The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The Arizona Supreme Court shook up the national abortion debate this week, ruling that a ban originally passed in 1864 — before the end of the Civil War and decades before Arizona became a state — could be enforced. As in some other states, including Florida, voters will likely have the chance to decide whether to enshrine abortion rights in the state constitution in November.

The Arizona ruling came just one day after former President Donald Trump declared that abortion should remain a state issue, although he then criticized the ruling as having gone “too far.”

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Roubein of The Washington Post, and Rachel Cohrs Zhang of Stat.

Panelists Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories. Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories.

Among the takeaways from this week’s episode:

• Former President Donald Trump’s remarks this week reflect only the latest public shift in his views on abortion access. During an appearance on NBC’s “Meet the Press” in 1999, he described himself as “very pro-choice,” but by the 2016 presidential campaign, he had committed to nominating conservative Supreme Court justices likely to overturn the constitutional right to an abortion. Trump later blamed Republican losses in the 2022 elections on the overturning of that right.
• Arizona officials, as well as doctors and patients, are untangling the ramifications of a state Supreme Court ruling this week allowing the enforcement of a near-total abortion ban dating to the Civil War. Yet any ban — even one that doesn’t last long — can have lasting effects. Abortion clinics may not survive such restrictions, and doctors and residents may factor them into their decisions about where to practice medicine.
• Also in abortion news, an appeals court panel in Indiana unanimously ruled that the state cannot enforce its abortion ban against a group of non-Christians who sued, siding with mostly Jewish plaintiffs who charged that the ban violates their religious freedom rights.
• A discouraging new study finds that paying off an individual’s medical debt once it has reached collections doesn’t offer them much financial — or mental health — benefit. One factor could be that the failure to pay medical debt is only a symptom of larger financial difficulties.

Also this week, Rovner interviews KFF Health News’ Molly Castle Work, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature about an air-ambulance ride for an infant with RSV that his insurer deemed not to be medically necessary. If you have an outrageous or baffling medical bill you’d like to send us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Stat’s “Your Dog Is Probably on Prozac. Experts Say That Says More About the American Mental Health Crisis Than Pets,” by Sarah Owermohle.

Rachel Cohrs Zhang: KFF Health News’ “Ten Doctors on FDA Panel Reviewing Abbott Heart Device Had Financial Ties With Company,” by David Hilzenrath and Holly K. Hacker.

Alice Miranda Ollstein: The Texas Tribune’s “How Texas Teens Lost the One Program That Allowed Birth Control Without Parental Consent,” by Eleanor Klibanoff.

Rachel Roubein: The Washington Post’s “As Obesity Rises, Big Food and Dietitians Push ‘Anti-Diet’ Advice,” by Sasha Chavkin, Caitlin Gilbert, Anjali Tsui, and Anahad O’Connor.

Also mentioned on this week’s podcast:

• Live Action’s “Hi, My Name’s Olivia” video.
• The New York Times’ “Insurers Reap Hidden Fees by Slashing Payment. You May Get the Bill,” by Chris Hamby.
• The Nation Bureau of Economic Research’s “The Effects of Medical Debt Relief: Evidence From Two Randomized Experiments,” by Raymond Kluender, Neale Mahoney, Francis Wong, and Wesley Yin.
• USA Today’s “The Database You Don’t Want to Need: Check to See if Your Health Data Was Hacked,” by Cecilia Garzella.

Click to open the transcript Transcript: Arizona Turns Back the Clock on Abortion Access

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 11, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: And we welcome back from her leave Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, happy to be here.

Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Molly Work about the latest KFF Health News-NPR “Bill of the Month,” about yet another very expensive air-ambulance ride that an insurer deemed “unnecessary.” As you will hear, that is hardly the case.

But first, this week’s news, and there is lots of it. We start again this week with abortion because, again, that’s where the biggest news is. I want to do this chronologically because there were a lot of things that happened and they all built on each piece before them. So on Monday, former President [Donald] Trump, as promised, issued his long-awaited statement on abortion, a four-minute video posted on his platform Truth Social, in which he took credit for appointing the justices who overturned Roe v. Wade, but then kind of declared the job done because abortion is now up to the individual states. And while he didn’t say so directly, that strongly suggested he would not be supporting efforts by anti-abortion groups to try to pass a federal 15-week ban, should Republicans retake the presidency and both houses of Congress. That alone was a big step away from some of his strongest anti-abortion supporters like the SBA List [Susan B. Anthony Pro-Life America], which helped got him elected in 2016, right, Alice? I see you nodding.

Ollstein: Yes. He kind of left himself some wiggle room. He made a statement that, at first, people could sort of read into it what they wanted. And so you had several anti-abortion groups going, “Well, he didn’t advocate for a national ban, but he also didn’t rule it out.” But then, as I’m sure we’ll get to, he was asked follow-up questions and he kind of did rule it out. He kind of did say, “No, I wouldn’t sign a national ban if it were presented to me.” And so the little crumbs of hope anti-abortion groups were picking up on may or may not be there. But it was both notable for what he did say and what he didn’t say. There are still a lot of unanswered questions about what he would do in office, both in terms of legislation, which is really a remote possibility that no one thinks is real, but he didn’t say anything.

Rovner: It would need 60 votes in the Senate.

Ollstein: Exactly.

Rovner: Legislation.

Ollstein: Exactly. And no one really on the right or left thinks that is going to happen, but he didn’t say anything about what he would do with executive powers, which, as we’ve discussed, could go a long, long way towards banning abortion nationwide.

Rovner: One of the things that sort of fascinates me, I’ve been covering abortion for a long time, longer than some of you have been alive, and I have seen lots of politicians switch sides on this. I mean, Joe Biden started out as very anti-abortion, now very in favor of abortion rights. So I’ve seen politicians go both ways, but the general rule has always been you get to switch once. You get to either go from being pro-life to pro-choice or being pro-choice to pro-life. You don’t get to go back and forth and yet that seems to be very much what Trump has done. He seems to have taken every conceivable position there is on this extraordinarily binary issue and gotten away with it.

Ollstein: One last thing I wanted to flag in the statement was that he kind of said the quiet part out loud and that he directly said that this is about winning elections. So he’s saying, “This is what we need to say in order to win,” which leaves open what he really believes or what he really would do.

Roubein: Yeah, I mean, going back to Trump’s shifting view on abortion, because that’s really important and that’s something that the anti-abortion movement is sort of looking towards. I mean, in 1999 in an interview in “Meet the Press,” he called himself “very pro-choice,” and then we kind of saw by 2016, he had committed to naming justices who had anti-abortion views. And as Alice mentioned then, after the midterms in 2022, he blamed Republican losses on that.

Rovner: Yeah, I assume that makes it hard for people who try to follow him. I know [Sen.] Lindsey Graham came out, Lindsey Graham, who’s been sort of the major backer of the 15-week abortion ban in Congress for some time now, and suddenly Lindsey Graham, who has been nothing but loyal to Trump, finds himself on the other side of a big, important issue. I mean, Trump seems to get away with it. The question is, are his followers going to get away with having different positions on this?

Cohrs Zhang: Oh, I also just wanted to say that I think it’ll be interesting to see who Trump chooses as his running mate on this because obviously his opinion and his position is very important, but I think we saw kind of last time around with him leaning on Mike Pence a little bit for credibility with the anti-abortion movement. So I think it’ll be interesting to see whether he chooses someone again who can mend some of these relationships or whether he’s just going to carry on and make those decisions himself and lean less on his VP.

Rovner: Well, let’s move on to Tuesday because on Tuesday the Trump abortion doctrine got a pretty severe test from the Arizona Supreme Court, which ruled that an almost absolute abortion ban that was passed in 1864, before Arizona was a state, before the end of the Civil War, can be enforced. Alice, what’s this law and when might it take effect?

Ollstein: So the Supreme Court kicked some of those issues back down to the lower court and so it’s still being worked out. Currently, abortion is banned after 15 weeks of pregnancy. The total ban could go into effect in a little over a month, but it’s really uncertain. And so you’re seeing a lot of the same fear and confusion that we saw in the immediate aftermath of Dobbs [v. Jackson Women’s Health Organization], where providers and patients don’t know what’s legal and whether they can provide or receive care and are, in some instances, over-complying and holding off on doing things that are still legal.

And so just a great example of how Trump and these national political figures, they can take whatever position they want, but that often gets overtaken by events. And so you saw Trump come out and say, “States should decide.” This is arguably an instance of states deciding, although the Supreme Court upholding a law from when no one was currently alive, was part of that, the law was implemented when women couldn’t vote, when Arizona wasn’t even a state yet. So whether this is an example of “will of the people,” that can be debated. But this is an example of “leave it to states.” And then Trump was asked about the Arizona decision, whether it went too far, and he said “Yes, it did go too far.” So it’s like should states be allowed to decide or not?

Rovner: It’s like, “Leave it to states unless they go too far.”

Roubein: And who decides what too far is, because a lot of anti-abortion groups were very complimentary of the Arizona ruling and said it was the right thing to do. So depends who you ask.

Rovner: So this obviously scrambles politics beyond just the presidential race, although I think it’s pretty clear to say that it puts Arizona, which had been teetering as being sort of purple state-ish, right back in play, but it’s going to affect things down the ballot and in other states, right?

Ollstein: I mean just looking at Arizona, I mean abortion rights and Democrats have really been pushing ballot measures here, and, I think as Julie was alluding to, there’s a ballot measure effort in Arizona, and I believe the organizers have said that they have enough signatures to qualify, then there’s steps to actually qualifying. So that’s going to really put a spotlight on Arizona. But, we’ve seen ballot measures in other states, Florida. Democrats really want Florida to be in play now that there’s been a Florida state Supreme Court ruling and there’s a ballot measure there. The threshold’s higher, it’s 60%, but all around the country it’s going to be putting increasing emphasis on this ballot measure effort.

Rovner: So the Republicans now really have no place to hide. I saw there was a Senate candidate in Wisconsin who had been very completely anti-abortion, now seems to be a lot less anti-abortion. I mean Republicans have spent a lot of time putting Democrats on the spot about not wanting to be specific on their abortion position, and that’s what leads to the, “You support abortion up until the ninth month,” which isn’t a thing. But now I feel like it’s a chance for Democrats to turn this on Republicans saying, “Now you have to say exactly what your position is rather than just you are ‘anti-abortion’ or ‘100% pro-life,’ which for many, many elections was plenty and all the candidates needed to say.

Cohrs Zhang: Just as we talk about all of these different, how this is playing out, certainly I think the instance you brought up was an example of a position on the larger issue of what a candidate is going to support generally, but I think there are these kind of tangential local issues too that candidates are going to have to take positions on. I think if we look back, like IVF, that’s something that candidates have never really had to weigh in on, and I think it is going to become local in a new way, which just seeing all these offshoot rulings and court decisions. And I think that it was an excellent catch, and, certainly, it’ll be interesting to see how candidates move across the spectrum as we see some more and more extreme local cases coming up even beyond the national standard.

Rovner: And as Alice points out, this is more than just political. This affects health care on the ground. Doctors either not wanting to train in states that have strict bans or doctors in some cases picking up and leaving states, not wanting to be threatened with jail or loss of license. So that affects what other kinds of women’s health care is available. Alice, you wanted to add something?

Ollstein: Yeah, I’ve been seeing a lot of people saying, both with the Florida ruling and with the Arizona ruling, so in both of these instances, a very sweeping abortion ban is expected to go into effect, but then there’s going to be a ballot referendum in the fall where voters will have the opportunity to get rid of those bans. And so you’re seeing a lot of people saying, “OK, well this is only temporary. Voters will be so outraged over this that they’ll vote to support these ballot measures to overturn it.” But I think it’s important to remember that a lot of the impacts will linger for a long time if these clinics can’t hang on even a few months under a near-total ban and shut their doors. You can’t just flip a switch and turn that back on. It’s incredibly hard to open a new abortion clinic.

Rovner: Or even to reopen one that you’ve closed down “temporarily.”

Ollstein: Exactly. And like you said, medical students and residents and doctors are making decisions about where to live and where to practice that could have impacts that last for years and years. And so people saying, “Oh, well, it’s not that important if these bans go into effect now because in November voters will have their say.” Even a few months can have a very long effect in a state.

Rovner: Yeah. I just want to continue to reiterate this is about more than politics. This is actually about health care on the ground.

Well, in other abortion news, a three-judge panel of the Indiana Court of Appeals ruled last week that the state cannot enforce its abortion ban against a group of plaintiffs who are non-Christians and charge that the ban violates their freedom of religion because some religions, notably Judaism but others too, include tenets that prioritize the life and health of the pregnant woman over that of the fetus. This is obviously not the last word on this case. It could still go to the Indiana Supreme Court or even the U.S. Supreme Court, but it does seem significant. I think it’s the first decision we’ve seen on one of these cases, and it was unanimous. And interestingly, it turns a lot of the recent decisions protecting religious freedom for Christians right back on those who would ban abortion. Alice, there are more of these … awaiting hearing, right?

Ollstein: Yes. There’s ones going on really around the country that are testing these legal theories, and part of it is that state-level religious freedom laws are often more expansive and protective than federal religious freedom laws. And so they’re leaning on that. And yeah, it’s a really fascinating test case of, were these religious freedom laws intended to only protect one particular religion that has hegemonic power in the United States right now or were they designed to protect every one of every religion? And I think Judeo-Christian values is a term that’s thrown out a lot, and this really shows that there are very different beliefs when it comes to pregnancy and abortion and which life to prioritize between the mother and the child. And when it even counts as an abortion, when it even counts as life beginning, that is a lot more muddled.

And look, in this case it was led by Jewish plaintiffs challenging, but I’ve been tracking cases that draw from many different religions, and these protections even apply to avowed atheists in some instances. And so I think this is definitely something to keep an eye on. In addition to Indiana, the other case I’ve been following most closely is in Missouri, so it’ll be really fascinating to see what happens.

Rovner: There was one in Kentucky, too. Did anything ever happen with that one? I think that was the first one we talked about.

Ollstein: They’re still waiting.

Rovner: Like two years ago.

Ollstein: Yeah. The wheels of justice turn slowly.

Rovner: Indeed, they do. Well, finally, Tennessee is on the verge of enacting a bill that would require students to be shown a three-minute video on fetal development and strongly recommends one made by the anti-abortion group Live Action. Not surprisingly, medical experts say the video is inaccurate and manipulative. I will post a link to it so you can watch it and judge for yourself. What jumped out to me in this story is that one Tennessee lawmaker, himself a physician, said, and I quote, “Whether all of the exact details are correct, I don’t think that is important.” Is that where we have come with this debate these days, that facts are no longer important?

Cohrs Zhang: I mean, I thought it was interesting that there was an amendment rejected that would’ve allowed parents to opt out of it. And I just feel like there’s so many permission slips in schools these days for any book or movie that something like this would be mandated is just kind of like an interesting twist on that. So again, we’ll be interested to see if it actually takes effect, but …

Rovner: I mean, it’s a pretty benign video. It’s basically purporting to show fetal development from the moment of fertilization up to birth. The big complaint about it is it’s misleading on the timing because it’s counting from a different place than doctors count from. It’s counting from the moment of fertilization. Doctors generally count pregnancy from the last missed period because it’s hard to tell. You don’t know when the moment of fertilization was. But when we talk about first trimester or however many weeks, medically you’re talking about weeks since last missed period. So this makes everything look like it happened earlier than it actually does in common parlance. Have I explained that right, Alice?

Ollstein: Yes. And we are seeing efforts on this front both to make these educational mandates for students, but we’re also seeing them mandated for doctors’ education in some states as well. Part of this is to address what everyone on all sides acknowledges is a problem, which is that doctors don’t understand when the exemptions to these abortion bans apply in terms of life and health of the parent coming into play. Oftentimes these bans are written with nonmedical language talking about serious threats. What’s serious? Talking about harm to a major bodily function. What’s major? So, you are seeing doctors holding off from providing abortions even in cases that they think should be exempt, these emergency situations, and so anti-abortion groups are pushing these bills mandating certain curricula for doctors to try to address this confusion. The medical groups I’ve spoken to don’t think this is a solution, but it’s interesting as an attempt.

Rovner: In some states, it has to be an affirmative defense. So as you, a doctor, consider an emergency, you perform the abortion and then instead of not getting charged, you get charged and you have to go hire a lawyer and go to court and say, “I decided that this was an emergency.” And that’s not something that’s very attractive to doctors either. And Rachel, you wanted to add …

Roubein: Oh yeah, I was just going to say I think one of the things that stuck out to me about this particular video, one of my colleagues, Dan Rosen, so I [inaudible 00:16: 52] in February, and he said that this is Live Action, which is the group that came under the spotlight in 2011 for releasing undercover videos seeking to discredit Planned Parenthood, but Live Action had been playing the Baby Olivia to legislative audiences, including at an influential conservative group, American Legislative Exchange Council. So just kind of looking at who’s kind of seeking to get this video into classrooms.

Rovner: All right, well now it is time for our weekly dive into why health care costs so darn much. We begin with a fascinating and infuriating investigation from The New York Times about another one of those third-party contractors most of us had never heard of, kind of like Change Healthcare before it got hacked. This one is called MultiPlan, and its job is to recommend how much insurers and/or employers, in self-insured plans, should pay providers. Except it turns out that MultiPlan has an incentive to pay providers less than they charge. It pockets part of the “savings.” And in most of the cases, these out-of-network charges are not covered by the surprise-billing law. I think because patients know they are going out-of-network, that part is not entirely clear to me. And of course, often patients have no other available providers, so they have no choice but to go out-of-network.

Sometimes indeed providers do overcharge outrageously. We’ve talked about that a lot. But in this case, it seems that a lot of these recommendations are to underpay outrageously. The firm told one therapist that her fair payment should be half of what Medicaid pays. Medicaid, traditionally the lowest payer of everyone. I feel like this story’s going to have legs, as they say. Apparently, the American Hospital Association has already asked the U.S. Department of Labor to investigate MultiPlan. Why do I feel like we’re all pawns in this huge competition between health care providers and insurers about who can pay who less or more and pocket the differences?

Cohrs Zhang: Yeah, I think we first heard about MultiPlan, kind of in the conversation around surprise billing, because that was just a different category of these out-of-network bills where patients were getting stuck in the middle. And I think over time we’ve seen more stories come out about loopholes in those protections. And this is another example where MultiPlan is … they have to fix their business model. And the arbitration process for these surprise bills is so backed up, in these certain cases, which are more emergency care, I think, and if patients don’t necessarily have control or knowledge of their provider being out-of-network.

But certainly, people, if you’re looking for a certain specialist or want to go to a certain place to have a procedure done, then you may just elect an out-of-network provider. And I think the part I found really interesting about this reporting, that I think we’ve seen reflected in larger trends on business reporting, is really understanding these business models better and the incentives. And I love the graphics, I think, where you’re showing that if MultiPlan can lowball these providers and manage to squeeze a little bit more of a discount for payers, then they’re taking a cut of that discount, and patients can be left on the hook for these too.

So I think, as with anything, these surprise-billing protections are going to be an iterative process. And certainly I think there’s more to be done in so many different individual cases to protect patients from some of these games that providers and insurers are engaged in and the firms that kind of specialize in brokering these negotiations.

Rovner: It feels very whack-a-mole, every time they sort of put a band-aid on one problem, another one pops up, that it’s just sort of this is what happens when a fifth of your economy goes to health care is that everybody says, “Oh, I can make money doing X.” And then, there’s an awful lot of people making money doing X, which is not necessarily having anything to do with providing or receiving medical care.

Cohrs Zhang: Absolutely. And correct me if I’m wrong, I think MultiPlan, it may be publicly traded as well. So if you look at some of these incentives here to kind of meet those quarterly targets and how that aligns with patients, I think that’s also just something we keep in mind.

Rovner: And there was private equity involved on both sides, too, which I didn’t even want to try to explain. You should really read the story, which is really very complicated and very well explained. Because this is how it works: They make it complicated so you can’t figure out what’s going on.

Well, meanwhile, in a sad payment story of the week, a new study has found that paying off people’s medical debt doesn’t actually fix their financial problems. According to a National Bureau of Economic Research working paper, paying off debts that have already gone to collection did not improve the financial status of the people who owed the money, nor their mental health, nor did it make it more likely that they would be able to pay future medical bills. One thing it did do was help their credit ratings. The researchers said that they hope maybe paying off debt before it reaches the collection status might be more helpful, but that would also be more expensive. What makes it easy to pay off medical debt after it’s gone to collections is they sell it for pennies on the dollar. And of course, the U.S. is already moving towards taking medical debt off of people’s credit report. So obviously we’re talking about patients getting stuck with these huge bills and they end up with this medical debt and now we can’t seem to figure out how to fix the medical debt problem either.

Cohrs Zhang: When I first saw the study, obviously I trust that Sarah Kliff edited her studies, but I scrolled right down to the conflict-of-interest section to see who funded this. And yeah, it was a very depressing study. But I think it’s important to keep in mind that a failure to pay medical debt is a symptom of larger economic problems. Certainly there may be cases where medical debt is the only outstanding debt somebody has or is a shocking surprise or is a lien on their home, something like that that might have just these massive consequences.

But I think one of the points that was brought up in the story was that when you have medical debt, sure, you have collections calls, you have bad impact on your credit, but you’re not getting evicted from your home. And we’ve heard about cases where providers have held outstanding balances against patients, but I don’t think that’s a general practice. You’re supposed to be seen if you go in for medical care. So I think just like the day-to-day challenges of poverty, of debt, are so overwhelming that it is a little discouraging to hear that these individual payments may not have changed someone’s life. But I think there may be anecdotal cases that would be different from that larger trend, but it was not an encouraging study.

Rovner: No. And speaking of conflict of interest, there was the opposite of conflict of interest. It was conducted in part by the group RIP Medical Debt, which was created to help pay off people’s medical debt. And they did say, obviously there are cases in this does make huge differences in individual people’s lives. It was just that, overall, apparently the model by which they are paying off people’s debt is not helping them as much as I guess they had hoped to. So they have to look on to other things.

Moving on to this week in health data security, or lack thereof, it seems that another cyberattack group is trying to get Change Healthcare to pay ransom. This is after the company reportedly paid $22 million. So it seems that after paying, the company didn’t get all of its stolen records back. Meanwhile, it seems that even though we’re not hearing as much about this as we were, there are still lots of providers that aren’t getting paid. I mean, Rachel, this thing as we predicted, has a really long tail.

Roubein: Absolutely does. Yeah, I think we’re seeing these multiple ransomware groups trying to extort money out of UnitedHealthcare. I mean, they have deep pockets. It’s such a mess. I think, who’s to say what’s true about what data they have as well. So it’s kind of hard to report on these kind of things. And I think only UnitedHealthcare has the answers to those questions. But I think we are going to see some more congressional oversight on this issue. I know providers, hospitals, and physician groups were absolutely using these arguments on Capitol Hill during the appropriations negotiations. They’re saying, “We’re in such financial distress.” Going to their lawmakers talking about how it wouldn’t be a good idea to cut provider payments or implement site-neutral payments for hospitals, all these long-term things that lawmakers have been thinking about. There were other political problems, too, but I think it’s definitely seeped into Washington how difficult this has been, how cumbersome some of the workarounds are for providers, large and small, I think who are trying to work around this fiasco.

Rovner: Yeah, I read one story, I mean it really does feel like a spy movie that they’re assuming that maybe the company that got the ransom that was supposed to split it with the company that actually did the hacking didn’t and made off with the money. And now the company that actually did the hacking is trying to get its own ransom and oh my goodness. I mean, again, this is what happens when a fifth of the economy goes through the health care system. But I mean, I want to keep on this story because this story really does keep on impacting the back-room goings-on, which keep the health care system functioning in some ways.

And while we are on the subject of health care data breaches, USA Today has now a searchable tool for you to find out if you’re one of the 144 million Americans whose medical information was stolen or exposed in the last year. Yay? I think? I suppose this is a necessary evil. It’s hard for me to imagine 10 years ago. It’s like, “Wow, you can take some time and find out if your medical information’s been exposed.”

Roubein: It’s better than not knowing because you can change your passwords, you can do some credit monitoring, you could protect your information in some ways. But it’s not the same as better protections for the breaches happening in the first place.

Rovner: I know Congress is talking about a privacy bill, but apparently it is in truly embryonic stages at this point because I don’t think Congress really knows what to do about this either. They just know that they probably should do something.

All right, that is the news for this week. Now we will play my bill of the month interview with Molly [Castle] Work. Then we will come back and do our extra credits.

I am pleased to welcome to the podcast my colleague Molly Work, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Molly, thanks for joining us.

Molly Castle Work: Thanks so much, Julie.

Rovner: So this month’s bill, like last month’s bill, is for an air-ambulance ride, a bill that should have been prevented by the federal No Surprises Act. But we’ll get to that in a minute. First, who is our patient this month?

Work: So our patient is Amari Vaca. He was a 3-month-old baby at the time from Salinas, California.

Rovner: And what happened to him?

Work: When Amari was a 3-month-old baby, he had issues with his breathing. His mother took him to a local ER and pretty quickly his team of doctors decided that he needed more specialized care at a larger hospital in San Francisco. So they organized an emergency transport.

Rovner: Via helicopter, yes?

Work: It was actually by air ambulance. So like a small airplane.

Rovner: Ah. OK. And before we get too far, he’s OK now, right?

Work: Yes, he is OK. Unfortunately, he was transported to the hospital. He was there for three weeks. They diagnosed him with RSV, but he’s fortunately doing well, now.

Rovner: Well, and then as we say, the bill came. And how much was it?

Work: It was $97,599.

Rovner: Of which the insurance paid how much?

Work: Zero.

Rovner: Now, as I mentioned at the top, the federal surprise-billing law should have prevented the patient from getting a big bill like this, except it didn’t in this case. So why not?

Work: Yeah, so this was really interesting. Cigna, which was Amari’s health plan at the time, decided that the care was not medically necessary. Their argument was that he could have taken a ground ambulance. There was nothing to prove that he had to take this emergency airplane. And so, because of this, Cigna was able to avoid No Surprises Act and they didn’t pay for any of the bill.

Rovner: And, therefore, the patient was left on the hook.

Work: Yes. Amari and his family were left on the hook for the entire bill.

Rovner: So this feels like something that should have been taken care of with a phone call. The insurer calls the doctor and says, “Hey, why’d you order an air ambulance when the hospital’s only 100 miles away?” And the doctor says, “Because it was an infant on a ventilator.” But that would’ve been too easy, right?

Work: Yeah, exactly. There’s a lot of issues with this. First off, one of the best things about No Surprises Act is it’s supposed to take patients out of this. It’s supposed to make it so health plans and providers deal with all these negotiations before it even goes to a patient. But because of how this was handled, instead, Amari’s family is having to do all these negotiations. They’re the ones who are writing letters, using his medical records, to Cigna, and doing multiple appeals.

Rovner: And so far, has there been any progress or is the bill still outstanding?

Work: It’s still outstanding. His mother, Sara, has done two internal appeals. So that means she applied to have the bill changed within Cigna. They denied her both times. Right now she’s working on an external appeal, where an outside provider helps evaluate, and she’s still waiting to hear back on that.

Rovner: So what’s the takeaway here? I mean, obviously you take your critically ill child to a hospital, and they say he has to go, he needs a higher level of care, and recommends an air ambulance. Are you supposed to say, “Wait, I have to call my insurer first to make sure they’re not going to deem this medically unnecessary?”

Work: Yeah, that’s what’s so frustrating because obviously if any of us were in that situation, we would’ve done the same thing. If our baby was sick, we would do the emergency air ambulance, or what we would do what the doctors told us to do. I think what I’ve been hearing from people is that, first off, hospitals should become better acquainted with what plans cover. Of course, we can only hope. But the hospital, for example, should have checked which air-ambulance providers are covered by Cigna before they made the call, because the one they did call was out-of-network for Amari’s family. As patients, what you can really do is you just need to advocate for yourself. It’s easy to be intimidated, but there are lots of times that hospitals just get the medical bill wrong or insurance companies. So do what Sara is doing and appeal. If internal appeals don’t work, go push for that external appeal as well.

Rovner: Yes, these days it helps to know your rights and to try to exercise them when you have them. Molly Work, thank you so much.

Work: Thank you so much, Julie.

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Rachel, Rachel Zhang. Why don’t you go first this week? Yep. We have both Rachels.

Cohrs Zhang: Yes. Confusing. So I chose a story in KFF Health News actually, and the headline is “Ten Doctors on FDA Panel Reviewing Abbott Heart Device Had Financial Ties With Company.” And I think this was just a really illuminating explanation of some of the loopholes in conflict-of-interest disclosures with FDA advisory committees. There’s a lot of controversy over what role these committees should play, when they should meet. But we’re seeing them play some very high-profile roles in drug approvals as well. But we have a medical device reporter on our team, and we just think it’s such an important coverage area as we’re looking at the money that the medical device industry spends. And I mean, you’re looking at some of these advisory board members who’ve received, on Open Payments, $200,000 from this company, and they’re not disclosing it because it’s not directly related to this individual device.

And I think it’s fair to say that some of them argued, “It was for a clinical study. The university got the money. I wasn’t spending it on a fancy car or something.” But nonetheless, I think there’s a good argument in this piece for some more stringent requirements for conflict of interest, especially if this data is publicly available.

Rovner: Yes, I was kind of taken this week about how very many good stories there were about investigations into conflicts of interest. Speaking of which, Rachel, other Rachel, why don’t you go next?

Roubein: My extra credit this week is titled “As Obesity Rises, Big Food and Dietitians Push ‘Anti-Diet’ Advice” and it’s a joint investigation by The Washington Post and The Examination, which is a new nonprofit newsroom that’s specializing in global health. And I thought it was a really fascinating window into the food industry and its practices at a time when the FDA and its commissioner wants to crack down, make front-of-package labeling more prevalent. And so basically the story dives into this anti-diet movement, which began as an effort to combat weight stigma and unhealthy obsession with thinness. And the movement has now become kind of a behemoth on social media, and basically food marketers are kind of trying to cash in here. The story kind of focused on one company in particular, General Mills, and its cereal, and the investigation found that the company launched a multipronged campaign to capitalize on the anti-diet movement and giveaways to registered dietitians who promote the cereals online. And I just thought it was kind of a fascinating exploration of all of these dynamics.

Rovner: Yes. Good journalism at work. Alice.

Ollstein: Yeah, I have a story from the Texas Tribune [“How Texas Teens Lost the One Program That Allowed Birth Control Without Parental Consent“] by Eleanor Klibanoff about the impact of the court ruling that said that Title X federal family planning clinics that all across the country have a policy of dispensing contraception, prescribing contraception to teens, whether or not they have parental consent, and doing that in a … advancing privacy and protecting them in that way. There was just a recent court ruling that said, just in Texas, the state’s parental consent laws override that. And they found that at a lot of these clinics, instances of teens coming in and seeking contraception have really fallen off. These are teens, the story documents, who don’t feel comfortable going to their parents. There’s instances of parents even getting violent with their kids when they find out about this. And so it really shows the effect of this, and this is something we should be continuing to track because it went to the 5th Circuit and it could go to the Supreme Court. We don’t know yet.

Rovner: Yeah, we talked about this case a couple of weeks ago. It was another of those cases that was very much aimed at a particular judge that they were confident would rule in their favor, who indeed did rule in their favor.

All right, well, my extra credit this week is not an investigation, it’s just a story I really liked from Stat News from Rachel’s colleague Sarah Owermohle, and it’s called “Your Dog Is Probably on Prozac. Experts Say That Says More About the American Mental Health Crisis Than Pets.” And full disclosure, that is one of my dogs in the background messing with a bone. My dogs are not on Prozac, but I am, and we are all three the better for it. It’s a serious story, though, about how our mental health impacts that of our pets, not just vice versa, and about how so few new medicines there are for anxiety and depression. And as an officer of a dog training club, I will say that it’s more than humans’ projections. We are definitely seeing more dogs with behavioral issues than at any time that I can remember, and I’ve owned dogs all my life.

OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. You can still find me mostly at X. Alice, where are you these days?

Ollstein: I’m at @AliceOllstein on X, and @alicemiranda on Bluesky.

Rovner: Rachel Zhang?

Cohrs Zhang: I’m at @rachelcohrs on X and also spending more time on LinkedIn these days. 

Rovner: Rachel Roubein?

Roubein: @rachel_roubein on X.

Rovner: We will be back in your feed next week. Until then, be healthy.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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LITTLE ROCK, Ark. — Sixth-grade boys were lining up to be measured in the Mann Arts and Science Magnet Middle School library. As they took off their shoes and emptied their pockets, they joked about being the tallest.

“It’s an advantage,” said one. “You can play basketball,” said another. “A taller dude can get more girls!” a third student offered.

Everyone laughed. What they didn’t joke about was their weight.

Anndrea Veasley, the school’s registered nurse, had them stand one by one. One boy, Christopher, slumped as she measured his height. “Chin up slightly,” she said. Then Veasley asked him to stand backward on a scale so he didn’t see the numbers. She silently noted his height as just shy of 4 feet, 7 inches, and his weight as 115.6 pounds.

His parents later would be among thousands to receive a letter beginning, “Many children in Arkansas have health problems caused by their weight.” The letter includes each student’s measurements as well as their calculated body mass index, an indicator of body fat. The BMI number categorizes each child as “underweight,” “normal,” “overweight,” or “obese.” Christopher’s BMI of 25.1 put him in the range of obesity.

In 2003, Arkansas became the first state to send home BMI reports about all students as part of a broader anti-obesity initiative. But in the 20 years since, the state’s childhood obesity rates have risen to nearly 24% from 21%, reflecting a similar, albeit higher, trajectory than national rates. During the pandemic, the state obesity rate hit a high of more than 26%.

Still, at least 23 states followed Arkansas’ lead and required height and weight assessments of students. Some have since scaled back their efforts after parents raised concerns.

One school district in Wyoming used to include a child’s BMI score in report cards, a practice it has since stopped. Ohio allows districts to opt in, and last year just two of 611 school districts reported BMI information to the state. And Massachusetts stopped sending letters home. Even Arkansas changed its rules to allow parents to opt out.

Multiple studies have shown that these reports, or “fat letters” as they’re sometimes mockingly called, have had no effect on weight loss. And some nutritionists, psychologists, and parents have criticized the letters, saying they can lead to weight stigma and eating disorders.

BMI as a tool has come under scrutiny, too, because it does not consider differences across racial and ethnic groups, sex, gender, and age. In 2023, the American Medical Association called the BMI “imperfect” and suggested it be used alongside other tools such as visceral fat measurements, body composition, and genetic factors.

All that highlights a question: What purpose do BMI school measurements and letters serve? Nearly 20% of American children were classified as obese just before the pandemic — up from only 5% some 50 years ago — and lockdowns made the problem worse. It’s unclear what sorts of interventions might reverse the trend.

Joe Thompson, a pediatrician who helped create Arkansas’ program and now leads the Arkansas Center for Health Improvement, said BMI letters are meant to be a screening tool, not a diagnostic test, to make parents aware if their child is at risk of developing serious health issues, such as heart disease, diabetes, and respiratory problems.

Sharing this information with them is critical, he said, given that many don’t see it as a problem because obesity is so prevalent. Arkansas is also a rural state, so many families don’t have easy access to pediatricians, he said.

Thompson said he’s heard from many parents who have acted on the letters. “To this day, they are still our strongest advocates,” he said.

The program also led to new efforts to reduce obesity. Some school districts in Arkansas have instituted “movement breaks,” while others have added vegetable gardens, cooking classes, and walking trails. One district sought funding for bicycles. The state does not study whether these efforts are working.

Researchers say the BMI data also serves an important purpose in illuminating population-level trends, even if it isn’t helpful to individuals.

Parents are generally supportive of weighing children in school, and the letters have helped increase their awareness of obesity, research shows. At the same time, few parents followed up with a health care provider or made changes to their child’s diet or physical activity after getting a BMI letter, several other studies have found.

In what is considered the gold-standard study of BMI letters, published in 2020, researchers in California found that the letters home had no effect on students’ weight. Hannah Thompson, a University of California-Berkeley assistant professor who co-authored the study, said most parents didn’t even remember getting the letters. “It’s such a tiny-touch behavioral intervention,” she said.

Arkansas now measures all public school students in even grades annually — except for 12th graders because by that stage, the pediatrician Joe Thompson said, the students are “beyond the opportunities for schools to have an impact.” The change also came after many boys in one school wore leg weights under their jeans as a prank, he said.

Kimberly Collins, 50, remembers being confused by the BMI letters sent to her from the Little Rock School District stating that all her children were considered overweight, and that one daughter was classified as obese.

“It offended me as a mama,” she said. “It made me feel like I wasn’t doing my job.”

She didn’t think her children looked overweight and the family pediatrician had never brought it up as a concern.

Hannah Thompson, the researcher from California, said that’s the biggest problem with BMI letters: Parents don’t know what to do with the information. Without support to help change behavior, she said, the letters don’t do much.

“You find out your child is asthmatic, and you can get an inhaler, right?” she said. “You find out that your child is overweight and where do you even go from there? What do you do?”

Kevin Gee, a professor at the University of California-Davis, who has studied BMI letters, said the mailings miss cultural nuances. In some communities, for example, people prefer their children to be heavier, associating it with comfort and happiness. Or some eat foods that they know aren’t very nutritious but are an important way of expressing love and traditions.

“There’s a lot of rich contextual pieces that we know influences rates of obesity,” Gee said. “And so how do we balance that information?”

Collins’ daughter, now 15, said that as she’s grown older she increasingly feels uncomfortable about her weight. People stare at her and sometimes make comments. (Collins’ mother asked that her daughter’s name not be published because of her age and the sensitive nature of the subject.)

“On my birthday, I went to get my allergy shots and one of the nurses told me, ‘You are getting chubbier,’” she said. “That didn’t make me feel the best.”

Collins said it pains her to see her soft-spoken daughter cover herself with her arms as if she’s trying to hide. The teenager has also begun sneaking food and avoids the mirror by refusing to turn on the bathroom light, Collins said. The girl signed up for tennis but stopped after other children made fun of her, her mother said.

Looking back, Collins said, while she wishes she had paid more attention to the BMI letters, she also would have liked practical suggestions on what to do. Collins said she had already been following the short list of recommended healthy practices, including feeding her children fruits and vegetables and limiting screen time. She isn’t sure what else she could have done.

Now everyone has an opinion on her daughter’s weight, Collins said. One person told her to put a lock on the fridge. Another told her to buy vegan snacks. Her mother bought them a scale.

“It’s a total uphill climb,” Collins said with a sigh.

This article was produced as a part of a project for the Spencer Education Journalism Fellowship.

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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Nearly two hours into a Capitol Hill hearing focused on rural health, Rep. Brad Wenstrup emphatically told the committee’s five witnesses: “Hang with us.”

Federal lawmakers face a year-end deadline to solidify or scuttle an array of covid-era payment changes for telehealth services that include allowing people to stay in their homes to see a doctor or therapist.

During the hearing in early March, Wenstrup and other House members offered personal anecdotes on how telehealth, home visits, and remote monitoring helped their patients, relatives, and constituents. Wenstrup, a Republican from Ohio who is also a podiatric surgeon and a retired Army reservist, told the audience: “Patients are less anxious and heal better when they can be at home.”

Most of the proposals focus on how Medicare covers telehealth services. But the rules affect patients on all types of insurance plans because typically private insurers and some government programs follow Medicare’s example. Without congressional action, virtual health care services like audio-only calls or meeting online with specialty doctors — such as an occupational therapist — could end. The bills would also continue to allow rural health clinics and other health centers to offer telehealth services while waiving a requirement for in-person mental health visits.

Telehealth use ballooned in the early months of the covid-19 pandemic and grew into a household term. The practice has become a popular issue for lawmakers on both sides of the aisle.

In one U.S. Census Bureau survey conducted from April 2021 to August 2022, Medicare and Medicaid enrollees reported using telehealth visits the most — 26.8% and 28.3%, respectively. The survey of nearly 1.2 million adults also found that Black patients and those earning less than $25,000 reported high rates of telehealth use. Notably, people of color were more likely to use audio-only visits.

Ensuring access to telehealth services “is the best public policy,” said Debbie Curtis, a vice president of McDermott+Consulting, a Washington, D.C.-based health care lobbying firm. “It’s the best business outcome. It’s the best patient care outcome.”

But it’s a presidential election year and Congress is a “deadline-driven organization,” Curtis said. She expects that Congress will be “kicking the can” past the November election.

Kyle Zebley, senior vice president of public policy at the American Telemedicine Association who also lobbies on Capitol Hill, said Congress “might well be in that lame-duck period.” “This is no way to run a health care system on a popular bipartisan issue,” he said.

In January, lawmakers — including senators from Mississippi and South Dakota — sent a letter to the Biden administration urging the White House to work quickly with Congress to ensure payments continue for Medicare patients who use telehealth, “especially for rural and underserved communities.”

Maya Sandalow, a senior policy analyst for the Bipartisan Policy Center, a Washington, D.C.-based think tank, said lawmakers and policymakers are likely to consider a temporary extension of the payments rather than permanent changes.

“Research is still coming out that covers more recent years than the acute effects of the pandemic,” Sandalow said. The center expects to release policy recommendations in the coming months.

Questions being considered include which kind of health care services are best for audio-only and video visits. Sandalow said researchers are also weighing how telehealth can “expand access to affordable, high-quality care while ensuring in-person options remain for patients.”

In North Dakota, Sanford Health’s David Newman said virtual care is often the only way some of his patients in the western part of the state can get sub-specialty care, such as with behavioral health.

Newman, an endocrinologist and Sanford’s medical officer of virtual care, said 10% to 20% of his patients are seen virtually during the summer, as compared with about 40% in the winter months because “the weather can be so bad” that roads are impassable.

In winters past, Newman would sit around “doing nothing for a day” because patients couldn’t visit him. Now, he has a full clinic using telehealth technology.

“I tell my patients that if you can make a restaurant reservation or if you can order a pizza online, you can do a virtual visit,” Newman said.

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DENVER — Pediatrician Patricia Braun and her team saw roughly 100 children at a community health clinic on a recent Monday. They gave flu shots and treatments for illnesses like ear infections. But Braun also did something most primary care doctors don’t. She peered inside mouths searching for cavities or she brushed fluoride varnish on their teeth.

“We’re seeing more oral disease than the general population. There is a bigger need,” Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

“Federally qualified health centers have a long history of co-locating dental services within their systems,” Braun said. “We’re taking that next step where care is not just co-located, meaning, say, we’re upstairs and dental is downstairs, but we’re integrated so that it becomes part of the same visit for the patient.”

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

“Providing these services during medical visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge of caring for their child’s teeth.” But obstacles remain.

Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to fluoridated water, which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. “Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states — including California, Texas, and Maryland — integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women gain dental coverage with Medicaid and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the “astronomical cost” of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her three others are uninsured, and they couldn’t otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE’s director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” — the process underway to reexamine post-pandemic eligibility for the government program that provides health coverage for people with low incomes and disabilities — has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they’ll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing dental therapists — midlevel providers who do preventive and restorative care — to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a metric that medical and dental integration capitalizes on, particularly for at-risk children. As part of Braun’s program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2½ years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. “It’s about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider — if they have one.”

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DENVER.- Un lunes reciente, la pediatra Patricia Braun y su equipo atendieron a unos 100 niños en una clínica comunitaria. Administraron vacunas contra la gripe y trataron infecciones de oído. Pero Braun también hizo algo que la mayoría de los médicos de atención primaria no hacen. Revisó las bocas de los pacientes en busca de caries o cepilló sus dientes con barniz de flúor.

“Estamos viendo más enfermedades bucodentales que en el resto de la población. La necesidad es mayor”, dijo Braun sobre los pacientes que trata en el Centro de Salud Familiar Bernard F. Gipson Eastside, que forma parte de Denver Health, el mayor hospital de la red social de Colorado, que atiende a residentes con bajos ingresos, sin seguro de salud o con seguro insuficiente.

Braun forma parte de una tendencia en todo el país que consiste en integrar la salud dental en los chequeos médicos de niños, embarazadas y otras personas que no pueden permitirse o no tienen fácil acceso a los dentistas.

Con financiación federal y privada, estos programas se han ampliado en los últimos 10 años, pero se enfrentan a barreras socioeconómicas, escasez de personal calificado y el reto de atender las necesidades de los nuevos inmigrantes.

Con una subvención federal de cinco años y $6 millones, Braun y sus colegas han ayudado a formar a 250 proveedores de atención primaria en salud bucodental en Colorado, Montana, Wyoming y Arizona.

En Illinois, Michigan, Virginia y Nueva York se están ultimando proyectos similares, financiados por la Oficina de Salud Maternoinfantil (MCHB) de la Administración de Recursos y Servicios de Salud (HRSA).

Además de la evaluación, la educación y la atención preventiva, los proveedores de atención primaria envían a los pacientes a dentistas internos o externos, o trabajan con higienistas dentales integrados en sus consultas.

“Los centros de salud federales tienen un largo historial de servicios dentales integrados en sus sistemas”, afirmó Braun. “Nosotros estamos dando el siguiente paso, en el que la atención no sólo es compartida, es decir, nosotros estamos en el piso de arriba y los dentistas en el de abajo, sino que está integrada en la misma visita del paciente”.

Contar con médicos, enfermeras y auxiliares que evalúen la salud bucodental, hagan derivaciones y apliquen flúor en los centros de salud comunitarios es fundamental para muchos niños que no tienen acceso a la atención dental, dijo Tara Callaghan, directora de operaciones de la Asociación de Atención Primaria de Montana, que representa a 14 centros de salud calificados a nivel federal y a cinco organizaciones Urban Indian.

“Ofrecer estos servicios durante las visitas médicas aumenta la frecuencia de aplicación del flúor”, señaló Callaghan, y “mejora el conocimiento de los padres sobre el cuidado de los dientes de sus hijos”. Pero sigue habiendo obstáculos.

Según Callaghan, debido a la gran extensión geográfica y a la escasa población de Montana, la contratación de profesionales dentales es difícil. Cincuenta de los 56 condados del estado están designados como zonas de escasez dental y algunos no tienen ni un solo dentista que acepte Medicaid, añadió. Montana ocupa uno de los últimos puestos en cuanto al acceso de los residentes al agua fluorada, que puede prevenir las caries y fortalecer los dientes.

Callaghan indicó que, concretamente, los especialistas en odontología pediátrica escasean en las zonas rurales, y las familias a veces tienen que conducir horas hasta los condados vecinos para recibir atención.

Tener higienistas dentales con los médicos es una forma de llegar a los pacientes en una sola visita.

La higienista dental Valerie Cuzella colabora estrechamente con Braun y otros profesionales de Denver Health, que atiende a casi la mitad de los niños de la ciudad y ha incorporado higienistas en cinco de sus clínicas infantiles.

Las normativas estatales varían en cuanto a los servicios que los higienistas pueden prestar sin la supervisión de un dentista. En Colorado, Cuzella puede, entre otras cosas, realizar radiografías de forma independiente y aplicar fluoruro de plata y diamina, una herramienta para endurecer los dientes y frenar la caries. Todo esto lo hace en un acogedor despacho situado en una esquina.

Braun y Cuzella trabajan tan estrechamente que a menudo una termina la frase de la otra. A lo largo del día se envían mensajes de texto, aprovechando las breves pausas en las que Cuzella puede asomarse a una sala de chequeos para detectar enfermedades de las encías o enseñar buenos hábitos de cepillado. También Braun aprovecha oportunidades similares para evaluar la salud bucodental durante sus exámenes, y ambas se centran en educar a los padres.

Tradicionalmente, la atención médica y la odontológica han estado separadas. “Las facultades están mejorando la colaboración y la formación interprofesional, pero en general nos formamos, y ejercemos, por separado”, afirmó Katy Battani, higienista dental y profesora de la Universidad Georgetown.

Battani trata de zanjar esta brecha ayudando a centros de salud comunitarios en nueve estados —entre ellos California, Texas y Maryland— a integrar la atención dental en las visitas prenatales. El embarazo crea oportunidades para mejorar la salud bucodental porque algunas mujeres obtienen cobertura dental con Medicaid y ven a los proveedores al menos una vez al mes, explicó Battani.

En Denver, la inestabilidad de la vivienda, las barreras del idioma, la falta de transporte y el “costo astronómico” de la odontología sin seguro hacen que la atención dental sea inaccesible para muchos niños, la comunidad inmigrante y las personas mayores, explicó Sung Cho, dentista que supervisa el programa dental del Centro de Salud Comunitario STRIDE, en el área metropolitana de Denver.

STRIDE intenta superar estas barreras ofreciendo servicios de interpretación y una escala móvil de pagos para quienes no tienen seguro.

Esto incluye a personas como Celinda Ochoa, de 35 años y residente en Wheat Ridge, que fue a STRIDE para que le hicieran una limpieza dental a su hijo Alexander, de 15 años. Alexander fue seleccionado para el cuidado dental durante un chequeo médico y ahora él y sus tres hermanos ven regularmente a un dentista e higienista en el centro.

Uno de los hijos de Ochoa tiene cobertura dental de Medicaid, pero los otros tres no tienen seguro, y nunca podrían permitirse la atención dental, dijo Ochoa. STRIDE ofrece un examen, radiografías y limpieza por $60 para los que no tienen seguro.

En el último año, Cho ha sido testigo del aumento de inmigrantes y refugiados que nunca habían visto a un dentista antes y necesitan una atención exhaustiva. Los exámenes médicos para los refugiados en STRIDE aumentaron de 1,300 en 2022 a 1,700 en 2023, dijo Ryn Moravec, director de desarrollo de STRIDE. Calcula que el programa ha atendido entre 800 y 1,000 nuevos inmigrantes en 2024.

Incluso con las crecientes necesidades, Cho señaló que el proceso de Medicaid en curso —que reexamina la elegibilidad post-pandemia para el programa gubernamental que proporciona cobertura de salud a las personas con bajos ingresos y discapacidades— ha creado incertidumbre económica. Dijo que le preocupa hacer frente a los costos iniciales de nuevo personal y de sustitución de equipos dentales obsoletos.

En la clínica de STRIDE en Wheat Ridge, dos higienistas trabajan entre odontología y pediatría como parte de la integración médico-dental. Sin embargo, Cho aseguró que necesita más higienistas en otros centros para satisfacer la demanda.

La pandemia creó cuellos de botella que sólo ahora se están resolviendo lentamente, sobre todo porque pocos dentistas aceptan Medicaid. Y, si lo aceptan, a menudo limitan el número de pacientes del programa, dijo Moravec. Idealmente, STRIDE podría contratar a dos higienistas y tres asistentes dentales, añadió.

En 2022, Colorado promulgó una ley para aliviar la escasez de personal que permite incorporar terapeutas dentales: proveedores de nivel medio que proporcionan atención preventiva y restauradora. Pero Colorado no tiene ninguna escuela para formarlos o acreditarlos.

Antes de los 3 años, los niños deben ir al pediatra para 12 visitas de control, una métrica que aprovecha la integración médica y dental, sobre todo para los niños en situación de riesgo. Como parte del programa de Braun en la región de las Montañas Rocosas, se han aplicado más de 17,000 barnices de flúor y ha aumentado el porcentaje de niños de 3 años o menos que recibieron atención bucodental preventiva al 78%, del 33% en los primeros 2 años y medio.

Callaghan, de la Asociación de Atención Primaria de Montana, es testigo de ello en los mismos centros de salud comunitarios del estado. “Se trata de aprovechar el hecho de que los niños ven a su proveedor médico para una visita rutinaria mucho más a menudo, antes de ver a su proveedor dental, si es que lo tienen”.

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Health and Human Services Secretary Xavier Becerra is racking up frequent-flier miles as he hopscotches the country to highlight health issues the White House hopes will become pivotal for voters this year — none more so than reproductive rights. 

“No woman today should fear [not having] access to the care that she needs. President Biden has made that clear,” Becerra said last Tuesday in Fort Lauderdale, Fla.

It was a timely visit. The day before, the state’s Supreme Court greenlit an abortion rights ballot measure that Democrats hope will drive turnout in November, while also upholding the six-week abortion ban signed into law by Gov. Ron DeSantis (R) last year. The ban takes effect May 1.

Becerra called the law “medical apartheid” in remarks following a field hearing House Democrats held in Fort Lauderdale on reproductive health care. The Democrats sought to highlight the GOP’s role in abortion bans that most Americans oppose.  

He drew a line connecting the Supreme Court’s 2022 decision overturning Roe v. Wade to recent state efforts to restrict fertility treatment and access to contraception.

“At the end of the day, Roe was about all of us and our care,” he said. “It was not simply about abortion.”

It wasn’t the first time this year that the secretary has arrived somewhere at an opportune moment. He traveled to Alabama in February in the wake of that state’s Supreme Court ruling declaring that embryos created through in vitro fertilization are children. He held a roundtable with IVF patients and framed the court’s decision as an assault on reproductive freedom. 

The week before he visited Florida, Becerra was in South Carolina, one of 14 states with severe abortion restrictions and among those with the highest maternal mortality rates.

Two days later, Becerra appeared in Michigan, one of the most competitive states in the upcoming presidential election, where he boasted about the Biden administration’s efforts to lower prescription drug prices and joined Gov. Gretchen Whitmer (D) for another roundtable on reproductive rights.

Becerra, a former California attorney general and House member, is a fluent Spanish speaker whose travels include a “National Latino Health Tour” — a key demographic for Biden’s reelection hopes. Becerra’s remarks often cover other Biden health priorities, including lowering drug prices, increasing mental health access, boosting funding for cancer research, and improving health insurance coverage and health equity.

“From Colorado, I head over to New Mexico,” Becerra said as he left the Florida event. “We’re going to go everywhere we need to go.”

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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.

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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.

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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.

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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.

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 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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This story can be republished for free (details).