For decades, concerns about automobile pollution have focused on what comes out of the tailpipe. Now, researchers and regulators say, we need to pay more attention to toxic emissions from tires as vehicles roll down the road.

At the top of the list of worries is a chemical called 6PPD, which is added to rubber tires to help them last longer. When tires wear on pavement, 6PPD is released. It reacts with ozone to become a different chemical, 6PPD-q, which can be extremely toxic — so much so that it has been linked to repeated fish kills in Washington state.

The trouble with tires doesn’t stop there. Tires are made primarily of natural rubber and synthetic rubber, but they contain hundreds of other ingredients, often including steel and heavy metals such as copper, lead, cadmium, and zinc.

As car tires wear, the rubber disappears in particles, both bits that can be seen with the naked eye and microparticles. Testing by a British company, Emissions Analytics, found that a car’s tires emit 1 trillion ultrafine particles per kilometer driven — from 5 to 9 pounds of rubber per internal combustion car per year.

And what’s in those particles is a mystery, because tire ingredients are proprietary.

“You’ve got a chemical cocktail in these tires that no one really understands and is kept highly confidential by the tire manufacturers,” said Nick Molden, CEO of Emissions Analytics. “We struggle to think of another consumer product that is so prevalent in the world and used by virtually everyone, where there is so little known of what is in them.”

Regulators have only begun to address the toxic tire problem, though there has been some action on 6PPD.

The chemical was identified by a team of researchers, led by scientists at Washington State University and the University of Washington, who were trying to determine why coho salmon returning to Seattle-area creeks to spawn were dying in large numbers.

Working for the Washington Stormwater Center, the scientists tested some 2,000 substances to determine which one was causing the die-offs, and in 2020 they announced they’d found the culprit: 6PPD.

The Yurok Tribe in Northern California, along with two other West Coast Native American tribes, have petitioned the Environmental Protection Agency to prohibit the chemical. The EPA said it is considering new rules governing the chemical. “We could not sit idle while 6PPD kills the fish that sustain us,” said Joseph L. James, chairman of the Yurok Tribe, in a statement. “This lethal toxin has no place in any salmon-bearing watershed.”

California has begun taking steps to regulate the chemical, last year classifying tires containing it as a “priority product,” which requires manufacturers to search for and test substitutes.

“6PPD plays a crucial role in the safety of tires on California’s roads and, currently, there are no widely available safer alternatives,” said Karl Palmer, a deputy director at the state’s Department of Toxic Substances Control. “For this reason, our framework is ideally suited for identifying alternatives to 6PPD that ensure the continued safety of tires on California’s roads while protecting California’s fish populations and the communities that rely on them.”

The U.S. Tire Manufacturers Association says it has mobilized a consortium of 16 tire manufacturers to carry out an analysis of alternatives. Anne Forristall Luke, USTMA president and CEO, said it “will yield the most effective and exhaustive review possible of whether a safer alternative to 6PPD in tires currently exists.”

Molden, however, said there is a catch. “If they don’t investigate, they aren’t allowed to sell in the state of California,” he said. “If they investigate and don’t find an alternative, they can go on selling. They don’t have to find a substitute. And today there is no alternative to 6PPD.”

California is also studying a request by the California Stormwater Quality Association to classify tires containing zinc, a heavy metal, as a priority product, requiring manufacturers to search for an alternative. Zinc is used in the vulcanization process to increase the strength of the rubber.

When it comes to tire particles, though, there hasn’t been any action, even as the problem worsens with the proliferation of electric cars. Because of their quicker acceleration and greater torque, electric vehicles wear out tires faster and emit an estimated 20% more tire particles than the average gas-powered car.

A recent study in Southern California found tire and brake emissions in Anaheim accounted for 30% of PM2.5, a small-particulate air pollutant, while exhaust emissions accounted for 19%. Tests by Emissions Analytics have found that tires produce up to 2,000 times as much particle pollution by mass as tailpipes.

These particles end up in water and air and are often ingested. Ultrafine particles, even smaller than PM2.5, are also emitted by tires and can be inhaled and travel directly to the brain. New research suggests tire microparticles should be classified as a pollutant of “high concern.”

In a report issued last year, researchers at Imperial College London said the particles could affect the heart, lungs, and reproductive organs and cause cancer.

People who live or work along roadways, often low-income, are exposed to more of the toxic substances.

Tires are also a major source of microplastics. More than three-quarters of microplastics entering the ocean come from the synthetic rubber in tires, according to a report from the Pew Charitable Trusts and the British company Systemiq.

And there are still a great many unknowns in tire emissions, which can be especially complex to analyze because heat and pressure can transform tire ingredients into other compounds.

One outstanding research question is whether 6PPD-q affects people, and what health problems, if any, it could cause. A recent study published in Environmental Science & Technology Letters found high levels of the chemical in urine samples from a region of South China, with levels highest in pregnant women.

The discovery of 6PPD-q, Molden said, has sparked fresh interest in the health and environmental impacts of tires, and he expects an abundance of new research in the coming years. “The jigsaw pieces are coming together,” he said. “But it’s a thousand-piece jigsaw, not a 200-piece jigsaw.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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Durante décadas, las preocupaciones sobre la contaminación automovilística se han centrado en lo que sale del tubo de escape. Ahora, investigadores y reguladores dicen que se necesita prestar más atención a las emisiones tóxicas de los neumáticos mientras los vehículos circulan por las carreteras.

Y primero en la lista de preocupaciones se encuentra un producto químico llamado 6PPD, que se agrega a los neumáticos para que duren más tiempo. Cuando los neumáticos se van desgastando por el roce con el pavimento, liberan 6PPD.

Al entrar en contacto con el ozono, esta sustancia reacciona y se convierte en un producto químico diferente, el 6PPD-q, que puede ser extremadamente tóxico, tanto que se ha relacionado con muertes de peces en el estado de Washington.

Pero los problemas no terminan ahí.

Los neumáticos están hechos principalmente de goma natural y goma sintética, pero contienen cientos de otros ingredientes, que a menudo incluyen acero y metales pesados como cobre, plomo, cadmio y zinc.

A medida que los neumáticos se desgastan, la goma desaparece en partículas, tanto trozos que se pueden ver a simple vista como micropartículas. Las pruebas realizadas por una empresa británica, Emissions Analytics, encontraron que los neumáticos de un automóvil emiten 1,000 millones de partículas ultrafinas por kilómetro conducido: entre 5 y 9 libras de goma por automóvil de combustión interna por año.

Y lo que hay en esas partículas es un misterio, porque los ingredientes de los neumáticos son de propiedad exclusiva.

“Tienes un cóctel químico en estos neumáticos que nadie realmente entiende y que los fabricantes de neumáticos mantienen en secreto”, dijo Nick Molden, CEO de Emissions Analytics. “Nos resulta difícil pensar en otro producto de consumo tan prevalente en el mundo y utilizado prácticamente por todos, donde se sepa tan poco sobre lo que contiene”.

Los reguladores apenas han comenzado a abordar el problema de la toxicidad en los neumáticos, aunque ha habido algunas acciones sobre el 6PPD.

El producto químico fue identificado por un equipo de investigadores, dirigido por científicos de la Universidad Estatal de Washington y de la Universidad de Washington, que estaban tratando de determinar por qué estaban muriendo masivamente los salmones coho que regresaban a arroyos del área de Seattle para desovar.

Trabajando para el Washington Stormwater Center, los científicos probaron alrededor de 2,000 sustancias para determinar cuál estaba causando las muertes, y en 2020 anunciaron que habían encontrado al culpable: 6PPD.

La Tribu Yurok en el norte de California, junto con otras dos tribus nativas de la costa oeste, han pedido a la Agencia de Protección Ambiental (EPA) que prohíba el producto químico. La EPA dijo que está considerando nuevas normas que lo regulen.

“No podríamos quedarnos de brazos cruzados mientras el 6PPD mata a los peces que nos sostienen”, dijo Joseph L. James, presidente de la Tribu Yurok, en un comunicado. “Esta toxina letal no tiene lugar en ninguna cuenca salmonera”.

California ha comenzado a tomar medidas para regular el producto químico. El año pasado comenzó a calificar a los neumáticos que lo contienen como un “producto prioritario”, lo que requiere que los fabricantes busquen y prueben sustitutos.

“El 6PPD juega un papel crucial en la seguridad de los neumáticos en las carreteras de California y, actualmente, no hay alternativas más seguras ampliamente disponibles”, dijo Karl Palmer, subdirector del Departamento de Control de Sustancias Tóxicas del estado. “Por esta razón, nuestro marco es ideal para identificar alternativas al 6PPD que sigan garantizado la seguridad de los neumáticos en las carreteras de California, protegiendo al mismo tiempo las poblaciones de peces y las comunidades que dependen de ellas”.

La Asociación de Fabricantes de Neumáticos de EE.UU. (USTMA) dice que ha movilizado un consorcio de 16 fabricantes para llevar a cabo un análisis de alternativas. Anne Forristall Luke, presidenta y CEO de la USTMA, dijo que “proporcionará la revisión más efectiva y exhaustiva posible de si existe una alternativa más segura al 6PPD en los neumáticos”.

Sin embargo, Molden dijo que hay un inconveniente. “Si no investigan, no se les permite vender en el estado de California”, dijo. “Si investigan y no encuentran una alternativa, pueden seguir vendiendo. No tienen que encontrar un sustituto. Y hoy no hay alternativa al 6PPD”.

California también está estudiando una solicitud de la California Stormwater Quality Association para clasificar los neumáticos que contienen zinc, un metal pesado, como un producto prioritario, lo que requeriría que los fabricantes busquen una alternativa. El zinc se utiliza en el proceso de vulcanización para aumentar la resistencia del caucho.

Sin embargo, cuando se trata de partículas de neumáticos, no ha habido ninguna acción, incluso cuando el problema empeora con la proliferación de automóviles eléctricos. Debido a su aceleración más rápida, los vehículos eléctricos desgastan los neumáticos más rápido y emiten aproximadamente un 20% más de partículas que los de un automóvil de gasolina promedio.

Un estudio reciente en el sur de California encontró que las emisiones de neumáticos y frenos en Anaheim representaban el 30% de PM2.5, un contaminante atmosférico de partículas pequeñas, mientras que las emisiones de escape representaban el 19%.

Las pruebas realizadas por Emissions Analytics han encontrado que los neumáticos producen hasta 2,000 veces más contaminación por partículas en masa que los tubos de escape. Estas partículas acaban en el agua y el aire y a menudo se ingieren. Los neumáticos también emiten partículas ultrafinas, incluso más pequeñas que PM2.5, que pueden ser inhaladas y viajar directamente al cerebro.

Nuevas investigaciones sugieren que las micropartículas de neumáticos deberían ser clasificadas como un contaminante de “alta preocupación”. En un informe el año pasado, investigadores del Imperial College de Londres dijeron que las partículas podrían afectar al corazón, los pulmones y los órganos reproductivos, y causar cáncer.

Las personas que viven o trabajan junto a carreteras, muchas veces de bajos ingresos, están expuestas a más de estas sustancias tóxicas.

Los neumáticos también son una fuente importante de microplásticos. Más de tres cuartas partes de los microplásticos que llegan al océano provienen de la goma sintética de los neumáticos, según un informe del Pew Charitable Trusts y la empresa británica Systemiq.

Y todavía hay muchas incógnitas sobre las emisiones de neumáticos, que pueden ser especialmente complejas de analizar porque el calor y la presión pueden transformar los ingredientes del neumático en otros compuestos.

Una pregunta pendiente de investigación es si el 6PPD-q afecta a las personas y qué problemas de salud, si los hay, podría causar. Un estudio reciente publicado en Environmental Science & Technology Letters encontró altos niveles del producto químico en muestras de orina de una región del sur de China, con niveles más altos en mujeres embarazadas.

Molden dijo que el descubrimiento del 6PPD-q ha generado un nuevo interés en el impacto sanitario y ambiental de los neumáticos, y espera una gran cantidad de nuevas investigaciones en los próximos años. “Las piezas del rompecabezas se están armando”, dijo. “Pero es un rompecabezas de mil piezas, no de doscientas”.

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Un equipo de investigadores de Montana está jugando un papel clave en el desarrollo de una vacuna más efectiva contra la tuberculosis, una enfermedad infecciosa que ha matado a más personas que ninguna otra.

La BCG (Bacille Calmette-Guérin), desarrollada en 1921, sigue siendo la única vacuna contra la tuberculosis (TB). Si bien tiene una eficacia del 40% al 80% en niños pequeños, su efectividad es muy baja en adolescentes y adultos, lo que impulsó un esfuerzo mundial para encontrar una vacuna que sea más potente.

El Centro de Medicina Translacional de la Universidad de Montana está llevando a cabo una iniciativa en este sentido. El Centro se especializa en mejorar y crear vacunas, agregando los que se denominan “adyuvantes novedosos”.

Un adyuvante es una sustancia que se incluye en la vacuna, por ejemplo moléculas grasas o sales de aluminio, y que potencia la respuesta inmunitaria. Los adyuvantes novedosos son los que aún no se han utilizado en humanos. Los científicos están comprobando que estos adyuvantes generan una inmunidad más fuerte, precisa y duradera que los antígenos, que solo crean anticuerpos.

Provocar respuestas específicas del sistema inmunológico, y profundizar y ampliar su efectividad con adyuvantes, es algo que se conoce como “vacunación de precisión”.

“No es una solución única para todos, no se trata de una vacuna única”, explicó Ofer Levy, profesor de Pediatría de la Universidad de Harvard y director del Programa de Vacunas de Precisión del Hospital Infantil de Boston. “Una vacuna puede funcionar de forma diferente en un recién nacido, un adulto mayor o en una persona de mediana edad”, agregó.

Una vacuna de precisión definitiva, según Levy, brindaría protección de por vida contra una enfermedad con un solo pinchazo. “Una protección de una sola dosis que fuera efectiva contra la gripe o contra el covid sería el Santo Grial”, enfatizó Levy.

Jay Evans dirige el Centro de la Universidad de Montana y, a la vez, es cofundador y director científico y de estrategias, de Inimmune, una empresa privada de biotecnología de Missoula. Evans contó que su equipo lleva 15 años trabajando en una vacuna contra la tuberculosis y que aún faltan cinco años para que ésta pueda distribuirse ampliamente. La asociación público-privada está desarrollando vacunas e intentando mejorar las existentes, afirmó.

En el Centro no ha pasado inadvertido que este trabajo de investigación y producción de vacunas de vanguardia se realiza en Montana, el estado que aprobó una de las leyes antivacunas más extremas del país en 2021, durante la pandemia.

La ley prohíbe a empresas y gobiernos dar un trato diferente a las personas que no estén vacunadas contra covid u otras enfermedades. De hecho, prohíbe a los empleadores públicos y privados que les exijan a los trabajadores que se vacunen contra covid o cualquier otra enfermedad. Un juez federal dictaminó después que la ley no puede aplicarse en entornos sanitarios, como hospitales y consultas médicas.

A mediados de marzo, el Instituto de Investigación Médica Bill y Melinda Gates anunció que había iniciado en siete países la tercera y última fase de los ensayos clínicos de la nueva vacuna contra la tuberculosis. Los ensayos tardarán unos cinco años en completarse. La investigación y la producción se están llevando a cabo en varios lugares, incluida una planta de fabricación en Hamilton, propiedad de GSK, un gigante farmacéutico.

Conocida como “la pandemia olvidada”, la tuberculosis, a pesar de que se puede prevenir y tratar, mata hasta a 1,6 millones de personas al año, la mayoría en zonas empobrecidas de Asia y África.

En Estados Unidos se ha producido un aumento de esta enfermendad en la última década. Muchos inmigrantes tienen TB sin saberlo; en 2022 el número de casos aumentó un 16%. La tuberculosis es la principal causa de muerte entre las personas que viven con VIH, cuyo riesgo de contraer esta enfermedad es 20 veces mayor que el de las personas sin el virus.

“La tuberculosis es un patógeno complejo que ha acompañado a los seres humanos durante siglos”, dijo Alemnew Dagnew, que dirige el programa para la nueva vacuna en el Instituto de Investigación Médica Gates. “Debido a esta situación, ha evolucionado y ha podido desarrollar mecanismos para evadir al sistema inmunológico. Y la inmunología de la TB aún no se comprende completamente”.

En conjunto, el Centro de Medicina Translacional de la Universidad de Montana e Inimmune tienen 80 empleados especializados en la investigación de una variedad de adyuvantes con el propósito de comprender los detalles de las respuestas inmunitarias a diferentes sustancias. “Hay que adaptarlos al patógeno contra el que se vacuna, como si fueran un instrumento en una caja de herramientas”, dijo Evans. “Tenemos toda una biblioteca de moléculas y formulaciones de adyuvantes”.

Las vacunas se vuelven en gran medida más precisas mediante el uso de adyuvantes. Hay tres tipos básicos de adyuvantes naturales: sales de aluminio; escualeno, que se obtiene del hígado de tiburón; y algunos tipos de saponinas, que son moléculas grasas. No se sabe muy bien cómo estimulan el sistema inmunitario. El Centro de Missoula también ha creado y patentado un adyuvante sintético, el UM-1098, que induce un tipo específico de respuesta inmunitaria y que se añadirá a las nuevas vacunas.

Una de las moléculas más prometedoras que se están utilizando para potenciar la respuesta del sistema inmunológico a las vacunas es una molécula de saponina de la corteza del árbol de quillay, recolectada en Chile de árboles que tienen por lo menos una década.

Estas moléculas fueron utilizadas por Novavax en su vacuna contra covid y por GSK en Shingrix, su vacuna contra la culebrilla (shingles), de uso generalizado. Estas moléculas también son un componente clave en la nueva vacuna contra la tuberculosis, conocida como la vacuna M72.

Pero hay margen para mejorar.

“La vacuna muestra una eficacia del 50%, lo que no parece mucho, pero como actualmente se carece de otra vacuna más efectiva, el 50% es bastante mejor que lo que hay”, sostuvo Evans. “Buscamos aprovechar lo que aprendimos de ese desarrollo de la vacuna con adyuvantes adicionales para tratar de mejorarla y llevar ese índice desde el 50% hasta el 80% o más”.

Las vacunas contra el sarampión, en cambio, han alcanzado una efectividad del 95%.

Según el sitio web Medscape, en este momento se están desarrollando alrededor de 15 vacunas que son candidatas a reemplazar la BCG, y tres de ellas se encuentran en la fase 3 de ensayos clínicos.

Una alternativa que el Centro de Evans está investigando para mejorar la eficacia de la nueva vacuna es tomar una parte de la bacteria que causa la tuberculosis, sintetizarla y combinarla con el adyuvante QS-21, elaborado a partir del árbol de quillay. “Estimula el sistema inmunológico de una manera específica para la tuberculosis y genera una respuesta inmune que se acerca aún más a lo que obtenemos de las infecciones naturales”, dijo Evans.

Por su parte, el Centro de la Universidad de Montana está investigando el tratamiento de varias afecciones que generalmente no se consideran susceptibles de ser abordadas mediante vacunación. Por ejemplo, están ingresando en la primera fase de ensayos clínicos para una vacuna contra las alergias y para otra, contra el cáncer.

Avanzado este año, comenzarán los ensayos clínicos para obtener vacunas capaces de bloquear los efectos de opioides como la heroína y el fentanilo. La Universidad de Montana recibió la mayor subvención de su historia, $33 millones, para investigar una vacuna contra los opioides. Funciona creando un anticuerpo que se une a la droga en el torrente sanguíneo, evitando que entre al cerebro y produzca el efecto de euforia.

Por ahora, sin embargo, los expertos en salud de todo el mundo tienen sus ojos puestos en los ensayos de las nuevas vacunas contra la tuberculosis, que, si tienen éxito, podrían ayudar a salvar innumerables vidas en las regiones más pobres del mundo.

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En una estrecha calle de townhouses y un taller mecánico en el vecindario Kensington, en el norte de Philadelphia, Marsella Elie subió los escalones y golpeó fuerte las puertas de las casas.

Un hombre de mediana edad abrió, con mirada cautelosa.

“Hola, señor, ¿cómo está hoy?”, le preguntó Elie, que tenía puesta una chaqueta con el logo de la Campana de la Libertad, del gobierno de la ciudad. “Mi nombre es Marsella. Estoy trabajando con la ciudad. ¿Ha oído hablar de las sobredosis que están ocurriendo en el vecindario, verdad?”.

El hombre asintió. Elie señaló los folletos que tenía sobre sobredosis de drogas y programas de tratamiento para la adicción. Levantó una caja de Narcan, una marca de naloxona, que puede revertir una sobredosis de opioides.

“Lo que estamos tratando de hacer es que esto llegue a todos los hogares. ¿Alguna vez ha oído hablar de esto antes?”, preguntó Elie antes de entregarle al hombre una bolsa de tela llena de folletos, tiras de prueba de fentanilo y la caja de Narcan.

Elie y otros trabajadores de medio tiempo de la ciudad y voluntarios forman parte de una campaña puerta a puerta a gran escala en Philadelphia que tiene como objetivo equipar los hogares con naloxona y otros suministros para prevenir sobredosis de drogas.

Los funcionarios de la ciudad esperan que este enfoque proactivo transforme a la naloxona en un artículo que esté en los botiquines, para evitar que las personas mueran por sobredosis, especialmente los residentes negros.

En Philadelphia, en 2022, según datos de la ciudad, un récord de 1,413 personas murieron por sobredosis de drogas. Entre los residentes negros, las muertes aumentaron un 20% respecto al año anterior, y muchas ocurrieron en casas.

“Lo mejor que podemos hacer para que estos productos sean más accesibles es simplemente dárselos a las personas”, dijo Keli McLoyd, subdirectora de la Unidad de Respuesta a Opioides de la ciudad, hablando sobre la bolsa de tela con naloxona y otros suministros.

“No le estamos preguntando si está usando drogas. El objetivo aquí es realmente construir una responsabilidad colectiva. Como personas de comunidades minoritarias, como vimos durante la epidemia de covid, nadie viene a salvarnos. Para nosotros, esta es una herramienta que podemos usar para salvarnos a nosotros mismos”.

Esta iniciativa de distribución tiene como objetivo llevar suministros de prevención directamente a personas que de otro modo no los buscarían por sí mismas, y concientizar sobre las sobredosis más allá de Kensington, el epicentro de la epidemia de adicción de la ciudad.

Los encuestadores planean golpear más de 100,000 puertas en los “puntos calientes” de Philadelphia, códigos postales con tasas crecientes de sobredosis de opioides, muchos en comunidades minoritarias.

El aumento de las disparidades raciales en las muertes por sobredosis es una de las consecuencias a largo plazo de la guerra contra las drogas, dijo McLoyd. Las políticas de esa campaña nacional llevaron a décadas de tácticas policiales agresivas, perfil racial y largas condenas de prisión, afectando de manera desproporcionada a personas de color y a sus comunidades.

La investigación muestra que los afroamericanos siguen representando un número desproporcionado de arrestos por drogas y servicios de protección infantil.

“Por eso, está muy claro por qué las personas de minorías podrían ser reacias a levantar la mano y decir: ‘Soy una persona que usa drogas, necesito esos recursos'”, dijo McLoyd.

Otras comunidades han distribuido naloxona y otros suministros, aunque en menor escala que Philadelphia. Lo que está haciendo Philadelphia podría convertirse en un modelo para otros lugares densamente poblados, dijo Daliah Heller, vicepresidenta de iniciativas sobre el uso de drogas en Vital Strategies, una organización de salud pública que trabaja con gobiernos locales en siete estados para abordar la epidemia de opioides.

“Hay algo intensamente personal en un compromiso humano”, dijo Heller. “Y que alguien toque a tu puerta para hablar sobre el uso de drogas y el riesgo de sobredosis y que haya algo que se pueda hacer, creo que es realmente poderoso”.

A lo largo de los años, la naloxona se ha vuelto más accesible que nunca, apuntó Heller. Ahora se puede pedir por internet y se puede recibir por correo, está disponible en máquinas expendedoras especializadas y algunas farmacias ahora venden el spray nasal de Narcan sin receta.

Pero decenas de miles de estadounidenses siguen muriendo por sobredosis de opioides cada año.

Eso significa que los esfuerzos de prevención y los mensajes sobre la crisis aún no llegan a algunas personas, dijo Heller. Y para Heller, llegar a las personas significa ir donde están. “Tenemos que pensar así cuando pensamos en la distribución de naloxona”.

El proyecto de divulgación en Philadelphia está financiado en parte por los pagos de acuerdos de demandas nacionales contra fabricantes y distribuidores de opioides, parte de los cuales recibió la ciudad.

Se espera que la ciudad reciba alrededor de $200 millones en aproximadamente 18 años de acuerdos con AmerisourceBergen, Cardinal Health, McKesson y Johnson & Johnson.

De la iniciativa forman parte muchas de las mismas personas que comenzaron a hacer divulgación como parte del censo de 2020.

No todos responden a la puerta. Algunos no están en casa. En esos casos, los trabajadores dejan un volante en el picaporte de la puerta que ofrece información sobre los riesgos de las sobredosis, y contactos para obtener más recursos.

Los equipos de encuestadores, a menudo con intérpretes de idiomas, hacen una segunda ronda de visitas en el vecindario para llegar a las personas que no vieron la primera vez.

En un jueves reciente, los encuestadores de Philadelphia estaban tocando puertas en los vecindarios de Franklinville y Hunting Park. Según datos de la ciudad, en este código postal, aproximadamente 85 personas murieron por sobredosis de drogas en 2022. Eso es menos que las 193 personas que murieron por sobredosis en Kensington el mismo año, pero mucho más que las pocas muertes vistas en los vecindarios más ricos de la ciudad.

Los encuestadores se acercaron a una residente, Katherine Camacho, en la acera, cuando salía de su garage. Camacho les dijo que estaba al tanto del problema de las sobredosis en su comunidad y luego aceptó con entusiasmo una caja de Narcan. “Voy a llevar esto conmigo, porque, como dije, a veces estás en la calle conduciendo a algún lugar y podrías salvar una vida”, les dijo Camacho.

En cuanto al esfuerzo de divulgación de Philadelphia, Camacho dijo que cree que “Dios está poniendo a estas personas para ayudar”. Mientras entraba en su casa llevando la caja de Narcan, agregó que quería hacer su parte para ayudar.

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MANTI, Utah — Garrett Clark estimates he has spent about six years in the Sanpete County Jail, a plain concrete building perched on a dusty hill just outside this small, rural town where he grew up.

He blames his addiction. He started using in middle school, and by the time he was an adult he was addicted to meth and heroin. At various points, he’s done time alongside his mom, his dad, his sister, and his younger brother.

“That’s all I’ve known my whole life,” said Clark, 31, in December.

Clark was at the jail to pick up his sister, who had just been released. The siblings think this time will be different. They are both sober. Shantel Clark, 33, finished earning her high school diploma during her four-month stay at the jail. They have a place to live where no one is using drugs.

And they have Cheryl Swapp, the county sheriff’s new community health worker, on their side.

“She saved my life probably, for sure,” Garrett Clark said.

Swapp meets with every person booked into the county jail soon after they arrive and helps them create a plan for the day they get out.

She makes sure everyone has a state ID card, a birth certificate, and a Social Security card so they can qualify for government benefits, apply to jobs, and get to treatment and probation appointments. She helps nearly everyone enroll in Medicaid and apply for housing benefits and food stamps. If they need medication to stay off drugs, she lines that up. If they need a place to stay, she finds them a bed.

Then Swapp coordinates with the jail captain to have people released directly to the treatment facility. Nobody leaves the jail without a ride and a drawstring backpack filled with items like toothpaste, a blanket, and a personalized list of job openings.

“A missing puzzle piece,” Sgt. Gretchen Nunley, who runs educational and addiction recovery programming for the jail, called Swapp.

Swapp also assesses the addiction history of everyone held by the county. More than half arrive at the jail addicted to something.

Nationally, 63% of people booked into local jails struggle with a substance use disorder — at least six times the rate of the general population, according to the federal Substance Abuse and Mental Health Services Administration. The incidence of mental illness in jails is more than twice the rate in the general population, federal data shows. At least 4.9 million people are arrested and jailed every year, according to an analysis of 2017 data by the Prison Policy Initiative, a nonprofit organization that documents the harm of mass incarceration. Of those incarcerated, 25% are booked two or more times, the analysis found. And among those arrested twice, more than half had a substance use disorder and a quarter had a mental illness.

“We don’t lock people up for being diabetic or epileptic,” said David Mahoney, a retired sheriff in Dane County, Wisconsin, who served as president of the National Sheriffs’ Association in 2020-21. “The question every community needs to ask is: ‘Are we doing our responsibility to each other for locking people up for a diagnosed medical condition?’”

The idea that county sheriffs might owe it to society to offer medical and mental health treatment to people in their jails is part of a broader shift in thinking among law enforcement officials that Mahoney said he has observed during the past decade.

“Don’t we have a moral and ethical responsibility as community members to address the reasons people are coming into the criminal justice system?” asked Mahoney, who has 41 years of experience in law enforcement.

Swapp previously worked as a teacher’s aide for those she calls the “behavior kids” — children who had trouble self-regulating in class. She feels her work at the jail is a way to change things for the parents of those kids. And it appears to be working.

Since the Sanpete County Sheriff’s Office hired Swapp last year, recidivism has dropped sharply. In the 18 months before she began her work, 599 of the people booked into Sanpete County Jail had been there before. In the 18 months after she started, that number dropped to 237.

In most places, people are released from county jails with no health care coverage, no job, nowhere to live, and no plan to stay off drugs or treat their mental illness. Research shows that people newly released from incarceration face a risk of overdose that is 10 times as high as that of the general public.

Sanpete wasn’t any different.

“For seven to eight years of me being here, we’d just release people and cross our fingers,” said Jared Hill, the clinical director for Sanpete County and a counselor at the jail.

Nunley, the programming sergeant, remembers watching people released from jail walk the mile to town with nothing but the clothes they’d worn on the day they were arrested — it was known as the “walk of shame.” Swapp hates that phrase. She said no one has made the trip on foot since she started in July 2022.

Swapp’s work was initially funded by a grant from the U.S. Health Resources and Services Administration, but it has proved so popular that commissioners in Sanpete County voted to use a portion of its opioid settlement money to cover the position in the future.

Swapp doesn’t have formal medical or social work training. She is certified by the state of Utah as a community health worker, a job that has become more common nationwide. There were about 67,000 people working as community health workers in 2022, according to the U.S. Bureau of Labor Statistics.

Evidence is mounting that the model of training people to help their neighbors connect to government and health care services is sound, said Aditi Vasan, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania who has reviewed the research on the relatively new role.

The day before Swapp coordinated Shantel Clark’s release, she sat with Robert Draper, a man in his 50s with long white hair and bright-blue eyes. Draper has been in and out of jail for decades. He was sober for a year and had been taking care of his ill mother. She kept getting worse. Then his daughter and her child came to help. It was all a little too much.

“I thought, if I can just go and get high, I can deal with this shit,” said Draper. “But after you’ve been using for 40 years, it’s kinda easy to slip back in.”

He didn’t blame his probation officer for throwing him back in jail when he tested positive for drugs, he said. But he thinks jail time is an overreaction to a relapse. Draper sent a note to Swapp through the jail staff asking to see her. He was hoping she could help him get out so he could be with his mom, who had just been sent to hospice. He had missed his father’s death years ago because he was in jail at the time.

Swapp listened to Draper’s story without interruptions or questions. Then she asked if she could run through her list with him so she would know what he needed.

“Do you have your Social Security card?”

“My card?” Draper shrugged. “I know my number.”

“Your birth certificate, you have it?”

“Yeah, I don’t know where it is.”

“Driver’s license?”

“No.”

“Was it revoked?”

“A long, long time ago,” Draper said. “DUI from 22 years ago. Paid for and everything.”

“Are you interested in getting it back?”

“Yeah!”

Swapp has some version of this conversation with every person she meets in the jail. She also runs through their history of addiction and asks them what they most need to get back on their feet.

She told Draper she would try to get him into intensive outpatient therapy. That would involve four to five classes a week and a lot of driving. He’d need his license back. She didn’t make promises but said she would talk to his probation officer and the judge. He sighed and thanked her.

“I’m your biggest fan here,” Swapp said. “I want you to succeed. I want you to be with your mom, too.”

The federal grant that funded the launch of Sanpete’s community health worker program is held by the regional health care services organization Intermountain Health. Intermountain took the idea to the county and has provided Swapp with support and training. Intermountain staff also administer the $1 million, three-year grant, which includes efforts to increase addiction recovery services in the area.

A similarly funded program in Kentucky called First Day Forward took the community health worker model a step further, using “peer support specialists” — people who have experienced the issues they are trying to help others navigate. Spokespeople from HRSA pointed to four programs, including the ones in Utah and Kentucky, that are using their grant money for people facing or serving time in local jails.

Back in Utah, Sanpete’s new jail captain, Jeff Nielsen, said people in small-town law enforcement weren’t so far removed from those serving time.

“We know these people,” Nielsen said. He has known Robert Draper since middle school. “They are friends, neighbors, sometimes family. We’d rather help than lock them up and throw away the key. We’d rather help give them a good life.”

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SACRAMENTO, Calif. — Gov. Gavin Newsom’s administration has compromised on long-sought rules that would protect indoor workers from extreme heat, saying tens of thousands of prison and jail employees — and prisoners — would have to wait for relief.

The deal comes a month after the administration unexpectedly rejected sweeping heat standards for workers in sweltering warehouses, steamy kitchens, and other dangerously hot job sites. The rules had been years in the making, and a state worker safety board voted to adopt them March 21. But in a controversial move, the administration upended the process by saying the cost to cool state prisons was unclear — and likely very expensive.

So the Democratic administration said the rules can proceed but must exempt tens of thousands of workers at 33 state prisons, conservation camps, and local jails, “in recognition of the unique implementation challenges,” said Eric Berg, of California’s Division of Occupational Safety and Health, at a Thursday hearing. A separate regulation will be drafted for correctional facilities, which could take a year, if not longer.

It’s unclear if the standards will become law in time to protect millions of other workers from summer’s intensifying heat. The compromise rules must go through a 15-day public comment period, and legal reviews within 100 days, which could push implementation well into summer. But that can’t even happen until the original regulation is rejected by the Office of Administrative Law, which has until next month.

“Summer is arriving, and many workers, unfortunately, are going to suffer heat conditions,” said Tim Shadix, legal director at the Warehouse Worker Resource Center. “Some will likely get really sick, potentially even die from heat illness, while we continue to wait for the standard.”

Berg told members of the Occupational Safety and Health Standards Board on April 18 that Cal/OSHA would try to accelerate the timeline and get protections in place for summer.

California has had heat standards on the books for outdoor workers since 2005, and rules for indoor workplaces have been in the works since 2016. The proposed standards would require work sites to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear protective clothing or are exposed to radiant heat, such as furnaces. Buildings could be cooled with air conditioning, fans, misters, and other methods.

The rules allow workarounds for businesses that can’t cool their workplaces sufficiently, such as laundries or restaurant kitchens.

Because the rules would have a sweeping economic impact, state law requires Newsom’s Department of Finance to sign off on the financial projections, which it refused to do last month when it was unclear how much the regulations would cost state prisons. The California Department of Corrections and Rehabilitation said implementing the standards in its prisons and other facilities could cost billions, but the board’s economic analysis pegged the cost at less than $1 million a year.

Department of Finance spokesperson H.D. Palmer couldn’t promise that the compromise rules would be signed off on, but “given that the earlier correctional estimates were the issue before, not having them in the revised package would appear to address that issue,” he said.

Business and agricultural groups complained repeatedly during the rulemaking process that complying with the rules would burden businesses financially. At the April 18 hearing, they highlighted the administration’s lack of transparency and questioned why one sector should be given an exemption over another.

“The massive state costs that are of concern, specifically around prisons in the billions of dollars, are also costs that California employers will bear,” said Robert Moutrie, a senior policy advocate at the California Chamber of Commerce.

Labor advocates asked board members not to exempt prisons, saying corrections workers need protection from heat, too.

“It’s a huge concern that prison workplaces all over are being excluded from the heat standard, leaving out not just guards, but also nurses, janitors, and the other prison workers across California unprotected from heat,” said AnaStacia Nicol Wright, an attorney with Worksafe, a workplace safety advocacy nonprofit. “California needs to prioritize the safety and well-being of their workers, regardless of whether they work in corrections, a farm, or a sugar refinery.”

Prisons will continue to provide cooling stations in air-conditioned areas, and make water stations, fans, portable cooling units, and ice more available to workers, according to the California Department of Corrections and Rehabilitation. Prison housing units, which house roughly 93,000 inmates as of April 17, all can be cooled, usually with evaporative coolers and fans. The department has 58,135 staff members, spokesperson Terri Hardy said.

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

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

“These are not overly cumbersome things to implement, and they are easy ways to keep people safe and healthy,” said Jessica Early, patient advocacy coordinator at the National Union of Healthcare Workers. “Now is the urgent time to make our workplaces safer and more resilient in the face of rising temperatures.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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A team of Montana researchers is playing a key role in the development of a more effective vaccine against tuberculosis, an infectious disease that has killed more people than any other.

The BCG (Bacille Calmette-Guérin) vaccine, created in 1921, remains the sole TB vaccine. While it is 40% to 80% effective in young children, its efficacy is very low in adolescents and adults, leading to a worldwide push to create a more powerful vaccine.

One effort is underway at the University of Montana Center for Translational Medicine. The center specializes in improving and creating vaccines by adding what are called novel adjuvants. An adjuvant is a substance included in the vaccine, such as fat molecules or aluminum salts, that enhances the immune response, and novel adjuvants are those that have not yet been used in humans. Scientists are finding that adjuvants make for stronger, more precise, and more durable immunity than antigens, which create antibodies, would alone.

Eliciting specific responses from the immune system and deepening and broadening the response with adjuvants is known as precision vaccination. “It’s not one-size-fits-all,” said Ofer Levy, a professor of pediatrics at Harvard University and the head of the Precision Vaccines Program at Boston Children’s Hospital. “A vaccine might work differently in a newborn versus an older adult and a middle-aged person.”

The ultimate precision vaccine, said Levy, would be lifelong protection from a disease with one jab. “A single-shot protection against influenza or a single-shot protection against covid, that would be the holy grail,” Levy said.

Jay Evans, the director of the University of Montana center and the chief scientific and strategy officer and a co-founder of Inimmune, a privately held biotechnology company in Missoula, said his team has been working on a TB vaccine for 15 years. The private-public partnership is developing vaccines and trying to improve existing vaccines, and he said it’s still five years off before the TB vaccine might be distributed widely.

It has not gone unnoticed at the center that this state-of-the-art vaccine research and production is located in a state that passed one of the nation’s most extreme anti-vaccination laws during the pandemic in 2021. The law prohibits businesses and governments from discriminating against people who aren’t vaccinated against covid-19 or other diseases, effectively banning both public and private employers from requiring workers to get vaccinated against covid or any other disease. A federal judge later ruled that the law cannot be enforced in health care settings, such as hospitals and doctors’ offices.

In mid-March, the Bill & Melinda Gates Medical Research Institute announced it had begun the third and final phase of clinical trials for the new vaccine in seven countries. The trials should take about five years to complete. Research and production are being done in several places, including at a manufacturing facility in Hamilton owned by GSK, a giant pharmaceutical company.

Known as the forgotten pandemic, TB kills up to 1.6 million people a year, mostly in impoverished areas in Asia and Africa, despite its being both preventable and treatable. The U.S. has seen an increase in tuberculosis over the past decade, especially with the influx of migrants, and the number of cases rose by 16% from 2022 to 2023. Tuberculosis is the leading cause of death among people living with HIV, whose risk of contracting a TB infection is 20 times as great as people without HIV.

“TB is a complex pathogen that has been with human beings for ages,” said Alemnew Dagnew, who heads the program for the new vaccine for the Gates Medical Research Institute. “Because it has been with human beings for many years, it has evolved and has a mechanism to escape the immune system. And the immunology of TB is not fully understood.”

The University of Montana Center for Translational Medicine and Inimmune together have 80 employees who specialize in researching a range of adjuvants to understand the specifics of immune responses to different substances. “You have to tailor it like tools in a toolbox towards the pathogen you are vaccinating against,” Evans said. “We have a whole library of adjuvant molecules and formulations.”

Vaccines are made more precise largely by using adjuvants. There are three basic types of natural adjuvants: aluminum salts; squalene, which is made from shark liver; and some kinds of saponins, which are fat molecules. It’s not fully understood how they stimulate the immune system. The center in Missoula has also created and patented a synthetic adjuvant, UM-1098, that drives a specific type of immune response and will be added to new vaccines.

One of the most promising molecules being used to juice up the immune system response to vaccines is a saponin molecule from the bark of the quillay tree, gathered in Chile from trees at least 10 years old. Such molecules were used by Novavax in its covid vaccine and by GSK in its widely used shingles vaccine, Shingrix. These molecules are also a key component in the new tuberculosis vaccine, known as the M72 vaccine.

But there is room for improvement.

“The vaccine shows 50% efficacy, which doesn’t sound like much, but basically there is no effective vaccine currently, so 50% is better than what’s out there,” Evans said. “We’re looking to take what we learned from that vaccine development with additional adjuvants to try and make it even better and move 50% to 80% or more.”

By contrast, measles vaccines are 95% effective.

According to Medscape, around 15 vaccine candidates are being developed to replace the BCG vaccine, and three of them are in phase 3 clinical trials.

One approach Evans’ center is researching to improve the new vaccine’s efficacy is taking a piece of the bacterium that causes TB, synthesizing it, and combining it with the adjuvant QS-21, made from the quillay tree. “It stimulates the immune system in a way that is specific to TB and it drives an immune response that is even closer to what we get from natural infections,” Evans said.

The University of Montana center is researching the treatment of several problems not commonly thought of as treatable with vaccines. They are entering the first phase of clinical trials for a vaccine for allergies, for instance, and first-phase trials for a cancer vaccine. And later this year, clinical trials will begin for vaccines to block the effects of opioids like heroin and fentanyl. The University of Montana received the largest grant in its history, $33 million, for anti-opioid vaccine research. It works by creating an antibody that binds with the drug in the bloodstream, which keeps it from entering the brain and creating the high.

For now, though, the eyes of health care experts around the world are on the trials for the new TB vaccines, which, if they are successful, could help save countless lives in the world’s poorest places.

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Heiress Paris Hilton is on a mission to shine a light on the “troubled teen industry,” a largely unregulated multibillion-dollar industry that is gaining public scrutiny for alleged abuse of vulnerable youths.

Hilton told state lawmakers in Sacramento on Monday she was subjected to abuse disguised as therapy decades ago when she was housed in residential facilities for teenagers struggling with substance abuse, mental illness and problematic behavior. 

She testified at the state Capitol in support of a bill ordering disclosure of the use of restraints or seclusion rooms in disciplining minors at residential facilities.

“When I close my eyes at night, I still have nightmares about solitary confinement 20 years later,” said Hilton, 43, at a news conference before the hearing. “The sounds of my peers screaming as they were physically restrained by numerous staff members and injected with sedatives will also never leave me.”

Having already won regulation in several other states, Hilton made clear that she wants federal oversight of the mental and behavioral health facilities — even as the reality star bumps up against the reality of this contentious Congress.

“If you are abusing children, I will find out,” Hilton said. “I will find you and I will come with my huge spotlight and shine it on wherever you are.”

Hilton visited D.C. last year to advocate the federal Stop Institutional Child Abuse Act, which would establish best practices and transparency in youth residential care programs.

But the proposal is stalled in Congress, and similar federal efforts have failed for more than a decade.

After the 2020 release of the documentary “This is Paris,” in which Hilton details abuses that she said she faced while attending Provo Canyon School in Provo, Utah, she has testified at state capitols, supporting successful bills in Missouri, Montana, Oregon and Utah.

Now, fresh off the Coachella slide with pal Kesha, Hilton is eyeing the most populous state.

There is no formal opposition to the bipartisan bill, which passed unanimously out of the state Senate’s Human Services Committee. It still has multiple steps before passage, including consideration by the full membership of both houses of the legislature.

The National Association of Therapeutic Schools and Programs, the nation’s largest such member organization, told KFF Health News that it supports the California bill as well as federal proposals.

Republican state Sen. Shannon Grove of Bakersfield, the bill’s lead author, said the goal is to protect young people housed in short-term residential therapeutic programs. Her legislation would require the California Department of Social Services — which licenses the facilities — to produce a public dashboard by 2026 on the use of restraints and seclusion rooms as well as serious injuries or deaths associated with them.

“There are complaints of broken arms, slammed hands in doors,” Grove said, noting that the facilities typically house vulnerable populations, including foster youths. “There’s no data to show what happened and what caused that. And so, the goal is to go after the data.”

Grove certainly found an ally in Hilton and her 16.4 million followers on the social platform X.

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On a narrow street lined with row houses and an auto body shop in the Kensington neighborhood of North Philadelphia, Marsella Elie climbs a home’s front steps and knocks hard on the door.

A middle-aged man appears with a wary look on his face.

“Hello, sir, how are you doing today?” asked Elie, wearing a royal-blue jacket embroidered with the city government’s Liberty Bell logo. “My name is Marsella. I’m working with the city. You heard about the overdoses that are going around in the neighborhood, right?”

The man gives a cautious nod.

Elie gestures to the pamphlets she’s holding about drug overdoses and addiction treatment programs. She holds up a box of Narcan, a brand of naloxone, which can reverse an opioid overdose.

“What we’re trying to do is get this in everybody’s household. Have you ever heard of this before?” Elie asked before handing the man a tote bag filled with more pamphlets, fentanyl test strips, and the box of Narcan.

Elie and other part-time city workers and volunteers are part of a large-scale, citywide door-to-door campaign in Philadelphia that aims to equip homes with naloxone and other drug overdose prevention supplies.

City officials hope that this proactive approach will normalize naloxone as an everyday item in the medicine cabinet, and prevent people from dying of overdoses, especially Black residents.

In Philadelphia in 2022, a record 1,413 people died from drug overdoses, according to city data. Among Black residents, deaths were up 20% from the year before, with many happening in private homes.

“The best thing we can do to make these things more accessible is to just give them to people,” said Keli McLoyd, deputy director of the city’s Opioid Response Unit, speaking about the tote bag with naloxone and other supplies. “We’re not asking you if you’re using drugs. The goal here is really to build sort of a collective responsibility. As Black and brown folks, as we saw during the covid epidemic, nobody’s coming to save us. For us, this is a tool that we can use to save ourselves.”

The canvassing initiative aims to take prevention supplies directly to people who might not otherwise seek it out themselves, and to spread awareness about overdoses beyond Kensington, the epicenter of the city’s addiction epidemic. Canvassers plan to knock on more than 100,000 doors in Philadelphia’s “hot spots” — ZIP codes with escalating rates of opioid overdoses, many in minority communities.

Widening racial disparities in overdose deaths are among the long-term consequences of the war on drugs, McLoyd said. Policies from that national anti-drug campaign led to decades of aggressive police tactics, racial profiling, and lengthy prison sentences, disproportionately affecting people of color and their communities.

Research shows that Black Americans still account for a disproportionate number of drug arrests and child protective services.

“Because of that, it’s very clear why Black or brown people might be hesitant to raise their hand and say, ‘I’m a person who uses drugs, I need those resources,’” McLoyd said.

Other communities have distributed naloxone and other supplies, albeit on a smaller scale than Philadelphia.

What Philadelphia is doing could become a model for other densely populated places, said Daliah Heller, vice president of drug use initiatives at Vital Strategies, a public health organization working with local governments in seven states to address the opioid epidemic.

“There’s something intensely personal about a human engagement,” Heller said. “And somebody knocking at your door to talk about drug use and overdose risk and that there’s something that can be done, I think is really powerful.”

Over the years, naloxone has become more accessible than ever before, Heller pointed out. It can now be ordered online and through the mail, it’s available in specialized vending machines, and some drugstores now sell Narcan nasal spray over the counter.

But tens of thousands of Americans are still dying from opioid overdoses every year. That means prevention efforts and messaging about the crisis are still not reaching some people, Heller said. And to her, reaching people means meeting them where they are. “That means physically, that means in terms of what they know about something, what their perception is of something, and their beliefs,” she said. “We need to think like that when we think about naloxone distribution.”

The Philadelphia canvassing project is funded in part by the city’s share of settlement payouts from national lawsuits against opioid manufacturers and distributors. The city is set to receive about $200 million over roughly 18 years from settlements with AmerisourceBergen, Cardinal Health, McKesson, and Johnson & Johnson.

The initiative is staffed by many of the same people who initially started canvassing as part of the 2020 census count.

Not everyone answers the door for the canvassers. Some aren’t home when they come around. In those cases, workers hang a flyer on the door handle that offers information about overdose risks and contacts for further resources. The teams of canvassers, often with language interpreters, later make a second sweep through a neighborhood to reach people they missed the first time.

On a recent Thursday, Philadelphia canvassers were knocking on doors in the Franklinville and Hunting Park neighborhoods. In this ZIP code, about 85 people died of drug overdoses in 2022, according to city data. That’s fewer than the 193 people who died of overdoses in Kensington in 2022, but much higher than the few deaths seen in the city’s most affluent neighborhoods.

The canvassers approached a resident, Katherine Camacho, on the sidewalk, as she came out of her garage. Camacho told the teams she was aware of the overdose problem in her community and then eagerly accepted a box of Narcan.

“I will carry this with me, because, like I said, sometimes you’re in the street driving somewhere and you could save a life,” Camacho told them. “And if you don’t have these things, it’s harder to do so, right?”

Camacho said she’s seen how the opioid crisis has caused suffering in her neighborhood and across the city. As for Philadelphia’s canvassing effort, she said she believes that “God is putting these people to help.”

As she headed into her house carrying the box of Narcan, Camacho said she wanted to do her part to help, too.

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HISLE, S.D. — Katherine Goodlow is only 20, but she has experienced enough to know that people around her are dying too young.

Goodlow, a member of the Lower Brule Sioux Tribe, said she’s lost six friends and acquaintances to suicide, two to car crashes, and one to appendicitis. Four of her relatives died in their 30s or 40s, from causes such as liver failure and covid-19, she said. And she recently lost a 1-year-old nephew.

“Most Native American kids and young people lose their friends at a young age,” said Goodlow, who is considering becoming a mental health therapist to help her community. “So, I’d say we’re basically used to it, but it hurts worse every time we lose someone.”

Native Americans tend to die much earlier than white Americans. Their median age at death was 14 years younger, according to an analysis of 2018-21 data from the Centers for Disease Control and Prevention

The disparity is even greater in Goodlow’s home state. Indigenous South Dakotans who died between 2017 and 2021 had a median age of 58 — 22 years younger than white South Dakotans, according to state data.

Donald Warne, a physician who is co-director of the Johns Hopkins Center for Indigenous Health and a member of the Oglala Sioux Tribe, can rattle off the most common medical conditions and accidents killing Native Americans.

But what’s ultimately behind this low life expectancy, agree Warne and many other experts on Indigenous health, are social and economic forces. They argue that in addition to bolstering medical care and fully funding the Indian Health Service — which provides health care to Native Americans — there needs to be a greater investment in case management, parenting classes, and home visits.

“It’s almost blasphemy for a physician to say,” but “the answer to addressing these things is not hiring more doctors and nurses,” Warne said. “The answer is having more community-based preventions.”

The Indian Health Service funds several kinds of these programs, including community health worker initiatives, and efforts to increase access to fresh produce and traditional foods.

Private insurers and state Medicaid programs, including South Dakota’s, are increasingly covering such services. But insurers don’t pay for all the services and aren’t reaching everyone who qualifies, according to Warne and the National Academy for State Health Policy.

Warne pointed to Family Spirit, a program developed by the Johns Hopkins center to improve health outcomes for Indigenous mothers and children.

Chelsea Randall, the director of maternal and child health at the Great Plains Tribal Leaders’ Health Board, said community health workers educate Native pregnant women and connect them with resources during home visits.

“We can be with them throughout their pregnancy and be supportive and be the advocate for them,” said Randall, whose organization runs Family Spirit programs across seven reservations in the Dakotas, and in Rapid City, South Dakota.

The community health workers help families until children turn 3, teaching parenting skills, family planning, drug abuse prevention, and stress management. They can also integrate the tribe’s culture by, for example, using their language or birthing traditions.

The health board funds Family Spirit through a grant from the federal Health Resources and Services Administration, Randall said. Community health workers, she said, use some of that money to provide child car seats and to teach parents how to properly install them to counter high rates of fatal crashes.

Other causes of early Native American deaths include homicide, drug overdoses, and chronic diseases, such as diabetes, Warne said. Native Americans also suffer a disproportionate number of infant and maternal deaths.

The crisis is evident in the obituaries from the Sioux Funeral Home, which mostly serves Lakota people from the Pine Ridge Reservation and surrounding area. The funeral home’s Facebook page posts obituaries for older adults, but also for many infants, toddlers, teenagers, young adults, and middle-aged residents.

Misty Merrival, who works at the funeral home, blames poor living conditions. Some community members struggle to find healthy food or afford heat in the winter, she said. They may live in homes with broken windows or that are crowded with extended family members. Some neighborhoods are strewn with trash, including intravenous needles and broken bottles.

Seeing all these premature deaths has inspired Merrival to keep herself and her teenage daughter healthy by abstaining from drugs and driving safely. They also talk every day about how they’re feeling, as a suicide-prevention strategy.

“We’ve made a promise to each other that we wouldn’t leave each other like that,” Merrival said.

Many Native Americans live in small towns or on poor, rural reservations. But rurality alone doesn’t explain the gap in life expectancy. For example, white people in rural Montana live 17 years longer, on average, than Native Americans in the state, according to state data reported by Lee Enterprises newspapers.

Many Indigenous people also face racism or personal trauma from child or sexual abuse and exposure to drugs or violence, Warne said. Some also deal with generational trauma from government programs and policies that broke up families and tried to suppress Native American culture.

Even when programs are available, they’re not always accessible.

Families without strong internet connections can’t easily make video appointments. Some lack cars or gas money to travel to clinics, and public transportation options are limited.

Randall, the health board official, is pregnant and facing her own transportation struggles.

It’s a three-hour round trip between her home in the town of Pine Ridge and her prenatal appointments in Rapid City. Randall has had to cancel several appointments when family members couldn’t lend their cars.

Goodlow, the 20-year-old who has lost several loved ones, lives with seven other people in her mother’s two-bedroom house along a gravel road. Their tiny community on the Pine Ridge Reservation has homes and ranches but no stores.

Goodlow attended several suicide-prevention presentations in high school. But the programs haven’t stopped the deaths. One friend recently killed herself after enduring the losses of her son, mother, best friend, and a niece and nephew.

A month later, another friend died from a burst appendix at age 17, Goodlow said. The next day, Goodlow woke up to find one of her grandmother’s parakeets had died. That afternoon, she watched one of her dogs die after having seizures.

“I thought it was like some sign,” Goodlow said. “I started crying and then I started thinking, ‘Why is this happening to me?’”

Warne said the overall conditions on some reservations can create despair. But those same reservations, including Pine Ridge, also contain flourishing art scenes and language and cultural revitalization programs. And not all Native American communities are poor.

Warne said federal, state, and tribal governments need to work together to improve life expectancy. He encourages tribes to negotiate contracts allowing them to manage their own health care facilities with federal dollars because that can open funding streams not available to the Indian Health Service.

Katrina Fuller is the health director at Siċaŋġu Co, a nonprofit group on the Rosebud Reservation in South Dakota. Fuller, a member of the Rosebud Sioux Tribe, said the organization works toward “wicozani,” or the good way of life, which encompasses the physical, emotional, cultural, and financial health of the community.

Siċaŋġu Co programs include bison restoration, youth development, a Lakota language immersion school, financial education, and food sovereignty initiatives.

“Some people out here that are struggling, they have dreams, too. They just need the resources, the training, even the moral support,” Fuller said. “I had one person in our health coaching class tell me they just really needed someone to believe in them, that they could do it.”

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Celebrity hotel heiress Paris Hilton is backing California lawmakers’ push to increase the transparency of residential teen therapeutic centers by requiring these programs to report the use of restraints or seclusion rooms in disciplining minors.

“We shouldn’t be placing youth in facilities without knowing what these children will be subjected to,” Hilton testified Monday to the Senate Human Services Committee in Sacramento. “The Accountability in Children’s Treatment Act is a simple transparency measure that would make a lasting impact and show the world what truly happens behind closed doors.”

Hilton, 43, has become a high-profile advocate for getting tough on what she describes as the “troubled teen industry,” which promises to rehabilitate teenagers struggling with substance abuse, mental illness, and problematic behavior. Such programs lack federal oversight and have been exposed for riots, assaults, and even deaths of minors, prompting a pushback to protect the rights of young people.

After releasing a documentary in 2020 detailing abuse she faced while attending Provo Canyon School in Provo, Utah, as a teenager, Hilton traveled back to the state, helping pass a bill strengthening inspection and oversight of the industry. Advocates have successfully passed related laws in Illinois, Missouri, Montana, and Oregon.

Last year, Hilton went to Washington, D.C., to advocate for the federal Stop Institutional Child Abuse Act, which would establish best practices and transparency in youth residential care programs. But national efforts have failed for more than a decade and the latest proposal has been stalled for a year.

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• Montana Adds Protections for Kids in Private Residential Treatment Programs Oct 17, 2014

Now, Hilton and others are eyeing the most populous state as an opportunity for change.

Senate Bill 1043 is a bipartisan bill by Republican state Sen. Shannon Grove and authored also by Democratic Sens. Aisha Wahab and Angelique Ashby. The bill aims to protect young people housed in short-term residential therapeutic programs licensed by the California Department of Social Services by requiring the agency to produce a public dashboard by 2026 on the use of restraint and seclusion rooms, and when it results in serious injuries or death. It would also require foster parents and guardians to be notified when restraints and seclusion rooms are used on minors.

“There are complaints of broken arms, slammed hands in doors,” said Grove, who noted that these facilities typically house vulnerable populations, including foster youth. “There’s no data to show what happened and what caused that. And so, the goal is to go after the data.”

There was no formal opposition. The National Association of Therapeutic Schools and Programs, the nation’s largest such member organization, told KFF Health News that it supports the California bill.

During Monday’s hearing, Hilton shared that while she was housed at facilities in California, Utah, and Montana, she was subjected to abuse disguised as therapy. She said if she tried to tell her parents about the abuse, facility staff would rip the phone from her hand, restrain her, and force her into solitary confinement.

“When I close my eyes at night, I still have nightmares about solitary confinement 20 years later,” Hilton said. “The sounds of my peers screaming as they were physically restrained by numerous staff members and injected with sedatives will also never leave me.”

Zoe Schreiber, another survivor, said she was sent at age 13 to a Utah facility, where she was restrained face down in the mud by six adults for hours in the rain. Schreiber described enduring seclusion, hard labor, and humiliation for four years.

Democratic state Sen. Marie Alvarado-Gil, who chairs the Human Services Committee, said she had worked in such residential treatment facilities and noticed that staff often didn’t have proper training.

“I don’t think they’re all bad, but I do think the ones that are bad, that impact the trauma of our children, that are unregulated, that are unstructured, that do not have evidence-based programming — I wonder how we get away with that here in California,” Alvarado-Gil said.

Wahab said it’s important for California to act in the absence of a federal bill. California enacted related legislation in 2021 to prevent the state from sending foster children to out-of-state facilities.

“I’m hoping that we do some justice to the kids here,” Wahab said.

The Senate Human Services Committee passed SB 1043 on a 5-0 vote. The bill now goes to the Appropriations Committee.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Abortion opponents have maneuvered in courthouses for years to end access to reproductive health care. In Arizona last week, a win for the anti-abortion camp caused political blowback for Republican candidates in the state and beyond.

The reaction echoed the response to an Alabama Supreme Court decision over in vitro fertilization just two months before.

The election-year ruling by the Arizona Supreme Court allowing enforcement of a law from 1864 banning nearly all abortions startled Republican politicians, some of whom quickly turned to social media to denounce it.

The court decision was yet another development forcing many Republicans legislators and candidates to thread the needle: Maintain support among anti-abortion voters while not damaging their electoral prospects this fall. This shifting power dynamic between state judges and state lawmakers has turned into a high-stakes political gamble, at times causing daunting problems, on a range of reproductive health issues, for Republican candidates up and down the ballot.

“When the U.S. Supreme Court said give it back to the states, OK, well now the microscope is on the states,” said Jennifer Piatt, co-director of the Center for Public Health Law and Policy at Arizona State University’s Sandra Day O’Connor College of Law. “We saw this in Alabama with the IVF decision,” she said, “and now we’re seeing it in Arizona.”

Multiple Republicans have criticized the Arizona high court’s decision on the 1864 law, which allows abortion only to save a pregnant woman’s life. “This decision cannot stand. I categorically reject rolling back the clock to a time when slavery was still legal and where we could lock up women and doctors because of an abortion,” state Rep. Matt Gress said in a video April 9. All four Arizona Supreme Court justices who said the long-dormant Arizona abortion ban could be enforced were appointed by former Gov. Doug Ducey, a Republican who in 2016 expanded the number of state Supreme Court justices from five to seven and cemented the bench’s conservative majority.

Yet in a post the day of the ruling on the social platform X, Ducey said the decision “is not the outcome I would have preferred.”

The irony is that the decision came after years of efforts by Arizona Republicans “to lock in a conservative majority on the court at the same time that the state’s politics were shifting more towards the middle,” said Douglas Keith, senior counsel at the left-leaning Brennan Center for Justice.

All the while, anti-abortion groups have been pressuring Republicans to clearly define where they stand.

“Whether running for office at the state or federal level, Arizona Republicans cannot adopt the losing ostrich strategy of burying their heads in the sand on the issue of abortion and allowing Democrats to define them,” Kelsey Pritchard, a spokesperson for Susan B. Anthony Pro-Life America, said in an emailed statement. “To win, Republicans must be clear on the pro-life protections they support, express compassion for women and unborn children, and contrast their position with the Democrat agenda.”

Two months before the Arizona decision, the Alabama Supreme Court said frozen embryos from in vitro fertilization can be considered children under state law. The decision prompted clinics across the state to halt fertility treatments and caused a nationwide uproar over reproductive health rights. With Republicans feeling the heat, Alabama lawmakers scrambled to pass a law to shield IVF providers from prosecution and civil lawsuits “for the damage to or death of an embryo” during treatment.

But when it comes to courts, Arizona lawmakers are doubling down: state Supreme Court justices are appointed by the governor but generally face voters every six years in retention elections. That could soon change. A constitutional amendment referred by the Arizona Legislature that could appear on the November ballot would eliminate those regular elections — triggering them only under limited circumstances — and allow the justices to serve as long as they exhibit “good behavior.” Effectively it would grant justices lifetime appointments until age 70, when they must retire.

Even with the backlash against the Arizona court’s abortion decision, Keith said, “I suspect there aren’t Republicans in the state right now who are lamenting all these changes to entrench a conservative majority on the Supreme Court.”

Meanwhile, abortion rights groups are trying to get a voter-led state constitutional amendment on the ballot that would protect abortion access until fetal viability and allow abortions afterward to protect the life or health of the pregnant person.

State court decisions are causing headaches even at the very top of the Republican ticket. In an announcement in which he declined to endorse a national abortion ban, presumptive Republican presidential nominee Donald Trump on April 8 said he was “proudly the person responsible” for ending Roe v. Wade, which recognized a federal constitutional right to abortion before being overturned by the U.S. Supreme Court in 2022, and said the issue should be left to states. “The states will determine by vote or legislation, or perhaps both, and whatever they decide must be the law of the land,” he said. But just two days later he sought to distance himself from the Arizona decision. Trump also praised the Alabama Legislature for enacting the law aiming to preserve access to fertility treatments. “The Republican Party should always be on the side of the miracle of life,” he said.

Recent court decisions on reproductive health issues in Alabama, Arizona, and Florida will hardly be the last. The Iowa Supreme Court, which underwent a conservative overhaul in recent years, on April 11 heard arguments on the state’s near-total abortion ban. Republican Gov. Kim Reynolds signed it into law in 2023 but it has been blocked in court.

In Florida, there was disappointment all around after dueling state Supreme Court decisions this month that simultaneously paved the way for a near-total abortion ban and also allowed a ballot measure that would enshrine abortion rights in the state constitution to proceed.

The Florida high court’s decisions were “simply unacceptable when five of the current seven sitting justices on the court were appointed by Republican Governor Ron DeSantis,” Andrew Shirvell, executive director of the anti-abortion group Florida Voice for the Unborn, said in a statement. “Clearly, grassroots pro-life advocates have been misled by elements within the ‘pro-life, pro-family establishment’ because Florida’s highest court has now revealed itself to be a paper tiger when it comes to standing-up to the murderous abortion industry.”

Tension between state judicial systems and conservative legislators seems destined to continue given judges’ growing power over reproductive health access, Piatt said, with people on both sides of the political aisle asking: “Is this a court that is potentially going to give me politically what I’m looking for?”

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SACRAMENTO, Calif. — Nearly a half-million health workers who stand to benefit from California’s nation-leading $25 minimum wage law could be in for a rude awakening if hospitals and other health care providers follow through on potential cuts to hours and benefits.

A medical industry challenge to a new minimum wage ordinance in one Southern California city suggests layoffs and reductions in hours and benefits, including cuts to premium pay and vacation time, could be one result of a state law set to begin phasing in in June. However, some experts are skeptical of that possibility.

The California Hospital Association brought a partly successful legal challenge to Inglewood’s $25 minimum wage ordinance, which barred employers from taking those sorts of steps to offset their higher costs.

“Layoffs, reductions in premium pay rates, reductions in non-wage benefits, reductions in hours, and increased charges are consequences of an employer having less money to spend—which will necessarily be the case given the significant increase in spending on wages due to the minimum wage,” the association said in its lawsuit. Additional examples include reducing health coverage and charging for parking or work-related equipment.

Inglewood voters approved the ordinance in November 2022, nearly a year before California legislators enacted a $25 minimum wage for health workers. Those statewide higher wages are to be phased in starting in June under California’s first-in-the-nation law, but Gov. Gavin Newsom has since said they are too expensive as the state faces a deficit estimated between $38 billion and $73 billion. It’s unclear if lawmakers will agree to a delay or take other steps to reduce the cost.

U.S. District Judge Dale S. Fischer agreed with the hospital industry in a March 11 tentative ruling when he shot down the portion of Inglewood’s ordinance banning layoffs and clawbacks by employers, while allowing the rest of the ordinance to remain in effect. He gave the sides time to object to his preliminary decision, though none did.

The California Hospital Association represents more than 400 hospitals and was a key backer of the state’s carefully crafted compromise law, which notably contains none of the employee safeguards included in the Inglewood ordinance.

Spokesperson Jan Emerson-Shea said the association doesn’t know how providers will react once the state law takes effect. “We don’t have any insights,” she said.

“The challenge for any health care organization is figuring out how to pay for the higher wages,” said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco. “Since labor costs are the largest part of any health care organization’s costs, it’s hard to figure out how to reduce spending without looking at labor costs.”

Providers can try to increase revenues by bargaining for higher reimbursements from commercial insurers, she said. Public hospitals, nursing homes, and community clinics get most of their money through Medi-Cal, the state’s Medicaid program.

Providers could reduce the services they offer, pare back charity care, and cut or delay capital investments, Spetz said. In the long term, she expects some combination of spending cuts and revenue increases.

Both the state law and local ordinance cover far more than doctors and nurses, with a definition of health worker that includes janitors, housekeepers, groundskeepers, security guards, food service workers, laundry workers, and clerical staff.

The most recent estimate by the Health Care Program at the University of California-Berkeley Labor Center is that as many as 426,000 health workers would make an average of $6,400 extra in the law’s first year, a 19% average pay bump mainly benefiting lower-income workers of color and women. State finance officials project that well over 500,000 workers will benefit.

Researchers didn’t include layoffs and other potential staffing and benefit reductions when they projected the state law’s costs and benefits, said Laurel Lucia, the program’s director. But she pointed to initial projections by hospitals, doctors, and business and taxpayer groups that the wage hike would cost $8 billion annually, thereby imperiling services and resulting in higher premiums and higher costs for state and local governments.

“It seems like a contradiction to say this law’s going to cost billions of dollars while at the same time saying it’s going to reduce workers’ total compensation,” said Lucia, who projects a far lower price tag.

She added that state finance officials had anticipated that Medi-Cal reimbursements would reflect the increased labor costs, while Medicare would eventually at least partially compensate for the higher labor costs.

Michael Reich, chair of the Center on Wage and Employment Dynamics at UC Berkeley’s Institute for Research on Labor and Employment, and affiliated economist Justin Wiltshire recently argued that California’s new $20 minimum wage law for fast-food workers won’t result in mass layoffs and price increases, as some have predicted.

Health care is much different than fast food, Reich acknowledged, but he argued for much the same positive result.

“A higher minimum wage will make it easier and cheaper for hospitals to recruit and retain these workers. The cost savings, and the productivity benefits of more experienced workers, could offset much of the labor cost increase,” Reich said.

The hospital association filed its lawsuit against Inglewood’s ordinance in July, while it was still opposing early versions of the statewide minimum wage legislation. Among many other provisions, the statewide law put on hold an initiative to cap hospital executives’ salaries in Los Angeles.

The hospital association’s legal challenge referenced in part layoffs and reduced working hours imposed by Centinela Hospital Medical Center after Inglewood’s ordinance took effect.

But Centinela said the reduction was entirely unrelated to the ordinance and that all staff were offered alternate positions, which many accepted.

“Centinela Hospital also has since added many more jobs in new clinical positions above minimum wage scale,” the hospital said in a statement.

Service Employees International Union-United Healthcare Workers West, the prime backer of both the local ordinance and the statewide law, sued the hospital in April 2023 alleging that it cut workers’ hours to offset the higher minimum wage. The case is still pending.

The union did not respond to repeated requests for comment.

In a court filing, however, the union and city of Inglewood said similar employer restrictions in previous minimum wage laws have survived.

The ordinance “merely sets the backdrop for collective bargaining negotiations,” and does not bar employers from locking out employees or hiring replacement workers during a strike. Employers can still lay off workers or reduce their hours, they said, so long as they don’t do so to fund the higher minimum wage.

But Fischer agreed with the hospital association that layoffs and reductions in employees’ total compensation packages are “obvious responses by an employer to rising compensation costs.”

Restricting employers’ options would violate federal labor relations rules, he said.

“The minimum wage an employer has to pay its employees will invariably affect the total amount of compensation it is able or willing to pay,” he wrote “This will then invariably affect the number of employees it can retain and the number of hours those employees will be scheduled to work.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Regina Barrett, una jubilada de 69 años que vive en Monroe, una pequeña ciudad de Carolina del Norte, al sureste de Charlotte, hace tiempo que no está contenta con el agua del grifo.

“Nuestra agua ha estado turbia y burbujeante, y parece lechosa”, dijo Barrett, que culpa al fluoruro, un mineral que comunidades de todo el país han agregado durante décadas al suministro de agua para ayudar a prevenir las caries y mejorar la salud dental.

“¡No quiero flúor en nada!”, dijo Barrett, haciéndose eco de un número creciente de personas que no sólo dudan de la eficacia del mineral sino que también creen que puede ser perjudicial a pesar de décadas de datos que destacan sus beneficios económicos y para la salud pública.

En febrero, la Junta de Comisionados del Condado de Union, cuya sede es Monroe, votó 3-2 para dejar de agregar fluoruro al agua potable en la Planta de Tratamiento de Agua del Río Yadkin, la única fuente de agua operada por el condado, que es de su propiedad. Pero la decisión se produjo después de fuertes discusiones entre residentes y funcionarios.

“Mis hijos tuvieron la bendición de crecer con fluoruro en el agua y… tienen muy pocos problemas dentales”, dijo el comisionado Richard Helms antes de votar. Un colega lo vio de otra manera: “Dejemos de poner en el agua algo que esté destinado a tratarnos, y demos a la gente la libertad de elegir”, dijo David Williams.

El agua de Barrett proviene de la ciudad de Monroe, no de las instalaciones de Yadkin. Así que, por ahora, seguirá bebiendo agua enriquecida con fluoruro. “Sospecho de por qué agregan eso a nuestra agua”, dijo a KFF Health News.

Es un escenario que se desarrolla a nivel nacional. Desde Oregon hasta Pennsylvania, en los últimos años cientos de comunidades han dejado de agregar fluoruro a sus suministros de agua o han votado para evitar agregarlo.

Los partidarios de estas prohibiciones argumentan que a las personas se les debería dar libertad de elección. Dicen que la amplia disponibilidad de productos dentales de venta libre que contienen el mineral hace que ya no sea necesario agregarlo al suministro público de agua.

Los Centros para el Control y Prevención de Enfermedades (CDC) dicen que si bien los productos que se compran en tiendas reducen las caries, la mayor protección se produce cuando se usan en combinación con la fluoración del agua.

El resultado de un caso federal en curso en California podría obligar a la Agencia de Protección Ambiental (EPA) a crear una norma que regule o prohíba el uso de fluoruro en el agua potable en todo el país.

Mientras tanto, la tendencia está haciendo sonar las alarmas entre los investigadores de salud pública que temen que, al igual que con las vacunas, el fluoruro pueda haberse convertido en víctima de su propio éxito.

Los CDC sostienen que la fluoración del agua comunitaria no sólo es segura y eficaz, sino que también produce importantes ahorros en los costos de tratamientos dentales. Los funcionarios de salud pública dicen que eliminar el fluoruro podría ser particularmente perjudicial para las familias de bajos ingresos, para quienes el agua potable puede ser la única fuente de atención dental preventiva.

“Si tienes que salir y recibir atención por tu cuenta, es un juego completamente diferente”, dijo Myron Allukian Jr., dentista y ex presidente de la Asociación Americana de Salud Pública. Millones de personas han vivido con agua fluorada durante años, “y no hemos tenido problemas de salud importantes”, afirmó. “Es mucho más fácil prevenir una enfermedad que tratarla”.

Según el grupo anti-fluoruro Fluoride Action Network, desde 2010, más de 240 comunidades en todo el mundo han eliminado el fluoruro de su agua potable o han decidido no agregarlo.

Sólo hay que mirar al condado de Union para ver cuán intensas pueden ser las discusiones. Generalmente cuando los comisionados se reúnen en el primer piso del Centro de Gobierno en el centro de Monroe, la mayoría de los asientos están vacíos. Pero las sesiones sobre la prohibición del fluoruro en los suministros públicos de agua estuvieron colmadas de gente, y los residentes que se inscribieron para hablar estaban divididos.

Una persona que habló el 5 de febrero comparó la fluoración del agua con un cinturón de seguridad. No “previene el accidente automovilístico, pero limita el daño causado”, dijo. Otro argumentó que no hay pruebas de que el fluoruro sea seguro o eficaz. “Es un hito potencial significativo para revertir más de 60 años de envenenamiento del público”, dijo, utilizando una afirmación no probada que a menudo utilizan los opositores a la fluoración.

Los opositores al fluoruro afirman que el mineral es responsable de todo, desde el acné hasta la presión arterial alta, desde los problemas de tiroides hasta el cáncer de huesos.

Los Institutos Nacionales de Salud (NIH) reconocen que, cuando se ingiere en cantidades extremadamente grandes, el fluoruro de los productos dentales o suplementos dietéticos puede causar náuseas, vómitos, dolor abdominal, diarrea, dolor de huesos e incluso la muerte en casos extremadamente raros.

Los bebés y niños que reciben demasiado fluoruro pueden sufrir decoloración o pequeñas lesiones en los dientes. En los adultos, el consumo excesivo de fluoruro durante períodos prolongados puede provocar fluorosis esquelética, una afección muy rara que causa dolor y rigidez en las articulaciones, huesos débiles, pérdida de masa muscular y problemas nerviosos.

Sin embargo, la dosis recomendada en el agua potable siempre ha sido pequeña. En 2015, el Departamento de Salud y Servicios Humanos (HHS) redujo la concentración óptima de fluoruro de 1,2 miligramos por litro a 0,7 mg/L.

Juneau, en Alaska, votó a favor de eliminar el fluoruro de su agua potable en 2007. Un estudio publicado en la revista BMC Oral Health en 2018 comparó los registros dentales de niños y adolescentes que recibieron atención dental por caries cuatro años antes y cinco años después que la ciudad dejara de agregar fluoruro al agua. El estudio encontró que los procedimientos relacionados con las caries y los costos de tratamiento fueron significativamente más altos en el último grupo.

Portland, en Oregon, es la ciudad más grande del país que se ha negado sistemáticamente a agregar fluoruro a su agua potable. Los votantes han rechazado repetidamente las medidas para agregarlo, primero en 1956 y la última vez en 2013.

A pesar de la fuerte recomendación de los médicos y dentistas locales, los votantes de Wichita, Kansas, han rechazado agregar fluoruro al agua varias veces, la más reciente en 2012.

El Distrito Municipal de Servicios Públicos de Brushy Creek en el condado de Williamson, en Texas, estuvo agregando fluoruro a su sistema de agua desde 2007, pero puso fin a esta práctica en diciembre pasado.

En 2016, los comisionados del condado de Collier, en Florida, optaron por no eliminar el fluoruro del sistema de agua. Pero revocaron por unanimidad esa decisión luego de una Declaración de Derechos de Libertad de Salud de 2023 en respuesta a covid-19 que emitió el condado a través de una ordenanza, “para salvaguardar los derechos y libertades de atención médica de los residentes del condado de Collier”.

La Autoridad del Agua de State College Borough, en Pennsylvania, dejó de agregar fluoruro al agua de sus 75,000 clientes en marzo de 2023. Los funcionarios citaron razones que habitualmente usan los activistas anti-fluoruro: la posible contaminación ambiental, preocupaciones sobre la libertad médica y posibles efectos adversos para la salud.

Un estudio publicado en JAMA Pediatrics en 2019, realizado en seis ciudades canadienses, asoció la exposición al fluoruro durante el embarazo con puntuaciones de coeficiente intelectual más bajas en los niños. Pero el estudio se basó en informes propios y ha sido criticado por sus aparentes deficiencias metodológicas.

En 2016, varios grupos de defensa del consumidor, incluidos Fluoride Action Network, Food & Water Watch y Moms Against Fluoridation, solicitaron a la EPA que pusiera fin a la fluoración del agua en virtud de la Ley de Control de Sustancias Tóxicas, alegando que importantes investigaciones demostraban que el fluoruro era neurotóxico en las dosis usadas actualmente. El mismo grupo presentó una demanda federal contra la EPA al año siguiente, después que la agencia denegara la petición.

Durante un juicio de 10 días en San Francisco, que concluyó a mediados de febrero, las dos partes debatieron los riesgos y las áreas de incertidumbre. Si el juez federal de distrito Edward Chen determina que la fluoración del agua presenta un “riesgo irrazonable” para la salud humana, la EPA se verá obligada a crear una norma que regule o prohíba la fluoración del agua en Estados Unidos. Se espera una decisión pronto.

Por el momento, las decisiones sobre la fluoración de los sistemas de agua comunitarios todavía se toman principalmente a nivel local, lo que Barrett espera que cambie.

“De todas las cosas, lo que más quieren es que nuestros dientes estén sanos cuando faltan las necesidades básicas de vivienda y alimentación”, expresó.

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Casi una cuarta parte de los adultos que fueron dados de baja de Medicaid el año pasado dicen que ahora no tienen seguro, según una encuesta que detalla cómo decenas de millones de estadounidenses lucharon por conservar la cobertura del gobierno para personas de bajos ingresos.

Las protecciones que tuvo el programa durante la pandemia, que impedían que se expulsaran beneficiarios, expiraron la primavera pasada.

La primera encuesta nacional sobre estas desafiliaciones de Medicaid halló que casi la mitad de las personas que perdieron la cobertura volvieron a inscribirse semanas o meses después, lo que sugiere que, en primer lugar, nunca debieron ser expulsadas.

Mientras que el 23% informó no tener seguro, un 28% adicional encontró otra cobertura: a través de un empleador, Medicare, el mercado de seguros de la Ley de Cuidado de Salud a Bajo Precio (ACA) o en programas para miembros de las Fuerzas Armadas, informó la encuesta de KFF.

“El 23% es una cifra sorprendente, especialmente si se piensa en la cantidad de personas que perdieron la cobertura de Medicaid”, dijo Chima Ndumele, profesora asociada de políticas de salud en la Escuela de Salud Pública de la Universidad de Yale.

Quedarse sin seguro, incluso por un período corto de tiempo, puede llevar a las personas a retrasar la búsqueda de atención médica, y exponerlas a riesgos financieros.

Siete de cada 10 adultos desafiliados dijeron que se quedaron sin seguro al menos temporalmente cuando perdieron su cobertura de Medicaid.

Adrienne Hamar, de 49 años, de Plymouth Meeting, Pennsylvania, dijo que tuvo dificultades para inscribirse en un plan de ACA este invierno después que el estado le informara que ella y sus dos hijos ya no calificaban para Medicaid. Estaban inscritos desde 2020. Dijo que las líneas telefónicas estaban siempre ocupadas en el mercado estatal y que no podía completar el proceso en línea.

Hamar, que trabaja como asistente de salud a domicilio, y sus hijos, estuvieron sin seguro durante marzo. Pero desde el 1 de abril, están inscritos en un plan del mercado que, con la ayuda de subsidios gubernamentales, cuesta $50 al mes para la familia.

“Me sentí muy aliviada”, dijo. Hamar dijo que, por esta situación, su hija de 23 años demoró en hacerse un chequeo dental.

Las luchas de Hamar eran comunes, según la encuesta.

De los adultos inscritos en Medicaid antes de la cancelación, alrededor del 35% que intentó renovar su cobertura describió el proceso como difícil, y cerca del 48% dijo que era al menos algo estresante.

Alrededor del 56% de las personas dadas de baja dicen que omitieron o retrasaron atención médica o buscar una receta mientras intentaban renovar su cobertura de Medicaid.

“Es probable que el estatus actual del seguro de las personas esté cambiando, y esperaríamos que al menos algunas de las que dicen que actualmente no tienen seguro se vuelvan a inscribir en Medicaid (muchos dijeron que todavía lo están intentando) o se inscriban en otra cobertura en poco tiempo”, dijo Jennifer Tolbert, coautora del informe de KFF y directora del Programa Estatal de Datos y Reforma de Salud de la fundación.

La encuesta no incluyó a niños, y los investigadores de KFF dijeron que, por lo tanto, sus hallazgos no podían extrapolarse para determinar cómo la reducción de Medicaid ha afectado la tasa general de personas sin seguro en el país, que alcanzó un mínimo histórico del 7,7% a principios de 2023. Casi la mitad de los afiliados a Medicaid y al Programa de Seguro Médico Infantil (CHIP) son niños.

El proceso de desafiliación, durante el cual los estados están reevaluando la elegibilidad para Medicaid entre millones de estadounidenses que se inscribieron antes o durante la pandemia —y eliminando a aquellos que ya no califican o no completaron el proceso de renovación— no se completará hasta finales de este año.

La inscripción en Medicaid y CHIP creció a un récord de casi 94,5 millones en abril del año pasado, tres años después que el gobierno federal prohibiera a los estados eliminar a las personas de sus listas durante la emergencia de salud pública de covid-19.

A nivel nacional, los estados cancelaron la inscripción e Medicaid de alrededor de 20 millones de personas el año pasado, la mayoría por razones de procedimiento, como no presentar la documentación requerida. Se espera que ese número aumente, ya que los estados tienen algunos meses más para redeterminar la elegibilidad de los inscritos.

Entre los adultos que tenían Medicaid antes del inicio de las desafiliaciones, el 83% retuvo su cobertura o se volvió a inscribir, mientras que el 8% encontró otro seguro y el 8% no tenía seguro.

La proporción que quedó sin seguro fue mayor en los estados que no han ampliado Medicaid bajo ACA (17%) comparado con los estados que sí lo han hecho (6%). Cuarenta estados han ampliado Medicaid para cubrir a todas las personas con ingresos inferiores al 138% de la tasa federal de pobreza, o $31,200 para una familia de cuatro en 2024.

La encuesta de KFF encontró que casi uno de cada 3 adultos a los que se les canceló el seguro descubrió que ya no tenían Medicaid recién cuando buscaron atención médica, como ir a un médico o a una farmacia.

Indira Navas, de Miami, descubrió que a su hijo Andrés, de 6 años, se le había dado de baja del programa de Medicaid de Florida cuando lo llevó a una cita con el médico en marzo. Había programado esa cita con meses de anticipación y está frustrada porque el niño sigue sin seguro y se interrumpió su terapia para la ansiedad y la hiperactividad.

Navas dijo que el estado no pudo explicar por qué su hija Camila, de 12, seguía cubierta por Medicaid a pesar de que los dos niños viven en el mismo hogar que sus padres.

“No tiene sentido que cubran a uno de mis hijos y al otro no”, dijo.

Kate McEvoy, directora ejecutiva de la Asociación Nacional de Directores de Medicaid, dijo que el gran volumen, de millones de personas, a las que se está analizando para determinar su elegibilidad ha abrumado a algunos centros de llamadas estatales que intentan apoyar a los afiliados.

Dijo que los estados han probado muchas formas de comunicarse con los inscritos, incluso a través de campañas de divulgación pública, mensajes de texto, correo electrónico y aplicaciones. “Hasta el momento en que su cobertura está en juego, es difícil penetrar en las vidas ocupadas de las personas”, dijo.

La encuesta de KFF, de 1,227 adultos que tenían cobertura de Medicaid a principios de 2023 antes del inicio del proceso de desafiliación, el 1 de abril de 2023, se realizó entre el 15 de febrero y el 11 de marzo de 2024. El margen de error de muestreo fue de más o menos 4 puntos porcentuales.

El corresponsal de KFF Health News, Daniel Chang, colaboró con este artículo.

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

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State and local governments are receiving billions of dollars in opioid settlements to address the drug crisis that has ravaged America for decades. But instead of spending the money on new addiction treatment and prevention services they couldn’t afford before, some jurisdictions are using it to replace existing funding and stretch tight budgets.

Scott County, Indiana, for example, has spent more than $250,000 of opioid settlement dollars on salaries for its health director and emergency medical services staff. The money usually budgeted for those salaries was freed to buy an ambulance and create a financial cushion for the health department.

In Blair County, Pennsylvania, about $320,000 went to a drug court the county has been operating with other sources of money for more than two decades.

And in New York, some lawmakers and treatment advocates say the governor’s proposed budget substitutes millions of opioid settlement dollars for a portion of the state addiction agency’s normal funding.

The national opioid settlements don’t prohibit the use of money for initiatives already supported by other means. But families affected by addiction, recovery advocates, and legal and public health experts say doing so squanders a rare opportunity to direct additional resources toward saving lives.

“To think that replacing what you’re already spending with settlement funds is going to make things better — it’s not,” said Robert Kent, former general counsel for the Office of National Drug Control Policy. “Certainly, the spirit of the settlements wasn’t to keep doing what you’re doing. It was to do more.”

Settlement money is a new funding stream, separate from tax dollars. It comes from more than a dozen companies that were accused of aggressively marketing and distributing prescription painkillers. States are required to spend at least 85% of the funds on addressing the opioid crisis. Now, with illicit fentanyl flooding the drug market and killing tens of thousands of Americans annually, the need for treatment and social services is more urgent.

Thirteen states and Washington, D.C., have restricted the practice of substituting opioid settlement funds for existing dollars, according to state guides created by OpioidSettlementTracker.com and the public health organization Vital Strategies. A national set of principles created by Johns Hopkins University also advises against the practice, known as supplantation.

Paying Staff Salaries

Scott County, Indiana — a small, rural place known nationally as the site of an HIV outbreak in 2015 sparked by intravenous drug use — received more than $570,000 in opioid settlement funds in 2022.

From August 2022 to July 2023, the county reported using roughly $191,000 for the salaries of its EMS director, deputy director, and training officer/clinical coordinator, as well as about $60,000 for its health administrator. The county also awarded about $151,000 total to three community organizations that address addiction and related issues.

In a public meeting discussing the settlement dollars, county attorney Zachary Stewart voiced concerns. “I don’t know whether or not we’re supposed to be using that money to add, rather than supplement, already existing resources,” he said.

But a couple of months later, the county council approved the allocations.

Council President Lyndi Hughbanks did not respond to repeated requests to explain this decision. But council members and county commissioners said in public meetings that they hoped to compensate county departments for resources expended during the HIV outbreak.

Their conversations echoed the struggles of many rural counties nationwide, which have tight budgets, in part because they poured money into addressing the opioid crisis for years. Now as they receive settlement funds, they want to recoup some of those expenses.

The Scott County Health Department did not respond to questions about how the funds typically allocated for salary were used instead. But at the public meeting, it was suggested they could be used at the department’s discretion.

EMS Chief Nick Oleck told KFF Health News the money saved on salaries was put toward loan payments for a new ambulance, purchased in spring 2023.

Unlike other departments, which are funded from local tax dollars and start each year with a full budget, the county EMS is mostly funded through insurance reimbursements for transporting patients, Oleck said. The opioid settlement funds provided enough cash flow to make payments on the new ambulance while his department waited for reimbursements.

Oleck said this use of settlement dollars will save lives. His staff needs vehicles to respond to overdose calls, and his department regularly trains area emergency responders on overdose response.

“It can be played that it was just money used to buy an ambulance, but there’s a lot more behind the scenes,” Oleck said.

Still, Jonathan White — the only council member to vote against using settlement funds for EMS salaries — said he felt the expense did not fit the money’s intended purpose.

The settlement “was written to pay for certain things: helping people get off drugs,” White told KFF Health News. “We got drug rehab facilities and stuff like that that I believe could have used that money more.”

Phil Stucky, executive director of a local nonprofit called Thrive, said his organization could have used the money too. Founded in the wake of the HIV outbreak, Thrive employs people in recovery to provide support to peers with mental health and substance use disorders.

Stucky, who is in recovery himself, asked Scott County for $300,000 in opioid settlement funds to hire three peer specialists and purchase a vehicle to transport people to treatment. He ultimately received one-sixth of that amount — enough to hire one person.

In Blair County, Pennsylvania, Marianne Sinisi was frustrated to learn her county used about $322,000 of opioid settlement funds to pay for a drug court that has existed for decades.

“This is an opioid epidemic, which is not being treated enough as it is now,” said Sinisi, who lost her 26-year-old son to an overdose in 2018. The county received extra money to help people, but instead it pulled back its own money, she said. “How do you expect that to change? Isn’t that the definition of insanity?”

Blair County Commissioner Laura Burke told KFF Health News that salaries for drug court probation officers and aides were previously covered by a state grant and parole fees. But in recent years that funding has been inadequate, and the county general fund has picked up the slack. Using opioid settlement funds provides a small reprieve since the general fund is overburdened, she said. The county’s most recent budget faces a $2 million deficit.

Forfeited Federal Dollars

Supplantation can take many forms, said Shelly Weizman, project director of the addiction and public policy initiative at Georgetown University’s O’Neill Institute. Replacing general funds with opioid settlement dollars is an obvious one, but there are subtler approaches.

The federal government pours billions of dollars into addiction-related initiatives annually. But some states forfeit federal grants or decline to expand Medicaid, which is the largest payer of mental health and addiction treatment.

If those jurisdictions then use opioid settlement funds for activities that could have been covered with federal money, Weizman considers it supplantation.

“It’s really letting down the citizens of their state,” she said.

Officials in Bucks County, Pennsylvania, forfeited more than $1 million in federal funds from September 2022 to September 2023, the bulk of which was meant to support the construction of a behavioral health crisis stabilization center.

“We were probably overly optimistic” about spending the money by the grant deadline, said Diane Rosati, executive director of the Bucks County Drug and Alcohol Commission.

Now the county plans to use $3.9 million in local and state opioid settlement funds to support the center.

Susan Ousterman finds these developments difficult to stomach. Her 24-year-old son died of an overdose in 2020, and she later joined the Bucks County Opioid Settlement Advisory Committee, which developed a plan to spend the funds.

In a September 2022 email to other committee members, she expressed disappointment in the suggested uses: “Please keep in mind, the settlement funds are not meant to fund existing programs or programs that can be funded by other sources, such as federal grants.”

But Rosati said the county is maximizing its resources. Settlement funds will create a host of services, including grief groups for families and transportation to treatment facilities.

“We’re determined to utilize every bit of funding that’s available to Bucks County, using every funding source, every stream, and frankly every grant opportunity that comes our way,” Rosati said.

The county’s guiding principles for settlement funds demand as much. They say, “Whenever possible, use existing resources in order that Opioid Settlement funds can be directed to addressing gaps in services.”

Ed Mahon of Spotlight PA contributed to this report.

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

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Tax season is never fun. But some tax filers this year face an added complication: Their returns are being rejected because they failed to provide information about Affordable Care Act coverage they didn’t even know they had.

While the concern about unscrupulous brokers enrolling unsuspecting people in ACA coverage has simmered for years, complaints have risen in recent months as consumers discover their health insurance coverage isn’t what they thought it was.

Now such unauthorized enrollments are also causing tax headaches. Returns are getting rejected by the IRS and some people will have to pay more in taxes.

“It’s definitely gotten worse over the past year. We’ve helped three to four dozen people this year already,” said Erin Kinard, director of systems and intake for the Health and Economic Opportunity Program at Pisgah Legal Services in North Carolina, which helps low-income families enroll in ACA plans and get tax help.

Neither the IRS nor the Centers for Medicare & Medicaid Services, which oversees the federal Obamacare marketplace, responded to questions about the problem.

The IRS did, however, issue an FAQ in February instructing consumers on what to do if their electronically filed returns are rejected because of ACA issues.

Unauthorized sign-ups can happen in several ways, Kinard and others said. Some rogue agents troll online enrollment portals that are accessible only to brokers but are integrated with the healthcare.gov website. When those agents open a new policy or switch an already enrolled policyholder to a different plan, they garner the associated monthly commissions. Other consumers unwittingly sign up when they respond to advertisements touting gift cards or government subsidies then are transferred to agents who enroll them in health coverage. It’s happening even after new rules were put in place requiring agents to get written or recorded consent from clients before making changes.

CMS has not released details on how many consumers have been affected or how many agents have been sanctioned for participating in such schemes.

There’s also no public tally of how many taxpayers are facing problems as a result. And the tax consequences can come as a surprise.

“Many people are finding out when they go to e-file their taxes and it bounces back and the IRS says it can’t accept your return,” said Christine Speidel, an associate professor and the director of the Federal Tax Clinic at Villanova University’s Charles Widger School of Law.

Returns are rejected if the IRS has information indicating the taxpayer has ACA coverage but the returns don’t include forms that help determine whether premium tax credits paid on the policyholder’s behalf to insurers were correct. If their income was misstated by the rogue broker who enrolled them, for example, they might not have qualified for the full amount paid. Or, if they had affordable employer coverage, they would not have been eligible for ACA subsidies at all.

Ashley Zukoski, an ultrasound technologist in Charlotte, North Carolina, had employer coverage but now faces a tax bill for an ACA plan she said she never signed up for. She reached out to KFF Health News after it reported on such unauthorized plan enrollments.

Unbeknownst to her, she said, a broker in Florida enrolled her family in an ACA plan in late February 2023, even though Zukoski had coverage starting that January through her job. The broker listed an income that qualified the household for a full subsidy, so Zukoski never received a premium bill.

Her first inkling that something was amiss came early in 2024 when she received a special form, called a 1095-A, which showed she had an ACA plan. After reporting the problem to the federal marketplace, she sought to get the 1095-A voided so she would not be liable for the plan’s premium subsidies paid by the government to the insurer.

But, because Zukoski’s pharmacy had billed the ACA plan instead of her job-based coverage, her request was denied. She plans to appeal.

In the meantime, the family has filed an extension on their taxes.

“Instead of getting a $4,100 refund, we now owe almost $700 in taxes based on the 1095-A and premium tax credit applied,” Zukoski said.

With the April 15 federal tax filing deadline upon us, there are some important steps for affected consumers to take, tax and insurance experts said.

First, because it could take weeks to get corrected forms, experts recommend filing for an extension to buy more time. When consumers file for that extension, they should also pay any taxes owed to avoid penalties and interest.

In general, consumers who at any point in the year think they are victims of an unauthorized enrollment or plan switch should report it immediately to the relevant federal or state ACA marketplace and request a corrected Form 1095-A. But move fast. Appeals to cancel coverage retroactively must be made within 60 days of discovering the fraudulent enrollment, Speidel said.

Consumers can ask for help filing a complaint with federal or state regulators by contacting their own insurance agents or seeking help from assisters or “navigator” programs, which are government-funded nonprofit groups that help people enroll or deal with insurance problems.

Navigators and assisters are fielding many such cases this year and can submit what are called “complex case forms,” which help federal officials investigate such complaints, said Lynn Cowles, program manager for Prosper Health Coverage, a navigator program in Texas.

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MONROE, N.C. — Regina Barrett, a 69-year-old retiree who lives in this small North Carolina city southeast of Charlotte, has not been happy with her tap water for a while.

“Our water has been cloudy and bubbly and looks milky,” said Barrett, who blames fluoride, a mineral that communities across the nation have for decades added to the water supply to help prevent cavities and improve dental health.

“I don’t want fluoride in my nothing!” said Barrett, echoing a growing number of people who not only doubt the mineral’s effectiveness but also believe it may be harmful despite decades of data pointing to public health and economic benefits.

In February, the Board of County Commissioners in Union County, whose seat is Monroe, voted 3-2 to stop adding fluoride to drinking water at the Yadkin River Water Treatment Plant, the only water source wholly owned and operated by the county. But the decision came after heated discussions among residents and county officials.

“My children had the blessing of growing up with fluoride in their water and … they have very little dental issues,” said Commissioner Richard Helms ahead of the vote. A fellow commissioner saw it differently: “Let’s stop putting something in the water that’s meant to treat us, and give people the freedom to choose,” said David Williams.

Barrett’s water comes from the city of Monroe, not the Yadkin facility. So, for now, she will continue to drink water enhanced with fluoride. “I’m suspicious as to why they add that to our water,” she told KFF Health News.

It is a scenario playing out nationwide. From Oregon to Pennsylvania, hundreds of communities have in recent years either stopped adding fluoride to their water supplies or voted to prevent its addition. Supporters of such bans argue that people should be given the freedom of choice. The broad availability of over-the-counter dental products containing the mineral makes it no longer necessary to add to public water supplies, they say. The Centers for Disease Control and Prevention says that while store-bought products reduce tooth decay, the greatest protection comes when they are used in combination with water fluoridation.

The outcome of an ongoing federal case in California could force the Environmental Protection Agency to create a rule regulating or banning the use of fluoride in drinking water nationwide. In the meantime, the trend is raising alarm bells for public health researchers who worry that, much like vaccines, fluoride may have become a victim of its own success.

The CDC maintains that community water fluoridation is not only safe and effective but also yields significant cost savings in dental treatment. Public health officials say removing fluoride could be particularly harmful to low-income families — for whom drinking water may be the only source of preventive dental care.

“If you have to go out and get care on your own, it’s a whole different ballgame,” said Myron Allukian Jr., a dentist and past president of the American Public Health Association. Millions of people have lived with fluoridated water for years, “and we’ve had no major health problems,” he said. “It’s much easier to prevent a disease than to treat it.”

According to the anti-fluoride group Fluoride Action Network, since 2010, over 240 communities around the world have removed fluoride from their drinking water or decided not to add it.

One needs only to look to Union County to see just how intense discussions can be. Usually when the commissioners meet on the first floor of the Government Center in downtown Monroe, there are more vacant seats than attendees. But sessions about the prohibition of fluoride in public water supplies were packed, and residents who signed up to speak were divided.

One person who came to the microphone on Feb. 5 compared water fluoridation to a seat belt. It does not “prevent the car crash, but it limits the harm done,” he said. Another argued that there is no proof fluoride is safe or effective. “It’s a significant potential milestone to reverse 60-plus years of poisoning the public,” he said, using an unproven claim often made by opponents of fluoridation.

Fluoride opponents claim the mineral is responsible for everything from acne to high blood pressure and thyroid dysfunction to bone cancer.

The National Institutes of Health acknowledges that, when ingested in extremely large amounts, fluoride from dental products or dietary supplements can cause nausea, vomiting, abdominal pain, diarrhea, bone pain, and even death in extremely rare cases.

Infants and children who receive too much fluoride can develop discoloration or small dents in their teeth. In adults, consumption of excessive fluoride for extended periods can lead to skeletal fluorosis, a very rare condition that causes joint pain and stiffness, weak bones, muscle loss, and nerve problems.

However, the recommended dosage in drinking water has always been small. In 2015, the Department of Health and Human Services lowered the optimal fluoride concentration from 1.2 milligrams per liter to 0.7 mg/L.

Juneau, Alaska, voted to remove fluoride from its drinking water in 2007. A study published in the journal BMC Oral Health in 2018 compared the dental records of children and adolescents who received dental care for decaying teeth four years before and five years after the city stopped adding fluoride to the water. Cavity-related procedures and treatment costs were significantly higher in the latter group, the study found.

Portland, Oregon, is the largest city in the nation that has consistently refused to fluoridate its drinking water. Voters have repeatedly rejected measures to add it, first in 1956 and the latest time in 2013.

Despite the strong recommendation of local doctors and dentists, voters in Wichita, Kansas, have rejected adding fluoride to the water several times, most recently in 2012.

The Brushy Creek Municipal Utility District in Williamson County, Texas, had been adding fluoride to its water system since 2007 but ended the practice in December.

In 2016, Collier County, Florida, commissioners opted not to remove fluoride from the water system. But they unanimously reversed that decision following a 2023 Health Freedom Bill of Rights county ordinance in response to covid-19 “to safeguard the healthcare rights and freedoms of Collier County residents.”

The State College Borough Water Authority in Pennsylvania stopped adding fluoride to the water of its 75,000 customers in March 2023. Officials used claims often cited by fluoride opponents, such as potential environmental contamination, concerns about medical freedom, and possible adverse health effects, like the potential for the appearance of faint white lines on the teeth and lowered IQ for babies.

A study published in JAMA Pediatrics in 2019, conducted in six Canadian cities, associated fluoride exposure during pregnancy with lower IQ scores in children. But the study was based on self-reporting and has been criticized for its perceived methodological shortcomings.

In 2016, several consumer advocacy groups, including the Fluoride Action Network, Food & Water Watch, and Moms Against Fluoridation, petitioned the EPA to end water fluoridation under the Toxic Substances Control Act, alleging that significant research showed fluoride was neurotoxic at the doses now used. The same group filed a federal lawsuit against the EPA the following year, after the agency denied their citizen petition.

During a 10-day bench trial in San Francisco that concluded in mid-February, the two sides debated the risks and areas of uncertainty. If Senior U.S. District Judge Edward Chen determines water fluoridation presents an “unreasonable risk” to human health, the EPA will be forced to create a rule regulating or banning water fluoridation in the U.S. A decision is expected soon.

For the time being, decisions about whether to fluoridate community water systems are still made primarily at the local level, which Barrett hopes will change.

“Of all things, they want our teeth healthy when basic needs of housing and food are lacking.”

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SACRAMENTO, Calif. — Thirty years after prisoners with disabilities sued the state of California and 25 years after a federal court first ordered accommodations, a judge found that state prison and parole officials still are not doing enough to help deaf and blind prisoners — in part because they are not using readily available technology such as video recordings and laptop computers.

U.S. District Judge Claudia Wilken’s rulings on March 20 centered on the prison system’s need to help deaf, blind, and low-vision prisoners better prepare for parole hearings, though the decisions are also likely to improve accommodations for hundreds of other prisoners with those disabilities.

“I believe I should have the same opportunity as hearing individuals,” a prisoner, deaf since birth, said in court documents.

The lawsuit is one of several class-action proceedings that have led the courts to assume oversight of the prison system’s treatment of those who are sick or suffer from mental illnesses.

“It is difficult not to despair,” a blind prisoner said in written testimony. “I am desperate for some kind of assistance that will let me prepare adequately for my parole hearing.”

The parole process can begin more than a year before an incarcerated person’s hearing and last long afterward. And the consequences of rejection are great: People denied parole typically must wait three to 15 years before they can try again.

Prisoners are expected to review their prison records and a psychologist’s assessment of whether they are at risk for future violence, write a release plan including housing and work plans, write letters of remorse, and prepare a statement to parole officials on why they should be released.

“It is a very time-consuming and important process,” said Gay Grunfeld, one of the attorneys representing about 10,000 prisoners with many different disabilities in the federal class-action lawsuit. “All of these tasks are harder if you are blind, low-vision, or deaf.”

The California Department of Corrections and Rehabilitation and its Board of Parole Hearings “remain committed to conducting fair hearings and ensuring access to the hearings for all participants. We are assessing the potential impact of the order and exploring available legal options,” said spokesperson Albert Lundeen.

The department counts more than 500 prisoners with serious vision problems and about 80 with severe hearing problems, though Grunfeld thinks both are undercounts.

California’s prison system has lagged in adopting technological accommodations that are commonly used in the outside world, Wilken found in her ruling.

For instance, California gives prisoners digital tablets that can be used for communications and entertainment, and since late 2021 has gradually been providing secure laptops to prisoners who are enrolled in college, GED, and high school diploma programs.

But officials balked at providing computers that Wilken decided are needed by some prisoners with disabilities. She required the department to develop a plan within 60 days of her order to, among many things, provide those individuals with laptops equipped with accommodations like screen magnification and software that can translate text to speech or Braille.

“It would make a huge difference to me to have equipment that would let me listen to and dictate written words, or produce written documents in another accessible manner,” testified the blind prisoner. He added that such accommodations “would finally let me properly prepare for my parole hearing with the privacy, independence, and dignity that all humans deserve.”

Similarly, California routinely uses video cameras during parole proceedings, including when it conducted hearings remotely during the coronavirus pandemic. But prison policy has prohibited videotaping the hearings, including sign language translations that some deaf prisoners rely on to understand the proceedings.

The deaf-since-birth prisoner, for example, testified that he also doesn’t speak, his primary method of communication is American Sign Language, and his English is so poor that written transcripts do him no good. He advocated for recorded sign language translations of the hearings and related documents that he could review whenever he wanted, in the same way that other inmates can review written text.

Wilken ordered prison officials to comply.

“They need to be able to watch it later, not read it later,” said Grunfeld. “It’s going to make a huge difference in the lives of deaf signers.”

The department recently acquired 100 portable electronic video magnifiers, at a cost of $1,100 each, that prisoners with low vision can check out to use in their cells. The technology will augment similar devices in prison libraries that prisoners say aren’t private and can be used only during libraries’ limited hours.

Wilken said officials acquired the magnifiers only after prodding by prisoners and their attorneys.

Grunfeld said the judge’s detailed order, which includes requirements like better assistance from attorneys, will “make sure that people with disabilities are on an equal footing as people who don’t have disabilities.”

“My colleagues and I have been working for several years to persuade CDCR to adopt this technology, and it’s been slow-going. But they’ve gradually accepted that they do need to do this,” Grunfeld said. “It’s long past due, but at least it’s coming.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

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

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

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

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

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

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

Rachel Roubein: Hi, happy to be here.

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

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

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

Rovner: It would need 60 votes in the Senate.

Ollstein: Exactly.

Rovner: Legislation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: They’re still waiting.

Rovner: Like two years ago.

Ollstein: Yeah. The wheels of justice turn slowly.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Molly Castle Work: Thanks so much, Julie.

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

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

Rovner: And what happened to him?

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

Rovner: Via helicopter, yes?

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

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

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

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

Work: It was $97,599.

Rovner: Of which the insurance paid how much?

Work: Zero.

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

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

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

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

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

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

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

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

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

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

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

Work: Thank you so much, Julie.

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

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

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

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

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

Rovner: Yes. Good journalism at work. Alice.

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

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

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

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

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

Rovner: Rachel Zhang?

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

Rovner: Rachel Roubein?

Roubein: @rachel_roubein on X.

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

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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