Press release for HHS Releases Report to Increase Language Access for Persons with Limited English Proficiency

民權辦公室發布為英语能力有限者減少障礙並採取措施增加語言使用服務的報告

民权办公室发布有关为英语水平有限人群减少障碍以及增加语言协助服务的报告

New HHS proposal would shed light on cost of prescription drugs and save states and federal government money in Medicaid

Surgeon General Urges Action to Ensure Social Media Environments are Healthy and Safe, as Previously-Advised National Youth Mental Health Crisis Continues

WEST WENDOVER, Nev. — In April, Mark Lee Dickson arrived in this 4,500-person city that hugs the Utah-Nevada border to pitch an ordinance banning abortion.

Dickson is the director of the anti-abortion group Right to Life of East Texas and founder of another organization that has spent the past few years traveling the United States trying to persuade local governments to pass abortion bans.

“Sixty-five cities and two counties across the United States” have passed similar restrictions, he told members of the West Wendover City Council during a mid-April meeting. The majority are in Texas, but recent successes in other states have buoyed Dickson and his group.

“We’re doing this in Virginia and Illinois and Montana and other places as well,” he said.

The quest to enact local bans has become particularly acute in small towns, like West Wendover and Hobbs, New Mexico, which are situated by borders between states that have restricted abortion and states where laws preserve access. They are crossroads where abortion advocates and providers have looked to establish clinics to serve people traveling from the large swaths of the U.S. where states have banned or severely restricted abortions after the U.S. Supreme Court overturned nearly 50-year-old nationwide abortion protections established by the court’s decision in Roe v. Wade.

Residents and leaders in West Wendover and many other towns and cities are grappling with the arrival of outside advocates, including Dickson, who now claim a stake in the governance of their small and otherwise quiet communities.

Dickson’s proposal to the West Wendover City Council came after council members voted against issuing a building permit to California-based Planned Parenthood Mar Monte in March. Officials from the Planned Parenthood affiliate told the local board the facility would offer primary care services in addition to abortion and other reproductive care. The vote followed hours of heated debate during public comment. Then, Mayor Jasie Holm vetoed the council’s decision, leaving the request for the permit in limbo.

Located in northeastern Nevada, West Wendover is more than 100 miles by car from Elko, the county seat, 120 miles west from Salt Lake City, and 170 miles south from Twin Falls, Idaho. The city has been a strategic location for casinos and a marijuana dispensary, which are legal in Nevada but restricted in Utah and Idaho. Similarly, its proximity to states that moved to restrict abortion access following the Dobbs decision overturning Roe has put a spotlight on the city.

Dickson’s anti-abortion proposal has drawn support from the town’s more conservative residents. But brothers Fernando and Marcos Cerros have challenged the anti-abortion efforts. In addition to wanting to protect and expand access to abortion, they both saw the primary care clinic that Planned Parenthood Mar Monte was seeking to establish as a potential victory in their rural community, which is designated a medically underserved area by the federal Health Resources and Services Administration.

Fernando Cerros, 22, said Planned Parenthood offered a solution to the area’s health care shortage “on a silver platter.”

“And it was denied. I need to do what I can do to get it here,” he said.

The Cerros brothers have tried to organize a group to support abortion access and establish the Planned Parenthood clinic in West Wendover, but have found it difficult to sustain. They said they feel outnumbered by residents who support Dickson. Marcos Cerros, 18, said he attends Catholic Mass every Sunday in West Wendover and that parishioners there are regularly exposed to inflammatory anti-abortion language.

Abortion up to 24 weeks is protected in Nevada law, and the state legislature recently approved a bill to enshrine the law in the state constitution. To become law, the measure will need to pass once more during Nevada’s next legislative session, in 2025, and be approved by voters in 2026.

Last year, following the Dobbs decision, then-Gov. Steve Sisolak, a Democrat, issued an executive order similar to ones in other states protecting patients who seek abortion care from facing prosecution by states where it is not legal.

Across Nevada’s eastern border, in Utah, abortion is legal up to 18 weeks while challenges to a trigger ban and a move to clamp down on abortion clinic licensure continue through the courts.

Idaho’s laws against abortion are among the most restrictive in the country. Currently, the state allows abortion only in certain cases of rape and incest or to save the mother’s life. In April, the state made headlines after lawmakers there passed an “abortion trafficking” law that criminalizes helping minors cross state borders to receive an abortion or obtain abortion pills without parental consent.

Extreme variations in abortion policy from state to state are the new normal, and local challenges are “what we’re in for,” said Rachel Rebouché, dean of the Beasley School of Law at Temple University and co-author of a recent research paper examining the post-Dobbs legal reality. “The theaters of conflict are multiplying, and this is the complex legal landscape that we live in.”

Dickson’s strategy in creating what he calls “sanctuary cities for the unborn” involves invoking a 150-year-old federal law that restricts the mailing of abortion pills. But Dickson argues the law goes further, banning any “paraphernalia,” including anything that could be used to perform an abortion, such as certain medical devices and tools.

Federal officials contend that although the abortion provision in the law has not been amended, previous court decisions have limited the reach of the Comstock Act. The Justice Department’s Office of Legal Counsel issued an opinion in December concluding that the law does not prohibit the mailing of abortion medication.

Dickson argues that the Comstock Act should supersede any state law or state constitutional protection. Rebouché said she’s unsure how it will shake out in the courts.

“There’s a number of jumps a court would have to take, the most significant of which would be that Comstock is still good law and it preempts abortion law,” she said. “That’s a controversial holding because Comstock has not been enforced or applied for decades.”

A spokesperson for Planned Parenthood Mar Monte declined to comment on whether the organization would continue to pursue the clinic in West Wendover, citing legal issues.

Dickson’s proposal now sits in the hands of the West Wendover City Council. He assured local leaders that, should they proceed with implementing the ordinance, his attorney will represent them at no cost. That attorney, Jonathan Mitchell, is a former solicitor general of Texas and is credited with helping shape the law that allows civil lawsuits against people and providers “aiding and abetting” pregnant women terminating a pregnancy.

An anti-abortion ordinance was walked back in at least one Ohio city, and other local bodies have voted against such ordinances or chosen not to put them to a vote, according to Dickson’s website.

Andrea Miller, president of the National Institute for Reproductive Health, said there’s an irony in Dickson’s multistate effort to stop people from crossing state lines for reproductive health care, including abortion.

“It would be laughable if it were not so tragic,” Miller said. “It’s an incredibly cynical, politically motivated effort largely aimed at sowing confusion and stigmatizing abortion care.”

Miller also pointed to other municipalities in the U.S. — urban centers like New York, Seattle, Philadelphia, and more — that have approved local ordinances protecting and expanding access to abortion care.

The West Wendover city manager, mayor, or council members would need to request that consideration of the proposal be added to a meeting agenda for it to move forward. Holm, the mayor, said she would not include the ordinance for consideration “at any time.” City Council member Gabriela Soriano, the only woman on the council, said in late April that she was unsure whether other council members would pursue the ordinance.

Holm said she was unaware of any outreach to the city from Planned Parenthood Mar Monte about moving forward with the clinic.

If the anti-abortion ordinance in West Wendover were instituted and prevented the opening of a clinic in the city, it would have far-reaching implications for residents. Currently, they face more than an hour drive in either direction to the nearest hospital.

For some community members, the decision isn’t so clear-cut.

The Cerros brothers said their mother, who is Catholic and Hispanic, is against abortion but in support of the Planned Parenthood clinic opening in West Wendover. Years ago, she had a miscarriage after driving an hour and a half to Salt Lake City for emergency care.

“There’s a big divide between people who think you’re killing babies versus people who think pregnancy is not black and white. Things come up,” Fernando Cerros said. “Sometimes you need emergency care. And a clinic like that would help.”

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California has allocated more than $1 billion in recent years to combat its opioid crisis. Much of the money has been used to distribute fentanyl test strips and the overdose reversal drug naloxone, as well as deliver medical care to people who are homeless. The state has an opioid awareness campaign tailored to youths and recently called on the National Guard to help detect drug traffickers.

Yet the problem keeps getting worse.

Driven largely by the prevalence of fentanyl, a synthetic opioid up to 100 times stronger than morphine, drug overdoses in California now kill more than twice as many people as car accidents, more than four times as many as homicides, and more than either diabetes or lung cancer, according to California Health Policy Strategies, a Sacramento consulting group. And the state’s overdose surveillance dashboard indicates most opioid overdose deaths involve fentanyl.

Provisional data for last year from the Centers for Disease Control and Prevention shows a small annual increase in overdose deaths in California, to nearly 12,000. Across the U.S., overdose deaths again topped 100,000.

“As a parent, it scares the hell out of me. As a governor, I see it, I recognize the nature of what’s occurred on the streets,” Gov. Gavin Newsom said May 12 in announcing more funding for California to produce its own naloxone.

Despite all the state is doing to reduce drug overdose deaths, public health policy experts say there are no easy or clear answers. Drug policy experts applaud California’s effort to make naloxone as commonly available as fire extinguishers in schools, bars, libraries, and gas stations, but they also recommend diverting more offenders from prisons and jails into treatment and encourage ramping up the use of anti-addiction medication.

“Even if we do a lot of things right in policy, we’re going to have a fair amount of deaths in the coming years,” said Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University and a drug policy expert.

He said lawmakers should examine the underlying, complex causes of addiction if they want to make lasting change. Lawmakers have created a Select Committee on Fentanyl, Opioid Addiction, and Overdose Prevention and are advancing a bill to create a Fentanyl Addiction and Overdose Prevention Task Force. The bill would require the task force to start meeting next year and submit an interim report by January 2025 and recommendations by July 2025.

“It really is something, like covid, that we have to focus on and make some permanent structural changes, like to health care, mental health care, and funding to deal with addiction,” Humphreys said.

Newsom acknowledged as much, saying, “We have a lot more work to do.”

The Democratic governor was joined last month by Attorney General Rob Bonta in calling on the California National Guard, California Highway Patrol, and state Department of Justice to crack down on fentanyl dealing in San Francisco, where fatal overdoses jumped more than 40% in the first three months of this year over 2022.

The move was criticized as “a law enforcement-first approach to matters of public health” in a joint statement from 28 organizations including the American Civil Liberties Union of Northern California and the San Francisco Public Defender’s Office.

While the governor has focused on fentanyl trafficking and making naloxone more readily available, state lawmakers have recently been debating whether and how to stiffen punishments for dealers.

Several proposals have already stalled, such as one to send dealers to jail for up to nine years if they sell fentanyl on a social media platform and another warning dealers they could be charged with murder if someone dies taking their drugs. Lawmakers kept alive two bills to boost punishments for dealers of large volumes of fentanyl and those who carry a gun.

Democrats who control the legislature’s public safety committees are reluctant to support tougher penalties for fear of sparking a new war on drugs or reprising steep penalties on crack cocaine that criminalized Black people disproportionately.

Black and Latino Californians experienced an increase in overdose deaths of more than 200% between 2017 and 2021, according to Konrad Franco, who conducted the research for California Health Policy Strategies. Black people make up 6% of California’s population but accounted for 13% of its overdose deaths in 2021.

“We cannot go backwards and fill our prisons with kids of color,” said Assemblymember Liz Ortega, a Democrat from San Leandro, during a special hearing last month on fentanyl-related bills.

Georges Benjamin, executive director of the American Public Health Association, questioned the effectiveness of increased penalties for people who are largely controlled by their addictions.

Benjamin said lawmakers should instead support drug courts that promote treatment programs over incarceration, though he said incarceration may be needed to protect the public mostly from violent offenders who refuse treatment and harm others.

Humphreys pointed to the Honest Opportunity Probation With Enforcement and 24/7 Sobriety programs as models. They combine regularly testing offenders for drugs and alcohol with short penalties for violations.

“You use the criminal justice system in a way that in the long run actually reduces incarceration rather than increasing it,” Humphreys said of the approach.

Yet Tanya Tilghman, a Black woman from San Francisco, supports tougher penalties for fentanyl dealers and said the issue crosses racial lines. She became an activist with Mothers Against Drug Addiction and Deaths after her son became addicted to methamphetamine and more recently to fentanyl.

“When people are doing drugs, it doesn’t see color or racial boundaries,” she said. “It’s killing a lot more people and it’s killing a lot of Black people.”

Daniel Ciccarone, a drug policy expert at the University of California-San Francisco, said enforcement efforts may be popular with the public but “simply don’t work as well as we want them to.” At minimum, he said, any crackdown should be coupled with an equal public health approach.

“We’ve thrown tens of billions of dollars at the war on drugs over two generations, almost three generations now, and believe it or not, drugs across category — from marijuana to cocaine to heroin/fentanyl — drugs are ever more pure and ever cheaper despite impressive levels of effort,” Ciccarone said. “The most honest answer is there’s no clear answer as to what to do about the fentanyl crisis.”

He recommended California allow supervised consumption sites where opioid users could legally inject drugs, an idea Newsom vetoed last fall but that Ciccarone said can ease people into treatment. Other harm reduction strategies, including expanding the use of test strips and other chemical analyses to check drugs for contamination with fentanyl, can also save lives, he said.

Humphreys led a 17-member commission that examined the opioid crisis and made recommendations including expanding the availability of prescription drugs such as buprenorphine, naltrexone, and methadone to ease addicts’ cravings and withdrawal symptoms.

Still, some parents of children who have experienced opioid addiction say tougher penalties must be part of the response.

“What they don’t understand is that fentanyl has changed the drug landscape like no other drug has in the history of the United States of America,” said Jaime Puerta, whose only son, Daniel, died from fentanyl in 2020 at age 16.

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

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California ha destinado más de $1,000 millones en los últimos años a combatir la crisis de los opioides. Gran parte del dinero se ha utilizado para distribuir tiras reactivas de fentanilo y naloxona, el fármaco que revierte las sobredosis, así como para prestar atención médica a las personas sin hogar. El estado ha puesto en marcha una campaña de concienciación sobre los opioides dirigida a los jóvenes y recientemente ha recurrido a la Guardia Nacional para que ayude a detectar a los traficantes de drogas.

Sin embargo, el problema sigue empeorando.

Impulsadas en gran medida por la prevalencia del fentanilo, un opioide sintético hasta 100 veces más potente que la morfina, las sobredosis de drogas en California matan ahora a más del doble de personas que los accidentes de tráfico, más del cuádruple que los homicidios y más que la diabetes o el cáncer de pulmón, según California Health Policy Strategies, un grupo consultor de Sacramento.

Y el registro de vigilancia de sobredosis del estado indica que la mayoría de las muertes por sobredosis de opiáceos están relacionadas con el fentanilo.

Los datos provisionales del año pasado de los Centros para el Control y Prevención de Enfermedades (CDC) muestran un pequeño aumento anual de las muertes por sobredosis en California, hasta casi 12,000. En todo Estados Unidos, las muertes por sobredosis volvieron a superar las 100,000.

“Como padre, me da mucho miedo. Como gobernador, lo veo, reconozco la naturaleza de lo que está ocurriendo en las calles”, dijo el gobernador Gavin Newsom el 12 de mayo al anunciar más fondos para que California produzca su propia naloxona.

A pesar de todo lo que el estado está haciendo para reducir las muertes por sobredosis de drogas, los expertos en políticas de salud pública dicen que no hay respuestas fáciles o claras. Los expertos en políticas antidrogas aplauden el esfuerzo de California por hacer que la naloxona esté tan comúnmente disponible como los extintores de incendios en escuelas, bares, bibliotecas y gasolineras, pero también recomiendan desviar a más delincuentes de las prisiones y cárceles hacia el tratamiento y fomentar el aumento del uso de medicamentos contra la adicción.

“Aunque hagamos muchas cosas bien en política, vamos a tener un buen número de muertes en los próximos años”, afirmó Keith Humphreys, profesor de psiquiatría y ciencias del comportamiento en la Universidad de Stanford y experto en política antidrogas.

Afirmó que los legisladores deben examinar las causas subyacentes y complejas de la adicción si quieren lograr un cambio duradero. Los legisladores han creado un Comité Selecto sobre Fentanilo, Adicción a Opiáceos y Prevención de Sobredosis y han presentado un proyecto de ley para crear un Grupo de Trabajo sobre Adicción al Fentanilo y Prevención de Sobredosis. El proyecto de ley exige que el grupo de trabajo empiece a reunirse el año que viene y presente un informe provisional antes de enero de 2025 y recomendaciones antes de julio de 2025.

“Realmente es algo, como el covid, en lo que tenemos que centrarnos y hacer algunos cambios estructurales permanentes, como en la atención sanitaria, la atención de salud mental y la financiación para hacer frente a la adicción”, dijo Humphreys.

Newsom lo reconoció: “Nos queda mucho trabajo por hacer”.

El gobernador demócrata se unió el mes pasado al fiscal general Rob Bonta para pedir a la Guardia Nacional de California, a la Patrulla de Carreteras de California y al Departamento de Justicia del estado que tomen medidas enérgicas contra el tráfico de fentanilo en San Francisco, donde las sobredosis mortales aumentaron más de un 40% en los tres primeros meses de este año respecto a 2022.

En una declaración conjunta de 28 organizaciones, entre ellas la Unión Americana de Libertades Civiles del Norte de California y la Oficina del Defensor del Pueblo de San Francisco, se criticó la medida como “un enfoque que da prioridad a la aplicación de la ley en cuestiones de salud pública”.

Mientras que el gobernador se ha centrado en el tráfico de fentanilo y en facilitar el acceso a la naloxona, los legisladores estatales han estado debatiendo recientemente si endurecer las penas para los traficantes y cómo hacerlo.

Varias propuestas ya se han estancado, como una que busca enviar a los traficantes a la cárcel hasta nueve años si venden fentanilo en una plataforma de medios sociales y otra que advierte a los traficantes de que podrían ser acusados de asesinato si alguien muere consumiendo sus drogas. Los legisladores mantuvieron vivos dos proyectos de ley para endurecer las penas a los traficantes de grandes volúmenes de fentanilo y a quienes porten armas.

Los demócratas que controlan los comités de seguridad pública de la legislatura son reacios a apoyar penas más duras por miedo a desencadenar una nueva guerra contra las drogas o a reeditar las duras penas contra el crack que criminalizaban a los negros de forma desproporcionada.

Los californianos negros y latinos experimentaron un aumento en las muertes por sobredosis de más del 200% entre 2017 y 2021, según Konrad Franco, quien realizó la investigación para California Health Policy Strategies. Los negros constituyen el 6% de la población de California, pero representaron el 13% de sus muertes por sobredosis en 2021.

“No podemos retroceder y llenar nuestras cárceles de chicos de color”, afirmó la asambleísta Liz Ortega, demócrata de San Leandro, durante una audiencia especial celebrada el mes pasado sobre proyectos de ley relacionados con el fentanilo.

Georges Benjamin, director ejecutivo de la Asociación Americana de Salud Pública, cuestionó la eficacia de aumentar las penas para personas que están dominadas en gran medida por sus adicciones.

Benjamin dijo que los legisladores deberían apoyar a los tribunales de drogas que promueven programas de tratamiento en lugar de encarcelamiento, aunque dijo que el encarcelamiento puede ser necesario para proteger al público sobre todo de los delincuentes violentos que rechazan el tratamiento y perjudican a los demás.

Humphreys señaló como modelos los programas Honest Opportunity Probation With Enforcement y 24/7 Sobriety. Estos combinan la realización periódica de pruebas de drogas y alcohol a los delincuentes con la imposición de penas cortas en caso de infracción.

“Se utiliza el sistema de justicia penal de forma que, a largo plazo, se reduce el encarcelamiento en lugar de aumentarlo”, explicó Humphreys.

Sin embargo, Tanya Tilghman, una mujer de raza negra de San Francisco, apoya el endurecimiento de las penas contra los traficantes de fentanilo y afirma que el problema trasciende las fronteras raciales. Tilghman se convirtió en activista de Madres contra la Drogadicción y las Muertes por Drogas después de que su hijo se volviera adicto a la metanfetamina y, más recientemente, al fentanilo.

“Cuando la gente se droga, no entiende de colores ni de razas”, dijo. “Está matando a mucha más gente y está matando a mucha gente negra”.

Daniel Ciccarone, experto en política antidrogas de la Universidad de California-San Francisco, dijo que las medidas de represión pueden ser populares entre el público, pero “simplemente no funcionan tan bien como quisiéramos”. Como mínimo, indicó, cualquier medida represiva debería ir acompañada de un enfoque de salud pública equitativo.

“Hemos tirado decenas de miles de millones de dólares en la guerra contra las drogas durante dos generaciones, casi tres generaciones ahora, y lo creas o no, las drogas en todas las categorías, desde la marihuana a la cocaína a la heroína/fentanilo, son cada vez más puras y cada vez más baratas a pesar de los impresionantes niveles de esfuerzo”, dijo Ciccarone. “La respuesta más honesta es que no hay una respuesta clara sobre qué hacer con la crisis del fentanilo”.

Recomendó que California permita sitios de consumo supervisado donde los consumidores de opioides puedan inyectarse drogas legalmente, una idea que Newsom vetó el otoño pasado pero que, según Ciccarone, puede facilitar el acceso al tratamiento. Otras estrategias de reducción de daños, como ampliar el uso de tiras reactivas y otros análisis químicos para comprobar si los fármacos están contaminados con fentanilo, también pueden salvar vidas, afirmó.

Humphreys dirigió una comisión de 17 miembros que examinó la crisis de los opiáceos y formuló recomendaciones como la ampliación de la disponibilidad de medicamentos de venta con receta, como la buprenorfina, la naltrexona y la metadona, para aliviar el ansia y los síntomas de abstinencia de los adictos.

Sin embargo, algunos padres de niños que han sufrido la adicción a los opiáceos afirman que el endurecimiento de las penas debe formar parte de la respuesta.

“Lo que no entienden es que el fentanilo ha cambiado el panorama de las drogas como ninguna otra droga lo ha hecho en la historia de los Estados Unidos de América”, dijo Jaime Puerta, cuyo único hijo, Daniel, murió de una sobredosis de fentanilo en 2020 a los 16 años.

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

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

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Last June, Jay Comfort flew to the United States from his home in Switzerland to attend his only daughter’s wedding. But the week before the ceremony — on a Friday evening — Comfort said he found himself in “excruciating pain.”

“I tried to gut it out for three hours because of the insurance situation,” said Comfort, a retired teacher and American citizen who has Swiss insurance.

When the pain became unbearable, Comfort called his brother, who drove him and his wife, Nazuna, a few miles to the nearest emergency department, at the University of Pittsburgh Medical Center’s hospital in Williamsport, Pennsylvania.

Every bump of the drive was “like someone taking something and just jabbing it into my abdomen,” he said.

At the hospital, Nazuna Konishi Comfort handed over her husband’s Swiss insurance card, which confirmed coverage by Groupe Mutuel. Jay recalled the staff making copies of his insurance card and then treating his acute appendicitis. Doctors performed emergency surgery to remove the inflamed appendix.

Diagnostic tests confirmed he had a rare cancer, which doctors in Switzerland later removed with another surgery after he returned home. “It was a miracle,” Comfort said, adding that the cancer was completely removed.

After his appendectomy, Comfort recalled vomiting and then waiting in a recovery room. In all, he spent about 14 hours at UPMC Williamsport before being released. He attended his daughter’s wedding and, eventually, traveled back to Switzerland.

Then the bill came.

The Patient: Leslie “Jay” Comfort, 66, a retired educator who worked in Japan and Switzerland. Comfort pays a monthly fee and deductible for Switzerland’s mandatory basic health insurance, which he has with the Swiss-based Groupe Mutuel. His benefits — and the prices for procedures — are defined by the Swiss government.

Medical Service: Emergency laparoscopic appendectomy and diagnostic tests, which showed Comfort had a rare subtype of cancer called goblet cell adenocarcinoma.

Service Provider: University of Pittsburgh Medical Center Williamsport, which is about 3½ hours northeast of Pittsburgh. The UPMC health system is one of the state’s largest employers, with 40 hospitals.

Total Bill: $42,156.50, covering emergency surgery, scans, laboratory testing, and three hours in a recovery room. His insurer has said it will pay him about $8,184 (7,260.40 in Swiss francs), which is double the procedure’s price in Switzerland. This left him to cover the remaining roughly $34,000.

What Gives: Although Comfort has health coverage, his Swiss insurance had no contract with the U.S. hospital where he underwent emergency surgery — or with any other provider outside Switzerland.

With what is considered an excellent health system, Switzerland has the highest prices for medical care in Europe. As in the U.S., the country relies on private insurers and hospitals. But the cost of care in Switzerland is substantially lower than what is charged in the U.S., so the reimbursement his insurer offered is a fraction of what Comfort owes the U.S. hospital.

“I’m trying to do the right thing and say I’m willing to pay my responsibility,” he said.

Groupe Mutuel does not have agreements with foreign providers, such as UPMC, and does not deal with them directly, said Lisa Flückiger, a spokesperson for Groupe Mutuel. The insurer originally agreed to reimburse Comfort what would have been paid in Switzerland for the same treatment in a public hospital and then double that because it was an emergency in a foreign country — a total of 4,838 in Swiss francs, or about $5,460.

While helpful, Comfort said, that amount wouldn’t pay off the $42,156.50 he owes UPMC.

UPMC has expanded its reach throughout Pennsylvania and is now the largest provider of care in many parts of the state. In 2016, it purchased a smaller health system and now runs two major hospitals, UPMC Williamsport and UPMC Williamsport Divine Providence Campus.

Studies show that in areas where hospital consolidation is high, prices go up. Because there is less competition, hospitals have more power to charge what they want when patients have private insurance or are paying out-of-pocket.

In the U.S., the amounts charged for medical care are “all over the map,” said Johnathan Clarke, vice president of strategy and business development at Penfield Care, a medical cost-containment company in Canada. The company negotiates medical bills on behalf of individuals, including international visitors to the U.S., but is not involved in Comfort’s case.

Clarke said he would expect an appendectomy to be priced between $6,500 and $18,800, based on his analysis of Medicare payments in the Pittsburgh area. Healthcare Bluebook — which evaluates insurers’ claims data to provide cost estimates based on what insurers have paid, rather than what providers charge — says a fair price for a laparoscopic appendectomy in Williamsport is about $14,554.

Comfort said a “reasonable price estimate” based on his own internet research would be between $7,500 and $12,000.

Comfort’s care included an X-ray and an EKG, or electrocardiogram for his heart, because “there was no information relating to past medical/surgical history for this patient,” wrote Susan Manko, vice president of public relations at UPMC. The staff also conducted pathology work that identified cancer.

But those additional services did not fully explain the gap between cost estimates and what the hospital charged. For instance, UPMC charged $8,357 for Comfort’s three-hour stay in the recovery room.

Manko said Comfort’s total bill aligns with UPMC’s standard charges.

The cost disparities highlight the stark difference in international pricing. Cost estimates last year showed the average amount paid for an appendectomy in the U.S. was “nearly exactly double” that paid in Switzerland, said Christopher Watney, chief executive of the International Federation of Health Plans, an industry association whose members include health insurers on six continents.

Health care in Switzerland, though, is often expensive compared with other European countries, Watney said. The Swiss pay double for an appendectomy compared with Germans, and more than three times that of those in Spain, he said. Across the globe, Watney said, many countries include an overnight stay in the cost of an uncomplicated appendectomy in contrast to Comfort’s experience, which was billed as outpatient care.

Comfort, who has dual residency in Switzerland and Japan after nearly three decades working abroad, said he worked in the U.S. long enough to qualify for Social Security benefits and Medicare. He said he had previously tried to gain Medicare coverage at one point but still is not enrolled, after being transferred to a couple of offices and “playing phone tag.”

Still, unlike many patients dealing with a five-figure medical bill, Comfort said he is not concerned about UPMC harming his financial reputation. The health system doesn’t “seem to put bad marks against people’s credit record — and I don’t have credit in the United States. I’ve been out for 30 years.”

Manko confirmed that, saying UPMC reviewed and updated its collection policy last year; it states the health system will not engage in “extraordinary collection actions” such as lawsuits, liens on homes, arrests, or reporting to credit agencies.

She said the health system — which, as a nonprofit system, is tax-exempt — maintains a “robust financial assistance program” for patients unable to pay. But “to our knowledge” Comfort has not applied for financial assistance, Manko told KFF Health News.

The Resolution: Comfort said he spent months waiting for a bill and finally reached out to UPMC because, if the bill had arrived this year, he would have had to pay his insurance deductible again on top of the charges.

Comfort received a full UPMC bill six months after his surgery. Manko said there was “confusion” at the time of Comfort’s ER registration. Comfort’s wife provided the insurance information, she said, “but there was no documentation in the patients record for address, policy number or policy holder information.”

Once Comfort received his bill, he realized it was much higher than his Swiss insurance reimbursement and, frustrated, contacted KFF Health News.

Flückiger said the original payment amount Comfort’s insurer calculated was by episode and did not include the scan or laboratory costs. After receiving questions from a KFF Health News reporter, Groupe Mutuel “realized that we have not included the laboratory analysis and the CT scan,” which are not routinely part of an appendectomy, Flückiger wrote.

After KFF Health News provided a detailed summary of the UPMC bill, the insurer increased the amount it would pay Comfort. In all, the insurer said, Comfort should receive 7,260.40 in Swiss francs, or about $8,184.

Comfort still hopes to negotiate directly with UPMC to reduce what he owes.

“I don’t want to try to walk away, saying I don’t owe you anything,” Comfort said. “That’s not right. We’re moral people, you know. But if you’re going to try to gouge me and play the power trip and think you’re going to try to get everything you can out of me, I won’t play that game.”

The Takeaway: Though the Affordable Care Act was meant to provide insurance to more Americans and bring down the cost of care, hospital bills remain extraordinarily high and highly variable.

For a nonemergency, Comfort could have tried to compare prices at other hospitals. But most hospitals in the area where he fell ill are owned by UPMC. And an inflamed appendix can’t wait for comparison shopping.

Clarke, the cost-containment expert, said the “only thing” Comfort could have done differently was to purchase a travel health insurance policy before leaving Switzerland. While prices for health care in continental Europe are comparable to Switzerland, the high cost of care in the U.S. means Groupe Mutuel insurance is “insufficient.”

That is especially important for visitors to the U.S. since, as Robin Ingle, CEO of travel insurance company Ingle International, said: U.S. prices are “kind of crazy numbers.”

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Los adultos jóvenes no actúan como sus padres: no beben tanto, enfrentan más problemas de salud mental y viven más tiempo con mamá y papá. Además, los videojuegos y las redes sociales se han convertido en una especie de sustituto de las relaciones físicas.

Todo eso significa que los jóvenes californianos no tienen tanto sexo.

La cantidad de adultos jóvenes que no tienen relaciones sexuales ya estaba aumentando antes de que covid-19 hiciera que las citas fueran más difíciles y riesgosas.

En 2011, alrededor del 22% de los californianos de 18 a 30 años informaron que no habían tenido parejas sexuales en los 12 meses anteriores. Eso aumentó al 29% en 2019, y saltó al 38% en 2021, según las últimas cifras de la California Health Interview Survey de la UCLA.

Otros grupos de edad en California también informaron un aumento en la abstinencia, pero la tendencia no fue tan marcada.

“Todo pasa más tarde”, dijo Jean Twenge, profesora de Psicología de la Universidad Estatal de San Diego, autora de “Generations: The Real Differences Between Gen Z, Millennials, Gen X, Boomers, and Silents — And What They Mean for America’s Future”.

Twenge dijo que los números reflejan cómo los adultos jóvenes retrasan cada vez más los eventos importantes de la vida, como mudarse de la casa familiar, y comenzar relaciones románticas a largo plazo.

Los solteros han visto el cambio más dramático.

Por largo tiempo, las personas solteras eran las más propensas a informar que no tenían relaciones sexuales, menos que las casadas o las que conviven. Pero a medida que los adultos jóvenes retrasan el matrimonio, la brecha se amplía.

Los adultos jóvenes pueden estar postergando las relaciones a largo plazo “por un status económico cada vez más precario o por el estrés relacionado con completar la educación y buscar trabajo”, dijo Lei Lei, profesora de Sociología en Rutgers, quien recientemente fue coautora de un artículo que examinó por qué más adultos jóvenes no están teniendo sexo. “Están ocupados con otros aspectos de la vida”.

Los investigadores también notaron que cientos de miles de adultos jóvenes se identifican como asexuales.

El aumento del uso de la computadora puede desempeñar un papel en la tendencia. Los adultos jóvenes forman cada vez más relaciones a través de videojuegos con personas que no conocen físicamente, dijo Lei. Estas relaciones a distancia a veces interfieren con la formación de relaciones sexuales.

Un informe del Pew Research Center de 2015 encontró la misma cantidad de hombres y mujeres que jugaban videojuegos, pero los hombres adultos jóvenes tenían más del triple de probabilidades que las mujeres adultas jóvenes de identificarse como “jugadores” serios.

Los adultos jóvenes también tienen acceso a cantidades ilimitadas de pornografía gratuita en internet, a diferencia de las revistas y DVD de porno que muchos de sus padres compraban.

Gran parte de la pornografía en línea más popular presenta violencia o coerción, lo que les da a algunos adultos jóvenes una perspectiva distorsionada del sexo y aleja a otros por completo, dijo Debby Herbenick, directora del Center for Sexual Health Promotion de la Escuela de Salud Pública de la Universidad de Indiana en Bloomington.

“Ese tipo de comportamientos están muy, muy vistos como algo normal entre los jóvenes”, dijo, refiriéndose al sexo duro.

El sexo también tiene una correlación con los ingresos. Los adultos jóvenes que ganan menos dinero tienen más probabilidades de no tener relaciones sexuales que sus pares que ganan más.

Gran parte del discurso reciente sobre la falta de sexo entre adultos jóvenes ha girado en torno a los llamados incels, hombres jóvenes que afirman —a menudo en tono despectivo misógino— que las aplicaciones de citas como Tinder facilitan que las mujeres encuentren hombres atractivos, ricos y de status, dejando de lado a los otros.

Erin Tillman, educadora sexual certificada y directora ejecutiva de la organización sin fines de lucro Sex-Positive Los Ángeles, dijo que le entristece escuchar que los hombres culpan a las mujeres por no querer tener sexo con ellos.

Agregó que esos hombres probablemente podrían cambiar su perspectiva y encontrar intimidad. “Tienen el poder de mejorarse a sí mismos”, dijo.

La tendencia de una vida sin sexo tiene el potencial de reducir las tasas de embarazo no planificado. Y también podría reducir la propagación de infecciones de transmisión sexual, aunque eso aún no ha sucedido.

Herbenick sí se preocupa por los adultos jóvenes que quieren sexo pero no lo tienen. “Puedes sentirte muy solo si sientes que las personas te rechazan o no están interesadas en ti”, dijo.

Pero Tillman sigue siendo optimista y señala que el último grupo de adultos jóvenes, como cada nueva generación, está encontrando su camino y enfocando el sexo de manera diferente a la de sus padres.

“No estoy preocupada, porque la gente básicamente está encontrando diferentes formas de conectarse entre sí”, dijo Tillman.

Phillip Reese es especialista en informes de datos y profesor asistente de periodismo en la Universidad Estatal de California-Sacramento.

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

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

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Today, May 22, 2023, U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra joined leaders from across the world in Geneva, Switzerland for

Bajo la dirección de una agresiva opositora al comportamiento empresarial que menoscaba la competencia, la Comisión Federal de Comercio (FTC) está actuando contra las empresas farmacéuticas y los intermediarios del sector, como parte de la campaña de la administración Biden para reducir los precios de los medicamentos en las farmacias.

El 16 de mayo, la FTC interpuso una demanda para bloquear la fusión de las farmacéuticas Amgen y Horizon Therapeutics, alegando que la enmarañada red de acuerdos de la industria  permitiría a Amgen aprovechar el poder monopolístico de dos de los principales medicamentos de Horizon que no tienen rivales.

En su demanda, la FTC alegó que si se permitía la compra que pretende Amgen por $27,800 millones, Amgen podría presionar a las empresas que gestionan el acceso a los medicamentos con receta —los gestores de beneficios de farmacia, o PBM— para que impongan los dos productos extremadamente caros de Horizon de una manera que eliminaría cualquier competencia.

Es la primera vez desde 2009 que la FTC intenta bloquear una fusión de empresas farmacéuticas, y esta demanda refleja el gran interés de la presidenta Lina Khan por las medidas antimonopolio. Al anunciar la demanda, la agencia declaró que al luchar contra los poderes monopolísticos pretendía controlar los precios y mejorar el acceso de los pacientes a productos más baratos.

Para Robin Feldman, profesor y experto en la industria farmacéutica de la Facultad de Derecho de la Universidad de California en San Francisco, la actuación de la FTC es “un golpe frontal a la industria farmacéutica”. David Balto, ex funcionario de la FTC y abogado que luchó contra las fusiones Bristol-Myers Squibb-Celgene en 2019 y AbbVie-Allergan en 2020, dijo que la acción de la FTC era necesaria desde hace mucho tiempo.

La fusión Horizon-Amgen “costaría a los consumidores precios más altos, menos opciones e innovación”, señaló. “La fusión habría dado a Amgen aún más herramientas para explotar a los consumidores y dañar la competencia”.

La FTC también anunció la ampliación de una investigación de un año sobre los PBM, indicando que se investigaban dos gigantescas empresas de compra de medicamentos, Ascent Health Services y Zinc Health Services. Los críticos afirman que los PBM crearon estas empresas para ocultar beneficios.

Cuando Amgen anunció la compra de Horizon en diciembre —la mayor operación biofarmacéutica de 2022— mostró especial interés por los medicamentos de Horizon para la enfermedad tiroidea ocular (Tepezza) y la gota grave (Krystexxa), por los que la empresa cobraba hasta $350,000 y $650,000, respectivamente, por un año de tratamiento. Según la demanda, la fusión perjudicaría a rivales biotecnológicos que tienen productos similares en fase avanzada de pruebas clínicas.

Según la FTC, Amgen podría promocionar los fármacos de Horizon a través de la “venta cruzada”. Esto significa exigir a los PBM que promocionen algunos de los medicamentos menos populares de Amgen —los productos Horizon, en este caso— a cambio de que Amgen ofrezca a los PBM grandes descuentos por sus superventas. Según la denuncia, Amgen tiene nueve medicamentos que el año pasado generaron más de $1,000 millones cada uno. El más popular es Enbrel, que trata la artritis reumatoide y otras enfermedades.

Los tres mayores PBM negocian los precios y el acceso al 80% de los medicamentos recetados en Estados Unidos, lo que les confiere un enorme poder de negociación. Su capacidad para influir en los medicamentos a los que tienen acceso los estadounidenses, y a qué precio, les permite obtener miles de millones en descuentos de los fabricantes.

“La posibilidad de que Amgen pudiera aprovechar su cartera de medicamentos superventas para obtener ventajas sobre sus rivales potenciales no es hipotética”, afirma la denuncia de la FTC. “Amgen ha desplegado esta misma estrategia para conseguir condiciones favorables de los pagadores y proteger así las ventas de los medicamentos de Amgen en dificultades”.

La denuncia señaló que la biotecnológica Regeneron demandó el año pasado a Amgen, alegando que la estrategia de reembolso de esta última perjudicó la capacidad de Regeneron para vender su medicamento competidor contra el colesterol, Praluent. Repatha, de Amgen, generó unos ingresos mundiales de $1,300 millones en 2022.

Según la demanda, “puede resultar completamente imposible” para los rivales más pequeños “igualar el valor de los reembolsos agrupados que Amgen podría ofrecer”, ya que aprovecha la colocación de los medicamentos de Horizon en los formularios de los planes de salud.

Los analistas de la industria se mostraron escépticos sobre el éxito de la acción de la FTC. Hasta ahora, la Comisión y el Departamento de Justicia han evitado cuestionar las fusiones farmacéuticas, un precedente difícil de superar.

Las investigaciones sobre el impacto de las fusiones han demostrado que a menudo benefician a los accionistas al aumentar el precio de las acciones; pero perjudican la innovación en el desarrollo de fármacos al recortar los proyectos de investigación y el personal.

Las olas de consolidación redujeron el número de empresas farmacéuticas líderes de 60 a 10 entre 1995 y 2015. Según Feldman, la mayoría de las fusiones de los últimos años se han producido entre “peces gordos que adquieren muchos peces pequeños”, como empresas de biotecnología con fármacos prometedores.

La gigantesca fusión Amgen-Horizon es una excepción obvia y, por tanto, una buena oportunidad para que la FTC demuestre la “teoría del daño” en las maniobras de consolidación de la industria farmacéutica con los PBM, dijo Aaron Glick, analista de fusiones de Cowen & Co.

Pero eso no significa que la FTC vaya a ganar.

Amgen puede incurrir o no en prácticas anticompetitivas, pero “otra cuestión es cómo encaja esta demanda en las leyes antimonopolio y los precedentes actuales”, señaló Glick. “Tal y como está configurada la ley hoy, parece poco probable que se sostenga en los tribunales”.

El argumento de la FTC sobre el comportamiento de Amgen con los productos Horizon es hipotético. La demanda pendiente de Regeneron contra Amgen, así como otras demandas que han prosperado, sugiere que existen normas para suprimir este tipo de comportamiento anticompetitivo cuando se produce, añadió Glick.

El juez que preside el caso en el Tribunal de Distrito de Estados Unidos en Illinois es John Kness, quien fue nombrado por el entonces presidente Donald Trump y es un ex miembro de la Federalist Society, cuyos miembros tienden a ser escépticos sobre los esfuerzos antimonopolio.

Es probable que el caso se resuelva antes del 12 de diciembre, fecha límite para que la fusión se lleve a cabo en los términos actuales.

Amgen trató de socavar los argumentos del Gobierno comprometiéndose a no agrupar los productos de Horizon en futuras negociaciones con los gestores de beneficios farmacéuticos (PBM). Esta promesa, aunque difícil de hacer cumplir, podría obtener una audiencia favorable en corte, apuntó Glick.

Sin embargo, incluso una derrota permitiría a la FTC arrojar luz sobre un problema en la industria y lo que considera una deficiencia en las leyes antimonopolio que quiere que el Congreso corrija, explicó.

Al día siguiente de ir a corte para detener la fusión, la FTC anunció que profundizaba en una investigación sobre los gestores de beneficios farmacéuticos que inició el pasado mes de junio. La agencia solicitó información a Ascent y Zinc, los dos llamados agregadores de reembolsos, organizaciones de compra de medicamentos creadas por los PBM Express Scripts y CVS Caremark.

En una audiencia celebrada el 10 de mayo, el CEO de Eli Lilly & Co., Dave Ricks, afirmó que la mayor parte de los $8,000 millones en cheques de reembolso que su empresa pagó el año pasado fueron a parar a los agregadores de reembolsos, en lugar de directamente a los PBM. Una “gran parte” de los $8,000 millones fue a parar al extranjero, indicó Ricks. Ascent tiene su sede en Suiza, mientras que Emisar Pharma Services, un agregador establecido por PBM OptumRx, tiene su sede en Irlanda. Zinc Health Services está registrada en Estados Unidos.

Los críticos afirman que los agregadores permiten a los PBM ocultar la cuantía y el destino de los reembolsos y otras comisiones que cobran como intermediarios en el negocio de los medicamentos.

Por su parte, los PBM aseguran que sus esfuerzos reducen los precios en el mostrador de la farmacia. Los testimonios en el Congreso y en las audiencias de la FTC del año pasado indican que, al menos en algunos casos, en realidad los aumentan.

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[UPDATED at 4 p.m. ET]

BAMBERG, S.C. — Years before the Bamberg County Hospital closed in 2012, and the next-closest hospital in neighboring Barnwell shut its doors in 2016, those facilities had stopped delivering babies.

These days, there’s not even an ultrasound machine in this rural county 60 miles south of Columbia, much less an obstetrician. Pregnant women here are left with few options for care.

Federally qualified health centers offer prenatal services in nearby Fairfax and Barnwell, but only when a pregnancy is uncomplicated and only through about 34 weeks of gestation.

During the final weeks of pregnancy, women must transfer their care to the nearest obstetrician, often in Orangeburg, which can be 20 miles away or more, depending on where they live in Bamberg County. Some women travel farther to hospitals in Aiken or Beaufort, where health outcomes are better.

“Most of our women are driving an hour or more from their homes to an OB provider,” said Tracy Golden, a doula and senior program manager for the South Carolina Office of Rural Health.

Although the regional hospital in the city of Orangeburg delivers babies, the birth outcomes in the county are awful by any standard. In 2021, nearly 3% of all Black infants in Orangeburg County died before their 1st birthday.

Nationally, the average is about 1% for Black infants and less than 0.5% for white infants.

Meanwhile, Orangeburg County’s infant mortality rate for babies of all races is the highest in South Carolina, according to the latest data published by the South Carolina Department of Health and Environmental Control.

By 2030, the federal government wants infant mortality to fall to 5 or fewer deaths per 1,000 live births. According to annual data compiled by the Centers for Disease Control and Prevention, 16 states have already met or surpassed that goal, including Nevada, New York, and California. But none of those states are in the South, where infant mortality is by far the highest in the country, with Mississippi’s rate of 8.12 deaths per 1,000 live births ranking worst.

Even in those few Southern states where infant mortality rates are inching closer to the national average, the gap between death rates of Black and white babies is vast. In Florida and North Carolina, for example, the Black infant mortality rate is more than twice as high as it is for white babies. A new study published in JAMA found that over two decades Black people in the U.S. experienced more than 1.6 million excess deaths and 80 million years of life lost because of increased mortality risk relative to white Americans. The study also found that infants and older Black Americans bear the brunt of excess deaths and years lost.

That makes Black infant mortality in the South a complex regional crisis that should alarm everyone, not just future parents, said Georgina Dukes-Harris, senior director for social care at Unite Us, a national technology company focused on societal needs. Birth outcomes for mothers and infants are a leading indicator of population well-being and they run much deeper than health care: They reflect politics. They’re a direct product of generational poverty and racism. They reveal our priorities, Dukes-Harris said.

Often, babies die under circumstances that states, communities, and parents can help control, like making sure infants don’t suffocate in beds or in unsafe cribs, or extending health coverage so that young women can afford to see a doctor before they become pregnant. In many of these respects, the South is failing.

“This is something that has to change,” Dukes-Harris said.

‘An Urgent Problem’ With No Easy Solution

Public health officials are still trying to parse the long-term impact of the covid-19 pandemic, but infant death rates in South Carolina were higher than the national average long before the health care landscape changed in 2020. And a report published by the South Carolina Department of Health and Environmental Control in April shows the rate for non-Hispanic Black babies — who died at a rate nearly 2½ times that of non-Hispanic white infants in South Carolina in 2021 — is growing worse. The death rate among infants born to Black mothers in the state increased by nearly 40% from 2017 to 2021.

“That’s just not acceptable,” said Edward Simmer, director of the South Carolina health department. “It’s absolutely an urgent problem to me.”

It’s a problem, though, without an apparent solution. Multimillion-dollar programs to improve South Carolina’s numbers over the past decade have failed to move the needle. To make things more complicated, separate state agencies have reached different conclusions about the leading cause of infant death.

The state Department of Health and Human Services — which administers Medicaid, the health coverage program for low-income residents, and pays for more than half of all births in South Carolina — claims accidental deaths were the No. 1 reason babies covered by Medicaid died from 2016 to 2020, according to Medicaid spokesperson Jeff Leieritz.

But the state health department, where all infant death data is housed, reported birth defects as the top cause for the past several years. Accidental deaths ranked fifth among all causes in 2021, according to the 2021 health department report. All but one of those accidental infant deaths were attributed to suffocation or strangulation in bed.

Meanwhile, infant mortality is a topic that continues to get little, if any, attention, especially in the South.

A group called the South Carolina Birth Outcomes Initiative meets regularly to talk strategy, but this consortium of the state’s top doctors, nurses, health insurers, and hospital leaders can’t solve fundamental problems, like teaching parents safe sleep habits or connecting all pregnant women to basic prenatal care. According to the Medicaid agency, nearly half of Medicaid-enrolled babies who died before their 1st birthday in 2021 were born to mothers who received no prenatal care.

“There’s good work going on. It’s just in little patches. It’s just not spread out enough to change our overall numbers,” said Rick Foster, a retired physician and former chairman of one of the Birth Outcomes Initiative’s working groups.

Expanding Access to Maternal Care

South Carolina and several other states recently extended postpartum Medicaid coverage for women who give birth, which means their coverage remains in place for one year after delivery. Historically, Medicaid coverage was cut off 60 days after having a baby.

Some experts believe expanding Medicaid coverage to single, working adults who aren’t pregnant and don’t have children — something most Southern states have failed to do — would also help curtail infant deaths. A woman who is healthy when heading into pregnancy is more likely to give birth to a healthy baby because the health of the mother correlates to the health of the infant. But many women don’t qualify for Medicaid coverage until they become pregnant.

Even when they become pregnant and are newly eligible for Medicaid, it isn’t unusual for women in South Carolina to put off seeing a doctor until the third trimester, physicians told KFF Health News. These women can’t afford to take time off work, can’t find child care, or don’t have a car, among other reasons.

Telehealth could improve access if the state’s broadband network were better, said Simmer, the state health department director. The department could also invest in a fleet of mobile vans that provide prenatal care. Each costs just under $1 million, he said. Ultimately, South Carolina needs more doctors willing to practice in rural areas. Fourteen of its 46 counties lack a single OB-GYN, Simmer said.

“We don’t have providers where we need them,” he said. To that end, he added, the state might consider using student loan forgiveness programs as an incentive for new medical school graduates to practice in rural areas of the state, where obstetricians are scarce. Meanwhile, two programs aimed at improving infant mortality in South Carolina, which were backed by millions of dollars in public and private funding over the past decade, were unsuccessful in hitting the goal.

The Nurse-Family Partnership, for example, which pairs expectant South Carolina mothers with nurses for at-home visits, didn’t have a statistically significant effect on birth outcomes, according to an analysis of the multiyear project, published by the Harvard T.H. Chan School of Public Health.

CenteringPregnancy, a separate program that offers small-group prenatal education to pregnant women, also failed to improve birth outcomes, said Amy Crockett, a maternal-fetal specialist in Greenville and one of the lead investigators for the state initiative.

Crockett said she recently returned about $300,000 in grant funding to the Duke Endowment, a nonprofit that funds health, faith, and education initiatives in the Carolinas, because the evidence to support ongoing CenteringPregnancy projects simply wasn’t there.

“It’s not the silver bullet we thought it would be,” Crockett said. “It’s time to move on.”

Birth outcomes experts agreed that racism and poverty lie at the heart of this difficult problem, which disproportionately threatens Black infants and mothers in the rural South. Research shows that white doctors are often prejudiced against Black patients and minimize their concerns and pain.

In South Carolina, the maternal mortality rate increased by nearly 10% from 2018 to 2019, according to the latest data, which found that the risk of pregnancy-related death for Black mothers was 67% higher than for white mothers. Upon review, the state health department determined 80% of those pregnancy-related deaths were preventable.

Disparities related to both infant and maternal deaths deserve urgent attention from both the federal and state governments, said Scott Sullivan, division chief of maternal-fetal medicine at Inova Health System in Northern Virginia. Hospitals also bear a huge responsibility as doctors and health care providers must learn how to fairly and adequately take care of Black women and children.

“The idea that we’re going to solve 400 years of racism in an hour’s worth of bias training is a cruel joke. Systems have to remodel their approach,” Sullivan said. “It’s going to take funding, and it’s going to take a sustained effort.”

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Young adults aren’t behaving the way their parents did: They’re not drinking as much, they’re facing more mental health challenges, and they’re living with their parents longer. On top of that, computer games and social media have become a sort of stand-in for physical relationships.

All that means young Californians aren’t having as much sex.

The number of young adults going without sex was rising even before covid-19 made dating harder and riskier. In 2011, about 22% of Californians ages 18 to 30 reported having no sexual partners in the prior 12 months. That crept up to 29% in 2019, and it jumped to 38% in 2021, according to the latest figures from UCLA’s California Health Interview Survey.

Other age groups in California also reported an increase in abstinence, but the trend was not nearly as pronounced.

“Everything happens later,” said San Diego State University psychology professor Jean Twenge, author of “Generations: The Real Differences Between Gen Z, Millennials, Gen X, Boomers, and Silents — And What They Mean for America’s Future.” She said the numbers reflect how young adults increasingly delay major life events, such as moving out of their parents’ homes and forging long-term romantic relationships.

Singles saw the most dramatic change.

It has long been the case that single people are more likely to report having no sex than married or cohabiting people. But as young adults delay marriage, the gap has widened.

Young adults may be putting off long-term relationships “due to their increasingly economically precarious status or stress related to completing education and looking for jobs,” said Lei Lei, a sociology professor at Rutgers who recently co-authored a paper that examined why fewer young adults are having sex. “They are busy with other domains of life.” Researchers also noted that hundreds of thousands of young adults identify as asexual.

Rising computer use may play a role in the trend. Young adults increasingly form relationships through playing video games with people they do not physically meet, Lei said. These distant relationships sometimes interfere with the formation of sexual relationships.

A Pew Research Center report from 2015 found equal numbers of men and women played video games but that young adult men were more than three times as likely as young adult women to identify as serious “gamers.”

Young adults also have access to endless amounts of free pornography online, a departure from the porn magazines, videotapes, and DVDs many of their parents bought. Much of the most popular online porn features violence or coercion, which gives some young adults a flawed perspective on sex and turns others off it entirely, said Debby Herbenick, director of the Center for Sexual Health Promotion at Indiana University Bloomington’s School of Public Health.

“Those kinds of behaviors are really, really normalized among young people,” she said, referring to rough sex.

Sex also has a correlation with income. Young adults who make less money were more likely to go without sex than peers making more.

Much recent discourse about lack of sex among young adults has revolved around so-called incels, young men who contend — often in vile, misogynistic terms — that dating apps like Tinder make it easier for women to find conventionally attractive, wealthy, or otherwise high-status men and ignore everyone else.

Erin Tillman, a certified sex educator and executive director of the nonprofit Sex-Positive Los Angeles, said it makes her sad when she hears men blame women for not wanting to have sex with them. She said those men could likely change their perspective and find intimacy.

“They hold the cards in terms of making themselves better,” she said.

The sexless trend has the potential to lower rates of unplanned pregnancy. And it could also reduce the spread of sexually transmitted infections, though that has not yet happened.

Herbenick does worry about young adults who want sex but aren’t having it. “It can feel really lonely if you feel like people are rejecting you or wouldn’t be interested in you,” she said.

But Tillman remains optimistic, noting the latest group of young adults, like every new generation, is finding its way and approaching sex differently than their parents.

“I'm not worried, because people are just basically finding different ways to connect with each other,” Tillman said.

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

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

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Under the leadership of an aggressive opponent of anti-competitive business practices, the Federal Trade Commission is moving against drug companies and industry middlemen as part of the Biden administration’s push for lower drug prices at the pharmacy counter.

On May 16, the FTC sued to block the merger of drugmakers Amgen and Horizon Therapeutics, saying the tangled web of drug industry deal-making would enable Amgen to leverage the monopoly power of two top Horizon drugs that have no rivals.

In its lawsuit, the FTC said that if it allowed Amgen’s $27.8 billion purchase to go through, Amgen could pressure the companies that manage access to prescription drugs — pharmacy benefit managers, or PBMs — to boost the two extremely expensive Horizon products in a way that would inhibit any competition.

The suit, the first time since 2009 that the FTC has tried to block a drug company merger, reflects Chair Lina Khan’s strong interest in antitrust action. In announcing the suit, the agency said that by fighting monopoly powers it aimed to tame prices and improve patients’ access to cheaper products.

FTC’s action is a “shot across the bow for the pharmaceutical industry,” said Robin Feldman, a professor and drug industry expert at the University of California College of the Law-San Francisco. David Balto, a former FTC official and attorney who fought the 2019 Bristol-Myers Squibb-Celgene and 2020 AbbVie-Allergan mergers, said FTC’s action was long overdue.

The Horizon-Amgen merger would “cost consumers in higher prices, less choice, and innovation,” he said. “The merger would have given Amgen even more tools to exploit consumers and harm competition.”

The FTC also announced an expansion of a yearlong investigation of the PBMs, saying it was looking at two giant drug-purchasing companies, Ascent Health Services and Zinc Health Services. Critics claim the PBMs set up these companies to conceal profits.

When Amgen announced its purchase of Horizon in December — the biggest biopharma transaction in 2022 — it showed particular interest in Horizon’s drugs for thyroid eye disease (Tepezza) and severe gout (Krystexxa), which the company was charging up to $350,000 and $650,000, respectively, for a year of treatment. The complaint said the merger would disadvantage biotech rivals that have similar products in advanced clinical testing.

Amgen could promote the Horizon drugs through “cross-market bundling,” the FTC said. That means requiring PBMs to promote some of Amgen’s less popular drugs — the Horizon products, in this case — in exchange for Amgen offering the PBMs large rebates for its blockbusters. Amgen has nine drugs that each earned more than $1 billion last year, according to the complaint, the most popular being Enbrel, which treats rheumatoid arthritis and other diseases.

The three biggest PBMs negotiate prices and access to 80% of prescription drugs in the U.S., giving them enormous bargaining power. Their ability to influence which drugs Americans can get, and at what price, enables the PBMs to obtain billions in rebates from drug manufacturers.

“The prospect that Amgen could leverage its portfolio of blockbuster drugs to gain advantages over potential rivals is not hypothetical,” the FTC complaint states. “Amgen has deployed this very strategy to extract favorable terms from payers to protect sales of Amgen’s struggling drugs.”

The complaint noted that biotech Regeneron last year sued Amgen, alleging that the latter’s rebating strategy harmed Regeneron’s ability to sell its competing cholesterol drug, Praluent. Amgen’s Repatha generated $1.3 billion in global revenue in 2022.

It “may be effectively impossible” for smaller rivals to “match the value of bundled rebates that Amgen would be able to offer” as it leverages placement of the Horizon drugs on health plan formularies, the complaint states.

Business analysts were skeptical that the FTC action would succeed. Until now the commission and the Department of Justice have shied away from challenging pharmaceutical mergers, a precedent that will be hard to overcome.

Research on the impact of mergers has shown that they often benefit shareholders by increasing stock prices, but hurt innovation in drug development by trimming research projects and staffing.

Waves of consolidation shrank the field of leading pharma companies from 60 to 10 from 1995 to 2015. Most of the mergers in recent years have involved “big fish buying up lots of little fish,” such as biotech companies with promising drugs, Feldman said.

The giant Amgen-Horizon merger is an obvious exception, and therefore a good opportunity for the FTC to demonstrate a “theory of harm” around drug industry bundling maneuvers with PBMs, said Aaron Glick, a mergers analyst with Cowen & Co.

But that doesn’t mean the FTC will win.

Amgen may or may not engage in anti-competitive practices, but “a separate question is, how does this lawsuit fit under current antitrust laws and precedent?” Glick said. “The way the law is set up today, it seems unlikely it will hold up in court.”

The FTC’s argument about Amgen’s behavior with Horizon products is hypothetical. The pending Regeneron suit against Amgen, as well as other, successful lawsuits, suggests that rules are in place to suppress this kind of anti-competitive behavior when it occurs, Glick said.

The judge presiding over the case in U.S. District Court in Illinois is John Kness, who was appointed by then-President Donald Trump and is a former member of the Federalist Society, whose membership tends to be skeptical of antitrust efforts. The case is likely to be settled by Dec. 12, the deadline for the merger to go through under current terms.

Amgen sought to undercut the government’s case by agreeing not to bundle Horizon products in future negotiations with pharmacy benefit managers. That promise, while hard to enforce, might get a sympathetic hearing in court, Glick said.

Still, even a loss would enable the FTC to shed light on a problem in the industry and what it sees as a deficiency in antitrust laws that it wants Congress to correct, he said.

The day after suing to stop the merger, the FTC announced it was pushing further into an investigation of pharmacy benefit managers that it began last June. The agency demanded information from Ascent and Zinc, the two so-called rebate aggregators — drug purchasing organizations set up by PBMs Express Scripts and CVS Caremark.

At a May 10 hearing, Eli Lilly & Co. CEO Dave Ricks said that most of the $8 billion in rebate checks his company paid last year went to rebate aggregators, rather than to the PBMs directly. A “big chunk” of the $8 billion went overseas, he said. Ascent is based in Switzerland, while Emisar Pharma Services, an aggregator established by PBM OptumRx, is headquartered in Ireland. Zinc Health Services is registered in the U.S.

Critics say the aggregators enable PBMs to obscure the size and destination of rebates and other fees they charge as intermediaries in the drug business.

The PBMs say their efforts reduce prices at the pharmaceutical counter. Testimony in Congress and in FTC hearings over the past year indicate that, at least in some instances, they actually increase them.

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

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KFF Health News Colorado correspondent Rae Ellen Bichell discussed Colorado facility schools on Rocky Mountain Community Radio on May 12.

• Click here to hear Bichell on Rocky Mountain Community Radio
• Read Bichell’s “Students in Rural Colorado Are Left Without Options as Specialized Schools Close”

KFF Health News former senior editor Andy Miller discussed lead contamination in an affluent Atlanta neighborhood on WUGA’s “The Georgia Health Report” on May 12.

• Click here to hear Miller on WUGA
• Read Miller’s “Lead Contamination Surfaces in Affluent Atlanta Neighborhood”

KFF Health News senior correspondent Aneri Pattani discussed a range of mental health issues, from the Biden administration’s investment in crisis hotlines to the enforcement of laws that require insurers to cover more mental health services, on WNYC Studios’ “Death, Sex & Money” podcast on May 11.

• Click here to hear Pattani on “Death, Sex & Money”

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HHS and Baby2Baby Announce Partnership to Support New Mothers with a Newborn Supply Kit During Visit by Vice President Kamala Harris

HHS Announces Over $65 Million to Address the Maternal Health Crisis and Invest in New Approaches to Care

Fue un error lamentable. Pero, en ese momento, Kim Sylvester pensó que estaba haciendo lo correcto.

Su madre, Harriet Burkel, de 80 años, se había caído en su casa en Raleigh, Carolina del Norte. Se fracturó la pelvis y fue a un centro de rehabilitación para recuperarse. Ocurrió pocos días después de la muerte del esposo de Burkel, de 82, quien había ingresado a un centro de atención de la memoria tres años antes.

Con una angustia creciente, Sylvester veía como su madre, quien padecía de enfisema y enfermedad arterial periférica, se volvía cada vez más frágil y aislada. “Yo le decía: ‘¿Puedo ayudarte?’ Y mi madre me respondía: ‘No, puedo hacer sola. No necesito nada. Puedo manejarlo'”, me contó Sylvester.

Finalmente, halló la oportunidad de obtener más información. Entró sin ser vista en la casa de su madre y revisó toda la documentación que pudo encontrar. “Era un desastre, completamente desorganizado, facturas por todas partes”, dijo. “Era claro que las cosas estaban fuera de control”.

Sylvester actuó de inmediato, cancelando los pedidos de suplementos anti envejecimiento de su madre, anulando dos pólizas de seguro de garantía para automóviles (Burkel ya no conducía), terminando un contrato de un año para inyecciones de rodilla con un quiropráctico, y desechando solicitudes de donación de docenas de organizaciones.

Cuando su madre se enteró, se puso furiosa.

“Estaba tratando de salvarla, pero me convertí en alguien en quien no podía confiar, en el enemigo. Realmente metí la pata”, dijo Sylvester.

Lidiar con un padre mayor que se resiste obstinadamente a aceptar ayuda no es fácil. Pero la solución no es que los padres sientan que se está pasando por encima de ellos, tomando el control de sus asuntos. En cambio, lo que se necesita es respeto, empatía y aprecio por la autonomía de la persona mayor.

“Es difícil cuando ves que una persona mayor toma decisiones y elecciones equivocadas. Pero si esa persona tiene sus facultades cognitivas intactas, no puedes obligarla a hacer lo que crees que debería hacer”, dijo Anne Sansevero, presidenta de la junta directiva de la Aging Life Care Association, una organización nacional de administradores de atención que trabajan con adultos mayores y sus familias. “Tienen derecho a tomar decisiones por sí mismos”.

Eso no significa que los hijos adultos preocupados por un padre mayor deban apartarse o aceptar todo lo que propone el padre. Más bien, se requiere un conjunto de habilidades especial.

Cheryl Woodson, autora y médica jubilada de la zona de Chicago, aprendió esto de primera mano cuando su madre, a quien describió como una mujer “muy poderosa”, desarrolló un deterioro cognitivo leve. Empezó a perderse mientras conducía, y compraba cosas que no necesitaba para luego regalarlas.

Retar a su madre no iba a funcionar. “No puedes presionar a personas como mi madre o tratar de controlarlas”, me dijo Woodson. “No les dices ‘Estás equivocada’, porque ellas te cambiaron los pañales y siempre serán tu mamá”.

En cambio, Woodson aprendió a apelar al orgullo de su madre como matriarca de la familia. “Cuando se enojaba, le preguntaba: ‘Madre, ¿en qué año se casó la tía Terri?’ o ‘Mamá, no recuerdo cómo hacer macarrones. ¿Cuánto queso se usa?’ Y ella olvidaba por qué estaba alterada y seguíamos adelante”.

Woodson, autora de “To Survive Caregiving: A Daugther’s Experience, a Doctor’s Advice”, también aprendió a aplicar un estándar de “¿realmente importa para la seguridad o la salud?” al comportamiento de su madre.

Esto la ayudó a dejar de lado sus expectativas a veces irracionales. Un ejemplo que mencionó fue: “Mi madre solía poner salsa picante en los panqueques. A mi hermano lo volvía loco, pero ella estaba comiendo, y eso era bueno”.

“No quieres echarles en cara su incapacidad”, dijo Woodson, cuya madre falleció en 2003.

Barry Jacobs, psicólogo clínico y terapeuta familiar, expresó ideas similares al describir a un psiquiatra de unos 70 años al que no le gustaba ceder ante la autoridad. Después de que su esposa falleciera, el hombre mayor dejó de afeitarse y cambiar de ropa regularmente. A pesar de tener diabetes, no quería ver a un médico y, en cambio, se recetaba medicamentos a sí mismo. Incluso después de varios accidentes cerebrovasculares que comprometieron su visión, insistía en seguir conduciendo.

La opinión de Jacobs es: “No debes enfrentarte directamente a alguien así, porque perderás. Casi te están desafiando para que les digas qué hacer y así demostrarte que no seguirán tu consejo”.

¿Cuál es la alternativa? “Yo emplearía la empatía y apelaría al orgullo de esta persona como base para enfrentar la adversidad o el cambio”, dijo Jacobs. “Podría decir algo así como: ‘Sé que no quieres dejar de conducir y que te causará mucho dolor. Pero has enfrentado cambios difíciles y dolorosos antes, y encontrarás la manera de superarlo'”.

“Estás apelando a su ‘ego’ en lugar de tratarlos como si no tuvieran derecho a tomar sus propias decisiones”, explicó. En el caso del psiquiatra mayor, el conflicto con sus cuatro hijos era constante, pero finalmente dejó de conducir.

Otra buena estrategia es presentarte por sorpresa, pero haciéndolo de una manera que mantenga la dignidad de tu padre. En lugar de preguntarle directamente si puedes visitarlo, puedes ir a su casa y decir algo como: “Los niños realmente querían verte. Espero que no te importe”. o “Hicimos demasiada comida. Espero que no te importe que la traiga”; o “Quería pasar por aquí. Espero que puedas darme algún consejo sobre este tema que me preocupa”.

Si crees que el deterioro cognitivo podría ser un factor en el comportamiento de tu padre, en lugar de tratar de persuadirlo para que acepte más ayuda en casa, intenta que tenga una evaluación médica, como sugiere Leslie Kernisan, autora de “When Your Aging Parent Needs Help: A Geriatrician’s Step-by-Step Guide to Memory Loss, Resistance, Safety Worries, and More”.

“La disminución de la función cerebral puede afectar la percepción, el juicio y la capacidad de comprender los riesgos de ciertas acciones o situaciones en un adulto mayor, lo que puede hacer que se pongan sospechosos y a la defensiva”, señala Kernisan.

Sin embargo, esto no significa que debas renunciar a hablar con un padre mayor que tenga un deterioro cognitivo leve o demencia en etapa inicial. “Si enmarcas tus sugerencias como una forma de ayudar a tu padre a alcanzar una meta que él considera importante, es más probable que las acepte”, afirma Kernisan.

Un punto de inflexión para Sylvester y su madre ocurrió cuando la mujer mayor, que desarrolló demencia, ingresó a una residencia a fines de 2021. Al principio, no se dio cuenta de que el traslado era permanente y estaba furiosa, por lo que Sylvester esperó dos meses antes de visitarla. Cuando finalmente entró en la habitación de Burkel llevando un regalo de San Valentín, su madre la abrazó y dijo: “Me alegra verte”, antes de alejarse y decir: “Pero estoy muy enojada con mi otra hija”.

Sylvester, que no tiene una hermana, respondió: “Lo sé, mamá. Ella tenía buenas intenciones, pero no manejó las cosas correctamente”. Aprendió el valor de un “pequeño engaño terapéutico”, como lo llama Kernisan, quien dirigió un grupo de cuidadores familiares al que Sylvester asistió entre 2019 y 2021.

Después de esa visita, Sylvester vio a su madre con frecuencia y todo se mantuvo bien entre las dos mujeres hasta la muerte de Burkel. “Si algo perturbaba a mi madre, simplemente decía: ‘Interesante’ o ‘Eso es algo para pensar’. Debes darte tiempo para recordar que esta no es la persona que solías conocer y simplemente es alguien que ha cambiado tanto”.

Nos gustaría escuchar de los lectores las preguntas que pueden tener, los problemas que han tenido con su atención y los consejos que necesitan para lidiar con el sistema de atención médica. Visita kffhealthnews.org/columnists para enviar tus solicitudes o sugerencias.

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It was a regrettable mistake. But Kim Sylvester thought she was doing the right thing at the time.

Her 80-year-old mother, Harriet Burkel, had fallen at her home in Raleigh, North Carolina, fractured her pelvis, and gone to a rehabilitation center to recover. It was only days after the death of Burkel’s 82-year-old husband, who’d moved into a memory care facility three years before.

With growing distress, Sylvester had watched her mother, who had emphysema and peripheral artery disease, become increasingly frail and isolated. “I would say, ‘Can I help you?’ And my mother would say, ‘No, I can do this myself. I don’t need anything. I can handle it,’” Sylvester told me.

Now, Sylvester had a chance to get some more information. She let herself into her mother’s home and went through all the paperwork she could find. “It was a shambles — completely disorganized, bills everywhere,” she said. “It was clear things were out of control.”

Sylvester sprang into action, terminating her mother’s orders for anti-aging supplements, canceling two car warranty insurance policies (Burkel wasn’t driving at that point), ending a yearlong contract for knee injections with a chiropractor, and throwing out donation requests from dozens of organizations. When her mother found out, she was furious.

“I was trying to save my mother, but I became someone she couldn’t trust — the enemy. I really messed up,” Sylvester said.

Dealing with an older parent who stubbornly resists offers of help isn’t easy. But the solution isn’t to make an older person feel like you’re steamrolling them and taking over their affairs. What’s needed instead are respect, empathy, and appreciation of the older person’s autonomy.

“It’s hard when you see an older person making poor choices and decisions. But if that person is cognitively intact, you can’t force them to do what you think they should do,” said Anne Sansevero, president of the board of directors of the Aging Life Care Association, a national organization of care managers who work with older adults and their families. “They have a right to make choices for themselves.”

That doesn’t mean adult children concerned about an older parent should step aside or agree to everything the parent proposes. Rather, a different set of skills is needed.

Cheryl Woodson, an author and retired physician based in the Chicago area, learned this firsthand when her mother — whom Woodson described as a “very powerful” woman — developed mild cognitive impairment. She started getting lost while driving and would buy things she didn’t need then give them away.

Chastising her mother wasn’t going to work. “You can’t push people like my mother or try to take control,” Woodson told me. “You don’t tell them, ‘No, you’re wrong,’ because they changed your diapers and they’ll always be your mom.”

Instead, Woodson learned to appeal to her mother’s pride in being the family matriarch. “Whenever she got upset, I’d ask her, ‘Mother, what year was it that Aunt Terri got married?’ or ‘Mother, I don’t remember how to make macaroni. How much cheese do you put in?’ And she’d forget what she was worked up about and we’d just go on from there.”

Woodson, author of “To Survive Caregiving: A Daughter’s Experience, a Doctor’s Advice,” also learned to apply a “does it really matter to safety or health?” standard to her mother’s behavior. It helped Woodson let go of her sometimes unreasonable expectations. One example she related: “My mother used to shake hot sauce on pancakes. It would drive my brother nuts, but she was eating, and that was good.”

“You don’t want to rub their nose into their incapacity,” said Woodson, whose mother died in 2003.

Barry Jacobs, a clinical psychologist and family therapist, sounded similar themes in describing a psychiatrist in his late 70s who didn’t like to bend to authority. After his wife died, the older man stopped shaving and changing his clothes regularly. Though he had diabetes, he didn’t want to see a physician and instead prescribed medicine for himself. Even after several strokes compromised his vision, he insisted on driving.

Jacobs’ take: “You don’t want to go toe-to-toe with someone like this, because you will lose. They’re almost daring you to tell them what to do so they can show you they won’t follow your advice.”

What’s the alternative? “I would employ empathy and appeal to this person’s pride as a basis for handling adversity or change,” Jacobs said. “I might say something along the lines of, ‘I know you don’t want to stop driving and that this will be very painful for you. But I know you have faced difficult, painful changes before and you’ll find your way through this.’”

“You’re appealing to their ideal self rather than treating them as if they don’t have the right to make their own decisions anymore,” he explained. In the older psychiatrist’s case, conflict with his four children was constant, but he eventually stopped driving.

Another strategy that can be useful: “Show up, but do it in a way that’s face-saving,” Jacobs said. Instead of asking your father if you can check in on him, “Go to his house and say, ‘The kids really wanted to see you. I hope you don’t mind.’ Or, ‘We made too much food. I hope you don’t mind my bringing it over.’ Or, ‘I wanted to stop by. I hope you can give me some advice about this issue that’s on my mind.’”

This psychiatrist didn’t have any cognitive problems, though he wasn’t as sharp as he used to be. But encroaching cognitive impairment often colors difficult family interactions.

If you think this might be a factor with your parent, instead of trying to persuade them to accept more help at home, try to get them medically evaluated, said Leslie Kernisan, author of “When Your Aging Parent Needs Help: A Geriatrician’s Step-by-Step Guide to Memory Loss, Resistance, Safety Worries, and More.”

“Decreased brain function can affect an older adult’s insight and judgment and ability to understand the risks of certain actions or situations, while also making people suspicious and defensive,” she noted.

This doesn’t mean you should give up on talking to an older parent with mild cognitive impairment or early-stage dementia, however. “You always want to give the older adult a chance to weigh in and talk about what’s important to them and their feelings and concerns,” Kernisan said.

“If you frame your suggestions as a way of helping your parent achieve a goal they’ve said was important, they tend to be much more receptive to it,” she said.

A turning point for Sylvester and her mother came when the older woman, who developed dementia, went to a nursing home at the end of 2021. Her mother, who at first didn’t realize the move was permanent, was furious, and Sylvester waited two months before visiting. When she finally walked into Burkel’s room, bearing a Valentine’s Day wreath, Burkel hugged her and said, “I’m so glad to see you,” before pulling away. “But I’m so mad at my other daughter.”

Sylvester, who doesn’t have a sister, responded, “I know, Mom. She meant well, but she didn’t handle things properly.” She learned the value of what she calls a “therapeutic fiblet” from Kernisan, who ran a family caregiver group Sylvester attended between 2019 and 2021.

After that visit, Sylvester saw her mother often, and all was well between the two women up until Burkel’s death. “If something was upsetting my mother, I would just go, ‘Interesting,’ or, ‘That’s a thought.’ You have to give yourself time to remember this is not the person you used to know and create the person you need to be your parent, who’s changed so much.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

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

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