En abril, cuando apenas llevaba 12 semanas de embarazo, Kathleen Clark estaba en la recepción de su ginecólogo-obstetra cuando le pidieron que pagara $960, el total que la consulta calculaba que tendría que pagar después del parto.

Clark, de 39 años, se sorprendió de que le pidieran pagar esa cantidad en su segunda visita prenatal. Normalmente, las pacientes reciben la factura después que el seguro haya pagado su parte, y en el caso de las embarazadas eso suele ocurrir cuando termina el embarazo. Pasarían meses antes de que la consulta presentara el reclamo a su seguro médico.

Clark dijo que se sintió atrapada. La consulta de obstetricia de Cleveland, Tennessee, estaba asociada a un centro de maternidad donde ella quería dar a luz. Además, ella y su marido llevaban mucho tiempo deseando tener un hijo. Y Clark se sentía especialmente sensible porque unas semanas antes había muerto su madre.

“Estás ahí, en la ventanilla, rodeada de gente, y tratas de ser lo más amable posible”, recordó Clark, entre lágrimas. “Así que lo pagué”.

En las comunidades sobre bebés en internet y en otros foros de las redes sociales, las embarazadas afirman que sus proveedores les piden que paguen antes de lo previsto. La práctica es legal, pero los defensores de los pacientes la califican de poco ética. Los médicos alegan que pedir el pago por adelantado les garantiza una compensación por sus servicios.

Es difícil saber con qué frecuencia ocurre porque se considera una transacción privada entre el proveedor y el paciente. Por lo tanto, los pagos no se registran en los datos de reclamos de seguros y, por ende, los expertos no los analizan.

Pacientes, expertos en facturación médica y activistas afirman que esta práctica de facturación provoca una ansiedad inesperada en un momento de estrés y presión financiera ya de por sí elevados. En ocasiones, las estimaciones pueden ser superiores a lo que el paciente deba en última instancia y obligan a las personas a luchar por un reembolso si la cantidad abonada era superior a la factura final.

Los pagos por adelantado también ponen trabas a las mujeres que quieran cambiar de proveedor si no están satisfechas con la atención. En algunos casos, pueden hacer que las mujeres renuncien por completo a la atención prenatal, sobre todo en lugares donde existen pocas opciones de atención materna.

Es como “secuestrar el tratamiento”, afirmó Caitlin Donovan, directora de la Patient Advocate Foundation.

Expertos en facturación médica y salud de la mujer creen que las consultas de ginecología y obstetricia adoptaron esta práctica para gestionar el elevado costo de la atención materna y la forma en que se factura en Estados Unidos.

Cuando un embarazo llega a término, los ginecólogos y obstetras suelen presentar un único reclamo al seguro por los cuidados prenatales rutinarios, el trabajo de parto, el parto y, a menudo, la atención posparto. Esta práctica de agrupar toda la atención materna en un único código de facturación comenzó hace tres décadas, según Lisa Satterfield, directora de salud y política de pagos del American College of Obstetricians and Gynecologists. Sin embargo, la facturación agrupada ha quedado obsoleta.

Antes, las pacientes embarazadas estaban sujetas a copagos por cada visita prenatal, lo que podía llevarlas a saltarse citas cruciales para ahorrar dinero. Pero ahora la Ley de Cuidado de Salud a Bajo Precio (ACA) exige que todas las aseguradoras comerciales cubran íntegramente determinados servicios prenatales. Además, cada vez es más frecuente que las embarazadas cambien de proveedor o que diferentes proveedores se encarguen de la atención prenatal y el parto, sobre todo en las zonas rurales, donde son frecuentes los traslados de pacientes.

Algunos proveedores afirman que los pagos por adelantado les permiten repartir los pagos únicos a lo largo del embarazo para asegurarse de que se los compensa por la atención que prestan, aunque finalmente no atiendan el parto.

“Desgraciadamente hay personas que no cobran por su trabajo”, afirmó Pamela Boatner, partera en un hospital de Georgia.

Aunque cree que las mujeres deben recibir atención durante el embarazo independientemente de su capacidad de pago, también entiende que algunos proveedores quieran asegurarse de que no se ignora su factura después de que nazca el bebé. Los nuevos padres pueden verse desbordados por las facturas del hospital y los costos de cuidar a un nuevo hijo, y pueden no tener ingresos suficientes si uno de los progenitores no trabaja, explicó Boatner.

En Estados Unidos, tener un bebé puede resultar caro. Las personas que están cubiertas por un seguro médico a través de grandes empresas pagan un promedio de unos $3.000 de su bolsillo por los cuidados durante el embarazo, el parto y el posparto, según el Peterson-KFF Health System Tracker. Además, muchos optan por planes médicos con deducibles elevados, lo que les obliga a asumir una mayor parte de los costos. De los 100 millones de estadounidenses con deudas médicas, el 12% atribuye al menos parte de ellas a los cuidados de maternidad, según una encuesta de KFF de 2022.

Las familias necesitan tiempo para ahorrar y poder así hacer frente a los elevados costos del embarazo, el parto y el cuidado de los hijos, en especial si no tienen licencia por maternidad remunerada, dijo Joy Burkhard, CEO del Policy Center for Maternal Mental Health, un think tank con sede en Los Angeles. Pedirles que paguen por adelantado “es un golpe bajo”, agregó. “¿Y si no tienes dinero? ¿Lo cargas a tarjetas de crédito y esperas que funcione?”.

Calcular los costos finales del parto depende de múltiples factores, como el momento del embarazo, las prestaciones del plan y las complicaciones de salud, afirmó Erin Duffy, investigadora de políticas de salud del Centro Schaeffer de Política y Economía de la Salud de la Universidad del Sur de California. La factura final para la paciente no está clara hasta que el plan de salud decide qué parte cubrirá, explicó.

Pero a veces se elimina la opción de esperar a la aseguradora.

Durante el primer embarazo de Jamie Daw, en 2020, su ginecólogo-obstetra aceptó su negativa a pagar por adelantado porque Daw quería ver la factura final. Pero en 2023, durante su segundo embarazo, en una consulta privada de obstetricia de Nueva York le dijeron que, como tenía un plan con deducible alto, era obligatorio pagar $2.000, en pagos mensuales.

Daw, investigadora de políticas de salud en la Universidad de Columbia, dio a luz en septiembre de 2023 y recibió un cheque de reembolso ese noviembre por $640 para cubrir la diferencia entre la estimación y la factura final.

“Yo me dedico a estudiar los seguros de salud”, dijo. “Pero una no se imagina lo enormemente complicado que es cuando lo vives en persona”.

Aunque ACA obliga a las aseguradoras a cubrir algunos servicios prenatales, no prohíbe a los proveedores enviar la factura final a los pacientes antes de tiempo. Sería un reto político y práctico para los gobiernos estatales y federal intentar regular el momento de la solicitud de pago, señaló Sabrina Corlette, codirectora del Centro de Reformas de Seguros de Salud de la Universidad de Georgetown. Los grupos de presión médicos son poderosos y los contratos entre aseguradoras y proveedores médicos están protegidos por derechos de propiedad intelectual.

Debido a la zona gris legal, Lacy Marshall, corredora de seguros de Rapha Health and Life en Texas, aconseja a sus clientes que pregunten a la aseguradora si pueden negarse a pagar por adelantado su deducible. Algunos planes prohíben a los proveedores de su red exigir el pago por adelantado.

Si la aseguradora les dice que pueden negarse a pagar por adelantado, Marshall les recomienda a los clientes establecer una relación con una consulta antes de negarse a pagar, de modo que el proveedor no pueda rechazar el tratamiento.

Clark dijo que alcanzó el deducible de su seguro después de pagar las pruebas genéticas, las ecografías adicionales y otros servicios con su cuenta de salud de gastos flexibles. Entonces llamó a la consulta de su ginecólogo y pidió que le devolvieran el dinero.

“Perdí el miedo”, dijo Clark, que antes había trabajado en una aseguradora de salud y en un consultorio médico. Recibió un primer cheque por la mitad de los $960 que había pagado inicialmente.

En agosto, Clark fue trasladada al hospital después que su presión arterial se disparara. Un especialista en embarazos de alto riesgo, y no su ginecólogo-obstetra original, atendió el parto prematuro de su hijo Peter mediante cesárea de urgencia a las 30 semanas de embarazo.

Hasta que no resolvió la mayoría de las facturas del parto no recibió el resto del reembolso de la otra consulta de ginecología y obstetricia.

El último cheque llegó en octubre, pocos días después de que Clark saliera del hospital con Peter para llevarlo a su hogar y tras múltiples llamadas a la consulta. Dijo que todo eso sumó estrés a un período ya de por sí estresante.

“¿Por qué tengo que pagar el precio como paciente?”, se preguntó. “Sólo intento tener un bebé”.

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 CONTENT

This story can be republished for free (details).

In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN’s office when she was asked to pay $960, the total the office estimated she would owe after she delivered.

Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Normally, patients receive the bill after insurance has paid its part, and for pregnant women that’s usually only when the pregnancy ends. It would be months before the office filed the claim with her health insurer.

Clark said she felt stuck. The Cleveland, Tennessee, obstetrics practice was affiliated with a birthing center where she wanted to deliver. Plus, she and her husband had been wanting to have a baby for a long time. And Clark was emotional, because just weeks earlier her mother had died.

“You’re standing there at the window, and there’s people all around, and you’re trying to be really nice,” recalled Clark, through tears. “So, I paid it.”

On online baby message boards and other social media forums, pregnant women say they are being asked by their providers to pay out-of-pocket fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for payment up front ensures they get compensated for their services.

How frequently this happens is hard to track because it is considered a private transaction between the provider and the patient. Therefore, the payments are not recorded in insurance claims data and are not studied by researchers.

Patients, medical billing experts, and patient advocates say the billing practice causes unexpected anxiety at a time of already heightened stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe and force people to fight for refunds if they miscarry or the amount paid was higher than the final bill.

Up-front payments also create hurdles for women who may want to switch providers if they are unhappy with their care. In some cases, they may cause women to forgo prenatal care altogether, especially in places where few other maternity care options exist.

It’s “holding their treatment hostage,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

Medical billing and women’s health experts believe OB-GYN offices adopted the practice to manage the high cost of maternity care and the way it is billed for in the U.S.

When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. That practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists. But such bundled billing has become outdated, she said.

Previously, pregnant patients had been subject to copayments for each prenatal visit, which might lead them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Plus, it’s become more common for pregnant women to switch providers, or have different providers handle prenatal care, labor, and delivery — especially in rural areas where patient transfers are common.

Some providers say prepayments allow them to spread out one-time payments over the course of the pregnancy to ensure that they are compensated for the care they do provide, even if they don’t ultimately deliver the baby.

“You have people who, unfortunately, are not getting paid for the work that they do,” said Pamela Boatner, who works as a midwife in a Georgia hospital.

While she believes women should receive pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill isn’t ignored after the baby is delivered. New parents might be overloaded with hospital bills and the costs of caring for a new child, and they may lack income if a parent isn’t working, Boatner said.

In the U.S., having a baby can be expensive. People who obtain health insurance through large employers pay an average of nearly $3,000 out-of-pocket for pregnancy, childbirth, and postpartum care, according to the Peterson-KFF Health System Tracker. In addition, many people are opting for high-deductible health insurance plans, leaving them to shoulder a larger share of the costs. Of the 100 million U.S. people with health care debt, 12% attribute at least some of it to maternity care, according to a 2022 KFF poll.

Families need time to save money for the high costs of pregnancy, childbirth, and child care, especially if they lack paid maternity leave, said Joy Burkhard, CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepay “is another gut punch,” she said. “What if you don’t have the money? Do you put it on credit cards and hope your credit card goes through?”

Calculating the final costs of childbirth depends on multiple factors, such as the timing of the pregnancy, plan benefits, and health complications, said Erin Duffy, a health policy researcher at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The final bill for the patient is unclear until a health plan decides how much of the claim it will cover, she said.

But sometimes the option to wait for the insurer is taken away.

During Jamie Daw’s first pregnancy in 2020, her OB-GYN accepted her refusal to pay in advance because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwifery practice in New York told her that since she had a high-deductible plan, it was mandatory to pay $2,000 spread out with monthly payments.

Daw, a health policy researcher at Columbia University, delivered in September 2023 and got a refund check that November for $640 to cover the difference between the estimate and the final bill.

“I study health insurance,” she said. “But, as most of us know, it’s so complicated when you’re really living it.”

While the Affordable Care Act requires insurers to cover some prenatal services, it doesn’t prohibit providers from sending their final bill to patients early. It would be a challenge politically and practically for state and federal governments to attempt to regulate the timing of the payment request, said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobbying groups are powerful and contracts between insurers and medical providers are proprietary.

Because of the legal gray area, Lacy Marshall, an insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring payment up front.

If the insurer says they can refuse to pay up front, Marshall said, she tells clients to get established with a practice before declining to pay, so that the provider can’t refuse treatment.

Clark said she met her insurance deductible after paying for genetic testing, extra ultrasounds, and other services out of her health care flexible spending account. Then she called her OB-GYN’s office and asked for a refund.

“I got my spine back,” said Clark, who had previously worked at a health insurer and a medical office. She got an initial check for about half the $960 she originally paid.

In August, Clark was sent to the hospital after her blood pressure spiked. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks.

It was only after she resolved most of the bills from the delivery that she received the rest of her refund from the other OB-GYN practice.

This final check came in October, just days after Clark brought Peter home from the hospital, and after multiple calls to the office. She said it all added stress to an already stressful period.

“Why am I having to pay the price as a patient?” she said. “I’m just trying to have a baby.”

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 CONTENT

This story can be republished for free (details).

The United States has made almost no progress in closing racial health disparities despite promises, research shows. The government, some critics argue, is often the underlying culprit.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients. 

During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

The video features senior correspondents Fred Clasen-Kelly and Renuka Rayasam, along with Morris Brown, a family care physician in Kingstree, South Carolina.

Learn more about the “Systemic Sickness” series 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 CONTENT

This story can be republished for free (details).

Many scientists at the federal health agencies await the second Donald Trump administration with dread as well as uncertainty over how the president-elect will reconcile starkly different philosophies among the leaders of his team.

Trump has promised he would allow Robert F. Kennedy Jr. to “go wild” on medicines, food, and health. With that, a radical antiestablishment medical movement with roots in past centuries could threaten the achievements of a science-based public health order painstakingly built since World War II, some of these scientists fear.

If Kennedy makes good on his vision for transforming public health, childhood vaccine mandates could wither. New vaccines might never win approval, even as the FDA allows dangerous or inefficient therapies onto the market. Agency websites could trumpet unproven or debunked health ideas. And if Trump’s plan to weaken civil service rights goes through, anyone who questions these decisions could be summarily fired.

“Never has anybody like RFK Jr. gotten anywhere close to the position he may be in to actually shape policy,” said Lewis Grossman, a law professor at American University and the author of “Choose Your Medicine,” a history of U.S. public health.

Kennedy and an adviser Calley Means, a health care entrepreneur, say dramatic changes are needed because of the high levels of chronic disease in the United States. Government agencies have corruptly tolerated or promoted unhealthy diets and dangerous drugs and vaccines, they say.

Means and Kennedy did not respond to requests for comment. Four conservative members of the first Trump health bureaucracy spoke on condition of anonymity. They eagerly welcomed the former president’s return but voiced few opinions about specific policies. Days after last week’s election, RFK Jr. announced that the Trump administration would immediately fire and replace 600 National Institutes of Health officials. He set up a website seeking crowdsourced nominees for federal appointments, with a host of vaccination foes and chiropractors among the early favorites.

At meetings last week at Mar-a-Lago involving Elon Musk, Tucker Carlson, Donald Trump Jr., Kennedy, and Means, according to Politico, some candidates for leading health posts included Jay Bhattacharya, a Stanford University scientist who opposed covid lockdowns; Florida Surgeon General Joseph Ladapo, who opposes mRNA covid vaccines and rejected well-established disease control practices during a measles outbreak; Johns Hopkins University surgeon Marty Makary; and Means’ sister, Stanford-trained surgeon and health guru Casey Means.

All are mavericks of a sort, though their ideas are not uniform. Yet the notion that they could elbow aside a century of science-based health policy is profoundly troubling to many health professionals. They see Kennedy’s presence at the heart of the Trump transition as a triumph of the “medical freedom” movement, which arose in opposition to the Progressive Era idea that experts should guide health care policy and practices.

It could represent a turning away from the expectation that mainstream doctors be respected for their specialized knowledge, said Howard Markel, an emeritus professor of pediatrics and history at the University of Michigan, who began his clinical career treating AIDS patients and ended it after suffering a yearlong bout of long covid.

“We’ve gone back to the idea of ‘every man his own doctor,’” he said, referring to a phrase that gained currency in the 19th century. It was a bad idea then and it’s even worse now, he said.

“What does that do to the morale of scientists?” Markel asked. The public health agencies, largely a post-WWII legacy, are “remarkable institutions, but you can screw up these systems, not just by defunding them but by deflating the true patriots who work in them.”

FDA Commissioner Robert Califf told a conference on Nov. 12 that he worried about mass firings at the FDA. “I’m biased, but I feel like the FDA is sort of at peak performance right now,” he said. At a conference the next day, CDC Director Mandy Cohen reminded listeners of the horrors of vaccine-preventable diseases like measles and polio. “I don’t want to have to see us go backward in order to remind ourselves that vaccines work,” she said.

Exodus From the Agencies?

With uncertainty over the direction of their agencies, many older scientists at the NIH, FDA, and Centers for Disease Control and Prevention are considering retirement, said a senior NIH scientist who spoke on the condition of anonymity for fear of losing his job.

“Everybody I talk to sort of takes a deep breath and says, ‘It doesn’t look good,’” the official said.

“I hear of many people getting CVs ready,” said Arthur Caplan, a professor of bioethics at New York University. They include two of his former students who now work at the FDA, Caplan said.

Others, such as Georges Benjamin, executive director of the American Public Health Association, have voiced wait-and-see attitudes. “We worked with the Trump administration last time. There were times things worked reasonably well,” he said, “and times when things were chaotic, particularly during covid.” Any wholesale deregulation efforts in public health would be politically risky for Trump, he said, because when administrations “screw things up, people get sick and die.”

At the FDA, at least, “it’s very hard to make seismic changes,” former FDA chief counsel Dan Troy said.

But the administration could score easy libertarian-tinged wins by, for example, telling its new FDA chief to reverse the agency’s refusal to approve the psychedelic drug MDMA from the company Lykos. Access to psychedelics to treat post-traumatic stress disorder has grabbed the interest of many veterans. Vitamins and supplements, already only lightly regulated, will probably get even more of a free pass from the next Trump FDA.

‘Medical Freedom’ or ‘Nanny State‘

Trump’s health influencers are not monolithic. Analysts see potential clashes among Kennedy, Musk, and more traditional GOP voices. Casey Means, a “holistic” MD at the center of Kennedy’s “Make America Healthy Again” team, calls for the government to cut ties with industry and remove sugar, processed food, and toxic substances from American diets. Republicans lampooned such policies as exemplifying a “nanny state” when Mike Bloomberg promoted them as mayor of New York City.

Both the libertarian and “medical freedom” wings oppose aspects of regulation, but Silicon Valley biotech supporters of Trump, like Samuel Hammond of the Foundation for American Innovation, have pressed the agency to speed drug and device approvals, while Kennedy’s team says the FDA and other agencies have been “captured” by industry, resulting in dangerous and unnecessary drugs, vaccines, and devices on the market.

Kennedy and Casey Means want to end industry user fees that pay for drug and device rules and support nearly half the FDA’s $7.2 billion budget. It’s unclear whether Congress would make up the shortfall at a time when Trump and Musk have vowed to slash government programs. User fees are set by laws Congress passes every five years, most recently in 2022.

The industry supports the user-fee system, which bolsters FDA staffing and speeds product approvals. Writing new rules “requires an enormous amount of time, effort, energy, and collaboration” by FDA staff, Troy said. Policy changes made through informal “guidance” alone are not binding, he added.

Kennedy and the Means siblings have suggested overhauling agricultural policies so that they incentivize the cultivation of organic vegetables instead of industrial corn and soy, but “I don’t think they’ll be very influential in that area,” Caplan said. “Big Ag is a powerful entrenched industry, and they aren’t interested in changing.”

“There’s a fine line between the libertarian impulse of the ‘medical freedom’ types and advocating a reformation of American bodies, which is definitely ‘nanny state’ territory,” said historian Robert Johnston of the University of Illinois-Chicago.

Specific federal agencies are likely to face major changes. Republicans want to trim the NIH’s 27 research institutes and centers to 15, slashing Anthony Fauci’s legacy by splitting the National Institute of Allergy and Infectious Diseases, which he led for 38 years, into two or three pieces.

Numerous past attempts to slim down the NIH have failed in the face of campaigns by patients, researchers, and doctors. GOP lawmakers have advocated substantial cuts to the CDC budget in recent years, including an end to funding gun violence, climate change, and health equity research. If carried out, Project 2025, a policy blueprint from the conservative Heritage Foundation, would divide the agency into data-collecting and health-promoting arms. The CDC has limited clout in Washington, although former CDC directors and public health officials are defending its value.

“It would be surprising if CDC wasn’t on the radar” for potential change, said Anne Schuchat, a former principal deputy director of the agency, who retired in 2021.

The CDC’s workforce is “very employable” and might start to look for other work if “their area of focus is going to be either cut or changed,” she said.

Kennedy’s attacks on HHS and its agencies as corrupted tools of the drug industry, and his demands that the FDA allow access to scientifically controversial drugs, are closely reminiscent of the 1970s campaign by conservative champions of Laetrile, a dangerous and ineffective apricot-pit derivative touted as a cancer treatment. Just as Kennedy championed off-patent drugs like ivermectin and hydroxychloroquine to treat covid, Laetrile’s defenders claimed that the FDA and a profit-seeking industry were conspiring to suppress a cheaper alternative.

The public and industry have often been skeptical of health regulatory agencies over the decades, Grossman said. The agencies succeed best when they are called in to fix things — particularly after bad medicine kills or damages children, he said.

The 1902 Biologics Control Act, which created the NIH’s forerunner, was enacted in response to smallpox vaccine contamination that killed at least nine children in Camden, New Jersey. Child poisonings linked to the antifreeze solvent for a sulfa drug prompted the modern FDA’s creation in 1938. The agency, in 1962, acquired the power to demand evidence of safety and efficacy before the marketing of drugs after the thalidomide disaster, in which children of pregnant women taking the anti-nausea drug were born with terribly malformed limbs.

If vaccination rates plummet and measles and whooping cough outbreaks proliferate, babies could die or suffer brain damage. “It won’t be harmless for the administration to broadly attack public health,” said Alfredo Morabia, a professor of epidemiology at Columbia University and the editor-in-chief of the American Journal of Public Health. “It would be like taking away your house insurance.”

Sam Whitehead, Stephanie Armour, and David Hilzenrath 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 CONTENT

This story can be republished for free (details).

Científicos de las agencias federales de salud esperan la segunda administración de Donald Trump con incertidumbre y temor, preguntándose cómo el presidente electo conciliará filosofías radicalmente diferentes entre los líderes de su equipo.

Trump anunció hace pocos días que nominará a Robert F. Kennedy Jr. (RFK) como secretario del Departamento de Salud y Servicios Humanos (HHS), después de decir durante la campaña presidencial que dejaría que el activista antivacunas implementase “sus locuras” en materia de medicamentos, alimentos y salud.

Si el Senado confirma a Kennedy, sus críticos dicen que un movimiento médico radical antisistema, con raíces en siglos pasados, tomaría el poder, amenazando los logros de un orden de salud pública basado en la ciencia y construido con esfuerzo desde la Segunda Guerra Mundial.

Trump dijo en un post en la red social X que “los estadounidenses han sido aplastados por el complejo industrial alimentario y las compañías farmacéuticas que se han dedicado al engaño, la información falsa y la desinformación cuando se trata de salud pública”, haciéndose eco de las quejas de Kennedy sobre el establishment médico.

RFK, ex candidato presidencial demócrata, “acabará con la epidemia de enfermedades crónicas” y “¡Hará que Estados Unidos vuelva a ser grande y saludable!”, escribió Trump.

Las acciones de los fabricantes de vacunas cayeron en medio de las noticias previas al anuncio de Trump sobre RFK.

Si Kennedy hace realidad su visión de transformar la salud pública, los mandatos de vacunación infantil podrían debilitarse. Las nuevas vacunas podrían no ser aprobadas nunca, incluso si la Administración de Alimentos y Medicamentos (FDA) permite la comercialización de terapias peligrosas o ineficaces.

Los sitios web de la agencia podrían diseminar ideas sobre la salud no probadas o desacreditadas. Y si el plan de Trump de socavar los derechos de los funcionarios sigue adelante, cualquiera que cuestione estas decisiones podría ser despedido de inmediato.

“Nunca nadie como RFK Jr. se había acercado a la posición en la que podría estar para dar forma real a estas políticas”, dijo Lewis Grossman, profesor de Leyes en la American University y autor de “Choose Your Medicine”, una historia de la salud pública estadounidense.

Kennedy y su asesor Calley Means, un empresario del sector de la salud, afirman que se necesitan cambios drásticos debido a los altos niveles de enfermedades crónicas en Estados Unidos. Según ellos, las agencias gubernamentales han tolerado o promovido, de forma corrupta, dietas poco saludables, y medicamentos y vacunas peligrosos.

Means y Kennedy no respondieron a las solicitudes de comentarios. Cuatro miembros conservadores que formaron parte de la primera burocracia de la salud de Trump hablaron bajo condición de anonimato.

Recibieron con entusiasmo el regreso del ex presidente, pero expresaron pocas opiniones sobre políticas específicas. Días después de las elecciones, RFK Jr. anunció que la administración Trump despediría y reemplazaría inmediatamente a 600 funcionarios de los Institutos Nacionales de Salud (NIH). Creó un sitio web en el que buscaba candidatos por crowdsourcing para nombramientos federales, con una gran cantidad de enemigos de las vacunas y quiroprácticos entre los primeros favoritos.

En reuniones celebradas recientemente en Mar-a-Lago, la residencia de Trump en Florida, en las que participaron Elon Musk, Tucker Carlson, Donald Trump Jr, Kennedy y Means, según Politico, entre los candidatos a los principales puestos en el área de salud estaba Jay Bhattacharya, un científico de la Universidad de Stanford que se opuso a los cierres durante covid. También el cirujano general de Florida, Joseph Ladapo, que se opone a las vacunas de ARNm contra covid-19 y rechazó prácticas de control de enfermedades bien establecidas durante un brote de sarampión; el cirujano de la Universidad Johns Hopkins Marty Makary; y la hermana de Means, la cirujana formada en Stanford y gurú de la salud Casey Means.

Todos ellos pueden ser calificados de inconformistas, aunque sus ideas no son uniformes. Sin embargo, la posibilidad de que puedan dejar de lado un siglo de políticas de salud basadas en la ciencia es profundamente preocupante para muchos profesionales. Ven la presencia de Kennedy en el corazón de la transición de Trump como un triunfo del movimiento de “libertad médica”, que surgió en oposición a la idea de la Era Progresista de que los expertos son los que deben guiar la política y las prácticas de atención de salud.

Podría representar un alejamiento de la expectativa de que los médicos convencionales sean respetados por sus conocimientos especializados, dijo Howard Markel, profesor emérito de pediatría e historia en la Universidad de Michigan, que comenzó su carrera clínica tratando a pacientes con sida y la terminó tras sufrir un año de covid de larga duración.

“Hemos vuelto a la idea de ‘cada uno es su médico’”, comentó, refiriéndose a una frase que se impuso en el siglo XIX. Era una mala idea entonces y es aún peor ahora, agregó.

“¿Cómo afectará eso a la moral de los científicos?”, se preguntó Markel. Las agencias de salud pública, en gran medida un legado posterior a la Segunda Guerra Mundial, son “instituciones notables, pero se pueden echar a perder estos sistemas, no sólo quitándoles financiación, sino desmoralizando a los verdaderos patriotas que trabajan en ellas”.

El Comisionado de la FDA, Robert Califf, declaró en una conferencia el 12 de noviembre que le preocupaban los despidos masivos en la agencia. “No soy imparcial, pero creo que la FDA está en una especie de pico de rendimiento en este momento”, expresó.

Al día siguiente, en una conferencia, la directora de los Centros para el Control y Prevención de Enfermedades (CDC), Mandy Cohen, recordó los horrores de las enfermedades prevenibles mediante vacunación, como el sarampión y la poliomielitis. “No quiero que tengamos que dar marcha atrás para recordarnos que las vacunas funcionan”, afirmó.

Las acciones de algunos de los principales fabricantes de vacunas cayeron después que los medios de comunicación, encabezados por Politico, informaran de que se esperaba la elección de RFK.

Moderna, creadora de una de las vacunas más populares contra covid-19, cerró con una baja del 5,6%. Pfizer, otro fabricante de vacunas contra covid, cayó un 2,6%. GSK, que produce la vacuna contra el virus respiratorio sincitial, la hepatitis A y B, el rotavirus y la gripe, cayó algo más del 2%. La farmacéutica francesa Sanofi, cuyo sitio web presume de que sus productos vacunan a más de 500 millones de personas al año, cayó casi un 3,5%.

¿Éxodo de las agencias?

Ante la incertidumbre sobre la dirección de sus agencias, muchos científicos de edad avanzada de los NIH, la FDA y los CDC consideran la posibilidad de jubilarse, contó un científico de alto nivel de los NIH que habló bajo condición de anonimato por temor a perder su trabajo.

“Todo el mundo con quien hablo respira hondo y dice: ‘Esto no pinta bien’”, explicó el funcionario.

“Sé de muchas personas que están preparando sus currículums”, dijo Arthur Caplan, profesor de bioética en la Universidad de Nueva York. Entre ellos se encuentran dos de sus antiguos alumnos que ahora trabajan en la FDA, dijo Caplan.

Otros, como Georges Benjamin, director ejecutivo de la American Public Health Association, han han dicho que esperarán y verán qué pasa. “Trabajamos con la administración Trump la última vez. Hubo momentos en que las cosas funcionaron razonablemente bien”, explicó, “y momentos en que las cosas fueron caóticas, particularmente durante covid”.

Cualquier esfuerzo de desregulación al por mayor en la salud pública sería políticamente arriesgado para Trump, señaló Benjamin, porque cuando las administraciones “arruinan las cosas, la gente se enferma y muere”.

En la FDA, al menos, “es muy difícil hacer cambios sísmicos”, dijo Dan Troy, ex consejero jefe de la FDA.

Pero la administración podría conseguir fáciles victorias de tinte libertario, por ejemplo, diciendo a su nuevo jefe de la FDA que revierta la negativa de la agencia a aprobar el fármaco psicodélico MDMA de la empresa Lykos. El acceso a los psicodélicos para tratar el trastorno de estrés postraumático ha despertado el interés de muchos veteranos.

Las vitaminas y los suplementos, que ya sólo están ligeramente regulados, probablemente recibirán aún más carta blanca de la próxima FDA de Trump.

Libertad médica o Estado niñera

Pero los “influencers” de la salud en la futura administración Trump no son monolíticos. Los analistas ven posibles enfrentamientos entre Kennedy, Musk y las voces más tradicionales del Partido Republicano.

Casey Means, un médico holístico en el centro del equipo “Make America Healthy Again” de Kennedy, pide que el gobierno corte los lazos con la industria y elimine el azúcar, los alimentos procesados y las sustancias tóxicas de las dietas estadounidenses. Los republicanos tacharon estas políticas de “Estado niñera” cuando Mike Bloomberg las promovió como alcalde de Nueva York.

Tanto el ala libertaria como el de la “libertad médica” se oponen a aspectos de la regulación. Pero los partidarios de la biotecnología de Silicon Valley que están con Trump, como Samuel Hammond de la Foundation for American Innovation, han presionado a la agencia para que acelere la aprobación de medicamentos y dispositivos. Mientras tanto, el equipo de Kennedy dice que la FDA y otras agencias han sido “capturadas” por la industria, lo que resulta en medicamentos, vacunas y dispositivos peligrosos e innecesarios en el mercado.

Es probable que algunos organismos federales sufran cambios importantes. Los republicanos quieren reducir los 27 institutos y centros de investigación de los NIH a 15, y recortar el legado de Anthony Fauci dividiendo el Instituto Nacional de Alergias y Enfermedades Infecciosas, que dirigió durante 38 años, en dos o tres partes.

Numerosos intentos anteriores de reducir los NIH han fracasado frente a las campañas de pacientes, investigadores y médicos.

Legisladores republicanos han defendido recortes sustanciales del presupuesto de los CDC en los últimos años, incluido el fin de la financiación de la investigación sobre la violencia con armas de fuego, el cambio climático y la equidad en salud. De llevarse a cabo el Proyecto 2025, un proyecto político de la conservadora Heritage Foundation, dividiría la agencia en dos ramas: la de recopilación de datos y la de promoción de la salud. Los CDC tiene una influencia limitada en Washington, aunque ex directores y funcionarios de salud pública defienden su valor.

“Me sorprendería que los CDC no estuvieran en el radar” de posibles cambios, dijo Anne Schuchat, ex subdirectora principal de la agencia, que se jubiló en 2021.

El personal de los CDC es “muy empleable” y podría empezar a buscar otro trabajo si “su área de interés va a ser recortada o modificada”, opinó Schuchat.

Los ataques de Kennedy contra el HHS y sus agencias como herramientas corruptas de la industria farmacéutica, y sus demandas de que la FDA permita el acceso a medicamentos científicamente controversiales, recuerdan mucho a la campaña de los años 70 por parte de los conservadores que defendían el Laetrile, un peligroso e ineficaz derivado de la semilla de albaricoque promocionado como tratamiento contra el cáncer.

Al igual que Kennedy defendió fármacos sin patente como la ivermectina y la hidroxicloroquina para tratar covid, los defensores del Laetrile afirmaron que la FDA y una industria con fines de lucro estaban conspirando para suprimir una alternativa más barata.

A lo largo de las décadas, el público y la industria se han mostrado escépticos ante las agencias reguladoras de la salud, afirmó Grossman. Los organismos tienen más éxito cuando se les pide que solucionen problemas, sobre todo cuando un medicamento defectuoso mata o lastima a un niño.

La Ley de Control Biológico de 1902, que creó el precursor de los NIH, se promulgó en respuesta a vacunas contra la viruela contaminadas que mataron al menos a nueve niños en Camden, Nueva Jersey. Las intoxicaciones infantiles relacionadas con el disolvente anticongelante de un medicamento con sulfamidas impulsaron la creación de la FDA moderna en 1938.

En 1962, la agencia adquirió la facultad de exigir pruebas de seguridad y eficacia antes de la comercialización de medicamentos tras el desastre de la talidomida, cuando los hijos de mujeres embarazadas que tomaban el medicamento contra las náuseas nacieron con extremidades terriblemente malformadas.

Si las tasas de vacunación caen en picada y proliferan los brotes de sarampión y tos ferina, los bebés podrían morir o sufrir daños cerebrales. “Sufriremos las consecuencias si la administración ataca abiertamente la salud pública”, afirmó Alfredo Morabia, catedrático de Epidemiología de la Universidad de Columbia y director del American Journal of Public Health. “Sería como quitarte el seguro de tu casa”.

Sam Whitehead, Stephanie Armour, David Hilzenrath y Darius Tahir colaboraron con este artículo.

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 CONTENT

This story can be republished for free (details).

Health researchers are noticing a growing problem in American pregnancies: more cases of blood pressure so high it can be deadly for the parent and baby.

U.S. rates of newly developed and chronic maternal high blood pressure skyrocketed from 2007 through 2019, and researchers say they haven’t slowed down. Hospitals are working to adjust their standards of care to match best practices.

Sara McGinnis died as a result of her pregnancy in 2018. Her Kalispell, Montana, medical team didn’t recognize her symptoms of rising high blood pressure: a severe headache, swollen body and fatigue beyond anything she’d experienced in her first pregnancy. She suffered a massive stroke and seizure late in pregnancy and never got to meet her son, who survived an emergency delivery.

McGinnis had eclampsia, a condition typically characterized by seizures late in pregnancy. The severe and sometimes deadly pregnancy complication generally develops from persistent high blood pressure. Rising blood pressure makes the heart work in overdrive, which damages organs along the way.

One reason for the big increase in cases is that more doctors are looking out for the condition. But that’s not enough to explain the increase in the nation’s overall maternal death rate.

Lifestyle and genetic factors play a role, but physician and health researcher Natalie Cameron, with Northwestern University’s Feinberg School of Medicine, said people who don’t have risk factors going into pregnancy are also getting sick more often. More research is needed to understand why.

“Pregnancy is a natural stress test. It’s unmasking this risk that was there all the time,” Cameron said. “And there’s a lot we don’t know.”

The federal government has worked for years to expand training in screening and treatment for severe high blood pressure in pregnancy. The nation’s best-practice guidelines go back to 2015.

Last year, the federal government boosted funding for training to expand implementation of best practices.

“So much of the disparity in this space is about women’s voices not being heard,” said Carole Johnson, head of the federal agency charged with improving access to health care.

But it takes time for hospitals to incorporate those kinds of changes, researchers said.

Take Montana, for example, which last year became one of 35 states to implement the federal patient safety guidelines. That year, more than two-thirds of hospitals in the state provided patients with timely care. Just over half of hospitals did so before the training.

Some hospitals had treatment plans for high blood pressure in pregnancy but found their doctors’ use was “hit or miss.” One health system found that even the way nurses checked pregnant patients’ blood pressure varied.

Wanda Nicholson, who chairs the independent U.S. Preventive Services Task Force, said blood pressure in pregnancy “can change in a matter of days, or in a 24-hour period.”

That’s why, she said, consistent monitoring for high blood pressure is key to keeping people safe.

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 CONTENT

This story can be republished for free (details).

A new federal watchdog audit is ratcheting up pressure on government officials to crack down on billions of dollars in overcharges linked to Medicare Advantage home visits.

But so far, the Centers for Medicare & Medicaid Services has rejected a recommendation from the Health and Human Services Inspector General to limit payments stemming from house visits that don’t result in any medical treatment — a potential red flag that may signal overcharges.

In late October, the HHS watchdog found that the health plans pocketed $7.5 billion in 2023 from diagnosing health conditions that prompted no medical services — about $4.2 billion of it through health assessments done in patients’ homes. And court records show that for a decade or more, CMS officials have failed to act on their concerns that the home visits waste tax dollars and should be limited.

UnitedHealthcare, the largest Medicare Advantage contractor, accounted for about two-thirds of the payments tied to home visits and chart reviews, in which health plans mine patient medical files to add new diagnoses that can bring in additional revenue, according to the audit.

Assistant Inspector General Erin Bliss said the health plans are making billions without offering any treatment for medical conditions they flag during the visits, such as diabetes and major depression.

“Frankly, it needs to stop,” Bliss said.

CMS, which runs the Medicare program, disagrees.

In a statement to KFF Health News by spokesperson Alexx Pons, the agency said it “appreciates the OIG’s review in this area” and will continue to study the issue.

However, CMS disagreed with the OIG’s call to restrict use of home health assessments in computing how much to pay health plans. People on Medicare “should have access to care that is appropriately provided in the home setting,” CMS wrote in a written response included in the audit report.

“One would think that CMS would kick its regulatory oversight up a notch or two,” said Richard Lieberman, a Colorado health data analytics expert.

“In contrast, CMS appears to be unconcerned and is telling OIG to stay out of their lane,” he said.

UnitedHealthcare spokesperson Heather Soule said in a statement that the OIG had drawn “inaccurate conclusions” in the audit.

The home visits are “among the most comprehensive and thorough assessments of a patient’s health and physical environment available in the healthcare system, helping to identify and drive needed follow-on care for the vast majority of the patients with whom we engage,” according to the company.

No Care Provided

Government spending on Medicare Advantage, which is dominated by UnitedHealthcare and a handful of other health insurance companies, is expected to hit $462 billion this year.

The industry, whose more than 33 million members make up over half of people eligible for Medicare, argues that most enrollees are satisfied with the care they receive and typically pay less out-of-pocket than those on original Medicare.

Whether Medicare Advantage is a good deal for taxpayers is another matter, largely because many health plans exaggerate how sick patients are to boost their payments, multiple federal audits and other investigations have shown. Medicare pays the health plans higher rates for sicker patients.

For fiscal year 2023, CMS identified $12.7 billion in overpayments linked to diagnoses not supported by patients’ medical records.

The OIG audit tied $7.5 billion in payments to health conditions that prompted no treatment, including serious diseases such as diabetes, congestive heart failure, and major depression. That suggests that the medical condition either didn’t exist or that the health plan failed to treat it adequately, auditors said.

“These are serious conditions. You would think you would see additional care during that year,” said Jacqualine Reid, who led the OIG audit team. “We are asking CMS to step up its oversight.”

Homegrown

The in-home visits have sparked controversy for more than a decade. A June 2014 media investigation found that a sharp rise in home visits had inflated Medicare’s costs by billions of dollars. The visits, which typically last less than an hour, are often conducted by nurse practitioners, who do not treat the patient, but go over a checklist of possible health conditions.

Sabrina Skeldon, a Texas lawyer who advises physicians on billing issues, said problems arise when health plans fail to order necessary medical tests to confirm a diagnosis made during a home visit — and treat it.

Skeldon noted that The Cigna Group in 2023 paid $172 million to settle a whistleblower lawsuit that alleged its Medicare Advantage plan illegally collected payments for medical diagnoses that were based solely on in-home assessments.

The OIG audit comes as the Justice Department presses a civil fraud case that accuses UnitedHealth Group of cheating Medicare out of more than $2 billion by mining patient records to churn up diagnoses that boosted revenue, while ignoring evidence of overpayments. The company denies the allegations.

Court filings from the case show CMS officials were concerned years ago that home visits and chart reviews could needlessly drive up costs.

In April 2014, CMS backed off a proposal to restrict their use amid complaints from the industry that it would lose billions of dollars as a result. Similarly, CMS officials scrapped a proposal to tighten scrutiny on the chart reviews after what one official called an “uproar” from the industry.

CMS officials also had concerns that unchecked home visits might affect efforts to recover overpayments through billing reviews known as “RADV” audits.

Former CMS official Thomas Hutchinson, who ran the agency’s Medicare Plan Payment Group from September 2006 through June 2010, testified in a deposition that officials had “heard about various folks that figured out how they could RADV-proof things by doing in-home visits.”

In a confidential April 2015 slide presentation, CMS officials observed that health plans were “now conducting health risk assessments in beneficiaries’ homes. One purpose of the assessments is to identify conditions and create medical records documentation that substantiates diagnoses.”

And an October 2015 CMS memo circulated among senior agency staff cites “limitations around home visits” among the possible ways to “strengthen” the RADV audits.

In its statement to KFF Health News, CMS said it was “committed” to ensuring that diagnoses health plans submitted for payment were accurate. But the agency declined to answer written questions about the impact of home visits on its audit program, which has yet to complete reviews of payments dating back as far as 2011.

UnitedHealthcare had the lowest rates of unconfirmed diagnoses among five large Medicare Advantage organizations audited in 2011, according to court records.

Overall, the company ended up with underpayments of more than $261 million for 15 of its plans audited for 2011-2013, court records show. The audit findings for other Medicare Advantage firms are blacked out in court filings.

CMS audits payments to just 30 out of more than 700 contracts a year. That’s not enough to protect tax dollars, said Matthew Fiedler, a health policy researcher at The Brookings Institution.

“They should be auditing 10 times as many contracts,” he said. “Where we are now you are not likely to get caught.”

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 CONTENT

This story can be republished for free (details).

HURON, S.D. — Kelly Engebretson was excited to get fitted for a prosthetic after having part of his leg amputated. But he wasn’t sure how he’d get to the appointment.

Nah Thu Thu Win’s twin sons needed vaccinations before starting kindergarten. But she speaks little English, and the boys lacked health insurance.

William Arce and Wanda Serrano were recovering from recent surgeries. But the couple needed help sorting out their insurance and understanding their bills.

Engebretson, Win, Arce, and Serrano were fortunate to have someone to help.

They’re all paired with community health workers in Huron, a city of 14,000 people known for being home to the state fair and what’s billed as the world’s largest pheasant sculpture.

Three workers, employed by the Huron Regional Medical Center, help patients navigate the health system and address barriers, like poverty or unstable housing, that could keep them from getting care. Community health workers can also provide basic education on managing chronic health problems, such as diabetes or high cholesterol.

Community health worker programs are spreading across the U.S., including in rural areas and small cities as health providers and state and federal governments increasingly invest in them. These initiatives gained attention during the coronavirus pandemic and have been found to improve people’s health and access to preventive care while reducing expensive hospital visits.

Community health worker programs can address common barriers in rural areas, where people face higher rates of poverty and certain health problems, said Gabriela Boscán Fauquier, who oversees community health worker initiatives at the National Rural Health Association.

The workers are “an extension of the health care system” and serve as a link “between the formality of this health care system and the community,” she said.

The programs are often based at hospital systems or community health centers. The workers have a median pay of $23 an hour, according to the federal Bureau of Labor Statistics. Patients are typically referred to programs by clinicians who notice personal struggles or frequent visits to hospital emergency departments.

South Dakota is among the states that have recently funded community health worker programs, developed training requirements for the workers, and approved Medicaid reimbursement for their services. The state’s certification program requires 200 hours of coursework and 40 hours of job shadowing.

Huron Regional Medical Center launched its initiative in fall 2022, after receiving a $228,000 federal grant. The program is now funded by the nonprofit hospital and Medicaid reimbursements.

Huron, a small city surrounded by rural areas, is mostly populated by white people. But thousands of Karen people — an ethnic minority from the Southeast Asian country of Myanmar — began arriving in 2006. Many are refugees. The city also has a significant Hispanic population from the Caribbean, Mexico, and Central and South America.

Mickie Scheibe, one of Huron’s community health workers, recently stopped by the house of client Kelly Engebretson. The 61-year-old hadn’t been able to work since he had part of his leg amputated, due to diabetes complications.

Scheibe helps with “the hoops you’ve got to jump through,” such as applying for Medicaid, Engebretson said.

He told Scheibe that he didn’t know how he was going to get to his prosthetic fitting in Sioux Falls — a two-hour drive from home. Scheibe, 54, said she would help find him a safe ride.

She also invited Engebretson to a diabetes education program.

“Put me down as a definitely absolutely,” he replied, adding that he’d invite his mother to tag along.

The same day, Scheibe’s co-worker Sau-Mei Ramos visited the apartment where William Arce and Wanda Serrano live. Arce was recovering from heart surgery, while Serrano was healing from knee and shoulder operations.

The couple, both 61, moved three years ago from Puerto Rico to be near their children in Huron. Ramos, who’s also from Puerto Rico, coordinated their appointments, answered their billing questions, and helped Arce find a walker and supplemental insurance.

Ramos, 29, handed Arce a pamphlet about heart health and asked him to read the section on angina, the pain that results when not enough blood flows to the heart.

“Qué entiende?” she said, asking Arce what he understood about his condition. Arce, speaking in Spanish, responded that he knew what angina was and what symptoms to watch for.

Later that day, Paw Wah Sa, the third community health worker in town, met with client Nah Thu Thu Win, who moved to Huron in February from Myanmar with her husband and twin 6-year-olds. The Win family, like Sa, are part of the local Karen community, whose people have been persecuted under the military rulers of Myanmar, the country formerly known as Burma.

Win, 29, had assumed the kids would qualify for Medicaid. But unlike most other states, South Dakota does not immediately offer coverage to children who legally immigrated into the U.S. The boys’ father hopes to eventually add them to his work-sponsored insurance.

Sa didn’t want the kids to have to wait for health care. The 24-year-old previously took the twins to a free mobile dental clinic in Huron. It turned out they needed more advanced dental work, which they could get free only in Sioux Falls. Sa helped make the arrangements.

Many Karen residents and people from rural parts of Latin America had little access to health care before moving to the U.S., Sa and Ramos said. They said a major part of their job is explaining what kind of care is available, and when it’s important to seek help.

The three community health workers sometimes take clients grocery shopping, to teach them how to understand labels and identify healthful food.

Boscán Fauquier, with the National Rural Health Association, said that because community health workers are familiar with the cultures they serve, they can suggest affordable food that clients are familiar with.

Rural America’s overall population is shrinking, but the 2020 census showed it has become more diverse as people representing ethnic minorities are drawn to jobs in industries such as farming, meatpacking, and mining. Others are attracted by rural areas’ lower crime rates and cheaper housing.

Boscán Fauquier said many rural community health worker programs serve people from minority groups, who are more likely than white people to face barriers to health care.

She pointed to programs serving Native American reservations, the Black Belt region of the South, and Spanish-speaking communities, where the workers are called promotoras. But community health workers also serve rural white communities, such as those in Appalachia impacted by the opioid crisis.

Medicare, the federal health program for adults 65 or older, has been reimbursing community health worker services since January. Boscán Fauquier said advocates hope more state Medicaid programs and private insurers will allow reimbursement too.

Engebretson said he’s happy to see community health workers across South Dakota, not just in big cities.

The more they “can branch out to the people, the better it would be,” he said.

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 CONTENT

This story can be republished for free (details).