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.

As Vice President Kamala Harris appears poised to become the Democratic Party’s presidential nominee, health policy in general and reproductive health issues in particular are likely to have a higher profile. Harris has long been the Biden administration’s point person on abortion rights and reproductive health and was active on other health issues while serving as California’s attorney general.

Meanwhile, Congress is back for a brief session between presidential conventions, but efforts in the GOP-led House to pass the annual spending bills, due by Oct. 1, have run into the usual roadblocks over abortion-related issues.

This week’s panelists are Julie Rovner of KFF Health News, Stephanie Armour of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.

Panelists Stephanie Armour KFF Health News @StephArmour1 Read Stephanie's stories. Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories.

Among the takeaways from this week’s episode:

• President Joe Biden’s decision to drop out of the presidential race has turned attention to his likely successor on the Democratic ticket, Vice President Kamala Harris. At this late hour in the campaign, she is expected to adopt Biden’s health policies, though many anticipate she’ll take a firmer stance on restoring Roe v. Wade. And while abortion rights supporters are enthusiastic about Harris’ candidacy, opponents are eager to frame her views as extreme.
• As he transitions from incumbent candidate to outgoing president, Biden is working to frame his legacy, including on health policy. The president has expressed pride that his signature domestic achievement, the Inflation Reduction Act, took on the pharmaceutical industry, including by forcing the makers of the most expensive drugs into negotiations with Medicare. Yet, as with the Affordable Care Act’s delayed implementation and results, most Americans have yet to see the IRA’s potential effect on drug prices.
• Lawmakers continue to be hung up on federal government spending, leaving appropriations work undone as they prepare to leave for summer recess. Fights over abortion are, once again, gumming up the works.
• In abortion news, Iowa’s six-week limit is scheduled to take effect next week, causing rippling problems of abortion access throughout the region. In Louisiana, which added the two drugs used in medication abortions to its list of controlled substances, doctors are having difficulty using the pills for other indications. And doctors who oppose abortion are pushing higher-risk procedures, like cesarean sections, in lieu of pregnancy termination when the mother’s life is in danger — as states with strict bans, like Texas and Louisiana, are reporting a rise in the use of surgeries, including hysterectomies, to end pregnancies.
• The Government Accountability Office reports that many states incorrectly removed hundreds of thousands of eligible people from the Medicaid rolls during the “unwinding” of the covid-19 public health emergency’s coverage protections. The Biden administration has been reluctant to call out those states publicly in an attempt to keep the process as apolitical as possible.

Also this week, Rovner interviews Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Wright spent the past two decades in California, working with, among others, now-Vice President Kamala Harris on various health issues.

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

Julie Rovner: NPR’s “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman.  

Alice Miranda Ollstein: Stat’s “A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges,” by Ed Silverman, and Politico’s “Federal HIV Program Set To Wind Down,” by Alice Miranda Ollstein and David Lim. 

Stephanie Armour: Vox’s “Free Medical School Won’t Solve the Doctor Shortage,” by Dylan Scott.  

Rachel Cohrs Zhang: Stat’s “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients,” by Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence. 

Also mentioned on this week’s podcast:

• States Newsroom’s “Anti-Abortion Researchers Back Riskier Procedures When Pregnancy Termination Is Needed, Experts Say,” by Sofia Resnick.
• KFF Health News’ “Louisiana Reclassifies Drugs Used in Abortions as Controlled Dangerous Substances,” by Rosemary Westwood, WWNO.
• The New York Times’ “Biden and Georgia Are Waging a Fight Over Medicaid and the Future of Obamacare,” by Noah Weiland.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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Not so long ago, Bonner General Health, the hospital in Sandpoint, Idaho, had four OB/GYNs on staff, who treated patients from multiple rural counties.

That was before Idaho’s near-total abortion ban went into effect almost two years ago, criminalizing most abortions. All four of Bonner’s OB/GYNs left by last summer, some citing fears that the state’s ban exposed them to legal peril for doing their jobs.

The exodus forced Bonner General to shutter its labor and delivery unit and sent patients scrambling to seek new providers more than 40 miles away in Coeur d’Alene or Post Falls, or across the state border to Spokane, Wash. It has made Sandpoint a “double desert,” meaning it lacks access to both maternity care and abortion services.

One patient, Jonell Anderson, was referred to an OB-GYN in Coeur d’Alene, roughly an hour’s drive from Sandpoint, after an ultrasound showed a mass growing in her uterus. Anderson made multiple trips to the out-of-town provider. Previously, she would have found that care close to home.

The experience isn’t limited to this small Idaho town.

A 2023 analysis by ABC News and Boston Children’s Hospital found that more than 1.7 million women of reproductive age in the United States live in a “double desert.” About 3.7 million women live in counties with no access to abortion and little to no maternity care.

Texas, Mississippi and Kentucky have the highest numbers of women of reproductive age living in double deserts, according to the analysis.

Amelia Huntsberger, one of the OB/GYNs who chose to leave Sandpoint — despite having practiced there for a decade — did so because she felt she couldn’t provide the care her patients needed under a law as strict as Idaho’s.

The growing provider shortages in rural states affect not only pregnant and postpartum women, but all women, said Usha Ranji, an associate director for Women’s Health Policy at KFF, a health information nonprofit that includes KFF Health News.

“Pregnancy is obviously a very intense period of focus, but people need access to this care before, during and after, and outside of pregnancy,” Ranji said.

The problem is expected to worsen.

In Idaho, the number of applicants to fill spots left by departing doctors has “absolutely plummeted,” said Susie Keller, CEO of the Idaho Medical Association.

“We are witnessing the dismantling of our health system,” she said.

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Sacramento, California. — Los californianos que trabajan en espacios interiores están recibiendo protecciones inmediatas contra el calor extremo, cuando el estado enfrenta temperaturas de tres dígitos.

California ha tenido estándares para proteger a los trabajadores al aire libre del calor desde 2005, pero el estado anunció el miércoles 24 de julio que ya había acelerado la revisión de un conjunto de reglas para los trabajadores en interiores.

La Junta de Normas de Seguridad y Salud Ocupacional del estado aprobó la regulación en junio, pero necesitaba ser evaluada para su cumplimiento legal.

“Esta regulación proporciona protecciones para los trabajadores en todo California y ayuda a preparar a los empleadores para enfrentar los desafíos de las temperaturas en aumento en ambientes interiores”, dijo Debra Lee, jefa de la División de Seguridad y Salud Ocupacional estatal.

California es uno de los pocos estados que están actuando frente a los crecientes impactos del cambio climático y el calor extremo con estándares de seguridad para los trabajadores.

A principios de este mes, la administración Biden propuso reglas federales para proteger a los trabajadores en interiores y exteriores, ya que el calor extremo, el asesino número 1 relacionado con el clima número en el país, se vuelve aún más peligroso.

Los estándares de California requieren que los lugares de trabajo en interiores se mantengan por debajo de los 87 grados Fahrenheit cuando hay empleados presentes, y por debajo de 82 grados en lugares donde los trabajadores usan ropa protectora o están expuestos al calor radiante, como hornos.

Los sitios de trabajo que no tienen aire acondicionado pueden usar ventiladores, nebulizadores y otros métodos para bajar la temperatura.

Las reglas permiten alternativas para los negocios si no pueden enfriar sus espacios lo suficiente. En esos casos, los empleadores deben proporcionar a los trabajadores agua, descansos, áreas donde puedan refrescarse, chalecos refrigerantes u otros medios para evitar el sobrecalentamiento.

Pero incluso con alternativas, las empresas están preocupadas por el costo de cumplir con la regulación, especialmente las pequeñas empresas que no son dueñas de sus locales o están en edificios antiguos, dijo Robert Moutrie, defensor de políticas senior en la Cámara de Comercio de California.

“La respuesta más simple a esta regulación es el aire acondicionado, y eso es una inversión costosa”, dijo Moutrie. “Si eres una pequeña empresa y no eres dueño de tu estructura, no puedes hacer cambios como crear un nuevo espacio para refrescarte”.

Las reglas se han estado desarrollando desde 2016, retrasadas, en parte, por la pandemia de covid. La Junta de Seguridad Laboral pidió que las regulaciones se aceleraran. Una revisión estándar habría retrasado la entrada en vigencia de la regulación hasta el otoño, dejando a los trabajadores en gran medida desprotegidos del calor del verano.

La regulación se aplica a la mayoría de los lugares de trabajo en interiores, incluidas aulas e incluso vehículos de reparto. Pero los reguladores estatales dejaron fuera a las prisiones y las instalaciones correccionales locales después que la administración del gobernador Gavin Newsom proyectara que podría costar miles de millones de dólares al Departamento de Correcciones y Rehabilitación de California implementarlas.

La junta tiene la intención de redactar una regulación separada para los miles de trabajadores en las 33 prisiones estatales, campamentos de conservación y cárceles locales del estado. Eso podría llevar un año, si no más.

En 2021, el Departamento de Salud y Servicios Humanos (HHS) informó que ocurrieron 1,602 muertes relacionadas con el calor a nivel nacional, lo que probablemente sea un subregistro porque los proveedores de atención médica no están obligados a informarlas.

En 2023, el HHS informó 2,302 muertes relacionadas con el calor. No está claro cuántas de estas muertes estuvieron vinculadas al trabajo, ya sea en interiores o exteriores.

Mientras tanto, en junio, las temperaturas globales registraron récords históricos por decimotercer mes consecutivo.

“Este es realmente uno de los mayores problemas de seguridad que vemos que los trabajadores experimentan en California en muchas industrias”, dijo Tim Shadix, director legal del Warehouse Worker Resource Center, que abogó por las protecciones. “Y el problema solo está empeorando con el cambio climático y los veranos más calurosos”.

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

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SACRAMENTO, Calif. — Californians working indoors are getting immediate protections from extreme heat as much of the state bakes in triple-digit temperatures this week.

California has had heat standards on the books for outdoor workers since 2005, but the state announced Wednesday that a set of rules for indoor workers had been finalized following an expedited review. The state’s Occupational Safety and Health Standards Board approved the regulation last month, but it needed to be vetted for legal compliance.

“This regulation provides protections for workers across California and helps prepare employers to deal with the challenges of rising temperatures in indoor environments,” said Debra Lee, chief of California’s Division of Occupational Safety and Health.

California is among a few states responding to the growing impacts of climate change and extreme heat with worker safety standards. Earlier this month, the Biden administration proposed federal rules to protect indoor and outdoor workers from heat exposure as extreme heat, already the No. 1 weather-related killer in the U.S., becomes even more dangerous.

California’s standards require indoor workplaces 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. Worksites that don’t have air conditioning may use fans, misters, and other methods to bring the room temperature down.

The rules allow workarounds for businesses if they can’t cool their workplaces sufficiently. In those cases, employers must provide workers with water, breaks, areas where they can cool down, cooling vests, or other means to keep them from overheating.

But even with workarounds, businesses are concerned about the cost of complying with the regulation, especially small businesses that don’t own their storefronts or are in old buildings, said Robert Moutrie, a senior policy advocate at the California Chamber of Commerce.

“The simplest answer to this regulation is AC, and that’s a costly investment,” Moutrie said. “If you’re a small business and you don’t own your structure, you can’t make changes like creating a new space to cool down.”

The rules have been in development since 2016 — delayed, in part, because of the covid pandemic. The worker safety board requested the regulations be expedited. A standard review would have delayed the regulation taking effect until the fall, leaving workers largely unprotected from the summer heat.

The regulation applies to most indoor workplaces, including classrooms and even delivery vehicles. But state regulators exempted prisons and local correctional facilities after Gov. Gavin Newsom’s administration projected it could cost the California Department of Corrections and Rehabilitation billions of dollars to implement.

The board intends to draft a separate regulation for the tens of thousands of workers at the state’s 33 state prisons, conservation camps, and local jails. That could take a year, if not longer.

In 2021, the Department of Health and Human Services reported, 1,602 heat-related deaths occurred nationally, which is likely an undercount because health care providers are not required to report them. In 2023, HHS reported, 2,302 heat-related deaths occurred. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

Meanwhile, global temperatures in June were a record high for the 13th straight month.

“This is really one of the biggest safety issues we see workers experiencing across California in many different industries,” said Tim Shadix, legal director at the Warehouse Worker Resource Center, which lobbied for the protections. “And the problem is only getting worse with climate change and hotter summers.”

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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California lawmakers are pursuing legislation aimed at protecting children from the dangers of social media, one of many efforts around the country to confront what U.S. Surgeon General Vivek Murthy and other public health experts say is a mental health emergency among young people.

But California’s efforts, like those in other states, will likely face the same legal challenges that have thwarted previous legislative attempts to regulate social media. The tech industry has argued successfully that imposing rules regulating how social media operate and how people can use the online services violates the free speech rights of the companies and their customers.

A previous effort at confronting the issue, the California Age-Appropriate Design Code Act in 2022, now rests with the U.S. Court of Appeals for the 9th Circuit. A tech trade association sued to block the law and won an injunction from a lower court, largely on First Amendment grounds. The appeals court heard oral arguments in the case on July 17.

“At the end of the day, unconstitutional law protects zero children,” said Carl Szabo, vice president and general counsel for NetChoice, which argued for the tech giants before the federal appellate court.

Like the design code act, the two proposals now working their way through the California Legislature would reshape the way social media users under 18 interact with the services.

The first bill, by state Sen. Nancy Skinner (D-Berkeley), prohibits sending push notifications to children at night and during school hours. Skinner’s measure also requires parental permission before platforms can send social media offerings via algorithms, which are designed to offer feeds that children didn’t ask for but might keep them looking at their phones longer, rather than the traditional chronological feeds of those they follow on the app.

The second measure, by Assemblymember Buffy Wicks (D-Oakland), would amend California’s privacy laws to prohibit businesses from collecting, using, selling, or sharing data on minors without their informed consent — or, for those under 13, without their parents’ approval.

Both bills have bipartisan support and are backed by state Attorney General Rob Bonta. “We need to act now to protect our children,” Bonta said earlier this year, by “strengthening data privacy protections for minors and safeguarding youth against social media addiction.”

California Gov. Gavin Newsom, a Democrat, has been vocal about youth and social media, too, and recently called for a statewide ban on cellphones in schools. His positions on the two social media proposals are not yet known. “But I think the governor, like most every other Californian, is concerned about the harms of social media on kids,” Skinner said.

California’s efforts are especially significant because its influence as the most populous state often results in its setting standards that are then adopted by other states. Also, some of the big tech companies that would be most affected by the laws, including Meta, Apple, Snap, and Alphabet, the parent company of Google, are headquartered in the state.

“Parents are demanding this. That’s why you see Democrats and Republicans working together,” said Wicks, who with a Republican colleague co-authored the design code act that is tied up in litigation. “Regulation is coming, and we won’t stop until we can keep our kids safe online.”

The fate of the design code act stands as a cautionary tale. Passed without a dissenting vote, the law would set strict limits on data collection from minors and order privacy settings for children to default to their highest levels.

NetChoice, which immediately sued to block the law, has prevailed in similar cases in Ohio, Arkansas, and Mississippi. It is challenging legislation in Utah that was rewritten after NetChoice sued over the original version. And NetChoice’s lawyers argued before the U.S. Supreme Court that efforts in Texas and Florida to regulate social media content were unconstitutional. Those cases were remanded to lower courts for further review.

Though the particulars differ in each state, the bottom line is the same: Each of the laws has been stifled by an injunction, and none has taken effect.

“When you look at these sweeping laws like the California laws, they’re ambitious and I applaud them,” said Nancy Costello, a clinical law professor at Michigan State University and the director of the school’s First Amendment Clinic. “But the bigger and broader the law is, the greater chance that there will be a First Amendment violation found by the courts.”

The harmful effects of social media on children are well established. An advisory from Surgeon General Murthy last year warned of a “profound risk of harm” to young people, noting that a study of adolescents from ages 12 to 15 found that those who spent more than three hours a day on social media were at twice the risk of depression and anxiety as nonusers. A Gallup survey in 2023 found that U.S. teenagers spent nearly five hours a day on social media.

In June, Murthy called for warnings on social media platforms like those on tobacco products. Later that month came Newsom’s call to severely restrict the use of smartphones during the school day in California. Legislation to codify Newsom’s proposal is working its way through the state Assembly.

Federal legislation has been slow to materialize. A bipartisan bill to limit algorithm-derived feeds and keep children under 13 off social media was introduced in May, but Congress has done little to meaningfully rein in tech platforms — despite Meta’s chief executive, Mark Zuckerberg, apologizing in a U.S. Senate hearing for “the types of things that your families have had to suffer” because of social media harms.

It remains unclear what kinds of regulation the courts will permit. NetChoice has argued that many proposed social media regulations amount to the government dictating how privately owned firms set their editorial rules, in violation of the First Amendment. The industry also leans on Section 230 of the 1996 Communications Decency Act, which shields tech companies from liability for harmful content produced by a third party.

“We’re hoping lawmakers will realize that as much as you may want to, you can’t end-around the Constitution,” said Szabo, the NetChoice attorney. “The government is not a substitute for parents.”

Skinner tried and failed last year to pass legislation holding tech companies accountable for targeting children with harmful content. This year’s measure, which was overwhelmingly passed by the California Senate and is pending in the state Assembly, would bar tech companies from sending social media notifications to children between midnight and 6 a.m. every day, and 8 a.m. to 3 p.m. on school days. The bill also calls for platforms to require minors to obtain parental consent to use their core offerings, and would limit their use to an hour to 90 minutes a day by default.

“If the private sector is not willing to modify their product in a way that makes it safe for Californians, then we have to require them to,” Skinner said, adding that parts of her proposal are standard practice in the European Union.

“Social media has already accommodated users in many parts of the world, but not the U.S.,” she said. “They can do it. They’ve chosen not to.”

Wicks, meanwhile, said she considers her data bill to be about consumer protection, not speech. The proposal would close a loophole in the California Electronic Communications Privacy Act to prevent social media platforms from collecting and sharing information on anyone under 18 unless they opt in. The Assembly approved Wicks’ measure without dissent, sending it to the state Senate for consideration.

Costello suggested that focusing the proposals more narrowly might give them a better chance of surviving court challenges. She is part of an effort coordinated by Harvard’s T.H. Chan School of Public Health to write model legislation that would require third-party assessments of the risks posed by the algorithms used by social media apps.

“It means that we’re not restricting content, we’re measuring harms,” Costello said. Once the harms are documented, the results would be publicly available and could lead state attorneys general to take legal action. Government agencies adopted a similar approach against tobacco companies in the 1990s, suing for deceptive advertising or business practices.

Szabo said NetChoice has worked with states to enact what he called “constitutional and commonsense laws,” citing measures in Virginia and Florida that would mandate digital education in school. “There is a role for government,” Szabo said. (The Florida measure failed.)

But with little momentum on actual regulation at the national level, state legislators continue to try to fill the vacuum. New York recently passed legislation similar to Skinner’s, which the state senator said was an encouraging sign.

Will NetChoice race for an injunction in New York? “We are having lots of conversations about it,” Szabo said.

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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KFF Health News chief Washington correspondent Julie Rovner discussed abortion in the GOP platform on KMOX’s “Total Information AM” on July 17.

• Click here to hear Rovner on “Total Information AM”
• Hear Rovner in “GOP Platform Muddies Abortion Waters”

KFF Health News contributor Andy Miller discussed a rise in covid cases on WUGA’s “The Georgia Health Report” on July 12.

• Click here to hear Miller on “The Georgia Health Report”

KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed Idaho’s worsening OB-GYN shortage on Apple News’ “Apple News Today” on July 8.

• Click here to hear Orozco Rodriguez on “Apple News Today”
• Read Orozco Rodriguez’s “Idaho’s OB-GYN Exodus Throws Women in Rural Towns Into a Care Void”

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 Tennessee government has agreed to begin scrubbing its sex offender registry of dozens of people who were convicted of prostitution while having HIV, reversing a practice that federal lawsuits have challenged as draconian and discriminatory.

For more than three decades, Tennessee’s “aggravated prostitution” laws have made prostitution a misdemeanor for most sex workers but a felony for those who are HIV-positive. Tennessee toughened penalties in 2010 by reclassifying prostitution with HIV as a “violent sexual offense” with a lifetime registration as a sex offender — even if protection is used.

At least 83 people are believed to be on Tennessee’s sex offender registry solely because of these laws, with most living in the Memphis area, where undercover police officers and prosecutors most often invoked the statute, commonly against Black and transgender women, according to a lawsuit filed last year by the American Civil Liberties Union and four women who were convicted of aggravated prostitution. The Department of Justice challenged the law in a separate suit earlier this year.

Both lawsuits argue that Tennessee law does not account for evolving science on the transmission of HIV or precautions that prevent its spread, like use of condoms. Both lawsuits also argue that labeling a person as a sex offender because of HIV unfairly limits where they can live and work and stops them from being alone with grandchildren or minor relatives.

“Tennessee’s Aggravated Prostitution statute is the only law in the nation that treats people living with HIV who engage in any sex work, even risk-free encounters, as ‘violent sex offenders’ subjected to lifetime registration,” the ACLU lawsuit states.

“That individuals living with HIV are treated so differently can only be understood as a remnant of the profoundly prejudiced early response to the AIDS epidemic.”

In a settlement agreement signed by Tennessee Gov. Bill Lee on July 15 and filed in both lawsuits on July 17, the Tennessee Bureau of Investigation said it would comb through the state’s sex offender registry to find those added solely because of aggravated prostitution convictions, then send letters alerting those people that they can make a written request to be removed. The language of the settlement suggests that people will need to request their removal from the registry, but the agency said in the agreement it will make “its best effort” to act on the requests “promptly in the order in which they are received.”

The Tennessee attorney general’s office, which represents the state in both the ACLU and DOJ lawsuits and approved the settlement agreement, said in an email statement it would “continue to defend Tennessee’s prohibition on aggravated prostitution.”

In an email statement, the ACLU celebrated the settlement as “one step toward remedying the harms by addressing the sex offender registration,” but said its work in Tennessee was not done because aggravated prostitution remained a felony charge that it would “fight to overturn.”

Molly Quinn, executive director of LGBTQ+ support organization OUTMemphis, another plaintiff in the ACLU lawsuit, said both organizations would help eligible people with the paperwork to get removed from the registry.

“We would not have agreed to settle if we did not feel like this was a process that would be extremely beneficial,” Quinn said. “But, we’re sad that the statute existed as long as it did and sad that there is any process at all that folks have to go through after living with this extraordinary burden of being on the sex offender registry for really an irrelevant reason.”

Michelle Anderson, a Memphis resident who is one of the plaintiffs in the ACLU lawsuit, said in court records that since being convicted of aggravated prostitution, the sex offender label has made it so difficult to find a home and a job that she was “unhoused for about a year” and has at times “felt she had no option but to continue to engage in sex work to survive.”

Like the other plaintiffs, Anderson said her conviction kept her minor relatives at a distance.

“Ms. Anderson has a nephew she loves, but she cannot have a close relationship with him,” the lawsuit states. “Even though Ms. Anderson’s convictions had nothing to do with children, she cannot legally be alone with her nephew.”

The Tennessee settlement comes months after state lawmakers softened the law so no one else should be added to the sex offender registry for aggravated prostitution. Lawmakers removed the registration requirement and made convictions eligible for expungement if the defendant testifies they were a victim of human trafficking.

State Sen. Page Walley (R-Savannah), who supported the original aggravated prostitution law passed in 1991 and co-sponsored the recent bill to amend it, said on the floor of the legislature that the changes do not prevent prosecutors from charging people with a felony for aggravated prostitution. Instead, he said, the amendments undo the 2010 law that put those who are convicted on the registry “along with pedophiles and rapists for a lifetime, with no recourse for removal.”

“Having stood, as I mentioned, in 1991 and passed this,” Walley said, “it is a particular gratifying moment for me to see how we continue to evolve and seek what’s just and what’s right and what’s best.”

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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About every 12 minutes, someone is killed on America’s roads and countless others are injured.

More than 42,500 people died in car crashes in 2022, a death toll that rivals or surpasses those of other major public health threats, such as the flu and gun violence.

“We have not recognized that traffic violence is a preventable public health crisis,” said Amy Cohen, a co-founder of Families for Safe Streets.

Traffic-related injuries and deaths cost the health-care system more than $55 billion in 2022, according to the Centers for Disease Control and Prevention. And pedestrian deaths have spiked, reaching 7,522in 2022, the highest level in more than four decades, according to the federal government.

“The transportation system shouldn’t hurt us, and it shouldn’t harm the environment,” said Johnathon Ehsani, an associate professor at the Johns Hopkins Bloomberg School of Public Health who uses policy and behavioral research to try to prevent car crashes.

Transportation experts blame traffic deaths on more reckless driving and less traffic enforcement than before the coronavirus pandemic, combined with larger and deadlier SUVs and trucks. But they primarily fault a transportation system that was designed for efficient movement and economic development — not safety.

To reverse that, the Biden administration is looking to the “safe system approach,” a transportation strategy that has achieved piecemeal adoption across the country.

The approach puts safety at the core of road and vehicle design and transportation policies, forcing traffic to move more slowly through communities, Ehsani said.

This translates into lowering speed limits, narrowing roads and creating separate lanes for bicyclists, and more buffers for pedestrians. He said the approach also de-emphasizes cars — which make people more sedentary and cause air pollution — and boosts public transportation.

The Biden administration in 2021 injected more than $20 billion in funding for transportation safety programs through the Infrastructure Investment and Jobs Act.

Some states and localities are also taking steps.

New York and Michigan adopted laws this spring allowing local jurisdictions to lower speed limits, and voters in Los Angeles approved a resident-sponsored ballot initiative to redesign streets, invest more in public transportation, add bike lanes and widen sidewalks to protect pedestrians.

But in a country where cars are inextricably linked to the culture and economy, political resistance remains entrenched.

Stuck in the middle are people whose lives and health have been devastated. I visited a Latino working-class neighborhood in Los Angeles where I met María Rivas Cruz, who in February 2023 was struck along with her fiancé, Raymond Olivares, by a driver going 70 in a 40-mph zone.

Rivas Cruz was severely injured. Olivares died at the scene.

Residents had pleaded for years for lower speed limits, safety islands and more marked crosswalks. After the crash, the county installed protective steel posts midway across the street, which Rivas Cruz called a “band-aid.”

“There’s so much death going on,” said Rivas Cruz, who now at age 28 walks with a cane and lives with chronic pain. “The representatives have failed us.”

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Caitlyn Mai woke up one morning in middle school so dizzy she couldn’t stand and deaf in one ear, the result of an infection that affected one of her cranial nerves. Though her balance recovered, the hearing never came back.

Growing up, she learned to cope — but it wasn’t easy. With only one functioning ear, she couldn’t tell where sounds were coming from. She couldn’t follow along with groups of people in conversation — at social gatherings or at work — so she learned to lip-read.

For many years, insurers wouldn’t approve cochlear implants for single-sided deafness due to concerns that it would be hard to train the brain to manage signals from a biological ear and one that hears with the aid of an implant. But research on the detrimental effects of single-sided deafness and improvements in technique changed all that.

So Mai, now 27 and living near Oklahoma City, was thrilled last fall to get a prior authorization letter from her insurer saying she was covered for cochlear implant surgery.

She had successful outpatient surgery to implant the device in December and soon after was eagerly attending therapy to get her brain accustomed to its new capabilities.

“It was amazing. When I’d misplaced my phone and it rang, I could tell where the sound was coming from and find it,” she said.

Then the bill came.

The Patient: Caitlyn Mai, who is insured through her husband’s job by HealthSmart, which is owned by UnitedHealth Group.

Medical Services: Cochlear implant surgery, including the operating room, anesthesia, surgical supplies, and drugs.

Service Provider: SSM Health Bone & Joint Hospital at St. Anthony, an orthopedic hospital in Oklahoma City that is part of SSM Health, a Catholic health system in the central U.S.

Total Bill: $139,362.74 — or, with a “prompt pay discount” if she paid about two months after surgery, $125,426.47.

What Gives: Providers and insurers often have disagreements over how a bill is submitted or coded, and as they work through them (or don’t), the patient is left holding the bag, facing sometimes huge bills.

“I almost had a heart attack when I opened the bill,” Mai said of the first monthly missive, which arrived in late December. She said she was so upset she left work to investigate. Before surgery, “I’d even checked that all hospitals and doctors were in-network and that I’d met my deductible,” she said.

While she was never threatened with having her bill sent to collections, she said she worried about that possibility when the same bills arrived in January, February, and March, with ominous warnings that “your balance is now past due.”

Mai said she first called the hospital billing office but that the representative could tell her only that the claim had been denied and didn’t know why. She called her insurer, and a representative there said the hospital didn’t adequately itemize its charges or include billing codes. She then called the hospital back and relayed exactly what her insurer said must be done to rectify the bill — and the name and number of the insurance employee to fax it to.

When her insurer told her a week or two later it hadn’t received a corrected bill, Mai said, she called the hospital again … and again.

“I said, ‘I’ve done your job for you — now can you please take it from here?’” she said.

Mai said a hospital staffer promised to fax over the corrected, itemized bill in two to three weeks. “How does it take that long to send a fax,” she wondered. She said she asked to speak with a supervisor and was told the person wasn’t available but would call her back. No one did.

After receiving another $139,000 bill in late February, Mai said, she checked back in with her insurer, but a representative said it had not yet received the revised bill.

Finally, she said, she told the hospital to “just send it to me and I’ll send it over.” This time, she forwarded the bill to her insurer herself. But in late March she got another bill demanding the full amount — and offering an $11,000-a-month payment plan.

Mai said she had met her out-of-pocket deductible and, with prior authorization in hand, expected the surgery to be fully covered.

SSM Health did not respond to multiple requests for comment about why it billed Mai.

“It’s outrageous that the patients end up umpiring the decisions,” said Elisabeth Ryden Benjamin, vice president of health initiatives at the Community Service Society of New York, an advocacy organization. “And it’s outrageous that providers are allowed to bill patients while they’re haggling with the insurer.”

Indeed, more and more patients are stuck with such bills as insurers and hospitals spend more and more time arguing in the trenches, data shows. A recent report by Crowe, an accounting firm that works with a large number of hospitals, found that more than 30% of claims submitted to commercial insurers early last year weren’t paid for more than 90 days — striking compared with the lower rates of such delays in Medicare, which were 12% for inpatient claims and 11% for outpatient claims.

The Crowe report found a particular justification for denying claims was cited at 12 times the rate by commercial insurers as by Medicare: that they needed more information before they would process the submission. Such a request allows insurers to sidestep laws in most states that require claims be paid in 30 to 40 days, automatically granting health plans the right to delay payment.

In a separate analysis, the American Hospital Association complained that increases in insurance denials and delays “strain hospital resources” and “inhibit medically necessary care.”

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More from the series

But perhaps no one is harmed as gravely as the patient, who is barraged with bills and believes they must pay up — particularly when the missives are stamped “past due” and contain offers of prompt-payment discounts or no-interest payment plans. “The stress and anxiety was huge,” Mai said.

Caroline Landree, a spokesperson for UnitedHealth Group, said the insurer could pay Mai’s claims only “after receiving a detailed bill from her provider.”

“We encourage our members to contact the number on their insurance cards for more information on the status of payments,” she added.

The Resolution: Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department: making sure the bill was coded as needed and that the insurer had what it wanted to process the payment.

More than 90 days after her surgery, after Mai had received four terrifyingly huge bills, her insurance finally paid the claim. Mai owed nothing more.

She added: “I’ve never got that call back from a supervisor to this day.”

The Takeaway: It’s not uncommon for an insurer to delay paying a claim until it receives an itemized bill; providers sometimes get creative with billing codes to increase revenue, and studies show that more than half of hospital bills contain errors. But studies also suggest insurers are wont to drag their feet, niggling over coding and charges — and, in doing so, delaying reimbursement and holding on to the cash.

Medical billing experts say it may not seem right for patients to receive bills as this process plays out but that it’s probably legal.

“Laws say ‘hold the patient harmless,’” Benjamin said. “What we didn’t say is, ‘Don’t send them a bill.’” She said it is also unfair that patients may be forced to act as the go-between for providers and insurers who should be talking to each other.

What’s a patient to do? First step: Don’t pay the bill (aside from a copay or coinsurance) for care or services preapproved by insurance. Call the health care provider and explain they should take up their bill with the insurer.

Second, ask the provider to send an itemized bill with all billing codes used, then review it for errors. As the patient, you would know that you never had an MRI, for example. Your insurer wouldn’t.

If submissions to “Bill of the Month” are reflective of trends, many patients these days are finding themselves ping-ponging between representatives for providers and insurers to get bills resolved and paid.

“Bravo for Ms. Mai for having the energy to keep at it and get resolution,” Benjamin said.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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During the Republican National Convention’s opening night, Sen. J.D. Vance (R-Ohio) spoke to Fox News for his first interview as former President Donald Trump’s vice presidential nominee.

Sitting in the Fiserv Forum, the convention’s Milwaukee venue, Vance took questions from host Sean Hannity and addressed criticism about his previous comments on domestic violence, abortion, and his 2016 disapproval of Trump.

A couple of times, Vance accused the media of twisting controversial comments about violent marriages and abortion exemptions. We took a closer look at four of his claims.

Vance Mischaracterizes Biden’s Stance on Abortion

Vance addressed his own and Trump’s position on abortion. He described Trump’s position “to let voters in states” decide abortion laws as “reasonable,” contrasting it with Biden’s. 

“Donald Trump is running against a Joe Biden president who wants taxpayer-funded abortions up until the moment of birth,” Vance said.

This is False and misleads about how rarely abortions are performed late in pregnancy. 

The vast majority of abortions in the U.S. — about 91% — occur in the first trimester. About 1% take place after 21 weeks, and far fewer than 1% occur in the third trimester and typically involve emergencies such as fatal fetal anomalies or life-threatening medical emergencies affecting the pregnant woman.

Biden has said he supported Roe v. Wade, the landmark 1973 U.S. Supreme Court ruling that legalized abortion and was overturned in June 2022, and wants federally protected abortion access. 

Roe didn’t provide unrestricted access to abortion. It legalized abortion federally but also enabled the states to restrict or ban abortions once a fetus is viable, typically around 24 weeks into pregnancy. Exceptions to that time frame typically were allowed when the pregnant woman’s life or health was at risk.

The Democratic-led Women’s Health Protection Act of 2021, which failed to pass the Senate, would have effectively codified a right to abortion while allowing for post-viability restrictions similar to Roe‘s.

During the 2020 presidential campaign, Biden promised to repeal the Hyde Amendment, which says federal funds can’t be used to pay for abortions, except in cases of rape or incest or to save the woman’s life. However, the amendment has continued to be included in congressional spending bills. 

Vance’s Comments About Women in Violent Marriages

Hannity asked Vance to explain controversial 2021 comments about women staying in violent marriages. 

“Both me and my mom actually were victims of domestic violence,” Vance told Hannity. “So, to say ‘Vance has supported women staying in violent marriages,’ I think it’s shameful for them to take a guy with my history and my background and say that that’s what I believe. It’s not what I believe. It’s not what I said.” 

The comments in question came from a 2021 event Vance participated in at Pacifica Christian High School in California. In a conversation about his 2016 memoir “Hillbilly Elegy,” the event moderator asked Vance about his experience being raised by his grandparents, following his mother’s divorces and struggles with drug addiction. 

“What is causing one generation to give up on fatherhood when the other one was so doggedly determined to stick it out even in tough times?” the moderator asked. 

Vance talked about the economic effect of men losing manufacturing jobs then discussed his grandparents’ marriage. 

In his memoirs, Vance detailed his grandparents’ relationship and told a story about Vance’s grandmother pouring lighter fluid on his grandfather and striking a match after he came home drunk. She had previously threatened to kill her husband if he came home drunk again, according to a 2016 book review published by The Washington Post. 

Vance commended his grandparents for staying together, comparing it with younger generations. 

“This is one of the great tricks that I think the sexual revolution pulled on the American populace, which is the idea that, like, ‘Well, OK, these marriages were fundamentally, you know, they were maybe even violent, but certainly they were unhappy. And so getting rid of them and making it easier for people to shift spouses like they change their underwear, that’s going to make people happier in the long term.’ 

“And maybe it worked out for the moms and dads, though I’m skeptical. But it really didn’t work out for the kids of those marriages.”

In response to a 2022 Vice News story highlighting the comments, Jai Chabria, a strategist for Vance, said the media missed Vance’s point.

“This is a comment that he made where he’s talking about how it’s important that couples stay together for the kids, that we actually have good kids first,” he said. “All he is saying is that it is far too often the case where couples get divorced, they split up, and they don’t take the kids’ needs into consideration.”

Vance’s Comments About Rape, Abortion, and ‘Inconvenience’

Hannity asked Vance to discuss his position on abortion, allowing the senator to address his past comments that have been criticized. 

“Let me go back to the issue of abortion,” Hannity said. “And there was this article that said, ‘Oh, J.D. Vance said it’s inconvenient.'”

Vance told Hannity, “The Democrats have completely twisted my words. What I did say is that we sometimes in this society see babies as inconveniences, and I absolutely want us to change that.”

We looked into comments Vance made on abortion while he was running for Senate in 2022. His opponent claimed Vance had said that rape was inconvenient, but we found that’s not directly what Vance said. 

In a 2021 interview, Vance was asked whether laws should allow women to get abortions if they were victims of rape or incest. He said society should not view a pregnancy or birth resulting from rape or incest as “inconvenient.” 

“My view on this has been very clear, and I think the question betrays a certain presumption that is wrong,” Vance said in 2021. “It’s not whether a woman should be forced to bring a child to term, it’s whether a child should be allowed to live, even though the circumstances of that child’s birth are somehow inconvenient or a problem to the society. The question really, to me, is about the baby.”

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The first time Tammy and Jordan Myers held their twins, the premature babies were so fragile that their tiny faces were mostly covered by oxygen masks and tubing. Their little hands rested gently on Tammy’s chest as the machines keeping them alive in a neonatal intensive care unit in Grand Rapids, Michigan, beeped and hummed around them.

It was an incredible moment, but also a terrifying one. A court had just denied the Myers’ parental rights to the twins, who were born via surrogate using embryos made from Jordan’s sperm and Tammy’s eggs. (Tammy’s eggs had been frozen before she underwent treatment for breast cancer.)

“In the early hours of their lives, we had no lifesaving medical decision-making power for their care,” Tammy Myers told lawmakers at a Michigan Senate committee hearing in March.

Instead, the state’s surrogacy restrictions required the Myers to legally adopt their biological twins, Eames and Ellison.

“Despite finally being granted legal parenthood of our twins almost two years after they were born, our wounds from this situation remain raw, casting a long shadow over the cherished memories that we missed,” Myers told lawmakers, her voice catching.

Until this spring, Michigan was the only state that had a broad criminal ban on surrogacy. Many families say that ban left them in legal limbo: They were compelled to leave the state to have children; find strangers on Facebook who would carry their child; or, like the Myers, be forced to legally adopt their own biological children.

Gov. Gretchen Whitmer of Michigan signed legislation in April repealing the 1988 criminal ban, legalizing surrogacy contracts and compensated surrogacy after more than three decades. But the legalization is raising fears among conservatives and religious groups, who echo Pope Francis’ concerns that surrogacy exploits women and makes children “the basis of a commercial contract.”

As reproductive technology advanced in recent decades, most states passed laws permitting and regulating surrogacy. But Michigan did not, said Courtney Joslin, a professor at the University of California-Davis School of Law who specializes in family law. Still, those restrictions didn’t prevent Michiganders from having children via surrogacy.

“Criminal bans, or even civil bans, don’t end the practice,” Joslin said. “People are still engaged in surrogacy, and it’s becoming more clear that the effect of a ban is just to leave the parties without any protection. And that includes the person acting as a surrogate.”

In 2009, a couple in western Michigan had to surrender custody of twins after their surrogate decided to keep the babies. The surrogate claimed that she hadn’t been aware of an arrest and a mental health issue in the intended mother’s past. In 2013, a surrogate from Connecticut fled to Michigan to give birth, knowing state law would give her parental rights. She and the intended parents had disagreed over whether to terminate the pregnancy following the discovery of major fetal abnormalities.

The Myers family, however, thought they would be able to avoid any protracted legal fights. They had the full support of their surrogate, Lauren Vermilye, a stranger who’d volunteered to be their surrogate after seeing Tammy’s posts on Facebook. Yet even with Vermilye and her husband, Jonathan, saying that the twins belonged to the Myers, Michigan judges denied the Myers’ request for a prebirth order giving them parental rights.

“As a devoted family already raising our kind, inclusive and gentle-hearted 8-year-old daughter, Corryn, we were forced to prove our worthiness through invasive psychological testing, home visits, and endless meetings to discuss our parenting plan to prove that we were fit to raise our twins, Eames and Ellison,” Tammy Myers told lawmakers in March.

Opponents of Michigan’s repeal of its surrogacy ban distinguish altruistic surrogacy — in which the surrogate mother does not receive any compensation, including for her medical and legal expenses — from a contract for a child.

Legislators in Michigan’s House of Representatives passed bills late last year to allow courts to recognize and enforce surrogacy contracts. These bills allowed parents to compensate surrogates, including for medical and legal expenses. But as the legislation moved forward early this year, religious and conservative groups, and some Republican lawmakers, continued voicing their opposition.

Michigan’s surrogacy laws were not preventing altruistic surrogacy in the state, argued Genevieve Marnon, the legislative director of Right to Life of Michigan, at a state Senate committee hearing in March.

“However, current law does require a legal adoption of a child who is born of one woman and then given to another person,” Marnon said. “That practice is child-protective, to prevent the buying and selling of children, and to ensure children are going to a safe home.”

Michigan’s ban on surrogacy is “in keeping with much of the rest of the world,” Marnon said in March. Several European countries ban or restrict surrogacy, including Italy, which is cracking down on international surrogacy, an arrangement involving a surrogate mother who lives in a different country than the biological parents.

“India, Thailand, and Cambodia had laws similar to those contemplated in these bills, but due to exploitation of their women caused by surrogacy tourism, they changed their laws to stop that,” Marnon told the senators in March.

In January, Pope Francis called for a universal ban on surrogacy, “which represents a grave violation of the dignity of the woman and the child, based on the exploitation of situations of the mother’s material needs,” he said.

Rebecca Mastee, a policy advocate with the Michigan Catholic Conference, told lawmakers that while she acknowledged the suffering of people with infertility, surrogacy can exploit women and treat babies like commodities.

“At the core of such agreements is a contract for a human being,” she said.

“That made my blood boil, hearing that,” said Eric Portenga. He and his husband, Kevin O’Neill, had traveled from their home in Ann Arbor to the Capitol in Lansing to attend the hearings in March.

If you’ve been through the surrogacy process “you know there’s no commodification at all,” Portenga said. “You want a family because you have love to give. And you want to build the love that you have, with your family.”

When Portenga and O’Neill were trying to become fathers, they reached out to surrogacy agencies in other states but were told the process would cost $200,000. “We would have had to have sold the house,” O’Neill said.

Like the Myers, the couple turned to Facebook and social media, “just putting our story out there that we wanted to become dads,” O’Neill said. A friend of a friend, Maureen Farris, reached out to the couple: She’d been wanting to help a family through surrogacy for years, she said. And Farris lived just a few hours south in Ohio, where surrogacy contracts and compensation are legal.

Farris’ contract with Portenga and O’Neill was fairly standard. Both sides had to undergo psychological background checks and have legal representation. The contract also set compensation for Farris, which covered medical and legal fees. The contract stipulated Farris couldn’t travel to Michigan beyond a certain point in her pregnancy because if she’d gone into labor and given birth in the state, she would be considered the legal parent of the child.

That contract, Portenga and O’Neill said, gave Farris more protection and agency than she would have had in Michigan at the time. “They’re carrying a human life inside of them,” O’Neill said of surrogates. “They’re not able to work. Their bodies will be changed forever. They’re getting compensated for the amazing gift they’re giving people.”

After the embryo transfer was successful, Portenga and O’Neill learned Farris was pregnant — with identical triplet girls.

“They came out and just unraveled this huge string of ultrasound photographs and, and that’s when we knew our life had changed,” Portenga said, sitting at home in the family’s kitchen. The girls were born in Ohio — where the dads could be legally named their parents — and then the family of five returned to Michigan.

Today, Sylvie, Parker, and Robin O’Neill are 2 years old, and very busy. Parker is the “leader of the pack,” while Robin is the “brains of the operation” — she can count to 10 but likes to skip the number five. Sylvie is “the most affectionate, the most sensitive, of the three of them,” O’Neill said. “But their bond is so amazing to watch. And we’re so lucky to be their dads.”

This article is from a partnership that includes Michigan Public, NPR, and KFF Health News.

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Cinco trabajadores de una granja avícola en el noreste de Colorado han dado positivo para la gripe aviar, informó el Departamento de Salud Pública estatal el 14 de julio. Esto eleva el número conocido de casos en Estados Unidos a nueve.

Es probable que las cinco personas se infectaran por manipular pollos, a los que se les había encargado sacrificar en respuesta a un brote de gripe aviar en esa granja.

Más de 99 millones de pollos y pavos se han infectado con una cepa altamente patógena de la gripe aviar que surgió en las granjas avícolas del país a principios de 2022.

Desde entonces, el gobierno federal ha compensado a los granjeros avícolas con más de $1,000 millones por destruir bandadas y huevos infectados para frenar la propagación de los brotes.

El virus de la gripe aviar H5N1 se ha estado propagando entre las granjas avícolas de todo el mundo durante casi 30 años. Se estima que 900 personas se han infectado por aves y aproximadamente la mitad han muerto por la enfermedad.

Este año, en Estados Unidos, el virus hizo un cambio sin precedentes “saltando” al ganado lechero. Esto representa una amenaza mayor porque significa que el virus se ha adaptado para replicarse dentro de las células de las vacas, que son más parecidas a las humanas.

Las otras cuatro personas diagnosticadas este año en el país trabajaban en tambos que estaban sufriendo brotes.

Los científicos han advertido que el virus podría mutar para propagarse de persona a persona, como la gripe estacional, y desencadenar una pandemia. Aún no hay señales de que esto esté ocurriendo.

Hasta ahora, los nueve casos reportados este año han sido leves: con irritación ocular, secreción nasal y otros síntomas respiratorios. Sin embargo, los números siguen siendo demasiado bajos para decir algo certero sobre la enfermedad porque, en general, los síntomas de la gripe pueden variar entre las personas y solo una minoría necesita hospitalización.

El número de personas que han contraído el virus de las aves de corral o el ganado puede ser mayor que nueve. Los Centros para el Control y Prevención de Enfermedades (CDC) han hecho pruebas solo a unas 60 personas en los últimos cuatro meses, y los laboratorios de diagnóstico más grandes, que típicamente detectan enfermedades, aún no tienen permitido realizar pruebas.

Es muy importante hacerles estas pruebas a los trabajadores de granjas para detectar el virus de la gripe aviar H5N1, estudiarlo y frenarlo antes que se convierta en parte de sus ecosistemas.

Los investigadores han instado a una respuesta más agresiva por parte de los CDC y otras agencias federales para prevenir futuras infecciones. Muchas personas expuestas regularmente al ganado y a las aves de corral en las granjas aún carecen de equipo de protección y no reciben ningún tipo de educación sobre la enfermedad.

Y todavía no tienen permiso para recibir una vacuna contra la gripe aviar.

Casi una docena de expertos en virología y brotes entrevistados recientemente por KFF Health News no están de acuerdo con la decisión de los CDC de no vacunar, lo que, dicen, podría ayudar a prevenir la infección y hospitalización por gripe aviar.

“Deberíamos hacer todo lo posible para eliminar las posibilidades de que los trabajadores en tambos y granjas de aves contraigan este virus”, dijo Angela Rasmussen, viróloga de la Universidad de Saskatchewan, en Canadá. “Si este virus tiene suficientes oportunidades para saltar de las vacas o las aves de corral a las personas, eventualmente se volverá mejor para infectarlas”.

Para comprobar si los casos no se están detectando, investigadores en Michigan han enviado a los CDC muestras de sangre de trabajadores de tambos. Si detectan anticuerpos contra la gripe aviar, es probable que las personas se infecten más fácilmente por el ganado de lo que se creía anteriormente.

“Es posible que las personas hayan tenido síntomas que no se sintieran cómodas informando, o que sus síntomas fueran tan leves que no pensaron que valiera la pena mencionarlos”, dijo Natasha Bagdasarian, directora ejecutiva de salud médica del estado de Michigan.

Con la esperanza de frustrar una posible pandemia, Estados Unidos, el Reino Unido, Países Bajos y una docena de otros países están almacenando millones de dosis de una vacuna contra la gripe aviar fabricada por la compañía de vacunas CSL Seqirus.

La formulación más reciente de Seqirus fue aprobada el año pasado por el equivalente europeo de la Administración de Drogas y Alimentos (FDA), y una versión anterior tiene la aprobación de la FDA. En junio, Finlandia decidió ofrecer vacunas a las personas que trabajan en granjas de pieles como medida de precaución porque sus granjas de visones y zorros sufrieron duros golpes por la gripe aviar el año pasado.

De manera controversial, los CDC han decidido no ofrecer vacunas contra la gripe aviar a los grupos de riesgo.

Aunque hay millones de dosis disponibles, Demetre Daskalakis, director del Centro Nacional para la Inmunización y Enfermedades Respiratorias de los CDC, dijo a KFF Health News que en este momento la agencia no está recomendando una campaña de vacunación por varias razones. Una de ellas es que los casos aún parecen ser limitados y el virus no se está propagando rápidamente entre las personas a medida que estornudan y respiran.

La agencia sigue calificando el riesgo público como bajo. En una declaración publicada en respuesta a los nuevos casos de Colorado, los CDC dijeron que sus recomendaciones sobre la gripe aviar siguen siendo las mismas: “Una evaluación de estos casos ayudará a determinar si esta situación justifica un cambio en la evaluación del riesgo para la salud humana”.

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HOUSTON — As Tina Kitzmiller sat inside her sweltering apartment, windows and doors open in the hope of catching even the slightest breeze, she was frustrated and worried for her dog and her neighbors.

It had been days since Hurricane Beryl blew ashore from the Gulf of Mexico on July 8, causing widespread destruction and knocking out power to more than 2 million people, including the Houston senior independent living facility where Kitzmiller lives. Outdoor temperatures had reached at least 90 degrees most days, and the heat inside the building was stifling.

Kitzmiller moved there not long ago with Kai, her 12-year-old dog, shortly after riding out 90-plus-mph winds from a May derecho under a comforter on the floor of the 33-foot RV she called home. She didn’t need medical care, as a nursing home would offer, and thought she and Kai could be safer at an independent senior facility than in the RV. She assumed her new home would have an emergency power system in place at least equivalent to that of the post offices she’d worked in for 35 years.

“I checked out the food. I checked out the activities,” said Kitzmiller, 61, now retired. “I didn’t know I needed to inquire about a generator.”

Even after multiple incidents of extreme weather — including a 2021 Texas winter storm that caused widespread blackouts and prompted a U.S. Senate investigation — not much has changed for those living in long-term care facilities when natural disasters strike in Texas or elsewhere.

“There has been some movement, but I think it’s been way too slow,” said David Grabowski, a professor of health care policy at Harvard Medical School. “We keep getting tested and we keep failing the test. But I do think we are going to have to face this issue.”

A power outage can be difficult for anyone, but older adults are especially vulnerable to temperature extremes, with medications or medical conditions affecting their bodies’ ability to regulate heat and cold. Additionally, some medications need refrigeration while others cannot get too cold.

Federal guidelines require nursing homes to maintain safe indoor temperatures but do not regulate how. For example, facilities face no requirement that generators or other alternative energy sources support heating and air conditioning systems. States are largely responsible for compliance, Grabowski said, and if states are failing in that regard, change doesn’t happen.

Furthermore, while nursing homes face such federal oversight, lower-care-level facilities that provide some medical care — known as assisted living — are regulated at the state level, so the rules for emergency preparedness vary widely.

Some states have toughened those guidelines. Maryland adopted rules for generators in assisted living facilities following Hurricane Isabel, which left more than 1.2 million residents in the state without power in 2003. Florida did so for nursing homes and assisted living facilities in 2018, after Hurricane Irma led to deaths at one facility.

But Texas has not. And no requirements for generators exist in Texas for the roughly 2,000 assisted living facilities or the even less regulated independent living sites, like Kitzmiller’s.

Generally, apartment complexes marketed to senior citizens, known in the industry as independent living facilities, don’t have any special regulations in Texas and many other states.

Nationally, assisted living facilities and independent living facilities have been the fastest-growing sectors in senior living. Residents at such facilities often have medical needs, Grabowski said, but for a variety of reasons have chosen to live in an environment that allows more independence than a nursing home, which would provide medical care. That doesn’t mean the residents in these lower-care-level facilities are any less susceptible to extreme temperatures when the power goes out.

“If you’re overwhelmed by the heat in your apartment, that’s unsafe,” he said.

Republican state Rep. Ed Thompson tried several times since 2020 to pass legislation requiring assisted living facilities in Texas to have backup generators. But the bills failed. He is not seeking reelection this year.

“It’s horrible what the state of Texas is doing,” said Thompson, blaming corporate greed and politicians more interested in stirring up their base and raising their national profile than improving the lives of Texans. “How we treat our elderly says something about us — and they’re not being treated right.”

Nim Kidd, chief of the Texas Division of Emergency Management, said at a July 11 press conference that senior facility operators are accountable if they do not keep residents safe. “That location is responsible for the health, safety, and welfare of the patients and residents that are there,” he told reporters. “It is that facility’s responsibility.”

Under Texas law, power restoration is supposed to be prioritized for nursing, assisted living, and hospice facilities.

The resistance to adding oversight or more governmental protections has not surprised Gregory Shelley, a senior manager at the Harris County Long-Term Care Ombudsman Program at UTHealth Houston’s Cizik School of Nursing. He said that while he believes the safety and health of residents are paramount, he recognizes that installing generators is expensive. He also said some people within the industry continue to believe extreme events are rare.

“But all of us in Houston this year already learned that they’re happening more frequently,” Shelley said. “This is already the third time since May that big portions of Houston have been without power for long periods of time.”

After the 2021 blackouts, Texas’ Health and Human Services Commission conducted a voluntary survey that found 47% of the assisted living and 99% of the nursing care facilities that responded reported having generators.

The U.S. Senate investigation following the 2021 Texas storm recommended a national requirement that assisted living facilities have emergency power supplies to both maintain safe temperatures and keep medical equipment running.

A 2023 annual report from Texas’ long-term care ombudsman, Patty Ducayet, also recommended requiring generators at assisted living centers. The report suggested that all long-term care facilities maintain safe temperatures in a location that can be accessed by every resident. The report recommended requiring assisted living facilities to annually submit emergency response plans to state regulators to be reviewed by state officials. The recommendations have not been adopted.

On July 15 — more than a week after Beryl hit — Kitzmiller said she just wanted the power back on. She praised the staff at her facility but said she worried for residents who were isolated on her building’s second and third floors, which were hotter amid the outage. Some were unable to keep required medicine refrigerated, she said. And without functioning elevators, many couldn’t get to the first floor, where it was cooler.

Mostly, Kitzmiller said, she was frustrated with companies and politicians who hadn’t yet fixed the problem.

“It’s their mothers, their grandmothers, and their family in these homes, these facilities,” she said. “All I can think is ‘Shame on you.’”

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Five people who work at a poultry farm in northeastern Colorado have tested positive for the bird flu, the Colorado public health department reported July 14. This brings the known number of U.S. cases to nine.

The five people were likely infected by chickens, which they had been tasked with killing in response to a bird flu outbreak at the farm.

More than 99 million chickens and turkeys have been infected with a highly pathogenic strain of the bird flu that emerged at U.S. poultry farms in early 2022. Since then, the federal government has compensated poultry farmers more than $1 billion for destroying infected flocks and eggs to keep outbreaks from spreading.

The H5N1 bird flu virus has spread among poultry farms around the world for nearly 30 years. An estimated 900 people have been infected by birds, and roughly half have died from the disease.

The virus made an unprecedented shift this year to dairy cattle in the U.S. This poses a higher threat because it means the virus has adapted to replicate within cows’ cells, which are more like human cells. The four other people diagnosed with bird flu this year in the U.S. worked on dairy farms with outbreaks.

Scientists have warned that the virus could mutate to spread from person to person, like the seasonal flu, and spark a pandemic. There’s no sign of that, yet.

So far, all nine cases reported this year have been mild, consisting of eye irritation, a runny nose, and other respiratory symptoms. However, numbers remain too low to say anything certain about the disease because, in general, flu symptoms can vary among people with only a minority needing hospitalization.

The number of people who have gotten the virus from poultry or cattle may be higher than nine. The Centers for Disease Control and Prevention has tested only about 60 people over the past four months, and powerful diagnostic laboratories that typically detect diseases remain barred from testing. Testing of farmworkers and animals is needed to detect the H5N1 bird flu virus, study it, and stop it before it becomes a fixture on farms.

Researchers have urged a more aggressive response from the CDC and other federal agencies to prevent future infections. Many people exposed regularly to livestock and poultry on farms still lack protective gear and education about the disease. And they don’t yet have permission to get a bird flu vaccine.

Nearly a dozen virology and outbreak experts recently interviewed by KFF Health News disagree with the CDC’s decision against vaccination, which may help prevent bird flu infection and hospitalization.

“We should be doing everything we can to eliminate the chances of dairy and poultry workers contracting this virus,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. “If this virus is given enough opportunities to jump from cows or poultry into people, it will eventually get better at infecting them.”

To understand whether cases are going undetected, researchers in Michigan have sent the CDC blood samples from workers on dairy farms. If they detect bird flu antibodies, it’s likely that people are more easily infected by cattle than previously believed.

“It’s possible that folks may have had symptoms that they didn’t feel comfortable reporting, or that their symptoms were so mild that they didn’t think they were worth mentioning,” said Natasha Bagdasarian, chief medical executive for the state of Michigan.

In hopes of thwarting a potential pandemic, the United States, United Kingdom, Netherlands, and about a dozen other countries are stockpiling millions of doses of a bird flu vaccine made by the vaccine company CSL Seqirus.

Seqirus’ most recent formulation was greenlighted last year by the European equivalent of the FDA, and an earlier version has the FDA’s approval. In June, Finland decided to offer vaccines to people who work on fur farms as a precaution because its mink and fox farms were hit by bird flu last year.

The CDC has controversially decided not to offer at-risk groups bird flu vaccines. Demetre Daskalakis, director of the CDC’s National Center for Immunization and Respiratory Diseases, told KFF Health News that the agency is not recommending a vaccine campaign at this point for several reasons, even though millions of doses are available. One is that cases still appear to be limited, and the virus isn’t spreading rapidly between people as they sneeze and breathe.

The agency continues to rate the public’s risk as low. In a statement posted in response to the new Colorado cases, the CDC said its bird flu recommendations remain the same: “An assessment of these cases will help inform whether this situation warrants a change to the human health risk assessment.”

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Colorado se encuentra entre los 10 estados que han desafiliado a la mayor proporción de beneficiarios de Medicaid desde que el gobierno de Estados Unidos levantara una restricción de la pandemia sobre la eliminación de afiliados al programa médico.

Es el único estado demócrata entre un grupo de estados republicanos con altas tasas de desafiliación, que incluye a Idaho, Montana, Texas y Utah, en un proceso de Medicaid que comenzó en la primavera de 2023.

Colorado también es el único estado que tenía todos los ingredientes políticos para amortiguar las consecuencias de este proceso, según analistas de políticas de Medicaid en KFF.

Pero al parecer esta amortiguación no se puso en marcha.

“Realmente hay una división en Colorado entre nuestras políticas progresistas y nuestra administración subfinanciada y fragmentada”, dijo Bethany Pray, directora legal y de políticas del Colorado Center on Law and Policy, un grupo de asistencia legal con sede en Denver.

Según los datos de KFF, durante las desafiliaciones, Colorado ha visto una caída neta en la inscripción a Medicaid y al Programa de Seguro Médico Infantil (CHIP), mayor que cualquier estado excepto Utah.

Defensores del acceso a la atención médica, investigadores y administradores de condados —quienes manejan la mayor parte de las redeterminaciones de Medicaid en Colorado— dicen que los problemas principales involucran una tecnología obsoleta y bajas tasas de renovaciones automáticas. Ambos crean obstáculos para la inscripción que socavan a las políticas progresistas del estado.

Los funcionarios estatales tienen una visión más optimista. Dicen que la caída en la inscripción es una señal de que hicieron un buen trabajo inscribiendo a las personas en el apogeo de la pandemia de covid-19. En segundo lugar, dicen que la economía de Colorado está funcionando bien, por lo que más personas pueden obtener seguro a través de sus trabajos.

“Cuando tenemos una tasa de desempleo realmente estelar, no tantas personas necesitan programas de la red de seguridad, y estamos orgullosos de eso. Nuestra gente está prosperando”, dijo Kim Bimestefer, quien lidera el Departamento de Política y Financiamiento de Atención Médica y es la principal funcionaria de Medicaid del estado. Su departamento también ha dicho que algunas personas optan por no llenar sus documentos de elegibilidad porque saben que sus ingresos son demasiado altos para calificar.

Los datos de la Oficina de Estadísticas Laborales muestran que, si bien es cierto que la tasa de desempleo de Colorado es más baja que la del país en su conjunto, es más alta de lo que era antes de la pandemia.

Funcionarios del estado dicen que creen que las inscripciones en Medicaid disminuyeron porque muchas de esas personas encontraron trabajo, como lo reflejan las tasas de desempleo más bajas. Pero ese escenario ocurrió en menos de la mitad de los condados del estado, según un análisis de KFF Health News.

Notablemente, en 11 condados donde el desempleo se estancó o aumentó de enero de 2020 a abril de 2024, la proporción de la población cubierta por Medicaid se redujo. Una baja tasa de desempleo no significa necesariamente que haya menos necesidad de cobertura de Medicaid, porque muchas personas empleadas ganan salarios lo suficientemente bajos como para seguir calificando para el programa.

Colorado aumentó la inscripción en Medicaid y CHIP en un 35% durante la emergencia de salud pública de covid, en comparación con aproximadamente el 30% a nivel nacional, y entre los estados que expandieron Medicaid.

“Crecimos más, lo que significa, lógicamente, que vamos a dar de baja a más personas”, dijo Bimestefer. “Subimos alto, vamos a bajar más bajo, porque nuestra economía es estelar”.

El sitio web de su departamento inicialmente afirmó que la inscripción en Medicaid de Colorado había crecido más que cualquier otro estado con Medicaid expandido, excepto Hawaii. Pero los datos de los Centros de Servicios de Medicare y Medicaid (CMS) muestran que el aumento de la inscripción durante la pandemia en otros estados, incluidos Indiana, Dakota del Norte, Virginia y Nevada, también superaron a la de Colorado.

Incluso si hubiera crecido más, el argumento de que lo que sube debe bajar no se sostiene, dijeron analistas de políticas de Medicaid.

“Un argumento contrario a eso es que sabemos que nunca hubo una participación total en Medicaid antes de la pandemia”, dijo Jennifer Tolbert, subdirectora del Program on Medicaid and the Uninsured de KFF.

Tolbert dijo que estaba sorprendida por la magnitud de las pérdidas de inscripción en Medicaid de Colorado, dado que era el único estado en la nación que cumplía con todos los criterios que KFF esperaba que amortiguaran los efectos de las desafiliaciones. Esas políticas incluyen haber expandido Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA) y el procesamiento automático de renovaciones.

Tolbert fue una de varios investigadores que dijeron que incluso si el desempleo volviera a los niveles previos a la pandemia, esperarían una proporción más alta, no más baja, de habitantes de Colorado inscritos en la cobertura de la red de seguridad.

Ally Sullivan, portavoz del gobernador demócrata Jared Polis, dijo que un factor que complica ls cosas en el sistema de Colorado es que es uno de los pocos estados donde la mayor parte del trabajo de verificación de elegibilidad recae en los condados, “lo que agregó complejidad al proceso de desafiliaciones”.

“Colorado está comprometido a garantizar que sus habitantes que ya no califican para la cobertura de Medicaid se conecten a otras fuentes asequibles de cobertura lo antes posible, y el estado está haciendo grandes esfuerzos para hacerlo”, decía el comunicado.

Minnesota es otro estado donde la verificación de elegibilidad recae en gran medida en los condados. Sin embargo, dio de baja solo al 26% de su población bajo Medicaid, en comparación con el 48% de Colorado.

Al igual que Colorado, Minnesota tiene un gobernador demócrata. También se parece a Colorado en su población, aumento de inscripción durante la pandemia, el porcentaje de sus residentes que viven en áreas prósperas y su tasa de desempleo, por debajo de la nacional.

Pero Bimestefer descartó cualquier comparación. “No me importa Minnesota”, dijo Bimestefer. “Esto es Colorado. No me importa lo que hizo Minnesota”.

Defensores del acceso a la atención médica e investigadores dijeron que un conjunto de problemas tecnológicos y administrativos han contribuido a que la tasa de desafiliaciones fuera alta.

Primero, la base de datos de elegibilidad de Colorado, el Sistema de Gestión de Beneficios de Colorado, está obsoleta, según personas que la usan o están familiarizadas con sistemas en otros estados.

“Es como seguir usando un viejo celular”, dijo Sarah Grusin, abogada del Programa Nacional de Ley de Salud. “Tenemos cosas mejores”.

Las organizaciones de Grusin y Pray presentaron una queja de derechos civiles ante varias agencias federales diciendo que los problemas del sistema que terminaron con la cobertura de los habitantes de Colorado discapacitados equivalían a discriminación.

“Tomó muchos meses arreglar algo que no parece tan complicado”, dijo Pray.

Bimestefer dijo que su departamento está trabajando en un plan para mejorar el sistema, que es administrado por Deloitte bajo un contrato de $354.4 millones hasta 2027. Una reciente investigación de KFF Health News sobre sistemas de elegibilidad administrados por Deloitte encontró problemas generalizados. En Colorado, una auditoría ordenada por el estado en 2020 halló que a muchos beneficiarios de Medicaid se les habían enviado avisos y plazos incorrectos.

Kenneth Smith, ejecutivo de Deloitte que lidera su división nacional de servicios humanos, dijo que Deloitte es uno de los muchos actores que administran los beneficios de Medicaid, y que los estados son los dueños de la tecnología y toman las decisiones sobre su implementación.

Los problemas tecnológicos de Colorado también han debilitado su capacidad para usar una herramienta poderosa en la inscripción: la renovación automática.

Bimestefer dijo que, el otoño pasado, su agencia tuvo que elegir entre arreglar el sistema para que dejara de dar de baja a niños que no debían perder la cobertura, o comenzar a renovar automáticamente a personas sin ingresos o con ingresos por debajo del nivel federal de pobreza. No podía hacer ambas cosas, dijo.

Expertos como Tricia Brooks, profesora investigadora del Centro de Niños y Familias de la Universidad de Georgetown, dijeron que es especialmente importante aumentar las renovaciones automáticas en estados como Colorado, donde la mayor parte del trabajo de renovación recae en personal de los gobiernos de los condados.

“¿Qué pasa cuando no se obtiene una alta tasa de renovaciones automáticas? Estás enviando esos formularios de renovación”, dijo Brooks, lo que significa más bajas. “No recibieron el correo. El aviso fue confuso. Intentaron obtener ayuda a través del centro de llamadas. La lista de por qué las personas no renuevan es larga”.

De hecho, dos tercios de los habitantes de Colorado dados de baja perdieron la cobertura por razones de procedimiento. Eso concuerda con el promedio nacional, según KFF. Pero junto con el hecho de que Colorado ha dado de baja a tanta gente en general, eso significa que más de 500,000 habitantes del estado, o aproximadamente el 9% de la población, fueron dados de baja por razones de procedimiento. Más que la población de su segunda ciudad más grande, Colorado Springs.

Se determinó que al menos un tercio de los dados de baja eran elegibles para Medicaid.

Funcionarios de centros comunitarios de salud de Colorado y centros de salud mental dicen que están viendo un aumento de pacientes que llegan a sus puertas sin seguro, una señal, dicen, de que los habitantes de Colorado dados de baja de Medicaid no necesariamente están mejor en términos de seguro de salud.

El 58% de los que fueron dados de baja han regresado a Medicaid o ahora tienen otro seguro. Pero el estado aún no sabe qué pasó con el 42% restante de las personas que fueron dadas de baja, y dijo que realizaría una encuesta para averiguarlo.

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SACRAMENTO — Sonja Verdugo lost her husband to an opioid overdose last year. She regularly delivers medical supplies to people using drugs who are living — and dying — on the streets of Los Angeles. And she advocates at Los Angeles City Hall for policies to address addiction and homelessness.

Yet Verdugo didn’t know that hundreds of millions of dollars annually are flowing to California communities to combat the opioid crisis, a payout that began in 2022 and continues through 2038.

The money comes from pharmaceutical companies that made, distributed, or sold prescription opioid painkillers and that agreed to pay about $50 billion nationwide to settle lawsuits over their role in the overdose epidemic. Even though a recent Supreme Court decision upended a settlement with OxyContin maker Purdue Pharma, many other companies have already begun paying out and will continue doing so for years.

California, the most populous state, is in line for more than $4 billion.

“You can walk down the street and you see someone addicted on every corner — I mean it’s just everywhere,” Verdugo said. “And I’ve never even heard of the funds. And to me, that’s crazy.”

Across the nation, much of this windfall has been shrouded in secrecy, with many jurisdictions offering little transparency on how they’re spending the money, despite repeated queries from people in recovery and families who lost loved ones to addiction.

Meanwhile, there’s plenty of jockeying over how the money should be used. Companies are lobbying for spending on products that range from medication bottles that lock to full-body scanners to screen people entering jails. Local officials are often advocating for the fields they represent, whether it’s treatment, prevention, or harm reduction. And some governments are using it to plug budget gaps.

In California, local governments must report how they spend settlement funds to the state’s Department of Health Care Services, but there’s no requirement that the reports be made public.

KFF Health News obtained copies of the documents via a public records request and is now making available for the first time 265 spending reports from local governments for fiscal year 2022-23, the most recent reports filed.

The reports provide a snapshot of the early spending priorities, and tensions.

Naloxone an Early Winner

As of June 2023, the bulk of opioid settlement funds controlled by California cities and counties — more than $200 million — had yet to be spent, the reports show. It’s a theme echoed nationwide as officials take time to deliberate.

The city and county of Los Angeles accounted for nearly one-fifth of that unspent total, nearly $39 million, though officials say that since the report was filed they’ve begun allocating the money to recovery housing and programs to connect people who are homeless with residential addiction treatment.

Among local governments that did use the cash in the first fiscal year, the most popular object of spending was naloxone, a medication that reverses opioid overdoses and is often known by the brand name Narcan. The medication accounted for more than $2 million in spending across 19 projects.

One of those projects was in Union City, in the San Francisco Bay Area. The community of about 72,000 residents had five suspected fentanyl overdoses, two of them fatal, within 24 hours in September.

The opioid settlement money “was invaluable,” Corina Hahn, the city’s director of community and recreation services, said in her report. “Having these resources available helped educate, train and distribute the Narcan kits to parents, youth and school staff.”

Union City bought 500 kits, each containing two doses of naloxone. The kits cost about $13,500, with an additional $56,000 set aside for similar projects, including backpacks containing Narcan kits and training materials for high school students.

Union City also plans to expand its outreach to homeless people to fund drug education and recovery services, including addiction counseling.

Those are the sorts of lifesaving services that Verdugo, the Los Angeles advocate, said are desperately needed as deaths of people living on the streets pile up.

She lost her 46-year-old husband, Jesse Baumgartner, in June of last year to an addiction that started after he was prescribed pain medications for a high school wrestling injury. He tried kicking his habit for six years using methadone, but each time prescribers lowered his dosage the cravings drove him back to illicit drugs.

“It was just this horrible roller coaster of him not being able to get off of it,” Verdugo said.

By then the couple had survived 4½ years of being homeless and had been in stable housing for about two years.

Fentanyl use, particularly among homeless people, “is just rampant,” she said. People sometimes are initially exposed to the cheap, highly addictive substance unknowingly when it is mixed with something else.

“Once they start using it, it's like they just can't backtrack,” said Verdugo, who works as a community organizer for Ground Game LA.

So she leaves boxes of naloxone at homeless encampments in the hope of saving lives.

“They definitely use it, because it's needed right then — they can't wait for an ambulance to come out,” she said.

Cities Backtrack on Spending for Law Enforcement

By contrast, the cities of Irvine and Riverside, both in Greater Los Angeles, listed plans to prioritize law enforcement by buying portable drug analyzers, though neither city did so in the first fiscal year, 2022-23. Their inclination mirrored patterns elsewhere in the country, with millions in settlement funds flowing to police departments and jails.

But such uses of the money have stirred controversy, and both cities backed away from the drug analyzer purchase after the Department of Health Care Services issued rules that opioid settlement funds may not be used for certain law enforcement efforts. The rules specifically excluded “equipment for the purpose of evidence gathering for prosecution, such as the TruNarc Handheld Narcotics Analyzer.”

In Hawthorne, also near Los Angeles, the police department had already spent about $25,000 of settlement funds on an initial installment to buy 80 BolaWraps, devices that shoot Kevlar tethers to wrap around a person’s limbs or torso.

After the state said BolaWraps were not an allowable expense, the city said it would find other funding sources to pay the remaining installments.

Santa Rosa, in California’s wine country, spent nearly $30,000 on police officer wellness and support.

The funds allowed the police department to boost its contracted wellness coordinator from a part-time to a full-time position, and to buy a mobile machine to measure electrical activity in the brain, said Sgt. Patricia Seffens, a spokesperson.

The goal is to use the technology on police officers to help “assess the traumatic impact of responding to the increasing overdose calls,” Seffens said in an email.

In Dublin, east of San Francisco, officials are using part of their $62,000 in settlement cash for a D.A.R.E. program.

D.A.R.E., which stands for Drug Abuse Resistance Education, is a series of classes taught by police officers in schools to encourage students to resist peer pressure and avoid drugs. It was initially developed during the “Just Say No” campaign in the 1980s.

Studies have found inconsistent results from the program and no long-term effects on drug use, leading many researchers to dismiss it as “ineffective.”

But on its website, D.A.R.E. cites studies since the program was updated in 2009, which found “a positive effect” on fifth graders and “statistically significant reductions” in drinking and smoking about four months after completing the program.

“The D.A.R.E. program when it first came out looks a lot, lot different than what it looks like right now,” said Nate Schmidt, the Dublin police chief.

Schmidt said additional settlement money will be used to distribute naloxone to residents and stock it at schools and city facilities.

Other local governments in California spent modest sums on a wide range of addiction-related measures. Ukiah, in Mendocino County, north of San Francisco, spent $11,000 for a new heating and air conditioning system for a local drug treatment center. Orange and San Mateo counties spent settlement funds in part on medication-assisted treatment for people incarcerated in their jails. The city of Oceanside spent $16,000 to showcase drug prevention art and videos made by middle school students in local movie theaters, in public spaces, and on buses and taxis.

The Department of Health Care Services said it plans to release a statewide report on how the funds were spent, as well as the individual city and county reports, by year’s end.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Medical debt is a growing burden for millions of people around the country, from parents in Illinois to immigrants in Colorado to residents of the “Diabetes Belt” across the South, and it’s now being recognized as a health-care problem. People often forgo care or prescriptions if they have debt, according to a KFF Health News investigation, and the psychological toll can be steep, too.

The Biden administration proposed barring medical debt from credit reports. This morning, Senate Health Committee Chair Bernie Sanders (I-Vt.) will convene a hearing in D.C. on medical debt.

Now local governments are looking at how they can assist residents by buying up medical debt on the cheap and retiring it.

Under a measure the Los Angeles County Board of Supervisors approved unanimously last month, the county will enter into a pilot program with Undue Medical Debt (previously known as RIP Medical Debt), a national organization that turns the debt collection process on its head. Instead of buying outstanding debt from hospitals and pursuing patients for payment, as commercial debt collectors do, Undue Medical Debt looks to buy debt, usually for pennies on the dollar, then retire it.

Los Angeles County’s $5 million investment is expected to allow Undue Medical Debt to help 150,000 low-income residents and eliminate $500 million in debt. It’s one component of the county’s larger medical debt plan, which includes tracking hospitals’ role in feeding the $2.9 billion problem, boosting bill retirement for low-income patients and monitoring debt collection practices.

Four in 10 adults in the United States struggle with health-care debt, and Los Angeles County has labeled it a public health issue on par with diabetes and asthma.

The logic behind the effort is simple. “Getting health care should never make anyone sicker,” said Naman Shah, medical and dental affairs director at the county public health department.

Undue Medical Debt has contracted with more than a dozen city, county and state governments across the country to provide local debt relief, including Cook County, Ill. (home to Chicago); Toledo; Arizona and New Jersey.

Since its inception, Undue Medical Debt has relieved almost $12 billion in medical debt across the country.

Beginning in 2022, Cook County has leveraged American Rescue Plan dollars — federal emergency funds made available during the coronavirus pandemic — to wipe out over $382 million in medical debt for more than 213,000 residents. About 15 other state or local governments have also used American Rescue Plan funds to retire medical debt, according to Undue Medical Debt, and other jurisdictions are developing similar plans.

Mona Shah of Community Catalyst, a national health equity and policy organization, applauds the local government moves but cautions that one-time debt relief goes only so far. She endorsed Los Angeles County’s approach: pairing debt relief with a longer-term effort to understand and address the root causes of medical debt, in part by getting a better handle on debt collection practices and helping hospitals improve their financial assistance programs.

“We don’t want to ever deny that relief, but we really need to focus on preventing medical debt from happening in the first place,” Shah said.

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Colorado stands out among the 10 states that have disenrolled the highest share of Medicaid beneficiaries since the U.S. government lifted a pandemic-era restriction on removing people from the health insurance program.

It’s the only blue state in a cluster of red states with high disenrollment rates — a group that includes Idaho, Montana, Texas, and Utah — in the Medicaid “unwinding” underway since spring 2023.

Colorado also is the only state that had all the policy ingredients in place to cushion the fallout from the unwinding, according to Medicaid policy analysts at KFF.

But it seems the cushion hasn’t been deployed.

“There’s really a divide in Colorado between our progressive policies and our underfunded and fragmented administration,” said Bethany Pray, chief legal and policy officer at the Colorado Center on Law and Policy, a Denver-based legal aid group.

According to KFF data, during the unwinding Colorado has seen a bigger net drop in enrollment in Medicaid and the Children’s Health Insurance Program than any state except Utah.

Advocates for health care access, researchers, and county administrators — the administrators handling the bulk of the Medicaid redeterminations in Colorado — say that the major issues involve outdated technology and low rates of automatic renewals. Both create obstacles to enrollment that undercut the state’s progressive policies.

State officials have a rosier view. They say the drop in enrollment is a sign that they did a good job enrolling people at the height of the covid-19 pandemic. Secondly, they say Colorado’s economy is doing well, so more people can get insurance through their jobs.

“When we have a really stellar unemployment rate, not as many people need safety-net programs, and we’re proud of that. Our people are rising and thriving,” said Kim Bimestefer, who leads the Department of Health Care Policy and Financing and is the state’s top Medicaid official. Her department has also said that some people choose not to fill out their eligibility paperwork because they know their incomes are too high to qualify.

Bureau of Labor Statistics data shows that while it’s true Colorado’s unemployment rate is lower than the nation’s as a whole, it’s higher than it was before the pandemic.

State officials say they believe Medicaid enrollments dropped because many of those people found jobs, as reflected by the lower unemployment rates. But that scenario happened in fewer than half of the state’s counties, a KFF Health News analysis found. Notably, in 11 counties where unemployment stagnated or increased from January 2020 to April 2024, the share of the population covered by Medicaid shrank. A low unemployment rate does not necessarily mean there is less of a need for Medicaid coverage, because many employed people earn wages low enough to still qualify for the program.

Colorado increased enrollment in Medicaid and the related Children’s Health Insurance Program by 35% during the covid public health emergency, compared with about 30% nationally and among Medicaid expansion states.

“We grew more, which means, logically, we’re going to disenroll more,” said Bimestefer. “We went up higher, we’re going to come down lower, because our economy is stellar.”

Her department’s website initially claimed Colorado’s Medicaid enrollment grew more than any other Medicaid expansion state except Hawaii. But data from the Centers for Medicare & Medicaid Services shows pandemic enrollment growth in other states, including Indiana, North Dakota, Virginia, and Nevada, also exceeded that of Colorado.

Even if it had grown the most, the argument that what comes up must come down doesn’t hold water, Medicaid policy analysts said.

“A counterargument to that is we know that there was never a full participation in Medicaid prior to the pandemic,” said Jennifer Tolbert, deputy director of the KFF Program on Medicaid and the Uninsured.

Tolbert said she was surprised by the extent of Colorado’s Medicaid enrollment losses, given it was the one state in the nation that met all the criteria that KFF expected would cushion the effects of the unwinding. Those policies include adopting the Affordable Care Act’s Medicaid expansion and the automatic processing of renewals.

Tolbert was among several policy researchers who said that even if unemployment returned to pre-pandemic levels, they would expect a higher, not lower, share of Coloradans to be enrolled in safety-net coverage.

Ally Sullivan, a spokesperson for Gov. Jared Polis, a Democrat, said one complicating factor in Colorado’s system is that it’s among the handful of states where most of the eligibility verification work falls on counties, “which added complexity to the state’s unwind process.”

“Colorado is committed to ensuring that Coloradans who no longer qualify for Medicaid coverage are connected to other affordable sources of coverage as soon as possible, and the state is going to great lengths to do so,” the statement said.

Minnesota is another state where verifying eligibility is largely left to the counties. Yet it disenrolled just 26% of its Medicaid population in the unwinding, compared with Colorado’s 48%. Like Colorado, Minnesota is led by a Democratic governor. Minnesota also mirrors Colorado in its population, pandemic-era increase in enrollment, the percentage of its residents living in prosperous areas, and its better-than-national unemployment rate. But Bimestefer dismissed any comparison.

“I don’t care about Minnesota,” Bimestefer said. “This is Colorado. I don’t care what Minnesota did.”

Advocates for health care access and researchers said a cluster of technological and administrative issues have contributed to Colorado’s high disenrollment rate.

First, Colorado’s eligibility database, the Colorado Benefits Management System, is outdated and clunky, according to people who use it or are familiar with systems in other states.

“It’s like still using the old flip phone where you’re trying to play Snake,” said Sarah Grusin, an attorney at the National Health Law Program. “We have better stuff.”

Grusin and Pray’s organizations filed a civil rights complaint with several federal agencies saying that the system issues that terminated disabled Coloradans’ coverage amounted to discrimination.

“It took many months to fix something that doesn’t sound that complicated,” Pray said.

Bimestefer said her department is working on a plan to improve the system, which is managed by Deloitte under a $354.4 million contract that lasts until 2027. A recent KFF Health News investigation of eligibility systems managed by Deloitte found widespread problems. In Colorado, a state-commissioned audit in 2020 found that many Medicaid beneficiaries were sent incorrect notices and deadlines.

Kenneth Smith, a Deloitte executive who leads its national human services division, said that Deloitte is one player among many who together administer Medicaid benefits, and that the states own the technology and make the decisions about their implementation.

Colorado’s technology woes have also weakened its ability to use a powerful tool in enrollment: automatic renewal.

Last fall, Bimestefer said, her agency had to choose between fixing the system so that it would stop disenrolling children who shouldn’t lose coverage, or start automatically renewing people with no income or with income below the federal poverty level. It couldn’t do both, she said.

Experts such as Tricia Brooks, a research professor with the Center for Children and Families at Georgetown University, said it’s especially important to increase automatic renewals in states like Colorado where most of the renewal work falls on county government staff.

“What happens when you’re not getting a high rate of automated renewals? You’re sending out those renewal forms,” Brooks said — meaning more disenrollments. “They didn’t get the mail. The notice was confusing. They tried to get help through the call center. The list goes on as to why people don’t renew.”

Indeed, two-thirds of disenrolled Coloradans lost coverage for procedural reasons. That’s in line with the national average, according to KFF. But paired with Colorado having disenrolled so many people overall, that means more than 500,000 Coloradans, or about 9% of the state’s people, were disenrolled for procedural reasons — more than the population of its second-largest city, Colorado Springs.

At least a third of those disenrolled were later determined to be eligible for Medicaid.

Officials at Colorado community health centers and mental health centers say they’re seeing a rise in uninsured patients coming through their doors — a sign, they say, that Coloradans dropped from Medicaid aren’t necessarily moving on to greener health insurance pastures.

Fifty-eight percent of those who were disenrolled have returned to Medicaid, or now have another form of insurance. But the state doesn’t yet know what happened to the remaining 42% of people who were dropped and said it would conduct a survey to find out.

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As bird flu spreads among dairy cattle in the U.S., veterinarians and researchers have taken note of Finland’s move to vaccinate farmworkers at risk of infection. They wonder why their government doesn’t do the same.

“Farmworkers, veterinarians, and producers are handling large volumes of milk that can contain high levels of bird flu virus,” said Kay Russo, a livestock and poultry veterinarian in Fort Collins, Colorado. “If a vaccine seems to provide some immunity, I think it should be offered to them.”

Among a dozen virology and outbreak experts interviewed by KFF Health News, most agree with Russo. They said people who work with dairy cows should be offered vaccination for a disease that has killed roughly half of the people known to have gotten it globally over the past two decades, has killed cats in the U.S. this year, and has pandemic potential.

However, some researchers sided with the Centers for Disease Control and Prevention in recommending against vaccination for now. There’s no evidence that this year’s bird flu virus spreads between people or causes serious disease in humans. And it’s unclear how well the available vaccine would prevent either scenario.

But the wait-and-see approach “is a gamble,” said Jennifer Nuzzo, director of the Pandemic Center at Brown University. “By the time we see severe outcomes, it means a lot of people have been infected.”

“Now is the time to offer the vaccines to farmworkers in the United States,” said Nahid Bhadelia, director of the Boston University Center on Emerging Infectious Diseases. Even more urgent measures are lagging in the U.S., she added. Testing of farmworkers and cows is sorely needed to detect the H5N1 bird flu virus, study it, and extinguish it before it becomes a fixture on farms — posing an ever-present pandemic threat.

Demetre Daskalakis, director of the CDC’s National Center for Immunization and Respiratory Diseases, said the agency takes bird flu seriously, and the U.S. is stockpiling 4.8 million doses of the vaccine. But, he said, “there’s no recommendation to launch a vaccine campaign.”

“It’s all about risk-benefit ratios,” Daskalakis said. The benefits are blurry because there hasn’t been enough testing to understand how easily the virus jumps from cows into people, and how sick they become. Just four people in the United States have tested positive this year, with mild cases — too few to draw conclusions.

Other farmworkers and veterinarians working on dairy farms with outbreaks have reported being sick, Russo said, but they haven’t been tested. Public health labs have tested only about 50 people for the bird flu since the outbreak was detected in March.

Still, Daskalakis said the CDC is not concerned that the agency is missing worrisome bird flu infections because of its influenza surveillance system. Hospitals report patients with severe cases of flu, and numbers are normal this year.

Another signal that puts the agency at ease is that the virus doesn’t yet have mutations that allow it to spread rapidly between people as they sneeze and breathe. “If we start to see changes in the virus, that’s another factor that would be part of the decision to move from a planning phase into an operational one,” Daskalakis said.

On July 8, researchers reported that the virus may be closer to spreading between people than previously thought. It still doesn’t appear to do so, but experiments suggest it has the ability to infect human airways. It also spread between two laboratory ferrets through the air.

In considering vaccines, the agency takes a cue from a 1976 outbreak of the swine flu. Officials initially feared a repeat of the 1918 swine flu pandemic that killed roughly half a million people in the United States. So they rapidly vaccinated nearly 43 million people in the country within a year.

But swine flu cases turned out to be mild that year. This made the vaccine seem unnecessarily risky as several reports of a potentially deadly disorder, Guillain-Barré Syndrome, emerged. Roughly one of every million people who get influenza vaccines may acquire the disorder, according to the CDC. That risk is outweighed by the benefits of prevention. Since Oct. 1, as many as 830,000 people have been hospitalized for the seasonal flu and 25,000 to 75,000 people have died.

An after-action report on the 1976 swine flu situation called it a “sobering, cautionary tale” about responding prematurely to an uncertain public health threat. “It’s a story about what happens when you launch a vaccine program where you are accepting risk without any benefit,” Daskalakis said.

Paul Offit, a virologist at the Children’s Hospital of Philadelphia, sides with the CDC. “I’d wait for more data,” he said.

However, other researchers say this isn’t comparable to 1976 because they aren’t suggesting that the U.S. vaccinate tens of millions of people. Rather they’re talking about a voluntary vaccine for thousands of people in close contact with livestock. This lessens the chance of rare adverse effects.

The bird flu vaccine on hand, made by the flu vaccine company CSL Seqirus, was authorized last year by the European equivalent of the FDA. An older variety has FDA approval, but the newer variety hasn’t gotten the green light yet.

Although the vaccine targets a different bird flu strain than the H5N1 virus now circulating in cows, studies show it triggers an immune response against both varieties. It’s considered safe because it uses the same egg-based vaccine technology deployed every year in seasonal flu vaccines.

For these reasons, the United States, the United Kingdom, the Netherlands, and about a dozen other countries are stockpiling millions of doses. Finland expects to offer them to people who work on fur farms this month as a precaution because its mink and fox farms were hit by the bird flu last year.

In contrast, mRNA vaccines being developed against the bird flu would be a first for influenza. On July 2, the U.S. government announced that it would pay Moderna $176 million for their development, and that the vaccines may enter clinical trials next year. Used widely against covid-19, this newer technology uses mRNA to teach the immune system how to recognize particular viruses.

In the meantime, Florian Krammer, a flu virologist at Mount Sinai’s Icahn School of Medicine, said people who work on dairy farms should have the option to get the egg-based vaccine. It elicits an immune response against a primary component of the H5N1 bird flu virus that should confer a degree of protection against infection and serious sickness, he said.

Still, its protection wouldn’t be 100%. And no one knows how many cases and hospitalizations it would prevent since it hasn’t been used to combat this year’s virus. Such data should be collected in studies that track the outcomes of people who opt to get one, he said.

Krammer isn’t assuaged by the lack of severe bird flu cases spotted in clinics. “If you see a signal in hospitals, the cat is out of the bag. Game over, we have a pandemic,” he said. “That’s what we want to avoid.”

He and others stressed that the United States should be doing everything it can to curb infections before flu season starts in October. The vaccine could provide an additional layer of protection on top of testing, wearing gloves, and goggles, and disinfecting milking equipment. Scientists worry that if people get the bird flu and the seasonal flu simultaneously, bird flu viruses could snag adaptations from seasonal viruses that allow them to spread swiftly among humans.

They also note it could take months to distribute the vaccines after they’re recommended since it requires outreach. People who work beside dairy cows still lack information on the virus, four months into this outbreak, said Bethany Boggess Alcauter, director of research at the National Center for Farmworker Health.

Health officials have talked with dairy farm owners, but Boggess’ interviews with farmworkers suggest those conversations haven’t trickled down to their staff. One farmworker in the Texas Panhandle told her he was directed to disinfect his hands and boots to protect cows from diseases that workers may carry. “They never told us if the cow could infect us with some illness,” the farmworker said in Spanish.

The slow pace of educational outreach is a reminder that everything takes time, including vaccine decisions. When deciding whether to recommend vaccines, the CDC typically seeks guidance from its Advisory Committee on Immunization Practices, or the ACIP. A consultant to the group, infectious disease researcher William Schaffner, has repeatedly asked the agency to present its thinking on Seqirus’ bird flu vaccine.

Rather than fret about the 1976 swine flu situation, Schaffner suggested the CDC consider the 2009-10 swine flu pandemic. It caused more than 274,000 hospitalizations and 12,000 deaths in the U.S. within a year. By the time vaccines were rolled out, he said, much of the damage had been done.

“The time to discuss this with ACIP is now,” said Schaffner, before the bird flu becomes a public health emergency. “We don’t want to discuss this until the cows come home in the middle of a crisis.”

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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A medida que la gripe aviar se propaga entre las vacas lecheras en Estados Unidos, veterinarios e investigadores han tomado nota de la decisión de Finlandia de vacunar a los trabajadores agrícolas que corren el riesgo de infectarse. Y se preguntan por qué su gobierno no se hace lo mismo.

“Los trabajadores agrícolas, veterinarios y productores están manejando grandes volúmenes de leche que pueden contener altos niveles del virus de la gripe aviar”, dijo Kay Russo, veterinaria de ganado y aves de corral en Fort Collins, Colorado. “Si una vacuna parece proporcionar algo de inmunidad, creo que también habría que ofrecérsela a ellos”.

La mayoría de una docena de expertos en virología y brotes epidémicos entrevistados por KFF Health News, está de acuerdo con Russo.

Dijeron que a las personas que trabajan en tambos se les debería ofrecer la vacuna contra una enfermedad que ha matado a aproximadamente la mitad de las personas que se sabe que la han contraído en todo el mundo durante las últimas dos décadas, que ha matado a gatos en Estados Unidos este año, y que tiene potencial pandémico.

Sin embargo, otros investigadores están de acuerdo con la posición de los Centros para el Control y Prevención de Enfermedades (CDC), que recomiendan no vacunar por ahora. Consideran que no hay evidencia de que el virus de la gripe aviar de este año se propague entre personas, o cause enfermedad grave en humanos. Y que tampoco está lo suficientemente claro qué tan eficaz es la vacuna disponible a la hora de prevenir cualquiera de estos escenarios.

Sin embargo, para Jennifer Nuzzo, directora del Centro Pandémico de la Universidad Brown, la táctica de esperar y ver “es una apuesta”. “Para cuando tengamos consecuencias graves, muchas personas ya se habrán contagiado”, aseguró.

“Ahora es el momento de ofrecer las vacunas a los trabajadores agrícolas en Estados Unidos”, dijo Nahid Bhadelia, directora del Centro de Enfermedades Infecciosas Emergentes de la Universidad de Boston. Agregó que en el país hasta las medidas más apremiantes están retrasadas.  Bhadelia considera que es urgente realizar análisis tanto a los trabajadores agrícolas como a las vacas para detectar la presencia del virus de la gripe aviar H5N1, estudiarlo y erradicarlo antes de que se establezca en las granjas, lo que representaría una amenaza pandémica constante.

Demetre Daskalakis, director del Centro Nacional de Inmunización y Enfermedades Respiratorias de los CDC, explicó que la agencia se toma muy en serio a la gripe aviar y que se están almacenando 4.8 millones de dosis de la vacuna. Pero admitió que “no hay ninguna recomendación para lanzar una campaña de vacunación”.

“Se trata de la relación riesgo-beneficio”, comentó Daskalakis. Los beneficios todavía son inciertos porque no contamos con suficientes testeos como para entender con qué facilidad el virus pasa de las vacas a las personas, y tampoco sabemos cuán grave puede ser la enfermedad.

Este año, en Estados Unidos, solo cuatro personas han dado positivo y fueron casos leves. Es un número muy limitado, que no permite sacar conclusiones definitivas.

También informaron que han estado enfermos otros trabajadores agrícolas y veterinarios que trabajan en granjas lecheras donde se han detectados casos de gripe aviar. Sin embargo, no se les hicieron los análisis correspondientes. Desde que se detectó el brote en marzo, los hospitales públicos han examinado solo a unas 50 personas que podrían haberse contagiado.

De todos modos, Daskalakis aseguró que los CDC no están preocupados por la posibilidad de que la agencia esté pasando por alto infecciones significativas de gripe aviar debido a su sistema de vigilancia de la influenza. Los hospitales reportan pacientes con casos graves de gripe y este año los números se mantienen normales.

Otro indicio que tranquiliza a la agencia es que el virus aún no ha desarrollado mutaciones que le permitan propagarse rápidamente cuando la gente estornuda o respira. “Si comenzáramos a ver cambios en el virus, ese sería un factor que incidiría en la decisión de pasar de una fase de planificación a una fase operativa”, explicó Daskalakis.

Para evaluar si administrar o no las vacunas, la agencia se basó en el brote de gripe porcina de 1976. En aquel momento, los funcionarios temían que se pudiera repetir la pandemia de gripe porcina de 1918, que mató aproximadamente a medio millón de personas en Estados Unidos. Por lo tanto, en un año vacunaron rápidamente a casi 43 millones de personas.

Pero ese año los casos de gripe porcina resultaron ser leves. Esto hizo que la campaña de vacunación se considerara innecesariamente riesgosa ya que surgieron varios informes de un trastorno potencialmente mortal, el síndrome de Guillain-Barré.

Hay que tener en cuenta que, según los CDC, aproximadamente una persona de cada millón que son vacunadas contra la influenza puede desarrollar ese síndrome. En el balance, el beneficio de la prevención supera al riesgo. Desde el 1 de octubre por lo menos 830,000 personas han sido hospitalizadas por la gripe estacional y entre 25,000 y 75,000 han muerto.

Un informe elaborado tiempo después respecto de las acciones frente a la gripe porcina de 1976 habló de una “experiencia aleccionadora y con moraleja” sobre qué pasa si se responde prematuramente a una amenaza incierta para la salud pública.

“Es una historia sobre lo que sucede cuando lanzas un programa de vacunación en el que se está aceptando correr riesgos sin que haya un beneficio demostrado”, señaló Daskalakis.

Paul Offit, virólogo del Hospital Infantil de Philadelphia, se alinea con la decisión que tomaron los CDC. “Esperaría a tener más datos”, dijo.

Sin embargo, otros investigadores dicen que el escenario de 1976 fue distinto. Nadie está sugiriendo vacunar a decenas de millones de personas: se está hablando de una vacuna totalmente voluntaria para los miles de trabajadores que están en contacto cotidiano con el ganado, lo que reduce la posibilidad de efectos adversos raros.

La vacuna contra la gripe aviar que está disponible, fabricada por la empresa de vacunas contra la gripe CSL Seqirus, fue autorizada el año pasado por el equivalente europeo de la Administración de Drogas y Alimentos (FDA). Una versión previa tiene la aprobación de la FDA, pero la más reciente aún no recibió la luz verde.

Aunque la vacuna está dirigida a una cepa diferente de gripe aviar que la H5N1, que es la que circula actualmente entre las vacas, los estudios muestran que desencadena una respuesta inmune contra ambas variantes. Se considera segura porque utiliza la misma tecnología en base a huevo que se despliega cada año en las vacunas contra la gripe estacional.

Por estas razones, Estados Unidos, el Reino Unido, Holanda y otra docena de países están almacenando millones de dosis. Finlandia espera ofrecérselas este mes también a quienes trabajan en granjas peleteras, como precaución porque sus granjas de visones y zorros fueron golpeadas por la gripe aviar el año pasado.

En contraste, las vacunas de ARNm que se están desarrollando contra la gripe aviar serían las primeras de su tipo también para la influenza. El 2 de julio, el gobierno de Estados Unidos anunció que pagaría a la farmacéutica Moderna $176 millones por su desarrollo y que las vacunas podrían entrar en la etapa de ensayos clínicos el próximo año.

Utilizadas ampliamente contra covid-19, esta nueva tecnología emplea ARNm para enseñar al sistema inmune cómo reconocer virus particulares.

Mientras tanto, Florian Krammer, virólogo especializado en gripe en la Escuela de Medicina Icahn de Mount Sinai, señaló que las personas que trabajan en tambos deberían tener la opción de recibir la vacuna basada en huevo. Esta vacuna desencadena una respuesta inmunitaria contra un componente principal del virus H5N1 de la gripe aviar, lo que debería brindar un grado de protección contra la infección y la enfermedad grave, explicó.

Aun así, la protección no sería del 100%. Y nadie sabe cuántos contagios y hospitalizaciones podría prevenir esta vacuna, ya que no se ha utilizado para combatir el virus de este año. Esos datos deben recopilarse en estudios que rastreen qué resultado tuvo en las personas que opten por ser vacunadas, agregó.

A Krammer no lo tranquiliza que no se hayan detectado casos graves de gripe aviar en las clínicas. “Porque cuando los indicios llegan a los hospitales, significa que la situación ya se encuentra fuera de control, que estamos frente a una pandemia”, dijo. “Y eso es lo que queremos evitar”.

El virólogo y otros especialistas enfatizaron que Estados Unidos debería estar haciendo todo lo posible para frenar las infecciones antes de octubre, cuando comienza la temporada de gripe. La vacuna podría proporcionar una capa adicional de protección, que se sumaría a las evaluaciones, el uso de guantes y gafas, y la desinfección del equipo de ordeñe.

Algunos científicos temen que, si las personas contraen la gripe aviar y la gripe estacional simultáneamente, los virus de la gripe aviar podrían generar adaptaciones de los virus estacionales que les permitieran propagarse rápidamente entre humanos.

También dicen que podría llevar meses distribuir las vacunas después que se recomiende oficialmente, ya que ese tipo de campaña requiere grandes esfuerzos de divulgación.

Bethany Boggess Alcauter, directora de investigación del National Center for Farmworker Health, comentó que las personas que trabajan con vacas lecheras aún carecen de información sobre el virus, cuatro meses después del inicio de este brote.

Los funcionarios de salud han hablado con los propietarios de tambos, pero las entrevistas de Boggess con los trabajadores agrícolas permiten pensar que esas conversaciones no han llegado a su personal.

Un trabajador agrícola en el Panhandle de Texas le contó a Boggess que en su trabajo le dijeron que se desinfectara las manos y las botas para proteger a las vacas de enfermedades que los trabajadores puedan transmitir. “Nunca nos dijeron que la vaca podría infectarnos con alguna enfermedad”, dijo el hombre en español.

El ritmo siempre lento en que se divulga la información es un recordatorio de que todo lleva tiempo, incluidas las decisiones sobre vacunación. Para resolver si recomendar las vacunas, los CDC normalmente buscan orientación de su Comité Asesor sobre Prácticas de Inmunización, o ACIP. Un consultor del grupo, el investigador de enfermedades infecciosas William Schaffner, ha pedido repetidamente a la agencia que presente su opinión sobre la vacuna contra la gripe aviar de Seqirus.

En lugar de preocuparse por la situación de la gripe porcina de 1976, Schaffner sugirió que los CDC consideren la pandemia de gripe porcina de 2009-10. Esta pandemia causó más de 274,000 hospitalizaciones y 12,000 muertes en Estados Unidos en un año. Para cuando comenzó la vacunación, dijo, gran parte del daño ya estaba hecho.

“El momento de discutir esto con ACIP es ahora”, sostuvo Schaffner. Es decir, antes de que la gripe aviar se convierta en una emergencia de salud pública. “No queremos que se comience a discutir cuando ya sea demasiado tarde”.

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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