[Update, Oct. 13: Gov. Newsom on Sunday signed AB 290, the measure to cap reimbursements to dialysis firms that was aimed at the big chains, DaVita and Fresenius.

[In his signing message, Newsom leveled criticism at the bill’s opponents for threatening to end charity assistance for Californians undergoing dialysis if the bill had been signed. The threat was mde by the American Kidney Foundation, which is largely funded by DaVita and Fresenius. “Charities that purport to impartially provide patient assistance, and the providers that substantially fund these charities, should act in good faith and continue providing assistance to patients,” Newsom wrote.]

The two major afflictions besetting the U.S. healthcare system are that its prices are too high, and that although big spending should give us better quality of care, it doesn’t.

These two conditions arise from the same cause: American healthcare is becoming less competitive. Hospital chains are growing larger, and within some specialties, providers have become more concentrated.

The result is that Americans get the worst of all possible worlds. Only two conditions can keep prices in check–competition, or regulation. The utility sector is monopolistic, but also price-regulated. As American healthcare becomes increasingly monopolistic, the absence of utility-style price controls means the sky’s the limit.

The late healthcare economist Uwe Reinhardt, and his colleagues saw the consequences clearly in his seminal paper on the fundamental malady of our system. It was titled, “It’s the Prices, Stupid.”

Lack of oversight result not only in higher prices, but lower quality. As a new study of the dialysis industry asserts, the acquisition of thousands of dialysis centers by major commercial firms resulted in higher hospitalization and mortality rates of patients and less access to kidney transplants.

“For-profit acquirers’ explicit mandate to maximize profits may lead them to sacrifice patient outcomes,” says the study, prepared by a team from Duke University on a grant from the National Science Foundation.

Their peer-reviewed paper is scheduled to be published by Harvard’s Quarterly Journal of Economics in an upcoming issue. The firms say the study is based on old data and outdated practices, and fails to acknowledge overall improvements in the health of dialysis patients over the years.

The Duke study is based on data from 1998 through 2010. The cutoff point was chosen because the reimbursement system of Medicare, the principal payer for dialysis, changed in 2011 — a change largely dictated by alleged financial abuses by dialysis centers.

That change and other improvements in standards and technology “make the historic data in this study not reflective of the current state of care,” Brad Puffer, a spokesman for Fresenius Medical Care, one of the two major commercial dialysis providers in the U.S., told me. The research team says it’s continuing its work to cover the post-2011 period.

In a prepared statement, DaVita Kidney Care, the second major provider, said it has “improved clinical outcomes for over 20 years.” The firm pointed to a 2010 study in a peer-reviewed medical journal that showed improved patient mortality after two years in clinics acquired by the firm in 2005. The study was co-written by five DaVita executives and used internal DaVita data.

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Denver-based DaVita and the German conglomerate Fresenius own or operate more than 5,000 dialysis clinics in the U.S., accounting for more than 60% of the U.S. locations, and collect roughly 90% of the sector’s revenues. During the period under study, they acquired 1,200 formerly independent dialysis facilities.

Paul J. Eliason, et al., in dialysis industry study

Increasing healthcare concentration and its consequences are beginning to face closer scrutiny in California. A San Francisco state court jury is scheduled to start hearing testimony this week in lawsuits alleging that the sprawling Sutter Health hospital chain ruthlessly exploited its regional dominance to fix prices. (A case brought by several Northern California employers and another filed by Atty. Gen. Xavier Becerra were combined for the trial.) Sutter is technically a nonprofit provider, but that doesn’t mean its management lacks incentives to maximize the chain’s income.

As for the dialysis industry, healthcare reformers have tried for years to rein in the profits enjoyed by the commercial dialysis industry.

A California ballot measure that would have capped their profits failed in 2018 after one of the most expensive ballot campaigns in history — about $130 million in total spending, including $100 million in opposition funding contributed by the two big dialysis firms alone. A bill that would cap insurance reimbursements for dialysis passed the Legislature this year and is awaiting a decision by Gov. Gavin Newsom.

The Sutter and dialysis situations raise somewhat different issues. The Sutter case is in the mainstream of antitrust law. It turns on the question of how the chain profited from its position in a regional market. (Sutter’s defense is that the prices in its contracts with insurers and other payers reflect conditions that have nothing to do with its market dominance.)

The roll-up of independent dialysis centers by the two big firms doesn’t have the same effect on regional markets, the Duke study acknowledges. Dialysis centers are typically too small, even in the aggregate, to fall within traditional antitrust law.

“Any individual facility is not going to move market concentration,” says Ryan C. McDevitt, an associate professor at Duke and one of the paper’s authors. He says that it would be more relevant to examine the concentration of the dialysis industry on a national scale.

The dialysis firms point to government statistics showing that overall mortality among dialysis patients has declined by nearly 30% from 2001 to 2016. (The rate is adjusted for the increasing age of the patients.) But that’s not necessarily inconsistent with a rise in mortality among patients at dialysis centers that have transitioned to chain ownership, McDevitt says.

Dialysis, which uses a machine to filter waste products from the blood when a patient’s kidneys can no longer do that job, has long been a special case among medical procedures. Patients typically undergo the hours-long procedure three times a week at a specialized clinic, although home dialysis is gradually becoming more common. It’s generally the only procedure that can keep patients alive until and unless they can secure a kidney transplant, for which waiting lists can be years long.

Because dialysis costs about $90,000 a year, renal patients used to be uninsurable. In 1973, Congress made those patients eligible for Medicare at any age. The procedure soon ranked among the program’s largest annual expenditures and Epogen (EPO), an anti-anemia drug needed by the patients, became Medicare’s largest single annual prescription expenditure.

Under the Affordable Care Act, however, private insurers could no longer refuse to cover kidney patients. DaVita and Fresenius have acknowledged that they profited from the change, because private insurers pay them as much as five times as much per treatment as the roughly $260 paid by Medicare. DaVita, for example, reported last year that while commercial insurers covered only 10% of the firm’s patients, they provided about 30% of its income.

One other change in this system is notable. Through 2010, Medicare paid only about $128 per dialysis session but covered injectable drugs separately. That led to accusations that dialysis providers were gaming the drug reimbursements by discarding partially filled containers instead of using up the contents, so they could charge Medicare for the additional vials. In 2015, DaVita agreed to pay up to $495 million to settle allegations that it inflated prescription billings to Medicare by “creating unnecessary waste.”

The company didn’t admit to the allegations, but the settlement was so large that it reduced DaVita’s annual profit by more than half. In announcing the settlement, federal prosecutors observed that after Medicare changed its reimbursement system in 2011 to bundle dialysis treatments and the drugs into a single payment of $260 per treatment, “wastage derived from single-use vials was no longer profitable, and, as a result, DaVita allegedly changed its practices and reduced its drug wastage dramatically.”

The Duke study appears to document a sharp increase in drug usage at dialysis centers acquired by big chains prior to 2011. “Perhaps reflecting the profits at stake,” the study says, EPO doses more than doubled at independent dialysis centers after they were acquired. DaVita says that drug prescriptions were dictated by physicians, not the firm. But those physicians typically were paid by the firms, and the whistleblower complaint that led to the 2015 settlement alleged that DaVita corporate protocols dictated how dosages were to be drawn from individual vials and ampules to maximize billings.

What’s most telling about the study is its conclusions about how the policies and protocols of the acquiring companies infiltrate the formerly independent dialysis centers they acquire. Using patient-level data from the Centers for Medicare and Medicaid Services (with the patients’ names kept confidential), the researchers found that patients at acquired facilities were 4.2% more likely to be hospitalized in a given month, while their survival rates fell by as much as 2.9%.

New patients who start dialysis at an acquired center were 8.5% less likely to receive a kidney transplant or be placed on a transplant waiting list during their first year of dialysis.

That was a “reflection of worse care,” the study says, “because transplants provide both a better quality of life and a longer life expectancy than dialysis.”

The study found that acquired facilities tended to have fewer nurses and more “less-skilled technicians,” and treated more patients per employee, “stretching resources and potentially reducing the quality of care received by patients.”

The study’s findings match some earlier research into changes in dialysis centers’ ownership. A 2014 survey of the kidney transplant landscape, for example, found that patients at facilities owned by for-profit chains were 13% less likely to be enrolled in transplant waiting lists, compared to those in facilities run by nonprofit chains.

“For-profit ownership of dialysis chain facilities appears to be a significant impediment to access to renal transplants,” the study concluded, but it could only conjecture about the reasons. The authors speculated that publicly-traded dialysis firms might be wary of referring patients for kidney transplants because ending their need for dialysis would result in “removing a constant stream of revenue from their facility.”

It’s true that great strides have been made in the quality of life and survivability of patients facing the burden of renal disease and dialysis. But much of the improvement can be attributed to the government’s role in the field and its incentives to control costs and improve outcomes. Some of its innovations in payment, for instance, were aimed at reducing the incentives of for-profit providers to extract greater revenues regardless of the health of their patients.

DaVita in its statement attributes improvements in its dialysis results to its “large-scale clinical investments,” including “investments that standardize clinical and infection control practices, support staff training and improve IT infrastructures.” The question is whether the for-profit dialysis industry would have undertaken these investments on its own, or it had to be pushed to do so by government pressure. The profit motive in American healthcare is still as troublesome as it ever was.

BEIJING — 

China’s trade with the United States fell by double digits again in September amid a tariff war that threatens to tip the global economy into recession.

Exports to the United States, China’s biggest foreign market, fell 17.8% to $36.5 billion, a deterioration from August’s 16% decline, customs data showed Monday. Imports of American goods sank 20.6% from the year before to $10.6 billion, a slight improvement over August’s 22% decline.

President Trump agreed Friday to put off an additional tariff hike planned for this week on Chinese imports. In exchange, he said Beijing agreed to buy up to $50 billion of American farm goods. But they reported no agreements on disputes over China’s trade surplus and technology policies that brought on the 15-month-old fight.

“The external environment facing China’s foreign trade development is still complicated and severe. Instability and uncertainty are increasing,” a customs agency spokesman, Li Kuiwen, said at a news conference.

Tit-for-tat tariff hikes on billions of dollars of each other’s goods have battered manufacturers and farmers on both sides and disrupted supply chains worldwide. Uncertainty has prompted some companies to postpone investments, adding to downward pressure on global growth and fueling financial market jitters.

China’s global exports fell 1.4% from a year earlier to $218.1 billion. Imports fell 5.8% to $178.5 billion.

The slump adds to pressure on President Xi Jinping’s government to shore up cooling economic growth and prevent politically risky job losses.

Chinese growth fell to its lowest level in at least 26 years in the quarter ending in June, decelerating to 6.2% over a year earlier.

Forecasters expect growth in the July-September quarter, due to be reported this week, to fall further to as low as 5.9%, sinking below the ruling Communist Party’s official target for the year of at least 6%.

“While import growth should start to recover soon, it will take longer before export growth bottoms out,” said Martin Lynge Rasmussen of Capital Economics in a report. “The mini U.S.-China trade deal reached on Friday doesn’t alter the outlook significantly.”

The country’s politically sensitive trade surplus with the United States contracted by 16.5% from a year earlier but stood at $25.9 billion.

Increased exports to Britain and other European countries and developing markets such as Vietnam helped to offset some of the losses. China’s global trade surplus expanded by 42.2% to $39.7 billion.

For the first nine months of the year, Chinese imports of American goods were off 26.4% at $90.6 billion. Exports to the United States were off 10.7% at $312 billion.

Trump put off a tariff hike planned for Tuesday on $250 billion of Chinese goods. But Washington still is planning a Dec. 15 tariff hike on $160 billion of smartphones and other imports.

Before then, Trump and Chinese President Xi Jinping are due to attend an economic conference in Chile in mid-November. That is raising hopes a face-to-face meeting might produce progress.

Talks broke down in May over Beijing’s insistence that Trump’s punitive tariffs had to be lifted once a deal took effect. Washington says some must remain in place to ensure Chinese compliance. Trump and Xi agreed in June to resume negotiations but they have announced no breakthroughs.

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I’m Business columnist David Lazarus, with a look today at being nicer to Mother Earth.

A couple of recent developments merit highlighting. One involves Legos, the greatest toy ever invented. I’ll get to that in a moment.

The other involves the little bottles of shampoo, conditioner and soap found in many hotels. California Gov. Gavin Newsom signed legislation this week that does away with the convenient but environmentally unfriendly personal-care items.

The bill — Assembly Bill 1162 — takes effect in 2023 for hotels with more than 50 rooms. Smaller establishments have until 2024.

Hotels that fail to comply with the law face a $500 fine for the first violation. All subsequent violations would result in a $2,000 fine.

This law doesn’t apply to hospitals, nursing homes, retirement communities, prisons, jails and homeless shelters.

Some hotel chains — including Marriott and Holiday Inn — already have announced moves to replace little shampoo bottles with refillable dispensers. California is building on such initiatives and creating a level playing field.

The Personal Care Products Council, an industry group, opposed the bill. It said businesses would be hurt. In fact, they’ll still be able to sell their products to hotels. They’ll just do so in more sensible containers.

From plastic grocery bags to plastic straws, California has been out front in trying to reduce some of the biggest forms of pollution, especially in rivers and oceans. A crackdown on wasteful shampoo bottles might seem like a modest gesture, but every little bit counts.

Meanwhile, the good people at Lego Group had their own flash of inspiration. Realizing that many families have boxes of old Lego bricks stashed away — or, worse, throw them out — Lego announced a pilot recycling program.

Dubbed Lego Replay, the program makes it easy to donate old Lego bricks to nonprofit groups that assist kids. Just visit Lego.com/replay to download a free UPS shipping label. Lego will sort and clean the bricks, and get them to where they can do some good.

“We know people don’t throw away their LEGO bricks,” said Tim Brooks, Lego Group’s vice president of environmental responsibility. “The vast majority hand them down to their children or grandchildren. But others have asked us for a safe way to dispose of or to donate their bricks. With Replay, they have an easy option that’s both sustainable and socially impactful.”

Added benefit: You won’t step on old Lego bricks with your bare feet any more.

Now then, here are some recent stories that caught my eye:

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STORY LINES:

Inland inequality: Income inequality isn’t just a problem on the coast. While cities such as Los Angeles, San Francisco and San Jose have become poster children for the gulf between the rich and the poor, the wealth gap has also hit hard in Bakersfield.

Up in smoke: The owner of two California marijuana dispensaries wanted to post pictures of weed on Instagram without running afoul of the social media app’s rules. So he hired engineers to create an Instagram without rules, where users could post what they wanted without fear of censorship from moderators. The results have not been pretty.

Fear of flying: After dealing with months of canceled flights and route changes due to the grounding of Boeing’s 737 Max aircraft, airlines will soon face a new challenge: convincing passengers to fly on these jets again. Here’s how they’re going to try to do it.

AROUND THE WEB:

The rise of Juul: How did vape-maker Juul go from a small start-up to a dominant player, essentially this era’s big tobacco? Bloomberg tells the story.

Fashion journalism’s future: Who needs a glossy fashion magazine to tell you what celebrities are wearing when there are teens on Instragram running “closet accounts,” which, according to the New York Times, painstakingly detail each and every garment worn by the stars and influencers?

Let me know what you think of the newsletter. My email is [email protected], or you can find me on Twitter @Davidlaz. Also, tell all your social media pals to join the party.

Until next time, see you in the Business section.

GENEVA — 

The World Trade Organization has formally given the go-ahead for the United States to impose trade sanctions on up to $7.5 billion worth of European Union goods following a ruling that European plane maker Airbus received illegal subsidies.

The move by the trade body’s dispute settlement body was largely a formality after the long-awaited Oct. 2 ruling by a WTO arbitration panel. For that ruling to be blocked, every country including the United States that attended the settlement body’s meeting Monday would have had to reject it.

The record $7.5 billion ruling found that the European bloc and member states Britain, France, Germany and Spain failed to remove improper subsidies for Airbus that hindered sales by U.S. rival Boeing.

The Trump administration plans to impose the sanctions starting Friday.

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We first connected on Tinder in February. I was out of town for the weekend, at my friends’ very Vegas wedding. I was surrounded by couples and was absently flipping through profiles when I saw him — early 40s, with thick, sandy blond hair, a college professor and musician. In his short bio, he mentioned that humanitarian efforts were of great interest to him. Also, that he liked breakfast for dinner. Noted.

He checked all my superficial boxes — attractive, educated, creative but grounded (and employed!) and seemingly altruistic. I was intrigued. We traded a few messages, and then the wedding celebrations went into full force, so as things happen, the messages waned. I spent the rest of the weekend helping with last-minute wedding errands, watching the happy couple say “I do” to a pretty convincing, if possibly drunk, Elvis and reveling in post-wedding shenanigans.

It’s easy to move on with matches like these, but a few weeks later, after a disappointing coffee date with zero chemistry, I found myself looking through old connections and decided to message him. To my surprise, he messaged back almost immediately and asked if I would like to go to dinner and a play the following night.

Color me impressed. This guy was classy. Normally, I am hesitant to commit to a lengthy first date with a perfect stranger, but I absolutely love theater, and quite frankly, I was both intrigued and delighted by the gesture.

Still, I did my research beforehand. I found his profile on LinkedIn and ratemyprofessor.com and found dozens of positive reviews from students (mostly female) who spoke to his dedication as a teacher, plus his bonus good looks.

He offered to pick me up for dinner, so after I’d assured myself that I wasn’t meeting up with the next Ted Bundy, I gave him my address. He arrived promptly and was waiting outside when I came downstairs. He greeted me with a hug and a kiss on the cheek and then held open the door to his black Porsche for me.

On the way to dinner, the conversation flowed. He was engaging, asking me about my work, passions and views on life. Over dinner, we talked about our backgrounds (he was from the Southwest, I’m from Louisiana), how different the culture was in Los Angeles and our families. I told him about my dog and asked if he had any pets. He said he had them as a child but no longer.

On the way to our seats for the play that night, my date ran into a colleague and introduced us. “How lovely,” I thought. Watching the play, I had a moment of perfect happiness. (Plays are one of my very favorite things, and for many years, I would attend them alone or with girlfriends, as past partners had been less enthusiastic.)

I knew it might be fleeting, but that night, for an instant, I felt the promise of something new, something good, something that might work.

Back at my apartment, he walked me to my door, and we shared a lingering kiss. I thanked him for a lovely time, and he left, like a perfect gentleman. I fell asleep grinning.

The next week, he invited me to dinner and a movie at the Grove. The movie wasn’t great, but sitting in the back with his arm around me, I didn’t really care. I was with a sweet, handsome, smart guy who was into me and treated me like a princess.

After the movie, I invited him up for a nightcap. Things progressed in a delicious way, his touch seemed natural and intuitive, and I felt free. At the end of the evening, I walked him out, we shared a warm embrace and we promised to see each other again soon.

The next few days, I was bursting with giddiness. We texted, sent each other selfies, and went back and forth about the banal particulars and little excitements of our days. We made plans for the following week. I was counting down the hours and annoying my friends with my newfound perkiness.

Enter Facebook.

The cause of (and solution to? Jury’s still out) all of life’s problems.

I searched his name, and up came a cozy photo of him — with a woman— and three children.

I stared at it quizzically for a moment. Could it be … a relative? A cousin? I did a little more clicking. And then I felt my skin go cold.

It was all there. Old photos from their wedding — they had been high school sweethearts. Their three beautiful children. Their kids’ baptisms and other family get-togethers. And a more recent photo of him taking her to a concert just a week earlier.

I was shaking. How could this be happening? I took a deep breath and texted him. “Hey, can you please call me when you get a moment? I need to ask you a question.” A few minutes passed. I couldn’t wait any longer.

Finally, I texted again: “Are you married?”

He called back a few minutes later.

He was calm, maybe resigned. He said they were separated and that she knew he was dating. He said he had planned to tell me but that our last evening together was going so well that he couldn’t bring himself to.

I told him that I was shocked. And disappointed. And that I felt betrayed. (I understand not unloading all your personal baggage on the first date. But by date No. 2? That’s the time to say: “By the way, I’m married and have three children.”) I felt like a sideshow attraction, a ride that he had taken on a whim, an alternate life that he had tried on for size. I told him I needed time to process.

A few days later I texted him to let him know I still wanted to see him but that I was working through my anger. He texted back that if I really felt like that, it was probably best not to move forward.

Needless to say, I was disappointed, but more so to lose the dream than the actual man. He was “too perfect,” as they say. I try not to be too cynical, but I suppose there had to be a catch somewhere. (And the Porsche made a lot more sense in hindsight.) Even if we had reconciled, I don’t think the relationship would have worked in the long run. I would have feared that he was always wearing a mask, always hiding the truth. It seemed so easy for him, so fundamental.

I thought about reaching out to the wife, to the college, posting a review on ratemyprofessor.com, but in the end, I just let it go.

I came across his profile on Bumble recently. Same photos, same line about philanthropy and breakfast for dinner. I swiped left this time.

The author is a recruiting and talent manager in Los Angeles.

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As the night’s first honoree at the Hammer Museum’s Gala in the Garden, Jordan Peele said his passion for filmmaking was less about making a commentary on society and more about eliciting a laugh or a scream from the audience.

“Any audible noise that an audience can make, that’s my passion,” said the actor-comedian and Oscar-winning screenwriter of “Get Out.”

He had already proved his point by getting laughs from the audience immediately after stepping onto the stage and joking that he expected a physical award, “something that had, like a base, gold — you know, a piece of art or something on top … to put on your desk — [looking] like a hammer.”

Peele then followed his joking by calling the evening “truly wonderful and surreal” and thanking the museum “for hosting this great event and doing such important work for the art community and for Los Angeles.”

The event

The Hammer Museum honored Peele, along with groundbreaking artist Judy Chicago, at the Saturday affair, which raised a record $2.7 million and featured a performance by seven-time Grammy-winning singer-songwriter Beck and a surprise appearance by Coldplay frontman Chris Martin. Author Roxane Gay and feminist icon Gloria Steinem respectively introduced Chicago and Peele.

The scene

In a conversation during the cocktail reception, Jane Lynch said, “This is probably my fifth or sixth year here. I love this museum and I love this event.” The five-time Emmy-winning actress then noted that she was wearing the same Alexander McQueen pantsuit she wore when she won her 2019 award for guest actress in “The Marvelous Mrs. Maisel.”

Other gala guests caught up over cocktails not only along the upper balconies of the museum but also in the galleries where “Bigger” actress Tanisha Long perused the museum’s newest exhibition, “Declaration of Independence,” from artist Lari Pittman. “I’m excited to be here to see the art,” Long said.

The crowd

Filmmaker J.J. Abrams and wife Katie McGrath (who run Santa Monica production company Bad Robot), along with fashion designer Tom Ford and husband Richard Buckley, served as gala co-chairs for the gathering of actors, artists, collectors, filmmakers and museum supporters.

Those in attendance included artists Pittman, Max Hooper Schneider, Larry Bell, Barbara Kruger, Lauren Halsey, Glenn Kaino, Charles Gaines, Julie Mehretu, Llyn Foulkes and Kenny Scharf; actors Joel McHale, Rita Wilson, Annabeth Gish, Catherine O’Hara, Philicia Saunders, Lynch and Long; Universal Pictures chair Donna Langley, NBCUniversal Vice Chairman Ron Meyer and Ann Philbin, director of the Hammer Museum.

The quotes

“I travel a lot, and I find myself often in wooded places, surrounded by wealthy white people,” Gay said jokingly after ascending the stage to introduce Peele. “During such trips, one or more of my friends will inevitably send me a text message with a sincere warning, ‘Don’t let them do to you like they did in “Get Out’ — and nothing more needs to be said.” Then she said, “That is the power of Jordan’s work. He has made the ‘sunken place’ … part of our cultural vernacular.”

She then praised Peele for his elegance, humor, razor-sharp dry wit, staggering intellect and uncanny understanding of the human condition. “He has carved a path for a different kind of black storytelling that goes beyond the tropes to which we have all too often been relegated,” she said.

For his part, Peele said, “I feel particularly humbled to receive such an honor so early in my film career. I know this is an institution that’s honored artists whose incredible work elevates the discourse of our time, artists whose work is brilliant, beautiful, eternal, nuanced.” Then he jokingly spoke of his own movies — “about brain transplantations” (“Get Out”) and “clones living underground with rabbits” (“Us”).

“So you can see how this is an unexpected turn of events to be here,” he said.

After dinner, Steinem said of Chicago, “You can pretty much divide the world, the art world, and certainly you can divide my life into before and after Judy Chicago.”

Steinem then recalled her encounter with the artist’s work in 1972, when “art was a lonely and isolated endeavor and not a communal creation, and it was kept in museums and galleries and seemed to be more about privilege than about community. Judy Chicago was the person who up-ended all of that.”

Then before closing, Steinem said, “We share a common humanity that needn’t be divided by gender or by race. We invented gender. We invented race. We can dis-invent it. In restoring our wholeness, Judy is restoring our humanity.”

Chicago then told her story by saying, “After I graduated [from college], I began to try and make a place for myself in the L.A. arts scene, which was singularly inhospitable to women. As a result, I had a pretty tough time.” She said resistance to her work began in graduate school. “My painting instructors hated my work,” she said.

Although there are more exhibitions by female artists today, Chicago said, “The truth is that history is not determined by exhibitions,” calling the percentages of acquisitions at major museums of works by female artists, and especially by female artists of color, shameful.

She closed by thanking the people who supported her over the years by saying, “I stand here tonight, bathed in the light of this somewhat unfamiliar recognition. What is important about my story is that it tells us that one person can make a difference — something really important to remember in these difficult times.”

The numbers

Tickets for the 500 people began at $2,500 each, with tables ranging upward to $100,000.

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AMMAN, Jordan — 

As President Trump ordered the withdrawal of the 1,000 remaining U.S. troops from northern Syria, hundreds of Islamic State family members Sunday escaped from a detention camp managed by Syrian Kurdish forces amid a Turkish air barrage.

Later in the day, the besieged Kurdish militia, which had previously served as the lead fighting force on behalf of the U.S. in routing the Islamic State extremists in Syria, announced its members were turning to the Syrian government to help stave off the Turkish onslaught.

The Russian-brokered deal came as the Kurds suffered a swift collapse in their lines in the face of a Turkish and Syrian opposition onslaught that followed Trump’s initial withdrawal of a much smaller group of American troops from the border area. Trump’s highly criticized move, in effect, served as a tacit blessing for Turkish President Recep Tayyip Erdogan’s invasion plans.

The Kurds, who had led an American-organized umbrella group known as the Syrian Democratic Forces, or SDF, announced the deal with the Syrian government in a statement saying that, though their cadres had fought “bravely,” they were unable to stop the Turkish advance.

“To prevent and thwart this aggression, there has been an agreement with the Syrian government for the Syrian army to enter and deploy along the Syrian-Turkish border,” said the statement, “and assist the Syrian Democratic Forces in thwarting this aggression and liberating the areas entered by the Turkish army and its hired mercenaries.”

The announcement followed a day of chaos in Syria and recriminations in Washington, with both Democratic and Republican critics accusing the Trump administration of abandoning an ally and opening the way for a resurgence of the Islamic State militias.

On Sunday morning, Defense Secretary Mark Esper announced that the U.S. would withdraw the remaining troops — just days after saying the U.S. was not “abandoning” its Kurdish allies in the region.

“We did not want to put American forces into harm’s way,” Esper said on CBS’ “Face the Nation,” referring to the Turkish offensive against the Kurdish forces that began last week after Trump initially ordered the withdrawal of U.S. troops from the border area. “We did not want to get involved in a conflict that dates back nearly 200 years between the Turks and the Kurds and get involved in another — yet another — war in the Middle East.”

But a wide-ranging host of critics said the White House actions amounted to an outright betrayal as well as a prescription for wholesale bloodshed.

“I can think of nothing more disgusting in all the years I’ve been in Congress than what this president is allowing to happen with the Kurds,” said Rep. Eliot L. Engel (D-N.Y.), chair of the House Foreign Affairs Committee, on NBC’s “Meet the Press.” “They have been our loyal and faithful allies for so many years, and after this, who again would trust the United States to be an ally of them? Who would think it pays to align themselves with us? Nobody. This is going to make people flee from us, and it’s just absolutely disgraceful that the president of the United States is facilitating all of this.”

“ISIS will resurge,” predicted former Trump administration Defense Secretary James N. Mattis, also on “Meet the Press,” using an acronym for Islamic State. “It’s absolutely a given that they will come back.”

Former Vice President and now Democratic presidential candidate Joe Biden declared: “This is an absolute disaster.”

“… What in God’s name is this man doing?”

Syrian state media announced army units had mobilized toward the north to “confront the Turkish aggression on Syrian lands.” Activists reported they were deploying west of the Kurdish-held city of Manbij and would be heading toward Kobani, a city on the border with Turkey.

With troops from various armies and factions on the move, control of Syria’s oil- and agriculture-rich north could well be at stake between Turkish forces and proxies and the Syrian government, which lost control of the area as a result of the civil war that began in 2011.

Yasin Aktay, an advisor to Erdogan, warned that if the Syrian army stood in the way of Turkey’s aims in northeastern Syria, there could be clashes between the two forces. “The Syrian army … is preparing to fight the Turkish army,” he said in an interview with the Russian government-owned Sputnik agency on Sunday. “If it’s capable of doing so, let it go ahead.”

U.S. officials, for their part, described an imminent catastrophe in northern Syria, with intensifying fighting between Kurdish fighters and Turkish-backed Syrian rebels, who have been carrying out assassinations and reprisals as they move south.

The incursion was swiftly moving beyond the 20-mile limit Turkey had first announced in launching its military operation against the Kurdish fighters. It was also beyond the scope of areas it said it aims to control along the 566-mile border it shares with Syria.

That would place the fighting in close vicinity to any remaining U.S. troops and raise the risk of a military confrontation if any of the Turkish units or their Syrian rebel allies fired on or threatened American positions.

“It’s a deteriorating situation that’s rapidly becoming untenable for U.S. forces, due to the increasing width and depth of the Turkish response,” said a senior U.S. official.

The expanding offensive is also threatening roughly 16 American bases and outposts in northern Syria, including the airfields used to supply troops.

Some American military officials said an assertion by Trump administration officials that U.S. troops would move south but remain in Syria were not realistic. Without Kurdish fighters to provide security, the U.S. would be exposed to potential attacks from a resurgent Islamic State. Nor could the U.S. troops be easily supplied in new locations.

On Sunday, activists posted images depicting U.S. Army mine-resistant vehicles rumbling down a highway away from an outpost in the Kurdish-held city of Ain Issa. Activists reported similar withdrawals near Manbij.

Even before the Turkish offensive, Kurdish fighters cautioned that the turmoil caused by a Turkish incursion would give the Islamist extremists held in Kurdish-run detention centers the chance to escape.

And on Sunday nearly 800 relatives of Islamic State’s cadres fled an annex of a detention camp near Ain Issa, after Turkish airstrikes and rocket fire hit nearby areas.

The camp’s Kurdish guards abandoned their posts to repel the incoming Turkish onslaught, said the Syrian Observatory for Human Rights, a pro-opposition Syrian war monitor.

According to the Save the Children aid group, 249 women and 700 children with ties to Islamic State had been housed in the annex.

The Syrian Democratic Forces, the U.S.-backed militias that are led by the Kurdish fighters, confirmed the breakout, saying that about 785 had escaped.

In all, roughly 11,000 Islamic State militants, including about 2,000 foreign fighters, have been held in detention by Kurdish forces in northern Syria. The U.S. has moved a small number of them to secure facilities elsewhere.

U.S. officials described as “credible” reports that Islamic State prisoners have escaped as the Kurdish militia members who had been guarding them abandon their positions to go fight the Turkish troops and their proxies.

Turkey said its offensive was intended to rout the Kurdish-led fighters from a thin strip of territory along the border. It came after Trump said the U.S. was withdrawing a small group of U.S. troops from the Kurdish-controlled area near the border, in effect clearing the path for Turkey to begin its assault.

Until Trump’s decision, the Americans had served as a buffer between Turkish troops and the Kurdish militia forces, who, in addition to fighting Islamic State for the U.S., had been jailers to the remaining members of the extremist group and their families.

Since the Turkish operation began last week, 52 civilians have been killed along with more than 100 Kurdish militia members, the Syrian Observatory group said, with a number of them summarily executed by Syrian rebels.

Eighteen Turkish civilians living near the border have been killed by Kurdish cross-border mortar and rocket attacks, according to Turkish officials.

An estimated 130,000 people have abandoned their homes, the United Nations’ office for coordination of humanitarian affairs said Saturday. Attacks on critical infrastructure have affected 400,000 people.

Meanwhile, the Turkish Defense Ministry and Syrian rebel groups announced Sunday that they had taken control of Tal Abyad, a border city that was a primary objective of the operation’s first phase.

Turkish warplanes and artillery also battered Ras al-Ayn, another strategic border town, striking neighborhoods where Kurdish fighters were holding off Syrian rebels closing in. Activists later reported a number of them had surrendered.

The Turkish-backed militants also overran parts of the M4, an important east-west highway that was the spine of the Kurdish-held territories, splitting them in two and potentially cutting off the exit for those seeking to flee.

The Kurds’ deal with Damascus means the end of a semiautonomous mini-state they had forged in northeastern Syria since 2015. Undergirded by support from the U.S., they had created a government bureaucracy meant to serve as an alternative to the rule of Syrian President Bashar Assad.

But their project infuriated Turkey, which considered the Kurdish fighters inextricably linked to Kurdish separatist guerrillas it has fought for decades at home. The United States’ largesse to the Kurds, which involved money, materiel, not to mention protection, soured relations between Ankara and Washington.

The rout of Kurdish militiamen since the initial U.S. withdrawal at the border, Esper said, prompted the pullout of remaining U.S. forces in northern Syria.

Reacting to Republicans and Democrats in Congress excoriating the U.S. for the withdrawal, Esper said the U.S. “didn’t sign up to fight the Turks on” behalf of the Kurds.

Trump himself has given a vigorous — albeit mercurial — defense of the pullout. On Twitter, he called it “very smart” to not be “involved in the intense fighting along the Turkish Border, for a change” and appeared to at least partially endorse the Turkish view that members of the outlawed Kurdistan Workers Party, or PKK, which is allied with the Syrian Kurds, are “terrorists.”

“The Kurds and Turkey have been fighting for many years. Turkey considers the PKK the worst terrorists of all. Others may want to come in and fight for one side or the other. Let them! We are monitoring the situation closely. Endless Wars!” Trump tweeted.

Trump has also threatened to “obliterate” Turkey’s economy if it oversteps its limits, and had prepared a raft of sanctions on Ankara. And on Sunday, he tweeted that he would support legislation to impose sanctions that has been drafted by Sens. Lindsey Graham (R-S.C.) and Chris Van Hollen (D-Md.).

“Treasury is ready to go, additional legislation may be sought,” he tweeted. “There is great consensus on this.”

However, Sen. Christopher S. Murphy (D-Conn.) expressed a view that appears to permeate both political parties on Capitol Hill.

“The hell you unleashed — by double crossing an ally and restocking ISIS — will cost thousands of U.S. lives in the long run,” he tweeted.

Bulos reported from Amman and Haberkorn from Washington. Times staff writer David S. Cloud in Washington contributed to this report.

AMMAN, Jordan — 

Foreign recruits of Islamic State, eager to migrate to the territory the militant group had carved out in Iraq and Syria, would prepare their staples — a phone, a solar charger, a few garments — before buying round-trip plane tickets (the better to avoid suspicion).

Their destination? Almost always Turkey.

Once having landed there, they continued on to towns dotting the 566-mile border Turkey shares with Syria, crossing over for a new life among those who shared their fanatical vision.

It was just one of the ways that Turkey was the conduit for all things extremist. Turkey was where Islamic State acquired food and other essentials, found medical treatment for injured fighters, and even got the fertilizer needed to make car bombs.

As Turkish troops and their Syrian rebel allies now march deeper into northeastern Syria to battle Kurdish fighters who long served as the United States’ surrogate fighting force against Islamic State, many fear a resurgent extremist threat that Turkey will be unable to contain. The disruption could give Islamic State’s dormant army, comprising sleeper cells and tens of thousands of fighters and their families in Kurdish-held detention centers, the chance to reinvigorate its insurgency and use Turkey as a launchpad for attacks in Europe or as far off as America.

Turkey began its cross-border assault Wednesday, after President Trump gave his implicit blessing by ordering the pullout of U.S. troops from the area. The objective, Turkey says, is to seize control of a 20-mile corridor of territory along Syria’s northern border and make it a safe zone that would house about 3.6 million Syrian refugees.

But Ankara is also moving to excise what it calls Kurdish terrorists of the People’s Protection Units, or YPG, which it sees as the Syrian offshoot of a banned Kurdish separatist group it fights at home, but which had become the United States’ top Syrian partner against Islamic State.

Facing a full-blown invasion, Kurdish authorities say they can no longer spare the manpower for counter-terrorism work.

Already, there are signs that Islamic State’s sleeper cells are benefiting from the distraction, even in places far from the front lines.

On Friday, the group claimed responsibility for planting a car bomb in the Kurdish-controlled city of Qamishli, 65 miles east of ground fighting in the border town of Ras al-Ayn. A day later, Kurdish authorities said another car bomb blew up near an Islamic State prison in the northern city of Hasakah. And on Sunday, hundreds of Islamic State family members escaped from a detention camp managed by Syrian Kurdish forces who were under attack by Turkish airstrikes and rocket fire.

Also in play is the fate of Islamic State detainees held in Kurdish-run prisons and camps, numbering an estimated 11,000 to 12,500 fighters and more than 60,000 family members. In the chaos, nearly 800 of them escaped Sunday from a camp near the Kurdish-run city of Ain Issa during an air barrage by Turkish forces. It followed a similar incident a day earlier, when five fighters escaped in Qamishli and others attempted to do so at another detention camp, Kurdish authorities said.

Turkish officials have done little to allay fears of an Islamic State resurgence beyond platitudes that they will monitor the prisoners in the area they intend to control. But it’s hard to expect the Kurds to cooperate in handing over Islamic State prisoners to their rebel and Turkish adversaries. Besides, some 50% of the interred extremists, Kurdish authorities say, are held in territory beyond the offensive’s stated limit. Also far afield is Dair Alzour, the eastern Syrian desert province where Islamic State remnants remain active.

At the heart of the matter is Turkey’s priorities versus those of the U.S. and its allies, said Aaron Stein, director of the Middle East program at the Philadelphia-based Foreign Policy Research Institute: Most of the latter view Islamic State, also known as ISIS, as a top threat.

“For Turkey it’s the YPG first and ISIS maybe second,” he said in a phone interview Saturday. “Turkey will achieve its military objectives, but those objectives don’t actually include much about ISIS.”

Nicholas Heras, a fellow at the Center for a New American Security think tank, agreed.

“The fact of the matter is that Turkey has never considered countering ISIS to be of utmost importance to its national security or its interests in Syria,” Heras said.

That attitude was especially clear in the early days of the Syrian civil war.

In 2011, the government’s crackdown on primarily peaceful protesters set off an armed rebellion in which Islamist and extremist groups — including Islamic State’s precursor — became dominant. These groups framed the war as a holy battle; Turkey, headed by a government with Islamist leanings, sought to empower the rebels against Syrian President Bashar Assad. Turkey gave them carte blanche to traverse its border with Syria.

The move made southern Turkish towns staging grounds for the opposition. Would-be jihadis from across the globe showed up in Turkey’s airports, many of them bearded men dressed in military-style fatigues and backpacks, determined to join the fight across the border. They would also frequently head back to Turkey for supplies.

Even though an estimated 40,000 foreign fighters crossed into Syria, along with weapons and explosives, Brett McGurk, Trump’s former envoy for countering Islamic State, said in a post on Twitter on Wednesday, “Turkey refused repeated and detailed requests to seal its side of the border with U.S. help and assistance.”

Turkey had also refused to allow U.S. warplanes stationed at Incirlik airbase to strike Islamic State positions, even as extremists poured into Syria.

It was only in July 2015, after the first Islamic State suicide attack on Turkish soil, that Ankara sealed the border. Even then, it did so more to block the Kurdish fighters who had begun working with the U.S. against Islamic State.

President Recep Tayyip Erdogan told reporters Sunday that Turkey had blocked 70,000 people and deported about 70,000 suspected of terrorist links from entering the country.

Turkey’s partners, the self-styled Syrian National Army, are made up of opposition factions that have seeded their ranks with former members of extremist groups, said Heras.

The U.S. turned to the Kurds, said McGurk, in large part because many rebel factions were reluctant to combat Islamic State, whether because they were sympathetic to the jihadists’ aims or wanted to focus on defeating Assad.

When blitzing through Kurdish-controlled areas in the past, rebel factions have engaged in widespread looting, human rights abuses and displacement of hundreds of thousands of Kurds, whom they see as atheists and separatists, rights groups say.

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On Saturday, video emerged that appeared to show Turkish-backed Syrian rebels summarily executing a Kurdish fighter they had stopped on a road in northeastern Syria. They also massacred nine Kurdish civilians, activists said. (The uproar following the atrocities prompted the Syrian National Army’s command to issue a statement on Saturday urging its cadres “not to take vengeance” or engage in looting against the Kurdish population.)

“That kind of environment, said Heras, primes the pump for an Islamic State comeback. “And there’s no guarantee these Syrian rebel proxies would have any interest in combating [its] reemergence.”

NEW YORK — 

Police were investigating Sunday whether a gambling dispute, robbery or something else led to the shooting deaths of four people at an illegal gambling club in Brooklyn that was just blocks from a police precinct.

The New York Police Department identified the dead as Terence Bishop, 36; Dominick Wimbush, 47; Chester Goode, 37; and John Thomas, 32 — all of Brooklyn. Three other people were wounded but expected to survive.

Police said just over a dozen people had been gambling with dice and cards at the small club when the violence erupted just before 7 a.m. Saturday.

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The unlicensed club had a sign identifying it as the “Triple A Aces Private & Social Event Space.” It was on the first floor of an older wood-frame townhouse on a block with some empty storefronts and boarded-up buildings.

Multiple shots were fired, and police recovered two handguns, but investigators were still working Sunday to determine what happened. There was no immediate sign that the shootings had any connection to gangs, which have been a problem in that part of Brooklyn.

The local police precinct headquarters is two blocks away, and authorities said officers had not previously received any complaints about the location.

But area residents told the New York Times that complaints had been made to the police. Jose Torres, who lives nearby, said officers had responded to a fight outside the club just a few weeks ago.

Isaac Mickens, a community organizer, described it to the Times as a “hole-in-the-wall gambling den” that was “real tight, real small, casual, low-key.” Samuel Revells told the Times that he was the building owner and had leased the event space out but didn’t say to whom.

Eddie Baldwin, who told CBS New York he was Bishop’s brother, was mourning the man he said he had recently gotten back in touch with.

“We need to put the guns down, that’s the main thing,” he said. “What was the reason? The man is innocent.”

TOKYO — 

Rescue crews in Japan dug through mudslides and searched near swollen rivers Monday as they looked for those missing from a typhoon that left as many as 36 dead and caused serious damage in central and northern Japan.

Typhoon Hagibis unleashed torrents of rain and strong winds Saturday that left thousands of homes on Japan’s main island flooded, damaged or without power.

Authorities warned more mudslides were possible with rain forecast for the affected area during the day Monday.

Kyodo News service, assembling information from a wide network, counted 36 deaths caused by the typhoon with 16 people missing. The official count from the Fire and Disaster Management Agency was 19 dead and 13 missing.

Hagibis dropped record amounts of rain for a period in some spots, according to meteorological officials, causing more than 20 rivers to overflow. In Kanagawa Prefecture, southwest of Tokyo, 39 inches of rainfall was recorded over the last 48 hours.

Some of the muddy waters in streets, fields and residential areas have subsided. But many places remained flooded, with homes and surrounding roads covered in mud and littered with broken wooden pieces and debris. Some places normally dry still looked like giant rivers.

Some who lined up for morning soup at evacuation shelters, which are housing 30,000 people, expressed concern about the homes they had left behind. Survivors and rescuers will also face colder weather with northern Japan turning chilly this week.

Rescue efforts were in full force with soldiers and firefighters from throughout Japan deployed. Helicopters could be seen plucking some of the stranded from higher floors and rooftops of submerged homes.

Prime Minister Shinzo Abe said the government will set up a special disaster team, including officials from various ministries, to deal with the fallout from the typhoon, including helping those in evacuation centers and boosting efforts to restore water and electricity to homes.

“Our response must be rapid and appropriate,” Abe said, stressing that many people remained missing and damage was extensive.

Damage was serious in Nagano prefecture, where an embankment of the Chikuma River broke. Areas in Miyagi and Fukushima prefectures in northern Japan were also badly flooded.

In such areas, rescue crew paddled in boats to each half-submerged home, calling out to anyone left stranded.

Tokyo Electric Power Co. said 56,800 homes were still without electricity Monday in Tokyo and nearby prefectures that the utility serves. Tohoku Electric Power Co. said 5,600 homes were without power in Miyagi, Iwate, Fukushima and Niigata.

East Japan Railway Co. said Hokuriku bullet trains were running Monday but reduced in frequency and limited to the Nagano city and Tokyo route.

An image of the aerodynamically curved bullet trains sitting in water, was seen by many as a sad but iconic symbol of the typhoon’s devastation.

Mimori Domoto, who works at Nagano craft beer-maker Yoho Brewing Co., said all 40 employees at her company had been confirmed safe. But deliveries had temporarily halted, and an event to promote the beer in Tokyo over the weekend was canceled for safety concerns.

“My heart aches when I think of the damage that happened in Nagano. Who would have thought it would get this bad?” she said.

Tama River in Tokyo also overflowed, but damage was not as great as other areas. Areas surrounding Tokyo, such as Tochigi, also suffered damage.

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Much of life in Tokyo returned to normal. People were out and about in the city, trains were running, and store shelves left bare when people were stockpiling were replenished.