Post-Helene, Patients Who Rely on IV Nutrition Face Severe Shortages
Hurricane Helene, which struck North Carolina last month, wrecked a Baxter International factory that produced 60 percent of the country’s IV fluids, according to the American Hospital Association. The company is rationing its products, and some hospitals have delayed or canceled surgeries that require large amounts of IV hydration.
Among the worst-hit patients are those who rely on parenteral nutrition — IV liquids containing amino acids, lipids, sugars, vitamins and electrolytes. These patients often get the fluid through a port connected to a vein near their heart because they can’t digest food through the intestines due to conditions ranging from autoimmune diseases to cancer.
In addition, two weeks after the hurricane hit, CVS Health, which owns one of the biggest home infusion pharmacies in the country — a subsidiary called Coram — began warning patients that it was getting out of the parenteral nutrition business.
With Baxter providing limited supplies of IV fluid to the remaining infusion pharmacies, many Coram patients are starting to run out of supplies. For some, hospitalization is the only answer.
We caught up with Lisa Trumble, a 52-year-old Pittsfield, Massachusetts, grandmother who was slammed by this double whammy. After entering Berkshire Medical Center with a respiratory illness on Oct. 1, she was ready to be discharged Oct. 9. But then Coram alerted her doctor that it could no longer supply her with home IV nutrition.
“I was dropped between Tuesday night and Wednesday morning with no care for my life or my health,” Trumble told me by phone after another week in the hospital.
Although another supplier stepped up for Trumble a few days after we talked, she isn’t the only one facing critical problems. Several IV nutrition patients we spoke with said they were running low on supplies and worried about getting sick. A couple of days without electrolytes can make you ill. Without sufficient carbohydrates, you starve. Some patients say they’ve had trouble getting enough of the special syringes and tubing needed to administer their fluids since the hurricane.
Even before the Baxter and Coram troubles, pharmacies were suffering shortages and low reimbursement rates. They have barely been able to care for existing patients, and the Baxter rationing left them no way to take new ones dropped by Coram, said David Seres, director of medical nutrition at Columbia University Medical Center in New York.
The Biden administration has triggered the Defense Production Act, under which it can commandeer supplies and labor to get the Baxter plant running at full speed again. Meanwhile, the FDA is allowing emergency imports of IV fluids wiped out by Helene as well as production of some of the fluids by U.S. compounding pharmacies.
But it’s unclear how long it will take to replenish supplies, said Manpreet Mundi, a Mayo Clinic endocrinologist who is a board member of the American Society for Parenteral and Enteral Nutrition. “We’re trying to raise awareness that this could get worse before it gets better,” he said.
Baxter says on its website that, “barring any unanticipated developments,” it expects to restart “the highest-throughput IV solutions manufacturing line” this week.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
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.
USE OUR CONTENTThis story can be republished for free (details).
Vance Wrongly Blames Rural Hospital Closures on Immigrants in the Country Illegally
“We’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”
Sen. JD Vance (R-Ohio) during a Sept. 17 rally
During a recent presidential campaign rally in Wisconsin, Sen. JD Vance (R-Ohio) was asked how a Trump administration would protect rural health care access in the face of hospital closures, such as two this year in Eau Claire and Chippewa Falls.
In response, he turned to immigration.
“Now, you might not think that rural health care access is an immigration issue,” said Vance, former President Donald Trump’s running mate. “I guarantee it is an immigration issue, because we’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”
More than 150 rural hospitals have closed or eliminated inpatient services since 2010, researchers at the University of North Carolina-Chapel Hill reported. Losing a hospital can resonate throughout a community — reducing access to timely care and disrupting the local economy.
The federal government has made efforts to keep the far-flung facilities afloat, but it’s not been an easy problem to solve.
What Is Plaguing Rural Hospitals?
Experts said Vance’s statement implies that immigrants who are in the country illegally strain the resources of these hospitals, which often operate on thin margins, by taking time and energy away from other patients without paying their bills.
We contacted both Vance and Trump campaign staff members for additional information. They did not respond.
Experts on hospital financing and industry representatives generally disagreed with Vance’s assertion, noting that many other factors figure in closures.
“When we speak with our rural hospital members, that is not what we hear,” said Shannon Wu, director of payment policy at the American Hospital Association, a trade group of more than 5,000 hospitals around the country.
Brock Slabach, chief operating officer of the National Rural Health Association, said border state hospitals face challenges treating immigrants who are in the country illegally. “But I’ve never, in my discussions, had anyone link it directly to a hospital closure,” he said.
The specific situations that lead a rural hospital to close its doors are unique to each facility, researchers said, but many face some of the same stressors.
Rural hospitals tend to have low patient volumes, which presents its own set of problems. They’re frequently located in small communities, and some residents may choose to travel to hospitals in bigger cities where they can get more complex care, what researchers call “hospital bypass.”
That small number of patients can cause financial losses at small rural hospitals, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a national health care payment and delivery systems policy center.
Hospitals have fixed costs, such as for running emergency departments, and need to have a high enough patient volume to cover them, he said.
“If a patient comes into the ED and doesn’t have insurance or can’t pay, it doesn’t really increase the cost to the hospital very much at all because the physician is already there,” he said, using an abbreviation for emergency department.
Rural hospitals treat a higher share of patients covered by Medicare and Medicaid compared with urban hospitals, according to the American Medical Association. The public insurance programs for older and low-income Americans generally pay providers less than private insurers do.
Nevertheless, Medicare is “one of the better payers” for small rural hospitals, Miller said. That’s partly because facilities with a special “critical access hospital” designation get paid more by Medicare — and, in some states, Medicaid.
Hospital industry officials and some experts say Medicare Advantage plans’ rising popularity has also hurt rural hospitals’ bottom lines because the private insurance companies that offer the plans tend to be less reliable payers than traditional Medicare.
For starters, the negotiated rates paid by Advantage plans can be lower, which is especially noticeable for those critical access facilities. Advantage plans also introduce extra levels of expensive, staff-intensive administrative burdens to ensure payment.
“They’ll deny the claim or say the patient really didn’t need that service through prior authorization, and so the hospitals don’t get paid for the service from someone who has insurance,” Miller said.
The insurance industry trade group AHIP pushed back on the assertion that Medicare Advantage plans harm rural hospitals, citing a federally supported study saying the plans actually increase rural hospital financial stability.
But the study did not compare actual payments between Medicare Advantage and traditional Medicare plans and looked at only 14 states.
People lacking legal immigration status generally cannot obtain Medicaid or Medicare coverage. But a provision within Medicaid law does allow some immigrants in the country illegally to temporarily obtain coverage, said Hayden Dublois, data and analytics director for the think tank Foundation for Government Accountability.
Medicaid, which pays less than Medicare and private insurance, “is not exactly a financial boon for hospitals,” and this could be some of what Vance is referring to, Dublois said.
In data from a few states, Dublois found a rise in people enrolling in Medicaid without being able to verify their immigration status. But his research hasn’t looked specifically at how this population might affect rural hospitals’ financial viability.
Some states have acted in recent years to expand health coverage to people in the country illegally — offering insurance to more than 1 million low-income immigrants.
One of those states, California, has had nine hospitals close or end in-patient services since 2005.
People may be able to pay out-of-pocket for care, researchers said, or may have access to private insurance through an employer.
Covering the costs for the uninsured is only one financial stressor rural hospitals face, said George Pink, deputy director of the North Carolina Rural Health Research Program.
“Is that going to be enough to drive a hospital into bankruptcy? Probably not,” he said.
A financial decline can take years, Pink said. As losses mount, hospitals can be forced to sell property or other assets, draw down any financial reserves, and max out their credit.
“This is not an overnight phenomenon,” he said.
Our Ruling
Vance said providing care for immigrants without legal status was “bankrupting” rural hospitals and forcing them to close.
Although that population is more likely to be uninsured, living in the country illegally does not mean people lack the ability to pay for health care — especially if they live in states that offer them insurance coverage.
Research shows many factors contribute to rural hospital closures — not solely financial losses from providing care for those without insurance, whether those people are migrants in the country illegally or U.S. citizens.
We rate Vance’s statement False.
Our sources:PBS NewsHour, “WATCH LIVE: Vance Addresses Campaign Rally in Eau Claire, WI,” Sept. 17, 2024.
HSHS Hospital Sisters Health System, “HSHS Sacred Heart Hospital and HSHS St. Joseph’s Hospital Closure Information,” accessed Sept. 26, 2024.
Cecil G. Sheps Center for Health Services Research, the University of North Carolina-Chapel Hill, “Rural Hospital Closures,” accessed Sept. 27, 2024.
GAO, “Rural Hospital Closures: Affected Residents Had Reduced Access to Health Care Services,” Dec. 22, 2020.
The Journal of Rural Health, “The Impact of Rural General Hospital Closures on Communities — A Systematic Review of the Literature,” Nov. 20, 2023.
Rural Health Information Hub, “Rural Emergency Hospitals (REHs),” accessed Sept. 30, 2024.
KFF Health News, “Federal Program To Save Rural Hospitals Feels ‘Growing Pains,’” Jan. 16, 2024.
Microsoft Teams interview, Shannon Wu, director of payment policy at the American Hospital Association, Oct. 1, 2024.
Zoom interview, Brock Slabach, chief operating officer, National Rural Health Association, Oct. 1, 2024.
Cecil G. Sheps Center for Health Services Research, the University of North Carolina-Chapel Hill, “Patterns of Hospital Bypass and Inpatient Care-Seeking by Rural Residents,” accessed Oct. 1, 2024.
Zoom interview, Harold Miller, president and CEO, Center for Healthcare Quality and Payment Reform, Sept. 26, 2024.
American Medical Association, “Issue Brief: Payment & Delivery in Rural Hospitals,” accessed Oct. 15, 2024.
Rural Health Information Hub, “Critical Access Hospitals (CAHs),” accessed Sept. 30, 2024.
KFF, “Medicare Advantage Enrollment, Plan Availability and Premiums in Rural Areas,” Sept. 7, 2023.
KFF Health News, “Tiny, Rural Hospitals Feel the Pinch as Medicare Advantage Plans Grow,” Oct. 23, 2023.
Email interview, James Swann, director of communications and public affairs, AHIP, Oct. 21, 2024.
Medicaid.gov, “Implementation Guide: Citizenship and Non-Citizen Eligibility,” accessed Oct. 10, 2024.
Zoom and email interview, Hayden Dublois, data and analytics director, the Foundation for Government Accountability, Oct. 1, 2024.
The Commonwealth Fund, “How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost,” Aug. 17, 2022.
KFF Health News, “States Expand Health Coverage for Immigrants as GOP Hits Biden Over Border Crossings,” Dec. 28, 2023.
Phone interview, George Pink, deputy director, North Carolina Rural Health Research Program, Sept. 30, 2024.
KFF, “State Health Coverage for Immigrants and Implications for Health Coverage and Care,” May 1, 2024.
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.
USE OUR CONTENTThis story can be republished for free (details).
California Mental Health Agency Director To Resign Following Conflict of Interest Allegations
California’s mental health commission on Thursday announced its executive director would resign amid revelations that he traveled to the U.K. courtesy of a state vendor while he sought to prevent a budget cut that would have defunded the company’s contract.
Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, will step down effective Nov. 22. Documents obtained by KFF Health News show that he tried in June to protect state funding for Kooth, a London-based digital mental health company with a contract to develop a virtual tool to help California tackle its youth mental health crisis.
He had been on paid administrative leave pending an investigation since September.
Ewing’s resignation was announced after a four-hour closed session of the mental health commission. During a public hearing before the announcement, advocates for mental health services accused the commission of favoring corporations over serving people with mental health and substance use issues.
The commission is an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services.
“You are being co-opted by big corporations,” said Susan Gallagher, executive director of Cal Voices, a mental health advocacy organization, during Thursday’s meeting. “You’re lobbying behind the scenes for these people to get money. That is not your job. You serve the people.”
Ewing declined to comment.
Kooth last year signed a four-year, $271 million contract with the Department of Health Care Services, which is separate from the commission, to create Soluna, a free mental health app for California users ages 13 to 25.
The app, along with one for younger users by the company Brightline, launched in January to fill a perceived need for young Californians and their families to access professional telehealth free of charge. It’s one component of Gov. Gavin Newsom’s $4.7 billion youth mental health plan.
The apps have seen very slow uptake since their launch in January. In May, the Newsom administration proposed a $140 million budget cut for the apps. Both the state Assembly and Senate budget committees proposed eliminating the entire program to save the state $360 million in the face of California’s $45 billion deficit.
But the funding for Kooth’s app wound up restored. It’s unclear why. Emails and calendars reviewed by KFF Health News showed Ewing pressed legislative staffers in June to restore the proposed cut.
About two weeks later, Ewing was accompanied by MHSOAC commissioners Mara Madrigal-Weiss, Bill Brown, and Steve Carnevale on a trip to London. Public disclosure forms show Kooth paid $15,000 in travel expenses for Ewing, Madrigal-Weiss, and Brown. The forms do not show the company paid for Carnevale’s travel.
While Ewing was in London, a colleague told him that the final state budget was approved with funding restored for Kooth’s app. Ewing emailed a Kooth executive ideas to improve its teletherapy app. About a week later he wrote, “We expect you to be involved in whatever we dream up.”
At Thursday’s commission meeting, Stacie Hiramoto, director of the Racial and Ethnic Mental Health Disparities Coalition, said the public will view the London trip as a serious conflict of interest.
“Maybe there was no wrongdoing, and maybe the company was good,” said Hiramoto, referring to Kooth. “But don’t you understand the appearance of the conflict?”
Carnevale said in Thursday’s meeting that the Newsom administration asked the commission to engage the legislature during budget negotiations.
“The governor’s office reached out to us to ask us to help them support the arguments and that’s what we did,” Carnevale said. “We went back and explained our positions on the digital solutions provided generally, without any particular comment on any company or any product in particular.”
Newsom’s office didn’t immediately respond.
Carnevale said the U.K. trip was not related to the budget. He said the trip “was very successful” for exchanging ideas with mental health policy leaders.
DHCS Director Michelle Baass told lawmakers in May that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps. Together, they had been used for only about 2,800 coaching sessions. The department has not provided more recent figures to KFF Health News.
Madrigal-Weiss defended her support of the mental health apps, lauding the youth-led design. She cited data that a majority of Kooth’s users liked the virtual coaching sessions and more than half were from underserved communities.
According to Kooth’s contract, obtained through a records request early this year, its payment is partially contingent on how many people use its app. Kooth will not get a pay increase until it reaches 366,000 users.
Kooth’s stock price fell about 20% on Thursday after KFF Health News published an article about Ewing’s efforts to restore funding for its contract and the London trip.
Gabe Brison-Trezise contributed to this report.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Presidential Election Puts Affordable Care Act Back in the Bull’s-Eye
Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it gives to more than 40 million people.
Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.
More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.
“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”
The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.
Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.
Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.
He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.
Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.
Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”
Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats retake control of the House in 2018.
In a KFF poll last winter, two-thirds of the public said it is very important to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.
“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”
Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.
“You want to make sure that preexisting coverage — conditions — are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.
Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.
Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.
Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.
The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”
But some ACA critics think there are ways to separate risk pools without undermining coverage.
“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.
Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.
People eligible for subsidies would likely buy comprehensive ACA plans because — with the financial help — they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.
He also said that in states that allowed people to buy non-ACA-compliant plans outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.
But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.
“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying ‘we’re making it better,’ but it’s all untrue.”
Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.
Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office estimated doing so would increase the federal deficit by more than $330 billion over 10 years.
In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.
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.
USE OUR CONTENTThis story can be republished for free (details).
Exclusive: Emails Reveal How Health Departments Struggle To Track Human Cases of Bird Flu
Bird flu cases have more than doubled in the country within a few weeks, but researchers can’t determine why the spike is happening because surveillance for human infections has been patchy for seven months.
Just this week, California reported its 15th infection in dairy workers and Washington state reported seven probable cases in poultry workers.
Hundreds of emails from state and local health departments, obtained in records requests from KFF Health News, help reveal why. Despite health officials’ arduous efforts to track human infections, surveillance is marred by delays, inconsistencies, and blind spots.
Several documents reflect a breakdown in communication with a subset of farm owners who don’t want themselves or their employees monitored for signs of bird flu.
For instance, a terse July 29 email from the Weld County Department of Public Health and Environment in Colorado said, “Currently attempting to monitor 26 dairies. 9 have refused.”
The email tallied the people on farms in the state who were supposed to be monitored: “1250+ known workers plus an unknown amount exposed from dairies with whom we have not had contact or refused to provide information.”
Other emails hint that cases on dairy farms were missed. And an exchange between health officials in Michigan suggested that people connected to dairy farms had spread the bird flu virus to pet cats. But there hadn’t been enough testing to really know.
Researchers worldwide are increasingly concerned.
“I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, formerly the assistant secretary for preparedness and response in the Obama administration.
Bird flu viruses have long been on the short list of pathogens with pandemic potential. Although they have been around for nearly three decades in birds, the unprecedented spread among U.S. dairy cattle this year is alarming: The viruses have evolved to thrive within mammals. Maria Van Kerkhove, head of the emerging diseases unit at the World Health Organization, said, “We need to see more systemic, strategic testing of humans.”
Refusals and Delays
A key reason for spotty surveillance is that public health decisions largely lie with farm owners who have reported outbreaks among their cattle or poultry, according to emails, slide decks, and videos obtained by KFF Health News, and interviews with health officials in five states with outbreaks.
In a video of a small meeting at Central District Health in Boise, Idaho, an official warned colleagues that some dairies don’t want their names or locations disclosed to health departments. “Our involvement becomes very sketchy in such places,” she said.
“I just finished speaking to the owner of the dairy farm,” wrote a public health nurse at the Mid-Michigan district health department in a May 10 email. “[REDACTED] feels that this may have started [REDACTED] weeks ago, that was the first time that they noticed a decrease in milk production,” she wrote. “[REDACTED] does not feel that they need MSU Extension to come out,” she added, referring to outreach to farmworkers provided by Michigan State University.
“We have had multiple dairies refuse a site visit,” wrote the communicable disease program manager in Weld, Colorado, in a July 2 email.
Many farmers cooperated with health officials, but delays between their visits and when outbreaks started meant cases might have been missed. “There were 4 people who discussed having symptoms,” a Weld health official wrote in another email describing her visit to a farm with a bird flu outbreak, “but unfortunately all of them had either already passed the testing window, or did not want to be tested.”
Jason Chessher, who leads Weld’s public health department, said farmers often tell them not to visit because of time constraints.
Dairy operations require labor throughout the day, especially when cows are sick. Pausing work so employees can learn about the bird flu virus or go get tested could cut milk production and potentially harm animals needing attention. And if a bird flu test is positive, the farm owner loses labor for additional days and a worker might not get paid. Such realities complicate public health efforts, several health officials said.
An email from Weld’s health department, about a dairy owner in Colorado, reflected this idea: “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too.” Pink eye, or conjunctivitis, is a symptom of various infections, including the bird flu.
Chessher and other health officials told KFF Health News that instead of visiting farms, they often ask owners or supervisors to let them know if anyone on-site is ill. Or they may ask farm owners for a list of employee phone numbers to prompt workers to text the health department about any symptoms.
Jennifer Morse, medical director at the Mid-Michigan District Health Department, conceded that relying on owners raises the risk cases will be missed, but that being too pushy could reignite a backlash against public health. Some of the fiercest resistance against covid-19 measures, such as masking and vaccines, were in rural areas.
“It’s better to understand where they’re coming from and figure out the best way to work with them,” she said. “Because if you try to work against them, it will not go well.”
Cat Clues
And then there were the pet cats. Unlike dozens of feral cats found dead on farms with outbreaks, these domestic cats didn’t roam around herds, lapping up milk that teemed with virus.
In emails, Mid-Michigan health officials hypothesized that the cats acquired the virus from droplets, known as fomites, on their owners’ hands or clothing. “If we only could have gotten testing on the [REDACTED] household members, their clothing if possible, and their workplaces, we may have been able to prove human->fomite->cat transmission,” said a July 22 email.
Her colleague suggested they publish a report on the cat cases “to inform others about the potential for indirect transmission to companion animals.”
Thijs Kuiken, a bird flu researcher in the Netherlands, at the Erasmus Medical Center in Rotterdam, said person-to-cat infections wouldn’t be surprising since felines are so susceptible to the virus. Fomites may have been the cause or, he suggested, an infected — but untested — owner might have passed it on.
Hints of missed cases add to mounting evidence of undetected bird flu infections. Health officials said they’re aware of the problem but that it’s not due only to farm owners’ objections.
Local health departments are chronically understaffed. For every 6,000 people in rural areas, there’s one public health nurse — who often works part-time, one analysis found.
“State and local public health departments are decimated resource-wise,” said Lurie, who is now an executive director at an international organization, the Coalition for Epidemic Preparedness Innovations. “You can’t expect them to do the job if you only resource them once there’s a crisis.”
Another explanation is a lack of urgency because the virus hasn’t severely harmed anyone in the country this year. “If hundreds of workers had died, we’d be more forceful about monitoring workers,” Chessher said. “But a handful of mild symptoms don’t warrant a heavy-handed response.”
All the bird flu cases among U.S. farmworkers have presented with conjunctivitis, a cough, a fever, and other flu-like symptoms that resolved without hospitalization. Yet infectious disease researchers note that numbers remain too low for conclusions — especially given the virus’s grim history.
About half of the 912 people diagnosed with the bird flu over three decades died. Viruses change over time, and many cases have probably gone undetected. But even if the true number of cases — the denominator — is five times as high, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, a mortality rate of 10% would be devastating if the bird flu virus evolved to spread swiftly between people. The case fatality rate for covid was around 1%.
By missing cases, the public health system may be slow to notice if the virus becomes more contagious. Already, delays resulted in missing a potential instance of human-to-human transmission in early September. After a hospitalized patient tested positive for the bird flu virus in Missouri, public health officials learned that a person in the patient’s house had been sick — and recovered. It was too late to test for the virus, but on Oct. 24, the CDC announced that an analysis of the person’s blood found antibodies against the bird flu, signs of a prior infection.
CDC Principal Deputy Director Nirav Shah suggested the two people in Missouri had been separately infected, rather than passing the virus from one to the other. But without testing, it’s impossible to know for certain.
The possibility of a more contagious variant grows as flu season sets in. If someone contracts bird flu and seasonal flu at the same time, the two viruses could swap genes to form a hybrid that can spread swiftly. “We need to take steps today to prevent the worst-case scenario,” Nuzzo said.
The CDC can monitor farmworkers directly only at the request of state health officials. The agency is, however, tasked with providing a picture of what’s happening nationwide.
As of Oct. 24, the CDC’s dashboard states that more than 5,100 people have been monitored nationally after exposure to sick animals; more than 260 tested; and 30 bird flu cases detected. (The dashboard hasn’t yet been updated to include the most recent cases and five of Washington’s reports pending CDC confirmation.)
Van Kerkhove and other pandemic experts said they were disturbed by the amount of detail the agency’s updates lack. Its dashboard doesn’t separate numbers by state, or break down how many people were monitored through visits with health officials, daily updates via text, or from a single call with a busy farm owner distracted as cows fall sick. It doesn’t say how many workers in each state were tested or the number of workers on farms that refused contact.
“They don’t provide enough information and enough transparency about where these numbers are coming from,” said Samuel Scarpino, an epidemiologist who specializes in disease surveillance. The number of detected bird flu cases doesn’t mean much without knowing the fraction it represents — the rate at which workers are being infected.
This is what renders California’s increase mysterious. Without a baseline, the state’s rapid uptick could signal it’s testing more aggressively than elsewhere. Alternatively, its upsurge might indicate that the virus has become more infectious — a very concerning, albeit less likely, development.
The CDC declined to comment on concerns about monitoring. On Oct. 4, Shah briefed journalists on California’s outbreak. The state identified cases because it was actively tracking farmworkers, he said. “This is public health in action,” he added.
Salvador Sandoval, a doctor and county health officer in Merced, California, did not exude such confidence. “Monitoring isn’t being done on a consistent basis,” he said, as cases mounted in the region. “It’s a really worrisome situation.”
KFF Health News regional editor Nathan Payne contributed to this report.
Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.
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.
USE OUR CONTENTThis story can be republished for free (details).
Long-Term Care Facilities Must Provide Addiction Care, Advocates Say
When you think about the opioid crisis, the image of adults in their 20s, 30s, even sometimes those who are middle-aged, may come to mind. Rightly so, since most overdose deaths occur in people between ages 25 and 64.
But did you know older adults are increasingly at risk of overdosing from opioids, too?
In fact, from 2021 to 2022, adults over 65 saw the largest increase — 10 percent — in overdose death rates across all age groups.
Yet their addiction care needs are often overlooked, even in places teeming with medical staff, such as long-term care facilities that primarily serve older patients. My colleague Aneri Pattani and I dug into the issue.
One study estimated that older adults were the least likely in 2022 to receive any type of care for opioid use disorder. They were also unlikely to receive medications such as buprenorphine and methadone — considered the treatment gold standard.
When people think of who actively uses drugs, “they don’t want to think about grandma, they don’t think about grandpa, and they certainly don’t want to think about what could be happening at a nursing home,” said A. Toni Young, executive director of Community Education Group, a nonprofit that advocates on substance use policy.
But Young’s organization, along with more than 50 other advocacy groups, is working to bring the issue front and center. In a letter shared exclusively with KFF Health News and the Health Brief, the coalition is urging the Centers for Medicare and Medicaid Services to ensure older patients get the help they need.
“Many Americans living in residential care facilities may not be in a position to effectively advocate for their own medical interests,” the letter says. “They must be able to trust you to hold their facility operators accountable to uphold the law.”
Facilities that receive Medicaid and Medicare payments are required to abide by federal laws, including the Americans With Disabilities Act and the Fair Housing Act. The laws bar discrimination due to current or past addiction and mandate appropriate medical care, including medications for opioid use disorder.
“However, without enforcement, the law is just words,” the letter notes.
To change that, the letter writers urge CMS to “undertake a systematic education, investigation, and enforcement effort, covering all categories of residential care facilities that you oversee.”
In a statement to KFF Health News, CMS said its updated staffing guidelines, released this year, require nursing facilities to ensure they have the staffing and resources to care for patients with serious mental illness or substance use disorder. The agency directs facilities to have care plans in place to “prevent adverse events, such as an overdose.” It has also partnered with other federal agencies to create free programs to boost nursing home care for patients with addiction and mental health concerns.
The agency did not directly address how such guidelines would be enforced.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
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.
USE OUR CONTENTThis story can be republished for free (details).
PBM Math: Big Chains Are Paid $23.55 To Fill a Blood Pressure Rx. Small Drugstores? $1.51.
CUTHBERT, Ga. — While customers at Adams Family Pharmacy picked up their prescriptions on a hot summer day, some stopped in for coffee, ice cream, homemade cake, or cookies.
It wasn’t a bake sale, but the sweets bring extra revenue as pharmacist and co-owner Nikki Bryant works to achieve profitability at her business on the town square.
Bryant said she is doing all she can to bolster it against a powerful force that threatens her and other independent pharmacists: the middlemen who manage virtually all prescriptions written in the U.S., called pharmacy benefit managers, or PBMs. Serving as brokers among drugmakers, pharmacies, and health insurers, these health care entities have drawn scrutiny from Congress, the Federal Trade Commission, and state legislatures for their role in the increase in drug prices.
Bryant and other independent pharmacists say PBMs not only create higher costs but also make it harder for patients to access medications. So they were hopeful about state legislation this year that would have increased their reimbursement to match the average prices paid to retail chain pharmacies through the state employee health plan. But Gov. Brian Kemp vetoed the bill.
Kemp cited a fiscal estimate that it would cost the state as much as $45 million a year and said “the General Assembly failed to fund this initiative.”
Underlining the Georgia legislative reform effort against pharmacy benefit managers was an analysis by the American Pharmacy Cooperative, which represents independent pharmacies, that reviewed the price differential paid to a north Georgia pharmacy and nearby chain stores.
The analysis early this year showed chains were paid well beyond the family business for many of the same medications: For example, the chains received an average of nearly $54 for the antidepressant bupropion, while Bell’s Family Pharmacy in Tate, Georgia, got $5.54, the analysis said. For a drug used to treat blood pressure, amlodipine, chain pharmacies received an average of $23.55, while Bell’s got $1.51.
Bell’s Family Pharmacy closed earlier this year.
“The differences in Georgia are unbelievable,” Antonio Ciaccia, who runs Ohio-based consulting firm 3 Axis Advisors. “If you’re a pharmacist, you don’t have any control over which drugs you dispense and which you don’t.”
By controlling prices and availability, pharmacy benefit managers cause patients and employers to spend more for medications, according to the Federal Trade Commission and pharmacy groups. On Sept. 20, the FTC sued three of the largest PBMs — CVS Health’s Caremark, Cigna’s Express Scripts, and UnitedHealth Group’s Optum Rx, which together control about 80% of U.S. prescription drug sales. The agency said they created a “perverse drug rebate system” that artificially inflates the price of insulin. Each company denied the allegations.
The lawsuit followed a scathing FTC report in July that said the “dominant PBMs can often exercise significant control over which drugs are available, at what price, and which pharmacies patients can use to access their prescribed medications.”
The trade group that represents PBMs, the Pharmaceutical Care Management Association, said the insulin market is working well and blamed drugmakers for historically higher prices of the medication.
Bryant and other independent pharmacists, though, say they lose money filling certain prescriptions while reimbursements favor chain pharmacies like CVS that have corporate ties to pharmacy benefit managers. And even the chain pharmacies have retrenched, with CVS, Rite Aid, and Walgreens announcing layoffs or store closures in recent months.
“PBMs are like the mafia,” Bryant said. “They pay us what they want to pay us. They are sucking all the money out of health care.”
Pharmacy benefit managers will charge some health insurance plans more for a medication than what they reimburse a pharmacy, keeping the extra money as profit, critics say. This practice is known as “spread pricing.” Large PBMs also take money from drugmakers as a “rebate” to give their drugs preferential treatment on health plans’ lists of medications, independent pharmacies say. And by favoring certain pharmacies with whom they have business ties, experts say, these drug brokers help force independent stores such as Bell’s to close.
The veto by Kemp, a Republican, came despite the GOP-led General Assembly voting overwhelmingly for Senate Bill 198 on the last day of the legislative session.
Kemp spokesperson Garrison Douglas said, “The governor remains entirely and wholeheartedly supportive of Georgia’s independent pharmacists and the need for PBM transparency.”
In his veto message, Kemp voiced support for a study of independent pharmacy drug reimbursements and PBM practices. And he said independent pharmacists are getting an extra $3 dispensing fee this year on state employee prescriptions.
The state Department of Community Health, which oversees the State Health Benefit Plan, told KFF Health News that CVS Caremark, the PBM handling the state employee business, supplied the cost estimate Kemp used to justify his veto.
Fiona Roberts, a spokesperson for Community Health, said the department didn’t have time to conduct its own analysis.
CVS Caremark said it used historical claims data to calculate the cost impact of the higher reimbursement.
Nationally, criticism of PBM practices intensified over the summer with the Federal Trade Commission report.
The Pharmaceutical Care Management Association pushed back, saying the report “is based on anecdotes and comments from anonymous sources and self-interested parties and supported only by two cherry-picked case studies that are implied to be representative of the entire market.”
Members of both parties in Congress have tackled PBM reform. House members recently introduced another proposal, known as the Pharmacists Fight Back Act, which supporters say would add transparency, limit costs for patients, ensure they get the benefit of drugmaker discounts, and protect their pharmacy choices.
The consolidation that has combined health insurers with PBMs — including their operating their own retail, mail-order, and specialty pharmacies — has created financial behemoths, said U.S. Rep. Buddy Carter, a Georgia Republican and a pharmacist. “I’m interested in busting them up,” he said.
Alexander Oshmyansky, co-founder of Mark Cuban Cost Plus Drug Company, said the PBMs siphon off about a third of the $400 billion a year spent on pharmaceuticals.
“What we could do as a society with $100 billion as opposed to paying some companies to process drug payments,” Oshmyansky said.
PCMA, the trade group, cited a report funded by the three biggest pharmacy benefit managers that said their operating margins are less than 5%.
And the group says that discussions about congressional reform “reflect a one-sided view informed directly by the pharmaceutical industry’s blame game designed to vilify PBMs to keep prescription drug prices high and increase drug company profits.”
Underpayments by PBMs, however, have accelerated the closures of mom-and-pop pharmacies across the country, said the National Community Pharmacists Association, which represents independent pharmacies.
The U.S. loses almost one such pharmacy a day, said Anne Cassity, a senior vice president of the association. Rural pharmacies, which are hard to reach for patients lacking transportation, are especially vulnerable, she said.
Bryant’s two pharmacies deliver to several counties, including to patients who have a disability or no transportation. The cost to patients: zero.
Most states have passed some version of oversight or restrictions on pharmacy benefit managers.
In Montana, state officials have collected financial reports from pharmacy benefit managers over the past two years after passing a bill to promote transparency in these businesses.
Data from 2022 shows that rebates in Montana rarely are directly returned to people buying prescriptions. Instead, they’re pocketed by the PBMs or returned to health plans.
Josh Morris, who owns three independent rural pharmacies in southwestern Montana, said his pharmacies have seen reimbursement rates for medications bought under PBM-managed plans drop.
Morris said his business routinely either breaks even or loses money. “Our plan is that once we reach a certain level of cash, that we will be out,” Morris said. “As in ‘closed.’”
Frank Cote, with Montana’s insurance commissioner’s office, said that the state has tried to make business easier for small pharmacies but that state officials still don’t control how much PBMs pay. Cote said the state will look for ways within existing rules or future legislation to support rural pharmacies.
Following Kemp’s veto in Georgia, the pharmacy pay differential sparked criticism from an unusual place: within the board of the state Department of Community Health, the agency that runs the State Health Benefit Plan.
Mark Shane Mobley, a board member, said at an August meeting that independent pharmacies’ pay in the state employee plan should be on par with a chain’s. The PBM profit “is going to line people’s pockets that are far outside of the state,” said Mobley, president of Avilys Sleep & EEG, a Georgia provider of sleep disorder and electroencephalogram testing. “Our independent pharmacies, they’re hiring people locally. They’re taking care of the local community.”
Community Health Commissioner Russel Carlson said the agency has an ongoing dialogue with CVS Caremark, the PBM handling the state employee plan medications.
“We don’t have our head in the sand. We know there are some frustrations out there that exist in this space,” he said. “But we acknowledge that we do have contractual responsibilities.”
In Cuthbert, Bryant said she can make more profit on cake and coffee than with many medications.
Still, she’s in business while a nearby CVS pharmacy closed recently. “We outcompeted them on service,” Bryant said.
Montana correspondent Katheryn Houghton and senior correspondent Arthur Allen contributed to this report.
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.
USE OUR CONTENTThis story can be republished for free (details).
A California Official Helped Save a Mental Health Company’s Contract. It Flew Him to London.
The director of California’s mental health commission traveled to London this summer courtesy of a state vendor while he was helping to prevent a $360 million budget cut that would have defunded the company’s contract.
Emails and calendars reviewed by KFF Health News show Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, made efforts to protect funding for Kooth, a London-based digital mental health company the state hired to develop a virtual tool to help tackle its youth mental health crisis. Ewing pressed key legislative staffers to maintain its contract, even as Democratic Gov. Gavin Newsom and lawmakers proposed cuts in the face of California’s $45 billion deficit.
When Ewing and three commissioners — Mara Madrigal-Weiss, the commission chair; Bill Brown; and Steve Carnevale — left for London in June, Ewing wasn’t sure whether he had saved Kooth’s funding. On the second day of their trip, staff informed him that lawmakers had restored the money.
A few days later, he emailed Kooth Chief Operating Officer Kate Newhouse suggestions he had shared with Assembly and Senate staff to improve Kooth’s youth teletherapy app. “We expect you to be involved in whatever we dream up,” Ewing wrote to Newhouse in another email.
It’s unclear why Kooth picked up a $15,000 tab for state officials to travel to London. It’s also unclear why Ewing pushed to protect its app from a spending cut. The commission is a 16-member independent body appointed by various elected officials to help ensure funds from a millionaires tax are used appropriately and effectively by counties for mental health services. Kooth’s contract is with the Department of Health Care Services, which is separate from the commission.
Kooth last year signed a four-year $271 million contract to create Soluna, a free mental health app for California users ages 13 to 25. The app, along with another, by the company Brightline, for younger users, launched in January to fill a need for young Californians and their families to access professional telehealth for free. It’s one component of Newsom’s $4.7 billion youth mental health plan.
Ewing, who reports to the commission, started in 2015 and earned $175,026 in 2023, according to The Sacramento Bee. He was placed on paid administrative leave in September pending an investigation. Commission chief counsel Sandra Gallardo said the commission does not comment on personnel matters. Ewing did not respond to requests for comment.
Three commission employees filed whistleblower complaints against Ewing in September with the California State Auditor. They spoke with KFF Health News on the condition that their names not be used due to fears of workplace retaliation. They say Ewing’s conduct advancing a private company’s agenda as a public official crossed a line.
The agenda for Thursday’s commission meeting listed a personnel matter to be discussed in closed session. The whistleblowers said Ewing is the subject of the discussion.
Madrigal-Weiss said she couldn’t comment on Ewing’s actions. However, she said the commission supports virtual mental health resources for youth.
“These resources are less expensive and have proven valuable for youth, especially those who struggle to access services in typical brick-and-mortar spaces,” said Madrigal-Weiss, who is also executive director of student wellness and school culture for the San Diego County Office of Education.
Brown and Carnevale didn’t respond to requests for comment.
Kooth is committed to advancing youth access to behavioral health services, said Caroline Curran, of Metis Communications, a public relations firm representing Kooth.
“As a leader in youth behavioral health services with over 20 years of experience in the United Kingdom and the United States, we regularly convene sector-leading organizations to facilitate learning through sharing expertise and diverse perspectives on youth behavioral health,” Curran said.
As KFF Health News reported in April, the Kooth and Brightline app rollouts have been slow, with few children using them. In May, Newsom proposed a $140 million budget cut. DHCS Director Michelle Baass said in a hearing that it was due to low use, but the state expects more users to come on board over time.
She told lawmakers on May 16 that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps, and they had been used for only about 2,800 coaching sessions.
State Sen. Caroline Menjivar (D-Van Nuys) asked Baass at the hearing whether “there’s room to get out” of the contract altogether. Senators later voted unanimously to cut the entire platform budget to save the state $360 million.
Ewing texted a colleague on June 3: “Kooth is freaking out. Is the cut coming from the Admin or the Leg.? Do we know if it’s a done deal?”
State lobbying records show Kooth has paid around $100,000 this year to the firm Capital Advocacy. At the same time, Ewing’s emails and calendars show that he pushed for Kooth’s funding to be retained. For instance, his June 4 calendar shows he was scheduled to meet with Laura Tully, an executive from Kooth USA, at a coffee shop near the Capitol.
The next day, a whistleblower said, Ewing met with key Senate staff members: Scott Ogus, deputy staff director of the Senate Budget and Fiscal Review Committee, and Marjorie Swartz, a consultant for Senate President Pro Tempore Mike McGuire. They said Ewing also discussed Kooth’s contract that week with Rosielyn Pulmano, a health policy consultant for Assembly Speaker Robert Rivas.
“Toby kept saying that ‘California has to have a digital strategy,’” recalled the whistleblower, who attended both meetings. “He kept pushing Marjorie and Scott, saying that he would give them ideas to make the platform better.”
Ewing emailed ideas to the legislative aides on June 10 and 12.
About two weeks later, he and the commissioners left for the seven-day trip to the U.K. According to documents filed with the state Fair Political Practices Commission, receipts, and emails reviewed by KFF Health News, Kooth covered the costs of four-star hotels, meals, train tickets, and international flights.
Public disclosure forms show Kooth paid expenses for Ewing, Madrigal-Weiss, and Brown. The forms do not show the company paid for Carnevale’s travel.
Under California law, state officials generally must report travel payments to the FPPC, which Ewing and his fellow commissioners did.
Kooth postponed a mental health investment conference in London in June, emails and documents show, but then organized new events for the California commissioners to attend instead.
On May 23, Newhouse informed Carnevale and Ewing in an email that Kooth needed to postpone the planned June event. Carnevale, a venture capitalist, described the news as “disappointing for all,” especially “because we have already booked trips, including family members of Commissioners who were planning to turn this into a holiday.”
Acknowledging the disruption, Newhouse told Carnevale that she “would like to think creatively as to whether we could try to arrange a meeting where you can talk about the CYBHI,” referring to Newsom’s Children and Youth Behavioral Health Initiative.
“I know though from our conversation that we need to cover the ‘purpose’ of your trip and not sure what is possible or not,” she wrote.
Curran, the Kooth spokesperson, said the company “adapted by holding a knowledge exchange between representatives from international policy institutes, research foundations, and non-profit organizations.”
Madrigal-Weiss defended the trip, which she said included meetings with “members of the government, service providers, education, and finance” who shared ideas on how “to enhance funds for public mental health needs” through private and philanthropic partnerships.
One of the whistleblowers said many of the commissioners back in California were not aware of the trip until their colleagues were halfway across the world. Sami Gallegos, a spokesperson for the California Health and Human Services Agency, said the Department of Health Care Services did not participate in the travel.
Ewing was put on leave before Kooth’s rescheduled conference this month in London.
Although it’s not unusual for state officials to travel overseas — often on the dime of private entities — it doesn’t look good, said Sean McMorris, a government ethics expert with California Common Cause, a nonprofit government watchdog group.
“It looks like undue influence,” McMorris said. “I think a lot of people would view something like this as a way to curry favor. You can connect the dots.”
Kooth has similarly gifted travel to state officials in Pennsylvania, where it had a $3 million contract with 30 school districts. In each case, Kooth invited the officials to speak to highlight their work. Pennsylvania has informed Kooth it intends to terminate the contract.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Can You Rely on Your Mammogram To Identify Heart Disease Risk?
Jackie Fortiér reported the audio story.
When people check in for their annual mammogram these days, some may face a surprising question: In addition to reviewing the mammogram for breast cancer, would the patient like the radiologist to examine the images for heart disease risk?
That’s what happened recently when a colleague visited Washington Radiology, a practice with more than a dozen locations in Washington, D.C., Maryland, and Virginia.
For $119, she was told, the practice would use artificial intelligence software to analyze her mammogram for calcification in the arteries of her breasts, which could indicate she’s at risk for cardiovascular disease.
Washington Radiology is one of a number of practices nationwide offering this type of screening. Here’s what to know about the screening and whether research supports it.
Although breast X-rays are typically used to detect and diagnose breast cancer, the pictures also indicate whether the arteries in the breast have calcifications, which show up as parallel white lines on the film. Calcifications, which are considered “incidental” findings unrelated to breast cancer, may be associated with someone’s heart disease risk. They’ve been visible on images for decades, and some radiologists have routinely noted them in their reports. But the information hasn’t typically been passed on to patients.
Now some practices make the results available to patients — sometimes for a fee.
Washington Radiology didn’t respond to interview requests, but in a video on its website describing the practice’s “Mammo+Heart” AI screening, Islamiat Ego-Osuala, a breast imaging radiologist there, said, “If the past few decades has taught us anything about the field of radiology, it is that the sky’s the limit. The possibilities are endless.”
Some imaging experts question that rosy assessment as it relates to screening for breast arterial calcification to gauge heart disease risk.
“What we’re seeing on the mammogram is calcification in the breast artery, but that’s not the same as the calcification in the coronary artery,” said Greg Sorensen, chief science officer at RadNet, which has nearly 400 imaging centers in eight states. RadNet doesn’t offer breast arterial calcification screening and has no plans to. “It doesn’t feel like it’s delivering value today,” Sorensen said.
(RadNet does offer patients an AI analysis of their mammograms to improve breast cancer detection. KFF Health News reported on that earlier this year.)
Coronary artery calcification is recognized as a strong marker of heart disease risk. But while studies have shown an association between breast arterial calcification and the risk of cardiovascular disease, questions remain.
For one thing, even women who don’t have breast arterial calcification might still be at risk of heart disease, heart attack, or stroke. In a study of postmenopausal women, 26% had breast arterial calcification, and over a 6½-year study period it was associated with a 23% increased risk of heart disease of any kind and a 51% increase in risk of heart attack or stroke. However, most cardiovascular events happened to women who did not have breast arterial calcification.
“I wouldn’t feel comfortable telling people they have a higher or lower risk of heart disease based on their breast arterial calcification,” said Sadiya Khan, a preventive cardiologist at Northwestern Medicine in Chicago who co-authored a medical journal editorial commenting on the study. “I think this is an exciting area, but we need to move cautiously.”
It’s understandable that women’s health clinicians would be eager to embrace the idea of using the annual breast cancer screening that millions of women get every year to screen for heart disease risk as well.
Heart disease is the No. 1 killer in the United States. It was responsible for more than 300,000 — or roughly 1 in 5 — women’s deaths in 2021.
Many women don’t recognize their heart disease risk or the many factors that increase it, such as high blood pressure, diabetes, high cholesterol, smoking, drinking too much alcohol, and being overweight.
Online calculators can help people assess their risk of cardiovascular disease. For those whose 10-year risk is 7.5% or higher, clinicians may recommend lifestyle changes and/or prescribe a statin to lower blood cholesterol. Laura Heacock, a radiologist who specializes in breast imaging at NYU Langone Health in New York City, pointed out that patients already can get much of the information resulting from breast arterial calcification scoring from their physicians and use of those risk calculators. The key is that breast arterial calcification screening provides another chance to talk about heart disease risk.
One study found that 57% of women who were informed that they had breast arterial calcification after a mammogram reported they had discussed their results with their primary care physician or a cardiologist.
Heacock said she’d like to see more studies showing that reporting breast arterial calcification leads to changes in patient care and fewer heart attacks and strokes.
Every woman who visits the Lynn Women’s Health and Wellness Institute in Boca Raton, Florida, for a mammogram is screened for breast arterial calcification. It’s been a standard service since 2020, said Heather Johnson, a preventive cardiologist at the center. If calcification is found, the woman is referred to a cardiologist or other health care practitioner at the center to discuss the findings and get more information about heart disease risk.
Johnson acknowledged that more studies are needed to understand the connection between calcification in breast arteries and heart disease. Still, she said, the screening “allows a communication pathway.”
Patients at the Boca Raton institute aren’t charged for the screening.
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.
USE OUR CONTENTThis story can be republished for free (details).
California Continues Progressive Policies, With Restraint, in Divisive Election Year
SACRAMENTO, Calif. — This year, Gov. Gavin Newsom affirmed abortion access, calling California “a proud reproductive freedom state” and criticizing Republicans across the country for trying to take away families’ rights.
He signed legislation mandating that insurance companies cover in vitro fertilization. He supported restricting students’ cellphone use in schools and signed a nation-leading ban on food dye in school snacks and drinks. And he endorsed a bill allowing businesses to operate Amsterdam-style cannabis cafés.
Still, in a heated election cycle with Vice President Kamala Harris, a Californian, on the presidential ticket, the Democratic governor was noticeably reluctant to impose additional industry regulations.
Newsom vetoed several health and safety bills, frequently citing cost concerns. But many of these proposals risked perpetuating California stereotypes trumpeted by presidential nominee Donald Trump and other Republicans. The governor rejected gas stove warning labels, as well as speeding alerts for new cars, even drawing tepid praise on social media from GOP Assembly leader James Gallagher, who credited Newsom for vetoing “some pretty bad/stupid bills.”
Most of the laws Newsom approved take effect Jan. 1, 2025, while some have longer phase-in times. Here are the governor’s actions on key health bills:
Health Care
Group health care service plans and disability insurance must cover infertility and fertility services under SB 729, including for LGBTQ+ people, generally starting in mid-2025. The California Association of Health Plans warns of higher premiums as a result.
Local health officers can inspect private detention facilities, including six immigration detention centers, under SB 1132.
And the governor signed AB 869, allowing small, rural, or “distressed” hospitals to get an extension of up to three years on a 2030 legal deadline for earthquake retrofits. But he vetoed SB 1432, which would have allowed all hospitals to apply for an extension of the deadline for up to five years.
Newsom also vetoed SB 966, which would have regulated the middlemen known as pharmacy benefit managers and banned some business practices that critics say increase costs and limit consumers’ choices. He also rejected AB 2467, which would have mandated health care coverage for menopause, and AB 3129, which would have required the state attorney general’s approval for transactions involving health care providers and private equity firms. And he vetoed AB 2104 and SB 895, which would have allowed some community college districts to offer bachelor’s degrees in nursing.
Medical Debt
Credit reporting agencies will be prohibited from including medical debt in consumers’ credit reports under SB 1061, but last-minute amendments weakened the protections. Earlier this year, the Biden administration proposed federal rules barring unpaid medical bills from affecting patients’ credit scores.
Medi-Cal
Medi-Cal, which provides health care for about 15 million low-income people, will cover hospital emergency rooms’ treatment of psychiatric emergencies under AB 1316.
But Newsom rejected AB 1975, which would have made medically supportive food and nutrition a Medi-Cal benefit, and AB 2339, which would have expanded Medi-Cal coverage of telehealth.
Mental Health
Newsom signed more than a dozen bills aimed at boosting behavioral health care, including through California’s new court-ordered treatment program.
But citing costs, Newsom rejected an annual scholarship fund for students pursuing a mental health profession if they worked for three years in that new treatment program. Critics say SB 26 should have broadened the scholarship to all county behavioral health programs.
Abortion
California will increase penalties for obstructing or impeding access to reproductive health care services, and for posting personal information or photographs of a patient or provider. These are currently misdemeanors; AB 2099 would make them punishable as misdemeanors or felonies.
Planned Parenthood Affiliates of California also backed AB 2085, smoothing approval of new health centers, and SB 1131, supporting California’s Family PACT (Planning, Access, Care, and Treatment) program for people with family incomes below 200% of the federal poverty level.
Aging
Newsom approved a dozen bills related to aging, including measures requiring increased training for law enforcement (AB 2541) and health care professionals (SB 639) in helping people with dementia. AB 1902 requires better access to prescription labels for those who have trouble seeing or who need translated instructions. And he signed another package of bills aimed more broadly at helping people with disabilities.
Violence Prevention
Assault or battery against a doctor, physician, nurse, or other health care worker within an ER could bring up to a year in county jail, a $2,000 fine, or both under AB 977. That makes it the same maximum punishment as for assaulting a medical worker in the field. California law previously set a lesser penalty for assault within an ER.
The state is taking more steps to deter gun violence with two dozen new laws. Among them, SB 53 increases requirements for safely storing firearms, in keeping with a push from the White House. AB 2621 will increase law enforcement training and revise policies on using gun violence restraining orders, while AB 2917 expands when courts can impose gun violence restraining orders.
And hospitals will eventually have to screen patients, family members, and visitors for weapons at entrances under AB 2975.
Substance Use
AB 1976 will require workplace first-aid kits to include naloxone or other drugs that can reverse opioid overdoses, while protecting those who administer the naloxone from civil liability.
Under AB 1775, local jurisdictions will allow retailers to sell noncannabis food and beverages and have live music and other performances in areas where cannabis consumption is allowed. Assembly member Matt Haney, a Democrat from San Francisco, said his intent is to allow Dutch-style cannabis coffeehouses. Newsom approved the measure despite vetoing Haney’s similar bill last year, amid critics’ concern that the measure would undermine California’s nation-leading effort outlawing indoor smoking.
And AB 3218 furthers enforcement of California’s ban on flavored tobacco, passed in 2020.
Youth Welfare
California is the first state to generally bar public schools from providing food containing red dye 40 or any of five other synthetic food dyes used in products including Froot Loops and Flamin’ Hot Cheetos. AB 2316 is Democratic Assembly member Jesse Gabriel’s follow-up to his legislation last year that banned a chemical found in Skittles candy.
A bill to increase transparency with the use of restraints and seclusion rooms in state-licensed short-term residential therapeutic programs became law with some high-profile help from celebrity Paris Hilton. She backed SB 1043, which will also require the state Department of Social Services to post the information on a public dashboard.
And school districts’ sex education curricula must include menstrual health under AB 2229.
But Newsom vetoed AB 2442, which would have sped licensing for providers of gender-affirming care, and SB 954, which would have provided free condoms in high schools.
Women’s Health
Selling menstrual products with intentionally added PFAS, also known as “forever chemicals,” will be banned under AB 2515. PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, have been linked to serious health problems.
AB 2319 was passed in an effort to improve enforcement of a 2019 law aimed at reducing the disproportionate rate of maternal mortality among Black women and other pregnant women of color.
AB 2527 is aimed at improving treatment of pregnant women who are incarcerated. Critics wanted the original version, which banned solitary confinement, and were upset when it was amended to allow up to five days of confinement if prison officials find a safety or security threat.
AB 518 is aimed at increasing participation in the CalFresh nutrition program, part of a package of healthy-food bills.
And under SB 1300, the public will get more notice when hospitals plan to close their maternity wards. The measure will increase the notice requirement to 120 days, up from the current 90.
But Newsom rejected AB 1895, which would have required six months’ notice to state agencies of potential maternity ward closures. The agencies would then have been required to conduct a community impact assessment.
Social Media
SB 1504 broadens California’s Cyberbullying Protection Act regulating social media platforms to apply to minors instead of pupils. Social media platforms that intentionally violate the law could face civil penalties of up to $10,000, along with compensatory and punitive damages. Those damages could be sought by a parent, a legal guardian, or various prosecutors. Under current law, damages are capped at $7,500 and may be pursued only by the state attorney general.
SB 976 restricts “addictive feeds” to minors, including banning social media notifications to minors during school hours.
And AB 3216 will limit the use of smartphones in schools.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Helene and CVS Land Double Whammy for 25,000 Patients Who Survive on IV Nutrition
The CVS representative popped into Lisa Trumble’s third-floor Berkshire Medical Center hospital room in Pittsfield, Massachusetts, to announce that everything was arranged for Trumble to return home, where she relies on IV nutrition because of severe intestinal problems that leave her unable to eat.
That was on Tuesday, Oct. 8. The next morning a social worker and a doctor woke Trumble to say her discharge was canceled. CVS would no longer provide her home nutrition, and she had to stay in the hospital. A week later, “I’m still here,” she said by telephone Wednesday. “I was dropped between Tuesday night and Wednesday morning with no care for my life or my health.”
Trumble is not the only one in crisis. She’s among 25,000 U.S. patients who depend on parenteral nutrition, or PN — IV bags containing life-sustaining amino acids, sugars, fats, vitamins, and electrolytes. Hurricane Helene wrecked a factory in North Carolina that produced 60% of the fluids their sustenance is mixed from. About two weeks later, CVS announced that its Coram division, a leading infusion pharmacy, was exiting the PN and IV antibiotics business.
The hurricane led Baxter International to ration its dwindling supplies. Pharmacies that supply Trumble and other patients like her were already plagued by shortages, and the rationing means the remaining infusion pharmacies can’t take on the customers cut off by CVS, said David Seres, director of medical nutrition at Columbia University Medical Center in New York.
At the Mayo Clinic in Rochester, Minnesota, seven or eight patients were ready to go home Tuesday but couldn’t be discharged because no infusion company would accept them, said Manpreet Mundi, a Mayo endocrinologist. The patients would fall ill within a day or two without this nutrition, he said.
Although the FDA is allowing emergency imports of IV fluids wiped out by Helene, as well as production of some of the fluids by U.S. compounding pharmacies, it’s unclear how long it will take to replenish supplies, said Mundi, who is a board member of the American Society for Parenteral and Enteral Nutrition and medical adviser to the Oley Foundation, which advocates for PN patients. “We’re trying to raise awareness that this could get worse before it gets better,” he said.
The patients who rely on PN have a variety of conditions that render them unable to digest food. Some have congenital abnormalities or disorders like Crohn’s disease that led to surgical removal of bowel sections. Others were scarred by cancer, car accidents, or gunfire, or are preemies born with underdeveloped intestines. In most patients, the fluid is pumped through a catheter into a large vein near the heart.
A crisis hit this community two years ago when CVS Health announced that it was shutting half of the 71 Coram pharmacies.
CVS, which recently announced nearly 3,000 layoffs amid reports of a possible restructuring, on Oct. 8 began telling its remaining 800 to 1,000 PN customers that they would have to find other infusion pharmacies. A news release provided to KFF Health News suggested the phaseout would last into January, but for patients like Trumble, the impact was immediate.
Highly specialized infusion medicine is “a challenging environment” for all companies “and Coram has not been immune to these challenges,” the CVS release said. “As such, we have reevaluated our service offerings.”
As far as Trumble, CVS Health spokesperson Mike DeAngelis said, “We’ll look into this matter and try to resolve it.”
It’s hard enough normally for such patients to find new suppliers for their materials, which can include 120 pounds of IV fluid per week.
Coram’s departure “made a big crisis that much worse,” Mundi said. “It’s become kind of a double whammy.”
The Baxter International North Cove plant produced most of the country’s high-concentration dextrose, a major source of energy for PN patients, as well as saline solution and sterile water, also vital supplies. A week after Helene hit, Hurricane Milton threatened sterile IV fluid supplier B. Braun Medical’s facility in Daytona Beach, Florida. The federal government helped truck 60 loads of the company’s inventory to a safe location, but the plant was spared the storm’s worst. It restarted production on Oct. 11.
That was a huge relief for Beth Gore, CEO of the Oley Foundation. She, her husband, and their six adopted children braved the storm’s seven hours of lashing wind in their home near Ruskin, Florida. Milton wrecked a car and part of the roof, but the family prayed through it all and somehow never lost power, though their neighbors did, Gore said. That kept the IV fluids fresh and the internet on, which calmed the kids.
Coram has supplied her youngest son, 15-year-old Manny, with PN for 13 years, and the family will need to find another supplier, she said.
“There’s been no relief” since Coram reduced its services in 2022, Gore said. “Now there’s this new twist.”
Her son gets care through Medicaid, whose reimbursement provides barely break-even margins for many infusion pharmacies, she said. Insurance limits, state licensing differences, and highly specific nutritional needs pose challenges for patients seeking new IV suppliers in the best of times, she said.
The FDA announced Oct. 9 that it would allow Baxter to import emergency supplies from Canada, China, Ireland, and the U.K. In the meantime, Baxter is prioritizing hospital patients over the home infusion companies — which lack backup supplies, Mundi said.
“We’re all on the phone 24/7,” said Kathleen Gura, president-elect of the American Society for Parenteral and Enteral Nutrition and pharmacy clinical research program manager at Boston Children’s Hospital. Her team is struggling to find new suppliers of IV nutrition at home for the 20 Coram patients among the 150 she sees.
“Some kids have a situation where they can’t absorb at all through their intestines and will die of dehydration if they can’t get IV,” Gura said.
The IV fluids lost in the Baxter disaster are key to all kinds of inpatient care. Many U.S. hospitals are conserving fluid by giving some patients oral hydration instead of IVs, or by delaying surgeries, said Soumi Saha, senior vice president of government affairs at Premier, which negotiates group hospital purchases.
President Joe Biden has invoked the Defense Production Act, which will enable the government to order companies to prioritize rebuilding the Baxter plant.
The military is flying in supplies from Baxter plants overseas, Saha said. Premier has also asked the FDA to put several more PN ingredients on its shortage list, which would allow large compounding facilities to produce the materials.
Ellie Rogers, 17, of Simpsonville, South Carolina, fears the worst if she can’t get her supplies. She suffers from a host of immunological and neurological ailments that require her to get four liters of IV fluid daily to stay alive, she said.
Her supplier, an Option Care Health pharmacy in South Carolina, informed the family Oct. 14 that instead of her weekly supply it was sending her enough bags for a day or two. “They really don’t know when they’re going to get what they need,” she said. Reducing the infusions in the past has led to dizziness, nausea, and pooling of her blood that “felt like my veins were going to explode.”
On Oct. 7, Crohn’s disease patient Hannah Hale’s infusion pharmacy called and said it couldn’t fill her standing weekly order of IV bags, urging her to find a new pharmacy.
“I called 14 infusion pharmacies and haven’t been able to find anyone to take me,” said the Dallas 37-year-old. She suffers from weight loss and low blood sugar, and rationing her supplies raises dangers of seizures or coma, she said.
Trumble, 52, who started on PN 13 months ago because of colon cancer and severe intestinal issues, said she’s grateful to the hospital and gets excellent care but misses her mother, son, and 8-year-old grandson, Jordan — and her cats.
What’s worse, Trumble said, her mother and son, who get Medicaid payments to care for her, haven’t been paid the two weeks she has been in the hospital.
But without IV nutrition at home, she said, “I’d starve.”
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.
USE OUR CONTENTThis story can be republished for free (details).
As Hospitals Get Bigger, Medical Debt Is Harder for Patients To Shake
If you get sick in America, there’s a good chance you’ll end up in debt. Four in 10 U.S. adults have some form of health-care debt, KFF has found.
One surprising risk: living in a community where hospitals have consolidated — an increasingly common development as health systems merge or large systems gobble up smaller hospitals.
That’s according to a new report shared exclusively with KFF Health News by the Urban Institute, a nonprofit that has been tracking medical debt across the United States for years and worked with KFF Health News on our Diagnosis: Debt project.
It’s already well-documented that hospitals raise prices when they gain market power, which can happen when systems get bigger or competitors close.
So researchers at Urban wondered if market concentration could also leave more patients in debt.
“With fewer alternatives and higher prices, patients may have limited options to seek more affordable care,” the report’s authors hypothesized. “They might delay seeking treatment, potentially leading to worse outcomes and even higher medical debt in the future.”
Making such a direct link is tricky, in part because many factors influence how much medical debt there is in a community.
Urban researchers have already established, for example, that medical debt is higher in counties with larger shares of uninsured residents and higher levels of chronic illnesses such as cancer or diabetes.
To explore the impact of consolidation, researchers first looked at hospital concentration in every U.S. county.
They then looked at credit bureau data to see the share of county residents with an unpaid medical bill on a credit report, which is one measure of medical debt in a community.
Nationally, the share of people with a medical bill on a credit report has been declining. But the researchers noticed that the declines were less pronounced in counties where hospitals had become more consolidated, even after accounting for other factors.
“While medical debt on credit reports declined across most U.S. counties between 2012 and 2022, increases in hospital market concentration prevented such improvements in many areas of the country,” they wrote.
Perhaps not surprisingly, the report drew criticism from the American Hospital Association (AHA), the industry’s largest trade group. Molly Smith, group vice president for public policy at the AHA, called it a “thin analysis” that didn’t account for more important factors driving medical debt such as the rise of high-deductible health plans.
“Until policymakers account for the real drivers in medical debt,” she said, “our country won’t be able to develop public policies that address this significant problem.”
The Urban Institute’s Breno Braga, one of the report’s authors, acknowledged that factors such as chronic illness remain stronger predictors of medical debt than market consolidation. But, he said, the new research should give policymakers another reason to scrutinize the growing market power of health systems across the country.
“Limiting hospital consolidation could be beneficial for consumers in limiting medical debt,” he said.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
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.
USE OUR CONTENTThis story can be republished for free (details).
Public Health Departments Face a Post-Covid Funding Crash
During the coronavirus pandemic, states received a rush of funding from the federal government to bolster their fight against the disease. In many cases, that cash flowed into state and local health departments, fueling a staffing surge to handle, among other things, contact tracing and vaccination efforts.
But public health leaders quickly identified a familiar boom-and-bust funding cycle as they warned about an incoming fiscal cliff once the federal grants sunset. Now, more than a year since the federal Department of Health and Human Services declared the end of the coronavirus emergency, states — such as Montana, California and Washington — face tough decisions about laying off workers and limiting public health services.
In California, Democratic Gov. Gavin Newsom proposed cutting the state’s public health funding by $300 million. And the Department of Health in Washington state slashed more than 350 positions at the end of last year and more than 200 this year.
Public health experts warn that losing staff who perform functions like disease investigation, immunization, family planning, restaurant inspection and more could send communities into crisis.
“You cannot hire the firefighters when the house is already burning,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, an organization that advocates for public health policy.
In late September, HHS Secretary Xavier Becerra declared a public health emergency for states affected by Hurricane Helene, allowing state and local health authorities in Florida, Georgia, North Carolina, South Carolina and Tennessee to more easily access federal resources. Last week, ahead of Hurricane Milton’s landfall in Florida, Becerra declared another public health emergency to aid the state’s response.
If states don’t have robust public health resources ready when disasters like this hit their communities, it can have devastating effects.
Local health department staffing grew by about 19 percent from 2019 to 2022, according to a report from the National Association of County and City Health Officials that examined 2,512 of the nation’s roughly 3,300 local departments. The same report found that half of those departments’ revenue in 2022 came from federal sources.
But in some places, the pandemic cash did little more than keep small health departments afloat. The Central Montana Health District, a public health agency serving five rural counties, received enough money to retain a staff member to help handle testing, contact tracing and rolling out the coronavirus vaccines. It wasn’t enough to hire extra workers, but it allowed officials to fill a position left empty when a staffer left the department, said Susan Woods, the district’s public health director.
Now, five full-time employees work for the health district — enough to scrape by, Woods said.
“Any kind of crisis, any kind of, God forbid, another pandemic, would probably send us crashing,” she said.
Adriane Casalotti, chief of government and public affairs for the national health officials’ group, said she expects layoffs and health department budget cuts to intensify. Those cuts come as health officials work to address issues that took a back seat in the pandemic, such as increases in rates of sexually transmitted infections, suicide and substance misuse.
And rural health departments deserve more attention, Casalotti said, as they are likely to be the most vulnerable and face compounding factors such as hospital closures and the loss of services including maternity and other women’s care.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
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.
USE OUR CONTENTThis story can be republished for free (details).
Harris Backs Slashing Medical Debt. Trump’s ‘Concepts’ Worry Advocates.
Patient and consumer advocates are looking to Kamala Harris to accelerate federal efforts to help people struggling with medical debt if she prevails in next month’s presidential election.
And they see the vice president and Democratic nominee as the best hope for preserving Americans’ access to health insurance. Comprehensive coverage that limits patients’ out-of-pocket costs offers the best defense against going into debt, experts say.
The Biden administration has expanded financial protections for patients, including a landmark proposal by the Consumer Financial Protection Bureau to remove medical debt from consumer credit reports.
In 2022, President Joe Biden also signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35-a-month cap on insulin. And in statehouses across the country, Democrats and Republicans have been quietly working together to enact laws to rein in debt collectors.
But advocates say the federal government could do more to address a problem that burdens 100 million Americans, forcing many to take on extra work, give up their homes, and cut spending on food and other essentials.
“Biden and Harris have done more to tackle the medical debt crisis in this country than any other administration,” said Mona Shah, senior director of policy and strategy at Community Catalyst, a nonprofit that has led national efforts to strengthen protections against medical debt. “But there is more that needs to be done and should be a top priority for the next Congress and administration.”
At the same time, patient advocates fear that if former President Donald Trump wins a second term, he will weaken insurance protections by allowing states to cut their Medicaid programs or by scaling back federal aid to help Americans buy health insurance. That would put millions of people at greater risk of sinking into debt if they get sick.
In his first term, Trump and congressional Republicans in 2017 tried to repeal the Affordable Care Act, a move that independent analysts concluded would have stripped health coverage from millions of Americans and driven up costs for people with preexisting medical conditions, such as diabetes and cancer.
Trump and his GOP allies continue to attack the ACA, and the former president has said he wants to roll back the Inflation Reduction Act, which also includes aid to help low- and middle-income Americans buy health insurance.
“People will face a wave of medical debt from paying premiums and prescription drug prices,” said Anthony Wright, executive director of Families USA, a consumer group that has backed federal health protections. “Patients and the public should be concerned.”
The Trump campaign did not respond to inquiries about its health care agenda. And the former president doesn’t typically discuss health care or medical debt on the campaign trail, though he said at last month’s debate he had “concepts of a plan” to improve the ACA. Trump hasn’t offered specifics.
Harris has repeatedly pledged to protect the ACA and renew expanded subsidies for monthly insurance premiums created by the Inflation Reduction Act. That aid is slated to expire next year.
The vice president has also voiced support for more government spending to buy and retire old medical debts for patients. In recent years, a number of states and cities have purchased medical debt on behalf of their residents.
These efforts have relieved debt for hundreds of thousands of people, though many patient and consumer advocates say retiring old debt is at best a short-term solution, as patients will continue to run up bills they cannot pay without more substantive action.
“It’s a boat with a hole in it,” said Katie Berge, a lobbyist for the Leukemia & Lymphoma Society. The patient group was among more than 50 organizations that last year sent letters to the Biden administration urging federal agencies to take more aggressive steps to protect Americans from medical debt.
“Medical debt is no longer a niche issue,” said Kirsten Sloan, who works on federal policy for the American Cancer Society’s Cancer Action Network. “It is key to the economic well-being of millions of Americans.”
The Consumer Financial Protection Bureau is developing regulations that would bar medical bills from consumer credit reports, which would boost credit scores and make it easier for millions of Americans to rent an apartment, get a job, or secure a car loan.
Harris, who has called medical debt “critical to the financial health and well-being of millions of Americans,” enthusiastically backed the proposed rule. “No one should be denied access to economic opportunity simply because they experienced a medical emergency,” she said in June.
Harris’ running mate, Minnesota Gov. Tim Walz, who has said his own family struggled with medical debt when he was young, signed a state law in June cracking down on debt collection.
CFPB officials said the regulations would be finalized early next year. Trump hasn’t indicated if he’d follow through on the medical debt protections. In his first term, the CFPB did little to address medical debt, and congressional Republicans have long criticized the regulatory agency.
If Harris prevails, many consumer groups want the CFPB to crack down even further, including tightening oversight of medical credit cards and other financial products that hospitals and other medical providers have started pushing on patients. These loans lock people into interest payments on top of their medical debt.
“We are seeing a variety of new medical financial products,” said April Kuehnhoff, a senior attorney at the National Consumer Law Center. “These can raise new concerns about consumer protections, and it is critical for the CFPB and other regulators to monitor these companies.”
Some advocates want other federal agencies to get involved, as well.
This includes the mammoth Health and Human Services department, which controls hundreds of billions of dollars through the Medicare and Medicaid programs. That money gives the federal government enormous leverage over hospitals and other medical providers.
Thus far, the Biden administration hasn’t used that leverage to tackle medical debt.
But in a potential preview of future actions, state leaders in North Carolina recently won federal approval for a medical debt initiative that will make hospitals take steps to alleviate patient debts in exchange for government aid. Harris praised the initiative.
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.
USE OUR CONTENTThis story can be republished for free (details).
Harris apoya la reducción de la deuda médica. Los “conceptos” de Trump preocupan a defensores.
Defensores de pacientes y consumidores confían en que Kamala Harris acelere los esfuerzos federales para ayudar a las personas que luchan con deudas médicas, si gana en las elecciones presidenciales del próximo mes.
Y ven a la vicepresidenta y candidata demócrata como la mejor esperanza para preservar el acceso de los estadounidenses a seguros de salud. La cobertura integral que limita los costos directos de los pacientes es la mejor defensa contra el endeudamiento, dicen los expertos.
La administración Biden ha ampliado las protecciones financieras para los pacientes, incluyendo una propuesta histórica de la Oficina de Protección Financiera del Consumidor (CFPB) para eliminar la deuda médica de los informes de crédito de los consumidores.
En 2022, el presidente Joe Biden también firmó la Ley de Reducción de la Inflación, que limita cuánto deben pagar los afiliados de Medicare por medicamentos recetados, incluyendo un tope de $35 al mes para la insulina. Y en legislaturas de todo el país, demócratas y republicanos han trabajado juntos de manera discreta para promulgar leyes que frenen a los cobradores de deudas.
Sin embargo, defensores dicen que el gobierno federal podría hacer más para abordar un problema que afecta a 100 millones de estadounidenses, obligando a muchos a trabajar más, perder sus hogares y reducir el gasto en alimentos y otros artículos esenciales.
“Biden y Harris han hecho más para abordar la crisis de deuda médica en este país que cualquier otra administración”, dijo Mona Shah, directora senior de política y estrategia en Community Catalyst, una organización sin fines de lucro que ha liderado los esfuerzos nacionales para fortalecer las protecciones contra la deuda médica. “Pero hay más por hacer y debe ser una prioridad para el próximo Congreso y administración”.
Al mismo tiempo, los defensores de los pacientes temen que si el ex presidente Donald Trump gana un segundo mandato, debilitará las protecciones de los seguros permitiendo que los estados recorten sus programas de Medicaid o reduciendo la ayuda federal para que los estadounidenses compren cobertura médica. Eso pondría a millones de personas en mayor riesgo de endeudarse si enferman.
En su primer mandato, Trump y los republicanos del Congreso intentaron en 2017 derogar la Ley de Cuidado de Salud a Bajo Precio (ACA), un movimiento que, según analistas independientes, habría despojado de cobertura médica a millones de estadounidenses y habría aumentado los costos para las personas con afecciones preexistentes, como diabetes y cáncer.
Trump y sus aliados del Partido Republicano continúan atacando a ACA, y el ex presidente ha dicho que quiere revertir la Ley de Reducción de la Inflación, que también incluye ayuda para que los estadounidenses de bajos y medianos ingresos compren seguros de salud.
“Las personas enfrentarán una ola de deuda médica por pagar primas y precios de medicamentos recetados”, dijo Anthony Wright, director ejecutivo de Families USA, un grupo de consumidores que ha apoyado las protecciones federales de salud. “Los pacientes y el público deberían estar preocupados”.
La campaña de Trump no respondió a consultas sobre su agenda de salud. Y el ex presidente no suele hablar de atención médica o deuda médica en la campaña, aunque dijo en el debate del mes pasado que tenía “conceptos de un plan” para mejorar la ACA. Trump no ha ofrecido detalles.
Harris ha prometido repetidamente proteger ACA y renovar los subsidios ampliados para las primas mensuales del seguro creados por la Ley de Reducción de la Inflación. Esa ayuda está programada para expirar el próximo año.
La vicepresidenta también ha expresado su apoyo a un mayor gasto gubernamental para comprar y cancelar deudas médicas antiguas de los pacientes. En los últimos años, varios estados y ciudades han comprado deuda médica en nombre de sus residentes.
Estos esfuerzos han aliviado la deuda de cientos de miles de personas, aunque muchos defensores dicen que cancelar deudas antiguas es, en el mejor de los casos, una solución a corto plazo, ya que los pacientes seguirán acumulando facturas que no pueden pagar sin una acción más sustantiva.
“Es un bote con un agujero”, dijo Katie Berge, una cabildera de la Sociedad de Leucemia y Linfoma. Este grupo de pacientes fue una de más de 50 organizaciones que el año pasado enviaron cartas a la administración Biden instando a las agencias federales a tomar medidas más agresivas para proteger a los estadounidenses de la deuda médica.
“La deuda médica ya no es un problema de nicho”, dijo Kirsten Sloan, quien trabaja en política federal para la Red de Acción contra el Cáncer de la Sociedad Americana de Cáncer. “Es clave para el bienestar económico de millones de estadounidenses”.
La Oficina de Protección Financiera del Consumidor está desarrollando regulaciones que prohibirían que las facturas médicas aparezcan en los informes de crédito de los consumidores, lo que mejoraría los puntajes crediticios y facilitaría que millones de estadounidenses alquilen una vivienda, consigan un trabajo o consigan un préstamo para un automóvil.
Harris, quien ha calificado la deuda médica como “crítica para la salud financiera y el bienestar de millones de estadounidenses”, apoyó con entusiasmo la propuesta de regulación. “No se debería privar a nadie del acceso a oportunidades económicas simplemente porque experimentó una emergencia médica”, dijo en junio.
El compañero de fórmula de Harris, el gobernador de Minnesota, Tim Walz, quien ha dicho que su propia familia luchó con la deuda médica cuando era joven, firmó en junio una ley estatal que reprime el cobro de deudas.
Los funcionarios de la CFPB dijeron que las regulaciones se finalizarán a principios del próximo año. Trump no ha indicado si seguiría adelante con las protecciones contra la deuda médica. En su primer mandato, la CFPB hizo poco para abordarla, y los republicanos en el Congreso han criticado durante mucho tiempo a la agencia reguladora.
Si Harris gana, muchos grupos de consumidores quieren que la CFPB refuerce aún más las medidas, incluyendo una mayor supervisión de las tarjetas de crédito médicas y otros productos financieros que los hospitales y otros proveedores médicos han comenzado a ofrecer a los pacientes. Por estos préstamos, las personas están obligadas a pagar intereses adicionales sobre su deuda médica.
“Estamos viendo una variedad de nuevos productos financieros médicos”, dijo April Kuehnhoff, abogada senior del Centro Nacional de Derecho del Consumidor. “Estos pueden generar nuevas preocupaciones sobre las protecciones al consumidor, y es fundamental que la CFPB y otros reguladores supervisen a estas empresas”.
Algunos defensores quieren que otras agencias federales también se involucren.
Esto incluye al enorme Departamento de Salud y Servicios Humanos (HHS), que controla cientos de miles de millones de dólares a través de los programas de Medicare y Medicaid. Ese dinero otorga al gobierno federal una enorme influencia sobre los hospitales y otros proveedores médicos.
Hasta ahora, la administración Biden no ha utilizado esa influencia para abordar la deuda médica.
Pero en un posible anticipo de futuras acciones, los líderes estatales en Carolina del Norte recientemente obtuvieron la aprobación federal para una iniciativa de deuda médica que obligará a los hospitales a tomar medidas para aliviar las deudas de los pacientes a cambio de ayuda gubernamental. Harris elogió la iniciativa.
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.
USE OUR CONTENTThis story can be republished for free (details).
California Hospitals Scramble on Earthquake Retrofits as State Limits Extensions
More than half of the 410 hospitals in California have at least one building that likely wouldn’t be able to operate after a major earthquake hit their region, and with many institutions claiming they don’t have the money to meet a 2030 legal deadline for earthquake retrofits, the state is now granting relief to some while ramping up pressure on others to get the work done.
Gov. Gavin Newsom in September vetoed legislation championed by the California Hospital Association that would have allowed all hospitals to apply for an extension of the deadline for up to five years. Instead, the Democratic governor signed a more narrowly tailored bill that allows small, rural, or “distressed” hospitals to get an extension of up to three years.
“It’s an expensive thing and a complicated thing for hospitals — independent hospitals in particular,” said Elizabeth Mahler, an associate chief medical officer for Alameda Health System, which serves Northern California’s East Bay and is undertaking a $25 million retrofit of its hospital in Alameda, on an island beside Oakland.
The debate over how seismically safe California hospitals should be dates to the 1971 Sylmar quake near Los Angeles, which prompted a law requiring new hospitals to be built to withstand an earthquake and continue operating. In 1994, after the magnitude 6.7 Northridge quake killed at least 57 people, lawmakers required existing facilities to be upgraded.
The two laws have left California hospitals with two sets of standards to meet. The first — which originally had a deadline of 2008 but was pushed to 2020 — required hospital buildings to stay standing after an earthquake. About 20 facilities have yet to meet that requirement for at least one of their buildings, although some have received extensions from the state.
Many more — 674 buildings, spread across 251 licensed hospitals — do not meet the second set of standards, which require hospital facilities to remain functional in the event of a major earthquake. That work is supposed to be done by 2030.
“The importance of it is hard to argue with,” said Jonathan Stewart, a professor at UCLA’s Samueli School of Engineering, citing a 2023 earthquake in Turkey that damaged or destroyed multiple hospitals. “There were a number of hospitals that were intact but not usable. That’s better than a collapsed structure. But still not what you need at a time of emergency like that.”
The influential hospital industry has unsuccessfully lobbied lawmakers for years to extend the 2030 deadline, though the state has granted various extensions to specific facilities. Newsom’s signature on one of the three bills addressing the issue this year represents a partial victory for the industry.
Hospital administrators have long complained about the steep cost of seismic retrofits.
“While hospitals are working to meet these requirements, many will simply not make the 2030 deadline and be forced by state law to close,” wrote Carmela Coyle, president and CEO of the California Hospital Association, in a letter to Newsom before he vetoed the CHA bill. A 2019 Rand Corp. study paid for by the CHA pinned the price of meeting the 2030 standards at between $34 billion and $143 billion statewide.
Labor unions representing nurses and other medical workers, however, say the hospitals have had plenty of time to get their buildings into compliance, and that most have the money to do so.
“They’ve had 30 years to do this,” Cathy Kennedy, a nurse in Roseville and one of the presidents of the California Nurses Association, said in an interview prior to the governor’s action. “We are kicking the can down the road year after year, and unfortunately, lives are going to be lost.”
In his veto message on the CHA bill, Newsom wrote that a blanket five-year extension wasn’t justified, and that any extension “should be limited in scope, granted only on a case-by-case basis to hospitals with demonstrated need and a clear path to compliance, and in combination with strong accountability and enforcement mechanisms.”
He also vetoed a bill directed specifically at helping several hospitals operated by Providence, a Catholic hospital chain.
But he signed a third bill, which allows small, rural, and “critical access” hospitals, and some others, to apply for a three-year extension, and directs the Department of Health Care Access and Information to offer them “technical assistance” in meeting the deadline.
The state designates 37 hospitals as providing “critical access,” while 56 are considered “small,” meaning they have fewer than 50 beds, 59 are considered “rural,” and 32 are “district” hospitals, meaning they are funded by special government entities called “health care districts.” They can seek a three-year extension as long as they submit a seismic compliance plan and identify milestones for implementing it.
Debi Stebbins, executive director of the Alameda Health Care District, which owns the Alameda Hospital buildings, said small hospitals face a big challenge. Even though Alameda is very close to San Francisco and Oakland, the tunnels, bridges, and ferries that connect it to the mainland could easily be shut in an emergency, making the island’s hospital a lifeline.
“It’s an unfunded mandate,” Stebbins said of the state’s 2030 deadline.
The Rand study estimated the average cost of a retrofit at more than $92 million per building, but the amount could vary greatly depending on whether it’s a building that houses hospital beds.
Small and rural hospitals can get some aid from the state via grants financed by the California Electronic Cigarette Excise Tax, but HCAI spokesperson Andrew DiLuccia said it would yield just $2-3 million total annually. He added that the Small and Rural Hospital Relief Program has also received a one-time infusion of $50 million from a tax on health insurers to help with the seismic work.
Labor unions and critics of the extensions often point to the large profits that some hospitals reap: A California Health Care Foundation report published in August found that California’s hospitals made $3.2 billion in profit during the first quarter of 2024. The study notes that there “continues to be wide variation in financial performance among hospitals, with the bottom quartile showing a net income margin of -5%, compared to +13% for the top quartile.”
Stebbins has had to help her district figure out a plan.
After Newsom vetoed a bill in 2022 that would have granted an extension on the seismic retrofit deadline specifically for Alameda Hospital, the hospital system and its partner health care district used parcel tax money to help back a loan.
The cost to retrofit will be about $25 million, and the system is also investing millions more into other projects, such as a new skilled nursing facility. The construction work is set to be completed in 2027.
“No one wants things crashing in an earthquake or anything else, but at the same time, it’s a burden,” Mahler, the Alameda Health System associate chief medical officer, said. “How do we make sure that they get what they need to stay open?”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Cash Shortages and Complex Rules Impede Native American Health-Care Access
Each year, the Indian Health Service rejects tens of thousands of requests to fund outside care that it doesn’t provide, forcing patients to go without treatment or pay big medical bills themselves.
The IHS is supposed to provide free care to Native Americans, but it does so only at scattered clinics and hospitals the agency funds and then manages or turns over to tribes to operate. Many of those are in rural areas and offer limited services. They might not provide cancer treatment or pregnancy care, for example.
That’s where the agency’s Purchased/Referred Care program is supposed to come in.
But funding shortages, complex rules and administrative fumbles impede access to the program, my colleague Katheryn Houghton and I reported after speaking with patients, elected officials and people who work with the federal agency.
Native Americans qualify for the referred-care program if they live on tribal land — only 13 percent do — or within their tribe’s “delivery area,” which usually includes surrounding counties. Those who live in another delivery area are eligible in some cases.
Jonni Kroll, a member of the Little Shell Tribe of Chippewa Indians of Montana, doesn’t qualify, because she lives in Washington state, nearly 400 miles from her tribe’s headquarters.
Tying program eligibility to tribal lands, Kroll said, echoes old government policies meant to keep Indigenous people in one place, even if it means reduced access to jobs, education and health care.
“What do we do? Sell our homes, leave our families and our jobs?” she said.
What about eligible Native Americans? They aren’t guaranteed funding or timely help. Some of the IHS’s 170 units exhaust their annual pool of referred-care funding or reserve it for the most serious medical concerns.
In fiscal 2022, for example, the program denied or deferred nearly $552 million in spending for about 120,000 requests from eligible patients.
Connie Brushbreaker, a member of the Rosebud Sioux Tribe in South Dakota, has been denied or wait-listed for funding at least 14 times since 2018. In March, she received a letter saying her referred-care program is reserved for patients at imminent risk of dying. It doesn’t make sense to her that the agency refuses to pay for treatment that will be approved once a health problem becomes more serious and expensive.
Another obstacle is the estimated 34 percent of program staffing positions that are vacant.
Multiple patients told us that staff rarely pick up the phone or return messages, or that they share confusing information about eligibility and the application process.
Brendan White, an agency spokesperson, said improving the referred-care program is a top IHS goal. He said about 83 percent of the health units it manages have approved all eligible funding requests this year.
The agency is tackling staff shortages and recently improved how funding is prioritized, he said. The IHS is also studying whether it can afford to create statewide eligibility in the Dakotas.
But many advocates say the only way to improve the referred-care program is to fully fund it — or even better, fully fund the IHS so patients don’t need as much outside care in the first place.
This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.
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.
USE OUR CONTENTThis story can be republished for free (details).
Happening in Springfield: New Immigrants Offer Economic Promise, Health System Challenges
When Republican vice presidential candidate JD Vance claimed Haitian immigrants had caused infectious-disease rates to “skyrocket” in Springfield, Ohio, local health commissioner Chris Cook checked the records.
They showed that in 2023, for example, there were four active tuberculosis cases in Clark County, which includes Springfield, up from three in 2022. HIV cases had risen, but sexually transmitted illnesses overall were decreasing.
“I wouldn’t call it skyrocketing,” said Cook, noting that there were 190 active cases in 2023 in all of Ohio. “You hear the rhetoric. But as a whole, reportable infectious diseases to the health department are decreasing.”
Tensions are running high in this industrial town of about 58,000 people. Bomb threats closed schools and public buildings after GOP presidential nominee Donald Trump falsely claimed that Haitian immigrants — who he alleged were there illegally — were stealing and eating household pets. City and county officials disputed the claims the former president levied during his Sept. 10 debate with Vice President Kamala Harris, his Democratic opponent.
Trump was amplifying comments made by Vance that — along with his claims about the immigration status of this population — were broadly panned as false. When asked during a CNN interview about the debunked pet-eating rumor, Vance, a U.S. senator from Ohio, acknowledged that the image he created was based not on facts but on “firsthand accounts from my constituents.” He said he was willing “to create” stories to focus attention on how immigration can overrun communities.
But Ohio Gov. Mike DeWine, also a Republican, has said immigrants have been an economic boon to Springfield. Many began arriving because businesses in the town, which had seen its population decrease, needed labor.
Largely lost in the political rancor is the way Springfield and the surrounding area responded to the influx of Haitian immigrants. Local health institutions tried to address the needs of this new population, which had lacked basic public health care such as immunization and often didn’t understand the U.S. health system.
The town is a microcosm of how immigration is reshaping communities throughout the United States. In the Springfield area, Catholic charities, other philanthropies, volunteers, and county agencies have banded together over the past three to four years to tackle the challenge and connect immigrants who have critical health needs with providers and care.
For instance, a community health center added Haitian Creole interpreters. The county health department opened a refugee health testing clinic to provide immunizations and basic health screenings, operating on such a shoestring budget that it’s open only two days a week.
And a coalition of groups to aid the Haitian community was created about two years ago to identify and respond to immigrant community needs. The group meets once a month with about 55 or 60 participants. On Sept. 18, about a week after Trump ramped up the furor at the debate, a record 138 participants joined in.
“We have all learned the necessity of collaboration,” said Casey Rollins, director of Springfield’s St. Vincent de Paul, a nonprofit Catholic social services organization that has become a lifeline for many of the town’s Haitian immigrants. “There’s a lot of medical need. Many of the people have high blood pressure, or they frequently have diabetes.”
Several factors have led Haitians to leave their Caribbean country for the United States, including a devastating earthquake in 2010, political unrest after the 2021 assassination of Haiti’s president, and ongoing gang violence. Even when health facilities in the country are open, it can be too treacherous for Haitians to travel for treatment.
“The gangs typically leave us alone, but it’s not a guarantee,” said Paul Glover, who helps oversee the St. Vincent’s Center for children with disabilities in Haiti. “We had a 3,000-square-foot clinic. It was destroyed. So was the X-ray machine. People have been putting off health care.”
An estimated 12,000 to 15,000 Haitian immigrants live in Clark County, officials said. About 700,000 Haitian immigrants lived in the United States in 2022, according to U.S. Census data.
Those who have settled in the Springfield area are generally in the country legally under a federal program that lets noncitizens temporarily enter and stay in the United States under certain circumstances, such as for urgent humanitarian reasons, according to city officials.
The influx of immigrants created a learning curve for hospitals and primary care providers in Springfield, as well as for the newcomers themselves. In Haiti, people often go directly to a hospital to receive care for all sorts of maladies, and county officials and advocacy groups said many of the immigrants were unfamiliar with the U.S. system of seeing primary care doctors first or making appointments for treatment.
Many sought care at Rocking Horse Community Health Center, a nonprofit, federally qualified health center that provides mental health, primary, and preventive care to people regardless of their insurance status or ability to pay. Federally qualified health centers serve medically underserved areas and populations.
The center treated 410 patients from Haiti in 2022, up more than 250% from 115 in 2021, according to Nettie Carter-Smith, the center’s director of community relations. Because the patients required interpreters, visits often stretched twice as long.
Rocking Horse hired patient navigators fluent in Haitian Creole, one of the two official languages of Haiti. Its roving purple bus provides on-site health screenings, vaccinations, and management of chronic conditions. And this school year, it’s operating a $2 million health clinic at Springfield High.
Many Haitians in Springfield have reported threats since Trump and Vance made their town a focus of the campaign. Community organizations were unable to identify any immigrants willing to be interviewed for this story.
Hospitals have also felt the impact. Mercy Health’s Springfield Regional Medical Center also saw a rapid influx of patients, spokesperson Jennifer Robinson said, with high utilization of emergency, primary care, and women’s health services.
This year, hospitals also have seen several readmissions for newborns struggling to thrive as some new mothers have trouble breastfeeding or getting supplemental formula, county officials said. One reason: New Haitian immigrants must wait six to eight weeks to get into a program that provides supplemental food for low-income pregnant, breastfeeding, or non-breastfeeding postpartum women, as well as for children and infants.
At Kettering Health Springfield, Haitian immigrants come to the emergency department for nonemergency care. Nurses are working on two related projects, one focusing on cultural awareness for staff and another exploring ways to improve communication with Haitian immigrants during discharge and in scheduling follow-up appointments.
Many of the immigrants are able to get health insurance. Haitian entrants generally qualify for Medicaid, the state-federal program for the low-income and disabled. For hospitals, that means lower reimbursement rates than with traditional insurance.
During 2023, 60,494 people in Clark County were enrolled in Medicaid, about 25% of whom were Black, according to state data. That’s up from 50,112 in 2017, when 17% of the enrollees were Black. That increase coincides with the rise of the Haitian population.
In September, DeWine pledged $2.5 million to help health centers and the county health department meet the Haitian and broader community’s needs. The Republican governor has pushed back on the recent national focus on the town, saying the spread of false rumors has been hurtful for the community.
Ken Gordon, a spokesperson for the Ohio Department of Health, acknowledged the difficulties Springfield’s health systems have faced and said the department is monitoring to avert potential outbreaks of measles, whooping cough, and even polio.
People diagnosed with HIV in the county increased from 142 residents in 2018 to 178 to 2022, according to state health department data. Cook, the Clark County health commissioner, said the data lags by about 1.5 years.
But Cook said, “as a whole, all reportable infections to the health department are not increasing.” Last year, he said, no one died of tuberculosis. “But 42 people died of covid.”
Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.
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.
USE OUR CONTENTThis story can be republished for free (details).
Some Employers Test Arrangement To Give Workers Allowance for Coverage
Dave Lantz is no stranger to emergency department or doctor bills. With three kids in their teens and early 20s, “when someone gets sick or breaks an arm, all of a sudden you have thousand-dollar medical bills,” Lantz said.
The family’s health plan that he used to get as the assistant director of physical plant at Lycoming College, a small liberal arts school in central Pennsylvania, didn’t start to cover their costs until they had paid $5,600 in medical bills. The Lantzes were on the hook up to that annual threshold. The high-deductible plan wasn’t ideal for the family of five, but it was the only coverage option available to them.
Things are very different now. In mid-2022, the college ditched its group health plan and replaced it with a new type of plan — an individual coverage health reimbursement arrangement, or ICHRA.
Now Lantz gets a set amount from his employer every month that he puts toward a family plan on the individual insurance market. He opted for a zero-deductible plan with a richer level of coverage than the group plan. Though its $790 monthly premium is higher than the $411 he used to pay, he ends up saving money overall by not having to pay down that big deductible. Plus, he now has more control over his health spending.
“It’s nice to have the choice to balance the high deductible versus the higher premium,” Lantz said. Before, “it was tough to budget for that deductible.”
As health insurance costs continue to rise, employers are eyeing this type of health reimbursement arrangement to control their health care spending while still providing a benefit that workers value. Some consumer advocates are concerned the plans could result in skimpier, pricier coverage for certain consumers, especially sicker, older ones.
The plans allow employers to make tax-preferred contributions to employees to use to buy coverage on the individual market. Employers thus limit their financial exposure to rising health care costs. Everybody wins, say backers of the plans, which were established in 2019 as part of a group of proposals the Trump administration said would increase health insurance choice and competition.
“It’s a way to offer coverage to more diverse employee groups than ever before and set a budget that controls costs for the companies,” said Robin Paoli, executive director of the HRA Council, an advocacy group.
Some health insurance specialists say the plans aren’t necessarily a good option for consumers or the individual insurance market. Even though the rules prevent employers from offering this type of coverage to specific workers who may be sicker and more expensive to cover than others, employers with relatively unhealthy workforces may find the arrangements appealing. This, in turn, may drive up premiums in the individual market, according to an analysis by the University of Southern California-Brookings Schaeffer Initiative for Health Policy.
Plans sold on the individual market often have smaller provider networks and higher deductibles than employer-sponsored coverage. Premiums are often higher than for comparable group coverage. Workers, especially lower-wage ones, might be better off financially with premium tax credits and cost-sharing reductions to buy an Affordable Care Act marketplace plan, but using the work-based ICHRA benefit would disqualify them.
“From a worker perspective, the largest impact is that being offered affordable coverage by your employer makes you ineligible for marketplace subsidies,” said Matthew Fiedler, a senior fellow at the Brookings Institution who co-authored the analysis of the rule establishing the plans.
The plans are currently offered to only a tiny slice of workers: an estimated 500,000 of the roughly 165 million people with employer-sponsored coverage, according to the HRA Council. But interest is growing. The number of employers offering ICHRAs and an earlier type of plan, called qualified small-employer HRAs, increased 29% from 2023 to 2024, according to the council. And, although small employers have made up the bulk of adopters to date, larger employers with at least 50 workers are the fastest-growing cohort.
Individual market insurers like Oscar Health and Centene see opportunities to expand their footprint through the plans. Some venture capitalists are touting them as well.
“The [traditional group] health insurance cornerstone from 60 years ago has outlived its usefulness,” said Matt Miller, whose Headwater Ventures has invested in the ICHRA administrator Venteur. “The goal is to ensure people have coverage, detaching it from the employment construct and making it portable.”
Employers can offer this type of health reimbursement arrangement to some classes of employees and group plans to others based on characteristics such as geography, full-time vs. part-time status, or salaried vs. hourly pay.
Lycoming College wasn’t aiming to be on the cutting edge when it made this coverage switch. Faced with a 60% premium increase after some members had high claims, the school, which covers roughly 400 faculty and staff and their family members, needed to look at alternatives, said Kacy Hagan, its associate vice president for human resources and compliance.
In the end, they opted to offer ICHRA coverage to any employee who worked at least 30 hours a week.
In the first year of offering the new benefit, the college saved $1.4 million in health care costs over what they would have spent if they’d stayed with its group plan. Employees saved an average of $1,200 each in premiums.
“The finance folks really like it,” Hagan said. As for employees, “from a cost standpoint, people tend to be pretty happy with it, and people really like having a choice of plans,” she said. However, there have been issues with the plan’s administration. Some employees’ coverage was dropped and had to be reinstated, she said. Those problems have been largely resolved since they switched plan administrators this year.
This coverage arrangement can be complicated to manage. Instead of a company paying one group health plan premium, dozens of individual health insurers may need to be paid. And employees who’ve never shopped for a plan before need help figuring out what coverage works for them and signing up.
The complexity can be off-putting. This year, a number of companies that have tried this type of health reimbursement arrangement decided they’d rather go back to a group plan, said Tim Hebert, managing partner of Sage Benefit Advisors, based in Fort Collins, Colorado.
“They say, ‘Employees are all over the place in different plans, and they don’t feel like they’re being taken care of,’” Hebert said.
Vendors continue to crop up to help employers like Lycoming College and their workers manage their plans.
“If you just say, ‘Here’s $1,000,’ it’s extremely discombobulating and confusing,” said Jack Hooper, CEO of Take Command Health, which now administers the Lycoming ICHRA.
It’s unclear whether the plans will take off or remain a niche product.
“It’s a big disrupter, like 401(k)s,” said Mark Mixer, board chair of the HRA Council and CEO of HealthOne Alliance in Dalton, Georgia. Still, it’s not for everyone. “It’s simply another tool that employers should consider. When it fits, do it.”
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.
USE OUR CONTENTThis story can be republished for free (details).