Fighting the problem presents tension for the administration: how to thwart the bad actors without affecting ACA sign-ups.

Complaints about these unauthorized changes — which can cause affected policyholders to lose access to medical care, pay higher deductibles, or even incur surprise tax bills — rose sharply in recent months, according to brokers who contacted Â鶹ŮÓÅ Health News and federal workers who asked not to be identified.

Ronnell Nolan, president and CEO of the trade association Health Agents for America, said her group has suggested to the Centers for Medicare & Medicaid Services that it add two-factor authentication to healthcare.gov or send text alerts to consumers if an agent tries to access their accounts. But the agency told her it doesn’t always have up-to-date contact information.

“We’ve given them a whole host of ideas,” she said. “They say, ‘Be careful what you wish for.’ But we don’t mind going an extra step if you can stop this fraud and abuse, because clients are being hurt.”

Some consumers are pursued when they respond to misleading social media marketing ads promising government subsidies, but most have no idea how they fell victim to plan-switching. Problems seem concentrated in the 32 states using the federal exchange.

CMS about unauthorized ACA plan switches and enrollments in the first quarter of 2024, according to the agency.

The problem is big enough that CMS says it’s working on technological and regulatory solutions. Affected consumers and agents have filed a civil lawsuit in federal district court in Florida against private-sector firms allegedly involved in unauthorized switching schemes.

Biden has pushed hard to make permanent the enhanced subsidies first put in place during the covid pandemic that, along with other steps including increased federal funding for outreach, helped fuel the strong enrollment growth. Biden for the ACA with the stance of former President Donald Trump, who supported attempts to repeal most of the law and presided over funding cuts and declining enrollment.

Most proposed solutions to the rogue-agent problem involve making it more difficult for agents to access policyholder information or requiring wider use of identity questions tied to enrollees’ credit history. The latter could be stumbling blocks for low-income people or those with limited financial records, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

“That is the knife edge the administration has to walk,” said Corlette, “protecting consumers from fraudulent behavior while at the same time making sure there aren’t too many barriers.”

Jeff Wu, acting director of the Center for Consumer Information & Insurance Oversight, said in a statement that the agency is evaluating options on such factors as how effective they would be, their impact on consumers’ ability to enroll, and how fast they could be implemented.

The agency is also working closely, he wrote, with insurance companies, state insurance departments, and law enforcement “so that agents violating CMS rules or committing fraud face consequences.” And it is reaching out to states that run their own ACA markets for ideas.

That’s because Washington, D.C., and the 18 states that run their own ACA marketplaces have reported far fewer complaints about unauthorized enrollment and plan-switching. Most include layers of security in addition to those the federal marketplace has in place — some use two-factor authentication — before agents can access policyholder information.

California, for example, allows consumers to designate an agent and to “log in and add or remove an agent at will,” said Robert Kingston, interim director of outreach and sales for Covered California, the state’s ACA marketplace. The state can also send consumers a one-time passcode to share with an agent of their choice. Consumers in Colorado and Pennsylvania can similarly designate specific agents to access their accounts.

By contrast, agents can more easily access policyholder information when using private-sector websites that link them to the federal ACA market — all they need is a person’s name, date of birth, and state of residence — to enroll them or switch their coverage.

of such “enhanced direct enrollment” websites run by private companies, which are designed to make it easier and faster for agents certified to offer insurance through healthcare.gov.

last June requiring agents to get written or recorded consent from clients before enrolling them or changing their coverage, but brokers say they’re rarely asked to produce the documentation. If CMS makes changes to healthcare.gov — such as adding passcodes, as California has — it would need to require all alternative-enrollment partners to do the same.

The largest is San Francisco-based HealthSherpa, which assisted 52% of active enrollments nationally for this year, said CEO George Kalogeropoulos.

The company has a 10-person fraud investigation team, he said, which has seen “a significant spike in concerns about unauthorized switching.” They report problems to state insurance departments, insurance carriers, and federal regulators “and refer consumers to advocates on our team to make sure their plans are corrected.”

Solutions must be “targeted,” he said. “The issue with some of the solutions proposed is it negatively impacts the ability of all consumers to get enrolled.”

Most people who sign up for ACA plans are aided by agents or platforms like HealthSherpa, rather than doing it themselves or seeking help from nonprofit organizations. Brokers don’t charge consumers; instead, they receive commissions from insurers participating in state and federal marketplaces for each person they enroll in a plan.

While California officials say their additional layers of authentication have not noticeably affected enrollment numbers, the state’s recent enrollment growth than in states served by healthcare.gov.

Still, Covered California’s Kingston pointed to a decreased number of uninsured people in the state. In 2014, when much of the ACA was implemented, 12.5% of Californians were uninsured, , according to data compiled by Â鶹ŮÓÅ. That year, the share of people uninsured nationwide was 8%.

Corlette said insurers have a role to play, as do states and CMS.

“Are there algorithms that can say, ‘This is a broker with outlier behavior’?” Insurance companies could then withhold commissions “until they can figure it out,” she said.

Kelley Schultz, vice president of commercial policy at AHIP, the trade association for large insurance companies, said sharing more information from the government marketplace about which policies are being switched could help insurers spot patterns.

CMS could also set limits on plan switches, as there is generally no legitimate need for multiple changes in a given month, Schultz said.

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“Yo dije, ¿Qué voy a hacer? ….Ìý“, recordó emocionada. Inmediatamente le preocupó que pudiera tener cáncer. “Iba y venía: tengo [cáncer], no tengo, sí tengo, no tengo”.ÌýY si estaba enferma, agregó, no podría trabajar ni pagar el alquiler. Al no tener seguro de salud, Pantoja Toribio no podía pagar para averiguar si tenía una enfermedad grave.

A partir de este año, , se amplió para incluir a los inmigrantes que no tienen residencia legal, algo que podría haber funcionado perfectamente para Pantoja Toribio, que ha vivido en la ciudad de Brentwood, en el Área de la Bahía, durante tres años. Pero su solicitud de Medi-Cal fue rechazada rápidamente porque, como trabajadora agrícola que gana $16 la hora, sus ingresos anuales de unos $24,000 eran demasiado altos para calificar para el programa.

California es el primer estado en ampliar Medicaid a todos los adultos que reúnan los requisitos, independientemente de su estatus migratorio, una medida celebrada por los activistas de la salud y por líderes políticos de todo el estado. Pero muchos inmigrantes sin estatus legal permanente, especialmente los que viven en zonas de California donde el costo de vida es más alto, ganan demasiado dinero como para calificar para Medi-Cal.

El estado paga la factura de la expansión de Medi-Cal, pero la ley federal prohíbe a los que llama “indocumentados” recibir subsidios de seguros u otros beneficios de la Ley de Cuidado de Salud a Bajo Precio (ACA), dejando a muchos empleados, sin opciones viables médico.

Ahora, los mismos activistas de salud que lucharon por la dicen que el siguiente paso para lograr la equidad en salud es ampliar Covered California, el mercado estatal de ACA, a todos los inmigrantes adultos mediante la aprobación de la AB 4.

“Hay personas en este estado que trabajan y son la columna vertebral de tantos sectores de nuestra economía y contribuyen con su trabajo e incluso con sus impuestos … pero están excluidos de nuestra red de seguridad social”, dijo Sarah Dar, directora del Centro de Política de Inmigración de California, una de las dos organizaciones que patrocinan el proyecto de ley, denominado .

Para calificar para Medi-Cal, una persona no puede ganar más del 138% del nivel federal de pobreza, que actualmente es de cerca de $21,000 al año para un individuo. Una familia de tres miembros tendría que ganar menos de $35,632 al año.

Para las personas que superan esos umbrales, el mercado de Covered California ofrece varios planes de salud, a menudo con subsidios federales y estatales, con primas tan bajas como $10 al mes. La esperanza es crear lo que los activistas llaman un “mercado espejo” en el sitio web de Covered California para que a los inmigrantes, independientemente de su estatus, se les pueda ofrecer los mismos planes de salud que serían subvencionados sólo por el estado.

A pesar de la mayoría demócrata en la Legislatura, el proyecto de ley podría tener dificultades para ser aprobado, ya que el estado se enfrenta a un déficit presupuestario previsto para el próximo año de entre $38 mil millones y $73 mil millones. El gobernador Gavin Newsom y líderes legislativos anunciaron un para empezar a reducir la brecha, pero parece inevitable que se produzcan recortes significativos en el gasto.

No está claro cuánto costaría extender Covered California a todos los inmigrantes, según el miembro de la Asamblea Joaquín Arambula, demócrata de Fresno que presentó el proyecto de ley.

El Centro de Política de Inmigración estima que la creación del mercado costaría al menos $15 millones. Si el proyecto de ley se aprueba, los patrocinadores tendrían que asegurar la financiación de los subsidios, que podrían ascender a miles de millones de dólares anuales.

“Es un momento difícil para pedir nuevos gastos”, señaló Dar. “El costo de la puesta en marcha del mercado espejo es una cifra relativamente baja. Así que tenemos esperanzas de que aún esté dentro de lo posible”.

Arambula dijo que es optimista en cuanto a que el estado continuará liderando en la mejora del acceso a la salud para los inmigrantes que no tienen residencia legal.

“Creo que seguiremos adelante, ya que estamos trabajando para hacer de ésta una California para todos”, expresó.

El proyecto de ley fue aprobado por la Asamblea en julio pasado en una votación de 64-9 y ahora falta la acción del Comité de Asignaciones del Senado, según la oficina de Arambula.

Se calcula que unas 520,000 personas en California podrían optar por un plan de Covered California si tuvieran un estatus legal, según el centro de investigación laboral de la Universidad de California-Berkeley. Pantoja Toribio, que emigró sola desde México huyendo de una relación abusiva, dijo que tuvo suerte. Se enteró de las opciones alternativas de atención médica cuando hizo su visita semanal a un banco de alimentos en Hijas del Campo, una organización de defensa de los trabajadores agrícolas del condado de Contra Costa, donde le dijeron que podría calificar para un plan que ayuda a personas de bajos ingresos a través de Kaiser Permanente.

Pantoja Toribio aplicó, justo antes que se cerrara el plazo de inscripción a finales de enero. Gracias al plan, supo que el bulto que tenía en el pecho no era canceroso.

“Diosito me oyó”, exclamó. “Gracias a Dios”.

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“I said, ‘What am I going to do?’” she said in Spanish, quickly getting emotional. She immediately worried she might have cancer. “I went back and forth — I have [cancer], I don’t have it, I have it, I don’t have it.” And if she was sick, she added, she wouldn’t be able to work or pay her rent. Without health insurance, Pantoja Toribio couldn’t afford to find out if she had a serious condition.

Beginning this year, , expanded to include immigrants lacking legal residency, timing that could have worked out perfectly for Pantoja Toribio, who has lived in the Bay Area city of Brentwood for three years. But her application for Medi-Cal was quickly rejected: As a farmworker earning $16 an hour, her annual income of roughly $24,000 was too high to qualify for the program.

California is the first state to expand Medicaid to all qualifying adults regardless of immigration status, a move celebrated by health advocates and political leaders across the state. But many immigrants without permanent legal status, especially those who live in parts of California where the cost of living is highest, earn slightly too much money to qualify for Medi-Cal.

The state is footing the bill for the Medi-Cal expansion, but federal law bars those it calls “undocumented” from receiving insurance subsidies or other benefits from the Affordable Care Act, leaving many employed but without viable health insurance options.

Now, the same health advocates who fought for the say the next step in achieving health equity is expanding Covered California, the state’s ACA marketplace, to all immigrant adults by passing AB 4.

“There are people in this state who work and are the backbone of so many sectors of our economy and contribute their labor and even taxes … but they are locked out of our social safety net,” said Sarah Dar, policy director at the California Immigrant Policy Center, one of two organizations sponsoring the bill, dubbed .

To qualify for Medi-Cal, an individual cannot earn more than 138% of the federal poverty level, which currently amounts to nearly $21,000 a year for a single person. A family of three would need to earn less than $35,632 a year.

For people above those thresholds, the Covered California marketplace offers various health plans, often with federal and state subsidies, yielding premiums as low as $10 a month. The hope is to create what advocates call a “mirror marketplace” on the Covered California website so that immigrants regardless of status can be offered the same health plans that would be subsidized only by the state.

Despite a Democratic supermajority in the legislature, the bill might struggle to pass, with the state facing a projected budget deficit for next year of anywhere from $38 billion to $73 billion. Gov. Gavin Newsom and legislative leaders announced a to start reducing the gap, but significant spending cuts appear inevitable.

It’s not clear how much it would cost to extend Covered California to all immigrants, according to Assembly member Joaquin Arambula, the Fresno Democrat who introduced the bill.

The immigrant policy center estimates that setting up the marketplace would cost at least $15 million. If the bill passes, sponsors would then need to secure funding for the subsidies, which could run into the billions of dollars annually.

“It is a tough time to be asking for new expenditures,” Dar said. “The mirror marketplace startup cost is a relatively very low number. So we’re hopeful that it’s still within the realm of possibility.”

Arambula said he’s optimistic the state will continue to lead in improving access to health care for immigrants who lack legal residency.

“I believe we will continue to stand up, as we are working to make this a California for all,” he said.

The bill passed the Assembly last July on a 64-9 vote and now awaits action by the Senate Appropriations Committee, Arambula’s office said.

An estimated 520,000 people in California would qualify for a Covered California plan if not for their lack of legal status, according to the labor research center at the University of California-Berkeley. Pantoja Toribio, who emigrated alone from Mexico after leaving an abusive relationship, said she was lucky. She learned about alternative health care options when she made her weekly visit to a food pantry at Hijas del Campo, a Contra Costa County farmworker advocacy organization, where they told her she might qualify for a plan for low-income people through Kaiser Permanente.

Pantoja Toribio applied just before open enrollment closed at the end of January. Through the plan, she learned that the lump in her breast was not cancerous.

“God heard me,” she said. “Thank God.”

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As states increasingly fracture along partisan lines, California Democrats are stamping their supermajority on legislation that they will consider until they adjourn at the end of August. But the cost of these proposals will be a major factor given the enormity of the state’s deficit, currently estimated at between and .

Health Coverage

Lawmakers are again considering whether to create a government-run, single-payer health care system for all Californians. is Democratic Assembly member Ash Kalra’s second such attempt, after a similar bill failed in 2022. The price tag would be enormous, though proponents say there would also be related savings. The high potential cost left Assembly Speaker Robert Rivas and others while the state faces a deficit.

would require , the state’s health insurance exchange, to offer health insurance policies to people who are otherwise not able to obtain coverage because of their immigration status, to the extent it can under federal law. That could eventually lead to similar to those .

Medical Debt

Health care providers and collection agencies would be barred from sharing patients’ medical debt with credit reporting agencies under . The bill would also prohibit credit reporting agencies from accepting, storing, or sharing any such information without consumer consent. Last year, the Biden administration announced plans to develop federal rules barring unpaid medical bills from affecting patients’ credit scores. California would be to remove medical bills from consumer credit reports.

Medi-Cal

The Medi-Cal program, which provides health care for low-income people, would be required to cover medically supportive food and nutrition starting July 1, 2026, under . The bill builds on an existing but limited pilot program. The legislation says Californians of color could benefit from adequate food and nutrition to combat largely preventable chronic health conditions, and it’s sought by the California Legislative Black Caucus as part of reparations for racial injustice.

More than 1.6 million California residents, , have been kicked off Medi-Cal since the state resumed annual eligibility checks that were halted during the covid-19 pandemic. would have the state seek federal approval to slow those disenrollments by taking steps such as letting people 19 and older keep their coverage automatically for 12 months.

Violence Prevention

An increase in attacks on health workers is prompting lawmakers to consider . In California, simple assault against workers inside an ER is considered the same as simple assault against almost anyone else, and carries a maximum punishment of a $1,000 fine and six months in jail. In contrast, simple assault against emergency medical workers in the field, such as an EMT responding to a 911 call, carries maximum penalties of a $2,000 fine and a year in jail. would set the same maximum penalties for assaulting emergency health care workers on the job, whether they are in the field or an ER.

California could toughen penalties for interfering with reproductive health care services. Posting personal information or photographs of a patient or provider would be a felony if one of them is injured as a result. also boosts penalties for intimidation or obstruction.

Under , gun owners would have to lock up their weapons in state-approved safes or lockboxes where they would be inaccessible to anyone but the owner or another lawfully authorized user. Democratic Sen. Anthony Portantino, the bill’s author, says that would make it tougher for anyone, including children, to use guns to harm themselves or others or use the weapons to commit crimes. Critics say it would make it harder to access the weapon when it’s needed, such as to counter a home invasion. Relatedly, and address gun violence restraining orders.

Substance Use

The has prompted several responses: would require the state’s public health department to partner with local public health agencies, wastewater treatment facilities, and others to pilot testing for traces of dangerous drugs in an effort to pinpoint drug hot spots and identify new drugs. would require workplace first-aid kits to include naloxone nasal spray, which . And senators have proposed aimed at curbing overdose deaths, particularly from the deadly synthetic opioid fentanyl.

Youth Welfare

Under , backed by a “” campaign, school districts’ sex education curricula would have to include menstrual health. There was no registered opposition.

Public schools would have to make free condoms available to all pupils in grades nine to 12 under , which would help prevent unwanted pregnancies and sexually transmitted infections, according to the author, Democratic Sen. Caroline Menjivar. Democratic last year.

Reality show star a bipartisan bill to require more reporting on the treatment of youth in state-licensed short-term residential therapeutic programs. would require the state Department of Social Services to post information on the use of restraints and seclusion rooms on a public dashboard.

California would expand its regulation of hemp products, which have become increasingly popular among youths as a way to bypass the state’s adults-only restrictions on legal cannabis. would build on that Assembly member Cecilia Aguiar-Curry said in hindsight .

Public schools would, under , generally be barred from providing food containing red dye 40, titanium dioxide, and other potentially harmful substances, which are currently used in products including . It’s Democratic Assembly member Jesse Gabriel’s to his legislation last year that attempted to ban a chemical used in Skittles.

Women’s Health

would ban the sale of menstrual products with intentionally added PFAS, also known as “.” PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, have been linked to serious health problems. Newsom .

Public grade schools and community colleges would, under , have to provide 14 weeks of paid leave for pregnancies, miscarriages, childbirth, termination of pregnancies, or recovery. Newsom in 2019.

would of a 2019 law aimed at reducing the disproportionate rate of maternal mortality among Black women and other pregnant women of color.

Social Media

Social media companies could face substantial penalties if they don’t do enough to protect children, under . The measure would allow financial damages of up to $1 million for each child under age 18 who proves in court they were harmed, or three times the amount of the child’s actual damages. The industry opposes the bill, calling it .

Cyberbullies could face civil liabilities up to $75,000 under , and those damages could be sought by anyone. Under current law, damages are capped at $7,500 and may be pursued only by the state attorney general.

Wellness

Bosses could be fined for repeatedly contacting employees after working hours under , a “right to disconnect” bill patterned after similar restrictions in 13 countries. The bill’s author, Democratic Assembly member Matt Haney, said despite the advent of smartphones that “ between work and home life,” employees shouldn’t be expected to work around the clock. The measure by the California Chamber of Commerce.

Finally, Democrat Anthony Rendon, a long-serving state Assembly speaker, is spending his last year in the chamber leading a first-in-the-nation on Happiness and Public Policy Outcomes. The committee isn’t planning any legislation but after lawmakers adjourn in August.

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But have you thought about how much your son’s or daughter’s dream school will charge for health coverage?

You might be in for a shock.

Hawley Montgomery-Downs was thrilled when daughter Bryn Tronco earned a scholarship that pays half the $63,000 annual tuition at the University of Southern California. But just as school was starting in August, she was stunned to receive a bill from USC for $3,000 to cover both a student health insurance premium and a fee that allows students to access on-campus clinics and other services. At home in West Virginia, she had paid nothing for her daughter’s health insurance, through the state’s Children’s Health Insurance Program, which serves lower- and middle-class families.

Montgomery-Downs, who lives in Morgantown, West Virginia, was especially upset that USC not only billed her for health insurance but a $1,050 annual health fee. “It would be nice for her to go to the student health center, but with buying insurance to go to a primary care provider, it feels like I am paying twice,” she said.

Mandatory medical insurance and health service fees are common at colleges as a condition of enrollment, saidÌý, a Fort Collins, Colorado, health and benefits consultant to colleges. While the health fee can help reduce students’ insurance premiums, parents may feel as though they are paying double. “That’s a big conundrum for our field,” he said.

For parents, these big payments might come as a surprise, making a barely affordable education feel even less so. After all, students can economize by choosing a skimpy meal plan and cooking their own dinners or buying used textbooks, but there is no way around the mandatory health fees.

The costs vary by school but often can amount to several thousand dollars a yearÌý— costs that health care advocates say should be carefully reviewed by parents and students to ensure they understand their options while also meeting university requirements.

Students can seek a waiver to university health insurance by showing they have their own insurance or are covered by their parent’s insurance that meets specific university criteria. Schools typically want to see that a student’sÌýownÌýinsurance covers local doctors and hospitals for little out-of-pocket cost.ÌýStudent health fees, however, generally can’t be waived.

USC, a private college, for its Aetna student health insurance plan. The average for public colleges is $2,712 and $3,540 at private universities, according to a by Beckley’s firm, Hodgkins Beckley & Lyon.

Other prominent colleges charge much more, such as and $4,163 at

The charges $4,700, and most services at its school health clinic are fully covered by its health plan. The charges $3,976.

, students buying the school’s insurance pay $4,080 annually and $1,304 for the student health fee.

The easiest solution to avoid these charges would be for students to stay on a parent’s health policy — which the Affordable Care Act allows until they turn 26. But that works only if the student’s parent has a policy that meets the school’s comprehensive requirements and offers in-network coverage where the college is located.

Otherwise, parents may want to shop among ACA marketplace plans to see if they can find a bargain. If their incomes are low enough, students can sometimes enroll in Medicaid or a CHIP plan in states where they go to school. But this strategy has limitations as well. Students must meet state residency requirements where they go to school, and parents cannot claim them as a dependent on tax returns. CHIP coverage also expires once a student turns 19.

Schools that charge a student health fee and require insurance coverage say the funding helps cover services at campus health clinics, which otherwise would cost students hundreds of dollars a year or more.

The — which covers primary and preventive health services — also helps the school pay for services not typically covered by insurance, such as monitoring disease outbreaks on campus.

Dr.Ìý, chief health officer of USC Student Health, noted that the student health fee provides funding for additional mental health providers on campus and a team focused on sexual assault prevention and education — services available to students without any copayments. She said these additions are vital because, even with insurance, students could face challenges finding private counselors to provide timely help and, if they do, students would have cost-sharing expenses.

“The student health fee supports our public health infrastructure on campus,” Van Orman said.

Because students can get primary health services on campus at the student health center, fewer of them seek care paid for by the insurance, she said, and that helps keep the monthly premium on the Aetna student health insurance plan lower. “These things are working together and are not at all duplicative,” Van Orman said.

USC’s student health insurance has an in-network annual deductible of $450 and a $20 copay for physician office visits. It also provides comprehensive services nationwide, so students are covered when at school and back at home — even if that’s across the country. About half the USC students buy the Aetna student insurance, according to Van Orman.

Other colleges have a different strategy. For instance,Ìý’s mandatory health insurance covers health center services on campus. Unless they get a waiver,Ìýundergraduates must enroll in the student health insurance plan — costing $2,700 a year — unless they prove they have another insurance plan that meets the school’s criteria. The health plan premium allows students to get many free services at the student health center, including medical office visits, some prescriptions, and routine screenings for sexually transmitted infections.

Beckley said college rules vary on whether they allow students to choose insurance plans other than what the school offers.

USC allows students to buy an alternative insurance policy through their parents’ plan or on the ACA marketplace as long as it meets the school’s requirements that include comprehensive health coverage in the Los Angeles area and covering preventive care with zero cost sharing. Out-of-state Medicaid or CHIP plans don’t meet the university’s criteria because they don’t have provider networks for routine care in California.

That was unwelcome news to Montgomery-Downs.

“This is not something we budgeted for,” she said of USC’s health costs.

Montgomery-Downs, a former associate professor at West Virginia University who now works as a freelance editor, said she wasn’t sure what to do when she got the USC health bill. She had thought Bryn, who turned 19 last week, would be covered initially because her CHIP plan provided coverage for treatment at emergency rooms and urgent care centers out of state. And Montgomery-Downs wanted to make sure her daughter had health coverage on summer and holiday breaks when home.

Unsure of which marketplace coverage options would meet the school’s rules and deadlines, she decided to go with the Aetna student plan USC offered.

A look at marketplace options on Covered California shows the $2,200 for the USC Aetna student plan is a competitive rate. The lowest-priced comparable PPO plan offered by California Blue Cross that would provide Bryn a national network of providers costs about $2,400 a year factoring in a government subsidy . PPOs provide some coverage for out-of-network doctors and hospitals.

Montgomery-Downs gets her coverage on the marketplace and said she will shop for a marketplace plan for Bryn for the next school year. She said she wishes they had been aware of all the health costs at the time of admission rather than just before classes began.

“It’s all nightmarish, even for someone with the privilege of time and some understanding of these bureaucracies — higher education and medical insurance,” Montgomery-Downs said.

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Last year, he said, in a single involving bogus “medicated” creams and unnecessary urine tests, a Beverly Hills couple was charged with defrauding 27 health insurers out of $40 million.

“That’s just the tip of the iceberg,” said Poizner, a Silicon Valley businessman. “Then there’s all of the fraud that never gets reported.”

Poizner held the office from 2007 to 2011 as a Republican but now is running as an unaffiliated candidate, and has made fighting fraud a centerpiece of his health care agenda.

He argues that the health industry may be forfeiting billions of dollars because the state insurance department’s fraud division is understaffed: 57 investigator jobs, or 24 percent, are unfilled.

Ultimately, that inflates health care costs and puts patients in harm’s way, he said.

“These vacancy rates are critical to fill,” Poizner said. “The less health care fraud there is, the better the quality of the health care system.”

Poizner is sounding a very different note from his Democratic opponent, state Sen. Ricardo Lara, who says reducing health care costs requires a broad transformation of health care, not just chasing criminals.

Lara, who co-authored the last year, said he believes health care costs will drop if people have coverage instead of postponing care until it is most urgent and expensive.

“If we can get everyone comprehensive primary care, that’s a good way to start,” Lara said.

The insurance commissioner oversees car, property and some health insurance plans. Rooting out illegal activity is part of the job.

But in a state dominated by liberal politicians, many challenging the very structure of the U.S. health care system, Poizner’s nuts-and-bolts focus stands out as traditional and politically pragmatic. Some political observers see his platform as a safe way to secure votes, or as one put it, “an old standby.”

Walter Zelman, professor of health science at California State University-Los Angeles, said focusing on other areas of health care, such as how doctors and hospitals get paid, would make a much bigger dent in cutting health care costs. But they’re less popular to implement, he said.

“To talk about fraud and abuse … that doesn’t really threaten anybody,” Zelman said. “It’s more maybe of a good campaign issue than it is an actual way of reducing costs.”

Democratic strategist Steve Maviglio agreed. “Who’s against combating fraud? I mean that’s the safest bet you can take, and that’s the one that’s in everybody’s platform, Republican or Democrat,” he said.

When candidates don’t have a comprehensive solution to health care issues, Maviglio added, “that’s their go-to talking point.”

Poizner said fraud is worth chasing because it poses a threat to patients, often involving unnecessary surgeries or prescriptions. And the costs are “all passed on, every dollar, to consumers, in the form of higher rates,” he said.

Vacancies in the department’s fraud unit have gone up and down over the years. In 2013, 1.5 percent of positions were unfilled, but in 2016, almost 30 percent were vacant.

When Poizner was insurance commissioner, the vacancy rate hovered between 12 percent and 23 percent.

The current insurance commissioner, Dave Jones, said one reason the rate is high now is because he has created more positions.

“It’s a challenge for any law enforcement agency to fill positions,” Jones said, pointing to the relatively low pay his department offers compared with other state offices.

The starting yearly salary for a fraud investigator —Ìýwho are sworn police officers —ranges from $54,280 to $88,000, Jones said, so his department is “hemorrhaging” those employeesÌýto higher-paying jobs at the state Department of Corrections and Rehabilitation and the attorney general’s office.

“There’s no question that we have more work than we have resources available to do,” Jones said.

To make the most of the manpower, his department prioritizes the biggest scams, he said, such as those that inflict the most patient harm.

In case, for instance, the insurance department joined whistleblowers in a lawsuit alleging that drug manufacturer Bristol-Myers Squibb paid doctors to prescribe their products, such as cholesterol and diabetes drugs. The company settled for $30 million.

California’s other health insurance regulator, the Department of Managed Health Care, oversees the vast majority of commercial health insurance plans in the state. But it has only three employees who look into fraud. On occasion, the Department of Insurance collaborates with them to root out criminal billing.

Poizner said he would fight to lure more people to insurance department jobs by lobbying for more state money to raise investigators’ wages.

Lara said he also wants the department’s fraud unit to be fully staffed, but “you can’t fix health care costs just from fighting fraud alone.” Instead, he said, he would try to prevent insurers from gouging consumers on premiums and look into reducing prescription drug costs.

A fraud investigator with the insurance department said his team could always use more help.

Vladislav Mikulich, a detective sergeant who supervises about a dozen investigators at the department’s southern fraud division, which covers the Los Angeles area, said health care scammers are savvy white-collar criminals that hide their illegal activities in “fantastic ways.”

He said he knows there’s much more fraud than his team can investigate, partly because of what they hear from informants.

“Every one of them could talk my ear off for the next month about the things that they have done in the past, or things they are currently seeing,” Mikulich said.

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Speaking Wednesday at the Commonwealth Club here, the administrator of the Centers for Medicare & Medicaid Services said she supports granting states flexibility on health care but indicated she would not give California the leeway it would need to spend federal money on a single-payer system.

“I think a lot of the analysis has shown it’s unaffordable,” Verma said during a question-and-answer session following her speech. “It doesn’t make sense for us to waste time on something that’s not going to work.”

During her speech, Verma issued a broader warning to advocates pushing for a Medicare-for-all program nationally. She said that “socialized” approach to medicine would endanger the program and the health care it provides for millions of older Americans.

“We don’t want to divert the purpose and focus away from our seniors,” Verma said in the address before more than 200 people. “In essence, Medicare for all would become Medicare for none.”

Single-payer has emerged as a key issue in the California governor’s race this year. The current front-runner for governor, Gavin Newsom, a Democrat and the current lieutenant governor, has vowed to pursue a state-run, single-payer system for all Californians if elected in November. Many California lawmakers have endorsed that idea as the next step toward achieving universal coverage and to tackling rising costs.

California has enthusiastically embraced the Affordable Care Act, and state leaders have struggled with — and even bucked — the Trump administration on a variety of health-policy fronts. The state stands to lose more than any other if the Trump administration is successful in further dismantling the ACA.

About 1.4 million Californians buy coverage through the state’s Obamacare exchange, Covered California, and nearly 4 million have joined Medicaid as a result of the program’s expansion under the law.

Verma wields enormous power as head of CMS, overseeing a $1 trillion budget. The agency sets policy for Medicare, Medicaid and the federal insurance exchanges under the ACA.

The landmark health law, she said, was so flawed it could not work without further action from Congress.

“It wasn’t working when we came into office and it continues not to work,” Verma said, responding to a question from moderator Mark Zitter, founder of the Zetema Project, a nonprofit organization that promotes debate on health care across partisan lines. “The program is not designed to be successful.”

Zitter billed the event as a rare chance for Californians to hear directly from a top Trump administration official, although Verma’s remarks broke little new ground, he said.

Trump health care policies figure into many of California’s congressional races this fall in which incumbent Republicans are fending off Democratic challengers. And in court, California Attorney General is leading a coalition of attorneys general who are defending the constitutionality of the ACA in a Texas case with national implications.

The Trump administration has sided with the officials waging the lawsuit, choosing not to defend the health law’s protections for people with preexisting conditions. Separately, the administration has backed work requirements for many people on Medicaid.

California’s state Senate passed a law in May banning such requirements as a condition for eligibility in Medi-Cal, the state’s Medicaid program. The bill is pending in the state Assembly.

“Making health insurance coverage contingent on work requirements goes against all we’ve worked for here in California,” state Sen. Ed Hernandez (D-West Covina), author of , said in May.

State lawmakers also are considering bills that would limit the GOP-backed sale of short-term health policies and prevent people from joining association health plans that don’t have robust consumer protections.

In an interview after the speech, Verma criticized those legislative efforts in California because they would limit consumer choice.

“Any efforts to thwart choice and competition and letting Americans make decisions about their health care is bad health policy,” she said.

Peter Lee, executive director of Covered California, the state’s ACA marketplace, has criticized the Trump administration for promoting those cheaper, skimpier policies as an alternative to ACA-compliant plans. He said he fears consumers will be harmed by “bait-and-switch products” that don’t provide comprehensive benefits.

“There have been a series of policies from Washington that have the effect of raising costs, particularly for middle-class Americans, and pricing them out of coverage,” Lee said in an interview last week. “This is not a failure of the ACA. This is entirely happening since the new administration.”

Most of Verma’s speech in San Francisco focused on Medicare. She outlined a number of initiatives designed to strengthen the program and protect taxpayers from ballooning costs. After the speech, CMS announced proposed changes to Medicare payment policies for outpatient care that could yield savings for the government and patients.

In her remarks, Verma reiterated the Trump administration’s efforts to reduce prescription drug prices, improve patients’ access to their own medical records and eliminate burdensome regulations on doctors and other medical providers.

Verma received a polite round of applause at the beginning and end of her appearance.

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The state marketplace, Covered California, said the rate increase for 2019 would have been closer to 5 percent if the federal penalty for going without health coverage had not been repealed in last year’s Republican tax bill.

The average increase in California is smaller than the double-digit hikes expected around the nation, due largely to a healthier mix of enrollees and more competition in its marketplace. Still, health insurance prices keep growing faster than wages and general inflation as a result of rising medical costs overall, squeezing many middle-class families who are struggling to pay their household bills.

The 8.7 percent increase in California ends two consecutive years of double-digit rate increases for the state marketplace.

“It’s not great that health care costs are still increasing that much, but the individual market is not sticking out like a sore thumb like it has in other years,” said Kathy Hempstead, senior adviser at the Robert Wood Johnson Foundation. “It’s falling back to earth.”

The future may be less bright. An estimated 262,000 Californians, or about 10 percent of individual policyholders in and outside the exchange, are expected to drop their coverage next year because the ACA fines were eliminated, according to the state. Peter Lee, executive director of Covered California, warned that the exodus of healthier consumers will drive up insurance costs beyond 2019 — not just for individual policyholders but for California employers and their workers.

“We are paying, in essence, a surcharge for federal policies that are making coverage more expensive than it should be,” Lee said in an interview. “There will be more of the uninsured and more uncompensated costs passed along to all of us.”

Critics of the Affordable Care Act say it has failed to contain medical costs and left consumers and taxpayers with heavy tabs . Nearly 90 percent of Covered California’s 1.4 million enrollees qualify for federal subsidies to help them afford coverage.

Foiled in its attempt to repeal Obamacare outright, the Trump administration has taken to rolling back key parts of the law and has slashed federal marketing dollars intended to boost enrollment. Instead, the administration backs cheaper alternatives, such as short-term coverage or association health plans, which don’t comply fully with ACA rules and tend to offer skimpier benefits with fewer consumer protections.

Taken together, those moves are likely to draw healthier, less expensive customers out of the ACA exchanges and leave sicker ones behind.

Nationally, 2019 premiums for silver plans — the second-cheapest and most popular plans offered — are expected to jump by 15 percent, on average, according to an of 10 states and the District of Columbia by the Avalere consulting firm. across the country, however. Decreases are expected in Minnesota while insurers in Maryland are seeking increases.

In California, exchange officials emphasized, consumers who shop around could pay the same rate as this year, or even a little less.

Christy McConville of Arcadia already spends about $1,800 a month on a Blue Shield plan for her family of four, opting for “platinum” coverage, the most expensive type. Her family doesn’t qualify for federal subsidies in Covered California.

She’s worried about further increases and doesn’t want to switch plans and risk losing access to the doctors she trusts. “We’re getting right up to the limit,” McConville said.

Amanda Malachesky, a nutrition coach in the Northern California town of Petrolia, said the elimination of the penalty for being uninsured makes dropping coverage more palatable. Her family of four pays almost $400 a month for a highly subsidized Anthem Blue Cross plan that has a $5,000 deductible.

“I’ve wanted to opt out of the insurance model forever just because they provide so little value for the exorbitant amount of money that we pay,” said Malachesky, who recently paid several hundred dollars out-of-pocket for a mammogram. “I’m probably going to disenroll … and not give any more money to these big bad insurance companies.”

Covered California is aiming to stem any enrollment losses by spending more than $100 million on advertising and outreach in the coming year. In contrast, the Trump administration spent only $10 million last year for advertising the federal exchange across the 34 states that use it.

Also, California lawmakers are looking at ways to fortify the state exchange. State legislators are considering bills that would limit the sale of short-term insurance and prevent people from joining association health plans that don’t have robust consumer protections.

However, California hasn’t pursued an insurance mandate and penalty at the state level, which both health plans and consumer advocates support. New Jersey and Vermont have enacted such measures.

Lee said it’s up to lawmakers to decide whether a state mandate makes sense.

David Panush, a Sacramento health care consultant and a former Covered California official, said some lawmakers may be reluctant to push the idea, even in deep-blue California.

“The individual mandate has always been the least popular piece of the Affordable Care Act,” he said.

Despite the constant uncertainty surrounding the health law, many insurers nationally are posting profits from their ACA business and some plans are looking to expand further on the exchanges.

In California, the same 11 insurers are returning, led by Kaiser Permanente and Blue Shield of California. Together, those two insurers control two-thirds of exchange enrollment. (Kaiser Health News, which publishes California Healthline, is not affiliated with Kaiser Permanente.)

The Covered California rate increases are fairly uniform across the state. Premiums are climbing 9 percent across most of Southern California as well as in San Francisco. Monterey, San Benito and Santa Cruz counties faced the highest increase at 16 percent, on average.

The rates are subject to state regulatory review but are unlikely to change significantly. Open enrollment on the exchange starts Oct. 15.

The ACA’s expansion of coverage has dramatically cut the number of uninsured Californians. The proportion of Californians lacking health insurance fell to 6.8 percent at the end of last year, down from 17 percent in 2013, federal data show.

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Pero a medida que se acerca el sexto período abierto de inscripción de ACA en noviembre, es poco probable que la falta de asistencia en persona sea un desastre para las personas que buscan cobertura, aseguran expertos en seguros de salud.

“Creo que solo tendrá un impacto muy pequeño en la inscripción para 2019”, dijo William Hoagland, vicepresidente senior del Centro de Políticas Bipartidistas en Washington.

Pero combinado con otras acciones recientes de la administración Trump, la decisión marca un tono negativo, agregó Hoagland.

“Por supuesto envía una señal de que la administración no está promoviendo la inscripción”, dijo.

Los Centros de Servicios de Medicare y Medicaid (CMS) anunciaron que están reduciendo el dinero para financiar el trabajo de los navegadores, expertos en navegar el mercado que ayudan a las personas a inscribirse y comprar o cambiar de plan de salud, o averiguar si califican para Medicaid, de $36 millones a de 45 días.

Esta reducción se produce un año después que la administración Trump bajara en un 40% el presupuesto de para los navegadores, además de eliminar la ayuda para publicidad y otras actividades de alcance comunitario.

Seema Verma, administradora de los CMS, dijo que los navegadores que operan en los 34 estados que utilizan el mercado federal -incluidas muchas organizaciones de salud y religiosas- fueron ineficaces y habían dejado de ser útiles.

Señaló que ayudaron con menos del 1% de las inscripciones en 2017, aunque reconoció que los navegadores “ayudan” solo si los consumidores se inscriben en persona.

Los CMS también señalaron que, después que se redujo la financiación de los navegadores el año pasado, la inscripción general en los planes de Obamacare (contando los que pagaron las primas del primer mes) a 10,6 millones de personas.

Florida Blue, la aseguradora que registra la mayor inscripción de consumidores a través del Obamacare a nivel nacional, dijo que no extrañará la ayuda de los navegadores financiados por el gobierno federal.

“Dada nuestra exclusiva estrategia utilizando nuestros corredores en centros minoristas junto con nuestros esfuerzos de televentas, nuestros agentes de campo y esfuerzos directos de inscripción en el mercado, no dependemos de los navegadores para inscribir a los miembros de ACA”, dijo Paul Kluding, vocero de Florida Blue.

Greg Fann, miembro de la Sociedad de Actuarios, dijo que el papel de los navegadores ha sido exagerado.

“Soy un hombre de números, y lo que realmente le importa a la gente son los números y el precio de la cobertura”, dijo. Casi 9 de cada 10 personas que compran cobertura en los intercambios de ACA califican para recibir subsidios federales en función de sus ingresos, y la cantidad de esos subsidios subieron el año pasado debido a un aumento en las primas de los planes de plata.

Fann agregó que los navegadores fueron más necesarios en 2013 y 2014 cuando los mercados estaban en sus primeros años y millones de personas que no habían comprado seguros antes consideraban las nuevas opciones de la ley de salud.

Las aseguradoras y los corredores deberían intervenir para compensar la financiación de los navegadores, remarcó Fann.

No cuente con eso, dijo Steve Israel, agente de seguros de Boynton Beach, Florida, y ex presidente de la Asociación de Aseguradores de Salud de Florida. Israel enfatizó que la mayoría de los corredores independientes no quieren tener nada que ver con los planes de ACA porque las aseguradoras han reducido sus comisiones. “Hemos estado enviando personas a los navegadores”, dijo Israel.

Sin embargo, algunos estados que operan sus propios mercados continúan invirtiendo en estos asistentes de base.

Covered California, por ejemplo, mantiene estables los fondos para navegadores, dedicándoles este año $6.5 millones del presupuesto.

Eso es más de la mitad de lo que cuidadodesalud.gov (healthcare.gov) está invirtiendo en navegadores en 34 estados.

California tiene 1.5 millones de consumidores en planes del Obamacare, la segunda inscripción más alta a nivel nacional detrás de Florida, que tiene 1.6 millones.

¿Muerte por 1,000 cortes?

Trump pasó su primer año en la oficina oval tratando de revocar la ley de salud y estuvo a un voto en el Senado de alcanzar esa meta. Inmediatamente después que el senador John McCain (republicano de Arizona) para bloquear el dramático esfuerzo de revocación, Trump imploró a los republicanos que dejaran que la ley se desintegre.

“Dejen que el Obamacare explote internamente, luego negocien”, tuiteó Trump el 28 de julio de 2017.

Pero su administración no se ha quedado de brazos cruzados.

En diciembre, el Congreso controlado por los republicanos aprobó una ley por la cual, a partir del próximo año, se eliminará el requisito que obligaba a la mayoría de los estadounidenses a tener seguro a riesgo de pagar una multa. Una medida que probablemente aleje a las personas más sanas del mercado y genere precios más altos para los que deben quedarse.

Hace pocos días, los CMS dijeron que, debido a una demanda pendiente, estaba creado por la ley para nivelar la carga de las aseguradoras de salud cuyos clientes son poco saludable o enfermos. Eso podría quitarles millones de dólares a algunas aseguradoras, lo que provocaría que aumenten los precios o abandonen los mercados.

La administración Trump también emitió nuevas reglas para tratar de facilitar que los individuos y las pequeñas empresas compren planes de salud que cuestan menos que la cobertura de ACA porque cubren menos servicios médicos. Estos planes no tendrían las protecciones de la ley de salud, que impiden que las aseguradoras cobren precios más altos a las mujeres, los adultos mayores y a los que tienen condiciones médicas preexistentes.

Los críticos ridiculizan estos planes llamándolos “seguros basura”.

Además de reducirles los fondos, los CMS ahora quieren que los navegadores no solo les hablen a los consumidores sobre los planes de ACA y Medicaid, sino que también promuevan estos otros seguros.

Esto se suma a la preocupación por la falta de financiación para los navegadores.

La disponibilidad de estos nuevos tipos de cobertura aumentará la demanda de los consumidores de navegadores más especializados, dijo Elizabeth Hagan, consultora senior de Transform Health.

Hagan dijo que el problema con la reducción de la asistencia al consumidor no es tanto que menos personas comprarán cobertura, sino que la gente comprará pólizas que no se ajustan a sus necesidades.

Jodi Ray, quien dirige el programa de navegadores de la Universidad del Sur de la Florida, el más grande del estado, dijo que su personal hace mucho más que ayudar con la inscripción. También ayudan a los consumidores a presentar apelaciones ante las aseguradoras.

“Así es como se agravan las disparidades en la atención de la salud: nos pondremos en la horrible posición de enfrentar a las poblaciones que necesitan asistencia entre sí para priorizar cómo podemos usar los recursos”, dijo.

La reportera de California Healthline, Ana B. Ibarra, colaboró con esta historia.

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But as the ACA’s sixth open-enrollment period under the health law approaches in November, the lack of in-person assistance is unlikely to be a disaster for people seeking coverage, insurance and health experts say.

“I think alone it will have a very small impact on enrollment for 2019,” said William Hoagland, a senior vice president with the Bipartisan Policy Center in Washington.

But combined with other recent actions by the Trump administration, the decision sets a negative tone, Hoagland said.

“It does send a signal of course that the administration is not promoting enrollment,” he said.

The Centers for Medicare & Medicaid Services announced it is cutting money to the groups known as navigators from $36 million to for the upcoming 45-day enrollment period.

This reduction comes a year after the Trump administration decreased navigators’ funding by 40 percent from — and cut advertising and other outreach activities.

CMS Administrator Seema Verma said the navigators that operate in the 34 states that use the federal marketplace — including many health and religious organizations — were ineffective and had outlived their usefulness.

She pointed out that they helped with fewer than 1 percent of enrollments in 2017 — though she counts navigators as “helping” only if consumers sign up in their presence.

CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans (when counting people who paid their first month’s premiums) to 10.6 million people.

Florida Blue, an insurer that enrolls among the largest number of Obamacare consumers nationwide, said it won’t miss the help from the federally funded grass-roots helpers.

“Given our large and unique distribution-channel strategy of utilizing our retail centers along with our telesales efforts, our dedicated field agents and our direct in-market enrollment efforts, we do not depend on navigators to enroll ACA members,” said spokesman Paul Kluding.

Greg Fann, a fellow with the Society of Actuaries, said the role of navigators has been overstated.

“I am a numbers guy, and what really matters to people are the numbers and price of the coverage,” he said. Nearly 9 in 10 people buying coverage on the ACA exchanges qualify for federal subsidies based on their incomes, and the amount those subsidies rose last year because of an increase in silver-plan premiums.

The navigators, Fann added, were needed more in 2013 and 2014 when the marketplaces were in their first years and millions of people who hadn’t bought insurance before were considering the health law’s new options.

Insurers and brokers, Fann said, should step in to make up for navigator funding.

Don’t count on it, said Steve Israel, a Boynton Beach, Fla., insurance agent and past president of the Florida Association of Health Underwriters. He said most independent brokers want nothing to do with ACA plans because insurers have cut their commissions. “We’ve been sending people to navigators,” Israel said.

Some states that operate their own marketplaces, however, are continuing to invest in these grass-roots aides.

Covered California, for example, is holding its navigator funding steady, dedicating $6.5 million to navigators in this year’s budget.

That’s more than half of what healthcare.gov is investing in navigators in 34 states.

California has 1.5 million people in Obamacare plans, second highest in the nation behind Florida, which has 1.6 million.

Death By 1,000 Cuts?Ìý

Trump spent his first year in office trying to repeal the health law and came within one vote in the U.S. Senate of achieving that goal. Immediately after Sen. John McCain (R-Ariz.) to block the dramatic repeal effort, Trump implored Republicans to let the law disintegrate.

“Let ObamaCare implode, then deal,” Trump tweeted on July 28, 2017.

But his administration has not stood idly by.

The Republican-controlled Congress in December passed a law that next year will eliminate the requirement that most Americans have insurance, a move likely to drive healthier people out of insurance market and lead to higher prices for those who are left.

Just last week, CMS said because of a pending lawsuit it was created by the law to even out the burden on health insurers whose customers are especially unhealthy or sick. That could take millions of dollars away from some insurers, causing them to hike prices or abandon markets.

The Trump administration also issued new rules to try to make it easier for individuals and small businesses to buy health plans that cost less than ACA coverage because they cover fewer medical services. These plans would bypass the law’s protections that prevent companies from charging higher prices to women, older people and those with preexisting medical conditions.

Critics deride such plans as “junk insurance.”

CMS now wants the navigators to promote these policies in addition to steering people toward ACA-compliant plans and Medicaid.

This adds to the concern about the lack of navigator funding.

The availability of such new types of coverage will increase consumer demand for specially trained navigators, said Elizabeth Hagan, a senior consultant with Transform Health, a consulting firm.

She said the problem with reducing consumer assistance is not so much that fewer people will buy coverage but that people will buy policies that don’t fit their needs.

Jodi Ray, who leads the University of South Florida’s navigator program — the largest one in the state — said her staffers do much more than help with enrollment. They also help consumers file appeals with insurers.

“This is how health care disparities are exacerbated — we will be put in the awful position of pitting populations that need assistance against each other in order to prioritize how we can use the resources,” she said.

California Healthline reporter Ana B. Ibarra contributed to this report.

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