Worried that President-elect Donald Trump will curtail federal efforts to take on the nation’s medical debt problem, patient and consumer advocates are looking to states to help people who can’t afford their medical bills or pay down their debts.

“The election simply shifts our focus,” said Eva Stahl, who oversees public policy at Undue Medical Debt, a nonprofit that has worked closely with the Biden administration and state leaders on medical debt. “States are going to be the epicenter of policy change to mitigate the harms of medical debt.”

New state initiatives may not be enough to protect Americans from medical debt if the incoming Trump administration and congressional Republicans move forward with plans to scale back federal aid that has helped millions gain health insurance or reduce the cost of their plans in recent years.

Comprehensive health coverage that limits patients’ out-of-pocket costs remains the best defense against medical debt.

But in the face of federal retrenchment, advocates are eyeing new initiatives in state legislatures to keep medical bills off people’s credit reports, a consumer protection that can boost credit scores and make it easier to buy a car, rent an apartment, or even get a job.

Several states are looking to strengthen oversight of medical credit cards and other financial products that can leave patients paying high interest rates on top of their medical debt.

Some states are also exploring new ways to compel hospitals to bolster financial aid programs to help their patients avoid sinking into debt.

“There’s an enormous amount that states can do,” said Elisabeth Benjamin, who leads health care initiatives at the nonprofit Community Service Society of New York. “Look at what’s happened here.”

New York state has enacted several laws in recent years to rein in hospital debt collections and to expand financial aid for patients, often with support from both Democrats and Republicans in the legislature. “It doesn’t matter the party. No one likes medical debt,” Benjamin said.

Other states that have enacted protections in recent years include Arizona, California, Colorado, Connecticut, Florida, Illinois, Minnesota, Nevada, New Jersey, New Mexico, Oregon, Rhode Island, and Washington. Many measures picked up bipartisan support.

President Joe Biden’s administration has proved to be an ally in state efforts to control health care debt. Such debt burdens 100 million people in the United States, a KFF Health News investigation found.

Led by Biden appointee Rohit Chopra, the Consumer Financial Protection Bureau has made medical debt a priority, going after aggressive collectors and exposing problematic practices across the medical debt industry. Earlier this year, the agency proposed landmark regulations to remove medical bills from consumer credit scores.

The White House also championed legislation to boost access to government-subsidized health insurance and to cap out-of-pocket drug costs for seniors, both key bulwarks against medical debt.

Trump hasn’t indicated whether his administration will move ahead with the CFPB credit reporting rule, which was slated to be finalized early next year. Congressional Republicans, who will control the House and Senate next year, have blasted the proposal as regulatory overreach that will compromise the value of credit reports.

And Elon Musk, the billionaire whom Trump has tapped to lead his initiative to shrink government, last week called for the elimination of the watchdog agency. “Delete CFPB,” Musk posted on X.

If the CFPB withdraws the proposed regulation, states could enact their own rules, following the lead of Colorado, New York, and other states that have passed credit reporting bans since 2023. Advocates in Massachusetts are pushing the legislature there to take up a ban when it reconvenes in January.

“There are a lot of different levers that states have to take on medical debt,” said April Kuehnhoff, a senior attorney at the National Consumer Law Center, which has helped lead national efforts to expand debt protections for patients.

Kuehnhoff said she expects more states to crack down on medical credit card providers and other companies that lend money to patients to pay off medical bills, sometimes at double-digit interest rates.

Under the Biden administration, the CFPB has been investigating patient financing companies amid warnings that many people may not understand that signing up for a medical credit card such as CareCredit or enrolling in a payment plan through a financial services company can pile on more debt.

If the CFPB efforts stall under Trump, states could follow the lead of California, New York, and Illinois, which have all tightened rules governing patient lending in recent years.

Consumer advocates say states are also likely to continue expanding efforts to get hospitals to provide more financial assistance to reduce or eliminate bills for low- and middle-income patients, a key protection that can keep people from slipping into debt.

Hospitals historically have not made this aid readily available, prompting states such as California, Colorado, and Washington to set stronger standards to ensure more patients get help with bills they can’t afford. This year, North Carolina also won approval from the Biden administration to withhold federal funding from hospitals in the state unless they agreed to expand financial assistance.

In Georgia, where state government is entirely in Republican control, officials have been discussing new measures to get hospitals to provide more assistance to patients.

“When we talk about hospitals putting profits over patients, we get lots of nodding in the legislature from Democrats and Republicans,” said Liz Coyle, executive director of Georgia Watch, a consumer advocacy nonprofit.

Many advocates caution, however, that state efforts to bolster patient protections will be critically undermined if the Trump administration cuts federal funding for health insurance programs such as Medicaid and the insurance marketplaces established through the Affordable Care Act.

Trump and congressional Republicans have signaled their intent to roll back federal subsidies passed under Biden that make health plans purchased on ACA marketplaces more affordable. That could hike annual premiums by hundreds or even thousands of dollars for many enrollees, according to estimates by the Center on Budget and Policy Priorities, a think tank.

And during Trump’s first term, he backed efforts in Republican-led states to restrict enrollment in their Medicaid safety net programs through rules that would require people to work in order to receive benefits. GOP state leaders in Idaho, Louisiana, and other states have expressed a desire to renew such efforts.

“That’s all a recipe for more medical debt,” said Stahl, of Undue Medical Debt.

Jessica Altman, who heads the Covered California insurance marketplace, warned that federal cuts will imperil initiatives in her state that have limited copays and deductibles and curtailed debt for many state residents.

“States like California that have invested in critical affordable programs for our residents will face tough decisions,” she said.

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California’s new initiative to compel treatment for some of the state’s most severely mentally ill residents — many of whom are living on the streets — is falling short of its initial objectives. But with the program expanding from 11 counties to all 58 on Dec. 1, state officials are projecting confidence that they can reach their goal to help 2,000 adults by the end of the year.

In the first nine months of CARE Court, 557 petitions were filed by first responders, families, or local health officials, all of whom can now request help for individuals who are ill. As of the end of June, 100 people had been placed in court-approved treatment plans, according to the latest data available.

“We’re pleased to see how many people have come through and how appropriate those referrals have been so far,” said Corrin Buchanan, a deputy secretary for the California Health and Human Services Agency, which oversees the program. “These are the right kinds of people we were hoping to serve.”

The Community Assistance, Recovery and Empowerment (CARE) Act — the first law of its kind in the nation — empowers civil court judges to order adults into monitored plans that include housing, social services, and treatment for addiction or mental illness. Until now, counties such as Los Angeles, San Diego, and San Francisco have been piloting the program, which Democratic Gov. Gavin Newsom has called a “paradigm shift” to prioritize the Californians who are sickest and most in need.

But officials in counties that have already launched the program said the low number of cases reflects the amount of time it takes — sometimes weeks or months — to find people and persuade them to enroll. And judges dismissed nearly 40% of petitions in the program’s first nine months, in part because of the program’s narrow criteria to target only those with untreated schizophrenia or other psychotic disorders.

State officials have estimated that between 7,000 and 12,000 people will be eligible for a CARE plan. The state has directed $358 million in one-time funding, and it projects it will spend $108 million a year on the program.

CARE Court is one of a raft of changes Newsom has spearheaded to address rampant homelessness, including overhauling the public mental health system and funneling billions of dollars for counties to execute those changes on the ground. Recent moves include loosening conservatorship laws and passing Proposition 1, a voter-approved measure that gives the state more control over mental health funding previously managed by counties.

Local health representatives say they’re juggling the governor’s initiatives as he demands results to reduce homelessness.

While CARE Court was meant to target people who cycle in and out of jails and hospitals and onto the streets, county officials said they’re encountering a substantial number of clients who already have housing and, in some cases, private health insurance.

Many family members have had their hopes dashed when they find that only a small number of people qualify for CARE Court resources and that ultimately treatment is largely voluntary, county officials said. Unlike in a conservatorship, which hands all decision-making power over to the state or an adult guardian, counties can’t treat or medicate participants against their will. But counties can rack up steep court fines if a judge determines the county hasn’t provided help.

“There’s been a tremendous need for the management of expectations, especially with family members,” said Amber Irvine, program manager for San Diego County’s CARE Court. She added that while she considers the program a success, “we need to, as a whole, adjust our expectations of what can be accomplished in a year with such a complicated program and such a complex population.”

San Diego County’s program has been among the most robust, with 221 petitions filed since it launched in October 2023, although a third of the county’s participants were already under conservatorship. Irvine said 76 of the state’s 100 CARE plan participants are from the county.

But it’s not easy. It takes county outreach workers there an average of 54 days of casual conversations, encounters in encampments, and distributing food or supplies — activities the state doesn’t typically reimburse for — to persuade someone to accept services. In some cases, that number stretches to more than four months, Irvine said.

She and others credit the state for funding CARE programs, which has enabled county staff to conduct intensive outreach. San Diego County boasts the state’s first CARE graduate, a participant who was able to exit conservatorship and leave a locked psychiatric facility.

Though Irvine thought the county was overprepared with 15 new hires, the staff was able to take on less than half the anticipated caseload. Other counties have had to shift personnel from understaffed departments to prepare for CARE Court.

Staffing needs remain uncertain with the remaining counties set to launch CARE programs, said Jacqueline Wong-Hernandez, chief policy officer for the California State Association of Counties. In September, Newsom vetoed a bill that would have provided scholarships to mental health professionals if they agreed to work for CARE Court, citing budget pressures.

Alameda County’s contractor has prepared for the Dec. 1 launch by hiring a team of more than a dozen, including a full-time nurse, case managers, employment coordinators, and a clinician to prescribe medications.

Officials there are identifying clients already known to cycle through crisis services, so they can file petitions on their behalf. And the county is figuring out how to tap state housing funds that allow clients to stabilize in short-term housing.

“It’s really a lot to set up,” said Kate Jones, who is helping to oversee the county’s rollout.

Mark Ghaly, who was the chief architect of the CARE program before leaving his post as California’s health secretary this fall, said he worked for many years at the county level and empathizes with counties struggling to implement multiple initiatives at the same time. He added that CARE Court was never meant to be launched in a vacuum.

“We’re going to have to see this whole tapestry of efforts come together to really make the kind of dent that I know we can as a state,” Ghaly said.

State Sen. Tom Umberg, a Democrat who co-authored CARE Court legislation, said that more health care providers need to be made aware of the program so they can help spot potential enrollees.

Still, one county representative worries that the public could conflate court-approved treatment plans for the severely mentally ill with solving homelessness. In 2023, California had an estimated homeless population of more than 180,000.

“The solution to homelessness in California is housing, and the more people are prevented from falling into homelessness in California, the fewer county behavioral health clients we will have,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.

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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Después de perder y recuperar las mismas 20 libras en más ocasiones de las que podía contar, Anita Blanchard concluyó que las dietas no le funcionaban.

Así que cuando esta profesora de la Universidad de Carolina del Norte-Charlotte se enteró de que Ozempic —desarrollado para tratar la diabetes tipo 2— ayudaba a las personas a perder peso, y mantenerlo, Blanchard supo que tenía que probarlo.

El seguro de salud para empleados estatales inicialmente cubrió la receta, y Blanchard solo tuvo un copago de $25. Dijo que en los siguientes siete meses perdió 45 libras y bajó su presión arterial y su nivel de colesterol.

Sin embargo, los beneficios más significativos fueron psicológicos.

“Paró el ruido que hacía la comida en en mi cabeza, alivió mi ansiedad, y dejé de beber como un pez”, dijo Blanchard, quien ahora tiene 60 años. “Ahora tomo una copa de vino y ya”.

Sin embargo, Carolina del Norte tuvo un shock al ver que Blanchard bajaba de peso y miles de otros empleados en el mismo seguro de salud estatal, que cubre a 76.000 empleados de 178 agencias, más a sus dependientes, intentaban hacer lo mismo.

Ozempic, y otros medicamentos similares, representaron el 10% del gasto anual en medicinas recetadas del seguro estatal, según una hoja informativa del Plan de Salud de Carolina del Norte. El tesorero estatal proyectó que esta clase de medicamentos costaría al estado más de $170 millones este año, y los costos aumentarían a más de $1,000 millones en los próximos seis.

“Esto supera la cantidad que el Plan de Salud del Estado gasta en medicamentos para el cáncer, la artritis reumatoide y la quimioterapia”, dijo el Plan de Salud en una declaración en marzo.

La junta de fideicomisarios del plan de salud eliminó la cobertura de esta clase de medicamentos para la pérdida de peso a partir de abril. El plan continúa cubriendo el fármaco para el manejo de la diabetes tipo 2.

Pero, en un giro de los acontecimientos en agosto, otra parte del gobierno de Carolina del Norte permitió que el programa de Medicaid comenzara a cubrir estos medicamentos para la pérdida de peso, no solo para la diabetes, para los residentes más pobres del estado, que están desproporcionadamente afectados por la obesidad y enfermedades relacionadas. En el estado, Medicaid cubre a más de 2 millones de personas.

Ahora, la administración saliente de Biden quiere seguir su ejemplo: el 26 de noviembre propuso que el gobierno federal cubra los medicamentos para tratar la obesidad en pacientes de Medicaid en todo el país, sumándose a los pacientes de Medicare que ya pueden utilizarlos.

A pesar de esto, el cambio en la cobertura en Carolina del Norte dejó a empleados estatales como Blanchard enfrentándose a una dura elección: dejar de tomar lo que ella considera un medicamento milagroso o pagar hasta $1,200 de su bolsillo cada mes.

“Saben que las dietas no funcionan a largo plazo para la pérdida de peso, sin embargo, están negando la cobertura de un medicamento que ha sido efectivo”, dijo Blanchard. “Resalta una mentalidad orientada a las ganancias, más enfocada en ahorrar costos que en priorizar la salud de los pacientes”.

El cambio en la cobertura destaca preocupaciones sobre el costo de estos medicamentos y las preguntas sobre si las aseguradoras deben cubrirlos.

Varios otros estados también están tratando de controlar el costo de estos medicamentos. West Virginia canceló su programa piloto para cubrir a sus empleados estatales. En Connecticut, los empleados estatales a los que se les han recetado estos medicamentos deben participar en un programa clínico de manejo del estilo de vida.

Los altos precios también han suscitado preocupaciones sobre el costo para programas de salud financiados por los contribuyentes, como Medicare.

Los Centros de Servicios de Medicare y Medicaid (CMS) estimaron que la cobertura bajo la propuesta de Biden costaría alrededor de $40,000 millones en 10 años, incluyendo un costo adicional de $3,800 millones para los estados.

Sin embargo, el requisito no entraría en vigencia hasta después que el presidente electo Donald Trump asuma el cargo el 20 de enero, dándole a su administración la oportunidad de cambiarlo.

Los medicamentos agonistas GLP-1, conocidos por los nombres comerciales Ozempic, Trulicity y Wegovy, han demostrado ser efectivos para la pérdida de peso y para el manejo de la diabetes tipo 2. Funcionan desencadenando la liberación de insulina por el páncreas, ralentizando el vaciado del estómago, aumentando el nivel de saciedad y regulando el apetito al enviar señales al cerebro para indicar que el cuerpo está satisfecho.

Sin embargo, los pacientes suelen necesitar seguir tomando estos medicamentos para mantener la pérdida de peso, lo que implica costos a largo plazo.

En ensayos clínicos, los pacientes que tomaron Ozempic también mostraron reducciones significativas en problemas como ataques cardíacos y accidentes cerebrovasculares, incluso aquellos sin diabetes o antes de comenzar a perder peso, dijo Nishant Shah, cardiólogo e investigador de la Universidad de Duke.

Hacer que estos medicamentos estén disponibles a través de Medicaid es un interés financiero a largo plazo para el estado, dijo Kody Kinsley, secretario del Departamento de Salud y Servicios Humanos de Carolina del Norte. A diferencia de los planes privados o de empleadores, Medicaid recibe generosos descuentos en este tipo de medicamentos, reduciendo significativamente el costo, explicó.

Apodando a Carolina del Norte “el cinturón de la barbacoa,” Kinsley señaló que la tasa de obesidad del estado supera el promedio nacional. El último análisis de NORC en la Universidad de Chicago mostró que el 45% de los adultos en el estado tenían un índice de masa corporal superior a 30, el umbral para la obesidad clínica, en comparación con el 42% a nivel nacional. Para los adultos negros no hispanos en el estado, esa cifra era del 55%.

Además, Kinsley dijo que, siendo Medicaid el principal pagador del cuidado a largo plazo, cubrir estos medicamentos ayuda a reducir la necesidad de atención en hogares de adultos mayores, a menudo impulsada por enfermedades crónicas mal manejadas.

“Estamos tratando de invertir nuestros recursos donde reduzcan costos a largo plazo”, afirmó. “Gasto casi mil millones de dólares al año en enfermedades relacionadas con la obesidad. Si puedo reducir ese gasto incluso en un 1%, estos medicamentos son lo más lógico”.

Pero, ¿qué pasa con las personas que no están en Medicaid? Shah, de Duke, dijo que el sistema de salud de Estados Unidos necesita eliminar las barreras que dificultan la obtención de estos medicamentos. Además de hacer que los medicamentos sean más asequibles, agregó, debería alentarse el uso de medicamentos para la pérdida de peso y el tratamiento de la obesidad como una enfermedad crónica, en lugar de estigmatizarla como un fracaso moral.

“Ya sea el costo del medicamento, las condiciones que requieren la aprobación del pagador, la cobertura médica del paciente o la inaccesibilidad de un plan que cubriría la pérdida de peso, hay barreras reales en nuestro sistema de salud”, explicó Shah.

Melissa Jones, médica de familia de Charlotte, dijo que a menudo ha observado un sesgo contra las personas en su práctica de manejo del peso cuando intentan que los seguros privados cubran estos medicamentos.

“No hay vergüenza en decir ‘tengo presión arterial alta’ o ‘heredé esta condición de mi familia,’” comentó Jones. “Pero, por alguna razón, hay vergüenza en decir, ‘Lucho con mi peso’”.

Aunque Blanchard ya no puede obtener la cobertura de Ozempic como empleada estatal, un médico de atención personalizada le recetó una versión del medicamento anti-obesidad producido en una farmacia de compuestos, disponible por ahora debido a la escasez de las versiones de marca. Aunque cree que es menos efectivo, paga $225 al mes por ella.

“Puedo manejar eso”, dijo.

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After losing and regaining the same 20-plus pounds more times than she could count, Anita Blanchard concluded that diets don’t work.

So when the University of North Carolina-Charlotte professor learned that Ozempic — developed to treat Type 2 diabetes — helped people lose weight and keep it off, Blanchard was determined to try it.

The state employee’s health insurance initially covered the prescription with Blanchard kicking in a $25 copayment. Over the next seven months, she said, she lost 45 pounds and lowered her blood pressure and cholesterol. The most significant benefits, though, were psychological.

“It stopped the food noise in my head, relieved my anxiety, and I was no longer drinking like a fish,” said Blanchard, now 60. “I’d have a glass of wine, and then that’s it.”

But North Carolina suffered from sticker shock as Blanchard shed pounds and thousands of others on the state insurance program — which covers more than 76,000 employees across 178 agencies, plus their dependents — tried to do the same. Ozempic and other glucagon-like peptide-1 (GPL-1) agonist medications accounted for 10% of the state employee health plan’s annual prescription drug spending, according to a North Carolina State Health Plan fact sheet. The state treasurer projected the class of drugs would cost the state more than $170 million this year, with costs jumping to more than $1 billion over the next six years.

“This exceeds the amount the State Health Plan spends on cancer, rheumatoid arthritis, and chemotherapy medications,” the State Health Plan said in a March statement.

The health plan’s board of trustees eliminated coverage of this class of medications for weight loss starting in April. The plan continues to cover the drug for Type 2 diabetes management.

But in a twist this August, a separate part of North Carolina’s government allowed the Medicaid program to start covering the drugs for weight loss — not just diabetes — for the state’s poorest residents, who are disproportionately affected by obesity and related diseases. The state’s Medicaid program covers more than 2 million people.

And now the outgoing Biden administration wants to follow suit, proposing on Nov. 26 for the federal government to cover the medications to treat obesity or Medicaid patients nationwide, in addition to Medicare patients.

Still, the North Carolina coverage change left state employees like Blanchard facing a stark choice — stop taking what she views as a miracle drug or pay as much as $1,200 out-of-pocket each month.

“They know diets don’t work long-term for weight loss, yet they are denying coverage for a medication that has been effective,” Blanchard said. “It’s indicative of a profit-driven mindset that is more about cost savings than prioritizing patients’ health.”

The coverage switch highlights concerns about the cost of these medications and ongoing questions about who should get to have such drugs covered by insurance.

Several other states are also trying to reel in the expense of the medications. West Virginia canceled its pilot program to cover the drugs for its state employees. Connecticut state employees who are prescribed the drugs must participate in a clinical lifestyle management program.

The high prices have also raised concerns about the cost for taxpayer-funded health care programs, such as Medicare. The Centers for Medicare & Medicaid Services estimated that coverage under the Biden proposal would cost about $40 billion over 10 years, including an extra $3.8 billion for states. But the requirement wouldn’t take effect until after President-elect Donald Trump takes office Jan. 20, giving his administration a chance to change it.

GLP-1 agonist medications, known by the brand names Ozempic, Trulicity, and Wegovy, have proved to be effective for weight loss as well as managing Type 2 diabetes. They work by triggering the pancreas to release insulin, slowing the rate at which the stomach empties, increasing satiety, and regulating appetite by sending signals to the brain to tell the body it is satisfied. But patients typically need to stay on the medications to maintain their weight loss, meaning they face long-term costs.

In clinical trials, patients taking Ozempic also showed significant reductions in cardiovascular problems such as heart attacks and strokes, even those without diabetes, or before weight loss started, said Duke University cardiologist and researcher Nishant Shah.

Making these drugs available through Medicaid is in the state’s long-term financial interest, said Kody Kinsley, secretary of the North Carolina Department of Health and Human Services, which doesn’t oversee the state employee health plan. Unlike private or employer insurance plans, the Medicaid program receives generous rebates on these types of drugs, significantly reducing the cost, he said.

Calling North Carolina the buckle of the “Barbecue Belt,” Kinsley noted that state’s obesity rate exceeds the national average. The latest analysis from NORC research organization at the University of Chicago showed that 45% of adults in the state had a body mass index above 30, the threshold for clinical obesity, compared with 42% nationwide. That number was 55% for non-Hispanic Black adults in the state.

In addition, Kinsley said, with Medicaid the primary payer for long-term care, covering the drugs helps Medicaid’s bottom line by reducing the need for nursing home care often driven by unmanaged chronic diseases.

“We’re trying to put our dollars where they will lower costs in the long run,” he said. “I spend almost a billion dollars a year on obesity-related diseases. If I can reduce that spend by even 1%, then these drugs are a no-brainer.”

But what about people who aren’t on Medicaid? Duke’s Shah said the U.S. health care system needs to eliminate hurdles that make it difficult to obtain the drugs. Besides making the medication more affordable, he said, it should encourage the use of weight loss drugs and treatment of obesity as a chronic disease instead of stigmatizing it as a moral failing.

“Whether it is drug cost, conditions that require the payer to approve them, the patient’s health insurance plan, or the unaffordability of a plan that would cover weight loss, there are real-world barriers in our health care system,” Shah said.

Family medicine physician Melissa Jones of Charlotte said she has often seen a bias against people in her weight management practice when they try to get these medications covered by private insurance.

“There’s no shame in saying ‘I have high blood pressure’ or ‘I inherited this condition from my family,’” Jones said. “But for some reason, there’s shame associated with saying, ‘I struggle with my weight.’”

Although Blanchard can’t get her Ozempic covered anymore as a state employee, a concierge doctor gave her a prescription for a nonbrand version of the anti-obesity medications from a compounding pharmacy, available for now because of shortages of the brand-name versions. Though she believes it is less effective, she pays $225 a month for it.

“I can handle that,” she said.

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

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KFF Health News chief Washington correspondent Julie Rovner discussed a proposed weight loss drug rule by the Centers for Medicare & Medicaid Services on CBS News’ “CBS News 24/7” on Nov. 26.

• Click here to watch Rovner on “CBS News 24/7”

KFF Health News South Carolina correspondent Lauren Sausser discussed racial disparities in maternal health on WFAE’s “Charlotte Talks” on Nov. 26.

• Click here to hear Sausser on “Charlotte Talks”
• Read the KFF Health News series “Systemic Sickness”

KFF Health News contributor Andy Miller discussed Robert F. Kennedy Jr.’s fluoride claims on WUGA’s “The Georgia Health Report” on Nov. 22.

• Click here to hear Miller on “The Georgia Health Report”
• Read PolitiFact’s “Does Fluoride Cause Cancer, IQ Loss, and More? Fact-Checking Robert F. Kennedy Jr.’s Claims” by Samantha Putterman

KFF Health News contributor Sarah Varney discussed the second week of a trial in Idaho in which four women are challenging the state’s abortion laws on BSPR’s “Idaho Matters” on Nov. 20.

• Click here to hear Varney on “Idaho Matters”
• Read Varney’s “Idaho Calls Abortion ‘Barbaric and Gruesome’ in Trial Challenging Strict Ban”

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Ryan Wettstein Nauman was inconsolable one evening last December. After being put down for bed, the 3-year-old from Peoria, Illinois, just kept crying and crying and crying, and nothing would calm her down.

Her mother, Maggi Wettstein, remembered fearing it could be a yeast or urinary tract infection, something they had been dealing with during potty training. The urgent care centers around them were closed for the night, so around 10:30 p.m. she decided to take Ryan to the emergency room at Carle Health.

The Medical Procedure

The ER wasn’t very busy when they arrived at 10:48 p.m., Wettstein recalled. Medical records indicate they checked in and she explained Ryan’s symptoms, including an intermittent fever. The toddler was triaged and given a nasal swab test to check for covid-19 and influenza A and B.

Wettstein said they sat down and waited to be called. And they waited.

As Wettstein watched Ryan in the waiting room’s play area, she noticed her daughter had stopped crying.

In fact, she seemed fine.

So Wettstein decided to drive them home. Ryan had preschool the next day, and she figured there was no point keeping her awake for who knew how much longer and getting stuck with a big ER bill.

There was no one at the check-in desk to inform that they were leaving, Wettstein said, so they just headed home to go to bed.

Ryan went to her preschool the next day, and Wettstein said they forgot all about the ER trip for eight months.

Then the bill came.

The Final Bill

$445 for the combined covid and flu test — from an ER visit in which the patient never made it beyond the waiting room.

The Billing Problem: A Healthy Hospital Markup and Standard Insurance Rules

Even though Ryan and her mother left without seeing a doctor, the family ended up owing $298.15 after an insurance discount.

At first, Wettstein said, she couldn’t recall Ryan being tested at all. It wasn’t until she received the bill and requested her daughter’s medical records that she learned the results. (Ryan tested negative for covid and both types of flu.)

While Wettstein said the bill isn’t going to break the bank, it seemed high to her, considering Walgreens sells an at-home covid and flu combination test for $30 and can do higher-quality PCR testing for $145.

Under the public health emergency declared in 2020 for the covid pandemic, insurance companies were required to pay for covid tests without copayments or cost sharing for patients.

That requirement ended when the emergency declaration expired in May 2023. Now, it is often patients who foot the bill — and ER bills are notoriously high.

“That’s a pretty healthy markup the hospital is making on it,” Loren Adler, associate director of the Brookings Institution Center on Health Policy, told KFF Health News when contacted about Ryan’s case.

The rates the insurance companies negotiate with hospitals for various procedures are often based on multipliers of what Medicare pays, Adler said.

Lab tests are one of the few areas in which insurance companies can often pay less than Medicare, he said — the exception being when the test is performed by the hospital laboratory, which is often what happens during ER visits.

Medicare pays $142.63 for the joint test that Ryan received, but the family is on the hook for more than twice that amount, and the initial hospital charge was over three times as much.

The hospital is “utilizing their market power to make as much money as possible, and the insurance companies are not all that good at pushing back,” Adler said. A markup of a few hundred dollars is a drop in the bucket for big insurers. But for the patients who get unexpected bills, it can be a big burden.

Brittany Simon, a public relations manager for Carle Health, did not respond to specific questions but said in a statement, “We follow policies that support the safety and wellbeing of our patients, which includes the initial triage of symptomatic patients to the Emergency Department.”

While Ryan’s family would not have had to pay for a covid test during the public health emergency, it was the family’s insurer, Cigna, that did not have to pay this time, since the family had not yet met a $3,000 yearly deductible.

A Cigna representative did not respond to requests for comment.

The Resolution

Wettstein said she knew she could just pay the bill and be done with it, “but the fact that I never saw a provider, and the fact that it was just for a covid test, is mind-blowing to me.”

She contacted the hospital’s billing department to make sure the bill was correct. She explained what happened and said the hospital representative was also surprised by the size of the bill and sent it up for further review.

“‘Don’t pay this until you hear from me,’” Wettstein remembered being told.

Soon, though, she received a letter from the hospital explaining that the charge was correct and supported by documentation.

Wettstein thought she was avoiding any charges by taking Ryan home without being seen. Instead, she got a bill “that they have verified that I have to pay.”

“Like I said, it’s mind-blowing to me.”

The Takeaway

ERs are among the most expensive options for care in the nation’s health system, and the meter can start running as soon as you check in — even if you check out before receiving care.

If your issue isn’t life-threatening, consider an urgent care facility, which is often cheaper (and look for posted notices to confirm whether it’s actually an urgent care clinic). The urgent care centers near Ryan’s home were closed that evening, but some facilities stay open late or around the clock.

In some ways, Wettstein was lucky. KFF Health News’ “Bill of the Month” has received tips from other patients who left an ER after a long wait without seeing a doctor — and got slapped with a facility fee of over $1,000.

Making the decision about where to go is tough, especially in a stressful situation — such as when the patient is too young to communicate what’s wrong. Trying to figure out what’s going on physically with a 3-year-old can feel impossible.

If you decide to leave an ER without treatment, don’t just walk out. Tell the triage nurse you’re leaving. You might get lucky and avoid some charges.

Wettstein won’t think twice about taking Ryan to the pediatrician or an urgent care center the next time she’s ailing. But, Wettstein said, after getting this bill, “I’m not going to create a habit out of going to the emergency room.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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

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GEO Group, una de las mayores contratistas privadas de prisiones del país, presentó en octubre una demanda federal contra funcionarios de California para anular una ley estatal que permite a oficiales de salud pública locales inspeccionar instalaciones de detención de inmigrantes.

La empresa con sede en Florida argumentó en su demanda que la ley de California, firmada por el gobernador Gavin Newsom en agosto, es inconstitucional porque invade la autoridad del gobierno federal para gestionar centros de detención. Por eso, GEO reclamó inmunidad intergubernamental como contratista.

“Este caso es el último de una serie de intentos del estado de California por prohibir la aplicación de las leyes de inmigración federal en el estado, o por obstaculizar tanto esos esfuerzos que agencias y contratistas federales implicados en esta función de seguridad nacional por mandato constitucional se vean forzados a abandonar California”, indica la demanda presentada en el Tribunal de Distrito de los Estados Unidos para el Distrito Este de California.

Christopher Ferreira, vocero de GEO, no respondió a las solicitudes de comentarios.

La demanda menciona a Newsom, a Rob Bonta, fiscal general del estado, y a Kristopher Lyon, oficial de salud del condado de Kern, como demandados. Los tres tampoco quisieron hacer comentarios. La primera audiencia está programada para febrero.

GEO Group podría expandir su control sobre las instalaciones de detención de inmigrantes ahora que el ex presidente Donald Trump ganó un segundo mandato.

Trump ha prometido una deportación masiva de inmigrantes que viven en los Estados Unidos sin papeles, y los inversores creen que las políticas de Trump crearán un auge para las empresas privadas de prisiones, como GEO. Las acciones de GEO se dispararon un 75% luego de la victoria de Trump.

Personas y grupos asociados con el gigante de prisiones privadas gastaron aproximadamente $5.6 millones en cabildeo y donaciones durante el último ciclo electoral, gran parte de ello destinado a comités de acción política conservadores, incluyendo $1 millón para Make America Great Again Inc., según OpenSecrets, una organización sin fines de lucro que rastrea datos de financiamiento de campañas y cabildeo.

César García Hernández, profesor de derecho migratorio en la Facultad de Derecho Moritz de la Universidad Estatal de Ohio, dijo que probablemente un juez bloqueará la implementación de la ley de California mientras el litigio esté pendiente.

En marzo, un juez federal bloqueó a Washington de aplicar la mayor parte de una ley destinada a aumentar la supervisión y mejorar las condiciones de vida en la única instalación de detención de inmigrantes privada de ese estado.

“GEO ha tenido bastante éxito al recurrir a los tribunales para bloquear el acceso a sus instalaciones”, dijo García Hernández. “La empresa privada de prisiones está tratando de protegerse bajo el hecho de que opera esta instalación por un contrato con el gobierno federal”.

La ley de California otorga a oficiales de salud pública locales, que inspeccionan rutinariamente cárceles y prisiones estatales, la capacidad de inspeccionar instalaciones privadas de detención, incluidas las seis instalaciones federales de inmigración en California.

Los detenidos han denunciado amenazas a la salud que van desde brotes de covid-19, paperas y varicela hasta agua contaminada, comida enmohecida y conductos de aire que expulsan polvo negro.

Los legisladores estatales han intentado regular las instalaciones de inmigración con resultados mixtos.

En 2019, el demócrata Newsom firmó una medida que prohíbe el funcionamiento de prisiones e instalaciones de detención privadas en California. Pero luego un tribunal federal declaró la ley inconstitucional, argumentando que interfería con las funciones federales.

En 2021, los legisladores de California aprobaron una ley que exige que los centros de detención privados cumplan con las órdenes de salud pública estatales y locales, así como con las regulaciones de seguridad y salud laboral. Esa medida se adoptó en el apogeo de la pandemia de covid-19, mientras el virus arrasaba instalaciones de detención donde las personas estaban hacinadas en dormitorios con poca o ninguna protección contra virus transmitidos por el aire.

Bajo la nueva ley, los oficiales de salud pública determinarán si las instalaciones cumplen con las normas ambientales, como garantizar una ventilación adecuada, ofrecer atención básica de salud fisica y mental, tratamiento de emergencia y alimentos preparados de manera segura. A diferencia de las instalaciones correccionales públicas, que se inspeccionan cada año, los oficiales de salud inspeccionarán los centros de detención privados según lo consideren necesario.

Los que están a favor de esto dicen que los oficiales de salud pública están bien capacitados para inspeccionar estas instalaciones porque entienden cómo hacer que los espacios confinados sean más seguros para grandes poblaciones.

Pero GEO argumentó que los códigos y regulaciones de salud de California no siempre son consistentes con los estándares federales.

Por ejemplo, la demanda señaló que California exige que los detenidos en riesgo de autolesión o suicidio sean trasladados a una instalación de salud mental. Pero las reglas de Inmigración y Control de Aduanas (ICE) permiten a los centros de detención mayor discreción: pueden transferir a un detenido a un centro de salud mental o mantenerlo en aislamiento contra el suicidio con monitoreo cada 15 minutos. GEO también advirtió en su queja que implementar la ley podría costar hasta $500,000.

Defensores de los inmigrantes dicen que el gobierno federal ha hecho un mal trabajo garantizando la salud y la seguridad. En un artículo publicado en junio, investigadores mostraron que los funcionarios de inmigración y un auditor privado realizaban inspecciones con poca frecuencia, al menos una vez cada tres años, y proporcionaban información pública limitada sobre las deficiencias y si o cómo se solucionaban.

En respuesta, los detenidos han presentado demandas alegando condiciones insalubres y hacinadas; la negación de atención médica y mental adecuada; negligencia médica; y muerte por suicidio a causa de negligencia.

“¿Por qué no dejan que un inspector entre a las instalaciones si están cumpliendo con los estándares?”, dijo José Rubén Hernández Gómez, quien estuvo detenido durante 16 meses y fue liberado en abril de 2023. “Si no tienen nada que ocultar, no deberían estar presentando una demanda”.

Hernández Gómez realizó una huelga de hambre durante 21 días después de presentar decenas de quejas alegando maltrato y malas condiciones de salubridad.

En octubre, ocho miembros de la delegación congresional de California instaron al Departamento de Seguridad Nacional a terminar sus contratos con dos centros de detención operados por GEO, Golden State Annex y Mesa Verde ICE Processing Center, donde este año realizaron múltiples huelgas de hambre y laborales. Los huelguistas exigieron el fin de servicios médicos y de salud mental inadecuados, malas condiciones de vida y el aislamiento solitario.

Defensores temen que las victorias legales de GEO puedan ser peligrosas para la salud de los inmigrantes.

Después que el Departamento de Salud del estado de Washington no pudo acceder al Northwest ICE Processing Center, el único centro de inmigración del estado, dos personas murieron en la instalación, incluyendo una en octubre.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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GEO Group, one of the nation’s largest private prison contractors, filed a federal lawsuit last month against California officials to strike down a state law allowing local public health officials to inspect immigration detention facilities.

The Florida-based company argued in a filing that California’s law, signed by Gov. Gavin Newsom in August, is unconstitutional because it steps on the federal government’s authority to manage detention centers. By extension, GEO claimed intergovernmental immunity as a contractor.

“This case involves the latest in a string of attempts by the State of California to ban federal immigration enforcement in the state, or so significantly burden such efforts as to drive federal agencies and contractors involved in that constitutionally mandated national security function from California,” according to the lawsuit filed in the U.S District Court for the Eastern District of California.

GEO spokesperson Christopher Ferreira did not respond to requests for comment. The lawsuit names Newsom, state Attorney General Rob Bonta, and Kern County health officer Kristopher Lyon as defendants. All three declined to comment. A first hearing is scheduled for February.

GEO Group could expand its grip on immigration detention facilities now that former President Donald Trump won a second term. Trump has promised a mass deportation of immigrants living in the U.S. without authorization, and investors sense Trump’s policies will create a boon for private prison companies such as GEO. GEO’s stock skyrocketed, increasing 75%, after Trump’s victory.

People and groups associated with the private prison giant spent roughly $5.6 million on lobbying and donations this past election cycle, much of it going to conservative political action committees, including $1 million to Make America Great Again Inc., according to OpenSecrets, a nonprofit that tracks campaign finance and lobbying data.

César García Hernández, an immigration law professor at Ohio State University’s Moritz College of Law, said a judge will most likely block implementation of the California law while litigation is pending. In March, a federal judge blocked Washington state from enforcing most of a law to increase oversight and improve living conditions at that state’s only private immigration detention facility.

“GEO has been rather successful in turning to the courts in order to block access to its facilities,” García Hernández said. “The private prison company is trying to insulate itself by taking cover under the fact that it is operating this facility under contract with the federal government.”

California’s bill grants local public health officers, who routinely inspect county jails and state prisons, the ability to inspect private detention facilities, including all six federal immigration centers in California. Detainees have complained of health threats ranging from covid-19, mumps, and chickenpox outbreaks to contaminated water, moldy food, and air ducts spewing black dust.

State lawmakers have attempted to regulate immigration facilities with mixed results.

In 2019, Newsom, a Democrat, signed a measure banning private prisons and detention facilities from operating in California. But a federal court later declared the law unconstitutional, saying it interfered with federal functions.

In 2021, California lawmakers passed a bill requiring private detention centers to comply with state and local public health orders and worker safety and health regulations. That measure was adopted at the height of the covid-19 pandemic, as the virus tore through detention facilities where people were packed into dorms with little or no protection from airborne viruses.

Under the new law, public health officers will determine whether the facilities are complying with environmental rules, such as ensuring proper ventilation, and offering basic mental and physical health care, emergency treatment, and safely prepared food. Unlike public correctional facilities, which are inspected every year, health officers will inspect private detention centers as they deem necessary.

Supporters say public health officers are well positioned to inspect these facilities because they understand how to make confined spaces safer for large populations.

But GEO argued that California health codes and regulations aren’t always consistent with federal standards.

The lawsuit pointed out, for instance, that California requires detainees at risk of self-harm or suicide to be transferred to a mental health facility. But Immigration and Customs Enforcement rules grant detention centers more discretion, allowing them to transfer a detainee to a mental health facility or keep them in suicide-resistant isolation at the detention center through monitoring every 15 minutes. GEO also warned in its complaint that implementing the law could cost up to $500,000.

Immigrant advocates say the federal government has done a poor job ensuring health and safety. In a paper published in June, researchers showed that immigration officials and a private auditor conducted inspections infrequently — at least once every three years — and provided limited public information about deficiencies and if or how they were addressed.

In response, detainees have filed suits alleging crowded and unsanitary conditions; denial of adequate mental and medical health care; medical neglect; and wrongful death by suicide.

“Why shouldn’t they let an inspector go inside the facilities if they are abiding by the standards,” said Jose Ruben Hernandez Gomez, who was detained for 16 months and released in April 2023. “If they have nothing to hide, they shouldn’t be filing a lawsuit.”

Hernandez Gomez went on a hunger strike for 21 days after filing dozens of grievances alleging abusive treatment and poor sanitation.

Last month, eight members of California’s congressional delegation urged the Department of Homeland Security to end its contracts with two GEO-operated immigration centers, Golden State Annex and Mesa Verde ICE Processing Center, where multiple hunger and labor strikes were held this year. Strikers demanded an end to inadequate medical and mental health services, poor living conditions, and solitary confinement.

Advocates fear GEO’s legal victories could be dangerous for the health of immigrants.

After Washington state’s Department of Health was denied access to the Northwest ICE Processing Center, the state’s only immigration center, two people died in the facility, including one in October.

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 President-elect Donald Trump’s announcement that he will nominate former TV host Mehmet Oz to lead the Centers for Medicare & Medicaid Services on WBUR’s “Here & Now” on Nov. 20. Rovner also discussed what it could mean for Robert F. Kennedy Jr. to run the Department of Health and Human Services on NPR’s “All Things Considered” on Nov. 15.

• Click here to hear Rovner on “Here & Now”
• Click here to hear Rovner on “All Things Considered”

KFF Health News correspondent Cara Anthony discussed the “Silence in Sikeston” project on St. Louis Public Radio’s “St. Louis on the Air” on Nov. 19.

• Click here to hear Anthony on “St. Louis on the Air”
• Read, listen to, and watch Anthony’s project “Silence in Sikeston”

KFF Health News senior correspondent Noam N. Levey discussed medical debt on The Pew Charitable Trusts’ podcast “After the Fact” on Nov. 15.

• Click here to hear Levey on “After the Fact”
• Read KFF Health News’ ongoing series “Diagnosis: Debt”

KFF Health News contributor Andy Miller discussed dental implants on WUGA’s “The Georgia Health Report” on Nov. 15.

• Click here to hear Miller on “The Georgia Health Report”
• Read Brett Kelman and Anna Werner’s “Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn”

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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ATLANTA — Lloyd Mills was tired of being stuck in a small, drab hospital room. On a rainy mid-September morning, a small TV attached to a mostly blank white wall played silently. There was nothing in the space to cheer it up — no cards, no flowers.

In February, the 32-year-old with autism, cerebral palsy, and kidney disease was brought to Grady Memorial Hospital from the group home where he had been living because he was having auditory hallucinations and suicidal thoughts, he said.

“Being here is not helping me, mentally, physically, emotionally,” Mills said.

He wanted to return to a group home or some other community setting where he could receive the care he needs without being confined. It’s his legal right. But it took the state agency overseeing his care more than eight months to get that done — and that placement would be short-lived.

Nearly 15 years ago, the U.S. Department of Justice sued Georgia for unnecessarily segregating people with developmental disabilities and mental illness. The state settled the case and agreed to a massive overhaul of the services it offers to that population. Despite hundreds of millions of dollars in investments and some notable improvements, the state’s system of caring for people with developmental disabilities and mental illness still has holes. The gaps often leave people like Mills sequestered in institutional settings and without the proper community supports.

Advocates said those failures continue to violate the rights of Georgians who have been historically marginalized and put their health at risk. “It’s an emergency,” said Susan Walker Goico, director of Atlanta Legal Aid Society’s Disability Integration Project. “Anytime somebody has to live in a segregated setting when they don’t want to, it’s terrible.”

The Americans with Disabilities Act, as clarified in a 1999 U.S. Supreme Court decision, says Mills and other people with disabilities have been legally entitled to receive care at home and in other community settings instead of being unnecessarily confined to places like hospitals and nursing homes.

That decision in Olmstead v. L.C. became the foundation for the lawsuit the Department of Justice levied against Georgia in 2010 that sought to force the state to fix its system.

Later that year, state officials agreed to stop putting people in state hospitals solely because they have developmental disabilities. They also agreed to use Medicaid to pay for people to receive care in the community, and to establish crisis response and housing services for those with mental illness.

The state agreed to make the fixes within five years. Nearly a decade and a half later, it’s still not finished.

Even critics acknowledge Georgia has made considerable improvements in the services it provides for people with developmental disabilities and mental illness. Since the start of the settlement, the state has invested nearly $521 million in community services. And, in late September, a federal judge released the state from many parts of its Olmstead settlement.

However, the DOJ, patient advocates, and even state officials acknowledge more work remains. They say there are many reasons it’s taking so long: the scale of the undertaking, loss of momentum over time, a workforce shortage that has limited appropriate community placements, and a lack of political will.

“The longer it continues, the more you sort of say, ‘Are we serious about solving this problem?’” said Geron Gadd, a senior attorney with the National Health Law Program.

The main challenges won’t be easy to solve without appropriate attention, investments, and commitment from lawmakers, advocates said. In a recent court filing, the state admitted it needs to remove more people with developmental disabilities from psychiatric hospitals, improve case management for people with mental illness, and provide more housing with mental health supports.

That final goal is the “bedrock” of Georgia’s mental health and developmental disability system, Goico said. “You have to have a place to live in order to get your services and to stay out of institutions.”

But people with developmental disabilities and mental illness regularly can’t find appropriate community placements, so they cycle in and out of hospitals and nursing homes, Goico and other observers noted.

In 2010, Georgia launched a housing voucher program for people with mental illness who are chronically homeless, incarcerated, or continually in and out of emergency rooms.

The state agreed to create the capacity to offer vouchers to 9,000 people by July 2015. Currently, only about 2,300 are in the program. Even so, state lawmakers declined to fund additional waivers in next year’s budget, saying they were waiting for an update on Georgia’s compliance with the DOJ settlement.

A legal settlement may dictate that states do certain things, but “the state legislature has to still vote to allocate funds,” said David Goldfarb, former director of long-term supports and services policy at the Arc of the United States, a disability rights organization.

The settlement has resulted in a huge transformation of Georgia’s service system, even though “it’s taking them quite a time to get there,” said Jennifer Mathis, a deputy assistant attorney general with the DOJ’s civil rights division.

For people with developmental disabilities, like Mills, that prolonged arrival means more time confined to hospitals and nursing homes.

Mills said he has had dozens of hospital stays, though none as long as his eight-month stint. “Sometimes it would go from two weeks to a month,” he said in September. “It’s stressful.”

Kevin Tanner, head of Georgia’s Department of Behavioral Health and Developmental Disabilities, noted that the number of people stuck in hospitals had been as high as 30 a day. It’s “down to the teens now,” he said, due in part to the recent opening of two homes for people with developmental disabilities in crisis, with eight beds to serve people statewide.

“No system’s perfect,” Tanner said.

Other states have struggled to achieve compliance. Virginia and North Carolina have been under similar federal oversight since 2012.

But some states have shown it’s possible to make fixes. Delaware entered an Olmstead settlement with the DOJ in 2011 and exited federal oversight five years later. Oregon settled a case in 2015 and achieved compliance in 2022.

In Georgia, a shortage of housing for people with developmental disabilities and mental illness has been exacerbated by the shuttering of home and community service providers in recent years, said Lisa Reisman, owner of Complete Care at Home, which offers home medical care to older adults and people with disabilities.

Many service providers blamed the shortage of home and community services on Georgia’s low Medicaid reimbursement rates, which have made it hard for providers to keep workers. Years of low rates “decimated the infrastructure,” said Ryan Whitmire, president of Developmental Disabilities Ministries of Georgia.

Reisman said she has had to turn down placement requests from the state because she couldn’t accommodate them. In those situations, she said, a state official said service providers would sometimes drop off clients at ERs because they “were out of money and they didn’t know where to put them.”

Service providers, including Whitmire, said nurses and other caregivers often leave for higher-paying jobs in fast food or retail.

This year, state lawmakers appropriated more than $106 million to increase Medicaid rates for mental health and developmental disability service providers. Some of those rates hadn’t been raised since 2008.

State lawmakers also recently passed a bill that would require a study every four years of rates it pays providers — though it would still be up to lawmakers to increase payments.

Not only was Lloyd Mills’ extended time in the hospital hard mentally and physically, it also made him lose his Medicaid coverage, said his representatives from the Georgia Advocacy Office, a nonprofit that represents people with disabilities.

Because he was in a hospital, he was unable to spend his monthly Supplemental Security Income payments, which accumulated until he had too much money to keep his health coverage.

In late October, eight months after his hospital stay began, the state moved him to a group home in Macon, about 85 miles southeast of Atlanta. In the days before his move, Mills said he was ready to start his next chapter.

“I’m just ready to live my life, and I don’t plan on ever coming back here again,” he said.

But his stay was short. In mid-November, after just a few weeks of living at the group home, Mills ended up back in a hospital. His advocates worry he won’t be heading to a community placement anytime soon.

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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GLENWOOD, Iowa — Hundreds of people who were separated from society because they had disabilities are buried in a nondescript field at the former state institution here.

Disability rights advocates hope Iowa will honor them by preventing the kind of neglect that has plagued similar cemeteries at other shuttered facilities around the U.S.

The southwest Iowa institution, called the Glenwood Resource Center, was closed this summer in the wake of allegations of poor care. The last of its living residents were moved elsewhere in June. But the remains of about 1,300 people will stay where they were buried on the grounds.

The graveyard, which dates to the 1800s, covers several acres of sloping ground near the campus’s brick buildings. A 6-foot-tall, weathered-concrete cross stands on the hillside, providing the most visible clue to the field’s purpose.

On a recent afternoon, dried grass clippings obscured row after row of small stone grave markers set flat in the ground. Most of the stones are engraved with only a first initial, a last name, and a number.

“If somebody who’s never been to Glenwood drove by, they wouldn’t even know there was a cemetery there,” said Brady Werger, a former resident of the facility.

During more than a century of operation, the institution housed thousands of people with intellectual disabilities. Its population declined as society turned away from the practice of sequestering people with disabilities and mental illness in large facilities for decades at a time. The cemetery is filled with residents who died and weren’t returned to their hometowns for burial with their families.

State and local leaders are working out arrangements to maintain the cemetery and the rest of the 380-acre campus. Local officials, who are expected to take control of the grounds next June, say they’ll need extensive state support for upkeep and redevelopment, especially with the town of about 5,000 people reeling from the loss of jobs at the institution.

Hundreds of such places were constructed throughout the U.S. starting in the 1800s. Some, like the one in Glenwood, served people with disabilities, such as those caused by autism or seizure disorders. Others housed people with mental illness.

Most of the facilities were built in rural areas, which were seen as providing a wholesome environment.

States began shrinking or closing these institutions more than 50 years ago. The shifts were a response to complaints about people being removed from their communities and subjected to inhumane conditions, including the use of isolation and restraints. In the past decade, Iowa has closed two of its four mental hospitals and one of its two state institutions for people with intellectual disabilities.

After closures in some other states, institutions’ cemeteries were abandoned and became overgrown with weeds and brush. The neglect drew protests and sparked efforts to respectfully memorialize people who lived and died at the facilities.

“At some level, the restoration of institutions’ cemeteries is about the restoration of humanity,” said Pat Deegan, a Massachusetts mental health advocate who works on the issue nationally. Deegan, who was diagnosed with schizophrenia as a teenager, sees the neglected graveyards as symbolic of how people with disabilities or mental illness can feel as if their individual identities are buried beneath the labels of their conditions.

Deegan, 70, helped lead efforts to rehabilitate a pair of overgrown cemeteries at the Danvers State Hospital near Boston, which housed people with mental illness before it closed in 1992. More than 700 former residents were buried there, with many graves originally marked only with a number.

The Massachusetts hospital’s grounds were redeveloped into a condominium complex. The rehabilitated cemeteries now have individual gravestones and a large historical marker, explaining what the facility was and who lived there. The sign notes that some past methods of caring for psychiatric patients seem “barbarous” by today’s standards, but the text portrays the staff as well-meaning. It says the institution “attempted to alleviate the problems of many of its members with care and empathy that, although not always successful, was nobly attempted.”

Deegan has helped other groups across the country organize renovations of similar cemeteries. She urges communities to include former residents of the facilities in their efforts.

Iowa’s Glenwood Resource Center started as a home for orphans of Civil War soldiers. It grew into a large institution for people with disabilities, many of whom lived there for decades. Its population peaked at more than 1,900 in the 1950s, then dwindled to about 150 before state officials decided to close it.

Werger, 32, said some criticisms of the institution were valid, but he remains grateful for the support the staff gave him until he was stable enough to move into community housing in 2018. “They helped change my life incredibly,” he said. He thinks the state should have fixed problems at the facility instead of shutting it.

He said he hopes officials preserve historical parts of the campus, including stately brick buildings and the cemetery. He wishes the graves had more extensive headstones, with information about the residents buried there. He would also like to see signs installed explaining the place’s history.

Two former employees of the Glenwood facility recently raised concerns that some of the graves may be mismarked. But officials with the Iowa Department of Health and Human Services, which ran the institution, said they have extensive, accurate records and recently placed stones on three graves that were unmarked.

Department leaders declined to be interviewed about the cemetery’s future. Spokesperson Alex Murphy wrote in an email that while no decisions have been made about the campus, the agency “remains committed to ensuring the cemetery is protected and treated with dignity and respect for those who have been laid to rest there.”

Glenwood civic leaders have formed a nonprofit corporation that is negotiating with the state over development plans for the former institution. “We’re trying to make the best of a tough situation,” said Larry Winum, a local banker who serves on the new organization’s board.

Tentative plans include tearing down some of the existing buildings and creating up to 900 houses and apartments.

Winum said redevelopment should include some kind of memorial sign about the institution and the people buried in the cemetery. “It will be important to us that those folks be remembered,” he said.

Activists in other states said properly honoring such places takes sustained commitment and money.

Jennifer Walton helped lead efforts in the 1990s to properly mark graves and improve cemetery upkeep at state institutions in Minnesota.

Some of the cemeteries are deteriorating again, she said. Activists plan to ask Minnesota legislators to designate permanent funding to maintain them and to place explanatory markers at the sites.

“I think it’s important, because it’s a way to demonstrate that these spaces represent human beings who at the time were very much hidden away,” Walton said. “No human being should be pushed aside and ignored.”

On a recent day, just one of the Glenwood graves had flowers on it. Retired managers of the institution said few people visit the cemetery, but amateur genealogists sometimes show up after learning that a long-forgotten ancestor was institutionalized at Glenwood and buried there.

Former grounds supervisor Max Cupp said burials had become relatively rare over the years, with more families arranging to have deceased residents’ remains transported to their hometown cemeteries.

One of the last people buried in the Glenwood cemetery was Kenneth Rummells, who died in 2022 at age 71 after living many years at the institution and then at a nearby group home overseen by the state. His guardian was Kenny Jacobsen, a retired employee of the facility who had known him for decades.

Rummells couldn’t speak, but he could communicate by grunting, Jacobsen said. He enjoyed sitting outside. “He was kind of quiet, kind of a touch-me-not guy.”

Jacobsen helped arrange for a gravestone that is more detailed than most others in the cemetery. The marker includes Rummells’ full name, the dates of his birth and death, a drawing of a porch swing, and the inscription “Forever swinging in the breeze.”

Jacobsen hopes officials figure out how to maintain the cemetery. He would like to see a permanent sign erected, explaining who is buried there and how they came to live in Glenwood. “They were people too,” he said.

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BOISE, Idaho — Physicians are expected to take the stand in Idaho’s capital on Tuesday to argue that the state’s near-total prohibition of abortion care is jeopardizing women’s health, forcing them to carry fetuses with deadly anomalies, and preventing doctors from intervening in potentially fatal medical emergencies.

Their testimony is scheduled to lead off the second week of a closely watched trial concerning one of the nation’s strictest abortion bans. The case, brought by four women, two physicians, and a group of medical professionals, seeks to limit the extent of the state’s ban, which prohibits abortion in almost all circumstances except to prevent a pregnant woman’s death, to stave off “substantial and irreversible impairment of a major bodily function,” or if the pregnancy was a result of a woman or girl being raped.

Over three days in district court last week, the women who brought the case shared emotional testimony about serious pregnancy complications that forced them out of state for medical care. That testimony drew objections from James Craig, an attorney with Idaho’s Office of the Attorney General, who interrupted the women frequently arguing that the details of their stories were not relevant.

Craig pushed back on assertions that Idaho’s criminal abortion laws are endangering women’s health care, while also casting abortion procedures in a negative light. Craig called abortion “barbaric and gruesome” in an opening statement.

“Abortion laws prevent unborn children from being exposed to pain,” he said.

At one point in the trial, Craig suggested that women could use any medical condition to sidestep the law, describing a scenario in which a pregnant woman who stepped on a rusty nail could claim she was at risk of infection and thus entitled to an abortion.

If the court finds in favor of the women, Craig said, “women [would] have a right to kill their unborn baby anytime it’s disabled, anytime they have an infection.”

During the plaintiffs’ testimony, as the women described what happened to their bodies during their pregnancies, Craig’s repeated objections drew reprimands from the 4th Judicial District Court judge overseeing the case, Jason Scott.

The patient plaintiffs’ testimony drew a warmer response from Scott, who said the women’s “circumstances are very worthy of sympathy.”

The case has drawn national attention to Idaho’s ban, one of the first enacted after the U.S. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization. As it proceeds, abortion rights advocates are watching to see whether court challenges — including in other Republican-led states, such as Tennessee, where a similar case is ongoing — will be successful.

The plaintiffs in the case are not seeking to overturn the Idaho ban but rather to enact medical exceptions to the law. Their prospects are unclear, though a similar challenge in Texas did not fare well.

As the trial played out in a Boise courtroom, Jillaine St. Michel sat with her husband as they tended to their 10-month-old son. St. Michel had faced a pregnancy in which her fetus developed in devastating ways — a lack of leg and arm bones, a missing bladder, fused kidneys. She was barred from ending her pregnancy.

“We were told in the state of Idaho an abortion was not legal, and my case was no exception,” she said. 

Instead, the family drove to Seattle for an abortion, she said, to spare the fetus she carried from further torment.

“The state talks about how barbaric it is, they keep using that term,” St. Michel said. “The idea of allowing your child to experience suffering beyond what is necessary, to me that feels barbaric. To put myself through that when that is not something I desired, that feels barbaric. To have that ripple down into my ability to parent my existing child, that feels barbaric.”

Earlier this year, the Texas Supreme Court ruled against 20 women and two OB-GYNs, upholding that state’s criminal law that allows abortion only to prevent a pregnant patient’s death. The court added one clarification ruling that abortions would be considered a crime when the amniotic sac breaks before 37 weeks of pregnancy, known as preterm premature rupture of membranes, because the condition can cause rapid and irreversible infection. That exception is not currently allowed in Idaho, and physicians who testified in the first week of the trial said they’d been forced to put their pregnant patients into cars and planes to receive abortions out of state.

In Idaho, a previous legal challenge to the state’s near-total abortion ban was rejected by the Idaho Supreme Court. In the case brought by Planned Parenthood, the justices wrote in a January 2023 ruling that the Idaho Constitution contains no right to an abortion, and that Idaho’s laws criminalizing abortion are constitutional.

This latest challenge, Adkins v. State of Idaho, comes on the heels of Donald Trump’s presidential victory. His Supreme Court appointments made way for the anti-abortion movement’s most vaunted goal of eliminating a woman’s constitutional right to abortion. 

Advocates for abortion rights say that a loss in the case would close off options for challenging bans.

“If this isn’t successful, it’s not really clear if there are really additional places to go for help,” said Gail Deady, a senior staff attorney at the Center for Reproductive Rights, a legal advocacy organization representing the plaintiffs.

Kayla Smith, one of the plaintiffs, sobbed during her testimony as she recalled suffering from preeclampsia during her pregnancy with her first child. When medication could not control the condition, physicians were concerned that the blood pressure disorder could cause Smith to have a stroke or seizure, so they induced birth early, and Smith delivered a daughter, who is now 4 years old.

She told the court her second pregnancy seemed normal until a routine anatomy scan showed her son had multiple lethal heart defects. She and her husband had named him Brooks.

Idaho’s abortion ban had taken effect two days earlier and no longer allowed a physician to allow women such as Smith to end a pregnancy involving lethal fetal anomalies.

Her husband recalled the moment when their doctor, Kylie Cooper, delivered the diagnosis. “I remember finally asking just her if Brooks was going to be able to survive, and Dr. Cooper, she broke down. And the three of us just cried. And I understood that we were helpless in Idaho at that point,” James Smith said.

Despite a frantic search, the Smiths could not find a fetal surgeon who would operate on Brooks. His heart could not be fixed.

“My son wasn’t going to survive,” Kayla said in an interview. “We wouldn’t bring a baby home. And we also didn’t want him to suffer, so we just decided to do the most compassionate thing for him and also for me.”

Idaho’s criminal abortion laws required either that Kayla stay pregnant until her condition deteriorated and an abortion would be needed to prevent her death, or that she give birth to Brooks, who would not survive.

“I was not willing to watch my son suffer and gasp for air,” she said about the couple’s decision to end the pregnancy.

The Smiths drove with their toddler to Seattle, where physicians induced labor at about 20 weeks into her pregnancy, and Kayla and James were able to hold Brooks, who did not survive.

Attorneys for the state of Idaho are expected to call one witness this week, Ingrid Skop, an OB-GYN anti-abortion advocate.

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SACRAMENTO – Funcionarios de salud pública de California están recurriendo a las reservas estatales y federales para equipar a cerca de 10.000 trabajadores agrícolas con máscaras, guantes, gafas y otros equipos de seguridad, luego que, a principios de noviembre, el estado confirmara por lo menos 21 casos de gripe aviar en humanos.

Es el ejemplo más reciente de los desafíos que enfrenta el estado para prepararse, a pesar de los déficits multimillonarios.

Las autoridades informaron que habían empezado a distribuir más de 2 millones de equipos de protección individual a finales de mayo, cuatro meses antes de que se confirmara el primer caso humano en el estado.

También indicaron que, desde abril, cuando se detectó por primera vez un caso de gripe aviar en el ganado vacuno del país, estaban intensificando la coordinación con las autoridades sanitarias.

Hasta el momento, se ha confirmado la presencia de gripe aviar en más de 270 granjas lecheras en el centro de California. También detectaron rastros del virus en un sitio de muestreo de aguas residuales en el condado de Los Ángeles. Recientemente, surgieron  casos en una parvada de una granja de pavos situada en el condado de Sacramento.

Mientras intenta limitar la propagación de la gripe aviar entre los humanos, California está poniendo en práctica una serie de lecciones extraídas de la pandemia de covid-19. Por ejemplo, la coordinación con las autoridades sanitarias locales para tener una adecuada respuesta de emergencia. O implementar el seguimiento de las enfermedades infecciosas mediante la vigilancia de las aguas residuales.

El estado también se está esforzando por mantener una reserva adecuada de suministros de emergencia que le permitan responder a una primera oleada de cualquier nueva catástrofe de salud pública sin que eso produzca un drenaje significativo del presupuesto estatal.

“Estamos mucho mejor preparados para responder a una pandemia que en 2020”, declaró Amy Palmer, vocera de la Oficina de Servicios de Emergencia del Gobernador de California (Cal OES).

Un caso concreto: antes de que el coronavirus golpeara en 2020, las reservas de suministros de emergencia del estado apenas alcanzaban para llenar dos canchas de baloncesto. Pero cuando California intensificó su respuesta a la pandemia logró acumular una cantidad de equipos de protección personal y otros suministros para desastres como para llenar 52 campos de fútbol americano.

California dispuso de $15.600 millones para dar respuesta directa a la pandemia durante los años de la crisis de covid. El gobierno federal fue quien proporcionó gran parte de esos recursos.

Hoy en día, la reserva de insumos cabe en unos 12 campos de fútbol, aunque el volumen cambia de un mes a otro.

Según el estado, hoy se cuenta con 101 millones de mascarillas, lo que representa 26 millones más que el suministro necesario para 90 días, según lo recomendado por las directrices estatales de preparación ante una pandemia.

Eso incluye 88 millones de mascarillas N95, un número que excede el que la agencia de servicios de emergencia consideró necesarias el año pasado. Las mascarillas de alta eficacia son un elemento crucial para protegerse de virus transmitidos por el aire como el que causa covid.

Aunque el estado está aumentando sus reservas, Palmer no pudo confirmar si el aumento de la reserva de mascarillas se relaciona con el temor a un aumento de la gripe aviar. Sólo dijo que los planificadores de salud pública trabajan siempre “para mantener  el ritmo ante el actual entorno de riesgo”.

El objetivo del estado, explicó Palmer, es garantizar la existencia de “un suministro inicial durante las emergencias que dé el tiempo suficiente para conseguir recursos”, ya sea a través del gobierno federal o comprándolos.

En los casos de gripe aviar detectados recientemente en California no se hallaron indicios de contagio entre humanos, y las autoridades sanitarias afirman que el riesgo para la población sigue siendo bajo.

La transmisión humana de la gripe aviar es uno de los peores escenarios posibles para una nueva pandemia, junto con la posibilidad de que resurja un coronavirus mutante; una mayor propagación internacional del mpox, el virus de Marburgo o el ébola. Otra opción es que aparezca un virus completamente nuevo para el que en principio no exista inmunidad ni vacuna.

Sin embargo, las autoridades sanitarias de todo el país han tenido dificultades para rastrear la transmisión de la gripe aviar. Y California tiene un historial de altibajos en su preparación ante emergencias.

En 2006, el gobernador republicano Arnold Schwarzenegger ordenó aumentar los planes de contingencia de California ante una pandemia, en respuesta a una amenaza anterior de gripe aviar. Esto incluyó tres hospitales móviles que podían desplegarse inmediatamente en caso de catástrofe.

Pero el gobernador demócrata Jerry Brown puso fin al programa en 2011, porque las finanzas del estado se desmoronaron. Cuando llegó el virus de la gripe aviar, el estado había distribuido 21 millones de mascarillas N95, algunas tan viejas que ya habían caducado.

Por una ley estatal aprobada en 2020, ahora los hospitales están obligados a mantener una reserva permanente para cubrir por un período de tres meses las necesidades de máscaras, batas y otros equipos de protección personal.

La normativa de California sobre enfermedades respiratorias que se transmiten por aire también exige que los hospitales y otros lugares de trabajo de alto riesgo tomen precauciones especiales, como el uso de salas de aislamiento con presión negativa y el nivel más avanzado posible de equipos de protección, hasta tanto se conozca mejor el nuevo patógeno.

Básicamente, estas medidas aseguran que ante el surgimiento de un virus desconocido, se tomen las máximas precauciones para evitar que se propague por el aire. Así se protege tanto a los trabajadores de la salud como a los pacientes.

“Es difícil exagerar sobre el nivel de falta de preparación demostrado por los hospitales, tanto dentro como fuera de California, para hacer frente al brote de covid-19 de 2020”, señala un análisis legislativo. “Imágenes desgarradoras de enfermeras caminando por los pasillos de los hospitales con máscaras improvisadas y bolsas de basura se convirtieron en algo habitual”.

Jan Emerson-Shea, portavoz de la Asociación de Hospitales de California, dijo que los hospitales “se preparan continuamente para responder a todo tipo de desastres, incluidos los brotes de virus transmisibles”.

Por otra parte, Palmer detalló que California tiene cinco hospitales móviles adquiridos al gobierno federal. Aunque tuvieron poco uso durante la pandemia, Palmer opinó que hay que mantenerlos. Y que es fundamental garantizar que estén equipados, en buenas condiciones. Por ejemplo, asegurándose de que los oxímetros de pulso tengan baterías que funcionen.

Pero, una vez más, el déficit actual hace que el estado intente encontrar un equilibrio en el uso de los recursos.

Aunque los legisladores rechazaron la mayor parte del recorte de $300 millones a la financiación de la salud pública propuesto por el gobernador demócrata Gavin Newsom, hace un año el estado redujo en un tercio el presupuesto para la reserva de equipos de protección personal. Esto se decidió después que el Departamento de Finanzas determinara que ya no era imprescindible hacer compras adicionales relacionadas con covid.

Además, California eliminó este año los fondos para la financiación de ocho remolques de 53 pies de largo que deberían haber transportado y distribuido los suministros entre los almacenes.

En los próximos 4 años también se recortarán $40 millones de los $175 millones del presupuesto que iban a ser destinados a la reserva para desastres.

La preparación decidida por el estado no convenció al grupo Californians Against Pandemics, que logró reunir más de un millón de firmas para presentar una propuesta a los votantes en noviembre. La idea era aumentar los impuestos a las personas con ingresos superiores a $5 millones y utilizar ese dinero para prevenir y combatir pandemias.

Pero esta iniciativa fracasó después que uno de sus principales impulsores, el ex ejecutivo de criptomonedas Sam Bankman-Fried, fuera condenado por estafar a clientes e inversores.

A cambio de que los partidarios de la iniciativa abandonaran la propuesta, las autoridades estatales acordaron ampliar el alcance de la Iniciativa de California para el Avance de la Medicina de Precisión, que se creó en 2015 para centrarse en el desarrollo de nuevos medicamentos y terapias, incluyendo tecnologías para prevenir otras pandemias.

“Al aprovechar el poder de la medicina de precisión, California se está colocando a la vanguardia en la preparación y prevención de pandemias”, dijo Newsom en ese momento.

Rodger Butler, vocero de la Agencia Estatal de Salud y Servicios Humanos, explicó que no está claro si esta iniciativa recibirá otros financiamientos adicionales.

Este artículo fue producido por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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If you bring a baby into the Hurley Children’s Center clinic in downtown Flint, Michigan, Mona Hanna will find you. The pediatrician, who gained national prominence for helping uncover the city’s water crisis in 2015, strode across the waiting room in her white lab coat, eyes laser-focused on the chubby baby in the lap of an unsuspecting parent.

“Hi! I’m Dr. Mona!” she said warmly. “Any chance you guys live in Flint?” She learned the family is from neighboring Grand Blanc.

“That’s so sad!” Hanna said. “You should move to Flint! And have another baby! And you could be part of the Rx Kids program!” The parents chuckled politely. But the doctor was not kidding.

Billed as the first-ever citywide cash aid program for pregnant moms and babies, Rx Kids gives Flint residents $1,500 mid-pregnancy, and $500 each month for the baby’s first year. There are no strings attached. No income limits. And it’s universal; nearly every baby born since the program launched in January is enrolled.

Parents who bring their babies in for checkups at this clinic rattle off the ways the money has helped, from the cribs, diapers, clothes, and wipes they’ve bought to how it’s “kept them afloat” during maternity leave or provided crucial income when a spouse died.

But the true goal of Rx Kids goes far beyond Flint, as Hanna acknowledged, scooping up one of the Rx Kids babies in an exam room. “Do you think we should do this for babies everywhere? What do you think?” she asked, cooing. The baby gurgled happily, smiling. “That was an affirmative yes.”

Cash Payments as a Tool To Reduce Child Poverty

Many other countries, including Austria, Belgium, Canada, France, Germany, Ireland, Norway, Sweden, and the United Kingdom, already offer a child cash benefit. The U.S. essentially did, too, during the coronavirus pandemic: The 2021 expanded child tax credit gave low- and middle-income families (including those previously excluded because of insufficient income) hundreds of dollars per kid in direct, monthly payments for six months.

The child poverty rate fell to a historic low. But the expanded program expired at the end of 2021 and Congress did not renew it. The child poverty rate went back up.

For Luke Shaefer, director of the Poverty Solutions initiative at the University of Michigan’s Ford School of Public Policy and a longtime advocate of child cash benefits, it was “the most brutal day” of his career.

Soon after, he got an email from Hanna asking if he wanted to collaborate on the program that would become Rx Kids. The program’s goals go beyond cash aid for Michigan families: It is also aimed at getting donors, lawmakers, and voters excited about how child cash benefits could help their communities.

The list of the recently converted includes Republican state Sen. John Damoose, who has become an outspoken advocate for expanding Rx Kids. Referring to himself as “a pro-life person,” Damoose said, “I sure as heck better be concerned about making it easier for mothers to make the decision to have their children.” He said the Republican Party needs to get serious about supporting programs like Rx Kids. “We’ve been accused for years about being pro-birth, not pro-life. And I think that’s not without merit. We need to put our money where our mouth is and support these children and support their mothers.”

Already, what once seemed like a moon shot is gaining traction: Shaefer and Hanna say their communications with Vice President Kamala Harris’ presidential campaign helped shape Harris’ “baby bonus” proposal. President-elect Donald Trump’s campaign also supported expanding the child tax credit.

Meanwhile, Michigan has budgeted some $20 million in state Temporary Assistance for Needy Families cash to partially fund an expansion of Rx Kids to a short list of communities, if those areas can raise local matching funds. Those areas include rural communities like Michigan’s remote eastern Upper Peninsula, part of which is in Damoose’s district. “We want to make the tent as big as possible,” Hanna said.

But some Upper Peninsula health officials were initially wary. Each new Rx Kids community will need to raise millions of dollars in private donations to start and sustain the program in their community. “It could be a good thing,” Leann Espinoza, maternal-infant health program manager for the eastern Upper Peninsula, said in August. “But I’m not getting my hopes up. I know that sounds terrible.”

Upper Peninsula Families ‘Fall Through the Cracks’

In the wood-paneled rec room of the Clark Township Community Center, Espinoza broke the news to her team this summer: Rx Kids is not a program the eastern Upper Peninsula will be able to fund on its own.

It’s about “$3 million that we would need to raise,” she said, looking at three other LMAS District Health Department staff members.

Tonya Winberg, the public health nurse for Mackinac County, looked stunned. “It’s just, where does that $3 million come from?” Winberg asked. Other potential Rx Kids expansion sites, like Kalamazoo, have wealthy private foundations that can fund the program. The eastern Upper Peninsula does not.

“And how do we sustain it?” Espinoza added. “We hate to start programs, and then the funding is gone and we have to tell people, ‘It’s not here anymore; we can’t do it anymore.’”

The ruggedly beautiful and densely forested Upper Peninsula is used to feeling forgotten. There’s a running joke about how often it’s mislabeled as Canada or Wisconsin on maps. It has about a third of Michigan’s land mass, but just 3% of its residents. The sheer scale and sparse population mean options for food, housing, and child care are limited. Poverty rates are higher than the state average in much of Espinoza’s territory, and the region has some of the highest rates of newborns suffering from prebirth drug exposure in the state, according to the state health department.

At the community center, Espinoza and her colleagues start listing all the ways Rx Kids would be a lifesaver for families in the Upper Peninsula, many of whom have some income and some resources but “don’t make enough to make it,” Espinoza said. “The fall-through-the-cracks families. And those are the ones that I really, really, really think this program would benefit, especially up here.”

Espinoza’s next meeting was with one of those families. Jessica Kline and her 18-month-old daughter, Aurora, live in Munising, a tourist town on Lake Superior. “She’s got a big personality, and her hair is red, so she came with a warning label,” Kline said of her daughter, laughing.

Aurora is a tiny force, speeding around the family’s apartment, unfazed by the nasal tube that connects her to an oxygen machine. She was born early, at just 24 weeks gestation, weighing less than 2 pounds. No hospital in the Upper Peninsula was equipped to care for a preemie that young. So Aurora and her parents spent seven months at a hospital in Ann Arbor, five hours south of their home. “We didn’t have a reliable vehicle,” Kline said. “We didn’t have a source of income.” Hospital social services provided $19 a day for food, which Kline would save up to buy supplies for Aurora.

When they finally got Aurora home to the Upper Peninsula, their house had been vandalized, the copper pipes stripped out. Espinoza’s team helped them find housing, and drove them to get groceries. Every day is a series of small battles, from finding the medical supplies Aurora needs to figuring out how to get to a revolving door of specialists hundreds of miles away. Still, Aurora’s dad has a job in town. They’ve got family nearby. They’re making it work, Kline said.

But having a program like Rx Kids could have made a huge difference in her daughter’s first year. “Five hundred dollars a month would have been enough to actually be able to get ourselves on our feet,” she said.

After Espinoza left Kline’s apartment, she drove south to her office in Manistique. It was late. Everyone else had gone home. Espinoza sat at her desk, trying to be pragmatic. She knows Rx Kids would not magically solve the lack of child care and housing and all the other things you need to break the cycle of poverty. But it would fix Kline’s car. It would help.

There will undoubtedly be critics, Espinoza said — people who believe parents will just use this money to buy drugs. “‘What did they do to earn it?’” she imagined them saying. “‘You’re just giving them free money, and they didn’t do anything to get it?’ Because they don’t understand. They don’t understand the barriers. They don’t understand that sometimes the choice isn’t always yours. Like, I’ve talked to moms who desperately want to go to work, and they want to support their family, but there’s no child care. And so they have no other choice.”

Espinoza recently got an update from Rx Kids’ Hanna: Largely because of private foundations outside the Upper Peninsula, the program has raised enough money to fund a “perinatal” version of Rx Kids for five counties in the eastern Upper Peninsula. The perinatal program would provide the $1,500 payment mid-pregnancy, plus $500 a month for a baby’s first three months, rather than the full year. “But the goal really is the full program, so we are still raising money,” Hanna said via email.

“I think it’s fantastic if we even just get the perinatal version to start,” Espinoza said. “That’s more than we had before.”

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

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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SACRAMENTO, Calif. — California public health officials are dipping into state and federal stockpiles to equip up to 10,000 farmworkers with masks, gloves, goggles, and other safety gear as the state confirms at least 21 human cases of bird flu as of early November. It’s the latest reminder of the state’s struggle to remain prepared amid multibillion-dollar deficits.

Officials said they began distributing more than 2 million pieces of personal protective equipment in late May, four months before the first human case was confirmed in the state. They said they began ramping up coordination with local health officials in April after bird flu was first detected in cattle in the U.S. Bird flu has now been confirmed at more than 270 dairies in central California, and traces were recently detected at a wastewater sampling site in Los Angeles County. Bird flu was also recently detected in a flock of commercial turkeys in Sacramento County.

California is putting a number of lessons from the covid-19 pandemic to use, such as coordinating emergency response with local health officials and tracking infectious diseases through wastewater surveillance, as the state tries to limit the spread of bird flu to humans. It’s striving to maintain an adequate emergency stockpile to withstand the first wave of any new public health disaster without hemorrhaging the state budget.

“We are far better prepared to respond to a pandemic than we were in 2020,” said Amy Palmer, a spokesperson for the Governor’s Office of Emergency Services.

For instance, before the coronavirus struck in 2020, the state’s emergency supplies stockpile was barely big enough to crowd two basketball courts.

By the time California ramped up its pandemic response, it had enough personal protective equipment and other disaster supplies to fill 52 football fields. California spent $15.6 billion on direct pandemic response during the covid crisis years, much of it provided by the federal government.

Today, the stockpile fits into about 12½ football fields, though it can seesaw from month to month.

According to the state, the current stockpile includes 101 million face masks, 26 million more than the 90-day supply recommended by the state’s pandemic preparedness guideline.

That includes 88 million N95 masks, more than the emergency services agency said was needed last year. The high-efficiency masks are considered crucial to protect against airborne viruses such as covid-19.

Although the state is building up its stockpile, Palmer could not say if the additional masks are related to fears of bird flu, only that planners are always working “to keep pace with the current risk environment.”

The state’s goal, Palmer said, is to have “an initial supply during emergencies to allow us the time to secure resources,” whether through the federal government or by buying more.

There is no indication of spread between humans in the recent California bird flu cases, and health officials say public risk remains low. Human transmission of bird flu is among several worst-case scenarios for a new pandemic, alongside the possibility of a resurgent mutant coronavirus; wider international spread of mpox, Marburg virus, or Ebola; or an entirely new virus for which there initially is no immunity or vaccine.

Yet, health officials nationwide have struggled to track bird flu transmission. And California has a history of swinging back and forth on preparedness.

Republican Gov. Arnold Schwarzenegger ordered an increase in California’s pandemic preparedness in 2006 in response to an earlier threat from bird flu. That included three mobile hospitals that could immediately be deployed during disasters.

Gov. Jerry Brown, a Democrat, ended the program in 2011 as state finances went bust. By the time covid struck, the state released 21 million N95 masks, some so old they were past their expiration date.

Now hospitals are required to maintain their own three-month supply of masks, gowns, and other personal protective equipment under a state law passed in 2020. California’s aerosol transmissible disease standard also uniquely requires hospitals and other high-risk workplaces to follow precautions such as using negative pressure isolation rooms and the highest level of protective equipment until more is known about a new pathogen.

“It is difficult to overstate the level of unpreparedness exhibited by hospitals both in and outside of California in dealing with the 2020 outbreak of COVID-19,” according to a legislative analysis. “Harrowing images of nurses walking the corridors of hospitals in makeshift masks and garbage bags became commonplace.”

California Hospital Association spokesperson Jan Emerson-Shea said hospitals “continuously prepare to respond to all types of disasters, including outbreaks of transmissible viruses.”

In addition, Palmer said California has five mobile hospitals acquired from the federal government, though they got little use during the pandemic. She said they have to be maintained, such as making sure pulse oximeters have working batteries.

But, once again, the current deficit has the state trying to strike a balance.

While lawmakers rejected most of Democratic Gov. Gavin Newsom’s $300 million proposed cut to public health funding, the state slashed funding for its stockpile of personal protective equipment by one-third a year ago after it determined that no additional covid-related purchases were necessary, according to the Department of Finance. California eliminated funding this year for eight 53-foot-long trailers that would have moved stockpiled items between warehouses. It’s also cutting nearly $40 million over the next four years from its $175 million disaster stockpile budget.

The state’s preparedness wasn’t good enough for Californians Against Pandemics, which gathered more than 1 million signatures to put a ballot measure before voters in November. The measure would have increased taxes on people with incomes over $5 million and used that money for pandemic prevention and response.

But that effort collapsed after one of its key financial supporters, former cryptocurrency executive Sam Bankman-Fried, was convicted of defrauding customers and investors. In exchange for initiative backers dropping the measure, state officials agreed to broaden the scope of the California Initiative to Advance Precision Medicine, which was created in 2015 to focus on developing new medicines and therapies, to include technologies for preventing another pandemic.

“By harnessing the power of precision medicine, California is moving to the forefront of pandemic preparedness and prevention,” Newsom said at the time.

Rodger Butler, a spokesperson for the state Health and Human Services Agency, said it’s unclear if the precision medicine initiative will receive additional funding.

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For Native American communities in the Great Plains, data paints a clear picture of the devastation caused by an ongoing syphilis outbreak.

According to the South Dakota Department of Health, 649 cases of syphilis have been documented this year. Of those, 546 were diagnosed among Native Americans, who make up only 9 percent of the state’s population.

“It’s completely preventable and curable, so something has gone horribly wrong that this has occurred,” said Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation.

This year, the tribal leaders’ health board asked the U.S. Department of Health and Human Services to declare the outbreak a public health emergency, which could ease access to other resources that tribal leaders asked for, including public health workers, data, national stockpile supplies and funding.

According to the Great Plains Tribal Epidemiology Center, syphilis rates among Native Americans in its region, which covers Iowa, Nebraska, North Dakota and South Dakota, soared by 1,865 percent from 2020 to 2022 — more than 10 times the increase nationwide during the same period. The epidemiology center also found that 1 in 40 Native American babies born in the region in 2022 had a potentially life-threatening syphilis infection.

O’Connell said HHS officials’ response to the Great Plains Tribal Leaders’ Health Board fell short of fulfilling its requests. More recently, the National Indian Health Board also sent a letter to the agency urging it to declare a public health emergency for all tribes in the United States.

Months later, no public health emergency has been declared, and tribal and health leaders are still responding to the outbreak with limited resources.

HHS officials pointed to their work in forming a task force and hosting workshops to guide tribes’ response to the outbreak. But tribal leaders insist they need greater federal investment.

“We know how to address this, but we do need extra support and resources in order to do it,” O’Connell said.

Still, some health officials serving Native American communities say they’re seeing improvement. Natalie Holt, a physician and the chief medical officer for the Great Plains Area Indian Health Service, one of 12 regional divisions of the federal agency responsible for providing health care to Native Americans, said new cases have been declining.

Indian Health Service facilities in the region have averaged more than 1,300 syphilis tests monthly, she said, and cases are down from 93 in January to 31 in October.

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In the two counties around nurse practitioner Samantha Marsee’s clinic in rural northeastern Maryland, there’s not a single clinic that provides abortions. And until recently, Marsee herself wasn’t trained to treat patients who wanted to end a pregnancy.

“I didn’t really have a lot of knowledge about abortion care,” she said.

After Roe v. Wade was overturned, she watched state after state ban abortion, and Marsee decided to take part in the first class of a new training program offered by the University of Maryland School of Medicine and the University of Maryland-Baltimore.

Marsee learned how to administer medication abortion pills, procedural abortions, and highly effective birth control methods, including hormonal implants and intrauterine devices.

She cares for patients with all sorts of everyday ailments and health conditions, including pregnancy. “I do have patients who come in for confirmation of pregnancies and then disclose they don’t want to continue with the pregnancy for whatever reason,” Marsee said.

Now, with her new training, she can help.

Expanding the pool of health care providers with reproductive health care skills outside of the state’s urban centers is vital, said Mary Jo Bondy, associate dean of the School of Graduate Studies at the University of Maryland-Baltimore. She helped create the new training program.

In 2022, Maryland lawmakers passed the Abortion Care Access Act, expanding the type of medical care nurse practitioners, physician assistants, and certified nurse-midwives could offer, including abortion, and the training program “prioritized that group,” Bondy said.

Those types of professionals have long provided abortions to rural patients in other states, Bondy said, and “we have proof that receiving this care from an advanced practice clinician is safe.”

As many as 120 health care providers will be trained over the next two years. Some participants have said they are returning to communities that are hostile to abortion rights.

On Nov. 5, voters approved a ballot measure to protect reproductive rights in the Maryland Constitution, by an overwhelming margin, preliminary results show. The state is widely considered a safe haven for patients who live in states with abortion bans. The number of abortions in Maryland increased 29% from 2019 to 2023, driven largely by out-of-state residents. But one training participant, a family physician from the Eastern Shore, said providing abortions makes her concerned for her physical safety and asked not to be identified.

“The rural catchment and politics really drive it either out or at least into the quiet,” she said of abortion availability where she lives. She worries that her employer will question the prescriptions she writes for medication abortion pills and said pharmacists often refuse to give the medication to her patients.

Even in Maryland, pharmacists are allowed to refuse to dispense medication abortion pills.

As more health care providers are trained in abortion care, they need help from the state’s medical schools and health officials to overcome these barriers, the family physician said. She wants help with “access to medication and pushing in some ways the hand of our employers, or normalizing, ‘This is just health care.’”

For Marsee, the next step is to figure out how to let her patients know she can provide abortions. She plans to tell her current patients and hopes they’ll tell others.

“I’m working on a way to let people know that I’m here and can provide it,” Marsee said. “This is a conservative area, so it’s walking that line. I want people to know I’m here, but I don’t want to cause too much outrage and attention.”

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Jason Farned and his team at the San Gabriel Valley Mosquito and Vector Control District had spent years preparing for the likely arrival of dengue, a dangerous virus typically found in tropical climates outside the mainland United States.

They’d watched nervously as invasive Aedes mosquito species that can carry the virus appeared in Los Angeles about a decade ago and began to spread, likely introduced by international trade and enticed to stay by a warming climate that makes it easier for mosquitoes to thrive.

Then, in October 2023, an email came from the Pasadena Public Health Department: A person in the city had contracted California’s first-known case of dengue from a local mosquito.

“When it happens in real time, real life, you know, it is very different,” Farned said. “There’s no room for error here. We have to be quick and effective in identifying the most at-risk areas and responding.”

Across California, public health and pest control authorities are facing a new reality as the Aedes mosquitoes bring the threat of dengue and potentially other tropical diseases, such as chikungunya, Zika, and yellow fever, that were once of concern only to international travelers.

So far this year, authorities have identified at least 13 cases of locally acquired dengue, up from two in 2023, with 11 in Los Angeles County and two in the San Diego area. The Aedes mosquitoes spread the disease by biting an infected person and then biting a previously uninfected person.

Mosquito-borne viral illnesses, chiefly malaria, have long been a scourge in many tropical regions, and preventive measures focus mainly on controlling the mosquitoes. The Aedes mosquitoes, known for their aggressive, daytime biting, are now present in at least 24 California counties. They breed in water, in as little as a capful.

“When these locally acquired cases occur, … we want to act on them pretty quickly so that it does not become an endemic infection in our region,” said Aiman Halai, director of the Los Angeles County Department of Public Health’s Vector-Borne Disease Unit.

California officials are hoping to beat back dengue by expanding mosquito surveillance, developing detailed response plans for mosquito outbreaks and human infections, and improving data sharing across agencies. They’re also going door to door in neighborhoods to remove standing water sources and apply pesticides. Residents are advised to wear bug repellent and long-sleeved clothing and control mosquitoes around their homes to prevent biting and infection.

Some vector control districts — local agencies charged with managing disease-bearing insects and other animals — are even growing their own sterile mosquitoes to release into the wild to reduce local Aedes populations.

Outside of California, locally acquired dengue cases have occurred in Arizona, Florida, Hawaii, and Texas. In March, Puerto Rico declared a public health emergency after a spike in cases there, where dengue is endemic. Meanwhile, worldwide dengue cases are on track to more than double this year, with 12.3 million documented through August, up from 6.5 million in 2023, according to the World Health Organization.

Most people who get dengue have no symptoms, but about 1 in 4 become ill. A mild case can feel like the flu and usually dissipates within a week, but about 5% of those infected with dengue become very sick, with symptoms that can include internal bleeding, shock, and organ failure, and the most severe cases can be fatal. People infected a second time are at especially high risk.

There is no specific medication to treat dengue. Japanese pharmaceutical company Takeda developed a vaccine that has won approval in Europe and elsewhere, though it withdrew an application to the FDA last year, saying it could not provide data requested by the agency. A vaccine developed in Brazil could soon be approved for use in that country. But the only FDA-approved vaccine is authorized only for children in narrow circumstances and will soon go out of production.

At the San Gabriel Valley Mosquito and Vector Control District, one of five agencies tasked with mosquito control across Los Angeles County, public health workers have put together an Aedes and dengue response plan based on updated guidance from the state.

When they discover a case, they identify all the properties and public spaces within 150 meters — roughly the distance an Aedes mosquito can fly — and then go door to door, removing standing water, where mosquitoes can breed; applying pesticides from backpacks or trucks; and educating residents about the risk of dengue and how to protect themselves. District officials also set traps to catch mosquitoes so they can figure out their prevalence and test them for dengue.

Since local dengue cases began to appear, the district has gotten more efficient in implementing its response plan, district manager Farned said. All full-time and seasonal staff members — about 40 people — have been trained in a variety of tasks, such as door-to-door education and coming in during off-hours to answer phones, Farned said.

While vector control teams respond to cases, separate teams from the Los Angeles County Public Health Department go door to door in the affected neighborhood when they determine that a dengue case was locally acquired, surveying residents and offering free dengue testing to try to identify others who may be infected.

Additionally, the department has been sending alerts to local health providers, advising them to be on the lookout for possible dengue cases and test for it when suspected, even among patients who haven’t traveled to a place where dengue is endemic. This advice follows a national alert put out by the Centers for Disease Control and Prevention in June. Health authorities are also emphasizing that people who travel to locations with dengue should continue to wear mosquito repellent when they get home, to reduce the risk of spreading the disease to local mosquitoes.

As happened during the covid-19 pandemic, mistrust of public health authorities can make outreach challenging for health and pest control teams in some neighborhoods, officials said.

Pest control officers can seek a warrant to enter and treat a property for mosquitoes if a homeowner refuses to give access, said Jeremy Wittie, a former president and the legislative committee chair for the Mosquito and Vector Control Association of California, which represents the more than 70 mosquito and vector control agencies in California. This is easier in districts such as his, the Coachella Valley Mosquito and Vector Control District, that have warrants giving officials standing permission to enter a property after 24 hours without needing to ask a judge.

In counties such as Santa Clara, where Aedes mosquitoes first appeared in 2022 but have yet to establish themselves, officials hope to suppress the threat with stepped-up surveillance, speedy eradication efforts, and more public outreach. Santa Clara County Vector Control District Manager Nayer Zahiri said the aim was to eliminate Aedes but acknowledged the climate conditions that encourage the mosquitoes’ spread are “totally out of our control.”

In some counties with pervasive mosquito problems, including San Diego, San Joaquin, and Stanislaus, officials have sprayed pesticides from planes or helicopters to address spikes in local mosquito populations, Wittie said. These sprayings typically aim to control the larvae of a different type of mosquito, Culex, that can spread West Nile virus and which — unlike the Aedes species, which thrive in urban habitats — are found in harder-to-reach rural environments, Wittie said.

Aerial spraying hasn’t been deployed to address the recent dengue outbreaks, which are in more urban environments where spraying from trucks is a better option, Wittie said. Drones are another option that some vector control authorities are exploring.

Some districts are experimenting with the decades-old sterile insect technique, commonly used for other pests such as fruit and screwworm flies, in which males are sterilized with radiation and then released to mate, resulting in eggs that don’t hatch. (Female mosquitoes are separated from the males before sterilization and not released. Only the females bite).

Ultimately, the public will have to take the mosquito threat more seriously and contribute to prevention efforts, Wittie said. “This mosquito is going to be here to stay, unfortunately. I hope it kind of wakes people up and pushes them to be part of that solution.”

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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Jason Farned y su equipo en el Distrito de Control de Mosquitos y Vectores del Valle de San Gabriel habían pasado años preparándose para la posible llegada del dengue, un virus peligroso que normalmente se encuentra en climas tropicales fuera de Estados Unidos continental.

Habían observado con nerviosismo cómo las especies de mosquitos Aedes invasores, que pueden transmitir el virus, aparecieron en Los Ángeles hace aproximadamente una década y comenzaron a propagarse, tal vez introducidos por el comercio internacional. Llegaron para quedarse, alentados por el calentamiento climático que facilita la supervivencia de estos insectos.

Entonces, en octubre de 2023, llegó un correo electrónico del Departamento de Salud Pública de Pasadena: una persona en la ciudad había contraído el primer caso conocido de dengue en California de un mosquito local.

“Cuando ocurre en tiempo real, en la vida real, sabes que es muy diferente”, dijo Farned. “Aquí no hay margen de error. Tenemos que ser rápidos y efectivos para identificar las áreas de mayor riesgo y responder”.

En toda California, las autoridades de salud pública y de control de plagas enfrentan una nueva realidad: los mosquitos Aedes traen la amenaza del dengue y potencialmente otras enfermedades tropicales, como el chikungunya, el Zika y la fiebre amarilla, que antes solo preocupaban a los viajeros internacionales.

En lo que va del año, las autoridades han identificado al menos 13 casos de dengue de transmisión local, frente a dos en 2023, con 11 en el condado de Los Ángeles y dos en el área de San Diego. Los mosquitos Aedes transmiten la enfermedad al picar a una persona infectada y luego picar a una persona que previamente no estaba infectada.

Las enfermedades virales transmitidas por mosquitos, principalmente la malaria, han sido una plaga en muchas regiones tropicales, y las medidas preventivas se centran principalmente en controlar a los mosquitos.

Los mosquitos Aedes, conocidos por sus picaduras agresivas durante el día, están ahora presentes en al menos 24 condados de California. Se reproducen en agua, en tan solo la tapa de botella.

“Cuando ocurren estos casos de transmisión local, … queremos actuar rápidamente para que no se convierta en una infección endémica en nuestra región”, dijo Aiman Halai, director de la Unidad de Enfermedades Transmitidas por Vectores del Departamento de Salud Pública del Condado de Los Ángeles.

Las autoridades de California esperan vencer al dengue expandiendo la vigilancia de los mosquitos, desarrollando planes de respuesta detallados para brotes de mosquitos e infecciones humanas y mejorando el intercambio de datos entre agencias.

También van de puerta en puerta en los vecindarios para eliminar fuentes de agua estancada y aplicar pesticidas. Se aconseja a los residentes que usen repelente de insectos y ropa de manga larga, y que controlen los mosquitos alrededor de sus hogares para evitar picaduras e infecciones.

Algunos distritos de control de vectores —agencias locales encargadas de manejar insectos y otros animales portadores de enfermedades— incluso están criando sus propios mosquitos estériles para liberarlos en la naturaleza y reducir las poblaciones locales de Aedes.

Fuera de California, se han reportado casos de dengue de transmisión local en Arizona, Florida, Hawaii y Texas. En marzo, Puerto Rico declaró una emergencia de salud pública tras un aumento de casos en la isla, en donde el dengue es endémico.

Mientras tanto, los casos de dengue a nivel mundial están en camino de más que duplicarse este año, con 12,3 millones documentados hasta agosto, frente a 6,5 millones en 2023, según la Organización Mundial de la Salud (OMS).

La mayoría de las personas que desarrollan dengue no presentan síntomas, pero alrededor de 1 de cada 4 enferma. Un caso leve puede sentirse como una gripe y generalmente desaparece en una semana, pero alrededor del 5% de los infectados se enferman gravemente, con síntomas que pueden incluir sangrado interno, shock y falla orgánica; los casos más graves pueden ser fatales. Las personas infectadas una segunda vez tienen un riesgo especialmente alto.

No existe un medicamento específico para tratar el dengue. La farmacéutica japonesa Takeda desarrolló una vacuna que ha sido aprobada en Europa y en otros lugares, aunque retiró una solicitud a la Administración de alimentos y Medicamentos de Estados Unidos (FDA) el año pasado, diciendo que no podía proporcionar los datos solicitados por la agencia.

Una vacuna desarrollada en Brasil podría ser aprobada pronto para su uso en ese país. Sin embargo, la única vacuna aprobada por la FDA está autorizada solo para niños en circunstancias específicas y pronto dejará de producirse.

En el Distrito de Control de Mosquitos y Vectores del Valle de San Gabriel, una de las cinco agencias encargadas del control de mosquitos en el condado de Los Ángeles, los trabajadores de salud pública han elaborado un plan de respuesta para el Aedes y dengue basado en la guía actualizada del estado.

Cuando descubren un caso, identifican todas las propiedades y espacios públicos dentro de los 150 metros —aproximadamente la distancia que puede volar un mosquito Aedes— y luego van de puerta en puerta, eliminando agua estancada donde los mosquitos pueden reproducirse; aplicando pesticidas desde mochilas o camiones; y educando a los residentes sobre el riesgo de dengue y cómo protegerse.

Los funcionarios del distrito también colocan trampas para capturar mosquitos y evaluar su prevalencia y analizarlos en busca de dengue.

Desde que comenzaron a aparecer casos locales de dengue, se han vuelto más eficientes en la implementación de su plan de respuesta, dijo Farned, gerente del distrito. Se ha capacitado a todo el personal a tiempo completo y temporal —unas 40 personas— en una variedad de tareas, como la educación puerta a puerta y responder llamadas fuera del horario laboral, explicó Farned.

Mientras los equipos de control de vectores responden a los casos, otros equipos del Departamento de Salud Pública del Condado de Los Ángeles van de puerta en puerta en el vecindario afectado cuando determinan que un caso de dengue fue adquirido localmente, encuestando a los residentes y ofreciendo pruebas gratuitas de dengue para tratar de identificar a otras personas que puedan estar infectados.

Además, el departamento ha estado enviando alertas a los proveedores de salud locales, aconsejándoles que estén atentos a posibles casos de dengue y lo examinen cuando se sospeche, incluso entre pacientes que no hayan viajado a un lugar donde el dengue es endémico.

Este consejo sigue una alerta nacional emitida por los Centros para el Control y Prevención de Enfermedades (CDC) en junio. Las autoridades sanitarias también están enfatizando que las personas que viajan a lugares con dengue deben continuar usando repelente de mosquitos cuando regresen a casa, para reducir el riesgo de propagar la enfermedad a los mosquitos locales.

Como sucedió durante la pandemia de covid-19, la desconfianza hacia las autoridades de salud pública puede dificultar el alcance comunitario para los equipos de salud y control de plagas en algunos vecindarios, dijeron las autoridades.

Los oficiales de control de plagas pueden solicitar una orden para entrar y tratar una propiedad en busca de mosquitos si un propietario se niega a dar acceso, dijo Jeremy Wittie, ex presidente y líder del comité legislativo de la Asociación de Control de Mosquitos y Vectores de California, que representa a las más de 70 agencias especializadas en el estado.

Esto es más fácil en distritos como el suyo, el Distrito de Control de Mosquitos y Vectores del Valle de Coachella, que tienen órdenes que otorgan permiso permanente para entrar en una propiedad después de 24 horas sin necesidad de pedirlo a un juez.

En condados como Santa Clara, donde los mosquitos Aedes aparecieron por primera vez en 2022 pero aún no se han establecido, las autoridades esperan reprimir la amenaza con una mayor vigilancia, esfuerzos de erradicación rápidos y más divulgación pública.

El gerente del Distrito de Control de Vectores del Condado de Santa Clara, Nayer Zahiri, dijo que el objetivo era eliminar los Aedes, pero reconoció que las condiciones climáticas que favorecen la propagación de los mosquitos están “totalmente fuera de nuestro control”.

En algunos condados con problemas generalizados de mosquitos, incluidos San Diego, San Joaquín y Stanislaus, las autoridades han rociado pesticidas desde aviones o helicópteros para atacar picos en las poblaciones locales de mosquitos, dijo Wittie. Tradicionalmente, estas fumigaciones buscan controlar las larvas de otro tipo de mosquito, Culex, que puede transmitir el Virus del Nilo Occidental y que, a diferencia de las especies de Aedes, que prosperan en hábitats urbanos, se encuentran en ambientes rurales de difícil acceso, dijo Wittie.

La fumigación aérea no se ha implementado para abordar los recientes brotes de dengue, que se encuentran en entornos más urbanos donde el rociado desde camiones es una mejor opción, explicó Wittie. Los drones son otra alternativa que algunas autoridades de control de vectores están explorando.

Algunos distritos están experimentando con la técnica de insectos estériles, una estrategia utilizada por décadas para otras plagas como las moscas de la fruta y los gusanos barrenadores, en la que los machos son esterilizados con radiación y luego liberados para aparearse, lo que resulta en huevos que no abren. (Las moscas hembras se separan de los machos antes de la esterilización y no se liberan. Solo las hembras pican).

En última instancia, el público tendrá que tomar la amenaza de los mosquitos más en serio y contribuir a los esfuerzos de prevención, dijo Wittie. “Desafortunadamente, este mosquito va a quedarse aquí. Espero que esto ponga en alerta a las personas y las impulse a ser parte de la solución”.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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Donald Hammen, 80, and his longtime next-door neighbor in south Minneapolis, Julie McMahon, have an understanding. Every morning, she checks to see whether he’s raised the blinds in his dining room window. If not, she’ll call Hammen or let herself into his house to see what’s going on.

Should McMahon find Hammen in a bad way, she plans to contact his sister-in-law, who lives in a suburb of Des Moines. That’s his closest relative. Hammen never married or had children, and his younger brother died in 2022.

Although Hammen lives alone, a web of relationships binds him to his city and his community — neighbors, friends, former co-workers, fellow volunteers with an advocacy group for seniors, and fellow members of a group of solo agers. McMahon is an emergency contact, as is a former co-worker. When Hammen was hit by a car in February 2019, another neighbor did his laundry. A friend came over to keep him company. Other people went on walks with Hammen as he got back on his feet.

Those connections are certainly sustaining. Yet Hammen has no idea who might care for him should he become unable to care for himself.

“I’ll cross that bridge when I come to it,” he told me.

These are fundamental questions for older adults who live alone: Who will be there for them, for matters large and small? Who will help them navigate the ever more complex health care system and advocate on their behalf? Who will take out the garbage if it becomes too difficult to carry? Who will shovel the snow if a winter storm blows through?

American society rests on an assumption that families take care of their own. But 15 million Americans 50 and older didn’t have any close family — spouses, partners, or children — in 2015, the latest year for which reliable estimates are available. Most lived alone. By 2060, that number is expected to swell to 21 million.

Beyond that, millions of seniors living on their own aren’t geographically close to adult children or other family members. Or they have difficult, strained relationships that keep them from asking for support.

These older adults must seek assistance from other quarters when they need it. Often they turn to neighbors, friends, church members, or community groups — or paid help, if they can afford it.

And often, they simply go without, leaving them vulnerable to isolation, depression, and deteriorating health.

When seniors living alone have no close family, can nonfamily helpers be an adequate substitute? This hasn’t been well studied.

“We’re just beginning to do a better job of understanding that people have a multiplicity of connections outside their families that are essential to their well-being,” said Sarah Patterson, a demographer and sociologist at the Institute for Social Research at the University of Michigan.

The takeaway from a noteworthy study published by researchers at Emory University, Johns Hopkins University, and the Icahn School of Medicine at Mount Sinai was this: Many seniors adapt to living solo by weaving together local social networks of friends, neighbors, nieces and nephews, and siblings (if they’re available) to support their independence.

Still, finding reliable local connections isn’t always easy. And nonfamily helpers may not be willing or able to provide consistent, intense hands-on care if that becomes necessary.

When AARP surveyed people it calls “solo agers” in 2022, only 25% said they could count on someone to help them cook, clean, get groceries, or perform other household tasks if needed. Just 38% said they knew someone who could help manage ongoing care needs. (AARP defined solo agers as people 50 and older who aren’t married, don’t have living children, and live alone.)

Linda Camp, 73, a former administrator with the city of St. Paul, Minnesota, who never married or had children, has written several reports for the Citizens League in St. Paul about growing old alone. Yet she was still surprised by how much help she required this summer when she had cataract surgery on both eyes.

A former co-worker accompanied Camp to the surgery center twice and waited there until the procedures were finished. A relatively new friend took her to a follow-up appointment. An 81-year-old downstairs neighbor agreed to come up if Camp needed something. Other friends and neighbors also chipped in.

Camp was fortunate — she has a sizable network of former co-workers, neighbors, and friends. “What I tell people when I talk about solos is all kinds of connections have value,” she said.

Michelle Wallace, 75, a former technology project manager, lives alone in a single-family home in Broomfield, Colorado. She has worked hard to assemble a local network of support. Wallace has been divorced for nearly three decades and doesn’t have children. Though she has two sisters and a brother, they live far away.

Wallace describes herself as happily unpartnered. “Coupling isn’t for me,” she told me when we first talked. “I need my space and my privacy too much.”

Instead, she’s cultivated relationships with several people she met through local groups for solo agers. Many have become her close friends. Two of them, both in their 70s, are “like sisters,” Wallace said. Another, who lives just a few blocks away, has agreed to become a “we’ll help each other out when needed” partner.

“In our 70s, solo agers are looking for support systems. And the scariest thing is not having friends close by,” Wallace told me. “It’s the local network that’s really important.”

Gardner Stern, 96, who lives alone on the 24th floor of the Carl Sandburg Village condominium complex just north of downtown Chicago, has been far less deliberate. He never planned for his care needs in older age. He just figured things would work out.

They have, but not as Stern predicted.

The person who helps him the most is his third wife, Jobie Stern, 75. The couple went through an acrimonious divorce in 1985, but now she goes to all his doctor appointments, takes him grocery shopping, drives him to physical therapy twice a week and stops in every afternoon to chat for about an hour.

She’s also Gardner’s neighbor — she lives 10 floors above him in the same building.

Why does she do it? “I guess because I moved into the building and he’s very old and he’s a really good guy and we have a child together,” she told me. “I get happiness knowing he’s doing as well as possible.”

Over many years, she said, she and Gardner have put their differences aside.

“Never would I have expected this of Jobie,” Gardner told me. “I guess time heals all wounds.”

Gardner’s other main local connections are Joy Loverde, 72, an author of elder-care books, and her 79-year-old husband, who live on the 28th floor. Gardner calls Loverde his “tell it like it is” friend — the one who helped him decide it was time to stop driving, the one who persuaded him to have a walk-in shower with a bench installed in his bathroom, the one who plays Scrabble with him every week and offers practical advice whenever he has a problem.

“I think I would be in an assisted living facility without her,” Gardner said.

There’s also family: four children, all based in Los Angeles, eight grandchildren, mostly in L.A., and nine great-grandchildren. Gardner sees most of this extended clan about once a year and speaks to them often, but he can’t depend on them for his day-to-day needs.

For that, Loverde and Jobie are an elevator ride away. “I’ve got these wonderful people who are monitoring my existence, and a big-screen TV, and a freezer full of good frozen dinners,” Gardner said. “It’s all that I need.”

As I explore the lives of older adults living alone in the next several months, I’m eager to hear from people who are in this situation. If you’d like to share your stories, please send them to khn.navigatingaging@gmail.com.

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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