This spring, a few days after his 2nd birthday, Brigland Pfeffer was playing with his siblings in their San Diego backyard.

His mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and came running from the stone firepit, holding his right hand. She noticed a pinprick of blood between his thumb and forefinger when her older son called out, “Snake!”

“I saw a small rattlesnake coiled up by the firepit,” she said.

Pfeffer called 911, and an ambulance transported Brigland to Palomar Medical Center Escondido.

The Medical Procedure

When they arrived, Brigland’s hand was swollen and purple.

Antivenom, an antibody therapy that disables certain toxins, is usually administered via an intravenous line, directly into the bloodstream. But emergency room staffers struggled to insert the IV.

“They had so many people in that room trying his head, his neck, his feet, his arms — like, everything to find a vein,” Pfeffer said.

Still unable to start the antivenom, a doctor asked for her permission to try drastic measures. “Just get something going,” she recalled pleading.

It worked. Using a procedure that delivers medicine into the bone marrow, the medical team gave Brigland a starting dose of the antivenom Anavip.

He was transferred to the pediatric intensive care unit at Rady Children’s Hospital, where he received more Anavip.

The swelling that had spread to his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.

Then the bills came.

The Final Bill

$297,461, which included two ambulance rides, an emergency room visit, and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.

The Billing Problem: The High Cost of Antivenom

The Centers for Disease Control and Prevention estimates venomous snakes bite 7,000 to 8,000 people in the United States every year. About five people die. That number would be higher, the agency says, if not for medical treatment.

Many snakebites happen far from medical care, and not all emergency rooms keep costly antivenom in stock, which can add big ambulance bills to already expensive care.

It often takes more than a dozen vials, typically costing thousands per vial, to treat a snakebite. The median number per patient is 18 vials, said Michelle Ruha, an emergency room doctor in Arizona and a former president of the American College of Medical Toxicology.

Manufacturing, which hasn’t fundamentally changed since antivenom was developed more than a century ago, does not explain the high price. Venomous creatures are milked, then a small, non-harmful amount of toxin is injected into animals like horses or sheep. Antibodies are extracted from their blood and processed to make antivenom.

Why the high price? One explanation is that hospitals mark up products to balance overhead costs and generate revenue.

Brigland received Anavip at two hospitals that charged different prices.

Palomar, where emergency staffers treated Brigland, charged $9,574.60 per vial, for a total of $95,746 for the starting dose of 10 vials of Anavip.

Rady, the largest children’s hospital on the West Coast, charged $5,876.64 for each vial. For the 20 vials Brigland received there, the total was $117,532.80.

Neither hospital responded to requests for comment.

Those charges are “eye-popping,” said Stacie Dusetzina, who is a professor of health policy at Vanderbilt University Medical Center and reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost.”

For instance, Medicare — the government program for those who are at least 65 or disabled — pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that is the price hospitals pay for it.

Leslie Boyer, a doctor and toxicology researcher, helped found a group that was instrumental in developing Anavip, as well as the other available snake antivenom, CroFab, which dominated the market for decades. In 2015, she published an editorial in the American Journal of Medicine breaking down the “true” cost of antivenom. (Boyer declined to comment for this article.)

Using cost data collected from factory supervisors, animal managers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antivenom, at a final cost of $14,624 per vial. She found the cost of venom, included in that total, was just 2 cents. Manufacturing accounted for $9 of the $14,624 total.

More than 70% of the price tag — $10,250 — is attributable to hospital markups, her research showed.

Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.

Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price later rose to cover the manufacturers’ millions of dollars in legal costs.

The Resolution

The insurer covering Brigland — Sharp Health Plan, which did not respond to requests for comment — negotiated down the antivenom charges by tens of thousands of dollars.

The cost was mostly covered by insurance. Brigland’s family paid $7,200, their plan’s out-of-pocket maximum.

Insurance did not pay all the claims, including one ambulance bill. Pfeffer said she received a letter this summer indicating they owe an additional $11,300 for Brigland’s care. While the landmark No Surprises Act protects patients from many out-of-network bills in emergencies, the law controversially exempted bills for ground ambulances.

Brigland’s hand healed, though nerve damage and scar tissue have left his right thumb less dexterous. He is now left-handed.

“He’s very, very lucky,” Pfeffer said.

The family has since installed snake fencing around the yard.

The Takeaway

There’s a saying in toxicology: Time is tissue. If bitten by a snake, “get to medical care,” Ruha said.

Not all emergency rooms have antivenom, and there are no online resources identifying which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom in stock than free-standing emergency rooms.

When the bill comes, be ready to negotiate, Dusetzina said. Providers know their charges are high and may be willing to take less.

You can compare the charges against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.

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

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Exactech, a Florida device manufacturer that faces more than 2,000 state and federal lawsuits from patients who allege the company sold defective hip and knee implants, filed for bankruptcy protection Tuesday.

The Gainesville-based company said in a statement it was restructuring and would be sold to an investor group of private equity and “alternative asset” firms, which would provide about $85 million in financing to fund the company’s operations.

Darin Johnson, Exactech’s president and chief executive officer, said in the statement that the device company faces “unsustainable liabilities associated with knee and hip litigation related to the packaging recalls we voluntarily initiated between 2021 and 2022.” The company said it would continue to operate during the bankruptcy proceedings.

“We take our commitment to patient well-being very seriously and have provided substantial out-of-pocket patient reimbursements and surgeon support for related expenses,” Johnson said.

The bankruptcy proceedings in federal court in Delaware will pause the lawsuits from patients seeking damages.

The surprise action dismayed lawyers representing injured patients.

“Exactech’s bankruptcy filing is a slap in the face to all the joint-implant patients and doctors who trusted the company. A medical device company that sells products for implantation in the human body has a special responsibility for public health,” said Joe Saunders, a Florida attorney who has sued the company on behalf of injured patients.

Saunders said the bankruptcy “serves to cover up public disclosure of the company putting profits ahead of safety.”

Injured patients were expecting one of the first jury trials against the company to begin in December in the circuit court in Alachua County, Florida. But the bankruptcy filing “stops the public trial and conceals the truth about the company’s conduct,” Saunders said.

Exactech, which grew over three decades from a small device manufacturer into a global entity, was the subject of a KFF Health News investigation published in October 2023.

The investigation found that, in hundreds of instances, the company took years to report adverse events to a federal database that tracks device failures.

Many of the lawsuits allege that the company’s knee and hip implants had an “unacceptable failure and complication rate.” Exactech has denied the allegations, and the company had no comment on the lawsuits.

Exactech began a series of recalls of artificial knees, hips, and ankles, starting in August 2021. Exactech initially blamed a packaging defect dating back as far as 2004 for possibly causing the plastic component to wear out prematurely in about 140,000 implants.

The KFF Health News analysis of more than 300 pending cases in Alachua County found that surgeons removed about 200 implants after less than seven years, far sooner than the 15 to 20 years these products typically last.

“I’m so angry. How did they [Exactech] think they are not responsible for this?” said Sue Sacher, 76, a New Jersey resident. She said she had her right knee replaced with an Exactech implant in 2006 and the left one done three years later, both at the Hospital for Special Surgery in New York.

Since then, she’s had both implants replaced.

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Hurricane Helene, which struck North Carolina last month, wrecked a Baxter International factory that produced 60 percent of the country’s IV fluids, according to the American Hospital Association. The company is rationing its products, and some hospitals have delayed or canceled surgeries that require large amounts of IV hydration.

Among the worst-hit patients are those who rely on parenteral nutrition — IV liquids containing amino acids, lipids, sugars, vitamins and electrolytes. These patients often get the fluid through a port connected to a vein near their heart because they can’t digest food through the intestines due to conditions ranging from autoimmune diseases to cancer.

In addition, two weeks after the hurricane hit, CVS Health, which owns one of the biggest home infusion pharmacies in the country — a subsidiary called Coram — began warning patients that it was getting out of the parenteral nutrition business.

With Baxter providing limited supplies of IV fluid to the remaining infusion pharmacies, many Coram patients are starting to run out of supplies. For some, hospitalization is the only answer.

We caught up with Lisa Trumble, a 52-year-old Pittsfield, Massachusetts, grandmother who was slammed by this double whammy. After entering Berkshire Medical Center with a respiratory illness on Oct. 1, she was ready to be discharged Oct. 9. But then Coram alerted her doctor that it could no longer supply her with home IV nutrition.

“I was dropped between Tuesday night and Wednesday morning with no care for my life or my health,” Trumble told me by phone after another week in the hospital.

Although another supplier stepped up for Trumble a few days after we talked, she isn’t the only one facing critical problems. Several IV nutrition patients we spoke with said they were running low on supplies and worried about getting sick. A couple of days without electrolytes can make you ill. Without sufficient carbohydrates, you starve. Some patients say they’ve had trouble getting enough of the special syringes and tubing needed to administer their fluids since the hurricane.

Even before the Baxter and Coram troubles, pharmacies were suffering shortages and low reimbursement rates. They have barely been able to care for existing patients, and the Baxter rationing left them no way to take new ones dropped by Coram, said David Seres, director of medical nutrition at Columbia University Medical Center in New York.

The Biden administration has triggered the Defense Production Act, under which it can commandeer supplies and labor to get the Baxter plant running at full speed again. Meanwhile, the FDA is allowing emergency imports of IV fluids wiped out by Helene as well as production of some of the fluids by U.S. compounding pharmacies.

But it’s unclear how long it will take to replenish supplies, said Manpreet Mundi, a Mayo Clinic endocrinologist who is a board member of the American Society for Parenteral and Enteral Nutrition. “We’re trying to raise awareness that this could get worse before it gets better,” he said.

Baxter says on its website that, “barring any unanticipated developments,” it expects to restart “the highest-throughput IV solutions manufacturing line” this week.

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When open enrollment for the Affordable Care Act, or Obamacare, starts nationwide this week, a group that had previously been barred from signing up will be eligible for the first time: The “Dreamers.” That’s the name given to children brought to the United States without immigration paperwork who have since qualified for the Deferred Action for Childhood Arrivals program.

Under a Biden administration rule that has become contentious in some states, DACA recipients will be able to enroll in — and, if their income qualifies, receive premium subsidies for — Obamacare coverage. The government estimates that about 100,000 previously uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, which is the sign-up season start date in all states except Idaho.

Yet the fate of the rule remains uncertain. It is being challenged in federal court by Kansas and 18 other states, including several in the South and Midwest, as well as Montana, New Hampshire, and North Dakota.

Separately, 19 states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many on the East and West coasts, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

The rule, finalized in May, clarifies that those who qualify for DACA will be considered “lawfully present” for the purpose of enrolling in plans under the ACA, which are open to American citizens and lawfully present immigrants.

“The rule change is super important as it corrects a long-standing and erroneous exclusion of DACA recipients from ACA coverage,” said Nicholas Espíritu, a deputy legal director for the National Immigration Law Center, which has also filed briefs in support of the government rule.

President Barack Obama established DACA in June 2012 by executive action to protect from deportation and provide work authorization to some unauthorized residents brought to the U.S. as children by their families if they met certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were a veteran.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The lawsuit, filed in August in U.S. District Court for the District of North Dakota, seeks to postpone the rule’s effective date and overturn it, saying the expansion of the “lawfully present” definition by the Biden administration violates the law.

On Oct. 15, U.S. District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, heard arguments in the case.

Plaintiff states are pushing for fast action, and it is possible a ruling will come in the days before open enrollment begins nationwide in November, said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

But the outlook is complicated.

For starters, in a legal battle like this, those who file a case must demonstrate the harm being alleged, such as additional costs the rule will force the states to absorb. There are only about 128 DACA recipients in North Dakota, where the case is being heard, and not all of them are likely to enroll in ACA insurance.

Furthermore, North Dakota is not among the states that run their own enrollment marketplace. It relies on the federal healthcare.gov site, which makes the legal burden harder to meet.

“Even though North Dakota does not pay any money to purchase ACA health care, they are still claiming somehow that they are harmed,” said Espíritu, at the immigration law center, which is representing several DACA recipients and CASA, a nonprofit immigrant advocacy group, in opposing the state efforts to overturn the rule.

During the hearing, Traynor focused on this issue and noted that a state running its own marketplace might be a better venue for such a case. He ordered the defendants to present more information by Oct. 29 and for North Dakota to respond by Nov. 12.

On Monday, the judge denied a motion from the federal government asking him to reconsider his order requiring it to provide the state with the names of 128 DACA recipients who live there, under seal, for the purpose of helping calculate any financial costs associated with their presence.

In addition, it’s possible the case will be transferred to another district court, but that could lead to delays in a decision, attorneys following the case said.

The judge also could take a number of directions in his decision. He could postpone the rule’s effective date, as requested in part of the lawsuit, preventing DACA recipients from enrolling in Obamacare while the case is decided. Or he could leave the effective date as it stands while the case proceeds.

With any decision, the judge could decide to apply the ruling nationally or limit it to just the states that challenged the government rule, Baron said.

“The approach taken by different judges has varied,” Baron said. “There has been a practice to vacate some regulatory provisions nationwide, but a lot of judges, including justices on the Supreme Court, also have cited concerns about individual judges being able to affect policy this way.”

Even as the case moves along, Espíritu said his organization is encouraging DACA recipients to enroll once the sign-up period begins nationally in November.

“It’s important to enroll as soon as possible,” he said, adding that organizations such as his will continue to monitor the case and give updates if the situation changes. “We know that getting access to good affordable health care can be transformative to people’s lives.”

This case challenging the rule is wholly separate from another case, brought by some of the same states as those opposed to the ACA rule, seeking to entirely end the DACA program. That case is currently in the appeals process in federal court.

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Cuando comience el período de inscripción abierta para adquirir cobertura médica en los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio, conocida como Obamacare, un grupo que antes no podía inscribirse será elegible por primera vez: los “Dreamers”. Ese es el nombre de los niños traídos a los Estados Unidos sin papeles que están bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA).

Bajo una normativa de la administración Biden, que ha sido objeto de controversia en algunos estados, los beneficiarios de DACA podrán inscribirse para la cobertura del Obamacare y, si cumplen con los requisitos de ingresos, recibir subsidios para pagar sus primas.

Del medio millón de beneficiarios de DACA, el gobierno estima que alrededor de 100.000 que anteriormente no tenían seguro podrían inscribirse a partir del 1 de noviembre, fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

Sin embargo, el destino de esta normativa sigue siendo incierto. Está siendo impugnada en un tribunal federal por Kansas y otros 18 estados, incluidos varios en el sur y el medio oeste, así como Montana, New Hampshire y Dakota del Norte.

Por otro lado, 19 estados y el Distrito de Columbia presentaron un escrito en apoyo a la normativa de la administración de Biden. Liderados por Nueva Jersey, estos estados incluyen a muchos en las costas este y oeste, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

La normativa, finalizada en mayo, aclara que aquellos que califican para DACA serán considerados como “presencia legal” para el propósito de inscribirse en lo planes médicos bao ACA, los cuales están abiertos a ciudadanos estadounidenses e inmigrantes con papeles.

“El cambio de normativa es muy importante, ya que corrige una exclusión errónea y de larga data de los beneficiarios de DACA para la cobertura de ACA,” dijo Nicholas Espíritu, director legal adjunto del National Immigration Law Center, que también ha presentado escritos en apoyo a este cambio.

El presidente Barack Obama estableció DACA en junio de 2012 mediante una acción ejecutiva para proteger de la deportación y proporcionar autorización de trabajo a algunos residentes sin documentos, que habían sido traídos al país de niños por sus familias. Esto si cumplían con ciertos requisitos, incluidos haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o haber servido en las fuerzas armadas.

Los estados que impugnan la normativa de ACA dicen que causará cargas administrativas y de recursos a medida que más personas se inscriban, y que fomentará que más personas permanezcan en el país sin papeles. La demanda, presentada en agosto en el Tribunal de Distrito de EE.UU. para el Distrito de Dakota del Norte, busca posponer la fecha de entrada en vigencia de la normativa y anularla, argumentando que la expansión de la definición de “presencia legal” por parte de la administración Biden viola la ley.

El 15 de octubre, el juez de distrito de EE.UU., Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, escuchó los argumentos en el caso.

Los estados demandantes están presionando para que se actúe rápido, y es posible que se emita un fallo antes del inicio de la inscripción abierta a nivel nacional, dijo Zachary Baron, experto legal en la Facultad de Derecho de Georgetown, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Sin embargo, el panorama es complicado.

Para empezar, en una batalla legal como ésta, quienes presentan el caso deben demostrar el daño que se alega, como los costos adicionales que la normativa obligará a los estados a absorber. Solo hay alrededor de 128 beneficiarios de DACA en Dakota del Norte, donde se está llevando a cabo el caso, y no todos probablemente se inscribirán en el seguro de ACA.

Además, Dakota del Norte no se encuentra entre los estados que administran su propio mercado de inscripción. Depende del sitio federal cuidadodesalud.gov, lo que hace que sea más difícil cumplir con la carga legal.

“Aunque Dakota del Norte no gasta dinero para adquirir atención médica de ACA, aún están afirmando de alguna manera que están siendo perjudicados,” dijo Espíritu, del centro de leyes de inmigración, que representa a varios beneficiarios de DACA y a CASA, una organización sin fines de lucro de defensa de los inmigrantes, en oposición a los esfuerzos estatales por anular la normativa.

Durante la audiencia, Traynor se centró en este tema y señaló que un estado que administre su propio mercado podría ser un mejor lugar para un caso así. Ordenó a los demandados presentar más información antes del 29 de octubre, y a Dakota del Norte responder antes del 12 de noviembre.

El lunes 28 de octubre, el juez denegó una moción del gobierno federal que le solicitaba reconsiderar su orden de proporcionar al estado, bajo sello, los nombres de 128 beneficiarios de DACA que residen allí, con el fin de ayudar a calcular los costos financieros asociados con su presencia.

Además, es posible que el caso sea transferido a otro tribunal de distrito, lo que podría causar demoras en una decisión, según los abogados que siguen el caso.

El juez también podría tomar decidir en varias direcciones. Podría posponer la fecha de vigencia de la normativa, como se solicita en parte de la demanda, impidiendo que los beneficiarios de DACA se inscriban en Obamacare mientras se resuelve el caso. O podría dejar la fecha de vigencia tal como está mientras el caso avanza.

Con cualquiera de las opciones, el juez podría decidir aplicar el fallo a nivel nacional o limitarlo solo a los estados que impugnaron la normativa gubernamental, explicó Baron.

“El enfoque adoptado por diferentes jueces ha variado”, dijo Baron. “Ha habido una práctica de anular algunas disposiciones reglamentarias a nivel nacional, pero muchos jueces, incluidos jueces de la Corte Suprema, también han expresado preocupaciones sobre que jueces individuales puedan afectar la política de esta manera”.

A medida que el caso avanza, Espíritu dijo que su organización está alentando a los beneficiarios de DACA a inscribirse apenas comience el período de inscripción a nivel nacional.

“Es importante inscribirse lo antes posible”, dijo, agregando que organizaciones como la suya continuarán monitoreando el caso y dando actualizaciones si la situación cambia. “Sabemos que obtener acceso a atención médica buena y asequible puede transformar la vida de las personas”.

Este caso que impugna la normativa es completamente separado de otro caso, presentado por algunos de los mismos estados que se oponen a la normativa de ACA, que busca terminar por completo el programa DACA. Ese caso actualmente está en el proceso de apelación en un tribunal federal.

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“We’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”

Sen. JD Vance (R-Ohio) during a Sept. 17 rally

During a recent presidential campaign rally in Wisconsin, Sen. JD Vance (R-Ohio) was asked how a Trump administration would protect rural health care access in the face of hospital closures, such as two this year in Eau Claire and Chippewa Falls.

In response, he turned to immigration.

“Now, you might not think that rural health care access is an immigration issue,” said Vance, former President Donald Trump’s running mate. “I guarantee it is an immigration issue, because we’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”

More than 150 rural hospitals have closed or eliminated inpatient services since 2010, researchers at the University of North Carolina-Chapel Hill reported. Losing a hospital can resonate throughout a community — reducing access to timely care and disrupting the local economy.

The federal government has made efforts to keep the far-flung facilities afloat, but it’s not been an easy problem to solve.

What Is Plaguing Rural Hospitals?

Experts said Vance’s statement implies that immigrants who are in the country illegally strain the resources of these hospitals, which often operate on thin margins, by taking time and energy away from other patients without paying their bills.

We contacted both Vance and Trump campaign staff members for additional information. They did not respond.

Experts on hospital financing and industry representatives generally disagreed with Vance’s assertion, noting that many other factors figure in closures.

“When we speak with our rural hospital members, that is not what we hear,” said Shannon Wu, director of payment policy at the American Hospital Association, a trade group of more than 5,000 hospitals around the country.

Brock Slabach, chief operating officer of the National Rural Health Association, said border state hospitals face challenges treating immigrants who are in the country illegally. “But I’ve never, in my discussions, had anyone link it directly to a hospital closure,” he said.

The specific situations that lead a rural hospital to close its doors are unique to each facility, researchers said, but many face some of the same stressors.

Rural hospitals tend to have low patient volumes, which presents its own set of problems. They’re frequently located in small communities, and some residents may choose to travel to hospitals in bigger cities where they can get more complex care, what researchers call “hospital bypass.”

That small number of patients can cause financial losses at small rural hospitals, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a national health care payment and delivery systems policy center.

Hospitals have fixed costs, such as for running emergency departments, and need to have a high enough patient volume to cover them, he said.

“If a patient comes into the ED and doesn’t have insurance or can’t pay, it doesn’t really increase the cost to the hospital very much at all because the physician is already there,” he said, using an abbreviation for emergency department.

Rural hospitals treat a higher share of patients covered by Medicare and Medicaid compared with urban hospitals, according to the American Medical Association. The public insurance programs for older and low-income Americans generally pay providers less than private insurers do.

Nevertheless, Medicare is “one of the better payers” for small rural hospitals, Miller said. That’s partly because facilities with a special “critical access hospital” designation get paid more by Medicare — and, in some states, Medicaid.

Hospital industry officials and some experts say Medicare Advantage plans’ rising popularity has also hurt rural hospitals’ bottom lines because the private insurance companies that offer the plans tend to be less reliable payers than traditional Medicare.

For starters, the negotiated rates paid by Advantage plans can be lower, which is especially noticeable for those critical access facilities. Advantage plans also introduce extra levels of expensive, staff-intensive administrative burdens to ensure payment.

“They’ll deny the claim or say the patient really didn’t need that service through prior authorization, and so the hospitals don’t get paid for the service from someone who has insurance,” Miller said.

The insurance industry trade group AHIP pushed back on the assertion that Medicare Advantage plans harm rural hospitals, citing a federally supported study saying the plans actually increase rural hospital financial stability.

But the study did not compare actual payments between Medicare Advantage and traditional Medicare plans and looked at only 14 states.

People lacking legal immigration status generally cannot obtain Medicaid or Medicare coverage. But a provision within Medicaid law does allow some immigrants in the country illegally to temporarily obtain coverage, said Hayden Dublois, data and analytics director for the think tank Foundation for Government Accountability.

Medicaid, which pays less than Medicare and private insurance, “is not exactly a financial boon for hospitals,” and this could be some of what Vance is referring to, Dublois said.

In data from a few states, Dublois found a rise in people enrolling in Medicaid without being able to verify their immigration status. But his research hasn’t looked specifically at how this population might affect rural hospitals’ financial viability.

Some states have acted in recent years to expand health coverage to people in the country illegally — offering insurance to more than 1 million low-income immigrants.

One of those states, California, has had nine hospitals close or end in-patient services since 2005.

People may be able to pay out-of-pocket for care, researchers said, or may have access to private insurance through an employer.

Covering the costs for the uninsured is only one financial stressor rural hospitals face, said George Pink, deputy director of the North Carolina Rural Health Research Program.

“Is that going to be enough to drive a hospital into bankruptcy? Probably not,” he said.

A financial decline can take years, Pink said. As losses mount, hospitals can be forced to sell property or other assets, draw down any financial reserves, and max out their credit.

“This is not an overnight phenomenon,” he said.

Our Ruling

Vance said providing care for immigrants without legal status was “bankrupting” rural hospitals and forcing them to close.

Although that population is more likely to be uninsured, living in the country illegally does not mean people lack the ability to pay for health care — especially if they live in states that offer them insurance coverage.

Research shows many factors contribute to rural hospital closures — not solely financial losses from providing care for those without insurance, whether those people are migrants in the country illegally or U.S. citizens.

We rate Vance’s statement False. 

Our sources:

PBS NewsHour, “WATCH LIVE: Vance Addresses Campaign Rally in Eau Claire, WI,” Sept. 17, 2024.

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Zoom interview, Brock Slabach, chief operating officer, National Rural Health Association, Oct. 1, 2024.

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Zoom and email interview, Hayden Dublois, data and analytics director, the Foundation for Government Accountability, Oct. 1, 2024.

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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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En una sofocante tarde de julio de 2020, Belinda Ramones recibió una llamada informándole que su hermano estaba en el hospital. La llamada fue de una mujer de la empresa de jardinería en Florida en donde había comenzado a trabajar esa semana, la empresa Davey Tree Expert Co. Cuando llegó, “mi hermano estaba hinchado de pies a cabeza”, dijo.

Dos días después, su hermano, José Leandro-Barrera, murió a los 45 años por una insuficiencia renal aguda causada por un golpe de calor, según el informe del médico forense del condado de Hillsborough. Su temperatura en la ambulancia había sido a 108 grados Fahrenheit (42 °C), según el informe.

El informe también describía las circunstancias previas a su muerte, según lo registrado por una enfermera. En el trabajo, Leandro-Barrera le informó a su supervisor que no se sentía bien, y el supervisor le dijo que se sentara en uno de los vehículos hasta que se sintiera mejor. Mientras estaba allí, “se orinó, tuvo actividad convulsiva” y perdió la conciencia.

“El empleado sufrió agotamiento por calor mientras hacía trabajo de jardinería”, indicó una investigación del incidente realizada por la Administración de Seguridad y Salud Ocupacional (OSHA). La agencia impuso una multa de $9,639 a la empresa Davey Tree Expert Co. La empresa no respondió a las solicitudes de comentarios.

Sin regulaciones nacionales sobre la prevención de enfermedades y muertes relacionadas con el calor, OSHA tiene dificultades, en general, para proteger a los trabajadores antes de que sea demasiado tarde, dijo Paloma Rentería, vocera del Departamento de Trabajo.

Los trabajadores están sufriendo cada vez más, a medida que los veranos se vuelven progresivamente más calurosos debido al cambio climático.

Pero los investigadores en políticas de salud y salud ocupacional afirman que estas muertes se pueden prevenir. Los empleadores pueden salvar vidas ofreciendo suficiente agua y descansos, y dándoles tiempo a los nuevos trabajadores para adaptarse al calor extremo.

Esta es la lógica detrás de las reglas nacionales propuestas que el presidente Joe Biden puso en marcha en 2021, con el objetivo de proteger a unos 36 millones de trabajadores expuestos al calor extremo. La Oficina de Estadísticas Laborales cuenta un promedio de 480 muertes de trabajadores por exposición al calor cada año. Sin embargo, estas son “vastas subestimaciones”, según OSHA, ya que el estrés térmico es un factor subyacente que generalmente no se registra en los informes médicos.

La organización de defensa Public Citizen estima que hasta 2.000 trabajadores en el país mueren por el calor cada año, según extrapolaciones de datos sobre lesiones por calor.

Ambas estimaciones son alarmantes, dijo Linda McCauley, decana de la Facultad de Enfermería de la Universidad de Emory e investigadora en salud ocupacional. “Nadie debería ir a trabajar esperando que podría morir”, dijo.

Las normas propuestas —un estándar de calor de OSHA— alcanzarán un hito el 30 de diciembre, cuando cierra el período de comentarios públicos. Pero es poco probable que se finalicen antes de que Biden deje el cargo.

La vicepresidenta Kamala Harris probablemente continuaría con las normas sobre el calor si gana la presidencia el próximo mes, dijo Jordan Barab, quien fue subsecretario adjunto de OSHA durante la administración Obama. Ella impulsó regulaciones sobre el calor en California en 2020.

Si Donald Trump gana, las normas se estancarían, predice Barab. En general, los republicanos se han opuesto a regulaciones de seguridad en el lugar de trabajo en los últimos 20 años, argumentando que son costosas para las empresas y los consumidores.

Y durante la primera administración de Trump, la cantidad de inspectores de OSHA encargados de monitorear la seguridad en el trabajo alcanzó un mínimo histórico en los 48 años de historia de la agencia. Las inspecciones de lugares de trabajo relacionadas con el estrés térmico se redujeron a la mitad durante el mandato de Trump, según un análisis del National employment Law Project.

Las normas de OSHA requerirían que los empleadores proporcionen agua potable fresca en abundancia y sombra o aire acondicionado para los descansos cuando las temperaturas superen los 80.6° Fahrenheit (27° C). Por encima de los 89.6° Fahrenheit (32° C), los empleadores tendrían que ofrecer descansos pagados de 15 minutos cada dos horas.

Dos aspectos adicionales del estándar abordan problemas que han sido pasados por alto y que contribuyen a las muertes por calor en el trabajo. Más del 70% de las muertes por el calor ocurren durante la primera semana en que el trabajador comienza en el empleo. Y el atraso en la atención médica es un tema común.

“Debemos dejar de decirle a las personas que se quejan de sentirse a punto de desmayarse que vayan a sentarse en el auto o que tomen un descanso”, dijo McCauley. “Los descansos son necesarios para prevenir el problema, pero una vez que alguien tiene síntomas, necesita ayuda rápida”.

Las normas propuestas requieren que los empleadores permitan a los nuevos trabajadores tiempo para aclimatarse a las altas temperaturas e implementen protocolos, como un sistema para ayudarse entre compañeros, para que los trabajadores reciban atención médica rápidamente tan pronto como muestren signos de enfermedad por calor, como mareos, confusión y calambres.

Para cuando un equipo médico de emergencia llegó a ayudar a un trabajador en julio de 2021, había dejado de respirar, según un comunicado de prensa del Departamento de Trabajo. Un supervisor en la empresa de restauración ecológica EarthBalance lo había visto más temprano ese día, y estaba “sudando mucho, sus manos temblaban y parecía confundido”. Descansó. “Solo 30 minutos después, el supervisor regresó y lo encontró inconsciente”.

Esa noche, Gilberto Macario-Giménez murió en el hospital, dijo un informe del caso del médico forense. Señaló que “el fallecido se había sobrecalentado” y atribuyó su muerte a una enfermedad cardíaca e hipertensión. El calor puede agravar esas condiciones.

OSHA investigó la situación. Multó a EarthBalance con $9,216, encontrando que “el empleador no garantizó que una persona adecuadamente capacitada para brindar primeros auxilios a los empleados estuviera trabajando en un área donde no había enfermería”.

EarthBalance no respondió a las solicitudes de comentarios.

OSHA ha recibido al menos 12.980 comentarios sobre sus propuestas publicadas en el registro federal. Una mujer escribió sobre su primo que murió mientras despejaba arbustos en un rancho en Texas cuando las temperaturas superaron los 100° Fahrenheit (37° C): “Tenía solo 34 años. No había agua ni descansos”.

Después que termine el período de comentarios en diciembre, OSHA realizará una audiencia pública, incluirá cambios y finalizará la regla. Si Harris es presidenta, dijo Barab, la agencia podría finalizar el proceso para 2026.

Para que la norma funcione, el Congreso necesitaría financiar adecuadamente a OSHA, para que pueda contratar personal que enseñe a los empleadores cómo implementar los estándares, y suficientes investigadores para hacer cumplir las normas.

Varios grupos de la industria se han opuesto al estándar. Un único conjunto de normas no es justo cuando los climas y trabajos varían ampliamente, además de la capacidad de los trabajadores para tolerar el calor, escribió la Associated General Contractors of America en una declaración en línea.

Algunos legisladores republicanos han llamado a la norma una extra limitación del gobierno. Rick Roth, representante republicano del estado de Florida, dijo a Al Jazeera que los trabajadores están presionando por descansos pagados porque “no quieren trabajar tan duro”. Si no se sienten seguros, podrían cambiar de trabajo. “Vayan a trabajar para otra persona”, dijo.

Los críticos también dicen que las regulaciones costarán a los empleadores. Pero un análisis de UCLA de los reclamos de compensaciones de trabajadores en California sugiere que un estándar nacional sobre el calor ahorraría dinero en general. El estudio estimó el costo de las lesiones relacionadas con el calor entre $750 millones y $1,25 mil millones anuales solo en California, incluidos gastos médicos, pérdida de salarios y reclamos por discapacidad.

Dado que seis estados tienen conjuntos de reglas variables para reducir las enfermedades relacionadas con el calor —California, Colorado, Maryland, Minnesota, Oregon y Washington—, los investigadores y representantes sindicales han podido ver dónde necesitan fortalecerse las políticas.

Un problema con la aplicación es que OSHA depende en gran medida de que los empleados reporten riesgos. Un estudio encontró que solo el 14% de casi 600 trabajadores agrícolas encuestados en California sabían sobre el período de aclimatación y cuánta agua necesitaban cuando las temperaturas eran altas.

Aunque Florida no tiene regulaciones específicas sobre el calor, Dominique O’Connor, de la Asociación de Trabajadores Agrícolas de Florida, dijo que el mayor obstáculo para garantizar la seguridad ocupacional es que los trabajadores tienen miedo de que los despidan por presentar una queja ante OSHA.

Esto es especialmente cierto para los trabajadores agrícolas con visas H-2A, que permiten a los no ciudadanos cubrir trabajos temporales. Debido a que estos trabajadores dependen de sus empleadores no solo para permanecer en el país, sino a menudo también para transporte y vivienda, las represalias de los empleadores serían un cambio de vida. “Este verano hablamos con trabajadores H-2A a quienes solo se les daba agua sucia en el trabajo”, dijo. “Les dijeron que pretendieran que era café”.

Si llega a emitirse, es probable que los líderes de varios estados controlados por republicanos se opongan al estándar federal. En abril pasado, el gobernador de Florida, Ron DeSantis, aprobó una legislación que bloquea a los gobiernos locales de exigir a los empleadores que ofrezcan agua y sombra a los trabajadores cuando las temperaturas aumentan.

Y la decisión de la Corte Suprema de anular la “doctrina Chevron” este año puede alentar a los empleadores a desafiar la capacidad de OSHA para hacer cumplir las normas.

Durante décadas, la doctrina Chevron había requerido que los tribunales se delegaran a la experiencia de las agencias reguladoras al interpretar regulaciones, pero el fallo de la Corte Suprema terminó con eso. “Estamos en territorio desconocido”, dijo Barab.

Jeremy Young, productor senior de Fault Lines en Al Jazeera English, colaboró con este informe.

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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On a sweltering afternoon in July 2020, Belinda Ramones got a call that her brother was in the hospital. The call was from a woman at the Florida landscaping business that he had joined that week, the Davey Tree Expert Co., Ramones said. By the time she arrived, she said, “My brother was swollen up from hands to toes.”

Two days later, her brother, Jose Leandro-Barrera, died at age 45 with acute kidney failure caused by heatstroke, according to a report from the Hillsborough County medical examiner. His temperature in the ambulance had been 108 F, said the report.

It described the circumstances preceding his death, as recorded by a nurse. At the jobsite, Leandro-Barrera had advised his supervisor that he was not feeling well, and the supervisor told him to sit in a vehicle until he felt better. While there, he “urinated himself, had seizure like activity” and became unresponsive.

“Employee suffers from heat exhaustion while doing landscaping,” said an investigation into the incident from the Occupational Safety and Health Administration. The agency issued a $9,639 fine to the Davey Tree Expert Co. The company did not respond to requests for comment.

Without national regulations on preventing heat-related illness and death, OSHA has difficulty, in general, protecting workers before it’s too late, said Paloma Rentería, a Department of Labor spokesperson.

Laborers have suffered as summers have grown progressively hotter with climate change. But health policy and occupational health researchers say that worker deaths are not inevitable. Employers can save lives by providing ample water and breaks and building in time for new workers to adjust to extreme heat.

This is the logic behind proposed national rules that President Joe Biden set in motion in 2021, aiming to protect an estimated 36 million workers exposed to extreme heat. The Bureau of Labor Statistics counts about 480 worker deaths from heat exposure each year, on average. But these are “vast underestimates,” according to OSHA, because heat stress is an underlying factor often unaccounted for in medical records.

The advocacy organization Public Citizen estimates that as many as 2,000 U.S. workers die of heat annually, based on extrapolations from heat injury data.

Both estimates are upsetting, said Linda McCauley, dean of the nursing school at Emory University and an occupational health researcher. “No one should go to work expecting that they might die,” she said.

The proposed rules — a heat standard from OSHA — reaches a milestone Dec. 30, when the public comment period closes. But it’s unlikely to be finalized before Biden leaves office.

Vice President Kamala Harris would likely carry the heat rules forward if she wins the presidency next month, said Jordan Barab, who was OSHA’s deputy assistant secretary during the Obama administration. She advanced heat regulations in California in 2020.

Should Donald Trump win, the rules would stall, Barab predicts. In general, Republicans have opposed workplace safety regulations over the past 20 years, saying they are costly to businesses and consumers. And during the first Trump administration, the number of OSHA inspectors tasked with monitoring workplace safety hit an all-time low across the agency’s 48-year history. Workplace inspections regarding heat stress dropped by half on Trump’s watch, according to an analysis by the National Employment Law Project.

OSHA’s rules would require employers to provide ample, cool drinking water, and shade or air conditioning for breaks, when temperatures exceed 80 degrees. Above 90 degrees, employers would need to provide paid 15-minute breaks every two hours.

Two additional aspects of the standard confront overlooked problems that contribute to heat deaths at work. More than 70% of workers who die of heat do so within their first week on the job. And delayed medical care is a common theme.

“We need to stop telling people who complain of being about to pass out to go sit in the car or take a break,” McCauley said. “Rest breaks are needed to prevent the problem, but once someone has symptoms, they need help fast.”

The proposed rules require employers to allow new workers time to acclimate to high temperatures and to institute protocols, like a buddy system, so that workers get rapid medical care as soon as they show signs of heat illness, like dizziness, confusion, and cramps.

By the time an emergency medical team arrived to help one laborer in July 2021, he had stopped breathing, according to one Department of Labor press release. A supervisor at the ecological restoration company EarthBalance had seen him earlier that day, it said, and he was “sweating heavily, his hands were trembling, and he seemed confused,” He rested. “Only 30 minutes later, the supervisor returned to the man finding him unresponsive.”

That evening, Gilberto Macario-Gimenez died at the hospital, said a medical examiner case report. It noted “the decedent had overheated” and attributed his death to heart disease and hypertension. Heat can exacerbate those conditions.

OSHA investigated the situation. It fined EarthBalance $9,216, finding that “the employer failed to ensure that a person adequately trained to provide first aid to employees [was] working in an area where there was no infirmary.”

EarthBalance did not respond to requests for comment.

OSHA has received at least 12,980 comments on its proposals posted to the federal register. One woman wrote about her cousin who died while clearing shrubs for a rancher in Texas when temperatures exceeded 100 degrees: “He was only 34. There was no water or rest breaks.”

After the comment period ends in December, OSHA will hold a public hearing, incorporate changes, and finalize the rule. If Harris is president, Barab said, the agency may finish the process by 2026. For the rule to work, Congress would need to fund OSHA adequately, so that it can hire staffers to teach employers how to implement the standards, and enough investigators to enforce them.

Several industry groups have opposed the standard. The Associated General Contractors of America called it “unnecessary, unworkable, and impractical.” A single set of rules isn’t fair when climates and jobs vary widely, in addition to workers’ abilities to tolerate heat, the group wrote in an online statement.

Some Republican lawmakers have called the rule government overreach. Rick Roth, a Republican Florida state representative, told Al Jazeera that workers are pushing for paid breaks because they “don’t want to work so hard.” If they didn’t feel safe, they could change jobs. “Go work for somebody else,” he said.

Critics also say that the regulations will cost employers. But a UCLA analysis of workers’ compensation claims in California suggests that a national heat standard saves money overall. The study estimated the cost of heat-related injuries between $750 million and $1.25 billion a year in California alone, including medical bills, lost wages, and disability claims.

Because six states have varying sets of rules to reduce heat-related illness — California, Colorado, Maryland, Minnesota, Oregon, and Washington — researchers and union representatives have been able to see where policies need strengthening. One issue with enforcement is that OSHA largely relies on employees to report hazards. One study found that just 14% of nearly 600 farmworkers surveyed in California knew about acclimatization and how much water they needed when temperatures were high.

Although Florida doesn’t have specific heat regulations, Dominique O’Connor of the Farmworker Association of Florida said the biggest obstacle in ensuring occupational safety is that workers are afraid of getting fired for filing a complaint with OSHA.

This is especially true for farmworkers with H-2A visas, which permit noncitizens to fill temporary jobs. Because these workers depend on their employers not only to remain in the country but often for transportation and housing, retaliation from employers would be life-altering. “This summer we talked with H-2A workers who were only given dirty water on the job,” she said. “They were told to just pretend it was coffee.”

Leaders in several Republican-led states are likely to push back against the federal standard if it’s issued. Last April, Florida Gov. Ron DeSantis approved legislation that blocks local governments from requiring employers to offer workers water and shade when temperatures rise.

And the Supreme Court’s decision to overturn the “Chevron doctrine” this year may embolden employers to challenge OSHA’s ability to enforce the rules. For decades, the Chevron doctrine had required courts to defer to expertise at regulatory agencies when interpreting regulations, but the high court’s ruling ended that. “We are in uncharted territory,” Barab said.

Jeremy Young, senior producer at Fault Lines on Al Jazeera English, contributed to this report.

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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KINGSTREE, S.C. — One morning in late April, a small brick health clinic along the Thurgood Marshall Highway bustled with patients.

There was Joshua McCray, 69, a public bus driver who, four years after catching covid-19, still is too weak to drive.

Louvenia McKinney, 77, arrived complaining about shortness of breath.

Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.

Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.

But Brown called them “lucky,” with enough health insurance or money to see a doctor. The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation.

“There is a lot of hopelessness here,” Brown said. “I was trained to keep people healthy, but like 80% of the people don’t come see the doctor, because they can’t afford it. They’re just dying off.”

About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris’ independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.

But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.

The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that constitute the Corridor of Shame, Brown said.

“There is a disconnect between policymakers and real people,” he said. The African Americans who make up most of the town’s population “are not the people in power.”

The U.S. health care system, “by its very design, delivers different outcomes for different populations,” said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities “also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity.”

Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.

And that’s not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people KFF Health News interviewed.

Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.

Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.

Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.

And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times as likely to suffer a gun homicide as their white counterparts.

“People are literally dying because of policy decisions in the South,” said Bakari Sellers, a Democratic former state representative in South Carolina.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.

From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and covid shortened lives even more.

Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.

All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life.

“So much of what we see is the long tail of slavery and Jim Crow,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.

Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: “Who are you to ask for health care?”

Past and Present

The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.

“I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision,” said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.

Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.

Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.

The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to “The Heckler Report,” released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the national academies report.

“When covid was first hitting, it was just sort of immediately clear who was going to suffer the most,” Ducas said, “not just because of differential access to care, but who was in a living environment that’s multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation.”

For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention Director Mandy Cohen, failed to get covid testing to vulnerable Black communities where people were getting sick and dying from covid-related causes at far higher rates than white people.

And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to covid, according to research.

Until McCray, the bus driver in Kingstree, South Carolina, got covid in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted covid in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.

Now he cannot work and at times has difficulty walking.

“I can tell you the truth now: It was only the good Lord that saved him,” said Brown, the rural physician who treated McCray and many patients like him.

Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children’s Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in “The Heckler Report” persist.

When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn’t pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.

She is convinced that being a Black woman made her challenges more likely.

“Think about how many centuries the same thing has been happening,” said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can’t afford to put her 8-year-old son on her health plan, so he’s covered by Medicaid.

“We consistently offer healthcare plans that are on par, if not better, than those available to most Americans through state and federal exchanges,” said Eileen Cassidy Rivera, a Maximus spokesperson.

In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.

President Joe Biden issued an executive order on his first full day in office in 2021 that said “the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America.” Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been “at times facilitated by the federal government.”

“The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities,” said Renata Miller, a spokesperson for the administration.

The CDC, along with some state and local governments, declared racism a serious public health threat.

U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for “Momnibus” legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.

“I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room,” Adams said.

In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.

“You have to have some sensitivity for this work,” Adams said. “And a lot of folks that I’ve worked with don’t have it.”

Governor’s Veto

The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks and a food vendor are the only Black people in the video, even though Black people make up 70% of the town’s population.

But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.

Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.

There is one primary care physician for every 5,080 residents in Williamsburg County. That’s far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.

Edward Simmer, the state’s interim public health director, said that if “you are African American in a rural zone, it is like having two strikes against you.”

Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.

“It is not a panacea,” he said.

But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.

“Every year we look at the data, we see the health disparities and we don’t have a plan to improve,” Brown said. “It has become institutionalized. I call it institutional racism.”

A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.

“Racism is the reason we don’t have Medicaid expansion. Full stop,” said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. “These are not accidents. There is an idea that you can stay in power by using racism.”

South Carolina’s Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be “fiscally responsible.”

Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.

Beyond health care coverage and provider shortages, Black people “have never been given the conditions needed to thrive,” said Barlow, the George Washington University professor. “And this is because of white supremacy.”

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Marketplace Open Enrollment

California’s mental health commission on Thursday announced its executive director would resign amid revelations that he traveled to the U.K. courtesy of a state vendor while he sought to prevent a budget cut that would have defunded the company’s contract.

Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, will step down effective Nov. 22. Documents obtained by KFF Health News show that he tried in June to protect state funding for Kooth, a London-based digital mental health company with a contract to develop a virtual tool to help California tackle its youth mental health crisis.

He had been on paid administrative leave pending an investigation since September.

Ewing’s resignation was announced after a four-hour closed session of the mental health commission. During a public hearing before the announcement, advocates for mental health services accused the commission of favoring corporations over serving people with mental health and substance use issues.

The commission is an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services.

“You are being co-opted by big corporations,” said Susan Gallagher, executive director of Cal Voices, a mental health advocacy organization, during Thursday’s meeting. “You’re lobbying behind the scenes for these people to get money. That is not your job. You serve the people.”

Ewing declined to comment.

Kooth last year signed a four-year, $271 million contract with the Department of Health Care Services, which is separate from the commission, to create Soluna, a free mental health app for California users ages 13 to 25.

The app, along with one for younger users by the company Brightline, launched in January to fill a perceived need for young Californians and their families to access professional telehealth free of charge. It’s one component of Gov. Gavin Newsom’s $4.7 billion youth mental health plan.

The apps have seen very slow uptake since their launch in January. In May, the Newsom administration proposed a $140 million budget cut for the apps. Both the state Assembly and Senate budget committees proposed eliminating the entire program to save the state $360 million in the face of California’s $45 billion deficit.

But the funding for Kooth’s app wound up restored. It’s unclear why. Emails and calendars reviewed by KFF Health News showed Ewing pressed legislative staffers in June to restore the proposed cut.

About two weeks later, Ewing was accompanied by MHSOAC commissioners Mara Madrigal-Weiss, Bill Brown, and Steve Carnevale on a trip to London. Public disclosure forms show Kooth paid $15,000 in travel expenses for Ewing, Madrigal-Weiss, and Brown. The forms do not show the company paid for Carnevale’s travel.

While Ewing was in London, a colleague told him that the final state budget was approved with funding restored for Kooth’s app. Ewing emailed a Kooth executive ideas to improve its teletherapy app. About a week later he wrote, “We expect you to be involved in whatever we dream up.”

At Thursday’s commission meeting, Stacie Hiramoto, director of the Racial and Ethnic Mental Health Disparities Coalition, said the public will view the London trip as a serious conflict of interest.

“Maybe there was no wrongdoing, and maybe the company was good,” said Hiramoto, referring to Kooth. “But don’t you understand the appearance of the conflict?”

Carnevale said in Thursday’s meeting that the Newsom administration asked the commission to engage the legislature during budget negotiations.

“The governor’s office reached out to us to ask us to help them support the arguments and that’s what we did,” Carnevale said. “We went back and explained our positions on the digital solutions provided generally, without any particular comment on any company or any product in particular.”

Newsom’s office didn’t immediately respond.

Carnevale said the U.K. trip was not related to the budget. He said the trip “was very successful” for exchanging ideas with mental health policy leaders.

DHCS Director Michelle Baass told lawmakers in May that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps. Together, they had been used for only about 2,800 coaching sessions. The department has not provided more recent figures to KFF Health News.

Madrigal-Weiss defended her support of the mental health apps, lauding the youth-led design. She cited data that a majority of Kooth’s users liked the virtual coaching sessions and more than half were from underserved communities.

According to Kooth’s contract, obtained through a records request early this year, its payment is partially contingent on how many people use its app. Kooth will not get a pay increase until it reaches 366,000 users.

Kooth’s stock price fell about 20% on Thursday after KFF Health News published an article about Ewing’s efforts to restore funding for its contract and the London trip.

Gabe Brison-Trezise contributed to this report.

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

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Hoy en día, cuando las personas se hacen su mamografía anual, algunos radiólogos les preguntan algo desconcertante. Además de analizar la prueba en busca de cáncer de mama dicen: ¿le gustaría que el médico examinara las imágenes para detectar su riesgo cardíaco?

Eso fue lo que sucedió recientemente cuando una colega visitó Washington Radiology, una red de centros de diagnóstico que tiene más de una docena de establecimientos en Washington, DC, Maryland y Virginia.

Le dijeron que, por $119, la clínica utilizaría un software de inteligencia artificial para analizar su mamografía en busca de calcificaciones en las arterias de sus senos, lo que podría indicar el riesgo de tener una enfermedad cardiovascular.

Confundida sobre lo que exactamente le estaban ofreciendo, mi colega dijo que no. Pero se preguntó si esa decisión había sido un error y si las investigaciones respaldaban este examen adicional.

Washington Radiology es uno de varios centros que ofrecen este tipo de pruebas en todo el país. Aunque las radiografías de mama generalmente se utilizan para detectar y diagnosticar cáncer, las imágenes también indican si las arterias de los senos tienen calcificaciones, que en la imagen aparecen como líneas blancas paralelas.

Las calcificaciones, que se consideran hallazgos “incidentales” no relacionados con el cáncer de mama, pueden estar asociadas con el riesgo de enfermedad cardíaca de una persona.

Estas calcificaciones han sido visibles en las imágenes durante décadas y algunos radiólogos las han anotado rutinariamente en sus informes. Sin embargo, no se solía dar esta información a los pacientes.

Ahora, algunas instituciones ofrecen informar los resultados a los pacientes, a veces por una tarifa.

Washington Radiology no respondió a las solicitudes de entrevista, pero en un video de su sitio web que describe la prueba “Mammo+Heart” con IA, Islamiat Ego-Osuala, una radióloga de imágenes mamarias de la clínica dijo: “Si las últimas décadas nos han enseñado algo sobre el campo de la radiología, es que el cielo es el límite. Las posibilidades son infinitas”.

Algunos expertos en imágenes cuestionan esta evaluación extra.

“Lo que estamos viendo en la mamografía es una calcificación en la arteria mamaria, pero eso no es lo mismo que la calcificación en la arteria coronaria”, dijo Greg Sorensen, director científico de RadNet, que tiene casi 400 centros de imágenes en ocho estados.

RadNet no ofrece detección de calcificación arterial mamaria y no tiene planes de hacerlo. “No parece que esté dando beneficios hoy”, dijo Sorensen.

(RadNet ofrece a los pacientes un análisis de IA de sus mamografías para mejorar la detección del cáncer de mama. KFF Health News informó sobre eso a principios de este año).

La calcificación de las arterias coronarias es reconocida como un marcador fuerte de riesgo de enfermedad cardíaca. Pero, aunque estudios han mostrado una asociación entre la calcificación arterial mamaria (CAM) y el riesgo de enfermedad cardiovascular, aún quedan muchos interrogantes por develar.

Por un lado, la ausencia de CAM no significa necesariamente que las mujeres no estén en riesgo de enfermedad cardíaca, ataque cardíaco o accidente cerebrovascular.

En un estudio de mujeres posmenopáusicas, el 26% tenía calcificación arterial mamaria, y durante un período de estudio de seis años y medio, esto se asoció con un aumento del 23% en el riesgo de enfermedad cardíaca de cualquier tipo y un aumento del 51% en el riesgo de ataque cardíaco o accidente cerebrovascular. Sin embargo, la mayoría de los eventos cardiovasculares ocurrieron en mujeres que no tenían calcificación arterial mamaria.

“No me sentiría tranquila diciéndole a la gente que tiene un mayor o menor riesgo de enfermedad cardíaca solo por la calcificación en las arterias de sus senos”, dijo Sadiya Khan, médica especializada en prevención de enfermedades cardíacas en Northwestern Medicine, en Chicago.

Khan es coautora de un editorial sobre estos estudios en una revista médica. “Creo que es un área interesante, pero debemos avanzar con cautela”.

Es comprensible que los médicos especialistas en salud femenina estén interesados en aceptar la idea de utilizar la mamografía, que millones de mujeres se realizan cada año, para también evaluar el riesgo de enfermedad cardíaca.

La enfermedad cardíaca es la principal causa de muerte en los Estados Unidos. Fue responsable de más de 300,000 —o aproximadamente 1 de cada 5— muertes de mujeres en 2021.

Muchas mujeres no reconocen su riesgo de enfermedad cardíaca ni los muchos factores que lo aumentan, como la hipertensión, la diabetes, el colesterol alto, fumar, beber demasiado alcohol y tener sobrepeso.

Las calculadoras en línea pueden ayudar a evaluar el riesgo de enfermedad cardiovascular personal. Para aquellos cuyo riesgo a 10 años sea del 7.5% o más, los médicos pueden recomendar cambios en el estilo de vida y/o recetar una estatina para reducir el colesterol en sangre.

Laura Heacock, radióloga especialista en imágenes mamarias en NYU Langone Health, en la ciudad de Nueva York, señaló que las pacientes ya pueden obtener gran parte de la información que resulta del cálculo de la CAM a través de sus médicos y el uso de esas calculadoras de riesgo.

La clave es que esta detección ofrece otra oportunidad para hablar sobre el riesgo de enfermedad cardíaca.

Un estudio encontró que el 57% de las mujeres a las que se les informó que tenían calcificación arterial mamaria luego de una mamografía dijeron haber discutido los resultados con su médico de atención primaria o con un cardiólogo.

Heacock mencionó que le gustaría ver más estudios que demuestren que reportar las CAM lleva a cambios en la atención de los pacientes y a una reducción en los ataques cardíacos y los accidentes cerebrovasculares.

A cada mujer que visita el Lynn Women’s Health and Wellness Institute en Boca Ratón, Florida, para hacerse una mamografía se la evalúa también en busca de calcificación arterial mamaria.

Es un servicio estándar desde 2020, dijo Heather Johnson, cardióloga especializada en prevención del instituto. Si se encuentra calcificación, la mujer es remitida a un cardiólogo u otro profesional de salud en el mismo centro para analizar los hallazgos y proporcionarle más información sobre el riesgo de enfermedad cardíaca.

Sin embargo, Johnson reconoció que se necesitan más estudios para comprender mejor la conexión entre la calcificación en las arterias mamarias y las enfermedades cardíacas. Aun así, comentó que esta prueba “permite una vía de comunicación”.

A las pacientes del instituto de Boca Ratón no se les cobra por la evaluación.

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Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it gives to more than 40 million people.

Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”

The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.

Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.

Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.

Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”

Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats retake control of the House in 2018.

In a KFF poll last winter, two-thirds of the public said it is very important to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.

“You want to make sure that preexisting coverage — conditions — are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.

Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without undermining coverage.

“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.

Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.

People eligible for subsidies would likely buy comprehensive ACA plans because — with the financial help — they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.

He also said that in states that allowed people to buy non-ACA-compliant plans outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.

“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying ‘we’re making it better,’ but it’s all untrue.”

Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office estimated doing so would increase the federal deficit by more than $330 billion over 10 years.

In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.

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Bird flu cases have more than doubled in the country within a few weeks, but researchers can’t determine why the spike is happening because surveillance for human infections has been patchy for seven months.

Just this week, California reported its 15th infection in dairy workers and Washington state reported seven probable cases in poultry workers.

Hundreds of emails from state and local health departments, obtained in records requests from KFF Health News, help reveal why. Despite health officials’ arduous efforts to track human infections, surveillance is marred by delays, inconsistencies, and blind spots.

Several documents reflect a breakdown in communication with a subset of farm owners who don’t want themselves or their employees monitored for signs of bird flu.

For instance, a terse July 29 email from the Weld County Department of Public Health and Environment in Colorado said, “Currently attempting to monitor 26 dairies. 9 have refused.”

The email tallied the people on farms in the state who were supposed to be monitored: “1250+ known workers plus an unknown amount exposed from dairies with whom we have not had contact or refused to provide information.”

Other emails hint that cases on dairy farms were missed. And an exchange between health officials in Michigan suggested that people connected to dairy farms had spread the bird flu virus to pet cats. But there hadn’t been enough testing to really know.

Researchers worldwide are increasingly concerned.

“I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, formerly the assistant secretary for preparedness and response in the Obama administration.

Bird flu viruses have long been on the short list of pathogens with pandemic potential. Although they have been around for nearly three decades in birds, the unprecedented spread among U.S. dairy cattle this year is alarming: The viruses have evolved to thrive within mammals. Maria Van Kerkhove, head of the emerging diseases unit at the World Health Organization, said, “We need to see more systemic, strategic testing of humans.”

Refusals and Delays

A key reason for spotty surveillance is that public health decisions largely lie with farm owners who have reported outbreaks among their cattle or poultry, according to emails, slide decks, and videos obtained by KFF Health News, and interviews with health officials in five states with outbreaks.

In a video of a small meeting at Central District Health in Boise, Idaho, an official warned colleagues that some dairies don’t want their names or locations disclosed to health departments. “Our involvement becomes very sketchy in such places,” she said.

“I just finished speaking to the owner of the dairy farm,” wrote a public health nurse at the Mid-Michigan district health department in a May 10 email. “[REDACTED] feels that this may have started [REDACTED] weeks ago, that was the first time that they noticed a decrease in milk production,” she wrote. “[REDACTED] does not feel that they need MSU Extension to come out,” she added, referring to outreach to farmworkers provided by Michigan State University.

“We have had multiple dairies refuse a site visit,” wrote the communicable disease program manager in Weld, Colorado, in a July 2 email.

Many farmers cooperated with health officials, but delays between their visits and when outbreaks started meant cases might have been missed. “There were 4 people who discussed having symptoms,” a Weld health official wrote in another email describing her visit to a farm with a bird flu outbreak, “but unfortunately all of them had either already passed the testing window, or did not want to be tested.”

Jason Chessher, who leads Weld’s public health department, said farmers often tell them not to visit because of time constraints.

Dairy operations require labor throughout the day, especially when cows are sick. Pausing work so employees can learn about the bird flu virus or go get tested could cut milk production and potentially harm animals needing attention. And if a bird flu test is positive, the farm owner loses labor for additional days and a worker might not get paid. Such realities complicate public health efforts, several health officials said.

An email from Weld’s health department, about a dairy owner in Colorado, reflected this idea: “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too.” Pink eye, or conjunctivitis, is a symptom of various infections, including the bird flu.

Chessher and other health officials told KFF Health News that instead of visiting farms, they often ask owners or supervisors to let them know if anyone on-site is ill. Or they may ask farm owners for a list of employee phone numbers to prompt workers to text the health department about any symptoms.

Jennifer Morse, medical director at the Mid-Michigan District Health Department, conceded that relying on owners raises the risk cases will be missed, but that being too pushy could reignite a backlash against public health. Some of the fiercest resistance against covid-19 measures, such as masking and vaccines, were in rural areas.

“It’s better to understand where they’re coming from and figure out the best way to work with them,” she said. “Because if you try to work against them, it will not go well.”

Cat Clues

And then there were the pet cats. Unlike dozens of feral cats found dead on farms with outbreaks, these domestic cats didn’t roam around herds, lapping up milk that teemed with virus.

In emails, Mid-Michigan health officials hypothesized that the cats acquired the virus from droplets, known as fomites, on their owners’ hands or clothing. “If we only could have gotten testing on the [REDACTED] household members, their clothing if possible, and their workplaces, we may have been able to prove human->fomite->cat transmission,” said a July 22 email.

Her colleague suggested they publish a report on the cat cases “to inform others about the potential for indirect transmission to companion animals.”

Thijs Kuiken, a bird flu researcher in the Netherlands, at the Erasmus Medical Center in Rotterdam, said person-to-cat infections wouldn’t be surprising since felines are so susceptible to the virus. Fomites may have been the cause or, he suggested, an infected — but untested — owner might have passed it on.

Hints of missed cases add to mounting evidence of undetected bird flu infections. Health officials said they’re aware of the problem but that it’s not due only to farm owners’ objections.

Local health departments are chronically understaffed. For every 6,000 people in rural areas, there’s one public health nurse — who often works part-time, one analysis found.

“State and local public health departments are decimated resource-wise,” said Lurie, who is now an executive director at an international organization, the Coalition for Epidemic Preparedness Innovations. “You can’t expect them to do the job if you only resource them once there’s a crisis.”

Another explanation is a lack of urgency because the virus hasn’t severely harmed anyone in the country this year. “If hundreds of workers had died, we’d be more forceful about monitoring workers,” Chessher said. “But a handful of mild symptoms don’t warrant a heavy-handed response.”

All the bird flu cases among U.S. farmworkers have presented with conjunctivitis, a cough, a fever, and other flu-like symptoms that resolved without hospitalization. Yet infectious disease researchers note that numbers remain too low for conclusions — especially given the virus’s grim history.

About half of the 912 people diagnosed with the bird flu over three decades died. Viruses change over time, and many cases have probably gone undetected. But even if the true number of cases — the denominator — is five times as high, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, a mortality rate of 10% would be devastating if the bird flu virus evolved to spread swiftly between people. The case fatality rate for covid was around 1%.

By missing cases, the public health system may be slow to notice if the virus becomes more contagious. Already, delays resulted in missing a potential instance of human-to-human transmission in early September. After a hospitalized patient tested positive for the bird flu virus in Missouri, public health officials learned that a person in the patient’s house had been sick — and recovered. It was too late to test for the virus, but on Oct. 24, the CDC announced that an analysis of the person’s blood found antibodies against the bird flu, signs of a prior infection.

CDC Principal Deputy Director Nirav Shah suggested the two people in Missouri had been separately infected, rather than passing the virus from one to the other. But without testing, it’s impossible to know for certain.

The possibility of a more contagious variant grows as flu season sets in. If someone contracts bird flu and seasonal flu at the same time, the two viruses could swap genes to form a hybrid that can spread swiftly. “We need to take steps today to prevent the worst-case scenario,” Nuzzo said.

The CDC can monitor farmworkers directly only at the request of state health officials. The agency is, however, tasked with providing a picture of what’s happening nationwide.

As of Oct. 24, the CDC’s dashboard states that more than 5,100 people have been monitored nationally after exposure to sick animals; more than 260 tested; and 30 bird flu cases detected. (The dashboard hasn’t yet been updated to include the most recent cases and five of Washington’s reports pending CDC confirmation.)

Van Kerkhove and other pandemic experts said they were disturbed by the amount of detail the agency’s updates lack. Its dashboard doesn’t separate numbers by state, or break down how many people were monitored through visits with health officials, daily updates via text, or from a single call with a busy farm owner distracted as cows fall sick. It doesn’t say how many workers in each state were tested or the number of workers on farms that refused contact.

“They don’t provide enough information and enough transparency about where these numbers are coming from,” said Samuel Scarpino, an epidemiologist who specializes in disease surveillance. The number of detected bird flu cases doesn’t mean much without knowing the fraction it represents — the rate at which workers are being infected.

This is what renders California’s increase mysterious. Without a baseline, the state’s rapid uptick could signal it’s testing more aggressively than elsewhere. Alternatively, its upsurge might indicate that the virus has become more infectious — a very concerning, albeit less likely, development.

The CDC declined to comment on concerns about monitoring. On Oct. 4, Shah briefed journalists on California’s outbreak. The state identified cases because it was actively tracking farmworkers, he said. “This is public health in action,” he added.

Salvador Sandoval, a doctor and county health officer in Merced, California, did not exude such confidence. “Monitoring isn’t being done on a consistent basis,” he said, as cases mounted in the region. “It’s a really worrisome situation.”

KFF Health News regional editor Nathan Payne contributed to this report.

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Assistant Secretary for Health, ADM Rachel L. Levine, MD, presented the Assistant Secretary for Health’s (ASH) Exceptional Service Medallion to Dr. Clarice Reid

Today, HHS Secretary Xavier Becerra released the following statement in response to new fluid supply increases from Baxter, Inc.

USDA/HHS Fact Sheet: Biden-Harris Administration Takes New Action to Halt the Spread of Bird Flu, including in California and Washington

When you think about the opioid crisis, the image of adults in their 20s, 30s, even sometimes those who are middle-aged, may come to mind. Rightly so, since most overdose deaths occur in people between ages 25 and 64.

But did you know older adults are increasingly at risk of overdosing from opioids, too?

In fact, from 2021 to 2022, adults over 65 saw the largest increase — 10 percent — in overdose death rates across all age groups.

Yet their addiction care needs are often overlooked, even in places teeming with medical staff, such as long-term care facilities that primarily serve older patients. My colleague Aneri Pattani and I dug into the issue.

One study estimated that older adults were the least likely in 2022 to receive any type of care for opioid use disorder. They were also unlikely to receive medications such as buprenorphine and methadone — considered the treatment gold standard.

When people think of who actively uses drugs, “they don’t want to think about grandma, they don’t think about grandpa, and they certainly don’t want to think about what could be happening at a nursing home,” said A. Toni Young, executive director of Community Education Group, a nonprofit that advocates on substance use policy.

But Young’s organization, along with more than 50 other advocacy groups, is working to bring the issue front and center. In a letter shared exclusively with KFF Health News and the Health Brief, the coalition is urging the Centers for Medicare and Medicaid Services to ensure older patients get the help they need.

“Many Americans living in residential care facilities may not be in a position to effectively advocate for their own medical interests,” the letter says. “They must be able to trust you to hold their facility operators accountable to uphold the law.”

Facilities that receive Medicaid and Medicare payments are required to abide by federal laws, including the Americans With Disabilities Act and the Fair Housing Act. The laws bar discrimination due to current or past addiction and mandate appropriate medical care, including medications for opioid use disorder.

“However, without enforcement, the law is just words,” the letter notes.

To change that, the letter writers urge CMS to “undertake a systematic education, investigation, and enforcement effort, covering all categories of residential care facilities that you oversee.”

In a statement to KFF Health News, CMS said its updated staffing guidelines, released this year, require nursing facilities to ensure they have the staffing and resources to care for patients with serious mental illness or substance use disorder. The agency directs facilities to have care plans in place to “prevent adverse events, such as an overdose.” It has also partnered with other federal agencies to create free programs to boost nursing home care for patients with addiction and mental health concerns.

The agency did not directly address how such guidelines would be enforced.

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HHS is awarding six winners for Phase 2 of the HHS Endocrine-Disrupting Chemicals (EDC) Innovator Award Competition.

Tom Zawierucha, 58, a building services worker in New Jersey, wishes candidates would talk more about protecting older Americans from big medical bills.

Teresa Morton, 43, a freight dispatcher in Memphis, Tennessee, with two teenagers, wants to hear more about how elected officials would help working Americans saddled with unaffordable deductibles.

Yessica Gray, 28, a customer support representative in Wisconsin, craves relief from high drug prices and medical bills that have driven her and her husband deep into debt. “How much are we going to pay?” she said. “It’s just something that’s always on my mind.”

Health care hasn’t figured prominently in this increasingly acrimonious presidential campaign. And the economy has generally topped the list of voters’ concerns.

But Americans remain intensely worried about paying for medical care, national surveys show.

Two in 3 U.S. adults in a recent nationwide poll by West Health and Gallup said they’re concerned a major health event would land them in debt. A similar share said health care isn’t getting enough attention in the campaign.

To better understand voters’ health care concerns as the 2024 campaign nears an end, KFF Health News worked with research firm PerryUndem, which convened a pair of focus groups last week with 16 people from across the country. PerryUndem, which paid to organize the focus groups, is a nonpartisan firm based in Washington, D.C., that studies public views on health care and other issues.

The focus group participants represented a broad swath of the electorate, with some favoring Republican candidates, and others Democrats. But nearly all shared a common complaint: Neither presidential candidate has talked enough about how they’d help people struggling to pay for medical care.

“You don’t really hear anything much about health care costs,” said Bob Groegler, 46, who works in residential financing in eastern Pennsylvania. Groegler said he’s worried he may never be able to retire because he won’t have enough money to pay his medical bills.

Former President Donald Trump, the Republican nominee, hasn’t offered a detailed health care agenda, though he criticizes current laws and said he has “concepts of a plan” to improve the 2010 Affordable Care Act, often called Obamacare.

Vice President Kamala Harris, a Democrat, has laid out more detailed health care proposals, including building on legislation signed by President Joe Biden to lower patients’ bills.

In 2022, Biden signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35 monthly cap on insulin. The legislation also provides additional federal aid to help Americans buy health insurance through the Affordable Care Act, though this aid will expire unless Congress and the president renew it next year.

Harris has said she will expand the aid and push for new assistance to Medicare enrollees who need home care. She also has pledged to continue federal efforts to relieve medical debt, a nationwide problem that burdens about 100 million people.

But most of the focus group participants said they knew little about these proposals, complaining that hot-button issues like abortion have dominated the campaign.

Many also expressed deep skepticism that either Harris or Trump would do much to lighten the burden of medical bills.

“I believe they’re out of touch with our reality,” said Renata Bobakova, 46, a teacher and mother outside Cleveland. “We never know when we’ll get sick. We never know when we’ll fall down or sprain an ankle. And prices really can be astronomical. … I’m constantly worried about that.”

Bobakova, who is from Slovakia, said she went back to Europe to give birth to her daughter 10 years ago to avoid crippling medical debt she knew she’d incur in this country. Parents with private health coverage face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance.

Other focus group participants said they or people they knew had left the country to get cheaper prescription drugs. The U.S. has the highest medical prices in the world, research shows.

Several focus group participants, such as Kevin Gaudette, 64, a retired semiconductor engineer in North Carolina, blamed large hospitals, drug companies, and insurers for blocking efforts to lower patients’ costs to protect their profits. “I think everybody has their finger in the pie,” Gaudette said.

Martha Chapman, 64, who is also retired and lives in Philadelphia, pointed to what she called “corporate greed.” “I just don’t think it’s going to change,” she said.

In the closing days of the campaign, that cynicism represents a particular problem for Harris, said PerryUndem co-founder Michael Perry, who led the two focus groups.

Harris has tried to distinguish herself as the candidate who is more serious about policy and more sympathetic to voters’ economic struggles, Perry said. And in recent weeks, she’s begun airing new ads highlighting health care issues.

But even focus group participants who said they lean Democratic seemed to blame both candidates for not addressing Americans’ health care concerns. “They’re not feeling listened to,” Perry said.

Many of the participants nevertheless continued to express hope that an issue as important as health care would someday get the attention of elected officials, regardless of political party.

“We’re all human beings here. We’re all people just trying to make it,” said Zawierucha, the building services worker in New Jersey. “If we get sick or have to go in and get something done, we should have that peace of mind that we can go in there and not have to worry about paying it off for the next 20 years.”

“Just give us some peace of mind,” he said.

[Clarification: This article was revised at 11:35 a.m. ET on Oct. 24, 2024, to more clearly describe how the focus groups were organized.]

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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