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productive sprint for the closely divided Senate. In recent weeks, the chamber has voted for a bipartisan gun bill, a boost for semiconductor manufacturing and aid for veterans exposed to toxic burn pits.

The Medicare drug negotiation policy – which Democrats have been pushing for nearly two decades – would mark a significant accomplishment that is likely to be popular with voters who are eager to go after drugmakers.

It amounts to the most substantial change in health care policy since the Affordable Care Act was passed in 2010. But it will initially have a limited impact on the pocketbooks of the nearly 64 million seniors in Medicare.

Negotiations between Medicare and drugmakers wouldn’t start until 2026, and would at first be limited to 10 drugs, adding more over time.

Sen. Bernie Sanders, I-Vt., a longtime proponent of Medicare price negotiations, called that portion of the bill “pretty weak.”

But Democrats rejected his amendment Sunday to strengthen the Medicare provisions.

Under the plan, Medicare will be able to negotiate over some of the most expensive drugs on the market, saving the federal government an estimated $288 billion over a decade, according to the nonpartisan Congressional Budget Office.

Likely targets for negotiations include Eliquis, an atrial fibrillation medication used by well over 2 million Medicare beneficiaries; the diabetes drug Januvia, the prostate cancer drug Xtandi; and the rheumatoid arthritis drug Orencia, according to industry players who are tracking the legislation. That list could change if pricier drugs enter the market in the next four years.

Chris Condeluci, founder of CC Law & Policy and a former staff member for Senate Finance Committee Republicans, predicted negotiations would not have a significant impact on the vast majority of Medicare beneficiaries, because most don’t use the most expensive drugs and are therefore unlikely to see direct savings.

“Unless your premiums go down, it doesn’t matter if Medicare is spending less” overall, he said.

But the bill would also cap Medicare beneficiaries’ out-of-pocket drug expenses at $2,000 per year, a policy that could help the approximately 1.4 million enrollees who hit that amount each year, according to the Kaiser Family Foundation.

Drugmakers generally like the out-of-pocket cap because the federal government will pick up the tab after patients spend the maximum.

The measure would also impose a cap on drugmakers’ price increases, though Democrats had to scale back the inflationary cap on Saturday when the nonpartisan Senate parliamentarian ruled that it didn’t adhere to Senate rules.

The inflationary cap isn’t a huge hit for the pharmaceutical industry because “companies have been self-policing,” said Ipsita Smolinski, a health policy adviser and managing director of Capitol Street, a research and consulting firm.

“They know they’d be on the front page of The Wall Street Journal or The New York Times if they obnoxiously price hike their products,” she said.

But drug manufacturers have strongly fought negotiating their prices with Medicare. Drugmakers and Republicans warn that allowing negotiations would stifle innovation of new drugs that pharmaceutical companies suspect would be affected. They also say the prospect of negotiations could prompt drugmakers to charge more when drugs first come on the market.

Medicare was barred from negotiating drug prices in 2003, with the establishment of the Medicare Part D drug program. The ban essentially allows pharmaceutical companies to set their own costs for Medicare, even though other government programs, such as Veterans Affairs, may negotiate for lower prices.

Drugmakers once had one of the most powerful lobbying groups in Washington, and still lead the pack in terms of spending to influence lawmakers. But their political power has waned in recent years amid high-profile price hikes, such as former Turing Pharmaceuticals Chief Executive Martin Shkreli’s decision to raise the price of one older drug by 5000%.

The legislation is a fraction of what Democrats had originally hoped to enact – a $3.5 trillion proposal that would have rewritten much of the nation’s social safety net, including home health care, child care and universal pre-K programs. That effort ended when Sen. Joe Manchin III, D-W.Va., said in December he would not go along with such an ambitious plan.

But after secret negotiations between Manchin and Senate Majority Leader Charles E. Schumer, D-N.Y., they resurrected portions of the bill last month.

The bill also seeks to address climate change. In an attempt to reduce emissions, it offers incentives for consumers to buy energy-efficient appliances and cars, and for manufacturers to make such products. According to Democrats, the climate policies would reduce emissions by roughly 40% by 2030.

About $9 billion would go to consumer home energy rebate programs. Lower- and middle-income people would be eligible for a $4,000 tax credit for buying a used clean car and up to $7,500 for buying a new one. Billions more would be spent to accelerate U.S. manufacturing of solar panels, electric vehicles and other clean products.

Finally, the bill would impose new taxes on wealthy corporations and their stock buyback programs – and would send new funding to the Internal Revenue Service, which the agency says it will use to crack down on wealthy tax cheats.

California Lottery | Sunday

Fantasy 5 Numbers picked

Match all five for top prize. Match at least three for other prizes. 9, 11, 13, 15, 23

Daily 4 Numbers picked 7, 3, 6, 9 Daily Derby 1st place 5, California Classic 2nd place 10, Solid Gold 3rd place 7, Eureka Race time 1:46.68 initially thought might not be possible–stemmed from a desire to improve understanding of the complicated underlying processes behind how nature’s intangible effects–such as opportunities for recreation and leisure or spiritual fulfillment–have an impact on well-being. One major challenge, though, is that much of the existing scientific literature on cultural ecosystem services has been “highly fragmented,” the review noted.

“You have all sorts of different people looking at [the intangible benefits of nature] through a different lens,” said Alexandros Gasparatos, an associate professor at the Institute of Future Initiatives at the University of Tokyo who co-authored the paper. Although having diverse research is critical, he said, “it becomes a little bit difficult to bring everything together.”

But the new study, a systematic review of roughly 300 peer-reviewed scientific papers, creates “an excellent knowledge base,” Gasparatos said.

“The whole point of doing this exercise is to understand the connection,” he added. “We give names to phenomenon.”

The review breaks down the hundreds of possible links between individual aspects of human wellbeing (mental and physical health, connectedness and belonging, and spirituality, among others) and cultural ecosystem services, such as recreation and tourism, aesthetic value and social relation. The researchers then went a step further and identified more than a dozen distinct underlying mechanisms through which people’s interactions with nature can affect their well-being.

Researchers found that the highest positive contributions were seen in mental and physical health. Recreation, tourism and aesthetic value appeared to have the greatest impact on human health through the “regenerative” mechanism, or experiencing restorative effects from being in nature such as stress relief, according to the paper. Meanwhile, the highest negative effects are linked to mental health through the “destructive” mechanism, or direct damages associated with the degradation or loss of cultural ecosystem services, the researchers wrote.

“In reality, you don’t just have one pathway,” and the effects aren’t always positive, Gasparatos said. “It’s not that if I go to the forest, I receive one thing.”

A well-designed park, for example, can be a place for recreation and leisure as well as connecting with other people. You might also find yourself appreciating the sight of towering trees and lush greenery or birds and other wildlife. On the other hand, a poorly maintained natural space could lead to an ugly or visually threatening landscape that might make you feel uncomfortable or scared to be there.

The paper can provide a road map of sorts, Huynh said, to help people, particularly decision-makers, understand that there are not only various intangible benefits to interactions with nature, but also how to try to achieve them.

“If we understand the underlying process, we can help to design better interventions for ecosystem management,” she said. “We can help to improve the contributions of nature to human well-being,” in addition to potentially bettering sustainable management practices and eliminating some of the negative effects on well-being.

The research was widely applauded by several outside experts who were not involved in the work.

“It’s a long time coming to have a study like this that makes some of these linkages a little clearer,” said Keith Tidball, an environmental anthropologist at Cornell University. “This stuff has been scattered all over the place for a long, long time, and this paper takes a huge step forward in sorting out what has been previously pretty muddled.”

Anne Guerry, chief strategy officer and lead scientist with the Natural Capital Project at Stanford University, agreed. “They did a really nice job of bringing together extraordinarily diverse literature,” she said. It’s been a challenge, she noted, among researchers to be able to present the science in a way that reveals where and how nature provides the greatest benefits to people, which could in turn help “inform and motivate investments in conservation and restoration that lead to better outcomes for both people and nature.”

For instance, the research could have an impact on the role nature potentially plays in human health. “What this is going to be seriously useful for is to be able to continue to work to make the case that physicians and clinicians can actually prescribe outdoor time, outdoor recreation, even outdoor space because of these pathways that they’ve identified in this paper,” Tidball said.

In one scenario, elements of this work could ultimately be included in the Diagnostic and Statistical Manual of Mental Disorders, said Elizabeth Haase, chair of the American Psychiatric Association’s Committee on Climate Change and Mental Health.

“That sets us up to be able to say that when we facilitate this kind of interaction with nature, you see this kind of benefit, and then prescribe these kinds of natural experiences, or have policies that say that you’re really depriving someone of their mental health if you destroy these natural landscapes,” she said.

But the review does have limitations, prompting some experts to caution against overinterpreting or overemphasizing its results.

One potential issue is that the existing research included in the review disproportionately focuses on individuals rather than groups.

“There are multiple times where something might be really good for an individual, but overall for the community, it might not be very good at all,” said Kevin Summers, a senior research ecologist with the Office of Research and Development at the Environmental Protection Agency.

“In many cases, there can be unintended consequences for things that look like very simple, straightforward decisions,” Summers added.

Research gaps should also be taken into account, Guerry said. While the review suggests that some connections between certain human wellbeing characteristics and cultural ecosystem services appear stronger than others, it doesn’t mean those other relationships might not be significant, she said.

“We have to be careful in terms of oversimplifying the results and thinking that a lack of a documented relationship in this paper means that something isn’t important,” she said. Instead, it may mean that “it hasn’t been studied and we haven’t found ways to quantify it and bring it into the scientific literature and out of our sort of implicit understanding.”

The researchers addressed the limitations of their work, noting in the paper that future research “should explore in-depth how these pathways and mechanisms manifest in less studied ecosystems and understand their differentiated effects to various stakeholders.”

In the meantime, though, the findings serve as an important reminder of nature’s necessity.

“It can justify, very well, a mind-set like, ‘Let’s invest in nature because it has all these benefits,’ ” Gasparatos said.

With such strong positive benefits related to creativity, belonging, regeneration and more, “it’s easy from this paper to feel that your constitutional right to the pursuit of happiness requires a country to preserve natural spaces,” Haase added.

In a time when many people are becoming further separated and distanced from “our ecological selves,” efforts to link humans and nature are not only interesting in terms of science, philosophy or ethics, Tidball said, but “there are also human security implications here that are significant.” And, he said, if steps aren’t taken to reconnect people with nature, the consequences could be dire.

“If we continue on a pathway as a species of being in a state of ecological amnesia,” he said, “we’re going to find ourselves out of habitat and out of time and, therefore, out of luck.”

Strike

From Page One

bargaining tactic this union has used every time it has bargained a new contract.”

Calling the union’s tactics “unethical and counterproductive,” Catsavas said the two sides were “close to an agreement” and that Kaiser is “committed to bargaining in good faith to reach a fair and equitable agreement that is good for our therapists and our patients.”

The company has drawn increased scrutiny from lawmakers for its mental health services in recent years. In May, the Department of Managed Health Care announced that it would be conducting a non-routine audit of Kaiser’s mental health services.

The union and Kaiser have one more bargaining session planned for Friday, Artz said. He said Kaiser Northern California’s mental health workers, including psychologists, social workers, therapists and addiction counselors, have gone on strike for short amounts of times six times in the past 4 years. This would be their first open-ended strike, which means the union is not establishing an end date.

Kaiser has 4.6 million enrollees in Northern California, Artz said, though that figure does not reflect how many currently access their mental health benefits.

In a letter sent Sunday to the Department of Managed Health Care, which regulates health plans, the union asked the department to ensure that Kaiser continues providing mental health care to patients during the strike, rather than canceling appointments.

Amanda Levy, deputy director for health policy and stakeholder relations for the Department of Managed Health Care, said the department is continuing to monitor access to services for patients impacted by the strike.

“The law requires health plans provide enrollees with medically necessary care within timely access and clinical standards at all times, which includes during an employee strike,” she said in an emailed statement.

Despite growing efforts at the state level to enforce mental health parity laws, Kaiser mental health practitioners say they still struggle to provide adequate and timely care for patients.

Sarah Soroken, who has worked as a therapist at Kaiser Fairfield for six years, said access to treatment has worsened during her time there. She said the pandemic has aggravated the situation, with more patients seeking care, even as more therapists are leaving.

“Right now we’re at a crisis point,” she said. “Things are worse than ever.”

Kaiser is not the only provider facing a shortage of mental health practitioners. Complaints of shortages also have been raised by counties, school districts and non-profit organizations around the state. Artz said some Kaiser providers are being recruited to work at telehealth start-ups, where money is good and work-fromhome options abound. Others are entering private practice.

The union says the rate at which mental health clinicians are leaving Kaiser nearly doubled in the past year, with 668 clinicians leaving between June 2021 and May 2022, compared to 335 clinicians the previous year. In a union survey of 200 of those departing clinicians, 85 percent said they were leaving because their workload was unsustainable or they felt they did not have enough time to complete the work, and 76 percent said they were unable to “treat patients in line with standards of care and medical necessity.”

Some of these concerns are not new, although the pandemic has exacerbated them.

In 2013, the Department of Managed Health Care fined Kaiser $4 million for failure to provide adequate mental health treatment.

In a hearing this spring, lawmakers raised concerns about the state’s plans to move an additional 200,000 Medi-Cal members onto Kaiser, given problems with mental health treatment. Democratic Sen. Scott Wiener of San Francisco has introduced a bill to significantly increase fines for health plans that fail to comply with state laws.

Another bill of Wiener’s, SB 221, which took effect July 1, is intended to ensure patients don’t face long delays for follow-up treatment through commercial providers like Kaiser. Specifically, the new law, which was sponsored by the union, requires that patients receive follow-up mental health care within 10 business days unless a provider determines that a longer wait will not be detrimental to the patient.

At a virtual press conference in late June, Kaiser mental health practitioners said the health giant wasn’t close to meeting those requirements.