When I’laysia Vital got accepted to Texas Southern University, a historically Black university in Houston, she immediately began daydreaming about the sense of freedom that would come with living on her own, and the sense of belonging she would feel studying in a thriving Black community.

Then, a nurse at her high school’s health clinic in Oakland, California, explained the legal landscape of her new four-year home in Texas — where abortion is now fully banned.

Vital watched TikTok videos of protesters harassing women outside clinics in other states. She realized her newfound freedoms would come at the expense of another. That’s when she added one more task to her off-to-college checklist: get a long-acting, reliable form of birth control before leaving California.

“I don’t want to go out there and not know anything, not know where to go, because I’m in a new state. So I’m trying to be as prepared as I can before I leave,” she said.

The change is a huge culture shock for Vital and some of her classmates, who for the past four years at Oakland Technical High School have had access to their own health clinic on campus.

The “TechniClinic” is a bright-purple building across from the football field and bleachers. The school’s bulldog mascot is painted near the door. On-site, students can get free, confidential birth control consults and screenings for sexually transmitted infections and be back at their desks for fourth-period math.

This summer, nurses at the Oakland clinic have formalized the “senior send-off” appointment, during which they counsel students about their legal rights and medical options before they leave for college.

After Roe v. Wade was overturned last year, clinic staffers realized students of color could be disproportionately affected by changes in state abortion laws. Many of them, like Vital, were choosing to go to historically Black colleges and universities in Southern states, where bans and limits on the procedure are more common.

“Many students here are just totally floored when I tell them that these laws are different in the states that they’re going to,” said Arin Kramer, a family nurse practitioner at the TechniClinic. Like many adults, “they can’t believe that they can’t get an abortion in this country.”

Kramer has been writing prescriptions for a year’s supply of contraceptive pills or patches, which students can pick up all at once.

Under California law, students can get contraception for free, without having to tell their parents or use a parent’s insurance plan. Students can pick up the prescription at the school clinic, or Kramer can call it in to a pharmacy near the student’s home.

During her own “senior send-off” appointment, Vital told nurse Kramer she was in the market for something even more reliable than pills.

“Because I’m very forgetful. Even if I set an alarm or write it down, it will still slip my mind,” Vital said.

She wanted a long-term contraceptive, like an IUD or a hormonal implant that would last for years and require no upkeep.

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have made these options their top recommendation for adolescents after research from both groups showed they were safe and highly effective at preventing teen pregnancy.

So at Oakland Tech and other school-based health clinics run by nonprofit La Clínica de La Raza, Kramer has trained other nurse practitioners how to insert these devices — so students can get them the same day they ask for them.

After reviewing the options, Vital decided she wanted a contraceptive implant. During their discussion, Kramer used clear, direct terms, even dropping in phrases students use themselves.

“Who are you talking to these days?” Kramer asked Vital, which is teen-speak for: Who are you having sex with?

“Same person,” Vital replied.

“You guys have been off and on, off and on,” Kramer said. “How do you feel going forward?”

“Well, now they’re on because he’s going to Texas, too,” Vital revealed with a smile. “He’s going with me.”

The clinic staff started preparing the exam room, so Vital could get the implant right away. Kramer turned on some calming music on her phone, washed her hands and had Vital lie down and raise her left arm over her head. Physician assistant Andrea Marquez came in to hold Vital’s other hand and offer words of encouragement.

“I’m going to count to three and then you’ll feel a little pinch,” Kramer said, before giving Vital a shot of numbing medication in her tricep area. Then she coached her through a series of deep breaths before inserting the tiny rod under the skin of her upper arm.

The whole procedure took less than 10 minutes, and Vital walked out with a birth control method that will last her up to five years. Now, she said, she can focus on her education and fully experience the new freedoms of college.

“I’m really excited for the growing up part of it,” she said.

Meanwhile, Kramer headed back to her office. She had a list of other patients to check up on, many headed to states that ban abortion. As they pack their books and bed linens for their new dorm rooms, she’s reminding them to also pack a year’s supply of contraception, too.

University-based health centers also are reconsidering their clinical protocols in the wake of the Dobbs v. Jackson Women’s Health Organization Supreme Court ruling that overturned Roe.

In 2020, only 35% of colleges offered on-site IUD insertion and 43% offered contraceptive implant insertion, according to a survey by the American College Health Association.

That group now recommends college clinics do routine pregnancy screenings to identify pregnancies as early as possible, to give students more time to consider their options, and to have legal counsel on call to advise clinicians on allowable practices.

Attorneys might even help advise university health centers about how to have conversations with patients, especially in states like Texas, where local law forbids clinicians from “aiding and abetting” patients who seek abortion care. These new threats — of prosecution or pulled funding — have complicated clinicians’ communication with their collegiate patients.

“So I’m going to be vague with my wording, purposefully,” said Yolanda Nicholson, director of clinical education at the North Carolina Agricultural and Technical State University health center, and chair for the coalition of Historically Black Colleges and Universities of the American College Health Association.

Nicholson thinks the concept of the senior send-off appointment in the student’s home state is a great one, given that college health centers in Texas and throughout the South have had to adjust their educational approach with students to be more general and “maybe not as specific or targeted as we would have previously done,” to stay aligned with local laws.

Out-of-state students are often shocked to discover they don’t have access to the same services as they do at home, she said.

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

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

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Last summer, Eloise Reynolds paid the bill for her husband’s final stay in the hospital.

In February 2022, doctors said that Kent, her husband of 33 years, was too weak for the routine chemotherapy that had kept his colon cancer at bay since 2018. He was admitted to Barnes-Jewish Hospital in St. Louis, not far from their home in Olivette, Missouri.

Doctors discovered a partial blockage of his bowel, Reynolds said, but she remained hopeful that his treatment would soon resume.

“I remember calling our kids and saying, ‘OK, this is all really good news. We just need to get him kind of bolstered back up and feeling well,’” she said.

But years of chemotherapy had taken a toll on his body, and he told his wife that he couldn’t go on any longer.

Kent was discharged and began hospice care at home. He died the next month at age 62.

When Reynolds received the bill for the hospital stay, she paid the $823.15 it said her husband owed. She scribbled “paid” on the bill, memorializing the date, June 30, 2022 — the financial endpoint, she thought, of Kent’s years of treatment.

Then the bill came (again).

The Patient: Kent Reynolds, deceased, had been covered by Blue Cross and Blue Shield of Illinois through his Illinois-based employer.

Medical Service: A 14-day hospital stay related to complications from colon cancer, including a partially blocked bowel.

Service Provider: BJC HealthCare, a tax-exempt health system that operates 14 hospitals, mostly in the St. Louis area, including Barnes-Jewish Hospital.

Total Bill: The hospital charged $110,666.46 for the stay before any payments or adjustments. The insurer negotiated that price down to $60,348.77, and Reynolds paid the $823.15 the hospital said the patient owed. Then, a year after her husband’s death, she received a new version of the bill from the hospital, charging her an additional $1,093.16.

What Gives: Reynolds encountered a perplexing reality in medical billing: Providers can — and do — come after patients to collect more money for services months or years after a bill has been paid.

The new bill said Kent Reynolds had been enrolled in a payment plan and that the first “monthly installment” on the nearly $1,100 balance was soon due.

She said she called both the hospital and Blue Cross and Blue Shield of Illinois in search of answers but didn’t get an explanation that made sense to her.

According to Reynolds, a BJC HealthCare representative told her that the insurer had paid more than it owed, meaning the health system had to reimburse the insurer and charge the patient more.

Reynolds said she grabbed a yardstick to use as a straight edge and went line by line, comparing both bills, to see what had changed, a task that evoked painful memories of her husband’s last days. The amount for each individual charge — medications, lab tests, supplies, and more — was the same on both bills. The total had not changed.

Only three aspects of the bill had changed: the adjustments; the amount paid by the insurance company; and what the patient owed.

Adjustments, or discounts, are amounts that may be subtracted from a medical bill, typically under the provider’s pre-negotiated contract with an insurer. Insurers and providers agree to lower, in-network rates for services provided to patients covered by the insurer.

Reynolds also received an EOB, or “explanation of benefits,” notice showing the insurer reviewed the bill again in February, a year after the hospital stay. The document said the hospital’s charges for her husband’s private room — amounting to nearly $77,000 — were more than his health plan’s negotiated room rates, which did not cover the full cost.

The EOB noted that the patient could still owe the hospital $50,216.31 for the room charges — a startling amount — although Reynolds ultimately received no bill indicating she owed that much.

Reynolds said she spent hours trying to understand the items on the hospital and insurance paperwork, since they used medical abbreviations and were grouped differently on the documents.

“It shouldn’t be this hard for a widow to figure out what the medical bills were,” said Erin Duffy, a research scientist at the University of Southern California’s Schaeffer Center for Health Policy and Economics.

Blue Cross and Blue Shield of Illinois declined to comment despite receiving a signed release from Reynolds waiving federal privacy protections.

The Resolution: Unclear about what had changed and how much she owed, Reynolds held off on paying the second bill. After KFF Health News contacted BJC HealthCare, Laura High, a media relations manager for the system, said the charges were the result of a “clerical error.” Reynolds no longer has a balance, High said in an email in May.

“I was shocked by it,” Reynolds said. “I’m convinced most of the people I know would have paid this.”

High did not answer questions about the cause of the billing error or how often such errors occur.

However, Duffy provided a different explanation for the charges. “This doesn’t seem like an error,” she said. “It seems consistent with their insurance plan design.”

She said it appeared the additional $1,100 charge — assessed a year later — represented Kent’s coinsurance share of the private room charges, which she found as a recurring line item on each page of the bill under the heading “Oncology/PVT.”

While his coinsurance responsibility could have amounted to 10% of what the insurer paid in room charges — potentially a huge amount — Kent had met his out-of-pocket payment maximum for the year, so the charges did not reach the full 10% of the room costs, Reynolds said.

The Takeaway: In the United States, medical bills and insurance statements create a burdensome puzzle for patients to sort through to determine what is actually owed. The first rule of thumb is: “Don’t pay the bill before you’ve gotten the EOB,” which is the insurer’s accounting of what you owe and what the insurer will pay, said Kaye Pestaina, co-director of KFF’s Program on Patient and Consumer Protections.

In addition, ask for an itemized breakdown of charges and compare it against the EOB.

Medical billing experts said standardizing terms and other details on medical bills and EOBs would help patients enormously in this undertaking.

A few states have taken steps toward giving patients more information about health care charges, including by simplifying medical bills. In 2019, New York state lawmakers proposed requiring hospitals to provide patients with bills in plain language, including an itemized list of services labeled as paid by the insurer or owed by the patient. The proposal, which did not advance, required hospitals to send patients a single bill within seven days of leaving the hospital.

Reynolds’ experience highlights the lack of laws and standards around how long providers have to bill — and review bills — for medical services. Insurers may dictate in their contracts how long providers have to submit claims; the Medicare program has a 12-month limit to file claims, for instance. However, Dave Dillon, a spokesperson for the Missouri Hospital Association, said no laws restrict how long providers have to send a bill to patients.

Creditors may seek payment from a deceased person’s estate to collect whatever they can, said Berneta Haynes, a senior attorney at the National Consumer Law Center. In Missouri, a living spouse can be held responsible for a deceased spouse’s medical bills in certain instances, said Terry Lawson, a managing attorney for Legal Services of Eastern Missouri.

Experts said they did not pinpoint anything Reynolds could have done differently, noting that it is the system that needs to change.

“When can she move on from these hospital bills?” Duffy asked.

Stephanie O’Neill Patison reported the audio story.

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BOULDER, Colo. — Mad-scientist kind of moments happen fairly often for nanoengineer Carson Bruns. A few months ago in his lab at the University of Colorado-Boulder, he tested his latest invention on his own arm and asked a colleague for help.

“We were like, ‘OK, we’re going to tattoo ourselves. Can you help us today?’” he said.

The tattoo is like a freckle, a little blue dot. But he can turn it on and off. Like the way a mood ring changes color with temperature, this tattoo changes with light: Ultraviolet light to turn it on, daylight (or even a flashlight) to turn it off.

“You can go to court and turn it off, and then go to the party and turn it on. And then go to Grandma’s house and turn it off,” said Bruns, who is affiliated with the university’s ATLAS Institute, which prides itself on fostering out-of-the-box ideas.

Bruns started a company with tattoo-artist-to-the-stars Keith “Bang Bang” McCurdy, along with a former doctoral student. Early next year, they plan to release their first product, Magic Ink, to a group of handpicked artists. The business partners have long-term hopes for smart tattoos that have a health value, but cosmetics are cheaper and simpler to get to consumers than medical devices. So, that’s where they’re starting.

The new ink will enter a market in a moment of flux for the regulation of cosmetics. The FDA steps in to urge a recall if an ink causes a bacterial outbreak but traditionally has not exercised its regulatory might over tattoo ink products as it does with other products that go into the body. (Tattoo inks don’t even have to be sterile.) But following the Modernization of Cosmetics Regulation Act of 2022, the FDA is expanding its authority over tattoo manufacturers. The agency is now accepting comments on draft guidance about tattoo ink preparation.

“To be honest with you, I don’t think either the FDA or the tattoo ink industry really knows what that’s going to look like,” said John Swierk, a chemist at the State University of New York-Binghamton. But, he said, the law does mean “the FDA has a new charge to really ensure that labeling is correct and good manufacturing practices are being followed.”

Bruns said Magic Ink is made of particles of dye, encased in beads of plexiglass — the same polymethyl methacrylate material in those dermal fillers people use to plump their lips. Dermal fillers are FDA-approved, whereas tattoo ink contents can be like a black box.

Swierk said many of the tattoo pigments in use now have been around a long time, which gives some users a base comfort level about their safety. But a new material comes with new unknowns.

“If somebody is going to get tattooed with Magic Ink, they have to accept a degree of uncertainty about what the future is going to hold with that ink,” Swierk said.

Bruns recently received funding from the National Science Foundation, which he plans to use for probing which size and type of nanoparticles are less likely to irritate the immune system and more likely to stay put where they’re placed. The immune system has been known to haul off bits of tattoo ink to the lymph nodes, dyeing them blue and green.

While Magic Ink is a cool party trick, Bruns and his colleagues have made other inks that align with their bigger goal: to make tattoos helpful.

Bruns and his colleagues have made one that changes color when exposed to gamma radiation — envisioning it might someday work as a built-in exposure meter. Another ink shows up when it is time to put on sunscreen. He developed yet another ink intended to act as a permanent sunscreen. None of those are available to consumers, though the permanent sunscreen is furthest along. That ink has been tested in a small group of mice; the others have been tested on pigskin.

Bruns started a company, Hyprskn, a few years ago, when Bang Bang came across his work and suggested they team up.

The name Bang Bang might not ring a bell, but the tattoos he’s done are very public: They’re cascading down Rihanna, scattered across Miley Cyrus, and peering out from LeBron James, among others. Turns out, Bang Bang loves tech.

“I would like to wave my hand and pay with my AmEx, or walk up to my car and it knows it’s me,” he said. Or, he continued, maybe there could even be health applications — like alerting him if his blood sugar is high or low, just by looking at the color of his tattoos.

Scientifically, that is still way far off. If tattoo ink were to make the leap from cosmetics into the medical realm, it would require clearing all sorts of regulatory hoops.

“There’s a lot of steps between where we are today and getting a functional tattoo that’s going to tell you something about your health,” Swierk said. “A lot of steps.”

But Bang Bang thinks the product they’re taking preorders for is step one toward building a consumer base that would be open to tattooable tech.

The first product they’re offering to consumers is Magic Ink. It’s a lot like that blue freckle on Bruns’ arm, except it’s red. For now, that’s the only color available for purchase.

“That’s how you can excite people,” said Bang Bang. “It’s almost a Trojan horse into that new goal of how do we bridge the gap between tattoo and technology.”

It’s $100 for a half-ounce bottle. That’s a lot more than regular ink costs. If the product takes off, the University of Colorado-Boulder will also benefit, as it owns the intellectual property.

Bang Bang is among a few dozen people, many of them tattoo artists, who are already wearing the ink in their skin.

Tattoo artist Selina Medina has been in the business more than 20 years and used to work for an ink manufacturer. She spends a lot of time advocating for tattoo safety, volunteering with several national and international groups focused on the issue.

“I’d probably give it a year in the market before I would buy it. But it does look really interesting,” said Medina, who is on the board of directors for the Alliance of Professional Tattooists.

Medina hopes this ink is different from the UV inks she saw pop up in the 2000s, which would glow under a black light.

“It seemed like an awesome idea, but then we noticed that it faded really fast,” she said. “It would just disappear. We didn’t know what it did. We didn’t know where it went. And that was just kind of like, ‘What the hell is this stuff?’”

She expects her customers will be clamoring for Magic Ink before she’s ready to purchase it.

Looking further afield, some companies are already investing in technology embedded in the skin. A European company called DSruptive makes injectable thermometers. It said about 5,000 people — living primarily in Sweden, Japan, the U.S., and the United Kingdom — have had the devices installed. Ali Yetisen, an engineer at Imperial College London, said for companies eyeing tech embedded in the skin, diabetes is a big focus.

“That’s where the money is. Most companies invest in this area,” said Yetisen. The dream is to create something like a tattoo that could measure blood sugar in real time, and be long-lasting, he said.

“That’s the holy grail of all medical diagnostics,” he said.

While Bruns’ inventions sense external factors like light and radiation, for manufacturers looking to develop in-body tech that reacts to the blood, there are other scientific hurdles. The immune system forms little shells around foreign bodies, effectively putting up a wall between a sensor and the blood.

No one has really figured a way around that yet, said Yetisen, but a lot of people are trying.

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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TAMPA, Fla. — If it weren’t for the traffic along South MacDill Avenue, Javonne Mansfield swears you could hear the sizzle of a frying pan.

The sun is scorching with such violent intensity that even weathered Floridians can’t help but take note. 

In a hard hat, Mansfield pushes a shovel into the earth. Heat radiates from the road, the concrete parking lots. It’s around 10:30 a.m., and his crew is starting a 10-hour shift fixing traffic lights in West Tampa. Cloud coverage is minimal — thin and wispy. There’s no greenery or trees to shield them, no refuge from the blistering sun.

“I can feel it,” Mansfield says, “like I’m cooking.”

A mile south, near Palma Ceia Golf and Country Club in South Tampa, Kiki Mercier walks a poodle mix along a row of stately homes. It’s the same city on the same July day, but here, the heat feels different.

Plush lawns spotted with children’s toys help absorb the sun’s rays. But it’s the dozens of live oak trees with sprawling branches that make the biggest difference to Mercier, who walks dogs for a living.

Here, it feels possible to be outside, protected by natural tunnels of shade.

As the climate warms, a person’s health and quality of life hinge, in part, on the block where they live or work. Green space and shade can be the difference between a child playing outside and being stuck inside on hot summer days, the difference between an elderly person fainting while waiting for a bus and boarding safely, the difference between a construction worker suffering heatstroke on the job and going home to their family.

Neighborhoods with more trees and green space stay cooler, while those coated with layers of asphalt swelter. Lower-income neighborhoods tend to be hottest, a city report found, and they have the least tree canopy.

The same is true in cities across the country, where poor and minority neighborhoods disproportionately suffer the consequences of rising temperatures. Research shows the temperatures in a single city, from Portland, Oregon, to Baltimore, can vary by up to 20 degrees. For a resident in a leafy suburb, a steamy summer day may feel uncomfortable. But for their friend a few neighborhoods over, it’s more than uncomfortable — it’s dangerous.

Last month was Tampa Bay’s hottest ever. As Americans brace for an increasing number of hot days and extreme weather events linked to climate change, medical professionals stress that rising heat will make health inequities worse.

“Heat affects quality of life,” said Cheryl Holder, co-founder and interim director of Florida Clinicians for Climate Action, a coalition of medical professionals that advocates for solutions to climate change. “It’s poor and vulnerable patients who are suffering.”

Now, cities like Tampa are trying to build heat resiliency into their infrastructure — including by boosting their tree canopy — all while experts warn of a public health threat growing more severe each year.

Unrelenting Heat

As a human body warms, sweat gathers and evaporates from the skin, transferring heat away and into the air.

But in Florida, humidity hangs like a blanket, making it harder for the body’s cooling system to work.

“The sweat just doesn’t evaporate, so you don’t lose heat as effectively,” said Patrick Mularoni, a sports medicine physician at Johns Hopkins All Children’s Hospital in St. Petersburg.

In these unrelenting summer months, doctors like Mularoni have seen up close the toll heat can take.

Muscle cramps and headaches. Fatigue. Heatstroke — which can be fatal.

Daily temperatures are one benchmark of heat’s impact, but factors like humidity, wind speed, and sun angle also affect the toll on the body.

The heat index, often called the “feels like” temperature, accounts for temperature plus the added burden of humidity. For instance, while the thermometer may read 91 degrees, the heat index means it can feel like 110 degrees. The National Weather Service defines any heat index of 105 degrees or higher as dangerous.

Between 1971 and 2000, Tampa saw about four days a year with a heat index greater than 105 degrees.

By 2036, that number is projected to jump to as many as 80 days a year.

Without extreme steps to reduce global temperatures, scientists predict, Tampa residents will experience 127 “dangerous” days annually by 2099 — more than a third of the calendar year.

When the body temperature goes up to 104 as a result of overheating, the body begins dysregulating and shutting down. Decreased blood flow to the organs can cause multisystem organ failure.

Without prompt intervention to lower the body temperature, according to the Centers for Disease Control and Prevention, heatstroke can be fatal.

This summer, heat waves have killed at least 13 people in Texas and one in Louisiana, where the heat index reached 115 degrees. In Arizona, at least 18 people have died, and 69 other deaths were being investigated for potential links to heat illness. Other Arizonans have been hospitalized for serious burn injuries after touching scalding concrete.

As far north as Maryland, a 52-year-old man died in July — the state’s first recorded heat-related death of the year.

And in Parkland, Florida, a 28-year-old farm worker died of heat exposure in January after he’d spent hours pulling weeds and propping up bell pepper plants. Investigators said his death was preventable. He’d recently moved from Mexico; it was his first day on the job.

In Tampa, a Shrinking Canopy

Last year was Tampa’s hottest to date.

The city’s average annual temperature has risen by 2.5 degrees since record-keeping began in 1891, according to the city’s Climate Action and Equity Plan.

All the while, a natural tool for reducing heat has been slowly disappearing. According to a 2021 study, tree canopy coverage in Tampa is at its lowest in 26 years.

Experts say vanishing tree cover coupled with hotter summers is a lethal combination.

The uneven distribution of trees — and therefore shade — means lower-income and Hispanic neighborhoods are more affected by heat, Tampa’s city report found.

MacFarlane Park, east of Tampa International Airport, ranks among the least shady areas of the city, according to the report. It has 21% canopy coverage, or nearly a third less than the city average.

Only 15% of East Ybor City and 18% of North Hyde Park benefit from tree cover. All these neighborhoods have gradually lost trees over the past few decades.

Many factors influence the shrinking canopy, the city’s analysis found, including the loss of old and dying trees and the removal of trees for construction. In some lower-income neighborhoods, residents have chosen to cut trees down because they can’t afford the upkeep, or because dangling branches pose a threat.

Some wealthier areas are seeing faster and more recent canopy loss as old trees die or are cut down, but their total tree cover is still double that of poorer neighborhoods.

On the upper end, the canopy of mansion-lined Bayshore Boulevard is not far behind those of a series of housing developments along Flatwoods Park in New Tampa, one of which hovers around 73% coverage.

Gray Gables, a neighborhood bordering West Kennedy Boulevard, lost the highest proportion of trees from 2016 to 2021, but canopy still covers 38% of its total area.

It’s not just shade the city is losing. Trees release water vapor, which helps cool people off. Each year, according to the city’s 2021 canopy study, Tampa’s trees remove 1,000 tons of air pollutants, capture the potential carbon dioxide emissions of 847 tanker trucks’ worth of gasoline, and reduce stormwater runoff equal to 850 Olympic swimming pools.

Natural shade also determines the paths people walk — or whether they walk at all — and how often their kids can play in the yard.

On a July day in West Tampa, a girl on a bike squints as she pedals, beads of sweat dripping from her brow. A woman pushing a stroller contorts her body while waiting for the bus, trying to make use of a strip of shade no wider than 6 inches, cast from a traffic pole.

Angela Morris stands in her sun-drenched driveway and rinses sandy beach toys with a hose. She’s layered in sunscreen, but in the blazing heat, her skin is already burning.

“It’s almost unbearable,” Morris says. Her kids — ages 2 and 5 — are inside.

Do they ever play outside in the summer?

“Never,” Morris says. “It’s a lot of younger families with kids who would benefit from some shade and a sidewalk.”

Data Deficiency Poses Problems

Heat-related deaths also prove difficult to track.

A doctor might code a fatal heart attack on an extremely hot day as a cardiovascular event without noting, for example, that heat likely exacerbated the condition.

“What often gets lost are the circumstances surrounding deaths and illness,” said Christopher Uejio, a Florida State University researcher who studies the effects of climate on health and has led data projects for cities around the country.

Extreme heat in the U.S. kills more people than hurricanes, floods, and tornadoes put together, according to the National Weather Service. It’s the country’s No. 1 weather-related cause of death.

About 67,500 emergency room visits and just over 9,000 hospitalizations across the U.S. each year are tied to heat, according to the CDC.

But those numbers account only for instances in which doctors specifically code the visit as a heat-related event.

Similarly, between 2004 and 2018, an average of only 702 heat-related deaths across the country were reported to the CDC.

“We know that’s a pretty gross underestimate,” said Uejio. “Our best scientific estimates are anywhere between 5,000 to 12,000 deaths in the United States due to conditions exacerbated by heat each year.”

Low reporting continues today, experts say.

Despite patchy reporting, it appears heat-related deaths are on the rise. Last year’s number of estimated deaths was more than double the number from a decade ago.

Medical schools must teach doctors to look for and document heat-related illness, said Holder, of Florida Clinicians for Climate Action. Her group has held lectures for students and doctors on topics like the effects of climate change on patients.

Holder said she has seen how heat exposure over time harms the predominantly low-income and minority patients she served in her community clinic in South Florida.

There was the elderly man who had signs of worsening kidney function on days when he worked long shifts selling fruit on hot Miami streets.

The mother whose asthma worsened as temperatures rose.

The Fort Lauderdale woman with chronic lung disease who was arrested for fighting with her daughter over a fan. She died three days after returning to her broiling apartment.

A More Resilient City

That the tree canopy is shrinking is no surprise to city officials. In April, Tampa Mayor Jane Castor set a goal of planting 30,000 trees by 2030.

Whit Remer, Tampa’s sustainability and resilience officer, said the target might be difficult to nail.

Remer said trees are competing for space in the right of way with sidewalks and utilities. Limited open land also poses a challenge. Tampa has no room for new parks, he said. Now, it’s about maximizing that finite green space.

“Planting trees has been the hardest thing that I have done as the city’s resilience officer,” Remer said.

Remer said he’s looking to other cities for solutions. In Phoenix, a “cool pavement” pilot program uses a water-based asphalt layer to reflect heat off roads. Last year, Miami-Dade County appointed the world’s first chief heat officer. Washington and Oregon have begun distributing thousands of air conditioning units to vulnerable residents and barred utility companies from cutting power to homes during heat waves.

Remer said Tampa is still in its “learning and listening” phase. Last year, the city was awarded $300,000 by the National Academies of Sciences, Engineering, and Medicine to develop a guide for understanding and fighting the effects of heat in East Tampa, a predominantly Black neighborhood, where at least a third of children live below the poverty line.

The project director is Taryn Sabia, an urban designer and associate dean at the University of South Florida who focuses on climate resiliency work, which spans hurricane preparedness, flooding, and, increasingly, extreme heat.

Planting trees is helpful, Sabia said, but they take time to grow and effort to maintain. Quicker actions could include erecting better shade structures at bus stops or implementing rules for construction to encourage the use of materials that generate less heat in the sun. For example, some cities in the Northeast — including Philadelphia and New York — provide financial incentives for “green roofs,” in which the top of a building is covered with plants.

Another easy step: painting everything white. Light colors reflect sunlight, while dark colors absorb heat.

And while Florida codes require homes to have a mechanism to provide heat in the winter, there are no codes requiring landlords to provide air conditioning.

“You can no longer be here and not have it,” Sabia said.

Tampa could better tailor weather advisories for specific needs and neighborhoods, she said. Heat becomes more dangerous more quickly on upper floors of older apartments, for example, because heat rises. Expanding access to cooling shelters is also key.

It’s the hottest week of the year so far in Tampa, and 75-year-old Benjamin Brown is walking home from the eye doctor, about a 30-minute walk.

There are few trees in sight, but Brown, who is without a car, makes a similar trek every day, running errands, visiting friends.

“It’s very oppressive. It does get to me,” Brown says as he nods, wipes his forehead, and continues down the street in the blistering Tampa sun.

Shade — any shade — would be a lifesaver, he said.

This article was produced in partnership with the Tampa Bay Times.

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 senior Colorado correspondent Markian Hawryluk discussed how the community of Pueblo is pushing back against a nonprofit hospitals’ lack of charity care on Colorado Public Radio on Aug. 17.

• Click here to hear Hawryluk on Colorado Public Radio
• Read Hawryluk’s “Community With High Medical Debt Questions Its Hospitals’ Charity Spending”

KFF Health News former senior editor Andy Miller discussed PFAS, otherwise known as “forever chemicals,” on WUGA’s “The Georgia Health Report” on Aug. 18. Miller also discussed a KFF survey on weight loss drugs and health care fraud on WUGA’s “The Georgia Health Report” on Aug. 11 and Aug. 4, respectively.

• Click here to hear Miller on the Aug. 18 “The Georgia Health Report”
• Click here to hear Miller on the Aug. 11 “The Georgia Health Report”
• Click here to hear Miller on the Aug. 4 “The Georgia Health Report”
• Read Miller’s “EPA Action Boosts Grassroots Momentum to Reduce Toxic ‘Forever Chemicals’”

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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HHS announces approximately $23 million in funding to foster innovation, provide new research, and expand the evidence to support and advance equity in the Teen

California doctors and state lawmakers are squaring off once again over the future of the Medical Board of California, which is responsible for licensing and disciplining doctors and has been criticized by patient advocates for years for being too lax.

A bill before the legislature would significantly increase the fees doctors pay to fund the medical board, which says it hasn’t had the budget to carry out its mission properly. It would also mandate new procedures for investigating complaints.

Patient advocates say the board, which oversees about 150,000 physicians and surgeons with active licenses in the state, is hamstrung by a lack of funding and clunky processes, and that its shortcomings pose a risk to the public by allowing bad doctors to continue practicing. The board opened only about 1,000 investigations out of nearly 10,000 complaints last year, according to its 2022 annual report.

But the California Medical Association, which represents physicians, is again fighting proposed increases in the fee, which was unchanged for more than a decade before being raised in 2021 after a contentious debate. Now lawmakers want to boost the license renewal fee to $1,289 every two years, up from $863 currently.

The doctors’ lobby largely defeated the 2021 efforts to strengthen the board, and critics say the group is trying to whittle away the board’s power by depriving it of funding.

The legislation, sponsored by Sen. Richard Roth, a Riverside Democrat, would also require board staff to interview patients or families before closing their complaints, create a unit to better facilitate communications, and improve efficiency by changing procedures and adjusting standards of evidence for investigations.

Another provision would allow patients and relatives to make a statement during the investigation about how a doctor’s negligence or misconduct affected them — similar to crime victims speaking during a sentencing hearing in criminal court.

The bill faces a pivotal vote in the state Assembly’s Appropriations Committee this month.

Most California licensing boards are funded through license fees. Currently, dentists pay $668 for a two-year license renewal, plus other permitting fees such as $325 for general anesthesia or $650 for oral surgery. Attorneys actively practicing in California pay $510 annually.

But the medical association insisted in a memo that it “cannot agree to a fee increase of nearly 50% that will primarily go toward building a multimillion-dollar reserve fund and future programs for the Medical Board.”

“If the bill is passed in its current form, it would have vast, negative impacts on the practice of medicine and health care delivery in California,” it added.

George Soares, a legislative advocate for the California Medical Association, told lawmakers last month that the association would be willing to accept a fee increase, but that $1,289 is too much — more than double the national average for state medical licenses. A July working paper from the National Bureau of Economic Research found that physicians’ annual earnings average $350,000 across the U.S.

The medical board supports the bill and says a fee hike is needed to cover operations, repay millions of dollars in loans, and establish a three-month reserve. Over the past two years, the Department of Consumer Affairs, which is responsible for the operations of the medical board and other licensing boards, has had to backfill the board’s $79 million budget, using a total of $18 million in loans from Bureau of Automotive Repair license fees to cover the gap.

“The simple reality is that the board is not able to pay its bills,” a spokesperson for the medical board read from a joint statement from Randy Hawkins, the vice president of the board, and Richard Thorp, a former president of the California Medical Association and current member of the board, at a committee hearing last month.

“We are physicians in private practice, and this fee increase will impact us personally, albeit at an increased cost of less than $20 per month,” the statement read. “We do not see this as a burden but rather as an investment into the organization that helps ensure that physicians have the confidence of the patients that we are privileged to treat.”

Roth points out that the medical board, which is composed of eight physicians and seven members of the public, has little control over staffing costs. Its 169 employees work for the state and are covered by labor agreements negotiated by statewide employee unions.

Consumer advocates say the opposition from the doctors’ lobby is part of a years-long effort to weaken the board and deprive it of adequate funding.

A report about the medical board’s operations conducted by a consulting firm that serves as the enforcement monitor for the board, Alexan RPM Inc., underscored the board’s financial challenges and recommended adopting automatic annual fee increases tied to the consumer price index, or something similar. Some lawmakers suggested the fees could be determined on a sliding scale based on doctors’ income.

Critics have complained for years that the medical board doesn’t hold doctors accountable often enough. Families that file complaints against doctors frequently go years without updates on the status of investigations, and often aren’t told why when their complaints are rejected.

“This is kind of the culmination of two things: patient advocacy trying to make changes and a few years of very recent, direct pushes by the legislature,” said Carmen Balber, the executive director of Consumer Watchdog, a consumer and patient advocacy organization.

The California Medical Association has already blunted some aspects of the bill, including securing the removal of a provision to add two more members of the public to the board, which would have made it a public-member majority instead of its current physician majority.

The association is also opposed to a provision currently in the bill that would lower the standard of proof for disciplining doctors in instances besides those in which they could lose their licenses.

Tracy Dominguez, a Bakersfield resident whose daughter, Demi, and grandson, Malakhi, died in 2019 from complications of severe preeclampsia, is among those advocating for reforms.

One of the physicians who treated Dominguez’s daughter prior to her death had already been accused by the medical board of gross negligence that led to the death of a young mother, according to medical board documents. Advocates at Consumer Watchdog allege his negligence had already caused death or permanent injury of other mothers and babies he treated, and that he was already banned from practicing in some hospitals at the time he treated Demi Dominguez but had been allowed to keep his license.

Tracy Dominguez said she hopes changing evidentiary standards and strengthening the medical board overall “will put dangerous doctors away.”

And a chance to provide a victim impact statement would be important for families hurt by medical neglect, she added. It would be “an opportunity for them to hear from the family, directly — to know that she was a person, not just a number.”

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

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

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Madera Community Hospital in California’s Central Valley, which ceased operations last December and filed for Chapter 11 bankruptcy in March, moved a step closer to reopening Thursday when California’s new fund for troubled hospitals said it was prepared to offer the facility up to $52 million in interest-free loans.

The program is offering an additional $240.5 million in no-interest loans to 16 other troubled hospitals, including Beverly Community Hospital in Montebello and Hazel Hawkins Memorial Hospital in Hollister, both of which filed for bankruptcy earlier this year.

Hazel Hawkins will get a loan of $10 million, and Beverly will get a bridge loan of $5 million while it is being purchased out of bankruptcy by Adventist Health’s White Memorial in Los Angeles, according to the state’s Department of Health Care Access and Information, which unveiled the lending details Thursday.

Adventist Health has also agreed conditionally to manage Madera if it reopens. If all goes well it would take six to nine months to reopen, officials said.

Madera will get a bridge loan of $2 million to cover basic costs while Adventist Health, a large multistate health system with 22 hospitals in California, works on a “comprehensive hospital turnaround plan,” the department said. Once such a plan is approved, Madera “can be eligible for an additional $50 million loan” from the distressed hospital program, it said.

For most of last year, Fresno-based St. Agnes Medical Center, part of the large Catholic hospital chain Trinity Health, appeared poised to rescue Madera Community Hospital from financial ruin in a planned acquisition that was approved by California Attorney General Rob Bonta. But Trinity walked away from the deal at the last minute with scant explanation, infuriating Bonta along with multiple other political leaders, community advocates, and health care officials.

Trinity, which had loaned Madera $15.4 million during their merger talks, became its largest creditor in the bankruptcy that ensued. At the time of its bankruptcy filing in March, Madera reported total debts of just over $30 million.

Adventist Health agreed last month to a nonbinding letter of intent to manage Madera. At the time, Kerry Heinrich, Adventist’s president and CEO, said that if the shuttered hospital got the requisite financing, Adventist Health would use its expertise in “helping to secure a sustainable future for healthcare” in the county.

Adventist Health spokesperson Japhet De Oliveira said Thursday that his organization remains intent on doing so. Reopening Madera “would be a really good thing, and we will put every effort into making that happen,” De Oliveira said. He added: “We will need all parties to be involved in developing the approved plan and negotiating the terms of management services.”

Karen Paolinelli, the CEO of Madera Community Hospital, did not respond to emailed questions by publication time.

State political leaders representing the region expressed satisfaction with Thursday’s news. “It brings me tremendous relief to know that Madera Community Hospital and Hazel Hawkins Memorial Hospital in San Benito County have received grant awards and will be able to ensure that community members can once again receive services in their own communities,” said Sen. Anna Caballero, a Democrat who represents the areas in which those facilities are located.

The Adventist letter of intent for Madera said that in addition to paying off creditors in the bankruptcy, the hospital would need to secure $55 million in the first year to pay for all aspects of reopening, plus an additional $30 million in the second year.

The $52 million the state proposes lending to Madera is significantly short of the $80 million the hospital applied for. Assuming the full $52 million materializes, the total amount loaned to the 17 hospitals would be $292.5 million — nearly the entire $300 million available to the fund for fiscal years 2023 and 2024. The program is scheduled to end after 2031.

With $52 million from the state, Madera Community Hospital would still need to find an additional $33 million. Madera said in a bankruptcy court filing earlier this year that it expects just over $33 million in revenues from “provider fees” and from the Federal Emergency Management Agency.

The law that created the distressed hospital loan fund, AB 112, initially provided for $150 million in lending to help troubled hospitals, mostly rural ones, that faced the risk of closing. Another $150 million was later added to the pot. Small hospitals across the state — and the country — have been buffeted by the ill economic winds of the covid-19 pandemic, which ratcheted up the cost of drugs, supplies, and labor.

Hospital industry officials have also pointed to low payment rates by government programs, especially Medi-Cal, California’s Medicaid program, which they say has saddled many hospitals with financial losses.

Madera made the same argument, but state data shows it received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients.

The hospitals awarded the largest loans by the distressed hospital fund are Tri-City Medical Center in Oceanside, with $33.2 million; Dameron Hospital Association in Stockton, with $29 million; Pioneers Memorial Healthcare District in Imperial County, with $28 million; and El Centro Regional Medical Center, with $28 million.

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

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

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Madera Community Hospital in California’s Central Valley, which ceased operations last December and filed for Chapter 11 bankruptcy in March, moved a step closer to reopening Thursday when California’s new fund for troubled hospitals said it was prepared to offer the facility up to $52 million in interest-free loans.

The program is offering an additional $240.5 million in no-interest loans to 16 other troubled hospitals, including Beverly Community Hospital in Montebello and Hazel Hawkins Memorial Hospital in Hollister, both of which filed for bankruptcy earlier this year.

Hazel Hawkins will get a loan of $10 million, and Beverly will get a bridge loan of $5 million while it is being purchased out of bankruptcy by Adventist Health’s White Memorial in Los Angeles, according to the state’s Department of Health Care Access and Information, which unveiled the lending details Thursday.

Adventist Health has also agreed conditionally to manage Madera if it reopens. If all goes well it would take six to nine months to reopen, officials said.

Madera will get a bridge loan of $2 million to cover basic costs while Adventist Health, a large multistate health system with 22 hospitals in California, works on a “comprehensive hospital turnaround plan,” the department said. Once such a plan is approved, Madera “can be eligible for an additional $50 million loan” from the distressed hospital program, it said.

For most of last year, Fresno-based St. Agnes Medical Center, part of the large Catholic hospital chain Trinity Health, appeared poised to rescue Madera Community Hospital from financial ruin in a planned acquisition that was approved by California Attorney General Rob Bonta. But Trinity walked away from the deal at the last minute with scant explanation, infuriating Bonta along with multiple other political leaders, community advocates, and health care officials.

Trinity, which had loaned Madera $15.4 million during their merger talks, became its largest creditor in the bankruptcy that ensued. At the time of its bankruptcy filing in March, Madera reported total debts of just over $30 million.

Adventist Health agreed last month to a nonbinding letter of intent to manage Madera. At the time, Kerry Heinrich, Adventist’s president and CEO, said that if the shuttered hospital got the requisite financing, Adventist Health would use its expertise in “helping to secure a sustainable future for healthcare” in the county.

Adventist Health spokesperson Japhet De Oliveira said Thursday that his organization remains intent on doing so. Reopening Madera “would be a really good thing, and we will put every effort into making that happen,” De Oliveira said. He added: “We will need all parties to be involved in developing the approved plan and negotiating the terms of management services.”

Karen Paolinelli, the CEO of Madera Community Hospital, did not respond to emailed questions by publication time.

State political leaders representing the region expressed satisfaction with Thursday’s news. “It brings me tremendous relief to know that Madera Community Hospital and Hazel Hawkins Memorial Hospital in San Benito County have received grant awards and will be able to ensure that community members can once again receive services in their own communities,” said Sen. Anna Caballero, a Democrat who represents the areas in which those facilities are located.

The Adventist letter of intent for Madera said that in addition to paying off creditors in the bankruptcy, the hospital would need to secure $55 million in the first year to pay for all aspects of reopening, plus an additional $30 million in the second year.

The $52 million the state proposes lending to Madera is significantly short of the $80 million the hospital applied for. Assuming the full $52 million materializes, the total amount loaned to the 17 hospitals would be $292.5 million — nearly the entire $300 million available to the fund for fiscal years 2023 and 2024. The program is scheduled to end after 2031.

With $52 million from the state, Madera Community Hospital would still need to find an additional $33 million. Madera said in a bankruptcy court filing earlier this year that it expects just over $33 million in revenues from “provider fees” and from the Federal Emergency Management Agency.

The law that created the distressed hospital loan fund, AB 112, initially provided for $150 million in lending to help troubled hospitals, mostly rural ones, that faced the risk of closing. Another $150 million was later added to the pot. Small hospitals across the state — and the country — have been buffeted by the ill economic winds of the covid-19 pandemic, which ratcheted up the cost of drugs, supplies, and labor.

Hospital industry officials have also pointed to low payment rates by government programs, especially Medi-Cal, California’s Medicaid program, which they say has saddled many hospitals with financial losses.

Madera made the same argument, but state data shows it received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients.

The hospitals awarded the largest loans by the distressed hospital fund are Tri-City Medical Center in Oceanside, with $33.2 million; Dameron Hospital Association in Stockton, with $29 million; Pioneers Memorial Healthcare District in Imperial County, with $28 million; and El Centro Regional Medical Center, with $28 million.

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

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

USE OUR CONTENT

This story can be republished for free (details).

Eight Republican hopefuls took the stage Wednesday night at Fiserv Forum in Milwaukee for the first debate of the 2024 presidential primary campaign.

The eight-way faceoff, generally chaotic and contentious, included Florida Gov. Ron DeSantis; entrepreneur Vivek Ramaswamy; former Vice President Mike Pence; U.S. Sen. Tim Scott (S.C.); former New Jersey Gov. Chris Christie; Trump administration ambassador to the United Nations and former South Carolina Gov. Nikki Haley; North Dakota Gov. Doug Burgum; and former Arkansas Gov. Asa Hutchinson. Fox News anchors Martha MacCallum and Bret Baier often struggled to keep the evening on track. Former President Donald Trump chose not to attend, leading Baier to refer to him as “the elephant not in the room.”

Our PolitiFact partners fact-checked the candidates on topics ranging from foreign aid to climate change in real time. You can read their full coverage here.

When it came to health care, Haley was the first on the stage to reference it, if only tangentially. About 15 minutes in, she blamed high government spending not just on Washington or Democrats but on her party, too. “The truth is that Biden didn’t do this to us,” she said. “Our Republicans did this to us, too. When they passed that $2.2 trillion covid stimulus bill, they left us with 90 million people on Medicaid, 42 million people on food stamps.”

Candidates sparred over whether, as the next U.S. president, they would sign a federal abortion ban into law, a discussion that highlighted how the GOP continues to struggle with the abortion question since the Supreme Court overturned Roe v. Wade. Haley maintained that such a ban does not have the necessary support to pass the Senate and make it to the president’s desk, pointing to other abortion-related issues that could offer promising avenues for consensus. Pence, however, pledged if elected to sign such a ban, saying it’s a matter of leadership, not consensus. Also, he said, it is not only a states’ issue but a moral one. DeSantis touted his signature of Florida’s ban on abortions after six weeks, but pivoted from the idea of a federal ban, instead underscoring his opposition to policies that would allow what he described as “abortion all the way up till birth.”

Others on the stage voiced varying opinions about a federal ban, at what point during the gestational period that ban should apply, and even whether the question should be decided by the states.

Ramaswamy, a newcomer to politics, spoke about gun violence and crime in the context of the nation’s mental health crisis. He misspoke, though, when he referred to it as a mental health epidemic rather than a mental illness epidemic.

Here are some health-related claims checked by PolitiFact:

Abortion

Pence: “A 15-week [abortion] ban is an idea whose time has come. It’s supported by 70% of the American people.”

Survey data on this question varies. Pence’s team pointed PolitiFact to a June poll sponsored by Susan B. Anthony Pro-Life America, an anti-abortion group, and conducted by the Tarrance Group. It found that 77% of respondents said abortions should be prohibited at conception, after six weeks, or after 15 weeks.

But this poll was sponsored by a group with a position on the issue, and questions were posed in a way that told respondents that fetuses can feel pain at 15 weeks — an assertion that lacks consensus among medical experts.

Independent polls have varied on the question of an abortion ban after 15 weeks. A June 2022 survey from Harvard University’s Center for American Political Studies and The Harris Poll found 23% of respondents said their state should ban abortion after 15 weeks, 12% said it should be banned at six weeks, and 37% said it should be allowed only in cases of rape and incest. Collectively, that’s 72% who supported a ban at 15 weeks or less.

In two subsequent polls, the support for abortion at 15 weeks or less was not as strong. A September Economist/YouGov poll found 39% of respondents supported a national ban on abortion after 15 weeks, and 46% opposed it. And a June Associated Press-NORC poll found that for abortion up to 15 weeks, 51% of respondents said they thought their state should allow it, while 45% thought their state should ban it.

Ron DeSantis: Democrats are “trying … to allow abortion all the way up to the moment of birth.”

This claim is false and misleads about how rarely abortions are performed later in pregnancy. Several other candidates repeated similar claims, saying Democrats such as President Joe Biden are pushing for proposals for “abortion on demand” up to the moment of birth.

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

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

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

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

Covid

Ron DeSantis: “In Florida, we led the country out of lockdown. We kept our state free and open.”

This is misleading. DeSantis revels in his record of snubbing public health recommendations to curb covid-19’s spread. But he largely omits the closures of schools and businesses that happened under his watch.

Seven states did not issue stay-at-home orders to their residents, but Florida did. On April 1, 2020, DeSantis issued an executive order directing all Florida residents to “limit their movements and personal interactions outside of their home.” The order expired at the end of the month, and Florida began a phased reopening in May.

Though he carved out an exception for religious services and some recreational activities, DeSantis didn’t exempt in-person classroom instruction. His Department of Education issued a March 13, 2020, recommendation that Florida schools close their facilities for an extended spring break and then lengthened the closure through the end of the school year in early June.

Schools reopened in person in August 2020.

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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WHIAANHPI Launches Effort to Demystify grants

The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

For the first time since 2004, it appears health insurance coverage will not be a central issue in the presidential campaign, at least judging from the first GOP candidate debate in Milwaukee Wednesday night. The eight candidates who shared the stage (not including absent front-runner Donald Trump) had major disagreements over how far to extend abortion restrictions, but there was not even a mention of the Affordable Care Act, which Republicans have tried unsuccessfully to repeal since it was passed in 2010.

Meanwhile, a new poll from KFF finds that health misinformation is not only rampant but that significant minorities of the public believe things that are false, such as that more people have died from the covid vaccine than from the covid-19 virus.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

Panelists Joanne Kenen Johns Hopkins Bloomberg School of Public Health and Politico @JoanneKenen Read Joanne's stories Victoria Knight Axios @victoriaregisk Read Victoria's stories Margot Sanger-Katz The New York Times @sangerkatz Read Margot's stories

Among the takeaways from this week’s episode:

• The first Republican presidential debate of the 2024 cycle included a spirited back-and-forth about abortion, but little else about health care — and that wasn’t a surprise. During the primary, Republican presidential candidates don’t really want to talk about health insurance and health care. It’s not a high priority for their base.
• The candidates were badly split on abortion between those who feel decisions should be left to the states and those who support a national ban of some sort. Former Vice President Mike Pence took a strong position favoring a national ban. The rest revealed some public disagreement over leaving the question completely to states to decide or advancing a uniform national policy.
• Earlier this summer, Stanford University’s Hoover Institute unveiled a new, conservative, free-market health care proposal. It is the latest sign that Republicans have moved past the idea of repealing and replacing Obamacare and have shifted to trying to calibrate and adjust it to make health insurance a more market-based system. The fact that such plans are more incremental makes them seem more possible. Republicans would still like to see things like association health plans and other “consumer-directed” insurance options. Focusing on health care cost transparency could also offer an opportunity for a bipartisan moment.
• In a lawsuit filed this week in U.S. District Court in Jacksonville, two Florida families allege their Medicaid coverage was terminated by the state without proper notice or opportunity to appeal. It seems to be the first such legal case to emerge since the Medicaid “unwinding” began in April. During covid, Medicaid beneficiaries did not have to go through any kind of renewal process. That protection has now ended. So far, the result is that an estimated 5 million people have lost their coverage, many because of paperwork issues, as states reassess the eligibility of everyone on their rolls. It seems likely that more pushback like this is to come.
• A new survey released by KFF this week on medical misinformation found that the pandemic seems to have accelerated the trend of people not trusting public health and other institutions. It’s not just health care. It’s a distrust of expertise. In addition, it showed that though there are people on both ends — the extremes — there is also a muddled middle.
• Legislation in Texas that was recently signed into law by Republican Gov. Greg Abbott hasn’t gotten a lot of notice. But maybe it should, because it softens some of the state’s anti-abortion restrictions. Its focus is on care for pregnant patients; it gives doctors some leeway to provide abortion when a patient’s water breaks too early and for ectopic pregnancies; and it was drafted without including the word “abortion.” It bears notice because it may offer a path for other states that have adopted strict bans and abortion limits to follow.

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

Julie Rovner: KFF Health News’ “Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials,” by Lauren Sausser.

Margot Sanger-Katz: KFF Health News’ “Life in a Rural ‘Ambulance Desert’ Means Sometimes Help Isn’t on the Way,” by Taylor Sisk.

Joanne Kenen: The Atlantic’s “A Simple Marketing Technique Could Make America Healthier,” by Lola Butcher.

Victoria Knight: The New York Times’ “The Next Frontier for Corporate Benefits: Menopause,” by Alisha Haridasani Gupta.

Also mentioned in this week’s episode:

• NPR’s “Two Families Sue Florida for Being Kicked off Medicaid in ‘Unwinding’ Process,” by Selena Simmons-Duffin
• NPR’s “Texas Has Quietly Changed Its Abortion Law,” by Selena Simmons-Duffin.
• KFF’s “Poll: Most Americans Encounter Health Misinformation, and Most Aren’t Sure Whether It’s True or False.”

Credits Francis Ying Audio producer Stephanie Stapleton Editor

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CMS announced today that the Medicare Shared Savings Program saved money for Medicare while continuing to support high-quality care.

UnitedHealthcare Pays $80,000 Settlement

As summer edges toward fall, thoughts turn to, well, vaccines.

Yes, inevitably, it’s time to think about the usual suspects — influenza and covid-19 shots — but also the new kid in town: recently approved vaccines for RSV, short for respiratory syncytial virus.

But who should get the various vaccines, and when?

“For the eligible populations, all three shots are highly recommended,” said Georges Benjamin, a physician and the executive director of the American Public Health Association.

Still, there’s no need to get them all at the same time, and there are reasons to wait a bit for two of them. Some people may also face cost issues. Let’s break this down.

What’s the Price?

It depends on the vaccine — and on your insurance coverage.

For covid shots, including the updated ones expected to be available this fall, most people will still be able to get the vaccines for free. People became accustomed to that no-cost availability during the pandemic, but the federal government stopped picking up the entire tab with the end of the public health emergency this spring.

Now the actual cost of the vaccine, which manufacturers said could be far higher than what the government paid during the pandemic, will be borne by private insurers and Medicare and Medicaid. For people without insurance, the Biden administration set up the Bridge Access Program, which will make free vaccines available this fall through community health centers and state health departments. Eventually, retail pharmacies may also participate.

Pfizer and Moderna, two of the companies producing updated covid vaccines, previously suggested they would charge $110 to $130 per dose, and plan to offer programs for people who cannot afford the vaccines. In July, the Biden administration urged both makers to set a “reasonable” rate for the updated versions. Another company, Novavax, has said it will also have an updated vaccine for the U.S. market. It is still unclear how prices will shake out. In a recent Moderna earnings call, company officials indicated they are negotiating contracts with payers but did not give per-dose figures. The company expects covid vaccine sales worldwide to tally $6 billion to $8 billion this year.

The Affordable Care Act says patients don’t have to pay for certain preventive care, including some vaccines. That means flu shots are offered at no cost to people with insurance, including those on Medicare and Medicaid. Those without insurance may be able to land a free or low-cost shot from some health centers and state health departments. The cost of the flu vaccine depends on the type of shot and the pharmacy or medical outlet providing it but can range from $20 to more than $70.

Similar rules apply to the new RSV vaccines, which may carry a price tag between $180 and $295 a shot. Because they are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, they are covered for people with private insurance without a copay. The Inflation Reduction Act did the same for Medicare beneficiaries and provided incentives for states to follow suit with Medicaid. Still, Medicare beneficiaries should note that the RSV vaccine is covered under Part D of the program, so those who have not signed up for the drug benefit may have to pay out-of-pocket.

It may take a while for insurers to list the RSV vaccine on their formularies, so patients are advised to check their health plans before making an appointment.

The uninsured, however, will need to turn to low-cost clinics or health departments, although those programs may vary.

Such lack of access “means we will have another health disparity for people who can’t afford it,” said Benjamin, of the public health association.

Luckily, most of those seeking the shot are likely to be on Medicare, which will cover it, he said. “But if you are 60 to 65 and not yet on Medicare, you might have some challenges.”

RSV Vaccines

The newest of the vaccines target RSV, a common respiratory illness. The season for RSV infections usually begins in the fall and lasts into the spring, potentially peaking in January and February.

The CDC estimates that 60,000 to 160,000 people 65 and older are hospitalized because of RSV annually, with approximately 6,000 to 10,000 deaths among that age group. Infants and older adults are most at risk.

Risk factors for having a more severe case include increased age, but also underlying conditions like lung diseases, cardiovascular problems like congestive heart failure, diabetes, and kidney and liver disorders, and being immunocompromised. The illness can also aggravate existing conditions such as asthma and chronic obstructive pulmonary disease.

The two new vaccines have been approved for older adults, with the CDC’s vaccine advisory panel saying people 60 or older should be able to get one of them if they and their doctor or other medical provider agree it would be a good precaution.

If you fall into those categories, don’t wait too long, said William Schaffner, a physician and professor of preventive medicine at Vanderbilt University. “That’s one you can do and get out of the way right now.”

Those who get one of the new RSV vaccines now should take a brief pause of at least two weeks before getting any other vaccination because there isn’t much data on whether they interact with other shots when received concurrently, he said.

The effectiveness of the RSV vaccines in preventing severe disease is expected to remain high through this year’s RSV season, and they may also provide some protection the following year, based on information from the clinical trials.

In early August a new monoclonal antibody, which contains lab-made antibodies against RSV, was approved for infants under 8 months and certain other young children, and it should be available soon. The shot is similar to a vaccine, but it works faster because it supplies the antibodies itself rather than spurring a baby’s immune system to produce them. Among children under 5, RSV causes 58,000 to 80,000 hospitalizations and 100 to 300 deaths each year, according to the CDC. On Monday, the FDA approved Pfizer’s RSV vaccine to be given during pregnancy to convey protection to infants after they are born until they are 6 months old. It isn’t yet known when the vaccine will become available or the specific recommendations the CDC will make about who should get it.

As with any drug or vaccine, side effects are possible with any of the new shots, including pain at the injection site, headache, fatigue, and some other, rarer side effects.

“It’s always good to sit down and talk with your doctor. They know your medical history,” said Mahdee Sobhanie, an infectious diseases physician at the Ohio State University Wexner Medical Center.

Covid and Influenza Vaccines

Both covid and flu shots are worth getting, but it might be a good idea to wait a little bit.

One reason is that updated covid shots awaiting approval are formulated to work against strains more commonly circulating now, known as the XBB lineage. The boosters will not directly target the new “Eris” variant currently rising in the U.S., though Eris is considered a descendant of XBB.

If approved, the updated vaccines are expected to become available around late September.

When to get vaccinated can be confusing, with the seasonality of the illnesses varying a bit. Flu season usually starts in late fall and runs into spring. We have fewer years’ data on covid, but it appears to vary with the seasons, too, with upticks in winter when people gather inside, but also during hot summer months, when people are more likely to seek air-conditioned indoor venues.

With the updated covid vaccines expected in the next couple of months, patients should be able to get a covid vaccination and an influenza shot at the same time, said Schaffner.

“We have good info they don’t interact,” he said.

The influenza vaccine is designed to last through the season, but effectiveness can wane. For that reason, even though you might start seeing ads in August, many experts suggest waiting until the end of September or early October to get a flu shot.

“If you get it too early, it might not cover you too well toward the end of the season,” Schaffner said.

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

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HOUSTON — Tonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child.

But, just five weeks after confirming her pregnancy, and the day after a gender-reveal party where she announced she was having a girl, she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain.

“I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.”

An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby, Tabitha Winnie Denkins.

Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates.

“This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.”

In fact, Harris County ranks third, behind only Chicago’s Cook County and Detroit’s Wayne County, in what are known as excess Black infant deaths, according to the federal Health Resources and Services Administration. Those three counties, which also are among the nation’s most populated counties, account for 7% of all Black births in the country and 9% of excess Black infant deaths, said Ashley Hirai, a senior scientist at HRSA. That means the counties have the largest number of Black births but also more deaths that would not occur if Black babies had the same chance of reaching their 1st birthdays as white infants.

No known genetic reasons exist for Black infants to die at higher rates than white infants. Such deaths are often called “deaths of disparity” because they are likely attributable to systemic racial disparities. Regardless of economic status or educational attainment, the stress from experiencing persistent systemic racism leads to adverse health consequences for Black women and their babies, according to a study published in the journal Women’s Health Issues.

These miscarriages and deaths can occur even in communities that otherwise appear to have vast health resources. In Harris County, for example, home to two public hospitals and the Texas Medical Center — the largest medical complex in the world, with more than 54 medical-related institutions and 21 hospitals — mortality rates were 11.1 per 1,000 births for Black infants from 2014 through 2019, according to the March of Dimes, compared with 4.7 for white infants.

The abundance of providers in Harris County hasn’t reassured pregnant Black patients that they can find care that is timely, appropriate, or culturally competent — care that acknowledges a person’s heritage, beliefs, and values during treatment.

Regardless of income or insurance status, studies show, medical providers often dismiss Black women’s questions and concerns, minimize their physical complaints, and fail to offer appropriate care. By contrast, a study of 1.8 million hospital births spanning 23 years in Florida found that the gap in mortality rates between Black and white newborns were halved for Black babies when Black physicians cared for them.

In 2013, Houstonian Kay Matthews was running a successful catering business when she lost the daughter she’d named Troya eight months and three weeks into pregnancy.

Matthews hadn’t felt well — she’d been sluggish and tired — for several days, but her doctor told her not to worry. Not long afterward, she woke up realizing something was terribly wrong. She passed out after calling 911. When she woke up, she was in the emergency room.

None of the medical staffers would talk to her, she said. She had no idea what was happening, no one was answering her questions, and she started having a panic attack.

“It kind of felt like I was watching myself lose everything,” she recalled. She said the nurse seemed annoyed with her questions and demeanor and gave her a sedative. “When I woke up, I did not have a baby.”

Matthews recalled one staffer insinuating that she and her partner couldn’t afford to pay the bill, even though she was a financially stable business owner, and he had a well-paying job as a truck driver.

She said hospital staffers showed minimal compassion after she lost Troya. They seemed to dismiss her grief, she said. It was the first time she could remember feeling as if she was treated callously because she is Black.

“There was no respect at all, like zero respect or compassion,” said Matthews, who has since founded the Shades of Blue Project, a Houston nonprofit focused on improving maternal mental health, primarily for Black patients.

To help combat these high mortality rates in Harris County, Robinson created a maternal child and health office and launched a home-visit pilot program to connect prenatal and postpartum patients with resources such as housing assistance, medical care, and social services. Limited access to healthy food and recreational activities are barriers to healthy pregnancy outcomes. Studies have also shown a connection between evictions and infant mortality.

For Hill, not having insurance was also likely a factor. While pregnant, Hill said, she had had just a single visit at a community health center before her miscarriage. She was working multiple jobs as a college student and did not have employer-provided medical coverage. She was not yet approved for Medicaid, the state-federal program for people with low incomes or disabilities.

Texas has the nation’s highest uninsured rate, with nearly 5 million Texans — or 20% of those younger than 65 — lacking coverage, said Anne Dunkelberg, a senior fellow with Every Texan, a nonprofit research and advocacy institute focused on equity in public policy. While non-Hispanic Black Texans have a slightly better rate — 17% — than that overall state level, it’s still higher than the 12% rate for non-Hispanic white Texans, according to census data. Health experts fear that many more people are losing insurance coverage as covid-19 pandemic protections end for Medicaid.

Without full coverage, those who are pregnant may avoid seeking care, meaning they skip being seen in the critical first trimester, said Fatimah Lalani, medical director at Houston’s Hope Clinic.

Texas had the lowest percentage of mothers receiving early prenatal care in the nation in 2020, according to the state’s 2021 Healthy Texas Mothers and Babies Databook, and non-Hispanic Black moms and babies were less likely to receive first-trimester care than other racial and ethnic groups. Babies born without prenatal care were three times as likely to have a low birth weight and five times as likely to die as those whose mothers had care.

If Hill’s miscarriage reflects how the system failed her, the birth of her twins two years later demonstrates how appropriate support has the potential to change outcomes.

With Medicaid coverage from the beginning of her second pregnancy, Hill saw a high-risk pregnancy specialist. Diagnosed early with what’s called an incompetent cervix, Hill was consistently seen, monitored, and treated. She also was put on bed rest for her entire pregnancy.

She had an emergency cesarean section at 34 weeks, and both babies spent two weeks in neonatal intensive care. Today, her premature twins are 3 years old.

“I believe God — and the high-risk doctor — saved my twins,” she said.

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

USE OUR CONTENT

This story can be republished for free (details).