Kaiser Health News
Amid Lack of Accountability for Bias in Maternity Care, a California Family Seeks Justice
by Sarah Kwon
Tue, 08 Aug 2023 09:00:00 +0000
Aniya was ready to leave. She was dressed in a fuzzy white onesie her mother had packed for her first trip home. Yet Aniya’s family had more questions than answers as they cradled the newborn out of the hospital, her mother’s body left behind.
April Valentine, a 31-year-old Black mother, died while giving birth in Inglewood, California, on January 10. Her family has raised questions of improper care: Why didn’t nurses investigate numbness and swelling in her leg, symptoms she reported at least 10 times over the course of 15 hours? Why did it take nearly 20 hours for her doctor to see her after she arrived at the hospital already in labor?
Valentine’s family wants the state to investigate how she died and whether systemic or interpersonal racism could have played a role. Los Angeles politicians and media have amplified their demands. “I think she would have been treated differently if she was white,” said Valentine’s cousin Mykesha Mack, who filed a complaint.
The official cause of death was a blood clot that formed in her leg and traveled to her lung — a preventable condition. The state has issued a $75,000 fine to Centinela Hospital for risking the health and safety of Valentine, and an inspection report suggests it failed to properly assess her risk for blood clots, take precautions, and alert her physician. Centinela announced last month that it would close its maternity services on Oct. 25.
Even so, the odds of finding discrimination and getting justice remain stacked against her family.
The statuses of the state’s investigations aren’t clear, and a federal investigation is pending. The hospital and Valentine’s OB-GYN deny allegations of improper care and reject assertions by some family members that Valentine’s care team, which was largely Black, could have harbored bias toward her. But a KFF Health News analysis shows state authorities are ill-equipped to investigate discrimination complaints and often avoid fining hospitals that violate regulations. That highlights a big gap in the state’s ability to hold doctors and hospitals accountable when it comes to reducing bias in maternal care.
Aiming to reduce stark health disparities, in 2019, California became the first state to require implicit bias training for maternity care providers. But the state hasn’t penalized physicians and hospitals that treat patients inequitably, as it hasn’t found discrimination in the incidents brought to their attention. Neither of the agencies overseeing health care facilities and physicians — the California Department of Public Health and Medical Board of California — has found discrimination, despite hundreds of complaints going back a decade, the KFF Health News analysis found.
In the unlikely event that regulators find discrimination, they usually prefer corrective actions for violations, such as improvement plans, as opposed to penalties. Karen Smith, a physician who led the Department of Public Health from 2015 to 2019, said the agency wants hospitals to provide high-quality care, not to shut them down. So when one violates a regulation, the agency typically tries to help it remedy the problem, depending on the severity. The medical board has come under fire for avoiding meaningful penalties, even for grossly negligent doctors.
California’s rate of maternal deaths is among the lowest in the country, but is up to 3.6 times as high for Black women as for women of other races. Multiple factors, including systemic racism and provider bias, implicit or not, are thought to contribute to this disparity. Valentine’s is not the only high-profile death of a Black mother whose family said her care providers dismissed her.
Some advocates believe these cases keep happening because the state’s oversight of hospitals and doctors is too lax. “There’s no accountability,” said Linda Jones, a co-founder of Black Women Birthing Justice, a nonprofit organization seeking birth equity. “Why should they do anything different?”
A Mother’s Pleas Are Dismissed
Valentine, who worked with at-risk youth and styled hair on the side, was acutely aware of the risks Black mothers face, so she diligently attended prenatal visits and sought a birth doula and Black doctor, her family said.
Valentine’s sister Kesiah Cordova said she accompanied the first-time mother to a late-afternoon visit on January 9 with her OB-GYN, Gwen Allen, who told them Valentine was dilated and that she would meet them at the hospital. Valentine went to Centinela Hospital Medical Center, owned by Prime Healthcare, one of the country’s largest for-profit health systems.
Cordova and Valentine’s partner, Nigha Robertson, were both with her throughout her stay. They said she got to the hospital around 8:30 p.m. While being admitted, Valentine was asked several questions by staff that made her feel uncomfortable, including if she knew who her baby’s father was and what type of housing her baby would live in, they said. Robertson said he doubts white mothers are asked these questions as often. Centinela responded in a statement that every patient is asked these questions to identify any nonmedical factors that could affect their health, so it can provide any necessary resources. Nurses then forbade her doula from attending her delivery, despite the hospital’s approval a month earlier, Robertson and Cordova added. The hospital said it welcomes doulas.
After receiving an epidural five hours later, Valentine reported leg numbness and, later, swelling, they said. Cordova and Robertson estimated that they witnessed Valentine ask nurses to examine her leg and call her doctor at least 10 times. Each time, they said, the nurses declined, saying her symptoms were normal.
“Every time they came to check on her, she would say, ‘Hey, can you look at my leg?’” said Cordova. “The nurse didn’t even lift up the blanket to check.”
Cordova and Robertson said nurses repeatedly told them they couldn’t call Valentine’s OB-GYN because she would get upset. They said Allen did not visit her until 4 p.m. the next day and did not address her concerns.
Two hours later, Cordova and Robertson said, Valentine coughed and vomited. A nurse told them this was normal. Then Valentine stopped breathing. Robertson and Cordova said the nurse in the room froze, so Robertson stepped in and gave Valentine CPR for about five minutes until additional staff, then Allen, arrived. They said her providers did not try to revive her before she was wheeled away. Centinela refuted these allegations but said it could not comment further.
Aniya was delivered via emergency cesarean section from her mother’s body.
No Track Record of Finding Discrimination
The state’s public health department and medical board would not comment on the details of Valentine’s case.
The California Department of Public Health is “deeply saddened” by what happened to Valentine and her family and takes “every action within its legal authority to safeguard patients,” including thoroughly investigating complaints, said spokesperson Ali Bay in a statement.
Asked how it evaluates the possibility of discrimination, the public health department sidestepped and said its role is to determine if any federal or state regulations were violated, and later added that hospitals must follow regulations that allow patients to exercise their rights without regard to race. It provided KFF Health News a copy of a letter dated Feb. 23 from Mark Ghaly, secretary of the California Health and Human Services Agency, to the Los Angeles County Board of Supervisors. Ghaly declined to be interviewed.
In the letter, he said the state would review medical records, interview medical staff, and assess the hospital’s policies and procedures in its investigation.
But the public health department’s track record shows it hasn’t substantiated a discrimination complaint yet. Statewide, the department has not found any violations of regulations protecting patients against discrimination since 2007, Bay said. She said the department found over 650 complaints that mention racism, discrimination, or both in all available records since 2007. It receives an average of around 45,000 total complaints and reported incidents across all facility types every year.
The medical board also hasn’t substantiated discrimination complaints against physicians. Since 2014, it has not found that a physician discriminated against a patient in any of the over 240 complaints it has closed, said Aaron Bone, the board’s chief of legislation and public affairs. He cautioned against drawing conclusions from a small sample; the agency received approximately 10,000 complaints of all types in 2020 alone.
Both agencies’ figures have limitations. The medical board tracks only discrimination resulting in a doctor’s refusal to treat. And neither agency knows exactly how many discrimination complaints were race-based.
The exact reasons for their limited track records are unclear, but some experts point to the high burden of proof for substantiating these cases.
Abbi Coursolle, a senior attorney at the National Health Law Program, said anti-discrimination laws and regulations can be hard to enforce. They are intended to protect people from intentional discrimination and policies or actions that disproportionately harm them. But people can unconsciously harbor biases, or there could be alternative explanations for ignoring a patient, such as a provider being busy, which can make discrimination hard to substantiate.
Racism “is complicated and hard to isolate, but the law hasn’t quite caught up to that,” she said.
State agencies, she added, can interpret the law so narrowly that people can’t take advantage of these protections.
The California agencies said they do their best within their legal authority. The medical board blamed current law, which, it said, requires “clear and convincing evidence” to discipline a physician, and it can be challenging to substantiate cases if the allegations aren’t documented or aren’t corroborated by witnesses. There may not always be sufficient evidence to find a violation, said Bay, of the public health department.
Smith, the former public health department director, said discrimination by a facility is typically hard to find unless investigators identify a pattern, but that type of research can be labor-intensive and hampered by underreporting of complaints.
So far, the public health department has imposed a $75,000 fine for risking Valentine’s health and safety. In his letter, Ghaly said the state could revoke or suspend the hospital’s license if it finds Centinela violated state or federal regulations. It could also refer the case to other agencies. The federal Department of Health and Human Services’ Office for Civil Rights acknowledged it is investigating Valentine’s case but declined to comment.
Centinela’s fine is the exception, not the rule. Last year, roughly 100 fines were levied against hospitals statewide out of nearly 12,000 complaints and incidents closed, according to a state database. The department cautioned that the data contains many redundant complaints and noted that not all violations require issuing fines. It declined to provide aggregated data on corrective actions, such as improvement plans, and nonfinancial penalties, such as license suspensions.
Evidence is mixed on whether financial penalties improve hospital care, illustrating how regulators’ hands may be tied.
‘Thoughts and Prayers’
The state public health department conducted an inspection of Centinela in February. It found the hospital failed to properly assess an unnamed labor and delivery patient’s risk for clotting and failed to notify her physician when she reported “leg heaviness” and when her vital signs were abnormal. Though the inspection, first reported by the Los Angeles Times, does not name Valentine, it describes the account her partner and family shared, including the date she was admitted to the hospital.
In its report, the department deemed the situation “immediate jeopardy,” meaning the hospital’s failure to meet requirements caused or could have caused death or serious injury. But regulators removed that label after the hospital submitted an improvement plan. Among other measures, it promised to reeducate nurses on how to prevent blood clots.
The report found Centinela made similar missteps with other patients, potentially increasing their risk for developing blood clots in deep veins, typically in the leg, which, when untreated, can travel to the lungs. Known as a pulmonary embolism, this condition is one of the most common causes of pregnancy-related deaths in the United States, and is preventable and treatable if discovered early, according to the Centers for Disease Control and Prevention. It was also the official cause of Valentine’s death, stated the Los Angeles County medical examiner’s website.
Centinela said it immediately addressed the inspection’s findings. Sue Lowe, a Centinela spokesperson, said it was the hospital, not the state, that decided to close its maternity and newborn units, “to create capacity for services of greatest benefit and need for patients.”
Robertson, Valentine’s partner, said he felt the report validated his account.
“They killed her,” said Robertson, who has retained an attorney. For him, justice would mean a punishment severe enough to ensure Valentine’s situation never happens again, but he wants Centinela to remain in business since it’s the only hospital in Inglewood.
Lowe said the hospital could not discuss specifics due to patient privacy laws but extended the hospital’s “thoughts and prayers” to Valentine’s family. She added, “We express our deepest condolences.”
Before the results of the state’s inspection report and the county’s autopsy report were publicized, Centinela implied the death was unpreventable. “Despite the highest standards of care,” said Lowe, “there are certain medically complex and emergent situations that cannot be overcome.” Centinela declined to comment on the autopsy results.
Lowe defended the hospital’s track record, noting it has won national awards for quality and patient safety. She said it had gone a decade without a maternal death in labor and delivery before Valentine’s. She also said the unit was appropriately staffed.
In 2020, the hospital registered 1.8 times the number of complaints and incidents as the state average. So far this year, it’s 9.5 times as many. Lowe responded that the state hasn’t substantiated many of these and that, in some recent years, the hospital had fewer total violations than the state average for hospitals of its size.
The hospital, Lowe said, maintains “robust policies prohibiting discrimination” and requires diversity and implicit bias training for staff. “Our staff reflects the community that we serve,” she added.
Allen, the OB-GYN, directed questions to her attorney, Ludlow B. Creary II, who said his client could not comment on the case, citing patient privacy protections. But he urged against drawing conclusions without both sides of the story and a medical expert’s assessment of whether Allen caused Valentine’s death. Allen, like the community she has served for 20 years, is Black, he added.
Doctors Oppose More Oversight
Mack, Valentine’s cousin, said Valentine’s providers being largely Black did not sway her view that they could have discriminated against her. She said she hopes the state evaluates whether interpersonal or systemic racism, or both, contributed to Valentine’s death. Did her clinicians dismiss her complaints due to bias, and did the hospital, located in a minority neighborhood, provide lower-quality care?
Both types of racism can be hard to see. The numbers, however, show they exist. Studies suggest Black mothers are more likely than white ones to report being ignored or mistreated by clinicians and to deliver at hospitals with lower-quality care.
The public health department considers how discrimination and systemic racism could have contributed to a maternal death in a quality improvement process known as the California Pregnancy-Associated Mortality Review. But this committee lacks authority to discipline hospitals or clinicians.
Attempts to reform laws often face resistance. Last year, the medical board asked the state to lower the burden of proof for disciplining physicians from “clear and convincing” to a standard equivalent to “more likely than not,” followed by most states. A bill including this request recently passed the California State Senate and is pending in the Assembly.
The California Medical Association, which represents physicians, opposes the bill, unless amended. “Clear and convincing” is the standard for disciplining professional license-holders in California, spokesperson Shannan Velayas said.
In Inglewood, a world away from bureaucrats and lobbyists, Robertson grieves and struggles as a single father. His job in crime scene and disaster cleanup can require long and unpredictable hours. He was recently called in to work at 2 in the morning, leaving him scrambling to get ahold of Aniya’s godmother to come watch her.
“It’s overwhelming, just all this juggling,” he said.
In periods of calm, father and daughter bond over picture books Valentine bought and go to the park with their dog. Robertson said Aniya, now over 6 months old and sitting up, is deeply loved.
Still, there’s a void that will only grow as Aniya gets older. He can’t style her hair the way Valentine would have and worries that he won’t be able to support her like a mother would when Aniya becomes a young woman.
“I don’t want nobody else to have to go through this hurt and pain,” Robertson said.
When told the state rarely finds discrimination, he paused, recognizing a gap in accountability. He said, “The government pick and choose which situations that they press the issue on.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
By: Sarah Kwon
Title: Amid Lack of Accountability for Bias in Maternity Care, a California Family Seeks Justice
Sourced From: kffhealthnews.org/news/article/maternity-care-bias-accountability-april-valentine/
Published Date: Tue, 08 Aug 2023 09:00:00 +0000
Kaiser Health News
US Judge Names Receiver To Take Over California Prisons’ Mental Health Program
SACRAMENTO, Calif. — A judge has initiated a federal court takeover of California’s troubled prison mental health system by naming the former head of the Federal Bureau of Prisons to serve as receiver, giving her four months to craft a plan to provide adequate care for tens of thousands of prisoners with serious mental illness.
Senior U.S. District Judge Kimberly Mueller issued her order March 19, identifying Colette Peters as the nominated receiver. Peters, who was Oregon’s first female corrections director and known as a reformer, ran the scandal-plagued federal prison system for 30 months until President Donald Trump took office in January. During her tenure, she closed a women’s prison in Dublin, east of Oakland, that had become known as the “rape club.”
Michael Bien, who represents prisoners with mental illness in the long-running prison lawsuit, said Peters is a good choice. Bien said Peters’ time in Oregon and Washington, D.C., showed that she “kind of buys into the fact that there are things we can do better in the American system.”
“We took strong objection to many things that happened under her tenure at the BOP, but I do think that this is a different job and she’s capable of doing it,” said Bien, whose firm also represents women who were housed at the shuttered federal women’s prison.
California corrections officials called Peters “highly qualified” in a statement, while Gov. Gavin Newsom’s office did not immediately comment. Mueller gave the parties until March 28 to show cause why Peters should not be appointed.
Peters is not talking to the media at this time, Bien said. The judge said Peters is to be paid $400,000 a year, prorated for the four-month period.
About 34,000 people incarcerated in California prisons have been diagnosed with serious mental illnesses, representing more than a third of California’s prison population, who face harm because of the state’s noncompliance, Mueller said.
Appointing a receiver is a rare step taken when federal judges feel they have exhausted other options. A receiver took control of Alabama’s correctional system in 1976, and they have otherwise been used to govern prisons and jails only about a dozen times, mostly to combat poor conditions caused by overcrowding. Attorneys representing inmates in Arizona have asked a judge to take over prison health care there.
Mueller’s appointment of a receiver comes nearly 20 years after a different federal judge seized control of California’s prison medical system and installed a receiver, currently J. Clark Kelso, with broad powers to hire, fire, and spend the state’s money.
California officials initially said in August that they would not oppose a receivership for the mental health program provided that the receiver was also Kelso, saying then that federal control “has successfully transformed medical care” in California prisons. But Kelso withdrew from consideration in September, as did two subsequent candidates. Kelso said he could not act “zealously and with fidelity as receiver in both cases.”
Both cases have been running for so long that they are now overseen by a second generation of judges. The original federal judges, in a legal battle that reached the U.S. Supreme Court, more than a decade ago forced California to significantly reduce prison crowding in a bid to improve medical and mental health care for incarcerated people.
State officials in court filings defended their improvements over the decades. Prisoners’ attorneys countered that treatment remains poor, as evidenced in part by the system’s record-high suicide rate, topping 31 suicides per 100,000 prisoners, nearly double that in federal prisons.
“More than a quarter of the 30 class-members who died by suicide in 2023 received inadequate care because of understaffing,” prisoners’ attorneys wrote in January, citing the prison system’s own analysis. One prisoner did not receive mental health appointments for seven months “before he hanged himself with a bedsheet.”
They argued that the November passage of a ballot measure increasing criminal penalties for some drug and theft crimes is likely to increase the prison population and worsen staffing shortages.
California officials argued in January that Mueller isn’t legally justified in appointing a receiver because “progress has been slow at times but it has not stalled.”
Mueller has countered that she had no choice but to appoint an outside professional to run the prisons’ mental health program, given officials’ intransigence even after she held top officials in contempt of court and levied fines topping $110 million in June. Those extreme actions, she said, only triggered more delays.
The 9th U.S. Circuit Court of Appeals on March 19 upheld Mueller’s contempt ruling but said she didn’t sufficiently justify calculating the fines by doubling the state’s monthly salary savings from understaffing prisons. It upheld the fines to the extent that they reflect the state’s actual salary savings but sent the case back to Mueller to justify any higher penalty.
Mueller had been set to begin additional civil contempt proceedings against state officials for their failure to meet two other court requirements: adequately staffing the prison system’s psychiatric inpatient program and improving suicide prevention measures. Those could bring additional fines topping tens of millions of dollars.
But she said her initial contempt order has not had the intended effect of compelling compliance. Mueller wrote as far back as July that additional contempt rulings would also be likely to be ineffective as state officials continued to appeal and seek delays, leading “to even more unending litigation, litigation, litigation.”
She went on to foreshadow her latest order naming a receiver in a preliminary order: “There is one step the court has taken great pains to avoid. But at this point,” Mueller wrote, “the court concludes the only way to achieve full compliance in this action is for the court to appoint its own receiver.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”
The post US Judge Names Receiver To Take Over California Prisons’ Mental Health Program appeared first on kffhealthnews.org
Kaiser Health News
Amid Plummeting Diversity at Medical Schools, a Warning of DEI Crackdown’s ‘Chilling Effect’
The Trump administration’s crackdown on DEI programs could exacerbate an unexpectedly steep drop in diversity among medical school students, even in states like California, where public universities have been navigating bans on affirmative action for decades. Education and health experts warn that, ultimately, this could harm patient care.
Since taking office, President Donald Trump has issued a handful of executive orders aimed at terminating all diversity, equity, and inclusion, or DEI, initiatives in federally funded programs. And in his March 4 address to Congress, he described the Supreme Court’s 2023 decision banning the consideration of race in college and university admissions as “brave and very powerful.”
Last month, the Education Department’s Office for Civil Rights — which lost about 50% of its staff in mid-March — directed schools, including postsecondary institutions, to end race-based programs or risk losing federal funding. The “Dear Colleague” letter cited the Supreme Court’s decision.
Paulette Granberry Russell, president and CEO of the National Association of Diversity Officers in Higher Education, said that “every utterance of ‘diversity’ is now being viewed as a violation or considered unlawful or illegal.” Her organization filed a lawsuit challenging Trump’s anti-DEI executive orders.
While California and eight other states — Arizona, Florida, Idaho, Michigan, Nebraska, New Hampshire, Oklahoma, and Washington — had already implemented bans of varying degrees on race-based admissions policies well before the Supreme Court decision, schools bolstered diversity in their ranks with equity initiatives such as targeted scholarships, trainings, and recruitment programs.
But the court’s decision and the subsequent state-level backlash — 29 states have since introduced bills to curb diversity initiatives, according to data published by the Chronicle of Higher Education — have tamped down these efforts and led to the recent declines in diversity numbers, education experts said.
After the Supreme Court’s ruling, the numbers of Black and Hispanic medical school enrollees fell by double-digit percentages in the 2024-25 school year compared with the previous year, according to the Association of American Medical Colleges. Black enrollees declined 11.6%, while the number of new students of Hispanic origin fell 10.8%. The decline in enrollment of American Indian or Alaska Native students was even more dramatic, at 22.1%. New Native Hawaiian or other Pacific Islander enrollment declined 4.3%.
“We knew this would happen,” said Norma Poll-Hunter, AAMC’s senior director of workforce diversity. “But it was double digits — much larger than what we anticipated.”
The fear among educators is the numbers will decline even more under the new administration.
At the end of February, the Education Department launched an online portal encouraging people to “report illegal discriminatory practices at institutions of learning,” stating that students should have “learning free of divisive ideologies and indoctrination.” The agency later issued a “Frequently Asked Questions” document about its new policies, clarifying that it was acceptable to observe events like Black History Month but warning schools that they “must consider whether any school programming discourages members of all races from attending.”
“It definitely has a chilling effect,” Poll-Hunter said. “There is a lot of fear that could cause institutions to limit their efforts.”
Numerous requests for comment from medical schools about the impact of the anti-DEI actions went unreturned. University presidents are staying mum on the issue to protect their institutions, according to reporting from The New York Times.
Utibe Essien, a physician and UCLA assistant professor, said he has heard from some students who fear they won’t be considered for admission under the new policies. Essien, who co-authored a study on the effect of affirmative action bans on medical schools, also said students are worried medical schools will not be as supportive toward students of color as in the past.
“Both of these fears have the risk of limiting the options of schools folks apply to and potentially those who consider medicine as an option at all,” Essien said, adding that the “lawsuits around equity policies and just the climate of anti-diversity have brought institutions to this place where they feel uncomfortable.”
In early February, the Pacific Legal Foundation filed a lawsuit against the University of California-San Francisco’s Benioff Children’s Hospital Oakland over an internship program designed to introduce “underrepresented minority high school students to health professions.”
Attorney Andrew Quinio filed the suit, which argues that its plaintiff, a white teenager, was not accepted to the program after disclosing in an interview that she identified as white.
“From a legal standpoint, the issue that comes about from all this is: How do you choose diversity without running afoul of the Constitution?” Quinio said. “For those who want diversity as a goal, it cannot be a goal that is achieved with discrimination.”
UC Health spokesperson Heather Harper declined to comment on the suit on behalf of the hospital system.
Another lawsuit filed in February accuses the University of California of favoring Black and Latino students over Asian American and white applicants in its undergraduate admissions. Specifically, the complaint states that UC officials pushed campuses to use a “holistic” approach to admissions and “move away from objective criteria towards more subjective assessments of the overall appeal of individual candidates.”
The scrutiny of that approach to admissions could threaten diversity at the UC-Davis School of Medicine, which for years has employed a “race-neutral, holistic admissions model” that reportedly tripled enrollment of Black, Latino, and Native American students.
“How do you define diversity? Does it now include the way we consider how someone’s lived experience may be influenced by how they grew up? The type of school, the income of their family? All of those are diversity,” said Granberry Russell, of the National Association of Diversity Officers in Higher Education. “What might they view as an unlawful proxy for diversity equity and inclusion? That’s what we’re confronted with.”
California Attorney General Rob Bonta, a Democrat, recently joined other state attorneys general to issue guidance urging that schools continue their DEI programs despite the federal messaging, saying that legal precedent allows for the activities. California is also among several states suing the administration over its deep cuts to the Education Department.
If the recent decline in diversity among newly enrolled students holds or gets worse, it could have long-term consequences for patient care, academic experts said, pointing toward the vast racial disparities in health outcomes in the U.S., particularly for Black people.
A higher proportion of Black primary care doctors is associated with longer life expectancy and lower mortality rates among Black people, according to a 2023 study published by the JAMA Network.
Physicians of color are also more likely to build their careers in medically underserved communities, studies have shown, which is increasingly important as the AAMC projects a shortage of up to 40,400 primary care doctors by 2036.
“The physician shortage persists, and it’s dire in rural communities,” Poll-Hunter said. “We know that diversity efforts are really about improving access for everyone. More diversity leads to greater access to care — everyone is benefiting from it.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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Kaiser Health News
Tribal Health Leaders Say Medicaid Cuts Would Decimate Health Programs
As Congress mulls potentially massive cuts to federal Medicaid funding, health centers that serve Native American communities, such as the Oneida Community Health Center near Green Bay, Wisconsin, are bracing for catastrophe.
That’s because more than 40% of the about 15,000 patients the center serves are enrolled in Medicaid. Cuts to the program would be detrimental to those patients and the facility, said Debra Danforth, the director of the Oneida Comprehensive Health Division and a citizen of the Oneida Nation.
“It would be a tremendous hit,” she said.
The facility provides a range of services to most of the Oneida Nation’s 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an “open-door policy,” Danforth said, which means that the facility is open to members of any federally recognized tribe.
But Danforth and many other tribal health officials say Medicaid cuts would cause service reductions at health facilities that serve Native Americans.
Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls from the Indian Health Service, the federal agency responsible for providing health care to Native Americans.
Medicaid has accounted for about two-thirds of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. More than a million Native Americans enrolled in Medicaid or the closely related Children’s Health Insurance Program also rely on the insurance to pay for care outside of tribal health facilities without going into significant medical debt. Tribal leaders are calling on Congress to exempt tribes from cuts and are preparing to fight to preserve their access.
“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit policy advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.
“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.
Tribes face an arduous task in providing care to a population that experiences severe health disparities, a high incidence of chronic illness, and, at least in western states, a life expectancy of 64 years — the lowest of any demographic group in the U.S. Yet, in recent years, some tribes have expanded access to care for their communities by adding health services and providers, enabled in part by Medicaid reimbursements.
During the last two fiscal years, five urban Indian organizations in Montana saw funding growth of nearly $3 million, said Lisa James, director of development for the Montana Consortium for Urban Indian Health, during a webinar in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.
The increased revenue was “instrumental,” James said, allowing clinics in the state to add services that previously had not been available unless referred out for, including behavioral health services. Clinics were also able to expand operating hours and staffing.
Montana’s five urban Indian clinics, in Missoula, Helena, Butte, Great Falls, and Billings, serve 30,000 people, including some who are not Native American or enrolled in a tribe. The clinics provide a wide range of services, including primary care, dental care, disease prevention, health education, and substance use prevention.
James said Medicaid cuts would require Montana’s urban Indian health organizations to cut services and limit their ability to address health disparities.
American Indian and Alaska Native people under age 65 are more likely to be uninsured than white people under 65, but 30% rely on Medicaid compared with 15% of their white counterparts, according to KFF data for 2017 to 2021. More than 40% of American Indian and Alaska Native children are enrolled in Medicaid or CHIP, which provides health insurance to kids whose families are not eligible for Medicaid. KFF is a health information nonprofit that includes KFF Health News.
A Georgetown Center for Children and Families report from January found the share of residents enrolled in Medicaid was higher in counties with a significant Native American presence. The proportion on Medicaid in small-town or rural counties that are mostly within tribal statistical areas, tribal subdivisions, reservations, and other Native-designated lands was 28.7%, compared with 22.7% in other small-town or rural counties. About 50% of children in those Native areas were enrolled in Medicaid.
The federal government has already exempted tribes from some of Trump’s executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would not be affected by an executive order that diversity, equity, and inclusion government programs be terminated, but that the Indian Health Service is expected to discontinue diversity and inclusion hiring efforts established under an Obama-era rule.
HHS Secretary Robert F. Kennedy Jr. also rescinded the layoffs of more than 900 IHS employees in February just hours after they’d received termination notices. During Kennedy’s Senate confirmation hearings, he said he would appoint a Native American as an assistant HHS secretary. The National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for tribes, in December endorsed elevating the director of the Indian Health Service to assistant secretary of HHS.
Jessica Schubel, a senior health care official in Joe Biden’s White House, said exemptions won’t be enough.
“Just because Native Americans are exempt doesn’t mean that they won’t feel the impact of cuts that are made throughout the rest of the program,” she said.
State leaders are also calling for federal Medicaid spending to be spared because cuts to the program would shift costs onto their budgets. Without sustained federal funding, which can cover more than 70% of costs, state lawmakers face decisions such as whether to change eligibility requirements to slim Medicaid rolls, which could cause some Native Americans to lose their health coverage.
Tribal leaders noted that state governments do not have the same responsibility to them as the federal government, yet they face large variations in how they interact with Medicaid depending on their state programs.
President Donald Trump has made seemingly conflicting statements about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn’t be touched. In a social media post the same week, Trump expressed strong support for a House budget resolution that would likely require Medicaid cuts.
The budget proposal, which the House approved in late February, requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid and Medicare, is instructed to slash $880 billion over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to 79 million people has drawn opposition from national and state organizations.
The federal government reimburses IHS and tribal health facilities 100% of billed costs for American Indian and Alaska Native patients, shielding state budgets from the costs.
Because Medicaid is already a stopgap fix for Native American health programs, tribal leaders said it won’t be a matter of replacing the money but operating with less.
“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.
Congress isn’t required to consult tribes during the budget process, Davis added. Only after changes are made by the Centers for Medicare & Medicaid Services and state agencies are tribes able to engage with them on implementation.
The amount the federal government spends funding the Native American health system is a much smaller portion of its budget than Medicaid. The IHS projected billing Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.
“We are saving more lives,” Malerba said of the additional services Medicaid covers in tribal health care. “It brings us closer to a level of 21st century care that we should all have access to but don’t always.”
This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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