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Updated: 23 hours 6 min ago

Part II: The State of the Abortion Debate 50 Years After ‘Roe’

January 27, 2023
The Host Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special, two-part podcast, taped the week of the 50th anniversary of the decision in Roe v. Wade, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Panelists Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories Sarah Varney KHN @sarahvarney4 Read Sarah's stories

Among the takeaways from this week’s episode:

  • Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
  • The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
  • A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
  • Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
  • Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
  • Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
  • Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

And for extra credit, the panelists recommend their most memorable reproductive health stories from the last year:

Julie Rovner: NPR’s “Because of Texas’ Abortion Law, Her Wanted Pregnancy Became a Medical Nightmare,” by Carrie Feibel

Alice Miranda Ollstein: The New York Times Magazine’s “She Wasn’t Ready for Children. A Judge Wouldn’t Let Her Have an Abortion,” by Lizzie Presser

Sandhya Raman: ProPublica’s “’We Need to Defend This Law’: Inside an Anti-Abortion Meeting with Tennessee’s GOP Lawmakers,” by Kavitha Surana

Sarah Varney: Science Friday’s and KHN’s “Why Contraceptive Failure Rates Matter in a Post-Roe America,” by Sarah Varney

Also mentioned in this week’s podcast:

Click to open the transcript Transcript: Part II: The State of the Abortion Debate 50 Years After ‘Roe’

KHN’s ‘What the Health?’Episode Title: Part II: The State of the Abortion Debate 50 Years After ‘Roe’Episode Number: 282Published: Jan. 26, 2023

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Julie Rovner: Hi, it’s Julie Rovner from KHN’s “What the Health?” What follows is Part II of a great panel discussion on the state of the abortion debate 50 years after Roe v. Wade, featuring Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN. If you missed Part I, you might want to go back and listen to that first. So, without further ado, here we go.

We already talked a little bit about the difficult legal situation that abortion providers or just OB-GYNs have been put into, worried about whether what they consider just medical care will be seen as an abortion and they’ll be dragged into court. But in Tennessee, doctors would actually have to prove in court that an abortion was medically necessary, which seems a bit backwards. So, basically, it’s do it, see if you get arrested, and then you’ll have to present an affirmative defense in court. But the other thing that we’re starting to see is doctors leaving states, women’s health clinics closing, medical students and residents choosing to train elsewhere. This could really lead to a doctor drain in significant parts of the country, right?

Sandhya Raman: Yeah, I was looking at before where some of the states that have some of the highest rates of maternal mortality, maternal morbidity, and just lower maternal health outcomes overall are some of the same ones that don’t have Medicaid expansion and also do not have access to abortion right now. And it’s one of the things where, looking ahead, there have been people sounding the alarm at how this is going to get amplified. And as folks that might be interested in this discipline that are in medical school, school or readying for residency, or another type of provider that works in this space, if they choose to not train in these states — and a lot of folks that train in states often end up staying in those states — even if there are changes in some of these laws in the near term, it could have a huge effect in the future in terms of who’s training and who’s staying there and who’s able to provide not just abortions, but other terms of pregnancy care and maternal care.

Sarah Varney: And the workaround has become much more difficult because it used to be that if you’re in a state where abortion was very difficult to access or even, say, Texas during S.B. 8, these medical students could go to other states for the training. But now that you have these huge swaths of the South and the Plains and the Midwest where they are not allowed to do abortions, there’s just not enough places for OB-GYN residents and medical students to go to train. I did a story about this last year as well and looked at these students who were in medical school, who were coming up to Match Day and at the end, at the very end before the deadline, actually changed their match altogether or changed their list of priorities altogether because they didn’t want to be in Texas. So instead of doing an OB-GYN residency in Texas, this one young woman changed to a family medicine practice in Maryland. And I think the thing that’s important for people to remember is that these are the future OB-GYNs that will help many of us with our pregnancies and births for many decades to come. And as we have seen, pregnancy is very complicated and it oftentimes doesn’t end well. You know, about 10% of all confirmed pregnancies end in miscarriage; a far higher number end in miscarriage that are not confirmed pregnancies. And these will be the doctors that are supposed to actually know how to do these procedures. So if you’re in a state like Texas and you have a daughter who’s 15 and you anticipate in 15 years she may want to have a baby, you have to think about what kind of medical care she can have access to then.

Rovner: I’ve talked to a lot of people, a lot of women, who want to get pregnant, who want to get pregnant and have kids, but they are worried about getting pregnant because if something goes wrong, they’re afraid they won’t be able to get appropriate medical care. They would like to get pregnant, but they would actually not like to risk their own lives in trying to have a baby. And that’s actually what we’re looking at in a number of these states. I guess this is the appropriate place to bring up the idea of “personhood,” the declaration, not medically based, that a separate person with separate rights is created at the moment of conception. That could have really sweeping ramifications, couldn’t it? They’re talking about that, I know, in several states.

Varney: Yes. You don’t have to probe far to find out that the pro-life movement is 100% behind a federal fetal rights … the Supreme Court last year didn’t take up a case about fetal rights yet, but many of the members of the court have expressed in previous writings, and even in the Dobbs [v. Jackson Women’s Health Organization] decision, you saw [Justice Samuel] Alito using the language of the state of Mississippi that essentially granted to the fetus all of the … even, like, personality of a full human being. So I think this is going to get really tricky because Kristan Hawkins and many of the leaders of the movement, Jeanne Mancini, they do believe that there is no distinction between a zygote and a fetus and a full human being. So now this is really a religious belief. And it was interesting. I really struggled last year. I had to … I was basically assigned to write a story about, you know, when does life begin? And I think it’s an interesting question we have to ask ourselves as journalists: Why should we do that story? Is that, in a sense, propaganda for the pro-life movement? When really what the question should be is, you have a full human being, the woman, at what point should her rights be impeded upon? Right? And that’s essentially what the Roe decision tried to do, was to strike that balance. But now we’re in a whole new world where fetal rights are really the … they almost have supremacy over women’s rights.

Rovner: Yeah, I did two stories on When Does Life Begin? And it turned into one of them is … really the question is when does pregnancy begin? One of the doctors I talked to said, rather, that pregnancy begins when we can detect it, which is in many ways true. A doctor can’t say that you’re pregnant unless they can detect it at that point. But that’s a really important distinction medically between, you know, when does life begin philosophically and when does a pregnancy actually begin. But, obviously, in places that are going to declare personhood, this is going to get really complicated really fast because it would mean that you mostly couldn’t do IVF, that you can’t create embryos and then not implant them. And of course, the way IVF works for most people who are infertile and would like to have children is that you take out the eggs, you fertilize them, you grow them to a certain cell size, and then you implant them back into the woman. But you don’t generally use all of the embryos. And that would be illegal if every one of those embryos was an actual person. Could you take tax deductions for children if the child hasn’t been born yet, but you’re pregnant? I think you can already do that in Georgia, right?

Varney: Correct. Yeah. The Department of Revenue did that there.

Rovner: Yeah. This could be really, really far-reaching.

Varney: I mean, that’s what’s been going on in Alabama for years. … When the Alabama state Supreme Court years ago agreed with this argument that a law that was put in place to try and go after parents who were bringing their children to meth labs, that the notion of the environment was no longer just the meth lab, but the womb itself. And a child also then meant a fetus in the womb. Now you’re in that territory already. So Alabama’s a very good way to look into the future, in a sense.

Rovner: So basically, if you’re pregnant and go into a bar, you could be threatening the fetus.

Varney: I mean, there’s kind of no limit, right? Like, did you drive recklessly? Did you slip or did you fall on purpose? I mean, that’s what I was saying earlier about it’s really going to be up to these local prosecutors to figure out how far they want to take this.

Rovner: And that’s not hypothetical. We’ve seen cases about a woman who fell down the stairs and had a miscarriage and was prosecuted for throwing herself down the stairs.

Varney: Or a woman who was pregnant and got into an altercation in a parking lot of a big-box store and got shot and the fetus died. And then she was arrested. I mean, eventually they dropped the charges, but. yeah.

Rovner: Well, moving on. So with narrow majorities in both houses of Congress for the party in charge, changing federal law in either direction seems pretty unlikely for the next two years, which leaves the Biden administration to try to reassure people who support abortion rights. But the Biden administration doesn’t have a long list of things that can be done by executive action either, beyond what they’ve done with the abortion pill, which we mentioned already — the FDA has loosened some of those restrictions. How has the Biden administration managed to protect abortion rights?

Alice Miranda Ollstein: First, along the lines of the FDA, the FDA has been called on by the pro-abortion rights side to drop the remaining restrictions on the abortion pill. So they’ve dropped some, but they still require a special certification for the doctors who prescribe it, a special certification for the pharmacies that are just newly allowed to dispense it. Patients have to sign something saying they understand the risks. These are called REMS. These are on drugs that are considered dangerous. And a lot of medical groups and advocates argue that there isn’t evidence that this is necessary, that the safety profile of these drugs is better than a lot of drugs that don’t have these kinds of restrictions. And so they said that it would improve access to drop these remaining rules around the pills. Some have even called for them to be available over the counter, although I don’t see that happening anytime soon. Along the lines of preventing unwanted pregnancies in the first place, the FDA also is sitting on a decision of whether or not to make just regular hormonal birth control available over the counter. So that’s one to watch as well. But the Biden administration have more things they could do. They have looked at providing abortions through the VA [ Department of Veterans Affairs]. That was a big one. Earlier this year, the president signed a memo just over the weekend directing the health secretary and others in the Cabinet to look at what they can do to improve access. We’ve seen similar statements and memos before. It’s not really clear what they’ll mean in practice. But I also want to go back to you saying that nothing is likely to happen in Congress. I agree on the legislative side, but I am watching closely on the appropriations side, because I think that’s where you could see some attempts to pull things in one direction or another in terms of where federal spending goes. And going back to the group’s wastewater strategy, one piece of that they want to do, the anti-abortion groups, is pressure Republican members of Congress to hold the FDA’s funding hostage until they do certain environmental studies on the impacts of the pills. That’s where I would watch.

Rovner: Yeah, and spending bills over the years have been the primary place to do legislating on abortion restrictions or take them off. It’s not just the Hyde Amendment that banned most federal spending for abortion. There are amendments tucked into lots of different spending bills restricting abortion and other types of reproductive health care. And when Democrats are in charge, they try to take them out. And when Republicans are in charge, they try to put them back in. So I agree with Alice. I think we’re going to see those fights, although it’s hard to imagine anything happening beyond the status quo. I don’t think either side has the ability to change it, but I suspect that they’re going to try. The administration has gone after some states on the federal EMTALA law, right? The Emergency Medical Treatment and Active Labor Act, which basically says that hospitals have to stabilize and take in women in active labor. And basically, if that conflicts with an abortion ban again, like with the FDA and drugs, federal law should supersede the state law. But we haven’t really seen any place where that’s come to a head, right?

Raman: Idaho has been the main one to watch with the lawsuit there. And the Justice Department did a briefing this week before their reproductive rights council met. And they had said that that was one of the cases they’re still doing — the Idaho, in addition to the lawsuit on the VA rule that Alice mentioned, and then also an FDA rule that we talked about earlier. But they’re monitoring different things going forward. But I think one of the interesting things is that they haven’t cast a very huge net in terms of the different things that they’ve been involved with in states. It’s mainly been these three situations. And even Idaho, they’ve already in that legislature introduced a bill that would amend their law as it is now, to deal with some of the nuances so that they would adhere to EMTALA. I don’t know how far that could go through or any of the logistics with that, but I mean, that sort of thing, the Idaho situation could be solved more quickly if they’re able to get that done. And DOJ [the Department of Justice] thinks that that aligns. But it is interesting that they haven’t dug into a lot of the other state efforts yet, but that they have that on their radar.

Varney: We have seen a sort of political battle being waged, of course. So on the anniversary of Roe v. Wade, Vice President Kamala Harris was in Florida, in Tallahassee, making the 50th-anniversary-of-Roe speech. Clearly, she wants [Gov. Ron] DeSantis to be on notice that should he become a candidate in the presidential election, that Florida is very much in play. And Florida is interesting because they still have a 15-week ban. So it would not have been allowed under Roe, but it’s not as draconian as what these other states have, which is essentially nothing.

Rovner: Most of the surrounding states, too.

Varney: Correct. Yeah, exactly. So Florida has really become a receiving state for abortions, particularly in the last six months. I’m going to be interested to see if somebody like a DeSantis can even run for president from a state with a 15-week ban. I mean, he’s going to be under a lot of pressure, not simply just to do a six-week ban, but to do an outright ban altogether. So I think if he tries to thread that needle and try and get anti-abortion groups on board to support him, he’s going to have to show them more.

Rovner: That’s just about what we’re going to get to. But before we leave, what the Biden administration has done, I need to mention, because it’s my own personal hobbyhorse — that the FDA has finally come out and changed the label on the “morning-after pill” to point out that it is not an abortion pill, that it does not cause abortion, that the way it works is by preventing ovulation. So there is no fertilized egg and that at least we can maybe put that aside, finally. That label change happened in Europe 10 years ago, and for some reason it took the FDA until now to make that clarification.

Varney: But as you said, Julie, it doesn’t matter because it’s just what you believe about the drug. You know, and just to remind listeners that that drug I did — I mean, we’ve all done stories on Plan B over the years — but the one I did recently was how Plan B is actually owned by a private equity company, actually two private equity companies. And they would not go to the mat to the FDA to get this thing changed. They could have done it years ago. So now that the FDA has made this … it’s just like anything, any kind of misinformation, that people who don’t support it can just simply say, well, the FDA is biased or that’s not actually how it works.

Rovner: True.

Varney: But I don’t think it will put it to bed.

Rovner: Well, quickly, let us turn to 2023 and what we might see for the rest of this year. We’ll start with the anti-abortion side. Obviously, overturning Roe was not the culmination of their efforts. They have some pretty ambitious goals for the coming year, right? Things like travel bans and limiting exceptions in some of these states. Sandhya, I see you nodding.

Raman: There are so many things, I think, on my radar that I’m hoping to watch this year just because we are in this whole new era where it might have been three years ago a lot easier for us to predict which things might be caught up in litigation, which things might be struck down. But I think now, after the Dobbs decision, even after the Texas S.B. 8 law that we mentioned earlier, it’s a lot more difficult to see what sort of things will go in effect that might not have been able to go into effect before. And one thing I think has been interesting is that the anti-abortion movement had been in unison before this on some of their traditional Hyde exceptions — that abortions to save the life of the mother, in cases of rape and incest were something that was broadly on board, that those would be allowed. And I think we’ve seen a lot increasingly in different states, things that have been brought up by different state lawmakers that would chip away at that, that vary by state, whether or not what defines is medically necessary to save a life. And even when we were talking about Idaho earlier with the EMTALA requirements or … there was a great piece in The New Yorker last year about the anti-abortion activist who really wants to lobby against rape exceptions because she was born as a product of rape and is using her own experience in that. And so I think that will be a very interesting thing to watch because there is not a uniform agreement on that. Whereas some of the things that have been taken out, there’s a lot more strong backing for across the board.

Rovner: Yeah, that’s actually my next question, which is we’re starting to see not only a split within the anti-abortion community about what to pursue, but a little bit of distance between the Republicans and the anti-abortion forces. And I think there’s a lot of Republicans who are uncomfortable with going further or who are uncomfortable even in some of the states that don’t have exceptions. I mean, are we looking at a potential breakup of this Republican anti-abortion team that’s been so valuable to both sides over the last few decades?

Ollstein: I wouldn’t call it a breakup, but the tension is absolutely there. I mean, I wouldn’t call it a breakup just because, where else are they going to go? I mean, the Democratic Party is much more supportive of abortion rights as a whole than even just a few years ago. And so, really, they know Republicans are their best bet for getting these restrictions passed. But there is this interesting tension right now. I think a lot of it is competing interpretations of what happened in this most recent election. You have anti-abortion groups who insist that the takeaway should be candidates didn’t run hard enough on banning and restricting abortion and were too wishy-washy, and that’s why they lost. And then you have a lot of other Republicans and party officials, party leaders who feel that they were too aggressive on promoting abortion restrictions and that’s why they lost. Also, you know, I will say this isn’t purely, purely cynical politics. A lot of Republican state lawmakers have told us they’re genuinely concerned now that they’re actually seeing the laws they drafted and voted for take effect and have consequences that they maybe didn’t intend. And they’re hearing from these state medical groups who are pleading for changes to be made. And so some of them say, OK, we want to get this right. We want to go back and make fixes. And the anti-abortion groups are telling them, no, don’t create loopholes. Don’t water down these laws. And so you do have this really interesting tug of war playing out at the state level right now. And because of what you said about the federal level, the state level is really where it’s at.

Varney: And I was going to make two points. One is that the split is also really developing between the national groups and the state and local groups. So while the national groups may say, yes, we support a 15-week ban in Florida as a step to get to something else, the local groups are gung-ho. I mean, they’re in extremely gerrymandered districts. You look at Florida and Texas, they elected the most anti-abortion state legislature in history so far. And, you know, these are people coming from extremely safe seats. And then you’ll see that the city level — the city sanctuary of the unborn, I believe it’s called — that movement, they really see them going down to even the local-local level to try and get that in effect.

Rovner: Well, I think in a lot of places, states that are very affirmatively supportive of abortion rights or have it in their constitution, are trying to move that down to the local level, to the city level, to see if they can actually have success in limiting abortion locality by locality. All right. Well, meanwhile, what’s the other side doing? What’s the agenda for the abortion rights side? It’s going to be, as we pointed out, it’s gonna be kind of hard for them to advance very much.

Ollstein: Yes. I think that there is a lot of excitement around the results last year using state-level ballot initiatives in red and purple states, putting the question of abortion rights to the general public, because on all six ballots last year, the abortion rights side prevailed. Some of those were more offensive, some of those were more defensive. But in all six, they swept. And so they are really excited about trying to replicate that this year. Of course, it’s not possible in every state to put a constitutional amendment on the ballot for a popular vote. But in states where it is possible and where it could make a difference, including some states where abortion is already banned and they could try to unban it through the popular vote process, that’s really something they’re looking at. And then, of course, even though our federal judiciary has become a lot more conservative over time with the appointments, courts have still been convinced to block a lot of these state abortion restrictions. And so there are efforts to bring lots of different, interesting legal theories. You know, one that caught my attention is trying to make religious freedom arguments against abortion bans, saying these abortion bans infringe on the rights of religious people who believe in the right to abortion, which is sort of flipping that narrative there.

Rovner: There have been a bunch of Jewish groups who have filed cases saying that.

Ollstein: Exactly. Judaism, Islam, certain Christian denominations, all support abortion rights. And so there’s an interesting tactic there. Also pointing to language in state constitutions about privacy rights and arguing that should extend to abortion. And so a lot of interesting stuff there.

Raman: I would add to that, in terms of another tactic that’s kind of flipping what the other side has been doing, a long-term strategy of the anti-abortion movement has been prioritizing judicial elections and a long-term thing of … just in the Senate, we saw, you know, wanting to get a lot of judges confirmed that had pro-life beliefs. And you can even look to where the women’s march over the weekend, that the state … one that they were prioritizing was in Wisconsin, which was held there, to jump-start the fact that they have a state Supreme Court race coming up. They were 4-3 conservative majority right now. And the judge that is retiring is conservative. So getting a new judge that supports abortion rights could really open a path to overturn the ban there. Even though judicial elections are considered nonpartisan, there are often ways to tell clues about where someone might rule in the future. And so, I think, looking at things like that in different states as a way to dial back some of the things that the other side has been doing will be an interesting thing to watch, too.

Rovner: All right. Well, I think that’s it for our discussion. Thank you, for those of you who have hung with us this long. I hope we’ve given a good overview of the landscape. Now it’s time for our extra-credit segment. Usually that’s when we each recommend a story we read this week we think you should read, too. But this week I’ve asked each of the panelists to choose their favorite or most meaningful story about reproductive health from the last year. As always, don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?

Ollstein: Yes, I think I’ve promoted this story before, but I just can’t say enough good things about it. It’s really stuck with me. It’s from the New York Times Magazine by Lizzie Presser, and it’s called “She Wasn’t Ready for Children. A Judge Wouldn’t Let Her Have an Abortion.” And it really digs into what happens to teenagers who need to get their parent’s consent and can’t in order to have an abortion. They have this judicial bypass process where their lives, the fate of their lives are in the hands of an individual judge, who, in many cases, as this article demonstrates, come with their own biases and preconceptions about abortion. And then it just follows this one teenager who was denied an abortion, ended up having twins, and just completely struggled financially, her mental health. And she in the end said, you know, I knew what was right for me. I knew I needed an abortion. And it’s a very moving, painful story that shines a light on a piece of the story that I think is overlooked.

Rovner: Yeah. Sandhya.

Raman: For my extra credit, I picked a story that also has stuck in my head for a long time, kind of like Alice. So it’s “‘We Need to Defend This Law’: Inside an Anti-Abortion Meeting with Tennessee’s GOP Lawmakers,” from Kavitha Surana from ProPublica. I really thought this was one of the most interesting pieces on this topic that I read last year. The author got audio from a webinar in Tennessee hosted by the Tennessee Right to Life on strategy on the movement going ahead in their state. They talk a lot about the Tennessee ban and how it has narrow life exceptions as a model for other states and how the burden of proof would be on the doctor. And then they have some quotes from a Tennessee lawmaker who suggests things that I think the other side has sounded the alarm about: mining data to investigate doctors, how to push back against rape and incest exceptions. And I think one of the things that really struck me was when they brought up IVF, some of the advocates during the meeting that they had said that two years from now, next year, or three years from now, IVF and contraception can be regulated on the table. But that’s like next steps.

Rovner: Absolutely. That was a great scoop, that story. Sarah.

Varney: So I actually picked a radio segment. It’s about a 12-minute-long radio segment that I did with Science Friday. On “Why Contraceptive Failure Rates Matter in a Post-Roe America.” So one of the things I kept hearing was, well, women are just going to have to really double up on contraception or make sure that they’re being responsible about taking their contraception. So it turns out that there’s a textbook on contraceptive technology and in that is a whole page on contraceptive failure rates, which show you what contraceptive failure rates should be in a laboratory and what they are actually out in the real world. So, for instance, the typical-use failure rate for birth control pills is 7%. So that means that seven out of 100 women on pills could experience pregnancy in the first year of use. So then I went and found the data that shows us the number of women ages 15 to 49 who are on specific methods of birth control, everything from the Depo-Provera to the contraceptive ring and patch to male condoms, to IUDs, to birth control pills. And you’ll see on both the Science Friday and the KHN website, we have these wonderful graphics where you can see that in one year of people using male condoms, because of their failure rate is about 13% in the real world, that could lead to up to 513,000 wanted pregnancies. Birth control pills, based on the number of women using birth control pills, up to 460,000 pregnancies a year in people who are actually using contraception to not get pregnant. So I think these data visualization is really important. And you can hear interviews that I did with the researcher and the physician who actually is the author of this textbook, as well as one of the world’s leading reproductive endocrinologists who talks about what’s next in contraceptive efficacy.

Rovner: Yes, I loved that story. Well, my story is also a radio story. It’s from NPR by Carrie Feibel. And it’s called “Because of Texas’ Abortion Law, Her Wanted Pregnancy Became a Medical Nightmare.” And it’s from July. And the events that it chronicles happened before the overturn of Roe v. Wade, because, as we’ve said, Texas’ abortion ban was already in effect. By now, we’ve heard this story many times. A woman with desired pregnancies, water breaks prematurely, which would normally result in a quote-unquote “medical termination.” Except the doctors and hospitals aren’t sure how sick the mom needs to be before the pregnancy actually threatens her life. And any other abortion is illegal, and they could get in legal trouble. So they put her through days of hell and sickness before she starts to show signs of sepsis and just before she and her husband were actually going to fly out of the state to get the pregnancy terminated. But this was the first of these stories that I read. And it hit me very hard. And I have such respect for the couple here who were willing to come forward and publicize all that the women called these gray areas of abortion, which lawmakers often think of as black-and-white. It was just one of those stories that sticks with you.

All right. That is our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Sandhya?

Raman: @SandhyaWrites

Rovner: Alice?

Ollstein: @AliceOllstein

Rovner: Sarah.

Varney: And @SarahVarney4

Rovner: Will be back in your feed with our regular news rundown next week. Until then, be healthy.

Credits Francis Ying Audio Producer Emmarie Huetteman Editor

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California’s Resolve Questioned After It Grants Medi-Cal Contract Concessions

January 27, 2023

California’s decision last month to cancel the results of a long-planned bidding competition among commercial health plans in its Medicaid program has some industry insiders and consumer advocates wondering whether the state can stand up to insurers and force improvements in care for millions of low-income beneficiaries.

In a backroom agreement announced in the final days of 2022, Gov. Gavin Newsom’s administration, facing lawsuits, granted concessions that allowed major insurers to claw back business they would have lost had health officials stuck with the state’s initial contract awards for managed-care plans. Oakland-based Blue Shield of California and St. Louis-based Centene Corp. — which owns Health Net, the largest commercial health plan in Medi-Cal, the state’s version of Medicaid — were among those that had aggressively challenged the initial results.

“They had this long process, and then they just sort of struck deals,” said Maya Altman, who retired a year ago after nearly 17 years as CEO of the Health Plan of San Mateo, which did not participate in the bidding. “It’s kind of weird. Not transparent — very much behind closed doors.”

It was a remarkable change of course that came four months after the state had announced its initial contract awards. The Department of Health Care Services, which oversees Medi-Cal, had spent years preparing for the bidding competition and touted it as an important means of addressing substandard care. Eight commercial Medi-Cal plans, covering around 30% of the program’s 13 million managed-care enrollees, were required to submit bids for contracts worth about $70 billion over five years.

Noncommercial, locally governed Medi-Cal plans that cover the other 70% of managed-care enrollees did not have to submit bids, but they will be required to sign the same new contract as the commercial plans, scheduled to take effect next year.

State officials said their new decision avoids uncertainty after the losing health plans — Health Net, Blue Shield of California, Community Health Group, and Aetna — threatened drawn-out legal action. It also dramatically reduces the number of Medi-Cal enrollees who will have to switch plans — from an estimated 2.3 million to about 1.2 million. And state officials said it strengthens their ability to enhance Medi-Cal through the new contracts, which will contain requirements for higher-quality care, greater transparency, and more equitable access.

Other states have faced legal disruption after they put their Medicaid contracts up for bid. In Louisiana, for example, Centene and Aetna in 2019 protested the results of a rebidding process, which led that state to nullify its awards and start over. The new results were announced nearly two years later, with Centene and Aetna among the winners.

“When you create disputes, and lawsuits, they always put some uncertainty into things,” Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, told KHN. “We feel that we ended up in a place where we achieved certainty. We have a set of [health] plans who are committed to this.”

Consumer advocates had worried that lingering uncertainty would hinder the rollout of a far-reaching nearly $12 billion, five-year Medi-Cal initiative to provide nonmedical social services that address socioeconomic factors such as homelessness and food insecurity, widely viewed as key health indicators.

Still, the state’s decision to throw out the bidding results has many patient advocates and some health plan executives questioning the value of future contract competitions and even whether health officials will effectively enforce the higher standards in the new contract.

“It would be extremely disappointing if poor-performing plans were able to litigate their way into participating in Medi-Cal,” said Abbi Coursolle, a senior attorney in the Los Angeles office of the National Health Law Program.

Tony Cava, a spokesperson for the Department of Health Care Services, said the bids submitted were still “incredibly valuable,” because they showed how the health plans intend to improve care. He said commitments made in the bids will be incorporated into the new contracts. Cava also said the department, which had not previously held a statewide bidding competition, now intends to hold one every five years.

Patient advocates and industry insiders gave the state credit for fining health plans that fell short of quality and access standards in a report issued late last year. But they also noted that several of the health plans that will continue to operate in Medi-Cal — including Molina Healthcare and Health Net — were among the lowest performers.

When the state announced its initial awards in August, Blue Shield was shut out, despite its large health care footprint statewide and its long-standing efforts to curry favor with the state’s political class. The state also said initially that it would take Los Angeles County, a huge Medi-Cal contract, away from Health Net.

Between 2018 and 2022, Blue Shield spent at least $31 million on lobbying, political donations, and other contributions, including $20 million to a state homelessness fund Newsom set up, according to a KHN analysis of filings with the secretary of state and the California Fair Political Practices Commission. Health Net parent Centene spent at least $5 million over that period, mostly on lobbying and political donations.

Under the new arrangement, Blue Shield will keep its San Diego County Medi-Cal business after initially losing it in the contract competition, though it will not get a contract in any of the other 12 counties where it bid. Its roughly 129,000 San Diego enrollees will not have to switch plans, but over 100,000 other Medi-Cal members in San Diego will still have to switch, as Health Net and Aetna exit.

In Los Angeles County, Health Net will retain its primary Medi-Cal contract, but will have to split its 1.1 million members 50-50 with Molina under a subcontract. Molina already subcontracts with Health Net in the county, but currently has only 80,000 enrollees under that arrangement.

Some observers questioned how the split can be maintained. Cava said half of new Medi-Cal enrollees in L.A. County don’t choose a plan and are assigned to one instead, according to the most recent data. These assignments will be used to help balance enrollment between Health Net and Molina, he said.

The state and the five participating health plans issued an unusual joint statement, and the plans put a positive spin on it. Centene said the state’s revised decision “is in the best interest of millions of members.” A Blue Shield executive said it was “honored to continue serving Medi-Cal beneficiaries in San Diego County.”

In an investor call this month, Molina’s CEO, Joseph Zubretsky, noted that his company’s Medi-Cal membership will double with the new agreement, though it would have tripled under the state’s initial decision. He summarized the situation for Molina as “taking three steps forward, taking one step back, and ending up being two steps ahead.”

Consumer advocates, patients, and medical professionals expressed relief that the new agreement allows Community Health Group, the largest Medi-Cal health plan in San Diego County, to keep operating there. Had the initial results held, it would have lost its contract, and its 335,000 members would have had to choose new plans.

Christine Xayalinh, a member of Community Health Group in Escondido, said the plan afforded her treatment for Type 2 diabetes and referred her to University of California-San Diego for a successful gastric bypass.

“I know some people do have concerns about their health insurance,” Xayalinh, 29, said, “but for me, it’s been a lifesaver.”

With the contract awards decided, the state’s hope of improving Medi-Cal will hinge on its ability to enforce the new contracts.

“The focus now needs to be on making sure that works,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “This is a very vulnerable population of Californians who are not getting what they need.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Montana Pharmacists May Get More Power to Prescribe

January 27, 2023

Mark Buck, a physician and pharmacist in Helena, Montana, said he’s been seeing more patients turn to urgent care clinics when they run out of medication. Their doctors have retired, moved away, or left the field because they burned out during the covid-19 pandemic, leaving the patients with few options to renew their prescriptions, he said.

“Access is where we’re really hurting in this state,” Buck said.

Senate Bill 112, sponsored by Republican Sen. Tom McGillvray, would address that need by expanding the limited authority Montana already gives pharmacists to prescribe medications and devices. Supporters said the measure could help fill health care gaps in rural areas in particular, while opponents worried it would give pharmacists physician-like authority without the same education.

Eleven states, including Montana, give pharmacists prescribing authority to some degree for medications such as birth control, naloxone, tobacco cessation products, preventive HIV drugs, and travel-related medications. The FDA has allowed pharmacists nationwide to prescribe the covid drug Paxlovid during the public health emergency.

According to a 2021 report by George Mason University’s Mercatus Center, there were about 228,000 primary care physicians nationwide in 2019 and more than 315,000 pharmacists in 2020. The report found that patients using Medicare visit a pharmacist twice as often as a primary care provider, and the difference is even larger in rural areas.

Pharmacists, who often work in grocery stores, “are open longer hours than most doctors’ offices, and no appointment is needed,” the authors of the Mercatus Center study wrote.

Under the bill, pharmacists could prescribe for patients who do not require a new diagnosis, for minor conditions, or in emergencies. They could not prescribe controlled substances.

During a Jan. 18 committee hearing on the bill, supporters said pharmacists also would be able to provide strep and flu tests, along with diabetic supplies.

Buck, the Helena doctor-pharmacist, said the bill wouldn’t solve the provider shortage, but it would “put a thumb in the dike that’s leaking.”

According to data from the University of Wisconsin Population Health Institute, Montana had one primary care physician per 1,210 people in 2019. Some counties have no primary care providers, but they usually have a pharmacy, said Kendall Cotton, executive director of the Frontier Institute, a public policy think tank in Montana. For example, Powder River County has no physician, he said, but a grocery store in the county seat, Broadus, has a pharmacy.

As a clinical pharmacist practitioner for 15 years, Travis Schule of Kalispell wouldn’t be much affected by the passage of SB 112. In Montana, providers like him with additional education and training already have authority to prescribe under Montana’s existing rules.

But he sees the bill’s potential to expand access to treatment in Montana. In some cases, people might have to drive three hours to see a physician, and SB 112 would allow a pharmacist to serve as a “first triage” before they travel that long distance, Schule said.

“This bill is a patient-centric bill,” Schule said. “It’s not for pharmacists. It’s for patients.”

SB 112 is modeled after a bill passed in Idaho. Tim Flynn, a pharmacist at an Albertsons grocery store in Meridian, Idaho, said the legislation lets patients be treated for minor conditions, such as urinary tract infections, when they can’t schedule a doctor’s appointment or get to an urgent care clinic.

The Montana Medical Association and the Montana chapter of the American Academy of Pediatrics oppose SB 112. They say SB 112 would fragment care, risk patient safety, and substitute pharmacists for emergency care physicians.

But Montana Medical Association CEO Jean Branscum said there was an opportunity to build on the Idaho model, by bringing pharmacists and physicians together while making sure patients get the same standard of care.

“Let’s come up with a model of care that will allow pharmacists to do more than they do now, be a part of that team, practice at the highest level, and also appreciate the value of the physicians as part of that team too,” Branscum told lawmakers at the Jan. 18 hearing.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Part I: The State of the Abortion Debate 50 Years After ‘Roe’

January 26, 2023
The Host Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special two-part podcast, taped the week of the 50th anniversary of the Roe decision, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Panelists Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories Sarah Varney KHN @sarahvarney4 Read Sarah's stories

Among the takeaways from this week’s episode:

  • Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
  • The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
  • A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
  • Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
  • Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
  • Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
  • Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

Also this week, Rovner interviews Elizabeth Nash, who tracks state reproductive health policies for the Guttmacher Institute, a reproductive rights research group.

Credits Francis Ying Audio Producer Emmarie Huetteman Editor

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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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More Californians Are Dying at Home. Another Covid ‘New Normal’?

January 26, 2023

The covid-19 pandemic has spurred a surge in the proportion of Californians who are dying at home rather than in a hospital or nursing home, accelerating a slow but steady rise that dates back at least two decades.

The recent upsurge in at-home deaths started in 2020, the first year of the pandemic, and the rate has continued to climb, outlasting the rigid lockdowns at hospitals and nursing homes that might help explain the initial shift. Nearly 40% of deaths in California during the first 10 months of 2022 took place at home, up from about 36% for all of 2019, according to death certificate data from the California Department of Public Health. By comparison, U.S. Centers for Disease Control and Prevention data shows that about 26% of Californians died at home in 1999, the earliest year for which data on at-home deaths is accessible in the agency’s public database.

The trend is amplified among California residents with serious chronic conditions. About 55% of Californians who died of cancer did so at home during the first 10 months of 2022, compared with 50% in 2019 and 44% in 1999. About 43% of Californians who died of Alzheimer’s disease in the first 10 months of 2022 did so at home, compared with 34% in 2019 and nearly 16% in 1999.

Nationwide, the share of deaths occurring at home also jumped in 2020, to 33%, then rose to nearly 34% in 2021. Nationwide data for 2022 is not yet available.

Covid’s early, deadly sweep across California does not in itself explain the increase in at-home death rates; the vast majority of people who have died of covid died in a hospital or nursing home. Instead, medical experts said, the surge — at least initially — appears to coincide with sweeping policy changes in hospitals and nursing homes as caregivers struggled to contain a virus both virulent and little understood.

The sweeping bans on in-person visitation in hospitals and nursing homes, even to the bedsides of dying patients, created an agonizing situation for families. Many chose to move a loved one back home. “It was devastating to have Mom in a nursing home and dying, and the only way you can see Mom is through the window,” said Barbara Karnes, a registered nurse who has written extensively about end-of-life care.

At the same time, fears of covid exposure led many people to avoid hospitals in the first years of the pandemic, in some cases neglecting treatment for other serious conditions. That, too, is thought to have contributed to the rise in at-home deaths.

Those who specialize in end-of-life care say it is no surprise the trend has continued even as visitation policies have eased. They said more people simply want to die in a comfortable, familiar place, even if it means not fighting for every second of life with medical interventions.

“Whenever I ask, ‘Where do you want to be when you breathe your last breath? Or when your heart beats its last beat?’ no one ever says, ‘Oh, I want to be in the ICU,’ or ‘Oh, I want to be in the hospital,’ or ‘I want to be in a skilled nursing facility.’ They all say, ‘I want to be at home,’” said John Tastad, coordinator for the advance care planning program at Sharp HealthCare in San Diego.

Meanwhile, the physicians who specialize in the diseases that tend to kill Americans, such as cancer and heart disease, have become more accepting of discussing home hospice as an option if the treatment alternatives likely mean painful sacrifices in quality of life.

“There's been a little bit of a culture change where maybe oncologists, pulmonologists, congestive heart failure physicians are referring patients to palliative care earlier to help with symptom management, advanced care planning,” said Dr. Pouria Kashkouli, associate medical director for hospice at UC Davis Health.

The trends have created a booming industry. In 2021, the California Department of Health Care Access and Information listed 1,692 licensed hospice agencies in its tracking database, a leap from the 175 agencies it listed in 2002.

That much growth — and the money behind it — has sometimes led to problems. A 2020 investigation by the Los Angeles Times found that fraud and quality-of-care issues were common in California’s hospice industry, a conclusion bolstered by a subsequent state audit. Gov. Gavin Newsom signed a bill in 2021 that placed a temporary moratorium on most new hospice licenses and sought to rein in questionable kickbacks to doctors and agencies.

When done correctly, though, home hospice can be a comfort to families and patients. Hospice typically lasts anywhere from a few days to a few months, and while services vary, many agencies provide regular visits from nurses, health aides, social workers, and spiritual advisers.

Most people using hospice are insured through the federal Medicare program. The amount Medicare pays varies by region but is usually around $200 to $300 a day, said Dr. Kai Romero, chief medical officer at the nonprofit Hospice by the Bay.

To find quality end-of-life care, Andrea Sankar, a professor at Wayne State University and author of “Dying at Home: A Family Guide for Caregiving,” recommends seeking out nonprofit providers and having a list of questions prepared: How often will nurses visit in person? In what circumstances do patients have access to a physician? What help will be available for a crisis in the middle of the night?

While hospice providers offer crucial guidance and support, families need to be prepared to shoulder the bulk of the caregiving. “It really takes a pretty evolved family system to be able to rally to meet all of the needs,” said Tastad at Sharp HealthCare.

Several end-of-life experts said they expect the proportion of Californians choosing to die at home to keep climbing, citing a variety of factors: Medical advances will make it easier for patients to receive pain management and other palliative care at home; telemedicine will make it easier for patients to consult doctors from home; and two powerful forces in American health care — insurance companies and the federal government — increasingly see dying at home as an affordable alternative to lengthy hospital stays.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Florida Gov. DeSantis Falsely Claims Bivalent Booster Boosts Chances of Covid Infection

January 26, 2023

“Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

Florida Republican Gov. Ron DeSantis, on Jan. 17, 2023, during a press conference

As he proposed to extend the state’s ban on mandates for covid vaccines and face masks, Florida Republican Gov. Ron DeSantis lobbed a flurry of criticism at President Joe Biden and “the medical establishment.” 

“They were not following the science,” DeSantis said at a Jan. 17 press conference in Panama City Beach. “Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

Fewer than 11% of eligible Floridians have received an updated booster vaccine, according to the Centers for Disease Control and Prevention

The bivalent booster, which contains components of the original covid virus and the omicron variant, is designed to provide broad protection against illness or hospitalization from those covid strains. 

Research into the efficacy of the bivalent booster in preventing infection continues. 

Broadly speaking, covid vaccines do not prevent infection; they prevent the virus from spreading within the body and causing severe illness, according to Johns Hopkins University. Early CDC research shows that people who got the booster were 84% less likely to be hospitalized from covid.

The data collected on the booster’s ability to curb infection is early and limited. Some clinical trials have shown that bivalent shots are no more equipped to prevent people from contracting covid than the original vaccines. 

Although some people have suggested the bivalent booster offers little protection against infection, DeSantis went further. He said people who received the bivalent booster shot were more susceptible to covid than those who hadn’t.

The governor’s press office responded to PolitiFact’s inquiry about the claim, citing two articles and three studies, two of which are not yet peer-reviewed. The most recent came from the Cleveland Clinic and was discussed in an opinion article in The Wall Street Journal.

Dr. Nabin Shrestha, an infectious-disease physician and one of the study’s authors, told PolitiFact the data did not find a link between the bivalent shot and a higher risk of contracting covid. The early conclusion was the opposite of what DeSantis said: The dose is, in fact, effective in preventing infection.

DeSantis’ Conclusion Could Not Be Drawn From That Study

Cleveland Clinic researchers examined the bivalent booster’s effectiveness in preventing infection among 51,011 health care workers — some of whom had not received the booster — from September to December 2022. Pfizer and Moderna offer the bivalent booster, which the FDA authorized in August. 

Over those four months, about 5% of the clinic’s employees contracted covid. The researchers then estimated that the bivalent booster was about 30% effective in reducing the likelihood of contracting the virus. 

The Cleveland Clinic researchers were not trying to determine the bivalent vaccine’s effectiveness in preventing severe illness or hospitalization. 

“The study wasn’t measuring the vaccine causing infection,” said Jill Roberts, a public health professor at the University of South Florida. “The study was measuring the efficacy of the bivalent vaccine in preventing infection.”

What drove coverage in outlets like The Wall Street Journal was an “unexpected” association researchers found between the number of prior vaccine doses and an increased risk of contracting covid. People with three or more doses of the vaccine had a higher chance of getting infected. 

That finding quickly overshadowed the protection the bivalent shot provided. The Wall Street Journal opinion piece cited the Cleveland Clinic’s study as evidence that vaccine boosters are making “the population as a whole” more vulnerable to covid. 

Andrea Pacetti, the Cleveland Clinic’s public and media relations director, told PolitiFact that the study population, whose average age was 42, is not reflective of the general public. 

“The study was done in a younger, relatively healthy, health care employee population. It included no children, very few elderly individuals and likely few immunocompromised individuals,” Pacetti said. “Therefore, we urge caution in generalizing the findings to the public, which can include different populations.” 

More than 50% of the health care workers participating in the clinic’s study had received three or more doses of a covid vaccine; only 12% were not vaccinated. 

Dr. René Najera, an epidemiologist and director of the Center for Public Health at the College of Physicians of Philadelphia, said the Cleveland Clinic study’s outcome was unsurprising given the characteristics of the research subjects — mostly vaccinated health care workers.

If the majority of the study population received three or more doses of a covid vaccine, for instance, then it is reasonable to assume that the majority of covid cases would occur in that population.

“Those who were studied were health care workers: more likely to be exposed, more likely to be vaccinated as well,” Najera told PolitiFact. “If the study is found to be sound through peer review, its findings would only be applicable to health care workers in large settings such as the Cleveland Clinic, not the general public.”

Pacetti further emphasized that the study has not yet been peer-reviewed, and “more research is needed to either confirm or refute this finding.” 

The Cleveland Clinic acknowledged that two other studies had found a similar association between the number of prior vaccine doses and an increased risk of contracting covid, though it had similar limitations. 

One of the studies had not yet been peer-reviewed, and the other examined only health care employees. And even with that finding, the Cleveland Clinic’s study did not suggest the bivalent booster increased the likelihood of infection. 

DeSantis’ “statement is incorrect,” Najera said. “That conclusion cannot be drawn from that study, and the authors state that it is not designed to evaluate that association.” 

Our Ruling

DeSantis said, “Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

An unpublished study from the Cleveland Clinic examined the bivalent covid booster’s effectiveness in preventing infection among a group of about 50,000 health care workers. 

However, one of the study’s authors told PolitiFact that the research did not find an association with the bivalent booster and a higher risk of covid. The study found that the bivalent booster is 30% effective in preventing infection from the virus.

The researchers did find that there could be an association between the number of prior vaccine doses and an increased risk of contracting covid. Still, that finding did not suggest the bivalent booster could cause infection or increase the likelihood of infection. 

We rate DeSantis’ claim False.

Our Sources

Gov. Ron DeSantis’ Rumble, “Permanent Protections Against the COVID-19 Biomedical Security State,” Jan. 17, 2023

Cleveland Clinic, “Effectiveness of the Coronavirus Disease 2019 (COVID-19) Bivalent Vaccine,” accessed Jan. 19, 2023

Email interview with Bryan Griffin, press secretary for Gov. Ron DeSantis, Jan. 19, 2023

Email interview with Jill Roberts, professor of public health at the University of South Florida, Jan. 19, 2023

Email interview with Dr. René Najera, an epidemiologist and director of the Center for Public Health at the College of Physicians of Philadelphia, Jan. 19, 2023

Email interview with Andrea Pacetti, director of public and media relations for the Cleveland Clinic, Jan. 19, 2023

The Washington Post, “No, Vaccines Aren’t Making New Covid Variants Worse,” Jan. 6, 2023

U.S. Centers for Disease Control and Prevention, COVID data tracker, accessed Jan. 19, 2023

U.S. Centers for Disease Control and Prevention, “Early Estimates of Bivalent mRNA Vaccine Effectiveness in Preventing COVID-19–Associated Hospitalization,” Jan. 20, 2023

The Wall Street Journal, “Are Vaccines Fueling New Covid Variants?” Jan. 1, 2023

U.S. Food and Drug Administration, “Rumor Control,” accessed Jan. 19, 2023

The Lancet, “The Vaccinated Proportion of People With COVID-19 Needs Context,” accessed Jan. 19, 2023

Tampa Bay Times, “DeSantis Wants Ban on COVID Mask and Vaccine Mandates to Be Permanent,” Jan. 17, 2023

PolitiFact, “Why Were the Recent COVID-19 Boosters Authorized Before Human Trials Were Completed?” Sept. 13, 2022

MedRxiv, “A Bivalent Omicron-Containing Booster Vaccine Against Covid-19,” accessed Jan. 19, 2023

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Wave of Rural Nursing Home Closures Grows Amid Staffing Crunch

January 25, 2023

WAUKON, Iowa — Marjorie Kruger was stunned to learn last fall that she would have to leave the nursing home where she’d lived comfortably for six years.

The Good Samaritan Society facility in Postville, Iowa, would close, administrators told Kruger and 38 other residents in September. The facility joined a growing list of nursing homes being shuttered nationwide, especially in rural areas.

“The rug was taken out from under me,” said Kruger, 98. “I thought I was going to stay there the rest of my life.”

Her son found a room for her in another Good Samaritan center in Waukon, a small town 18 miles north of Postville. Kruger said the new facility is a pleasant place, but she misses her friends and longtime staffers from the old one. “We were as close as a nice family,” she said.

The Postville facility’s former residents are scattered across northeastern Iowa. Some were forced to move twice, after the first nursing home they transferred to also went out of business.

Owners say the closures largely stem from a shortage of workers, including nurses, nursing assistants, and kitchen employees.

The problem could deepen as pandemic-era government assistance dries up and care facilities struggle to compete with rising wages offered by other employers, industry leaders and analysts predict. Many care centers that have managed to remain open are keeping some beds vacant because they don’t have enough workers to responsibly care for more residents.

The pandemic brought billions of extra federal dollars to the long-term care industry, which was inundated with covid-19 infections and more than 160,000 resident deaths. Many facilities saw business decline amid lockdowns and reports of outbreaks. Staff members faced extra danger and stress.

The industry is still feeling the effects.

From February 2020 to November 2021, the number of workers in nursing homes and other care facilities dropped by 410,000 nationally, according to the federal Bureau of Labor Statistics. Staffing has rebounded only by about 103,000 since then.

In Iowa, 13 of the 15 nursing homes that closed in 2022 were in rural areas, according to the Iowa Health Care Association. “In more sparsely populated areas, it’s harder and harder to staff those facilities,” said Brent Willett, the association’s president. He noted that many rural areas have dwindling numbers of working-age adults.

The lack of open nursing home beds is marooning some patients in hospitals for weeks while social workers seek placements. More people are winding up in care facilities far from their hometowns, especially if they have dementia, obesity, or other conditions that require extra attention.

Colorado’s executive director of health care policy and financing, Kim Bimestefer, told a conference in November that the state recognizes it needs to help shore up care facilities, especially in rural areas. “We’ve had more nursing homes go bankrupt in the last year than in the last 10 years combined,” she said.

In Montana, at least 11 nursing homes — 16% of the state’s facilities — closed in 2022, the Billings Gazette reported.

Nationally, the Centers for Medicare & Medicaid Services reported recently that 129 nursing homes had closed in 2022. Mark Parkinson, president of the American Health Care Association, said the actual count was significantly higher but the federal reports tend to lag behind what’s happening on the ground.

For example, a recent KHN review showed the federal agency had tallied just one of the 11 Montana nursing home closures reported by news outlets in that state during 2022, and just eight of the 15 reported in Iowa.

Demand for long-term care is expected to climb over the next decade as the baby boom generation ages. Willett said his industry supports changing immigration laws to allow more workers from other countries. “That’s got to be part of the solution,” he said.

The nursing home in Postville, Iowa, was one of 10 care centers shuttered in the past year by the Good Samaritan Society, a large chain based in South Dakota.

“It’s an absolute last resort for us, being a nonprofit organization that would in many cases have been in these communities 50 to 75 years or more,” said Nate Schema, the company’s CEO.

The Evangelical Lutheran Good Samaritan Society, the full name of the company, is affiliated with the giant Sanford Health network and serves 12,500 clients, including residents of care facilities and people receiving services in their homes. About 70% of them live in rural areas, mainly in the Plains states and Midwest, Schema said.

Schema said many front-line workers in nursing homes found less stressful jobs after working through the worst days of the covid pandemic, when they had to wear extra protective gear and routinely get screened for infection in the face of ongoing risk.

Lori Porter, chief executive officer of the National Association of Health Care Assistants, said nursing home staffing issues have been building for years. “No one that’s been in this business is in shock over the way things are,” she said. “The pandemic put a spotlight on it.”

Porter, who has worked as a certified nursing assistant and as a nursing home administrator, said the industry should highlight how rewarding the work can be and how working as an aide can lead to a higher-paying job, including as a registered nurse.

Care industry leaders say that they have increased wages for front-line workers but that they can’t always keep up with other industries. They say that’s largely because they rely on payments from Medicaid, the government program for low-income Americans that covers the bills for more than 60% of people living in nursing homes.

In recent years, most states have increased how much their Medicaid programs pay to nursing homes, but those rates are still less than what the facilities receive from other insurers or from residents paying their own way. In Iowa, Medicaid pays nursing homes about $215 per day per resident, according to the Iowa Health Care Association. That compares with about $253 per day for people paying their own way. When nursing homes provide short-term rehabilitation for Medicare patients, they receive about $450 per day. That federal program does not cover long-term care, however.

Willett said a recent survey found that 72% of Iowa’s remaining nursing homes were freezing or limiting admissions below their capacity.

The Prairie View nursing home in Sanborn is one of them. The facility, owned by a local nonprofit, is licensed for up to 73 beds. Lately, it has been able to handle only about 48 residents, said administrator Wendy Nelson.

“We could take more patients, but we couldn’t give them the care they deserve,” she said.

Prairie View’s painful choices have included closing a 16-bed dementia care unit last year.

Nelson has worked in the industry for 22 years, including 17 at Prairie View. It never has been easy to keep nursing facilities fully staffed, she said. But the pandemic added stress, danger, and hassles.

“It drained the crud out of some people. They just said, ‘I’m done with it,’” she said.

Prairie View has repeatedly boosted pay, with certified nursing assistants now starting at $21 per hour and registered nurses at $40 per hour, Nelson said. But she’s still seeking more workers.

She realizes other rural employers also are stretched.

“I know we’re all struggling,” Nelson said. “Dairy Queen’s struggling too, but Dairy Queen can change their hours. We can’t.”

David Grabowski, a professor of health care policy at Harvard Medical School, said some of the shuttered care facilities had poor safety records. Those closures might not seem like a tragedy, especially in metro areas with plenty of other choices, he said.

“We might say, ‘Maybe that’s the market working, the way a bad restaurant or a bad hotel is closing,’” he said. But in rural areas, the closure of even a low-quality care facility can leave a hole that’s hard to fill.

For many families, the preferred alternative would be in-home care, but there’s also a shortage of workers to provide those services, he said.

The result can be prolonged hospital stays for patients who could be served instead in a care facility or by home health aides, if those services were available.

Rachel Olson, a social worker at Pocahontas Community Hospital in northwestern Iowa, said some patients wait a month or more in her hospital while she tries to find a spot for them in a nursing home once they’re stable enough to be transferred.

She said it’s particularly hard to place certain types of patients, such as those who need extra attention because they have dementia or need intravenous antibiotics.

Olson starts calling nursing homes close to the patient’s home, then tries ones farther away. She has had to place some people up to 60 miles away from their hometowns. She said families would prefer she find something closer. “But when I can’t, I can’t, you know? My hands are tied.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Unmet Needs: Critics Cite Failures in Health Care for Vulnerable Foster Children

January 25, 2023

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One night last month, a 9-year-old boy who had autism and talked about killing himself was among about 70 foster care children and youth under state supervision sleeping in hotels across Georgia.

Georgia’s designated health insurer for foster care, Amerigroup Community Care, had denied the boy placement in a psychiatric residential treatment facility, said Audrey Brannen, coordinator of complex care for Georgia’s child welfare agency. He stayed in a hotel for more than a month before receiving a temporary emergency placement in a foster home, she said.

The boy and the other children staying in the hotels lacked permanent placements, Brannen said, and many weren’t getting help for their complex mental and behavioral needs.

The frustration over gaps in care had gotten so bad that Candice Broce, commissioner of the Georgia Department of Human Services, sent a scathing six-page letter to the state Medicaid agency in August — signaling an unusual interagency conflict. She argued that Amerigroup, a unit of Elevance Health, isn’t being held accountable for failures in care, and that its foster care contract should not be renewed.

“Simply put, the state’s most vulnerable children cannot access the physical, mental, or behavioral health treatment they need — and deserve,” Broce wrote.

Amerigroup declined to comment on Broce’s remarks specifically, saying it had not seen her letter. But Michael Perry, an Amerigroup Georgia spokesperson, said the insurer hosts collaborative monthly meetings with state agencies to hear any concerns and will “continue to work on behalf of these vulnerable individuals to ensure they have access to the appropriate healthcare and support services they need to be successful.”

Such problems extend beyond Georgia, according to Sandy Santana, executive director of the national advocacy group Children’s Rights. While foster care grabs headlines mainly in cases of abuse or neglect — even deaths — the failures of states and insurers in providing adequate health care for these children are widespread and occur largely without public scrutiny.

“These kids cycle in and out of ERs, and others are not accessing the services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care problems. “This is an issue throughout the country.”

Nearly all children in foster care are eligible for Medicaid, the state-federal program for those with low incomes, but states decide on the delivery mechanism. Georgia is among at least 10 states that have turned to managed-care companies to deliver specialized services exclusively for foster kids and others under state supervision. At least three more — North Carolina, New Mexico, and Oklahoma — are taking similar steps. But regardless of the structure, getting timely access to care for many of these vulnerable kids is a problem, Santana said.

Obtaining mental health care for privately insured children can be a struggle too, of course, but for children in state custody, the challenge is even greater, said Dr. Lisa Zetley, a Milwaukee pediatrician and chair of the American Academy of Pediatrics’ Council on Foster Care, Adoption, and Kinship Care.

“This is a unique population,” she said. “They have experienced quite of bit of toxic stress prior to entering foster care.”

For states that use specialty managed care for these kids, transparency and oversight remain spotty and the quality of the care remains a troubling unknown, said Andy Schneider, a research professor at Georgetown University’s Center for Children and Families.

Illinois, for example, has paid more than $350 million since 2020 to insurance giant Centene Corp. to manage health coverage for more than 35,000 current and former foster care children. But last year, an investigation by the Illinois Answers Project newsroom found Centene’s YouthCare unit repeatedly failed to deliver basic medical services such as dental visits and immunizations to thousands of these kids. Federal officials are now probing allegations about the contract.

Centene said YouthCare has not been informed of any probe. In a statement, the company said Illinois Answers Project’s reporting was based on outdated information and didn’t account for its recent progress as it works “to ensure that families have the access they need to high-quality care and services.”

In some cases, child advocates say, the care kids do get is not appropriate. In Maryland, the local branch of the American Civil Liberties Union, Disability Rights Maryland, and Children’s Rights filed a lawsuit this month against the state accusing it of failing to conduct adequate oversight of psychotropic drug prescribing for children in its foster care system. As many as 34% the state’s foster children are given psychotropic drugs, court documents said, although most of them don’t have a documented psychiatric diagnosis.

In Georgia, Lisa Rager said she and her husband, Wes, know well the hurdles to obtaining services for foster kids. The suburban Atlanta couple has cared for more than 100 foster children and adopted 11 of them from state custody.

She said one child waited more than a year to see a specialist. Getting approvals for speech or occupational therapy is “a lot of trouble.”

Rager said she pays out-of-pocket for psychiatric medications for three of her children because of insurance hassles. “It’s better for me to pay cash than wait on Amerigroup,” she said.

Such problems occur often, Broce said in her letter. Amerigroup’s “narrow definition for ‘medically necessary services’ is — on its face — more restrictive than state and federal standards,” she wrote.

“Far too often, case managers and foster families are told that the next available appointment is weeks or months out,” she told the state’s Joint Appropriations Committee on Jan. 17. Broce added that her agency has formed a legal team to fight Amerigroup treatment denials.

Amerigroup’s Perry said its clinical policies are approved by the state, and follow regulatory and care guidelines.

In a recent 12-month period, Amerigroup received $178.6 million in government funds for its specialty foster care plan that serves about 32,000 Georgia children, with the large majority being foster children and kids who have been adopted from state custody. The contract is currently up for rebidding.

David Graves, a spokesperson for the Department of Community Health, which runs Medicaid in the state, said the agency would not comment on Broce’s letter because it’s part of the contract renewal process. Graves said the agency regularly monitors the quality of care that children in state custody receive. He pointed to a state report that showed Amerigroup did well on several metrics, such as use of asthma medication.

But Melissa Haberlen DeWolf, research and policy director for the nonprofit Voices for Georgia’s Children, said the majority of kids cycling through the state’s emergency departments for mental illness are in foster care.

“The caregivers we speak to are desperate for behavioral health care coordination help — finding providers and getting appointments, understanding how to manage behaviors and medication, and prevent crises, and sharing health information between providers,” she said.

To fix these problems, Zetley, the pediatrician, recommends creating a larger benefit package for foster kids, coordinating care better, and raising Medicaid reimbursement rates to attract more providers to these managed-care networks.

Contracts with managed-care companies also should be performance-based, with financial penalties if needed, said Kim Lewis, managing attorney of the National Health Law Program’s Los Angeles offices.

“Managed care is only as good as the state’s ability to manage the contract and to make sure that what they’re getting is what they are paying for,” she said. “It doesn’t work by just, you know, hoping for the best and ‘Here’s the check.’”

But in Georgia, the state has never financially penalized Amerigroup for failing to meet contractually mandated quality standards, Department of Community Health spokesperson Graves confirmed. He said the agency and Amerigroup work to resolve any issues brought to their attention.

Georgia has set up an oversight committee, with public meetings, to monitor the quality of Amerigroup’s performance. But the committee hasn’t met since August 2020, the state said last month. After KHN queries, Graves said the panel would start meeting again this year.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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As States Seek to Limit Abortions, Montana Wants to Redefine What Is Medically Necessary

January 24, 2023

Montana’s conservative leaders, stymied by the courts from passing laws that impose significant statewide abortion restrictions, seek to tighten the state’s Medicaid rules to make it more difficult for low-income women to receive abortions.

The Montana Department of Public Health and Human Services is proposing to define when an abortion is medically necessary, limit who can perform such services, and require preauthorization for most cases.

The push to change the regulations is borne of a belief by Republican Gov. Greg Gianforte’s administration that health providers are using existing rules that allow Medicaid reimbursements to cover abortions that aren’t medically necessary.

“Taxpayers shouldn’t foot the bill for elective abortions,” said Gianforte spokesperson Brooke Stroyke.

Medical professionals have said the term “elective abortions” can misrepresent the complex reasons someone may seek an abortion and constrain health providers from making their best clinical judgment. Laurie Sobel, associate director of Women’s Health Policy at KFF, said that appears to be the aim of the Montana proposal’s focus on defining medically necessary abortions.

“It looks like Montana’s trying to curtail abortion access under Medicaid and take the conversation of ‘medically necessary’ away from a physician and a patient,” Sobel said.

Democratic lawmakers and many health providers have said existing state rules ensure providers consider and document why an abortion is needed to protect a patient.

Democratic state Rep. Ed Stafman, who recently chaired the Children, Families, Health, and Human Services Interim Committee, said the proposed changes are unnecessary because the state already complies with federal Medicaid rules on abortion.

“It’s clear that this is part of the anti-abortion agenda,” Stafman said.

States are barred from using federal funds to pay for abortions except in cases of rape or incest, or when a woman’s life is at risk. However, states have the option of using their own money to allow reimbursements under the joint state-federal Medicaid program in other circumstances.

Montana is one of 16 states that allow the use of state Medicaid funds for abortions deemed medically necessary. A study published in 2017 in the journal Obstetrics & Gynecology found that states with Medicaid coverage of medically necessary abortions had a reduced risk of severe maternal morbidity for that population, 16% on average, compared with states without that coverage.

Montana’s proposed changes are more restrictive than the rules in many of the other states that allow medically necessary Medicaid abortions. At least nine states that use state funds to pay for Medicaid abortions don’t require health providers to report the circumstances for an abortion, according to a 2019 U.S. Government Accountability Office report on state compliance with abortion coverage rules. For example, California’s Medi-Cal program does not require any medical justification for abortions, and requires preauthorization only when the patient needs to be hospitalized.

Most of the states that permit medically necessary Medicaid abortions, including Montana, are under court orders to fund the procedure as they would other general health services for low-income people.

Montana’s coverage is tethered to a 1995 court case that determined the state’s Medicaid program was established to provide “necessary medical services” and the state can’t exclude specific services. The state’s existing eligibility rules governing when a Medicaid-funded service is medically necessary include when a pregnancy would cause suffering, pain, or a physical deformity; result in illness or infirmity; or threaten to cause or aggravate a disability.

Under the health department’s new proposal, abortions would be determined to be medically necessary only when a physician — not another type of provider — certifies a patient suffers from an illness, condition, or injury that threatens their life or has a physical or psychological condition that would be “significantly aggravated” by pregnancy.

Elsewhere, courts have rejected some states’ attempts to create a definition for medically necessary abortions apart from existing Medicaid standards as constitutional violations of equal protection. The Alaska Supreme Court struck down a 2013 state law changing the definition of a medically necessary abortion because it treated Medicaid beneficiaries who wanted an abortion differently than those seeking pregnancy-related procedures like a cesarean section. And New Mexico’s high court said in 1999 that a state rule limiting Medicaid-funded abortions applied different standards of medical necessity to men and women.

Montana opponents of the proposed changes have threatened to sue if the regulations are adopted.

The state’s Medicaid program covers more than 153,900 women. From 2011 through 2021, the program paid for 5,614 abortion procedures, which typically represents nearly a third of all abortions in the state, according to state data.

Currently in Montana, doctors, physician assistants, and advanced nurse practitioners are allowed to perform abortions. At least one Montana clinic that provides abortions to Medicaid beneficiaries is run by a nurse practitioner, All Families Healthcare’s Helen Weems, who is suing the state for trying to block nurses from performing abortions.

Medical providers make the decision of whether an abortion is medically necessary and submit a form afterward to the state health department.

The proposed change would require providers to get state approval before performing an abortion, except in emergencies, and submit supporting documents to justify the medical necessity. That preauthorization process would entail providing state officials details of patients’ medical history, such as how many pregnancies a person has had, the date of their last menstrual cycle, whether they smoke, the results of any pregnancy tests, and whether they have ever had behavioral health issues or substance use disorders.

Martha Fuller, president and CEO of Planned Parenthood of Montana, said providers already collect that information but don’t send it to the state. If they are required to do so, she said, that will have a chilling effect that may keep people from seeking help or lead them to pay for it out-of-pocket, if they can.

“Patients could feel like, ‘Oh, and everything that I tell you, it’s going to be now shared with my insurer for the purpose of them making a decision about whether or not I can have an abortion?’” Fuller said.

In Montana, a patient seeking an abortion via medication typically gets that through nurse practitioners or physician assistants instead of going through one of the few physicians who provide that care through Medicaid, Fuller said. She said Medicaid patients would see longer wait times if the new rules are put in place as they wait to see a physician. And waiting for prior authorization would add to the time in limbo.

Telehealth helps provide access amid scattered resources across the big, rural state, but Montana’s proposed changes would require a physical examination.

“Patients might have to make a more invasive procedure. They may have to travel. They have to take more time off from work,” Fuller said. “There will be patients who will decide not to seek abortion care because they cannot afford it.”

Of the 1,418 abortions covered by Montana Medicaid in 2020 and 2021, state records show, one was performed because a person’s life was in danger. The rest were performed under the broader medically necessary justification, with paperwork about those cases including a brief explanation for why the procedure was needed.

According to the state’s proposed rules, the lack of supporting documentation for the procedures leads “the department to reasonably believe that the Medicaid program is paying for abortions that are not actually medically necessary.”

In 2021, state lawmakers passed and Gianforte signed three laws restricting abortions that a court temporarily blocked. The Montana Supreme Court upheld the injunction, arguing that the state constitution’s right-to-privacy provision extends to abortion.

Gianforte and the state attorney general have called on the Montana Supreme Court to strike down the two-decade-old ruling that tied abortion to the right to privacy. Republican lawmakers also have filed a slew of abortion-related bills in the legislative session, including one proposal to exclude abortion from the state’s right-to-privacy protections.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Latino Teens Are Deputized as Health Educators to Sway the Unvaccinated

January 24, 2023

Classmates often stop Alma Gallegos as she makes her way down the bustling hallways of Theodore Roosevelt High School in southeast Fresno, California. The 17-year-old senior is frequently asked by fellow students about covid-19 testing, vaccine safety, and the value of booster shots.

Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help prevent serious illness, hospitalization, and death, and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, 51% of unvaccinated Latinos said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although nearly 88% of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated fewer than 13% of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. FACES for the Future Coalition, a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the Health Information Project in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called Promotoritos, adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. Studies show that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of Fresno Building Healthy Communities, one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a widespread labor shortage in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a California Health Care Foundation report.

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Adolescentes latinos se entrenan para educar sobre las vacunas contra covid

January 24, 2023

Los compañeros de clase paran a menudo a Alma Gallegos en los bulliciosos pasillos de la secundaria Theodore Roosevelt, en el sureste de Fresno. Le preguntan a la estudiante de 17 años sobre pruebas para covid-19, la seguridad de las vacunas, y el valor de las inyecciones de refuerzo.

Alma se ganó su reputación como fuente de información fiable gracias a sus prácticas como trabajadora comunitaria de salud.

Fue una de los 35 estudiantes del condado de Fresno a los que se formó recientemente para explicar cómo las vacunas de covid ayudan a prevenir enfermedades graves, hospitalizaciones y muertes, y para animar a familiares, compañeros y miembros de la comunidad a estar al día con sus vacunas, incluidas las de refuerzo.

Cuando Alma terminó sus prácticas en octubre, ella y siete compañeros de equipo evaluaron su trabajo en un proyecto final. Los estudiantes estaban orgullosos de poder llevar a cabo este trabajo de divulgación sobre las vacunas.

Alma convenció a su familia para que se vacunara. Dijo que sus familiares, que habían recibido información sobre covid a través de las noticias en español, no creían en los riesgos hasta que murió un amigo cercano de la familia.

“Te dan ganas de saber más”, dijo Alma. “Ahora toda mi familia está vacunada, pero aprendimos por las malas”.

Organizaciones comunitarias de salud en California y en todo el país forman a adolescentes, muchos de ellos latinos, para que actúen como educadores de la salud en la escuela, en las redes sociales y en las comunidades donde persiste el miedo a la vacuna contra covid.

Según una encuesta de 2021 encargada por Voto Latino y realizada por Change Research, el 51% de los latinos no vacunados dijeron que no confiaban en la seguridad de las vacunas. La cifra se dispara hasta el 67% en el caso de aquellos cuyo idioma principal en casa es el español. Las razones más comunes para rechazar la vacuna incluyen no confiar en su eficacia y no confiar en los fabricantes de la vacuna.

Y las dudas sobre las vacunas no solo prevalecen entre los no vacunados. Aunque casi el 88% de hispanos y latinos han recibido al menos una dosis de la vacuna contra covid, pocos afirman estar al día en sus vacunas, según los Centros para el Control y la Prevención de Enfermedades (CDC).

Los CDC estiman que menos del 13% de los latinos han recibido un refuerzo bivalente, una vacuna actualizada que los funcionarios de salud pública recomiendan para proteger contra las nuevas variantes del virus.

Proveedores y activistas de salud creen que los jóvenes, como Alma, están bien posicionados para ayudar a aumentar esas cifras de vacunación, especialmente cuando ayudan a navegar por el sistema sanitario a sus familiares hispanohablantes.

“Tiene sentido que consideremos a nuestros jóvenes como educadores en materia de vacunas ante sus compañeros y familias”, afirmó el doctor Tomás Magaña, profesor del departamento de pediatría de la Universidad de California-San Francisco. “Y cuando hablamos de la comunidad latina, tenemos que pensar con seriedad y creatividad en cómo llegar a ellos”.

Algunos programas de formación utilizan modelos para estudiantes en los campus, mientras que otros enseñan a los adolescentes a abrirse camino en sus comunidades.

FACES for the Future Coalition, una organización de jóvenes con sede en Oakland, aprovecha programas en California, Nuevo México, Colorado y Michigan para convertir a los estudiantes en educadores sobre la vacuna contra covid.

Y el Health Information Project de Florida, que forma a estudiantes de primer y segundo año de secundaria para que enseñen a los de primer año sobre salud física y emocional, integra la seguridad de la vacuna contra covid en su plan de estudios.

En Fresno, el programa para jóvenes trabajadores comunitarios de la salud, llamado Promotoritos, adoptó el modelo promotoras.

Las promotoras son trabajadoras sanitarias, sin licencia, de las comunidades latinas encargadas de orientar a las personas hacia los recursos médicos y promover mejores opciones de estilo de vida. Los estudios demuestran que las promotoras son miembros de confianza de la comunidad, lo que las sitúa en una posición privilegiada para ofrecer educación y divulgación sobre las vacunas.

“Los adolescentes se comunican de forma diferente, y obtienen una gran respuesta”, afirmó Sandra Celedon, CEO de Fresno Building Healthy Communities, una de las organizaciones que ayudó a diseñar el programa de prácticas para estudiantes de 16 años o más. “Durante los eventos de divulgación, todos quieren hablar con los jóvenes”.

Los adolescentes que participan en Promotoritos son principalmente latinos, inmigrantes indocumentados, estudiantes refugiados o hijos de inmigrantes. Reciben 20 horas de formación, que incluyen estrategias de campaña en las redes sociales. Por ello, obtienen créditos escolares y el año pasado les pagaron $15 la hora.

“Nadie piensa en estos chicos como becarios”, señaló Celedon. “Así que queríamos crear una oportunidad para ellos porque sabemos que estos son los estudiantes que más se pueden beneficiar de unas prácticas remuneradas”.

El otoño pasado, Alma, que es latina, y otros tres jóvenes trabajadores comunitarios de salud distribuyeron kits de pruebas covid en negocios locales de su barrio.

Su primera parada fue Tiger Bite Bowls, un restaurante de fusión asiática. Los adolescentes hablaron con el propietario del restaurante, Chris Vang, y le preguntaron si tenía alguna duda sobre covid. Al final de la conversación, le entregaron un puñado de kits de pruebas.

“Creo que es bueno que estén concienciados y no tengan miedo de compartir sus conocimientos sobre covid”, afirmó Vang. “Voy a entregar estas pruebas a quien las necesite: clientes y empleados”.

Otro beneficio del programa: los jóvenes se familiarizan con las carreras en el campo de la salud.

California se enfrenta a una escasez generalizada de mano de obra en el sector sanitario, y los profesionales de la salud no siempre reflejan la creciente diversidad de la población del estado.

Hispanos y latinos representan el 39% de la población de California, pero son solo el 6% de los médicos del estado y el 8% de los licenciados en medicina, según un informe de la California Health Care Foundation.

Alma se unió al programa en junio después de ver un folleto en la oficina del consejero escolar. Dijo que era su forma de ayudar a evitar que otras familias perdieran a un ser querido.

Ahora está interesada en convertirse en radióloga.

“A mi edad”, añadió Alma, “esta es la manera perfecta de contribuir con mi comunidad”.

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Transgender People in Rural America Struggle to Find Doctors Willing or Able to Provide Care

January 23, 2023

For Tammy Rainey, finding a health care provider who knows about gender-affirming care has been a challenge in the rural northern Mississippi town where she lives.

As a transgender woman, Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’”

So Rainey drives around 170 miles round trip every six months to get a supply of estrogen from a clinic in Memphis, Tennessee, to take home with her.

The obstacles Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural U.S. often face: a general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama-Birmingham.

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states to estimate that roughly 1 in 6 transgender adults in the U.S. live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, according to the Williams Institute, a nonprofit think tank at the UCLA School of Law.

One in 3 trans people in rural areas experienced discrimination by a health care provider in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. Additionally, a third of all trans individuals report having to teach their doctor about their health care needs to receive appropriate care, and 62% worry about being negatively judged by a health care provider because of their sexual orientation or gender identity, according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as all transgender adults to travel 25 to 49 miles for routine care.

In Colorado, for example, many trans people outside Denver struggle to find proper care. Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the Colorado Transgender Health Survey published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health themes in their curriculum, with half providing three or fewer classes on this topic.

Perhaps because of this, almost 77% of students from 10 medical schools in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use appropriate pronouns and trans-inclusive language.

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the organization created a four-week boot camp in 2021 for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Dr. Caroline Kirsch, director of osteopathic education at the University of Wyoming Family Medicine Residency Program-Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide experience a rise in harassment and threats. For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the target of far-right hate on social media last year. After growing pressure from Tennessee’s Republican lawmakers, the clinic paused gender-affirmation surgeries on patients younger than 18, potentially leaving many trans kids without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Abortion Debate Ramps Up in States as Congress Deadlocks

January 23, 2023

Anti-abortion advocates are pressing for expanded abortion bans and tighter restrictions since the Supreme Court overturned the national right to abortion. But with the debate mostly deadlocked in Washington, the focus is shifting to states convening their first full legislative sessions since Roe v. Wade was overturned.

Although some state GOP lawmakers have filed bills to ban abortion pills or make it more difficult for women to travel out of state for an abortion, others seem split about what their next steps should be. Some are even considering measures to ease their states’ existing bans somewhat, particularly after Republicans’ less-than-stellar showing in the 2022 midterm elections and voters’ widespread support for abortion on state ballot measures.

Meanwhile, Democratic-led states are looking to shore up abortion protections, including Minnesota and Michigan, where Democrats sewed up legislative majorities in the November elections.

Anti-abortion groups said their goal in overturning Roe v. Wade was to turn the decision back to the states, but now they are making clear that what they want is an encompassing national abortion ban.

“Legislation at the state and federal levels should provide the most generous protections possible to life in the womb,” says the “Post-Roe Blueprint” of the anti-abortion group Students for Life.

The new Republican-led House showed its anti-abortion bona fides on its first day of formal legislating, Jan. 11, passing two pieces of anti-abortion legislation that are unlikely to become law with a Senate still controlled by Democrats and President Joe Biden in the White House.

So at the federal level, the fight is taking shape in the courts over the abortion pill mifepristone, which has been used as part of a two-drug regimen for more than two decades, and recently became the way a majority of abortions in the U.S. are conducted.

The Biden administration has moved to make mifepristone more widely available by allowing it to be distributed by pharmacies, as well as clarifying that it is legal to distribute the pills via the U.S. mail. But the conservative legal group Alliance Defending Freedom, on behalf of several anti-abortion groups, filed a federal lawsuit in Texas in November, charging that the FDA never had the authority to approve the drug in the first place.

In Texas, some lawmakers are exploring new ways to chip away at Texans’ remaining sliver of access to abortions. For example, one proposal would prevent local governments from using tax dollars to help people access abortion services out of state, while another would prohibit tax subsidies for businesses that help their local employees obtain abortions out of state.

Those measures could get lost in the shuffle of the state’s frantic 140-day, every-other-year session, if legislative leaders don’t consider them a priority. The state’s trigger law banning almost all abortions that went into effect last year “appears to be working very well,” said Joe Pojman, founder and executive director of Texas Alliance for Life, an anti-abortion group. In August 2022, three abortions were documented in the state, down from more 5,700 reported during the same month a year earlier, according to the most recent state data.

The top state House Republican said his priority is boosting support for new moms, for example, by extending postpartum Medicaid coverage to 12 months.

It’s “an opportunity for the Texas House to focus more than ever on supporting mothers and children,” said Republican House Speaker Dade Phelan.

South Dakota Gov. Kristi Noem, a Republican, struck a similar theme in a Jan. 10 speech, saying she will introduce bills to expand a program for nurses to visit new mothers at home and help state employees pay for adoptions. Previously, Noem said South Dakota needs to focus “on taking care of mothers in crisis and getting them the resources that they need for both them and their child to be successful.”

Some Texas GOP lawmakers indicated they may be open to carving out exceptions to the abortion ban in cases of rape and incest. And a Republican lawmaker plans to attempt to modify South Dakota’s ban, which allows abortions only for life-threatening pregnancies, to clarify when abortions are medically necessary.

“Part of the issue right now is that doctors and providers just don’t know what that line is,” said state Rep. Taylor Rehfeldt, a nurse who has experienced miscarriages and high-risk pregnancies herself.

Rehfeldt wants to reinstate a former law that allows abortions for pregnancies that could cause serious, irreversible physical harm to a “major bodily function.” Rehfeldt said she is also working on bills to allow abortions for people carrying non-viable fetuses, or who became pregnant after rape or incest.

Some anti-abortion activists in Georgia are pushing lawmakers to go further than the state’s ban on most abortions at about six weeks of pregnancy. They want a law to ban telehealth prescriptions of abortion pills and a state constitutional amendment declaring that an embryo or a fetus has all the legal rights of a person at any stage of development.

Roe is out of the way,” said Zemmie Fleck, executive director of Georgia Right to Life. “There’s no more roadblock to what we can do in our state.”

Republican leaders, however, are biding their time while Georgia’s high court weighs a legal challenge of the six-week ban. “Our focus remains on the case before the Georgia Supreme Court and seeing it across the finish line,” said Andrew Isenhour, spokesperson for Republican Gov. Brian Kemp.

Abortion rights lawmakers and advocates have few options to advance their initiatives in these Republican-controlled statehouses.

A Georgia Democrat filed a bill that would make the state compensate women who are unable to terminate pregnancies because of the state’s abortion ban. State Rep. Dar’shun Kendrick acknowledged her bill likely won’t go far, but she said she hopes it keeps attention on the issue and forces GOP lawmakers to “put their money where their mouth is” in supporting families.

In Missouri, where nearly all abortions are now banned, abortion rights advocates are mulling the idea of circumventing the state’s Republican-dominated legislature by asking voters in 2024 to enshrine the right to an abortion in the state’s constitution.

But those efforts could be upended by a slew of bills filed by Republican lawmakers seeking to make it more difficult to place constitutional initiatives on the ballot, and for those measures that do make it on the ballot, by requiring the approval of at least 60% of voters for passage.

Democrats in Michigan and Minnesota are likely to use their newfound control of both legislative chambers and the governors’ office to protect abortion access. While Michigan voters already passed a ballot measure in November that enshrines the right to abortions in the state constitution, Democrats are trying to repeal a 1931 abortion law from the books.

In Illinois, Democrats in control of the legislature recently bolstered abortion protections amid increased demand from out-of-state residents. New York lawmakers this year may send voters a proposed state constitutional amendment to protect abortion, while New Jersey lawmakers decided against a similar proposal.

The November elections brought divided government to Arizona and Nevada, with Arizona now having a Democratic governor and Nevada having a Republican one. Any abortion-related bills that pass the legislatures in those states could be vetoed.

Some Republican-controlled legislatures, including those in Montana, Florida, and Alaska, also are limited in passing sweeping abortion bans because of court rulings that tie abortion access to right-to-privacy provisions in those states’ constitutions.

In Montana, a state judge blocked three anti-abortion laws passed in 2021 on that basis. State government attorneys have asked the Montana Supreme Court to reverse the precedent, and a decision is pending.

In the meantime, Republican state Sen. Keith Regier has filed a bill there seeking to exclude abortion from the state’s definition of a right to privacy. Regier said he believes an individual’s right to privacy should not apply to abortion because an unborn child also is involved.

Democratic leaders said Republicans are out of sync with the people they represent on this issue. In November, Montana voters rejected a “born alive” ballot initiative that would have required doctors to apply medical care to newborns who draw breath or have a heartbeat after a failed abortion or any other birth.

“Montanans said so clearly that they do not want government overreach in their health care decisions,” said Democratic state Rep. Alice Buckley.

KHN correspondents Renuka Rayasam and Sam Whitehead in Atlanta; Arielle Zionts in Rapid City, South Dakota; Bram Sable-Smith in St. Louis; and Katheryn Houghton in Missoula, Montana, contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Journalists Follow Up on Radon Mine Health Spas, Open Enrollment, and Health Fraud

January 21, 2023

KHN Montana correspondent Katheryn Houghton discussed Montana’s radon mine health spas on Montana Public Radio’s “The Big Why” podcast on Jan. 18.

KHN correspondent Julie Appleby discussed this year’s open enrollment period for Affordable Care Act health plans on NPR’s “Weekend Edition Sunday” on Jan. 15.

KHN senior correspondent Sarah Jane Tribble discussed gaps in the government system that bans bad actors from federal health programs on America’s Heroes Group on Jan. 7.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Luring Out-of-State Professionals Is Just the First Step in Solving Montana’s Health Worker Shortage

January 20, 2023

Jenna Eisenhart spent nearly six years as a licensed therapist in Colorado before deciding to move to a place with a greater need for her services. She researched rural states facing a shortage of behavioral health providers and accepted a job as a lead clinical primary therapist at Shodair Children’s Hospital in Helena, Montana, in January 2018.

But she couldn’t start her new job right away because state officials denied her application for a license to practice in Montana on the grounds that her master’s degree program required only 48 credits to complete instead of 60.

Eisenhart spent nearly $7,000 to earn 12 more credits to meet the requirement, something she acknowledged not every provider would be able, or want, to do.

“I’m coming here as a licensed therapist to provide services that Montana desperately needs and you’re saying, no, you’re educationally deficient, when that’s not actually true,” said Eisenhart, now the director of clinical services at Shodair. “It kind of made me feel unwanted.”

Eisenhart’s difficulties are an example of the problems that health professionals can have in obtaining a Montana license to practice. State lawmakers are considering proposals to make it easier for professionals with out-of-state licenses to work in Montana. The need to attract more workers is particularly acute amid a national mental health crisis and a worker shortage, both heightened by the covid-19 pandemic. But lawmakers, behavioral health advocates, and providers say the need is so great, they doubt that lowering barriers for out-of-state practitioners will be enough.

One measure, House Bill 101, sponsored by Republican Rep. Jane Gillette and drafted by the Children, Family, Health and Human Services Interim Committee, covers social workers, professional counselors, addiction counselors, marriage and family therapists, and behavioral health peer support specialists. It would let the Department of Labor & Industry automatically license those providers in Montana if they meet certain requirements, like having an active license from another state for at least a year and having proper educational credentials.

Eisenhart said if the bill had been in effect in 2018, she wouldn’t have had to jump through as many hoops to work in Montana.

Another, House Bill 152 sponsored by Republican Rep. Bill Mercer and requested by the state Department of Labor & Industry as part of Gov. Greg Gianforte’s “Red Tape Relief” initiative, aims to streamline the licensing process for all occupations regulated by the department, from nurses to real estate appraisers.

HB 152 is designed to simplify the process for licensing the more than 50 professions and 150 types of licenses under the purview of the labor department, Eric Strauss, administrator of the department’s Employment Standards Division, said in a Jan. 18 committee hearing on the bill.

Last year, the department received more than 21,300 applications for licensure across professions, and half of those were from out-of-state professionals, said Dave Cook, the department’s deputy administrator of professional licensing. Health care-related licenses had an even higher share of out-of-state applicants — 60%, he said.

HB 152 would improve license mobility by creating a standard the department uses across professions to determine whether out-of-state license holders are qualified to work in Montana, department officials said. It also would establish a timeline of 30 days for the agency to issue a license after receiving a completed application.

“This helps the engineer, psychologist, social worker, or cosmetologist who has practiced for 20 years to get licensed without being required to get additional education or take an examination,” said department spokesperson Jessica Nelson.

Though the two bills have the same aim, labor department officials criticized Gillette’s bill on behavioral health worker licensing as not going far enough to remove obstacles for out-of-state workers.

HB 101 “creates additional burdens to licensure, including requiring residency and mandating that a particular licensing examination has been taken,” Nelson wrote in an email. “These are issues that HB 152 is attempting to reform.”

Gillette said she doesn’t think her bill or Gianforte’s bill alone would solve the workforce problem in health care. To make a substantial change, Gillette said, Medicaid provider reimbursement rates need to be higher.

“It’ll do something but it’s not going to fix it by any stretch,” Gillette said, referring to streamlining the licensing process.

A study commissioned by the 2021 legislature found that Montana’s Medicaid provider rates were too low to cover the cost of many of those who work with seniors, people with disabilities, and children and adults with mental illness.

The study found that the state’s Medicaid program is now paying, on average, 85% of the actual cost of care for adult behavioral health services, for example. Gianforte’s proposed budget would boost that funding next year to 94% of costs, on average, before lowering it again to 91%. The budget proposal is before lawmakers, and, to fully fund the services, providers are asking them to raise the rates higher than the governor proposes.

Mary Windecker, executive director of the Behavioral Health Alliance of Montana, which strives to make community-based services more accessible to patients, said that her organization recommended the interim committee come up with what became HB 101 but that HB 152 goes further than they could have hoped.

Windecker said every agency that her organization represents is experiencing staffing shortages of 25% to 30%. Up to 90% of the alliance members’ income comes from Medicaid reimbursements, she said, and it’s not enough. She said speeding up the licensure process and raising the Medicaid provider rates in accordance with a study the Montana Department of Public Health and Human Services instigated are the main strategies needed to satisfy demand for behavioral health services.

“We’ve got to get people in here to work,” Windecker said. “We have a huge labor shortage and with the Medicaid reimbursement so low, we’re having a really hard time hiring people.”

According to the Board of Behavioral Health, there were 5,126 active behavioral health providers in Montana as of last April. The Montana chapter of the National Alliance on Mental Illness reported 163,000 adults in Montana have a mental health condition.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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A $30 Million Gift to Build an Addiction Treatment Center. Then Staffers Had to Run It.

January 19, 2023

DECATUR, Ill. — The question came out of the blue, or so it seemed to Crossing Healthcare CEO Tanya Andricks: If you had $30 million to design an addiction treatment facility, how would you do it?

The interim sheriff of Macon County, Illinois, posed the question in 2018 as he and Andricks discussed the community’s needs. When she responded that she’d have to do some research, she was told not to take too long because the offer wouldn’t be there forever.

“I thought: ‘Oh, my God, he’s serious,’” Andricks said.

That sheriff was Howard Buffett, the philanthropist son of billionaire investor Warren Buffett. The younger Buffett ended up giving Crossing about $30 million from his charitable foundation to build an addiction treatment center in Decatur, a city with a population of just over 69,000 in the heart of Macon County.

There was a caveat, though. The donation to Crossing was a one-time gift to pay only for the buildings. It was up to Andricks and her team to find money to run the programs. And that has proven difficult.

The covid-19 pandemic upended everything mere months after the facilities opened in October 2019. An audited financial statement said the inpatient recovery center had lost $2.5 million by June 2021, and management worried about its ability to continue operating. Even so, the center remained open while other addiction treatment facilities around the country shuttered.

Now communities nationwide are preparing for an unprecedented windfall of their own for addiction treatment from a nearly $26 billion national opioid settlement and a more than $300 million expansion of a federal pilot program for mental health. The experience at Crossing offers them a model but also a warning: It will take more than a single shot of money to build a treatment program that can last.

Drug addiction wasn’t on Howard Buffett’s radar, he told KHN, until he joined the Macon County sheriff’s office as an auxiliary deputy in 2012. While the county has had some treatment resources, like a behavioral health center, it has one of the state’s higher death rates from opioid overdoses.

Buffett moved to the area in 1992 to work for food-processing giant Archer Daniels Midland. He runs a farm nearby and his Decatur-based foundation donates hundreds of millions of dollars for initiatives ranging from helping people kidnapped by Joseph Kony’s Lord’s Resistance Army in central Africa to revitalizing the cacao industry in El Salvador.

Soon after Buffett was appointed interim sheriff in 2017, he toured Crossing to learn more about local social services. The health center offers primary care, including mental health, for all ages and sees roughly 17,500 patients a year. Most Crossing patients are on Medicaid, the public health insurance for people with low incomes.

“He was impressed with what we were able to provide patients,” Andricks recalled. “I don’t think he expected the scope and size of what we do.”

Addiction treatment, though, is notoriously difficult. Evidence supports treating addiction like a chronic illness, meaning even after difficult short-term behavior changes, it requires a lifetime of management. Research suggests relapse rates can be more than 85% in the first year of recovery. So any new treatment program is likely to face headwinds.

Buffett didn’t set Crossing up for failure. In fact, he has helped fund other aspects of the organization’s work. Part of the idea behind paying for the addiction treatment buildings but not the operations, Buffett said, is to keep his foundation “creative.” If it spends all its money on the same programming every year, that means less is available to fund other work around the globe. Buffett said it’s also about sustainability.

“If Tanya can show ‘with this investment I made this work,’” Buffett said, “then other people should be making that investment.”

Crossing’s inpatient recovery center holds eight beds for medication-assisted detox, 48 beds for rehabilitation, and a cafeteria where meals are cooked with input from dietitians working with patients. An outpatient treatment center also has classrooms for continuing education, a gym with a small bowling alley, and a movie theater. Buffett insisted on the last two amenities. (“People have to feel good about getting better,” he said.)

A separate building holds 64 beds of transitional housing, and just across the street are 20 rent-controlled apartments. Buffett spent an additional $25 million on buildings at that campus for other organizations focused on housing, workforce development, and education, among other things.

“There’s a lot to like in this program,” said Dr. Bradley Stein, director of Rand Corp.’s Opioid Policy and Tools Information Center.

As positives, Stein pointed specifically to the spectrum of care offered to patients as they progress in their recovery, the use of medication-assisted treatment to help stave off physical cravings for opioids, the connection to the health center, and even the involvement of law enforcement.

Laura Cogan, a 36-year-old mother who has struggled with addiction since she was 14, is one of the patients working their way through the system.

Cogan said she was the first patient in the doors when the recovery center opened. Less than 24 hours later, she was also the first patient to walk out.

The biggest challenge with Cogan’s previous attempts at recovery, she said, was never being sure about her next steps: What was she supposed to do after getting out of detox and residential treatment?

Crossing’s approach was designed to address that by providing transitional housing, easy access to outpatient services, and educational programming.

On her third attempt, Cogan got a round of applause after completing the first three days in detox. After six days, she joined residential treatment. After a month, she moved over to transitional housing, began outpatient treatment, and started offering peer support at Crossing. She tutored other patients, taught a writing class, and helped them get on computers and fill out job applications.

Then the pandemic hit.

Like other health centers around the nation, Crossing turned its attention to providing covid testing and vaccines. Meanwhile, just about every aspect of addiction treatment became more expensive. Crossing halved the number of residential treatment beds so each room would have only one patient and converted the rooms into negative pressure chambers to reduce the risk of covid transmission.

Staffing grew harder amid a nationwide nursing shortage. The number of patients in residential treatment dropped, Andricks said, because few people wanted to live inside a facility and wear masks. It was common to have as few as 10 beds occupied on a given day. The women’s unit was temporarily closed due to lack of demand and staffing constraints.

Cogan said several other transitional housing residents left once the $1,200 pandemic stimulus checks arrived, with some resuming treatment when that money dried up. But Cogan continued. Eventually she moved into Crossing’s rent-controlled apartments, where she has been one of just a few tenants.

Without the federal Paycheck Protection Program’s $1,375,200 forgivable loan in 2020, Andricks said, the outpatient treatment program might have had to close altogether.

But momentum at the recovery center started to change last spring as covid cases tapered off, Andricks said. Hiring became easier. More patients arrived. In October, the center received a grant to use the apartments for women with a history of substance misuse who are pregnant or who have given birth within the prior year. They’ve placed six women, in addition to Cogan, there already. The inpatient recovery center now averages about 27 occupied beds a day, within striking distance of the 30 that Andricks said the inpatient center needs to survive.

Rand’s Stein suggested another measurement of a treatment program’s success: whether people in the community get into treatment when they need it. National “secret shopper” reports have found significant barriers to service, such as long wait times.

Crossing’s program quadrupled the number of residential treatment beds in Macon County, according to Andricks. In the three years since the inpatient recovery center opened, it has had over 1,300 admissions. While most patients haven’t stayed in recovery, staffers have seen a pattern of success with those like Cogan who stay on campus and become involved with recovery offerings — although Andricks estimated that’s fewer than 10% of the patients.

Cogan said she hopes Crossing doesn’t get discouraged. People are going to mess up, she said, but she’s living proof of the impact the recovery center can have.

“I’m one of the lucky ones and I don’t know why,” Cogan said, sitting on a couch in the apartment on Crossing’s campus that she shares with her 12-year-old son since regaining custody of him. “I just know that today I am. And I hope that more people get the opportunity.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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After a Brief Pandemic Reprieve, Rural Workers Return to Life Without Paid Leave

January 18, 2023

ELKO, Nev. — When Ruby B. Sutton found out she was pregnant in late 2021, it was hard to envision how her full-time job would fit with having a newborn at home. She faced a three-hour round-trip commute to the mine site where she worked as an environmental engineer, 12-plus-hour workdays, expensive child care, and her desire to be present with her newborn.

Sutton, 32, said the minimal paid maternity leave that her employer offered didn’t seem like enough time for her body to heal from giving birth or to bond with her firstborn. Those concerns were magnified when she needed an emergency cesarean section.

“I’m a very career-driven person,” Sutton said. “It was really difficult to make that decision.”

Sutton quit her job because she felt even additional unpaid time off wouldn’t be enough. She also knew child care following maternity leave would cost a substantial portion of her salary if she returned to work.

Tens of millions of American workers face similar decisions when they need to care for themselves, a family member, or a baby. Wild variations in paid leave regulations from state to state and locally mean those choices are further complicated by financial factors. And workers in rural areas face even more challenges than those in cities, including greater distances to hospitals and fewer medical providers, exacerbating health and income disparities. Companies in rural areas may be less likely to voluntarily offer the benefit because they tend to be smaller and there are fewer employers for workers to choose from.

While a growing number of states, cities, and counties have passed paid sick leave or general paid time off laws in recent years, most states where more than 20% of the population is rural haven’t, leaving workers vulnerable. Vermont and New Mexico are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave.

Experts say the gaps in paid leave requirements mean workers in rural areas often struggle to care for themselves or loved ones while making ends meet.

“The problem is, because it’s a small percentage of the population, it’s often forgotten,” said Anne Lofaso, a professor of law at West Virginia University.

The covid-19 pandemic steered attention toward paid leave policies as millions of people contracted the virus and needed to quarantine for five to 10 days to avoid infecting co-workers. The 2020 Families First Coronavirus Response Act temporarily required employers with fewer than 500 employees and all public employers to give workers a minimum of two weeks of paid sick leave, but that requirement expired at the end of 2020.

The expiration left workers to rely on the Family and Medical Leave Act of 1993, which requires companies with 50 or more employees to provide them with up to 12 weeks of unpaid time off to care for themselves or family members. But many workers can’t afford to go that long without pay.

By March 2022, 77% of workers at private companies had paid sick leave through their employers, according to the Bureau of Labor Statistics — a small increase from 2019, when 73% of workers in private industry had it. But workers in certain industries — like construction, farming, forestry, and extraction — part-time workers, and lower-wage earners are less likely to have paid sick leave.

“Paid leave is presented as a high-cost item,” said Kate Bronfenbrenner, director of labor education research at the School of Industrial and Labor Relations at Cornell University.

But it comes with a payoff: Without it, people who feel pressure to go to work let health conditions fester and deteriorate. And, of course, infectious workers who return too early unnecessarily expose others in the workplace.

Advocates say a stronger federal policy guaranteeing and protecting paid sick and family leave would mean workers wouldn’t have to choose between pushing through illness at work or losing income or jobs.

A recent report by New America, a left-leaning think tank, argues that creating policy to ensure paid leave could boost employment numbers; reduce economic, gender, and racial disparities; and generally lift up local communities.

Support for paid sick and family leave is popular among rural Americans, according to the National Partnership for Women & Families, which found in 2020 polling that 80% of rural voters supported a permanent paid family and medical leave program, allowing people to take time off from work to care for children or other family members.

But lawmakers have been divided on creating a national policy, with opponents worrying that requiring paid leave would be too big a financial burden for small or struggling businesses.

In 2006, voters in San Francisco approved the Paid Sick Leave Ordinance, making it the first U.S. city to mandate paid sick leave. Since then, 14 states, the District of Columbia, and 20 other cities or counties have done so. Two other states, Nevada and Maine, have adopted general paid time off laws that provide time that can be used for illness.

Federal workers are offered 12 weeks of paid parental leave in the Federal Employee Paid Leave Act, adopted in October 2020. It covers more than 2 million civilian workers employed by the U.S. government, though the law must be reapproved each fiscal year and employees are not eligible until they’ve completed one year of service.

The patchwork of laws nationwide leaves workers in several mostly rural states — places like Montana, South Dakota, and West Virginia where more than 40% of residents live outside cities — without mandated paid sick and family leave.

Sutton said she “would have definitely loved” to stay at her job if she could’ve taken a longer paid maternity leave. She said she wants to return to work, but the future is unclear. She has more things to consider, like whether she and her husband want more children and when she might feel healthy enough to try for a second baby after last summer’s C-section.

Sutton recalled a friend she worked with at a gold mine years ago who left the job a few months after having a baby. “And I understand now all the things she was telling me at that time. … She was like, ‘I can’t do this,’ you know?”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Rural Seniors Benefit From Pandemic-Driven Remote Fitness Boom

January 17, 2023

[UPDATED at 11 a.m. ET]

MALMO, Minn. — Eight women, all 73 or older, paced the fellowship hall at Malmo Evangelical Free Church to a rendition of Daniel O’Donnell’s “Rivers of Babylon” as they warmed up for an hourlong fitness class.

The women, who live near or on the eastern shore of Mille Lacs Lake, had a variety of reasons for showing up despite fresh snow and slippery roads. One came to reduce the effects of osteoporosis; another, to maintain mobility after a stroke.

Most brought hand and ankle weights, which they would use in a later portion of the program focused on preventing falls, known as Stay Active and Independent for Life, or SAIL. The class meets twice a week in Malmo, a township of about 300 residents. It is run by Juniper, a statewide network of providers of health promotion classes.

A few years ago, older adults who were interested in taking an evidence-based class like SAIL — meaning a class proved by research to promote health — had only one option: attend in person, if one was offered nearby.

But then the covid-19 pandemic and physical distancing happened. Along with social isolation came the rapid introduction of remote access to everything from work to workouts.

After widespread lockdowns began in March 2020, agencies serving seniors across the U.S. reworked health classes to include virtual options. Isolation has long since ended, but virtual classes remain. For older adults in rural communities who have difficulty getting to exercise facilities, those virtual classes offer opportunities for supervised physical activity that were rare before the pandemic.

And advocates say online classes are here to stay.

“Virtually the whole field knows that offering in-person and remote programming — a full range of programming — is a great way to reach more older adults, to increase access and equity,” said Jennifer Tripken, associate director of the Center of Healthy Aging at the National Council on Aging. “This is where we need to move together.”

Since April 2020, the National Council on Aging has organized monthly conference calls for service providers to discuss how to improve virtual programs or begin offering them.

“We found that remote programming, particularly for rural areas, expanded the reach of programs, offering opportunities for those who have traditionally not participated in in-person programs to now have the ability to tune in, to leverage technology to participate and receive the benefits,” Tripken said.

In 2022, at least 1,547 seniors participated in an online fitness program through Juniper, part of a Minnesota Area Agency on Aging initiative. More than half were from rural areas.

Because of grant funding, participants pay little or nothing.

Juniper’s virtual classes have become a regular activity both for people who live far from class locations and others who because of medical needs can’t attend. Carmen Nomann, 73, frequented in-person exercise classes near her home in Rochester before the pandemic. After suffering a rare allergic reaction to a covid vaccine, she’s had to forgo boosters and limit in-person socializing.

Virtual classes have been “really a great lifeline for keeping me in condition and having interaction,” she said.

Since 2020, Nomann has participated in online tai chi and SAIL, at one point logging on four days a week.

“Now, we would never go away from our online classes,” said Julie Roles, Juniper’s vice president of communications. “We’ve learned from so many people, particularly rural people, that that allows them to participate on a regular basis — and they don’t have to drive 50 miles to get to a class.”

When seniors drive a long way to attend a class with people from outside their communities, “it’s harder to build that sense of ‘I’m supported right here at home,’” she said.

Roles said both virtual and in-person exercise programs address social isolation, which older adults in rural areas are prone to.

Dr. Yvonne Hanley has been teaching an online SAIL class for Juniper since 2021 from her home near Fergus Falls. She had recently retired from dentistry and was looking for a way to help people build strength and maintain their health.

At first, Hanley was skeptical that students in her class would bond, but over time, they did. “I say ‘Good morning’ to each person as they check in,” she said. “And then during class, I try to make it fun.”

AgeOptions, an Illinois agency serving seniors, has seen similar benefits since introducing virtual fitness programs. Officials at the agency said last year that their operations “may have changed forever” in favor of a hybrid model of virtual and in-person classes.

That model allows AgeOptions to maintain exercise programs through Illinois’ brutal winters. Organizers previously limited winter activities to keep older adults from traveling in snow and ice, but now AgeOptions leans on remote classes instead.

“If the pandemic didn’t happen, and we didn’t pivot these programs to virtual, we wouldn’t be able to do that,” said Kathryn Zahm, a manager at AgeOptions. “We would just potentially spend months limiting our programming or limiting the types of programming that we offered. So now we can still continue to offer fall-prevention programs throughout the year because we can offer it in a safe way.”

But the new approach has challenges.

AgeOptions has identified increasing access to technology as a funding priority for the next few years, to ensure seniors can sign on.

The agency found that for many “folks in rural communities it was a challenge not only for them to have the device but to have the bandwidth to be able to do video conference calls,” Zahm said.

Tripken said providers and participants need guidance and support to facilitate access to virtual classes.

“For older adults in particular, that includes ensuring those with vision loss, those with hearing loss, those with low English proficiency” can participate in virtual classes, she said.

Some programs have created accommodations to ease the technology barrier.

Participants in Bingocize — a fall-prevention program licensed by Western Kentucky University that combines exercise and health education with bingo — can use a printed copy of the game card mailed to them by AgeOptions if they lack the proficiency to play on the game’s app. Either way, they’re required to participate on video.

The mail option emerged after Bingocize fielded requests from many senior service organizations trying to figure out how to offer it remotely, said Jason Crandall, the creator and international director of Bingocize.

Crandall designed Bingocize as a face-to-face program and later added the online application to use during in-person classes. Then covid hit.

“All of a sudden, all of these Area Agencies on Aging are scrambling, and they were scrambling trying to figure out, ‘How do we do these evidence-based programs remotely?’” Crandall said.

He said Bingocize was one of the few programs at the time that could quickly pivot to strictly remote programming, though it had never done so before.

“From when the pandemic began to now, we’ve come light-years on how that is done,” he said, “and everybody’s getting more comfortable with it.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Why People Who Experience Severe Nausea During Pregnancy Often Go Untreated

January 13, 2023

Mineka Furtch wasn’t bothered by the idea of morning sickness after going through a miscarriage and the roller coaster of fertility medication before she finally became pregnant with her son.

But when the 29-year-old from suburban Atlanta was five weeks pregnant in 2020, she started throwing up and couldn’t stop. Some days she kept down an orange; other days, nothing. Furtch used up her paid time off at work with sick days, eventually having to rely on unpaid medical leave. She remembered her doctor telling her it was just morning sickness and things would get better.

By the time Furtch was 13 weeks pregnant, she had lost more than 20 pounds.

“I fought so hard to have this baby, and I was fighting so hard to keep this baby,” Furtch said. “I was like ‘OK, something is not right here.’”

Now, Furtch’s son is 18 months old, and she is suffering again from severe nausea and vomiting well into the second trimester of a new, unplanned pregnancy.

The nausea that comes with morning sickness is common in the first trimester of pregnancy, but some women, like Furtch, experience symptoms that linger much longer and require medical attention. However, those often go untreated or undertreated because the condition is misunderstood or downplayed by their doctors or the patients themselves.

Mothers have said they went without care for fear that medicine would hurt their fetus, because they couldn’t afford it, or because their doctor didn’t take them seriously. Left alone, symptoms get more difficult to control, and such delays can become medical emergencies. Extreme cases are called hyperemesis gravidarum and may last throughout a pregnancy, even with treatment.

“For most women, it’s not until they end up in the ER and go, ‘Well, most of my friends haven’t been to an ER,’ they realize this isn’t normal,” said Kimber MacGibbon, executive director of the Her Foundation, which researches and raises awareness of hyperemesis gravidarum.

There are a lot of unknowns around the cause of nausea and vomiting in pregnancy. Research has indicated genetics plays a role in its severity, and hyperemesis is estimated to occur in up to 3% of pregnancies. But there’s no clear line differentiating morning sickness from hyperemesis or consistent criteria to diagnose the condition, which MacGibbon said results in underestimating its impact.

Wide-ranging estimates suggest at least 60,000 peoplepossibly 300,000 or more — go to a hospital in the U.S. each year with pregnancy-related dehydration or malnourishment. An untold number go to walk-in clinics or don’t seek medical care.

The effects ripple into every aspect of a person’s life and the economy. One study estimated the total annual economic burden of severe morning sickness and hyperemesis in the U.S. in 2012 amounted to more than $1.7 billion in lost work, caregiver time, and the cost of treatment.

Research for this article was personal. I’m pregnant, and by the fifth week I was vomiting five to seven times a day. My primary care doctor in Missoula, Montana, directed pregnancy-related questions to my obstetrician’s medical team, whom I wouldn’t see until my first prenatal appointment, more than a month later. Taking advice from an on-call nurse, I tried over-the-counter supplements and medication to ease the nausea.

It didn’t stop the vomiting. Nearly a month after my symptoms began, all I could keep down was brown rice. My husband and I had hoped for this pregnancy, but at that point, part of me thought a miscarriage would at least end the retching.

The next week, a remote on-call doctor prescribed anti-nausea medication after I went 24 hours without food. Now, well into my second trimester, the nausea remains but my symptoms are manageable and continue to improve.

For this story, I spoke with women who went weeks without being able to keep solids down and could no longer take in water before they received IVs for hydration. For many, it can be difficult to know when to seek medical attention.

“There’s not a number, like, ‘OK, you vomited five times, so now you meet the criteria,’” said Dr. Manisha Gandhi, an American College of Obstetricians and Gynecologists vice chair who helps determine clinical practice guidelines for obstetrics. “The key is, ‘Are you keeping liquids down? Are you tolerating anything by mouth?’”

Gandhi said, in her experience, a small segment of patients experience severe symptoms, which for the majority peak around the eighth or 10th week of pregnancy. She said it’s standard for doctors to ask during a first prenatal visit whether a patient has felt nauseated, and patients should call if issues arise before then. Treatment is gradual — changing the diet or taking a natural supplement like vitamin B6 — before considering an anti-nausea prescription medication.

First prenatal visits vary but can happen as late as 10 to 12 weeks into the pregnancy, once it’s possible to confirm the fetus’s heartbeat. JaNeen Cross, a perinatal social worker and assistant professor at Howard University in Washington, D.C., said that leaves a gap in care for women early in pregnancy.

“That’s a lot of time for nausea, sickness, bleeding to go on as they think ‘Is this normal?’” Cross said. “And we’re assuming people have access to providers.”

Barriers to care include whether someone has insurance or can afford their copays, or if they have child care and paid time off work to go to the doctor.

About two-thirds of Black patients in the U.S. saw a doctor in their first trimester in 2016, compared with 82% of white patients, according to a report released by the Centers for Disease Control and Prevention. Overall, roughly half of people who have to pay out-of-pocket went without that first-trimester checkup.

Cross said she’d like to see more services and resources built into communities, so that as soon as someone finds out they’re pregnant, they’re linked to support groups, community health workers, or programs that make home visits. That could help with another hurdle for care: trust that treatment is safe.

Some of that mistrust may be rooted in the 1950s and ’60s, when the morning sickness drug thalidomide led to thousands of babies being born with severe birth defects. Research has found today’s anti-nausea medications used in pregnancy pose little if any risk to the fetus.

By her sixth week of pregnancy with her first child, Helena Schwartz, 33, of Brooklyn, New York, was on at-home IVs because she couldn’t keep food down. That helped for about two days; then her body began rejecting food again. Schwartz said her doctor, who had been quick to help her, prescribed anti-nausea medication. She left the medicine untouched for three weeks as her symptoms got worse.

“I was scared it would hurt the baby,” Schwartz said. “I waited until it was impossible.”

Even with a diagnosis and supportive medical team, people like Schwartz have experienced extreme symptoms throughout their pregnancies, and healing is slow.

As for Furtch, the prescription medication she used in her first pregnancy didn’t do enough this time around to ease her symptoms.

Her new obstetrician takes her symptoms seriously, but at times she has still faced roadblocks to care. At first, she couldn’t afford thousands of dollars out-of-pocket for a medical device that would constantly pump anti-nausea medication through her system. When her doctor prescribed a series of drugs as a backup plan, her insurance initially refused to cover the cost. She went days without medicine, which meant throwing up about eight times a day.

Since she started the prescription medicines, she typically can keep some food down. But she still has her bad days, and had to go to the hospital again in late December to get IVs.

Her baby girl is due this spring. After that, she plans to see her doctor again to have her tubes tied.

“Giving birth is nothing compared to 10 months of hell,” Furtch said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Ending Involuntary Commitments Would Shift Burden of Dementia Care to Strapped Communities

January 13, 2023

HELENA, Mont. — State lawmakers from both parties have shown support for a plan to stop the practice of committing people with Alzheimer’s disease, other types of dementia, or traumatic brain injuries without their consent to the troubled Montana State Hospital and instead direct them to treatment in their communities.

But a budget estimate attached to the proposed legislation raises questions about whether Montana communities, many of which are still reeling from past budget cuts and insufficient Medicaid reimbursement rates, will have the capacity to care for them by July 2025, when involuntary commitments would cease under the plan.

Health department officials essentially acknowledged as much in the fiscal note accompanying House Bill 29, sponsored by Republican state Rep. Jennifer Carlson. Health officials wrote in the unsigned fiscal note that 24-hour skilled nursing facilities are often the only appropriate settings for such patients, and that few of those facilities “are willing to take these individuals as an alternative placement to the Montana State Hospital.”

As a result, health department officials anticipate having to transfer patients with a diagnosis of Alzheimer’s, other dementia, or a traumatic brain injury from the Montana State Hospital to the state Mental Health Nursing Care Center, a long-term, 117-bed residential facility in Lewistown for people with mental health disorders, if the bill passes. The health department says the facility is for people who “require a level of care not available in the community, but who cannot benefit from the intensive psychiatric treatment available at Montana State Hospital.”

Department officials expect to move 24 patients from the state hospital to the Lewistown facility between fiscal years 2025 and 2027 if the bill passes. The cost of caring for those patients at the Lewistown facility would start at $181,062 per patient, per year, for a total cost of about $10 million over three years. The beds they vacate at Montana State Hospital would likely be immediately filled by other patients, so there would be no expected cost savings there, according to the fiscal note.

Department of Public Health and Human Services spokesperson Jon Ebelt did not immediately comment on the document outlining the expected transfers.

Carlson said she was surprised health department officials expected to relocate patients to another state-run facility when the point of the bill is to facilitate community treatment.

But, she added, that cost would be lowered if the state raised its Medicaid reimbursement rates. If the state raised its reimbursement rates to nursing homes to $300 per patient, per day, from its current $208 rate, those same 24 patients could end up costing the state a lot less, she said.

Carlson said some dementia patients are committed to the state hospital as a last resort because there are no other options for providing the intensive care they need.

“But that excuse is not good enough for me,” Carlson said. “There should be somewhere else for them to go.”

Carlson’s bill is just one of several measures to overhaul operations at the Montana State Hospital.

The Centers for Medicare & Medicaid Services revoked the hospital’s certification after an investigation into a series of deaths and injuries there, leading to the loss of federal funding. The hospital has been strained by high rates of staff vacancies and employee turnover, leading to a reliance on higher-priced temporary staff and contributing to the hospital’s waiting list for admissions.

The bill’s goal of removing patients with dementia or traumatic brain injuries from the Montana State Hospital and into community care has bipartisan support. The Children, Families, Health, and Human Services interim committee voted unanimously last summer to forward the bill to the full legislature. Carlson’s HB 29 was scheduled for its first hearing on Jan. 13 in the House Human Services Committee.

Matt Kuntz, executive director of Montana’s chapter of the National Alliance on Mental Illness, said there is broad agreement that the state hospital isn’t the place for Alzheimer’s patients. The reason the state is in this situation is that community centers don’t have the capacity to care for a growing Alzheimer’s population, he said.

“The positive thing is at least someone’s moving proactively and saying this isn’t right,” Kuntz said of the bill.

Kuntz said the health department is probably right that some patients would end up at the Mental Health Nursing Care Center in Lewistown if the bill passes. But, he added, the bill is meant to reduce institutionalization, not raise the cost of institutionalization.

“Institutionalization of a patient is incredibly expensive and needs to be avoided whenever possible, and that is the crux of Carlson’s bill,” Kuntz said.

Democratic House Minority Leader Kim Abbott said the health and safety of the most vulnerable members of the community is a top priority for the Democratic caucus.

“Community-based care that’s closer to family makes a lot of sense, but we want to make sure that we’re giving it a good vetting,” Abbott said.

Carlson said HB 29 does two things: First, it ends the involuntary commitment of people who shouldn’t be in a mental institution, she said, unless they are an immediate threat to themselves or others. Second, the measure outlines a plan to provide appropriate care within the patients’ communities.

Kuntz said the bill’s 2025 deadline for ending involuntary commitments gives room for officials and legislators to figure out ways to improve it.

The bill would create a transition committee made up of legislators, governor appointees, and state employees with expertise in nursing facilities, Alzheimer’s and other types of dementia, and traumatic brain injuries. The panel would be tasked with finding answers to some big questions, such as where patients can go for care instead of the hospital and figuring out the logistics of relocating patients already in the state hospital. The panel also would track the progress of developing community-based services until involuntary commitments end in 2025.

Gov. Greg Gianforte’s two-year budget proposal, the starting point for legislative budget writers, also includes spending $300 million on behavioral health and improvements to the Montana State Hospital.

Carlson’s bill also directs the health department to give geriatric state hospital residents or those with Alzheimer’s, other forms of dementia, or traumatic brain injuries priority admission to nursing homes.

“This is a mandate that we improve our community-based systems,” Carlson said.

But those nursing homes face problems of their own, with 11 announcing closures last year amid staffing vacancies and Medicaid reimbursement rates too low to cover the cost of care. A study commissioned by the state government recommended raising those rates to $278.75 per patient, per day. But Gianforte’s budget proposal includes funding for only a portion of that recommended increase: $238.77 per patient, per day, by 2025.

The Montana Health Care Association represents the state’s nursing homes. Executive Director Rose Hughes said nursing homes are probably the places that should be caring for these patients. But there has to be a step between ending involuntary commitment and transitioning all the patients to community centers that can’t yet support them, she said.

“For it to be successful, there really has to be an effort made to support the community providers,” Hughes said.

She doesn’t believe there should be a hard deadline to end involuntary commitments until those community resources are in place. But, she added, there will be another legislative session before the 2025 deadline for lawmakers to extend the process if needed.

“It may not be enough time to solve the problem,” Hughes said. “But I don’t think the problem is going to be worked on unless there is a deadline.”

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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