By Ana B. Ibarra, CalMatters

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A health worker union has accused Kaiser Permanente of screening patients and making care recommendations through “a digital, automated algorithm” without clinician oversight — a practice the union says violates state law. 

The complaint, filed with state regulators by the National Union of Healthcare Workers, targets the integrated healthcare provider’s e-visit screening tool, which evaluates patients who think they may be experiencing anxiety or depression. Patients answer a multiple choice questionnaire, and the tool “automatically and instantaneously generates care recommendations and referral pathways based on the responses provided,” the complaint states. 

That’s not necessarily an appointment with an in-person therapist: recommendations also include referrals to virtual therapy, health education classes and self care apps, according to the complaint. 

The union represents therapists and social workers among other health workers at Kaiser facilities. According to the Department of Managed Health Care, which oversees health plans, this is the first time a union has filed a complaint against a health plan related to its supposed use of algorithms and artificial intelligence in behavioral healthcare.

Union members say they’ve seen no evidence that licensed mental health clinicians review patients’ e-visit answers in real-time, or at all, before the tool issues recommendations for follow-up care. At a hearing held by the San Francisco Board of Supervisors on this issue last week, therapists and social workers said that digital automated screenings cannot replace a clinician’s assessment. 

“Artificial intelligence and algorithms don't capture what trained humans can,” said Ilana Marcucci-Morris, a therapist and a member of the union’s bargaining committee. She notes that people with depression commonly minimize their symptoms — so an algorithm relying solely on a patient's answers may miss signs of a more severe condition.

Kaiser skipped last week’s hearing. But in an emailed statement to CalMatters, Kaiser pushed back on the union’s characterization of its behavioral health processes.

The e-visit tool “does not use AI to diagnose patients, make clinical decisions, or determine medical necessity. Clinical decisions remain with licensed healthcare professionals,” said Lena Howland, a Kaiser spokesperson. She did not provide more details about the technology behind the tool.

Howland said patients can still reach a live person by calling a phone number displayed during the e-visit process. “The online screening tool “is an additional path to getting care—not the only path,” she said. 

In a blog post from last year, Kaiser describes the e-visit tool as increasingly popular, especially among younger members, and available for about 30 health concerns. In the post, Kaiser says patients’ answers “are reviewed by a health care professional” and that members “receive a response by secure message within 4 hours, and usually sooner.”

Union leaders counter that care recommendations typically come in almost immediately after completing the questionnaire. They argue no clinician can realistically be reviewing patients’ answers that quickly.

The union contends Kaiser’s screening practice violates state law, which requires that medical decisions come from a licensed healthcare professional and bars “artificial intelligence, algorithms, or other software tools” from supplanting that judgment. 

The Department of Managed Health Care said it has received the union’s complaint and is investigating. “Details of ongoing enforcement investigations are confidential in compliance with the law and to protect the integrity of the investigation,” the department said. 

A shift in mental health triage

The complaint lands in the middle of contract negotiations between the healthcare union and Kaiser Northern California, which have dragged on for more than a year without an agreement. 

Therapists and health workers who spoke at last week’s hearing said that a new triage system including the e-visit tool started in 2023. Before that, dedicated Kaiser triage teams made up of licensed clinicians — who could pick up on cues like tone of voice — took patients’ brief histories over the phone, screened for self-harm, and provided a preliminary diagnosis and next steps in care.

Now, the union says clerical staff or the tool do most mental health triaging. The healthcare union filed a separate complaint last year alleging Kaiser used telephone service representatives, instead of clinicians, to answer mental health calls.

Kaiser Permanente mental health care workers picket outside the Kaiser Permanente Downey Medical Center during a companywide strike on Dec. 12, 2024. Photo by Jules Hotz for CalMatters

Marcucci-Morris said she typically sees patients about two weeks after Kaiser’s new system triages them. “The acuity and critical nature of symptoms I am seeing has increased significantly because the app, AI, an algorithm, or an unlicensed telephone operator incorrectly determined that they could wait 10 days to see me,” she said.

San Francisco Supervisor Chyanne Chen said she called last week’s hearing because of concerns she’d been hearing from constituents — both Kaiser employees and patients — about the health giant’s mental health services. Kaiser serves about a third of San Francisco’s population. 

Chen called Kaiser’s absence from the hearing “unacceptable,” and said it left many of her questions unanswered.

“As a San Franciscan, I’m not against technology,” Chen said. “For me it's making sure we’re not shortcutting our quality of care and safety.”

Kaiser’s troubled mental health record 

This isn’t the first time Kaiser has skipped a hearing on its mental health services. Last year, state legislators criticized the health plan after it declined to participate in an informational hearing about its behavioral health services. 

Kaiser’s mental healthcare problems are well documented. In 2023, Kaiser agreed to pay a $50 million fine and to invest $150 million to improve its programs in exchange for settling state findings that its behavioral health patients were experiencing serious delays in care. In 2021, California regulators had noted a jump in behavioral health-related complaints, which prompted regulators to conduct a survey that led to the settlement. Kaiser now operates under  a corrective action plan and must submit quarterly progress reports to the state.

In 2014, state regulators fined Kaiser $4 million for long wait times between therapy appointments. Kaiser has largely attributed its past problems to a shortage of care providers.

The health plan is also facing mounting criticism over its broader use of AI and digital tools in care.

Kaiser’s own mental health workers have objected to transcription tools that record patient appointments, saying  the company won’t disclose how it uses or shares the data. Separately, call center nurses have also raised concerns about Kaiser using AI and software to monitor their calls.

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

This article was originally published on CalMatters and was republished under the Creative Commons Attribution-NonCommercial-NoDerivatives license.

By Annie Sciacca, KFF Health News

California public school teacher Mollie Blustein planned her pregnancy so that her daughter would arrive during summer break. But when the elementary school teacher went into premature labor and delivered her baby two weeks before the end of school, she faced another stressor: a huge pay cut.

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

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

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

It’s a reversal for Newsom in his final year in office. In 2019, the governor vetoed a bill that would have given school employees at least six weeks of paid leave, and he did not publicly support a similar Assembly bill that died on the Senate floor in 2024. Several analysts said the issue appeals to voters on both sides of the aisle, ahead of Newsom’s potential 2028 presidential run.

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

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

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

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

In 2019, President Donald Trump signed into law a bill that gave federal workers 12 weeks of paid leave. But Shabo said the current administration hasn’t made any moves to expand paid leave.

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

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

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

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

The proposal would close a gap that many Californians don’t realize exists. The state was one of the first to offer paid family leave — under its current program, eligible workers get up to 90% of their pay for up to 20 weeks of combined leave and disability benefits.

But most California teachers, 72% of whom are women, are shut out. The program is funded through a payroll deduction for state disability insurance, and public agencies are exempt from it. Districts can opt in, but the move must be bargained collectively, as recently happened in the Los Angeles Unified School District.

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

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

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

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

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

SACRAMENTO, Calif. — Sen. John Kennedy of Louisiana is taking aim at California’s Medicaid program for providing housing assistance, food, and other social services to high-need, low-income patients who tend to rack up big healthcare costs and, he argued, strain taxpayer funds.

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

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

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

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

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

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

The Medicaid fight is putting patients in limbo.

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

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

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

Lucy Rodriguez, an enrollee in California’s Medicaid program, known as Medi-Cal, has benefited from social services the program covers, including a care manager who helps her manage her diabetes and kidney diseaseAngela Hart/KFF Health News

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

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

In a further escalation, the Justice Department put out a recent memo allowing states to institutionalize people with disabilities and severe mental illness instead of providing community-based care. Republicans have also targeted states, mostly blue ones, for what they say is a failure to go after waste, fraud, and abuse in Medicaid. In May, CMS Administrator Mehmet Oz stood alongside JD Vance as the vice president announced the deferral of $1.3 billion in Medicaid money to California over suspicions of fraud.

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

Social healthcare

Health policy researchers say roughly 80% of health outcomes are linked to socioeconomic, environmental, and behavioral factors, such as housing instability, homelessness, food insecurity, and exposure to violence, whereas 20% is associated with medical care delivered in hospitals and clinics. That evidence fueled the Biden administration’s efforts to tackle social services.

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

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

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

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

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

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

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

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

Rodriguez tests her blood sugar to help manage her diabetes. Conservatives say that spending healthcare funds on nontraditional services such as housing and nutrition assistance is inappropriate, but liberals say it saves money in the long run.Angela Hart/KFF Health News

New front in healthcare

California offers most of its health-related social services under Biden-era waivers within Medi-Cal, which has a proposed budget of $217 billion. Although there are more than 14 million residents on Medi-Cal, the state has been selective about who gets help from 15 types of social services in its program, called California Advancing and Innovating Medi-Cal, or CalAIM. Patients with complex needs can also receive help navigating their health and social needs from specialized social workers under a benefit known as enhanced care management.

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

CalAIM had provided social services to more than 528,000 patients as of September 2025, the most recent state data available. And nearly 453,000 low-income Californians have received intensive case management. Some patients receive both services.

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

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

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

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

In Orange County, officials with CalOptima Health credited CalAIM housing services for contributing to a nearly 27% drop in unsheltered homelessness. “We’ve been able to expand our street medicine programs, too,” said Yunkyung Kim, the insurer’s chief operating officer.

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

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

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

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

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

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

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

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

Cuts on the horizon

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

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

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

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

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

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

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

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

This story was originally published by CalMatters. Sign up for their newsletters.

Kaiser Permanente nurses who answer advice and triage calls say their duty of care for patients is being increasingly threatened by workplace surveillance.

Seven current and former nurses told CalMatters that those who spend more than 15 minutes on a call with a patient routinely face criticism from Kaiser management or get called into performance evaluation meetings. Call time, they said, factors into monthly performance scores they receive.

In addition to tracking call length, they said Kaiser uses software that tries to predict on a daily basis whether they’re being unproductive or failing to answer calls quickly. Artificial intelligence systems have also been used to rate their empathy and tone of voice.

Their comments come as the California Nurses Association begins negotiating a new contract with Kaiser this month with AI a likely issue. Kaiser nurses went on strike against AI for one day in March and picketed against AI last fall. The CNA is bargaining for 25,000 nurses, including 1,000 in call centers. 

At the same time, California lawmakers are considering several bills regulating AI in the workplace, including one that would protect from retaliation doctors and nurses who override automated care recommendations.

Kaiser defended its use of AI, saying it deploys the technology with patient safety in mind and does not use “average handle time” to assess performance.

Kaiser Permanente is the largest private employer in California, providing healthcare services to more than 9 million people in the state and to 3 million other Americans. That means the company’s use of artificial intelligence could set important precedents for managing workers with AI. It could also have a big impact on patient care, providing an early example of how the healthcare sector balances cost-cutting automation with human presence or touch.

Raquel Alvarez Sanchez, a Kaiser Permanente advice nurse in Vallejo since 2010, said she was on a call with a patient who was suicidal last year that took more than an hour because she had to wait for police to arrive before hanging up. She tried to make the man feel cared for, even though she was cognizant that staying on the call that long would throw off her average call time for weeks and could lead to questions from management. Sanchez, a union steward, said she’s accompanied colleagues to performance evaluation meetings, where they were found to have done everything right on a call — except staying on the line for more than 15 minutes. She said she hasn’t seen nurses get fired for doing that, but she fears that continued pressure can lead nurses to quit or retire early.

“I think at some point all of the nurses have been talked to about their average handle time,” she said. “The only thing I can think of is they’re doing it for profit.”

Another nurse who spoke with CalMatters on condition of anonymity due to fear of retribution described how that surveillance affected a call with a patient last year. Initially she thought her patient, an elderly woman who just received a terminal cancer diagnosis, was suicidal, but quickly came to understand that she was in shock and really needed somebody to talk to.

The nurse wanted to take time to show compassion or comfort to the woman, who acts as a caretaker for her daughter, but she stopped herself out of fear it would hurt her monthly performance score and lead to a reprimand from her manager. She became a nurse to provide people with compassionate care, but “I had to ask myself: Am I going to get disciplined for going off script or saying more than what is necessary?”

Kaiser Permanente advice nurse Raquel Alvarez Sanchez works from her home office in Santa Rosa on April 6, 2026. Kaiser Permanente nurses have raised concerns about the growing use of AI to monitor their work ahead of upcoming contract negotiations.Chad Surmick/CalMatters

Kaiser Permanente says its performance evaluations help improve patient outcomes. A company spokesperson said, “Kaiser Permanente does not use Average Handle Time to assess agent performance or enforce call time metrics. Any tools used in contact center settings support our quality assurance efforts and have human review and oversight.” In a statement provided to CalMatters, spokesperson Vincent Staupe added that Kaiser uses AI responsibly, with human oversight, and by “prioritizing patient safety, privacy, and equity,” but he said, “As a large organization, we do not share specific information about internal technology systems for security and operational reasons.”

Is technology putting patients at risk?

It’s not clear how patient care is affected by algorithmic management, nor is the impact of limiting the length of triage and advice calls on patients. Kaiser call center nurses can’t say for certain whether the pressures they face results in adverse outcomes for patients because their contact with patients ends after they hang up the phone. A 2024 public records request by CalMatters to the California Department of Managed Health Care found no complaints by patients against Kaiser related to call times. But nurses insist the risk to patient safety and quality of care is real. 

Consumer Watchdog patient advocate Michele Ramos said many Kaiser patients begin their care on the advice line. They later complain to her, mostly about things that happen in Kaiser facilities, but “I can see now where a lot of the problems” start, given the call constraints nurses are under. 

Ramos said the time pressures may fit a broader pattern at Kaiser of putting costs over quality. The health giant was hit with a record fine, $50 million, as part of a settlement over findings from the California Department of Managed Health Care that it delayed behavioral health appointments beyond statutory limits and too often moved patients into group rather than individual therapy. Kaiser also settled with the U.S. Department of Labor after investigations into its substance use and mental health services. Kaiser faced criticism in 2002 for paying bonuses to call center workers who aren’t nurses for keeping calls short, though call center nurses who spoke with CalMatters said they encountered no such practices today.

“Kaiser’s been known through the years to manage dollars over managing care, and I think this would be a contributor to that, which is only going to fail patients,” Ramos added.

Nurses said they are pressured to stay under 15 minutes even for the sorts of calls that often take more time, like diagnosing a patient with multiple symptoms, chronic illnesses, new parents in need of advice and assurance, people who desire extended health education, or people who are overwhelmed after receiving life-altering news who could use some compassion. Nurses say calls that involve interpreters often take 30 minutes or more. About four in 10 Californians speak a language other than English and half of them do not speak English well, according to a state environmental health agency.

“The amount of time that Kaiser is giving us to complete a call is sometimes not safe,” said one nurse, who asked to remain anonymous due to fear of retaliation.

“People can get hurt,” said Charlotte Capulong, who has worked in nurse call centers for 22 years and helped organize Kaiser nurses against the AI tone-of-voice tool. Capulong said nurses felt harassed by managers in meetings she attended as a union rep, even if they successfully carried out all other duties of their jobs except completing calls within 15 minutes.

“You aren’t calling Comcast. We’re dealing with life here,” she said.

Kaiser Permanente Sacramento Medical Center in Sacramento on Monday, Aug. 15, 2022. More than 2,000 mental health physicians went on strike throughout Northern California over staffing issues leading to patients waiting longer to access help.Rahul Lal/CalMatters

Nurses are instructed to stick to a script on phone calls and give no more than two to three pieces of advice, Capulong and other nurses said, which means they may sometimes need to decide whether to withhold advice or face a performance evaluation hearing.

The nurses say artificial intelligence could make the surveillance nurses encounter on the job worse.

In summer 2024, Kaiser began testing an AI tool that attempts to assess empathy and tone in the voices of nurses and patients, according to nurses who spoke with CalMatters. In response, nurses circulated and signed a petition in favor of the right to patient privacy, more transparency,  and the right to exercise their professional judgement and encouraged management to involve nurse’s input and feedback. The signature campaign used the same tag line that nurses used at protests outside San Francisco hospitals earlier that year: “Trust nurses, not AI. The AI tests ended in November 2024, but union representatives were told that managers may bring the program back in the future. 

Nurses reported feeling harassed by existing surveillance, “and that was intensified when they said we’re going to use AI to evaluate our calls and grade us,” said Sanchez.

Another nurse speaking on condition of anonymity said “AI did not understand our job and would grade us wrong all the time.”

A Kaiser spokesperson declined to respond to questions about the AI tool or answer questions about the use of AI and other automated systems in the company’s call centers and healthcare facilities, including for evaluating nurse performance or whether patients were informed about the use of AI to evaluate their empathy and tone.

Nurses also said they get little time between calls even if that call involves speaking with a patient who is suicidal, experiencing a mental health episode, or near death. In years past, nurses got around 10 minutes to finish writing notes in a patient’s chart or collect themselves after a particularly tough call. Today they say they typically get 30 seconds or less when lines are busy, although more at slow times, like late at night, or if they get a manager’s permission after a particularly challenging call. The overall pace they say, can lead to mistakes like missing important cues into a patient’s wellbeing.

CNA reps declined to talk about specific provisions they intend to seek related to AI ahead of their talks with Kaiser this summer.

How surveillance and AI shape nursing

Critics say excessive workplace monitoring can lead to lower morale as employees feel less trusted and autonomous, relegated to being no more than algorithm monitors. UC Berkeley Labor Center Technology and Work Program director Annette Bernhardt has warned that algorithmic management can turn people into fleshy robots, echoing complaints from an Amazon factory worker who CalMatters interviewed last year. A 2023 academic survey of call centers in four developed countries found that using AI for management or monitoring left workers with less time between calls and more likely to feel emotionally drained by their work. Nearly half of respondents said that AI tools made their jobs more stressful. A prior study by the same researchers, Virginia Dolleghast of Cornell University and Sean O’Brady of McMaster University found that performance monitoring leads to higher rates of emotional exhaustion.

Dolleghast, who has studied the impact of surveillance technology on call center workers for more than a decade, said what Kaiser call center nurses are experiencing is part of a broader trend: Across different industries, persistent surveillance is increasing stress levels for workers who are resolving complex, emotionally-charged issues. 

“Stress and burnout can lead to more mistakes across a range of areas, and in the healthcare setting that is much higher risk because you’re dealing with people’s lives and their health,” she said.

The converse can be true: Workers who are given more discretion to decide the pace and timing of their work experience higher levels of job satisfaction and less absenteeism.

The 9-1-1 call center at the San Francisco Department of Emergency Management in San Francisco, on Aug. 2, 2019.Eric Risberg/AP Photo

Nurses nationwide are more frequently encountering artificial intelligence and similar software systems in the workplace. Half of more than 2,000 nurses who responded to a 2024 survey by the National Nurses United union said their employer uses algorithmic systems to analyze health records. Such systems can do things like determine how fragile a patient is or predict how many hours of care they will need. Two-thirds of the surveyed nurses said their own assessments had at some point disagreed with a computer-generated prediction. Six out of 10 respondents said they don’t trust their employer to prioritize patient safety when using AI.

Pa Vue has worked as a nurse in call centers for the better part of the past decade. She said she and other Kaiser nurses routinely have conversations with managers about call efficiency and receive evaluation scores once a month. She recalls having a score reduced for repeating advice to a patient that she worried had unusual symptoms and possible heart issues.

As a union representative in some performance meetings, Vue has seen managers raise efficiency questions about calls they deem too long. She’s also seen nurses receive lower performance scores if they go against software recommendations based on their professional opinion or make an appointment for a patient without consulting a doctor.

She believes that efficiency aims accelerated by technology can hinder a nurse’s ability to focus and reduce the quality of care that patients pay for.

“I’m not against the use of AI as long as it’s beneficial to the patient but in this particular use [empathy and tone monitoring] it’s to increase productivity and improve efficiency and cut costs. Kaiser is forgetting we aren’t just a call center for customer support, we’re nurses, and we’re there to take care of patients,” she said.

As AI improves and businesses push workers to use it, unions are, in turn, increasingly demanding that employers address issues raised by AI when bargaining for new contracts. Surveillance technology has become a common way for managers to collect data about workers in a number of industries, used for everything from improving safety to hunting for ways to increase profit gains or train AI to do a job.

At Kaiser, AI is a key issue not only among nurses but also for mental health workers, 2,400 of whom are in contract negotiations in Northern California with Kaiser Permanente. Kaiser therapists have said they are concerned about use of therapy session transcripts to train AI models and about the health-care giant using AI to take their jobs. National Union of Healthcare Workers spokesperson Matt Artz told CalMatters contract negotiations are ongoing.

How Kaiser uses AI

Kaiser Permanente is exploring or using AI in many parts of the healthcare experience far beyond nurse call centers. Kaiser uses AI to identify patients in hospitals at risk of adverse events by evaluating data on their electronic health records. An AI system called Preventus is used to determine when to discharge patients. Doctors and therapists use Abridge to record interactions and translate speech to text during in-person visits with patients instead of taking notes. Remote monitoring with AI for patients that need extra care has been tested at Kaiser Permanente facilities in the Bay Area, according to nurses who encountered the technology in the course of doing their jobs.

National Nurses United and CNA President Cathy Kennedy sees the use of AI to detect nurse empathy as part of a long series of steps by Kaiser to limit their autonomy and make them more efficient. She believes AI threatens to automate and fragment the work that nurses do, and companies developing and deploying AI systems should establish that those systems are effective and equitable before deploying them.

Kaiser Permanente in Oakland on Aug. 2, 2022.Martin do Nascimento/CalMatters

Notification of new tech deployments is part of the nurse union’s contract with Kaiser but sometimes nurses don’t receive notification, CNA says. So union leaders are attempting to track the number of AI models in use at Kaiser Permanente, advising its members to inform them when they encounter new tech. This paves the way for CNA to push back as it did with the empathy and tone AI last summer or as it did when it stopped a pilot program that would have replaced nurses that sit at the bedside of confused patients with cameras.

Debru Carthan, a Kaiser radiologist, is on the front line of worker-management fights over AI at the company. A member of Service Employees International Union, she is also part of the Coalition of Kaiser Permanente Unions, where she sits on a committee to discuss use of AI and emerging technology at Kaiser. The coalition also has a “see something, say something,” campaign for frontline workers to report when they notice AI deployments; the coalition says that too often management quietly implements AI into workflows without notice or worker input. She worries that the AI tone detector used on advice nurses could discriminate against nurses from different cultures and has come to believe that the use of AI in healthcare generally has more to do with money and corporate greed than patient care.

California lawmakers have responded to worker AI concerns both inside and outside the healthcare sector. They tried and failed last year to address how AI impacts workers like call center nurses. Assembly Bill 1018 and Senate Bill 7, two bills endorsed by the CNA, would have required employers to inform workers before using automated systems on the job to do things like promote or discipline workers or evaluate job performance, but Gov. Gavin Newsom vetoed SB 7, and, facing strong opposition from companies including Kaiser Permanente, AB 1018 failed to pass for the third consecutive year. 

Earlier this year, lawmakers reintroduced a new version of Senate Bill 7, now called Senate Bill 947. Another bill would prohibit employers using AI to predict the emotional state of their employees. Yet another bill would protect doctors and nurses from retaliation if they override recommendations generated by an automated system and require healthcare providers to supply employees with an inventory of automated systems once a year. Kaiser declined to share a comprehensive list of AI systems in use when asked by CalMatters.

Altogether CNA and the affiliated California Labor Federation support roughly half a dozen bills to regulate use of AI in the workplace. Calling AI a central issue in the next presidential election, members of the California Labor Federation and labor leaders from Democratic primary states held a press conference in Sacramento earlier this year to say that if Newsom wants to become president then he needs to pass laws protecting workers from AI. “It’s an ongoing fight, and it’s a fight well worth having,” Kennedy said. “Whenever there are other unions in discussion about artificial intelligence we are in solidarity with them.”

The nurse that withheld compassion to a terminal cancer patient she thought was suicidal said she believes monitoring and scoring systems turn nurses into automatons that check boxes.

“I used to use humor as a way to help patients heal, and I don’t feel comfortable doing that here because I know the calls are being recorded. You can always tell when a patient appreciates the humor or your personal compassion, but I don’t feel like call centers have tolerance for that because that’s not part of the script,” she said. “That really takes away from the whole point of being a nurse and what patients come to know from nurses.”

This story was reported with contributions from Lam Thuy Vo and Ana Ibarra.

Update 2 p.m. Friday July 10.

The California Department of Education (CDE) building in Sacramento will get a full treatment for bed bugs at the request of State Superintendent Tony Thurmond following over a month of complaints from employees.

Deputy Superintendent of Public Instruction Abel Guillén sent an email to CDE staff July 9 at 3:36 p.m confirming the Department of General Services (DGS), which manages the building, has agreed to a full pest control treatment to  “ensure that any infestations are eradicated.”

DGS has contracted EagleShield, which had only recommended a localized treatment, to begin treating the full building as soon as Friday, July 10. 

“The treatment process is anticipated to take approximately one day per floor, and the entire building will need to be vacated during treatment,” the email read.

Another independent pest control vendor, All Day West, has been contracted to do additional inspections and treatment recommendations. Both vendors will utilize a variety of inspection methods including dogs which have already indicated more treatment is needed. 

In the email, Guillén noted to staff additional treatments would not guarantee bed bugs from being reintroduced in the future. Employees are expected to work remotely until July 27 at the earliest. 

Original story:

Bed bugs continue to be a problem for employees at the California Department of Education (CDE) who say the building at 1430 N St. in Sacramento has been infested.

“I saw with my own eyes at least 50 bugs,” said Gina Garcia-Smith, an education programs consultant at CDE. 

Garcia-Smith said what began as an isolated incident in one area of the building has now spread to multiple floors, causing widespread anxiety about working conditions among staff, forcing them to work entirely remotely until at least July 13. It comes as state workers are beginning to return to the office following Governor Gavin Newsom’s mandate, which has been met with intense pushback.

The department isn't under the RTO mandate and is still hybrid, coming into the office only two days a week. But a recent bill pushed through the legislature placing CDE under the Governor’s control could change that, potentially exposing more workers.

“When you are a leader, you have a responsibility to make sure that your employees are safe in the office and not be on their hands and knees with a flashlight,” Garcia-Smith said. 

Service Employees International Union Local 1000 (SEIU), which represents 96,000 state workers, released a statement saying exposure to bed bugs risks workers having to replace their belongings or pay out of pocket to fumigate their own homes.

“California's affordability crisis is already crushing state workers, and now unsafe worksites threaten to pile on more unexpected costs,” said Anica Walls, SEIU Local 1000 President.

In a statement to CapRadio, the Department of General Services (DGS), which manages the building, acknowledged the presence of bed bugs but denied there was an infestation.

“When DGS was notified of the presence of bedbugs at the building, we acted immediately,” the statement said. “The building was closed to allow for a thorough inspection and implementation of industry standards by subject matter experts that help with the eradication of the bed bugs. All areas were inspected, and areas were treated as recommended by the subject matter experts.”

On June 3, two bed bugs were seen in an employee’s cubicle on the third floor. CDE leadership was immediately notified, according to Garcia-Smith. 

An internal email was sent later that day asking all employees to work remotely for the rest of the day out of an abundance of caution “given the past history of the building.” The CDE headquarters had previously been the site of a possible infestation back in 2024.

The next day on June 4, staff were informed by DGS that a contracted pest control inspector determined that “no bed bug activity was detected” but a deep cleaning would be done, and the situation would continue to be monitored.

But on June 23, more bed bugs were spotted in a conference room, the same location as the previous sightings back in 2024. Garcia-Smith said it was 15 ft from where the two bugs had been seen weeks prior.

“[Employees] moved the table and pulled up the cord cover and bugs just scattered. Swarms. It was disturbing,” Garcia-Smith said. 

Garcia-Smith described the bugs as a reddish-brown color and “plump.”

“These are bed bugs that have been eating the human blood of my colleagues who have unknowingly been sitting in these chairs, in meetings, and being bitten,” Garcia-Smith said. 

Emily Ingram, an education programs consultant at CDE, said working in a building with bed bugs has taken a toll on everyone’s psyche.

“It kind of gets to your head a bit,” Ingram said. “You start to worry that maybe during the two weeks in June that they told us we had to come back to the office two days a week and that everything was all clear. Well, clearly it wasn't, so did I bring something home during that time?”

The union SEIU Local 1000 filed a formal complaint and State Superintendent Tony Thurmond sent a request to DGS to treat the entire building which hasn’t been done. Ingram and Garcia-Smith said they felt disrespected and betrayed that they are being allowed to work in this environment while DGS “refuses” to treat the building.

DGS stated their pest management consultants didn’t recommend treating the whole building after inspection. 

“Bedbugs are generally pesticide resistant, there is no way to simply spray/fumigate a building – the methods used to treat an office building are more complicated,” DGS said. "We are working with the Department of Education on next steps."

While DGS denies bed bugs are present in other state buildings, workers have highlighted multiple agencies that have other hazardous conditions including the presence of legionella bacteria in the tap water, asbestos, and rats, according to the union.

In 2024, CalMatters reported legionella bacteria, which can lead to pneumonia and cause Legionnaires Disease, had been found in 37 buildings since it began testing in June 2022

“State workers keep California working, and they never should have been forced into offices with unsafe or unsanitary conditions in the first place,” Walls said.

This story was originally published by CalMatters. Sign up for their newsletters.

Community college students in California could gain access to medication abortion through campus health centers under a proposal that would extend reproductive health services already required at the state’s public universities.

Assembly Bill 2540 would require community colleges with student health centers to offer access to medication abortion beginning in 2029, if the Legislature provides funding. The bill builds on Senate Bill 24, a 2019 law that requires University of California and California State University student health centers to provide medication abortion beginning in 2023.

Supporters say the bill would close an access gap for community college students who may face transportation, cost, privacy or insurance barriers when care is only available off campus. But campus health center directors warn that many community colleges may not have the funding, staffing or clinical capacity to provide the service.

Authored by Assemblymember Catherine Stefani, a Democrat from San Francisco, the bill would apply to community colleges with student health centers — estimated at roughly 92 campuses statewide. If the Legislature provides funding, those campuses would have to offer access to abortion by medication techniques beginning in 2029.

“We are closing a critical gap by ensuring that community college students, one of the most diverse and economically vulnerable populations in our state, have the same access to care as their peers at four-year institutions,” Stefani told lawmakers during an Assembly Health Committee hearing in April. 

The bill would also require all campuses to promote awareness of the service, provide information to students and post availability online. The awareness requirement would extend to universities, which were not compelled to publicize medication abortion services under the previous law. 

Community colleges fill healthcare gap for students

“Healthcare is a basic need for any human,” said Stephanie Goldman, executive director of the Faculty Association of California Community Colleges, a statewide advocacy organization that represents community college faculty and supports AB 2540. “And of course, abortion access and abortion is a healthcare issue.”

Goldman said community colleges increasingly operate under a “whole student” model that goes beyond academics to include food access, housing support, childcare, mental health and healthcare services. Reproductive healthcare access can directly affect whether students are able to remain focused on school, she said.

“It’s helpful that they understand that they have this kind of healthcare on campus and available to them, should they need it,” Goldman said.

Mifepristone and misoprostol at a Wyoming abortion clinic in Casper on March 10, 2025.Natalie Behring/Getty Images

Student leaders backing the bill say community college students often face challenges accessing reproductive healthcare outside campus systems, particularly in rural areas.

“Where you go to school should not determine what access you get just because you went to a community college system versus a four-year system,” said Alisha Nagpal, a student at Folsom Lake College who serves as vice president of legislative affairs for the Student Senate for California Community Colleges.

Nagpal said some community college students live hours away from providers, lack transportation or may not know what health services already exist on campus. She pointed to online-only students, low-income students and undocumented students as groups that may face additional barriers obtaining reproductive healthcare off campus.

Community college health centers vary in size and services

But while supporters frame the bill as a matter of equal access, health center directors say implementing the proposal statewide may be far more complicated than applying the UC and Cal State models.

According to the Assembly Appropriations Committee analysis, the community college health centers “vary widely in structure and capacity, with many operating under limited staffing models or contracting services out to community providers and hospitals.”

The Health Services Association of California Community Colleges, which represents student health programs across the system, opposes the bill. In an April 15 letter to lawmakers, the organization said many community college health centers do not prescribe medication, nor do they have sufficient staffing or the infrastructure needed to provide medication abortion onsite.

Michelle Barkley, president of the association and a nurse at Cosumnes River College, said many community college health centers function more as public health entry points than full-service clinics.

“Some of our campuses have 5,000 students,” Barkley said. “Their health center is run by a single registered nurse.”

Barkley said many campuses currently rely on referrals to outside providers rather than onsite reproductive healthcare services. 

Funding may be a challenge

The bill’s projected cost has become a key point of disagreement between supporters and community college health center directors.

The California Community Colleges Chancellor’s Office estimates implementing the bill could cost between $7 million and $27.9 million in one-time startup costs across all 93 community college health centers, plus between $5.6 million and $9.3 million annually to maintain services. Those estimates are not limited to the cost of medication. The appropriations analysis says the expenses could include staffing, training, equipment, telehealth services, billing support and other infrastructure needed for campuses to provide or coordinate care.

Community college health centers may be partially funded through student health fees, though not all campuses charge them. The analysis said most campuses charge an average health fee of about $23 per academic term. The California Community Colleges Chancellor’s Office lists the 2025-26 maximum health services fee at $27 per semester and $22 for summer, intersession or quarter terms.

Supporters of the bill argue the projected costs may overstate the financial burden. According to the committee analysis, Stefani’s office argues medication abortion services could become financially sustainable through Medi-Cal reimbursement, private insurance billing, third-party vendors and telehealth partnerships.

Nagpal pointed to language making the bill contingent on legislative funding, saying community colleges would not be expected to implement the requirement without state support.

“If funding is not provided at community college campuses, there’s no legal expectation for (community colleges) to provide the service,” Nagpal said.

The bill was put on hold in the Assembly Appropriations Committee on May 6 because of its potential cost. On May 14, the committee advanced the bill on an 11-4 vote after making amendments.

The amendments changed how the bill would apply to community colleges. Earlier language would have required community colleges with student health centers to offer medication abortion onsite, but the amended bill now says campuses must “offer access” to the service beginning in 2029. The bill still allows care to be provided by campus staff, through telehealth or through contracted external agencies, but it now also includes partnerships with community health providers “as appropriate.”

The amendments also broadened what colleges would report to the state, allowing campuses to count services provided through outside healthcare providers instead of only those performed at campus health centers. 

AB 2540 was referred to the Senate Health and Education committees on June 10. After additional amendments, the bill was re-referred July 2 to the Senate Appropriations Committee, where lawmakers will review its fiscal impact.

The latest amendments further define how community colleges could comply, including through referrals, “warm handoffs,” written partnerships with licensed providers or a statewide provider agreement through the Chancellor’s Office. They also clarify that state funding could support costs such as telehealth, staffing, training, billing support, outreach and reporting.

Andrea Baltodano is a contributor with the College Journalism Network, a collaboration between CalMatters and student journalists from across California. CalMatters higher education coverage is supported by a grant from the College Futures Foundation.

Angel Foster had a backup plan.

It was the first weekend in May. A federal appeals court had just made it illegal to mail mifepristone, a pill that’s part of the most widely used abortion method in the U.S.

But Foster, a doctor who specializes in reproductive health, was prepared. As leader of the Massachusetts Medication Abortion Access Project, which ships abortion pills to some 3,500 patients a month nationwide, including in states with abortion bans, she told patients they had three options.

They could get a refund. They could wait to see if the legal situation changed. Or she could ship them only misoprostol — a second drug already used in most medication abortions. Combined, mifepristone and misoprostol are considered the “gold standard.” Misoprostol can be taken alone to induce an abortion, but some studies have suggested it’s less effective, Foster warned patients. Plus, it can make the process longer and more painful, with more side effects, such as nausea and vomiting.

Still, the vast majority of patients said the same thing: Just send it.

“They didn’t care,” Foster said. “Their response was: ‘Whatever can get to me the fastest.’”

Two developments often get lost in the public’s perception of the abortion wars. One is that the number of abortions in the U.S. has increased dramatically year over year since the Supreme Court overturned Roe v. Wade in 2022, according to the Society of Family Planning’s latest #WeCount report. By December, 29% of abortions were through telehealth. The second is that, because the mailing of abortion pills has become so widespread in the post-Dobbs era, abortion opponents may simply be unable to stop it.

Massive legal battles are being waged by states with abortion bans, seeking to block the shipment of mifepristone across their borders. In a suit brought by Louisiana, the U.S. Supreme Court recently restored telehealth access to mifepristone while a lower court hears the case. And abortion opponents continue their push to get the Trump administration to crack down on the pills’ availability, either through a Food and Drug Administration safety review or more drastic measures.

But many telehealth experts who help patients get abortions aren’t too worried.

“We like to say the genie is out of the bottle,” said Elisa Wells, who co-founded and is the access director at Plan C, which provides information about accessing abortion pills online.

“Now that people know that they can get safe, fast, effective, affordable care through the mail, there's no going back,” Wells said.

If mifepristone is restricted, many telehealth groups will immediately switch to using only misoprostol instead, they say.

Misoprostol is approved by the FDA to treat ulcers and is also widely used off-label to manage miscarriages, induce labor, and end pregnancies. And while states could individually ban misoprostol, the FDA doesn’t typically regulate how a drug is used off-label, according to David Cohen, a law professor at Drexel University and national expert on abortion law.

“There would have to be some finding that it is not safe or effective for ulcer treatment, something that there’s no argument anyone could possibly show,” Cohen said.

Some telehealth companies already used that alternative back in 2021, when the Supreme Court temporarily reinstated a requirement that mifepristone be dispensed in person. Carafem, a company that provides telehealth abortion, switched to using only misoprostol during that period “and has been prepared for this possibility ever since,” said Melissa Grant, a co-founder of the company and its chief operating officer.

Other organizations are already directing patients to mifepristone from outside the U.S., through groups such as Aid Access and online pharmacies in places like India.

Even if the Trump administration tried to enforce the Comstock Act, an 1873 law that bans the mailing of obscene matter and anything intended to produce an abortion, it would be extremely difficult to stop the flow of pills, Cohen said.

“We’ve had the ‘War on Drugs’ for what, half a century, maybe longer?” he said. “And everyone, if they wanted, could find illegal drugs within minutes, and have it probably delivered to their doorstep within hours.”

Abortion pills were called “the single greatest threat to unborn children in a post-Roe world” in the Project 2025 blueprint for the second Trump administration produced by the conservative Heritage Foundation, and abortion opponents are increasingly vocal about their frustration with the Trump administration over them.

“People's patience is at an end on this point,” said Kristi Hamrick, vice president of media and policy for Students for Life of America. The group recently met with the Department of Justice to discuss priorities of the anti-abortion movement, such as enforcement of the Comstock Act.

The ability to use telehealth to circumvent state abortion bans is a key target of Louisiana’s lawsuit, which a federal appeals court is currently weighing. The suit, which has the backing of 21 other states, argues that the FDA under the Biden administration acted illegally when it allowed mifepristone to be prescribed without an in-person visit to a doctor. Without that change, “activists in New York and California could not blanket pro-life states like Louisiana with mifepristone by mail,” the suit argues.

But because medication abortion is now the most common form of abortion in the U.S., restricting mifepristone would have a wide impact even in states without abortion bans.

“Stopping the FDA’s unlawful mail-order mifepristone scheme will surely decrease the number of chemical abortions across the country,” said Gabriella McIntyre, a lawyer for Alliance Defending Freedom, which partnered with Louisiana in its suit.

And there are signs the administration may be feeling the pressure, even if it’s tempered by worries that further abortion restrictions could hurt Republicans in this fall’s midterm elections.

For one, it looks like the FDA’s safety evaluation of mifepristone — which abortion opponents have long pushed for — may be moving forward, potentially allowing the administration to restrict the drug’s use. It’s too soon to tell, said Hamrick, who refers to the long-promised evaluation as a “unicorn.”

“It feels mythical,” she said. “I look forward to seeing it. But it’s taking too long.”

And if mifepristone is restricted and providers switch to misoprostol-only regimens, abortion opponents say they're ready to highlight the risks.

“We call it the new coat hanger,” said Hamrick. Providers will prescribe it, she said, “knowing it fails more often, knowing that the complications are worse, because they're so committed to online distribution of pills for the purpose of abortion.”

Telehealth providers agree that patients need to be informed about what to expect with any medication abortion. “Our experience globally suggests that if you continue to give additional doses of misoprostol, you can get comparable success rates,” Foster said.

Foster said her practice didn’t have to mail patients the misoprostol-only packages that weekend in May because the Supreme Court put the lower court’s ruling on hold while the case plays out. But if needed, the pills would have gotten to patients, she said.

The group has seen a recent spike in demand, especially from patients in Louisiana. Foster thinks all the media coverage is reaching people who didn’t know they could get abortion pills online. “Maybe this is the first time you've been exposed to that,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

This story was originally published by CalMatters. Sign up for their newsletters.

Legislators this week approved a health tax bill meant to continue critical federal funding for the state’s Medicaid program, also known as Medi-Cal. Their approval comes despite warnings from health industry leaders that the tax, as designed, will raise premiums for privately insured Californians.

New federal rules are forcing the state to restructure its managed care organization tax, or MCO tax, which the state collects from health insurance plans that coordinate care for their members. California has been charging Medi-Cal insurance plans at a higher rate than private plans. The state’s newly-designed solution, Senate Bill 125, will lower the tax on Medi-Cal plans and raise the tax on private plans to the same level. If finalized by the governor, and accepted by the federal government, the new plan would shift more of the cost burden onto people who buy private insurance but bring in less revenue overall. 

Senate President Pro Tem Monique Limón, a Santa Barbara Democrat, told reporters earlier this week that there was no perfect plan for redesigning the tax and that the Senate still has concerns, but the proposal they voted through is one that would bring in money quickly. 

“We have as a Senate been very clear that we needed revenue … it was a matter of making a decision which we could troubleshoot given what is happening at the federal level,” Limón said.

As part of the tax and spending law Congress passed last summer, the federal government imposed new restrictions on provider taxes, including the one imposed on health plans. Under existing rules, California received almost $8 billion annually from this tax; the new limits mean the state will receive billions less. The Legislature’s plan tries to fill at least some of that gap.

The plan does not directly raise health insurance premiums. Instead it imposes a higher tax on private plans, which have said they’d pass the cost down to consumers.

The proposal would require all health plans, both public and private, to pay a monthly rate of $8.85 per enrollee – a total cost of about $1.5 billion a year for private plans. If health plans pass the entire tax to their members, Californians could see  about a 1.5% increase in their monthly premiums, according to the independent Legislative Analyst’s Office. That’s on top of the yearly premium rate increases that people see year to year. 

The California Association of Health Plans, the health insurance lobby, estimates this would translate to consumers paying about $100 more in premiums each year. That means a family of four could be looking at $400 more a year in health premiums. 

Charles Bacchi, president of the association, said health plans roll taxes and fees into the administrative portion of premiums. “That is just actuarial science,” he said. “So when you increase taxes on health plans and insurers, that is built into premium rates and the customer pays it.”

Affordability is key concern

The Legislature’s plan largely mirrors what Gov. Gavin Newsom and his Department of Finance proposed last month. Bacchi argues the state could have imposed a smaller tax to lessen the impact on plans and consumers. 

From left, David Webb talks to Christy McCurdy, a registered nurse, at Hope Clinic in San Jose on Dec. 2, 2019. The clinic provides assistance such as addiction treatment and monitoring chronic conditions to formerly homeless.Randy Vazquez/Bay Area News Group

The Department of Finance said it tried to balance affordability for privately insured patients with generating enough revenue to keep the safety net afloat amid federal funding cuts. The department settled on the $8.85 a month assessment because that  rate would generate $2.3 billion a year – roughly the amount that the state generated before 2023 to support Medi-Cal, said H.D. Palmer, a spokesperson for the Department of Finance.

Of that total, $2 billion would support existing Medi-Cal services, while roughly $300 million would fund previously established rate increases for providers delivering primary, maternal, and mental health care to enrollees, Palmer said. 

Some legislators continued to raise concerns late into the week. Sen. Akilah Weber Pierson, a San Diego Democrat, said she found the tax plan “extremely problematic” as she questioned the administration during a hearing Wednesday. “I am very uncomfortable with this proposal and the economic burden it will have on the families I serve as a Senator but also a physician.” She voted for the measure on Thursday.

Bacchi’s organization, along with physician groups and the California Hospital Association, urged legislators to reject the tax proposal as is.

“What makes this vote especially disappointing is that California leaders continue to talk about affordability as a top priority,” health plans said in a statement after the Assembly approved the measure. “It is difficult to reconcile those statements with a vote that will increase health insurance premiums on the very people policymakers say they are trying to help.”

Industry leaders also argued that the tax measure conflicts with Proposition 35, which voters passed in 2024 and which limits the taxes charged to private health plans. Prop. 35 also requires that much of the revenue be used to expand Medi-Cal services and increase provider rates, rather than offset general fund spending on the program. 

“Raising health insurance premiums to help balance the state budget is simply robbing Peter to pay Paul,” said Dr. René Bravo, president of the California Medical Association, which represents doctors around the state. “It will only make it harder for families to keep coverage and get the care they need.”

New federal rules prompt tax redesign

California is redesigning its MCO tax to comply with new federal rules implemented through H.R. 1, the spending plan Congress approved last year. California currently charges Medicaid plans, which are reimbursed jointly by the state and federal government, a significantly higher tax than private plans. The state then uses revenue from this tax to draw down matching federal funds. 

The Trump administration argues states “exploit” this funding mechanism by effectively pushing their share of Medicaid costs onto the federal government. Critics of the tax describe its “net effect” this way: Insurers remain financially whole, federal Medicaid spending increases, and states reduce their own costs.

To close what federal officials call a “loophole,” the Centers for Medicare and Medicaid Services issued a final rule earlier this year prohibiting states from taxing Medicaid plans more than commercial plans. Now that the legislature has approved California’s revised MCO tax plan, Newsom must sign the measure in order for the state to seek approval for it from the federal government.

Consumer advocates say that maintaining strong revenues from the MCO tax is key to keeping the Medi-Cal program running. But if the state knows that insurers will pass the cost onto private customers through higher premiums, California legislators should ensure the money remains within the health system and improves care. 

“What we don’t find acceptable is to have individual healthcare consumers pay increased premiums to support the MCO tax, and then just have that money backfill the general fund,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. 

Because the Legislature’s plan resembles the governor’s proposal, budget experts expect Newsom to sign it as part of the larger budget package. One major hurdle remains, however: federal approval. The Trump administration must approve the state’s revised tax plan for California to continue drawing down federal matching funds. 

The job of lawmakers is to put together a proposal that is compliant with new federal rules, said Adriana Ramos-Yamamoto, a senior policy fellow at the California Budget and Policy Center. 

But, she added, “it’s not a guarantee that the federal government will approve our new MCO tax proposal.”

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

By Kristen Hwang, CalMatters

A union wants California’s billionaires to rescue the state’s healthcare system. The billionaires have other ideas.

On June 17, an initiative to tax the state’s wealthiest residents qualified for the ballot, according to the secretary of state’s office, which verifies petition signatures.

Gov. Gavin Newsom, who has consistently swatted down the idea of tax increases throughout his tenure, emerged early as an opponent of the proposed tax. Wealthy allies in Silicon Valley joined the fray armed with deep pockets and threats to leave the state, which depends disproportionately on high earners for revenue.

The union funding the measure, Service Employees International Union-United Healthcare Workers West, says California needs the revenue that would be generated by the measure to rescue the healthcare system from deep cuts that the Trump administration made last year in the president’s tax reform package, known as the “One Big Beautiful Bill Act.”

Newsom is reportedly trying to negotiate a last-minute deal that would pull the initiative before the ballot is finalized on June 25.

What would it do?

The proposed initiative would levy a one-time 5% tax on California residents whose net worth exceeded $1 billion at the start of this year. The tax would hit roughly 200 people, and billionaires could pay in installments over five years. 

Proponents of the measure estimate it would generate $100 billion for the state. The revenue would go into a special fund with 90% reserved for healthcare spending and 10% for education and food assistance programs. 

The Legislature would control the funds and could allocate up to $25 billion annually to designated programs including Medi-Cal and CalFresh.

It needs a simple majority to pass. 

Who is supporting it?

The state’s largest healthcare workers union is bankrolling the measure, pouring more than $31 million into the campaign. “We are facing literally a collapse of our healthcare system here in California and elsewhere,” Dave Regan, president of SEIU-UHW, said in October when the campaign launched.

The union, which is known for wielding ballot measures aggressively, argues that federal healthcare cuts will result in hospital and clinic closures, worsened patient access and thousands of lost jobs if the state doesn’t step in to backfill tens of billions of federal dollars. The group also points out that the Trump tax breaks for income, businesses and investments disproportionately benefit the wealthy people who would then be subject to the proposed billionaire tax.

“Whether or not folks support this, they can’t deny that these massive cuts to healthcare are coming,” said union spokesperson Renée Saldaña. “Nobody else has a solution to fill this massive $100 billion funding gap that is facing California.”

Saldaña noted that people signing the initiative petition were supportive and sometimes wanted the tax to be continuous rather than one-time. 

“This is popular. The public is feeling the strain of their own healthcare costs,” she said.

The measure has won high-profile support from Vermont Sen. Bernie Sanders and former Secretary of Labor Robert Reich. A handful of local unions as well as the Teamsters and AFSCME California have also backed the measure.

Who is opposed to it?

Newsom is an unsurprising and vocal critic of the proposal. He has long argued that increased taxes would drive wealthy people and businesses out of the state. In a recent appearance on Real Time with Bill Maher, Newsom claimed that “we’ve already seen dozens and dozens of people leave the state.”

Google co-founder Sergey Brin, with a net worth of $300 billion, according to Forbes, reportedly moved to Nevada because of the tax threat. Brin, a one-time supporter of liberal causes turned Trump supporter, is also the biggest spender among opponents. As of June 15, he has contributed $82 million to Building a Better California, which is funding multiple countermeasures designed to invalidate or weaken the initiative should it pass. The committee has not, however, taken a position on the wealth tax.

The top two measures — the Retirement and Personal Savings Protection Act and the Improving Transparency, Effectiveness and Efficiency in California Government Act — will also likely appear on the November ballot. The retirement act would prohibit new state taxes on personal property, effectively canceling the billionaire tax if both measures pass. The transparency act would require audits of state programs funded by special taxes.

Other tech and industry titans, including Google CEO Eric Schmidt, worth $43.3 billion, Kleiner Perkins chairman John Doerr, worth $25 billion, and The Wonderful Company president Stewart Resnick, worth $5.4 billion, have donated millions of dollars to Brin’s committee.

Ripple Labs co-founder Chris Larsen, worth an estimated $12.4 billion, also started Golden State Promise, a political action committee dedicated to opposing the tax initiative directly. Venture capitalist Ron Conway, who does not appear on Forbes’ billionaires list, is funding a third group, Stop The Squeeze.

Collectively, the opposition campaigns have raised $107.9 million as of June 15, according to state campaign finance data.

Robert Lapsley, president of the California Business Roundtable, said one of the most concerning parts of the proposal is a provision allowing the Legislature to amend the tax after passage. “They can change the level of taxation; they can change how often they get taxed; they can keep ratcheting down the income level of who pays it.” The union disputes this claim.

Progressive groups like Planned Parenthood and the California Teachers Association have opposed the measure in recent weeks. Healthcare industry groups like the California Medical Association, California Primary Care Association and California Hospital Association also oppose it.

What’s really going on with healthcare?

The “One Big Beautiful Bill Act,” which Congress passed last year, enacts a number of sweeping changes to Medicaid, the health insurance program for low-income people and those with disabilities. 

Over time, experts say the changes will dramatically reduce the number of people with publicly funded insurance through mandates such as work requirements and shorter eligibility periods. The law also limits federal Medicaid spending. Because Medicaid programs draw on state and federal dollars, reductions in enrollment or federal spending mean less money for states like California.

The state Department of Health Care Services projected early on that federal cuts could cost California $30 billion annually. Roughly 14 million people rely on Medicaid, also known as Medi-Cal, in California.

State lawmakers have also grappled with successive budget deficits and ballooning program costs. Last year, Newsom and the Legislature limited Medi-Cal enrollment for low-income people without legal status. State leaders are eyeing additional cuts this year to align with new federal requirements.

Miranda Dietz, director of the Health Care Program at the UC Berkeley Labor Center, said close to 3 million Californians will lose healthcare over the next two years as a result of state and federal changes. 

“The need for health insurance and healthcare is not going anywhere,” Dietz said.

What are the challenges?

Should the measure pass, it will surely face legal challenges that could tie the potential revenue up for years, experts say. The seemingly retroactive nature of the tax invites a constitutional challenge, many say, though supporters reject those concerns. The initiative proposes taxing those who are California residents as of Jan. 1, 2026, meaning those who have since left the state would still owe it. 

Mark Peterson, a public policy professor at UCLA School of Law, said revenue from the initiative would “make a huge difference” in helping the state offset federal funding losses, but that’s only if the initiative survives legal challenges and efforts by billionaires to move or hide assets.

Economists and state budget watchers are also wary of the number of billionaires who have already left the state, taking their assets and businesses with them. Only six people moved out of state last year before the proposed tax would apply to them, but their collective worth would have generated the state $27 billion, Fortune reported. Others, including Meta CEO Mark Zuckerberg, worth $231 billion, have also reportedly moved out but not before Jan. 1.

On the other hand, there’s no evidence yet that a majority of the state’s 200 billionaires are leaving. Some, including former gubernatorial candidate and billionaire Tom Steyer, have stated they support the proposal.

Early polling shows 50% of voters favor the initiative, with most strongly behind it, according to the UC Berkeley Citrin Center for Public Opinion Research-POLITICO poll. But that is not as strong a position as it may seem: 54% of voters are concerned about wealthy individuals leaving the state, and 63% are concerned about them taking their businesses with them. A UC Berkeley Institute of Government Studies-Los Angeles Times poll from March showed similar division among voters with 52% in support. 

Generally, campaigns running ballot initiatives want their early polling numbers to be much higher because support nearly always dwindles as the election creeps closer. 

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

By Roxsy Lin, CalMatters

This story was originally published by CalMatters. Sign up for their newsletters.

This story was originally published by American Community Media.

In 2024, Kaiser Permanente announced the rollout of Abridge. Described in a press release as “ambient listening technology,” the AI-powered scribe is designed to help clinicians including mental health providers securely capture clinical notes during patient visits.

But what the description fails to indicate is that the tool records entire medical appointments, including deeply personal mental health sessions.

During these sessions, mental health professionals are required to obtain patients’ consent before using the tool. However, as shared by multiple providers, that consent process does not include explanations about how the information is handled. Nor does it say how long and where recordings are stored, or who has access to the data.

This happens in part because that information has not been shared with providers, despite their attempts to obtain it.

‘Empty assurances’

Ilana Marcucci-Morris chose not to use the platform with her patients. She is a licensed clinical social worker with Kaiser psychiatry in Oakland. She is also a member of a bargaining committee. In that role, she regularly meets with various Kaiser representatives, including Northern California’s director of mental health.

Marcucci-Morris describes how, during those meetings, she and other committee members have asked questions about patient privacy protections, HIPAA compliance, and the safeguards in place for the use of these technologies.

According to her, the response from leadership has often been empty assurances: “We are compliant. That’s it. That’s all you need to know. We vet the technology, therapist. Don’t worry. That’s not your job. We have tech experts. That’s their job,” Marcucci-Morris said in an interview with American Community Media.

“They won’t show us, right? And my feeling is, if you have nothing to hide and you’re doing it totally […] ethically, then you would show us, prove it. They can’t, and they won’t, and they declined to when we ask.”

Ligia Pacheco is a psychiatric social worker who provides remote therapy services for Kaiser patients in Southern California. She said Kaiser also refused her requests to provide further explanations.

In an interview with American Community Media, Pacheco recalled how a coworker once raised concerns to a supervisor. The response: that “it’s unprofessional for you to provide your personal beliefs on AI in our work setting.”

For Pacheco, “that leads to just low morale, no space to advocate for patients. We’re supposed to be the voice of patients who are coming in their most vulnerable state. And we can’t even be that voice for them, so we feel discouraged.”

'Patient after patient after patient'

Providers have been required to see more patients in recent years. That creates intense pressure to keep up with documentation and workloads, Marcucci-Morris highlighted.

“You’re just like seeing patient after patient after patient after patient with barely enough time to go to the bathroom, eat a snack […] get some fresh air,” she said.  

According to Marcucci-Morris, refusing to manage the increased patient volume can be treated as a failure to meet job expectations. It may also lead to disciplinary action.

As a union steward, she said she often represents colleagues during workplace investigations related to delayed documentation or difficulties managing heavy caseloads. In those situations, she said management frequently recommends the use of Abridge to save time and avoid further discipline.

In her view, the providers she knows who use the technology are not doing so because they support or trust it. Rather, it is because they feel pressured to protect their jobs and comply with workplace demands.

“I consider that to be coercive because you’re putting someone in a position to either lose their job or use the software. That’s another choice that’s under duress,” she explained.

Provider, patient concerns

Brian Hoberman is chief information officer for The Permanente Medical Group. In a Kaiser press release, he said, “Abridge’s advanced technology supports our doctors’ well-being by reducing the documentation burden.”

He added, “We implemented this new technology after careful review and diligent testing and found it to be well received by patients and doctors…”

For at least one patient interviewed for this story such assurances fall short.  

“I fear that this kind of information that’s being recorded now can get into the wrong hands,” said the patient, who asked not to be identified for privacy reasons. “I may not want my employers, I may not want my family members, I might not want people to know some of these very kind of intimate conversations and deep conversations I have with my doctors [and] with my mental health provider.”

Adriana Webb is a social worker at Kaiser Panorama City in Los Angeles. “I work with patients who have sensitive medical diagnoses, like […] HIV and AIDS, and a lot of times my patients don’t even want that in their chart.”

A spokesperson for Kaiser Permanente insisted in an emailed response to American Community Media that clinicians are required to gain patient consent prior to using Abridge. “No one is recorded without their knowledge and consent,” the statement read.

It added that recordings are stored for no longer than 14 days, and that data processing meets all HIPAA requirements as well as Kaiser Permanente’s own privacy and security standards.

“Abridge helps clinicians spend more time focused on patients and less time on administrative tasks,” it said.

Weaponizing mental health data

According to Nicole Alvarez, senior analyst for technology policy at the Center for American Progress, “a record of someone’s lowest moments can be used against them in ways that, you know, […] a high blood pressure reading cannot.”

She said mental health data can be especially sensitive because of the stigma surrounding mental health conditions. For patients, that stigma carries real-world consequences in areas such as employment, child custody cases, immigration matters, and security clearances. She emphasized that, like other forms of personal data, mental health information can be weaponized against individuals.

Agreements between health systems and AI vendors can vary widely, she said. This includes terms related to whether audio recordings or transcripts can be used to train AI models, whether patient data is de-identified, how long the data is retained, whether it can be shared with other clients, and what happens to the information once a contract ends.

Kaiser insists any data it collects is not used to train AI models.

Still, in Alvarez’ experience, patients often have little visibility into these arrangements. She argued that health systems have a responsibility to clearly disclose how patient information is being handled and used.

Alvarez also emphasized that, in most cases, patients have the right to refuse recordings. But, she said, the opt-out process is not always clearly presented. According to her, consent options may range from direct questions at check-in to language buried in intake paperwork, making it important for patients to carefully review forms and disclosures.

She said meaningful consent requires patients not only to know they are being recorded and that they can decline, but also to understand how their information may be stored, shared, or used afterward.

Coercive consent

Pacheco experienced this during a personal appointment at Kaiser. Her doctor did not ask for permission to use the app and instead informed her that it would be used. After a moment, she decided to refuse the platform’s use. Although the doctor stopped the recording, she felt a noticeable discomfort in the doctor’s demeanor afterward.

She later decided to change doctors.

Situations like this are a concern for Marcucci-Morris, who said the company’s approach to obtaining consent for the use of Abridge during appointments can feel manipulative and coercive. In her view, providers are trained to present the tool in a way that places the needs of patients and doctors in opposition to one another.

She explained that patients are often told the system will help doctors with documentation, reduce burnout, and allow them to spend more time with their families. As a result, patients may feel guilty declining the use of the tool because they do not want to make their provider’s job harder.

She believes this framing pressures patients into agreeing rather than allowing them to make a fully comfortable and independent decision.

According to Kaiser, Abridge is available in “40 hospitals and more than 600 medical offices in eight states and the District of Columbia,” part of a larger embrace of AI technology by the health care industry. Abridge operates in more than 14 languages.

American Community Media reached out multiple times to Abridge AI Inc. for comment but received no response. According to the company’s website, Abridge describes itself as a “Business Associate” to providers. Patients are advised to consult providers’ privacy policies for information on how their data is protected.

“Therapy is most effective in privacy and when trust is achieved through two human beings,” said Marcucci-Morris. For her, “healing occurs when human empathy is offered sincerely as part of any sort of mental health treatment relationship.”

She added, “I believe recording a therapy session changes human behavior.  It changes the patient’s demeanor.”

Roxsy Lin is a California Local News Fellow with the UC Berkeley Graduate School of Journalism.

This article was originally published on CalMatters and was republished under the Creative Commons Attribution-NonCommercial-NoDerivatives license.

By Paula Span, KFF Health News

Jules Netherland traveled from her home in the Bronx to the New York state Capitol in Albany several times in the past few years, hoping to persuade the legislature to pass a medical aid in dying bill, allowing terminally ill patients to end their lives with a lethal prescription.

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

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

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

“My energy is really limited,” she said.

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

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

A similar law is slated to take effect in September in Illinois, which would become the 13th state (plus the District of Columbia) where medical aid in dying is legal.

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

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

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

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

‘You need A, B, and C’

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

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

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

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

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

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

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements to settle lawsuits brought by Compassion & Choices. (Courts ruled against a similar suit in New Jersey.)

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

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

Hotly debated, seldom used

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

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

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

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

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

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

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

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

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

The New Old Age is produced through a partnership with The New York Times.

Asaiah Washington died in Sacramento County Jail on July 26, 2024, and nearly two years later, his family is still calling to hold the Sacramento County Sheriff’s office accountable for his death.

On Thursday, his family and supporters gathered outside the Sacramento County Jail on what would have been Washington’s 42nd birthday. His wife Tonette Washington spoke at the rally, and said she couldn’t believe the call she received from the Sacramento County Coroner’s office.

“He’s the type of person that is not supposed to be gone. He’s the type of person that’ll go in the store and say, ‘Why are you selling water? It should be free.’” Washington said. “I just talked to him 10:07 a.m., and he died 11:30 a.m., within an hour.”

Washington said that her husband struggled for a long time with his mental health, and that she believes he wasn’t being provided with his medication. She said that when he collected his property from the jail, Washington found notes kept by her husband detailing his repeated requests for treatment.

“I’m just reading this, and it’s just giving me chills,” Washington said. “He was basically begging for his medication.”

Tonette Washington said she was worried about inmates who remain in Sacramento County Jail, and that she doesn’t believe what happened to her husband is an isolated incident. Other advocates and supporters from groups like the Anti-Police Terror Project and Decarcerate Sacramento held signs and spoke at the rally.

Christopher-Camilo Carbajal-Carbajal, an organizer with Decarcerate Sacramento, said that there has been a consistent problem with people dying in Sacramento County Jail.

“There’s not enough resources for mental health support, medical support,” Carbajal-Carbajal said. “We also know that sheriffs, from what people have told us, the sheriff deputies have been gatekeepers to medical care.”

The Sacramento County Sheriff’s office did not immediately respond to a request for comment about the rally or calls for accountability in the jail system.

Keyan Bliss (right), an organizer with the Anti-Police Terror Project reads the names of inmates who have died in Sacramento County Jail since 2018, in front of Tonette Washington(left), her family and the rally of advocates on May 28, 2026.Ruth Finch/CapRadio

Since January 2021, at least 41 people have died in Sacramento County Jail, according to reporting by the Sacramento Bee. In 2024, a lawsuit was filed against Sacramento County seeking damages for one detainee’s family after he died of septic shock and kidney failure, even though according to the lawsuit, he repeatedly requested and was denied medical assistance.

AJ Albano, another organizer with Decarcerate Sacramento, said that a number of the deaths in the jail have been drug-related.

“At least a dozen of them were related to drug overdose, like Asaiah,” Albano said. “That happens because of negligence and neglect of the staff, failure to respond to drug overdoses when they happen, and also failure to prevent drugs from getting into the jail.”

Tonette Washington said she has concerns with how an institution like the county jail could allow something like what happened to her husband to happen within its walls.

“Now we are left trying to understand how a vulnerable human being under institutional supervision lost his life,” Washington said. “Families are not seeking accountability because they hate institutions. Families seek accountability because they love the person they lost.”

On July 30th, 2025 Washington filed a lawsuit regarding the death of her husband against the County of Sacramento. Albano said that families can sometimes only find accountability in court.

“The sheriff has no structured accountability at all,” Albano said. “The only way that there is accountability is through lawsuits.”

This story was originally published by EdSource. Sign up for their daily newsletter.

Top Takeaways

• The cost of health benefits has surged nearly 500% since 2013-14, outpacing school funding growth.
• Teachers’ share of their healthcare premiums has reached $1,600 a month in some cases, fueling labor battles.
• California school districts spent 8% of their per-student funding on health benefits last school year.

Twin Rivers Unified School District teachers in Sacramento spent 12 days on strike in March, in part, because healthcare premiums for some teachers and their families had reached $1,600 a month — a growing burden now fueling labor battles in school districts across California.

Little Lake City teachers in Sante Fe Springs, Norwalk and Downey walked out of their classrooms for 10 days; Natomas Unified teachers in Sacramento for seven days; and Dublin Unified, West Contra Costa Unified and San Francisco Unified teachers for four days this school year.

All six unions ended their strikes with health coverage victories. Other unions reached agreements with their districts on improved health benefits at the bargaining table; some are still trying.

As school districts grapple with declining enrollment, expiring federal aid and rising pension costs, healthcare premiums have become one of the most contentious issues in labor negotiations. Teachers say escalating out-of-pocket costs are swallowing salary gains, while district leaders say schools can’t continue to shoulder the entire cost of employee health benefits without having to cut elsewhere.

Teachers in Modesto City Schools have been negotiating a contract with their district since the fall. The sticking point: health benefits. Teachers would like the district to pay more toward rising health benefit costs, which some of them say are now more than their mortgages, according to the Modesto Bee.

The cost of health and welfare benefits has surged nearly 500% since 2013-14, far outpacing school funding growth, according to School Services Inc., a California education consulting firm.

During the 2024-25 school year, California school districts, on average, spent 8% of their average daily attendance funding on health and welfare benefits for school employees, according to a report released recently as part of the Getting Down to Facts III collection of education research.

Health premiums outpace salary gains

The average healthcare premium for a public school employee increased 14%, while teacher salaries increased by 10% between 2018 and 2022, according to a National Council on Teacher Quality study.

Since then, insurance rates have continued to increase at a steady pace.

A July 2025 survey of nearly 2,000 California teachers found that 69% said that high, out-of-pocket costs for often inadequate healthcare benefits were eating into their paychecks.

“Health insurance premiums are rising faster than teachers’ salaries are increasing, and so this is, of course, making it harder for teachers to be able to afford to stay in the profession,” said Heather Peske, president of NCTQ.

The popular perception is that California public school teachers have generous healthcare benefits, but the reality is that some teachers pay as much as $1,600 per month in out-of-pocket costs, said California Teachers Association President David Goldberg.

Teachers feel that budgets “have basically been balanced on their backs for years,” Goldberg said during an EdSource Roundtable in February. “About a third of the association’s members report that they’re living paycheck to paycheck and are even delaying needed healthcare.”

Paul Bruno, assistant professor at the University of Illinois Urbana-Champaign, says teacher salaries have been mostly flat over the last 20 years as unions and school districts have prioritized health benefits during contract negotiations.

“Teacher compensation has gone up pretty substantially, it’s just not in salary,” said Bruno, lead author of “District Dollars 3: Recent Patterns in California School District Finances, Trends in Teacher Compensation, and Within-District, Between-School Spending.”

Higher rates are impacting district budgets

California school districts are also struggling financially. They have lost average daily attendance funding due to declining enrollment, and federal Covid dollars. At the same time, districts are paying more for pensions, healthcare, supplies and special education.

Between the 2004-05 and 2024-25 school years, healthcare costs for California districts increased 46%, or $6,345 per teacher, according to Bruno’s research. Medical benefit costs increased 52% to $18,839 per teacher, while the cost of dental and vision plans dropped slightly.

Although the cost of health benefits has increased in all industries at a faster rate than inflation most years, schools are harder hit because they generally are responsible for a larger share of their employees’ benefit costs than most other industries, according to the report.

The pain is not spread equally

Health benefits, which are collectively bargained between local districts and their teachers unions, vary greatly across the state.

About half of the state’s districts that reported data to the state during the 2024-25 school year paid between 70% and 90% of their teachers’ health benefits; about 13% of the districts paid the entire cost, according to a California Teachers Association analysis of benefits data submitted to the state by 783 school districts.

It is unclear how many California districts, if any, require teachers to pay the full cost of the insurance.

Agreeing to pay 100% of health benefits can put a district in the position of shouldering the entire cost of increases, Bruno said. It also removes incentives for employees to select less expensive health plans, he said.

Kern County is the gold standard

Kern County schools are the most generous to their teachers in terms of health benefits, with 18 of the 37 districts that reported data to the California Department of Education paying 100% of their teachers’ health premiums. Another 15 of the county’s districts reported paying between 90% and 99.58% of teachers’ health benefits.

“Not only do we have our benefits 100% paid for, we have extremely good benefits. Like we’re talking gold plan PPO benefits,” said Megan Harwell, president of the Kern County Education Association, the union for the county Office of Education.

Kern County school districts have paid a majority of teachers’ health benefits for as long as Harwell, a special education teacher, can remember. But the issue still comes up annually during contract negotiations because of rising costs, she said.

“So, it’s never been a given,” Harwell said. “It’s always been something we’ve fought very hard for.”

This year, the Kern County Office of Education paid approximately $1,700 a month for health benefits for each of their teachers and their families, Harwell said. Next year, the cost is expected to be about $2,000.

Harwell said Kern County teachers are often shocked to hear that teachers in other school districts pay between $500 and $1,700 a month for their family’s health benefits.

With healthcare costs soaring, holding the line on health insurance premiums should be a priority for teachers, even if it means accepting a smaller pay increase, Harwell said.

“Because if you open that floodgate, then when does it stop? Like, it’s $50 now, but next year it’s going to be $100, then $200, then $300 and then whatever we get in COLA (cost-of-living adjustment) will be eaten up by the amount of money we’re paying for our benefits,” she said.

Districts could share costs

Bruno said the share of health insurance costs covered by school districts declined during the early 2000s. The trend leveled off around 2012, however, as California increased state funding for education. Since then, school districts have consistently covered about 85% of employee health benefit costs, he said.

But, this school year some districts have asked teachers to pay more for their health insurance.

Peske said shifting more healthcare costs onto teachers could make it harder for districts to recruit and retain teachers, especially if benefits become less competitive. Instead, she said, district leaders should negotiate for lower-cost insurance plans, seek better rates from providers or partner with other districts to buy insurance at lower prices. The state could also help school districts improve their rates, she added.

“States are in a particularly unique and favorable position to negotiate better health insurance rates for their employees,” Peske said. “So, for example, the state of North Carolina provides state-level health insurance. So, they’re able to negotiate a plan with much better rates since they have many more employees, obviously, than a single district does.”

Peske acknowledges that a statewide program could be difficult in California, where each district has its own collective bargaining agreement with its teachers.

"We were more worried about getting crushed by slabs or getting cut with blades and stuff like that," he says, "not getting a lung disease."

He says he made some countertops out of granite, but mostly he cut "quartz," a popular composite made by factories that take bits of quartz mined from quarries and mix it with binders and pigments. Compared to granite or marble, manufactured quartz contains far more of the mineral silica — and silica dust can cause lung damage if you breathe it in.

That danger has become dramatically clear in California, where officials have been grappling with an epidemic of silicosis, an irreversible lung disease. They've tracked over 550 sickened countertop workers, almost all Hispanic men, with most of the cases emerging over the last few years. Over 30 workers have died, and more than 50 have had lung transplants, according to a public dashboard where the numbers keep going up.

On May 21, a workplace safety board in California will vote on whether the state should ban the cutting of high-silica quartz countertop material, as a group of doctors has petitioned the state to do. Those doctors say the severity of workers' disease suggests that it's caused by exposure to toxic ingredients in addition to silica, like pigments or resins.

Rebecca Shult, a lawyer for the major quartz company Cambria, said in a March hearing that her company objected to the idea that any one subset of silica-containing products was to blame. "For this reason, we take issue with the very nomenclature of 'engineered stone silicosis'" used on California's disease-tracking dashboard, she said.

Meanwhile, other states — like Hanicker's home state of Florida — haven't reported seeing large numbers of countertop workers getting sick.

"Please keep in mind, there is only a handful of silicosis cases in the other 49 states," Shult told lawmakers in Congress during a hearing earlier this year.

But David Michaels, an epidemiologist with George Washington University and an expert on workplace safety, says California is seeing a large number of sick workers because it's been actively and thoroughly looking for cases, unlike other states.

Thousands of countertop workers across the country likely have unrecognized lung damage, says Michaels.

"We could easily have 10,000 workers here with silicosis and possibly far more," he says, noting that an estimated 100,000 people work in this industry in the U.S., and studies done in Australia found lung disease in over 10% of the countertop workforce there.

"This is life-changing"

Many doctors aren't familiar with silicosis, says Michaels, and they don't always ask about a person's job. So workers who do seek medical help often get misdiagnosed.

That's what happened to Hanicker about five years ago, when he developed a knot of pain under his shoulder. He took ibuprofen and powered through. When the pain started creeping around his chest, his wife worried about his heart and insisted that he seek emergency care.

"We didn't think," he says, "that it could be, you know, work-related, from the dust."

The doctors took an X-ray, diagnosed pneumonia, and sent him home with antibiotics, which didn't help. Next, he had a CT scan. It found nodules in his lungs, and a biopsy showed silicosis. He remembers breaking down and crying with his wife.

"We realized that, hey, this is life-changing. There is no cure for this," says Hanicker, 39, who suffers from pain, weakness and shortness of breath. Doctors say he'll eventually need a lung transplant, and he also has a silica-related autoimmune disease.

"The two biggest things that hurt me is how it affects my marriage and not being able to be a father the way I want to with my kids," he says, saying he can't play sports with his young children or run along beside them to teach them to ride a bike. He's sued the makers and distributors of quartz slabs.

Quartz manufacturers like Cambria point out that breathing in dust while cutting any high-silica material — such as the natural stone quartzite — can be dangerous. They maintain that their products are safe if the fabrication workshops that cut the slabs use sufficient precautions such as vacuum systems and water sprays to control the dust.

"Workplace safety is a huge thing," says attorney Khaled Taqi-Eddin, who represents Cambria. "If you don't have good workplace safety practices, whether it's a quote-unquote 'natural' stone or whether it's a quartz stone, you are going to end up having people continuously getting sick."

Occupational health experts who have petitioned California to ban quartz, however, say this material "is too toxic to fabricate and install safely, and education and enforcement alone will not be sufficient to curtail the escalating occupational health emergency caused by this product."

A few weeks ago, in the first quartz and silicosis lawsuit to come to trial outside of California, a jury in Colorado awarded damages to an injured worker named Tyler Jordan, finding that actions by several companies led to his illnesses. 

Jordan, in an interview with NPR, said he'd started working in his family's small countertop shop as a teenager and worked full time after graduating from high school. After about a decade, he was diagnosed with silicosis. Shocked, he struggled to believe it was real.

"I felt like I was too young. It felt like there was going to be some sort of mistake. It felt wrong," says Jordan, who had hoped to take over the family business but now can't work anywhere near silica. He developed silica-related kidney failure and had to go on dialysis and have a kidney transplant from his father.

"The worst situation"

One of Jordan's doctors is Cecile Rose, an occupational pulmonologist with National Jewish Health and the University of Colorado in Denver. She was part of a team that reported on some of the first cases of severe silicosis in young U.S. countertop workers.

Back then, in 2019, she'd seen seven cases in Colorado — including a couple of women who worked as cleaners and got exposed when they swept up silica dust. The severity of the disease and the young age of the victims alarmed Rose.

Now, she and other doctors have seen about 20 cases in their state, she says. And she and her colleagues created a voluntary registry where doctors can share their experiences. 

"We have cases from Illinois, from Missouri, Montana, New Mexico, South Carolina, Wyoming," says Rose, adding that this effort is scattershot, because physicians hear about it through word of mouth.

James Nevin, an attorney whose firm represents both Jordan and Hanicker, says he and his colleagues represent other workers in about 25 states, and there are reasons why countertop laborers wouldn't want to talk to reporters, lawyers, or doctors. "They're terrified of losing their jobs, if they are still able to work. They're terrified of being deported," he says. "They're afraid to come forward."

In December, Massachusetts made headlines when that state announced its first case. Since then, state officials have found two more.

New York Department of Health officials, meanwhile, told NPR that they knew of only four cases in their state. Officials in Washington state similarly knew of four cases of silica-related lung disease that occurred across three different businesses handling quartz. At one countertop-maker in Chicago, federal inspectors found several cases.

"I'm 100% sure that there are many more cases in Florida, and New York, and probably every state in this country," says Rose.

"This is the worst situation I've seen affecting a workforce in my 35 years," says Kurt Hegmann, director of the Rocky Mountain Center for Occupational and Environmental Health in Utah.

He says sick workers have started showing up in clinics in his state and that although no one knows how many cases there are in Utah because it's not being systematically tracked, "we know that in a case of one of the fabricators, that 38% of the workforce is affected."

"I believe that California is actually leading the country, correctly, in how to address this problem," says Hegmann.

"We're probably missing 95%"

In 2023, because of concerns about silicosis in this industry, the Department of Labor's Occupational Safety and Health Administration started a targeted inspection program. Since then, its staff has inspected over 400 countertop workplaces in at least 25 states, effectively checking the worksites of more than 7,500 workers, according to a spokesperson with the Department of Labor who shared details about the program's findings.

There's a procedure for sampling airborne silica, and it turns out that about 20% of the samples taken during this inspection program were high enough to exceed the "permissible exposure limit," which is the maximum that workers can be legally exposed to, the spokesperson told NPR.

What's more, 33% of the samples collected during this program were above the "action level" for silica. That's the level that requires employers to take additional precautions like health screenings for workers and increased air testing.

But inspectors also issued over 75 citations for lack of medical surveillance of workers, according to the Department of Labor spokesperson, who added "there is evidence from publicly available research that demonstrates there is a general lack of medical surveillance occurring related to silica exposure."

Kenneth Rosenman, an expert on silicosis and workplace disease at Michigan State University, points to a recent survey showing most countertop shops don't offer medical exams to their workers.

Plus, studies have highlighted the inadequacies of the federal system for trying to collect data on nonfatal workplace accidents or illnesses, he says.

"We have a lousy system that is dependent on employer reporting," says Rosenman. "We're missing at least half of the work-related amputations in the country that occur. We're probably missing 95% of the cases of silicosis that occur in the country."

The situation in California is truly concerning, he says: "This is nothing that I've ever personally seen in my 43 years of working with silicosis."

But to know how widespread lung damage is in the U.S. countertop industry, he says, "we need somebody to go out and do a survey of fabricators in multiple states — a sample — and see how many people actually have the disease that we're not aware of."

Michaels, who used to direct the Department of Labor's Occupational Safety and Health Administration, says that this is the kind of study that a research agency called the National Institute for Occupational Safety and Health could do, but the current administration fired almost all of its staff — those positions were reinstated earlier this year — and wanted to cut its budget by about 80%, although Congress didn't go along with that.

He thinks that unless something drastic is done to reduce worker exposures, the numbers will continue to rise. That's why he favors the ban on quartz being considered in California this week.

"There is no reason," says Michaels, "to think that workers doing the same work in other states will avoid the same terrible consequences that workers in California are facing."

As Christine Ruiz sits in an exam room for some aesthetic skin treatments, she looks nervous. She's not new to injectables like Botox, but this is the first time she's received them at a Planned Parenthood clinic.

"So, I usually do the elevens and then across the forehead. I really like the little lip flip," Ruiz says to her clinician, describing what she wants done.

The Sacramento clinic is part of Planned Parenthood Mar Monte, the largest Planned Parenthood affiliate in the country, covering Northern California and parts of Nevada.

It has started offering a new set of services, ranging from Botox to IV hydration for skin rejuvenation, or for after a night of drinking, all of which patients pay for with cash. They can also request sedation for certain procedures, like the placement of an intrauterine device.

The shift comes as Planned Parenthood faces financial uncertainty after President Donald Trump and Congress stripped funding for the abortion-rights organization as part of the tax and spending package passed last year. The cuts, which prevent Planned Parenthood and other organizations that perform abortions from accepting Medicaid as payment for non-abortion services, are set to expire this summer. Congress could renew them for another year.

The affiliate says about 75 to 80% of its patients are on Medi-Cal, California's Medicaid program. Revenue from the new offerings could allow the affiliate to continue providing reproductive healthcare while it tries to fill the funding gap.

"I'm really excited by the idea of patients coming to us because it's a way they can support us financially. I think that's exciting and we get to hear their stories," says Dr. Laura Dalton, the Chief Medical Operating Officer of Planned Parenthood Mar Monte.

The affiliate has closed five clinics since the cuts.

"It is spicy," Ruiz says, trying not to flinch as the needle pokes her upper lip.

She says she relied on Planned Parenthood for access to birth control and reproductive healthcare when she was younger. She's now in her early 50s.

"I felt respected. I felt supported. I felt like the care that I got was without judgment," Ruiz says. "So, when the opportunity came up, I was like, 'Sure, why not support that?'"

Planned Parenthood charges $9 per unit of Botox, which, depending on location, could be 25 to 50% cheaper than other providers.

California Gov. Gavin Newsom, a Democrat, and state lawmakers have allocated hundreds of millions of dollars in state funding to Planned Parenthood and other organizations like it since the federal cuts, including $90 million in February.

The organization's leaders, though, say it isn't clear whether that will cover costs for core services, including cancer screenings, STI testing and contraceptive care, in the long run if Congress reinstates cuts.

That spending has sparked a backlash among politicians and groups opposing abortion rights. "We'd be shocked if California taxpayers support Gavin Newsom's $90 million 'Botox bailout' for Planned Parenthood, which happens to be a key backer of California Democrats," wrote Marjorie Dannenfelser, the president of Susan B. Anthony Pro-Life America, an anti-abortion lobbying group, in a statement to NPR.

According to Dalton, the affiliate's providers are seeing a spiked interest in aesthetic services, many for cosmetic reasons. But, she points out, Botox can also be used for migraines and gender affirming care. These aesthetic services, she says, are a way for patients to exercise bodily autonomy.

But that argument doesn't sit well with some who support the organization's overall mission.

"I'm concerned about creating a closer association between anti-aging procedures like Botox and feminism," says Jessica DeFino, a beauty critic and author of the popular Substack beauty newsletter called Flesh World.

"I think Planned Parenthood is associated, you know, rightly, in the cultural imagination with women's rights, with feminism," DeFino says. "I don't think the aesthetic use of Botox is really in line with the push for freedom from gender-based discrimination."

Planned Parenthood Mar Monte says this shift is about making sure reproductive care remains available.

While the affiliate offers Botox and IV hydration at select locations for now, it's exploring an expansion into cosmetic fillers and GLP-1 weight-loss treatments. Dalton says the new services could serve as a blueprint for other clinics trying to keep their doors open.