If the state Office of Health Care Affordability adopts the fines next week, hospitals, medical groups, insurers, and others could face penalties that amount to as much as 125% of the total they spend above the state’s annual growth targets.

The penalty proposal comes after healthcare entities in California were asked to limit growth by 3.5% last year and ramp down to 3% by 2029. Seven hospitals that state officials consider particularly expensive face even smaller growth targets: 1.8% in 2026, dropping to 1.6% by 2029.

Consumer advocates argue that state financial deterrents are critical to bring relief to millions of Californians struggling with high insurance premiums and out-of-pocket expenses. Hospitals accounted for in U.S. health spending from 2022 to 2024, compared with 11% from retail prescription drugs. But adding teeth to those targets sets up a fight with the powerful hospital industry, which has a challenging the spending limits as unreasonable. Hospitals warned that they will cut back on vital services, including in emergency rooms, obstetrics, and behavioral health.

Healthcare industry representatives said the state affordability office hasn’t accounted for year-to-year volatility or other factors beyond the industry’s control, such as rising minimum wages, state earthquake retrofit requirements, and expensive new drugs.

“They’re building the plane while flying it,” said Ben Johnson, group vice president for financial policy at the California Hospital Association. “We know improvements in affordability are needed, but we have serious questions about how and about what the unintended consequences could be under OHCA’s rather stringent approaches.”

When calculating penalties, California regulators would consider various factors, including a healthcare entity’s financial situation, its market impact, and the gravity and number of offenses, according to a in June. And entities would first be given opportunities to implement performance improvement plans to bring their spending into line before penalties are imposed. For those that don’t comply, the board is considering penalties of $10,000 a day or a flat $500,000.

The penalties, which the affordability office’s eight-member board is required by to adopt, are slated for discussion, and a potential vote, at the board’s . The soonest healthcare providers would be subject to penalties is 2028, because it’s expected it will take two years to collect and publicly report spending data to measure against the 2026 targets. The state is still collecting data on how entities performed against the 2025 targets, which aren’t enforceable, according to Andrew DiLuccia, a spokesperson for the California Department of Health Care Access and Information.

States Set Targets

California is one of at least eight states that have set spending targets as part of an expanding effort to curb soaring healthcare spending across the nation. Connecticut, Massachusetts, Oregon, and Rhode Island have also authorized the use of some type of financial penalty. The specifics of each vary widely, although so far no state has applied them.

A by the California Health Care Foundation found that 4 out of 10 state residents said they had medical debt, and 6 in 10 reported that they or a family member had skipped or delayed medical care in the previous 12 months because of cost. Nationwide, about say it is difficult to afford healthcare costs.

After Rosalyn Book got stiches on her chin, the elementary school teacher received a $15,000 ER bill from a local hospital, despite having insurance. Many teachers in her district leave because they can’t afford the cost of healthcare and insurance premiums, she said.

“The healthcare charges are just insanity, and what we get as patients for the care, it’s not the best either,” said Book, president of the Monterey Bay Teachers Association. “If you’re a working, regular individual in terms of how much you make, the cost of living and especially the healthcare is just not doable.”

Meanwhile, hospitals are warning there’s a risk of more closures. According to Yale University’s , 17 hospitals have closed in the state since 2016, compared with only six openings.

Hospitals and other healthcare providers have said the proposed multimillion-dollar penalties are too steep and could destabilize their operations at a time when they’re facing funding challenges, including massive federal cuts to Medicaid, the end of enhanced federal subsidies for Affordable Care Act plans, and a sharp rise in uninsured patients. The One Big Beautiful Bill Act, passed by congressional Republicans and signed by President Donald Trump last summer, is expected to reduce federal Medicaid spending by more than — including by in California — and increase the rolls of the uninsured in the U.S. by over a decade.

Johnson said hospitals raise prices on commercial payers to offset the expense of treating uninsured patients, as well as patients on Medicaid and Medicare, which can reimburse care providers at rates that fall short of treatment costs.

In addition, said Anete Millers, vice president of legal and regulatory affairs at the California Association of Health Plans, tax increases on managed-care plans recently to offset federal Medicaid cuts will force plans to increase their prices for consumers.

“Some spending pressures originate outside of the control of health plans and are the result of public policy decisions rather than underlying changes in healthcare utilization or efficiency,” she told the affordability office’s .

Kristof Stremikis, the director of market analysis and insight at the nonprofit California Health Care Foundation, acknowledged that external forces can drive costs but said that plenty of unnecessary spending is within the healthcare system’s control, such as administrative waste and duplicative tests and procedures. of U.S. healthcare spending is considered wasteful, according to .

Elizabeth Mitchell, a former Office of Health Care Affordability board member whose term ended in May, agreed.

“Every business has external challenges,” said Mitchell, who is now president and CEO of Purchaser Business Group on Health, a nonprofit coalition representing large employers. “The hospital industry has not taken accountability to actually manage costs. I have heard those excuses for decades, and at some point, they have to make changes.”

First Step To Bring Down Costs

of five states with cost growth benchmarks, published in June, found that some have succeeded in modestly slowing healthcare spending, particularly those with enforcement mechanisms. However, spending growth in most states has still set. 

Jeremy Vandehey, a consultant with the Peterson-Milbank Program for Sustainable Health Care Costs, said setting benchmarks and collecting data to analyze which entities meet them is only a first step. Armed with information about what and who is driving up costs, states are more empowered to take additional action, such as imposing penalties or regulating prices, to bring down costs, he said.

“I don’t think anybody in any state is declaring victory on healthcare costs, but I wouldn’t say that that means the programs are a failure,” Vandehey said. “In all of these states, there’s much more robust conversations happening about, OK, we haven’t solved our cost crisis, so we need additional action.”

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“I’ve seen nurses get shoved, pushed, scratched. The biggest one is bitten,” said Dhooghe, who works at in Grand Blanc, Michigan.

The in healthcare has in states such as , , , , and , where Dhooghe and many of her co-workers have been on the picket line since Labor Day last year.

“People will question me and be like, ‘Why are you still working in a place if you’re treated like this?’” said Dhooghe, who gets by on strike benefits and working extra shifts at another hospital. The problem, she said, is that other hospitals aren’t any better. “It’s the same everywhere I go.”

In a statement, spokesperson Dana Jay acknowledged violence against healthcare workers is a “national epidemic” and said the health system’s efforts to address the problem include metal detectors, armed security officers trained to make “misdemeanor arrests,” and de-escalation training.

“We have zero tolerance for violence of any kind,” said Jay, asserting the strike is not about safety but is instead “simply an economic strike.”

Nationwide, hospital workers are seven times as likely to be injured on the job due to violent acts as members of the general working population, according to the available from the Bureau of Labor Statistics. The outcry over workplace violence in healthcare is pitting workers’ demands for better compensation and staffing against hospital operators pressured to cut costs.

‘A Powder Keg’

Violent outbursts are so common that they’ve been dramatized on the popular medical TV series . “Emergency rooms right now are like a powder keg,” said Rachel Odes, an assistant professor at the University of Wisconsin-Madison School of Nursing.

In hospitals, a combative or violent patient is known as a “.” Outbursts can be spontaneous and unpredictable, making some almost impossible to prevent. But research shows the increases when hospitals are understaffed or employees are insufficiently trained or experienced.

Mental health worker Andrew Kimball-Mirzaie said he got hurt in February 2024 at Butler Hospital in Providence, Rhode Island.

He’d been working at the private psychiatric hospital for about six weeks and said he hadn’t yet worked in the ER. He said he was sent there to “monitor” a man in his 20s who was waiting for an inpatient bed.

The patient was alone in a back room watching a Knicks basketball game on TV, he recalled. Kimball-Mirzaie said he got the patient a drink and a snack. They were watching the game when, suddenly, he said, the patient stood up and punched him in the face. He said the assault left him with a concussion and broken nose. His injuries were documented in the hospital’s.

“I understand that there is an inherent danger with the job,” Kimball-Mirzaie said. He doesn’t blame the patient, who was very ill at the time. “We should have had at least another staff member with us,” he said, “and I should have been adequately trained on the unit.”

The attack emboldened Kimball-Mirzaie to join some 700 other unionized Butler workers last spring and summer in a months-long strike, which forced the hospital to close . Service Employees International Union 1199 New England declared the strike a win.

Employees received wage increases that union leaders said would enable the hospital to attract and retain more staff. The hospital also agreed to provide financial support for workers violently injured on the job. And the hospital and union agreed to jointly fund a “time bank” to supplement workers’ compensation for injured workers who need more time to recover.

But five months later, a nurse supervisor at Butler had to call 911 because an unarmed patient in the hospital’s ER was assaulting staff. According to the police report, by the time police arrested the patient, he’d injured two nurses, a security guard, and a police officer.

“Butler recognizes the importance of being proactive in protecting those who provide care,” Mary Marran, Butler’s president and chief operating officer, said in a statement. She added that hospital leadership meets regularly with staff to review safety measures and “identify opportunities to strengthen protection for everyone.”

The patient was charged with four counts of , including against the two nurses.

The American Hospital Association has said punishment is key to preventing violence. It has been to make assaulting healthcare workers a that would carry in prison. At least , including and , have enacted similar laws. But workplace safety experts say there is no evidence that such laws have reduced the incidence of violence against healthcare workers.

Calls for ‘Safe Staffing’

Striking healthcare workers around the country often have demanded “safe staffing” instead of stronger punishments for patients who cause injuries.

The against healthcare workers has caught the attention of the , the accreditation organization for more than 80% of U.S. hospitals and health systems. The commission released national performance goals that and require hospitals to be and that staff be trained “to provide safe, quality care.”

But no federal law limits the number of patients in a nurse’s care across healthcare settings, despite the nation’s largest nurses union, National Nurses United, having pressed for a national standard . Hospitals must “safely staff all units” to enable nurses to “provide the care that patients need before they get agitated or disoriented,” said , lead industrial hygienist for .

Some states have passed their own staffing laws. Only has enacted broad mandatory nurse staffing ratios, which were associated with lower mortality rates and likely higher retention. Oregon enacted a staffing law, . Legislators in and have introduced similar bills, but they have failed to advance to floor votes.

The American Hospital Association opposes mandatory minimum nurse staffing ratios in hospitals, saying they would “remove real-time clinical judgment and flexibility,” , and potentially force some hospitals to turn away patients or delay care, spokesperson Colleen Kincaid said. And she pointed to California, whose for psychiatric hospitals reportedly in at least four counties.

“There are a lot of other things you can do to prevent workplace violence than just increasing staffing levels,” said , who was a deputy assistant secretary of labor for the Occupational Safety and Health Administration during the Obama administration and helped develop OSHA’s for healthcare and social service workers.

Barab said hospitals can, for example, train employees in de-escalation, install metal detectors, or have specially trained security guards on-site so staff don’t have to wait for police to arrive when an incident happens.

, a worker safety and health policy expert at Georgetown University, said the in congressional Republicans’ One Big Beautiful Bill Act will in the next few years.

When funding dries up, she said, “protecting workers is going to be the first thing that gets cut.”

This article is from a partnership that includes and ³Ô¹Ï²»´òìÈ.

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While knee replacement procedures have become standard, however, the prices charged have not.

At Catawba Valley Medical Center in Hickory, North Carolina, for example, the cost of the procedure under a Blue Cross Blue Shield health plan this year was about $16,000, according to data from Serif Health, a San Francisco startup that collects recently released data from hospitals and insurers. Little more than an hour’s drive west, however, at Mission Hospital in Asheville, the cost of the procedure under the same health plan was around $40,000, or more than double, the data showed.

Formed by the merger of the two largest hospitals in the region, Mission has little competition and more power to demand the higher price.

This comparison between these two hospitals illuminates how large hospital systems created by a in recent decades can dominate the competition and push up healthcare costs.

While many factors affect the price of a medical procedure, hospitals with few competitors can charge more, health economists say.

The hospital price hikes mean patients and their insurers must pay more for an episode of healthcare. But there is an important side effect, too, even for people who don’t require medical care. When insurers face higher hospital prices, they pass the costs on and raise the prices they charge for everyone’s health insurance.

Using Serif Health’s pricing data, it is possible to see how mergers like the one that created Mission Hospital influence costs. For years, it was difficult to determine how much hospital monopolies boosted charges. But since 2021, the Centers for Medicare & Medicaid Services to disclose prices, making it possible to gather comprehensive data such as Serif Health’s.

The connection between market power and prices exists across the country. In Melbourne, Florida, Holmes Regional Medical Center is part of a health system, Health First, that dominates surrounding Brevard County. The center has charged Cigna two times what a hospital two hours north did for a knee replacement this year, the Serif Health data shows.

Banner North Colorado Medical Center, which ranks as the leading healthcare provider in Weld County, Colorado, charged a UnitedHealthcare patient $20,000 more for the surgery in Greeley than a health system an hour’s drive south in Denver, according to Serif’s figures.

The American Hospital Association that hospital mergers can improve quality and reduce healthcare costs by creating “a fiscally sustainable environment.” A Mission Hospital spokesperson said comparing hospitals’ prices was unfair or misleading because their practices and constraints vary so much.

For years, economists suspected that the run of mergers beginning in the late 1990s was a main driver of the rising costs of U.S. healthcare. From 2002 to 2020 alone, unfolded in the United States.

But until the recent federal disclosure rule, the effect of healthcare monopolies on pricing was often overlooked or harder to detect. Hospitals do not advertise their prices, and even when they are revealed on a bill, patients scarcely notice the bottom line because they don’t pay most of it — their insurers do.

“What the data shows pretty clearly is that when hospitals have bargaining leverage, they tend to have higher prices,” said Zack Cooper, an associate professor of public health and economics at Yale University who has spent more than a decade studying hospital monopolies.

Over the last quarter century, Cooper said, hospital prices have risen faster than those for any other economic sector, and “hospital consolidation is one of the primary drivers.”

Federal and state officials have wavered over when to intervene when hospitals are proposing to merge. Last summer, former President Joe Biden’s that urged federal agencies to challenge mergers that could harm consumers, reversing course from Biden’s more aggressive enforcement of antitrust law. In a , however, Federal Trade Commission Chairman Andrew Ferguson called for a task force on healthcare mergers that are leading to “higher prices” and “decreased quality” of care.

Several states have sought to curb healthcare monopolies. In 2023, Minnesota banning anticompetitive healthcare mergers and bolstering state oversight. In 2022, requiring healthcare businesses to give the state a 90-day notice of large mergers and to investigate their effects on competition. And in 2021 enabling the state health department to block acquisitions and mergers of hospitals.

Nothing has stopped the overall trend, however, as hospitals seek to grow and gain leverage over insurers and competitors. Last year alone, hospital and health systems announced 46 mergers and acquisitions, , a healthcare business consulting firm. Five ranked as “mega-mergers,” meaning they were valued at more than $1 billion. One across Connecticut and New York into a powerful interstate health system. Another linked , a deal that created a 56-hospital system across the Midwest — including Iowa, Michigan, Minnesota, Wisconsin, and Wyoming — with combined revenue of about $10 billion.

Other mergers have been proposed in , , and Minnesota.

Asheville’s Dominant Hospital

Few places in the United States better exemplify how hospital mergers reshape healthcare than Asheville.

In 1998, the state authorized a deal that joined the city’s two acute-care hospitals, St. Joseph’s Hospital and Memorial Mission Medical Center, . Ever since, its effects have been studied and its prices fiercely contested.

Marcelle Crago, a nurse and lactation consultant, is one of many patients who have accused Mission Health, which operates Mission Hospital, of gouging consumers. Last year, she tweaked her knee while cross-country skiing.

“My knee went ‘pop, pop, pop,’” she recalled. She had torn her meniscus, the rubbery cartilage around the knee that acts as a shock absorber. A doctor advised her to have a portion of it removed.

Two days before the surgery, Mission Health told her the total charge would be over $9,000, according to paperwork on her case filed with the state’s Consumer Protection Division.

“I was shocked at the number,” she said.

Crago’s insurance policy from UnitedHealth Group had a high deductible, so she would have had to pay most of the cost. She decided to postpone the surgery and shop around, eventually arranging to have it done at an outpatient center not affiliated with Mission. There, the bill came to less than a third of the price Mission Health charged, according to paperwork she kept.

“The way Mission Health handled the whole thing felt predatory,” Crago recalled, noting that when she balked at the $9,000 figure, the hospital offered a 20% discount if she paid up-front. “It makes you wonder how much they are playing with prices.”

In responding to Crago’s complaint with the state, an attorney for Mission and HCA Healthcare, which owns the hospital, wrote that hospital charges “represent the cost for supporting the entire episode of care” and must cover the hospital’s investments in advanced technology, training, staff, and other critical needs.

“Patients are certainly entitled to ‘shop around’ for surgical procedures,” wrote the attorney, Phillip Jackson.

It is not just patients who bear the burden of rising hospital prices.

Over time, anyone who pays for health insurance pays a price for hospital monopolies, as insurers boost premiums as medical costs rise. The full cost for an employer to pay for an average family health insurance plan rose to more than $27,000 in 2025, up from $21,000 just six years ago, according to .

Around Asheville, employers and employees complain that their insurance premiums are higher because Mission’s prices are so high.

As the chef and co-founder of Cúrate restaurant in Asheville, a business with about 100 employees, Katie Button provides employee health coverage and believes she has been paying for Mission Hospital’s excessive prices, according to a pending class-action lawsuit she filed in 2021 with five residents who say the monopoly has harmed them.

Any insurance plan in Asheville must include Mission Hospital, she said, because it is the only one around. This makes the burden of its prices unavoidable.

“We are where we are because we don’t have a choice of hospitals,” Button said. “There is no other option.”

The steady creep of healthcare costs is top of mind not just in Asheville but for most U.S. voters, according to . Nearly two-thirds of U.S. adults were worried about being able to afford healthcare, the poll found.

Yet while federal law allows regulators to step in and block mergers deemed to create monopolies, the FTC intervened in only from 2002 to 2020 to stop a hospital merger, according to a Yale University study. The FTC has since announced challenges to five other hospital mergers.

Birth of a Monopoly

When Mission Health was formed by a merger in 1998, state officials recognized that Asheville’s new dominant hospital system would have the power to raise prices and required Mission to sign an agreement to limit spending and profit margins.

Even with these restrictions, the hospital , according to economic research cited by the FTC. But Mission’s prices were about to go up even more. In 2015, Mission Health lobbied the state legislature to drop the state restrictions, abandoning the profit limits.

“After 20 years of the hospital behaving itself, the state decided to terminate its oversight,” said Mark Hall, a professor emeritus at Wake Forest University who of the hospital’s merger history. Then, three years later, HCA, the largest hospital corporation in the country, bought Mission Health. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund ³Ô¹Ï²»´òìÈ’ coverage.)

“This put a prepackaged monopoly into the hands of the world’s largest for-profit hospital corporation,” Hall said.

Across a range of services, Mission Hospital charges more than other North Carolina hospitals, according to figures from Serif Health.

Consider the prices that Mission negotiated with UnitedHealthcare compared with those the insurer pays at Catawba Valley Medical Center. For a breast biopsy, UnitedHealth pays $7,500 at Mission and $1,700 at Catawba, according to Serif. For a hernia repair, it pays $17,700 at Mission and $9,600 at Catawba.

“The prices hospitals charge are one of the leading drivers of rising healthcare costs,” according to a UnitedHealthcare statement sent by spokesperson Cole Manbeck.

Mission spokesperson Katie Czerwinski, in a statement, said that it can be misleading to compare one hospital with another.

Mission Hospital is almost three times as large as Catawba Valley Health and is a Level 1 trauma center serving a different population, Czerwinski said. She also said that pulling individual rates for comparison paints an incomplete picture.

But other figures indicate that prices at Mission Hospital are relatively high, even when viewed collectively.

A team at the think tank Rand, led by Christopher Whaley, now a Brown University health economist, uses commercial insurance records to compare average hospital prices across the U.S. relative to those paid by Medicare. , Mission Hospital in 2024 charged prices that were 334% of prices set by Medicare. Catawba Valley Medical Center charged 237%. The state benchmark for prices is 280% of Medicare, Rand figures showed.

“The prices we pay for healthcare vary tremendously and are uncorrelated to the value we receive,” according to the Rand website.

For many in Asheville, the primary complaints about Mission Hospital focus on the quality of patient care. This is consistent with showing that the quality of care declines when hospitals have little competition.

Amid rising complaints about hospital services, North Carolina state Sen. Julie Mayfield, a Democrat, helped launch a nonprofit organization two years ago called Reclaim Healthcare WNC to hold Mission “accountable for its harmful practices.”

“Within a year of the HCA sale, I started hearing stories from physicians and other friends about all the terrible things that were happening there,” Mayfield said, most of them caused by severe staff cuts and physicians leaving.

Three times since 2024, state health inspectors working on behalf of CMS have issued “immediate jeopardy” findings to Mission Hospital, indicating problems so severe that they posed an imminent risk of serious injury or death to patients.

In the most , an 88-year-old woman recovering from a fall and hip surgery at Mission Hospital died after going a night without receiving a blood transfusion.

Czerwinski, the Mission Hospital spokesperson, said a proposed plan of correction “allows Mission to address the findings from the survey and complete a comprehensive review of operations.”

As more hospitals across the United States plan to merge, Mayfield said, the experience in Asheville represents a cautionary tale.

“Unregulated monopolies have never gone well for the public.”

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The majority of California’s roughly 300,000 teachers don’t have access to the state-funded paid leave program that most new parents in the private sector do. Instead, many local school districts deduct the cost of a substitute teacher from educators’ pay during parental leave.

Because her daughter arrived before the school year ended, Blustein used 10 of her accrued sick days — paid time off she wanted to bank for later to bond with her baby or to care for her if she got sick.

Now, California lawmakers have given public school and community college employees up to 14 weeks of paid pregnancy leave in the education bill accompanying the , after Gov. Gavin Newsom this year.

It’s a reversal for Newsom in his final year in office. In 2019, the governor that would have given school employees at least six weeks of paid leave, and a similar Assembly bill that died on the Senate floor in 2024. Several analysts said the issue appeals to voters on both sides of the aisle, ahead of Newsom’s potential 2028 presidential run.

State Department of Finance spokesperson H.D. Palmer said in an email that “educator workforce recruitment and retention has been a priority for the administration since the governor’s first day in office” but that the funding was not previously available.

Paid leave policies for educators and other state workers have garnered bipartisan support in recent years, including in conservative-led states such as Alabama, Louisiana, and Georgia, and blue states such as , said Vicki Shabo, a senior fellow specializing in gender equity and paid leave at the think tank New America.

After the Supreme Court’s 2022 Dobbs decision overturned the constitutional right to abortion, some conservative lawmakers in states that banned abortion embraced paid leave for public employees to signal support for babies after they were born, Shabo said. Many limited the benefit to state employees and framed it as a tool to recruit and retain them.

Elizabeth Gedmark, a vice president at A Better Balance, a nonprofit that advocates for workplace equality, said paid leave “polls incredibly well across all political lines, because everyone agrees that you shouldn’t have to go back to work a day after you had a baby.”

In 2019, President Donald Trump signed into law a bill that of paid leave. But Shabo said the current administration hasn’t made any moves to expand paid leave.

Palmer, of the Department of Finance, said the state can now afford the roughly $218 million leave program because of billions of dollars in unexpected tax revenue, largely tied to tech workers’ stock options. Much of that revenue is constitutionally guaranteed to schools, so it can’t cover other public workers who are also shut out of California’s paid leave system.

Many school district administrators have largely opposed paid leave in the past because of the cost. The state’s plan calls for districts to pay for the leave out of their annual cost-of-living raise, which this year is bigger than the law requires.

David Roth, superintendent of Buckeye Union School District in El Dorado County, said the math still isn’t great for some schools, and that “the real value reaching the classroom is smaller than the headline number suggests.”

The California Association of School Business Officials had opposed previous related legislation, saying it would create an “unfunded mandate,” but largely supports the new plan now that the start date has been pushed from July 1 to January 2027. The organization’s chief governmental relations officer, Sara Pietrowski, said concerns remain but that the group would work with the state to avoid additional fiscal challenges.

The proposal would close a gap that many Californians don’t realize exists. The state was one of the first to offer — under its current program, eligible workers get of their pay for up to 20 weeks of combined leave and disability benefits.

But most California teachers, , are shut out. The program is funded through a payroll deduction for state disability insurance, and public agencies are . Districts can opt in, but the move must be bargained collectively, as in the Los Angeles Unified School District.

Most educators must use up their accrued sick days before receiving a fraction of their pay for the remainder of their leave, under a provision of the .

Because of that, it’s not uncommon for teachers to plan their pregnancy leave for summer breaks to try to avoid burning up their sick leave. But that can be challenging for those who have pregnancy complications or early deliveries, like Blustein, or those who experience challenges getting pregnant.

Erika Jones, an elementary school teacher in Los Angeles and the secretary-treasurer of the California Teachers Association, said her colleagues routinely teach until they go into labor, which can be disruptive.

It took one colleague around seven years to bank 77 sick days to use for a single pregnancy.

“Women go back sooner than they should have, because they don’t have the days,” Jones said. “You end up in this deficit zone.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Source: <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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³Ô¹Ï²»´òìÈ will update this database as more states respond to emails and public records requests for their documents.

Note: Data collected as of Aug. 18, 2026. ³Ô¹Ï²»´òìÈ reporters searched state websites, requested documents, and filed public records requests. ³Ô¹Ï²»´òìÈ continues to collect documents.

Sources: Documents publicly posted online or released in response to ³Ô¹Ï²»´òìÈ requests; <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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“I want to stay here,” she vowed. “And die here.”

She might pull that off. In relatively good health, Jennett still drives to lunch with friends, does her own housekeeping and grocery shopping, and plows through a book a day, usually a mystery. But her children worry about her living alone at 89, especially after she has had a couple of falls.

Enter her new housemate, Susan Beese. Despite working four days a week in retail, Beese could no longer afford her nearby one-bedroom apartment as the rent topped $1,500 a month. She moved out, first staying with friends and then in what she delicately called “a senior women’s facility.”

Now Beese, who is 79, pays Jennett $800 monthly for a bright two-bedroom space, with a bath and a kitchen, on the lower level of her house. As part of the agreement the housemates worked out, she helps plant and water Jennett’s garden, takes out the trash, and cooks occasional meals.

“It’s been a lifesaver,” Beese said. Jennett even welcomed her dog.

Meet the real-life Golden Girls. In the  1980s sitcom, still in perpetual reruns, the four wisecracking women who share a house in Miami met through an ad on a supermarket bulletin board.

In Denver, the housing matchmaker was Sunshine Home Share Colorado, a local nonprofit that Alison Joucovsky, a senior services administrator, founded in 2016 when the problem became urgent. “My phone was ringing off the hook,” she said, recalling anxious pleas from older residents spending most of their Social Security checks on rising rent or facing years-long waiting lists for subsidized senior housing.

Home sharing “is a really efficient way to create affordable housing and to support older people ,” Joucovsky said. Carefully vetting both “home providers,” who may be rattling around in family houses now too big and too empty, and “home sharers” seeking reasonable rents, Sunshine facilitated 31 shares last year, a record for the nonprofit.

“The cost of developing and building new housing is astronomical, and so is the length of time it takes,” said Laura Fanucchi, president of the National Shared Housing Resource Center and an administrator with HIP Housing, a home-share organization in San Mateo County, California. “Why not make use of existing housing stock?”

About  offer these services — and demand is growing, driven by housing shortages, rising rents, and sales prices that affect both the old and the young. Legislators in several states are working to promote home sharing as an option. (Personal care is not part of these arrangements.)

The need is acute. About a third of households headed by someone 65 or older were “cost-burdened” in 2024, according to  by the Harvard Joint Center for Housing Studies. That means they spent more than 30% of their income on housing.

Although nearly 80% of those people were homeowners, the center found, an increasing proportion are still paying off mortgages or home equity loans, and most contend with higher taxes, utility and maintenance costs, and insurance premiums.

“A lot of the people calling me to complain about property taxes and inflation are senior citizens on fixed incomes whose children have left, and maybe their spouse has died,” said Pennsylvania state Rep. Abby Major, a Republican co-sponsor of a bill that would facilitate home sharing. “They’re a single older adult living in a four-bedroom house.”

Yet most don’t want to relocate. Even if they do, many older adults will find that downsizing has also  as home prices rise and very low interest rates become a memory.

Younger people are similarly cost-burdened, including 37% of those age 25 to 34 and 31% of those 35 to 44, the Joint Center has reported.  both older homeowners who need income and people of any age in search of lower-cost housing.

To help increase their reach, some home-share programs now supplement or replace the traditionally labor-intensive matching process with online platforms. (For-profit companies like Nesterly or roommates.com also facilitate shared housing.)

“It’s like online dating, except that people who have rooms can meet people who need rooms,” said Candice Smith, executive director of HomeShare Oregon. “And it’s a lot more secure.” HomeShare’s online platform has drawn close to 7,000 providers and seekers over five years.

Further support has come from the city of Portland, which this year announced  to pay $1,000 to homeowners who make a spare room available (or $1,500 for two rooms) through qualified home-share programs.

In addition, legislators in several states have introduced or passed bills that prohibit municipalities from unduly restricting homeowners who want to rent spare rooms to nonfamily members. Sponsors in Pennsylvania and Connecticut actually call them Golden Girls bills, and they’ve drawn bipartisan support.

“So many young people have basically given up on buying a home,” said Colorado state Rep. Manny Rutinel. The Democrat helped pass  prohibiting cities and counties from limiting the number of unrelated people who could live together in a single dwelling.

In Pennsylvania, state Rep. Tarik Khan steered  through the House in June; it awaits a Senate vote. “It doesn’t make sense that your cousin can move in but someone unrelated to you can’t,” said Khan, a Democrat.

The Pennsylvania bill caps the number of nonfamily occupants in a home at five; Connecticut’s limit would be three.  passed the Senate in April and then died without a vote in the House. But the bill sponsors plan to reintroduce it next session.

Home sharing can’t solve the housing crisis, its fans acknowledge. But it could make a dent, potentially unlocking thousands of spare bedrooms across the country without requiring new construction that would change the character of neighborhoods.

Admittedly, matching homeowners with those who want to rent a room becomes a delicate process. Home-share staff members typically interview the individual parties, run background checks, verify incomes, coordinate initial phone calls and meetings, and mediate if problems later arise.

They also help applicants sift through the myriad lifestyle preferences that can torpedo a match. “Living together isn’t easy,” Fanucchi said. Will the home provider accept smokers, pets, visitors? Does the sharer work from home? Or need to park a car? Who sets the thermostat?

Sometimes the agreement includes a “service exchange,” in which the newcomer does a few hours of chores like snow shoveling, shopping, or some meal preparation in return for reduced rent.

Jenlyn and Larry Boyer, for instance, have lived in their ranch house in suburban Broomfield, Colorado, for 31 years and never want to leave. But Jenlyn, who is 80, has “gotten unsteady” and uses a walker. Her husband, 70, suffers chronic fibromyalgia pain and needs a wheelchair.

Because they now pay for tasks that they used to undertake themselves, and because inflation has undermined their finances, “I had an epiphany,” Jenlyn said. “We need more help and we need more money.”

Six months ago, through Sunshine Home Share, they met a 46-year-old graduate student whose monthly rent had doubled to an unmanageable $2,000.

The student moved into their furnished downstairs bedroom/family room with a bathroom, a small refrigerator, and a microwave. In exchange for about 10 hours of dishwashing a month, she pays a reduced rent of $600.

The additional income has helped the Boyers cover expenses like van repairs and wheelchair batteries. But they also enjoy chatting with their new housemate.

“She turns out to be just a gem,” Jenlyn said. “We laugh together a lot.”

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California lawmakers an expired law that would require the state to identify companies that employ 100 or more people and have employees enrolled in Medi-Cal, the state’s Medicaid program. Nevada has had a similar law in place since 2017, though a proposal for one in Oregon stalled when its legislative session ended in March.

The California bill author, Democratic state Sen. Lola Smallwood-Cuevas, said she is deeply troubled by what is going to happen when work requirements kick in. According to the state, out of more than on Medi-Cal will be subject to the rule.

“We think this is a bill that’s about fairness,” Smallwood-Cuevas said. “It’s a basic principle that taxpayers deserve transparency about which large employers are shifting their healthcare costs onto the public.”

Large employers that regularly top Nevada’s list, such as Walmart and Amazon, have said that the state included part-time and seasonal workers in their counts and that their full-time hourly employees to qualify for Medicaid.

Walmart spokesperson Katrina Proffitt said that the company offers affordable medical coverage to most employees, including eligible part-time workers, and that most of its plans include no-cost virtual care options.

“Healthcare affordability and access to quality care remain real barriers for many Americans, and Walmart continues to be committed to being part of the solution,” Proffitt said.

The push to name and shame companies reflects dueling narratives about the biggest abusers of the joint state-federal Medicaid program, which reached nearly in government spending in 2024. The Trump administration, led by Centers for Medicare & Medicaid Services Administrator Mehmet Oz, has called out blue states for not doing enough to fight insurer fraud and abuse. State Democratic leaders, meanwhile, are pushing back by calling attention to big employers that don’t offer affordable health benefits, which leaves taxpayers subsidizing healthcare costs for the low-wage workforce.

Some states have considered financial penalties. Democratic New Jersey Gov. Mikie Sherrill signed a bill in June that have at least 50 Medicaid-enrolled employees. Companies with 50 to 249 workers on Medicaid per person, and those with at least 500 will pay $725.

Bills that would have penalized companies with workers enrolled in Medicaid failed in this year.

In Sacramento, California, Democrats want to figure out a way to make large businesses pay for their employees’ health coverage. State lawmakers struck a deal with Democratic Gov. Gavin Newsom, who is contemplating a presidential bid as he wraps up his final year in the governor’s office, to explore tax options. Any tax hike would be up to the new governor.

States face of dollars under HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, notably through that requires nondisabled Medicaid enrollees ages 19 to 64 in most states to prove they are working, volunteering, or going to school at least 80 hours a month to keep their coverage.

Yet federal work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the . Nebraska and Montana have begun enforcing the rule.

One health policy researcher said employer Medicaid reports highlight the lack of affordable healthcare options available to low-wage workers. More than half of adults enrolled in Medicaid who don’t have dependent children already meet the 80-hour-a-month requirement or face challenges that would likely qualify them for an exemption, .

“There’s a whole set of people who are working — they may not satisfy the work requirement provisions, they may not get the exemption that they’re qualified for, and they don’t have access to that employer-sponsored insurance either,” said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

Employers Push Back

While employer lists haven’t succeeded in bringing down Medicaid costs, supporters say measuring the burden can be the first step and help lawmakers make the case for further action.

In Nevada, Amazon has employed more Medicaid enrollees than any other company since 2020, according to the state’s report . For state fiscal year 2025, Walmart, the Clark County School District, the state government, and Tesla rounded out the top five.

Employers that the reports are misleading because they have included part-time and seasonal employees. The state’s includes only full-time employees, plus those who could not be confirmed as either full- or part-time employees.

That came to 4,914 Amazon employees and 3,503 Walmart workers in Nevada on Medicaid in 2025.

There are no penalties for companies on the list.

Amazon said it pays its workers more than double the $7.25-an-hour federal minimum wage and noted that Medicaid eligibility is based on household income and size rather than an individual’s wage. That means two employees who earn the same pay may have different eligibility depending on whether they have children or live with parents.

“Pointing fingers at Amazon over Medicaid is a red herring,” said spokesperson Alisa Carroll. “What really needs to happen is a significant and large increase in the federal minimum wage — that would be a big boost for American families.”

Nevada Medicaid spent nearly $950 million on healthcare for more than 133,000 full-time employees and more than 140,000 of their dependents. While the total amount spent dipped in fiscal year 2025, the average cost per member per year increased by nearly 17%.

Yvanna Cancela, a former Nevada lawmaker who sponsored the legislation on Medicaid work reports, said the annual reports force an important conversation “about whether or not this is the kind of economy we want and whether or not it is right or just that people who work full-time don’t make enough to have health insurance.”

A Fraying Safety Net

Health researchers say that uninsured people delay or skip and that their children may end up losing coverage, too.

One analysis found that more than were enrolled in Medicaid and the Children’s Health Insurance Program this April than in January 2025. California is among the states with the among children.

The loss in healthcare coverage among residents will be compounded by the loss of public food assistance benefits, Smallwood-Cuevas said. is pending in the legislature.

She compared Medi-Cal to a trampoline that has become a “very tattered kind of fishnet” overwhelmed by people falling into it. President Donald Trump’s spending-and-tax law pulls and rips at the safety net, she said.

When people lose food assistance and health benefits, they must choose between paying for medicine and paying for rent, Smallwood-Cuevas said.

“We’re going to see more people in their cars, more people on the street, and a lot more people in the emergency room,” she said. “That is dangerous for all of California.”

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When Gov. Gavin Newsom, using his , refused to extradite a physician accused of prescribing and mailing abortion pills to a Louisiana woman, he said California would “not ever” allow “extremist politicians” to punish its doctors.

Newsom, who is considering a run for president, has long championed reproductive rights, but state lawmakers in the Democratically controlled California legislature know future governors might not have the same political beliefs.

Republican gubernatorial candidate Steve Hilton, a former Fox News host endorsed by President Donald Trump, has vowed to honor these types of extradition requests from other states if he’s elected, Louisiana “is trying to uphold what its people voted for, and California is undermining it.” His opponent, Democrat Xavier Becerra, has said he would deny the requests.

Legislation advancing in Sacramento is the latest chapter in a tit for tat that’s been happening between conservative and liberal states since 2022, when the U.S. Supreme Court overturned Roe v. Wade, ending federal legal protections for abortion.

by state Assembly member Rebecca Bauer-Kahan, which is being heard in committee, would take some decisions out of the governor’s hands, requiring governors to deny extradition requests for healthcare providers who prescribe abortion medication or administer gender-affirming care. It would also shield anyone in California who helped patients travel to California or another state to receive legal care. While opponents cast “shield laws” as an incursion on other states’ authority, supporters of the bill view it as insurance — even with Becerra leading Hilton 52% to 31%, according to by the University of California-Berkeley Institute of Government Studies.

Newsom spokesperson Marissa Saldivar said the governor doesn’t comment on pending legislation. Hilton and Becerra didn’t return calls for comment.

“Protecting providers from prosecution should not rely on shifting political winds or a single person’s decision,” said Alyssa Sherer, a nurse practitioner who spoke in support of the bill at a Senate committee hearing in June. Sherer is also the medical director at Hey Jane, a telehealth medication abortion provider. 

Thirteen states have banned abortion outright, and 28 other states ban abortion somewhere between six weeks and viability. At the same time, other states that allow abortion have enacted shield laws to protect doctors and nurses from liability when they prescribe across state lines.

People living in states with total abortion bans are increasingly getting abortion pills prescribed via telehealth, from 74,000 abortions in 2024 to 92,000 abortions in 2025, according to the Guttmacher Institute, citing numbers from its Monthly Abortion Provision Study.

Critics of shield laws say that states have a legitimate interest in enforcing their own statutes and that such laws represent an attempt by some states, like California, to nullify the legal decisions of others.

“If California says, ‘We’re not going to honor any other state’s laws. We’re going to ship abortion pills into your states. You can’t have a law that says abortion is illegal,’ I don’t know — that doesn’t seem like a workable situation,” said Greg Burt, who is vice president of the California Family Council and has spoken in opposition to shield laws at the State Capitol.

Twenty-one other states and Washington, D.C., have similar shield laws, but Arizona, California, Michigan, North Carolina, and Pennsylvania’s rely on an executive order, which could be reversed by a successor, according to the Guttmacher Institute.

Amanda Barrow, a senior staff attorney at the Center on Reproductive Health, Law, and Policy at UCLA Law, said passing extradition protections would put California on firmer footing, because an executive order “could be revoked by a governor who is anti-abortion or anti-gender-affirming-care.”

Hilton has said he would do just that if elected.

“Just as I wouldn’t want to see Louisiana coming in and undermining something that we voted for here in California,” the GOP candidate told KQED in January. 

During a , Becerra said he was strident about protecting reproductive rights as the state’s attorney general. “Absolutely no,” Becerra said of allowing California physicians to be extradited. 

This year, ±á²¹·É²¹¾±â€˜i to its existing shield laws. And Oregon , including banning law enforcement from cooperating with out-of-state or federal investigations into care that’s legal in the state.

But Republican legislators in conservative states have cast telehealth visits as an end run around their laws. And some have moved to restrict abortion pill access.

The governors of , , and have signed bills this year that criminalize the sale, purchase, or distribution of medication that induces an abortion. Those states make it a felony to provide medication abortion drugs to people who are seeking to end a pregnancy. The laws impose up to 10 years in prison with potentially tens of thousands of dollars in fines.

Mississippi amended the state’s controlled substances code to add abortion pills as a criminal category. Although the state already prohibits abortion broadly, the measure specifically addresses distribution, which could subject out-of-state providers to prosecution.

In January, Louisiana a California doctor, Remy Coeytaux, mailing abortion pills to a patient. Newsom denied the request. Likewise, New York Gov. Kathy Hochul denied Louisiana’s February 2025 extradition request for a .

Texas has taken a slightly different legal tact. Attorney General Ken Paxton, a Republican running for the U.S. Senate, obtained a default judgment of more than $100,000 against the New York doctor targeted by Louisiana, but a , citing New York’s shield law. Neither Paxton nor Louisiana Attorney General Liz Murrill responded to requests for comment. 

Fear of being charged with a crime for providing quality medical care is contributing to physicians leaving medicine, said Sacramento emergency room doctor Kamara Graham, who is vice president of the California chapter of the American College of Emergency Physicians, which is supporting the bill.

“It’s really conflicting and hard for us to weigh that concern of: Will I get extradited and charged and potentially be taken away from my family? Or do I do the right thing for my patient?” Graham said.

The availability of medication used in most abortions could soon change nationwide. Under the leadership of Health and Human Services Secretary Robert F. Kennedy Jr., the Food and Drug Administration it is conducting a safety review of mifepristone, one of two medications in pill form that is used in most U.S. abortions. The FDA maintains the drug is safe and effective.

If the FDA were to decide that mifepristone is not safe, such a ruling would supersede state laws, even in states where abortion is legal. If mifepristone is restricted, many telehealth groups have said they would switch to using only the other medication, misoprostol.

“The elephant in the room is whether the Trump administration, particularly after the midterms, makes some kind of move to put national limits on access to abortions,” said Mary Ziegler, a law professor at UC-Davis who has written several books on reproductive health law.

“Not everything is something that the legislature can solve for,” Ziegler said, “because there’s some uncertainty about how the federal courts are going to react to all of this.”

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The Republican blasted California during back-to-back political attacks in May, saying the heavily Democratic state is committing “outrageous fraud” and “stealing” by spending state and federal Medicaid money meant for basic medical treatment on unconventional services such as housing and nutrition assistance, gym memberships, and even tribal prayers and, he claimed, exorcisms.

“The California Medicaid program will pay for herbal medicines, meal deliveries. They’ll pay for housing,” Kennedy said. “I don’t know what housing has to do with healthcare.”

“California, they’re just setting all kind of records,” he added. “They’re wild people.”

Despite criticism from congressional Republicans and growing scrutiny from the Trump administration, Gov. Gavin Newsom, a Democrat considering a presidential run, said he’s proud of California’s spending on social services in Medi-Cal, the state’s Medicaid program. It’s a multibillion-dollar experiment to help medically frail patients meet their housing, food, and other social needs that Newsom says is not only legal but also a more cost-effective and evidence-backed approach to providing healthcare for Californians with complex health conditions. He counters that investing in services outside clinical settings can help people avoid emergency rooms and hospital admissions, improve their long-term health, and ultimately save taxpayers money.

“It’s about whole-person care,” Newsom said, adding that he hopes President Donald Trump’s administration sees California’s leadership and agrees with the “reforms we’re advancing as national best practices.”

Now one of the governor’s marquee health initiatives is at the center of an intensifying partisan battle with Republicans in Washington, D.C., who have moved to rein in billions in healthcare spending on low-income and disabled people across red and blue states. It’s a philosophical divide: Conservatives say social services are a financial strain on Medicaid and shouldn’t be considered healthcare, while liberals argue that investing in prevention ultimately saves money. While experiments proliferated across the country under President Joe Biden, the Trump administration federal policy encouraging state Medicaid programs to address health-related social needs.

The Medicaid fight is putting patients in limbo.

Lucy Rodriguez teaches Mexican folk dancing in the town of Hollister, in California’s Central Coast region. She said her life turned around this year once an intensive case manager with Titanium Healthcare, which contracts with health insurers to provide services, began helping her manage her chronic diseases and stay on top of her medical appointments and prescriptions, even picking up free food boxes for her. The 73-year-old is on Medicare and Medi-Cal, which offers more extensive benefits. The low-income health program has helped pay her utility bills, and she was recently approved for home-delivered meals.

“This has been a godsend,” said Rodriguez, who has diabetes, high blood pressure, and kidney disease. “I was getting so stressed out and depressed. It’s really hard when you’re on a fixed income. Groceries are so expensive, and with summer, electricity gets even more expensive. But this is really improving my life.”

She worries the Trump administration will cut benefits to low-income older people.

Last year, the Centers for Medicare & Medicaid Services warned states that federal funding for social services would be determined on a . CMS spokesperson Christopher Krepich said the agency is not ending current agreements, known as waivers, that grant states temporary permission to provide social services, which are paid for with state and federal dollars. But future applications, for new services or to extend existing initiatives, could be at risk if they veer too far from traditional healthcare.

“Moving forward, CMS will work with states on innovative waivers that address core healthcare needs, as consistent with evidence-based approaches tied to clinical diagnoses and services, to the goal of ultimately improving health outcomes in the Medicaid population,” Krepich said in a statement.

In a further escalation, the Justice Department put out a allowing states to institutionalize people with disabilities and severe mental illness instead of providing community-based care. Republicans have also targeted states, mostly blue ones, for what they say is a failure to go after waste, fraud, and abuse in Medicaid. In May, CMS Administrator Mehmet Oz stood alongside JD Vance as the vice president announced the deferral of in Medicaid money to California over suspicions of fraud.

California Attorney General Rob Bonta said Republicans are simply trying to score political points while ignoring the healthcare needs of poor people. “The federal government wants to politicize fraud,” Bonta said, “and use it, unfortunately, as a bludgeon and a cajole to beat up on blue states.”

Social Healthcare

Health policy researchers say roughly are linked to socioeconomic, environmental, and behavioral factors, such as housing instability, homelessness, food insecurity, and exposure to violence, whereas 20% is associated with medical care delivered in hospitals and clinics. That evidence to tackle social services.

At least 24 states use their own money while drawing federal Medicaid funds for . Colorado, Massachusetts, New York, North Carolina, Oregon, and Pennsylvania are among those that provide housing and nutrition assistance.

As the Trump administration pulls back on social services, states are rethinking how to fund benefits that have improved preventive care for low-income people. Some have launched new benefits under what’s known as a state plan amendment, a mechanism states use to modify their Medicaid programs that doesn’t need federal waiver approval. and , for example, use this to add recuperative care for homeless patients after hospitalization. These short-term care facilities offer people the opportunity to recover, bridging the gap between hospital discharge and independent living.

This approach “has the advantage of establishing a permanent, statewide benefit that does not require ongoing federal renewals, offering greater stability and predictability,” said Lynn Sutfin, a spokesperson for the Michigan Department of Health and Human Services.

Other states, meanwhile, rely on federal waivers, which require renewal to provide social services. Arizona officials said the state intends to submit a request by the end of September to continue to provide housing and other services to homeless patients, or those at risk of homelessness, with a serious mental illness and a chronic health condition or recent incarceration.

“When members have access to stable housing and supportive services, they are more likely to engage in ongoing care and less likely to experience avoidable emergency department visits and inpatient admissions,” said Roberta Harrison, interim director of the Arizona Health Care Cost Containment System.

California, which has been the most aggressive state in adopting social services, has taken a two-pronged approach to keep its vast offerings funded past this year. The state is using its authority to make most of its existing social services and benefits permanent in Medi-Cal managed-care coverage. That regulatory maneuver bypasses federal waiver approval — a move that could attract further Republican scrutiny.

But not everything the state offers can be funded without permission from the federal government. As some services are made permanent, the Newsom administration is seeking new waivers to continue other social services, while also adding more.

It’s an ambitious approach that would expand California’s social healthcare experiment. Newsom said he’s worried that the federal government will decline the . “How could you not be with this administration?” he said. “I’m always concerned.”

New Front in Healthcare

California offers most of its health-related social services under within Medi-Cal, which has a proposed budget of . Although there are more than 14 million residents on Medi-Cal, the state has been selective about who gets help from in its program, called California Advancing and Innovating Medi-Cal, or . Patients with complex needs can also receive help navigating their health and social needs from specialized social workers under a benefit known as .

Since 2022, California has been offering social services, spending nearly $12 billion in joint state and federal money, long-term Medi-Cal spending by keeping enrollees out of costly institutions including emergency rooms, jails, nursing homes, and mental health crisis centers.

CalAIM had provided social services to more than patients as of September 2025, the most recent state data available. And nearly low-income Californians have received intensive . Some patients receive both services.

Among the services California is making permanent: Homeless patients can get help finding an apartment, with Medi-Cal paying rental and six months of rent. Patients with chronic conditions such as diabetes and heart disease are eligible for home-delivered meals. Asthmatic patients can get mold removed from their homes to control flare-ups. Low-income seniors with disabilities can get a wheelchair ramp installed free of charge. And inmates leaving jail or prison can be connected immediately with primary care, mental health, and substance use treatment.

The social services — especially housing, food assistance, and home modifications — are success in stabilizing the health of the most complex patients, while achieving savings for Medi-Cal through reductions in emergency room visits and hospitalizations and less reliance on institutional care such as nursing homes, the state Department of Health Care Services.

In the Central Valley, for instance, Health Plan of San Joaquin CEO Lizeth Granados said CalAIM has helped place homeless patients who were routinely hospitalized into housing. And patients with uncontrolled diabetes saw their blood sugar drop after receiving nutrition counseling and home-delivered meals.

Overall, Granados said, the health plan has seen major improvements in chronic disease management and reductions in hospital stays, dropping to 44 inpatient hospitalizations per 1,000 members since it launched in 2022, down from 61 per 1,000 before CalAIM.

In Orange County, officials with CalOptima Health credited CalAIM housing services for contributing to a nearly . “We’ve been able to expand our street medicine programs, too,” said Yunkyung Kim, the insurer’s chief operating officer.

Around the state, Medi-Cal health insurers said they’re optimistic that CalAIM will continue to save money and improve patient health. Yet, the fate of some services will be decided by the Trump administration.

California has asked CMS to continue enrolling jail and prison inmates in Medi-Cal 90 days before their release to maintain consistent treatment for substance use, mental disorders, or physical conditions, a .

The state has also proposed a new job assistance benefit that counties could opt into to help patients find and retain work in response to upcoming federal work requirements imposed by congressional Republicans’ One Big Beautiful Bill Act, signed by Trump last summer.

And the state wants to continue its array of traditional healers and natural helpers for Californians with tribal affiliations, including music therapy, dancing, drumming, and referrals to sweat lodges for mental health treatment and substance use recovery. While it covers spiritual services, such as ceremonies, rituals, and herbal remedies, state officials said Medi-Cal does not cover exorcisms.

Already, the Trump administration’s positioning has forced the state to eliminate room-and-board benefits, which is threatening local efforts to provide recovery beds.

The state is cutting short-term post-hospitalization housing, which was meant to prevent hospitals from or those at risk of homelessness onto the streets. The CalAIM service providing up to six months of temporary housing and ongoing care is ending at the close of this year. And the state is cutting recuperative care benefits, no longer paying for beds for patients to recover from illness or injury, instead offering only wraparound services.

In San Francisco, these beds have been crucial in reducing overdose deaths, helping transition homeless people off the streets and into housing, and reducing hospital bed usage, said Neal Sheran, a medical director with the city’s Department of Public Health. The city’s health plan operates a sobering center, and recuperative care facilities where patients can recover from hospitalizations.

“We’re concerned,” Sheran said. “Funding for the overnight piece of these programs is really crucial to their success.”

Cuts on the Horizon

Even without federal threats, state budget pressures have strained CalAIM financing. Newsom has proposed for social services by $68.3 million this fiscal year. The cut will deepen next year and remain at $150.2 million per year beginning in 2028.

Providers worry that Medi-Cal patients will lose access. And services, such as home-delivered meals and housing assistance, will be further restricted.

“It’s moving us back to the old days where our healthcare system is more expensive and reactive, instead of investing in prevention,” said Anwar Zoueihid, a vice president and the chief strategy officer at the Los Angeles-based Partners in Care Foundation, a CalAIM provider. “It’s contradictory to Make America Healthy Again.”

To save money, the state is tightening eligibility to limit services and . For instance, Medi-Cal patients with food insecurity would no longer be eligible for home-delivered healthy meals without a qualifying condition like diabetes. And a homeless patient would get capped at six months for help finding an apartment.

Some of the biggest providers of CalAIM say services should be continuously evaluated and curtailed if health plans were too permissive. In some cases, food and housing services were given to low-income patients who didn’t necessarily qualify as the highest-need.

“It’s important everybody takes a look with a very sober view at whether we’re truly benefiting people so we’re spending money in the right places,” said Charlie Robinson, the chief health equity officer at L.A. Care, one of the state’s largest Medi-Cal health insurers.

Dorothy Seleski, the Medi-Cal president for Health Net, said the health insurer isn’t deterred by state and federal cuts.

“Regardless of what happens at the federal level, we are committed,” she said. “This is a significant transformation of the healthcare system, and we are already seeing major reductions in avoidable emergency room trips, avoidable hospital admissions, and we’ve closed gaps in preventive care.”

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She spoke at rallies. With other members of the advocacy organization Compassion & Choices, she visited legislators’ offices. In 2024, as the state Assembly was debating the aid in dying bill, she helped unfurl a banner in the chamber gallery that read, “Stop the Suffering.”

Her activism was becoming difficult. Netherland, who is 59 and works for a nonprofit, was diagnosed with breast cancer in 2019. “I did a full year of aggressive treatment,” she said. “Chemotherapy. A mastectomy. Radiation treatment every weekday for five weeks. Six months of two oral medications.”

She recovered and felt well until the cancer returned a few years later. Although metastatic breast cancer is incurable, drugs are keeping her disease at bay for now. Netherland feels fortunate but also fatigued, and she contends with brain fog, gastrointestinal symptoms, and joint pain.

“My energy is really limited,” she said.

As she emailed and called legislators, Netherland feared she might die before the aid in dying bill — first introduced in New York in 2016 — could become law.

‘A Breakthrough Moment’

On June 9, 2025, after the Assembly approved the bill, Netherland was in the state Senate chamber, watching the aye votes mount, and seeing it pass.  an amended version in February; it is scheduled to take effect Aug. 5.

A similar law is  in September in Illinois, which would become the (plus the District of Columbia) where medical aid in dying is legal.

“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years — Oregon’s law, the first in the country, was enacted in 1997 — the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Díaz said.

Polls consistently back that claim. A  last spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue. Support crossed many political and religious lines: A narrow majority of Republicans and 76% of Democrats both found “physician-assisted death” (also sometimes called “physician-assisted suicide”) permissible; so did most Catholics, Jews, and nonevangelical white Protestants.

In New York,  that 54% of respondents supported aid in dying, including majorities of men and women, of all age groups, and of city, suburban, and upstate residents. A plurality of Latinos supported it; Black respondents narrowly opposed it.

Passing these laws has grown somewhat easier, said Thaddeus Pope, a bioethicist and professor at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such policies. “You can say, ‘We have 10 years in California, 18 years in Washington, and 29 years in Oregon, and nothing bad has happened.’ It becomes more accepted.”

‘You Need A, B, and C’

Yet legalizing medical aid in dying, or MAID, has been and remains a long, contentious process. Catholic leadership and many disability organizations staunchly oppose it. (Pope Leo XIV personally  not to sign the bill.)

The American Medical Association says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer” and poses “serious societal risks,” although a number of state medical organizations have opted to remain neutral or, as in New York, to .

The Patients’ Rights Action Fund, through a sister organization, has lawsuits pending or on appeal in California, Delaware, and Colorado, arguing that aid in dying laws discriminate against people with disabilities by steering them toward physician-assisted suicide instead of treatment.

“This is a litigation strategy we’ve developed to ultimately get to the Supreme Court,” said Matt Vallière, the group’s executive director, who declined to say whether it would sue to block the Illinois and New York laws.

Even when aid in dying laws succeed, using them can prove challenging. In every state (except Montana, where it became legal through a court decision, so there is no statute governing eligibility), aid in dying is available only to people with incurable illnesses who are expected to die within six months.

It typically involves oral and written requests to two doctors, with mandated waiting periods between requests. Patients must have the mental capacity to make the decision, which disqualifies those with dementia, and they must ingest the medication without assistance. (An amendment Hochul insisted on adds a psychologist or psychiatrist to the process.)

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements  brought by Compassion & Choices. ( a .)

Moreover, any doctor, hospital, or healthcare system can legally decline to provide aid in dying, and religiously affiliated institutions often opt out. Those that participate can add their own requirements.

“The state can say ‘You need A, B, and C,’ and Columbia-Presbyterian can say, ‘We also want D, E, and F,’” said Pope, the Minnesota bioethicist.

Hotly Debated, Seldom Used

Perhaps these restrictions, or a lack of public awareness, help explain why, despite the headlines and fervent debates, the number of people who actually use the law is tiny in every state — usually 1% or fewer of the deaths recorded annually. The support for giving patients this kind of autonomy at the end of life remains widespread, but the desire to personally exercise it apparently is not.

Still, after studies showed that many patients seeking MAID were dying , the trend has been to loosen restrictions. California cut its 15-day waiting period to 48 hours; New Mexico allows physician assistants and advanced-practice nurses to write prescriptions along with doctors.

“Most states have now amended their laws two or three times,” Pope said. “We have liberalized.” Telehealth can also facilitate access to participating doctors.

Compassion & Choices is planning legal challenges to end residency requirements in additional states, Díaz said. It is also considering how to “make inroads in jurisdictions with a much different cultural and political environment,” he added, mentioning Florida and other Southern states.

Medical aid in dying represents a shift in power, Díaz said. “The person who has to bear the burden of the suffering should have the ability to decide when it’s enough,” he added.

Anne Gurnett Bander, 72, a retired research scientist in Carmel, New York, cared for her husband for four years as ALS — the relentlessly disabling neurological disorder also known as Lou Gehrig’s disease — rendered him bedridden and dependent on feeding and breathing tubes. “By the time he died, the only thing he could do was nod his head,” she recalled.

So being diagnosed with ALS herself last year was “my worst possible nightmare,” Gurnett Bander said. She was planning to fly to Switzerland, where the nonprofit organization Dignitas provides medical aid in dying, when she learned about the New York bill and began speaking publicly in support of it, her voice faltering as her illness advanced.

Gurnett Bander and Netherland say they’re not certain they’ll use lethal drugs to end their lives as their symptoms intensify. Not infrequently, patients complete the necessary steps, secure the prescribed medication, decide they don’t need it after all, and die of their diseases. But both women insist that the choice should be theirs.

“It can offer so much peace of mind,” Netherland said. “I thought, ‘People should have this option.’ Now, they will.”

The New Old Age is produced through a partnership with .

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