President Donald J. Trump visits approximately 200 National Guard troops Saturday, Aug, 29, 2020, at Cougar Stadium in Lake Charles, La., during his visit to view damage caused by Hurricane Laura. (Official White House Photo by Shealah Craighead)
A report uncovered Tuesday night shows federal funding potentially being slashed in sanctuary cities like New York, Portland, Ore., Washington, D.C. and Seattle, Wash. The areas on the chopping block include coronavirus relief, HIV treatment, newborn screenings, and other programs that regularly help the middle and lower class residents of these states.
In the new documents obtained by Politico, President Donald J. Trump referred to the sanctuary cities as “anarchist jurisdictions."A month earlier in a Sept. 2 order, Trump called on federal agencies to limit funding to jurisdictions that “disempower” police departments and promote “lawlessness" -- a move that stemmed from protests over systemic racism and police violence.
"My Administration will do everything in its power to prevent weak mayors and lawless cities from taking Federal dollars while they let anarchists harm people, burn buildings, and ruin lives and businesses,” Trump tweeted.
Within three weeks' time, Attorney General Bill Barr labeled New York City, Portland and Seattle “anarchist jurisdictions.” The White House budget office then instructed departments to scrutinize funding for Washington, D.C. The Office of Management and Budget (OMB) will make the final budget decisions.
“As the data comes in, OMB will collect it and make a decision,” said the official, who requested anonymity. “We need to review the information with agencies before we know. Grant programs all have different authorities so it’s going to be case by case."
“The bottom line is there's no extra money lying around, and this is not a time to be playing politics with people’s health,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, a national group that represents health departments in major U.S. cities — including the four targeted by Trump.
“This is nothing more than political retribution,” said Laura Feyer, a spokesperson for New York City Mayor Bill de Blasio.
The United States Conference of Mayors has joined officials from Seattle and New York City in threatening legal action should the Trump administration deny life-saving funding in their cities.
Bitter and earthy. Fit for instant brews only. Robusta coffee has a dire reputation, but a small group of farmers in Vietnam is trying to turn the bean's fortunes around as a warming world threatens the industry.
As an interior designer in trendy Ho Chi Minh City, Tran Thi Bich Ngoc, 42, largely stayed clear of Vietnamese coffee, puzzling over why it didn't taste as good as cups from abroad.
Now, nearly a decade later, she runs her own coffee farm -- "Mori" -- in the remote Central Highlands, cultivating robusta she believes can match the world's favorite bean, arabica, in quality and flavor.
"My beans have a fruity, flowery smell, and they taste strong -- but in a gentle way," Ngoc told AFP at her farm close to the city of Pleiku, in the heart of the Vietnamese robusta region.
"Vietnamese farmers need to know it is possible to make these beans taste good."
'Vicious circle of bad quality'
Long scorned by giants such as Starbucks, robusta -- which has almost double the caffeine content of arabica -- is found in most instant coffees, as well as some espresso blends.
Most experts agree that the bean has potential, but is stuck in a "vicious circle of bad quality", said Mario Fernandez of the Specialty Coffee Association.
"We get bad quality from robusta, therefore it gets a bad reputation, therefore no one wants to pay a premium for it, therefore there's no motivation to improve the quality," he said.
But robusta has advantages over its competitor: the yields are greater, and it can better cope with higher temperatures.
Climate change presents a serious concern for the multi-billion-dollar coffee industry, with scientists predicting lower yields and fewer areas suitable for growing.
Arabica, which makes up around 60 percent of the world's coffee production, originates in the highlands of Ethiopia and South Sudan, and prefers average annual temperatures of around 19 degrees Celsius (66 degrees Fahrenheit).
Robusta, although by no means immune to a warming world, may be able to endure up to around 23C.
Should global production of arabica start to fall short, "people will have to find an alternative supply", said Pham Thi Diep Giang, deputy director general of Trung Nguyen, one of Vietnam's top coffee brands.
A tumble in arabica supply caused by extreme weather in Brazil already helped Vietnam earn $4 billion in 2022, a 32 percent rise from a year earlier, the government said in a recent report.
At a coffee fair in Buon Ma Thuot city, farmer Hoang Manh Hung tries his best to convince visitors to take sips of his "fruity and elegant" robusta.
"I really wish more people would love robusta, as it's truly a 'wow' drink," Hung told AFP.
The 53-year-old transformed a farm that had produced low-quality coffee cherries for decades, first under the French and then his parents.
"We can now produce robusta with a completely different taste, and a scent that anyone would love," Hung said.
Key to the change, Hung said, is that the cherries are now hand-picked, and only when they're fully ripe.
"And they're fully organic," he added.
Robusta was first brought to Vietnam by the French in the late 19th century, and in 1991 the country exported its first beans -- 104,000 tonnes.
By 2022, that figure had climbed to 1.8 million tonnes -- almost all of it as raw material for instant coffee and other blends -- making it the world's largest robusta producer and the second-largest coffee producer overall, after Brazil.
Still, outside the country, "Vietnam is regarded as the lowest-quality coffee there is", Fernandez of the Specialty Coffee Association said.
Producers aiming for high quality will have "a harder time because of this perception", he added.
But there are some positive signs. The trend forecasting company WGSN says a change in attitudes toward robusta has already begun.
And Nguyen Coffee Supply -- which says it is the first specialty Vietnamese coffee company in the United States -- is now being sold by the high-end supermarket chain Whole Foods.
Meanwhile, at their hilly farms in Vietnam's Central Highlands, Hung and Ngoc are beginning to see their hard work pay off.
Their produce is gaining recognition domestically and is also being sold by online roasteries in Germany, the United States and elsewhere in Asia.
"It's the perfect time for Vietnamese fine beans to find their place in the world," Ngoc said.
Omar Buddakey emerges from a nondescript building in Los Angeles with a joint in his hand.
Five years after cannabis was legalized in California, black market transactions like this one -- where no one pays any taxes, and the product is not regulated -- remain commonplace.
"Legal shops are too expensive," the 27-year-old tells AFP, as he lights up his preroll.
Over the course of a year Buddakey estimates he saves the equivalent of a paycheck from his patient transport job by avoiding the state-sanctioned outlets.
"I'd rather pay less for the same thing. And I know it's the same thing, because it gives me the same feeling."
Buddakey's working-class neighborhood in east Los Angeles is teeming with stores like this one, many marked by a green cross.
Although they are illegal, they openly advertise online, and many have their own websites.
Inside one of them, a man who gives his name only as "Joe" welcomes a steady stream of customers who are offered a selection of buds and leaves.
Here, an ounce (30 grams) of weed sells for $100 -- $35 less than at a state-regulated store.
"Cops have raided this shop probably eight to 10 times," he tells AFP. "They take the weed, our cameras and all the cash.
"We just re-open the next hour or the next day."
'Nickelled and dimed'
A 2016 referendum legalized recreational use of cannabis in California, 20 years after it was permitted for medical use with a prescription.
The idea was to rid the streets of illegal sellers, to regulate the substance to ensure it was of sufficient quality, and to raise tax for state coffers -- goals shared by other jurisdictions, including Canada, Uruguay and Germany.
The first legal shops opened in 2018, and are now found in many cities throughout the state.
Few thoroughfares in Los Angeles are without one, from straightforward holes-in-the-wall to glitzy boutiques, where a cannabis sommelier -- or "budtender" -- can recommend the right blend, and expects a tip for their services.
But the rush of stores has not dented the size of the underground market, which has remained steady at around $8 billion a year, according to Tom Adams of Global Go Analytics.
The legal business is struggling. In 2022, sanctioned cannabis sales fell 8.2 percent to $5.3 billion.
"California is now paying for the two fatal errors it made when designing its program," says Adams. "They loaded it up with too many taxes, and too many regulations."
Indeed the rules around cannabis selling are complicated, and -- like many things in California -- are subject to separate, and sometimes overlapping, jurisdictions.
Each city or county has the final say in whether to allow the sale of recreational cannabis on its turf. As a result, less than 40 percent of them have given the green light.
The state's 40 million inhabitants can buy cannabis from 1,100 legal stores, but they are far from evenly spread, leaving a large base of customers who have no option but to buy from illegal vendors.
And in areas where trade is allowed, "we're just nickelled and dimed to death," says Nathan Holtz-Poole, of Green Goddess Collective in Venice Beach, which employs 18 people.
"Unfortunately, that is putting a real strain on the industry."
Excise and sales taxes imposed by both the California government and the city add 35 percent to the cost of weed bought legally, Holtz-Poole explains.
His lavishly decorated, herbalist-like dispensary offers everything from home-grown plants to ultra-potent cannabis concentrates, from gummies to drinks.
Despite chasing the premium sector of the market, he's not exactly coining it in, the 57-year old businessman says.
"We're barely surviving. We break even, at best."
Competition from illegal sellers eats into his bottom line, he says, estimating that he loses 30 percent of his customers to outlets who don't have to file tax returns.
It's common knowledge, Holtz-Poole says, that you can get products containing THC -- the psychoactive ingredient in marijuana that causes a high -- from some places that are only supposed to be selling CBD, a marijuana derivative that doesn't give users a buzz.
Despite his regular reports to police, "there is just no enforcement at all," he sighs. "We feel completely abandoned."
Police officers say they are climbing a mountain with one hand tied behind their backs.
"We're working our butts off," says Michael Boylls, who heads the Cannabis Support Unit in the Los Angeles Police Department's Gang and Narcotics Division.
His men carry out 300 to 400 searches a year and sometimes have illegal businesses shut down.
But sellers rarely face more than a fine and quickly return to business.
"The problem is there's no teeth in the law," he says.
Dr. Sara McLin thought she made the right choice by going to an in-network emergency room near her Florida home after her 4-year-old burned his hand on a stove last Memorial Day weekend.
Her family is insured through her husband’s employer, HCA Healthcare, a Nashville-based health system that operates more hospitals than any other system in the nation. So McLin knew that a nearby stand-alone emergency room, HCA Florida Lutz Emergency, would be in their plan’s provider network.
But McLin said a doctor there told her she couldn’t treat her son, Keeling, because he had second- and third-degree burns that needed a higher level of care. The doctor referred them to the burn center at HCA Florida Blake Hospital, about a 90-minute drive away.
McLin, who is a dentist, said the doctor told her the stand-alone ER would not charge for the visit because they did not provide treatment.
“I don’t remember exactly how she phrased it. But something along the lines of, ‘Well, we won’t even call this a visit, because we can’t do anything,’” McLin said.
At Blake Hospital, she said, a doctor diagnosed Keeling with a second-degree burn, drained the blisters, bandaged his hand, and sent them home with instructions on how to care for the wound.
“I didn’t think anything more of it,” McLin said.
Then the bills came.
The Patient: Keeling McLin, now 5, is covered by UnitedHealthcare through his father’s employer.
Medical Service: At the stand-alone emergency room, a physician assessed Keeling and sent him to another facility for treatment. “Keeling needs a burn center,” the doctor wrote in the record of his visit.
Service Provider: Envision Physician Services, which employed the emergency room physician at HCA Florida Lutz Emergency in Lutz, Florida, near Tampa, and HCA Florida Trinity Hospital, the main, for-profit hospital to which the stand-alone emergency room belonged.
Total Bill: For the emergency room visit, Envision Physician Services billed $829 to insurance and about $72 to the family. HCA Florida Trinity Hospital billed Keeling about $129, noting it had applied an “uninsured discount.” An itemization showed the original charge had been nearly $1,509 before adjustments and discounts.
What Gives: The stand-alone emergency room and ER doctor, who saw Keeling but referred him to another hospital, billed for his visit. But McLin soon learned she was unable to dispute some of the charges — because her young child’s name was on one of the bills, not hers.
Months after the ER visit, McLin received a bill addressed to the “parents of Keeling McLin” from Envision Physician Services, the provider staffing service that employed the ER doctor at Lutz. McLin recalled the doctor’s promise that they would not be billed. “I should have made them write something down to that effect,” she said.
She said she called her insurer, UnitedHealthcare, and a representative told her not to pay the bill.
She received an insurance statement that identified the bill from Envision’s doctor — an out-of-network provider working in an in-network emergency room — as a “surprise bill” for which the provider may charge only copays or other cost-sharing costs under federal law. McLin said she had not heard anything since then about the bill.
After being contacted by KHN, Aliese Polk, an Envision spokesperson, said in an email that Envision would waive the debt, apologizing to Keeling’s family “for the misunderstanding.”
She described the ER doctor’s evaluation, determination, and referral as a medical service. She said the bill was for cost sharing for the visit — not the difference between what the doctor charged and what insurance paid, as the law prohibits.
“We recognize the patient’s family may have understood at the time of treatment that there would be no charge for the visit, including the medical service provided by our physician,” Polk said. “Unfortunately, this courtesy adjustment was not captured when the claim was processed.”
Maria Gordon Shydlo, a UnitedHealthcare spokesperson, said the insurer believed the matter had been resolved and did not follow up on requests for an interview, even after McLin waived federal health privacy protections, which would allow the insurer to speak to the reporter about the case.
McLin also received a bill from HCA Florida Trinity Hospital for its stand-alone ER at Lutz and decided to dispute the charges.
But after calling the hospital to appeal, McLin said, the billing department would not discuss the debt with her because the statement was in her young son’s name.
“They had him as the guarantor,” McLin said. Unlike Envision, which billed Keeling’s parents and their insurance, McLin said the hospital listed the child as “unemployed, uninsured.”
The child’s ER record also included his date of birth and doctor’s notes referencing his age. McLin said she wrote to HCA in November asking to appeal the bill and that a billing representative told her over the phone that it would put the debt on hold and review the dispute.
“I never heard anything back and assumed we were good,” McLin said.
Then, in January, she received a letter from Medicredit, a collection agency and an HCA subsidiary, stating that Keeling owed $129 and that he had until mid-February to contest the debt. KHN was unable to make contact with Medicredit representatives, and HCA Healthcare did not respond to requests for comment from its subsidiary.
Once again, Sara McLin’s name was not on the debt collector’s letter, and she said Medicredit representatives refused to discuss the debt with her because it was in her son’s name. She said she called HCA, too. “They said, ‘We can’t help you. We don’t have the case anymore,’” she said.
Erin Fuse Brown, a law professor and director of the Center for Law, Health & Society at Georgia State University, said McLin did everything right and that it is unusual for a parent to be barred from discussing a debt related to their minor child.
“The fact that the hospital wouldn’t even talk to her strikes me as the part that is absurd. It’s absurd as a business matter. It’s absurd as a privacy matter,” Fuse Brown said, adding that federal health privacy laws allow a parent or legal guardian to access their dependent’s medical information.
Fuse Brown said the hospital should have been able to correct the error quickly with more information, such as a birth certificate or other document establishing that McLin was Keeling’s parent. At the very least, she said, it could have given McLin notice before sending the bill to collections.
“You get the feeling that it’s this large, automated process, that there’s no human to get through to, that there’s no human to talk to and override the mistake,” Fuse Brown said. “Maybe it’s routine, but she couldn’t even talk to someone to correct a correctable billing error, and then the system just steamrolls over the patient.”
The Resolution: When the collection agency’s deadline passed without resolution, McLin said she felt frustrated. “Nobody can explain to me who has to approve talking to me,” she said. “I don’t know who that person is or what the process is.”
After KHN contacted the health system, HCA Healthcare canceled the family’s debt. HCA representatives declined to be interviewed on the record despite also receiving a privacy waiver from McLin.
“We have attempted to contact Mrs. McLin to apologize to her for the inconvenience this has caused her and to let her know that there is a zero balance on the account,” Debra McKell, marketing director for HCA West Florida Division, said in an email on March 3. “We also will be sharing with her that we are reviewing our processes to ensure this does not happen again.”
McLin later received a letter from HCA stating that the account had been cleared. She also said she received a call from a customer service representative informing her that the debt had not been reported to any credit agencies.
She said she was pleased, but that patients should not have to struggle to correct a billing error before it is sent to a collection agency and potentially ruins their credit.
“It’s the principle of the thing that’s annoying me at this point,” she said.
The Takeaway: Though the notion of a debt collector pursuing a 4-year-old boy may seem farcical, it happens. When seeking medical care for a minor, it is important for the parent or guardian to ensure their name is listed as the responsible party.
Consumers who find themselves fighting a medical billing error need to “think like a lawyer,” Fuse Brown said, including documenting every interaction with the debt collector, getting any promises in writing, and recording phone calls. (State laws vary about how many parties on a call must give permission to record a conversation.)
Patients do not have to give up once a bill goes to collections, Fuse Brown said. “Once you hear from a debt collector, it’s not like the game is over and you lose,” she said. “Consumers do have rights.”
François de Brantes, a home health company executive and expert on how money flows through the health care system, said that hospital billing errors are not uncommon but that he had never heard of a situation like the one McLin experienced. He called it “puzzling” that HCA would issue a formal claim in a dependent child’s name.
De Brantes said those in a similar situation should also ensure that the collection agency removes any record of a debt against a minor to protect the child’s financial future.
“This stuff happens, where you have children who are improperly billed for stuff that they shouldn’t be billed, and they end up in collection,” he said. “Then the kid finds themselves with a collection record and they can’t get loans in the future, potentially student loans.”
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.