Science
California communities are banning syringe programs. Now the state is fighting back in court
As Indiana officials struggled to contain an outbreak of HIV among people who injected drugs, then-Gov. Mike Pence reluctantly followed the urgings of public health officials and cleared the way for an overwhelmed county to hand out clean syringes.
Pence was far from enthusiastic about launching the program in Scott County, but after it rolled out in 2015, the percentage of injection drug users there who said they shared needles dropped from 74% to 22%. Within a few years, the number of new HIV infections plummeted by 96% and new cases of hepatitis C fell by 76%.
The Sierra Harm Reduction Coalition wanted to keep those same diseases in check in California. The tiny nonprofit got approval from the state to deliver syringes in El Dorado County to prevent the spread of life-threatening illnesses.
Yet when the program was discussed at a December meeting of the county’s Board of Supervisors, the success story in Indiana held little sway. Faced with complaints about discarded needles and overdose deaths, the supervisors voted to prohibit syringe programs in the county’s unincorporated areas.
“These programs may work in other parts of California and throughout the United States, although I have my doubts,” Sheriff Jeff Leikauf said at the meeting. “El Dorado County does not want or need these types of programs.”
El Dorado is among a growing number of California communities that have banned syringe programs, testing the state’s power and political will to defend them as a public health strategy. It is part of a broader pushback against “harm reduction” — the practical philosophy of trying to reduce the negative effects of drug use — as overdose deaths have soared.
Now California is fighting back. In a recently filed lawsuit, the Department of Public Health argued that local ordinances prohibiting syringe programs in El Dorado County were preempted by state law, making them unenforceable.
The state is seeking a court order telling El Dorado County and the city of Placerville, its county seat, to stop enforcing their bans and allow syringe programs to resume.
An El Dorado County spokesperson said Monday that the county does not comment on pending legal issues. Its district attorney, however, said he was outraged to learn of the lawsuit, saying that state leaders were “seeking to impose the normalization of hardcore drug use.”
“Don’t come into our county and double down on your failed policy,” El Dorado County Dist. Atty. Vern Pierson said in a statement. “Allowing addicts to use fentanyl and other hardcore drugs is exactly what has caused other California counties to experience a death rate that is out of control and getting worse.”
Mona Ebrahimi, the city attorney for Placerville, said the city had put a 45-day temporary moratorium in place “to study the ongoing effects of syringe service programs in the city.”
“The city wants to protect the health, safety and welfare of its residents,” Ebrahimi said.
The California Department of Public Health has long endorsed handing out sterile syringes as a proven way to prevent dangerous infections from running rampant when people share contaminated syringes. Researchers have linked syringe programs with a roughly 50% reduction in HIV and hepatitis C.
“It sounds crazy: ‘Wait, you want to give out the tools to people to do this thing that we all agree is a bad idea?’” said Peter Davidson, a medical sociologist at UC San Diego. But it works, said Davidson, who called the programs “probably the best studied public health intervention of the last 70 years.”
Public health officials also see them as a crucial way to reach people who use drugs and link them to addiction and overdose-prevention services. In Seattle, for instance, researchers found that injection drug users who started going to a needle exchange were five times more likely to enter drug treatment than those who never went.
Signs direct visitors to the syringe-exchange program at the Austin Community Outreach Center in Austin, Ind., in 2015. The program was set up to curb an outbreak of HIV among people who injected drugs.
(Darron Cummings / Associated Press)
And in California, harm reduction groups have been particularly effective in getting Narcan — a nasal spray that can reverse opioid overdoses — into the hands of people who need it.
It’s “hugely important to reduce overdose in the community, and these are the programs that do that,” said Barrot Lambdin, a health policy fellow at RTI International who studies the implementation of health interventions.
Yet leaders in some cities and counties have strenuously rejected the health benefits of syringe programs.
In El Dorado County, local leaders asserted that the efforts of the Sierra Harm Reduction Coalition had not “meaningfully reduced” HIV or hepatitis C cases since its syringe program began four years ago and said the free needles were ramping up the risk of deadly overdoses, which they argued were a bigger threat.
The El Dorado County Courthouse in Placerville, Calif.
(Max Whittaker / For The Times)
Alessandra Ross, a harm reduction expert at the California Department of Public Health, disputed such arguments in a letter to county officials. Ross pointed out that in just one year, the coalition handed out more than 2,200 doses of medication to reverse opioid overdoses, saving at least 421 lives. Without the group’s efforts, she wrote, “El Dorado County could have potentially lost more than ten times as many people to overdose.”
Under state law, the California Department of Public Health has the authority to approve syringe programs anywhere that deadly or disabling infections might spread through used needles, “notwithstanding any other law” that might say otherwise.
The agency argued that the “significant state and public interest in curtailing the spread of HIV, hepatitis, and other bloodborne infections extends to every jurisdiction in the state, especially since Californians travel freely throughout the state.”
After El Dorado County prohibited syringe services in unincorporated areas, the state public health department adjusted its authorization for the Sierra Harm Reduction Coalition program, limiting its operations to Placerville. In the court filing, the agency said it made the change out of concern for the coalition’s staff and volunteers, who could be at risk of arrest if they provided syringes in the unincorporated areas.
The nonprofit said when it stopped providing syringes outside of Placerville city limits, roughly 40% of its clients were cut off. In February, Placerville city officials passed their own urgency ordinance banning syringe programs for 45 days, exempting needle provision at health facilities.
Ebrahimi, its city attorney, said officials took that step “after CDPH concentrated their use by authorizing them only in Placerville and nowhere else in the county.”
The Sierra Harm Reduction Coalition stopped providing syringes in Placerville as well, according to the state lawsuit. The coalition did not respond Monday to requests for comment on the suit.
El Dorado County and Placerville are not alone: A wave of local bans went into effect last year in Placer County after a harm reduction group from Sacramento sought state approval to hand out clean syringes. The county’s sheriff and its probation chief said in a letter to the state that the syringe program proposed by Safer Alternatives thru Networking and Education, or SANE, would “promote the use of addicting drugs” and lead to more “dirty needles discarded recklessly in our parks.”
The Placer County Board of Supervisors voted unanimously to ban syringe programs in its unincorporated areas. Cities including Auburn, Loomis and Rocklin banned them too.
“We are the ones who should make these kinds of decisions,” then-Mayor Alice Dowdin Calvillo said at a September meeting of the Auburn City Council, “and not allow the state to just bully us.”
Public health researchers stress that studies have found that free needle programs do not increase crime or drug use, or worsen syringe litter. Yet as much of Placer County became a no-go zone, SANE withdrew its application for a syringe program there.
“Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health,” said Ricky Bluthenthal, a USC sociologist whose research has documented the effectiveness of syringe programs. It doesn’t help that “the populations at risk are often marginalized or not politically active.”
Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health.
— Ricky Bluthenthal, a USC sociologist who studies syringe programs
The California Department of Public Health declined to address whether it planned to challenge local bans on syringe programs elsewhere in the state, saying it “cannot comment on active litigation strategy.”
Syringe programs have long faced public skepticism: In a 2017 survey, only 39% of U.S. adults said they supported legalizing them in their communities.
Experts say the programs have faced increasing jeopardy as public concern wanes about the threat of HIV and frustration swells over other problems like soaring numbers of overdose deaths and the spread of homeless encampments. Even in Indiana’s Scott County, local leaders voted three years ago to shutter its needle exchange.
Clashes are also arising because programs are making moves into new parts of California, bolstered in some cases by state funding. California officials also have taken steps to help syringe programs overcome local opposition, including exempting them from review under the California Environmental Quality Act.
“It’s not surprising that cities and counties are motivated to protect the public health and safety of their residents through whatever tools they have at their disposal,” said attorney David J. Terrazas, who represented a group that successfully sued to overturn state approval of a syringe program in Santa Cruz County.
In that case, a state appeals court ruled last year that the California Department of Public Health conducted an insufficient review of a program run by the Harm Reduction Coalition of Santa Cruz County. The department didn’t do enough to consult with law enforcement agencies in the area, among other shortcomings, the court said.
Although the state health department had considered some comments from law enforcement, “it never engaged with them directly about their concerns,” the appeals court concluded. Internal records showed department staff had decided not to respond to some of their comments and called one police chief an “imbecile.”
Terrazas said local officials are best poised to know what works for their communities. But Denise Elerick, founder of the Harm Reduction Coalition of Santa Cruz County, argued it made no sense for law enforcement to hold sway in public health decisions.
“We wouldn’t consult with them on what to do about COVID,” Elerick said.
A bag is filled with boxes of Narcan nasal spray, one of several harm-reduction supplies distributed to people living on the street in Los Angeles.
(Francine Orr / Los Angeles Times)
Weeks after the court ruling, the state health department rolled back its approval for a syringe program in Orange County that would have been run by the Santa Ana-based Harm Reduction Institute, saying it wanted to consult more with local officials.
The decision was celebrated by city leaders in Santa Ana, who had banned syringe programs in 2020 and sharply opposed efforts to restart one. At a recent meeting, interim city manager Tom Hatch said a previous program was “an epic failure” that left its downtown littered with used syringes.
Orange County is currently the most populous county in the state without any syringe services programs — to the alarm of health researchers who found that syringe reuse increased after a local program was shut down.
The Santa Cruz court ruling was also invoked by the Santa Monica City Council, which directed city officials to investigate how Los Angeles County came to approve a program run by the Venice Family Clinic. That program sends outreach workers into Santa Monica parks once a week to offer clean syringes, Narcan and other supplies and connect people with healthcare, including for addiction.
Devon O’Malley, left, a harm reduction case manager with the Venice Family Clinic, hands out Narcan to Ken Newark at Tongva Park in Santa Monica.
(Mel Melcon / Los Angeles Times)
Critics want the program to relocate indoors, which they say would better protect parkgoers from discarded syringes. In addition, “if someone has to walk inside, there’s a chance for counselors to suggest strongly that it’s time for them to get off the drugs,” said Santa Monica Mayor Phil Brock, who wants the city to formally express its opposition to the program. “We can’t just facilitate their demise.”
Last month, a group called the Santa Monica Coalition filed suit to get L.A. County to halt the program it approved, saying it should instead be in a government building.
But Venice Family Clinic staffers said unhoused people can be reluctant to leave behind their belongings to go elsewhere. Even offering services out of a van reduced participation, said Arron Barba, director of the clinic’s Common Ground program.
“Bringing the service directly to the people is what we know works,” Barba said.
The Trump administration announced a major overhaul of American nutrition guidelines Wednesday, replacing the old, carbohydrate-heavy food pyramid with one that prioritizes protein, healthy fats and whole grains.
“Our government declares war on added sugar,” Health and Human Services Secretary Robert F. Kennedy Jr. said in a White House press conference announcing the changes. “We are ending the war on saturated fats.”
“If a foreign adversary sought to destroy the health of our children, to cripple our economy, to weaken our national security, there would be no better strategy than to addict us to ultra-processed foods,” Kennedy said.
Improving U.S. eating habits and the availability of nutritious foods is an issue with broad bipartisan support, and has been a long-standing goal of Kennedy’s Make America Healthy Again movement.
During the press conference, he acknowledged both the American Medical Association and the American Assn. of Pediatrics for partnering on the new guidelines — two organizations that earlier this week condemned the administration’s decision to slash the number of diseases that U.S. children are vaccinated against.
“The American Medical Association applauds the administration’s new Dietary Guidelines for spotlighting the highly processed foods, sugar-sweetened beverages, and excess sodium that fuel heart disease, diabetes, obesity, and other chronic illnesses,” AMA president Bobby Mukkamala said in a statement.
I recently saw a patient complaining of shortness of breath and a persistent cough. Worried he was developing pneumonia, I ordered a chest X-ray — a standard diagnostic tool. He refused. He hadn’t met his $3,000 deductible yet, and so his insurance would have required him to pay much or all of the cost for that scan. He assured me he would call if he got worse.
For him, the X-ray wasn’t a medical necessity, but it would have been a financial shock he couldn’t absorb. He chose to gamble on a cough, and five days later, he lost — ending up in the ICU with bilateral pneumonia. He survived, but the cost of his “savings” was a nearly fatal hospital stay and a bill that will quite likely bankrupt him. He is lucky he won’t be one of the 55,000 Americans to die from pneumonia each year.
As a physician associate in primary care, I serve as a frontline witness to this failure of the American approach to insurance. Medical professionals are taught that the barrier to health is biology: bacteria, viruses, genetics. But increasingly, the barrier is a policy framework that pressures insured Americans to gamble with their lives. High-deductible health plans seem affordable because their monthly premiums are lower than other plans’, but they create perverse incentives by discouraging patients from seeking and accepting diagnostics and treatments — sometimes turning minor, treatable issues into expensive, life-threatening emergencies. My patient’s gamble with his lungs is a microcosm of the much larger gamble we are taking with the American public.
The economic theory underpinning these high deductibles is known as “skin in the game.” The idea is that if patients are responsible for the first few thousand dollars of their care, they will become savvy consumers, shopping around for the best value and driving down healthcare costs.
But this logic collapses in the exam room. Healthcare is not a consumer good like a television or a used car. My patient was not in a position to “shop around” for a cheaper X-ray, nor was he qualified to determine if his cough was benign or deadly. The “skin in the game” theory assumes a level of medical literacy and market transparency that simply doesn’t exist in a moment of crisis. You can compare the specs of two SUVs; you cannot “shop around” for a life-saving diagnostic while gasping for air.
A 2025 poll from the Kaiser Family Foundation points to this reality, finding that up to 38% of insured American adults say they skipped or postponed necessary healthcare or medications in the past 12 months because of cost. In the same poll, 42% of those who skipped care admitted their health problem worsened as a result.
This self-inflicted public health crisis is set to deteriorate further. The Congressional Budget Office estimates roughly 15 million people will lose health coverage and become uninsured by 2034 because of Medicaid and Affordable Care Act marketplace cuts. That is without mentioning the millions more who will see their monthly premiums more than double if premium tax credits are allowed to expire. If that happens, not only will millions become uninsured but also millions more will downgrade to “bronze” plans with huge deductibles just to keep their premiums affordable. We are about to flood the system with “insured but functionally uninsured” patients.
I see the human cost of this “functional uninsurance” every week. These are patients who technically have coverage but are terrified to use it because their deductibles are so large they may exceed the individuals’ available cash or credit — or even their net worth. This creates a dangerous paradox: Americans are paying hundreds of dollars a month for a card in their wallet they cannot afford to use. They skip the annual physical, ignore the suspicious mole and ration their insulin — all while technically insured. By the time they arrive at my clinic, their disease has often progressed to a catastrophic event, from what could have been a cheap fix.
Federal spending on healthcare should not be considered charity; it is an investment in our collective future. We cannot expect our children to reach their full potential or our workforce to remain productive if basic healthcare needs are treated as a luxury. Inaction by Congress and the current administration to solve this crisis is legislative malpractice.
In medicine, we are trained to treat the underlying disease, not just the symptoms. The skipped visits and ignored prescriptions are merely symptoms; the disease is a policy framework that views healthcare as a commodity rather than a fundamental necessity. If we allow these cuts to proceed, we are ensuring that the American workforce becomes sicker, our hospitals more overwhelmed and our economy less resilient. We are walking willingly into a public health crisis that is entirely preventable.
Joseph Pollino is a primary care physician associate in Nevada.
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Perspectives
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Ideas expressed in the piece
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High-deductible health plans create a barrier to necessary medical care, with patients avoiding diagnostics and treatments due to out-of-pocket cost concerns[1]. Research shows that 38% of insured American adults skipped or postponed necessary healthcare or medications in the past 12 months because of cost, with 42% reporting their health worsened as a result[1].
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The economic theory of “skin in the game”—which assumes patients will shop around for better healthcare values if they have financial responsibility—fails in medical practice because patients lack the medical literacy to make informed decisions in moments of crisis and cannot realistically compare pricing for emergency or diagnostic services[1].
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Rising deductibles are pushing enrollees toward bronze plans with deductibles averaging $7,476 in 2026, up from the average silver plan deductible of $5,304[1][4]. In California’s Covered California program, bronze plan enrollment has surged to more than one-third of new enrollees in 2026, compared to typically one in five[1].
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Expiring federal premium tax credits will more than double out-of-pocket premiums for ACA marketplace enrollees in 2026, creating an expected 75% increase in average out-of-pocket premium payments[5]. This will force millions to either drop coverage or downgrade to bronze plans with massive deductibles, creating a population of “insured but functionally uninsured” people[1].
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High-deductible plans pose particular dangers for patients with chronic conditions, with studies showing adults with diabetes involuntarily switched to high-deductible plans face 11% higher risk of hospitalization for heart attacks, 15% higher risk for strokes, and more than double the likelihood of blindness or end-stage kidney disease[4].
Different views on the topic
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Expanding access to health savings accounts paired with bronze and catastrophic plans offers tax advantages that allow higher-income individuals to set aside tax-deductible contributions for qualified medical expenses, potentially offsetting higher out-of-pocket costs through strategic planning[3].
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Employers and insurers emphasize that offering multiple plan options with varying deductibles and premiums enables employees to select plans matching their individual needs and healthcare usage patterns, allowing those who rarely use healthcare to save money through lower premiums[2]. Large employers increasingly offer three or more medical plan choices, with the expectation that employees choosing the right plan can unlock savings[2].
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The expansion of catastrophic plans with streamlined enrollment processes and automatic display on HealthCare.gov is intended to make affordable coverage more accessible for certain income groups, particularly those above 400% of federal poverty level who lose subsidies[3].
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Rising healthcare costs, including specialty drugs and new high-cost cell and gene therapies, are significant drivers requiring premium increases regardless of plan design[5]. Some insurers are managing affordability by discontinuing costly coverage—such as GLP-1 weight-loss medications—to reduce premium rate increases for broader plan members[5].
Science
Trump administration slashes number of diseases U.S. children will be regularly vaccinated against
The U.S. Department of Health and Human Services announced sweeping changes to the pediatric vaccine schedule on Monday, sharply cutting the number of diseases U.S. children will be regularly immunized against.
Under the new guidelines, the U.S. still recommends that all children be vaccinated against measles, mumps, rubella, polio, pertussis, tetanus, diphtheria, Haemophilus influenzae type B (Hib), pneumococcal disease, human papillomavirus (HPV) and varicella, better known as chickenpox.
Vaccines for all other diseases will now fall into one of two categories: recommended only for specific high-risk groups, or available through “shared clinical decision-making” — the administration’s preferred term for “optional.”
These include immunizations for hepatitis A and B, rotavirus, respiratory syncytial virus (RSV), bacterial meningitis, influenza and COVID-19. All these shots were previously recommended for all children.
Insurance companies will still be required to fully cover all childhood vaccines on the CDC schedule, including those now designated as optional, according to the Department of Health and Human Services.
Health Secretary Robert F. Kennedy Jr., a longtime vaccine critic, said in a statement that the new schedule “protects children, respects families, and rebuilds trust in public health.”
But pediatricians and public health officials widely condemned the shift, saying that it would lead to more uncertainty for patients and a resurgence of diseases that had been under control.
“The decision to weaken the childhood immunization schedule is misguided and dangerous,” said Dr. René Bravo, a pediatrician and president of the California Medical Assn. “Today’s decision undermines decades of evidence-based public health policy and sends a deeply confusing message to families at a time when vaccine confidence is already under strain.”
The American Academy of Pediatrics condemned the changes as “dangerous and unnecessary,” and said that it will continue to publish its own schedule of recommended immunizations. In September, California, Oregon, Washington and Hawaii announced that those four states would follow an independent immunization schedule based on recommendations from the AAP and other medical groups.
The federal changes have been anticipated since December, when President Trump signed a presidential memorandum directing the health department to update the pediatric vaccine schedule “to align with such scientific evidence and best practices from peer, developed countries.”
The new U.S. vaccination guidelines are much closer to those of Denmark, which routinely vaccinates its children against only 10 diseases.
As doctors and public health experts have pointed out, Denmark also has a robust system of government-funded universal healthcare, a smaller and more homogenous population, and a different disease burden.
“The vaccines that are recommended in any particular country reflect the diseases that are prevalent in that country,” said Dr. Kelly Gebo, dean of the Milken Institute School of Public Health at George Washington University. “Just because one country has a vaccine schedule that is perfectly reasonable for that country, it may not be at all reasonable” elsewhere.
Almost every pregnant woman in Denmark is screened for hepatitis B, for example. In the U.S., less than 85% of pregnant women are screened for the disease.
Instead, the U.S. has relied on universal vaccination to protect children whose mothers don’t receive adequate care during pregnancy. Hepatitis B has been nearly eliminated in the U.S. since the vaccine was introduced in 1991. Last month, a panel of Kennedy appointees voted to drop the CDC’s decades-old recommendation that all newborns be vaccinated against the disease at birth.
“Viruses and bacteria that were under control are being set free on our most vulnerable,” said Dr. James Alwine, a virologist and member of the nonprofit advocacy group Defend Public Health. “It may take one or two years for the tragic consequences to become clear, but this is like asking farmers in North Dakota to grow pineapples. It won’t work and can’t end well.”
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