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Updated: 18 hours 8 min ago

Sports Programs in States in Northern Climes Face a New Opponent: Scorching Septembers

September 30, 2022

BIGFORK, Mont. — On a recent afternoon, it was a crisp 70 degrees on the football field at the high school in this northwestern Montana community less than 200 miles south of the U.S.-Canada border.

Vikings head coach Jim Benn was running his team through drills in the pristine fall weather, without much interruption. Just a couple of weeks earlier, though, players needed frequent water breaks as they sweated through temperatures in the low to mid-90s, about 15 degrees higher than average for the time of year.

Although temperatures have started to drop now that autumn is underway, Montana and many other states in the northern U.S. are getting hotter — and staying hot for longer. August is when many high school sports ramp up, and this year’s was either the hottest on record or close to it for many communities across Montana, according to the National Weather Service and other meteorologists. The heat wave stretched into September, and at least six Montana cities broke the 100-degree mark during the first half of the month.

This August was the hottest on record for the nearby states of Idaho, Washington, and Oregon. Nationwide, this summer was the third-hottest on record, according to the National Oceanic and Atmospheric Association.

Health experts and researchers say states — especially the states in the northern U.S., such as Idaho, Maine, Montana, and North Dakota — aren’t adapting fast enough to keep high school athletes safe. Students and their families have sued schools, accusing them of not doing enough to protect athletes. Many states that have taken action did so only after an athlete died.

“Between high school and college, we’re losing roughly six athletes each year to exertional heatstroke, and the majority of those are high school athletes,” said Rebecca Stearns, chief operating officer at the University of Connecticut’s Korey Stringer Institute, which is named after a Minnesota Vikings player who died from heatstroke in 2001. The institute studies and tries to prevent the condition.

The true number of heat-related deaths could be higher, she said, because death certificates aren’t always accurately filled out. Exertional heat illness is the second-leading cause of death for high school and college athletes, behind cardiac arrest, she said.

In Bigfork, Benn said he hadn’t seen one of his athletes experience an exertional heat illness — such as heat exhaustion or heatstroke, which can cause fainting, vomiting, and even death — during his nearly 30-year coaching career in Montana until last year. An athlete became overheated at an early summer football camp during the record-shattering 2021 heat wave.

“We immediately got water on him, got him cooled down,” he said.

The player recovered after he was sprayed with a hose. Benn said he didn’t have an immersion tub filled with ice water on hand, which is what Stearns said is the recommended treatment.

“It is exactly why we need standard policies that have medical best practices incorporated,” Stearns said.

The Korey Stringer Institute ranks all 50 states and Washington, D.C., based on how well they follow best practices for preventing and responding to exertional heat illness among high school athletes, as well as other health risks such as cardiac arrest. Montana is 48th on the list, followed by Minnesota, Maine, and California.

California is last, according to the institute’s report, because it’s the only state that doesn’t regulate high school athletic trainers, which are generally responsible for the health and safety of athletes. Stearns said the institute is working with California sports officials who are pushing for laws that require licensing of athletic trainers.

States in the northern U.S. dominate the bottom third of the institute’s rankings. Stearns said many states the institute has approached about improving heat safety think it isn’t an issue or resist some policies because implementing them could come with a hefty price tag.

But some of the efforts don’t cost a penny, she said. At Bigfork High School, for example, Benn has implemented a three-day acclimatization period, without football pads, when his players return to the field in early August. “That’s really low-hanging fruit, in my perspective,” Stearns said.

Stearns added that most heat-related illnesses occur during the first days of practice, which are typically the hottest and when athletes are not accustomed to exerting themselves in the heat. But she said the state’s high school sports association should mandate acclimatization periods.

Montana and many other states also don’t have a system dictating when practices need to be modified — for example, by removing pads or reducing the length and the number of workouts — or canceled altogether, said Stearns. Policies that require an emergency plan for responding to an exertional heat illness are lacking in many northern states, as well.

Stearns and other researchers, such as Bud Cooper at the University of Georgia, said states should use what’s known as the “wet bulb globe temperature” — which accounts for air temperature, humidity, and radiant heat from surfaces such as turf that absorb sunlight — to make those determinations, rather than the heat index. The heat index doesn’t account for radiant heat, which increases the risk of developing heat illness. The foundation of the National Federation of State High School Associations said in February that it was sending 5,000 of the special thermometers to high schools across the country.

Stearns said that research suggests acclimatization periods reduce the number of exertional heat illnesses by as much as 55% and that states that have used the wet bulb globe temperature to mandate changes to practice have seen an 80% reduction.

In Georgia, Cooper’s work documenting heat-related deaths among high school athletes led to sweeping policy changes in 2012. Since the policy shift, Georgia has gone from being the state with the highest number of heat-related deaths among high school football players to having no deaths.

Researchers such as Cooper have begun to provide regional policy guidelines based on the local average wet bulb globe temperatures to help states understand the risks for high school athletes and give them a starting point for making policy changes.

New Jersey was among the early adopters of the wet bulb system among states in the northern U.S. when it approved a law in 2020 requiring school districts to buy the thermometers. The state also requires hundreds of schools to put cold immersion tubs on-site when temperatures reach a certain level. The state is now second in the institute’s rankings of sports safety policies, behind Florida and ahead of Georgia.

In the Pacific Northwest, Oregon and Washington have policies that mandate changes to school sports practices based on the heat index, not the wet bulb globe temperature. Heat and sports safety researchers say that’s better than nothing.

The Montana High School Association, which regulates high school athletics, has implemented heat guidance that allows referees to call for extra breaks during football or soccer games, said executive director Brian Michelotti. The association also asks other sports, such as cross-country running, to schedule meets early in the day.

While Montana health officials say the state has never documented a death related to heat illness among the state’s high school athletes, the historic heat waves over the past two summers have athletic officials considering additional precautions. “It really has triggered us to have more discussions about that and really come back and revisit with some sport science committees,” Michelotti said.

He said any policy changes would have to be approved by the association’s seven-member board and wouldn’t happen until at least next year.

Heat and sports safety experts such as Stearns at the Korey Stringer Institute said adding statewide policies and mandates saves lives by ensuring that all coaches and schools are following best practices before a death happens.

“One life is too much a price for all of the games in a season,” she said.

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

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Turned Away From Urgent Care — And Toward a Big ER Bill

September 29, 2022

Frankie Cook remembers last year’s car crash only in flashes.

She was driving a friend home from high school on a winding road outside Rome, Georgia. She saw standing water from a recent rain. She tried to slow down but lost control of her car on a big curve. “The car flipped about three times,” Frankie said. “We spun around and went off the side of this hill. My car was on its side, and the back end was crushed up into a tree.”

Frankie said the air bags deployed and both passengers were wearing seat belts, so she was left with just a headache when her father, Russell Cook, came to pick her up from the crash site.

Frankie, then a high school junior, worried she might have a concussion that could affect her performance on an upcoming Advanced Placement exam, so she and her father decided to stop by an urgent care center near their house to get her checked out. They didn’t make it past the front desk.

“‘We don’t take third-party insurance,’” Russell said the receptionist at Atrium Health Floyd Urgent Care Rome told him, though he wasn’t sure what she meant. “She told me, like, three times.”

The problem didn’t seem to be that the clinic lacked the medical expertise to evaluate Frankie. Rather, the Cooks seemed to be confronting a reimbursement policy that is often used by urgent care centers to avoid waiting for payments from car insurance settlements.

Russell was told to take Frankie to an emergency room, which by law must see all patients regardless of such issues. The nearest one, at Atrium Health Floyd Medical Center, was about a mile down the road and was owned by the same hospital system as the urgent care center.

There, Russell said, a doctor looked Frankie over “for just a few minutes,” did precautionary CT scans of her head and body, and sent her home with advice to “take some Tylenol” and rest. She did not have a concussion or serious head injury and was able to take her AP exam on time.

Then the bill came.

The Patient: Frankie Cook, 18, now a first-year college student from Rome, Georgia.

Medical Services: A medical evaluation and two CT scans.

Service Provider: Atrium Health Floyd, a hospital system with urgent care centers in northwestern Georgia and northeastern Alabama.

Total Bill: $17,005 for an emergency room visit; it was later adjusted to $11,805 after a duplicate charge was removed.

What Gives: The Cooks hit a hazard in the health care system after Frankie’s car struck that tree: More and more hospital systems own urgent care centers, which have limits on who they treat — for both financial and medical reasons.

Russell was pretty upset after he received such a large bill, especially when he had tried to make a quick, inexpensive trip to the clinic. He said Frankie’s grandmother was seen at an urgent care center after a car wreck and walked out with a bill for just a few hundred dollars.

“That’s kind of what I was expecting,” he said. “She just really needed to be looked over.”

So why was Frankie turned away from an urgent care center?

Lou Ellen Horwitz, CEO of the Urgent Care Association, said it’s a pretty standard policy for urgent care centers not to treat injuries that result from car crashes, even minor ones. “Generally, as a rule, they do not take care of car accident victims regardless of the extent of their injuries, because it is going to go through that auto insurance claims process before the provider gets paid,” she said.

Horwitz said urgent care centers — even ones owned by big health systems — often operate on thin margins and can’t wait months and months for an auto insurance company to pay out a claim. She said “unfortunately” people tend to learn about such policies when they show up expecting care.

Fold in the complicated relationship between health and auto insurance companies and you have what Barak Richman, a health care policy professor at Duke University’s law school, called “the wildly complex world that we live in.”

“Each product has its own specifications about where to go and what it covers. Each one is incredibly difficult and complex to administer,” he said. “And each one imposes mistakes on the system.”

Atrium Health did not respond to repeated requests for comment on Frankie’s case.

Horwitz dismissed the idea that a health system might push people in car wrecks from urgent care centers to emergency rooms to make more money off them. Still, auto insurance generally pays more than health insurance for the same services.

Richman remained skeptical.

“At the risk of sounding a little too cynical, there are always dollar signs when a health care provider sees a patient come through the door,” Richman said.

Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School, said it was likely strategic for the urgent care center to be right down the street from the ER. Part of the strategy makes sense medically, he said, “because if a bad thing happens, you want to get them to some place with more skill really quickly.”

But he also said urgent care centers are “one of the most effective ways” for a health system to generate new revenue, creating a pipeline of new patients to visit its hospitals and later see doctors for testing and follow-up.

Mehrotra also said urgent care centers are not bound by the Emergency Medical Treatment and Labor Act, a federal law known as EMTALA that requires hospitals to stabilize patients regardless of their ability to pay.

At the time of Frankie’s visit, both the urgent care center and emergency room were owned by Floyd health system, which operated a handful of hospitals and clinics in northwestern Georgia and northeastern Alabama. Since then, Floyd has merged with Atrium Health — a larger, North Carolina-based company that operates dozens of hospitals across the Southeast.

Frankie got a CT scan of her head and body in the emergency room, tests KHN confirmed she couldn’t have gotten at the urgent care center regardless of whether the test was medically necessary or just part of a protocol for people in car wrecks who complain of a headache.

Resolution: Sixteen months have passed since Frankie Cook’s hospital visit, and Russell has delayed paying any of the bill on advice he got from a family friend who’s an attorney. After insurance covered its share, the Cooks’ portion came to $1,042.

Getting to that number has been a frustrating process, Russell said. He heard about the initial $17,005 bill in a letter from a lawyer representing the hospital — another unnerving wrinkle of Frankie’s care resulting from the car wreck. The Cooks then had to pursue a lengthy appeal process to get a $5,200 duplicate charge removed from the bill.

Anthem Blue Cross Blue Shield, the Cooks’ insurer, paid $4,006 of the claim. It said in a statement that it’s “committed to providing access to high-quality medical care for our members. This matter was reviewed in accordance with our clinical guidelines, and the billed claims were processed accordingly.”

“It’s not going to put us out on the street,” Russell said of the $1,042 balance, “but we’ve got expenses like everybody else.”

He added, “I would have loved a $200 urgent care visit, but that ship has sailed.”

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The Takeaway: It’s important to remember that urgent care centers aren’t governed by the same laws as emergency rooms and that they can be more selective about who they treat. Sometimes their reasons are financial, not clinical.

It’s not uncommon for urgent care centers — even ones in large health systems — to turn away people who have been in car wrecks because of the complications that car insurance settlements create.

Although urgent care visits are less expensive than going to an emergency room, the clinics often can’t offer the same level of care. And you might have to pay the cost of an urgent care visit just to find out you need follow-up care in the emergency room. Then you could be stuck with two bills.

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

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

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Environmental Justice Leader Says Proposition 30 Would Help Struggling Areas Clear the Air

September 29, 2022

RIALTO, Calif. — Ana Gonzalez grew up watching the Inland Empire transform from citrus groves and grapevines into warehouses and retail distribution centers. The booming region east of Los Angeles now comprises 4.65 million people — and 1 billion square feet of warehouse space.

In 2015, one of those warehouses was built right in front of her old house, blocking her view of her suburban neighborhood. Soon thereafter, her son battled bronchitis and pneumonia. “It got so bad that I ended up taking him to the ER about three to four times a year,” she said. Her son, now 16, like so many others in the region developed asthma due to air pollution. She grew concerned that state policies were overlooking predominantly Hispanic and low-income residents in her community.

Gonzalez, 35, has evolved from a concerned parent into an environmental advocate. Her years as an educator specializing in bilingual and special education, along with a bout of homelessness, fuel her passion for advocating for marginalized communities. Today, she serves as executive director of the Center for Community Action and Environmental Justice, which works on air quality and environmental justice issues on behalf of the region.

Gonzalez and the organization have endorsed Proposition 30 on the November ballot. Funded primarily by the ride-hailing company Lyft, it would impose an additional 1.75% tax on what Californians earn above $2 million per year to fund zero-emission vehicle purchases, electric charging stations, and wildfire prevention programs.

While the initiative would provide subsidies for low-income consumers, it would also subsidize businesses, such as Lyft and other ride-hailing companies, by helping them add clean cars to their fleet. Lyft and other ride-hailing companies are under a mandate to make at least 90% of their vehicle fleets electric by 2030.

The once-popular measure has slipped into toss-up territory. A September poll by the Public Policy Institute of California found 55% of likely voters back the measure, down from 63% in April. And it has divided environmentalists and Democrats.

The measure would generate an estimated $3.5 billion to $5 billion a year, growing over time, according to the nonpartisan Legislative Analyst’s Office. Of that, 45% would primarily subsidize zero-emission vehicles and 35% would boost construction of residential and public charging stations, with at least half of each category directed to low-income households and communities. The remaining 20% would fund wildfire suppression and prevention.

The state Democratic Party and the American Lung Association endorsed Proposition 30, calling it an innovative measure that will expand access to electric vehicle chargers for every Californian, regardless of where they live or work.

But opponents include the California Teachers Association and Democratic Gov. Gavin Newsom, who recently called the measure “a Trojan horse that puts corporate welfare above the fiscal welfare of our entire state.”

California is a leader in pushing — and paying for — clean energy, but the state has been criticized for failing to distribute California’s clean-car subsidies equitably. For example, a 2020 study found wealthier communities in Los Angeles County had more electric and plug-in hybrid vehicles than its disadvantaged communities. And state Assembly member Jim Cooper, a Black Democrat from Elk Grove who will become Sacramento County sheriff next year, has said the state’s push for electric vehicles fuels “environmental racism.”

Gonzalez points to studies, such as a report by Earthjustice, showing how people who live close to warehouses are more likely to be low-income and at higher risk of asthma due to the air pollution generated by diesel trucks.

KHN reporter Heidi de Marco met with Gonzalez at her new home, where a development is proposed behind her property, to discuss why she and her organization endorsed Proposition 30. Gonzalez said she has not been paid by Lyft. The interview has been edited for length and clarity.

Q: Why is Proposition 30 important for your community?

Our families are dying, and nobody is doing anything about it. We’re seeing all the illnesses that are connected to pollution, such as asthma, pneumonia, lung cancer, COPD [chronic obstructive pulmonary disease], and even diabetes.

We just decided to support it because we felt, as a team, that it was the right thing to do given how impacted we are by car and truck pollution. There are layers upon layers of pollution.

Along with the influx of warehouses bringing tons of trucks and their diesel exhaust emissions, the Inland Empire is unique when it comes to pollution. We have all the polluting industries that you can think of, from rail yards bringing more diesel emissions, from the trains to gas plants, which are emitting a lot of pollution. We have toxic landfills, airports, and all the car traffic from the intersections of the 10, 60, 215, and the 15 freeways.

Q: Proposition 30 is funded by Lyft, and Newsom opposes it, calling it a “cynical scheme” by the company to get more clean cars for its fleet. Lyft has been criticized by labor groups for lowering compensation through gig work instead of paying fair wages and benefits. Why are you siding with Lyft?

I see it two ways. One, yes, we need to hold Lyft accountable for the way they treat their drivers and making sure they’re paying them fair wages. I do believe Lyft should do better. But the way that I see it, the fact that they’re transitioning into clean-energy vehicles is where I have to give them props.

Even the developers in our communities have the money to transition their diesel trucks to clean energy, but they’re not investing in that. We have a climate change crisis, and I don’t necessarily see them as the enemy. I see them as folks trying to be part of the solution and transitioning to clean energy.

Q: Will the initiative make a difference when so much of the Inland Empire’s pollution is from Los Angeles and the warehouse industry?

It will make electric vehicles and clean energy vehicles more affordable. And it would create those incentives that our low-income community needs, especially our small-business owners like our self-employed truck drivers that cannot afford to transition to a clean-energy vehicle or a truck. This program would give them those subsidies that they need so they can afford to transition.

This proposition will also give money to expand the clean-vehicle infrastructure that we need. Because here we are telling everybody to change to clean-energy vehicles, but we don’t have the infrastructure. Where are they going to charge their cars when they go to work? Or when they go to school? Or even in their own homes?

So, this campaign would put us in the right direction because I don’t see any other efforts being done, including with the state. I feel like sometimes the governor is a little hypocritical because here he is trying to be a champion for climate change, but he’s not showing a real plan to transition compared to this proposition, where they at least have a plan in place to tackle that transition.

Q: The state and federal governments have already invested billions in clean-car programs. Why is Proposition 30 needed?

It’s going to take a while before the money gets to the appropriate agencies. Another thing that I see that the government fails at is that they always leave out the most affected, marginalized, disenfranchised communities such as the Inland Empire. We have been overseen for so long, and every time the government creates these programs, all this investment and infrastructure, local agencies sometimes don’t know about it — or they don’t do the work to ask for the money.

And what this program does through Prop. 30 is that it’s taxing the rich, the people that make over $2 million. We always give the tax breaks to the rich and it’s about time that the rich pay their fair share.

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

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

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Montana Health Officials Aim to Boost Oversight of Nonprofit Hospitals’ Giving

September 28, 2022

Montana health officials are proposing to oversee and set standards for the charitable contributions that nonprofit hospitals make in their communities each year to justify their access to millions of dollars in tax exemptions.

The proposal is part of a package of legislation that the state Department of Public Health and Human Services will ask lawmakers to approve when they convene in January. It comes two years after a state audit called on the department to play more of a watchdog role and nine months after a KHN investigation found some of Montana’s wealthiest hospitals lag behind state and national averages in community giving.

Montana state Sen. Bob Keenan, a Republican who has questioned whether nonprofit hospitals deserve their charity status, said the proposal is a start that could be expanded on later.

“Transparency is the name of the game here,” Keenan said.

The IRS requires nonprofit hospitals to tally what they spend to “promote health” to benefit “the community as a whole.” How hospitals count such contributions to justify their tax exemptions is opaque and varies widely. National researchers who study community benefits have called for tightening standards for what counts toward the requirement.

Montana is one of the most recent states to consider imposing new rules or increasing oversight of nonprofit hospitals amid questions about whether they pay their fair share. Dr. Vikas Saini, president of the national health care think tank Lown Institute, said that both at a state and local level, people in California are exploring whether to monitor hospital community benefits and enforce new standards. Last year, Oregon initiated a minimum amount that nonprofit hospitals must spend on community benefits. And Massachusetts updated its community benefits guidelines in recent years, pushing hospitals to give more detailed assessments of how the spending lines up with identified health needs.

Montana hospital industry officials said they want to work with the state to shape the proposed legislation, which they said the industry would support if it doesn’t conflict with federal rules. Saini said that to have an impact, any legislation would have to go beyond federal requirements.

In recent years, more people, like Keenan and Saini, have questioned whether nonprofit hospitals are contributing enough to their communities to deserve the major tax breaks they get while becoming some of the largest businesses in town.

“The hospitals are sort of the pillars of communities, but people are starting to ask these questions,” Saini said.

Saini’s institute reviews hospitals’ giving each year and has found that the majority of nonprofit systems nationwide spend less on what the institute calls “meaningful” benefits than the estimated value of their tax breaks. Actions the institute counts include patient financial aid and community investments such as food assistance, health education, or services offered at a loss, including addiction treatment.

The 2020 Montana audit found that hospitals in the state report benefits vaguely and inconsistently, making it difficult to determine whether their charity status is justified. However, state lawmakers didn’t address the issue in their 2021 biennial legislative session, and a Legislative Audit Division memorandum issued in June found the state health department had “made no meaningful progress” toward developing oversight of nonprofit hospitals’ charitable giving since then.

KHN found that Montana’s nearly 50 nonprofit hospitals directed roughly 8% of their total annual expenses, on average, toward community benefits in the tax year that ended in 2019. The national average was 10%.

In some cases, hospitals’ giving percentages have declined since then. For example, in the tax year that ended in 2019, Logan Health-Whitefish — a small hospital that’s part of the larger Flathead Valley health system — reported that less than 2% of its overall spending went toward community benefits. In its latest available documents, for the period ending in 2021, the hospital reported spending less than 1% of its expenses on community benefits while it made $15 million more than it spent.

Logan Health spokesperson Mellody Sharpton said the medical system’s overall community benefit is equal to nearly 9% of its spending, reaching across its six hospitals. It also has clinics throughout the valley. “It’s important to consider our organization’s community benefit as a whole as our facilities collaborate to ensure the appropriate care is provided at the appropriate facility to meet our patients’ health needs,” Sharpton said.

State health officials asked lawmakers to allow the agency to draft a bill that would give the health department clear authority to require hospitals to submit annual reports that include community benefit and charity care data. The measure also would allow the department to develop standards for that community benefit spending, according to the department’s description of its proposal.

“We see a great need here to move the ball forward,” state health department leader Charlie Brereton told lawmakers in August.

Montana Hospital Association President Rich Rasmussen said his organization wants to work with the health department in honing the legislation but said the definition of what counts as benefits should remain broad so hospitals can respond to their area’s most pressing needs.

Furthermore, he said, hospitals are already working on their own reporting standards. This year, the association created a handbook for members and set a 2023 goal for hospitals to uniformly report their community benefits, Rasmussen said. The association declined to provide a copy of the handbook, saying it would be available to the public once hospitals are trained on how to use it later this fall.

The association also plans to create a website that will serve as a one-stop shop for people who want to know how hospitals are reporting community benefits and addressing local health concerns, among other things.

Republican state Rep. Jane Gillette said she supports increased health department oversight and the idea behind the association’s website but doesn’t think the hospital industry should produce that public resource alone. Gillette said she plans to introduce legislation to require hospitals to report community benefits data to a group outside the industry — such as the state — which would then post the information online.

In the past, hospitals have resisted attempts to impose new rules on community benefit spending. In an interview with KHN last year, Jason Smith, then Bozeman Health’s chief advancement officer, said the system supported efforts to improve reporting contributions “outside of new legislation,” adding that hospitals can do better work without “state oversight bodies being placed in the arena with us.”

Asked whether the health system still stands by that statement, Denise Juneau, Bozeman Health’s chief government and community affairs officer, said hospital officials hope any new legislation will align with existing federal guidelines. She said Bozeman Health will continue to work with the Montana Hospital Association to define and provide better community benefit information, with or without new legislation.

A lawmaker would have to back the state’s proposal by mid-December to keep it alive.

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

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$2,700 Ambulance Bill Pulled Back From Collections

September 28, 2022

Peggy Dula is as surprised as she is relieved. The 55-year-old resident of St. Charles, Illinois, had been fighting a $2,700 ambulance bill for nearly a year. Now, the amount she owes from her September 2021 car wreck appears to be zero.

This summer, KHN, NPR, and CBS News spotlighted Dula in the Bill of the Month series. The initial $3,600 charge for Dula’s ambulance ride was significantly higher than the charges received by her two siblings, who were riding in her car at the time and were transported to the same hospital. The siblings rode in separate ambulances, each from a different nearby fire protection district. All three were billed different amounts for the same services. Dula’s injuries were the least serious, but her bill was the most expensive.

Even after Dula’s insurer paid $900, her bill from Pingree Grove and Countryside Fire Protection District was still roughly twice what each of her siblings had been charged.

Dula’s attempts to resolve the bill were unsuccessful.

Paramedic Billing Services, the company that handles billing for Pingree Grove, said she’d have to dispute charges directly with the fire protection district. But Dula said she couldn’t get a fire district representative on the phone. Then, in June, she received a letter from collections agency Wakefield & Associates seeking payment for her ambulance bill.

Dula remained resolute about not paying until the price was lowered to be more in line with what her siblings had been charged. But the collections agency was equally firm. And that’s where the bill stood for months, in a stalemate.

Last week, Dula called the hospital where she was transported after the crash. She had recently received a bill from the hospital saying she owed nearly $1,500, but when she called she was told her balance was zero. The surprise resolution of her hospital bill prompted her to call Wakefield & Associates to check on her ambulance bill. She said she was told the bill had been pulled back from collections and her balance was zero.

The apparent resolution came approximately a month after “CBS Mornings” covered Dula’s Bill of the Month saga. Wakefield & Associates confirmed to KHN that the bill had been pulled back and that her balance with the agency is zero. Pingree Grove Fire Chief Kieran Stout did not return multiple requests for comment.

“It feels great,” Dula said. “It was a real monkey on my back.”

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

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At This Recovery Center, Police Cope With the Mental Health Costs of the Job

September 27, 2022

HAVRE DE GRACE, Md. — Ken Beyer can’t think of a day in the past few months when his phone didn’t flutter with calls, text messages, and emails from a police department, a sheriff’s office, or a fire station seeking help for an employee. A patrol officer threatening to kill himself with his service weapon before roll call. A veteran firefighter drowning in vodka until he collapses. A deputy overdosing on fentanyl in his squad car.

“It’s the worst that I’ve seen in my career,” said Beyer, co-founder and CEO of Harbor of Grace Enhanced Recovery Center, a private mental health and substance use recovery and treatment center for first responders in the waterfront Maryland town of Havre de Grace. Established in 2015, Harbor of Grace is one of only six treatment centers in the U.S. approved by the Fraternal Order of Police, the world’s largest organization of law enforcement officers.

Public safety is a profession plagued by high rates of mental health and addiction problems. Considering the unrelenting pressures on first responders, Beyer said, the treatment centers can’t keep up with the demand.

Specialized recovery facilities like Harbor of Grace focus on treating law enforcement officers, firefighters, emergency medical technicians, and dispatchers — people who regularly encounter violence and death at work. In the past two years, Beyer said, the number of police officers admitted for treatment at his facility alone has more than tripled. “And we always have up to 20 cops in the queue,” he said. Other treatment centers for first responders reported a similar spike in patients.

Anger at police and policing practices soared after a Minneapolis officer murdered George Floyd in 2020, and it put additional strain on officers’ mental health, said Dr. Brian Lerner, a psychiatrist and the medical director at Harbor of Grace. “Officers feel disparaged by the public and often, they also feel unsupported by their agencies,” he said.

That’s part of the reason “we’re looking at a significant rate of burnout among police officers,” said Jennifer Prohaska, a clinical psychologist in Kansas City, Kansas, who focuses on helping law enforcement personnel.

The poor state of many officers’ mental health, combined with low morale, has contributed to an exodus of police across the country that has left departments understaffed and the remaining officers overworked and exhausted. Atlanta, Seattle, Phoenix, and Dallas are hit particularly hard by officer shortages. “That’s creating enormous stress on the system,” Prohaska said. “It’s a perfect storm.”

Even before the most recent stressors, rates of burnout and depression were up among first responders. Rates of post-traumatic stress disorder are five times as high in police officers as in the civilian population. Some studies estimate that as many as 30% of police officers have a substance use problem. Alcohol dependence is at the top of the list.

Last year alone, 138 law enforcement officers died by suicide — more than the number killed — 129 — in the line of duty, according to the FBI. A recent report from the Ruderman Family Foundation suggests that police suicides are often undercounted because of stigma.

Harbor of Grace has a small campus of eight single-story brick buildings with light blue and yellow accents and looks more like a seaside inn than a clinical setting. The center can treat 47 patients at a time. It has seven acute care beds, mostly for detox.

It offers help for a wide range of mental health conditions, including addiction, sleep disorders, anxiety, depression, suicidal ideation, and PTSD.

To date, more than 500 law enforcement agencies — federal, state, and local — have sent employees to Harbor of Grace. The center has 45 full-time clinical staffers, including an emergency physician and several psychiatrists, nurses, and counselors. Many have previously worked as first responders — from Army medics and firefighters to police officers.

On a recent morning at Harbor of Grace, the sun burned hot over the Chesapeake Bay. A group of patients, mostly men and a few women in their 30s, gathered on the small patio. Some sat alone, while others stood in small groups chatting.

“We get all types, from all backgrounds, and at all stages of brokenness,” said Beyer, 66, a former firefighter and EMT who overcame a problem with alcohol several decades ago. “All our patients and most of our staff know what it’s like to hold a dead or a dying child,” he said.

Sgt. Ryan Close has held several dead children. The 37-year-old police officer works as a patrol supervisor for a small law enforcement agency in New England that he did not want to identify to protect the identities of his colleagues. He has been a police officer for 15 years and has worked for several departments. When he started, he said, officers did not receive psychological training or have access to designated peer support programs.

He said that almost every time he was involved in a critical incident — like a shooting or an accident with burnt and disfigured bodies — “my supervisor ordered me to the bar afterwards.” One incident in particular has stuck in his memory — when a young boy shot himself in the head with a rifle. Washing down the horror with alcohol “was the culture back then,” he said.

But Close didn’t drink much at the time and was mocked by his peers for ordering only small beers. It wasn’t until years later, when memories of his experiences at work reemerged and he had trouble sleeping, that he started to self-medicate with alcohol. He developed social anxiety, and his marriage suffered.

His department pushed him to get help, and he entered Harbor of Grace in April 2021 for a 28-day treatment cycle. There, he learned to let go of his hardened veneer and his impulse to always be in control. He saw many other cops struggle with that too when they got to the center. “I witnessed grown men have a fit like a 6-year-old because a staff member wouldn’t let them use their cellphone.”

Many first responders develop heavy defense mechanisms and are “insecure, non-trusting, controlling,” Beyer said. They often wait way too long before they seek help, he added.

Police officers tend to be “very closed, very unwilling to be vulnerable,” Lerner said. But he finds that most first responders make model patients after they take the first steps. “At that point, they’re all in,” he said. “They don’t do anything halfway.”

At Harbor of Grace, the communication style mirrors the tone at a police station or firehouse, said Beyer. “We don’t waste time on the feel-good stuff,” he said. “We’re blunt. We call people out if necessary.”

Psychologist Prohaska said it’s important that specialized behavioral treatment centers for first responders exist. But, she said, there must also be better investment on the front end — for hands-on initiatives that teach resiliency to public safety employees, like the one she developed for the Kansas City Police Department.

Robust mental health training needs to be part of the academy curriculum and embedded in police culture, she said. “Just like we teach officers safety, we need to teach them resiliency,” she added. “A two-hour PowerPoint course won’t do it.”

Beyer expects the situation to get worse before it gets better. Over the past two years, he has seen more police officers resign while they’re in treatment. Previously, most went back to work. “Now, once they gain clarity, many say, ‘I want to stay healthy, and the way to stay healthy is get out of police work,’” he said.

Ryan Close decided to return to work in law enforcement. He has become an advocate for peer-to-peer support in his agency and beyond. He said his own mental health journey has made him a better police officer, with more empathy and improved communication skills.

His advice to fellow officers is to learn about the possible effects of trauma before they develop a serious problem. Also, he said, “establish a good dialogue with your family, your supervisors, your peers. Know what your limitations are. And learn healthy coping skills. Alcohol isn’t one.”

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

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In Jackson, the Water Is Back, but the Crisis Remains

September 23, 2022

JACKSON, Miss. — In mid-September, Howard Sanders bumped down pothole-ridden streets in a white Cadillac weighed down with water bottles on his way to a home in Ward 3, a neglected neighborhood that he called “a war zone.”

Sanders, director of marketing and outreach for Central Mississippi Health Services, was then greeted at the door by Johnnie Jones. Since Jones’ hip surgery about a month ago, the 74-year-old had used a walker to get around and hadn’t been able to get to any of the city’s water distribution sites.

Jackson’s routine water woes became so dire in late August that President Joe Biden declared a state of emergency: Flooding and water treatment facility problems had shut down the majority-Black city’s water supply. Although water pressure returned and a boil-water advisory was lifted in mid-September, the problems aren’t over.

Bottled water is still a way of life. The city’s roughly 150,000 residents must stay alert — making sure they don’t rinse their toothbrushes with tap water, keeping their mouths closed while they shower, rethinking cooking plans, or budgeting for gas so they can drive around looking for water. Many residents purchase bottled water on top of paying water bills, meaning less money for everything else. For Jackson’s poorest and oldest residents, who can’t leave their homes or lift water cases, avoiding dubious water becomes just that much harder.

“We are shellshocked, we’re traumatized,” Sanders said.

Jackson’s water woes are a manifestation of a deeper health crisis in Mississippi, whose residents have pervasive chronic diseases. It is the state with the lowest life expectancy and the highest rate of infant mortality.

“The water is a window into that neglect that many people have experienced for much of their lives,” said Richard Mizelle Jr., a historian of medicine at the University of Houston. “Using bottled water for the rest of your life is not sustainable.”

But in Jackson an alternative doesn’t exist, said Dr. Robert Smith. He founded Central Mississippi Health Services in 1963 as an outgrowth of his work on civil rights, and the organization now operates four free clinics in the Jackson area. He often sees patients with multiple health conditions such as diabetes, hypertension, or heart problems. And unsafe water could lead to death for people who do their dialysis at home, immunocompromised individuals, or babies who drink formula, said Smith.

Residents filed a lawsuit this month against the city and private engineering firms responsible for the city’s water system, claiming they had experienced a host of health problems — dehydration, malnutrition, lead poisoning, E. coli exposure, hair loss, skin rashes, and digestive issues — as a result of contaminated water. The lawsuit alleges that Jackson’s water has elevated lead levels, a finding confirmed by the Mississippi State Department of Health.

While Jackson’s current water situation is extreme, many communities of color, low-income communities, and those with a large share of non-native English speakers also have unsafe water, said Erik Olson, senior strategic director for health and food at the Natural Resources Defense Council. These communities are more frequently subjected to Safe Drinking Water Act violations, according to a study by the nonprofit advocacy group. And it takes longer for those communities to come back into compliance with the law, Olson said.

The federal infrastructure bill passed last year includes $50 billion to improve the country’s drinking water and wastewater systems. Although Mississippi is set to receive $429 million of that funding over five years, Jackson must wait — and fight — for its share.

And communities often spend years with lingering illness and trauma. Five years after the start of the water crisis in Flint, Michigan, about 20% of the city’s adult residents had clinical depression, and nearly a quarter had post-traumatic stress disorder, according to a recent paper published in JAMA.

Jones, like many locals, hasn’t trusted Jackson’s water in decades. That distrust — and the constant vigilance, extra expenses, and hassle — add a layer of psychological strain.

“It is very stressful,” Jones said.

For the city’s poorest communities, the water crisis sits on top of existing stressors, including crime and unstable housing, said Dr. Obie McNair, chief operating officer of Central Mississippi Health Services. “It’s additive.”

Over time, that effort and adjustment take a toll, said Mauda Monger, chief operating officer at My Brother’s Keeper, a community health equity nonprofit in Jackson. Chronic stress and the inability to access care can exacerbate chronic illnesses and lead to preterm births, all of which are prevalent in Jackson. “Bad health outcomes don’t happen in a short period of time,” she said.

For Jackson’s health clinics, the water crisis has reshaped their role. To prevent health complications that can come from drinking or bathing in dirty water, they have been supplying the city’s most needy with clean water.

“We want to be a part of the solution,” McNair said.

Community health centers in the state have a long history of filling gaps in services for Mississippi’s poorest residents, said Terrence Shirley, CEO of the Community Health Center Association of Mississippi. “Back in the day, there were times when community health centers would actually go out and dig wells for their patients.”

Central Mississippi Health Services had been holding water giveaways for residents about two times a month since February 2021, when a winter storm left Jackson without water for weeks.

But in August, things got so bad again that Sanders implored listeners of a local radio show to call the center if they couldn’t get water. Many Jackson residents can’t make it to the city’s distribution sites because of work schedules, lack of transportation, or a physical impairment.

“Now, all of a sudden, I am the water man,” Sanders said.

Thelma Kinney Cornelius, 72, first heard about Sanders’ water deliveries from his radio appearances. She hasn’t been able to drive since her treatment for intestinal cancer in 2021. She rarely cooks these days. But she made an exception a few Sundays ago, going through a case of bottled water to make a pot of rice and peas.

“It’s a lot of adjustment trying to get into that routine,” said Cornelius. “It’s hard.”

The day that Jackson’s boil-water advisory was lifted, Sanders was diagnosed with a hernia, probably from lifting heavy water cases, he said. Still, the following day, Sanders drove around the Virden Addition neighborhood with other volunteers, knocking on people’s doors and asking whether they needed water.

He said he has no plans to stop water deliveries as Jackson residents continue to deal with the long-term fallout from the summer’s crisis. Residents are still worried about lead or other harmful contaminants lurking in the water.

“It’s like a little Third World country over here,” Sanders said. “In all honesty, we will probably be on this for the next year.”

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

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Opponents of California’s Abortion Rights Measure Mislead on Expense to Taxpayers

September 22, 2022

“With Proposition 1, the number of abortion seekers from other states will soar even higher, costing taxpayers millions more.”

California Together, No on Proposition 1, on its website, Aug. 16, 2022

California Together, a campaign led by religious and anti-abortion groups, is hoping to persuade voters to reject a ballot measure that would cement the right to abortion in the state’s constitution. The group is warning that taxpayers will be on the hook for an influx of abortion seekers from out of state.

Proposition 1 was placed on the ballot by the Democratic-controlled legislature in response to the U.S. Supreme Court’s decision to overturn Roe v. Wade. If passed, it would protect an individual’s “fundamental right to choose to have an abortion,” along with the right to birth control.

California Together’s website says: “With Proposition 1, the number of abortion seekers from other states will soar even higher, costing taxpayers millions more.”

The campaign raised similar cost concerns in a voter information guide that will be mailed out to every registered voter ahead of the Nov. 8 election. One prominent argument is that Proposition 1 will turn California into a “sanctuary state” for abortion seekers, including those in late-term pregnancy — and that would be a drain on tax dollars.

We decided to take a closer look at those eye-catching statements to see how well they hold up when broken down.

We reached out to California Together to find out the basis for its arguments against the measure. The campaign cited an analysis from the pro-abortion rights Guttmacher Institute, which estimated before Roe was overturned that the number of women ages 15 to 49 whose nearest abortion provider would be in California would increase 3,000% in response to state abortion bans. The Guttmacher analysis said most of California’s out-of-state patients would likely come from Arizona because it’s within driving distance.

California Together does not cite a specific cost to taxpayers for the measure. Rather, it points to millions of dollars the state has already allocated to support abortion and reproductive health services as an indication of how much more the state could spend if the proposed amendment passes.

Sources indicate that people are already coming to the state for abortion services.

Jessica Pinckney, executive director of Oakland-based Access Reproductive Justice, which provides financial and emotional support for people who have abortions in California, said the organization had experienced an increase in out-of-state calls even before the high court ruled in June. Pinckney anticipates handling more cases as more states restrict abortion — regardless of Proposition 1’s outcome.

Will It Cost Taxpayers Millions?

In its fiscal year 2022-23 budget, California committed more than $200 million to expanding reproductive health care services, including $20 million for a fund to cover the travel expenses of abortion seekers, regardless of what state they live in. Once it’s up and running in 2023, the fund will provide grants to nonprofit organizations that help women with transportation and lodging.

However, none of that spending is connected to Proposition 1, said Carolyn Chu, chief deputy legislative analyst at the nonpartisan Legislative Analyst’s Office. It’s already allocated in the budget and will be doled out next year regardless of what happens with the ballot measure.

In the end, the Legislative Analyst’s Office found “no direct fiscal effect” if Proposition 1 passes because Californians already have abortion protections. And people traveling from out of state don’t qualify for state-subsidized health programs, such as Medi-Cal, the state’s Medicaid program, Chu added in an interview. “If people were to travel to California for services, including abortion, that does not mean they’re eligible for Medi-Cal,” she said.

Still, Proposition 1 opponents see the cost argument playing out in a different way.

Richard Temple, a campaign strategist for California Together, said a “no” vote will send lawmakers a mandate to stop the support fund. “Defeat Prop. 1, and you send a loud signal to the legislature and to the governor that you don’t want to pay for those kinds of expenses for people coming in from out of state,” Temple said.

What About an Influx of Abortion Seekers?

A key element of California Together’s argument is pegged to the idea that California will become a sanctuary state for abortion seekers. Opponents assert that Proposition 1 opens the door to a new legal interpretation of the state’s Reproductive Privacy Act. Currently, that law allows abortion up to the point of viability, usually around the 24th week of pregnancy, or later to protect the life or health of the patient.

An argument made in the voter guide against the constitutional amendment is that it would allow all late-term abortions “even when the mother’s life is not in danger, even when the healthy baby could survive outside the womb.”

Because the proposition says the state can’t interfere with the right to abortion, opponents argue that current law restricting most abortions after viability will become unconstitutional. They contend that without restrictions, California will draw thousands, possibly millions, of women in late-term pregnancy.

Statistically, that’s unlikely. The state doesn’t report abortion figures, but nationwide only 1% of abortions happen at 21 weeks or later, according to the Centers for Disease Control and Prevention.

Whether there will be a new interpretation if Proposition 1 passes is up for debate.

UCLA law professor Cary Franklin, who specializes in reproductive rights, said that just because Proposition 1 establishes a general right to abortion doesn’t mean all abortion would become legal. Constitutional language is always broad, and laws and regulations can add restrictions to those rights. For example, she said, the Second Amendment to the U.S. Constitution grants the right to bear arms, but laws and regulations restrict children from purchasing guns.

“The amendment doesn’t displace any of that law,” Franklin said.

But current law was written and interpreted under California’s current constitution, which doesn’t have an explicit right to abortion, said Tom Campbell, a former legislator who teaches law at Chapman University. If Proposition 1 passes, courts might interpret things differently. “Any restriction imposed by the state on abortion would have to be reconsidered,” Campbell said.

The Legislative Analyst’s Office concluded that “whether a court might interpret the proposition to expand reproductive rights beyond existing law is unclear.”

California voters will soon have their say.

Polling has found widespread support for the constitutional amendment. An August survey by the Berkeley IGS Poll found 71% of voters would vote “yes” on Proposition 1. A September survey by the Public Policy Institute of California pegged support at 69%.

Our Ruling

California Together warns voters: “With Proposition 1, the number of abortion seekers from other states will soar even higher, costing taxpayers millions more.”

Proposition 1 would protect an individual’s “fundamental right to choose to have an abortion.”

While it could lead to more people coming to California for abortion services, that’s already happening, even before voters decide on the measure.

In addition, Proposition 1 doesn’t allocate any new spending. So the $20 million state fund to cover travel expenses for abortion seekers would exist regardless of whether the constitutional amendment is adopted. Bottom line: A nonpartisan analyst found there will be no direct fiscal impact to the state, and out-of-state residents don’t qualify for state-subsidized health programs.

It’s speculative that Proposition 1 would expand abortion rights beyond what’s currently allowed or that the state would allocate more money for out-of-state residents.

Because the statement contains some truth but ignores critical facts to give a different impression, we rate the statement Mostly False.

Sources

California Together, No on Proposition 1, “Q&A: What You Should Know About Prop 1,” accessed Aug. 22, 2022

Legislative Analyst’s Office, Analysis of Proposition 1, accessed Aug. 22, 2022

Email interview with Kelli Reid, director of client services at McNally Temple Associates, Aug. 24, 2022

Phone interview with Carolyn Chu, chief deputy legislative analyst, Legislative Analyst’s Office, Sept. 12, 2022

CalMatters, “California Fails to Collect Basic Abortion Data — Even as It Invites an Out-of-State Influx,” June 27, 2022

California Health Benefits Review Program, “Analysis of California Senate Bill 245 Abortion Services: Cost Sharing,” accessed Sept. 12, 2022

SB 1142, Abortion Services, accessed Sept. 12, 2022

Phone interview with Richard Temple, campaign strategist for California Together, Sept. 12, 2022

Phone interview with Cary Franklin, law professor at UCLA School of Law, Sept. 13, 2022

Phone interview with Luke Koushmaro, senior policy analyst, Legislative Analyst’s Office, Sept. 13, 2022

Gov. Gavin Newsom, remarks in Sacramento, California, June 27, 2022

Public Policy Institute of California, “PPIC Statewide Survey: Californians and Their Government,” accessed Sept. 13, 2022

California state budget, Health and human services summary document, accessed Sept. 14, 2022

Phone interview with Jessica Pinckney, executive director of Access Reproductive Justice, Sept. 15, 2022

Phone interview with Tom Campbell, law professor at Chapman University, Sept. 15, 2022

SB 1301, Reproductive Privacy Act, accessed Sept. 19, 2022

Email interview with H.D. Palmer, deputy director for external affairs at the California Department of Finance, Sept. 20, 2022

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

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

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Covid Still Kills, but the Demographics of Its Victims Are Shifting

September 21, 2022

As California settles into a third year of pandemic, covid-19 continues to pose a serious threat of death. But the number of people dying — and the demographics of those falling victim — has shifted notably from the first two years.

Given the collective immunity people have garnered through a combination of mass vaccination and protections built from earlier infections, Californians overall were far less likely to die from covid in 2022, when the omicron variant dominated, than during the first two years of the pandemic, when other variants were largely at play, amplifying a national trend.

Still, each week, the virus is killing hundreds of Californians, hitting hardest among the unvaccinated. The virus remained among the state’s leading causes of death in July, trailing heart disease, cancer, stroke, and Alzheimer’s disease but outpacing diabetes, accidental death, and a host of other debilitating diseases. In the first seven months of the year, about 13,500 California residents died of covid, according to preliminary death certificate data from the state Department of Public Health. By comparison, the virus killed about 31,400 people in 2020 and almost 44,000 in 2021.

From April 2020 through December 2021, covid killed an average of 3,600 people a month, making it the third-leading cause of death in the state cumulatively for that time period, behind heart disease and cancer. From December 2020 through February 2021, it briefly overtook heart disease as the leading cause of death, taking the lives of more than 38,300 Californians in just three months. During its most recent peak, in January 2022, covid took about 5,900 lives.

Covid fell out of the top 10 causes of death for a brief period in the spring only to reenter this summer as the omicron variant continued to mutate. In July, even with more than 70% of Californians fully vaccinated, covid was the fifth-leading cause of death, cutting short more than 1,000 lives, state data show.

Clearly vaccinations made a difference. Covid death rates fell in recent months as covid shots and prior infections afforded much of the population significant protection against severe illness, said Dr. Timothy Brewer, a professor of medicine and epidemiology at UCLA. Brewer said the omicron variant, while more transmissible than earlier strains, appears to be a milder version of the virus. Research into that question is ongoing, but preliminary data suggests omicron is less likely to cause serious disease and death, according to the Centers for Disease Control and Prevention, which also notes that the severity of symptoms can be affected by vaccination status, age, and other health conditions.

The decline in deaths was particularly striking among California’s Latino population.

In 2020 and 2021, Latino residents accounted for 47% of covid deaths in California — about 35,400 deaths — although they make up 40% of the state’s population. By comparison, Latinos accounted for 34% of covid deaths from January through July 2022, according to state data. That translates to about 4,600 deaths.

Conversely, the proportion of covid deaths involving white residents increased from 32% in the first two years of the pandemic to 44% in the first seven months of 2022. That equates to 24,400 deaths involving white residents in 2020-21 and about 6,000 deaths in the first seven months of 2022. White people make up about 35% of the state’s population.

Researchers point to several factors in the shift. During the first two years of the pandemic, large numbers of the workers deemed essential, who continued to report to job sites in person, were Latino, while white residents were more likely to be employed in occupations that allowed them to work from home, U.S. Census Bureau surveys show.

“They just got exposed more,” said Dr. George Rutherford, a professor of epidemiology and biostatistics at the University of California-San Francisco. “They're doing essential jobs and had to leave the house and go to work.”

An imbalance in remote work remains, census data shows, but today the large majority of both Latino and white workers in California are reporting to work in person.

Seciah Aquino, deputy director of the Latino Coalition for a Healthy California, said efforts to make sure that testing, treatment, and vaccinations were available to underserved communities of color also had an impact. And because Latino communities were hit so hard during the pandemic, she said, many California Latinos are still wearing masks. “They are still making sure that they're staying home if they're sick,” she said. “They're still abiding by those policies even if the greater narrative is changing.”

Age is also a key factor in the demographic shifts, Brewer said.

Californians age 75 and older made up 53% of covid deaths through July in 2022, up from 46% in 2020 and 2021. Only about 6% of the state’s residents are 75 and older. And white Californians 75 and older outnumber Latinos in that age group about 3 to 1.

In the initial vaccination rollout, California prioritized seniors, first responders, and other essential workers, and for several months in 2021 older residents were much more likely to be vaccinated than younger Californians.

“Now, the vaccination rates have caught up pretty much with everybody except for kids, people under 18,” Brewer said. “You're seeing it go back to what we saw before, which is that age remains the most important risk factor for death.”

More than 86% of Californians age 65 and older have completed their primary covid shot series. But the protection afforded by vaccines wanes over time, and since many seniors got their shots early, enough time passed between their second shot and the omicron wave of early 2022 to leave them vulnerable. About one-third of Californians 65 and older had not received a booster by early 2022, when the omicron wave peaked, and about one-quarter still haven’t received a booster.

Geographic shifts in covid prevalence have occurred throughout the pandemic: Outbreaks hit one area while another is spared, and then another community serves as the epicenter a few months later.

Residents of the San Francisco-Oakland metro area accounted for 7.8% of the state’s deaths in 2022, through early September, up from 5.4% in 2020-21. The area is home to about 12% of the state’s residents. The Sacramento metro area has also accounted for a higher share of covid deaths this year: 6% in 2022 versus 4.5% in 2020-21.

At the same time, Los Angeles-Long Beach-Anaheim metro residents made up 42% of covid deaths in 2022, down slightly from 43% in 2020-21. The area is home to about 33% of the state’s residents. A similar dip happened in the nearby Riverside-San Bernardino metro area.

Again, age could be a factor in the geographic shifts. A higher proportion of residents in San Francisco and Sacramento are 75 and older than in Los Angeles and Riverside, census data show.

It’s unclear whether this shift will last. As the Los Angeles Times reported, covid deaths grew at a faster pace in July in L.A. County than they did in the Bay Area.

The data also shows that vaccination remains one of the strongest deterrents to death from covid. From January through July, unvaccinated Californians died at roughly five times the rate as vaccinated Californians. But the gap has narrowed. From April through December 2021, California's unvaccinated residents died, on average, at around 10 times the rate of vaccinated Californians.

Brewer said the gap lessened because the omicron variant was more likely than earlier variants to “break through” and cause infection in vaccinated Californians. The omicron variant, while less deadly, also infected many more people than earlier variants.

This trend, too, may prove short-lived: The next generation of covid booster shots are rolling out across the state.

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

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

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

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Texas, Battling Teen Pregnancy, Recasts Sex Education Standards

September 20, 2022

DALLAS — J.R. Chester got pregnant the summer before her senior year of high school. A bright student with good grades, she gave birth, graduated, and was pregnant again when she arrived at college that fall.

She was a teen mom — like her mother, her grandmother, and her great-grandmother. Her school did not teach sexual health education, and preventing pregnancy was a foreign concept. Her sons are now teenagers.

“If you don’t know your options, you don’t have any,” said Chester, now a program director for Healthy Futures of Texas, a nonprofit sexual health advocacy and education organization. “Everyone was pregnant. And it just felt like: When it happens, it happens.”

While teen pregnancies have declined in the state and across the country in recent decades, Texas continues to have one of the highest state rates of teens giving birth at 22.4 births per 1,000 girls and women ages 15-19 — the lowest, in Massachusetts, is 6.1. Along with Alabama, Texas has the nation’s highest rate of repeat teen pregnancies. This fall, school districts across Texas are marking a shift to what educators call an “abstinence-plus” curriculum — the first time the state has revised its standards for sexual health education in more than 20 years.

Although districts may choose their own curriculum and teach more than the state requires, the state’s minimum health standards now go beyond focusing on abstinence to stop pregnancies and include teaching middle schoolers about contraceptives and giving additional information about preventing sexually transmitted infections, such as the human papillomavirus (HPV) that has been linked to several cancers.

Previously, a 2017 report showed 58% of Texas school districts offered “abstinence-only” sexual health education, while only 17% offered curriculums that expanded beyond that. A quarter of schools offered no sex ed.

Research shows that sex education programs that teach about contraception are effective at increasing contraceptive use and even delaying sexual activity among young people. Abstinence-focused education programs, on the other hand, have not been shown to be particularly effective at curbing sexual activity among teens.

Whether Texas teens receive any sex ed at all, though, depends on whether their parents sign them up. While parents previously had to “opt out” of sex ed portions of their kids’ health classes, they now have to “opt in” for their children to receive those lessons. That means parents must sign and return a permission slip — a change some fear could lead to kids missing out not so much due to parental objections but because of lost forms and language barriers.

These changes in sex education come as the state ratchets down abortion access following the Supreme Court decision in June overturning Roe v. Wade, which guaranteed a constitutional right to abortion. Texas has one of the nation’s most restrictive abortion laws. The question of how schools educate young people about their sexual health and development has taken on new urgency now that many state governments have enacted abortion bans.

Health advocates say many women may have no choice but to carry a pregnancy to term and that has created a new class of haves and have-nots: those who have the knowledge, resources, and agency to protect themselves from getting pregnant, and those who do not.

Texas is big and diverse enough to need education policies that can be adapted for remote border towns and sprawling metropolitan areas — both of which have high rates of unintended teen pregnancy.

In 2019, the Texas Board of Education began rewriting the health education standards that had been in place since the 1990s. It kept in place the standards stating “that there are risks associated with sexual activity and that abstinence from sexual activity is the only 100% effective method to avoid risks.”

According to the Guttmacher Institute, a reproductive health research organization, 39 states, plus the District of Columbia, mandate that sex ed classes provide information about abstinence, with 29 of them requiring that it must be “stressed.” Just 20 states and D.C. require that the classes provide information about contraception.

Under Texas law, sex ed must still present abstinence as “the preferred choice.” When schools teach about condoms and other forms of contraception, they must provide what Texas calls “human use reality rates” — or, as it is described in medical literature, “typical use” — that detail the effectiveness of those methods outside laboratory settings.

The changes taking effect this year primarily address if and when a Texas student learns about certain sexual health subjects. Under the state’s previous standards, Texas schools could teach about birth control methods beyond abstinence, but only in high school health classes, which are optional. Now, information about contraceptives, as well as more about STIs, is taught in middle school health classes, which are required.

In May, the Dallas Independent School District, one of the nation’s largest, approved lesson materials to meet the state’s new requirements. But school officials here wanted to do more given the scope of the problem. Advocates say Dallas County has the highest rate of repeat teen pregnancies in the nation.

The district curriculum goes beyond the state minimum and includes gender identity and extra information about contraceptives, as well as a contract with Healthy Futures of Texas to teach an optional after-school program for high school students.

The previous curriculum was “very scientific” and “very dry,” said Dustin Marshall, a member of the school district’s board of trustees, and left out basic information about contraceptives, like how to put on a condom.

“One of the primary ways to reduce teen pregnancy and relieve generational poverty from teen pregnancy is to teach contraception,” he said. “Not to just assume that if you teach abstinence, every kid will obey. That’s a little too head-in-the-sand, from my perspective.”

Some critics say the state’s standards, while an improvement, are inadequate when it comes to consent and LGBTQ+ issues, including gender identity. The state board does require that schools teach about healthy relationships and setting personal boundaries for sexual activity.

Under Texas law, parents have the ultimate say over not only whether their child receives sexual health education, but also what is covered in those lessons.

For nearly 30 years, school districts have been required to create and appoint school health advisory councils, tasked with reviewing and recommending health curriculums, including on sexual health. Most members must be parents and not district employees, so the content of sex ed classes can still vary widely by district.

Jen Biundo, senior director of policy and research at Healthy Futures of Texas, described a study she helped conduct asking parents and teenagers who they would prefer to teach teens about sex. While parents and teens ranked them differently, she said their choices were the same: schools, doctors, and parents. Health advocates point out that not all parents can or do educate their children about sex — and that many teens live in unstable situations like foster care.

Biundo said that when they asked teens where they learn about sex, the top answers were “my friends and the internet.”

Indeed, some parents, especially those who were teen mothers themselves, may not know about birth control or how to access it. “Where are the parents supposed to get the knowledge from?” Chester said. “Because they came through the same school system that didn’t teach sex ed, and all of a sudden they’re supposed to know what to teach their kids.”

“We are trying to end that generational curse of being uneducated,” she said.

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

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Private Equity Sees the Billions in Eye Care as Firms Target High-Profit Procedures

September 19, 2022

ST. LOUIS — Christina Green hoped cataract surgery would clear up her cloudy vision, which had worsened after she took a drug to fight her breast cancer.

But the former English professor said her 2019 surgery with Ophthalmology Consultants didn’t get her to 20/20 vision or fix her astigmatism — despite a $3,000 out-of-pocket charge for the astigmatism surgical upgrade. Green, 69, said she ended up feeling more like a dollar sign to the practice than a patient.

“You’re a cow among a herd as you just move from this station to this station to this station,” she said.

Ophthalmology Consultants is part of EyeCare Partners, one of the largest private equity-backed U.S. eye care groups. It is headquartered in St. Louis and counts some 300 ophthalmologists and 700 optometrists in its networks across 19 states. The group declined to comment.

Switzerland-based Partners Group bought EyeCare Partners in 2019 for $2.2 billion. Another eye care giant, Texas-based Retina Consultants of America, was formed in 2020 with a $350 million investment from Massachusetts-based Webster Equity Partners, a private equity firm, and now it says on its website it has 190 physicians across 18 states. Other private equity groups are building regional footprints with practices such as Midwest Vision Partners and EyeSouth Partners. Acquisitions have escalated so much that private equity firms now are routinely selling practices to one another.

In the past decade, private equity groups have gone from taking over a handful of practices to working with as many as 8% of the nation’s ophthalmologists, said Dr. Robert E. Wiggins Jr., president of the American Academy of Ophthalmology.

They are scooping up eye care physician practices nationwide as money-making opportunities grow in medical eye care with the aging of the U.S. population. Private equity groups, backed by wealthy investors, buy up these practices — or unify them under franchise-like agreements — with the hopes of raising profit margins by cutting administrative costs or changing business strategies. They often then resell the practices at a higher price to the next bidder.

The profit potential for private equity investors is clear: Much like paying to upgrade plane seats to first class, patients can choose expensive add-ons for many eye procedures, such as cataract surgery. For example, doctors can use lasers instead of cutting eye lenses manually, offer multifocal eye lenses that can eliminate the need for glasses, or recommend the astigmatism fix that Green said she was sold. Often, patients pay out-of-pocket for those extras — a health care payday unconstrained by insurance reimbursement negotiations. And such services can take place in outpatient and stand-alone surgery centers, both of which can be more profitable than in a hospital setting.

The investments that private equity groups provide can help doctors market and expand their practices, as well as negotiate better prices for drugs and supplies, Wiggins said. But he warned that private equity companies’ quest to maximize profitability runs the risk of compromising patient care.

“The problems are accumulating and driving up prices,” added Aditi Sen, director of research and policy at the nonprofit Health Care Cost Institute, which provides data and analysis about the economics of health care.

Yashaswini Singh, a health economist at Johns Hopkins University, and her colleagues analyzed private equity acquisitions in ophthalmology, gastroenterology, and dermatology and found that practices charged insurance an extra 20%, or an average of $71, more after the acquisition. Private equity-owned practices also saw a substantial rise in new patients and more frequent returns by old patients, according to their research, published Sept. 2 in the JAMA medical journal.

A KHN analysis also found that private equity firms are investing in the offices of doctors who prescribe at high rates two of the most common macular degeneration eye drugs, meaning the doctors are likely seeing high volumes of patients and thus are more profitable.

KHN analyzed the top 30 prescribers of the macular degeneration eye drugs Avastin and Lucentis in 2019 through a Centers for Medicare & Medicaid Services database. Private equity companies went on to invest in 23% of the top Avastin prescribers, and 43% of the top Lucentis prescribers — far higher than the 8% of ophthalmologists in which private equity currently holds a stake. Retina Consultants of America, for example, has invested in the practices of four of the top Avastin prescribers, and nine of the top Lucentis prescribers.

“The private equity model is a model that focuses on profitability, and we know they are not selecting practices randomly,” Sen said.

She noted that the volume of patients would be attractive to private equity, as well as the idea of investing in practices utilizing expensive Lucentis prescriptions, which cost roughly $1,300 an injection. Furthermore, she said, after being acquired by private equity, doctors could potentially change their prescription habits from the cheaper Avastin that costs about $40 to Lucentis – improving the bottom line.

Retina Consultants of America did not respond to requests for comment.

Last summer, Craig Johnson, then 74, decided it was finally time to have cataract surgery to fix his deteriorating eyes. He decided to go to CVP Physicians in Cincinnati, calling it “the cream of the crop locally for having eye surgery” as they do “100 a day.” The practice was already part of a private equity investment but has since been acquired by another investor, behemoth EyeCare Partners, for $600 million.

Johnson, while happy with the results of his surgery, did not know about the manual cutting version of the surgery — the cheaper but just as effective alternative to using a laser. Johnson was using private insurance because he was still working, and he said that resulted in over $2,000 out-of-pocket charges for each eye. Laser surgery typically costs more than manual and may not be covered by insurance plans, according to the American Academy of Ophthalmology.

Johnson explained that a salesperson, as well as a physician, walked him through options to improve his eyesight.

“Seniors are a vulnerable population because they’re on a fixed income, they’re a little older, they trust you … you’re wearing a white coat,” said Dr. Arvind Saini, an ophthalmologist who runs an independent practice in California’s San Diego County.

Many patients have no idea whether private equity investors have a stake in the practices they choose because they are often referred to them by another doctor or are having an eye emergency.

David Zielenziger, 70, felt lucky to get a quick appointment at one of Vitreoretinal Consultants of NY’s practices after his retina detached. Zielenziger, a former business journalist, didn’t know it was associated with Retina Consultants of America. He loved his doctor and had no complaints about the emergency care he received — and continued to go there for follow-ups. Medicare covered just about everything, he said.

“It’s a very busy practice,” he said, noting that it has expanded to more locations, which must be making the investors happy.

In 2018, Michael Kroin co-founded Physician Growth Partners, a group that helps doctors sell their practices to private equity firms, to capitalize on the explosion of interest. Eye care is one of the largest areas of investment, he said, because the specialty health care services apply to such a broad market of people.

Sixteen of the 25 private equity firms identified by industry tracker PitchBook as the biggest health care investors have bought stakes in optometry and ophthalmology practices, a KHN analysis found.

Kroin expects private equity investment in practices will only continue to accelerate because of competition from the “1,000-pound gorilla” of hospitals that also are acquiring practices and as the bureaucracy of insurance reimbursement forces more physicians to seek outside help. “If you’re not growing, it’s going to be tough to survive and make a similar level of income as you had historically,” he said.

Some health care experts worry that private equity companies could eventually be left holding an overly leveraged bag if other firms don’t want to buy the practices they’ve invested in, which could lead to the closures of those practices and ultimately even more consolidation.

“I’m not sure that most physician practices are so inefficient that you can get 20% more profit out of them,” said Dr. Lawrence Peter Casalino, chief of the division of health policy and economics at Weill Cornell Medicine’s Department of Population Health Sciences. And, he said, investors count on reselling to a buyer who will pay more than what they paid. “If that doesn’t work, the whole thing unravels.”

KHN investigative reporter Fred Schulte contributed to this article.

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

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Many Refugees Dealing with Trauma Face Obstacles to Mental Health Care

September 19, 2022

As a young boy living in what was then Zaire, Bertine Bahige remembers watching refugees flee from the Rwandan genocide in 1994 by crossing a river that forms the two Central African nations’ border.

“Little did I know that would be me a few years later,” said Bahige.

Bahige’s harrowing refugee journey began when he was kidnapped and forced to become a child soldier when war broke out in his country, which became the Democratic Republic of Congo in 1997. He escaped at age 15 to a Mozambique refugee camp, where he lived for five years until he arrived in Baltimore in 2004 through a refugee resettlement program.

Bahige, now 42, said the way he grew up was to “just buckle up and tough it out,” and he carried that philosophy into adjusting to life in the U.S. He worked multiple jobs and took community college classes until he went to the University of Wyoming on a scholarship. He is now an elementary school principal in Gillette, Wyoming, and said his coping strategy, then and now, is to keep himself busy.

“In retrospect, I don’t think I ever even dealt with my own trauma,” he said.

Refugees are arriving in the U.S. in greater numbers this year after resettlement counts reached a 40-year low under President Donald Trump. These new arrivals, like those refugees before them, are 10 times as likely as the general population to have post-traumatic stress disorder, depression, and anxiety. Many of them, like Bahige, fled their homelands because of violence or persecution. They then must deal with the mental toll of integrating into new environments that are as different as, well, Wyoming is from Central Africa.

This has Bahige concerned about the welfare of the new generation of refugees.

“The type of system that a person lived in might be completely different than the new life and system of the world they live in now,” Bahige said.

While their need for mental health services is greater than that of the general population, refugees are much less likely to receive such care. Part of the shortfall stems from societal differences. But a big factor is the overall shortage of mental health providers in the U.S., and the myriad obstacles and barriers to receiving mental health care that refugees encounter.

Whether they end up in a rural area like the Northern Rocky Mountains or in an urban setting such as Atlanta, refugees can face months-long waits for care, plus a lack of clinicians who understand the culture of the people they are serving.

Since 1975, about 3.5 million refugees have been admitted to the United States. The annual admissions dropped during the Trump administration from about 85,000 in 2016 to 11,814 in 2020, according to the State Department.

President Joe Biden raised the cap on refugee admissions to 125,000 for the 2022 federal fiscal year, which ends Sept. 30. With fewer than 18,000 arrivals by the beginning of August, that ceiling is unlikely to be reached, but the number of people admitted is increasing monthly.

Refugees receive mental health screening, along with a general medical assessment, within 90 days of their arrival. But the effectiveness of that testing largely depends on a screener’s ability to navigate complex cultural and linguistic issues, said Dr. Ranit Mishori, a professor of family medicine at Georgetown University and the senior medical adviser for Physicians for Human Rights.

Although rates of trauma are higher in the refugee population, not all displaced people need mental health services, Mishori said.

For refugees dealing with the effects of stress and adversity, resettlement agencies like the International Rescue Committee provide support.

“Some folks will come in and immediately request services, and some won’t need it for a few years until they feel fully safe, and their body has adjusted, and the trauma response has started to dissipate a little bit,” said Mackinley Gwinner, the mental health navigator for the IRC in Missoula, Montana.

Unlike Bahige’s adopted state of Wyoming, which has no refugee resettlement services, IRC Missoula has placed refugees from the Democratic Republic of the Congo, Syria, Myanmar, Iraq, Afghanistan, Eritrea, and Ukraine in Montana in recent years. A major challenge in accessing mental health services in rural areas is that very few providers speak the languages of those countries.

In the Atlanta suburb of Clarkston, which has a large population of refugees from Myanmar, the Democratic Republic of the Congo, and Syria, translation services are more available. Five mental health clinicians will work alongside IRC caseworkers under a new program by the IRC in Atlanta and Georgia State University’s Prevention Research Center. The clinicians will assess refugees’ mental health needs as the caseworkers help with their housing, employment, education, and other issues.

Seeking mental health care from a professional, though, can be an unfamiliar idea for many refugees, said Farduus Ahmed, a Somali-born former refugee mental health clinician at the University of Colorado School of Medicine.

For refugees needing mental health care, stigma can be a barrier to treatment. Some refugees fear that if U.S. authorities find out they’re struggling with mental health, they could face deportation, and some single mothers worry they will lose their children for the same reason, Ahmed said.

“Some people think seeking services means they’re ‘crazy,’” she said. “It’s very important to understand the perspective of different cultures and how they perceive mental health services.”

Long wait times, lack of cultural and language resources, and societal differences have led some health professionals to suggest alternative ways to address the mental health needs of refugees.

Widening the scope beyond individual therapy to include peer interventions can rebuild dignity and hope, said Dr. Suzan Song, a professor of psychiatry at George Washington University.

Spending time with someone who shares the same language or figuring out how to use the bus to go to the grocery store are “incredibly healing and allow someone to feel a sense of belonging,” Song said.

In Clarkston, the Prevention Research Center will soon launch an alternative allowing refugees to play a more direct role in caring for the mental health needs of community members. The center plans to train six to eight refugee women as “lay therapists,” who will counsel and train other women and mothers using a technique called narrative exposure therapy to address complex and multiple traumas.

The treatment, in which patients create a chronological narrative of their lives with the help of a therapist, focuses on traumatic experiences over a person’s lifetime.

The therapy can be culturally adapted and implemented in underserved communities, said Jonathan Orr, coordinator of the clinical mental health counseling program at Georgia State University’s Counseling and Psychological Services.

The American Psychological Association, though, only conditionally recommends narrative exposure therapy for adult patients with PTSD, advising that more research is needed.

But the method worked for Mohamad Alo, a 25-year-old Kurdish refugee living in Snellville, Georgia, after arriving in the U.S. from Syria in 2016.

Alo was attending Georgia State while working full time to support himself when the covid-19 pandemic started. While downtime during the pandemic gave him time to reflect, he didn’t have the tools to process his past, which included fleeing Syria and the threat of violence.

When his busy schedule picked back up, he felt unable to deal with his newfound anxiety and loss of focus. The narrative exposure therapy, he said, helped him deal with that stress.

Regardless of treatment options, mental health is not necessarily the top priority when a refugee arrives in the United States. “When someone has lived a life of survival, vulnerability is the last thing you’re going to portray,” Bahige said.

But Bahige also sees resettlement as an opportunity for refugees to address their mental health needs.

He said it’s important to help refugees “understand that if they take care of their mental health, they can be successful and thrive in all facets of the life they’re trying to create. Changing that mindset can be empowering, and it’s something I am still learning.”

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

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Journalists Look Into Wildfire Trauma and the South’s Monkeypox Response

September 17, 2022

KHN reporter and producer Heidi de Marco discussed the impact of wildfire trauma on children in Northern California on CapRadio’s “Insight With Vicki Gonzalez” on Sept. 13.

KHN Florida correspondent Daniel Chang discussed the Southern response to the monkeypox outbreak on C-SPAN’s “Washington Today” on Sept. 14.

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

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A Disability Program Promised to Lift People From Poverty. Instead, It Left Many Homeless.

September 16, 2022

CHARLOTTE, N.C. — After two months of sleeping in the Salvation Army Center of Hope homeless shelter, Margaret Davis has had no luck finding an apartment she can afford.

The 55-year-old grandmother receives about $750 a month from the federal government. She’s trying to live on just $50 cash and $150 in food stamps each month so she can save enough for a place to call home.

Davis is homeless even though she receives funds from the Supplemental Security Income program, a hard-to-get federal benefit that was created nearly 50 years ago to lift out of poverty Americans who are older, blind, or disabled.

Davis’ job options are limited because she gets dialysis treatment three times a week for kidney failure. As she prepared to spend another night in the crowded shelter, she checked her phone to see whether a doctor wanted her to have her left leg amputated.

“My therapist is trying to help me stay positive but sometimes I just want to end this life and start over,” Davis said.

Falling into homelessness is not a new issue for people who receive supplemental income from the Social Security Administration. But moving recipients out of shelters, crime-ridden motels, and tent encampments and into stable housing has been getting harder, according to nonprofit attorneys, advocates for people with disabilities, and academic researchers.

Rapidly rising rents and inflation deserve a share of the blame.

But SSI recipients, activists, and others said the issue underscores for them how the program itself locks millions of people into housing instability and deep poverty even as President Joe Biden promises to fix it.

“We are trapping people in a place where dignity is out of reach,” said Rebecca Vallas, a senior fellow at the Century Foundation, a progressive think tank that conducts research on economic equity. “The program started with good intentions,” she said. “It is hard for me to see this as anything but willful neglect.”

In a country where roughly 1 in 4 residents live with some type of disability, supplemental income is meant to ensure that the most vulnerable can get housing and other basic needs. Most SSI recipients automatically qualify for Medicaid, a joint federal and state program that covers medical costs for people with low incomes.

In addition to people who are blind or who are 65 or older, those who prove they have a medical condition that prevents them from working for at least one year are eligible for a monthly payment from SSI, which maxes out at $841. But there’s a catch that makes seeing a better financial future difficult for people like Davis. The monetary benefit decreases if the person earns more than $85 a month in additional income. And both the income and Medicaid benefits are revoked if the person saves more than $2,000, which critics say discourages people from saving.

The amount that recipients receive has not kept pace with rising rent prices, advocacy groups say.

The amount of money Davis said she gets each month from the program is about $60 more than the maximum amount offered 10 years ago, when she first started receiving the benefit. Yet the average apartment in Charlotte, where Davis lives, now rents for $1,500 a month, about 70% more than it did nearly a decade ago, according to Zumper, which has been tracking rental prices since 2014.

There’s no chance she can afford her dream: an apartment or house in a safe neighborhood where she can spend afternoons crocheting. “I don’t like to talk like this, but I am not sure what’s going to happen to me,” Davis said.

When Congress created SSI in 1972, the legislation promised that recipients “would no longer have to subsist on below-poverty-level incomes.”

Today, nearly 8 million people rely on the federal program for income.

Over the past five decades, Congress under both Republican and Democratic leadership has declined to make major changes to the program. The $85 outside income limit, for instance, has never been adjusted to account for inflation.

The Social Security Administration, which oversees the program, did not respond to multiple requests for comment about how the rates are set.

Biden committed to reforming SSI during his 2020 presidential campaign, saying that he would “protect and strengthen economic security for people with disabilities.”

But for seven months, Delisa Williams has been stuck in the same homeless shelter as Davis. Diabetes, hypertension, and osteoporosis have left her body weakened, and the stress of living in the Salvation Army Center of Hope is taking a toll on her mental health.

Williams’ only real chance to get out had been the combined $881 she got each month from SSI and the Social Security Disability Insurance program, which has similar limits and requirements. She quickly realized that would not be enough to afford the rent for most places.

“God will see me through,” she said. “He didn’t bring me this far for nothing.”

Among developed nations, the United States is one of the hardest places for people to meet the criteria for disability payments, according to the Organization for Economic Cooperation and Development, a global intergovernmental group the U.S. helped create to advance social well-being.

If a person applies for disability income, they can wait months or even years to get benefits. Thousands go broke or die while waiting for help. A data analysis by the U.S. Government Accountability Office found that from 2014 to 2019, about 48,000 people filed for bankruptcy while trying to get a final decision on a disability appeal. The same report said that from 2008 to 2019 more than 100,000 people died waiting.

The situation was made worse during the covid-19 pandemic because the Social Security Administration closed more than 1,200 field offices across the nation and kept them shuttered for roughly two years.

That decision left hundreds of thousands of needy people unable to seek benefits, since phone lines were jammed with calls and the agency provides no way to submit applications online, said David Weaver, a former associate commissioner for research, demonstration, and employment support at the Social Security Administration.

“The number of SSI awards just collapsed,” Weaver said.

Homeless shelters and other nonprofits often help clients apply for the supplemental income in hopes that the money will help get them a place to live. Rachael Mason, a social worker at the Triune Mercy Center in Greenville, South Carolina, has learned to temper people’s expectations.

“Any time someone shows up and says I want to pursue housing, my heart drops a little bit,” Mason said. “I have to be honest and tell them it could be a year to three years. Even if someone wants to just rent a room in a house, it could take up their entire check.”

As the 50th anniversary of SSI approaches this fall, Congress is deciding whether to make changes to the program.

In an April 2021 letter to Biden and Vice President Kamala Harris, more than 40 lawmakers lobbied them to raise cash benefits above the poverty level, increase the amount of money recipients can save, and eliminate reductions for taking help from loved ones, among other changes. “People with disabilities and older adults receiving SSI represent some of the most marginalized members of our society,” the letter said. “History will not forgive us if we fail to address their needs in the recovery effort.”

A group of Republican and Democratic legislators have now proposed the SSI Savings Penalty Elimination Act, which would raise the asset limit for recipients from $2,000 to $10,000 for individuals and from $3,000 to $20,000 for couples.

Davis, the woman whose leg might be amputated, is trying to remain hopeful. She started seeing a therapist to cope with depression. She stopped smoking to save money for an apartment.

Asked when she might be able to move out of the shelter, she said, “I don’t know.”

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

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Court Ruling May Spur Competitive Health Plans to Bring Back Copays for Preventive Services

September 15, 2022

Tom and Mary Jo York are a health-conscious couple, going in for annual physicals and periodic colorectal cancer screening tests. Mary Jo, whose mother and aunts had breast cancer, also gets regular mammography tests.

The Yorks, who live in New Berlin, Wisconsin, are enrolled in Chorus Community Health Plans, which, like most of the nation’s health plans, is required by the Affordable Care Act to pay for those preventive services, and more than 100 others, without charging deductibles or copays.

Tom York, 57, said he appreciates the law’s mandate because until this year the deductible on his plan was $5,000, meaning that without that ACA provision, he and his wife would have had to pay full price for those services until the deductible was met. “A colonoscopy could cost $4,000,” he said. “I can’t say I would have skipped it, but I would have had to think hard about it.”

Now health plans and self-insured employers — those that pay workers’ and dependents’ medical costs themselves — may consider imposing cost sharing for preventive services on their members and workers. That’s because of a federal judge’s Sept. 7 ruling in a Texas lawsuit filed by conservative groups claiming that the ACA’s mandate that health plans pay the full cost of preventive services, often called first-dollar coverage, is unconstitutional.

U.S. District Judge Reed O’Connor agreed with them. He ruled that the members of one of the three groups that make coverage recommendations, the U.S. Preventive Services Task Force, were not lawfully appointed under the Constitution because they were not nominated by the president and confirmed by the Senate.

If the preventive services coverage mandate is partly struck down, the result could be a confusing patchwork of health plan benefit designs offered in various industries and in different parts of the country. Patients who have serious medical conditions or are at high risk for such conditions may have a hard time finding a plan that fully covers preventive and screening services.

O’Connor also held that requiring the plaintiffs to pay for HIV prevention drugs violates the Religious Freedom Restoration Act of 1993. He’s also considering throwing out the mandate for first-dollar coverage for contraceptives, which the plaintiffs also challenged under that statute. O’Connor postponed ruling on that and legal remedies until after he receives additional briefs from the parties to the lawsuit on Sept. 16. No matter what the judge does, the case is likely to be appealed by the federal government and could reach the Supreme Court.

If O’Connor were to order an immediate end to the no-cost coverage mandate for services that won approval from the preventive services task force, nearly half the recommended preventive services under the ACA would be in jeopardy. These include screening tests for cancer, diabetes, depression, and sexually transmitted infections.

Many health plans and self-insured employers would likely react by imposing deductibles and copays for some or all the services recommended by the task force.

“Larger employers will evaluate what they cover first-dollar and what they don’t cover,” said Michael Thompson, CEO of the National Alliance of Healthcare Purchaser Coalitions, a nonprofit group of employer and union health plans that work together to help reduce prices. He thinks employers with high employee turnover and health insurance companies are the likeliest to add cost sharing.

That could destabilize the health insurance markets, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation.

Insurers will design their preventive service benefits to attract the healthiest people so they can reduce their premiums, she predicted, saddling sicker and older people with skimpier coverage and higher out-of-pocket costs. “It reintroduces the chaos that the ACA was designed to fix,” she said. “It becomes a race to the bottom.”

The most probable services to be targeted for cost sharing are HIV prevention and contraception, said Dr. Jeff Levin-Scherz, population health leader at WTW (formerly Willis Towers Watson), who advises employers on health plans.

Studies have shown that eliminating cost sharing boosts the use of preventive services and saves lives. After the ACA required that Medicare cover colorectal cancer screenings without cost sharing, diagnoses of early-stage colorectal cancer increased 8% per year, improving life expectancy for thousands of seniors, according to a 2017 study published in the journal Health Affairs.

Adding cost sharing could mean hundreds or thousands of dollars in out-of-pocket spending for patients because many Americans are enrolled in high-deductible plans. In 2020, the average annual deductible in the individual insurance market was $4,364 for single coverage and $8,439 for family coverage, according to eHealth, a private, online insurance broker. For employer plans, it was $1,945 for an individual and $3,722 for families, according to KFF.

O’Connor upheld the constitutional authority of two other federal agencies that recommend preventive services for women and children and for immunizations, so first-dollar coverage for those services seemingly is not in jeopardy.

If the courts strike down the mandate for the preventive services task force’s recommendations, health plan executives will face a tough decision. Mark Rakowski, president of the nonprofit Chorus Community Health Plans, said he strongly believes in the health value of preventive services and likes making them more affordable to enrollees by waiving deductibles and copayments.

But if the mandate is partly eliminated, he expects that competitors would establish deductibles and copays for preventive services to help make their premiums about 2% lower. Then, he said, he would be forced to do the same to keep his plans competitive on Wisconsin’s ACA marketplace. “I hate to admit that we’d have to strongly consider following suit,” Rakowski said, adding that he might offer other plans with no-cost preventive coverage and higher premiums.

The ACA’s coverage rule for preventive services applies to private plans in the individual and group markets, which cover more than 150 million Americans. It is a popular provision of the law, favored by 62% of Americans, according to a 2019 KFF survey.

Spending on ACA-mandated preventive services is relatively small but not insignificant. It is 2% to 3.5% of total annual expenditures by private employer health plans, or about $100 to $200 per person, according to the Health Care Cost Institute, a nonprofit research group.

Several large commercial insurers and health insurance trade groups did not respond to requests for comment or declined to comment about what payers will do if the courts end the preventive services mandate.

Experts fear that cost sharing for preventive services would hurt growing efforts to reduce health disparities.

“If it’s left up to individual plans and employers to make these decisions about cost sharing, underserved Black and brown communities that have benefited from the removal of cost sharing will be disproportionally harmed,” said Dr. A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design, who helped draft the ACA’s preventive services coverage section.

One service of particular concern is preexposure prophylaxis for HIV, or PrEP, a highly effective drug regimen that prevents high-risk people from acquiring HIV. The plaintiffs in the lawsuit in Texas claimed that having to pay for PrEP forces them to subsidize “homosexual behavior” to which they have religious objections.

Since 2020, health plans have been required to fully cover PrEP drugs and associated lab tests and doctor visits that otherwise can cost thousands of dollars a year. Of the 1.1 million people who could benefit from PrEP, 44% are Black and 25% are Hispanic, according to the Centers for Disease Control and Prevention. Many also are low-income. Before the PrEP coverage rule took effect, only about 10% of eligible Black and Hispanic people had started PrEP treatment because of its high cost.

O’Connor, despite citing the evidence that PrEP drugs reduce HIV spread through sex by 99% and through injection drug use by 74%, held that the government did not show a compelling governmental interest in mandating no-cost coverage of PrEP.

“We’re trying to make it easier to get PrEP, and there are plenty of barriers already,” said Carl Schmid, executive director of the HIV + Hepatitis Policy Institute. “If first-dollar coverage went away, people won’t pick up the drug. That would be extremely damaging for our efforts to end HIV and hepatitis.”

Robert York, an LGBT activist who lives in Arlington, Virginia, who is not related to Tom York, has taken Descovy, a brand-name PrEP drug, for about six years. Having to pay cost sharing for the drug and associated tests every three months under his employer’s health plan would force changes in his personal spending, he said. The retail price of the drug alone is about $2,000 a month.

But York, who’s 54, stressed that reestablishing cost sharing for PrEP would affect people in lower-income and marginalized groups even more.

“We’ve been working so hard with the community to get PrEP into the hands of people who need it,” he said. “Why is anyone targeting this?”

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

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California y Nueva York buscan frenar la venta de píldoras para adelgazar a menores

September 14, 2022

California y Nueva York están a punto de ir un paso más allá que la Administración de Drogas y Alimentos (FDA) en la restricción de la venta de píldoras dietéticas sin receta a menores de edad, mientras pediatras y defensores de la salud pública tratan de protegerlos de las trampas para perder de peso de forma extrema que circulan por internet.

Un proyecto de ley presentado al gobernador Gavin Newsom prohibiría a los menores de 18 años en California la compra de suplementos para adelgazar sin receta, ya sea en línea o en tiendas. Otro proyecto similar aprobado por los legisladores de Nueva York está en la mesa de la gobernadora Kathy Hochul. Ninguno de los dos demócratas han indicado qué harán.

Si ambas medidas se convierten en ley, sus defensores esperan que den impulso a la  restricción de la venta de píldoras dietéticas a niños y adolescentes en más estados. Massachusetts, Nueva Jersey y Missouri han presentado proyectos de ley similares y sus defensores planean seguir presionando el próximo año.

Casi 30 millones de personas en Estados Unidos padecerán un trastorno alimentario a lo largo de su vida; el 95% de ellas tiene entre 12 y 25 años, según el Johns Hopkins All Children’s Hospital. Agrega que los trastornos alimentarios conforman el mayor riesgo de mortalidad de todos los trastornos mentales. Y ahora es más fácil que nunca que los menores consigan las pastillas que se venden en internet o en las estanterías de las farmacias.

Todos los suplementos dietéticos, incluidos los destinados a la pérdida de peso, representaron casi el 35% de los  productos de salud que se venden sin receta dentro de una industria que generó $63,000 millones en 2021, según Vision Research Reports, una empresa de investigación de mercado.

Los suplementos dietéticos, que abarcan una amplia gama de vitaminas, hierbas y minerales, están clasificados por la FDA como alimentos y no se someten a pruebas científicas y de seguridad como se hace con los medicamentos que se venden con y sin receta.

Los defensores de la salud pública quieren mantener los productos para adelgazar —con anuncios que pueden prometer “¡Baja 2 libras a la semana!” y nombres de pastillas como Slim Sense— alejados de los jóvenes, sobre todo de las chicas, ya que investigaciones han relacionado algunos productos con los trastornos alimentarios.

Un estudio publicado en el American Journal of Public Health, en el que se realizó un seguimiento a más de 10,000 mujeres de entre 14 y 36 años durante 15 años, halló que “las que usaban píldoras para adelgazar tenían una probabilidad ajustada cinco veces mayor de recibir un diagnóstico de trastorno alimentario por parte de un proveedor de atención médica en un plazo de 1 a 3 años que las que no las utilizaban”.

Se ha descubierto que muchas píldoras están contaminadas con ingredientes prohibidos y peligrosos que pueden causar cáncer, ataques cardíacos, derrames cerebrales y otros males. Por ejemplo, la FDA aconsejó al público que evitara Slim Sense de Dr. Reade porque contiene lorcaserina, que puede causar trastornos psiquiátricos y alteraciones de la atención y de la memoria. La entidad ordenó su retiro y no se pudo contactar con la empresa para que ofreciera declaraciones.

“Los fabricantes sin escrúpulos están dispuestos a correr riesgos con la salud de los consumidores, y están mezclando sus productos con ingredientes farmacéuticos ilegales, esteroides, estimulantes excesivos e incluso estimulantes experimentales”, dijo Bryn Austin, director fundador de Strategic Training Initiative for the Prevention of Eating Disorders, o STRIPED, que apoya las restricciones. “Los consumidores no tienen ni idea de que esto es lo que hay en este tipo de productos”.

STRIPED es una iniciativa de salud pública con sede en la Escuela de Salud Pública T.H. Chan de Harvard y el Hospital Infantil de Boston.

La Natural Products Association, un grupo comercial que representa a la industria, refuta que las píldoras dietéticas causen trastornos alimentarios y citan la ausencia de quejas de los consumidores a la FDA sobre efectos adversos de los productos de sus miembros. “Según los datos de la FDA, no existe ninguna relación entre ambas cosas”, dijo Kyle Turk, director de asuntos gubernamentales de la asociación.

La asociación sostiene que sus miembros adhieren a procesos de fabricación seguros, pruebas aleatorias de los productos y directrices de comercialización adecuadas. A los representantes también les preocupa que si los menores no pueden comprar suplementos sin receta, puedan comprarlos a “delincuentes” en el mercado negro y socavar la integridad de la industria. Según los proyectos de ley, los menores que compren productos para adelgazar deberán presentar una identificación junto con una receta médica.

No todos los grupos empresariales se oponen a la prohibición. La American Herbal Products Association, un grupo comercial que representa a fabricantes y minoristas de suplementos dietéticos, dejó de oponerse al proyecto de ley de California una vez que se modificó para eliminar las categorías de ingredientes que se encuentran en suplementos no dietéticos y vitaminas, según Robert Marriott, director de asuntos regulatorios de esa entidad.

Los defensores de los niños han encontrado tendencias preocupantes entre los jóvenes que imaginan su tipo de cuerpo ideal según lo que ven en las redes sociales. De acuerdo a un estudio encargado por Fairplay, una organización sin fines de lucro que trata de poner fin a las prácticas de marketing perjudiciales dirigidas a los niños, descubrió que niños de tan solo 9 años seguían tres o más cuentas de desórdenes alimentarios en Instagram, mientras que la edad media era de 19 años. Los autores lo llamaron una “burbuja a favor de los trastornos alimentarios“.

Meta, propietaria de Instagram y Facebook, dijo que el informe carece de matices, como reconocer la necesidad humana de compartir los momentos difíciles de la vida. La compañía sostiene que la censura generalizada no es la respuesta.

“Los expertos y las organizaciones de seguridad nos han dicho que es importante encontrar un equilibrio y permitir que la gente comparta sus historias personales al tiempo que se elimina cualquier contenido que fomente o promueva los trastornos alimentarios”, dijo Liza Crenshaw, una vocera de Meta, en un correo electrónico.

El doctor Jason Nagata, pediatra que atiende a niños y adultos jóvenes con trastornos alimentarios que ponen en peligro su vida, cree que el fácil acceso a las pastillas para adelgazar contribuye a las condiciones de sus pacientes en el Hospital Infantil UCSF Benioff de San Francisco. Ese fue el caso de una de sus pacientes, una niña demacrada de 11 años.

“Básicamente había entrado en un estado de inanición porque no recibía suficiente nutrición”, dijo Nagata, que aportó un testimonio de apoyo al proyecto de ley de California. “Estaba tomando estas píldoras y teniendo otro tipo de comportamientos extremos para perder peso”.

Nagata dijo que el número de pacientes con trastornos alimentarios que atiende se ha triplicado desde que comenzó la pandemia. Están desesperados por conseguir pastillas para adelgazar, algunas con resultados modestos. “Hemos tenido pacientes que han sido tan dependientes de estos productos que son hospitalizados y siguen pidiendo estos productos por Amazon”, dijo.

Los defensores de la salud pública recurrieron a las legislaturas estatales en respuesta a la limitada autoridad del gobierno federal para regular las píldoras dietéticas. En virtud de una ley federal de 1994 conocida como Ley de Educación y Salud sobre Suplementos Dietéticos, la FDA “no puede intervenir hasta que haya un problema claro de daño a los consumidores”, dijo Austin.

Al no poder hacer frente a la fuerte presión de la industria de los suplementos en el Capitolio, defensores de la salud pública han optado por centrarse en los estados. Sin embargo, existe una presión para que la FDA mejore la supervisión de lo que se incluye en las píldoras dietéticas.

El senador federal Dick Durbin, de Illinois, presentó en abril un proyecto de ley que exigiría a los fabricantes de suplementos dietéticos registrar sus productos, junto con los ingredientes, ante el organismo regulador.

Sus defensores afirman que el cambio es necesario porque se sabe que los fabricantes incluyen ingredientes peligrosos. C. Michael White, de la Facultad de Farmacia de la Universidad de Connecticut, encontró que el 35% de los productos sanitarios contaminados procedía de suplementos para la pérdida de peso, en una revisión de una base de datos sobre fraudes sanitarios.

Algunos ingredientes han sido prohibidos, como la sibutramina, un estimulante. “Era un suplemento para adelgazar muy utilizado que acabó siendo retirado del mercado estadounidense por su elevado riesgo de provocar cosas como ataques cardíacos, derrames cerebrales y arritmias”, dijo White.

Otro ingrediente era la fenolftaleína, que se utilizaba en los laxantes hasta que se identificó como presunto carcinógeno y se prohibió en 1999. “Pensar que ese producto siga en el mercado estadounidense es simplemente inconcebible”, dijo.

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

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

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California and New York Aim to Curb Diet Pill Sales to Minors

September 14, 2022

California and New York are on the cusp of going further than the FDA in restricting the sale of non-prescription diet pills to minors as pediatricians and public health advocates try to protect kids from extreme weight-loss gimmicks online.

A bill before Gov. Gavin Newsom would bar anyone under 18 in California from buying over-the-counter weight loss supplements — whether online or in shops — without a prescription. A similar bill passed by New York lawmakers is on Gov. Kathy Hochul’s desk. Neither Democrat has indicated how he or she will act.

If both bills are signed into law, proponents hope the momentum will build to restrict diet pill sales to children in more states. Massachusetts, New Jersey, and Missouri have introduced similar bills and backers plan to continue their push next year.

Nearly 30 million people in the United States will have an eating disorder in their lifetime; 95% of them are between ages 12 and 25, according to Johns Hopkins All Children’s Hospital. The hospital adds that eating disorders pose the highest risk of mortality of any mental health disorder. And it has become easier than ever for minors to get pills that are sold online or on drugstore shelves. All dietary supplements, which include those for weight loss, accounted for nearly 35% of the $63 billion over-the-counter health products industry in 2021, according to Vision Research Reports, a market research firm.

Dietary supplements, which encompass a broad range of vitamins, herbs, and minerals, are classified by the FDA as food and don’t undergo scientific and safety testing as prescription drugs and over-the-counter medicines do.

Public health advocates want to keep weight loss products — with ads that may promise to “Drop 5 pounds a week!” and pill names like Slim Sense — away from young people, particularly girls, since some research has linked some products to eating disorders. A study in the American Journal of Public Health, which followed more than 10,000 women ages 14-36 over 15 years, found that “those who used diet pills had more than 5 times higher adjusted odds of receiving an eating disorder diagnosis from a health care provider within 1 to 3 years than those who did not.”

Many pills have been found tainted with banned and dangerous ingredients that may cause cancer, heart attacks, strokes, and other ailments. For example, the FDA advised the public to avoid Slim Sense by Dr. Reade because it contains lorcaserin, which has been found to cause psychiatric disturbances and impairments in attention or memory. The FDA ordered it discontinued and the company couldn’t be reached for comment.

“Unscrupulous manufacturers are willing to take risks with consumers’ health — and they are lacing their products with illegal pharmaceuticals, banned pharmaceuticals, steroids, excessive stimulants, even experimental stimulants,” said Bryn Austin, founding director of the Strategic Training Initiative for the Prevention of Eating Disorders, or STRIPED, which supports the restrictions. “Consumers have no idea that this is what’s in these types of products.”

STRIPED is a public health initiative based at the Harvard T.H. Chan School of Public Health and Boston Children’s Hospital.

An industry trade group, the Natural Products Association, disputes that diet pills cause eating disorders, citing the lack of consumer complaints to the FDA of adverse events from their members’ products. “According to FDA data, there is no association between the two,” said Kyle Turk, the association’s director of government affairs.

The association contends that its members adhere to safe manufacturing processes, random product testing, and appropriate marketing guidelines. Representatives also worry that if minors can’t buy supplements over the counter, they may buy them from “crooks” on the black market and undermine the integrity of the industry. Under the bills, minors purchasing weight loss products must show identification along with a prescription.

Not all business groups oppose the ban. The American Herbal Products Association, a trade group representing dietary supplement manufacturers and retailers, dropped its opposition to California’s bill once it was amended to remove ingredient categories that are found in non-diet supplements and vitamins, according to Robert Marriott, director of regulatory affairs.

Children’s advocates have found worrisome trends among young people who envision their ideal body type based on what they see on social media. According to a study commissioned by Fairplay, a nonprofit that seeks to stop harmful marketing practices targeting children, kids as young as 9 were found to be following three or more eating disorder accounts on Instagram, while the median age was 19. The authors called it a “pro-eating disorder bubble.”

Meta, which owns Instagram and Facebook, said the report lacks nuance, such as recognizing the human need to share life’s difficult moments. The company argues that blanket censorship isn’t the answer. “Experts and safety organizations have told us it’s important to strike a balance and allow people to share their personal stories while removing any content that encourages or promotes eating disorders,” said Liza Crenshaw, a Meta spokesperson, in an email.

Dr. Jason Nagata, a pediatrician who cares for children and young adults with life-threatening eating disorders, believes that easy access to diet pills contributes to his patients’ conditions at UCSF Benioff Children’s Hospital in San Francisco. That was the case for one of his patients, an emaciated 11-year-old girl.

“She had basically entered a starvation state because she was not getting enough nutrition,” said Nagata, who provided supporting testimony for the California bill. “She was taking these pills and using other kinds of extreme behaviors to lose weight.”

Nagata said the number of patients he sees with eating disorders has tripled since the pandemic began. They are desperate to get diet pills, some with modest results. “We’ve had patients who have been so dependent on these products that they will be hospitalized and they’re still ordering these products on Amazon,” he said.

Public health advocates turned to state legislatures in response to the federal government’s limited authority to regulate diet pills. Under a 1994 federal law known as the Dietary Supplement Health and Education Act, the FDA “cannot step in until after there is a clear issue of harm to consumers,” said Austin.

No match for the supplement industry’s heavy lobbying on Capitol Hill, public health advocates shifted to a state-by-state approach.

There is, however, a push for the FDA to improve oversight of what goes into diet pills. U.S. Sen. Dick Durbin of Illinois in April introduced a bill that would require dietary supplement manufacturers to register their products — along with the ingredients — with the regulator.

Proponents say the change is needed because manufacturers have been known to include dangerous ingredients. C. Michael White of the University of Connecticut’s School of Pharmacy found 35% of tainted health products came from weight loss supplements in a review of a health fraud database.

A few ingredients have been banned, including sibutramine, a stimulant. “It was a very commonly used weight loss supplement that ended up being removed from the U.S. market because of its elevated risk of causing things like heart attacks, strokes, and arrhythmias,” White said.

Another ingredient was phenolphthalein, which was used in laxatives until it was identified as a suspected carcinogen and banned in 1999. “To think,” he said, “that that product would still be on the U.S. market is just unconscionable.”

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

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

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Journalists Delve Into Inflation Policy, Hospital Closures, and Needle Exchanges

September 10, 2022

KHN chief Washington correspondent Julie Rovner discussed provisions of the Inflation Reduction Act with Newsy’s “The Why” on Sept. 2.

KHN senior editor Andy Miller discussed the upcoming closure of a trauma hospital in metro Atlanta with WUGA’s “The Health Report” on Sept. 6.

KHN correspondent Jazmin Orozco Rodriguez discussed rural needle exchanges with The Nevada Independent’s “IndyMatters” on Sept. 6.

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

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Niños del norte de California aprenden a lidiar con el trauma que dejan los incendios

September 09, 2022

SONOMA, California. – Maia y Mia Bravo salieron de su casa en un brillante día de verano y sintieron el peligro.

Humo de madera quemada flotaba sobre su jardín. Maia, de 17 años, buscó la fuente mientras Mia, de 14, buscaba la manguera, abría el grifo y rociaba el perímetro de la propiedad con agua.

Ese olor a humo transportó a las hermanas a una ventosa tarde de octubre de 2017, cuando un incendio forestal llegó a su anterior casa. Desde la parte trasera de la minivan, las niñas vieron las llamas que rodeaban su trailer en Glen Ellen, un pueblo en la región vinícola del norte de California.

Abandonaron sus pertenencias, incluida la muñeca favorita de Mia, y se fueron sin su gata, Misi, que estaba asustada por el fuego. Lo único que la familia salvó fue una manta del bebé de 3 meses.

La familia se alejó por caminos oscuros iluminados por árboles y plantas en llamas. Mía estaba tranquila. Maia vomitó.

A medida que los incendios forestales de California se vuelven más intensos, frecuentes y generalizados, muchos niños que los sobreviven experimentan traumas psicológicos duraderos, como ansiedad, depresión y trastorno de estrés postraumático.

Los niños también pueden desarrollar problemas de sueño o de atención, o tener dificultades en la escuela. Si no se aborda, el trauma emocional puede afectar su salud física, lo que puede conducir a problemas de salud crónicos, enfermedades mentales y adicciones.

Desde 2020, el estado ha pedido a los médicos que participan en el programa estatal de Medicaid para personas de bajos ingresos que evalúen a niños y adultos para detectar eventos potencialmente traumáticos relacionados con experiencias infantiles adversas.

En el último reporte ACE (Adverse Childhood Experiences) del estado, que se llevó a cabo entre enero de 2020 y septiembre de 2021, se descubrió que los niños y adultos tenían un mayor riesgo de estrés tóxico o trauma si vivían en los condados del norte, una región principalmente rural castigada por los incendios.

Si bien hay las evaluaciones pueden ayudar a detectar negligencia, abuso o disfunción en el hogar,  médicos y funcionarios de salud han sugerido que los incendios forestales contribuyeron a las altas puntuaciones de ACE en las zonas rurales del norte de California.

En un informe anual, se descubrió que el 70% de los niños y adultos del condado de Shasta, donde ardió el incendio de Carr en 2018, tenían un alto riesgo de trauma. En el condado de Napa, donde el incendio de Tubbs arrasó la región vinícola en 2017, se consideró que el 50% de los niños y adultos tenían un alto riesgo de trauma.

En un análisis complementario, investigadores encontraron que el 75% de los adultos en algunos condados del norte de California han experimentado uno o más eventos traumáticos, en comparación con el 60% en todo el estado. Eso incluye el condado de Butte, donde el Camp Fire se cobró la vida de 85 personas.

“Para empezar, cuando la población ya tiene un alto rango de trauma y se agrega el  trauma ambiental, simplemente vuelve todo más difícil”, dijo el doctor Sean Dugan, pediatra en el Centro de Salud Comunitario de Shasta que realizó algunas de las evaluaciones ACE.

Los incendios forestales interrumpen las rutinas, obligan a las personas a mudarse y crean inestabilidad para los niños que necesitan consuelo y seguridad. En los últimos años, los demógrafos de California han atribuido algunos cambios dramáticos en la población a los incendios forestales que destruyen hogares y desplazan familias.

“No hay nada más estresante para un niño que ver a sus padres enloquecidos”, dijo Christopher Godley, director de manejo de emergencias del condado de Sonoma, que desde 2015 ha sido afectado por cinco de los incendios forestales más devastadores del estado.

Los niños también pueden ser víctimas indirectas de los incendios forestales. Según un estudio publicado por los Centros para el Control y la Prevención de Enfermedades, aproximadamente 7,4 millones de niños en el país se ven afectados anualmente por el humo de los incendios forestales, que no solo afecta el sistema respiratorio sino que puede contribuir al trastorno por déficit de atención/hiperactividad, autismo, deterioro del rendimiento escolar y problemas de memoria.

En 2017, la familia Bravo escapó del Incendio Tubbs, que quemó partes de los condados de Napa y Sonoma y la ciudad de Santa Rosa. En ese momento, fue el incendio más destructivo en la historia del estado, arrasó vecindarios y mató a casi dos docenas de personas.

La primera noche durmieron en su minivan y luego se refugiaron con su familia en las cercanías de Petaluma.

“Tenía miedo, estaba en estado de shock”, recordó Maia. “Me quedaba despierta toda la noche”.

Las hermanas encontraron a su gato Misi acurrucado debajo del trailer de un vecino 15 días después de que evacuaran. Sus patas tenían graves quemaduras.

Durante los primeros años después del incendio, Maia tuvo pesadillas llenas de llamas, cenizas y casas carbonizadas. Se despertaba sobresaltada con el sonido de las sirenas de los camiones de bomberos.

Los niños pueden responder de manera diferente al trauma dependiendo de su edad. Los más pequeños pueden sentirse ansiosos y temerosos, comer mal o desarrollar ansiedad por la separación de sus padres o adultos de confianza. Los niños mayores pueden sentirse deprimidos y solos, desarrollar trastornos alimentarios o comportamientos autodestructivos, o comenzar a consumir alcohol o drogas.

“Cuando tienes a estos niños que han tenido estas evacuaciones intensas, experimentado pérdidas de vidas, destrucción completa de la propiedad, es importante que tengan apoyo social”, dijo Melissa Brymer, directora de programas contra el terrorismo y desastres del  UCLA-Duke University National Center for Child Traumatic Stress.

Brymer dijo que los niños también necesitan herramientas para mantener la calma. Esas incluyen mantener rutinas, jugar juegos familiares, hacer ejercicio o ver a un consejero, explicó Sarah Lowe, psicóloga clínica y profesora asociada de la Escuela de Salud Pública de Yale.

“Para los niños, es realmente importante infundir una sensación de estabilidad y restablecer cierta sensación de rutina y normalidad”, agregó.

Los socorristas han comenzado a integrar el bienestar mental, tanto para adultos como para niños, en sus planes de respuesta ante desastres.

Funcionarios del condado de Sonoma ahora publican recursos para las personas que enfrentan el estrés durante los incendios forestales junto con consejos para armar kits de emergencia, y desarrollar un plan de escape.

Y el condado desplegará trabajadores de salud mental durante los desastres como parte de su nuevo plan de operaciones de emergencia, dijo Godley. Enviará especialistas en salud conductual a refugios de emergencia y trabajará con grupos comunitarios para rastrear las necesidades de los sobrevivientes de incendios forestales.

“Muchas de las poblaciones más vulnerables van a necesitar salud conductual especializada y eso será especialmente cierto para los niños”, dijo Godley.

Maia y Mia se mudaron tres veces desde que se incendio su trailer. Maia comenzó a ver al consejero escolar unas semanas después de regresar a la escuela. Mia era más reacia a aceptar ayuda y no comenzó a recibir asesoramiento hasta enero de 2018.

“Hablar de eso con el consejero me tranquilizó”, dijo Maia. “Ahora, puedo dormir. Pero cuando escucho sobre incendios, me pongo nerviosa de que vuelva a suceder”.

Su madre, Erandy Bravo, alentó a sus hijas a controlar su ansiedad escribiendo en un diario, pero las hermanas optaron por un enfoque más práctico para sobrellevar su trauma: preparon un bolso con sus libros escolares, computadoras portátiles y objetos personales que querrían en caso de otro incendio.

Las niñas asisten a talleres sobre cómo manejar la ansiedad en un centro local para adolescentes y se han convertido en líderes de un grupo de apoyo. Maia, quien se graduó de la secundaria en junio, estudiará psicología cuando comience en Santa Rosa Junior College en el otoño. Mia, que está en décimo grado, quiere ser despachadora de emergencias.

Aún así, las hermanas Bravo permanecen alertas.

En su nuevo hogar, cuando las hermanas olieron humo en su patio a principios de este año, pronto se dieron cuenta de que provenía de la chimenea del vecino. Se sintieron seguras y volvieron a la casa.

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

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

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Children in Northern California Learn to Cope With Wildfire Trauma

September 09, 2022

SONOMA, Calif. — Maia and Mia Bravo stepped outside their house on a bright summer day and sensed danger.

A hint of smoke from burning wood wafted through their dirt-and-grass yard anchored by native trees. Maia, 17, searched for the source as Mia, 14, reached for the garden hose, then turned on the spigot and doused the perimeter of the property with water.

The smoky smell sent the sisters back to one gusty October evening in 2017 when wildfire came for their previous home. From the back of the family’s minivan that night, the girls watched flames surround their trailer in Glen Ellen, a village in Northern California’s wine country. They abandoned their belongings, including Mia’s favorite doll, and left without their cat, Misi, who was spooked by the fire. The only thing the family saved was the 3-month-old’s baby blanket.

The family drove away, weaving through dark roads illuminated by burning trees and flaming tumbleweeds. Mia was quiet. Maia vomited.

As California wildfires grow more intense, frequent, and widespread, many children who live through them are experiencing lasting psychological trauma such as anxiety, depression, and post-traumatic stress disorder. Children may also develop sleep or attention problems, or struggle in school. If not managed, their emotional trauma can affect their physical health, potentially leading to chronic health problems, mental illness, and substance use.

Since 2020, the state has asked doctors who participate in the state’s Medicaid program for low-income people to screen children — and adults — for potentially traumatic events related to adverse childhood experiences, which are linked to chronic health problems, mental illness, and substance use. In the state’s most recent batch of so-called ACEs screenings that took place from January 2020 through September 2021, children and adults were found to be at higher risk for toxic stress or trauma if they live in the state’s northern counties, a primarily rural region that has been struck by large wildfires in recent years.

While the screenings can help detect neglect, abuse, or household dysfunction, doctors and health officials have suggested wildfires contributed to the high ACEs scores in rural Northern California. In an annual report, 70% of children and adults in Shasta County, where the Carr Fire burned in 2018, were found to be at high risk of trauma. In Napa County, where the Tubbs Fire ripped through wine country in 2017, 50% of children and adults were deemed to be at high risk of trauma.

In a supplemental analysis, researchers found that 75% of adults in some counties in Northern California have experienced one or more traumatic event, compared with 60% for the state as a whole. That includes Butte County, where the Camp Fire took the lives of 85 people.

“When the population has a high range of trauma to begin with and you throw in environmental trauma, it just makes it that much worse,” said Dr. Sean Dugan, a pediatrician at Shasta Community Health Center who has conducted some of the screenings, known as ACEs Aware.

Wildfires disrupt routines, force people to move, and create instability for children who need to be comforted and assured of safety. In recent years, California demographers have attributed some dramatic population shifts to wildfires that destroy homes and displace families.

“There’s nothing more stressful for a child than to see their parents freaking out,” said Christopher Godley, director of emergency management for Sonoma County, which since 2015 has been hit by five of the state’s most destructive wildfires.

Children can also be indirect victims of wildfires. According to a study published by the Centers for Disease Control and Prevention, an estimated 7.4 million kids in the United States are affected annually by wildfire smoke, which not only affects the respiratory system but may contribute to attention-deficit/hyperactivity disorder, autism, impaired school performance, and memory problems.

In 2017, the Bravo family escaped the Tubbs Fire, which burned parts of Napa and Sonoma counties and the city of Santa Rosa. At the time, it was the most destructive fire in state history, leveling neighborhoods and killing nearly two dozen people.

They slept in their minivan the first night, then took shelter with family in nearby Petaluma.

“I was afraid, in shock,” Maia recalled. “I would stay up all night.”

The sisters were overjoyed to find their cat cowering underneath a neighbor’s trailer 15 days after they evacuated. Misi’s paws had been badly burned.

For the first few years after the fire, Maia had nightmares filled with orange flames, snowing ash, and charred homes. She would jolt awake in a panic to the sound of firetruck sirens.

Children may respond differently to trauma depending on their age. Younger kids may feel anxious and fearful, eat poorly, or develop separation anxiety from parents or trusted adults. Older kids may feel depressed and lonely, develop eating disorders or self-harming behaviors, or begin to use alcohol or drugs.

“When you have these kids who have had these intense evacuations, experienced losses of life, complete destruction of property, it’s important they have social support,” said Melissa Brymer, director of terrorism and disaster programs at the UCLA-Duke University National Center for Child Traumatic Stress.

Brymer said children also need coping tools to help them stay calm. These include maintaining routines, playing familiar games, exercising, or seeing a counselor. “Do they need comfort from their parents? Need to distract themselves? Or do some breathing exercises?” she said.

Sarah Lowe, a clinical psychologist and associate professor at Yale School of Public Health, said that while a little anxiety can motivate adults, it doesn’t do the same for children. She recommends they maintain sleep schedules and eating times.

“For kids, instilling a sense of stability and calm is really important and reestablishing some sense of routine and normalcy,” Lowe said.

Emergency responders have begun to integrate mental wellness, for both adults and kids, into their disaster response plans.

Sonoma County officials now post resources for people coping with stress during wildfires alongside tips for assembling emergency kits, known as “go bags,” and developing an escape plan.

And the county will deploy mental health workers during disasters as part of its new emergency operations plan, Godley said. For example, the county will send behavioral health specialists to emergency shelters and work with community groups to track the needs of wildfire survivors.

“Many of the more vulnerable populations are going to need specialized behavioral health and that’s going to be especially true for children,” Godley said. “You just can’t pop them in front of a family and marriage therapist and expect that the kids are going to immediately be able to be really supported in that environment.”

Maia and Mia moved three times after their trailer burned down. Maia started seeing the school counselor a few weeks after returning to school. Mia was more reluctant to accept help and didn’t start counseling until January 2018.

“Talking about it with the counselor made me calm,” Maia said. “Now, I can sleep. But when I hear about fires, I get nervous that it’s going to happen again.”

Their mother, Erandy Bravo, encouraged her daughters to manage their anxiety by journaling, but the sisters opted for a more practical approach to cope with their trauma. They focused on preparation and, over summer break, kept a go bag with their schoolbooks, laptops, and personal belongings they would want in case of another fire.

The girls attend workshops on how to handle anxiety at a local teen center and have become leaders in a support group. Maia, who graduated from high school in June, will study psychology when she starts at Santa Rosa Junior College in the fall. Mia, who is in the 10th grade, wants to be an emergency dispatcher.

Still, the Bravo sisters remain vigilant.

At their new home, when the sisters smelled smoke in their yard earlier this year, they soon realized it came from the neighbor’s chimney. Mia turned off the water and coiled up the hose. The sisters, feeling safe, let down their guard and headed back inside.

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

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This story can be republished for free (details).

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