Medical debt weighs heavily on the lives of millions of Californians. It can ding their credit scores and hurt their chances of landing a rental or securing a home mortgage.

Earlier this year, the Biden administration announced a proposal to stop medical debt from showing up on credit reports. That proposed rule is under consideration with an uncertain timeline.

California lawmakers are moving faster with a similar measure that would take effect as soon as January if it becomes law.

Sen. Monique Limón, a Santa Barbara Democrat, is carrying Senate Bill 1061, which would remove medical debt from credit reports and prohibit debt collectors from reporting patients’ medical debt information to credit agencies. It would pertain specifically to debt owed to a medical provider, such as a hospital or a doctor’s office.

It passed the Assembly on Monday and is heading to the Senate for a final vote. Until recently, the bill would have also included debt charged to medical credit cards and specialty loans, but changes in the Assembly Appropriations Committee redefined “medical debt” to exclude these.

Limón was surprised by the changes. The amendments were a win for a coalition of bankers and lenders that had been requesting that change for months. Following the amendments, the coalition removed its opposition to the proposal.

“This legislation passed through three Assembly policy committees without the most recent amendments by Assembly Appropriations, which substantially weaken the bill,” Limon told CalMatters in an emailed statement. “It is clear that … influential entities opposed to the measure prevailed.

“In spite of this disappointing setback, I plan to continue pushing for the passage of SB 1061 in the hope that we can provide partial relief to consumers.”

Representatives for Assembly Speaker Robert Rivas would not comment on the bill and Assembly Appropriations Committee Chairperson Buffy Wicks did not reply to messages and emails asking why the changes were made. Those lawmakers can change bills in the Appropriations Committee.

Supporters of Limon’s bill say even though the feds are moving in a similar direction, California’s bill still has merit.

“The (federal) rulemaking right now, it’s just a proposal. It could get watered down, they take a long time. And then, of course, depending on what happens with the election, there’s a big question mark of what happens to any of our federal rules,” said Jenn Engstrom, state director with the California Interest Research Group, a co-sponsor of the bill. “So rather than leaving it up to the uncertainty of the federal government, we think it’s really important that California has a strong role here.”

The bill is backed by Attorney General Rob Bonta and the California Nurses Association, among other health advocates. Proponents argue that people acquire medical debt through no fault of their own. After all, going into debt because you need surgery is not the same as going into debt for a luxury vacation. Experts and advocates say medical debt is also more prone to inaccuracies because of mistakes in billing or disputes with insurers.

The bill “does not forgive debt, but it does ensure that when it’s not reported we don’t negatively impact credit scores for a lifetime for people,” Limón said.

If the bill makes it to the governor’s desk and he signs the bill, California would join states such as Colorado and New York in prohibiting medical debt from damaging credit scores.

The burden of medical debt

About 4 in 10 Californians report carrying some type of medical debt, according to the California Health Care Foundation. Nationally, the average medical balance on credit reports is around $3,100.

“The impact of this debt is so well-known that many people take it into consideration when deciding whether to seek care when they need it, and many opt not to, deciding to steer clear of the (medical) bill, which puts their health at risk,” said Katie Van Deynze, a policy and legislative advocate with the consumer advocacy group Health Access California.

In June, the Biden administration announced a proposal that would bar medical debt from appearing on credit reports. It’s expected to help raise the credit scores of approximately 15 million Americans by an average of 20 points, according to the administration’s announcement. The administration estimates that would translate to the approval of about 22,000 additional mortgages every year.

The federal proposal also leaves out medical credit cards, a gap Limón was hoping to close.

Medical credit cards may be offered by medical providers as an option to cover the cost of a procedure. They can be enticing, offering people the option of no payment upfront and a promotional period of deferred interest. However, if interest does kick in, it can be higher than that of a regular credit card.

Groups such as the California Bankers Association argued that the definition of “medical debt” in Limón’s bill was too broad. The only debt that should be included in this legislation, they said, is the kind that is directly owed to a medical facility or provider. In hearings and letters to the Legislature, lobbyists for these groups argued that medical credit cards could also be used for elective procedures, fitness programs and veterinary services, among other expenses. That type of debt, they argued, should not be hidden from creditors.

Medical debt forgiveness

The topic of medical debt resonates so much with the public that some local governments and states are going one step further and pushing for debt relief programs.

This summer the Los Angeles County Board of Supervisors announced a pilot program to buy off millions worth of its residents’ medical debt through a partnership with the national nonprofit Undue Medical Debt. Hospitals and other providers can sell unpaid debt to companies that would profit from collecting that money. Undue Medical Debt leverages this arrangement and purchases debt for cents on the dollar, but instead of collecting the debt, it cancels it.

Through this model, county supervisors estimate they can spend $5 million to cancel $500 million worth of debt for 150,000 low-income residents. Medical debt in Los Angeles County surpasses $2.9 billion, according to an analysis by the county’s public health department.

New York City and Arizona have done similar deals with the same nonprofit. And just last week, New Jersey Democratic Gov. Phil Murphy announced that the state would use leftover pandemic relief dollars to eliminate $100 million worth of medical debt for 50,000 residents.

Democratic presidential nominee Kamala Harris has pledged to build on the current administration’s efforts to wipe medical debt from credit reports by incorporating debt forgiveness. Among her campaign promises: “Work with states to cancel medical debt for millions of Americans.”

Last month, the Washington Post reported that Harris had been working with North Carolina to incentivize hospitals there to forgive patients’ medical debt in exchange for additional Medicaid dollars. In mid-August, North Carolina Democratic Gov. Roy Cooper announced that all of the state’s 99 hospitals agreed to participate in this program. About 2 million low- and middle-income North Carolina residents are expected to benefit starting next summer.

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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.

CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Brad Mettam was born on November 12, 1952 in San Francisco to Ron and Dolores Mettam. On October 16, 1976 he married Diane Yee and her son David became his son too. On March 27, 1978 their daughter Jessica Joy was born. Their family complete, Brad and Diane moved as their jobs demanded, living in San Francisco, Half Moon Bay, South Lake Tahoe, Dyer, Nevada and Bishop, California before finally relocating in Eureka, where Brad was the Deputy District Director for Planning and Local Assistance with CalTrans. His office was always open to anyone needing help or advice. Upon his retirement he was presented with a resolution from the California State Legislature.

Prior to his carer with CalTrans, Brad worked with Esmeralda and Inyo Counties seeking to impede the negative aspects of the proposed nuclear waste facility at Yucca Mountain, Nevada. He served as chair of the Esmeralda County School District, and in Bishop he served as chairman of the Great Basin Air Pollution Control District Hearing Board.

Brad and Diane believed in sharing their blessings. While the children were school-age they coached soccer, led 4-H groups, taught dance, tutored students, and offered a temporary home to kids who needed a roof over their heads. They welcomed three AFS exchange students for various periods of time from Thailand, China and Norway. Brad and Diane served as soccer coaches in South Lake Tahoe. As a couple and a family, they did things together.

Brad served as Santa’s elf each year at the Bishop Christmas Parade, riding with Santa on the fire engine and helping with the children in line. Diane made his elf costume. Brad had a long affiliation with firefighting. He served as a volunteer firefighter in Half Moon Bay and South Lake Tahoe, and reorganized and served as Chief of the Fish Lake Valley Fire Protection District in Dyer, Nevada.

Some time after settling in Bishop, Brad joined the local Rotary Club. He served in several offices before becoming President. He also became a member of the Paul Harris Society. When Brad and Diane moved to Eureka, Brad joined the Eureka Rotary Club and was again elected to serve as President. He remained active in Rotary until his death.

He was also a devoted church member, serving as the sound tech for the Eureka First United Methodist Church. He served a similar position at the Bishop First United Methodist Church, as well as keeping the books. When Diane was pastor at Pioneer Memorial United Methodist Church in Independence Brad ran the music system, proof-read and folded the bulletins, made sure there was a dish for the potlucks, and Diane had a clean robe and stole.

Brad and Diane loved animals, especially dogs, although there was a time when the family had seven sheep. For the past 45 years they had at least one rescue dog - at one time they had five. Lately they were always accompanied by Hannah, a bichon, and Jack, a miniature schnauzer. They also have a large feeder in their back yard to take care of the local birds and squirrels.

Brad passed away suddenly on August 6, 2024 in Eureka. Memorial services will be held on Saturday, August 31st at 11 a.m. at the Eureka First United Methodist Church at 1901 F St, Eureka.

In lieu of flowers, the family recommends donations to the Eureka First United Methodist Church or the Eureka Rotary Club. Condolences may be sent to Rev. Diane Mettam, 4381 Cedar St., Eureka, CA 95503.

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Lyn Anderson was born in Puyallup, Washington on August 27, 1947. She passed away on August 20, 2024, in Fortuna.

Lyn was the eldest child of 5 born to Emil and Inez Blomberg. She graduated from McKinleyville high school in 1965. She accomplished several things throughout her life such as going to school for cosmetology and later getting her CNA. She worked for many years at Sea View Conv. Hospital beginning as a CNA, then doing physical therapy and eventually becoming the office manager. She then ventured out doing transcription and running the office for Psychiatry & Psychology Assoc. led by Dr. Tanenhaus and Dr. Clausen where she retired.

Lyn enjoyed reading every night before bed, traveling, crafting, camping, cooking and spending time with her family. She spent many summers in South Lake Tahoe and visiting her father in Nevada. She loved hot tubbing, raising her fur babies and gardening while living many years in Arcata with her husband. She was an amazing, loving, devoted mother to her four children who are heartbroken at this loss.

She was blessed with 15 grandchildren and 7 great-grandchildren who love her dearly. Lyn made many friends in her life, who would describe her as the kindest, most genuine, and loving woman they have ever met.

Lyn is preceded in death by her parents Emil and Inez Blomberg, her brother Mark Blomberg, grandson Matthew Middleton, her grandparents and many aunts and uncles. Lyn is survived by her husband Richard Anderson of Fortuna, her brother Terry Blomberg (Sonya), sisters Randi Whitney (Lonnie) and Jeri Pettit. Her children Tracie Middleton (Jim), Anthony Hernandez (Elesha), Lori Hutchinson (Joe), and Matthew Hernandez. She will be greatly missed by all those who knew and loved her!

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Quite a few Humboldt County residents with sub-par internet access will soon be net surfin’ and content streamin’ at broadband speeds thanks to a new wave of state grant money slated for final approval next month.

Last week, the California Public Utilities Commission recommended awarding Humboldt County more than $35.3 to complete several broadband infrastructure projects aimed at enhancing connectivity and bridging our region’s digital divide. Plus, there’s another $14,111,494 in recommended grants from the CPUC that would fund multi-county projects that include Humboldt.

The Humboldt County projects include:

• The Karuk Tribe Fiber-To-The-Home Project, recommended to receive up to $27,445,463 to serve an estimated 767 currently unserved people in and around Orleans.
• The Vero Fiber Networks Arcata Bay Project (which we’ve written about before), receiving up to $4,396,29. This project will eventually serve residents along the 299 corridor, but in the short term this grant award would benefit 244 unserved locations in Indianola, Fairhaven and Manila.​
• A trio of AT&T projects, with a suggested award of $3,462,021 to serve unserved communities including Myers Flat, Miranda, Phillipsville, Weott and Kneeland.

The projects also commit to providing low-cost plans, maintaining prices for years, and participating in programs like Lifeline to ensure affordability and accessibility for residents. 

Press release from the incident management team:

• Acres: 12,907
• Crews: 25
• Containment: 43%
• Engines: 47
• Detection Date: August 9, 2024
• Dozers: 7
• Cause: Under investigation
• Helicopters: 11 + 2 UAS
• Total resources: 886
• Fixed wing: available as needed

Headlines

•Traffic control remains in place along the Salmon River Road between Butler Flat and Nordheimer Flat for the safety of firefighters and residents. Expect up to 30-minute delays. Incident personnel driving vehicles with more than two axels will not be allowed on the road.

•Fire information phone: (707) 572-4860 or email at 2024.Boise@firenet.gov

•Get all your Boise Fire information in one mobile-friendly place! See this link.

•Evacuations are in place for residents near the fire area in Humboldt County. For the most current evacuation information please visit the Boise Fire linktree or visit— or visit—

✓Humboldt County: Link.

✓Siskiyou County: Link.

Leader’s Intent

The Boise Fire is being managed with a full suppression strategy.

Operational Update: On the west side of the fire, firefighters continue to mop up, patrol, and chip vegetation along the roadways. Some damaged roads have been repaired to allow crews to access the fire’s edge. Two new spike camps have been created along the east side of the fire to decrease the travel time for crews. Additionally, new heli-spots have been created to facilitate the movement of equipment and personnel. Multiple crews are being inserted into the China Creek area to create handline along the fire’s edge.

Weather and Fire Behavior:

Drier and warmer weather is expected to return to the area. With the recent moisture, no significant fire movement is expected. As conditions continue to dry, fire activity may pick up.

During Zuleima Baquedano’s first year as a teacher, she faced an important choice.

One of her students had difficulty controlling her emotions. One day, she had a meltdown and kicked Baquedano down.

The principal asked Baquedano if she wanted to call the police, because the incident legally counted as assault. But not long before, the student had moved in with her family after being in and out of foster care, was beginning the diagnostic process for her disability and had been working with Baquedano on coping mechanisms.

“Any contact with police would have really put all of that in jeopardy,” Baquedano said. “Calling the police, getting Child Protective Services involved and all that would have completely just ruined any kind of progress she’d made.”

Baquedano decided against calling the police. “I’m never going to regret advocating for her, despite the fact that several teachers told me I couldn’t let her get away with it, and that she did this on purpose when they didn’t even know her,” she said.

She had a choice because she worked at a charter school in Los Angeles. Staff at traditional public schools don’t have the same freedom: Under California law, they are required to make a police report if a student assaults them — and can be prosecuted if they don’t.

A bill before the Legislature in its final week would change that.

But what supporters see as a common sense bill, opponents see as going too far, raising partisan tensions in an election year in which crime and education are top of mind for many voters.

A difficult path to the Senate

Assemblymember Ash Kalra, a San Jose Democrat, has been trying to get similar legislation passed for four years.

“The data very clearly shows that when law enforcement is required to come onto campus, those that they choose to arrest are disproportionately people with disabilities and students of color,” Kalra said in an interview.

A 2021 study by the ACLU of Southern California found that students with disabilities make up 26% of school arrests, despite being 11% of total enrollment. According to a 2024 report by the California Racial and Identity Profiling Advisory Board, students of color are handcuffed by police at a disproportionate rate — 20% of Black students compared to 9% of white students.

“This bill is really a turning point in addressing issues around school climate,” said Oscar Lopez, an associate managing attorney at Disability Rights California, a sponsor of the bill.

Assemblymember Ash Kalra at the state Capitol in Sacramento on June 13, 2023. Photo by Semantha Norris, CalMatters

This is the first time Kalra’s bill has made it to the Senate, and it wasn’t easy. It barely squeaked out of the Assembly by a vote of just 41-22, with seven Democrats voting “no.”

“It’s unfortunate that a common sense bill like this has struggled so hard to make it through the Legislature,” Kalra said.

And opposition is organizing.

Last week, Senate Republicans released their own bill analysis, listing concerns about school safety, drug possession and the relationship between schools and law enforcement.

“The bottom line is this is going to make our school campuses less safe,” Senate GOP Leader Brian Jones of San Diego told CalMatters. “It’s going to endanger our students, teachers, administrators and even the law enforcement professionals who have to serve on these campuses.”

Law enforcement officials worry that AB 2441 could open the door to eliminating school resource officers.

“School officials and law enforcement should work together, especially when it comes to pupils whose behavior violates the law and puts school safety in jeopardy,” said Cory Salzillo, legislative director of the California State Sheriffs’ Association. “Removing requirements just runs counter to that notion.”

If AB 2441 were to pass, there would still still be times when staff are required to call the police. Under federal law, local education agencies must call law enforcement if a student has a firearm or is caught selling controlled substances.

“School officials and law enforcement should work together, especially when it comes to pupils whose behavior violates the law and puts school safety in jeopardy.”
— Cory Salzillo, legislative director of the California State Sheriffs’ Association

Some opponents have also raised concerns about school administrators’ ability to discern between students who are selling controlled substances or just possessing them — a task they think should be left to law enforcement, particularly amid the fentanyl crisis.

“Schools are not isolated in the community, so when there are crimes being committed, even if it’s simple possession of a controlled substance, that’s something that law enforcement should be aware of,” Salzillo said.

The California Department of Public Health plans to announce a new fentanyl education campaign on Wednesday.

“Fentanyl is so dangerous that we need to be all hands on deck on dealing with that crisis on our school campuses,” Jones said. “Removing this requirement of reporting is just unbelievable to me at this point in time.”

Because of an amendment to the bill, staff would also need to notify law enforcement if someone needed immediate medical attention.

After the Senate Republican Caucus released its analysis — and sent it to its entire press list for the first time — supporters of the bill accused them of fear mongering and spreading misinformation.

“There’s been a lot of untruths shared and promoted by the opposition to this bill,” said Rachel Bhagwat, legislative advocate at ACLU California Action, a bill sponsor.

Jones denied that’s what’s happening.

“California voters and taxpayers are fed up with the criminal justice system in California right now,” he said. “They’re fed up with the progressive wing that’s continuing to decriminalize crime.”

Preventing the school-to-prison pipeline

Research has shown that when young people face severe discipline at school — such as police interaction, suspension or expulsion — they are less likely to graduate high school and more likely to go to prison.

“The interpretation of normal, age-appropriate behaviors as being threatening and criminal and dangerous is leading to a situation where young people are not getting educational opportunities in school, and they’re being funneled into further criminal contact and the criminal system,” Bhagwat said.

Under current state law, staff are required to try other methods — such as meeting with parents, speaking with a psychologist, creating an individualized education plan or restorative justice programs — before resorting to something more severe.

“Between counseling and other programs, there are methods to use that don’t involve punitive consequences such as a misdemeanor crime,” Naj Alikhan, senior director of marketing and communications for the Association of California School Administrators, wrote in a statement to CalMatters.

The bill would also get rid of a clause that makes it a crime to “willfully disturb” public schools and meetings. Under this provision, students could be criminally prosecuted for running in hallways or knocking on doors.

“It’s somewhat of a vague term,” Kalra said, “and it’s been used against students who might have behavior issues. There’s a lot of different reasons why a student may be causing a disturbance and we want to give schools the ability to decide how they want to handle those situations.”

“There’s an assumption that we’re going to stop calling the police, and that’s not the case. The idea that we wouldn’t have that common sense is a little insulting.”
— Zuleima Baquedano, a charter school teacher

An amendment to the bill would make it an infraction for someone to prevent a school staff member from calling the police.

Baquedano — who testified on the bill before the Senate education committee in July and now teaches in Santa Ana — said that if the bill passes, there are serious situations, like having a deadly weapon or being in possession of drugs, where she would still call.

“There’s an assumption that we’re going to stop calling the police, and that’s not the case,” she said. “The idea that we wouldn’t have that common sense is a little insulting.”

It’s a decision Baquedano said teachers deserve to have.

“People should trust us — the professionals in the situation, who’ve been trained, who’ve gone through education to do this — they should be trusting our judgment,” she said. “We’re the ones who best know our students. We spend all these hours with them a year, sometimes more than parents do.”

Kalra remains optimistic that AB 2441 will pass the Senate this week and make it to Gov. Gavin Newsom’s desk.

“You would hope,” he said, “that legislators would understand the need for us to support all students, and I’m hopeful that at least we can get this bill through to see that it’s not going to create some doomsday outcome.”

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CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

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This story, produced by CalMatters, is published jointly with San Diego Magazine.

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Colorful collages line the hallways of Best Start Birth Center in San Diego, the squishy faces of hundreds of newborns carefully cut out and framed. A picture of executive director Karen Roslie’s son, born in 2003, hangs among the smiling, crying and squinting babies.

Thirty years ago, Roslie’s mother, Roberta Frank, opened Best Start after training to become a certified nurse midwife. Since that time, state agencies and national organizations have recognized the birth center as a model for alternative birth practices. The Canadian health ministry even visited in the 1990s as it developed plans to fund midwifery services, Roslie said.

But in March, Best Start closed its doors, unable to keep up with escalating costs. TRICARE, a major military insurer and Best Start’s biggest contractor, wouldn’t pay for licensed midwives — only nurses, who can make much more money in a hospital. In a community where the Navy is a major employer, it was a debilitating blow to the birth center. The photos Roslie meticulously framed over the years will most likely have to be destroyed to avoid any medical privacy violations — evidence of more than 5,600 births shredded.

“It feels like I’m mourning a death,” Roslie said, gazing at the pictures.

Best Start was the first licensed and accredited birth center in California, and even those credentials couldn’t save it. In fact, they may have hindered the birth center’s survival, requiring expensive renovations that many midwives say aren’t relevant to the care they provide or the safety of their practice. Its closure was one of at least 19 birth center shutdowns and service reductions in the past four years, according to the California chapter of the American Association of Birth Centers.

Those closures deepen a crisis of declining women’s health services across California. More than 50 California hospital labor and delivery wards have closed in the past decade, creating maternity care deserts in rural communities and overburdening the remaining labor wards in cities and suburbs.

Health experts have pointed to birth centers as a way to expand capacity in communities where hospitals no longer deliver babies. The midwife-run clinics handle low-risk births and direct higher-risk pregnancies to hospitals.

Left to right, Founder Roberta Frank and Executive Director Karen Rosalie at the Best Start Birthing Center in San Diego on March 20, 2024. Photo by Ariana Drehsler for CalMatters

But California has some of the toughest licensing requirements in the country, according to the American Association of Birth Centers, and facilities such as Best Start have long argued that California’s onerous regulations and an uncooperative Public Health Department prevent them from succeeding.

Only six operating birth centers are licensed in California. Another 26 are unlicensed. Licensure isn’t required, but it helps enable a practice to work with insurance plans and serve lower-income families who can’t pay birthing costs out of pocket.

Increasingly, only wealthy families who pay cash can afford a midwife.

“The system is just a mess. It’s flawed. It’s set up to prevent providers that can provide really good care from even getting started,” Frank, the founder of Best Start, said.

While most California births happen in hospitals, birth centers serve a small but growing number of families. Planned out-of-hospital births attended by midwives have doubled over the past decade even as birth rates overall declined, according to data from the Medical Board of California. And a statewide survey conducted in 2018 by the California Health Care Foundation indicated that more than one-third of pregnant people would be interested in having a midwife for a future birth.

Frequently, those who seek the services of midwives and birth centers cite the desire for more personalized care, or poor experiences with previous hospital births. Studies show that for low-risk pregnancies, midwife-led deliveries at birth centers are safe and lead to fewer interventions such as cesarean sections.

“Women deserve this,” Frank said. “Every human deserves to find their own strength, find their place, exercise their initiative, and I wanted to share it.”

But even as demand for out-of-hospital births increases, birth centers across the state are shutting their doors, unable to withstand the joint battering ram of financial and regulatory challenges.

Last year, the Santa Rosa Birth Center stopped delivering babies, reducing options in a Wine Country community that recently lost a hospital maternity ward and another birth center.

A Sacramento midwife closed her birth center in February and left the country because she said California’s health system was too unfriendly to make ends meet. Another Sacramento birth center is also on the verge of closure because it cannot get a state license.

Midwife Madeleine Wisner measures and checks Chloé Mick’s belly during a maternity care consultation at Mick’s home in Sacramento on Feb. 6, 2024. Photos by Miguel Gutierrez Jr., CalMatters

In September, Monterey Birth and Wellness Center will close, citing high costs and poor insurance reimbursement.

The California Public Health Department refused multiple requests for an interview about licensing, responding only to emailed questions. Licensing requires facilities to meet “minimum standards” for patient care, which include regulations about proper equipment and staff competency, the department said in an unsigned statement.

“We cannot speculate or comment on any reason why providers chose to close these facilities, aren’t seeking licensure for new (birth centers), or what could be done to improve the process,” the department statement said.

Years-long wait for a health department license

Nancy Myrick, a co-founder of the San Francisco Birth Center, said it took four-and-a-half years of back-and-forth with the state health department to obtain a license. In one instance, Myrick said, she asked for a list of items an inspector would check and the health department referred her to regulations that had not yet been written.

“In the process of opening, the state bureaucracy was like the Great Wall of China. It was such a horrible barrier,” Myrick said.

It wasn’t until Myrick called her state assemblymember’s office to complain about the inability to get licensed and see Medi-Cal patients that the application was approved, she said. The birth center was licensed in 2020.

“It literally took calling in the political dogs to get it done,” Myrick said.

Many providers noticed that getting a license became much more difficult after the state centralized the process under the public health department in 2018. Since then, nearly all birth center applications — 11 out of 13 — have been rejected, according to department-provided data.

The department said in a statement the change was necessary to improve “standardization and consistency” in licensing multiple kinds of facilities. Previously, the department’s 14 regional offices processed applications and approved 11 out of 12 applications.

Yet midwives and advocates say obstacles continue to plague the process. It’s slow, often taking years; it’s expensive, costing tens of thousands of dollars to retrofit buildings and maintain a license; and the standards are frequently at odds with midwives’ scope of practice. What results is a “de facto ban” on birth center licensure in California, said Sandra Poole, a lobbyist with the Western Center on Law and Poverty.

Without licensing reform, more birth centers will close, said Bethany Sasaki, president of the state chapter of the American Association of Birth Centers.

Sally K., right, thirty-eight weeks pregnant, talks to midwife Andrea Bergleen, left, during a check-up at the Best Start Birthing Center in San Diego on March 20, 2024. Photo by Ariana Drehsler for CalMatters

A key problem, Sasaki said, is that birth centers are expected to comply with building standards designed for hospitals. For example, the standards include negative pressure rooms for infection control and cast iron plumbing for water supply and drainage.

Many midwives argue the standards don’t make sense because their patients are legally required to be healthy with low-risk pregnancies. Any condition that would require the additional medical intervention the standards are meant to accommodate, such as surgery, would force the patient to be transferred to a doctor or hospital, Sasaki said.

“There’s no reason to hold a birth center to the same standards as a hospital because it’s not a hospital, and that’s the whole point, Sasaki said.

According to the state Department of Health Care Access and Information, which sets building codes for health facilities, it would take legislative changes to make exceptions for birth centers. Poole and a number of groups representing midwives and Black maternal health advocates tried to introduce a bill earlier this year that would ease licensing requirements but were unable to find a legislator to carry it.

The state denied Sasaki’s licensure application for Midtown Nurse Midwives in Sacramento in 2020. The holdup is the building’s ventilation system, which doesn’t meet hospital building code.

In March, Sasaki requested an appeal and emergency license after TRICARE, the same insurer that Best Start relied on, stopped contracting with unlicensed facilities. As of mid-July, she has not received a response from the state, though the department told CalMatters the appeal deadline for Sasaki’s application had passed.

Without the TRICARE contract, which made up about 30% of her clients, Sasaki said the birth center will close by November.

“We’ve had to turn away so many people that we stopped answering our phone, because I don’t want to listen to another person cry,” Sasaki said.

Birth centers must get licensed for Medi-Cal

Why is licensure such a stumbling block for birth centers? Medi-Cal, the state’s public insurance program for low-income families, pays for half of all births in the state, and it requires birth centers to be licensed.

“The single biggest thing that will help with sustainability is if birth centers can take Medi-Cal and if Medi-Cal can actually reimburse appropriately,” Sasaki said.

The majority of Medi-Cal births — more than 80% — are babies of color. A statewide survey also indicates that people of color, particularly Black women, want alternative birth support such as midwives and doulas more than any other demographic group. White women and those with private insurance were the highest users of midwives, the survey shows. While those who wanted a midwife but didn’t use one most commonly cited lack of insurance coverage as a barrier.

Birthing rooms at the Best Start Birthing Center in San Diego on March 20, 2024. Photos by Ariana Drehsler for CalMatters

Caroline Cusenza, a midwife and owner of the Monterey Birth and Wellness Center, said taking insurance allowed her to serve a more diverse population in the working class Latino enclave where the birth center is located. She wanted to take Medi-Cal patients, but couldn’t. Cusenza applied for licensure twice but was also rejected because the building didn’t meet ventilation standards.

The birth center will close in September after seven years.

“It was a hard decision to walk away, but we really just could see no path forward,” Cusenza said.

The Western Center for Law and Poverty has pointed to accreditation as a possible alternative to licensure. The Commission for the Accreditation of Birth Centers is the national organization that sets standards for birth center quality and safety. California regulators have used accreditation to help license other kinds of health facilities, but health department officials see no need to provide birth centers with alternate options. They argue, in an email to CalMatters, that very few have tried to get a license in the first place. Only 23 birth centers have applied in the past decade.

Holly Smith, a certified nurse midwife and co-lead of Midwifery Access California, contends the low number of applicants reflects the difficulty of the process. Midwives know licensure is nearly impossible, so they don’t bother applying, Smith said.

“If (the Public Health Department) can be much more involved in figuring out solutions to help birth centers exist and be licensed should they want to be, then we would see a greater proliferation of it,” Smith said.

Midwifery Access California is working with another state agency to improve access for low-income patients, Smith said. The advocates hope to convince the Department of Health Care Services to increase Medi-Cal payments to midwives. Right now a licensed birth center gets about $1,300 per birth while the midwife gets $400.

At those rates, some birth centers say even Medi-Cal wouldn’t be enough to save them.

“If our birth center were to accept Medi-Cal, we would go bankrupt,” said Trisha Wimbs, owner of the California Birth Center in Rocklin.

Wimbs’ facility was one of only three birth centers to get licensed since the public health department took over and tightened building codes. It was licensed in 2023. Wimbs said it cost $1 million to build the “hospital grade facility” to code, including $80,000 to move a fire hydrant two feet closer to the building. The birth center does not take Medi-Cal because it pays too little to recoup expenses. Instead, the birth center caters to cash pay and commercially insured clients in the affluent suburb of Sacramento. Licensure was essential to securing commercial insurance contracts, Wimbs said.

To sustain birth centers, Medi-Cal needs to pay around $8,000 per birth, Smith said. At that price point, delivering at a birth center would cost less than half as much as a hospital delivery.

Saying goodbye to Best Start

Eighteen years ago, Ellary Alonso was born at Best Start Birth Center when her mom, a former labor and delivery nurse, sought a more personalized birth experience. Alonso, who was 21 weeks along in March, wanted to deliver her son in the same place, surrounded by midwives she knew, maybe even in a bath. She wanted the emotional support of the team, she said, because her husband is a Marine, and there’s no guarantee he’ll be able to make it to the birth.

But a week before her first prenatal appointment at Best Start, Alonso got a call that the center was closing permanently. No other birth centers in Southern California take her insurance.

“In this time when everything is about choice, you can choose not to have a baby, but you can’t choose how to have your baby,” Alonso said. “Hospitals are the only option.”

Ellary Alonso, right, 18 years old and twenty-one weeks pregnant, with her mom Hannah Fraley, left, at the Best Start Birthing Center in San Diego on March 20, 2024. Fraley had two of her kids at the center. Photo by Ariana Drehsler for CalMatters

Compared to a hospital room, Best Start offers a homey atmosphere and the promise that the midwife attending each birth will be familiar to the laboring client. The birthing rooms come with queen-sized beds, floral duvets, and white porcelain tubs for water births. A marble-topped “crash cart” sits in each room. With the doors closed, the cart looks just like an end table that matches the decor. Inside it’s filled with medical supplies for emergency resuscitations or to stitch up lacerations. The rooms are homey, but bear the hallmarks of a by-the-book clinic. Boxes of nitrile gloves are in each room, hazardous waste bins are mounted discreetly to the wall. Best Start was the only birth center in the state to have a licensed clinical laboratory to confirm water breakage.

It has never lost a mother or baby, Roslie said. Its transfer rate for cesarean sections was less than half the statewide target set for low-risk births. In the past five years, no episiotomies have been performed. And 96% of newborns are exclusively breastfed before leaving Best Start compared to the statewide hospital rate of 69%.

Despite the center’s recognized success, keeping it running has always been a labor of love, Roslie said.

“It’s never been a thriving business,” Roslie said. “Roberta’s gone without pay. I’ve gone with reduced pay. That’s what it takes to run a birth center.”

When Roberta Frank, Roslie’s mother, graduated from UC San Diego with her nursing midwifery degree in 1981, she was told “San Diego will never accept midwives.”

Sometimes — in the face of Best Start’s closure — it still feels that way.

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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.

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