In Matthew Roach’s two years as vital statistics manager for the Arizona Department of Health Services, and 10 years previously in its epidemiology program, he has witnessed a trend in mortality rates that has rural health experts worried.

As Roach tracked the health of Arizona residents, the gap between mortality rates of people living in rural areas and those of their urban peers was widening.

The health disparities between rural and urban Americans have long been documented, but a recent report from the Department of Agriculture’s Economic Research Service found the chasm has grown in recent decades. In their examination, USDA researchers found rural Americans from the ages of 25 to 54 die from natural causes, like chronic diseases and cancer, at wildly higher rates than the same age group living in urban areas. The analysis did not include external causes of death, such as suicide or accidental overdose.

The research analyzed Centers for Disease Control and Prevention death data from two three-year periods — 1999 through 2001 and 2017 through 2019. In 1999, the natural-cause mortality rate for people ages 25 to 54 in rural areas was only 6% higher than for city dwellers in the same age bracket. By 2019, the gap widened to 43%.

The researchers found the expanding gap was driven by rapid growth in the number of women living in rural places who succumb young to treatable or preventable diseases. In the most rural places, counties without an urban core population of 10,000 or more, women in this age group saw an 18% increase in natural-cause mortality rates during the study period, while their male peers experienced a 3% increase.

Within the prime working-age group, cancer and heart disease were the leading natural causes of death for both men and women in both rural and urban areas. Among women, the incidence of lung disease in remote parts of the nation grew the most when compared with rates in urban areas, followed by hepatitis. Pregnancy-related deaths also played a role, accounting for the highest rate of natural-cause mortality growth for women ages 25 to 54 in rural areas.

The negative trends for rural non-Hispanic American Indian and Alaska Native people were especially pronounced. The analysis shows Native Americans 25 to 54 years old had a 46% natural-cause mortality rate increase over those two decades. Native women had an even greater mortality rate jump, 55%, between the two studied time periods, while the rate for non-Hispanic White women went up 23%.

The rural-urban gap grew in all regions across the nation but was widest in the South.

The increased mortality rates are an indicator of worsening population health, the study authors noted, which can harm local economies and employment.

As access to and quality of health services in rural areas continue to erode, rural health experts said, the USDA findings should spur stronger policies focused on rural health.

Alan Morgan, CEO of the National Rural Health Association, said he found the report “shocking,” though, “unfortunately, not surprising.”

The disparity warrants greater attention from state and national leaders, Morgan said.

The study does not address causes for the increase in mortality rates, but the authors note that differences in health care resources could compromise the accessibility, quality, and affordability of care in rural areas. Hospitals in small and remote communities have long struggled, and continued closures or conversions limit health care services in many places. The authors note that persistently higher rates of poverty, disability, and chronic disease in rural areas, compounded by fewer physicians per capita and the closure of hospitals, affect community health.

Roach said his past job as an epidemiologist included working with social vulnerability indexes, which factor in income, race, education, and access to resources like housing to get a sense of a community’s resilience against adverse health outcomes. A map of Arizona shows that rural counties and reservations have some of the highest vulnerability rankings.

Janice C. Probst, a retired professor at the University of South Carolina whose work focused on rural health, said many current rural health efforts are focused on sustaining hospitals, which she noted are essential sources of health care. But she said that may not be the best way to address the inequities.

“We may have to take a community approach,” said Probst, who reviewed the report before its release. “Not how do we keep the hospital in the community, but how do we keep the community alive at all?”

The disparities among demographics stood out to Probst, along with something else. She said the states with the highest rates of natural-cause mortality in rural areas included South Carolina, Mississippi, Georgia, Alabama, and others that have not expanded Medicaid, the joint federal and state health insurance program for low-income people, though there are efforts to expand it in some states, particularly Mississippi.

It’s an observation the USDA researchers make as well.

“Regionally, differences in State implementation of Medicaid expansion under the 2010 Affordable Care Act could have increased implications for uninsured rural residents in States without expansions by potentially influencing the frequency of medical care for those at risk,” they wrote.

Wesley James, founding executive director of the Center for Community Research and Evaluation, at the University of Memphis, said state lawmakers could address part of the problem by advocating for Medicaid expansion in their states, which would increase access to health care in rural areas. A large group of people want it, but politicians aren’t listening to their needs, he said. James also reviewed the report before it was published.

According to KFF polling, two-thirds of people living in nonexpansion states want their state to expand the health insurance program.

Morgan added the study focused on deaths that occurred prior to the covid-19 pandemic, which had a devastating effect in rural areas.

“Covid really changed the nature of public health in rural America,” he said. “I hope that this prompts Congress to direct the CDC to look at rural-urban life expectancies during covid and since covid to get a handle on what we’re actually seeing nationwide.”

In Arizona, the leading cause of death for people 45 to 64 in 2021 in both rural and urban areas was covid, according to Roach.

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Para las latinas embarazadas, la elección de los alimentos podría reducir el riesgo de preeclampsia, un tipo especialmente peligroso de hipertensión. Un nuevo estudio muestra que es más probable que una dieta basada en preferencias alimentarias culturales, en lugar de las guías oficiales, ayude a prevenir esta enfermedad.

Investigadores de la Escuela de Medicina Keck de la USC encontraron que una combinación de grasas sólidas, granos refinados y queso se relacionaba con mayores tasas de preeclampsia entre un grupo de latinas de bajos ingresos de Los Ángeles. Por el contrario, las mujeres que consumían vegetales, frutas y comidas preparadas con aceites saludables tenían menos probabilidades de desarrollar la enfermedad.

La combinación de vegetales, frutas y aceites saludables, como el de oliva, mostró una correlación más fuerte con tasas más bajas de preeclampsia que el Índice de Alimentación Saludable-2015, una lista de recomendaciones nutricionales diseñadas por el Departamento de Agricultura de Estados Unidos (USDA) y el Departamento de Salud y Servicios Humanos (HHS).

El estudio, publicado en la edición de febrero de la revista de la Asociación Americana del Corazón (AHA), proporcionó información importante sobre qué combinaciones de alimentos afectan a las latinas embarazadas, explicó Luis Maldonado, investigador principal y becario postdoctoral del Departamento de Ciencias de la Población y Salud Pública de USC Keck. El trabajo sugiere que las recomendaciones dietéticas para estas latinas deberían incorporar más alimentos propios de sus culturas, apuntó.

“Muchos estudios que se han realizado con mujeres embarazadas en general han sido predominantemente blancos [no hispanos], y la dieta está muy ligada a la cultura”, dijo Maldonado. “Tu cultura puede facilitar cómo comes porque sabes cuál es tu comida favorita”.

En Estados Unidos, se estima que la preeclampsia ocurre en aproximadamente el 5% de los embarazos, y está entre las principales causas de morbilidad materna, según los Centros para el Control y Prevención de Enfermedades (CDC). Suele presentarse durante el tercer trimestre de gestación y está asociada con la obesidad, la hipertensión y la enfermedad renal crónica, entre otras afecciones.

No hay una forma de curar o predecir la preeclampsia. La enfermedad puede dañar el corazón y el hígado, y causar otras complicaciones tanto para la madre como para el bebé, incluido el parto prematuro e incluso la muerte.

Las tasas de preeclampsia han aumentado en las últimas dos décadas a nivel nacional. En California, aumentaron un 83%, y las tasas de hipertensión un 78% entre 2016 y 2022, según los datos más recientes disponibles, y son más altas entre los residentes negros y los habitantes de las islas del Pacífico.

Maldonado dijo que el 12% de las 451 mujeres latinas que participaron en el estudio desarrollaron preeclampsia, un número que representa casi el doble del promedio nacional. Más de la mitad de las participantes, de 28 años promedio, tenían factores de riesgo antes de embarazarse, como índice de masa corporal alto y diabetes.

Maldonado y su equipo utilizaron datos del Maternal and Developmental Risks from Environmental and Social Stressors Center, un grupo de investigación de la USC que estudia los efectos de las exposiciones ambientales y disparadores sociales de estrés en la salud de las madres y sus hijos.

Las participantes, que eran predominantemente latinas de bajos ingresos de Los Ángeles, completaron dos cuestionarios sobre su dieta durante el tercer trimestre de sus embarazos. Los investigadores identificaron dos patrones alimenticios significativos: uno en el que los alimentos más consumidos eran vegetales, aceites, frutas, granos enteros y yogur; y un segundo en el que la dieta de las mujeres consistía principalmente en grasas sólidas, granos refinados, queso, azúcar agregado y carne procesada.

El grupo de mujeres que siguió el primer patrón nutricional tuvo una tasa más baja de preeclampsia que el que se ajustó al segundo patrón.

Cuando Maldonado y su equipo buscaron una correlación entre tasas más bajas de preeclampsia y el Índice de Alimentación Saludable-2015, encontraron que no era estadísticamente significativa excepto en las mujeres que tenían sobrepeso antes del embarazo.

El Índice de Alimentación Saludable incluye combinaciones de nutrientes y alimentos, como lácteos y ácidos grasos. Maldonado dijo que se necesita más investigación para determinar el perfil exacto de frutas, vegetales y aceites que podría beneficiar a las mujeres latinas.

Cuando se trata de la dieta, el mensaje y las recomendaciones adecuadas son vitales para ayudar a las latinas embarazadas a tomar decisiones informadas, expresó A. Susana Ramírez, profesora asociada de comunicación de salud pública en la Universidad de California-Merced.

Ramírez ha realizado estudios sobre por qué los mensajes de alimentación saludable, aunque bien intencionados, no han tenido éxito en las comunidades hispanas. Encontró que estos mensajes han llevado a algunos latinos a creer que la comida mexicana es menos saludable que la comida estadounidense.

Ramírez dijo que necesitamos pensar en promover dietas que sean relevantes para una población particular. “Ahora entendemos que la dieta es tremendamente importante para la salud, y por lo tanto, en la medida en que cualquier asesoramiento nutricional sea culturalmente acorde, esto mejorará la salud en general”, dijo Ramírez.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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

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Un joven de 17 años, con el pelo rubio desgreñado, se subió a la balanza del Centro de Salud Familiar Tri-River de Uxbridge, en Massachusetts.

Después que lo pesaran, caminó hacia un consultorio decorado con calcomanías de planetas y personajes de dibujos animados. Una enfermera le tomó la presión arterial. Un pediatra le preguntó por sus estudios, su vida familiar y sus amigos.

Parecía un examen de rutina para adolescentes, de los miles que se hacen a diario en consultas pediátricas en el país. Hasta que el doctor Safdar Medina le preguntó:

“¿Tienes deseos de consumir opioides?”. El paciente negó con la cabeza.

“¿Ninguno, en absoluto?”, volvió a preguntar Medina para confirmar.

“Ninguno”, respondió el adolescente, llamado Sam, con voz tranquila pero segura.

(En este artículo sólo se utiliza el nombre de pila de Sam porque, si se publicara su apellido, en el futuro podría ser discriminado en la búsqueda de vivienda y empleo por haber consumido drogas).

El doctor Medina está tratando a Sam por su adicción a estas drogas. Le receta un medicamento llamado buprenorfina, que reduce las ansias de consumir las píldoras de opioides más peligrosas y adictivas. Los análisis de orina de Sam no muestran signos de Oxycontin o Percocet, las pastillas que él compraba en Snapchat y que alimentaron su adicción.

“Lo que realmente me enorgullece de tí, Sam, es tu esfuerzo por estar mejor”, lo felicitó Medina, que trabaja en el UMass Memorial Health.

La Academia Americana de Pediatría recomienda ofrecer buprenorfina a los adolescentes adictos a los opiáceos. Sin embargo, según los resultados de una encuesta, solo el 6% de los pediatras informa haberlo hecho alguna vez.

De hecho, al mismo tiempo que las recetas de buprenorfina para adolescentes fueron disminuyendo, se duplicaron las muertes por sobredosis en niños y adolescentes entre 10 y 19 años. Estas sobredosis, junto con los envenenamientos accidentales por opioides en niños pequeños, se han convertido en la tercera causa de muerte infantil en Estados Unidos.

“Estamos realmente lejos de donde deberíamos estar y nos encontramos bastante atrasados en varios aspectos”, comentó Scott Hadland, jefe de Medicina para Adolescentes del Hospital General de Niños de Massachusetts y coautor de una encuesta entre pediatras sobre el tratamiento de adicciones.

Los resultados de las entrevistas mostraron que muchos pediatras no creen tener ni la formación adecuada ni el personal necesario para atender pacientes con adicciones, aunque Medina y otros médicos que sí lo hacen afirmaron que no han tenido que contratar más personal.

Algunos entrevistados explicaron que no atienden un número de pacientes que justifique formarse en esa especialización y otros piensan que la atención de adictos no es responsabilidad de la Pediatría.

“Gran parte de esas ideas son producto de la educación que reciben los médicos”, dijo Deepa Camenga, directora asociada al área pediátrica del Programa de Medicina de Adicciones de la Escuela de Medicina de Yale. “Como se considera algo muy especializado, no está incluido en la formación médica habitual”, explicó.

Camenga y Hadland mencionaron que las escuelas de Medicina y los programas de residencia pediátrica están trabajando para incorporar información sobre trastornos por consumo de sustancias a los planes de estudio. Esto incluye cómo abordar el consumo de drogas y alcohol con niños y adolescentes.

Sin embargo, los programas de estudio no cambian lo suficientemente rápido como para ayudar a la cantidad de jóvenes que luchan contra una adicción y mucho menos a los que mueren después de tomar una sola pastilla.

Es una paradoja perversa y mortífera: mientras disminuye el consumo de drogas entre los adolescentes, las muertes asociadas a las drogas han aumentado.

La principal causa es la falsificación de pastillas de Xanax, Adderall o Percocet, adulteradas con fentanilo, un poderoso opioide. Casi el 25% de las muertes recientes por sobredosis en jóvenes de 10 a 19 años se atribuyeron a estas pastillas.

“El fentanilo y las pastillas falsificadas realmente están complicando nuestros esfuerzos para frenar las sobredosis”, dijo Andrew Terranella, experto en Medicina de adicción y prevención de sobredosis en adolescentes de los Centros para el Control y Prevención de Enfermedades (CDC). “Muchas veces, estos jóvenes sufren una sobredosis sin siquiera darse cuenta de lo que están tomando.”

Terranella, que ejerce en Tucson, Arizona, opina que los pediatras pueden ayudar mucho si refuerzan la detección del consumo de drogas en sus pacientes y conversan con ellos sobre los riesgos.

También sugiere que receten más naloxona, el aerosol nasal que puede revertir una sobredosis. Está disponible sin receta, pero Terranella cree que una receta médica puede tener más relevancia para los pacientes.

De vuelta en el consultorio, Sam estaba a punto de recibir su primera inyección de Sublocade, una forma de buprenorfina que dura 30 días. Está cambiando a las inyecciones porque no le gusta el sabor de Suboxone, unas tiras orales de buprenorfina que debía disolver debajo de su lengua. Las escupía antes de recibir una dosis completa.

Muchos médicos prefieren recetar las inyecciones porque los pacientes no tienen que recordar tomarlas todos los días. Pero la inyección es dolorosa y Sam se sorprendió cuando le dijeron que se la aplicarían en el vientre durante 20-30 segundos.

“¿Ya casi terminamos?”, preguntó Sam, mientras una enfermera le pedía que respirara hondo. Cuando terminó, el personal bromeó en voz alta diciendo que incluso los adultos suelen decir palabrotas cuando les ponen esa inyección. Sam dijo que no sabía que eso estaba permitido. Lo que más lo preocupaba era si un dolor residual podría interferir con los planes que tenía esa noche.

“¿Cree que podré hacer snowboard esta noche?”, le preguntó al doctor.

“Estoy absolutamente seguro de que podrás hacer snowboard esta noche”, lo tranquilizó Medina.

Sam iba a ir con un nuevo amigo. Hacer nuevos amigos y cortar lazos con su antiguo círculo social de adolescentes que consumen drogas ha sido una de las cosas más difíciles, dijo Sam, desde que entró en rehabilitación hace 15 meses.

“Hay que concentrase en encontrar la gente adecuada”, dijo Sam. “Ese sería mi mayor consejo”.

Para Sam, encontrar un tratamiento contra la adicción en un consultorio repleto de rompecabezas, juguetes y libros ilustrados no ha sido tan extraño como imaginaba.

Su madre, Julie, lo había acompañado a la consulta. Dice que está agradecida de que la familia haya encontrado un médico que entiende a los adolescentes y a las adicciones.

Antes de empezar a ir el Centro de Salud Familiar Tri-River, Sam estuvo siete meses en tratamiento residencial y ambulatorio, sin que le ofrecieran buprenorfina para ayudarlo a controlar los impulsos de consumir y prevenir las recaídas. Sólo uno de cada cuatro tratamientos residenciales para jóvenes la ofrece. Cuando Sam volvió a sentir fuertes deseos de consumir opioides, un consejero le sugirió a Julie que llamara a Medina.

“Dios mío, ojalá hubiera traído a Sam aquí hace dos o tres años”, dijo Julie. “¿Habría cambiado lo que sucedió? No lo sé, pero hubiera sido un nivel de atención más adecuado para él”.

A algunos padres y pediatras les preocupa administrar buprenorfina a un adolescente, ya que puede producir efectos secundarios, incluida la dependencia a largo plazo. Los pediatras que la recetan evalúan el efecto de los posibles efectos secundarios en relación con la amenaza de una sobredosis de fentanilo.

“En esta época, en la que los jóvenes mueren a un ritmo realmente sin precedentes por sobredosis de opiáceos, es fundamental que salvemos vidas”, afirmó Hadland. “Y sabemos que la buprenorfina es un medicamento que salva vidas”, agregó.

El tratamiento de una adicción le puede insumir mucho tiempo a un pediatra. Sam y Medina se envían mensajes de texto varias veces a la semana y el pediatra recalca que no comparte ningún intercambio que Sam haya pedido que fuera confidencial.

Medina dice que tratar el trastorno por consumo de sustancias es una de las cosas más gratificantes que hace. “Si podemos solucionarlo”, dice, “habremos formado un adulto que ya no tendrá que preocuparse por estos problemas de por vida”.

Este artículo es producto de una asociación que incluye a WBUR, NPR y KFF Health News.

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

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A 17-year-old boy with shaggy blond hair stepped onto the scale at Tri-River Family Health Center in Uxbridge, Massachusetts.

After he was weighed, he headed for an exam room decorated with decals of planets and cartoon characters. A nurse checked his blood pressure. A pediatrician asked about school, home life, and his friendships.

This seemed like a routine teen checkup, the kind that happens in thousands of pediatric practices across the U.S. every day — until the doctor popped his next question.

“Any cravings for opioids at all?” asked pediatrician Safdar Medina. The patient shook his head.

“None, not at all?” Medina said again, to confirm.

“None,” said the boy named Sam, in a quiet but confident voice.

Only Sam’s first name is being used for this article because if his full name were publicized he could face discrimination in housing and job searches based on his prior drug use.

Medina was treating Sam for an addiction to opioids. He prescribed a medication called buprenorphine, which curbs cravings for the more dangerous and addictive opioid pills. Sam’s urine tests showed no signs of the Percocet or OxyContin pills he had been buying on Snapchat, the pills that fueled Sam’s addiction.

“What makes me really proud of you, Sam, is how committed you are to getting better,” said Medina, whose practice is part of UMass Memorial Health.

The American Academy of Pediatrics recommends offering buprenorphine to teens addicted to opioids. But only 6% of pediatricians report ever doing do, according to survey results.

In fact, buprenorphine prescriptions for adolescents were declining as overdose deaths for 10- to 19-year-olds more than doubled. These overdoses, combined with accidental opioid poisonings among young children, have become the third-leading cause of death for U.S. children.

“We’re really far from where we need to be and we’re far on a couple of different fronts,” said Scott Hadland, the chief of adolescent medicine at Mass General for Children and a co-author of the study that surveyed pediatricians about addiction treatment.

That survey showed that many pediatricians don’t think they have the right training or personnel for this type of care — although Medina and other pediatricians who do manage patients with addiction say they haven’t had to hire any additional staff.

Some pediatricians responded to the survey by saying they don’t have enough patients to justify learning about this type of care, or don’t think it’s a pediatrician’s job.

“A lot of that has to do with training,” said Deepa Camenga, associate director for pediatric programs for the Yale Program in Addiction Medicine. “It’s seen as something that’s a very specialized area of medicine and, therefore, people are not exposed to it during routine medical training.”

Camenga and Hadland said medical schools and pediatric residency programs are working to add information to their curricula about substance use disorders, including how to discuss drug and alcohol use with children and teens.

But the curricula aren’t changing fast enough to help the number of young people struggling with an addiction, not to mention those who die after taking just one pill.

In a twisted, deadly development, drug use among adolescents has declined — but drug-associated deaths are up.

The main culprits are fake Xanax, Adderall, or Percocet pills laced with the powerful opioid fentanyl. Nearly 25% of recent overdose deaths among 10- to 19-year-olds were traced to counterfeit pills.

“Fentanyl and counterfeit pills is really complicating our efforts to stop these overdoses,” said Andrew Terranella, the Centers for Disease Control and Prevention’s expert on adolescent addiction medicine and overdose prevention. “Many times these kids are overdosing without any awareness of what they’re taking.”

Terranella said pediatricians can help by stepping up screening for — and having conversations about — all types of drug use.

He also suggests pediatricians prescribe more naloxone, the nasal spray that can reverse an overdose. It’s available over the counter, but Terranella, who practices in Tucson, Arizona, believes a prescription may carry more weight with patients.

Back in the exam room, Sam was about to get his first shot of Sublocade, an injection form of buprenorphine that lasts 30 days. Sam is switching to the shots because he didn’t like the taste of Suboxone, oral strips of buprenorphine that he was supposed to dissolve under his tongue. He was spitting them out before he got a full dose.

Many doctors also prefer to prescribe the shots because patients don’t have to remember to take them every day. But the injection is painful. Sam was surprised when he learned that it would be injected into his belly over the course of 20-30 seconds.

“Is it almost done?” Sam asked, while a nurse coaches him to breathe deeply. When it was over, staffers joked out loud that even adults usually swear when they get the shot. Sam said he didn’t know that was allowed. He’s mostly worried about any residual soreness that might interfere with his evening plans.

“Do you think I can snowboard tonight?” Sam asked the doctor.

“I totally think you can snowboard tonight,” Medina answered reassuringly.

Sam was going with a new buddy. Making new friends and cutting ties with his former social circle of teens who use drugs has been one of the hardest things, Sam said, since he entered rehab 15 months ago.

“Surrounding yourself with the right people is definitely a big thing you want to focus on,” Sam said. “That would be my biggest piece of advice.”

For Sam, finding addiction treatment in a medical office jammed with puzzles, toys, and picture books has not been as odd as he thought it would be.

He mom, Julie, had accompanied him to this appointment. She said she’s grateful the family found a doctor who understands teens and substance use.

Before he started visiting the Tri-River Family Health Center, Sam had seven months of residential and outpatient treatment — without ever being offered buprenorphine to help control cravings and prevent relapse. Only 1 in 4 residential programs for youth offer it. When Sam’s cravings for opioids returned, a counselor suggested Julie call Medina.

“Oh my gosh, I would have been having Sam here, like, two or three years ago,” Julie said. “Would it have changed the path? I don’t know, but it would have been a more appropriate level of care for him.”

Some parents and pediatricians worry about starting a teenager on buprenorphine, which can produce side effects including long-term dependence. Pediatricians who prescribe the medication weigh the possible side effects against the threat of a fentanyl overdose.

“In this era, where young people are dying at truly unprecedented rates of opioid overdose, it’s really critical that we save lives,” said Hadland. “And we know that buprenorphine is a medication that saves lives.”

Addiction care can take a lot of time for a pediatrician. Sam and Medina text several times a week. Medina stresses that any exchange that Sam asks to be kept confidential is not shared.

Medina said treating substance use disorder is one of the most rewarding things he does.

“If we can take care of it,” he said, “We have produced an adult that will no longer have a lifetime of these challenges to worry about.”

This article is from a partnership that includes WBUR, NPR, and KFF Health News.

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

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For pregnant Latinas, food choices could reduce the risk of preeclampsia, a dangerous type of high blood pressure, and a diet based on cultural food preferences, rather than on U.S. government benchmarks, is more likely to help ward off the illness, a new study shows.

Researchers at the USC Keck School of Medicine found that a combination of solid fats, refined grains, and cheese was linked to higher rates of preeclampsia among a group of low-income Latinas in Los Angeles. By contrast, women who ate vegetables, fruits, and meals made with healthy oils were less likely to develop the illness.

The combination of vegetables, fruits, and healthy oils, such as olive oil, showed a stronger correlation with lower rates of preeclampsia than did the Healthy Eating Index-2015, a list of dietary recommendations designed by the U.S. Department of Agriculture and the Department of Health and Human Services.

The study, published in February by the Journal of the American Heart Association, yielded important information on which food combinations affect pregnant Latinas, said Luis Maldonado, the lead investigator and a postdoctoral scholar at the Department of Population and Public Health Sciences at USC Keck. It suggests that dietary recommendations for pregnant Latinas should incorporate more foods from their culture, he said.

“A lot of studies that have been done among pregnant women in general have been predominantly white, and diet is very much tied to culture,” Maldonado said. “Your culture can facilitate how you eat because you know what your favorite food is.”

Preeclampsia is estimated to occur in about 5% of pregnancies in the U.S. and is among the leading causes of maternal morbidity, according to the Centers for Disease Control and Prevention. It typically occurs during the third trimester of pregnancy and is associated with obesity, hypertension, and chronic kidney disease, among other conditions.

There isn’t a way to cure or predict preeclampsia. The disease can damage the heart and liver and lead to other complications for both the mother and the baby, including preterm birth and even death.

Rates of preeclampsia have increased in the past two decades nationally. In California, rates of preeclampsia increased by 83% and hypertension by 78% from 2016 to 2022, according to the most recent data available, and the conditions are highest among Black residents and Pacific Islanders.

Maldonado said 12% of the 451 Latina women who participated in the study developed preeclampsia, a number almost twice the national average. More than half of the participants, who averaged 28 years old, had pre-pregnancy risks, such as diabetes and high body mass index.

Maldonado and his team used data from the Maternal and Developmental Risks from Environmental and Social Stressors Center, a USC research group that studies the effects of environmental exposures and social stressors on the health of mothers and their children.

The subjects, who were predominantly low-income Latinas in Los Angeles, completed two questionnaires about their diet during the third trimester of their pregnancy. The researchers identified two significant patterns of eating: one in which the most consumed foods were vegetables, oils, fruits, whole grains, and yogurt; and a second in which the women’s diet consisted primarily of solid fats, refined grains, cheese, added sugar, and processed meat.

Women who followed the first eating pattern had a lower rate of preeclampsia than those who followed the second.

When Maldonado and his team tested for a correlation between lower rates of preeclampsia and the Healthy Eating Index-2015, they found it was not statistically significant except for women who were overweight before pregnancy.

The Healthy Eating Index includes combinations of nutrients and foods, like dairy and fatty acids. Maldonado said more research is needed to determine the exact profile of fruits, vegetables, and oils that could benefit Latina women.

When it comes to diet, the right messaging and recommendations are vital to helping pregnant Latinas make informed decisions, said A. Susana Ramírez, an associate professor of public health communication at the University of California-Merced.

Ramírez has conducted studies on why healthy-eating messages, while well intended, have not been successful in Hispanic communities. She found that the messaging has led some Latinos to believe that Mexican food is unhealthier than American food.

Ramírez said we need to think about promoting diets that are relevant for a particular population. “We understand now that diet is enormously important for health, and so to the extent that any nutrition counseling is culturally consonant, that will improve health overall,” Ramírez said.

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For Cindy Westman, $30 buys a week’s worth of gas to drive to medical appointments and run errands.

It’s also how much she spent on her monthly internet bill before the federal Affordable Connectivity Program stepped in and covered her payments.

“When you have low income and you are living on disability and your daughter’s disabled, every dollar counts,” said Westman, who lives in rural Illinois.

More than 23 million low-income households — urban, suburban, rural, and tribal — are enrolled in the federal discount program Congress created in 2021 to bridge the nation’s digital connectivity gap. The program has provided $30 monthly subsidies for internet bills or $75 discounts in tribal and high-cost areas.

But the program is expected to run out of money in April or May, according to the Federal Communications Commission. In January, FCC Chairwoman Jessica Rosenworcel asked Congress to allocate $6 billion to keep the program running until the end of 2024. She said the subsidy gives Americans the “internet service they need to fully participate in modern life.”

The importance of high-speed internet was seared into the American psyche by scenes of children sitting in parking lots and outside fast-food restaurants to attend school online during the covid-19 pandemic. During that same period, health care providers and patients like Westman say, being connected also became a vital part of today’s health care delivery system.

Westman said her internet connection has become so important to her access to health care she would sell “anything that I own” to stay connected.

Westman, 43, lives in the small town of Eureka, Illinois, and has been diagnosed with genetic and immune system disorders. Her 12-year-old daughter has cerebral palsy and autism.

She steered the $30 saved on her internet toward taking care of her daughter, paying for things such as driving 30 minutes west to Peoria, Illinois, for two physical therapy appointments each week. And with an internet connection, Westman can access online medical records, and whenever possible she uses telehealth appointments to avoid the hour-plus drive to specialty care.

“It’s essential for me to keep the internet going no matter what,” Westman said.

Expanding telehealth is a common reason health care providers around the U.S. — in states such as Massachusetts and Arkansas — joined efforts to sign their patients up for the federal discount program.

“This is an issue that has real impacts on health outcomes,” said Alister Martin, an emergency medicine physician at Massachusetts General Hospital. Martin realized at the height of the pandemic that patients with means were using telehealth to access covid care. But those seeking in-person care during his ER shifts tended to be lower-income, and often people of color.

“They have no other choice,” Martin said. “But they probably don’t need to be in the ER action.” Martin became a White House fellow and later created a nonprofit that he said has helped 1,154 patients at health centers in Boston and Houston enroll in the discount program.

At the University of Arkansas for Medical Sciences, a federal grant was used to conduct dozens of outreach events and help patients enroll, said Joseph Sanford, an anesthesiologist and the director of the system’s Institute for Digital Health & Innovation.

“We believe that telehealth is the great democratization to access to care,” Sanford said. New enrollment in the discount program halted nationwide last month.

Leading up to the enrollment halt, Sen. Peter Welch (D-Vt.) led a bipartisan effort to introduce the Affordable Connectivity Program Extension Act in January. The group requested $7 billion — more than the FCC’s ask — to keep the program funded. “Affordability is everything,” Welch said.

In December, federal regulators surveyed program recipients and found that 22% reported no internet service before, and 72% said they used their ACP-subsidized internet to “schedule or attend healthcare appointments.”

Estimates of how many low-income U.S. households qualify for the program vary, but experts agree that only about half of the roughly 50 million eligible households have signed on.

“A big barrier for this program generally was people don’t know about it,” said Brian Whitacre, a professor and the Neustadt chair in the Department of Agricultural Economics at Oklahoma State University.

Whitacre and others said rural households should be signing up at even higher rates than urban ones because a higher percentage of them are eligible.

Yet, people found signing up for the program laborious. Enrollment was a two-step process. Applicants were required to get approved by the federal government then work with an internet service provider that would apply the discount. The government application was online — hard to get to if you didn’t yet have internet service — though applicants could try to find a way to download a version, print it, and submit the application by mail.

When Frances Goli, the broadband project manager for the Shoshone-Bannock Tribes in Idaho, began enrolling tribal and community members at the Fort Hall Reservation last year, she found that many residents did not know about the program — even though it had been approved more than a year earlier.

Goli and Amber Hastings, an AmeriCorps member with the University of Idaho Extension Digital Economy Program, spent hours helping residents through the arduous process of finding the proper tribal documentation required to receive the larger $75 discount for those living on tribal lands.

“That was one of the biggest hurdles,” Goli said. “They’re getting denied and saying, come back with a better document. And that is just frustrating for our community members.”

Of the more than 200 households Goli and Hastings aided, about 40% had not had internet before.

In the tribal lands of Oklahoma, said Sachin Gupta, director of government business and economic development at internet service provider Centranet, years ago the funding may not have mattered.

“But then covid hit,” Gupta said. “The stories I have heard.”

Elders, he said, reportedly “died of entirely preventable causes” such as high blood pressure and diabetes because they feared covid in the clinics.

“It’s really important to establish connectivity,” Gupta said. The end of the discounts will “take a toll.”

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Work requirements in Medicaid expansion programs are back on the agenda in many statehouses — despite their lackluster track record.

In Mississippi, the idea has momentum from GOP lawmakers advancing legislation to expand Medicaid. In Kansas, the Democratic governor proposed work requirements to try to soften Republican opposition to expansion. (She’s had little luck, so far.)

The controversial policy even has fresh traction in states that expanded Medicaid years ago, including Idaho and Louisiana.

Just two states have implemented a special program to require low-income adults to prove they’re working in exchange for health coverage under Medicaid. In 2019, a court ended Arkansas’s initiative, but not before 18,000 people lost coverage.

Since then, only the signature Medicaid experiment of Georgia Gov. Brian Kemp (R), called Pathways to Coverage, has survived legal challenges and gotten off the ground.

Yet it’s off to a rocky start, with low enrollment and mounting administrative costs already exceeding $20 million. “It doesn’t work, and it’s perfectly clear in Georgia,” said Joan Alker, executive director and co-founder of the Georgetown Center for Children and Families.

Only about 3,500 people have enrolled so far. That’s a small fraction of the Georgians who would be eligible if the state adopted the Affordable Care Act’s Medicaid expansion without work requirements.

Some Georgia Republicans blocked a bill in March that would have authorized a full Medicaid expansion, arguing that Pathways needs more time. The program is just one part of an overall plan to move people into private insurance, Kemp spokesperson Garrison Douglas told us.

Work requirements can come with big administrative price tags, according to a 2019 report from the Government Accountability Office, which recommended that the Centers for Medicare & Medicaid Services consider administrative costs in waiver applications.

States have to set up technology to check compliance, plus hire staff to keep all the paperwork straight. Under Georgia’s plan, people earning up to the federal poverty level — $15,060 for an individual adult — must document that they’re working, in school, doing community service or performing other qualifying activities. Taking care of a child or parent doesn’t count.

Documents obtained by KFF Health News show that administrative costs along with consulting fees have absorbed more than 90 percent of the Georgia program’s spending. As of Dec. 31, about $2 million went to Medicaid managed-care companies; $24 million was spent on administration and consultants. The administrative costs are expected to balloon to $122 million over four years.

Critics argue that the red tape keeps people from getting health care. And while work requirements don’t significantly boost employment, simply providing health coverage can, according to a 2023 KFF brief.

But don’t expect the idea to disappear — especially if former president Donald Trump returns to the White House. The first Trump administration approved Medicaid work-requirement programs in 13 states.

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Patients hurl verbal abuse at Michelle Ravera every day in the emergency room. Physical violence is less common, she said, but has become a growing threat.

Ravera, an ER nurse at Sutter Medical Center in Sacramento, recalled an incident in which an agitated patient wanted to leave. “Without any warning he just reached up, grabbed my glasses, and punched me in the face,” said Ravera, 54. “And then he was getting ready to attack another patient in the room.” Ravera and hospital security guards subdued the patient so he couldn’t hurt anyone else.

Violence against health care workers is on the rise, including in the ER, where tensions can run high as staff juggle multiple urgent tasks. Covid-19 only made things worse: With routine care harder to come by, many patients ended up in the ER with serious diseases — and brimming with frustrations.

In California, simple assault against workers inside an ER is considered the same as simple assault against almost anyone else, and carries a maximum punishment of a $1,000 fine and six months in jail. In contrast, simple assault against emergency medical workers in the field, such as an EMT responding to a 911 call, carries maximum penalties of a $2,000 fine and a year in jail. Simple assault does not involve the use of a deadly weapon or the intention to inflict serious bodily injury.

State Assembly member Freddie Rodriguez, who worked as an EMT, has authored a bill to make the punishments consistent: a $2,000 fine and one year in jail for simple assault on any on-the-job emergency health care worker, whether in the field or an ER. The measure would also eliminate the discrepancy for simple battery.

Patients and family members are assaulting staff and “doing things they shouldn’t be doing to the people that are there to take care of your loved ones,” said Rodriguez, a Democrat from Pomona. The bill passed the state Assembly unanimously in January and awaits consideration in the Senate.

Rodriguez has introduced similar measures twice before. Then-Gov. Jerry Brown vetoed one in 2015, saying he doubted a longer jail sentence would deter violence. “We need to find more creative ways to protect the safety of these critical workers,” he wrote in his veto message. The 2019 bill died in the state Senate.

Rodriguez said ERs have become more dangerous for health care workers since then and that “there has to be accountability” for violent behavior. Opponents fear stiffer penalties would be levied disproportionately on patients of color or those with developmental disabilities. They also point out that violent patients can already face penalties under existing assault and battery laws.

Data from the California Division of Occupational Safety and Health shows that reported attacks on ER workers by patients, visitors, and strangers jumped about 25% from 2018 to 2023, from 2,587 to 3,238. The rate of attacks per 100,000 ER visits also increased.

Punching, kicking, pushing, and similar aggression accounted for most of the attacks. Only a small number included weapons.

These numbers are likely an undercount, said Al’ai Alvarez, an ER doctor and clinical associate professor at Stanford University’s Department of Emergency Medicine. Many hospital staffers don’t fill out workplace violence reports because they don’t have time or feel nothing will come of it, he said.

Ravera remembers when her community rallied around health care workers at the start of the pandemic, acting respectfully and bringing food and extra N95 masks to workers.

“Then something just switched,” she said. “The patients became angrier and more aggressive.”

Violence can contribute to burnout and drive workers to quit — or worse, said Alvarez, who has lost colleagues to suicide, and thinks burnout was a key factor. “The cost of burnout is more than just loss of productivity,” he said. “It's loss of human beings that also had the potential to take care of many more people.”

The National Center for Health Workforce Analysis projects California will experience an 18% shortage of all types of nurses in 2035, the third worst in the country.

Federal legislation called the Safety From Violence for Healthcare Employees Act would set sentences of up to 10 years for assault against a health care worker, not limited to emergency workers, and up to 20 years in cases involving dangerous weapons or bodily injury. Though it was introduced in 2023, it has not yet had a committee hearing.

Opponents of the California bill, which include ACLU California Action, the California Public Defenders Association, and advocates for people with autism, argue it wouldn’t deter attacks — and would unfairly target certain patients.

“There's no evidence to suggest that increased penalties are going to meaningfully address this conduct,” said Eric Henderson, a legislative advocate for ACLU California Action. “Most importantly, there are already laws on the books to address assaultive conduct.”

Beth Burt, executive director of the Autism Society Inland Empire, said the measure doesn’t take into account the special needs of people with autism and other developmental disorders.

The smells, lights, textures, and crowds in the ER can overstimulate a person with autism, she said. When that happens, they can struggle to articulate their feelings, which can result in a violent outburst, “whether it’s a 9-year-old or a 29-year-old,” Burt said.

She worries that hospital staff may misunderstand these reactions, and involve law enforcement when it’s not necessary. As “a parent, it is still my worst fear” that she’ll get a phone call to inform her that her adult son with autism has been arrested, she said.

Burt would rather the state prioritize de-escalation programs over penalties, such as the training programs for first responders she helped create through the Autism Society Inland Empire. After implementing the training, hospital administrators asked Burt to share some strategies with them, she said. Hospital security staffers who do not want to use physical restraints on autistic patients have also sought her advice, she said.

Supporters of the bill, including health care and law enforcement groups, counter that people with mental health conditions or autism who are charged with assault in an ER may be eligible for existing programs that provide mental health treatment in lieu of a criminal sentence.

Stephanie Jensen, an ER nurse and head of governmental affairs for the Emergency Nurses Association, California State Council, said her organization is simply arguing for equity. “If you punch me in the hospital, it’s the same as if you punch me on the street,” she said.

If lawmakers don’t act, she warned, there won’t be enough workers for the patients who need them.

“It’s hard to keep those human resources accessible when it just seems like you’re showing up to get beat up every day,” Jensen said. “The emergency department is taking it on the chin, literally and figuratively.”

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SACRAMENTO, Calif. — California Gov. Gavin Newsom’s administration has abandoned proposed protections for millions of California workers toiling in sweltering warehouses, steamy kitchens, and other dangerously hot workplaces — upending a regulatory process that had been years in the making.

The administration’s eleventh-hour move, which it attributed to the cost of the new regulations, angered workplace safety advocates and state regulators, setting off a mad scramble to implement emergency rules before summer.

But it’s unclear how, when, or if the emergency rules will come down, and whether they’ll be in place in time to protect workers from the intensifying heat.

“It’s the administration’s moral obligation to fix this,” said Lorena Gonzalez Fletcher, a former state lawmaker and the chief officer of the California Labor Federation, which represents more than 1,300 unions. “There needs to be emergency regulations or legislation quickly, because we can’t stop summer.”

California has had heat standards on the books for outdoor workers since 2005, and indoor workplaces were supposed to be next. The proposed standards would have required work sites to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear protective clothing or are exposed to radiant heat, such as furnaces. Buildings could be cooled with air conditioning, fans, misters, and other methods.

The rules would have allowed workarounds for businesses that couldn’t cool their workplaces sufficiently, such as laundries or restaurant kitchens.

Despite concerns from the administration, the California Occupational Safety and Health Standards Board approved the rules at its March 21 meeting, prompting a tense political standoff between workplace safety advocates and Newsom, the second-term Democratic governor who has sought to elevate his national profile and claim progressive leadership on climate change and worker rights — key platforms for the Democratic Party.

State Department of Finance spokesperson H.D. Palmer said the issue isn’t the state’s ballooning budget deficit — estimated between $38 billion and $73 billion — but a legal requirement to nail down the cost of the rules to the state government.

“It wasn’t, ‘We’re trying to sink these regulations,’” Palmer said.

Palmer said the administration received a murky cost estimate from the California Department of Corrections and Rehabilitation indicating that implementing the standards in its prisons and other facilities could cost billions. The board’s economic analysis, on the other hand, pegged the cost at less than $1 million a year.

“Without our concurrence of the fiscal estimates, those regulations in their latest iteration will not go into effect,” he said.

According to Corrections spokesperson Albert Lundeen, the rules would entail major spending that could require the legislature to fund “extensive capital improvements.” He added that the agency is committed to discussing “how these regulations could be implemented cost-effectively at our institutions to further bolster worker safety.”

Board members argue the state has had years to analyze the cost of the proposed standards, and that it must quickly impose emergency regulations. But it’s not clear how that might happen, whether in days by the administration or months via the state budget process — or another way.

“This is a public health emergency,” said Laura Stock, a board member who is also an expert on workplace safety and health at the University of California-Berkeley.

Newsom spokesperson Erin Mellon defended the move to halt permanent regulations, saying approving them would be “imprudent” without a detailed cost estimate.

“The administration is committed to implementing the indoor heat regulations and ensuring workplace protections,” she said in a statement. “We are exploring all options to put these worker protections in place, including working with the legislature.”

Only Minnesota and Oregon have adopted heat rules for indoor workers. Legislation has stalled in Congress, and even though the Biden administration has initiated the long process of establishing national heat standards for outdoor and indoor work, they may take years to finalize.

Seven workers died in California from indoor heat between 2010 and 2017. Heat stress can lead to heat exhaustion, heatstroke, cardiac arrest, and kidney failure. In 2021, the Centers for Disease Control and Prevention reported, 1,600 heat-related deaths occurred nationally, which is likely an undercount because health care providers are not required to report them. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

The process to adopt California’s indoor head standards started in 2016 and involved years of negotiations with businesses and labor advocates.

Several board members acknowledged that they were frustrated by the administration’s lack of support when they adopted the regulations in March — after their meeting was temporarily halted by angry, chanting warehouse workers — knowing they would not go into effect. Instead, they said, they wanted to amplify pressure on Newsom.

“Every summer is hotter than the last, and workers who aren’t protected are going to suffer heat illness or death,” said Dave Harrison, a board member and powerful union leader with Operating Engineers Local 3. “Our hope was that the vote would be symbolic in sending a message to the state government that, listen, this is important, so we decided to vote on it anyway and put it back into the state’s court.”

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First, her favorite doctor in Providence, Rhode Island, retired. Then her other doctor at a health center a few miles away left the practice. Now, Piedad Fred has developed a new chronic condition: distrust in the American medical system.

“I don’t know,” she said, her eyes filling with tears. “To go to a doctor that doesn’t know who you are? That doesn’t know what allergies you have, the medicines that make you feel bad? It’s difficult.”

At 71, Fred has never been vaccinated against covid-19. She no longer gets an annual flu shot. And she hasn’t considered whether to be vaccinated against respiratory syncytial virus, or RSV, even though her age and an asthma condition put her at higher risk of severe infection.

“It’s not that I don’t believe in vaccines,” Fred, a Colombian immigrant, said in Spanish at her home last fall. “It’s just that I don’t have faith in doctors.”

The loss of a trusted doctor is never easy, and it’s an experience that is increasingly common.

The stress of the pandemic drove a lot of health care workers to retire or quit. Now, a nationwide shortage of doctors and others who provide primary care is making it hard to find replacements. And as patients are shuffled from one provider to the next, it’s eroding their trust in the health system.

The American Medical Association’s president, Jesse Ehrenfeld, recently called the physician shortage a “public health crisis.”

“It’s an urgent crisis, hitting every corner of this country, urban and rural, with the most direct impact hitting families with high needs and limited means,” Ehrenfeld told reporters in October.

In Fred’s home state of Rhode Island, the percentage of people without a regular source of routine health care increased from 2021 to 2022, though the state’s residents still do better than most Americans.

Hispanic residents and those with less than a high school education are less likely to have a source of routine health care, according to the nonprofit organization Rhode Island Foundation.

The community health centers known as federally qualified health centers, or FQHCs, are the safety net of last resort, serving the uninsured, the underinsured, and other vulnerable people. There are more than 1,400 community health centers nationwide, and about two-thirds of them lost between 5% and a quarter of their workforce during a six-month period in 2022, according to a report by the National Association of Community Health Centers.

Another 15% of FQHCs reported losing between a quarter and half of their staff. And it’s not just doctors: The most severe shortage, the survey found, was among nurses.

In a domino effect, the shortage of clinicians has placed additional burdens on support staff members such as medical assistants and other unlicensed workers.

Their extra tasks include “sterilizing equipment, keeping more logs, keeping more paperwork, working with larger patient loads,” said Jesse Martin, executive vice president of District 1199 NE of the Service Employees International Union, which represents 29,000 health care workers in Connecticut and Rhode Island.

“When you add that work to the same eight hours’ worth of a day’s work you can’t get everything done,” Martin said.

Last October, scores of SEIU members who work at Providence Community Health Centers, Rhode Island’s largest FQHC, held an informational picket outside the clinics, demanding improvements in staffing, work schedules, and wages.

The marketing and communications director for PCHC, Brett Davey, declined to comment.

Staff discontent has rippled through community health care centers across the country. In Chicago, workers at three health clinics held a two-day strike in November, demanding higher pay, better benefits, and a smaller workload.

Then just before Thanksgiving at Unity Health Care, the largest federally qualified health center in Washington, D.C., doctors and other medical providers voted to unionize. They said they were being pressed to prioritize patient volume over quality of care, leading to job burnout and more staff turnover.

The staffing shortages come as community health centers are caring for more patients. The number of people served by the centers between 2015 and 2022 increased by 24% nationally, and by 32.6% in Rhode Island, according to the Rhode Island Health Center Association, or RIHCA.

“As private practices close or get smaller, we are seeing patient demand go up at the health centers,” said Elena Nicolella, RIHCA’s president and CEO. “Now with the workforce challenges, it’s very difficult to meet that patient demand.”

In Rhode Island, community health centers in 2022 served about 1 in 5 residents, which is more than twice the national average of 1 in 11 people, according to RIHCA.

Job vacancy rates at Rhode Island’s community health centers are 21% for physicians, 18% for physician assistants and nurse practitioners, and 10% for registered nurses, according to six of the state’s eight health centers that responded to a survey conducted by RIHCA for The Public’s Radio, NPR, and KFF Health News.

Pediatricians are also in short supply. Last year, 15 pediatricians left staff positions at the Rhode Island health centers, and seven of them have yet to be replaced.

Research shows that some of the biggest drivers of burnout are workload and job demands.

Community health centers tend to attract clinicians who are mission-driven, said Nelly Burdette, who spent years working in health centers before becoming a senior leader of the nonprofit Care Transformation Collaborative of Rhode Island.

These clinicians often want to give back to the community, she said, and are motivated to practice “a kind of medicine that is maybe less corporate,” and through which they can they develop close relationships with patients and within multigenerational families.

So when workplace pressures make it harder for these clinicians to meet their patients’ needs, they are more likely to burn out, Burdette said.

When a doctor quits or retires, Carla Martin, a pediatrician and an internist, often gets asked to help. The week before Thanksgiving, she was filling in at two urgent care clinics in Providence.

“We’re seeing a lot of people coming in for things that are really primary care issues, not urgent care issues, just because it’s really hard to get appointments,” Martin said.

One patient recently visited urgent care asking for a refill of her asthma medication. “She said, ‘I ran out of my asthma medicine, I can’t get a hold of my PCP for refill, I keep calling, I can’t get through,’” Martin said.

Stories like that worry Christopher Koller, president of the Milbank Memorial Fund, a nonprofit philanthropy focused on health policy. “When people say, ‘I can’t get an appointment with my doctor,’ that means they don’t have a usual source of care anymore,” Koller said.

Koller points to research showing that having a consistent relationship with a doctor or other primary care clinician is associated with improvements in overall health and fewer emergency room visits.

When that relationship is broken, patients can lose trust in their health care providers.

That’s how it felt to Piedad Fred, the Colombian immigrant who stopped getting vaccinated. Fred used to go to a community health center in Rhode Island, but then accessing care there began to frustrate her.

She described making repeated phone calls for a same-day appointment, only to be told that none were available and that she should try again tomorrow. After one visit, she said, one of her prescriptions never made it to the pharmacy.

And there was another time when she waited 40 minutes in the exam room to consult with a physician assistant — who then said she couldn’t give her a cortisone shot for her knee, as her doctor used to do.

Fred said that she won’t be going back.

So what will she do the next time she gets sick or injured and needs medical care?

“Well, I’ll be going to a hospital,” she said in Spanish.

But experts warn that more people crowding into hospital emergency rooms will only further strain the health system, and the people who work there.

This article is from a partnership that includes The Public’s Radio, NPR, and KFF Health News.

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When Deanna Gomez found out she was pregnant in September 2023, she felt the timing couldn’t have been worse.

The college senior at California State University-San Bernardino worked 60 hours a week at two jobs. She used birth control. Motherhood was not in the plan. Not yet. “I grew up poor. And I don’t want that for my children, like, ever,” she said.

She wanted a medication abortion. It’s a two-step process: one drug taken at a doctor’s office, and another a day later to induce cramping and bleeding and empty the uterus. Gomez didn’t bother going to the university health clinic, thinking it was only for basic health needs.

She ended up driving more than 300 miles and paying hundreds of dollars in medical and travel expenses to obtain a medication abortion. She missed a month of classes, which put her graduation date in jeopardy. She had no idea she was entitled to a free medication abortion right on campus.

An LAist investigation has found that one year after California became the first state to require its public universities to provide abortion pills to students, basic information on where or how students can obtain the medication is lacking and, often, nonexistent.

“I was really upset when I found out,” Gomez told LAist. “I had to really push myself to make that money happen.”

LAist initially found that 11 of 23 CSU campus clinics did not have any information about medication abortion on their clinic websites, nor did they list it as a service offered. Of the University of California’s 10 campuses, eight mentioned medication abortion on their clinic websites. (Five CSU campuses and one UC campus added information after LAist published a version of this article.)

Through conversations with students and faculty at multiple campuses, LAist found there was little information for students to obtain the pills.

“If I had known that, I would have taken advantage of it,” Gomez said. “I spent a lot of time driving around after work, switching schedules, putting my homework on the back burner.”

California legislators in 2019 passed the law that requires all the state’s 33 public university campuses to provide abortion pills. It took effect in January 2023.

“We wanted to make sure that students, female students, had access to this right,” said Connie Leyva, the former Pomona-area state senator who authored the bill.

The legislature created a $10.3 million fund of privately raised money to help universities implement the new law. Each campus received $200,000 in one-time funding to pay for the medication and cover costs such as facility upgrades, equipment, training, telehealth services, and security upgrades.

The funding did not include any requirement that campus clinics inform students the medication was available to them.

Leyva said she doesn’t recall any conversations about “including something on advertising that you could get a medicated abortion on campus.” She said she’s disappointed in the law’s implementation, but not surprised.

“Everything starts at the top. And if the president or chancellor of the university knows they have to offer it, but if they don’t agree that women should have access to abortion services, then they might just think, ‘We’ll leave it off, we don’t have to worry about it,’” Leyva said.

Spokesperson Ryan King said UC President Michael Drake was not available to comment.

“The student communities at each UC campus are unique,” Heather Harper, a spokesperson for UC Health in Drake’s office, wrote in an email. “As a result, communication to students at each location takes different forms and may include website content, flyers, emails, person-to-person conversations or other methods.”

The office of CSU Chancellor Mildred García did not reply to a request for comment.

At Gomez’s San Bernardino campus, abortion as an option was mentioned only in one place: in small letters on a poster inside exam rooms at the health center.

A student wouldn’t see that until they were already waiting for a doctor or nurse.

“We need to work harder if there is a student who needed the service and wasn’t aware that they could access it through us and not have to pay for it,” said Beth Jaworski, executive director of health, counseling, and wellness at CSU-San Bernardino. “But it’s one student. We haven’t been providing the service very long. It’s been just about a year now.”

Medication abortion has since been added to the list of services on the clinic’s website.

Ray Murillo, California State University’s interim assistant vice chancellor of student affairs, said he and other administrative staffers are developing guidance so campuses share the same information “to help in our training efforts for the frontline staff and providers when they’re being asked questions about the service and what we provide.”

Gomez wants more done, including flyers, emails, and social media posts directed at both faculty and students.

“You want to market the football games, you want to market the volleyball games. Why is that important, and abortions are not?” she said.

Gomez did graduate in December 2023, becoming the first person in her family to earn a bachelor’s degree. But she’s angry at her alma mater for keeping the abortion pills a secret.

This article is from a partnership that includes LAist, NPR and KFF Health News.

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

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State and local governments are receiving billions of dollars in settlements from companies that made, sold, or distributed prescription painkillers and were accused of fueling the opioid crisis. More than a dozen companies will pay the money over nearly two decades. As of late February 2024, more than $4.3 billion had landed in government coffers.

KFF Health News has been tracking how that money is used — or misused — nationwide.

But determining how much of that windfall arrived in a specific county or city — and how much will follow in the future — can be challenging. Most localities are not required to make the information public.

BrownGreer, the court-appointed firm administering the settlements, tracks much of this data but kept it private until KFF Health News negotiated to obtain it last year. KFF Health News made that information public for the first time last June.

Five months later, BrownGreer began quietly posting updated versions of the information on a public website.

Roma Petkauskas, a partner at BrownGreer, told KFF Health News that the change was made to assist state and local governments in accessing the information easily and “to promote transparency into the administration” of the settlements. She said the data is updated “regularly when new payments are issued,” which can be as frequent as twice a month.

KFF Health News downloaded the data on March 4 and transformed it from state-by-state spreadsheets with separate entries for each settling company to a searchable database. Users can determine the total dollar amount their city, county, or state has received or expects to receive each year.

Determining how much money has arrived is the first step in assessing whether the settlements will make a dent in the nation’s addiction crisis.

Although this is the most comprehensive data available at a national scale, it provides just a snapshot of all opioid settlement payouts.

The information currently reflects only the largest settlement to date: $26 billion to be paid by pharmaceutical distributors AmerisourceBergen (now called Cencora), Cardinal Health, and McKesson, as well as opioid manufacturer Janssen (now known as Johnson & Johnson Innovative Medicine).

Most states have also settled with drug manufacturers Teva and Allergan, as well as Walmart, Walgreens, and CVS. Petkauskas said BrownGreer began distributing payments from these five companies in 2024 and plans to update its data to reflect such payments in July.

Other settlements, including with OxyContin manufacturer Purdue, are still pending.

This data does not reflect additional settlements that some state and local governments have entered into beyond the national deals, such as the agreement between Illinois, Indiana, Kentucky, Michigan, and Ohio and regional supermarket chain Meijer.

As such, this database undercounts the amount of opioid settlement money most places have received and will receive.

Payment details for some states are not available because those states were not part of national settlement agreements, had unique settlement terms, or opted not to have their payments distributed via BrownGreer. A few examples include:

• Alabama and West Virginia declined to join several national settlements and instead reached individual settlements with many of these companies.
• Texas and Nevada were paid in full by Janssen outside of the national settlement, so their payout data reflects payments only from AmerisourceBergen, Cardinal Health, and McKesson.
• Florida, Louisiana, and Pennsylvania, among others, opted to receive a lump-sum payment via BrownGreer then distribute the money to localities themselves.

KFF Health News’ Colleen DeGuzman contributed to this report. Jai Aslam also contributed.

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

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Cuando estaba en noveno grado, Fiona Lu cayó en una depresión. Tenía problemas para adaptarse a su nueva escuela en Orange County, California, y se sentía tan aislada y agotada que lloraba todas las mañanas.

Lu quería recibir ayuda, pero su plan de Medi-Cal no cubría la terapia a menos que tuviera el permiso de uno de sus padres o tutores.

Su madre, inmigrante china y madre soltera, trabajaba muchas horas para mantener a Fiona, a su hermano y a su abuela. Encontrar tiempo para explicarle a su madre en qué consistía la terapia y por qué la necesitaba le parecía una tarea imposible.

“No me la imaginaba firmando todos esos formularios y luego yendo a terapia conmigo”, dijo Lu, que ahora tiene 18 años y estudia primer año en la UCLA. “En las culturas inmigrantes existe esta idea de que tener problemas de salud mental y recibir tratamiento es un fenómeno de las culturas occidentales”.

En su último año de secundaria, Lu convirtió su experiencia en activismo. Hizo campaña para cambiar la política estatal y permitir que los menores a partir de los 12 años, que viven en hogares de bajos ingresos, reciban consejería de salud mental sin el consentimiento de sus padres.

En octubre del año pasado, el gobernador Gavin Newsom firmó una nueva ley que amplió el acceso a los pacientes jóvenes cubiertos por Medi-Cal, el Medcaid de California.

Los adolescentes con seguro privado han tenido este privilegio en el estado durante más de una década. Sin embargo, los padres de los jóvenes que ya tenían la posibilidad de acceder a la atención por su cuenta fueron los que más se opusieron a la ampliación de esa cobertura de Medi-Cal.

Muchos padres aprovecharon el proyecto de ley para expresar sus quejas sobre el control que, en su opinión, ejerce el Estado sobre sus hijos, especialmente en lo relativo a la identidad de género y la atención de salud.

La primavera pasada, una madre que apareció en Fox News llamó a los terapeutas escolares “adoctrinadores” y dijo que el proyecto de ley les permitía llenar la cabeza de los niños con ideas sobre el “transexualismo” sin que sus padres lo supieran.

Estos argumentos se repitieron en las redes sociales y en las protestas que tuvieron lugar en California y otras partes del país a finales de octubre.

En el Capitolio de California, varios legisladores republicanos votaron en contra del proyecto de ley, AB 665. Uno de ellos fue el miembro de la Asamblea estatal James Gallagher, del condado de Sutter.

“Si mi hijo está sufriendo una crisis de salud mental, quiero saberlo”, declaró Gallagher, durante una sesión sobre el proyecto de ley en la Asamblea, la primavera pasada. “Esta tendencia equivocada, y creo que ilícita, en nuestra política actual que continúa excluyendo a los padres de la ecuación, diciendo que no necesitan ser informados, es un agravio”.

Los sueldos de los legisladores estatales son demasiado altos para que ellos o sus familias puedan tener Medi-Cal. En su lugar, se les ofrece la posibilidad de elegir entre 15 planes comerciales de seguro médico, lo que significa que niños como los de Gallagher ya tienen los privilegios a los que se opuso en su discurso.

A Lu esto le pareció frustrante e hipócrita. Dijo que los opositores que se alineaban en contra del proyecto AB 665, en las audiencias legislativas, eran en su mayoría padres de clase media tratando de apropiarse del tema.

“No es creíble que aboguen contra una política que no les afecta directamente”, afirmó Lu. “No se dan cuenta de que se trata de una política que afectará a cientos de miles de otras familias”.

Los patrocinadores del proyecto AB 665 dijeron que agregaba sentido común a una ley existente. En 2010, los legisladores habían facilitado a los jóvenes el acceso a tratamientos ambulatorios de salud mental y a centros de acogida de emergencia sin el consentimiento de sus padres, al eliminar el requisito de tener que estar en medio de una crisis inminente para tener acceso.

Pero en el último momento, los legisladores eliminaron en 2010 la ampliación de la cobertura de Medi-Cal para los adolescentes por razones de costo. Más de una década después, el proyecto de ley AB 665 pretende acabar con la disparidad entre los seguros públicos y privados e igualar las condiciones.

“Se trata de equidad”, expresó la legisladora estatal Wendy Carrillo, demócrata de Los Angeles y autora del proyecto de ley.

La ley original, que regulaba los planes de seguros privados, fue aprobada con apoyo bipartidista y contó con escasa oposición en la Legislatura, dijo. La ley fue firmada por un gobernador republicano, Arnold Schwarzenegger.

“Desde entonces, los extremos de ambos bandos se han vuelto tan radicales que nos cuesta hablar sobre la necesidad de la salud mental”, añadió.

Después que Carrillo presentara el proyecto de ley el año pasado, su oficina recibió amenazas de muerte. Ella aseguró que el objetivo de la ley no es dividir a las familias, sino fomentar la comunicación entre padres e hijos a través de la consejería.

Más de 20 estados permiten a los jóvenes dar su consentimiento para el tratamiento ambulatorio de salud mental sin el permiso de sus padres, incluyendo Colorado, Ohio, Tennessee y Alabama, según un informe de 2015 realizado por investigadores de la Universidad Rowan.

Para los detractores de la nueva ley, como Erin Friday, una abogada del Área de la Bahía de San Francisco, AB 665 forma parte de una campaña más amplia para quitar derechos a los padres en California, algo a lo que ella se opone independientemente del tipo de seguro médico que tengan los niños.

Friday se considera demócrata de toda la vida. Pero un día descubrió que su hijo adolescente se había declarado transgénero en la escuela y que, durante meses, los profesores se habían referido a él con un nombre y pronombres diferentes, sin que Friday lo supiera. Se dedicó a luchar contra los proyectos de ley que, en su opinión, fomentaban la “ideología transgénero”. Dijo que va a presentar una demanda legal para intentar anular la nueva ley de California antes de que entre en vigencia este verano.

“Estamos dando a los niños una autonomía que nunca deberían tener”, afirmó Friday.

Según la nueva ley, los jóvenes podrán hablar con un terapeuta sobre la identidad de género sin el consentimiento de sus padres. Pero no podrán recibir tratamiento residencial, medicación o cirugía de afirmación de género sin el visto bueno de sus padres, como han sugerido algunos opositores.

Los menores tampoco pueden fugarse de casa o emanciparse al amparo de la ley, como también han sugerido los opositores.

“Esta ley no trata de los centros psiquiátricos de hospitalización. Esta ley no trata de cambiar las leyes de custodia de menores”, explicó Rachel Velcoff Hults, abogada y directora de salud del National Center for Youth Law, que apoyó la AB 665.

“Esta ley trata de garantizar que cuando un joven necesite asesoramiento o un techo temporal para garantizar su propia seguridad y bienestar, queremos asegurarnos de que va a poder contar con una manera de tenerlo”, agregó.

La eliminación del requisito de consentimiento de los padres también podría ampliar el número de médicos de salud mental en California dispuestos a tratar a los jóvenes en Medi-Cal. Sin el consentimiento de los padres, bajo las viejas reglas, Medi-Cal no podía pagar a los médicos por el asesoramiento que ofrecen, ya sea en una práctica privada o en la oficina de un consejero de la escuela.

Esther Lau tuvo problemas de salud mental cuando era estudiante de secundaria en Fremont. A diferencia de Lu, tuvo el apoyo de sus padres, pero no podía encontrar un terapeuta que aceptara Medi-Cal. Al ser la única angloparlante nativa de su familia, tuvo que navegar sola la burocracia del sistema de salud.

Para ella, la AB 665 incentivará a los médicos a aceptar en sus consultas a más jóvenes de familias de bajos ingresos.

“Para la oposición, se trata sólo de tácticas políticas y de promover su agenda”, dijo Lau. “El proyecto de ley fue diseñado para ampliar el acceso a los jóvenes de Medi-Cal, y punto”.

Esta historia forma parte de una alianza que incluye a KQED, NPR, y KFF Health News.

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

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Céline Gounder, KFF Health News’ senior fellow and editor-at-large for public health, discussed the 2024 U.S. measles outbreak on WAMU’s “A1” on March 26.

• Click here to hear Gounder on “A1.”

KFF Health News former senior editor Andy Miller discussed Medicaid expansion on the The Atlanta Journal-Constitution’s “Politically Georgia” on March 22.

• Click here to hear Miller on “Politically Georgia.”
• Read Miller and Renuka Rayasam’s “Georgia’s Medicaid Work Requirements Costing Taxpayers Millions Despite Low Enrollment.”

KFF Health News rural health care correspondent Arielle Zionts discussed Montana as an island of abortion access on WVON 1690AM’s “America’s Heroes Group podcast” on March 16.

• Click here to hear Zionts on “America’s Heroes Group podcast.”
• Read Zionts’ “Montana, an Island of Abortion Access, Preps for Consequential Elections and Court Decisions.”

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

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When Karla Adkins looked in the rearview mirror of her car one morning nearly 10 years ago, she noticed the whites of her eyes had turned yellow.

She was 36 at the time and working as a physician liaison for a hospital system on the South Carolina coast, where she helped build relationships among doctors. Privately, she had struggled with heavy drinking since her early 20s, long believing that alcohol helped calm her anxieties. She understood that the yellowing of her eyes was evidence of jaundice. Even so, the prospect of being diagnosed with alcohol-related liver disease wasn’t her first concern.

“Honestly, the No. 1 fear for me was someone telling me I could never drink again,” said Adkins, who lives in Pawleys Island, a coastal town about 30 miles south of Myrtle Beach.

But the drinking had caught up with her: Within 48 hours of that moment in front of the rearview mirror, she was hospitalized, facing liver failure. “It was super fast,” Adkins said.

Historically, alcohol use disorder has disproportionately affected men. But recent data from the Centers for Disease Control and Prevention on deaths from excessive drinking shows that rates among women are climbing faster than they are among men. The Biden administration considers this trend alarming, with one new estimate predicting women will account for close to half of alcohol-associated liver disease costs in the U.S. by 2040, a $66 billion total price tag.

It’s a high-priority topic for the Department of Health and Human Services and the Department of Agriculture, which together will release updated national dietary guidelines next year. But with marketing for alcoholic beverages increasingly geared toward women, and social drinking already a huge part of American culture, change isn’t something everyone may be ready to raise a glass to.

“This is a touchy topic,” said Rachel Sayko Adams, a research associate professor at the Boston University School of Public Health. “There is no safe level of alcohol use,” she said. “That’s, like, new information that people didn’t want to know.”

Over the past 50 years, women have increasingly entered the workforce and delayed motherhood, which likely has contributed to the problem as women historically drank less when they became mothers.

“Parenthood tended to be this protective factor,” but that’s not always the case anymore, said Adams, who studies addiction.

More than 600,000 people in the U.S. died from causes related to alcohol from 1999 to 2020, according to research published in JAMA Network Open last year, positioning alcohol among the leading causes of preventable death in this country behind tobacco, poor diet and physical inactivity, and illegal drugs.

The World Health Organization and various studies have found that no amount of alcohol is safe for human health. Even light drinking has been linked to health concerns, like hypertension and coronary artery disease and an increased risk of breast and other cancers.

More recently, the covid-19 pandemic “significantly exacerbated” binge-drinking, said George Koob, director of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health, as people used alcohol to cope with stress. That is particularly true of women, who are more likely to drink alcohol because of stress than men, he said.

But women are also frequently the focus of gender-targeted advertising for alcoholic beverages. The growth of rosé sales and low-calorie wines, for example, has exploded in recent years. New research published by the International Journal of Drug Policy in February found that the “pinking of products is a tactic commonly used by the alcohol industry to target the female market.”

Also at play is the emergence of a phenomenon largely perpetuated by women on social media that makes light of drinking to deal with the difficulties of motherhood. The misperception of “mommy wine culture,” said Adams, is that “if you can drink in a normal way, a moderate way, if you can handle your alcohol, you’re fine.”

And while it’s unclear to what extent memes and online videos influence women’s drinking habits, the topic merits further study, said Adams, who with colleagues last year found that women without children at age 35 are still at the highest risk for binge-drinking and alcohol use disorder symptoms among all age groups of women. But over the past two decades, the research concluded, the risk is escalating for both childless women and mothers.

These factors at play, coupled with the pressure to fit in, can make excessive drinking a difficult conversation to broach.“It’s a very taboo topic,” Adams said.

And when it does come up, said Stephanie Garbarino, a transplant hepatologist at Duke Health, it’s often surprising how many patients are unaware how their drinking affects their health.

“Often, they didn’t know there was anything wrong with what they’re doing,” she said. She is more frequently seeing younger patients with liver disease, including men and women in their 20s and 30s.

And public health and addiction experts fear that alcohol-related liver disease among women will become a costly issue for the nation to address. Women accounted for 29% of all costs associated with the disease in the U.S. in 2022 and are expected to account for 43% by 2040, estimated a new analysis published in the American Journal of Gastroenterology in February.

National dietary guidelines advise women to drink no more than one alcoholic drink a day. Those guidelines are up for a five-year review next year by the USDA and HHS, which has called a special committee to examine, among other questions, the relationship between alcohol consumption and cancer risks. The report will be made public in 2025.

When Canada published guidance in 2023 advising that drinking any more than two alcoholic beverages a week carried health risks, Koob sparked backlash when his comments to the Daily Mail suggested that U.S. guidelines might move in the same direction. The CDC report published in February suggested that an increase in alcohol taxes could help reduce excessive alcohol use and deaths. Koob’s office would not comment on such policies.

It’s a topic close to Adkins’ heart. She now works as a coach to help others — mostly women — stop drinking, and said the pandemic prompted her to publish a book about her near-death experience from liver failure. And while Adkins lives with cirrhosis, this September will mark 10 years since her last drink.

“The amazing thing is, you can’t get much worse from where I got,” said Adkins. “My hope is really to change the narrative.”

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

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Emergency room doctors say insurers are increasingly declining to cover costly air-ambulance rides for critically ill patients, claiming they aren’t medically necessary. And the National Association of EMS Physicians says the No Surprises Act, enacted in 2022, is partly to blame.

The law protects patients from many out-of-network medical bills by requiring insurers and providers to haggle over fair payment. But insurers can sidestep the law if they determine care is “not medically necessary” — and insurers themselves get to decide what that means.

In the fall of 2022, Sara England of Salinas, Calif., learned about this firsthand when ER doctors at a hospital in her town had her 3-month-old, Amari, transferred by air to the University of California at San Francisco Medical Center for what turned out to be an RSV infection. Her insurer, Cigna, determined the baby’s plane ride wasn’t necessary because his medical records didn’t show a ground ambulance would “impede timely and appropriate medical care.”

(Ground ambulances are exempt from the No Surprises Act.)

England is on the hook for the full cost of the air-ambulance ride: more than $97,000. “I thought there must have been a mistake,” England said. “There’s no way we can pay this. Is this a real thing?”

Cigna spokesperson Justine Sessions called the bill “egregious” and said, “We are working diligently to try to resolve this for the family.”

The emergency physician association said it frequently encounters denials like England’s. The group wrote to Health and Human Services Secretary Xavier Becerra, acting labor secretary Julie Su and Treasury Secretary Janet L. Yellen in February urging the federal government to require insurers to presume medical necessity for air-ambulance use, subject to retrospective review.

“Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan,” read the letter from José Cabañas, the group’s president. The Association of Critical Care Transport has made a similar request.

HHS spokesperson Sara Lonardo said the agency is committed to strengthening protections in the No Surprises Act.

Insurers point the finger at air-ambulance providers. Robert Traynham, a spokesperson for industry group AHIP, said providers often don’t submit medical records, impeding a full evaluation. He said AHIP also suspects that air-ambulance companies sometimes favor more distant hospitals that contract with them over closer facilities.

The air-ambulance industry — much of it controlled by private equity firms — is known for fast-growing prices, limited in-network contracting and surprise out-of-network bills averaging nearly $20,000. And the Centers for Medicare and Medicaid Services data shows that when insurers and providers go head-to-head in No Surprises arbitration, 8 in 10 cases are settled in the provider’s favor, incentivizing them to raise prices higher.

Lack of medical necessity is cited in the bulk of air-ambulance claims denials, said Loren Adler, who studies the industry for the Brookings Institution.

More than a year later, England is still fighting her bill. “I don’t know what else to do other than to be a squeaky wheel and make as much noise about it as possible, because it’s not right,” she said.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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OCALA, Fla. — Fire Capt. Jesse Blaire steered his SUV through the mobile home park until he spotted the little beige house with white trim and radioed to let dispatchers know he’d arrived.

There, Shawnice Slaughter waited on the steps, wiping sleep from her eyes.

“Good morning, Shawnice,” Blaire said. “How are you feeling today?”

“I’ve been good, I’ve been good,” Slaughter said. “Much better.”

Three days earlier, Blaire — a paramedic who leads the fire department’s emergency medical team — met Slaughter at a nearby hospital. She had overdosed on opioids. It took four vials of an overdose reversal medication and dozens of chest compressions to get her breathing again.

At the hospital, Blaire told Slaughter about a free program that could help. It wouldn’t just connect her with a recovery center but would also get her doctors’ appointments, plus rides there. More important, she would get medicine to alleviate withdrawal symptoms so she wouldn’t search for drugs to ease the sickness. Blaire would bring that medication, daily, to her home.

“I have a son,” Slaughter, 31, told Blaire. “I need to be alive for him.”

Every morning since, Blaire had driven over for a check-in. He reminded Slaughter of appointments and took note of what she needed: clothes, food, help with bills.

And at the end of each visit, from a lockbox in the back of his car, he dispensed to her a couple of tiny, lifesaving tablets.

Those tablets — a medicine called buprenorphine — represent a tidal change in the way counties in Florida and other states are addressing the opioid crisis. The idea: Get addiction medication to people who need it by meeting them where they are. Sometimes, that’s on the street. Sometimes, it’s in the driveway of a big house with a swimming pool. Sometimes on the steps of a modest home like Slaughter’s.

********

For a long time, many people who could benefit from buprenorphine, commonly known by the brand name Subutex, couldn’t get it.

Until recently, doctors needed a federal waiver to prescribe it to treat opioid use disorder. Amid misconceptions about treating opioid use disorder with medication, only about 5% of doctors nationally underwent the training to qualify. And in 2021, only 1 in 5 people who could have benefited from opioid addiction medication were receiving buprenorphine or another drug therapy.

But as evidence supporting the drug’s efficacy grew and the urgency mounted to curb opioid deaths, Congress axed the waiver requirement in late 2022, clearing the way for greater availability.

And in rare cases, such as in Ocala, medics on the front lines began bringing treatment to patients’ front doors.

In Florida, the state-run Coordinated Opioid Recovery Network, known as the CORE Network, provides guidelines on medicine distribution to areas hit hard by overdoses. Services through the network are free for patients, funded by money from the state’s opioid settlement.

The network looks different in each of its 13 counties. Not all hand-deliver buprenorphine. But the common goal is to create a single entry point for services that have typically been siloed and difficult for patients to navigate, such as mental health care and housing support.

In a recovery landscape rife with shoddy facilities and prohibitive price tags, simplifying the path for patients stands to make a meaningful difference.

“We know that the more people are in contact with services, the more they’re treated with respect, the more likely they are to reduce or cease drug use,” said Susan Sherman, a public health professor at Johns Hopkins University.

As opioid settlement dollars continue to come in, state officials have said they hope to expand to more counties.

********

Becoming a firefighter and paramedic satisfied Blaire’s craving for adrenaline and his conviction, informed in part by his Christian background, that he was put on this Earth to help others.

At 20, he imagined responding to car crashes and heart attacks, broken bones and punctured flesh. But after years on the job with Ocala Fire Rescue, the calls began to change.

At first, Blaire felt some resentment toward the people overdosing. His team was suddenly responding to hundreds of such calls a year. He viewed drug use as a moral failure. What if a grandmother had a heart attack or a kid drowned while his team was on an overdose call?

Unlike with other emergencies, he never really felt he was saving a life when responding to an overdose. It was more like delaying death.

Over and over, he’d pump a patient full of naloxone, an overdose reversal medication often known by one of its brand names, Narcan, and drop them at the hospital, only to find they’d overdosed again after being discharged. One Christmas, he said, he responded to the same person overdosing five times on a single shift.

“I didn’t understand it. I thought that they wanted to die,” said Blaire, 47. “I’m embarrassed to say that now.”

About a decade ago, the scope of the epidemic had already come into full view to Blaire’s crew. It seemed the team was responding to overdoses at big houses in wealthy neighborhoods nearly as often as they were in the park and under the bridge.

One week, his team went to a home on a cul-de-sac with two kids and a swing set — the kind of place families take their children trick-or-treating.

The dad had overdosed. The next week, it was the mom.

“Money can mask any problem, but we’ve seen it from the top to the bottom,” Blaire said.

Over time, Blaire began to understand addiction as the disease it is: a physiological change to someone’s brain that traps them in a dangerous cycle. Maybe it started with a prescription painkiller after surgery, or an indulgence at a party, but the majority of people weren’t using drugs to get high, he realized. They were using them to avoid being sick.

“Imagine the worst flu you’ve ever had, then make it a lot worse,” Blaire said.

When a person dependent on opioids stops taking them, their body goes into withdrawal, often accompanied by shakes, nausea, fever, sweating, and chills. Though rare, people can die from opioid withdrawal syndrome. Still, historically, the emergency health care system has focused on reversing overdoses, rather than treating the withdrawal side effects that keep people returning to drugs.

In the past, Blaire said, he saw patients released from the hospital with little more than a phone number for a recovery center. Getting an appointment could be challenging, not only because of wait times or insurance complications, but because the patients weren’t stable — they were in withdrawal. To make it through the day, Blaire said, they’d often use again.

“‘Good luck, you’re on your own,’” Blaire said. “That’s how it was. And that doesn’t work for somebody who is sick.”

Under Blaire’s leadership, Ocala Fire Rescue sought to stop the revolving door by launching its Community Paramedicine program and the Ocala Recovery Project in 2020.

They modeled it after overdose quick-response teams around the country, which vary in makeup. These mobile teams, typically helmed by paramedics like Blaire, connect people who have overdosed with services aimed at stabilizing them long-term. On some, a registered nurse embeds with paramedics in an ambulance or SUV. Others have a therapist or peer recovery coach on board. Some are bare-bones: a single responder with a phone on 24 hours a day. Some get in touch with patients through a call or a home visit after a reported overdose.

Others, like Blaire’s team, intercept patients at the hospital.

Blaire likens the system to that of a trauma alert — a message sent to medical centers to ready a response to near-fatal car wrecks or shootings. When a trauma alert goes out, operating tables are cleared, CT scanners are prepped, and responders stand by for arrival.

“We set the same system up for overdoses,” Blaire said.

Now, when somebody in Ocala overdoses, whether it’s on opioids, alcohol, meth, or cocaine, an alert goes out, notifying Blaire and his team, a peer recovery coach, a behavioral health specialist, and a local recovery center.

His team usually beats the ambulance to the hospital.

The next day, team members follow up at the patient’s home.

Then, last May, under the guidance of the EMS medical director, Blaire’s team started offering addiction medication to opioid users, too.

Since then, Blaire said, his team has connected 149 patients with treatment. Only 28 of them have needed additional intervention, he said.

********

When Blaire first heard about buprenorphine, he was skeptical.

How could giving somebody with an addiction more narcotics help?

That common response misunderstands the reality of addiction, said Nora Volkow, director of the National Institute on Drug Abuse.

People perceive that one drug is being substituted for another, Volkow said. Instead, the use of medications like buprenorphine is more akin to those that treat other psychiatric conditions, like mood disorders or depression.

Research shows that opioid addiction medication — including drugs like methadone — can greatly reduce the risk of overdose deaths, and increase a person’s retention in treatment. But a study out of the New York University Grossman School of Medicine found that nearly 87% of people with opioid use disorders don’t receive any.

Such addiction medications work by stimulating opioid receptors in the brain.

Opioids — like oxycodone or fentanyl — are what experts refer to as “full agonists.” Imagine an opioid receptor as a rounded bowl. A full agonist — like fentanyl — fits perfectly in that bowl and latches tightly to the receptor.

Buprenorphine is a “partial agonist.” It fits in the bowl — and satiates a craving — but doesn’t completely bind like a full agonist. Instead, it eliminates withdrawal symptoms so people won’t get sick or crave illicit drugs, without producing a high. Second, it counteracts the effects of other drugs, so a person can’t overdose on other opioids like fentanyl or heroin while taking it.

And for somebody who already uses opioids, overdosing from buprenorphine is nearly impossible.

“They help a person regain control of their everyday life,” Volkow said.

********

On this Monday in January, Blaire pulled into Beacon Point, a local treatment center, just past 2 p.m.

He’d spent his morning calling on people like Slaughter, but now he was meeting paramedics from his team. After nearly three weeks of home visits, a man in the recovery network program was set to have his first appointment with a doctor.

Blaire has found that once people are stable on buprenorphine, more often than not they want to get into a treatment program.

While Blaire waited, a woman walking out of the center approached, smiling.

“I just got my first clean urine analysis,” she said. “I’m doing great, I’m so excited.”

“That’s awesome news,” Blaire said, a smile stretched across his face. He’s often stoic, straight-laced, with combed hair and aviators. But when he lights up, his all-business exterior gives way to gentleness.

Jacqueline Luciano is sober for the first time in 30 years. She’s proud, glowing, and Blaire is proud, too.

Luciano first came to Blaire through a referral when she was living at a women’s shelter. She said she had $20 in her pocket and wanted to get high — needed to.

Fentanyl withdrawal had left her shaky and cold. Her stomach was seizing, her muscles spasming. To quell the agony that day in early January, she went on the hunt.

Luciano said she had first used drugs when she was 9. Her family had been torn apart by pills and powders, she said, a sickness she’d inherited.

But this time, a woman — “like an angel” — passed her a number for someone who she promised could guide her into a brighter future, blame-free. Luciano, 39, paused, skeptical.

Then she gave Blaire a call.

For about a week, Blaire delivered her a daily dose of buprenorphine using a Safe RX bottle — essentially a trackable pill bottle with a lock code to limit who can open it. He helped connect her with food and clothing donations.

And as Luciano started to feel more like herself, absent of cravings, she began to hope.

Blaire got her an appointment with doctors at Beacon Point, then drove her to her first screening. Now, in the parking lot, she thanked him for everything.

“It made all the difference in the world,” Luciano told Blaire. “I really didn’t think that I could get better. I didn’t. But I am.”

As a tear rolled down Luciano’s face, Blaire’s phone rang.

********

The call came from the health department. A man in his 40s or 50s had come some 40 miles from Gainesville, Florida, for help, steered through word of mouth.

He’d tried to get into a recovery center there but said he was turned away. Something about insurance and a criminal record had stood in the way.

It’s a pattern that drives Blaire crazy. He’d seen it a lot before his team was formed. People would get a moment of courage or clarity, only to be told “not yet.”

“Your first answer has to be ‘yes,’” he said. “‘Yes, I can help you.’”

He knew about a woman who had come from 25 miles out of town, then was told to come back days later. She didn’t have a car or a home to return to.

“They didn’t even offer her a ride,” Blaire said. “Sometimes you only have one shot.”

Blaire has learned that building trust starts with a small offering. A car ride. A sandwich. Help getting a government ID. Anything to show that you care, that you’re useful. That you see someone trying.

Outside the health department, a man in muddied jeans and a frayed T-shirt stood waiting on the curb. He introduced himself as Jetson and didn’t give a last name. Blaire shook his hand before they loaded into the car.

“So what brings you this way?” Blaire asked, once both were buckled in.

“I heard there were services here,” Jetson said, his voice gruff, quivering. “I’ve tried to stop using so many times, but I keep messing it up.”

Jetson shook his head.

“Well, I’m glad you found us,” Blaire said. He asked the man if he wanted to go to the recovery center for a screening. He did.

Over the 10-minute drive to Beacon Point, Blaire and Jetson talked, not about drugs or meds, but life. Baseball. Cabbage (good when fried).

When they pulled up, Blaire handed Jetson a card.

“Please call me,” Blaire said. “If you need anything. We can get you help.”

For a moment, the men sat there. Jetson pulling at his fingers. Taking deep breaths.

Then, he got out of the car — Blaire’s card in hand — and walked through the glass door.

This article was produced in partnership with the Tampa Bay Times.

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

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