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Harvard Poll Shows Dramatic Decline in Trust in Federal Health Agencies

One Year In: Public Views of a Changing Public Health Landscape is a national poll by Harvard T.H. Chan School of Public Health and the de Beaumont Foundation’s Public Health Listening Lab. The poll was conducted March 19 – April 1, 2026, among a probability-based, nationally representative sample of 2205 U.S. adults ages 18 and older, to better understand people’s views about the changing public health landscape one year into the new federal administration.

It was fielded online and via telephone (cell phone and landline) by SSRS, an independent research company. This survey is nationally representative of U.S. adults. Interviews were conducted in English and Spanish, March 19 – April 1, 2026, among a sample of 2205 adults ages 18 or older in the United States. Republicans include adults who lean Republican, Democrats include adults who lean Democrat, and Independents includes adults who identify as “other” or are unaffiliated. The margin of error at the 95% confidence interval is +/- 2.0 percentage points.

For decades, the Centers for Disease Control and Prevention was one of the most trusted institutions in American life. Trust in the CDC remained relatively stable in the wake of the COVID-19 pandemic, hovering around 75% from 2022 to 2025. These new national poll findings show concerning declines in the American public’s trust in federal health agencies one year into the new federal administration. One year into new leadership of the U.S. public health system, trust in the Centers for Disease Control and Prevention (CDC) and other federal health institutions has dropped dramatically. Only 50% of the public says they now trust health recommendations from the CDC, compared to 77% in spring 2025.

This decline in trust is driven by deep partisan divides. From 2025 to 2026, trust in CDC health recommendations has fallen from 92% to 34% among Democrats and from 77% to 47% among Independents, (92% to 34%) and 30 percentage points among Independents (77% to 47%), while trust among Republicans has increased very slightly from 63% to 67%.

The steep drop in public trust also translates to losses in trust across many demographic groups. Trust in the CDC has fallen more than 30 percentage points among women (80% to 48%); Black and Hispanic adults (77% to 43% and 81% to 50% respectively); those living in urban areas (80% to 48%); and those with a college degree (80% to 46%).

When examining public trust across prominent leaders and groups, the top trusted sources for health recommendations in 2026 are clinicians – nurses (89%), doctors (88%), and pharmacists (85%) – followed by friends and family (81%), nonprofit health and healthcare groups (79% – 80%), and researchers (78%).

State and local public health agencies are now substantially more trusted than the CDC. Trust in state and local public health agencies has also fallen in the last year, but not by as much. A majority of the public still trusts health recommendations from their local (70%) and state (66%) public health agencies.

A slim majority disapproves of federal public health agency actions in the past year, with a high level of concern about the influence of leaders’ personal beliefs, misplaced priorities, and budget cuts. With 55% public disapproval of federal health agencies’ actions in the past year, top concerns about their actions under new leadership include wide agreement that their recommendations have been influenced too much by leaders’ personal beliefs (68%), leaders are focused on the wrong priorities (66%), and programs have been cut or scaled back too much (61%).

Public support for routine childhood vaccination policies remains strong, though a substantial minority supports reductions to the routine vaccine schedule. More than three-quarters (77%) of the public – including majorities across party lines – say that parents should be required to vaccinate their children in order to attend school. A majority (58%) also oppose reducing the childhood vaccine schedule, which forms the basis of childhood vaccine requirements, but there is substantial minority support (42%) for this change.

Views of vaccine safety have dropped closer to pre-COVID-19 levels. As another indication that support for vaccines may be softening, the fraction of the public saying childhood vaccines are “very safe” has dipped from 63% in 2025 to 57% in 2026, trending back to pre-pandemic levels (54% in 2019) from a high of 70% during COVID-19 (2022).

A majority of the public supports federal changes to the Dietary Guidelines for Americans, with higher support for individual recommendations on less sugar and more protein. Six in ten (60%) support the recent changes to the food pyramid and dietary guidelines, and even stronger majorities support specific measures, like recommendations to avoid or sharply limit sugar and highly-processed food (90%) and to increase protein intake (85%). A much smaller majority (62%) supports recommendations to increase beef and whole milk consumption.

Support is bipartisan for limiting sugar and highly-processed food (Republicans: 94%, Democrats: 89%) and for increasing protein intake (Republicans: 92%, Democrats: 79%).

However, there is more division when considering overall support for changes, with 83% of Republicans saying they support the overall changes, compared to only 37% of Democrats. Support for recommendations to increase beef and whole milk consumption is also divided, with 80% support among Republicans and 44% support among Democrats.

Rising SoCal CT Claims Are Shifting Costs and Claim Patterns

The Workers’ Compensation Insurance Rating Bureau of California (WCIRB) has released Emerging Patterns of Cumulative Trauma Claims. The new report finds that cumulative trauma (CT) claims have increased sharply in recent years and are contributing to notable changes in claim characteristics, costs and claim outcomes.

CT claims have long been a part of the California workers’ compensation system. Recently, while claim frequency for non-CT claims has been relatively flat, the proportion of claims involving CT has increased sharply. This contrasts with the rest of the country, where rates of CT claims have remained stable since 2013. This report explores the key drivers of the recent CT claim increases and their impact on system costs.

The report shows CT claims are playing a growing role in system-wide trends, with higher levels of litigation and earlier involvement of medical-legal and interpreter services than non-CT claims. These differences are influencing both medical and allocated loss adjustment expense (ALAE) costs and shaping overall claim severity trends.

While the frequency of non-CT claims has remained relatively stable, the rising share of CT claims has shifted the composition of claims in California’s workers’ compensation system, with implications for pricing, reserving and trend analysis.

The report examines:

– – Key drivers of the recent increase in CT claims
– – The extent to which CT claim growth is affecting medical and ALAE cost trends
– – How changes in CT claim filings are influencing claim severity trends

Summary of Key Findings:

– – The share of CT claims filed post-termination has risen sharply, and these claims are highly likely to be litigated, driving significant increases in allocated loss adjustment expenses (ALAE) costs across the system
– – Whether claims are valued at 18 months or at a projected ultimate level, the share of indemnity claims involving CT was relatively stable prior to the pandemic and has increased since.
– – The shares in 2023 and 2024 are almost double the share in 2012 and the highest levels observed in this period.
– – CT claims are consistently more common in Southern California, with the highest rates in Los Angeles (LA) and surrounding areas followed by San Diego, likely reflecting higher litigation activity and larger workforce concentrations in industries with high rates of CT filings
– – Regardless of where in the state the injured worker is located, the vast majority of litigated CT claims are represented by firms based in the LA area.
– – CT claims are more likely to involve medical-legal and interpreter services early on, contributing significantly to increases in these medical costs for the system.
– – The share of CT claims without medical payments at 18 months past policy inception is consistently much higher than for non-CT claims and has increased since accident year (AY) 2019.
– – Since 2021, changes in average indemnity and medical costs have been lower for CT claims than for non-CT claims, suggesting the increase in CT claims is dampening overall claim severity trends. Changes in average ALAE costs have been lower for CT claims than for non-CT claims.
– – Since 2020, total costs (pure premium) for CT claims have more than doubled, while costs for non-CT claims have increased by more than 30%. CT claims now account for roughly a quarter of total pure premium costs.

This study relies on WCIRB unit statistical report (USR), medical transaction and CT survey data. Access the report on the Research Studies and Reports page, where you can also explore related WCIRB research.

Tesla Freemont Yard Hostlers Engage in Interstate Commerce

Kenneth Doss worked for Tesla, Inc. at the company’s Fremont distribution center, first as a materials handler and then as a “yard hostler.” Yard hostlers drive tractor trucks to move, position, and park 53-foot trailers around Tesla’s factory grounds. The trailers contained auto parts — including, by Doss’s account, battery parts shipped in from Nevada — that had arrived from out of state and would be unloaded into a warehouse and eventually used to assemble Tesla vehicles. Doss never crossed state lines or physically left the factory grounds; his job was to reposition the still-loaded trailers from the parking and docking area to the warehouse dock so the parts could be unloaded.

Doss filed a putative class action against Tesla in Alameda County Superior Court, alleging eight causes of action for wage-and-hour violations under the Labor Code and the Unfair Competition Law (“UCL”), covering unpaid wages, overtime, meal and rest periods, wage statements, final-pay timing, and business-expense reimbursement. When he was hired, Doss had electronically signed an offer letter containing an arbitration provision with both a class action waiver and a clause stripping the arbitrator of authority to consolidate employee claims or award class-wide relief. Tesla moved to compel individual arbitration.

The central legal question was whether the Federal Arbitration Act (“FAA”) governed the agreement. The FAA exempts from its coverage the employment contracts of transportation workers “engaged in foreign or interstate commerce” (9 U.S.C. § 1). If that exemption applied, the FAA would not preempt California law that could defeat or limit arbitration.

The trial court denied Tesla’s motion to compel arbitration in its entirety. The court found that (1) the yard hostlers were transportation workers engaged in interstate commerce, so the arbitration agreement was exempt from the FAA under section 1 — reasoning that “the flow of commerce does not stop at the loading dock door”; (2) Labor Code section 229 (which lets courts disregard arbitration agreements in certain wage actions) rendered the agreement ineffective as to seven of Doss’s eight causes of action; (3) the class waiver was invalid under the four-factor test of Gentry v. Superior Court, 42 Cal. 4th 443 (2007); and (4) severance of the class waiver was inappropriate because the agreement was tainted with illegality.

The Court of Appeal issued a mixed disposition: affirmed in part, reversed in part, and remanded in the partially published case of Doss v. Tesla, Inc., No. A173210 (June, 2026). It affirmed the core holding that Doss and the putative class are exempt from the FAA under section 1. It reversed the trial court’s application of Labor Code section 229 to four of the causes of action, and it found legal error in the trial court’s severance analysis, remanding for the trial court to decide unconscionability issues it had not yet reached. The court affirmed the trial court’s Gentry ruling in the unpublished portion of the opinion.

The FAA section 1 exemption (affirmed — published). Reviewing the legal question de novo, the court held the yard hostlers are exempt “transportation workers.” Drawing on Circuit City Stores v. Adams, 532 U.S. 105 (2001), and Southwest Airlines Co. v. Saxon, 596 U.S. 450 (2022), the court explained that the inquiry focuses on the actual work performed, that a worker need not be in the transportation industry (Bissonnette v. LePage Bakeries Park St., LLC, 601 U.S. 246 (2024)) and need not personally cross state lines. Saxon held that loading and unloading cargo from vehicles in interstate transit is activity within the flow of commerce; the Ninth Circuit extended that logic to a warehouse worker in Ortiz v. Randstad Inhouse Services, LLC, 95 F.4th 1152 (9th Cir. 2024). The court placed the yard hostlers along this continuum: because their handling of the trailers was “a necessary step” in completing the interstate journey of the auto parts, they fell within the exemption.

Labor Code section 229 (reversed in part — published). Section 229 applies only to actions “for the collection of due and unpaid wages” arising from Labor Code sections 200–244. Applying Lane v. Francis Capital Management LLC, 224 Cal. App. 4th 676 (2014), and Kirby v. Immoos Fire Protection, Inc., 53 Cal. 4th 1244 (2012), the court held that Doss’s second (overtime), third (meal periods), fourth (rest periods), and fifth (wage statements) causes of action are not collection-of-wages actions within section 229 — the second and third because they arise outside sections 200–244, and the fourth and fifth because their underlying legal violation is the denial of breaks or accurate statements, not the nonpayment of wages. The court rejected Doss’s argument that Naranjo v. Spectrum Security Services, Inc., 13 Cal. 5th 93 (2022), superseded Lane, reading Naranjo to reaffirm that characterization turns on the nature of the violation, not the remedy. But the court affirmed application of section 229 to the first (unpaid wages) and sixth (final pay under sections 201–203) causes of action, plus the derivative UCL claim — disagreeing with Lane to the extent it suggested a section 203 waiting-time-penalty claim falls outside section 229, and aligning with Villalobos v. Maersk, Inc., 114 Cal. App. 5th 1170 (2025).

The Gentry factors (affirmed — unpublished). Reviewing for abuse of discretion, the court upheld the finding that the class waiver was invalid. Counsel’s declaration adequately supported a modest individual recovery (~$25,000), consistent with figures accepted in Garrido v. Air Liquide Industrial U.S. LP, 241 Cal. App. 4th 833 (2015), and Betancourt v. Transportation Brokerage Specialists, Inc., 62 Cal. App. 5th 552 (2021). The court found the trial court could reasonably infer real-world obstacles to individual arbitration, and noted that not all four Gentry factors must point the same way to support invalidation.

Severance (reversed for legal error; remanded — unpublished). The court agreed with Tesla that the trial court’s refusal to sever was based on legal error. Under Ramirez v. Charter Communications, Inc., 16 Cal. 5th 478 (2024), severance is the strongly preferred course unless the agreement is “permeated” by unconscionability. The trial court wrongly treated the presence of a class waiver as itself evidence of a systematic effort to disadvantage employees, contrary to Gentry, which says severance is “particularly appropriate” for class-waiver provisions. Because Doss had argued other provisions were substantively unconscionable and the trial court never ruled on them, the appellate court remanded for the trial court to decide those unconscionability issues in the first instance.

Judge Said Use of AI Was “Worst Example of Misconduct by a Lawyer”

In June 2024, the Lipeles Law Group (“LLG”) filed a wage-and-hour class action in Los Angeles County against Harbor Distributing and related entities (the Ascensao action). Six months later, in December 2024, the same firm filed a nearly identical class action in San Francisco County against the same defendants on behalf of a different named plaintiff, Jaime Arguello Amaya Quinteros — an “overlapping, duplicate, copycat action,” in the words of the defense.

When Harbor moved to stay the San Francisco case under the doctrine of exclusive concurrent jurisdiction, LLG filed an opposition brief that proved to be a disaster. A contract attorney, James Sansone, had drafted it. Associate Jasmine Badawi reviewed it for flow but did not read the cited cases or check the citations; partners Kevin Lipeles and Thomas Schelly did not read the brief at all. The brief turned out to be riddled with fabrication: two case citations did not exist, and the trial court counted no fewer than eight fabricated quotations from five different cases, with the court observing that “[l]iterally every other purported quotation from a case in the brief is similarly fictitious.” The hallmarks pointed to undisclosed use of generative AI. Sansone denied using AI and insisted a Lexis citation check had validated everything — a claim the court found wholly incredible.

The trial court granted the stay and separately issued an order to show cause (“OSC”) re sanctions. After receiving declarations and holding a hearing — at which the firm’s lawyers apologized but could not coherently explain why they had filed a duplicative second action or opposed the stay, and continued to disclaim awareness of their own earlier-filed Los Angeles case — the court imposed sanctions under Code of Civil Procedure section 128.7(b). It ordered LLG and attorneys Lipeles, Schelly, and Badawi, jointly and severally, to pay $5,000 to Harbor and $1,000 to the court, to serve the order on the Los Angeles judge and on any San Francisco judge before whom they appeared for a year, and it referred the matter to the State Bar. The court called this “the worst example of misconduct by a lawyer” it had seen on the bench. Sansone, the court found, was “particularly blameworthy” for using AI and then denying it under oath, but the court held the firm bore “ultimate responsibility” because its name was on the brief.

The Court of Appeal affirmed the sanctions order in full in the published case of Quinteros v. Harbor Distributing, LLC (Lipeles et al., Objectors and Appellants), No. A174202 (June 2026). It held that LLG had forfeited two of its three arguments — the “safe harbor” procedural challenge and the objection to sanctions being paid to Harbor — and that the remaining argument, that the conduct did not warrant sanctions, had no merit because the trial court did not abuse its discretion.

The forfeited “safe harbor” challenge. LLG argued that section 128.7(c)(2) entitled it to 21 days to withdraw the offending opposition before sanctions could issue, and that the court’s compressed timeline denied that protection. The court rejected this for several reasons. First and foremost, LLG conceded it never raised section 128.7 in the trial court, and arguments not asserted below are forfeited. It declined to exercise its discretion to reach the forfeited issue, observing that a safe-harbor provision is not a matter of “vital public policy” (City of Rocklin v. Legacy Family Adventures-Rocklin, LLC, 86 Cal. App. 5th 713 (2022)). The court further invoked the invited-error doctrine: LLG had stipulated to the tentative ruling and never sought to cure, so any lost opportunity to withdraw was self-manufactured (Transport Insurance Co. v. TIG Insurance Co., 202 Cal. App. 4th 984 (2012)). Finally, the court noted LLG had buried its request for discretionary review in a footnote — itself a forfeiture (Golden Door Properties, LLC v. County of San Diego, 50 Cal. App. 5th 467 (2020)) — and raised the “important public policy” framing for the first time in its reply brief, too late to consider (American Indian Model Schools v. Oakland Unified School District, 227 Cal. App. 4th 258 (2014)).

The merits of the sanctions (abuse-of-discretion review). Reviewing under the deferential standard of Noland v. Land of the Free, L.P., 114 Cal. App. 5th 426 (2025), the court held the trial court acted well within its discretion. Section 128.7 lets a court sanction a filing made for an improper purpose or unwarranted by existing law; a claim is frivolous if any reasonable attorney would agree it is totally without merit (Kumar v. Ramsey, 71 Cal. App. 5th 1110 (2021)). The court surveyed the rapidly growing body of law on AI-fabricated citations, emphasizing that a fake opinion is not “existing law” and citing it abuses the adversary system — drawing on Noland, the seminal federal decision Mata v. Avianca, Inc., 678 F. Supp. 3d 443 (S.D.N.Y. 2023), and People v. Alvarez, 114 Cal. App. 5th 1115 (2025).

The forfeited objection to paying Harbor. LLG argued sanctions cannot be paid to an opposing party when the court issues an OSC on its own motion. The court found this forfeited too — not raised below (Doe WHBE 3 v. Uber Technologies, Inc., 102 Cal. App. 5th 1135 (2024)) and inadequately briefed, occupying only five lines with a miscited authority and no analysis (Dilbert v. Newsom, 101 Cal. App. 5th 317 (2024)). The court added that California Rules of Court, rule 2.30(b), independently permits awarding sanctions to an aggrieved party. It also observed in a footnote that the combined $6,000 sanction was far less than the “conservative” $10,000 imposed on a single attorney in Noland, and that LLG had improperly raised new authorities and a challenge to the amount for the first time at oral argument (Ramirez v. Charter Communications, Inc., 16 Cal. 5th 478 (2024)).

Court Must Decide if Federal or State Arbitration Law Applies

Rebecca Orr worked briefly for United Parcel Service, Inc. (“UPS”) as a Seasonal Support Driver in late 2023, picking up packages from other UPS drivers and delivering them to their final destinations during the holiday rush. When she applied, she signed an “Arbitration Agreement/Seasonal Hiring Agreement” through an online portal. The agreement was drafted to be “as broad as legally permissible” and contained four provisions that mattered to her case: a Delegation Clause giving the arbitrator exclusive authority over disputes about the agreement’s validity and enforceability; a Class Action Waiver; a PAGA Individual Action Requirement Clause; and a “How This Agreement Applies” section declaring the contract governed by the Federal Arbitration Act (“FAA”) — unless the FAA “does not apply to a particular dispute or to one or both parties.”

Orr’s experience on the job was rocky. Although UPS told her she would work eight-hour days, six days a week, her routes were shortened or canceled the morning of a scheduled shift on at least seven occasions. After a December route cancellation, she contacted HR and was told there were not enough packages to deliver. She received no further assignments despite repeated requests for work.

Orr sued UPS in the Superior Court of California for the County of Riverside, raising five state-law claims (including a claim that UPS failed to pay drivers their required “reporting time pay”) on behalf of three putative classes, later adding a sixth claim under California’s Private Attorneys General Act (“PAGA”). UPS removed the case to federal court and moved to compel arbitration and stay proceedings.

A central dispute emerged: Orr and UPS disagreed over whether the FAA or the California Arbitration Act (“CAA”) governed the agreement. The distinction was not merely academic — the two statutes differ in ways that could change which of Orr’s claims could be heard in court versus arbitration.

The district court granted UPS’s motion. It ordered Orr to arbitrate her individual claims “consistent with the terms of the binding arbitration agreement,” while staying litigation of the class claims pending arbitration. Critically, the court declined to decide whether the FAA or CAA applied, reasoning that the “result is the same” under either statute, so the question need not be resolved. It also concluded that Orr had forfeited any challenge to the Delegation Clause.

Orr moved for clarification under Federal Rule of Civil Procedure 60(a) and (b), arguing the court itself had to decide whether her contract fell within the FAA’s exemption for certain employment contracts (9 U.S.C. § 1). The district court denied the motion, holding it had “properly refrained” from determining whether a Section 1 exemption applied because, in its view, the CAA does not require that analysis before compelling arbitration.

Because neither the FAA nor California law allows an ordinary appeal from an order granting arbitration, Orr sought a writ of mandamus from the Ninth Circuit.

This was a mandamus proceeding, not a conventional appeal, so the Ninth Circuit did not “affirm” or “reverse.” Instead, the panel granted Orr’s petition for a writ of mandamus and directed the district court to determine the appropriate statutory basis for its authority to compel arbitration in the published case of In re Rebecca Orr, No. 25-2330 (9th Cir. June 9, 2026). The court made clear it was not ordering that arbitration is improper — only that the legal basis for it must be decided first, with the remaining arbitrability issues left to the district court to address afterward.

The panel evaluated the five factors governing mandamus relief from Bauman v. U.S. District Court, 557 F.2d 650, 654–55 (9th Cir. 1977): (1) the absence of another adequate remedy such as direct appeal; (2) prejudice not correctable on appeal; (3) clear legal error by the district court; (4) an oft-repeated error or persistent disregard of the rules; and (5) a new and important problem or issue of first impression. The third factor — clear error — is a necessary condition, so the court began there.

Clear legal error (Factor 3). The court held the district court clearly erred by compelling arbitration without identifying the source of its authority, thereby improperly handing the FAA § 1 exemption question to the arbitrator. Under New Prime Inc. v. Oliveira, 586 U.S. 105, 111 (2019), a court — not an arbitrator — must decide whether the § 1 “contracts of employment” exclusion applies before ordering arbitration under the FAA, because a court’s power to compel arbitration is bounded, not “unconditional.”

Two features made the error especially clear here. First, the agreement’s own choice-of-law clause assumed the FAA would control unless found inapplicable, making the FAA question a contractual prerequisite. Second, the choice of governing law was not a mere technicality: under Perry v. Thomas, 482 U.S. 483, 490–91 (1987), the FAA preempts California Labor Code § 229 (which lets employees pursue unpaid-wage claims in court despite an arbitration agreement), but California courts allow such suits when only the CAA applies, Garrido v. Air Liquide Industries U.S. LP, 241 Cal. App. 4th 833, 845 (2015).

The panel rejected UPS’s argument that New Prime does not apply where state law offers an alternative basis for arbitration, noting that no federal court of appeals has allowed a district court to skip the § 1 question simply because a state statute might also compel arbitration. It pointed to its own precedents Romero v. Watkins & Shepard Trucking, Inc., 9 F.4th 1097, 1100 (9th Cir. 2021), and In re Van Dusen, 654 F.3d 838, 846 (9th Cir. 2011), as well as decisions from sister circuits, including Harper v. Amazon.com Services, Inc., 12 F.4th 287, 296 (3d Cir. 2021), and Cunningham v. Lyft, Inc., 17 F.4th 244, 253 (1st Cir. 2021).

With the first three factors — including the critical clear-error factor — strongly favoring relief, the panel granted the writ.

CVS Resolves Insulin Pen Overbilling Medi-Cal Case for $36.5M

The California Attorney General in collaboration with the United States Department of Justice, announced a settlement with national pharmacy chain CVS Pharmacy, Inc. (CVS) over its submissions of false claims to the Medi-Cal program for excessive dispensing of insulin pens.

The settlement resolves allegations that between January 2010 and December 2020, CVS broke the law by submitting fraudulent claims to Medi-Cal, intentionally giving patients more insulin than prescribed and lying about refill timelines to get paid for unauthorized, unnecessary medication.

The settlement agreement requires CVS to pay $36.5 million total with California’s share being over $2.7  million.

Insulin pens (hard plastic, pen-shaped cases containing syringes filled with insulin solution) are a common way for diabetic patients to self-administer insulin.  During the relevant period, manufacturers frequently distributed insulin pens in five-pen cartons with each pen containing 300 units (3 mL) of insulin solution.  Insulin prescriptions must set forth the “directions for use,” which typically designate both how much insulin to administer and the frequency and/or timing of when to administer it.

When pharmacies seek reimbursement from Group Health Plans (GHPs) for insulin pens, they are required to report, among other data, the “quantity dispensed” and the “days-of-supply.”  The “quantity dispensed” means the total amount of medication dispensed to a patient when the pharmacy fills the prescription, and the “days-of-supply” refers to the number of days that the quantity dispensed is expected to last if taken as directed by the prescriber.  Typically, pharmacists calculate days-of-supply by dividing the total quantity of medication dispensed by the patient’s “daily dose,” i.e., the amount of medication that the prescriber directs the patient to use each day.

GHP plans, and pharmacy benefit managers (“PBMs”) working on their behalf, typically set limits on the days-of-supply that a pharmacy may dispense when filling prescriptions (such as a 30-day supply), and reject reimbursement claims for fills that exceed those limits.  GHPs and PBMs also deny reimbursement for prematurely refilled prescriptions—refills dispensed before the beneficiary would have consumed a substantial portion of the previously-dispensed quantity of medication if taken as prescribed.  PBMs use automated processes to review claims for reimbursement submitted by pharmacies and deny claims that are submitted too far in advance of the expected refill date.  The ability of PBMs to detect and reject reimbursement claims for premature refills depends on pharmacies complying with their obligations to accurately report days-of-supply data.

Dispensing insulin in full cartons containing five pens can exceed applicable days-of-supply limits, resulting in claim rejections.  PBMs developed rules to address reimbursement when dispensing medications like insulin in the smallest commercially-available container would exceed the days-of-supply limit.  Some PBMs required pharmacies to seek an override of the limit and then to resubmit the claim reporting the accurate days-of-supply actually dispensed so the PBM could verify when the next refill would be needed.  Other PBMs permitted pharmacies to submit claims reporting the maximum days-of-supply allowed, even if that number was lower than the actual supply dispensed.  Importantly, however, those PBMs still required pharmacies to track and use the actual days-of-supply dispensed to determine when patients would actually need a refill.  All PBMs prohibited pharmacies from seeking reimbursement for premature refills, regardless of container size.  

As alleged in the Government’s Complaint: From January 1, 2010, through December 31, 2020 (the “Covered Period”), CVS violated the FCA by knowingly submitting, or causing to be submitted, false claims to GHPs for reimbursement for insulin pens where CVS: dispensed more insulin to GHP beneficiaries than was specified by their prescriptions and refilled GHP beneficiary prescriptions substantially before GHP beneficiaries needed the refills; falsely under-reported the days-of-supply for the insulin refills, which often prevented PBMs from detecting that the refills were premature; and failed to comply with applicable rules when refilling insulin prescriptions requiring pharmacies to calculate refill dates using the actual days-of-supply dispensed.

To fill insulin prescriptions as quickly as possible and to ensure that reimbursement claims for insulin pens were not rejected, CVS instructed its pharmacy staff simply to report the maximum days-of-supply allowed under the beneficiary’s plan when dispensing full insulin pen cartons, which was often lower than the actual days-of-supply dispensed.  Many CVS pharmacies did not internally document and use the actual days-of-supply dispensed to determine when patients could next refill their prescription.  To the contrary, CVS’ dispensing software calculated refill dates automatically based on inaccurate days-of-supply data reported to the PBM.  As a result, CVS pharmacy staff repeatedly refilled prescriptions prematurely, dispensing substantially more insulin to GHP beneficiaries than they actually needed and substantially sooner than they needed it according to their prescriptions. As a result, some GHP beneficiaries accumulated large quantities of unused insulin, which was both wasteful and potentially dangerous as insulin can expire.

CVS management was well aware that it was over-dispensing insulin.  PBMs conducted periodic audits of CVS pharmacies and repeatedly found violations of the dispensing rules, including reporting invalid days-of-supply data, refilling insulin pen prescriptions too soon, and dispensing insulin pens in excess of the quantities authorized by the prescription.  PBMs issued chargebacks to CVS based on these violations.  For several years, CVS management knew that insulin pens were among the drug products most frequently subject to chargebacks for premature refills.   Yet, despite these audit findings, CVS failed to take necessary steps to address this long-standing problem during the Covered Period.

Under the settlement, CVS admitted, among other things, that:

– – During much of the covered period, many CVS pharmacies did not break open insulin pen cartons when dispensing insulin pens. As a result, at times, CVS pharmacies dispensed amounts of insulin that exceeded applicable days-of-supply limits. When a claim for reimbursement was rejected for exceeding the limit, some CVS pharmacies did not obtain overrides and re-submit the claim listing the actual days-of-supply dispensed as required by some PBMs. Instead, CVS pharmacies often reported the maximum days-of-supply allowed under the beneficiary’s insurance plan for insulin pens when resubmitting the claim, which was lower than the actual days-of-supply dispensed. While certain PBMs allowed this practice because the carton was the smallest commercially-available container for the medication, CVS pharmacies at times did not adhere to the appropriate refill intervals for patients that were to be based on the actual days-of-supply dispensed.
– – During much of the covered period, CVS customers with insulin-pen prescriptions who enrolled in CVS’ optional auto-refill program received automatic prompts notifying them that their refilled prescriptions were available to be picked up. CVS’ auto-refill logic calculated prescription refill dates based on the days-of-supply data recorded by pharmacy staff and sent customers refill notifications based on those dates. When pharmacy staff recorded days-of-supply numbers that were lower than the actual days-of-supply dispensed, the system would at times calculate refill dates for patients that were premature. As a result, some CVS pharmacies dispensed insulin pen refills to GHP beneficiaries before the beneficiaries needed more insulin and before the GHP plan or PBM would have approved such refills for reimbursement.
– – At times during the covered period, GHPs and the payors working on their behalf paid CVS substantial amounts for insulin pen refills that were ineligible for reimbursement, and CVS pharmacies dispensed more insulin to GHP beneficiaries than they needed.

In connection with the filing of the lawsuit and settlement, the Government joined five private whistleblower lawsuits that had previously been filed under seal pursuant to the False Claims Act.

DOJ Declares EEOC’s Disparate-Impact Guidelines Unconstitutional

The Justice Department’s Office of Legal Counsel (OLC) issued an opinion on June 9 concluding that the Equal Employment Opportunity Commission’s longstanding guidelines on disparate-impact liability under Title VII are unconstitutional. The opinion, signed by Assistant Attorney General T. Elliot Gaiser and Deputy Assistant Attorney General Joshua Craddock, asserts that the EEOC’s approach pressures employers into race-based decision-making to avoid liability—and that, properly read, Title VII reaches only practices reflecting “a significant likelihood of intentional discrimination.”

In an unusual move, DOJ announced the opinion jointly with the EEOC. OLC opinions are not court rulings, but they are treated as binding within the executive branch – meaning the EEOC and other agencies are now expected to enforce Title VII consistent with this reading.

Disparate-impact liability holds employers responsible for facially neutral practices that disproportionately burden a protected group, even absent discriminatory intent. Its origin is the Supreme Court’s 1971 decision in Griggs v. Duke Power Co., which held that Title VII bars practices “fair in form, but discriminatory in operation” – in that case, a high-school-diploma requirement and an aptitude test that screened out Black applicants without being shown to predict job performance.

In 1978, the EEOC, DOL, DOJ, and the Civil Service Commission jointly adopted the Uniform Guidelines on Employee Selection Procedures (29 C.F.R. part 1607), which remain in force and require employers to “validate” any selection procedure producing an adverse impact. The Court refined the framework in Wards Cove Packing Co. v. Atonio (1989), tightening the plaintiff’s burden to identify the specific practice causing a disparity. Congress responded in the Civil Rights Act of 1991, codifying the three-step burden-shifting test at 42 U.S.C. § 2000e-2(k): the plaintiff identifies a specific practice causing a disparity; the employer shows the practice is “job related” and “consistent with business necessity”; and the plaintiff may still prevail by identifying an equally effective, less-discriminatory alternative the employer refused to adopt.

Two later decisions – Ricci v. DeStefano (2009) and Texas Department of Housing v. Inclusive Communities (2015) – flagged the “serious constitutional questions” that arise if liability turns on statistical disparity alone, and emphasized that the doctrine needs limiting safeguards to avoid pushing employers toward quotas. Justice Scalia’s Ricci concurrence, that the “war between disparate impact and equal protection” would eventually be waged, is quoted prominently in the new opinion.

Rather than declaring the 1991 statute itself void, OLC deploys constitutional avoidance to reinterpret Title VII narrowly and then finds specific EEOC regulations unlawful. It lays out three limiting principles:

– –  1)  A low business-necessity bar. Employers need only show a challenged practice is “rational, convenient, or helpful” to a valid business purpose. Background checks, aptitude and knowledge tests, SAT scores, high-school-graduation requirements, and blind auditions are deemed presumptively job-related. Only “irrational or arbitrary” practices with no plausible job-relatedness can create liability.
– –  2)  A robust causation requirement. Plaintiffs must show – at the pleading stage and beyond – that the specific challenged practice itself, not external factors, caused the disparity.
– –  3)  A demanding alternative-practice requirement. Plaintiffs must identify a concrete alternative that is both less discriminatory and equally effective, including as to cost and other burdens.

Applying these principles, the opinion concludes that two parts of the EEOC’s framework are independently unlawful: the validation-study requirements in the Uniform Guidelines (which it calls atextual, “labyrinthine,” and improperly burden-shifting), and the Affirmative Action Guidelines (29 C.F.R. part 1608), which it says unconstitutionally encourage racial preferences without an established Title VII violation.

OLC frames the opinion as a response to the Supreme Court’s June 2 per curiam decision in Allen v. Milligan and its companion Louisiana v. Callais, which reread Section 2 of the Voting Rights Act to impose liability “only when the circumstances give rise to a strong inference that intentional discrimination occurred.” OLC imports that logic into Title VII.

The opinion is also the latest step in a sequence that began with President Trump’s April 2025 Executive Order 14281, Restoring Equality of Opportunity and Meritocracy, directing agencies to eliminate disparate-impact enforcement. That was followed by the EEOC pausing disparate-impact investigations in 2025 and DOJ’s December 2025 rule rescinding Title VI disparate-impact regulations. EEOC Chair Andrea Lucas, who formally requested the opinion in February, welcomed it as providing “clarity” on the constitutional limits of the doctrine; Acting Attorney General Todd Blanche said it would let businesses “hire based on performance.”

Theoretical practical takeaways for employers and their counsel to consider at this early stage.

– –  Enforcement posture has shifted, but the statute has not. The 1991 codification of disparate impact remains on the books, and courts – not OLC – decide what Title VII requires. Plaintiffs can still sue in federal court, and the private bar has signaled it will continue bringing disparate-impact claims regardless of EEOC inaction.
– –  Expect agency charges to get harder to win. The EEOC is unlikely to pursue impact-only theories, and the validation and affirmative-action regulations are now treated as unenforceable within the agency.
– –  Selection tools are on firmer footing – at the federal level. Tests, background checks, and similar screens face a lighter justification standard under this reading. But state and local fair-employment laws (and their own disparate-impact provisions) are unaffected and remain a live source of exposure.
– –  DEI-style “voluntary affirmative action” carries fresh risk. The opinion’s hostility to race-conscious “goals and timetables” reinforces the post-SFFA, post-Ames trend against preference programs.

Critics, including former Civil Rights Division attorneys, argue the opinion contradicts Supreme Court precedent and will lead to “a sharp increase in unchecked discrimination.” Because an OLC opinion binds the executive branch but not the judiciary, the doctrine’s ultimate fate will turn on litigation now likely to accelerate – and, eventually, on whether the Supreme Court takes up the question Justice Scalia flagged sixteen years ago.

NOTE: This summary is for informational purposes and is not legal advice. Employers should consult counsel about how these developments interact with applicable federal, state, and local law.

S.F. Telehealth Company Resolves False Claims Case for $3.325M

San Francisco-based Circle Medical Care of California, Circle Medical Technologies, Inc., and their Chief Medical Officer and medical director Dr. Nicole Tsang, D.O., have agreed to pay a total of $3,325,000 to the United States and the State of California to settle allegations that they knowingly submitted claims for payments to federal healthcare programs and California commercial insurers for services by providers who did not actually provide or supervise those services, in violation of the federal False Claims Act and corresponding state statute.

Circle operates an online telehealth platform through which it offers mental health treatment and primary care medical services through contract providers, including nurse practitioners and physician assistants located throughout the country.  Circle submits claims for payment to federally funded health programs, including Medicare, Medicaid, and TRICARE, and to California commercial insurers.  

The United States and California allege that Circle submitted claims for payment to these programs and insurers for services, and received reimbursement, between January 1, 2018, and May 31, 2025, despite knowingly identifying the name and NPI (National Provider Identifier) number of rendering providers who did not actually provide or supervise the services rendered, and failed properly to supervise the nurse practitioners and physician assistants who rendered medical services to its patients during this period.

Under the settlement agreement, Circle will pay $475,000 to the United States and $2,850,000 to California.

United States Attorney Craig H. Missakian, Special Agent in Charge Robb R. Breeden of the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), and Assistant Inspector General and Health Care Fraud Division Director Jennifer K. Dietz of the Defense Health Agency Office of Inspector General (DHA-OIG) made the announcement.

The settlement resolves claims brought under the qui tam or whistleblower provisions of the False Claims Act by Jason Vellen.  Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery.  The qui tam case is captioned United States and State of California ex rel. Jason Vellen v. Circle Medical Care of California, Circle Medical Technologies, Inc., Dr. Nicole Tsang, D.O, and George Favvas, No. 3:24-cv-02024-TSH (N.D. Cal.).  In connection with the settlement, Mr. Vellen will receive $80,750 from the United States and $997,500 from California.

Assistant U.S. Attorney Savith Iyengar handled this matter.  The resolution resulted from a coordinated effort among the U.S. Attorney’s Office for the Northern District of California, the California Department of Insurance, and the San Francisco District Attorney’s Office.

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

CWCI Reports Private Self-Insured Claims Fall But Losses Rise

Private self insurers are required to file Self Insurer’s Annual Reports by March 1 each year. Each private Self Insurer’s report is required to include paid, estimated future, and total incurred claims costs for each of the past five calendar years (claims reported from January 1 through December 31 for each year), as well as paid, estimated future, and total incurred claims costs for any claims still open from earlier reported years.

California private self-insured employers reported fewer workers’ compensation claims in 2025, driving private, self-insured claim frequency to a 5-year low, but initial data show signs of rising claim costs according to a new California Workers’ Compensation Institute (CWCI) analysis of first-report data from the state Office of Self-Insurance Plans (OSIP).

The latest data show private self-insured employers in California covered nearly 2.22 million employees in 2025, down 1.5% from the prior year. Despite the slight reduction in the covered workforce, private self-insured wages and salaries totaled nearly $152.5 billion, up 1.1% from the prior year. At the same time, the number of reported claims in the private self-insured sector fell for the third year in a row, declining 2.7% to 84,996 claims. That total is 18.5% below the 2022 peak, when thousands of COVID-19 cases pushed the private self-insured claim count up to 104,278.

Overall, private self-insured claim frequency edged down from 3.88 claims per 100 employees in 2024 to 3.83 claims per 100 employees last year, the lowest level since 2020. The Institute notes that both indemnity and medical-only claim frequency have fallen since the pandemic-era spike in COVID-related claims, with the decline in indemnity frequency contributing just slightly more to the overall reduction in private self-insured claim frequency.

Despite the declines in private self-insured claim volume and frequency, comparing the initial loss data from all 2024 and 2025 claims (medical-only and indemnity) show total paid losses remained essentially unchanged at $352.4 million. At the same time, total incurred losses (paid benefits plus reserves for future payments) rose 4.8% to $979.2 million, reflecting increases in expected claim costs, as the average incurred loss per claim increased 7.7% last year, driven largely by growth in medical reserves.

The Institute also found that both average paid and average incurred losses on private self-insured claims have been trending up for several years. Comparing first-report loss payments on all private self-insured claims from recent years, the Institute found that the average paid loss rose 2.5% to $4,147 in 2025, marking the third consecutive annual increase. Since bottoming out at $2,983 in 2022, the average paid loss has increased 39.0%. Meanwhile, the average incurred loss climbed to $11,520 last year, up 48.1% since 2022. Higher indemnity and medical losses both contributed to these increases, but rising medical losses have been the key cost driver, as the first report data from 2022 and 2025 show the average paid medical loss per claim increased 48.4% and the average incurred medical loss per claim increased 55.2%; so even with the 18.5% reduction in claim volume, total paid medical losses increased 20.9%; and total incurred medical losses increased 26.5%.

OSIP’s newly released data summary provides the first look at California private self-insured workers’ compensation experience for calendar year 2025 and includes updated experience for claims reported from 2021 through 2024. OSIP has posted its latest summary, along with those from the previous 24 years.

Study Shows High Attrition Rate for Surgeons Nationwide

Every workers’ compensation claim involving a serious injury eventually runs into a question of access: Is there a surgeon available to operate, and how soon? Surgeon supply drives surgical wait times, which drive temporary disability duration, return-to-work timelines, and ultimately claim cost.

A new study “National Analysis of Trends and Factors Associated with Surgeon Attrition in the US” published in the Journal of the American College of Surgeons (2026, published ahead of print) is the largest national look to date at how surgeons are leaving active practice — and it gives a data-backed sense of where the supply pressure is, and is not, building.

The team of researchers tracked 224,629 surgeons across 19 surgical specialties using Medicare billing data from 2013 through 2023, following them for a median of 8 years. They defined “attrition” as a surgeon who stopped showing meaningful clinical activity (fewer than 50 evaluation-and-management services per year) for three straight years. They then used statistical modeling to identify which factors predicted leaving practice.

Nearly one in ten U.S. surgeons left active practice over eight years, but the loss is concentrated — heaviest among mid-career surgeons and a handful of specialties, lightest in the orthopedic and podiatric fields that drive most workers’ comp surgical care. The supply picture is best understood specialty by specialty, not as a single national number.

– – Roughly 1 in 10 surgeons (9.7%) left active clinical practice over the 8-year window. That works out to about 15,753 surgeons.
– – Annual attrition held steady at 1.5–1.7% per year from 2013 to 2018, then spiked to 2.5% in 2019 before dropping to 1.3% in 2020. The authors attribute the spike largely to the early COVID-19 period.
– – If that rate holds, the authors project a loss of roughly 2,000 surgeons per year — about 25,000 to 30,000 over the next decade.
– – The workforce is aging: median years in practice nearly doubled from 7 (2013) to 16 (2023).
– – The share of women surgeons rose from 21% to 29%.
– – Rural surgical presence shrank — from about 10.5% of surgeons in rural/non-metro areas in 2013 to 8.5% in 2023.

The detail that matters most: it varies enormously by specialty. Attrition is not uniform — and for workers’ compensation purposes, the differences cut in a reassuring direction for the specialties that are critical..

High-attrition specialties 5-Year Cumulative Attrition

– – Oral & Maxillofacial Surgery – 25.1%
– – Obstetrics & Gynecology – 23.2%
– – Plastic & Reconstructive Surgery – 19.3%

Low-attrition specialties 5-Year Cumulative Attrition

– – Otolaryngology (ENT) – 1.8%
– – Podiatry / Foot & Ankle – 1.8%
– – Orthopedic Surgery – 2.4%
– – Vascular Surgery – 3.1%

The specialties that handle the bulk of occupational injuries — orthopedic surgery, podiatry/foot-and-ankle, and to a lesser extent vascular and neurosurgery — show among the lowest attrition rates and the shallowest decline curves. Orthopedics in particular, the workhorse of musculoskeletal injury care, is a relatively stable specialty in this data. That’s encouraging for surgical access on most lost-time claims.

The authors suggest the high-attrition specialties are pressured by heavy call burdens, malpractice exposure, market competition, and the availability of non-clinical career exits — while the more stable specialties tend to offer more predictable schedules and clearer paths to dialing back late-career rather than leaving outright.

One of the more surprising results: attrition does not rise steadily with age. Instead, surgeons 10–14 years into practice were more than twice as likely to leave as those 5–9 years in (hazard ratio 2.58). Both newer surgeons (under 5 years) and those 15–19 years in were less likely to leave. The authors link this “mid-career spike” to peak burnout, administrative burden, and competing leadership and family demands.

Other notable findings

– – Sex made no difference. Female and male surgeons left at essentially identical rates (HR 0.99) — contrary to some prior studies in academic medicine.
– – Geography mattered modestly. Compared to the Northeast, surgeons in the South had somewhat lower attrition; the West was slightly higher. Rural versus urban differences were small in the adjusted model.
– – Surgical access for orthopedic and podiatric claims looks comparatively secure based on this data — useful context when evaluating treatment-delay arguments or utilization-review timelines.
– – Rural claims face a compounding squeeze. Fewer surgeons in non-metro areas means longer travel and potential delay for injured rural workers — a recurring access issue worth flagging in case management.
– – Provider relationships are fragile mid-career. Networks and treating-physician arrangements built around a single surgeon carry succession risk.

A key caveat the authors flag: because the data is administrative billing data, they cannot always tell the difference between a true retirement, a move to a non-clinical or part-time role, or a shift in how someone bills. So “attrition” here means departure from active clinical surgical practice as Medicare sees it — not necessarily retirement.