The Brief

Faced with potential federal spending cuts that threaten health coverage and falling childhood vaccination rates, Monica Soni, the chief medical officer of Covered California, has a lot on her plate — and on her mind.

California’s Affordable Care Act health insurance exchange covers nearly 2 million residents and 89% of them receive federal subsidies that reduce their premiums. Many middle-income households got subsidies for the first time after Congress expanded them in 2021, which helped generate a boom in enrollment in ACA exchanges nationwide.

From the original and enhanced subsidies, Covered California enrollees currently get $563 a month on average, lowering the average monthly out-of-pocket premium from $698 to $135, according to data from Covered California.

The 2021 subsidies are set to expire at the end of this year unless Congress renews them. If they lapse, enrollees would be on the hook to pay an average of $101 a month more for health insurance — not counting any premium hikes in 2026 and beyond. And those middle-income earners who did not qualify for subsidies before would lose all financial assistance — $384 a month, on average — which Soni fears could prompt them to drop out.

At the same time, vaccination rates for children 2 and under declined among 7 of the 10 Covered California health plans subject to its new quality-of-care requirements. Soni, a Los Angeles native who came to Covered California in May 2023, oversees that program, in which health plans must meet performance targets on blood pressure control, diabetes management, colorectal cancer screening, and childhood vaccinations — or pay a financial penalty.

Lack of access to such key aspects of care disproportionately affects underserved communities, making Covered California’s effort one of health equity as well. Soni, a Harvard-trained primary care doctor who sees patients one day a week at an urgent care clinic in Los Angeles County’s public safety net health system, is familiar with the challenges those communities face.

Covered California reported last November that its health plans improved on three of the four measures in the first year of the program. But childhood immunizations for those under 2 declined by 4%. The decline is in line with a national trend, which Soni attributed to postpandemic mistrust of vaccines and “more skepticism of the entire medical industry.”

Most parents have heard at least one untrue statement about measles or the vaccine for it, and many don’t know what to believe, according to an April KFF poll.

Health plans improved on the other three measures, but not enough to avoid penalties, which yielded $15 million. The exchange is using that money to fund another effort Soni manages, which helps 6,900 Covered California households buy groceries and contributes to over 250 savings accounts for children who get routine checkups and vaccines. Some of the penalty money will also be used to support primary care practices around California.

In addition to her bifurcated professional duties, Soni is the mother of two young children, ages 4 and 7. KFF Health News senior correspondent Bernard J. Wolfson spoke with Soni about the impact of possible federal cuts and the exchange’s initiative to improve care for its enrollees. This interview has been edited for length and clarity.

Soni worries about a decline in childhood vaccination rates and potential federal budget cuts that could lead to large-scale disenrollments.

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Rich Pedroncelli

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KFF Health News

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Q: Covered California has record enrollment of nearly 2 million, boosted by the expanded federal subsidies passed under the Biden administration, which end after this year. What if Congress does not renew them?

A: Our estimates are that it will approach 400,000 Californians who would drop coverage immediately. We hear every day from our folks that they’re really living on the margins. Until they got some of those subsidies, they could not afford coverage.

As a primary care doctor, I am the one to treat folks who show up with preventable cancers because they were too afraid to think about what their out-of-pocket costs would be. I don’t want to go back to those days.

Q: Congress is considering billions in cuts to Medicaid. How would that affect Covered California and the state’s population more broadly, given that more than 1 in 3 Californians are on Medi-Cal, the state’s version of Medicaid?

A: Those are our neighbors, our friends. Those are the people working in the restaurants we eat at. Earlier cancer screenings, better chronic disease control, lower maternal mortality, more substance use disorder treatment: We know that Medicaid saves lives. We know it helps people live longer and better. As a physician, I would be hard-pressed to argue for rolling back anything that saves lives. It would be very distressing to watch that come to California.

Q: Why did Covered California undertake the Quality Transformation Initiative?

A: We were incredibly successful at covering nearly 2 million, but frankly we didn’t see improvements in quality, and we continue to see gaps for certain populations in terms of outcomes. So, I think the question became much more imperative: Are we getting our money’s worth out of this coverage? Are we making sure people are living longer and better, and if not, how do we up the ante to make sure they are?

Q: There’s a penalty for not meeting the targets, but no bonuses for meeting them: You meet the goals or else, right?

A: We don’t say it like that, but that is true. And we didn’t make it complicated. It’s only four measures. It’s things that as a primary care doctor I know are important, that I take care of when I see people in my practice. We said get to the 66th percentile on these four measures, and there’s no dollars that you have to pay. If you don’t, then we collect those funds.

Q: And you use the penalty money to fund the grocery assistance and child savings accounts.

A: That’s exactly right. We had this opportunity to think about what would we use these dollars for and how we actually make a difference in people’s lives. So, we cold-called hundreds of people, we sent surveys out to thousands of folks, and what we heard overwhelmingly was how expensive it is to live in California; that folks are making trade-offs between food and transportation, between child care and food — just impossible decisions.

Q: You will put up to $1,000 a child into those savings accounts, right?

A: That’s right. It’s tied to doing those healthy behaviors, going to child well visits and getting recommended vaccines. We looked at the literature, and once you get to even just $500 in an account, the likelihood of a kid going to a two- or four-year school increases significantly. It’s actually because they’re hopeful about their future, and it changes their path of upward mobility, which we know changes their health outcome.

Q: Given the rise in vaccine skepticism, are you worried that the recent measles outbreak could grow?

A: I am very concerned about it. I was actually reading some posts from a physician colleague who trained decades earlier and was talking about all the diseases that my generation of physicians have never seen. We don’t actually know how to diagnose and take care of a number of infectious diseases because they mostly have been eradicated or outbreaks have been really contained. So, I feel worried. I’ve been brushing off my old textbooks.

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

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

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

A federal judge has ordered Los Angeles to pay more than $1.8 million in attorneys’ fees and costs to the L.A. Alliance for Human Rights and other organizations that sued the city over what it deemed an inadequate response to the homelessness crisis.

The city is appealing the decision.

The details

L.A. Alliance is a group of business owners and residents who sued the city and county of Los Angeles in 2020 in an effort to push both governments to provide more shelter to unhoused people in the region.

The city of L.A. settled with the plaintiffs in 2022, and U.S. District Judge David O. Carter is overseeing the city’s progress in keeping up with the terms of that agreement. The judge found the city breached its agreement in multiple ways in a ruling last summer.

Specifically, the judge found that the city did not provide a plan for how it intends to create 12,915 shelter beds, as promised, by 2027. The court also found the city “flouted” its responsibilities by failing to provide accurate, comprehensive data when requested and did not provide evidence to support the numbers it was reporting, according to court documents.

In addition to $1.6 million in attorneys’ fees and $5,000 in costs to L.A. Alliance, Carter awarded about $200,000 in fees and $160 in costs to the Los Angeles Catholic Worker and Los Angeles Community Action Network.

The organizations are considered “intervenors” in the suit, representing people experiencing homelessness on Skid Row. Their attorneys include those from the Legal Aid Foundation of Los Angeles.

Why it matters

In his order, released Tuesday, Carter compared the recent award to the millions of taxpayer dollars city officials agreed to pay an outside law firm representing L.A. in the settlement.

Carter wrote in the order that the attorneys' fees and costs to L.A. Alliance and others “is reasonable, especially in light of the approximately $5.9 million that the City’s outside counsel is charging.”

LAist’s housing and homelessness coverage was cited several times in the order.

“It has fallen to plaintiff, intervenors, and journalists to point out the deficiencies in the city’s reporting,” Carter wrote, referring to data the city is required to report to the court as part of the settlement.

“Plaintiff and intervenors must be compensated for this,” he said.

The city’s response 

Attorneys representing the city filed a notice of appeal with the U.S. District Court in Los Angeles on Thursday.

L.A. City Attorney Hydee Feldstein-Soto’s office did not respond to LAist’s requests for comment by phone or email.

Shayla Myers, senior attorney with the Unhoused People's Justice Project at the Legal Aid Foundation of Los Angeles, told LAist the intervenors participated in the case without compensation “because it's incredibly important given what is at stake in these proceedings that unhoused folks have a voice.”

Matthew Umhofer, an attorney for L.A. Alliance, told LAist he’s thrilled the court is imposing accountability on the city, including sanctions for violating the settlement agreement. But Umhofer said he’s saddened that L.A. Alliance is going to have to keep fighting to hold the city to its promises.

“The obvious city strategy here is hire a big, good law firm to fight on absolutely every front in hopes that the plaintiffs, the intervenors or the court will ultimately give up trying to hold the city accountable,” he said.

What's next

The parties are scheduled to appear in federal court in downtown L.A. on Monday, when a hearing will resume to determine whether the judge will hold the city of Los Angeles in contempt of court.

Carter has said in documents that he’s concerned “the city has demonstrated a continuous pattern of delay” in meeting its obligations with court orders under the settlement and that the “delay continues to this day.”

Every January, the open-air downtown food fair reopens after its winter break and announces new additions to its carefully selected group of regular vendors.

This year’s new vendor class demonstrates the resilience of L.A.'s independent food scene, ranging from a Grammy-nominated producer's Persian-influenced pizza to Southern fried fish celebrating Black American culinary traditions, to an LAist 2025 Tournament of Cheeseburger heavyweight contender.

The reopening also marks the start of Smorgasburg LA's 10th anniversary year, and will feature 41 returning vendors, who've helped build the regular event into a fun, family-friendly opportunity to try new, often cutting-edge food you may not be familiar with.

Doors open from 10 a.m. to 4 p.m. at DTLA’s The Row, with free entry and free parking for the first two hours.

A new year

General manager Zach Brooks said this is his favorite time of year. "We add the new vendors at the beginning of the new year, everyone's excited."

Vendors apply through Smorgasburg's website, and the team meets with every applicant to taste their food before acceptance. Brooks said it's not a vetting process like "Shark Tank" but rather a matter of seeing if it's a good fit. Competition remains fierce, with many more applicants than available spots.

"I think it's just a testament to L.A. and the resilience of people who love this business and have a passion for it, and are going to continue to persevere and start their businesses and want to be out there selling food," Brooks said.

Here are a few highlights:

Viral orange chicken sandwich 

Long Beach-based Terrible Burger becomes Smorgasburg's new permanent burger vendor after standout appearances at LAist's Tournament of Cheeseburgers and the market's rotating Smorgasburger Stand. The smashburger pop-up, run by husband-and-wife team Nicole and Ryan Ramirez, specializes in burgers that draw from pop culture and global influences. They've made waves with a Korean barbecue burger topped with bulgogi barbecue sauce and a viral orange chicken sandwich, previously available only at their Tuesday night residency at Long Beach's Midnight Oil, making its L.A. debut Sunday.

Terrible Burger's viral orange chicken sandwich makes its LA debut at Smorgasburg after being available only in Long Beach.

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Courtesy Terrible Burger

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"We have been big Smorgasburg fans for a really long time before we even started Terrible Burger. We would go to Smorgasburg on dates, just eat and hang out. And it was just always a little dream of, "oh, what if we ever sold food here?" Nicole Ramirez said.

Crispy fried snapper and thick-cut fries 

Orange County-based Hot Grease, run by Asha Starks, is among four vendors graduating from residencies to permanent status. The Southern fried fish pop-up celebrates Black American history through food that honors Starks' family heritage.

"Folks often forget that there are Black folks in Orange County. My family came to Orange County during the second wave of the Great Migration, and they settled in Santa Ana... my food is very cultural. And the story, I feel like, is just as important to highlight," Starks said.

Hot Grease's crispy buttermilk fried snapper with thick-cut fries and "Ill Dill" tartar sauce.

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Courtesy Hot Grease

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Hot Grease serves crispy buttermilk fried snapper with thick-cut fries and small-batch sauces like "Ill Dill" tartar. Honoring the fish fry's history as a site of mutual aid, Starks directs 3% of sales to the Potlikker Line, Hot Grease's reproductive justice mutual aid fund. For January, she's added fish and grits, black-eyed peas and collard greens.

Pizza with a Persian twist

Mamani Pizza brings studio-born energy to Smorgasburg LA with pies featuring Persian-inspired creativity.

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Courtesy Mamani Pizza

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Mamani Pizza, from the Grammy-nominated producer Farsi, part of the music production team Wallis Lane, started making Neapolitan-style pizzas at his West L.A. recording studio a year ago. What began as late-night pies for friends and artists became an underground hit. Most pizzas are traditional, but Farsi adds Persian touches like The Mamani, topped with ground wagyu koobideh, roasted Anaheim chilis, Persian herbs and pomegranate molasses.

Other new vendors

Banana Mama - Asian-inspired pudding
Barranco's Yogurt - Oaxacan fruit yogurt
Franzl's Franks - Austrian sausages
Melnificent Wingz - Gourmet chicken wings
Piruchi - Peruvian street food
RuRu's Golden Tea - Karak chai
Stick Talk - vegan corn dogs
SouuLA - Taiwanese breakfast concept
Unreal Poke - Hawaiian poke
Zindrew Dumpling Shop - Spicy wontons