Two years later, Democrats are defending the seven seats they flipped from red to blue in California. And once again, they plan to go after their Republican opponents on health care in this year’s elections.

But this time around, it’s not just about the Affordable Care Act, now rests with the federal courts. Democrats are highlighting the high costs of prescription drugs, surprise medical bills and cuts to safety-net programs.

Health care “remains the single-biggest priority for most voters in 2020,” said U.S. Rep. Josh Harder, a Democrat who represents California’s 10th congressional district, in the northern San Joaquin Valley, which includes the cities of Modesto, Turlock, Tracy and Manteca.

Harder, who defeated Republican Jeff Denham in 2018, made the case then that eliminating the federal health law and its protections for people with would harm thousands of people in his district, including his younger brother, whose premature birth yielded $2 million in hospital bills.

Health care affordability — from drug costs to premiums — is still the No. 1 issue his constituents raise in conversations with him, he said.

“The problems haven’t been solved,” said Harder, who blamed the Republican-controlled U.S. Senate for stalling on addressing prescription and other health care costs. “A lot of folks out here feel like there’s still an unbelievably long period before they can see a doctor, and they think that the costs are way too high.”

Multiple calls and emails to Republican congressional candidates and the California Republican Party requesting comment were not returned. California voters will select their party’s congressional candidates in the Super Tuesday primary March 3.

Health care is indeed a top issue for voters, confirmed Mollyann Brodie, executive director of public opinion and survey research for the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“What concerns people the most is health care costs and their own affordability of health care,” Brodie said. “And when we asked people what they thought Congress should be working on, prescription drug costs came right on top.”

A national Kaiser Family Foundation tracking poll from found that 81% of Democrats and 62% of Republicans surveyed said lowering prescription drug costs should be a top priority for Congress. Voters in both parties also want Congress to maintain protections for people with preexisting conditions and limit surprise medical bills.

Both Democratic and Republican candidates are taking note and are likely to feature health care prominently in their campaigns, but their messages will be different, said Nathan Gonzales, editor and publisher of , a campaign analysis site.

For example, progressive Democrats often advocate for “Medicare for All,” a national health care program that would cover everyone in the U.S.

Republicans oppose this idea fervently.

“Republicans will talk about a government takeover of health care, socialism, Democratic efforts to get rid of private health insurance and the cost of Democratic plans,” Gonzales said.

Ted Howze, one of three Republicans gunning in the primary to replace Harder, fits this description. He is running for Congress after “personally struggling with the failure of the health care system,” he said during in Modesto. His first wife died in 2013 from an undiagnosed heart condition “that could have been treated,” according to his .

Among his top three priorities, he said, is making quality health care affordable for all Americans. But he proposes to do so through the private market, not more government-run programs.

“I will support any plan that covers preexisting conditions and that increases transparency and competition to drive costs down,” he said during the debate.

In at least one California district, health care has popped up in campaign advertising.

Twelve candidates are vying for the 25th Congressional District seat, which includes portions of Los Angeles and Ventura counties. The seat was vacated by former U.S. Rep. Katie Hill, a Democrat in October.

Voters in that district will face a double election on March 3: The first is a special election for the remainder of Hill’s term, which runs through the end of this year. The second is the primary for the full 2021-23 congressional term.

Among the candidates is former U.S. Rep. Steve Knight, the Republican who lost his seat to Hill in 2018. After voting to repeal Obamacare in Congress, he that he argued would have protected people with preexisting conditions. His campaign did not return multiple calls and emails for comment.

State Assembly member Christy Smith, a Democrat who is running for the seat, shared a personal story about prescription drug costs in .

Smith’s mom, a nurse, “died too young because she couldn’t afford the insulin to treat her diabetes and heart disease,” Smith says in the ad.

“My mom couldn’t afford the medicine and care she needed. I’m running for Congress to make sure you can.”

Another Democratic candidate, Cenk Uygur, co-founder of “The Young Turks,” a progressive YouTube news show, the topic of his first TV ad. Tens of thousands of people die every year because they don’t have health insurance, he says in the ad. “What if your own child was one of them?”

Democrats may find more health care fodder for their campaigns as the year progresses, said Ivy Cargile, an assistant professor of political science at California State University-Bakersfield.

For instance, she said, on Feb. 10 the Trump administration released its $4.8 trillion 2020 , which includes deep cuts to Medicaid, the public health insurance program for low-income people.

Medi-Cal, California’s Medicaid program, has about 13 million enrollees. “Let’s assume this goes through,” she said. “That’s going to be fresh in the mind of voters going into the general election.”

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The details of their proposals vary, but the general idea is to create a government-sponsored plan that could compete with private insurance.

“We have a public option, just so folks know,” California Gov. Gavin Newsom claimed last month as he unveiled his proposed 2020-21 state budget. “It’s called Covered California.”

Hmm, really?

California does not have a public option in the way most people understand the term. According to Newsom’s definition, offering a public option simply means ensuring that consumers have choices and affordable coverage, and that health plans are held accountable, things Covered California already does, his office said.

That’s a stretch, say some health care and political experts.

Covered California “is manifestly not a public option,” said Thad Kousser, chair of the political science department at the University of California-San Diego.

Kousser theorized that Newsom may be co-opting the term to make it seem like the state is making progress toward his goal of creating a single-payer system.

But if Newsom wants to flout the term, the state should “create a public option that doesn’t involve insurance companies, and Covered California is a market to buy insurance from insurance companies,” Kousser said.

Covered California is the state-run exchange, created under the Affordable Care Act, where some individuals, families and small businesses can purchase insurance.

A public option is considered less sweeping than single-payer, a system in which health care is paid for by a single public authority. , Newsom, a Democrat, campaigned for the creation of a single-payer program.

But that isn’t likely to happen anytime soon, for a variety of reasons. For one, the Trump administration has said any state plans to use federal dollars to implement single-payer.

At the national level, Democratic presidential candidates including former Vice President and former South Bend, Indiana, Mayor have pitched public-option plans that would allow, but not require, people to buy into government-run plans similar to Medicare.

The idea is to boost competition by allowing people to choose between private plans and a government-run plan — and reduce costs.

Only one state, Washington, is implementing its own version of a public option, but other states are considering it.

, a hybrid system in which the state will contract with an insurer to administer a public-option plan, will debut in 2021. The state will attempt to control costs by setting payment rates at 160% of what Medicare would pay for the same service. is proposing a similar idea.

This version is different from the presidential candidates’ proposals because an insurance company will be responsible for running the public-option plan — not the government. But, ultimately, Washington will give its residents a new health insurance option, and that’s not the case in California, said Billy Wynne, chairman of the Wynne Health Group, which recently launched the , a group analyzing the implementation of public-option programs.

But in California’s defense, he said, what constitutes a public option “is in the eye of the beholder.”

Peter Lee, executive director of Covered California, is also calling the exchange . He argues that public-option plans assume different forms, just like single-payer or Medicare for All proposals.

On the exchange, “plans don’t compete on their own terms; they compete on our terms,” Lee said.  So, “is a public option only a government plan, or is it a public program that sets the rules of how private plans compete?”

Linda Blumberg, a health policy fellow at the Urban Institute, hazards an answer: While Covered California actively negotiates with health plans to keep premiums down, it “doesn’t quite have the spirit of a public option” because it doesn’t bear the financial risk that insurance companies do.

Newsom’s Healthy California for All Commission, which is debating how to get every Californian covered — with an emphasis on single-payer — gathered in Sacramento last month for its inaugural meeting. The commissioners briefly discussed the possibility of implementing a public option as a steppingstone to achieving universal coverage.

But the concept didn’t get much love, and some commissioners suggested that instead of creating a public option, the state should strengthen existing public programs. One commissioner said the idea of a public option had already fizzled.

“Whatever happened to Vanilla Ice, and whatever happened to Tiny Tim and Miss Vicki? Whatever happened to public option?” asked Dr. Robert Ross, president of the California Endowment, a foundation that focuses on expanding health care access among Californians. “It just kind of went away.”

The closest thing to a functioning public option in California, under the traditional definition, may be the L.A. Care Health Plan, a public, nonprofit insurer equally available to Los Angeles County residents with Medi-Cal, the state’s Medicaid program for low-income residents, and to those who earn too much to qualify for Medi-Cal.

John Baackes, the plan’s CEO, like the public-option plan described in the U.S. House version of the Affordable Care Act, before it was axed in the Senate. “Their definition of the public option was a public entity that did not have shareholders that would compete with commercial insurers in the individual market,” Baackes said.

L.A. Care, created to serve Medi-Cal patients, later opened to individuals and families who purchase their own insurance through Covered California or the open market.

For some time, Baackes said, the plan was the lowest-priced option in the Los Angeles area.

“Our enrollment skyrocketed because this is a very price-sensitive market, but in 2020, we were underbid by competition,” Baackes said. “To me, that’s exactly what the public option was supposed to do: put pressure in the marketplace. So I’m saying if you want to see how it works, look here.”

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Los proyectos de ley de atención médica y las iniciativas presupuestarias de los políticos están llenas de ideas y dólares, y se oponen a industrias poderosas. Ponen a California, una vez más, a la vanguardia.

Estas propuestas reducirían los costos de los medicamentos recetados, aumentarían el acceso a la cobertura de salud y restringirían e impondrían impuestos al vapeo. Pero la mayoría de los legisladores están de acuerdo en que la falta de vivienda dominará la agenda, incluidas las propuestas para que las personas accedan a un techo mientras reciben tratamiento por problemas de salud física y mental.

“Este presupuesto se duplica en la guerra contra la falta de acceso, desde asumir los costos de atención médica y hacer que el estado produzca nuestros propios medicamentos genéricos hasta expandir el uso de propiedades estatales para construir viviendas rápidamente”, dijo el gobernador Gavin Newsom en una carta a la Legislatura, que acompañó que presentó el viernes 10 de enero. Alrededor de un tercio de ese dinero se asignaría a programas de salud y servicios sociales.

Pero incluso con una súper mayoría demócrata, estas propuestas no son un éxito garantizado. “Hay otros factores en juego, como los grupos de interés con una fuerte presencia en el Capitolio”, incluidos la industria farmacéutica y los hospitales, dijo Shannon McConville, investigadora principal del Instituto de Public Policy Institute of California.

Precios de los medicamentos

El plan de Newsom para crear una marca estatal de medicamentos genéricos es quizás su propuesta de atención médica más audaz en el presupuesto de este año, ya que convertiría a California en el primer estado en ingresar al negocio de fabricación de medicamentos. También puede ser el menos concreto.

Newsom quiere que el estado firme contratos con uno o más fabricantes de genéricos para producir medicamentos que estarían disponibles para los californianos a precios más bajos. La oficina de Newsom proporcionó pocos detalles sobre cómo funcionaría esto o qué medicamentos se producirían. El costo del plan y los ahorros potenciales tampoco se especificaron. (La senadora Elizabeth Warren de Massachusetts, que busca la nominación presidencial demócrata, propuso ).

Debido a que el mercado de genéricos ya es competitivo y los medicamentos genéricos representan una pequeña porción del gasto total en medicamentos, una oferta estatal de drogas genéricas probablemente resultaría en ahorros modestos, dijo Geoffrey Joyce, director de política de salud del Leonard D. Schaeffer Center for Policy & Economics de la USC.

Sin embargo, agregó que podría hacer una diferencia para medicamentos específicos como la insulina, que casi duplicó su precio de 2012 a 2016.

Los representantes farmacéuticos dijeron que están más preocupados por una propuesta de Newsom para establecer un mercado único para la fijación de precios de medicamentos en el estado. Según este sistema, los fabricantes de medicamentos tendrían que ofertar para vender sus medicamentos en California, y tendrían que ofrecer precios iguales o inferiores a los ofrecidos a cualquier otro estado o país.

Los californianos podrían perder el acceso a tratamientos en curso y medicamentos innovadores, advirtió Priscilla VanderVeer, vicepresidenta de Pharmaceutical Research and Manufacturers of America, el brazo de cabildeo de la industria.

Esta propuesta podría “dejar que el gobierno decida qué medicamentos van a obtener los pacientes”, dijo. “Cuando el gobernador establece un precio artificialmente bajo para los medicamentos, eso significa que habrá menos dinero para invertir en innovación”.

Las propuestas de precios de medicamentos de Newsom se basan en su orden ejecutiva del año pasado que ordena al estado negociar los precios de los medicamentos para los aproximadamente 13 millones de afiliados de Medi-Cal, el programa de Medicaid del estado para residentes de bajos ingresos.

Falta de vivienda

California tiene la mayor población de personas sin hogar a nivel nacional, estimada en más de 151,000 personas en 2019, según el Departamento de Vivienda y Desarrollo Urbano de los Estados Unidos. Alrededor del 72% de las personas sin hogar del estado en lugar de en refugios o viviendas temporales.

Newsom ha pedido $1.4 mil millones en el presupuesto estatal 2020-21 para personas sin hogar, la mayoría de los cuales se destinarían a vivienda y atención médica. Por ejemplo, $695 millones impulsarían la atención médica y los servicios sociales para personas sin hogar a través de Medi-Cal. El dinero financiaría programas como la atención de recuperación para personas sin hogar que necesitan un lugar para quedarse después de haber sido dados de alta del hospital, y asistencia para pagar el alquiler si la falta de vivienda de una persona está vinculada a los altos costos médicos.

Una inyección por separado de $24.6 millones iría al Departamento de Hospitales del Estado para un programa piloto para mantener a algunas personas con necesidades de salud mental fuera de los hospitales estatales y en programas comunitarios y viviendas.

Cuentas médicas sorpresa

California tiene algunas de las protecciones más fuertes contra facturas médicas sorpresa en la nación, pero ante cargos exorbitantes porque las leyes no cubren todos los planes de las aseguradoras.

La facturación sorpresa se da cuando un paciente recibe atención de un hospital o profesional de salud fuera de la red de proveedores de su plan médico, y luego el médico u hospital le factura al paciente la cantidad que el seguro no cubrió.

El año pasado, el miembro de la Asamblea estatal David Chiu (demócrata de San Francisco) que habría limitado la cantidad que los hospitales podrían cobrar a los pacientes con seguro privado por servicios de emergencia fuera de la red. El proyecto habría requerido que los hospitales trabajaran directamente con los planes de salud en la facturación, dejando a los pacientes solo a cargo de sus copagos, coseguros y deducibles dentro de la red.

Pero Chiu retiró la medida debido a la fuerte oposición de los hospitales, que la criticaron como una forma de fijación de tarifas. Dijo que retomará la batalla este año.

Medi-Cal para inmigrantes sin papeles

California es el primer estado en ofrecer beneficios completos de Medicaid a los residentes elegibles según los ingresos , independientemente de su estatus migratorio.

Ahora los demócratas proponen otra acción pionera: California podría convertirse en la primera en ofrecer Medicaid a adultos de 65 años o más que son indocumentados.

Si bien Medicaid es un programa conjunto estatal-federal, California debe financiar la cobertura total de inmigrantes sin papeles por sí solo.

Newsom apartó $80.5 millones en su propuesta de presupuesto para 2020-21 para cubrir a unos 27,000 adultos mayores en el primer año. Su oficina estimó que los costos actuales serían de aproximadamente $350 millones al año.

Los republicanos se oponen vocalmente a tales propuestas.

Vapeo

de California han restringido la venta de productos de tabaco saborizados en un esfuerzo por frenar el vapeo juvenil.

Pero el año pasado, legisladores estatales sacaron de la mesa la prohibición en todo el estado después de enfrentar la presión de la industria del tabaco.

Ahora, el senador estatal Jerry Hill (demócrata de San Mateo) está de regreso con su propuesta de prohibición a nivel estatal, que puede tener más impulso este año. Desde el verano pasado, una misteriosa enfermedad de vapeo ha enfermado a más de 2.600 personas en todo el país, lo que lleva a 60 muertes, según los Centros para el Control y Prevención de Enfermedades (CDC)., al menos 199 personas se enfermaron y cuatro murieron.

El proyecto de ley de Hill prohibiría las ventas minoristas de productos aromatizados relacionados con cigarrillos electrónicos y dispositivos de vapeo, incluido el sabor a mentol. También prohibiría la venta de todos los productos de tabaco con y sin sabor, como cigarros, puritos, pipas, tabaco de mascar, tabaco y tabaco para mascar.

Newsom también ha pedido un nuevo impuesto sobre los productos de cigarrillos electrónicos: $2 por cada 40 miligramos de nicotina, además de los impuestos al tabaco ya existentes sobre los cigarrillos electrónicos. El impuesto tendría que ser aprobado por la Legislatura y podría enfrentar una fuerte oposición de la industria.

Esta historia de KHN fue publicada primero en , un servicio de la .

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The politicians’ health care bills and budget initiatives are heavy on ideas and dollars — and on opposition from powerful industries. They put California, once again, at the forefront.

The proposals would lower prescription drug costs, increase access to health coverage, and restrict and tax vaping. But most lawmakers agree that homelessness will dominate the agenda, including proposals to get people into housing while treating some accompanying physical and mental health problems.

“This budget doubles down on the war on unaffordability — from taking on health care costs and having the state produce our own generic drugs to expanding the use of state properties to build housing quickly,” Gov. Gavin Newsom said in a letter to the legislature, which accompanied the he unveiled last Friday. About a third of that money would be allocated to health and human services programs.

But even with a Democratic supermajority in the legislature, these proposals aren’t a slam-dunk. “There are other factors that come into play, like interest groups with strong presence in the Capitol,” including Big Pharma and hospitals, said Shannon McConville, a senior researcher at the nonpartisan Public Policy Institute of California.

Drug Pricing

Newsom’s plan to create a state generic drug label is perhaps his boldest health care proposal in this year’s budget, as it would make California the first state to enter the drug-manufacturing business. It may also be his least concrete.

Newsom wants the state to contract with one or more generics manufacturers to make drugs that would be available to Californians at lower prices. Newsom’s office provided little detail about how this would work or which drugs would be produced. The plan’s cost and potential savings are also unspecified. (Sen. Elizabeth Warren of Massachusetts, who is seeking the Democratic presidential nomination, at the federal level.)

Because the generics market is already competitive and generic drugs make up a small portion of overall drug spending, a state generic-drug offering would likely result in only modest savings, said Geoffrey Joyce, director of health policy at USC’s Leonard D. Schaeffer Center for Health Policy & Economics.

However, it could make a difference for specific drugs such as insulin, he said, which nearly doubled in price from 2012 to 2016. “It would reduce that type of price gouging,” he said.

Representatives of Big Pharma said they’re more concerned about a Newsom proposal to establish a single market for drug pricing in the state. Under this system, drug manufacturers would have to bid to sell their medications in California, and would have to offer prices at or below prices offered to any other state or country.

Californians could lose access to existing treatments and groundbreaking drugs, warned Priscilla VanderVeer, vice president for the Pharmaceutical Research and Manufacturers of America, the industry’s lobbying arm.

This proposal could “let the government decide what drugs patients are going to get,” she said. “When the governor sets an artificially low price for drugs, that means there will be less money to invest in innovation.”

Newsom’s drug pricing proposals build on his executive order from last year directing the state to negotiate drug prices for the roughly 13 million enrollees of Medi-Cal, the state’s Medicaid program for low-income residents. He also ordered a study of how state agencies could band together — and, eventually, with private purchasers such as health plans — to buy prescription drugs in bulk.

Homelessness

California has the largest homeless population in the nation, estimated at , according to the U.S. Department of Housing and Urban Development. About 72% of the state’s homeless or in cars rather than in shelters or temporary housing.

Newsom has asked for $1.4 billion in the 2020-21 state budget for homelessness, most of which would go to housing and health care. For instance, would boost health care and social services for homeless people via Medi-Cal. The money would fund programs such as recuperative care for homeless people who need a place to stay after they’ve been discharged from the hospital, and rental assistance if a person’s homelessness is tied to high medical costs.

A separate infusion of $24.6 million would go to the Department of State Hospitals for a pilot program to keep some people with mental health needs out of state hospitals and in community programs and housing.

Surprise Bills

California has some of the strongest protections against surprise medical bills in the nation, but to exorbitant charges because the laws don’t cover all insurance plans.

Surprise billing occurs when a patient receives care from a hospital or provider outside of their insurance network, and then the doctor or hospital bills the patient for the amount insurance didn’t cover.

Last year, state Assembly member David Chiu (D-San Francisco) that would have limited how much hospitals could charge privately insured patients for out-of-network emergency services. The bill would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

But because of strong opposition from hospitals, which criticized it as a form of rate setting.

Chiu said he plans to resume the fight this year, likely with amendments that have not been finalized. But hospitals remain opposed to the provision that would cap charges, a provision that Chiu says is essential.

“We continue to fully support banning surprise medical bills, but we believe it can be done without resorting to rate setting,” said Jan Emerson-Shea, a spokesperson for the California Hospital Association.

Medi-Cal For Unauthorized Immigrants

California is the first state to offer full Medicaid benefits to income-eligible residents , regardless of their immigration status.

Now Democrats are proposing another first: California could become the first to open Medicaid to adults ages 65 and up who are in the country illegally.

Even though Medicaid is a joint state-federal program, California must fund full coverage of unauthorized immigrants on its own.

Newsom set aside $80.5 million in his 2020-21 proposed budget to cover about 27,000 older adults in the first year. His office estimated ongoing costs would be about $350 million a year.

Republicans vocally oppose such proposals. “Expanding such benefits would make it more difficult to provide health care services for current Medi-Cal enrollees,” state Sen. Patricia Bates (R-Laguna Niguel) said in a prepared statement.

Vaping

have restricted the sale of flavored tobacco products in an effort to curb youth vaping.

But last year, state legislators on a statewide ban on flavored tobacco sales after facing pressure from the tobacco industry.

Now, state Sen. Jerry Hill (D-San Mateo) is back with his proposed statewide flavor ban, which may have more momentum this year. Since last summer, a mysterious vaping illness has sickened people nationwide, leading to 60 deaths, according to the Centers for Disease Control and Prevention. , at least 199 people have fallen ill and four have died.

Hill’s bill would ban retail sales of flavored products related to electronic cigarettes, e-hookahs and e-pipes, including menthol flavor. It also would prohibit the sale of all flavored smokable and nonsmokable tobacco products, such as cigars, cigarillos, pipe tobacco, chewing tobacco, snuff and tobacco edibles.

Newsom has also called for a new tax on e-cigarette products — $2 for each 40 milligrams of nicotine, on top of already existing tobacco taxes on e-cigarettes. The tax would have to be approved by the legislature as part of the budget process and could face heavy industry opposition.

Tobacco-related bills are usually heard in the Assembly Governmental Organization Committee, “and that is where a lot of tobacco legislation, quite frankly, dies,” said Assembly member Jim Wood (D-Healdsburg), who supports vaping restrictions.

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Cuarenta años después, García, de 66 años, es la directora ejecutiva de la organización, que ahora opera más de 30 clínicas en los condados de Alameda, Contra Costa y Solano, y atiende a unos 90,000 pacientes al año. Cerca del 65% son latinos, muchos de ellos inmigrantes.

García, quien tiene raíces mexicanas, creció en la ciudad fronteriza de El Paso, en Texas. Recuerda que su familia visitaba con frecuencia Juárez, en México, para comprar alimentos, cargar gasolina o cortarse el cabello.

Por eso, abogar por los inmigrantes fue algo natural, dijo García. Pero la mujer no ha limitado su defensa a las clínicas comunitarias.

En la década de los 90, California experimentó una oleada de ataques antiinmigrantes, similares a las que se han manifestado en otras partes de los Estados Unidos en la actualidad. El entonces gobernador, el republicano Pete Wilson, tomó medidas enérgicas contra la inmigración ilegal y defendió la , que negaba el acceso de inmigrantes sin papeles a la atención médica y a la educación públicas. La medida, adoptada por los votantes en 1994, nunca entró en vigencia porque fue declarada por una corte federal.

García demandó a la administración de Wilson en 1997 por sus intentos de cancelar la atención prenatal para embarazadas indocumentadas a través de Medi-Cal, la versión estatal del programa federal de Medicaid para personas de bajos ingresos. Presentó la demanda en nombre de las mujeres inmigrantes indocumentadas, y ganó.

“En ese entonces, fue algo muy valiente poner a la clínica en medio de esa lucha y ser la vocera de esa demanda”, dijo Carmela Castellano-García, CEO de la Asociación de Atención Primaria de California, que representa a las clínicas comunitarias de salud. “Recuerdo haber estado impresionada por su audacia”.

Hoy, La Clínica es la principal demandante en una de varias acciones legales que desafían el intento de la administración Trump de expandir la , lo que permitiría a funcionarios federales de inmigración negar más fácilmente la residencia permanente a quienes dependen de ciertos beneficios públicos, como Medicaid.

Los jueces federales bloquearon temporalmente la entrada en vigencia de la norma a mediados de octubre, por lo que la demanda de García está suspendida.

La Clínica de La Raza tiene una larga historia. Fue fundada en 1971 por estudiantes de la Universidad de California-Berkeley que eran objetores de conciencia a la Guerra de Vietnam, contó García. En lugar de servir en las fuerzas armadas, llegaron a un acuerdo con el gobierno federal para establecer una clínica gratuita en el vecindario Fruitvale de Oakland, en donde la principal preocupación de sus residentes era el acceso a la atención médica.

García habló con Ana B. Ibarra, de California Healthline, en su oficina, ubicada al otro lado de la calle de la clínica original de Fruitvale. El lugar está lleno de plantas, retratos del activista César Chávez, imágenes de Nuestra Señora de Guadalupe y un póster enmarcado de “Salud para todos”.

-Ampliar el acceso a la atención médica para inmigrantes ha sido su misión desde el primer día. ¿Qué la atrajo a esta causa?

Crecí en el barrio de El Paso, Texas. Mi familia recibió muchos servicios a través de los departamentos de salud pública o de las escuelas. Por ejemplo, nuestras vacunas. Entendí desde siempre la importancia de los programas de salud pública.

Al comienzo de mi carrera universitaria estaba en medicina, pero decidí que la química y la biología no eran para mí. Cuando estaba estudiando en Yale, trabajé en un centro de salud comunitario como traductora, con familias principalmente puertorriqueñas.

Luego llegué a La Clínica y realmente me fascinó lo que estaban haciendo. Me encantó de lo que se trataba este movimiento: era sobre justicia social.

– ¿Por qué cree que es importante que todos tengan acceso a una atención médica integral, independientemente de su estatus migratorio?

Solo brindando servicios a todos podemos tener un verdadero impacto. Cuando llega la temporada de gripe, no te pregunta sobre tu estatus migratorio.

Nos corresponde a todos mantener sanas a todas nuestras comunidades y proporcionar acceso al nivel más básico para evitar la sala de emergencias.

Mi hija es enfermera de urgencias y me dice: “Mamá, no sabes cuántas personas usan la sala de emergencias de manera inapropiada”. Y eso es porque no tienen acceso a nada más. Esa es su atención primaria.

-A partir de 1986, las mujeres inmigrantes indocumentadas de bajos ingresos pudieron comenzar a recibir atención prenatal a través de Medi-Cal, pero usted pasó muchos años defendiendo esa cobertura, incluso en los tribunales. ¿Por qué fue algo tan polémico?

Nuestro enfoque siempre ha sido las familias, por lo que realmente nos enfocamos en brindar acceso a la atención primaria básica, y la atención prenatal era un gran problema para nuestras comunidades en ese entonces porque era como una papa caliente para los políticos: mujeres indocumentadas buscando servicios.

Tuvimos que luchar para asegurarnos que los hospitales a los que íbamos a dar a luz a nuestros bebés admitieran a nuestras pacientes. Y que nuestras pacientes se sintieron cómodas. Las ayudamos a acceder a Medi-Cal, o a negociar planes de pago con el hospital. Recuerdo que nuestros médicos escuchaban comentarios como: “Estás convirtiendo nuestro hospital en una instalación comunal”.

Presentamos una demanda en nombre de algunas mujeres indocumentadas en 1997. Ellas fueron las verdaderas guerreras. Yo solo fui la intermediaria.

-Ahora La Clínica está desafiando el intento de la administración Trump de expandir la regla de “carga pública”. ¿En qué se parece esta situación a su pelea de los 90?

Cuando surgió este problema de la “carga pública”, era una reminiscencia de aquellos días y todo al respecto me recordó la Proposición 187.

Esa fue una época en la que todo giraba en torno a ser antiinmigrante. Y hoy estamos viendo lo mismo: los padres mantienen a sus hijos en casa y nuestro número de citas disminuye. Esta es como la segunda ola de la misma situación, salvo que, creo, hemos podido cambiar un poco la narrativa.

Particularmente aquí en California, no vemos tanto la palabra “ilegal”, y vemos menos visualizaciones de personas que cruzan la frontera como “cucarachas”. Los mensajes que le estábamos dando a los pacientes en ese momento no eran muy diferentes de los que les damos ahora. Son: continúa recibiendo tus servicios aquí, somos un lugar seguro y no compartimos tu información.

– ¿Pensaba que el país entraría en el año electoral 2020 con esta situación?

Como país, definitivamente hemos dado algunos pasos hacia atrás, no hay duda, pero no estamos comenzando desde cero. Como defensores, estamos mucho mejor armados con datos y podemos mostrarte la cantidad de impuestos que pagan las familias inmigrantes, podemos decirte lo importantes que son para la fuerza laboral.

Creo que California, les guste o no, es líder. Y con el compromiso del estado de cubrir a todos, podremos demostrar que, al final, esa estrategia es el camino a seguir para tener comunidades más saludables y una sociedad más productiva.

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Forty years later, Garcia, 66, is the chief executive officer of the organization, which now operates more than 30 clinics in Alameda, Contra Costa and Solano counties and serves about 90,000 patients a year. About 65% of its patients are Latino, many of whom are immigrants.

Garcia, who has Mexican roots, grew up in the border town of El Paso, Texas. Her family frequently visited the Mexican city of Juárez for groceries, gas and haircuts, she recalled.

So advocating for immigrants came naturally to her as an adult, Garcia said, but she hasn’t limited her advocacy to the clinics.

In the 1990s, California experienced a paroxysm of anti-immigrant attitudes, similar to those that have manifested elsewhere in the United States today. Then-California Gov. Pete Wilson, a Republican, cracked down on illegal immigration and championed , which denied unauthorized immigrants access to public health care and education. The measure, adopted by voters in 1994, never took effect because it was by a federal court.

Garcia took Wilson’s administration to court in 1997 over its attempts to defund prenatal care for unauthorized immigrant women through Medi-Cal, the state’s version of the federal Medicaid program for low-income people. She filed the lawsuit on behalf of undocumented immigrant women — and won.

“It was a very brave thing to do back then, to put her clinic in the middle of this fight and be the spokesperson in this lawsuit,” said Carmela Castellano-Garcia, CEO of the California Primary Care Association, which represents health clinics. “I just remember being so impressed by her boldness.”

Today, La Clínica is the lead plaintiff in one of several lawsuits challenging the Trump administration’s attempt to expand the “, which would allow federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid.

Federal judges temporarily blocked the rule from taking effect in mid-October, so Garcia’s lawsuit is on hold.

La Clínica de La Raza, though, has a longer history. It was founded in 1971 by students at the University of California-Berkeley who were conscientious objectors to the Vietnam War, Garcia said. Instead of serving in the armed forces, they made a deal with the federal government to set up a free clinic in Oakland’s Fruitvale neighborhood, where residents had identified health care access as a main concern.

Garcia spoke with California Healthline’s Ana B. Ibarra in her office across the street from the original Fruitvale clinic. Garcia’s office is filled with plants, portraits of farmworker activist Cesar Chavez, images of Our Lady of Guadalupe and a framed “Health for All” poster.

The interview has been edited for length and clarity.

Q: Expanding health care access to immigrants has been your mission since Day One. What drew you to this cause?

I grew up in el barrio in El Paso, Texas. My family got many services from public health departments or through schools. Our shots, for example. So, I understood the importance of public health programs.

At the very beginning of my college career I was pre-med, but decided that chemistry and bio were not for me. When I was at Yale as an undergrad, I worked at a community health center as a translator and worked with mostly Puerto Rican families.

Then I got to La Clínica and really loved what they were doing. I just loved what the clinic movement was all about — social justice. And it really called to me.

Q: Why do you believe it’s important that everyone has access to comprehensive health care, regardless of immigration status?

Only by providing services to everybody can we have a true impact on the delivery system. When the flu season comes, it doesn’t ask your immigration status.

It behooves us all to keep all our communities healthy and to provide access at the most basic level so that we avoid emergency room utilization.

My daughter is an ER nurse and she tells me, “Mom, you don’t know how many people come in there using the ER inappropriately.” And that’s because they don’t have access to anything else. That’s their primary care.

Q: , low-income undocumented immigrant women could get prenatal care through Medi-Cal, but you’ve spent many years defending that coverage, including in court. Why was this so contentious?

Our focus has always been families, so we really focused on providing access to basic primary care, and prenatal care was a big issue for our communities back then because it was a political lightning rod — you had women who were undocumented seeking services.

We had to fight to make sure that the hospitals we went to to deliver our babies would admit our patients. And that our patients felt comfortable being there. We helped our patients access Medi-Cal or develop payment plans with the hospital. I remember our physicians hearing comments like, “You’re turning our hospital into a county facility.”

We filed a lawsuit on behalf of some undocumented women in 1997. They were the real soldiers in this. I was just the interface.

Q: Now La Clínica is challenging the Trump administration’s attempt to expand the public charge rule. How is this situation similar to your fight in the 1990s?

When this public charge issue came up, it was reminiscent from those days and everything about it reminded me about Prop. 187.

That was just one big period in time that was all about being anti-immigrant. And we are seeing the same things today: parents keeping their children at home and our number of appointments going down. This is round two of the same situation except that I think we have been able to change the narrative somewhat.

Particularly here in California, we don’t see the word “illegal” as much, and we see fewer visualizations of people crossing the border like cucarachas [cockroaches]. The messages that we were giving to patients at that time were not very different from the messages that we’re giving to patients right now. They are: Continue to get your services here, we’re a safe place, and we don’t share your information.

Q: Is this where you thought the country would be going into the 2020 election?

As a country, we’ve definitely taken some steps backward, there’s no question about that, but we’re not starting from point zero. As advocates, we’re way better armed with data and we can show you how much taxes immigrant families pay, we can tell you how significant they are to the workforce.

I think California, whether folks like it or not, is a leader. And with the state’s commitment to cover everybody, we will be able to demonstrate that, in the end, that strategy is the way to go in terms of having more healthy communities and a more productive society.

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For coverage next year, the Elk Grove, Calif., resident qualifies for new state-funded health insurance subsidies totaling about $870 per month. This aid allows him to buy a better plan with a lower deductible for about $1,200 per month.

That’s still high, he said, but any help is welcome.

“It made a huge difference,” said Winlock, 61, a small-business owner who provides accounting and point-of-sales systems to other businesses. “We were thinking that in 2020 we wouldn’t be able to keep our plan,” let alone afford an upgrade, he said.

Heather Altman, an independent environmental consultant in Long Beach, also hoped to qualify for the new state financial aid. But, after checking with a health insurance agent, she learned she won’t get anything. “At first I thought it might be a mistake,” she said. “It was disappointing.”

Starting Jan. 1, California to some consumers who buy health coverage through Covered California, the state’s Affordable Care Act insurance exchange.

Some of the subsidies will go to people who already qualify for the federal tax credits available to some Covered California consumers, primarily those with low incomes. But the assistance will also be extended to middle-income people such as Winlock who make too much money to qualify for the federal tax credits and have had to bear the entire cost of their premiums. California will be the first state to offer such help to middle-class consumers.

With open enrollment for Covered California going full steam — sign-ups for 2020 coverage end Jan. 31 — consumers are eagerly trying to determine whether they might qualify for the new aid and, if so, how much.

The results are mixed.

“It’s brought higher-income earners to call me, but most still earn too much” to qualify, said Kevin Knauss, a Sacramento-area insurance agent who also has clients in Los Angeles and the Bay Area. “Others are picking up $15 to $25.”

More than 486,000 people have already qualified for the new state subsidies, with more expected as open enrollment continues, Covered California announced Thursday. This includes about 23,000 middle-income enrollees who make too much to qualify for federal tax credits, said Covered California Executive Director Peter Lee.

Lee added that new enrollment is up by 16% compared with this time last year, largely due to the new state financial aid and insurance requirement.

This “is a small slice of who will sign up,” he said. “We’re optimistic there will be many, many more people covered by these state subsidies for the middle class.”

Earlier this year, Gov. Gavin Newsom signed a 2019-20 state budget that includes nearly $429 million for the subsidies. To help pay for them, the state is imposing a starting next year on people who don’t have health insurance — similar to the federal penalty the Republican-controlled Congress eliminated effective this year.

Covered California has estimated that nearly 1 million Californians could benefit from the new state money.

Some of the aid will go to low- and moderate-income people who earn between 200% and 400% of the federal poverty level, or roughly $25,000 to $50,000 for an individual and $51,500 to $103,000 for a family of four, based on 2019 figures. This group also qualifies for federal tax credits. The average household state subsidy in this category would be $21 a month, Covered California estimates.

The majority of the state assistance, however, will go to people whose incomes are between 400% and 600% of the poverty level — too high for federal aid but still low enough to make health care financially challenging. That’s between about $50,000 and $75,000 a year for an individual and $103,000 to $154,500 for a family of four. The average state assistance for this group will be about $460 a month, according to Covered California.

But falling into this income bracket doesn’t guarantee subsidies, as Altman learned.

She estimated she will make $60,000 next year, which puts her within the income range to qualify as an individual, but she won’t be getting any aid, and she doesn’t quite understand why.

Besides income, household size, location and age play a role in eligibility for the subsidies, Covered California’s Lee explained. For example, older people who live in areas with high health care costs have a higher chance of getting help, he said.

Altman, 47, who has severe asthma and is on multiple medications, said she can’t go without coverage, so she will pay $640 every month for a health plan next year, up $70 from this year.

“I was just glad that it was only an 11% increase,” she said. “In previous years, I’ve seen a 20-something percent increase.”

Winlock said he feels grateful he qualified for the state financial aid because it allowed him to buy a better plan. Now he can seek care that he has been avoiding.

“We’re pretty healthy, and I’m very active, but I do have an issue with arthritis that I haven’t been pursuing because just testing alone is very expensive,” he said.

Evette Tsang, an insurance agent in Sacramento, said that while news of financial aid is driving some customers to her office, the new insurance requirement — and the accompanying tax penalty — are ultimately motivating most people to sign up.

People who don’t have insurance in 2020 will have to pay the penalty when they file their state tax returns in 2021. The penalty will amount to $695 for an adult and half that much for dependent children. Some people with higher incomes instead will have to pay 2.5% of their income, which could make their penalty quite a bit heftier.

Tsang saw clients drop their coverage when the federal penalty was eliminated. “Now they’re coming back,” she said.

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Sin embargo, surge una pregunta central: ¿lo harán?

Algunos jóvenes ya están diciendo que no se inscribirán para tener cobertura pública porque temen que las políticas federales de inmigración puedan luego penalizarlos, aunque ese temor podría ser infundado.

Además, está el tema de la edad. Los adultos jóvenes, inmigrantes o no, son notoriamente difíciles de convencer de la necesidad de un seguro de salud. La industria de seguros incluso ha acuñado un término especial para ellos: .

“Los adultos jóvenes, indocumentados o no, tienden a considerarse saludables”, dijo Cathy Senderling-McDonald, subdirectora ejecutiva de la County Welfare Directors Association de California, que representa a los directores de servicios humanos de los condados. No piensan que es algo que deba preocuparlos.

Medi-Cal es la versión de California del programa Medicaid para personas de bajos ingresos. En mayo de 2016, el estado comenzó a ofrecer cobertura completa de Medi-Cal a niños y jóvenes inmigrantes sin papeles hasta los 19 años, financiada con fondos estatales. Casi 129,000 se inscribieron en el programa en marzo de 2019, según los datos más recientes disponibles.

Cuando debatieron el presupuesto, este año, los legisladores votaron para usar más dólares estatales para expandir el programa a todos los adultos elegibles por ingresos de entre 19 y 25 años, lo que convertirá a California en el primer estado en ofrecer cobertura completa de Medicaid a inmigrantes adultos indocumentados. El Departamento de Servicios de Atención Médica del estado espera inscribir a unos 90,000 adultos jóvenes en el primer año.

De ellos, casi el 75% están inscritos actualmente en una cobertura limitada de Medi-Cal, que incluye atención de emergencia y del embarazo. El departamento dijo que planea transferir a esas personas a una cobertura integral.

Funcionarios de salud y defensores de los derechos de los inmigrantes tendrán que ver la forma de persuadir a todos los demás que son elegibles para que presenten sus solicitudes.

Los adultos inmigrantes indocumentados de California sin seguro de salud, alrededor del 58%, según el Insure the Uninsured Project.

“El mensaje que debemos difundir es que hay que pensar en la prevención y las condiciones crónicas, que podrían desarrollarse temprano en la vida”, dijo Jeffrey Reynoso, director ejecutivo de la Coalición Latina para una California Saludable.

Para llegar a los adultos jóvenes, las redes sociales son clave, agregó Reynoso. Su grupo está creando un conjunto de herramientas, que incluye fotos para Instagram y ejemplos de tweets, que estarán disponibles para las organizaciones que forman parte de la coalición.

También planea usar la radio y los medios étnicos, en cooperación con otros grupos, con el fin de difundir el mensaje entre las familias, para que padres y abuelos puedan alentar a los miembros más jóvenes a inscribirse, explicó.

“No podemos usar los medios tradicionales para llegar a esta población”, opinó Sarah Reyes, directora de comunicaciones de California Endowment, una fundación que promueve la cobertura de salud para todos los californianos, independientemente de su estatus migratorio. La entidad también está planeando postear mensajes en las redes sociales y anuncios de radio en estaciones que escuchan los más jóvenes, y está diseñando anuncios para exhibir en tienda y mercados, dijo Reyes.

Aquellos que ganan hasta el 138% del nivel federal de pobreza ($17,237 para un individuo y $35,535 anuales para una familia de cuatro) .

Pero la edad no es una barrera tan grande para la inscripción como el miedo a la retórica y las políticas federales de inmigración, dijo Sarah Dar, gerente senior de salud y beneficios públicos del California Immigrant Policy Center.

Por ejemplo, desde 2017, la administración Trump ha estado tratando de cancelar el programa de Acción Diferida para los Llegados en la Infancia (DACA), que permite a algunas personas indocumentadas (conocidas como “dreamers”), cuyos padres los trajeron al país cuando eran niños, vivir y trabajar temporalmente en el país. El destino del programa está ahora en la Corte Suprema de los Estados Unidos, que escuchó los del caso el 12 de noviembre.

La administración Trump también está tratando de expandir su , lo que permitiría a los funcionarios de inmigración negar más fácilmente la residencia permanente a quienes dependen de ciertos beneficios públicos, como Medicaid. Los jueces federales bloquearon temporalmente su entrada en vigencia, que iba a ser mediados de octubre.

Pero los temores pueden estar equivocados, dijo Dar. Los “dreamers” ya son elegibles para Medi-Cal si cumplen con las pautas de ingresos. Y solicitar Medi-Cal no pesaría en contra de los adultos jóvenes indocumentados, si llegaran en el futuro a poder aplicar para la residencia permanente, porque su cobertura se pagará con dinero estatal, no federal, agregó.

“Necesitamos transmitir un mensaje claro de que la carga pública no debería ser una preocupación”, dijo Dar.

Esmeralda, de 20 años, de Santa María, California (se usó solo su nombre de pila por su estatus legal), trabaja recogiendo fresas y asiste a la universidad comunitaria cuando no es temporada de cosecha. Necesita anteojos y ha luchado contra el dolor de espalda desde que era una niña en México. A veces tiene que dejar de trabajar por un día a causa del dolor.

La última vez que fue al médico fue hace casi cinco años, cuando comenzó la escuela en los Estados Unidos y tuvo que vacunarse, contó. Dijo que le gustaría inscribirse en Medi-Cal pero que esperará para ver cómo funciona el proceso para otros. También quiere estar segura que su información personal estará a salvo de los oficiales de inmigración.

“Esperaría para asegurarme que no haya problemas”, dijo en español. “Obviamente, siendo indocumentado, hay miedo”.

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But a fundamental question looms: Will they?

Some young people already say they won’t enroll in public coverage because they fear federal immigration policies could later penalize them for participating — though that fear might be unfounded.

Add to that their age. Young adults — both immigrants and non-immigrants — are notoriously hard to convince of the necessity of health insurance. The insurance industry even has coined a special term for them: “.”

“Young adults, undocumented or not, tend to consider themselves healthy,” said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California, which represents county human services directors. “They’re not thinking ‘This is something I need to worry about.’”

Medi-Cal is California’s version of the federal-state Medicaid program for low-income residents. In May 2016, the state began offering undocumented immigrant children up to age 19 full Medi-Cal coverage, funded by state money. Nearly 129,000 were enrolled in the program in March 2019, according to the most recent data available.

During budget negotiations this year, California lawmakers voted to use more state dollars to expand the program to all income-eligible adults ages 19 to 25, which will make California the first state to offer full Medicaid coverage to unauthorized immigrant adults. The state Department of Health Care Services expects to enroll about 90,000 young adults in the first year.

Of those, nearly 75% are currently enrolled in limited Medi-Cal coverage, which includes emergency and pregnancy-related care. The department plans to transition those individuals into comprehensive coverage, it said.

That leaves health officials and immigrant rights advocates grappling with how to persuade everyone else who is eligible to apply.

Undocumented immigrant adults of California’s uninsured population, about 58%, according to the Insure the Uninsured Project.

“The message we have to spread is to think about prevention and chronic conditions, which could start early in life,” said Jeffrey Reynoso, executive director of the Latino Coalition for a Healthy California.

Advocates must meet young adults where they are, Reynoso said, which means social media is key. His group is creating a social media toolkit that includes Instagram posts and sample tweets tailored to young adults, which will be available to partner organizations.

It also plans to use radio and ethnic media, in cooperation with other groups, to spread the message to families so parents and grandparents can encourage younger family members to sign up, he said.

“We can’t use traditional media to reach this population,” said Sarah Reyes, managing director of communications at the California Endowment, a foundation that promotes health insurance coverage for all Californians, regardless of immigration status. The endowment also is planning social media posts and radio spots on stations that cater to younger people, and is designing ads for display in convenience stores and markets, Reyes said.

Those who make up to 138% of the federal poverty level . This year, that means individuals with annual incomes of up to about $17,200 qualify.

Because Medi-Cal is free for most participants, most young people won’t have to worry about taking a financial hit, said Sarah Dar, senior manager of health and public benefits for the California Immigrant Policy Center. That makes them different from the so-called — who generally fall into the 18-to-34 age group — looking for private health coverage, where cost is a major consideration.

But age is not as great a barrier to enrollment as fear of federal immigration rhetoric and policies, Dar said.

For example, since 2017 the Trump administration has been fighting to end the Deferred Action for Childhood Arrivals (DACA) program, which allows some undocumented people, whose parents brought them into the country illegally as children, to live and work in the U.S. temporarily. The fate of the program rests with the U.S. Supreme Court, in the case Nov. 12.

The Trump administration is also trying to expand its , which would allow immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid. Federal judges from taking effect in mid-October.

But the fears may be misguided, Dar said. Participants of the DACA program already are eligible for Medi-Cal if they meet the income guidelines. And applying for Medi-Cal wouldn’t count against undocumented young adults should they become eligible to apply for permanent residency later because their coverage will be paid for with state, not federal, money, she said.

“We need to get out a clear message that public charge should not be a concern,” Dar said.

Esmeralda, 20, of Santa Maria, Calif., works in the fields picking strawberries and attends community college when the fruit isn’t in season. She agreed to speak to California Healthline on the condition that her last name not be used.

She needs glasses and has struggled with occasional but debilitating back pain since she was a child in Mexico. The pain sometimes forces her to stop working for the day.

The last time she went to a doctor was almost five years ago, when she started school in the U.S. and had to get vaccinated, she said.

Esmeralda said she would like to sign up for Medi-Cal but will wait to see how the process works for others. She wants to know whether they feel their personal information is being kept safe from federal immigration officials, she said.

“I would wait to make sure there are no problems,” she said in Spanish. “Obviously, with being undocumented, there is fear.”

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The organization informed Desmond, who has kidney failure and needs dialysis three times a week, that it will no longer help him pay for his private health insurance plan — to the tune of about $800 a month.

“I am depressed about the whole situation,” said the 58-year-old Sacramento resident. “I have no clue what I’m going to do.”

Desmond has Medicare, but it doesn’t cover the entire cost of his care.  So, with assistance from the American Kidney Fund, he pays for a private plan to cover the difference.

Now, the fund, which helps about 3,700 Californians pay their premiums and out-of-pocket costs, is threatening to pull out of California because of a new state law that is expected to cut into the dialysis industry’s profits — leaving patients like Desmond scrambling.

The letter portrayed the fund as helpless. “We are heartbroken at this outcome,” it read. “Ending assistance in California is the last thing we want to do.”

But supporters of the new law are calling the threat a scare tactic. State Assemblyman Jim Wood (D-Healdsburg), the author of AB-290, said there is nothing in the measure that prohibits the fund from continuing to provide financial assistance to patients.

“AKF has simply made a conscious decision, without merit, to leave the state despite the many accommodations I made by amending the bill in the Senate to ensure that it can continue to operate in California,” Wood said in a written statement.

What’s behind this dispute is the tight relationship between the American Kidney Fund and the companies that provide dialysis, which filters the blood of people whose kidneys are no longer doing the job.

People on dialysis usually qualify for Medicare, the federal health insurance program for people 65 and older, and those with kidney failure and certain disabilities. If they’re low income, they may also qualify for Medicaid, which is called Medi-Cal in California.

But dialysis companies can get higher reimbursements from private insurers than from public coverage. And one way to keep dialysis patients on private insurance is by giving them financial assistance from the American Kidney Fund, which helps nearly 75,000 low-income dialysis patients across the country.

The fund gets from DaVita and Fresenius Medical Care, the two largest dialysis companies in the country. The fund does not disclose its donors, but an reveals that 82% of its funding in 2018 — nearly $250 million — came from two companies.

Insurance plans, consumer advocacy groups and unions have accused the American Kidney Fund of helping dialysis providers steer patients into private insurance plans in exchange for donations from the dialysis industry. Wood said his bill is intended to discourage that practice.

American Kidney Fund CEO LaVarne Burton denied the accusations and said her group plays no role in patients’ coverage choices.

Starting in 2022, will limit the private-insurance reimbursement rate that dialysis companies receive for patients who get assistance from groups such as the American Kidney Fund to the rate that Medicare pays. The rate change won’t apply to patients who are currently receiving assistance as long as they keep the same health plans. The bill will also address a similar dynamic in drug treatment programs.

To determine which patients receive financial aid, the law will require third-party groups to disclose patients’ names to health insurers starting July 1, 2020.

These disclosure requirements are spurring the American Kidney Fund’s decision to leave, Burton said. She argues that they conflict with federal rules and violate patient privacy.

“AKF has no choice but to leave or seek legal relief,” Burton said.

In mid-October, the fund started sending letters to its financial aid recipients in California warning of its departure. And Nov. 1, it joined two dialysis patients , asking a U.S. District Court to rule the law unconstitutional.

Gov. Gavin Newsom cautioned against such actions , and urged “both opponents and supporters to put patients first.”

But as the threats and legal battle play out, patients are caught “squarely in the middle,” said Bonnie Burns, a consultant with California Health Advocates, a Medicare advocacy group.

Their options may be limited, she said. Those who don’t work won’t have access to employer-sponsored coverage to make up the difference. And in California, Medicare recipients under age 65 to purchase supplemental insurance known as Medigap.

The state Department of Managed Health Care offers a for affected patients, directing them to programs such as Covered California and Medi-Cal.

DaVita and Fresenius said insurance counselors and social workers at their clinics are working with patients to find other options.

“We will continue to treat all patients, regardless of insurance status,” said Paige Hosler, vice president of insurance management at DaVita. Hosler noted that some patients may qualify for DaVita’s charity care program.

Dialysis companies have been at the center of recent legislative and ballot-box battles, and have spent big to defend their bottom lines. Last year, they poured a record-breaking $111 million into a campaign to defeat Proposition 8, a ballot initiative that would have capped their profits. The measure failed.

The industry also in California on lobbying and campaign contributions in the first half of this year to oppose Wood’s measure.

Desmond said he understands why lawmakers targeted the dialysis industry but can’t fathom why they did so at the expense of patients.

Desmond was laid off from his job as a computer programmer in Massachusetts in 2009 and moved to California to join his brother. One year later, he was diagnosed with kidney failure.

He lives off his Social Security Disability Insurance benefits, which come to about $2,000 a month after his Medicare premiums are deducted. Medicare pays for 80% of his care.

He also qualifies for Medi-Cal coverage that comes with high out-of-pocket costs, so he relies instead on a private Aetna insurance plan to cover the remaining 20%. The American Kidney Fund has been paying the premiums for his private plan since 2015.

“What they did is take away our life raft and left us to drown,” he said of lawmakers.

Brian Carroll, 40, of Sacramento, has been on dialysis for five years. He moved back in with his parents in 2016 because, he said, dialysis left him too weak to work.

“I am now completely depending on other people,” Carroll said. The American Kidney Fund pays the $270 monthly premium for his private insurance plan that covers what Medicare doesn’t. “That’s an entire month of groceries and gas for me,” he said.

Carroll said he supported Proposition 8, even though dialysis companies argued it would force them to cut back services and shut down clinics.

In this situation, he’s not sure whom to blame — the lawmakers, who passed the law with no backup plan for patients, or the fund, which is essentially holding patients hostage.

“What I do know is that you can’t just leave dialysis patients like this,” Carroll said. “It’s cruel.”

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