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Lost Sleep and Jangled Nerves: The Rising Onslaught of Noise Harms Mind and Body

Kaiser Health News:States - January 05, 2023

SACRAMENTO — Mike Thomson’s friends refuse to stay over at his house anymore.

Thomson lives about 50 yards from a busy freeway that bisects California’s capital city, one that has been increasingly used as a speedway for high-speed races, diesel-spewing big rigs, revving motorcycles — and cars that have been illegally modified to make even more noise.

About the only time it quiets down is Saturday night between 3 and 4 a.m., Thomson said.

Otherwise, the din is nearly constant, and most nights, he’s jolted out of sleep five or six times.

“Cars come by and they don’t have mufflers,” said Thomson, 54, who remodels homes for a living. “It’s terrible. I don’t recommend it for anyone.”

Thomson is a victim of noise pollution, which health experts warn is a growing problem that is not confined to our ears, but causes stress-related conditions like anxiety, high blood pressure, and insomnia.

California legislators passed two laws in 2022 aimed at quieting the environment. One directs the California Highway Patrol to test noise-detecting cameras, which may eventually issue automatic tickets for cars that make noise above a certain level. The other forces drivers of illegally modified cars to fix them before they can be re-registered.

“There’s an aspect of our society that likes to be loud and proud,” said state Sen. Anthony Portantino (D-Glendale), author of the noise camera law. “But that shouldn’t infringe on someone else’s health in a public space.”

Most states haven’t addressed the assault on our eardrums. Traffic is a major driver of noise pollution — which disproportionately affects disadvantaged communities — and it’s getting harder to escape the sounds of leaf blowers, construction, and other irritants.

California’s laws will take time and have limited effect, but noise control experts called them a good start. Still, they do nothing to address overhead noise pollution from circling police helicopters, buzzing drones, and other sources, which is the purview of the federal government, said Les Blomberg, executive director of the Noise Pollution Clearinghouse.

In October 2021, the American Public Health Association declared noise a public health hazard. Decades of research links noise pollution with not only sleep disruption, but also a host of chronic conditions such as heart disease, cognitive impairment, depression, and anxiety.

“Despite the breadth and seriousness of its health impacts, noise has not been prioritized as a public health problem for decades,” the declaration says. “The magnitude and seriousness of noise as a public health hazard warrant action.”

When there’s a loud noise, the auditory system signals that something is wrong, triggering a fight-or-flight response in the body and flooding it with stress hormones that cause inflammation and can ultimately lead to disease, said Peter James, an assistant professor of environmental health at Harvard University’s T.H. Chan School of Public Health.

Constant exposure to noise increases the risk of heart disease by 8% and diabetes by 6%, research shows. The European Environment Agency estimated in 2020 that noise exposure causes about 12,000 premature deaths and 48,000 cases of heart disease each year in Western Europe.

While California Highway Patrol officials will spend the next few years researching noise cameras, they acknowledge that noise from street racing and so-called sideshows — where people block off intersections or parking lots to burn out tires or do “doughnuts” — has surged over the past several years and disturbs people right now.

Cars in California are supposed to operate at 95 decibels — a little louder than a leaf blower or lawn mower — or less. But drivers often modify their cars and motorcycles to be louder, such as by installing “whistle tips” on the exhaust system to make noise or removing mufflers.

In 2021, the last full year for which data is available, the highway patrol issued 2,641 tickets to drivers for excessive vehicle noise, nearly double 2018’s 1,400 citations.

“There’s always been an issue with noise coming from exhausts, and it’s gained more attention lately,” said Andrew Poyner, a highway patrol captain. “It’s been steadily increasing over the past several years.”

The American Public Health Association says the federal government should regulate noise in the air, on roads, and in workplaces as an environmental hazard, but that task has mostly been abandoned since the federal Office of Noise Abatement and Control was defunded in 1981 under President Ronald Reagan.

Now the task of quieting communities is mostly up to states and cities. In California, reducing noise is often a byproduct of other environmental policy changes. For instance, the state will ban the sale of noisy gas-powered leaf blowers starting in 2024, a policy aimed primarily at reducing smog-causing emissions.

One of the noise laws approved in California in 2022, AB 2496, will require owners of vehicles that have been ticketed for noise to fix the issue before they can re-register them through the Department of Motor Vehicles. Currently, drivers can pay a fine and keep their illegally modified cars as they are. The law takes effect in 2027.

The other law, SB 1097, directs the highway patrol to recommend a brand of noise-detecting cameras to the legislature by 2025. These cameras, already in use in Paris, New York City, and Knoxville, Tennessee, would issue automatic tickets if they detected a car rumbling down the street too loudly.

Originally, the law would have created pilot programs to start testing the cameras in six cities, but lawmakers said they wanted to go slower and approved only the study.

Portantino said he’s frustrated by the delay, especially because the streets of Los Angeles have become almost unbearably loud.

“It’s getting worse,” Portantino said. “People tinker with their cars, and street racing continues to be a problem.”

The state is smart to target the loudest noises initially, the cars and motorcycles that bother people the most, Blomberg said.

“You can make every car coming off the line half as loud as it is right now and it would have very little impact if you don’t deal with all the people taking their mufflers off,” he said. “That outweighs everything.”

Traffic noise doesn’t affect everyone equally. In a 2017 paper, James and colleagues found that nighttime noise levels were higher in low-income communities and those with a large proportion of nonwhite residents.

“We’ve made these conscious or subconscious decisions as a society to put minority-race communities and lower-income communities who have the least amount of political power in areas near highways and airports,” James said.

Elaine Jackson, 62, feels that disparity acutely in her neighborhood, a low-income community in northern Sacramento sandwiched between freeways.

On weekends, sideshows and traffic noise keep her awake. Her nerves are jangled, she loses sleep, her dogs panic, and she generally feels unsafe and forgotten, worried that new development in her neighborhood would just bring more traffic, noise, and air pollution.

Police and lawmakers don’t seem to care, she said, even though she and her neighbors constantly raise their concerns with local officials.

“It’s hard for people to get to sleep at night,” Jackson said. “And that’s a quality-of-life issue.”

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.


This story can be republished for free (details).

In North Carolina, More People Are Training to Support Patients Through an Abortion

Lauren Overman has a suggested shopping list for her clients preparing to get an abortion. The list includes a heating pad, a journal, aromatherapy oils — things that could bring physical or emotional comfort after the procedure.

Overman is an abortion doula.

She has worked as a professional birth doula for many years. Recently, Overman also began offering advice and emotional support to people as they navigate having an abortion, often a lonely time. She makes her services available either free or on a sliding scale to abortion patients. Other abortion doulas charge between $200 and $800.

Overman is one of around 40 practicing abortion doulas in North Carolina, according to an estimate from local abortion rights groups — a number that could soon grow. North Carolina groups that train doulas said they’ve seen an uptick in people wanting to become abortion doulas in the months since Roe v. Wade was overturned.

Every three months, the Carolina Abortion Fund offers free online classes for aspiring abortion doulas. Those sessions used to have 20 sign-ups at most, according to board member Kat Lewis. Now they have 40.

“It’s word of mouth. It’s people sharing ‘This is how I got through my abortion or miscarriage experience with the help of a doula.’ And someone being like, ‘That’s amazing. I need that. Or I wanna become that,’” Lewis said.

Demand for training has also surged at the Mountain Area Abortion Doula Collective in western North Carolina, which started in 2019. Ash Williams leads the free four-week doula training and includes talks on gender-inclusive language and the history of medical racism. The course also includes ways to support clients struggling with homelessness or domestic violence.

“The doula might be the only person that that person has told that they’re doing this. … That’s a big responsibility,” Williams said. “So we really want to approach our work with so much care.”

Going to the clinic and holding a patient’s hand during the procedure are among the services abortion doulas can offer, but some clinics don’t allow a support person in the room. So doulas like Overman find other ways to be supportive, such as sitting down with a woman afterward, to listen, share a meal, or just watch TV together.

It’s “holding space — being there so that they can bring something up if they want to talk about it. But also, there are no expectations that you have to talk about it if you don’t want to,” Overman said.

Overman uses Zoom to consult with people across the country, even in states where abortion is restricted or banned. She can help them locate the closest clinics or find transportation and lodging if they’re traveling a long distance.

Overman makes sure her clients know what to expect from the procedure, like how much bleeding is normal after either a surgical or medication abortion.

“You can fill up a super maxi pad in an hour. That’s OK,” she explained. “Fill up one or more pad every hour for two to three hours consecutively, then that’s a problem.”

Abortion doulas are not required to have medical training, and many do not. It’s not clear how many work across the U.S., because the job is not regulated.

There has been a jump in the number of people requesting her abortion doula services over the past several months, Overman said, from around four people a month to four every week.

If people are afraid to talk to their friends or relatives about an abortion, she said, sometimes the easiest thing to do is reach out to someone on the internet. A doula may start out as a stranger but can become a person who can be relied on for support.

This article is from a partnership that includes NPR, WFAE, and KHN.

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.


This story can be republished for free (details).

Muchas familias con cobertura de empleador inasequible ahora son elegibles para subsidios de Covered California

Kaiser Health News:States - January 04, 2023

Si tener a la familia en el plan de salud patrocinado por tu empleador ha sido una dificultad financiera, o imposible de pagar, la ayuda puede estar en camino.

El gobierno federal ha corregido recientemente una controversial norma del Departamento del Tesoro vinculada a la Ley de Cuidado de Salud a Bajo Precio (ACA), que denegaba la ayuda a muchas familias cuya cobertura basada en sus trabajos se salía de sus presupuestos.

Debido a la llamada “falla familiar”, si un trabajador tenía acceso a una cobertura solo para empleados considerada asequible según las directrices federales, un cónyuge o dependientes no podían recibir ayuda para comprar un plan de salud a través de Covered California, el mercado de seguros de ACA del estado, aunque no pudieran pagar el plan del empleador.

Esto afectó a unas 5,1 millones de personas en todo el país, más de la mitad de ellos niños, ya que los empleadores a menudo contribuyen solo por un empleado, y los trabajadores tienen que pagar la tarifa completa para otros miembros de la familia.

En virtud de una nueva norma que entró en vigencia el 12 de diciembre pasado, si el costo de tenerte a ti y a tu familia en un plan del lugar de trabajo supera un umbral —fijado en el 9,12% de los ingresos familiares para 2023—, tu cónyuge y dependientes podrían calificar para ayuda financiera para adquirir un seguro a través de Covered California.

La asequibilidad se determinará en función de cuánto tendrías que pagar para incluirlos —e incluirte— en el plan de salud más barato de tu empleador.

Los subsidios de ACA se otorgan en forma de créditos fiscales federales que pueden recibirse por adelantado o liquidarse con el IRS cuando declares los impuestos al año siguiente.

Las estimaciones del Centro de Investigación de Políticas de Salud de la UCLA y el Centro Laboral de UC Berkeley muestran que 391,000 californianos, previamente excluidos de los subsidios en Covered California, serían elegibles ahora bajo la nueva normativa. De ellos, unos 149,000 se inscribirían probablemente en un plan de Covered California. Aquellos que cambien de un plan patrocinado por el empleador ahorrarían un promedio de $1,478 por persona en 2023, según los dos centros.

“Arreglar la ‘falla familiar’ es un paso crítico para cumplir realmente la promesa de ACA”, dijo Jessica Altman, directora ejecutiva de Covered California. “Si no tienes cobertura asequible de otra fuente, el mercado es donde deberías poder acudir para obtenerla”.

Así que, si estás pagando demasiado para cubrir a los miembros de tu familia en el plan de salud de tu empleador, vale la pena averiguar si puedes obtener un crédito fiscal para ayudar a pagar sus primas en un plan de Covered California. Pero averiguarlo es complicado y requerirá cierto esfuerzo.

Si tienes un empleo estable, los ingresos de 2022 servirán para calcular 2023, añadiendo cualquier aumento de sueldo que esperes. También tendrás que calcular cuánto pagarías por el plan de salud más barato de tu empresa, tanto por la cobertura exclusiva para empleados como por la cobertura familiar.

Si el costo para ti solo está por debajo del umbral del 9,12%, no tendrás derecho a un plan subsidiado de Covered California, aunque tu cónyuge y dependientes sí lo tengan. Eso significa que una familia podría estar dividida entre dos pólizas, con deducibles distintos y redes de proveedores diferentes.

También es necesario determinar si el plan de menor costo ofrecido por tu empleador cumple con la norma de cobertura mínima de ACA. Esto significa que debe cubrir al menos el 60% del total de tus gastos médicos permitidos durante el año y proporcionar cobertura suficiente para servicios hospitalarios y médicos. Si no cumples esos requisitos, tú y tu familia podrían obtener un plan subvencionado a través de Covered California, en función de tus ingresos.

Si dos cónyuges tienen acceso a la cobertura del empleador, tendrás que realizar este ejercicio para ambas opciones.

¿Ya estás mareado? No me extraña.

“Es realmente complicado”, señaló Kevin Knauss, un agente de seguros en Granite Bay. “¿Y cómo podemos esperar que las familias que están tan ocupadas —los niños, las fiestas— se centren en estas cosas?”.

Pero no ignores la nueva normativa, porque podrías estar dejando dinero sobre la mesa. Covered California ofrece una planilla para ayudar a calcular tu elegibilidad para los subsidios. El departamento de recursos humanos podría ayudarte a llenarla. O podrías buscar ayuda profesional, ya sea un agente de seguros un navegador certificado. No tendrás que pagar por ninguno de los dos.

Para encontrar un agente de seguros o un navegador, entra en la página web de Covered California ( y haz clic en la pestaña “Support”. O llama al 800-300-1506. Covered California tiene un Preguntas Frecuentes (FAQ) muy útil sobre la solución al “fallo familiar”.

El período de inscripción para la cobertura de 2023 comenzó el 1 de noviembre y se extiende hasta el 31 de enero. Si compras este mes, la cobertura comenzará el 1 de febrero.

La solución a la “falla familiar” no es lo único nuevo de Covered California. A partir de este año, puedes incluir un padre/madre dependiente o padrastro/madrastra en tu plan de salud, siempre y cuando no sean elegibles o estén inscritos en Medicare.

Y, por si no lo sabías, el Congreso amplió hasta 2025 los créditos fiscales suplementarios que aumentan la ayuda a las personas que ya recibían alguna antes, y están disponibles para muchos hogares de clase media que antes no cumplían los requisitos para recibir asistencia financiera.

La idea de la ayuda financiera es limitar la cantidad que se gasta en primas de salud a no más del 8,5% de los ingresos familiares, independientemente de cuánto dinero se gane.

Knauss contó que habló con un hombre en el condado de Marin que estaba buscando un plan de salud de Covered California para su familia de cuatro y calificó para un subsidio mensual de $1,400, a pesar de que gana $200,000 al año. Tener más de 60 años y vivir en el norte de California, una región cara, aumentó la prima de su familia a un nivel que abrió la puerta a una ayuda financiera significativa, añadió Knauss.

Si ya estás inscrito en Covered California, no te limites a renovar la cobertura para 2023. Los precios y las redes de proveedores pueden cambiar de un año a otro, y podría haber una nueva opción más barata en tu región. Así que compara precios.

Y tanto si eres nuevo como si vuelves a Covered California, infórmate sobre cuáles serán tus necesidades médicas. Si tienes una condición que requiere servicios intensivos, podrías considerar el pago de una prima más alta a cambio de menores deducibles y coseguros cuando busques atención.

Feliz búsqueda.

Jessica Altman es la hija de Drew Altman, presidente y CEO de KFF. KHN es un programa editorialmente independiente de KFF.

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.


This story can be republished for free (details).

Public Health Agencies Try to Restore Trust as They Fight Misinformation

Kaiser Health News:States - January 04, 2023

OKLAHOMA CITY — By the summer of 2021, Phil Maytubby, deputy CEO of the health department here, was concerned to see the numbers of people getting vaccinated against covid-19 slipping after an initially robust response. With doubt, fear, and misinformation running rampant nationwide — both online and offline — he knew the agency needed to rethink its messaging strategy.

So, the health department conducted something called an online “sentiment search,” which gauges how certain words are perceived on social media. The tool found that many people in Oklahoma City didn’t like the word “vaccinate” — a term featured prominently in the health department’s marketing campaign.

“If you don’t know how your message is resonating with the public,” Maytubby said, “you’re shooting in the dark.”

Across the country, health officials have been trying to combat misinformation and restore trust within their communities these past few years, a period when many people haven’t put full faith in their state and local health departments. Agencies are using Twitter, for example, to appeal to niche audiences, such as NFL fans in Kansas City and Star Wars enthusiasts in Alabama. They’re collaborating with influencers and celebrities such as Stephen Colbert and Akbar Gbajabiamila to extend their reach.

Some of these efforts have paid off. By now, more than 80% of U.S. residents have received at least one shot of a covid vaccine.

But data suggests that the skepticism and misinformation surrounding covid vaccines now threatens other public health priorities. Flu vaccine coverage among children in mid-December was about the same as December 2021, but it was 3.7 percentage points lower compared with late 2020, according to the Centers for Disease Control and Prevention. The decrease in flu vaccination coverage among pregnant women was even more dramatic over the last two years: 18 percentage points lower.

Other common childhood vaccination rates are down, too, compared with pre-pandemic levels. Nationally, 35% of all American parents oppose requiring children to be vaccinated for measles, mumps, and rubella before entering school, up from 23% in 2019, according to a KFF survey released Dec. 16. Suspicion swirling around once-trusted vaccines, as well as fatigue from so many shots, is likely to blame.

Part of the problem comes down to a lack of investment that eroded the public health system before the pandemic began. An analysis conducted by KHN and The Associated Press found local health department spending dropped by 18% per capita between 2010 and 2020. State and local health agencies also lost nearly 40,000 jobs between the 2008 recession and the emergence of the pandemic.

This made their response to a once-in-a-century public health crisis challenging and often inadequate. For example, during covid’s early days, many local health departments used fax machines to report covid case counts.

“We were not as flexible as we are now,” said Dr. Brannon Traxler, director of public health at the South Carolina Department of Health and Environmental Control.

At the start of the pandemic, Traxler said, only two people worked on the media relations and public outreach team at South Carolina’s health department. Now, the team has eight.

The agency has changed its communication strategies in other ways, too. Last year was the first year, for example, that South Carolina published data on flu vaccinations every two weeks, with the goal of raising awareness about the effectiveness of the shots. In South Carolina, not even one-quarter of adults and children eligible for a flu shot had been vaccinated by early December, even as flu cases and hospitalizations climbed. The flu vaccine rate across all age groups in the U.S. was 51.4% last season.

Those who have opted out of both the covid and flu shots seem to be correlated, Traxler said.

“We’re really just trying to dispel misinformation that’s out there,” Traxler said. To that end, the health department has partnered with local leaders and groups to encourage vaccinations. Agency staffers have also become more comfortable talking to the press, she said, to better communicate with the public.

But some public health experts argue that agencies are still failing on messaging. Scientific words such as “mRNA technology,” “bivalent vaccine,” and “monoclonal antibodies” are used a lot in public health even though many people find them difficult to understand.

A study published by JAMA found that covid-related language used by state-level agencies was often more complex than an eighth-grade reading level and harder to understand than the language commonly used by the CDC.

“We have to communicate complex ideas to the public, and this is where we fail,” said Brian Castrucci, CEO of the de Beaumont Foundation, a charitable group focused on strengthening public health. “We have to own the fact that our communication missteps created the environment where disinformation flourished.”

Most Americans support public health, Castrucci said. At the same time, a small but vocal minority pushes an anti-science agenda and has been effective in sowing seeds of distrust, he said.

The more than 3,000 public health departments nationwide stand to benefit from a unified message, he said. In late 2020, the foundation, working with other public health groups, established the Public Health Communications Collaborative to amplify easy-to-understand information about vaccines.

“The good guys need to be just as well organized as those who seek to do harm to the nation,” he said. “One would think we would learn from this.”

Meanwhile, a report published in October by the Pew Research Center found 57% of U.S. adults believe “false and misleading information about the coronavirus and vaccines has contributed a lot to problems the country” has faced amid the pandemic.

“I was leery like everyone else,” said Davie Baker, 61, an Oklahoma City woman who owns a business that sells window treatments. When the shots became widely available in 2021, she thought they had been developed too quickly, and she worried about some of the things she’d read online about side effects. A pharmacist at Sam’s Club changed her mind.

“She just kind of educated me on what the shot was really about,” Baker said. “She cleared up some things for me.”

Baker signed up for her first covid shot in May 2021, around the same time the health department in Oklahoma City noticed the number of vaccines administered daily was starting to decline.

The department updated its marketing campaign in early 2022. Instead of using the word “vaccinate” to encourage more people to get their covid shots — the term the agency’s social media analytics revealed people didn’t like — the new campaign urged people to “Choose Today!”

“People don’t trust like they used to,” Maytubby said. “They want to make up their own minds and make their own decisions.” The word “choose” acknowledged this preference, he said.

Maytubby thinks the “Choose Today!” campaign worked. A survey of 502 adults in Oklahoma City conducted during the first half of 2022 found fewer than 20% of respondents reacted negatively or very negatively to a sample of “Choose Today!” advertisements. And an estimated 86.5% of adults in Oklahoma City have received at least one dose of a covid vaccine — a rate higher than the state average of about 73%.

Other factors are likely at play that have helped bolster Oklahoma City’s vaccine numbers. In the same survey of Oklahoma City adults, some people who were recently vaccinated said family members or church leaders urged them to get the vaccine, or they knew someone who had died from covid. One person said money was the motivation — they received $900 from their employer for getting the covid vaccine.

Meanwhile, the war against misinformation and disinformation wages on. Childhood vaccination rates for the immunizations students typically need to enter kindergarten are down 4.5% in Oklahoma County since the 2017-18 academic year as parents increasingly seek exemptions to the requirements.

That worries Maytubby. He said the primary tactic among those trying to sow distrust about vaccinations has been to cast doubt — about everything from the science to their safety.

“In that aspect, they’ve been pretty successful,” Maytubby said. “Misinformation has changed everything.”

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.


This story can be republished for free (details).

Many Families With Unaffordable Employer Coverage Now Eligible for Covered California Subsidies

Kaiser Health News:Insurance - January 04, 2023

If having the family on your employer-sponsored health plan has been a financial hardship, or outright impossible to afford, help may be on the way.

The federal government recently fixed a controversial Treasury Department rule tied to the Affordable Care Act that denied assistance to many families whose workplace coverage busted their budgets.

Because of the so-called family glitch, if a worker had access to employee-only coverage deemed affordable under federal guidelines, a spouse or dependents could not get help to buy a health plan through Covered California, the state’s ACA insurance marketplace, even if it was not affordable to put them on the employer plan.

This affected an estimated 5.1 million people nationally, more than half of them children, since employers often contribute only to an employee’s premium, leaving workers to pay full fare for other family members.

Under a new rule that took effect Dec. 12, if the cost of having you and your family on a workplace plan exceeds an affordability threshold — set at 9.12% of household income for 2023 — your spouse and dependents could qualify for financial aid to purchase insurance through Covered California. Affordability will be determined by how much you would have to pay to have them — and you — on your employer’s cheapest health plan.

ACA insurance subsidies come in the form of federal tax credits that can be taken upfront or settled with the IRS when you file your taxes the following year.

Estimates from the UCLA Center for Health Policy Research and the UC Berkeley Labor Center show that 391,000 Californians previously excluded from subsidies in Covered California would be eligible for them under the new rule. Of those, an estimated 149,000 would likely enroll in a Covered California plan. Those switching from an employer-sponsored plan would save an average of $1,478 per person this year, according to the two centers.

“Fixing the family glitch is a critical step in really delivering on the promise of the ACA,” says Jessica Altman, executive director of Covered California. “If you don’t have affordable coverage from another source, the marketplace is where you should be able to come for affordable coverage.”

So, if you are paying too much to cover your family members on your employer’s health plan, it is definitely worth finding out whether you can get a tax credit to help pay their premiums on a Covered California plan. But finding the answer is complicated and will take considerable legwork.

If you have steady employment, last year’s income will probably be a good proxy for 2023, adding any pay raise you expect in the coming year. You’ll also need to calculate how much you would pay for your employer’s lowest-cost health plan — both for employee-only coverage and for family coverage. If the cost for you alone is under the 9.12% threshold, you will not qualify for a subsidized Covered California plan, even if your spouse and dependents do. That means a family could be split between two policies, with separate deductibles and different provider networks.

You also need to determine whether the lowest-cost plan offered by your employer meets the minimum coverage standard under the ACA. That means it must cover at least 60% of your total allowed medical expenses during the year and provide sufficient coverage for hospital and physician services. If it does not meet those requirements, you and your family might be able to get a subsidized plan through Covered California, depending on your income.

If two spouses have access to employer coverage, you’ll need to perform this exercise for both options.

Is your head spinning yet? You’re not alone.

“This stuff is just really complicated,” says Kevin Knauss, an insurance agent in Granite Bay. “And how can we possibly expect families that are doing all kinds of different things — kids, Christmas — to really focus on this stuff?”

But don’t ignore the new rule, because you could be leaving money on the table. Covered California has a worksheet to help calculate your eligibility for subsidies. Your human resources department might be willing to help you fill it out. Or you could seek professional help, whether an insurance agent or other certified enroller. You wouldn’t need to pay a penny for either.

To find an insurance agent or certified enroller, log on to Covered California’s website ( and click on the “Support” tab. Or call 800-300-1506. Covered California has a very useful FAQ all about the fix to the family glitch.

The enrollment period for 2023 coverage started on Nov. 1 and runs through Jan. 31. If you buy coverage this month, it will start on Feb. 1.

The family glitch fix isn’t the only new thing with Covered California. Starting this year, you can put a dependent parent or stepparent on your health plan, as long as they are not eligible for or enrolled in Medicare.

And, in case you missed it, Congress extended through 2025 the supplemental tax credits that increase aid to people who were already getting some before and are available to many middle-class households that did not previously qualify for financial assistance.

The idea behind the expanded financial help is to limit the amount people spend on health care premiums to no more than 8.5% of household income, no matter how much money they make.

Knauss said he talked to a man in Marin County who was seeking a Covered California health plan for his family of four and qualified for a monthly subsidy of $1,400, even though he makes $200,000 a year. Being over 60 and living in Northern California, an expensive region, pushed his family’s premium to a level that opened the door for significant financial assistance, Knauss said.

If you are already enrolled in Covered California, don’t simply renew coverage for this year. Prices and provider networks can change from year to year, and there might be a new, cheaper option in your region. So shop around.

And whether you are new or returning to Covered California, know what your medical needs are likely to be. If you have a condition that requires intensive services, you might consider paying a higher premium in exchange for lower deductibles and coinsurance when you seek care.

Happy hunting.

Jessica Altman is the daughter of Drew Altman, who is president and CEO of KFF. KHN is an editorially independent program of KFF.

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.


This story can be republished for free (details).

Telehealth Brings Expert Sexual Assault Exams to Rural Patients

Kaiser Health News:States - January 03, 2023

Amanda Shelley was sitting in her dentist’s waiting room when she received a call from the police. A local teenage girl had been sexually assaulted and needed an exam.

Shelley, a nurse in rural Eagle County, Colorado, went to her car and called a telehealth company to arrange an appointment with a sexual assault nurse examiner, or SANE. The nurse examiners have extensive training in how to care for assault survivors and collect evidence for possible criminal prosecution.

About an hour later, Shelley met the patient at the Colorado Mountain Medical urgent care clinic in the small town of Avon. She used a tablet to connect by video with a SANE about 2,000 miles away, in New Hampshire.

The remote nurse used the video technology to speak with the patient and guide Shelley through each step of a two-hour exam. One of those steps was a colposcopy, in which Shelley used a magnifying device to closely examine the vagina and cervix. The remote nurse saw, in real time, what Shelley could see, with the help of a video camera attached to the machine.

The service, known as “teleSANE,” is new at Shelley’s hospital. Before, sexual assault patients faced mountains of obstacles — literally — when they had to travel to a hospital in another county for care.

“We’re asking them to drive maybe over snowy passes and then [be there] three to four hours for this exam and then drive back home — it’s disheartening for them,” Shelley said. “They want to start the healing process and go home and shower.”

To avoid this scenario, teleSANE services are expanding across the country in rural, sparsely populated areas. Research shows SANE programs encourage psychological healing, provide comprehensive health care, allow for professional evidence collection, and improve the chance of a successful prosecution.

Jennifer Pierce-Weeks is CEO of the International Association of Forensic Nurses, which created the national standards and certification programs for sexual assault nurse examiners. She said every sexual assault survivor faces health consequences. Assaults can cause physical injuries, sexually transmitted infections, unwanted pregnancies, and mental health conditions that can lead to suicide attempts and drug and alcohol misuse.

“If they are cared for on the front end, all of the risks of those things can be reduced dramatically with the right intervention,” Pierce-Weeks said.

Pierce-Weeks said there’s no comprehensive national data on the number and location of health care professionals with SANE training. But she said studies show there’s a nationwide shortage, especially in rural areas.

Some rural hospitals struggle to create or maintain in-person SANE programs because of staffing and funding shortfalls, Pierce-Weeks said.

Training costs money and takes time. If rural hospitals train nurses, they still might not have enough to provide round-the-clock coverage. And nurses in rural areas can’t practice their skills as often as those who work in busy urban hospitals.

Some hospitals without SANE programs refer sexual assault survivors elsewhere because they don’t feel qualified to help and aren’t always legally required to provide comprehensive treatment and evidence collection.

Avel eCare, based in Sioux Falls, South Dakota, has been providing telehealth services since 1993. It recently added teleSANE to its offerings.

Avel provides this service to 43 mostly rural and small-town hospitals across five states and is expanding to Indian Health Service hospitals in the Great Plains. Native Americans face high rates of sexual assault and might have to travel hours for care if they live in one of the region’s large, rural reservations.

Jen Canton, who oversees Avel’s teleSANE program, said arriving at a local hospital and being referred elsewhere can be devastating for sexual assault survivors. “You just went through what is potentially the worst moment of your life, and then you have to travel two, three hours away to another facility,” Canton said. “It takes a lot of courage to even come into the first hospital and say what happened to you and ask for help.”

Patients who receive care at hospitals without SANE programs might not receive trauma-informed care, which focuses on identifying sources of trauma, determining how those experiences may affect people’s health, and preventing the retraumatizing of patients. Emergency department staffers may not have experience with internal exams or evidence collection. They also might not know about patients’ options for involving police.

Patients who travel to a second hospital might struggle to arrange for and afford transportation or child care. Other patients don’t have the emotional bandwidth to make the trip and retell their stories.

That’s why some survivors, like Ada Sapp, don’t have an exam.

Sapp, a health care executive at Colorado Mountain Medical, was assaulted before the hospital system began its SANE program. She was shocked to learn she would need to drive 45 minutes to another county for an exam. “I didn’t feel comfortable doing that by myself,” Sapp said. “So, my husband would have had to come with me, or a friend. The logistics made it feel insurmountable.”

Sapp’s experience inspired her to help bring SANE services to Colorado Mountain Medical.

Shelley and several other of the hospital system’s nurses have SANE training but appreciate having telehealth support from the remote nurses with more experience. “We are a rural community and we’re not doing these every single day,” Shelley said. “A lot of my nurses would get really anxious before an exam because maybe they haven’t done one in a couple months.”

A remote “second set of eyes” increases the confidence of the in-person nurse and is reassuring to patients, she said.

Avera St. Mary’s Hospital in Pierre, South Dakota, recently began using teleSANE. Rural towns, farms, and ranches surround this capital city, home to about 14,000 people. The nearest metropolitan area is about a three-hour drive.

Taking a break from a recent busy morning in the emergency department, nurse Lindee Miller rolled out the mobile teleSANE cart and colposcope device from Avel eCare. She pulled out a thick binder of instructions and forms and opened drawers filled with swabs, evidence tags, measuring devices, and other forensic materials.

“You’re never doing the same exam twice,” Miller said. “It’s all driven by what the patient wants to do.”

She said some patients might want only medicine to prevent pregnancy and sexually transmitted infections. Other patients opt for a head-to-toe physical exam. And some might want her to collect forensic evidence.

Federal and state laws provide funding to pay for these sexual assault exams, but some survivors are billed because of legal gaps and a lack of awareness of the rules. A proposed federal law, the No Surprises for Survivors Act, would close some of those gaps.

SANE programs, including telehealth versions aimed at rural communities, are expected to continue expanding across the country.

President Joe Biden signed a bill last year that provides $30 million to expand SANE services, especially those that use telehealth and serve rural, tribal, and other underserved communities. The law also requires the Justice Department to create a website listing the locations of the programs and grant opportunities for starting them.

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.


This story can be republished for free (details).