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Los hospitales derivan pacientes de atención primaria a centros de salud “semejantes” para mejorar las finanzas

Kaiser Health News:Health Industry - September 09, 2022

Cada vez más hospitales subcontrantan servicios ambulatorios, a menudo poco rentables, para los pacientes más pobres, mediante la creación de organizaciones independientes, sin fines de lucro, que proporcionan atención primaria.

Medicare y Medicaid pagan a estas clínicas, conocidas como centros de salud semejantes con certificación federal, mucho más de lo que pagarían si fueran propiedad de los hospitales.

Al igual que los casi 1,400 centros de salud certificados a nivel federal —que también reciben esos dólares adicionales—, una clínica designada por el gobierno como “organización semejante” también puede acogerse a programas federales que podrían ayudar a reducir los costos y a contratar proveedores. Las clínicas pueden obtener medicamentos recetados con grandes descuentos, y atraer a nuevos médicos haciéndolos elegibles para un programa gubernamental, que les ayuda a pagar su deuda estudiantil si trabajan en un área con escasez de doctores.

Pero, a diferencia de los centros de salud comunitarios, los semejantes no reciben una subvención federal anual para cubrir los costos operativos. Tampoco obtienen la cobertura económica del gobierno federal para casos de negligencia médica.

Aunque no formen parte de un sistema hospitalario, muchos de los centros semejantes, creados por los hospitales, cuentan con clínicas en los campus de los hospitales o a poca distancia. Por ello, las clínicas pueden absorber a los pacientes menos graves y alejarlos de las costosas salas de urgencias.

Esto ayuda a reducir pérdidas económicas, especialmente de los pacientes sin seguro que podrían haber utilizado las urgencias para recibir atención primaria. Convertir clínicas en “centros semejantes” suele ser una estrategia de los hospitales que tienen una alta proporción de pacientes inscritos en Medicaid, que generalmente reembolsa a tasas más bajas que los planes de salud comerciales, dijo Jeffrey Allen, de la consultora Forvis. “Es una tendencia que está ganando impulso”, afirmó.

Los hospitales apuestan por salir airosos si derivan un servicio que pierde dinero y conceden una subvención a su “semejante” para que siga siendo solvente, señaló Allen. Al mismo tiempo, los hospitales esperan que muchos de los pacientes de las clínicas semejantes que necesitan ingresar, o requieren atención especializada, sean enviados a sus hospitales, añadió.

Al menos ocho sistemas hospitalarios han convertido clínicas existentes o han construido otras nuevas que recibieron la designación de “organización semejante” desde 2019 hasta 2022, según un análisis de KHN basado en datos federales. Entre ellos están los siguientes:

  • Parkview Health, un gran sistema hospitalario en Indiana y Ohio, que abrió un centro semejante llamado Alliance Health Centers en Fort Wayne, Indiana, designado en 2021. Tami Brigle, portavoz del hospital, dijo que el estatus de semejante ofrecía al sistema una mejor manera de proporcionar atención a las personas desatendidas.
  • Parrish Medical Center de Titusville, Florida, que ayudó a abrir Space Coast Health Centers, y que fue designado como “organización semejante” en 2022. Parrish gastó $1,2 millones para establecer la clínica, que ofrece atención primaria y de salud mental, a pocas cuadras del hospital. “Muchos de nuestros pacientes no han tenido atención primaria durante años y tienen múltiples necesidades médicas y de comportamiento”, expresó el CEO de Space Coast, Arvin Lewis, en una declaración a KHN. “Estamos trabajando para mejorar el acceso a la atención”.
  • Wabash General Hospital, que se asoció con un departamento de salud local para formar el  Wabash Community Health Center, una clínica “semejante” junto al hospital en Mount Carmel (Illinois). Danielle Stevens, vicepresidenta ejecutiva de desarrollo empresarial del hospital, dijo que el hospital trataba a algunos pacientes de la clínica en su sala de urgencias y que el nuevo centro ofrecía servicios de salud mental y física en un solo lugar. “La intención es ampliar los servicios, que actualmente no se ofrecen a la comunidad, gracias a la mejora del reembolso”, señaló.
  • Beverly Hospital en Montebello, una ciudad del condado de Los Angeles, que proporcionó un préstamo de $3 millones y donó su clínica para mujeres para poner en marcha el centro “semejante” BeverlyCare, según contó la directora ejecutiva de BeverlyCare, Corali Nakamatsu. El centro renta al hospital un espacio de oficinas para su clínica de adultos y pediatría. Esa clínica ayuda a los pacientes que necesitan atención de seguimiento después de visitar la sala de urgencias del hospital. La clínica también ofrece a los pacientes una opción más económica que la de acudir a las urgencias.

El presidente de la Asociación de Hospitales de Indiana, Brian Tabor, apuntó que los hospitales a veces se muestran cautelosos a la hora de crear una “semejante”, ya que supone ceder el control a una nueva organización. Sin embargo, dijo, la conversión puede beneficiar tanto a los hospitales como a los pacientes: “Los hospitales están explorando diferentes modelos de pago para apoyar el acceso a la salud en las zonas rurales y subatendidas, y el estatus de “semejante” ha surgido para algunos como una herramienta vital”.

A nivel nacional funcionan 108 centros de salud designados como “semejantes”, lo que supone un aumento respecto a los 87 existentes en 2020, según la Administración de Recursos y Servicios de Salud federal (HRSA). La mayoría no fueron creados por hospitales.

Los centros de salud “semejantes” están supervisados por un consejo de administración, y se requiere que al menos el 51% de los directores sean pacientes, como ocurre en los centros de salud comunitarios. Los “semejantes” tratan a los pacientes según una escala de cuotas basada en sus ingresos.

Las organizaciones suelen solicitar al gobierno federal el estatus de “semejante” como paso previo a convertirse en un centro de salud totalmente subvencionado por el gobierno federal.

En la zona de Allentown (Pennsylvania), los dos principales sistemas de salud (St. Luke’s University Health Network y Lehigh Valley Health Network) han transformado recientemente muchas de sus clínicas de atención primaria en centros similares. Ninguno de los dos hospitales quiso facilitar un portavoz para comentar los cambios, pero ambos respondieron a las preguntas por escrito.

St. Luke’s inició Star Community Health en 2018; recibió su designación de “semejante” en 2020. “Star ha sido capaz de tratar a un grupo más amplio de pacientes que de otra manera no tendrían acceso a la atención”, declaró el CEO de Star, Mark Roberts, aunque no proporcionó detalles sobre la expansión.

Lehigh Valley convirtió varios de sus consultorios de atención primaria al estatus de “semejante” bajo el nombre de Valley Health Partners Community Health Center. La financiación adicional de Medicare y Medicaid ha permitido a las clínicas ampliar los servicios de salud mental y drogadicción, así como ofrecer asistencia de asesores financieros, trabajadores sociales y farmacéuticos clínicos, escribió el portavoz Jamie Stover.

Lee Health, un sistema hospitalario con sede en Fort Myers, Florida, convirtió más de dos docenas de sus clínicas ambulatorias a la designación de “semejantes” a partir de 2014. Bob Johns, vicepresidente de Lee Community Healthcare, es el único ejecutivo a tiempo completo de los semejantes. El resto del personal sigue siendo empleado del sistema hospitalario.

La mayor financiación de Medicaid ha ayudado a pagar cuatro nuevas clínicas de medicina familiar para adultos y una clínica de salud mental pediátrica, explicó Johns. Y una clínica de salud móvil, que va a las zonas subatendidas, también se financia en parte a través de los reembolsos mejorados de Medicaid.

Johns apuntó que la clínica semejante recibe unos $120 por la visita de un paciente de Medicaid al consultorio de atención primaria, casi el doble del pago que recibían las clínicas cuando eran propiedad de Lee Health.

Johns atribuyó a las clínicas semejantes la reducción de las visitas innecesarias a urgencias en los hospitales de Lee Health en al menos un 20%. Muchas de esas visitas eran de pacientes sin seguro, dijo.

Las clínicas también se benefician del programa federal 340B, que les permite comprar medicamentos con grandes descuentos para venderlos a los pacientes. Las aseguradoras de los pacientes suelen pagar a los centros una tarifa más alta, y las clínicas se quedan con la diferencia. Las clínicas pueden reducir los costos de bolsillo de los pacientes, pero no están obligadas a hacerlo, aunque Johns afirmó que Lee Health reduce los costos de los medicamentos para los pacientes que no tienen seguro o tienen bajos ingresos.

Los sistemas hospitalarios, como Lee Health, que se acogen al programa 340B pueden utilizarlo solo para sus pacientes ingresados, según Johns.

El estatus de semejante también permite a las clínicas participar en el National Health Service Corps, un programa federal que paga los préstamos estudiantiles de los médicos que aceptan trabajar en un área con escasez de proveedores de atención médica. “Es una forma estupenda de retener a los profesionales”, señaló Johns.

El traslado de la atención a las “organizaciones semejantes” ha ayudado a Lee Health a encontrar nuevos fondos para llevar la atención médica a las personas desatendidas, añadió.

“Es un modelo genial y una forma muy eficiente de utilizar recursos limitados”, concluyó Johns.

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

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Many Preventive Medical Services Cost Patients Nothing. Will a Texas Court Decision Change That?

Kaiser Health News:Marketplace - September 09, 2022

A federal judge’s ruling in Texas has thrown into question whether millions of insured Americans will continue to receive some preventive medical services, such as cancer screenings and drugs that protect people from HIV infection, without making a copayment.

It’s the latest legal battle over the Affordable Care Act, and Wednesday’s ruling is almost certain to be appealed.

A key part of the ruling by Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas says one way that preventive services are selected for the no-cost coverage is unconstitutional. Another portion of his ruling says a requirement that an HIV prevention drug therapy be covered without any cost to patients violates the religious freedom of an employer who is a plaintiff in the case.

It is not yet clear what all this means for insured patients. A lot depends on what happens next.

O’Connor is likely familiar to people who have followed the legal battles over the ACA, which became law in 2010. In  2018, he ruled that the entire ACA was unconstitutional. For this latest case, he has asked both sides to outline their positions on what should come next in filings due Sept. 16.

After that, the judge may make clear how broadly he will apply the ruling. O’Connor, whose 2018 ruling was later reversed by the U.S. Supreme Court, has some choices. He could say the decision affects only the conservative plaintiffs who filed the lawsuit, expand it to all Texans, or expand it to every insured person in the U.S. He also might temporarily block the decision while any appeals, which are expected, are considered.

“It’s quite significant if his ruling stands,” said Katie Keith, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at the Georgetown University Law Center.

We asked experts to weigh in on some questions about what the ruling might mean.

What does the ACA require on preventive care?

Under a provision of the ACA that went into effect in late 2010, many services considered preventive are covered without a copayment or deductible from the patient.

A recent estimate from the U.S. Department of Health and Human Services found that more than 150 million people with insurance had access to such free care in 2020.

The federal government currently lists 22 broad categories of coverage for adults, an additional 27 for women, and 29 for children.

To get on those lists, vaccines, screening tests, drugs, and services must have been recommended by one of three groups of medical experts. But the ruling in the Texas case centers on recommendations from only one group: the U.S. Preventive Services Task Force, a nongovernmental advisory panel whose volunteer experts weigh the pros and cons of screening tests and preventive treatments.

Procedures that get an “A” or “B” recommendation from the task force must be covered without cost to the insured patient and include a variety of cancer screenings, such as colonoscopies and mammograms; cholesterol drugs for some patients; and screenings for diabetes, depression, and sexually transmitted diseases.

Why didn’t the ACA simply spell out what should be covered for free?

“As a policymaker, you do not want to set forth lists in statutes,” said Christopher Condeluci, a health policy attorney who served as tax and benefits counsel to the U.S. Senate Finance Committee during the drafting of the ACA. One reason, he said, is that if Congress wrote its own lists, lawmakers would be “getting lobbied in every single forthcoming year by groups wanting to get on that list.”

Putting it in an independent body theoretically insulated such decisions from political influence and lobbying, he and other experts said.

What did the judge say?

It’s complicated, but the judge basically said that using the task force recommendations to compel insurers or employers to offer the free services violates the Constitution.

O’Connor wrote that members of the task force, which is convened by a federal health agency, are actually “officers of the United States” and should therefore be appointed by the president and confirmed by the Senate.

The decision does not affect recommendations made by the other two groups of medical experts: the Advisory Committee on Immunization Practices, which makes recommendations to the Centers for Disease Control and Prevention on vaccinations, and the Health Resources and Services Administration, a part of the Department of Health and Human Services that has set free coverage rules for services aimed mainly at infants, children, and women, including birth control directives.

Many of the task force’s recommendations are noncontroversial, but a few have elicited an outcry from some employers, including the plaintiffs in the lawsuit. They argue they should not be forced to pay for services or treatment they disagree with, such as HIV prevention drugs.

Part of O’Connor’s ruling addressed that issue separately, agreeing with the position taken by plaintiff Braidwood Management, a Christian, for-profit corporation owned by Steven Hotze, a conservative activist who has brought other challenges to the ACA and to coronavirus mask mandates. Hotze challenged the requirement to provide free coverage of preexposure prophylaxis (PrEP) drugs that prevent HIV. He said it runs afoul of his religious beliefs, including making him “complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman,” according to the ruling.

O’Connor said forcing Braidwood to provide such free care in its insurance plan, which it funds itself, violates the federal Religious Freedom Restoration Act.

What about no-copay contraceptives, vaccines, and other items that are covered under recommendations from other groups not targeted by the judge’s ruling?

The judge said recommendations or requirements from the other two groups do not violate the Constitution, but he asked both parties to discuss the ACA’s contraceptive mandate in their upcoming filings. Currently, the law requires most forms of birth control to be offered to enrollees without a copayment or deductible, although courts have carved out exceptions for religious-based employers and “closely held businesses” whose owners have strong religious objections.

The case is likely to be appealed to the 5th U.S. Circuit Court of Appeals.

“We will have a conservative court looking at that,” said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms. “So I would not say that the vaccines and the women’s health items are totally safe.”

Does this mean my mammogram or HIV treatment won’t be covered without a copayment anymore?

Experts say the decision probably won’t have an immediate effect, partly because appeals are likely and they could continue for months or even years.

Still, if the ruling is upheld by an appellate court or not put on hold while being appealed, “the question for insurers and employers will come up on whether they should make changes for 2023,” said Keith.

Widespread changes next year are unlikely, however, because many insurers and employers have already drawn up their coverage rules and set their rates. And many employers, who backed the idea of allowing the task force to make the recommendations when the ACA was being drafted, might not make substantial changes even if the ruling is upheld on appeal.

“I just don’t see employers for most part really imposing copays for stuff they believe is actually preventive in nature,” said James Gelfand, president of the ERISA Industry Committee, which represents large, self-insured employers.

For the most part, Gelfand said, employers are in broad agreement on the preventive services, although he noted that covering every type or brand of contraceptive without a patient copayment is controversial and that some employers have cited religious objections to covering some services, including the HIV preventive medications.

Religious objections aside, future decisions may have financial consequences. As insurers or employers look for ways to hold down costs, they might reinstitute copayments or deductibles for some of the more expensive preventive services, such as colonoscopies or HIV drugs.

“With some of the higher-ticket items, we could see some plans start cost sharing,” said Corlette.

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

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Children in Northern California Learn to Cope With Wildfire Trauma

Kaiser Health News:States - September 09, 2022

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Still, the Bravo sisters remain vigilant.

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

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

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Hospitals Divert Primary Care Patients to Health Center ‘Look-Alikes’ to Boost Finances

Kaiser Health News:Health Industry - September 09, 2022

A growing number of hospitals are outsourcing often-unprofitable outpatient services for their poorest patients by setting up independent, nonprofit organizations to provide primary care.

Medicare and Medicaid pay these clinics, known as federally qualified health center look-alikes, significantly more than they would if the sites were owned by hospitals.

Like the nearly 1,400 federally qualified health centers — which get those additional dollars as well — a clinic designated by the government as a “look-alike” is also eligible for federal programs that could help reduce costs and recruit providers. They allow the clinics to obtain prescription drugs at deep discounts and attract doctors by making them eligible for a government program that helps them pay off their student debt if they work in an area with a shortage of medical providers.

But unlike the community health centers, the look-alikes do not get an annual federal grant to cover operational costs. Nor do the look-alikes get the financial benefit in which the federal government covers their malpractice risks.

Even though they are not part of a hospital system, many of the hospital-formed look-alikes have clinics on hospital campuses or within a short distance. As a result, the clinics can help divert patients without urgent needs from expensive emergency rooms.

That helps reduce losses, especially from uninsured patients who might have been using the ER for primary care. Converting clinics to look-alikes is also often a strategy for hospitals that have a high proportion of patients enrolled in Medicaid, which generally reimburses hospitals at lower rates than commercial health plans do, said Jeffrey Allen, a partner with the consulting firm Forvis. “It’s a trend that’s gaining momentum,” he said.

Hospitals are betting that they will come out ahead by spinning off a money-losing service and providing grant funding to the look-alike to keep it solvent, he said. At the same time, hospitals expect many patients from the look-alike clinics who need to be admitted for services or require specialized care to be routed to their hospitals, he said.

At least eight hospital systems have converted existing clinics or built new ones that received look-alike designation from 2019 through 2022, according to a KHN analysis of federal data. They include:

  • Parkview Health, a large hospital system in Indiana and Ohio, which opened a look-alike called Alliance Health Centers in Fort Wayne, Indiana, that was designated in 2021. Tami Brigle, a hospital spokesperson, said look-alike status offered the system a better way to provide care to underserved people.
  • Parrish Medical Center in Titusville, Florida, which helped open Space Coast Health Centers, designated as a look-alike in 2022. Parrish spent $1.2 million to set up the clinic, which provides primary care and mental health care, a few blocks from the hospital. “Many of our patients have not had primary care for years and have multiple medical and behavioral needs,” Space Coast CEO Arvin Lewis said in a statement to KHN. “We are working to improve access to care.”
  • Wabash General Hospital, which partnered with a local health department to form Wabash Community Health Center, a look-alike clinic near the hospital in Mount Carmel, Illinois. Danielle Stevens, the hospital’s executive vice president of business development, said that the hospital was treating some clinic patients in its emergency room and that the new facility provided mental health services and physical health in one location. “The intent is to expand services that are currently not offered to the community with the enhanced reimbursement,” she said.
  • Beverly Hospital in Montebello, a city in Los Angeles County, which provided a $3 million loan and donated its women’s clinic to get the look-alike BeverlyCare started, according to BeverlyCare Executive Director Corali Nakamatsu. The look-alike leases office space from the hospital for its adult and pediatrics clinic. That clinic helps patients who need follow-up care after visiting the hospital emergency room. The clinic also gives patients a lower-cost option than using the ER.

Indiana Hospital Association President Brian Tabor said hospitals are sometimes wary of forming a look-alike because it means giving control to a new organization. But, he said, the conversion can benefit both hospitals and patients: “Hospitals are exploring different payment models to support access in rural and underserved areas, and look-alike status has emerged for some as a real critical tool.”

Nationally, 108 look-alike health centers operate today, an increase from 87 in 2020, according to the federal Health Resources and Services Administration. The majority were not started by hospitals.

Look-alike health centers are overseen by a board of directors, and at least 51% of the directors are required to be patients — just like full-fledged community health centers. Look-alike health centers treat patients on a sliding fee scale based on their income.

Organizations typically seek look-alike status from the federal government as a precursor to becoming a fully funded federally qualified health center.

In the Allentown, Pennsylvania, area, both major health systems — St. Luke’s University Health Network and Lehigh Valley Health Network — recently transitioned many of their primary care clinics to look-alikes. Neither hospital would provide a spokesperson to talk about the changes, but both answered questions in writing.

St. Luke’s started Star Community Health in 2018; it received its look-alike designation in 2020. “Star has been able to treat a broader group of individuals that would otherwise not have access to care,” Star CEO Mark Roberts said, although he provided no details about the expansion.

Lehigh Valley converted several of its primary care practices to look-alike status under the name Valley Health Partners Community Health Center. The extra funding from Medicare and Medicaid has allowed the clinics to expand services for mental health and substance use, as well as to offer assistance from financial counselors, social workers, and clinical pharmacists, said spokesperson Jamie Stover.

Lee Health, a hospital system based in Fort Myers, Florida, converted more than two dozen of its outpatient clinics to look-alike status starting in 2014. Bob Johns, senior vice president for Lee Community Healthcare, is the lone full-time executive of the look-alike. The other personnel are still employed by the hospital system.

The higher Medicaid funding has helped pay for four new adult family practice clinics and a pediatric mental health clinic, Johns said. And a mobile health clinic that goes to underserved areas is also partly funded through the enhanced Medicaid reimbursements.

Johns said the look-alike clinic gets about $120 for a Medicaid primary care office visit, nearly double the payment that the clinics received when they were owned by Lee Health.

Johns credits the look-alike clinics for reducing unnecessary ER visits at Lee Health hospitals by at least 20%. Many of those visits were from uninsured patients, he said.

Look-alikes also benefit from the federal 340B program, which allows them to buy medicines at deeply discounted rates to sell to patients. The patients’ insurers typically pay the centers a higher rate, and the clinics keep the difference. Clinics can reduce the out-of-pocket costs for patients but are not required to, although Johns said Lee Health does reduce the drug costs for patients who are uninsured or have low incomes.

Hospital systems like Lee Health that qualify for the 340B program typically can use it for only their admitted patients, Johns said.

The look-alike status also allows the clinics to participate in the National Health Service Corps, a federal program that pays the student loans of clinicians who agree to work in an area with a shortage of health care providers, he said. “It’s a great way for us to hang on to providers,” Johns said.

Shifting care to look-alikes has helped Lee Health find new funding to expand care to the medically underserved, he said.

“It’s a cool model and a very efficient way to use limited resources,” Johns said.

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

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KHN’s ‘What the Health?’: Judge Takes Aim at the Affordable Care Act’s Preventive Care Benefits

Kaiser Health News:The Health Law - September 08, 2022

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

The same federal judge in Texas who tried — unsuccessfully — to strike down the entire Affordable Care Act in 2018 has ruled that portions of the health law’s preventive care benefit package are unconstitutional. But it will be a long time, with many more court actions, before it becomes clear whether the decision will change how the law works.

Meanwhile, the U.S. Department of Veterans Affairs, after several weeks of deliberations, has decided to make abortions available to patients and some dependents in some circumstances. And in Michigan, a closely watched ballot measure on abortion scheduled for this fall may not get a vote after all because of a printing problem.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Among the takeaways from this week’s episode:

  • A decision announced this week by a federal judge in Texas could have a major impact on a popular provision of the Affordable Care Act that gives consumers no-cost access to a host of preventive care tests and treatments. Judge Reed O’Connor said the group that determines which services are eligible for that coverage does not have proper authorization from Congress.
  • O’Connor also ruled that employers with deep religious beliefs should not have to provide HIV prevention medications to workers if the employers believe those drugs encourage improper sexual behavior. The judge has not yet announced how he will suggest both these issues be remedied.
  • The Biden administration announced Thursday that it is overturning a rule implemented by the Trump administration that restricted immigrants’ ability to apply for permanent status in the U.S. if they had received government subsidies.
  • The U.S. Department of Veterans Affairs said it will now provide limited abortions for veterans and their eligible dependents at VA facilities in states that have restricted access to the procedure. The care will be available to veterans and dependents if the pregnancy is a result of rape or incest or is jeopardizing the life of the woman.
  • In Michigan, a state judge ruled that a 1931 ban on abortions is unconstitutional, but that is expected to be appealed. In the meantime, abortion-rights supporters are seeking to get a ballot measure that would guarantee access approved for consideration in the November election. The supporters have enough signatures, but the measure was drafted with a typographical error that could invalidate it. A court is expected to rule on the issue soon.
  • New covid-19 booster immunizations are rolling out to health centers and pharmacies across the country. The administration is encouraging anyone 12 or older (who hasn’t had a vaccination in the past two months) to get the shot. Administration health experts suggest this is the beginning of an effort to simplify the vaccination schedule and hope that most people will need only one shot a year after this. But that goal will depend on how the virus continues to mutate.
  • The Senate is back at work on Capitol Hill, and the House will return next week. The lawmakers still must come up with funding for the fiscal year that begins Oct. 1. Most people expect that they will turn to a temporary funding measure for the short term.
  • Three senators are out with covid, and one key Republican, Sen. Richard Burr of North Carolina, is absent because of a hip replacement. His absence comes at an inopportune time because he has worked with Democrats to try to push through a bill that extends the FDA’s ability to charge user fees to drugmakers to help pay for the agency’s assessments of drugs. He has also helped pull together a bill with Sen. Patty Murray (D-Wash.) to fund more efforts for public health preparedness.

Also this week, Rovner interviews KHN’s Lauren Sausser, who reported and wrote the latest KHN-NPR “Bill of the Month” installment, about a patient in need of a biopsy who did all the right things in advance and still got stuck with a giant bill. If you have an enormous or outrageous medical bill you’d like to send us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “When Does Life Begin? As State Laws Define It, Science, Politics, and Religion Clash,” by Sarah Varney

Alice Miranda Ollstein: The New Yorker’s “When Private Equity Takes Over a Nursing Home,” by Yasmin Rafiei

Joanne Kenen: ProPublica’s “‘The Human Psyche Was Not Built for This,’” by Marilyn W. Thompson and Jenny Deam

Sarah Karlin-Smith: Stat’s “Study Raises Concerns About the Effectiveness of the Monkeypox Vaccine,” by Helen Branswell

Also mentioned in this week’s episode:

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

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

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HHS Approves 12-Month Extension of Postpartum Medicaid and CHIP Coverage in Indiana and West Virginia

HHS Gov News - September 08, 2022
Up to 15,000 more people eligible for care for year after pregnancy, thanks to American Rescue Plan & Administration efforts to improve maternal health

HHS Joins CFPB to Protect Nursing Home Residents and Their Caregivers from Illegal Debt Collection Practices

HHS Gov News - September 08, 2022
In Joint letter with CFPB, HHS Stresses to Nursing Homes & Debt Collectors Prohibition on Requiring Caregivers to Assume Responsibility for Cost of Resident's

En centros de llamadas del 988 se lucha contra el suicidio… y la falta de recursos

Kaiser Health News:Health Industry - September 08, 2022

Un viernes por la tarde, en un centro de llamadas del sureste de Pennsylvania, Michael Colluccio removió su té caliente, se puso los auriculares y encendió la computadora. La pantalla mostraba las llamadas que llegaban a la línea de prevención del suicidio en todo el estado.

Colluccio, de 38 años, dijo que sabe lo que es estar del otro lado de la línea.

“Intenté suicidarme cuando tenía 10 u 11 años”, contó. “Y ahora recibimos llamadas de personas de esa edad, muy jóvenes, que están pasando por situaciones de estrés similares”.

Para las personas que sufren una crisis de salud mental, llamar al 988 puede ser una decisión que les salve la vida. Pero lo que ocurra después de la llamada depende de en donde vivan. El nuevo sistema 988 se puso en marcha a mediados de julio y, según una primera estimación, las llamadas aumentaron un 45% a nivel nacional durante la primera semana.

Aunque es probable que las llamadas aumenten a medida que se conozca la línea de ayuda, en algunos centros de llamadas sienten que la falta de recursos locales limita su trabajo.

Colluccio afirmó que las personas que llaman en su área —el condado de Bucks, al norte de Philadelphia— tienen acceso a más servicios que en otras partes de Pennsylvania. Su trabajo en la Asociación de Servicios para la Familia del condado de Bucks, que gestiona la línea telefónica a nivel local, implica a veces poner en contacto a quienes llaman con servicios como refugios, terapeutas o consejeros sobre drogas y alcohol.

Pero, sobre todo, su trabajo consiste en escuchar.

La primera llamada que Colluccio atendió aquella tarde fue de una mujer que parecía aterrada. Su pareja había estado consumiendo drogas y había empezado a amenazarla violentamente.

Colluccio pasó mucho más tiempo escuchando que hablando. Aseguró que al escuchar atentamente a la persona que llama, ofrece alivio, empatía y conexión humana.

Cuando habla suele hacer preguntas para buscar, con delicadeza, formas concretas de ayuda. En este caso, sus preguntas le llevaron a poner a la persona que llamaba en contacto con los servicios locales de maltrato doméstico y con un trabajador social.

Un servicio al que rara vez recurre es el 911. Parte de la idea del 988 es ofrecer una alternativa a la intervención de la policía o la ambulancia en una crisis de salud mental. Colluccio afirmó que solo utilizaría el 911 si alguien fuera una amenaza inmediata para sí mismo o para otros. Quienes han tenido malas experiencias con el sistema de salud mental han expresado su preocupación y han advertido que si se llamaba al 988 acudiría la policía.

Tras hablar con la mujer durante media hora, Colluccio le hizo preguntas clave para determinar si tenía ideas suicidas. Es un paso importante para asegurarnos de que cada persona que llama está segura después de colgar, señaló.

Al principio de la llamada, parecía que la mujer quería ayuda para su pareja. Pero cuando Colluccio le preguntó directamente, en una escala del 1 al 5, cómo sentía la posibilidad del suicidio, dijo que era un 2 o quizá 3, y que ya había intentado suicidarse.

Antes de colgar, Colluccio le preguntó si quería que la llamaran al día siguiente. Ella dijo que sí, así que programó una llamada.

Colluccio tuvo el tiempo justo para tomar un sorbo de té antes de que entrara otra llamada. Era un joven universitario, agobiado por el estrés. Hablaron durante más de una hora.

Fue una tarde bastante típica, afirmó.

“A veces se trata de hacer una intervención inmediata porque hay quien llama con pastillas en la mano, pensando claramente en acabar con su vida”, expresó Colluccio. “Hay personas que han llamado y han dicho: ‘Si no respondes, me habría suicidado'”.

En todo el país hay más de 200 centros como éste. Las llamadas están vinculadas a códigos de área. Si nadie responde la llamada a nivel local, se envía a otro lugar. La promesa es que siempre habrá alguien al otro lado del teléfono.

En algunos lugares, como el condado de Bucks, hay recursos adicionales para quienes llaman y necesitan más ayuda de la que pueden ofrecer por teléfono. Colluccio puede enviar un equipo de trabajadores de salud mental para visitar a alguien en su casa. Pero en Hanover, Pennsylvania, una ciudad a unas horas al oeste, el centro de llamadas 988 no tiene esa opción.

Jayne Wildasin dirige ese centro y dice que los trabajadores a veces tienen que dejar los auriculares, subirse a sus autos e ir a a ver a la persona que llama, que puede vivir hasta a una hora de distancia.

“Así que ahora mismo, si hay una crisis en la casa de alguien, tendríamos que ir allí”, indicó Wildasin.

En otra parte del estado —el condado rural de Centre— el centro de llamadas local 988 depende de voluntarios, en su mayoría estudiantes universitarios de Penn State. Denise Herr McCann dirige el centro y dijo que su equipo puede llamar a expertos en salud mental, pero que se necesitan más.

Durante décadas, los centros de llamadas para la prevención del suicidio han reunido fondos de fuentes locales, estatales y federales. Con el cambio al 988, ahora deben cumplir con nuevas regulaciones federales, como la recopilación de datos y los requisitos de licencias, puntualizó Julie Dees, que supervisa el centro de llamadas en el condado de Bucks. Todo eso cuesta dinero.

“Los centros de llamadas tienen más responsabilidades, pero no hay fondos adicionales para ello”, añadió Dees.

Se trata de un problema en todo Estados Unidos, según un reciente análisis de Pew Charitable Trusts. La organización de encuestas e investigación señaló que los estados tienen que pagar la factura del cambio al 988, y que muchos de los centros de crisis que realizan esta labor llevan años sin recibir fondos suficientes. Recomendó que los responsables políticos estatales evalúen las necesidades de financiación para garantizar que los servicios de crisis conectados al 988 sean sostenibles y eficientes.

El gobierno de Biden invirtió $432 millones para el desarrollo de la capacidad de los centros de llamadas locales y de refuerzo, así como para servicios asociados. Pero la expectativa es que los estados aporten las principales fuentes de financiación.

La ley de 2020 que promulgó el número 988 también permite a los estados aprobar una legislación para añadir una tasa a las facturas de los teléfonos móviles, como fuente permanente de fondos para el 988 y los servicios de salud mental asociados.

Por temor a que un exceso de llamadas inunden el sistema, Pennsylvania ha decidido no publicitar el nuevo número 988 hasta el próximo año. Los condados necesitan más tiempo para establecer la financiación, contratar trabajadores y crear capacidad para cosas como los equipos móviles de crisis.

Esta historia es parte de una alianza que incluye NPRWITF, y KHN.

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

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New Rule Makes Clear that Noncitizens Who Receive Health or Other Benefits to which they are Entitled Will Not Suffer Harmful Immigration Consequences

HHS Gov News - September 08, 2022
Accessing Children’s Health Insurance Program and Most Medicaid Benefits Will Not Affect Immigration Status

At 988 Call Centers, Crisis Counselors Offer Empathy — And Juggle Limited Resources

Kaiser Health News:Health Industry - September 08, 2022

On a Friday evening at a call center in southeastern Pennsylvania, Michael Colluccio stirred his hot tea, put on his headset, and started up his computer. The screen showed calls coming in to the suicide prevention lifeline from around the state.

Colluccio, 38, said he knows what it’s like to be on the other end of one of those calls.

“So, I had a suicide attempt when I was about 10, 11 years old,” Colluccio said. “And we do get callers who are about that age, or quite young, and they are going through similar stressors.”

For people experiencing a mental health crisis, calling 988 can be a lifesaving decision. But what happens after they call depends on where they are. The new 988 system launched in mid-July, and one early estimate said calls went up 45% nationally during the first week.

With calls likely to increase as more people learn about the helpline, some call centers said there are limits to what they can accomplish without boosting local resources.

Colluccio said callers in his service area — Bucks County, just north of Philadelphia — have access to more services than in many other parts of Pennsylvania. His job with the Family Service Association of Bucks County, which runs the hotline locally, sometimes involves connecting callers with services such as homeless shelters, therapists, or drug and alcohol counselors.

More than anything, his job is to listen.

Colluccio’s first call of the evening was from a woman who sounded panicked. Her partner had been using drugs and started making violent threats.

Colluccio spent a lot more time listening than talking. He said that by listening closely to what a caller has to say, he offers relief, validation, and human connection.

When he does talk, he usually asks questions — gently searching for specific ways to help. In this case, his questions led him to connect the caller with local domestic abuse services and a social worker.

One service he rarely turns to is 911. Part of the idea behind 988 is to offer an alternative to involving police or an ambulance in a mental health crisis. Colluccio said he would typically use 911 only if someone was an immediate threat to themselves or others. Some people who’ve had poor experiences with the mental health system have voiced concerns and warned others about the possibility of a brush with law enforcement if they call 988.

After talking with the woman for a half-hour, Colluccio asked her key questions to determine whether she felt suicidal. It is an important step to make sure each caller is safe after they hang up, he said.

At the start of the call, it seemed the woman wanted help for her partner. But when Colluccio asked her directly on a scale of 1 to 5 how suicidal she was, she said that she was a 2 or maybe a 3 — and that she had attempted suicide before.

Before they ended the call, Colluccio asked her if she would like a call back the next day. She said yes, so he scheduled one.

Colluccio had just enough time for a sip of tea before another call came in. It was a young man in college, overwhelmed by stress. They talked for over an hour.

This was a pretty typical evening, he said.

“Sometimes it’s more of an immediate intervention because sometimes people call with pills in hand and are actively considering ending their lives,” Colluccio said. “There are people who have called and said, ‘If you did not pick up, I’d have killed myself.’”

Nationwide, there are more than 200 call centers like this one. Calls are tied to area codes. If nobody picks up locally, the call gets kicked to somewhere else. The promise is to always have someone pick up the phone.

In some places, like Bucks County, additional resources are available for callers who need more help than counselors can offer on the phone. Colluccio can dispatch a mobile crew of mental health workers to visit someone at home. But in Hanover, Pennsylvania, a town a few hours west, the 988 call center doesn’t have that option.

Jayne Wildasin runs that center and said workers sometimes have to put down their headsets, get in their cars, and go meet with a caller who might live as far as an hour away.

“So right now, if there’s a crisis at someone’s house, we could potentially go there,” Wildasin said.

In another part of the state — rural Centre County — the local 988 call center relies on volunteers — mostly college students from Penn State. Denise Herr McCann runs the operation and said that her team can call in mobile mental health experts, but more of them are needed.

There is also a need for additional mental health professionals who can help once a crisis has passed.

“Sometimes those resources are other counseling services, and they don’t have capacity,” Herr McCann said. “People are calling, and providers are six weeks out if they’re lucky. That’s not any good.”

For decades, suicide prevention call centers have scraped together funding from local, state, and federal sources. With the switch to 988, they now must meet new federal regulations, such as data collecting and licensure requirements, said Julie Dees, who oversees the call center in Bucks County. That all costs money.

“There are increased responsibilities that are being put on the call centers, but there’s really no additional funding being put on that,” Dees said.

It’s an issue around the U.S., according to a recent analysis from the Pew Charitable Trusts. The polling and research organization noted that states are largely left to foot the bill for the change to 988 — and many of the crisis centers doing the work have been underfunded for years. It recommended that state policymakers evaluate funding needs to ensure that crisis services connected to 988 will be sustainable and seamless.

The Biden administration invested $432 million toward building the capacity of local and backup call centers and providing associated services. But the expectation is that states will come up with the main funding streams.

The 2020 law enacting the 988 number also allows states to pass legislation to add a fee to cellphone bills as a permanent source of funds for 988 and associated mental health services.

Pennsylvania’s outgoing Democratic governor has proposed a funding fee model but it hasn’t yet gained traction in the Republican-controlled legislature. The lack of a funding mechanism worries Kevin Boozel, who heads the County Commissioners Association of Pennsylvania.

“This is life or death,” Boozel said. “And you can’t halfway do it.”

Fearing that too many calls could flood the system, Pennsylvania has decided to hold back on publicizing the new 988 number until next year. Counties need more time to set up funding, hire workers, and build capacity for things like those mobile crisis teams.

This story is from a partnership that includes NPR, WITF, and KHN.

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

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Patient Satisfaction Surveys Earn a Zero on Tracking Whether Hospitals Deliver Culturally Competent Care

Kaiser Health News:Health Industry - September 08, 2022

Each day, thousands of patients get a call or letter after being discharged from U.S. hospitals. How did their stay go? How clean and quiet was the room? How often did nurses and doctors treat them with courtesy and respect? The questions focus on what might be termed the standard customer satisfaction aspects of a medical stay, as hospitals increasingly view patients as consumers who can take their business elsewhere.

But other crucial questions are absent from these ubiquitous surveys, whose results influence how much hospitals get paid by insurers: They do not poll patients on whether they’ve experienced discrimination during their treatment, a common complaint of diverse patient populations. Likewise, they fail to ask diverse groups of patients whether they’ve received culturally competent care.

And some researchers say that’s a major oversight.

Kevin Nguyen, a health services researcher at Brown University School of Public Health, who parsed data collected from the government-mandated national surveys in new ways, found that — underneath the surface — they spoke to racial and ethnic inequities in care.

Digging deep, Nguyen studied whether patients in one Medicaid managed-care plan from ethnic minority groups received the same care as their white peers. He examined four areas: access to needed care, access to a personal doctor, timely access to a checkup or routine care, and timely access to specialty care.

“This was pretty universal across races. So Black beneficiaries; Asian American, Native Hawaiian, and Pacific Islander beneficiaries; and Hispanic or Latino or Latinx/Latine beneficiaries reported worse experiences across the four measures,” he said.

Nguyen said that the Consumer Assessment of Healthcare Providers and Systems surveys commonly used by hospitals could be far more useful if they were able to go one layer deeper — for example, asking why it was more difficult to get timely care, or why they don’t have a personal doctor — and if CMS publicly posted not just the aggregate patient experience scores, but also showed how those scores varied by respondents’ race, ethnicity, and preferred language. Such data can help discover whether a hospital or health insurance plan is meeting the needs of all versus only some patients.

Nguyen did not study responses of LGBTQ+ individuals or, for example, whether people received worse care because they were obese.

The CAHPS survey is required by the federal government for many health care facilities, and the hospital version of it is required for most acute care hospitals. Low scores can induce financial penalties, and hospitals reap financial rewards for improving scores or exceeding those of their peers.

The CAHPS Hospital Survey, known as HCAHPS, has been around for more than 15 years. The results are publicly reported by the Centers for Medicare & Medicaid Services to give patients a way to compare hospitals, and to give hospitals incentive to improve care and services. Patient experience is just one thing the federal government publicly measures; readmissions and deaths from conditions including heart attacks and treatable surgery complications are among the others.

Dr. Meena Seshamani, director of the Center for Medicare, said that patients in the U.S. seem to be growing more satisfied with their care: “We have seen significant improvements in the HCAHPS scores over time,” she said in a written statement, noting, for example, that the percentage of patients nationally who said their nurses “always” communicated well rose from 74% in 2009 to 81% in 2020.

But for as long as these surveys have been around, doubts about what they really capture have persisted. Patient experience surveys have become big business, with companies marketing methods to boost scores. Researchers have questioned whether the emphasis on patient satisfaction — and the financial carrots and sticks tied to them — have led to better care. And they have long suspected institutions can “teach to the test” by training staff to cue patients to respond in a certain way.

National studies have found the link between patient satisfaction and health outcomes is tenuous at best. Some of the more critical research has concluded that “good ratings depend more on manipulable patient perceptions than on good medicine,” citing evidence that health professionals were motivated to respond to patients’ requests rather than prioritize what was best from a care standpoint, when they were in conflict. Hospitals have also scripted how nurses should speak to patients to boost their satisfaction scores. For example, some were instructed to cue patients to say their room was quiet by making sure to say out loud, “I am closing the door and turning out the lights to keep the hospital quiet at night.”

About a decade ago, Robert Weech-Maldonado, a health services researcher at the University of Alabama-Birmingham, helped develop a new module to add to the HCAHPS survey “dealing with things like experiences with discrimination, issues of trust.” Specifically, it asked patients how often they’d been treated unfairly due to characteristics like race or ethnicity, the type of health plan they had (or if they lacked insurance), or how well they spoke English. It also asked patients if they felt they could trust the provider with their medical care. The goal, he said, was for that data to be publicly reported, so patients could use it.

Some of the questions made it into an optional bit of the HCAHPS survey — including questions on how often staffers were condescending or rude and how often patients felt the staff cared about them as a person — but CMS doesn’t track how many hospitals use them or how they use the results. And though HCAHPS asks respondents about their race, ethnicity and language spoken at home, CMS does not post that data on its public patient website, nor does it show how patients of various identities responded compared with others.

Without wider use of explicit questions about discrimination, Dr. Jose Figueroa, an assistant professor of health policy and management at the Harvard School of Public Health, doubts HCAHPS data alone would “tell you whether or not you have a racist system” — especially given the surveys’ slumping response rates.

One exciting development, he said, lies with the emerging ability to analyze open-ended (rather than multiple-choice) responses through what’s called natural language processing, which uses artificial intelligence to analyze the sentiments people express in written or spoken statements as an addendum to the multiple-choice surveys.

One study analyzing hospital reviews on Yelp identified characteristics patients think are important but aren’t captured by HCAHPS questions — like how caring and comforting staff members were, and the billing experience. And a study out this year in the journal Health Affairs used the method to discover that providers at one medical center were much more likely to use negative words when describing Black patients compared with their white counterparts.

“It’s simple, but if used in the right way can really help health systems and hospitals figure out whether they need to work on issues of racism within them,” said Figueroa.

Press Ganey Associates, a company that a large number of U.S. hospitals pay to administer these surveys, is also exploring this idea. Dr. Tejal Gandhi leads a project there that, among other things, aims to use artificial intelligence to probe patients’ comments for signs of inequities.

“It’s still pretty early days,” Gandhi said. “With what’s gone on with the pandemic, and with social justice issues, and all those things over the last couple of years, there’s just been a much greater interest in this topic area.”

Some hospitals, though, have taken the tried-and-true route to understanding how to better meet patients’ needs: talking to them.

Dr. Monica Federico, a pediatric pulmonologist at the University of Colorado School of Medicine and Children’s Hospital Colorado in Denver, started an asthma program at the hospital several years ago. About a fifth of its appointments proved no-shows. The team needed something more granular than patient satisfaction data to understand why.

“We identified patients who had been in the hospital for asthma, and we called them, and we asked them, you know, ‘Hey, you have an appointment in the asthma clinic coming up. Are there any barriers to you being able to come?’ And we tried to understand what those were,” said Federico. At the time, she was one of the only Spanish-speaking providers in an area where pediatric asthma disproportionately affects Latino residents. (Patients also cited problems with transportation and inconvenient clinic hours.)

After making several changes, including extending the clinic’s hours into the evening, the no-show appointment rate nearly halved.

CAHPS surveys are embedded in American health care culture and are likely here to stay. But CMS is now making tentative efforts in surveys to address the issues that were previously overlooked: As of this summer, it is testing a question for a subset of patients 65 and older that would explicitly ask if anyone from a clinic, emergency room, or doctor’s office treated them “in an unfair or insensitive way” because of characteristics including race, ethnicity, culture, or sexual orientation.

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

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This story can be republished for free (details).

Statement from HHS Secretary Xavier Becerra on CDC’s Recommendation of An Updated COVID-19 Vaccine

HHS Gov News - September 07, 2022
Updated COVID-19 shots are expected to protect against the currently circulating Omicron variant

HHS Secretary Becerra Issues 564 Declaration to Expand the Availability of Testing for Monkeypox

HHS Gov News - September 07, 2022
HHS Secretary Becerra signed a declaration under section 564 of the Federal Food, Drug, and Cosmetic Act to allow emergency use authorizations.

‘It’s Becoming Too Expensive to Live’: Anxious Older Adults Try to Cope With Limited Budgets

Kaiser Health News:Medicaid - September 07, 2022

Economic insecurity is upending the lives of millions of older adults as soaring housing costs and inflation diminish the value of fixed incomes.

Across the country, seniors who until recently successfully managed limited budgets are growing more anxious and distressed. Some lost work during the covid-19 pandemic. Others are encountering unaffordable rent increases and the prospect of losing their homes. Still others are suffering significant sticker shock at grocery stores.

Dozens of older adults struggling with these challenges — none poor by government standards — wrote to me after I featured the Elder Index, a measure of the cost of aging, in a recent column. That tool, developed by researchers at the Gerontology Institute at the University of Massachusetts-Boston, suggests that 54% of older women who live alone have incomes below what’s needed to pay for essential expenses. For single men, the figure is 45%.

To learn more, I spoke at length to three women who reached out to me and were willing to share highly personal details of their lives. Their stories illustrate how unexpected circumstances — the pandemic and its economic aftereffects, natural disasters, and domestic abuse — can result in unanticipated precarity in later life, even for people who worked hard for decades.

Bettye Cohen

“After 33 years living in my apartment, I will have to move since the new owners of the building are renovating all apartments and charging rents of over $1,800 to 2,500/month which I cannot afford.”

Cohen, 79, has been distraught since learning that the owners of her Towson, Maryland, apartment complex are raising rents precipitously as they upgrade units. She pays $989 monthly for a one-bedroom apartment with a terrace. A similar apartment that has been redone recently went on the market for $1,900.

This is a national trend affecting all age groups: As landlords respond to high demand, rent hikes this year have reached 9.2%.

Cohen has been told that her lease will be canceled at the end of January and that she’ll be charged $1,200 a month until it’s time for her apartment to be refurbished and for her to vacate the premises.

“The devastation, I cannot tell you,” she said during a phone conversation. “Thirty-three years of living in one place lets you know I’m a very boring person, but I’m also a very practical, stable person. I never in a million years would have thought something like this would happen to me.”

During a long career, Cohen worked as a risk manager for department stores and as an insurance agent. She retired in 2007. Today, her monthly income is $2,426: $1,851 from Social Security after payments for Medicare Part B coverage are taken out, $308 from an individual retirement account, and $267 from a small pension.

In addition to rent, Cohen estimates she spends $200 to $240 a month on food, $165 on phone and internet, $25 on Medicare Advantage premiums, $20 on dental care, $22 for gas, and $100 or more for incidentals such as cleaning products and toiletries.

That doesn’t include non-routine expenses, such as new partial dentures that Cohen needs (she guesses they’ll cost $1,200) or hearing aids that she purchased several years ago for $3,400, drawing on a small savings account. If forced to relocate, Cohen estimates moving costs will top $1,000.

Cohen has looked for apartments in her area, but many are in smaller buildings, without elevators, and not readily accessible to someone with severe arthritis, which she has. One-bedroom units are renting for $1,200 and up, not including utilities, which might be an additional $200 or more. Waiting lists for senior housing top two years.

“I’m miserable,” Cohen told me. “I’m waking up in the middle of the night a lot of times because my brain won’t shut off. Everything is so overwhelming.”

Carrie England

“It’s becoming too expensive to be alive. I’ve lost everything and break down on a daily basis because I do not know how I can continue to survive with the cost of living.”

England, 61, thought she’d grow old in a three-bedroom home in Winchester, Virginia, that she said she purchased with her partner in 1999. But that dream exploded in January 2021.

Around that time, England learned to her surprise that her name was not on the deed of the house she’d been living in. She had thought that had been arranged, and she contacted a legal aid lawyer, hoping to recover money she’d put into the property. Without proof of ownership, the lawyer told her, she didn’t have a leg to stand on.

“My nest was the house. It’s gone. It was my investment. My peace of mind,” England told me.

England’s story is complicated. She and her partner ended their longtime romantic relationship in 2009 but continued living together as friends, she told me. That changed during the pandemic, when he stopped working and England’s work as a caterer and hospitality specialist abruptly ended.

“His personality changed a lot,” she said, and “I started encountering emotional abuse.”

Trying to cope, England enrolled in Medicaid and arranged for eight sessions with a therapist specializing in domestic abuse. Those ended in November 2021, and she hasn’t been able to find another therapist since. “If I wasn’t so worried about my housing situation, I think I could process and work through all the things that have happened,” she told me.

After moving out of her home early in 2021, England relocated to Ashburn, Virginia, where she rents an apartment for $1,511 a month. (She thought, wrongly, that she would qualify for assistance from Loudoun County.) With utilities and trash removal included, the monthly total exceeds $1,700.

On an income of about $2,000 a month, which she scrambles to maintain by picking up gig work whenever she can, England has less than $300 available for everything else. She has no savings. “I do not have a life. I don’t do anything other than try to find work, go to work, and go home,” she said.

England knows her housing costs are unsustainable, and she has put her name on more than a dozen waiting lists for affordable housing or public housing. But there’s little chance she’ll see progress on that front anytime soon.

“If I were a younger person, I think I would be able to rebound from all the difficulties I’m having,” she told me. “I just never foresaw myself being in this situation at the age I am now.”

Elaine Ross

“Please help! I just turned 65 and [am] disabled on disability. My husband is on Social Security and we cannot even afford to buy groceries. This is not what I had in mind for the golden years.”

When asked about her troubles, Ross, 65, talks about a tornado that swept through central Florida on Groundhog Day in 2007, destroying her home. Too late, she learned her insurance coverage wasn’t adequate and wouldn’t replace most of her belongings.

To make ends meet, Ross started working two jobs: as a hairdresser and a customer service representative at a convenience store. With her new husband, Douglas Ross, a machinist, she purchased a new home. Recovery seemed possible.

Then, Elaine Ross fell twice over several years, breaking her leg, and ended up having three hip replacements. Trying to manage diabetes and beset by pain, Ross quit working in 2016 and applied for Social Security Disability Insurance, which now pays her $919 a month.

She doesn’t have a pension. Douglas stopped working in 2019, no longer able to handle the demands of his job because of a bad back. He, too, doesn’t have a pension. With Douglas’ Social Security payment of $1,051 a month, the couple live on just over $23,600 annually. Their meager savings evaporated with various emergency expenditures, and they sold their home.

Their rent in Empire, Alabama, where they now live, is $540 a month. Other regular expenses include $200 a month for their truck and gas, $340 for Medicare Part B premiums, $200 for electricity, $100 for medications, $70 for phone, and hundreds of dollars — Ross didn’t offer a precise estimate — for food.

“All this inflation, it’s just killing us,” she said. Nationally, the price of food consumed at home is expected to rise 10% to 11% this year, according to the U.S. Department of Agriculture.

To cut costs, Ross has been turning off her air conditioning during peak hours for electricity rates, 1 p.m. to 7 p.m., despite summer temperatures in the 90s or higher. “I sweat like a bullet and try to wear the least amount of clothes possible,” she said.

“It’s awful,” she continued. “I know I’m not the only old person in this situation, but it pains me that I lived my whole life doing all the right things to be in the situation I’m in.”

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

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

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Organ Transplants Are Up, but the Agency in Charge Is Under Fire

Kaiser Health News:Health Industry - September 07, 2022

For the past decade, Precious McCowan’s life has revolved around organ transplants. She’s a doctoral candidate studying human behavior in Dallas who has survived two kidney transplants. And in the midst of her end-stage renal disease, her 2-year-old son died. She chose to donate his organs in hopes they would save a life.

Now her kidney function is failing again, and she’s facing the possibility of needing a third transplant. But the process of finding that lifesaving organ is rife with problems. Roughly 5,000 patients a year are dying on the waitlist — even as perfectly good donated organs end up in the trash. The agency that oversees donations and transplants is under scrutiny for how many organs are going to waste. The agency, the United Network for Organ Sharing, received a bipartisan tongue-lashing at a recent congressional hearing.

“Patients, we’re not looking at that,” McCowan said, referring to the policy debates. “We’re like, ‘Hey, I need a kidney for me. I need it now. I’m tired of dialysis. I feel like I’m about to die.’”

The number of kidney transplants increased last year by 16% under a new policy implemented by UNOS that prioritizes sicker patients over those who live closest to a transplant center. Still, nearly 100,000 patients are waiting on kidneys and even more for other organs.

A two-year inquiry by the Senate Finance Committee uncovered numerous incidents previously undisclosed publicly. A few examples:

  • Charleston, South Carolina: In November 2018, a patient died after receiving an organ with the wrong blood type.
  • Las Vegas: In July 2017, two kidney recipients contracted a rare infection. One died days later.
  • Kettering, Ohio: In June 2020, a transplant recipient was informed that he had accidentally received an organ from a donor with cancer and would likely develop cancer.

UNOS has held the contract to manage organ distribution since the beginning of the nation’s transplant system in 1984, and now U.S. senators — both Democrats and Republicans — are questioning whether it’s time for another entity to step in.

“The organ transplant system overall has become a dangerous mess,” Sen. Elizabeth Warren (D-Mass.) said during the Aug. 3 hearing. “Right now, UNOS is 15 times more likely to lose or damage an organ in transit as an airline is to lose or damage your luggage. That is a pretty terrible record.”

The investigation places blame on antiquated technology. The UNOS computer system has gone down for an hour or more at a time, delaying matches when every hour counts. There’s also no standard way to track an organ, even as companies like Amazon can locate any package, anywhere, anytime.

“I can’t even get a kidney that’s 20 miles away from my transplant center, with UNOS thinking it was in Miami,” said Barry Friedman, executive director of the transplant center at AdventHealth in Orlando, Florida. “It was actually in Orlando, 20 miles away.”

In the decade from 2010 to 2020, the congressional report found, UNOS received 53 complaints about transportation including numerous missed flights leading to canceled transplants and discarded organs. The report also cited a 2020 KHN investigation that uncovered many more incidents — nearly 170 transportation failures from 2014 to 2019. Even when organs do arrive, transplant surgeons say the lack of tracking leads to longer periods of “cold time” — when organs are in transit without blood circulation — because transplant surgeons often can’t start a patient on anesthesia until the organ is physically in hand.

One in 4 potential donor kidneys, according to the latest UNOS data, now go to waste. And that number has gotten worse as organs travel farther to reach sicker patients under the new allocation policy.

At the University of Alabama-Birmingham, a kidney arrived frozen solid and unusable in 2014, said Dr. Jayme Locke, who directs the transplant program. In 2017, a package came “squished” with apparent tire marks on it (though, remarkably, the organ was salvaged). And in one week in May of this year, Locke said, four kidneys had to be tossed for avoidable errors in transportation and handling.

“Opacity at UNOS means we have no idea how often basic mistakes happen across the country,” she said.

UNOS CEO Brian Shepard has announced he’s stepping down at the end of September. He defends the organization he has led for a decade, pointing to the rising rate of transplants.

The new kidney allocation policy, which was challenged in court, is partly responsible for that increased transplant rate. The policy also contributed to equity gains, boosting transplants for Black patients by 23%. Black patients, who are more likely to experience kidney failure, have had difficulty getting onto transplant lists.

“While there are things we can improve — and we do every day — I do think it’s a strong organization that has served patients well,” Shepard said.

Another independent government report, published this year, found that any blame should be shared with the hospital transplant centers and the local organizations that procure organs from donors. The three entities work together but tend to turn into a triangular firing squad when people start asking why so many patients still die waiting for organs.

“[UNOS] is not the only source of problems with efficiency in the system,” said Renée Landers, a law professor who leads the biomedical concentration at Suffolk University in Boston. She was on the committee that helped produce the broader report. “Everybody had some work that they needed to do.”

The recent watchdog reports, as well as several ongoing legal battles over revised organ distribution maps, are just noise to McCowan, the Dallas transplant patient, as she faces the prospect of trying to get on yet another waitlist. She said she’s encouraged by the rising transplant rate, especially for Black patients like herself, but also fears she may not get so lucky with a third round on the waitlist.

“I just need a kidney that works for me,” she said. “And I need it now.”

This story is part of a partnership that includes Nashville Public RadioNPR, and KHN.

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

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‘Science Friday’ and KHN: Examining Medicine’s Definition of Death Informs the Abortion Debate

Kaiser Health News:Health Industry - September 07, 2022

There is a widespread consensus in medicine on the definition of death, and those standards have been codified into laws in nearly every U.S. state.

There’s no such medical consensus on the answer to another big question: When does human life begin? With the overturning of Roe v. Wade, that question has big implications for health care.

“There has not been the same effort to really define what constitutes the beginning of life,” said KHN senior correspondent Sarah Varney.

Varney shared her reporting with “Science Friday” host Ira Flatow after interviewing experts, including David Magnus, a bioethicist and director of the Stanford Center for Biomedical Ethics.

“Biological occurrences are processes, not events,” Magnus said. “That means deciding where you want to draw lines is a decision to be made, not something to be discovered. So we have to decide where lines make the most sense.”

It can be a complicated decision. 

“When people talk about beginning at the time of conception, do they mean when the sperm first comes in contact with the zona pellucida of the egg cell? Is it when that actual nucleic material, that DNA, actually starts to play a role, which isn’t till a few cell divisions in? Somewhere in that process we call that conception,” Magnus said.

People on all sides of the abortion debate want answers, but some bioethicists said science suggests that conception might be too early a point to consider the onset of personhood.

Ultimately, asking doctors “What is life?” or “What is death?” may miss the point, Magnus said.

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

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HHS Awards $20 Million Contract to AmerisourceBergen to Expand, Quicken Distribution of Vaccines and Treatments for Monkeypox

HHS Gov News - September 06, 2022
HHS Awards $20 Million Contract to AmerisourceBergen to Expand, Quicken Distribution of Vaccines and Treatments for Monkeypox

When Does Life Begin? As State Laws Define It, Science, Politics, and Religion Clash

Kaiser Health News:Marketplace - September 06, 2022

As life-preserving medical technology advanced in the second half of the 20th century, doctors and families were faced with a thorny decision, one with weighty legal and moral implications: How should we define when life ends? Cardiopulmonary bypass machines could keep the blood pumping and ventilators could maintain breathing long after a patient’s natural ability to perform those vital functions had ceased.

After decades of deliberations involving physicians, bioethicists, attorneys, and theologians, a U.S. presidential commission in 1981 settled on a scientifically derived dividing line between life and death that has endured, more or less, ever since: A person was considered dead when the entire brain — including the brainstem, its most primitive portion — was no longer functioning, even if other vital functions could be maintained indefinitely through artificial life support.

In the decades since, the committee’s criteria have served as a foundation for laws in most states adopting brain death as a standard for legal death.

Now, with the overturning of Roe v. Wade and dozens of states rushing to impose abortion restrictions, American society is engaged in a chaotic race to define the other pole of human existence: When exactly does human life begin? At conception, the hint of a heartbeat, a first breath, the ability to survive outside the womb with the help of the latest technology?

That we’ve been able to devise and apply uniform clinical standards for when life ends, but not when it begins, is due largely to the legal and political maelstrom around abortion. And in the two months since the U.S. Supreme Court issued its opinion in Dobbs v. Jackson Women’s Health Organization, eliminating a long-standing federal right to abortion, state legislators are eagerly bounding into that void, looking to codify into law assorted definitions of life that carry profound repercussions for abortion rights, birth control, and assisted reproduction, as well as civil and criminal law.

“The court said that when life begins is up to whoever is running your state — whether they are wrong or not, or you agree with them or not,” said Mary Ziegler, a law professor at the University of California-Davis who has written several books on the history of abortion.

Unlike the debate over death, which delved into exquisite medical and scientific detail, the legislative scramble to determine when life’s building blocks reach a threshold that warrants government protection as human life has generally ignored the input of mainstream medical professionals.

Instead, red states across much of the South and portions of the Midwest are adopting language drafted by elected officials that is informed by conservative Christian doctrine, often with little scientific underpinning.

A handful of Republican-led states, including Arkansas, Kentucky, Missouri, and Oklahoma, have passed laws declaring that life begins at fertilization, a contention that opens the door to a host of pregnancy-related litigation. This includes wrongful death lawsuits brought on behalf of the estate of an embryo by disgruntled ex-partners against physicians and women who end a pregnancy or even miscarry. (One such lawsuit is underway in Arizona. Another reached the Alabama Supreme Court.)

In Kentucky, the law outlawing abortion uses morally explosive terms to define pregnancy as “the human female reproductive condition of having a living unborn human being within her body throughout the entire embryonic and fetal stages of the unborn child from fertilization to full gestation and childbirth.”

Several other states, including Georgia, have adopted measures equating life with the point at which an embryo’s nascent cardiac activity can be detected by an ultrasound, at around six weeks of gestation. Many such laws mischaracterize the flickering electrical impulses detectible at that stage as a heartbeat, including in Georgia, whose Department of Revenue recently announced that “any unborn child with a detectable human heartbeat” can be claimed as a dependent.

The Supreme Court’s 1973 decision in Roe v. Wade that established a constitutional right to abortion did not define a moment when life begins. The opinion, written by Justice Harry Blackmun, observed that the Constitution does not provide a definition of “person,” though it extends protections to those born or naturalized in the U.S. The court majority made note of the many disparate views among religions and scientists on when life begins, and concluded it was not up to the states to adopt one theory of life.

Instead, Roe created a framework intended to balance a pregnant woman’s right to make decisions about her body with a public interest in protecting potential human life. That decision and a key ruling that followed generally recognized a woman’s right to abortion up to the point medical professionals judge a fetus viable to survive outside the uterus, at about 24 weeks of gestation.

In decisively overturning Roe in June, the Supreme Court’s conservative majority drew on legal arguments that have shaped another contentious end-of-life issue. The legal standard employed in Dobbs — that there is no right to abortion in the federal Constitution and that states can decide on their own — is the same rationale used in 1997 when the Supreme Court said terminally ill people did not have a constitutional right to medically assisted death. That decision, Washington v. Glucksberg, is mentioned 15 times in the majority opinion for Dobbs and a concurrence by Justice Clarence Thomas.

Often, the same groups that have led the fight to outlaw abortion have also challenged medical aid-in-dying laws. Even after Dobbs, so-called right-to-die laws remain far less common than those codifying state abortion rights. Ten states allow physicians to prescribe lethal doses of medicine for terminally ill patients. Doctors are still prohibited from administering the drugs.

James Bopp, general counsel for the National Right to Life Committee who has been central to the efforts to outlaw abortion, said that both abortion and medically assisted death, which he refers to as physician-assisted suicide, endanger society.

“Every individual human life has inherent value and is sacred,” said Bopp. “The government has the duty to protect that life.”

Both issues raise profound societal questions: Can the government keep a patient on life support against his wishes, or force a woman to give birth? Can states bar their own residents from going to other states to end a pregnancy, or prohibit out-of-state patients from coming in to seek medically assisted death? And who gets to decide, particularly if the answer imposes a singular religious viewpoint?

Just as there are legal implications that flow from determining a person’s death, from organ donation to inheritance, the implied rights held by a legally recognized zygote are potentially vast. Will death certificates be issued for every lost pregnancy? Will miscarriages be investigated? When will Social Security numbers be issued? How will census counts be tallied and congressional districts drawn?

Medical professionals and bioethicists caution that both the beginning and end of life are complicated biological processes that are not defined by a single identifiable moment — and are ill suited to the political arena.

“Unfortunately, biological occurrences are not events, they are processes,” said David Magnus, director of the Stanford Center for Biomedical Ethics.

Moreover, asking doctors “What is life?” or “What is death?” may miss the point, said Magnus: “Medicine can answer the question ‘When does a biological organism cease to exist?’ But they can’t answer the question ‘When does a person begin or end?’ because those are metaphysical issues.”

Ben Sarbey, a doctoral candidate in Duke University’s department of philosophy who studies medical ethics, echoed that perspective, recounting the Paradox of the Heap, a thought experiment that involves placing grains of sand one on top of the next. The philosophical quandary is this: At what point do those grains of sand become something more — a heap?

“We’re going to have a rough time placing a dividing line that this counts as a person and this does not count as a person,” he said. “Many things count as life — a sperm counts as life, a person in a persistent vegetative state counts as life — but does that constitute a person that we should be protecting?”

Even as debate over the court’s abortion decision percolates, the 1981 federal statute that grew out of the presidential committee’s findings, the Uniform Determination of Death Act, is also under review. This year, the Uniform Law Commission, a nonpartisan group of legal experts that drafts laws intended for adoption in multiple states, has taken up the work to revisit the definition of death.

The group will consider sharpening the medical standards for brain death in light of advances in the understanding of brain function. And they will look to address lingering questions raised in recent years as families and religious groups have waged heated legal battles over terminating artificial life support for patients with no brain wave activity.

Bopp, with the National Right to Life Committee, is among those serving on advisory panels for the effort, along with an array of doctors, philosophers, and medical ethicists. The concept of “personhood” that infuses the anti-abortion movement’s broader push for fetal rights is expected to be an underlying topic, albeit in mirror image: When does a life form cease being a person?

Magnus, who is also serving on an advisory panel, has no doubt the commission will reach a consensus, a sober resolution rooted in science. What’s less clear, he said, is whether in today’s political environment that updated definition will hold the same sway, an enduring legal standard embraced across states.

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

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‘He Stood His Ground’: California State Senator Will Leave Office as Champion of Tough Vaccine Laws

Kaiser Health News:States - September 06, 2022

SACRAMENTO, Calif. — A California lawmaker who rose to national prominence by muscling through some of the country’s strongest vaccination laws is leaving the state legislature later this year after a momentous tenure that made him a top target of the boisterous and burgeoning movement against vaccination mandates.

State Sen. Richard Pan, a bespectacled and unassuming pediatrician who continued treating low-income children during his 12 years in the state Senate and Assembly, has been physically assaulted and verbally attacked for working to tighten childhood vaccine requirements — even as Time magazine hailed him as a “hero.” Threats against him intensified in 2019, becoming so violent that he needed a restraining order and personal security detail.

“It got really vicious, and the tenor of these protests inside the Capitol building didn’t make you feel safe, yet he stood his ground,” said Karen Smith, director of the California Department of Public Health from 2015 to 2019. “Dr. Pan is unusual because he has the knowledge and belief in science, but also the conviction to act on it.”

“That takes courage,” she added. “He’s had a tremendous impact in California, and there’s going to be a hole in the legislature when he’s gone.”

The Democrat from Sacramento is leaving the Capitol because of legislative term limits that restrict state lawmakers to 12 years of service. He has overseen state budget decisions on health care and since 2018 has chaired the Senate Health Committee, a powerful position that has allowed him to shape health care coverage for millions of Californians.

Pan, 56, helped lead the charge to restore vision, dental, and other benefits to California’s Medicaid program, called Medi-Cal, after they were slashed during the Great Recession. Since then, he has pushed to expand social services to some of the most vulnerable enrollees.

He was instrumental in implementing the Affordable Care Act in California, and when Republicans attacked the law after Donald Trump was elected president, Pan spearheaded measures to cement its provisions in state law. After the Republican-controlled Congress axed the federal coverage mandate in 2017, he led the effort to create the state penalty for not having health insurance. And he negotiated with the governor to expand health insurance subsidies for low- and middle-income Californians.

In 2020, Pan authored legislation that will put California in the generic drug-making business, starting with insulin.

“What drives me is my commitment to health and healthy communities,” Pan told KHN.

But he hasn’t always succeeded. Some of his bills — including those to expand benefits and improve the quality of care for Medi-Cal enrollees — were stalled by the influential health insurance industry or opposition from his own party. And this year, Pan retreated on his contentious proposal to require schoolchildren to get vaccinated against covid-19.

Pan has also faced criticism that he’s too closely aligned with the health care industry, including the California Medical Association, or CMA, a deep-pocketed group that lobbies in Sacramento on behalf of doctors. On contentious policy fights, such as those dealing with provider pay or physician authority, Pan has often sided with his fellow doctors.

For instance, he rallied with the doctor association against a long-sought attempt to give nurse practitioners the ability to practice without physician supervision — a bill that was one of the association’s top legislative targets but one that ultimately passed despite its vehement opposition. And two key bills that sought to rein in health care costs died in his committee after clearing the state Assembly — one in 2019 to limit surprise medical bills for emergency room visits and another this year to give the state attorney general authority over some hospital and health system mergers.

“He’s inseparable from the doctors’ lobby, and obviously he carries water for the CMA,” said Jamie Court, president of the advocacy group Consumer Watchdog, arguing that Pan has stood in the way of progressive health care bills such as a proposal to create a government-run, single-payer health care system.

Pan rejected claims that he’s too close to the industry. “I’m proud to be a member of the CMA, but I don’t just blindly follow CMA,” he said. When it came to the nurse practitioner legislation, he said, his concerns “came from my knowledge about professional medical education and how that influences patient outcomes.”

Pan isn’t running for anything this year but isn’t ruling out the possibility of doing so in the future. For now, he said, he’s focusing on his work in Sacramento until his term ends Nov. 30. After that, he plans to practice medicine full time.

Pan said the public hasn’t heard the last of him when it comes to improving Medi-Cal. The state must do more to ensure high-quality care and equitable access for the 14.5 million Californians enrolled in the low-income health program, he said.

Pan said he entered politics to improve community health. He left his job as a faculty member and head of the pediatric residency program at the University of California-Davis to run for state Assembly in 2010. He served two terms before being elected to the state Senate in 2014.

Early on, he found himself at the forefront of California’s wars over vaccination mandates.

In 2012, he authored a law making it more difficult for parents to obtain personal belief exemptions for vaccines that are required for children entering public and private schools and that prevent communicable diseases such as measles and polio. In 2015, he succeeded in banning personal belief exemptions for schoolchildren altogether.

In 2019, when lawmakers were voting on Pan’s bill that cracked down on bogus medical exemptions for required school immunizations, a protester hurled menstrual blood at them on the Senate floor. Pan also clashed with Gov. Gavin Newsom, who watered down the bill by demanding amendments that allowed doctors to retain significant authority over the exemptions. Newsom ultimately signed the measure.

“I didn’t run for the legislature because I was planning to do vaccine legislation, but I care about children and that’s what I’ve devoted my life to,” said Pan, who got his medical degree from the University of Pittsburgh and a master’s degree in public health from Harvard University. “We had a whooping cough outbreak, and 10 infants died. And I was very concerned about the fact that we could prevent these diseases, yet we were failing.”

This year, Pan introduced legislation to require covid vaccinations for school-age kids but pulled it in April, saying it would be difficult for California officials to enforce. At the time, the covid vaccination rate for schoolchildren “was too low — around 30%,” Pan said. He concluded the state should redouble its efforts to increase vaccination rates before instituting a mandate.

Pan also noted that covid-19 was mutating fast and that emerging research indicated that the vaccines weren’t very good at combating new variants. “The vaccine is very effective protecting against death, but its ability to slow down transmission seemed to decrease,” Pan said. “Unfortunately, it has also been so politicized, so we have more work to do.”

As chair of California’s Asian & Pacific Islander Legislative Caucus, Pan in 2021 helped secure a $157 million investment to combat violence and hate crimes against Asian Americans and was a powerful force advocating for more money for the state’s beleaguered public health system — a fight Democrats finally won last year when Newsom approved $300 million in ongoing funding.

State Sen. Scott Wiener (D-San Francisco) said that Pan inspired his interest in introducing tough vaccination and public health bills and that he regularly asks Pan’s advice before unveiling legislative proposals. “I’d randomly call him all the time,” Wiener said. “There’s really no one in the Senate with the experience and knowledge he has.”

Brainy and studious, Pan regularly delves deep into scientific evidence during legislative floor debates. Interviews with reporters often result in lengthy discourses about the history of the U.S. health care system — like the time a question about hospital financing led to a lesson in how hospitals are both profit-earning enterprises and institutions that provide charity care.

“How serious you are about every undertaking — it really can be a joy and an irritation,” said Senate leader Toni Atkins, who affectionately thanked Pan for his work on the floor of the Senate in mid-August. “You took a lot of flak from folks in a lot of ways, and through it all, your integrity, your sense of humor, and your very good nature has withstood it all.”

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

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

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Watch: The Mysterious Death of a Congressman’s Wife

Kaiser Health News:States - September 06, 2022

KHN senior correspondent Samantha Young appeared on CBS News to discuss her exclusive coverage of the death of Lori McClintock, the wife of Northern California congressman Tom McClintock.

When Lori McClintock died in December 2021, what caused her death wasn’t clear. The original death certificate, dated Dec. 20, 2021, listed the cause of death as “pending.”

Months later, the Sacramento County coroner’s office determined that she died from dehydration due to gastroenteritis — an inflammation of the stomach and intestines — that was caused by “adverse effects of white mulberry leaf ingestion,” according to a report from the coroner.

White mulberry leaf, a plant that is generally considered safe, is used as an herbal remedy for a variety of ailments, including diabetes, obesity, and high cholesterol. It’s unclear from the Sacramento County coroner’s autopsy report whether Lori McClintock took a dietary supplement containing white mulberry leaf, ate fresh or dried leaves, or drank them in a tea, but a “partially intact” white mulberry leaf was found in her stomach, according to the report.

Her death underscores the potential risks of dietary supplements and herbal remedies.

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

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