,000 people. But the that more than 75% of cancellations were due to clients’ failure to respond to a state letter asking for more information. Wagner said similar issues have occurred in other states.

“In many cases, those individuals remain eligible, but they have a gap in coverage and they have to reapply and do what they can to get back on the program,” said Wagner. “There’s a large cohort of people who never get that done.”

Of all the people Illinois dropped, nearly 20% had reenrolled by the end of the year. That issue — people getting knocked off when they’re eligible — already happens in annual renewals. But Wagner said more checks means more people losing benefits, and more work for states to bring those people back onboard.

Centorino, with Opportunity Solutions Project, said systems that remove qualified people aren’t being implemented properly, but added it’s not too heavy of a lift to respond to an eligibility question.

“The alternative is not is not resolving the discrepancy at all and just assuming that there is no discrepancy and continuing to fund benefits for somebody who may be ineligible,” he said.

In Montana, even with the bill’s clearer shot at becoming law, some elements that opponents criticized were rolled back after the state estimated it would need to hire 42 employees to run the new system. Smith reduced how many programs would fall under its scrutiny and pulled back eligibility checks to twice a year instead of quarterly. He removed a rule that the system pay for itself, and he cut a section that would have disenrolled people who don’t respond to eligibility questions or notices within 10 business days.

Nonetheless, if a new system flags issues in people’s enrollment, the state will have to go out searching for why. The bill is under consideration in the Senate and must also pass the House before it goes to Gianforte for signing.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Now, those health officials worry more cuts are coming, even as they brace for a spike in demand for substance abuse and mental health services. That would be no small challenge in a poor farming and ranching region where stigma often prevents people from admitting they need help, said Katherine Buckley-Patton, who chairs the county’s Mental Health Local Advisory Council.

“I find it very challenging to find the words that will not make one of my hard-nosed cowboys turn around and walk away,” Buckley-Patton said. “They’re lonely, they’re isolated, they’re depressed, but they’re not going to call a suicide hotline.”

States across the U.S. are still stinging after businesses closed and millions of people lost jobs due to covid-related shutdowns and restrictions. Meanwhile, the pandemic has led to a dramatic increase in the number of people who say their mental health has suffered, (KHN is an editorially independent program of KFF.)

The full extent of the mental health crisis and the demand for behavioral health services may not be known until after the pandemic is over, mental health experts said. That could add costs that budget writers haven’t anticipated.

“It usually takes a while before people feel comfortable seeking care from a specialty behavioral health organization,” said , president and CEO of the nonprofit National Council for Behavioral Health in Washington, D.C. “We are not likely to see the results of that either in terms of people seeking care — or suicide rates going up — until we’re on the other side of the pandemic.”

Last year, states slashed agency budgets, froze pay, furloughed workers, borrowed money and tapped into rainy day funds to make ends meet. Health programs, often among the most expensive part of a state’s budget, were targeted for cuts in several states even as health officials led efforts to stem the spread of the coronavirus.

This year, the outlook doesn’t seem quite so bleak due in part to relief packages passed by Congress last spring and in December that buoyed state economies. Another major advantage was that income increased or held steady for people with well-paying jobs and investment income, which boosted states’ tax revenues even as millions of lower-income workers were laid off.

“It has turned out to be not as bad as it might have been in terms of state budgets,” said Mike Leachman, vice president for state fiscal policy for the nonpartisan .

But many states still face cash shortfalls that will be made worse if additional federal aid doesn’t come, Leachman said. to push through Congress a $1.9 trillion relief package that includes aid to states, while congressional Republicans are proposing a package worth about a third of that amount. States are banking on federal help.

New York Gov. Andrew Cuomo, a Democrat, with spending cuts and tax increases if a fresh round of aid doesn’t materialize. Some states, such as New Jersey, borrowed to make their budgets whole, and they’re going to have to start paying that money back. Tourism states such as Hawaii and energy-producing states such as Alaska, Wyoming continue to face grim economic outlooks with oil, gas and coal prices down and tourists cutting back on travel, Leachman said.

Even states with a relatively rosy economic outlook are being cautious. In Colorado, for example, Democratic that restores the cuts made last year to Medicaid and substance abuse programs. But health providers are doubtful the legislature will approve any significant spending increases in this economy.

“Everybody right now is just trying to protect and make sure we don’t have additional cuts,” said Doyle Forrestal, CEO of the .

That’s also what Buckley-Patton wants for Montana’s Beaverhead County, where most of the 9,400 residents live in poverty or earn low incomes.

She led the county’s effort to recover from the loss in 2017 of a wide range of behavioral health services, along with offices to help poor people receive Medicaid health services, plus cash and food assistance.

Through persuasive grant writing and donations coaxed from elected officials, Buckley-Patton and her team secured office space, equipment and a part-time employee for a resource center that’s open once a week in the county in the southwestern corner of the state, she said. They also convinced the state health department to send two people every other week on a 120-mile round trip from the Butte office to help county residents with their Medicaid and public assistance applications.

But now Buckley-Patton worries even those modest gains will be threatened in this year’s budget. Montana is one of the few states with a budget on a two-year cycle, so this is the first time lawmakers have had to craft a spending plan since the pandemic began.

predict healthy tax collections over the next two years.

In January, at the start of the legislative session, the panel in charge of building the state health department’s budget proposed starting with nearly $1 billion in cuts. The panel’s chairperson, Republican Rep. , pledged to add back programs and services on their merits during the months-long budget process.

It’s a strategy Buckley-Patton worries will lead to a net loss of funding for Beaverhead County, which covers more land than Connecticut.

“I have grave concerns about this legislative session,” she said. “We’re not digging out of the hole; we’re only going deeper.”

Republicans, who are in control of the Montana House, Senate and governor’s office for the first time in 16 years, are considering reducing the income tax level for the state’s top earners. Such a measure that could affect state revenue in an uncertain economy has some observers concerned, particularly when an increased need for health services is expected.

“Are legislators committed to building back up that budget in a way that works for communities and for health providers, or are we going to see tax cuts that reduce revenue that put us yet again in another really tight budget?” asked Heather O’Loughlin, co-director of the .

Mary Windecker, executive director of the , said that health providers across the state are still clawing back from more than $100 million in budget cuts in 2017, and that she worries more cuts are on the horizon.

But one bright spot, she said, is a proposal by new Gov. Greg Gianforte, a Republican, to create that would put $23 million a year toward community substance abuse prevention and treatment programs. It would be partially funded by tax revenue the state will receive from recreational marijuana, which voters approved in November, with sales to begin next year.

Windecker cautioned, though, that mental health and substance use are linked, and the governor and lawmakers should plan with that in mind.

“In the public’s mind, there’s drug addicts and there’s the mentally ill,” she said. “Quite often, the same people who have a substance use disorder are using it to treat a mental health issue that is underlying that substance use. So, you can never split the two out.”

[Correction: This article was updated at 4:45 p.m. ET on Feb. 6 to correct the value of President Joe Biden’s proposed relief package.]

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Wilson, a retiree who worked as a public health department nurse supervisor in Duval County for 35 years, had just been diagnosed with COVID-19-induced pneumonia. She had a telemedicine appointment with her doctor.

Staring back from her screen was Dr. Rogers Cain, who runs a tidy little family medical clinic a couple of blocks from the Trout River in north Jacksonville, a predominantly Black area where the coronavirus is running roughshod. Wilson, 81, was one of Cain’s patients who’d tested positive — he had seven other COVID patients that morning before noon. Three of her grown children had contracted the virus, too.

“It started as a drip, drip, drip in May,” said Cain, his voice muffled by his mask. “Now it’s more like a faucet running.”

Cain and Wilson are nervous. Over the past two decades, both watched as the county health department was gutted of money and people, hampering Duval’s ability to respond to outbreaks, including a small cluster of tuberculosis cases in 2012. And now they face the menace of COVID-19 in a city once slated to host this week’s Republican National Convention, in one of the states leading the latest U.S. surge.

Florida is both a microcosm and a cautionary tale for America. intended to protect communities against disease, staffing and funding fell faster and further in the Sunshine State, leaving it especially unprepared for the worst health crisis in a century.

Although Florida’s population grew by 2.4 million since 2010 to make it the nation’s third-most-populous state, a joint investigation by KHN and The Associated Press has found, the state slashed its local health departments’ staffing — from 12,422 full-time equivalent workers to 9,125 in 2019, the latest data available.

According to an analysis of state data, the state-run local health departments spent 41% less per resident in 2019 than in 2010, dropping from $57 to $34 after adjusting for inflation. Departments nationwide have also cut spending, but by less than half as much ― an average of 18%, according to data from the National Association of County and City Health Officials.

Even before the pandemic hit, that meant fewer investigators to track, trace and contain diseases such as hepatitis. It meant fewer public health nurses to teach people how to protect themselves from HIV/AIDS or the flu. When the wave of COVID-19 inundated Florida, the state was caught flat-footed when it mattered most, its main lines of defense eviscerated.

Now, confirmed cases have soared past 588,000 and deaths have risen to more than 10,000. Concerns over the virus prompted Republicans to cancel plans for an in-person convention in Jacksonville, opting for a pared-down version in North Carolina.

Health experts blame the funding cuts on the Great Recession and choices by a series of governors who wanted to move publicly funded state services to for-profit companies.

And when the pandemic took hold, they say, residents got mixed messages about prevention strategies like wearing masks from Republican Gov. Ron DeSantis and other political leaders. Voices within the health departments were muzzled.

“The reality, unfortunately, is people are going to die because of the irresponsibility of the decisions being made by the people crafting the budgets,” said , president of the , a nonprofit in Washington, D.C., offering tools and training. “Public health can’t help us get out of this situation without our elected officials giving us the resources.”

State officials neither answered specific, repeated questions from KHN and The Associated Press about changes in public health funding, nor made staffers available for deeper explanations.

Dr. , a former deputy secretary of Florida’s state health department, said failing to prepare for a foreseeable disaster “is governmental malpractice.” The nation’s pandemic response is only as good as the weakest link, he said. Since the virus respects no borders, other states feel the ripples of Florida’s failings.

Those failings are clear in Duval County, which had employed the equivalent of 852 full-time workers and spent $91 per person in 2008 but in 2019 had only 422 workers and spent just $34 per resident, according to the KHN-AP analysis of state data. That’s less than the of a single COVID test. Former county health director Dr. Jeff Goldhagen said the county’s team has been “dismantled to the extent that it could not really manage an outbreak.”

Yet it must.

Cain’s private north Jacksonville medical clinic alone has had about 60 confirmed COVID cases and eight deaths. “We are all on fire right now,” he said. “You have to have a fire department that is adequately equipped to put out the fire. ”

Dwindling Budgets

Florida faced similar shortcomings around the time of the last great pandemic, the 1918 flu. Back then, according to a , public health workers faced too many demands and their efforts were “to some extent scattered and transitory.” The state could have used at least three more district health officers, the report said: “It is a source of regret and a matter of grave concern to public health workers that the funds available are not sufficient.”

County-based health departments began in 1930, providing more robust services closer to home. About 50 years later, legislation created state-administered primary care programs in which county health departments provided low-income Floridians with the type of basic health care and treatment most people now get at private doctors’ offices.

The 1990s saw a move toward privatization, particularly as Medicaid managed care took hold, said a . Still, per-person spending on local public health rose until the late 1990s, when adjusted for inflation to 2019 dollars, peaking at $59.

Wilson, the retired public health nurse stricken with COVID-19, recalled how Duval County’s department started feeling the financial pain during former Republican Gov. Jeb Bush’s administration in the early 2000s and kept losing nurses and other staff until they were “very, very short.”

Beitsch, who worked for the state health department in the 1990s, said the downward trend continued under former Republican governors Charlie Crist and Rick Scott, fueled by a growing belief in shrinking government that flourished in many states. Florida’s leaders exerted more control over public health, Beitsch said, and “the amount of local autonomy has been diminishing with successive administrations.”

The recession that began in late 2007 sparked public health reductions across the nation that were especially harsh in Florida. By 2011, budget cuts and lack of money were the most frequently cited challenges in a Florida public health workforce survey, which pointed to growing needs. In the following years, the state had some of the nation’s highest rates of heart disease and diabetes.

Squeezed departments struggled and sometimes stumbled. A from the state health department’s inspector general for the 2018-19 fiscal year, for example, found a series of lost and inconsistent shipments of lab specimens from county health departments to the state lab — not long before the pandemic would make labs more important than ever.

As governor, Scott presided over the state from 2011 to 2019, when funding and staffing dropped most. Now a U.S. senator, he said through a spokesperson that he was unapologetic for health department cuts, which he characterized as a move toward “making government more efficient” without endangering public health.

“I’m sure that he had no problem with the cuts that were being made,” said , an associate professor in health administration at Florida Atlantic University. “To put it all on him is not fair because a bunch of little henchmen from the counties had to vote that way. … We keep voting in people who undervalue public health.”

Democratic state Sen. Janet Cruz, a legislator who has represented the Tampa region for a dozen years and sat on health care committees, said she watched lawmakers systematically cut money for health departments. When she questioned it, she said, some colleagues claimed the need wasn’t as great because the state was moving toward private family health care centers. “Public health in Florida has been wholly underfunded,” she said.

Some places have suffered more than others. Departments serving at least half a million residents spent $29 per person in 2019 on average, compared with $90 per person in departments serving 50,000 or fewer — a difference starker than the typical gap between larger and smaller departments nationally, according to an KHN-AP analysis. Experts can’t say exactly why the gap is wider in Florida, which has a state-run system, but point to politics and historical decisions about budgets.

Duval County’s health department spending was the equivalent of $34 per person, down 63% since 2008. Typically, about 22 workers, or 5% of the total staff, have been dedicated to preparing for and tracking disease outbreaks.

But when the pandemic hit, many there and elsewhere were diverted to fight the coronavirus, leaving little time for their typical duties such as mosquito abatement and tracking sexually transmitted infections such as syphilis.

“Current events demonstrate how bad a decision” the deep cuts to public health were, said , a professor of public health and family medicine at the University of South Florida. “It’s really come back to haunt us.”

Mixed and Muzzled Messages

The pandemic caught fire in Florida this summer as the state’s rapid reopening allowed people to flock to beaches, Disney World, movie theaters and bars.

The state has had more than half a million confirmed cases ― among them, players and workers for baseball’s Miami Marlins ― and 35,000 hospitalizations, yet DeSantis still hasn’t issued a mask mandate. Some local governments have. Jacksonville adopted one in late June, and about a week later Republican Mayor Lenny Curry announced he and his family were self-quarantining because he’d been exposed to someone who tested positive for the virus.

, director of infection prevention at the University of Florida-Jacksonville, lauded the mayor for the mask requirement, saying, “We know that masking works.” But he pointed out that other counties have different rules and that the inconsistent messaging breeds confusion.

St. Johns County began requiring masks in late July but only in county facilities. And DeSantis has appeared in public without a mask numerous times, including at

target=”_blank” rel=”noopener noreferrer”>an Aug. 13 coronavirus update

briefing during which some other speakers wore them.

“One voice is so critical during a pandemic,” said Dr. Jonathan Kantor, a Jacksonville epidemiologist and dermatologist. “We have to have one voice, and consistent leadership that is modeling behavior if we want to get people to change their behaviors.”

Instead, experts in Florida said, public health workers have been silenced or told by top state officials what to say. For example, that state leaders told school boards they needed health department approval to keep schools closed, then instructed health directors not to give it.

“All the communication is directed by the state, and localities are very limited in what they can do,” said Levine, the University of South Florida professor. “Anything to do with a mandate, there’s resistance to do at a state level. This includes the hot debate on masks. The locals have to extend the state messaging.” Local health officials “are being told bluntly: ‘Shut up,’” Bernet said. “They literally cannot speak.”

Beitsch, who now chairs the department of behavioral sciences and social medicine at Florida State University, said such limitations ― and similar mixed messages and silencing of medical experts at the national level ― fuels the politicization of public health and undermining of science.

“People think they should be listening to politicians and state legislative leaders about their health care. They’re not listening to health experts and the epidemiologists who say if you just wear a mask and if you just wash your hands, we can really, really reduce the spread of the virus,” said Cruz, the state senator. “People are confused, and they think this is a hoax and it’s nothing more than the flu.”

Meanwhile, the COVID caseload continues to rise, surpassing 25,000 in Duval County, with minorities stricken disproportionately, as elsewhere in the nation. In a county that’s 29% Black and 60% white, Black residents with COVID have been hospitalized at more than double the rate of white residents. Rates are also high for Floridians grouped together as “other,” including Native American, Asian and multiracial residents.

Duval County’s overall caseload is rising so fast that Goldhagen, the former health department director, said the agency has given up on contact tracing, which means trying to curb the virus by identifying and warning people who have been exposed.

“It’s impossible,” Goldhagen said. “Dismantling the system was a complete disregard for the health and well-being of the citizens of Florida.”

With an unequipped public health system, Wilson, the retired public health nurse, said it falls to everyone to lead Jacksonville, and Florida, out of the coronavirus crisis.

“My hope is that everybody begins to take this virus seriously, and wear their mask and stay social distancing. It can work if we do that,” said Wilson, whose condition has improved. “So, that’s my hope. Eventually there will be a vaccine that will curtail this virus. But until then, it’s up to us to help do that. And if we’re not serious about it, then we’re doomed.”

This story is a collaboration between KHN and The Associated Press.

Methodology

Spending and staffing data for Florida’s local health departments is from the Florida Department of Health. Florida Atlantic University professor Patrick Bernet provided additional state data on staffing by program area. KHN-AP adjusted spending data for inflation using the Bureau of Economic Analysis’ state and local government deflator.

COVID-19 data by race is from the Florida Department of Health. KHN-AP calculated rates per 10,000 people using data on race, regardless of ethnicity, from the U.S. Census Bureau’s 2018 American Community Survey. Statewide COVID-19 cases per day are from Johns Hopkins University.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

“That’s the exact thing that makes you feel significantly worse,” the 26-year-old Denver woman said. “It creates a cycle where you’re constantly getting dug into a deeper hole.”

Part of her recovery involved forcing herself to leave her room to socialize or to exercise outside. But the COVID-19 pandemic has made all of that much harder. Instead of interacting with people on the street in her job as a political canvasser, she is working at home on the phone. And with social distancing rules in place, she has fewer opportunities to meet with friends.

“Since the virus started,” she said, “it’s been a lot easier to fall back into that cycle.”

Between the challenges of the pandemic, the social unrest and the economic crisis, mental health providers are warning that the need for behavioral health services is growing. Yet faced with budgetary shortfalls, Colorado is cutting spending on a number of mental health and substance use treatment programs.

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets. State legislatures have been forced to consider health care cuts and delay new health programs even in the midst of a health care crisis. But many lawmakers and health experts are concerned the cuts needed to balance state budgets now could exacerbate the pandemic and the recession down the line.

“Health care cuts tend to be on the table, and of course, it’s counterproductive,” said , a health policy professor at Georgetown University. When there’s a recession, people lose their jobs and health insurance, he noted, the very moment when people need those health programs the most.

‘Everything Has To Be On The Table’

In Colorado, for example, lawmakers had to fill a $3.3 billion hole in the budget for fiscal year 2020, which started July 1. That included cuts to a handful of mental health programs, with small overall savings but potentially significant impact on those who relied on them.

They cut $1 million from a program designed to keep people with mental illness out of the hospital and another million from mental health services for juvenile and adult offenders. Lawmakers reduced funding for substance abuse treatment in county jails by $735,000 and eliminated $5 million earmarked for addiction treatment programs in underserved communities. And that’s all on top of a 1% cut to Medicaid community providers who offer health care to the state’s poorest residents.

Some of those cuts were offset by $15.2 million in federal CARES Act funding allocated to behavioral health care programs. But some programs were completely defunded. Cuts were targeted primarily at programs that hadn’t started yet or hadn’t been fully implemented. The rationale: Those cuts wouldn’t have as deep an impact.

Doyle Forrestal, CEO of the , which represents 23 behavioral health care providers, worries that resources won’t be there for an emerging wave of people who have developed mental health or addiction issues during the pandemic.

“People who are isolated at home are drinking a lot more, maybe having other problems — isolation, economic despair,” she said. “There’s going to be a whole new influx once all of this takes hold.”

State legislators said they tried to avoid cutting programs that would hamper the response to the pandemic or the economic recovery.

“There was a desire on both sides to do everything we could to protect health care spending in Colorado,” said Democratic Rep. . “But when you’re looking at across-the-board cuts, everything has to be on the table.”

Every state is facing a similar conundrum. With tax filing deadlines pushed back to July 15, states are unsure how much income tax revenue they will collect.

So in addition to cutting back where possible, states are raiding discretionary funds — Colorado repurposed money from the tobacco settlement and marijuana taxes — to shore up their budgets. States are also tapping rainy day funds, which, according to the National Association of State Budget Officers, grew to  after the 2008 recession.

New Policies Delayed

Overall, at least have made some changes to facilitate access to Medicaid or the Children’s Health Insurance Program as many people have lost their job-based health insurance in the COVID crisis. And in late June, voters in Oklahoma approved expanding Medicaid to more residents. But since the start of the pandemic, states including Kansas and California have put off plans to expand eligibility for Medicaid, which provides health care to low-income people.

“These are symptoms of states that can’t deficit-spend, despite this great need for more coverage,” said , vice president for health care coverage and access at the Commonwealth Fund, an independent health policy research foundation based in New York. “If they spend more in one area, that means cuts in another.”

Colorado has had an aggressive health agenda in recent years but had to defer plans for a public health insurance option that could have provided a more affordable plan for people buying insurance on their own.

The legislature killed to create an annual mental health checkup. The measure would have cost the state only $13,000, but Democratic Gov. Jared Polis signaled he wouldn’t sign any bills that included new mandates for insurance companies.

Democratic Rep. , who sponsored the checkup measure, was disappointed.

“Not every one of us is going to catch COVID, but every single one of us will have a mental health impact,” she said.

Long-Term Implications

Once the economic crisis eases, Roberts said, lawmakers will look to restore funding to some of the programs they cut.

But cuts are often easier to make than to restore — as illustrated by cutbacks made during the 2008 recession, according to Georgetown’s Park.

“Many cuts were never fully restored, even though we were in one of the longer economic expansion periods in our country’s history,” Park said.

He also worries many of the smaller primary care and behavioral health providers, who saw fewer patients come through their doors because of stay-at-home orders during the pandemic, might not survive.

“That means less access to care, including routine care like vaccinations,” he said. “If kids aren’t vaccinated, they may be more vulnerable to flu and measles, making them more vulnerable to COVID-19. That makes it more difficult for a stressed health care system to try to deal with a potential second wave of infections.”

The longer-term mental health toll may be harder to catalog.

Castle, for one, has focused on establishing routines to help her manage her mental health during the pandemic. Every Wednesday night, she plays games online with her friends. And every Friday night, she and her boyfriend build a fire in the backyard.

“If I know people are expecting me to be somewhere at 6 o’clock, that obligation encourages me to go out,” she explained. “There are days it’s a struggle. I have to focus on baby steps.”

Still, Castle worries about others who may be struggling during the pandemic. She has signed on to work with the Colorado chapter of , which lobbies for health care, higher education and workforce policies to help young adults. Even as states and the federal government have found the money to help hospitals and doctors treat the physical effects of the COVID pandemic, she doesn’t see the same commitment to treating its mental health toll.

“We need to start treating mental health the same as we do physical health,” she said. This is an issue we need to stop keeping in the dark.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Yet California Gov. Gavin Newsom and the state’s Democratic-controlled legislature are expected to reject a plea from local public health officials for an additional $150 million a year to battle the COVID-19 pandemic and protect against future public health threats.

“I’m not holding my breath,” said Riverside County Public Health Director Kim Saruwatari. “Right now, more than ever, the gaps that we have in our public health infrastructure have been exposed.”

Public health officials vow to continue making their case. But persuading lawmakers to increase spending in a time of cuts will be even more difficult because public health doesn’t carry the same political clout in the Capitol as other power players such as hospitals, doctors or public employee unions, which plow millions of dollars into lobbying each year.

“I’ve not met anybody who is a lobbyist for public health,” said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee. “The organizations that wear the whitest of hats have the least resources. Consequently, it’s easier to say ‘No.’”

The novel coronavirus has decimated California’s economy and, like local and state governments around the country, the state faces unprecedented budget challenges. Newsom is projecting a $54 billion deficit for the 2020-21 fiscal year, and says the state must make painful decisions before his July 1 deadline to sign a balanced budget into law.

The budget lawmakers are poised to send to Newsom on Monday does not include the additional public health funding.

Similar funding battles are taking place elsewhere, such as in Wisconsin, where the state faces and officials are asking for .

“We need to have a plan to build up public health,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “We have to figure out how to afford it, otherwise we’re going to have the same kind of economic consequences the next time something like this happens.”

California’s 61 local health departments are the backbone of the state’s public health system, and the two leading public health organizations representing local health officials have spent pennies on the dollar to lobby the governor, lawmakers and state agencies compared with big-name groups.

The Health Officers Association of California spent almost $7,000 on lobbying from January 2019, the start of the current legislative session, through March 2020, according to lobbying disclosures from the California Secretary of State office. The County Health Executives Association of California spent $191,000 over the same period. And while other groups employ in-house lobbyists to influence Capitol decision-makers full time, the public health organizations’ executive directors pull double duty, serving as head lobbyists when they can fit it in.

Among the top spenders on lobbying were the powerful California Teachers Association, at $7.4 million, and the Service Employees International Union California, at $5.3 million.

Deep-pocketed health industry groups have also outspent public health interests. DaVita Inc. and Fresenius Medical Care, the two dominant dialysis companies operating in the U.S., spent $5.3 million on lobbying during that period. The California Hospital Association spent $3.4 million and the California Medical Association, representing doctors, spent $2.7 million. The groups collectively employ at least 15 in-house lobbyists.

In addition to paying for lobbyists, the money is used to curry favor with the governor, lawmakers and agency officials. California lobbyists are allowed to give gifts, and to wine and dine officials.

In October, for example, the California Medical Association hosted a “” and dinner that included lawmakers, with the tab at the Napa Rose restaurant at the Disneyland Resort totaling more than $22,500.

Although political spending doesn’t always get big industry groups everything they want, it has gained them more access to the governor and other state leaders steering pandemic response plans. It has also enabled moneyed health industry groups to continue working on other legislative priorities, such as relaxing hospital seismic safety standards and opposing a proposal granting nurse practitioners the ability to work without doctor oversight.

By comparison, lobbying by public health groups consists primarily of visiting lawmakers’ offices, often accompanied by health officials from the lawmakers’ jurisdictions.

Public health leaders are regularly invited to testify at legislative hearings tackling issues like measles outbreaks, the opioid epidemic or teen vaping, but they don’t have anywhere near the “lobbying muscle” that major health industry groups have cultivated, said Kat DeBurgh, executive director of the Health Officers Association of California.

“We have no money; we advocate with our ideas,” DeBurgh said. “We don’t have millions of dollars to spend on billboards, and we can’t call in a hundred people to stand up at a hearing and say ‘I didn’t get sick because of public health measures.’”

State spending for state and county public health programs has declined over the past decade. The governor’s budget proposal for 2020-21 would continue that trend, reducing the current $3.4 billion public health budget to $3.2 billion.

Counties also are confronting a $1.7 billion loss in public health dollars due to pandemic-related declines in sales tax revenue and vehicle license fees, county health officials said, and they have asked Newsom to provide $1 billion from the state’s general fund to help make up for it.

Newsom has said the state to do that given other financial demands.

Health officials say the additional $150 million they’re requesting would help them hire public health nurses and disease investigators, fund public health labs and purchase protective gear. They say addressing the underfunding of public health is especially critical now because counties are primarily responsible for providing adequate testing and contact tracing before easing stay-at-home restrictions.

“That $150 million, that doesn’t even get anywhere close to where we need to be because so much of our funding has eroded away,” said Mimi Hall, president of the County Health Executives Association of California, who is also the director of the Santa Cruz County health department.

State Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee, is also a pediatrician. Pan has consistently pushed for public health funding during his time in the legislature, and Capitol insiders view him as a de facto lobbyist for public health.

Pan said he plans to continue to advocate for the additional public health funding — despite the economic turmoil.

“It’s hard because what public health does is invisible and you have to move people’s hearts,” Pan said.

Other lawmakers acknowledged concerns about public health shortfalls but said it would be difficult to increase spending this year. However, organizations that can afford to hire high-priced lobbying firms “will probably do OK in this budget,” said Wood, the Santa Rosa Assembly member.

He is among the lawmakers considered most friendly to public health and said he supports more money, but wants to understand how it would be spent before deciding.

“They have been underfunded for years,” Wood said. “But some of that happens at the local level, too.”

Last year, public health officials sought $50 million a year from state lawmakers to help rebuild public health infrastructure following years of recession-era budget cuts. Newsom denied their request.

County health directors say chronic underfunding has forced them to make difficult decisions to curtail spending and cut programs like public health labs — 11 of 40 have shuttered in the past two decades.

And for years, they have warned California leaders that the state would be quickly overwhelmed should a public health crisis strike. Their pleas have gone largely ignored.

The impact of the relentless cuts has been felt across the state, including in Riverside County, which has slashed its public health staff by about 60% over the past decade, leaving just 30 disease investigators, contact tracers and public health nurses to serve the sprawling region of 2.5 million people, said Saruwatari, its public health director.

“Had we had the ability to test earlier, I think we would have been able to get out in front of this a little bit more,” she said.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Her daughters, 55-year-old Carrie and 60-year-old Kristy Madden, both use wheelchairs and need a second caregiver to help them navigate their own daily lives.

But that critical caregiving support, along with other health care benefits for millions of Californians, could be scaled back to help plug a massive budget deficit triggered by the coronavirus.

California Gov. Gavin Newsom has proposed sweeping budget cuts to safety-net health care programs ― including Medi-Cal, California’s Medicaid program for low-income people ― just as enrollment is projected to spike because of record job losses related to the pandemic.

Health care experts also fear the cuts could jeopardize billions of dollars in emergency federal health funding allotted to California.

“I understand there’s a pandemic and it’s really bad and everybody is hurting,” said Carrie Madden of Chatsworth, California. Carrie and her sister have muscular dystrophy and their mother is a heart attack survivor who struggles with dementia.

Madden’s fears are compounded by the COVID-19 crisis, which has hit older people and those with chronic health conditions the hardest. She doesn’t want her mother, her sister or herself to end up in a nursing home or other long-term care facility — the settings with the most outbreaks of COVID-19.

“This is the wrong approach,” she said. “This will make disabled people end up in nursing homes.”

States across the country are eyeing Medicaid cuts to balance their budgets, in part because health care is usually the biggest portion of state spending, after education. They also project that more people will sign up for the public health care program, as the number of unemployed Americans hits astronomical heights. More than 20 million Americans filed for in April, raising the unemployment rate at least to 14.7%, the worst since the Great Depression of the 1930s.

approved Medicaid cuts that will take effect after the federal emergency ends, while has instructed all its agencies to reduce spending by 14%.

In California, where almost 2.9 million people have filed for in the past two months, Newsom described the proposed budget cuts as “prudent” and “strategic,” a huge pivot from the he unveiled earlier this year to expand health care to some of the neediest residents.

To address an estimated $54 billion deficit in the 2020-21 state budget, Newsom proposes a $205 million cut — or a 7% reduction in caregiver hours — to the In-Home Supportive Services program the Maddens rely on. The program, primarily funded by Medi-Cal, pays caregivers to make meals for people who need help to live independently, do their laundry, bathe them, administer medical treatments and keep their home clean.

of his other proposed cuts is lengthy: He would scale back or eliminate other programs intended to keep low-income seniors and people with disabilities in their own homes, such as adult day health care and support from social workers. He proposes to make it easier for the state to collect from deceased Medi-Cal enrollees 55 and older for a broad range of medical costs through the controversial “Estate Recovery .” He suggests reinstituting for some older people and those with disabilities to qualify for free Medi-Cal.

And he is calling on lawmakers to remove $54.7 million in “optional” Medi-Cal benefits, such as adult podiatry care, eyeglasses, speech therapy and hearing exams — benefits that lawmakers recently restored after they were cut during the last recession.

“These don’t feel optional to people if they have had a stroke or need teeth to eat their food,” said Tricia Berke Vinson, an attorney with the Legal Aid Society of San Mateo County.

“I understand we are in a budget crisis,” she added. “I just don’t think it can be balanced on the old and the sick.”

Physicians, dentists and other health care providers who treat Medi-Cal patients also stand to lose $1.2 billion in supplemental Medi-Cal payments that flow from Proposition 56, a tobacco tax that voters approved in 2016.

The Democratic governor’s proposal includes an automatic “trigger” to restore the cuts if the state gets more federal COVID relief dollars, shifting the responsibility to Congress to negotiate another stimulus package.

Whether lawmakers will make the sweeping Medi-Cal cuts the governor has proposed is uncertain. For example, the state Senate plan preserves Medi-Cal funding and assumes Congress will pass another stimulus bill.

Both houses of the legislature must come to an agreement and present their version of the budget to the governor for consideration by June 15.

“Save these programs and you save lives and money,” said Assembly member Jim Wood (D-Santa Rosa), chair of the Assembly Health Committee. “Cut these programs and costs will increase and lives will be lost.”

Health care experts and some lawmakers also fear Newsom’s approach could jeopardize billions of dollars in emergency federal health funding already allotted to California.

States that drop Medicaid enrollees or reduce benefits risk losing out on additional federal health authorized by Congress this spring, said Edwin Park, an expert on Medicaid and a professor at Georgetown University McCourt School of Public Policy.

“The federal government has said you can’t cut eligibility or disenroll or cut benefits,” Park said. He noted that New York lawmakers delayed their state Medicaid cuts until after the federal emergency ends to ensure they still receive the added federal help now.

The Centers for Medicare & Medicaid Services did not respond to requests for comment. posted on its website suggests states must keep Medicaid programs intact.

California is expected to receive $5.1 billion in additional federal funding for Medi-Cal through June 30, 2021, according to the proposed budget Newsom released in mid-May.

The Newsom administration is not convinced its Medi-Cal budget cuts will cost the state the additional federal money already approved by Congress.

“There’s never a guarantee until we have that conversation with the federal government. So until then, it’s hard for us to tell what the fed’s going to do,” said Yang Lee, an analyst at the state Department of Finance.

Newsom’s administration predicts about 2 million Californians will sign up for Medi-Cal by July as a result of the pandemic, bringing the program’s enrollment to 14.5 million, more than one-third of all Californians.

The administration anticipates $3.1 billion in added costs to cover the new enrollees. The Legislative Analyst’s Office believes that is $750 million too high, in part because new sign-ups will primarily be younger and healthier individuals who do not need as much care as low-income seniors and people with disabilities.

For many current enrollees, Newsom’s proposals would cut into multiple benefits.

Cynde Soto, 63, said it felt like “someone had punched me in the gut” when she heard about the governor’s plan to cut the In-Home Supportive Services budget. As a quadriplegic, the Long Beach resident worries state cutbacks could force her into a nursing home. On top of that, she fears she might lose her Medi-Cal dental and vision care if Newsom’s other cuts are approved.

“I’ve had nightmares about it. I don’t know what I’m going to do,” Soto said. “Why do we always get hit first?”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Democratic Gov. Gavin Newsom in January unveiled to help him achieve his goal of getting every Californian health care coverage. Though it was far less than the single-payer promise Newsom had made on the gubernatorial campaign trail, his plans, if adopted, would have expanded the health care system as no other state has.

His $47 billion health care agenda, fueled by a once-booming economy and pressure from legislative Democrats, sought to expand the pool of undocumented immigrants covered by Medicaid, enable California its own generic drugs, to address chronic homelessness and dramatically increase mental health and addiction treatment statewide.

Then, the novel coronavirus swept in, decimating those ambitions.

“The world has radically changed,” Newsom said this month, as he prepared California for a mid-May surge in COVID-19 hospitalizations.

Once buoyed by record economic growth and a $21 billion rainy-day fund to protect California from a major downturn, Newsom warned of a “budgetary crisis that is starting to manifest,” suggesting he can no longer follow through on his health care promises.

“All of that is being recalibrated,” he said.

But Democratic lawmakers who control both houses of the state legislature — and will negotiate with Newsom over the scope of the 2020-21 state budget — aren’t necessarily convinced they have to abandon their plans.

“If those workers providing the products, the services, the food that we eat don’t have health care, we’re all in danger,” said state Sen. Maria Elena Durazo (D-Los Angeles), who has pressed Newsom to expand Medicaid coverage to unauthorized immigrants ages 65 and up. “Our reasoning is a lot stronger now because if they don’t have health care, it weakens our ability to stop the spread of COVID-19.”

Newsom says he has no choice but to scale back his initial .

The state may be able to fund only existing programs and coronavirus response and recovery, said state Finance Director Keely Bosler. There could even be cuts, .

Exactly how much money will be available to keep the state running will not be known until mid-May. The legislature, which recessed in mid-March in the midst of the pandemic, isn’t scheduled to reconvene until May 4 and may conduct business remotely for the remainder of the session.

Staggering stock market and job losses have thrown the state’s fiscal outlook into turmoil, with California receiving more than since mid-March. Medi-Cal, California’s Medicaid program for the poor, already covers about 13 million Californians, and state budget analysts expect caseloads to explode.

“It is going to be bad, but we have not yet been able to determine how bad because of the fluid and dynamic nature of this pandemic,” said H.D. Palmer, spokesperson for the state Department of Finance. “Clearly what we are in the midst of is much more severe than a midpoint recession.”

Meanwhile, the state has already begun draining its rainy-day reserves and spending from its general fund to respond to the crisis.

Newsom has spent more than $850 million in response to the pandemic, such as boosting California’s supply of ventilators and other protective gear needed for a projected surge in COVID-19 cases. On Tuesday night, the state had inked a $1 billion deal to get 200 million masks per month — enough for California and possibly to share with other states.

Newsom is also funding food and senior assistance programs, sending money to counties to house more jail inmates while state prisons temporarily pause intake, and paying for hotel and motel rooms for homeless people. And the state will help pay nearly 40,000 health care workers it is recruiting for the surge.

Some of the costs will be reimbursed by the federal government, Newsom said, but it’s not clear how much.

Not long ago, Newsom and the legislature were in a very different place, enacting policies that made California a national testing ground for expanding health coverage.

, they approved a $100 million-per-year expansion of Medi-Cal to low-income undocumented immigrants ages 19 to 25, earning praise from national party leaders and ire from President Donald Trump. And they approved $1.5 billion over the next three years to fund for some low- and middle-income Californians purchasing health coverage on the state health insurance exchange, Covered California.

This year would have been even bigger.

“We have a unique responsibility to show the way,” Newsom said in January.

Newsom sought to funnel state and federal Medicaid dollars into emergency rental programs to help homeless people get housing, and to bolster treatment for substance use disorders and mental health for homeless people, at-risk youth and incarcerated people.

He threatened steeper fines against health insurers that didn’t provide adequate access to behavioral health treatment, vowed to stop surprise medical billing, promised to lower prescription drug costs and hatched a sweeping plan to cut overall health care spending by going after the health care industry for jacking up prices.

Democratic leaders and even Republicans embraced his focus.

“California is certainly the most aggressive at trying to push towards universal coverage,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“Typically, you find states focusing on either cost or universal coverage, but what sets California apart is a drive to deal with both.”

Some Democratic lawmakers acknowledge they must reimagine their health care agenda, including state Assembly member Phil Ting (D-San Francisco), chair of the Assembly Budget Committee.

“We’re going to have to be very disciplined,” Ting said. “I don’t think we’re going to spend money on much else other than coronavirus and economic recovery.”

But others argue that proposals to expand coverage and access are even more pressing because of COVID-19.

“Every person who can’t get health care and gets sick could potentially spread the disease to more people. We need to take care of that,” said state Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee and leads the state Senate budget process for health-related expenditures.

also are flooding Newsom with asking him not only to stick with existing proposals, such as protecting people from getting hit with surprise medical bills, but also to expand coverage even more and increase state subsidies for insurance. Doctor groups are asking the governor to provide relief for health care providers who have lost income due to declines in patient revenue, while organized labor is asking him to assist businesses so they don’t cut health employee health benefits.

County behavioral health directors argue the state must fund more mental health and substance use disorder treatment because the need is greater today, especially for students who can’t attend school and for those who have lost homes and work.

“We need to marshal additional attention and resources for lifesaving behavioral health treatment and services, unless we intend to deepen inequality,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association. “This year, right now.”

Although Newsom has sought to quell the spending push by health advocates, he said Saturday that health care remains a top priority and he’s “committed” to adopting reforms within California’s budgetary constraints — even if it might not happen this year.

“We will do everything in our power to lean into the future despite these circumstances,” he said. “Reforms can happen on a good day or a bad day.”

California Healthline correspondent Rachel Bluth contributed to this report.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

That doesn’t amount to much in the pricey desert enclave of Palm Springs, Calif. — especially for someone who contends with a host of expensive medical problems, including a blood vessel disorder, complications from a recent stroke and frequent bouts of colitis.

“Right now, I don’t really have the money to do much. I just stay here and that’s it,” Manganello said with a sigh, sad at the thought of being stuck in her apartment.

Because she is 71 and has a low income, Manganello qualifies for Medi-Cal, the state’s Medicaid program for disadvantaged people, as well as Medicare, the public insurance program for people 65 and older.

But there’s a catch: Her monthly Social Security check puts her slightly above the income level for free care under Medi-Cal. So, she reduces the amount of income counted for Medi-Cal eligibility by buying a dental insurance policy she doesn’t really need, just so she can qualify for the free coverage and avoid a $672 monthly deductible.

Things are expected to change next year for Manganello and others in similar situations. In the state budget for 2019-20, legislators approved $62.4 million to help about 25,000 older people and those with disabilities get free Medi-Cal. Gov. Gavin Newsom must sign the budget by June 30.

That’s one of several major investments the $215 billion budget makes in Medi-Cal enrollment and services. About 13 million Californians — or about a third of the state’s population — have Medi-Cal.

The spending plan also includes money to restore medical benefits that were cut 10 years ago during the recession, such as podiatry and speech therapy. It also provides full Medi-Cal coverage to low-income young adults ages 19 through 25 who are in the country illegally. That will make California the first state in the nation to offer full Medicaid benefits to unauthorized immigrant adults.

Plus there’s for outreach and enrollment and $769.5 million to boost the amount Medi-Cal pays participating doctors and dentists.

For Manganello, who worked as a manager for a signage shop in Buffalo, N.Y., before moving west, qualifying for free Medi-Cal would make a tangible difference in her life.

“I could cancel that extra insurance and buy myself a medical alert bracelet. I would also have some money to maybe pay off some other medical bills,” she said. “It would help with groceries, things like Depends. And maybe I could go out to lunch once in a while.”

The Medi-Cal expansions in the budget represent another radical departure by California from the federal government on health care and immigration. In addition to on illegal immigration, the Trump administration is pushing policies, such as for Medicaid enrollees, that often lead to reductions in enrollment.

The budget measures also bring California a step closer to Newsom’s goal of achieving universal health care coverage. The state’s estimated 1.8 million unauthorized immigrants, for example, make up of the state’s remaining uninsured residents.

“It seems like what has occurred in California this year is a very conscious, systematic and well-designed effort to close gaps” in coverage, said Judy Solomon, a senior fellow at the Center on Budget and Policy Priorities.

Many other states face similar coverage gaps but few can afford to address them, Solomon said.

‘Senior Penalty’

Most adults who don’t have a disability and are under 65 are eligible for free Medi-Cal with incomes up to 138% of the federal poverty level, or about $17,200 for an individual.

But adults in Medi-Cal’s have to meet stricter income requirements — up to 122% of the poverty level, or just under $15,240 a year for an individual.

If, like Manganello, they make slightly more than that, they must pay a certain amount of their health costs — essentially, a deductible — before Medi-Cal coverage kicks in. That can translate into hundreds of dollars or more per month.

Linda Nguy, a policy advocate at the Western Center on Law & Poverty, said that many people are simply skipping medical care because they can’t afford the deductible.

“We call this the senior penalty, because basically you’re being penalized with a stricter eligibility limit based fully on your age or disability,” said Amber Christ, an attorney with Justice in Aging, a nonprofit advocacy group focused on senior poverty.

Many states that expanded their Medicaid programs under the Affordable Care Act also have this disparity, Christ said. The 2019-20 California budget would end it by raising the income eligibility threshold for that group to 138% of the poverty level.

Restoring Benefits

During the Great Recession, California, like many other states, cut several Medicaid benefits that aren’t required by the federal government.

Starting Jan. 1, Medi-Cal will restore five areas of coverage: audiology, optical services, podiatry, incontinence supplies and speech therapy.

“People of all ages wear glasses, so this can really benefit anyone,” Nguy said. “But things like podiatry, audiology, speech therapy are probably of most benefit to people with chronic conditions.”

The new budget includes $17.4 million for these services, which could disappear again in 2022 unless lawmakers decide to extend them.

Optional benefits are usually the first to go in bad economic times, and bringing them back can take years. Full dental benefits, also cut during the recession, were restored for adults in Medi-Cal last year.

Immigrant Coverage

Lawmakers allocated $98 million to offer free health coverage for unauthorized young immigrant adults who meet the income requirements, starting next year. Of this, $74.3 million will come from the state, while the rest will come from funds the federal government provides for labor and delivery and emergency care only.

About 90,000 young adults are expected to become eligible in the first year.

Covering young adults became the most controversial health care issue in this year’s budget. Republicans criticized the effort, arguing that Medi-Cal should be fixed before it is expanded.

“Every day, my district offices get calls from my constituents who are unable to see a doctor, even though they are technically covered by Medi-Cal, because so few doctors in my district are able to take the low reimbursement rates that Medi-Cal provides,” state Assemblyman Jay Obernolte (R-Big Bear Lake) said before the Assembly’s budget vote on June 13.

In 2016, California started offering full Medi-Cal benefits to unauthorized immigrant children. The state’s current-year budget allocates $365.2 million to fund that coverage. In February 2019, 127,845 kids were enrolled in the program.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .