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May 16 2024 KFF Health News

For much of his young life, Jorge Sanchez regularly gasped for air, at times coughing so violently that he'd almost throw up. His mother whisked him to the emergency room late at night and slept with him to make sure he didn't stop breathing.

"He's had these problems since he was born, and I couldn't figure out what was triggering his asthma," Fabiola Sandoval said of her son, Jorge, now 4. "It's so hard when your child is hurting. I was willing to try anything."

In January, community health workers visited Sandoval's home in Turlock, a city in California's Central Valley where dust from fruit and nut orchards billows through the air. They scoured Sandoval's home for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.

The team also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor — goods that retail for hundreds of dollars. Within a few months, Jorge was breathing easier and was able to run and play outside.

The in-home consultation and supplies were paid for by Medi-Cal, California's Medicaid health insurance program for low-income residents. Gov. Gavin Newsom is spearheading an ambitious $12 billion experiment to transform Medi-Cal into both a health insurer and a social services provider, one that relies not only on doctors and nurses, but also community health workers and nonprofit groups that offer dozens of services, including delivering healthy meals and helping homeless people pay for housing.

These groups are redefining health care in California as they compete with businesses for a share of the money, and become a new arm of the sprawling Medi-Cal bureaucracy that serves nearly 15 million low-income residents on an annual budget of $158 billion.

But worker shortages, negotiations with health insurance companies, and learning to navigate complex billing and technology systems have hamstrung the community groups' ability to deliver the new services: Now into the third year of the ambitious five-year experiment, only a small fraction of eligible patients have received benefits.

"This is still so new, and everyone is just overwhelmed at this point, so it's slow-going," said Kevin Hamilton, a senior director at the Central California Asthma Collaborative.

The collaborative has served about 3,650 patients, including Sandoval, in eight counties since early 2022, he said. It has years of experience with Medi-Cal patients in the Central Valley and has received about $1.5 million of the new initiative's money.

By contrast, CalOptima Health, Orange County's primary Medi-Cal insurer, is new to offering asthma benefits and has signed up 58 patients so far.

"Asthma services are so difficult to get going" because the nonprofit infrastructure for these services is virtually nonexistent, said Kelly Bruno-Nelson, CalOptima's executive director for Medi-Cal. "We need more community-based organizations on board because they're the ones who can serve a population that nobody wants to deal with."

Newsom, a Democrat in his second term, says his signature health care initiative, known as CalAIM, seeks to reduce the cost of caring for the state's sickest and most vulnerable patients, including homeless Californians, foster children, former inmates, and people battling addiction disorders.

In addition to in-home asthma remediation, CalAIM offers 13 broad categories of social services, plus a benefit connecting eligible patients with one-on-one care managers to help them obtain anything they need to get healthier, from grocery shopping to finding a job.

The 25 managed-care insurance companies participating in Medi-Cal can choose which services they offer, and contract with community groups to provide them. Insurers have hammered out about 4,300 large and small contracts with nonprofits and businesses.

So far, about 103,000 Medi-Cal patients have received CalAIM services and roughly 160,000 have been assigned personal care managers, according to state data, a sliver of the hundreds of thousands of patients who likely qualify.

"We're all new to health care, and a lot of this is such a foreign concept," said Helena Lopez, executive director of A Greater Hope, a nonprofit organization providing social services in Riverside and San Bernardino counties, such as handing out baseball cleats to children to help them be active.

Tiffany Sickler runs Koinonia Family Services, which offers California foster children mental health and other types of care, and even helped a patient pay off parking tickets. But the program is struggling on a shoestring budget.

"If you want to do this, you have to learn all these new systems. It's been a huge learning curve, and very time-consuming and frustrating, especially without adequate funding," she said.

Brandon Richards, a Newsom spokesperson, defended CalAIM, saying that it was "on the cutting edge of health care" and that the state was working to increase "awareness of these new services and support."

For nonprofits and businesses, CalAIM is a money-making opportunity — one that top state health officials hope to make permanent. Health insurers, which receive hefty payments from the state to serve more people and offer new services, share a portion with service providers. Related StoriesStudy links higher-potency cannabis use in youth to increased risk of psychotic experiencesUncovering the psychological toll of entrenched school practices on childrenClinical trial in Seattle aims to transform treatment approaches for pediatric IBD

In some places, community groups are competing with national corporations for the new funding, such as Mom's Meals, an Iowa-based company that delivers prepared meals across the United States.

Mom's Meals has an advantage over neighborhood nonprofit groups because it has long served seniors on Medicare and was able to immediately start offering the CalAIM benefit of home-delivered meals for patients with chronic diseases. But even Mom's Meals isn't reaching everyone who qualifies, because doctors and patients don't always know it's an option, said Catherine Macpherson, the company's chief nutrition officer.

"Utilization is not as high as it should be yet," she said. "But we were well positioned, because we already had departments to do billing and contracting with health care."

Middleman companies also have their eye on the billions of CalAIM dollars and are popping up to assist small organizations to go up against established ones like Mom's Meals. For instance, the New York-based Nonprofit Finance Fund is advising homeless service providers how to get more contracts and expand benefits.

Full Circle Health Network, with 70 member organizations, is helping smaller nonprofit groups develop and deliver services primarily for families and foster children. Full Circle has signed a deal with Kaiser Permanente, allowing the health care giant to access its network of community groups.

"We're allowing organizations to launch these benefits much faster than they've been able to do and to reach more vulnerable people," said Camille Schraeder, chief executive of Full Circle. "Many of these are grassroots organizations that have the trust and expertise on the ground, but they're new to health care."

One of the biggest challenges community groups face is hiring workers, who are key to finding eligible patients and persuading them to participate.

Kathryn Phillips, a workforce expert at the California Health Care Foundation, said there isn't enough seed money for community groups to hire workers and pay for new technology platforms. "They bring the trust that is needed, the cultural competency, the diversity of languages," she said. "But there needs to be more funding and reimbursement to build this workforce."

Health insurers say they are trying to increase the workforce. For instance, L.A. Care Health Plan, the largest Medi-Cal insurer in California, has given $66 million to community organizations for hiring and other CalAIM needs, said Sameer Amin, the group's chief medical officer.

"They don't have the staffing to do all this stuff, so we're helping with that all while teaching them how to build up their health care infrastructure," he said. "Everyone wants a win, but this isn't going to be successful overnight."

In the Central Valley, Jorge Sanchez is one of the lucky early beneficiaries of CalAIM.

His mother credits the trust she established with community health workers, who spent many hours over multiple visits to teach her how to control her son's asthma.

"I used to love cleaning with bleach" but learned it can trigger breathing problems, Sandoval said.

Since she implemented the health workers' recommendations, Sandoval has been able to let Jorge sleep alone at night for the first time in four years.

"Having this program and all the things available is amazing," said Sandoval, as she pointed to the dirty dust cup in her new vacuum cleaner. "Now my son doesn't have as many asthma attacks and he can run around and be a normal kid."

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism. Source:

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US Supreme Court will not review IRS case involving Coinbase user data

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US Supreme Court will not review IRS case involving Coinbase user data

US Supreme Court will not review IRS case involving Coinbase user data

A lower court ruling will stand in a case involving a Coinbase user who filed a lawsuit against the IRS after the crypto exchange turned over transaction data.

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Solar and wind industry faces up to $7 billion tax hike under Trump’s big bill, trade group says

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Solar and wind industry faces up to  billion tax hike under Trump's big bill, trade group says

Witthaya Prasongsin | Moment | Getty Images

Senate Republicans are threatening to hike taxes on clean energy projects and abruptly phase out credits that have supported the industry’s expansion in the latest version of President Donald Trump‘s big spending bill.

The measures, if enacted, would jeopardize hundreds of thousands of construction jobs, hurt the electric grid, and potentially raise electricity prices for consumers, trade groups warn.

The Senate GOP released a draft of the massive domestic spending bill over the weekend that imposes a new tax on renewable energy projects if they source components from foreign entities of concern, which basically means China. The bill also phases out the two most important tax credits for wind and solar power projects that enter service after 2027.

Republicans are racing to pass Trump’s domestic spending legislation by a self-imposed Friday deadline. The Senate is voting Monday on amendments to the latest version of the bill.

The tax on wind and solar projects surprised the renewable energy industry and feels punitive, said John Hensley, senior vice president for market analysis at the American Clean Power Association. It would increase the industry’s burden by an estimated $4 billion to $7 billion, he said.

“At the end of the day, it’s a new tax in a package that is designed to reduce the tax burden of companies across the American economy,” Hensley said. The tax hits any wind and solar project that enters service after 2027 and exceeds certain thresholds for how many components are sourced from China.

This combined with the abrupt elimination of the investment tax credit and electricity production tax credit after 2027 threatens to eliminate 300 gigawatts of wind and solar projects over the next 10 years, which is equivalent to about $450 billion worth of infrastructure investment, Hensley said.

“It is going to take a huge chunk of the development pipeline and either eliminate it completely or certainly push it down the road,” Hensley said. This will increase electricity prices for consumers and potentially strain the electric grid, he said.

The construction industry has warned that nearly 2 million jobs in the building trades are at risk if the energy tax credits are terminated and other measures in budget bill are implemented. Those credits have supported a boom in clean power installations and clean technology manufacturing.

“If enacted, this stands to be the biggest job-killing bill in the history of this country,” said Sean McGarvey, president of North America’s Building Trades Unions, in a statement. “Simply put, it is the equivalent of terminating more than 1,000 Keystone XL pipeline projects.”

The Senate legislation is moving toward a “worst case outcome for solar and wind,” Morgan Stanley analyst Andrew Percoco told clients in a Sunday note.

Shares of NextEra Energy, the largest renewable developer in the U.S., fell 2%. Solar stocks Array Technologies fell 8%, Enphase lost nearly 2% and Nextracker tumbled 5%.

Trump’s former advisor Elon Musk slammed the Senate legislation over the weekend.

“The latest Senate draft bill will destroy millions of jobs in America and cause immense strategic harm to our country,” The Tesla CEO posted on X. “Utterly insane and destructive. It gives handouts to industries of the past while severely damaging industries of the future.”

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Nissan is in crisis mode as job cuts begin and suppliers are caught in the crosshairs

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Nissan is in crisis mode as job cuts begin and suppliers are caught in the crosshairs

Is Nissan raising the red flag? Nissan is cutting about 15% of its workforce and is now asking suppliers for more time to make payments.

Nissan starts job cuts, asks supplier to delay payments

As part of its recovery plan, Nissan announced in May that it plans to cut 20,000 jobs, or around 15% of its global workforce. It’s also closing several factories to free up cash and reduce costs.

Nissan said it will begin talks with employees at its Sunderland plant in the UK this week about voluntary retirement opportunities. The company is aiming to lay off around 250 workers.

The Sunderland plant is the largest employer in the city with around 6,000 workers and is critical piece to Nissan’s comeback. Nissan will build its next-gen electric vehicles at the facility, including the new LEAF, Juke, and Qashqai.

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According to several emails and company documents (via Reuters), Nissan is also working with its suppliers to for more time to make payments.

Nissan-delays-supplier-payments
The new Nissan LEAF (Source: Nissan)

“They could choose to be paid immediately or opt for a later payment,” Nissan said. The company explained in a statement to Reuters that it had incentivized some of its suppliers in Europe and the UK to accept more flexible payment terms, at no extra cost.

The emails show that the move would free up cash for the first quarter (April to June), similar to its request before the end of the financial year.

Nissan-delays-supplier-payments
Nissan N7 electric sedan (Source: Dongfeng Nissan)

One employee said in an email to co-workers that Nissan was asking suppliers “again” to delay payments. The emails, viewed by Reuters, were exchanged between Nissan workers in Europe and the United Kingdom.

Nissan is taking immediate action as part of its recovery plan, aiming to turn things around, the company said in a statement.

Nissan-Micra-EV
The new Nissan Micra EV (Source: Nissan)

“While we are taking these actions, we aim for sufficient liquidity to weather the costs of the turnaround actions and redeem bond maturities,” the company said.

Nissan didn’t comment on the internal discussions, but the emails did reveal it gave suppliers two options. They could either delay payments at a higher interest rate, or HSBC would make the payment, and Nissan would repay the bank with interest.

Nissan-delays-supplier-payments
Nissan’s upcoming lineup for the US, including the new LEAF EV and “Adventure Focused” SUV (Source: Nissan)

The company had 2.2 trillion yen ($15.2 billion) in cash and equivalents at the end of March, but it has around 700 billion yen ($4.9 billion) in debt that’s due later this year.

As part of Re:Nissan, the Japanese automaker’s recovery plan, Nissan looks to cut costs by 250 billion yen. By fiscal year 2026, it plans to return to profitability.

Electrek’s Take

With an aging vehicle lineup and a wave of new low-cost rivals from China, like BYD, Nissan is quickly falling behind.

Nissan is launching several new electric and hybrid vehicles over the next few years, including the next-gen LEAF, which is expected to help boost sales.

In China, the world’s largest EV market, Nissan’s first dedicated electric sedan, the N7, is off to a hot start with over 20,000 orders in 50 days.

The N7 will play a role in Nissan’s recovery efforts as it plans to export it to overseas markets. It will be one of nine new energy vehicles, including EVs and PHEVs, that Nissan plans to launch in China.

Can Nissan turn things around? Or will it continue falling behind the pack? Let us know your thoughts in the comments below.

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