What if you had to go to the hospital, and when it came time to return home your landlord said you couldn’t move back in? Across the country, thousands of nursing home residents face that situation every year. In most cases, it’s a violation of federal regulations. But those rules are rarely enforced by the states. So, in California, some nursing home residents are suing the state, hoping to force it to take action.

One of the plaintiffs is Bruce Anderson. Currently, he lives in a hospital room at the Sutter Medical Center in Sacramento. He’s been there since May 28, 2015. That’s when his former nursing home sent him to be treated for pneumonia. When he was cured, the nursing home refused to re-admit him. The hospital hasn’t yet found him another nursing home to go to. So this hospital room has been his home for 260 days. The cost to Medicaid to keep him there is about 2.5 times what his nursing home cost.

Bruce Anderson has a severe brain injury. It happened 11 years ago, when he had a heart attack and went without oxygen for several minutes. He was just 55 years old, and has lived in nursing homes ever since.

When his daughter Sara Anderson comes to visit, she asks what he did all day. He replies in a gravelly voice: “Nothing.”

At the nursing home, Sara explains, there were activities for her dad. Bingo was a favorite. And the family could take him on outings. But when you’re in a hospital, you can’t simply come and go as you please. So Bruce Anderson has just been sitting in his bed for the past nine months.

He has good days and bad days, says his sister, Sonja Bentley, who visits along with Sara. This is one of the good days, Bentley says.

Sara agrees: “He knew my name.”

And that’s rare, since Bruce Anderson usually thinks he’s still in his 30s. Back then, Sara was only a baby. When she and Sonja visit now, they reminisce with him about his glory days, when he was a hunter, a fisherman and a well-known prankster in his small, Central Valley town. Everybody remembers him, says Sara.

“Every single one of them goes, ‘Oh, Bruce! He tried to drive a jeep up a tree once.’ Or they all have some story about him,” Sara says. “He was a legend.”

Anderson is still a hell-raiser, but not in a good way, according to his former nursing home, Norwood Pines Alzheimer’s Care Center. The home’s legal representatives wouldn’t comment. But in a recent court document they say that Bruce Anderson was combative, a danger to the staff and other residents. That would have been a legal reason to discharge him. Yet Norwood Pines never tried to do that in the nearly four years Bruce lived there.

So Sara Anderson was shocked when Norwood Pines wouldn’t take him back. She appealed to the California Department of Health Care Services, which oversees Medicaid. The department held a hearing. And she won. Norwood Pines was ordered to readmit her father.

The nursing home still refused.

That’s no surprise to Tony Chicotel, a staff attorney with California Advocates for Nursing Home Reform.

“We have lots of cases where the state has found that it’s appropriate for the residents to return, but then they don’t do anything afterward,” says Chicotel.

That’s why his organization has joined with Bruce Anderson and two other nursing home residents in suing the state of California. They want a federal judge to make the state enforce its own rulings.

One reason that doesn’t happen, says Chicotel, is that the department in charge of the appeal hearings for such evictions (the Department of Health Care Services) has nothing to do with disciplining nursing homes. That’s the job of the Department of Public Health.

“It’s easy to describe this situation as a Catch-22,” says Chicotel. “Each agency does its own thing and they don’t work together very well and the residents fall through the hole. But at this point I think [the problem] is indifference.”

Chicotel says the residents most likely to be refused re-admission fit a particular type. First, they’re all on Medicaid, which pays nursing homes less than they get from Medicare or private insurance. Second, he says, these are patients who are behaviorally difficult to manage — for example, “residents with mental health issues or significantly advanced dementia, or maybe traumatic brain injury.” They’re undesirable, says Chicotel, “because they might take a disproportionate amount of labor-time.”

In other words, they’re expensive to care for. Bruce Anderson, for example, requires someone to watch over him 24/7.

This is not just a California issue. Nationwide, between 8,000 and 9,000 people complain to the government about nursing home evictions every year. It’s the leading category of all nursing home complaints, according the federal Administration for Community Living.

Robyn Grant thinks the problem is even larger than reported. And she would know. She’s the public policy director for the non-profit National Consumer Voice for Quality Long-Term Care, so she hears about many nursing home evictions around the country like the ones in California.

“A lot of individuals, residents and their families, if they’re told ‘you have to find another home,’ just accept what the people in authority tell them and don’t think they have any choices,” Grant says. “They may not know that they have rights to challenge that eviction.”

California officials wouldn’t comment because of the lawsuit. But in their motion to dismiss it, they argue that nursing home residents already have plenty of options for defending their rights. Deborah Pacyna agrees. She’s the director of Public Affairs for the California Association of Health Facilities, which represents nursing homes.

Nursing home residents can complain to the Department of Public Health, says Pacyna.

“The Department can then investigate,” she says. They can impose daily fines, force the facility to put in a plan of correction. So, in our view, there are plenty of regulations on the books.”

But California’s Department of Public Health rarely uses those rules. State records show that, on average, just 11 nursing homes are fined each year for wrongly discharging a resident. And the average fine is only around $2,000.

Meanwhile, California taxpayers have paid well over $100,000 to keep Bruce Anderson in a hospital room that he tells his sister he can’t wait to leave.

“I know,” Bentley says, trying to soothe him. “We’re going to get you out of here. We are.”

Though when that might be — and where he’ll go — no one in the family knows for sure.

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A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, N.C., it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable. The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed.

Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.

“It was kind of scary for a while,” Murphy remembers. But at the time the staff of the local, 25-bed hospital included Murphy, two other family physicians trained in obstetrics and experienced nurses — so the situation was manageable. Both mother and baby were fine.

Things are different now. Alleghany Memorial, like a growing number of rural hospitals, shuttered its labor and delivery unit several years ago. Pregnant women have to travel either to Winston-Salem or to Galax, Va., about 30 minutes away by car, weather permitting.

“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, says Murphy, who teaches at the Cabarrus family medicine residency program in Concord, N.C. For prenatal care, women typically see the physician they expect will handle the delivery, though that’s not essential.

Each year, about 500,000 women in the United States give birth in rural hospitals, yet easy access to labor and delivery units has been declining. Though comprehensive figures are spotty, a recent analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

“The fact that closures continue happening — over time that means the nearest hospital gets farther and farther away,” says Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health. She co-authored the analysis, which appears in the January issue of Health Services Research.

There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

“A labor and delivery unit is functionally no different than an intensive care unit,” says Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. Staffing requirements are high in obstetrics — often one nurse for every patient — and the rooms typically include monitors, infusion pumps and other equipment.

It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and may rely instead on local family physicians. It also can be difficult to get enough of these doctors to fully provide services for a hospital, and nurses with obstetrics experience can be scarce as well.

Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be tough because insurance payments are often low.

Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, says Kozhimannil. Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she says.

Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.

For example, encouraging medical professionals to move to rural areas is key, they say. A bipartisan bill introduced in Congress last year would require the federal government to focus efforts on areas that are experiencing a shortage in health professionals who specialize in maternity care. Such designations exist for primary care, mental health and dental care.

The National Health Services Corps awards scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in a designated shortage area. Once they get to a community and put down some roots, the hope is that they’ll stay.

Expanding the use of midwives and birthing centers could be cost effective, too, since they are generally less expensive than physicians and hospital obstetric units.

“You can deal with lower volume and still be sustainable,” says Shah.

Kozhimannil sees great opportunity in the ongoing national dialogue about health reform. But so far, much of the research has focused on reforming health care in cities.

“That’s why,” she says, “it’s crucial to have rural people at the table.”

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As the drug-related death toll rises in the United States, communities are trying to open more treatment beds. But an ongoing labor shortage among drug treatment staff is slowing those efforts.

Each year, roughly one of every four substance-abuse clinicians nationally chooses to leave the job, according to recent research. And that’s not just turnover — leaving one job for another in the same field. As an Institute of Medicine report documented in 2006, there’s been a shortage of addiction workers for decades. And the demand is only increasing; the Affordable Care Act and other federal laws have given millions more people insurance to help them pay for those services. If only there were enough counselors to treat them.

Amelie Gooding runs Phoenix House in Keene, New Hampshire, and says she’s been short a full-time counselor for a year and half.

“Everybody thinks, “Oh, there aren’t enough beds!” Gooding says. “But there’s not enough treatment staff to open more beds.”

Because she’s understaffed, Gooding has to leave three of her 18 residential beds empty. And she cut her outpatient groups down to 50 percent capacity.

So where have all the counselors gone?

“For me, it got to be … too heavy,” says former counselor Melissa Chickering, who used to work for Gooding at the Phoenix House, and still lives in the area.

Clinical directors would give their right arm to hire someone with Chickering’s long resume, Gooding says. She has a Master’s degree in social work and 10 years of experience. Instead, the valued counselor now spends her days teaching courses in psychology and health sciences at local New Hampshire colleges.

The problem with addiction treatment, Chickering says, is you take on your clients’ pain. Plus, she says, she found the lack of funding and coordination from the state “criminal.”

She remembers a particularly bad time when she was running an addiction program for teenagers.

“I had open beds,” she says. “But … a girl came in and was on the waiting list — she just didn’t have the right funding.” Because of the rules, Chickering had to reserve empty beds for clients who had a different kind of health insurance than the girl in front of her had.

“So she died while she was sitting on the waiting list,” Chickering remembers. “And I went home that night, and I was like, ‘I had an open bed!’ “

“How do you sit with that and be OK the next day?” she asks.

And the problem isn’t just burnout, other addiction counselors say, though the job entails many late nights and loads of paperwork. The biggest problem, they say, is the low pay — though wages vary around the country, addiction counselors earn an average of about $40,000 a year, according to the Bureau of Labor Statistics.

Anne Herron leads workforce development for the federal Substance Abuse and Mental Health Administration — the agency that oversees services for the treatment of substance abuse. Federal officials are well-aware of the counseling shortage, and are working on it, Herron says. Her agency is reaching out to high schools and colleges, developing training curricula.

Those initiatives are a start, she says, adding “we would like to see more.”

Becky Vaughn, an executive with the National Council for Behavioral Health, an industry group for state associations of addiction services, says she would like the federal government to reimburse tuition for people who are taking courses in addiction treatment.

In the meantime, the directors of a few clinics in New Hampshire say that the expanded coverage for addiction services that has come with Obamacare is already boosting counselor salaries. Staff will come, these employers say – if the clinics have the money to pay them.

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The HPV vaccine has lowered the number of women with HPV, a sexually transmitted disease that can lead to cancer, according to a study in the journal Pediatrics. NPR’s Audie Cornish talks to Dr. Joseph Bocchini from Louisiana State University to get his read on the results.

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Hillary Clinton wants you to know that she was doing health care before health care was cool.

“You know, before it was called Obamacare it was called Hillarycare,” Clinton said recently at a rally in Elko, Nev.

It’s a stock line these days in her stump speeches and debates.

The term Hillarycare was coined back in the 1990s, when Clinton tried and failed to restructure the U.S. health care system during her husband’s first term as president. It was supposed to be an insult, but now she’s embracing it.

That’s because Clinton-the-presidential-candidate has made the Affordable Care Act — or Obamacare — the center of her health care plan.

She’s not looking to be a revolutionary like her opponent, Vermont Sen. Bernie Sanders. He wants to replace private health insurance with a universal health care system in which the government pays the bills.

Instead, Clinton has gone all in with Obamacare, embracing the controversial health law and promising to defend and expand it.

“I am a staunch supporter of President Obama’s principal accomplishment, namely the Affordable Care Act,” she said in a debate in Milwaukee on Feb. 11.

Her plan to expand Obamacare consists of a slew of wonky measures that together are intended to cut costs and improve coverage for patients.

“There are as many as 20 separate proposals and none of them by themselves are giant proposals. Each one is an incremental step,” says Drew Altman, president of the Kaiser Family Foundation. “But taken together it actually is a significant package of what I think of as beyond the ACA, consumer-oriented proposals.”

Among the ideas:

• Create a tax credit for people whose out-of-pocket costs amount to more than 5 percent of their income.
• Guarantee three sick visits a year to a doctor without having to meet a deductible.
• Eliminate drug companies’ ability to deduct marketing costs from their taxes. No more discounts for all those TV ads hawking pills.
• Require a minimum investment by pharmaceutical companies in research and development.
• Make it harder for health insurance companies to merge.

Altman says Kaiser Family Foundation polls show voters are frustrated because they keep paying more for health care. Employers are shifting more and more of their health care costs onto employees. As a result, deductibles have more than tripled in the past 10 years and copays are also on the rise.

Clinton’s proposals are designed to reduce those out-of-pocket costs.

“Her bona fides as knowledgeable on health insurance really are beyond question whether you agree with her proposals or not,” says Henry Aaron, a health care economist at the Brookings Institution. “And she understands that a lot of the changes are down in the weeds.”

But this smorgasbord of tweaks doesn’t generate huge applause like Sanders does when he promises free health care for everyone.

And many in the health care industry — including drug manufacturers — are gearing up to oppose her proposals to reduce costs by putting tighter regulations on how they do business.

“Putting in place onerous regulations and mandates that make it harder to develop new treatments and cures for patients is the wrong approach,” says Robert Zirkelbach, a spokesman with the Pharmaceutical Research and Manufacturers of America, the lobbying group for the drug industry.

Zirkelbach says medications hold down health costs because they keep people out of the hospital, which is far more expensive than almost any prescription drug. Clinton, he says, shouldn’t be making drug companies the bad guys.

“These proposals are being driven by the false notion that medicine spending is what is fueling rising health care costs in this country,” Zirkelbach says.

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Patients looking for home health care services will be impressed if they check out the federal government’s ratings of Brookdale Senior Living. Four of the company’s home health agencies — in Florida, North Carolina, Ohio and Rhode Island — each earned five stars, the top quality score, primarily based on Medicare’s assessment of how often patients got better.

But further research may lead to confusion. Medicare also posts stars to convey how patients rate agencies after their care is over. There, these same four Brookdale agencies earned no more than two stars.

“We understand that we have work to do on our patient perception results,” Kristin Puckett, a Brookdale spokeswoman, said in an email. “It is vital that our patients’ perception of their care is as positive as the outcomes from the quality care we provide.”

Such contradictory results between how patients view home health agencies and how the government rates them are hardly unusual. One in five agencies had clinical and patient ratings that differed by two stars or more, a Kaiser Health News analysis of government records shows.

Skilled home health services, where Medicare sends nurses, aides and physical and occupational therapists to people’s houses, are becoming more important amid pressures to keep homebound patients from going to the hospital. To help doctors and patients select among more than 12,000 agencies, Medicare published star ratings in 2015 for clinical quality on its Home Health Compare website, and in January it added star ratings to reflect the views of patients.

Medicare was liberal in giving top marks based on patients’ opinion scores, awarding four or five stars to 74 percent of agencies it rated. Of those, 2,152 agencies got five stars.

But for clinical quality, Medicare used a different formula that ensured three-star ratings would be most common. Only 27 percent of agencies received four or five stars. Just 286 agencies received the maximum five stars.

Only 30 agencies got five stars from both ratings systems, the Kaiser analysis found.

In a statement, the Centers for Medicare & Medicaid Service said the different star ratings shouldn’t be confusing. “CMS stresses that website users should look at all of the different types of measures available for a given provider type, including for home health care agencies,” the statement said. “By providing both clinically based and survey-based measures, CMS hopes to make available to the public a range of perspectives and information that consumers can evaluate to help inform their decision about an agency.”

As the number of quality measures has proliferated, star ratings follow other Medicare efforts to distill complex assessments into a consumer-friendly format. Medicare also assigns stars for dialysis center quality, hospital patient experience and several aspects of nursing home care.

Some of the differences between home health care patient experience and clinical quality stars can be chalked up to the fact that they focus on different facets of home health care. The clinical quality measures look at how quickly the agency began care; how much patients’ mobility improved, getting in and out of bed and bathing; how much pain and shortness of breath decreased and how many patients end up in the hospital.

The patient surveys examine how well health care workers explained to patients how to take care of themselves, and whether they treated patients with gentleness, courtesy and respect. The questionnaires also probe whether the workers checked patients’ medications for side-effects and properly explained how and why they were being taken.

“We’re really talking about very different sets of metrics,” said Teresa Lee, director of the Alliance for Home Health Quality and Innovation, a nonprofit research group. “It’s unfortunate, but maybe it’s the truth that patient experience and clinical quality of care do not go hand in hand.”

Adding to potential confusion, 41 percent of the star ratings summing up patient views are not reliable — by the government’s own admission — because fewer than 100 surveys were returned, records show. Home Health Compare warns consumers in footnotes to use the scores “with caution as the number of surveys may be too low to accurately tell how an agency is doing.” Medicare did not assign stars for agencies if fewer than 40 surveys were returned.

Brookdale’s Puckett said it has been challenging to get more patients to return the surveys, which she characterized as “complex,” particularly for the very ill. “It is important to point out that our patient population has an average age of 86 and often relies on family members, powers of attorney and/or guardians to complete” the survey, she said.

Some elder care specialists have broader reasons to question the ratings.

Dr. Joanne Lynn, a geriatrician at the Altarum Institute, a nonprofit research and consulting firm, said much of a patient’s health was beyond the control of home health workers, who can visit as infrequently as once every two weeks.

“Medicare-covered home health services are so limited, and what they are measuring includes a number of things that, for many people, are not fixable,” she said, referring to assessments of how often patients got better in their daily activities.

Instead, she said, poor ratings for an agency may reflect an absence of other important services in a region. “If you’re in an area that doesn’t have a lot of advanced care planning, has a yearlong waiting list for Meals on Wheels, and no doctors who are able to visit people at home, you’re going to be stuck with sending sick people back to the hospital,” Lynn said.

Margaret Murphy, associate director of the Center for Medicare Advocacy, a nonprofit that aids Medicare beneficiaries seeking health services, said she fears that agencies that avoid particularly sick patients may end up looking better in the ratings.

“We find that agencies don’t want to take those people on,” she said. “They can get someone who has just come out of a hospital, maybe after a heart attack and they need a little bit of watching to get back on their feet, maybe they need a little bit of therapy. But they’re going to go back to their regular life, as opposed to someone with Parkinson’s, who is losing strength and losing balance. They are a big burden on agencies.”

It is not clear how many patients use Medicare’s star ratings, and whether those who do understand them. Lee said, “If you have patients who are very sick, the question is to what extent will they be in a position, because of their health, to really look extensively at this kind of information.”

If you’d like to share your reaction to this article and your experience with a skilled home health agency, you can contact Kaiser Health News. Send an email to patients@kff.org.

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When Vermont Sen. Bernie Sanders stumps for health care for everyone, it always gets huge applause.

“I believe that the U.S. should do what every other major country on earth is doing,” he told a crowd at Eastern Michigan University on Feb. 15. “And that is, guarantee health care to all people as a right.”

The Democratic presidential hopeful basically wants to nationalize the U.S. health insurance industry, and have Uncle Sam foot the bill for medical bills, office visits and prescriptions.

Get rid of copays. Get rid of deductibles. Get rid of lots of forms.

The voters love it.

But the proposal has ignited a lively debate among left-leaning economists and policy analysts, and some are challenging his numbers.

“I like the goal of the plan,” Jared Bernstein, formerly a top economic adviser to Vice President Biden, tells Shots. “I’m not sure the numbers add up, but the aspirations add up.”

Though Sanders calls his plan Medicare for All, the system he proposes would be far more generous than the current health care program for senior citizens. It would cover more, and beneficiaries would pay far less out of pocket.?

Sanders says he can pay for it — by raising people’s federal income tax by 2.2 percent and charging employers 6.2 percent of their payroll.

The typical family would pay $466 more in premiums and save more than $5,000 in health care costs each year, according to the outline of the plan on his web site.

To back it up, he cites an analysis titled “United States Can Afford Single Payer Health Care Program” from Gerald Friedman, an economics professor at the University of Massachusetts.

Longtime backers of single-payer health plans are circling Sanders to promote his proposal. His team has posted a letter on the campaign web site signed by 130 economists, physicians and university professors endorsing the plan.

“The medical insurance industry is really a group of middlemen — there’s no need to have middlemen between paying for care and actually receiving care,” says Dr. Steffie Woolhandler, an internist and professor at the City University of New York’s school of public health at Hunter College. Woolhandler signed the letter and has written several editorials defending Sanders’ ideas.

She says such systems operated around the world and many countries spend as much as 40 percent less, per capita, than the U.S. spends on health care.

Many liberal economists and policy makers, however, disagree with the practicality of the plan, and are challenging his math regarding the cost and savings.

“The government would make public something like 8 to 9 percent of the economy that’s currently private,” says Bernstein, who is now a Fellow at the nonpartisan Center on Budget and Policy Priorities. “That would be hugely disruptive to those on that private side.”

And Kenneth Thorpe, chair of the health policy and management program at Emory University’s school of public health, estimates that Sanders plan will cost twice as much as the Senator claims.

“A single payer plan would create enormous financial winners and losers among households and businesses,” Thorpe writes in a recent analysis.

Economist Henry Aaron of the Brookings Institution called the Sanders plan an impossible pipe dream in a widely reprinted story published last month.

And four former White House economic advisers wrote an open letter to Sanders and Friedman, describing the economic claims underpinning Sanders’ proposal as “extreme.”

“As much as we wish it were so, no credible economic research supports economic impacts of these magnitudes,” wrote the economists — all former chairs of the White House Council of Economic Advisers.

One of the letter’s authors, Austan Goolsbee, of the University of the Chicago Booth School of Business, was chairman of President Obama’s council of economic advisers. He says Sanders overestimates the savings from the single-payer program and underestimates the costs and necessary tax increases.

“If you promise, ‘I’m going to take you to the finest French restaurant and give you Chateaubriand and it’s only going to cost you $2.79,’ it’s right to be a little skeptical and say, ‘How do I know you’re not going to just give me a Wendy’s spicy chicken wrap and call it a day?” Goolsbee tells Shots.

Goolsbee and other skeptics admit they don’t relish opening another gigantic fight over health care just a few years after Obama’s Affordable Care Act was signed into law.

“I was there when we were doing Obamacare and that was a really hard job,” he says. “The thought of re-fighting that battle? That does make me nervous.”

The Sanders campaign has dismissed such critics as “establishment voices” that just don’t want to disrupt the status quo.?

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