States are preparing to remove millions of people from Medicaid as protections put in place early in the covid-19 pandemic expire.

The upheaval, which begins in April, will put millions of low-income Americans at risk of losing health coverage, threatening their access to care and potentially exposing them to large medical bills.

It will also put pressure on the finances of hospitals, doctors, and others relying on payments from Medicaid, a state-federal program that covers lower-income people and people with disabilities.

Almost three years ago, as covid sent the economy into free fall, the federal government agreed to send billions of dollars in extra Medicaid funding to states on the condition that they stop dropping people from their rolls.

But legislation enacted in December will be phasing out that money over the next year and calls for states to resume cutting off from Medicaid people who no longer qualify.

Now, states face steep challenges: making sure they don’t disenroll people who are still entitled to Medicaid and connecting the rest to other sources of coverage.

Even before the pandemic, states struggled to stay in contact with Medicaid recipients, who in some cases lack a stable address or internet service, do not speak English, or don’t prioritize health insurance over more pressing needs.

“We have no illusion that this will be beautiful or graceful, but we will be doing everything we can not to lose anyone in the process,” Dana Hittle, Oregon’s interim Medicaid director, said of the so-called Medicaid unwinding.

With the rate of uninsured Americans at an all-time low, 8%, the course reversal will be painful.

The Biden administration has predicted that 15 million people — 17% of enrollees — will lose coverage through Medicaid or CHIP, the closely related Children’s Health Insurance Program, as the programs return to normal operations. While many of the 15 million will fall off because they no longer qualify, nearly half will be dropped for procedural reasons, such as failing to respond to requests for updated personal information, a federal report said.

Certain states may be hit particularly hard: Nevada’s enrollment in Medicaid and CHIP has risen 47% since February 2020. Many signed up toward the start of the pandemic, when the state’s unemployment rate spiked to nearly 30%.

Ordinarily, people move in and out of Medicaid all the time. States, which have significant flexibility in how they run their Medicaid programs, typically experience significant “churn” as people’s incomes change and they gain or lose eligibility.

The unwinding will play out over more than a year.

People who lose Medicaid coverage — in the more than 30 states covered by the federal marketplace — will have until July 31, 2024, to sign up for ACA coverage, CMS announced on Jan. 27. It’s unclear whether the state-based marketplaces will offer the same extended open-enrollment period.

Even states that are taking far-reaching action to make sure people don’t end up uninsured worry the transition will be rough.

In California alone, the state government forecasts that at least 2 million people out of 15 million in the program today will lose Medicaid coverage because of loss of eligibility or failure to reenroll.

“We acknowledge that this is going to be a bumpy road,” California Health and Human Services Secretary Mark Ghaly said. “We’re doing all we can to be prepared.”

In an all-hands-on-deck effort, states are enlisting Medicaid health plans, doctors, hospitals, state insurance marketplaces, and an assortment of nonprofit groups, including schools and churches, to reach out to people at risk of losing coverage.

States will also use social media, television, radio, and billboards, as well as websites and mobile phone apps, to connect with enrollees. That’s in addition to letters and emails.

Nevada has developed a mobile app to communicate with members, but only 15,000 of its 900,000 Medicaid enrollees have signed up so far.

“[T]he transient nature of Nevada’s population means that maintaining proper contact information has been difficult,” a state report said in November. At least 1 in 4 letters sent to enrollees were returned on account of a wrong address.

The law that allows states to begin disenrolling ineligible Medicaid recipients on April 1 bars states from disenrolling anyone because mail was returned as undeliverable until the state has made a “good faith effort” to contact the person at least one other way, such as by phone or email.

To further reduce disruption, the law requires states to cover children in Medicaid and CHIP for 12 months regardless of changes in circumstances, but that provision doesn’t take effect for almost a year.

States will give Medicaid recipients at least 60 days to respond to requests for information before dropping them, said Jack Rollins, director of federal policy at the National Association of Medicaid Directors.

States will use government databases such as those from the IRS and Social Security Administration to check enrollees’ income eligibility so they can renew some people’s coverage automatically without having to contact them. But some states aren’t taking full advantage of the databases.

States have until February to submit their unwinding plans to the federal Centers for Medicare & Medicaid Services, which will monitor the process.

But it is already clear that some states are doing much more than others to keep people insured.

Oregon plans to allow children to stay on Medicaid until age 6 and allow everyone else up to two years of eligibility regardless of changes in income and without having to reapply. No other state provides more than one year of guaranteed eligibility.

Oregon is also creating a subsidized health plan that would cover anyone who no longer qualifies for Medicaid but has an annual income below 200% of the federal poverty level, which amounts to about $29,000 for an individual, state officials said. The program will have benefits similar to Medicaid’s at little or no cost to enrollees.

Rhode Island will automatically move people who are no longer eligible for Medicaid — and with annual incomes below 200% of the poverty rate — into an Affordable Care Act plan and pay their first two months of premiums. State officials hope the shift will be seamless for many enrollees because they’ll be moving between health plans run by the same company.

California will move some people to a subsidized private plan on the state’s marketplace, Covered California. Enrollees will have to agree and pay a premium if they don’t qualify for a free plan. However, the premium could be as low as $10 a month, said Jessica Altman, executive director of Covered California. (Altman’s father, Drew Altman, is president and CEO of KFF. KHN is an editorially independent program of KFF.)

“We want to make it easier to say yes to coverage,” Altman said.

But experts worry about what will become of Florida Medicaid enrollees.

Florida doesn’t have its own ACA marketplace. As in most states, its residents use the federal exchange to shop for ACA plans. As a result, the handoff of people from Medicaid to marketplace may not be as efficient as it would be if it involved two state agencies that regularly work together, said Jodi Ray, director of Florida Covering Kids and Families, a nonprofit that helps people find coverage.

Another concern for advocates is that Florida makes less use of government databases than other states to check enrollees’ incomes. “We make everyone jump through hoops to get reenrolled instead of utilizing all the acceptable data,” Ray said.

Florida typically takes weeks to process Medicaid applications, while some states do it in a day, she said.

Florida’s unwinding plan illustrates the difficulty of reaching enrollees. The plan said that, since 2020, the state has identified 850,000 cases in which Medicaid recipients did not respond to requests for information.

Florida Medicaid officials did not return calls for comment.

While state officials struggle to manage the unwinding, health care providers are bracing for the fallout.

Dennis Sulser, chief executive of Billings, Montana-based Youth Dynamics, which provides mental health services to many children on Medicaid, expects some will lose coverage because they get lost in the process.

That could leave patients unable to pay and the nonprofit financially stretching to try to avoid children facing an interruption in treatment.

“If we had to discharge a child who is in our group home care, and they're only halfway through it and don't have all of the fundamentals of the care support needed, that could be tragic,” Sulser said.

KHN correspondents Daniel Chang in Hollywood, Florida; Angela Hart in Sacramento, California; Katheryn Houghton in Missoula, Montana; Bram Sable-Smith in St. Louis; and Sam Whitehead in Atlanta contributed to this report.

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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Céline Gounder, KHN’s editor-at-large for public health, discusses new data showing an excess of deaths in 2020 related to heart disease. The deaths — from heart attack and heart failure — show that the virus can affect the heart and that cardiac problems can show up months after an initial covid-19 infection has apparently resolved. Vaccines reduce the risk both of serious infections and subsequent heart problems.

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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After the nursing home where Leann Sample worked was bought by private investors, it started falling apart. Literally.

Part of a ceiling collapsed on a nurse, the air conditioning conked out regularly, and a toilet once burst on Sample while she was helping a resident in the bathroom, she recalled in a court deposition.

“It’s a disgusting place,” Sample, a nurse aide, testified in 2021.

The decrepit conditions Sample described weren’t due to a lack of money. Over seven years, The Villages of Orleans Health & Rehabilitation Center, located in western New York near Lake Ontario, paid nearly $16 million in rent to its landlord — a company that was owned by the same investors who owned the nursing home, court records show. From those coffers, the owners paid themselves and family members nearly $10 million, while residents injured themselves falling, developed bedsores, missed medications, and stewed in their urine and feces because of a shortage of aides, New York authorities allege.

At the height of the pandemic, lavish payments flowed into real estate, management, and staffing companies financially linked to nursing home owners throughout New York, which requires facilities to file the nation’s most detailed financial reports. Nearly half the state’s 600-plus nursing homes hired companies run or controlled by their owners, frequently paying them well above the cost of services, a KHN analysis found, while the federal government was giving the facilities hundreds of millions in fiscal relief.

In 2020, these affiliated corporations collectively amassed profits of $269 million, yielding average margins of 27%, while the nursing homes that hired them were strained by staff shortages, harrowing injuries, and mounting covid deaths, state records reveal.

“Even during the worst year of New York’s pandemic, when homes were desperately short of staffing and their residents were dying by the thousands, some owners managed to come out millions of dollars ahead,” said Bill Hammond, a senior fellow at the Empire Center for Public Policy, a think tank in Albany, New York.

Some nursing home owners moved money from their facilities through corporate arrangements that are widespread, and legal, in every state. Nationally, nearly 9,000 for-profit nursing homes — the majority — outsource crucial services such as nursing staff, management, and medical supplies to affiliated corporations, known as “related parties,” that their owners own, invest in, or control, federal records show. Many homes don’t even own their buildings but rent them from a related company. Homes pay related parties more than $12 billion a year, but federal regulators do not make them reveal how much they charge above the cost of services, and how much money ends up in owners’ bank accounts.

In some instances, draining nursing home coffers through related parties may amount to fraud: Along with The Villages’ investors, a handful of other New York owners are facing lawsuits from Attorney General Letitia James that claim they pocketed millions from their enterprises that the authorities say should have been used for patient care.

Deciphering these financial practices is timely because the Centers for Medicare & Medicaid Services is weighing what kind of stringent staffing levels it may mandate, potentially the biggest change to the industry in decades. A proposal due this spring is sure to spark debate about what homes can additionally afford to spend versus what changes would require greater government support. Federal Medicaid experts warned in January that related-party transactions “may artificially inflate” the true cost of nursing home care in reports that facilities file to the government. And the U.S. Department of Health and Human Services’ inspector general is investigating whether homes properly report related-party costs.

‘A Dog Would Get Better Care’

Beth Martino, a spokesperson for the American Health Care Association, said there is no evidence that related companies charge more than independent contractors do for the same services. “The real story is that nursing homes are struggling right now — to recruit and retain caregivers and to keep their doors open,” Martino said.

Lawyers for The Villages and its investors have asked the judge in the case for a delay until April to respond to the allegations of fraud and resident neglect in the lawsuit that the attorney general filed last November. One of the lawyers, Cornelius Murray, said in court papers that many allegations of short-staffing occurred during the pandemic when workers were out sick and the facility was required to accept any patient with covid-19. Lawyers declined to discuss the case with KHN.

In a deposition for that case, Ephram “Mordy” Lahasky, one of Fulton’s owners, disputed that he and fellow investors improperly depleted The Villages’ resources to the detriment of residents.

“I can assure you there was a lot of money left in the facility to make sure that it was not running on a shoestring budget,” he testified. The Villages, Lahasky said, was a “beautiful facility” with “beautiful gardens” where “residents look great” and employee morale was strong.

That wasn’t the opinion of Margarette Volkmar. She said in an affidavit filed with the state lawsuit that her husband was left in his bed with only a diaper on, was bruised by a fall, choked by another resident, given the wrong medication doses, dressed in other residents’ clothes, and covered in unexplainable bruises. After she moved him to another home, he gained back the 60 pounds he had lost and never fell at the new facility, she testified.

“I wouldn’t put a dog in Villages,” she said. “A dog would get better care than he did.”

Owners Invested in Hundreds of Homes

Both The Villages and its related real estate corporation, Telegraph Realty, were controlled by the same trio of investors, although they arranged for the nursing home to be listed in regulatory filings as solely owned by a silent partner and did not disclose their co-ownership of The Villages, court records show. One co-owner, David Gast, disclosed his net worth was $22 million and revealed that he had shares in more than 100 nursing homes, according to a loan application included in court records. Lahasky, whose disclosed net worth was nearly $73 million, said in a deposition he was the biggest nursing home proprietor in Pennsylvania and owned one of New York’s largest ambulance companies.

A third co-owner, Sam Halper, who reported a net worth of about $23 million, is under federal criminal indictment in Pennsylvania on charges of submitting false reports to the government about staffing and patient health at two nursing homes. He has pleaded not guilty. Added together, all the investors in corporations tied to The Villages have stakes or official roles in 275 other facilities across 28 states, federal records show.

The lease that The Villages had with Telegraph Realty required the home to pay up to $1 million in profits on top of the costs of debts and $50,000 a month for rent, according to a copy filed with the lawsuit. The attorney general alleged that, over seven years, the owners gave themselves and other investors more than $18 million from outsized rent profits, management fees, and proceeds from refinancing the property, an act that saddled The Villages with higher debt.

Lindsay Heckler, a supervising attorney at Center for Elder Law & Justice in Buffalo, which provides free legal help to older, disabled, and low-income adults, said she is concerned other nursing home owners in the state fail to provide quality care after purchasing facilities.

“When you see quality of care decline after an ownership change, the question needs to be asked: What’s going on with the finances?” she said.

Inflated Rents and a Plea to Die

Separating a nursing home operation and its building into two corporations is a common practice around the country. In New York, for-profit nursing homes with related-party realty companies spent 19% more of their operating revenue toward rent in 2020 than did for-profits that leased from unaffiliated firms, KHN found.

Fulton Commons Care Center, a nursing home on Long Island, spent nearly a third of its 2020 revenue on rent, a higher portion than all but three other facilities in New York, financial records show. In a lawsuit filed in December, the attorney general charged that the rent paid to Fulton Commons Realty, the company that owned its East Meadow, New York, building, was grossly inflated. Both the home and real estate company were owned by Moshe Kalter and his extended family, according to documents filed with the lawsuit.

In 2020, the nursing home paid nearly $10 million in rent to Fulton Realty, but an auditor for the attorney general calculated the property expenses that year were less than $6 million. The owners of Fulton and their families gave themselves nearly $16 million over four years from inflated rent, substantial management fees, and “no-show” jobs for Kalter’s eight children, the attorney general alleged.

“Rather than honor their legal duty to ensure the highest possible quality of life for the residents in their care, the Fulton Commons owners allegedly maintained insufficient staffing so they could take more money for their own personal gain,” James said in a statement.

Raul Tabora Jr. and David Yaffe, lawyers for Kalter, called the lawsuit’s charges “one-sided” in a written statement to KHN. They said that the payments to the children were not for jobs but because they were shareholders, and that Fulton kept an average balance of $3 million on hand to cover any pressing needs. “The evidence will demonstrate that any time resources are needed, they are provided by Mr. Kalter,” the lawyers wrote.

Residents’ families told investigators that staff shortages existed well before the pandemic. In an affidavit filed with the lawsuit, Frank Hoerauf Jr. said workers left his father sitting in adult diapers without pants and let his hair grow so long it covered his eyes. Another time, they left him screaming in pain from a urinary tract infection, he said.

“Fulton Commons seems like it was operated to be a cash machine for the owners where the care and the quality of life for residents there was very poor,” Hoerauf said.

Another resident, Elena Milack, who had lost one foot to diabetes, complained about poor care for years, including having to ring the call bell for an hour to get help to get to the bathroom, according to an affidavit filed by her daughter-in-law and health proxy. “GET ME OUT OF HERE OR TELL ME WHAT I CAN TAKE TO KILL MYSELF,” she texted her son in summer 2019. In 2020, she contracted an infection that turned her remaining foot black.

“Toes are all infected now,” Milack, a retired law school secretary, texted. “[M]y upper foot is dying and will soon fall off. I am hoping the good Lord will take me before that happens.” She died in November 2020.

Kalter said in a deposition he had never stepped inside his nursing home and did not supervise the quality of the care. He testified he granted full authority over the facility to its administrator and relied on his nephew, who was the controller of the home, to interact with the home’s leadership, according to court records.

In his deposition, Kalter said: “I have no personal knowledge of anything that’s going on in the nursing home.”

According to an affidavit from an auditor for the attorney general’s office, over the course of four years, Kalter deposited nearly $12 million from Fulton into his joint bank account with his wife, Frady.

KHN data editor Holly K. Hacker contributed to this report.

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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The “An Arm and a Leg” podcast is back. This season, host Dan Weissmann will tell stories about patients finding creative ways to fight back against outrageous bills.

This first episode of Season 9 updates a story from 2019 about a listener who got a $35 bill from a medical testing lab she had never heard of. Soon a follow-up bill arrived demanding $1,300 if she didn’t pay right away.

This jump in price left her wondering: Can they freaking do that?!?

The answer: They can try. And they often get away with it.

But if patients have the time and moxie, they can propose a fair price and even take providers to court to force them to accept the counter offer.

The original version of this story covered a couple of topics the show has explored: Surprise bills (for which new legal protections were enacted in 2022) and how private equity has been expanding into health care and how some doctors are trying to fight back.

The Host

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

Credits

Emily Pisacreta Producer Marian Wang Editor Ann Heppermann Editor Adam Raymonda Audio Wizard Click to open the transcript Transcript: Can They Freaking Do that?! (2023 Edition)
Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Hey there–

I have to start with a big THANK YOU to everybody who supports this show. It’s January, we wrapped up our big fund-raising campaign at New Year’s, and more than six hundred of you came through for us. We hit all our targets, including our stretch goal. It’s huge.

I’ll have a LOT of people to thank at the end of this episode, and I want to think about how to celebrate. Thanks to you, this year is off to an amazing start.

And for this first episode of 2023, I’m going back to a story we first put out more than three years ago, in 2019.

Because: this story changed my whole conception of what this show can aim to do.

When I meet people today and tell them about An Arm and a Leg for the first time, this is the story I tell them about.

Because this is a story about legal rights I never suspected we had– and how we can sometimes use them to fight back.

I learned a lot of other stuff while reporting this story — about surprise bills, and the role of private equity. It was early days for the show.

We’re leaving out those parts out this time– we’ve gone deeper on them in other episodes, and some of the underlying facts have changed.

Some things have gone out of date in good ways, thanks to the federal No Surprises Act, which took effect last year.

But the part about fighting back? Standing up for our legal rights? That holds up. And it’s ready for some follow-up.

OK, here it is:

Dan: Miriam visited a fertility clinic a couple years ago in Washington and DC where she lives, and she got some tests done. She was lucky. Her insurance actually covered fertility stuff, so she got the bill and her share was like 30 bucks. She paid it. Then this other envelope arrives from someplace she never heard of.

Not the fertility clinic or anyplace else she’s ever been, and it’s hot pink. She thinks it looks fake. It says it’s a bill and they want 35 bucks for some lab work

and perhaps unwisely, Miriam ignores it.

Okay. Uh, definitely unwisely and there are a couple of follow ups also in hot pink envelopes. And on the one hand, Miriam looks more closely and they are connected to her visit to the fertility clinic on the other. The follow ups say this other thing. They say, Hey, pay up now, or This thing’s going up, way up, up to about 1300 bucks from 35, which

Miriam: was so outrageous that I thought, this is definitely bullshit.

Bullshit. . Sorry, can I say that?

Dan: Yes, absolutely. Yeah. So Miriam does a dumb thing and ignores it and a follow up, and then in September she gets a note from a collections agency. They want that $1,300. And can they freaking do that? Can some lab send you a bill for 35 bucks outta nowhere and then be like, Hey, better pay now while we’re in a good mood.

Otherwise it’s gonna be $1,300. Is that even legal?

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.

And what’s more useful than knowing what our rights are?

Because as consumers. No idea. I mean, I get a bill from the electric company. Well, for one thing, it’s not a surprise. I’ve been running the lights and it’s the same rates as last month, and everybody’s paying basically the same rates as me, like whatever I owe this, but a hot pink envelope from some ancillary lab.

And then a follow-up saying they’re gonna take you for 1300, you’d. Well, maybe they can freaking do that.

I mean, how would you even know? Who would you even ask? Well, now you can ask me and I’ll go find out. This whole thing happened to Miriam a couple years ago. She ended up settling with the collections agency for like $217, which was a sixth of what they were asking for, but it was also six times that original $35 charge.

It still bugs her. Like was that even legal? What happened there? It is so messed up. So she wrote to me and I was. I really want to figure this out.

When I talked to Miriam, she actually had a theory about what I might find.

Miriam: It might just be illegal to have such a, a big jump from, um, what the original copay was to what it ended up being after I was late.

Dan:Yeah! I was off– ready to test that theory out.

So, I made some calls. And I FOUND OUT SOME STUFF.

It took a minute. I started out calling national legal experts and policy nerds, and they were like, “I don’t really know. The law is complicated, it varies from state to state, blah blah blah”

So then I started calling folks who help consumers challenge wild medical bills — like, for a fee, that’s how they make a living. One of them was Braden Pan, his company’s called Resolve Medical bills.

I described Miriam’s story to him, the pink envelope, the fine print that was like….

…is for a charge of $1,287 for which you get a great discount and will take $35 from you if you pay by date.

Wow. . Okay.

It’s like he was kind of impressed by how brazen this was.

And even though he didn’t know the answer, he had some smart thoughts about what questions to start asking.

Braeden Pan: I’m gonna tell you right now that I’m not a lawyer. Yeah. Um, now I can tell you that the, the idea of what hospitals or clinics can charge for services that hasn’t been settled.

Dan: In other words, he thought you’d need a lawyer if you wanted to fight it, and you don’t know how it’s gonna come out.

Braeden Pan: What might actually be going on with this company is they know this, they know that there’s confusion out there about this, uh, that you need a lawyer to actually figure it out, whether or. Someone can can do this and for a thousand bucks it’s not worth it to hire a lawyer to tell you because they’re gonna charge you 1200 bucks just to tell you whether or not they can do this

Dan: Right, right.

So himself, Braden Pan wasn’t so sure they were good answers here, but he pointed me to a couple of other people and they actually had some very hopeful answers. Some serious self-defense tools. You might wanna grab a pen. We’ll have that right after.

This season of an Arm and a Leg is a co-production of Public Road Productions and Kaiser Health News.

That’s a nonprofit newsroom that covers healthcare in America. Kaiser Health News is not affiliated with the giant healthcare provider, Kaiser Permanente. We’ll have a little more on Kaiser Health News at the end of this episode.

Sir, here’s where we meet the folks who are going to give us our big strong weapons for fighting off totally unreasonable bills.

Lisa Berry Blackstock: My name is Lisa Berry Blackstock, and I have been a patient advocate since 1990.

Dan: That’s like almost 30 years. And I asked her, is there anything you can do in a situation like this when you’re getting hit up for 1300 bucks for some stupid lab test? And she was like, well, You could take ’em to small claims court and you don’t have to be a lawyer to do that.

I was like, wait, you’ve done this?

Lisa Berry Blackstock: Oh, I, I’ve lost count. I can’t tell you how many times I’ve done it and in how many different, uh, counties.

Dan: Huh? So it works.

Lisa Berry Blackstock: Oh, it works. It’s worked for me.

Dan: She says it works every single time. And here’s something I learned in this conversation that I absolutely had not known.

When you go to court, it does not have to be to make somebody else give you. You can go to court and say, judge, this lab says I owe them 1300 bucks, but I have researched it and 35 bucks is fair. I’m offering them 35. Would you please order them to take 35?

It takes a plan to do this and it takes work.

Lisa Berry Blackstock: You have to demonstrate in writing that you have made a good faith effort to resolve this to your best ability and that you’ve been unable to, and that’s why you’re asking the court to intervene.

Dan: And so you’re asking the court basically to approve. A settlement offer that you’re making. Correct?

Lisa Berry Blackstock: Correct.

Dan: That’s what Lisa Berry Blackstock says she does. There’s some serious homework involved. If you grabbed a pen earlier, here’s where you start taking notes first. Lisa says, you call whoever’s sending the bill and make them give you the billing codes for everything on the bill.

itemized. Each one has a five digit code called a C P T Code, C P T. And honestly, this sounds like it could be the hardest part. You gotta get them to cough up this information. You have a right to it, but getting it, once you’ve got that, you figure out what a fair price is in your area, and there are a couple of websites that actually can help you do this.

Lisa uses one from a group called Fair Health. The site is fair health consumer.org. You put in your zip code and that five digit medical billing code, they will tell you what the going rates are in your area.

And that’s my basis of my offer. It’s fair I, I mean, I have independently verified information.

Lisa Berry Blackstock: It’s not a number that I’ve made up and it’s not like you’re trying to rip people off .

Dan: Then you write to whoever’s billing, you use certified mail. So you get a signed receipt, you can prove they got it, and you say, here’s what I’m offering. Here is how I determine this number. I want to hear from you by date X, that you will accept it.

Otherwise

Lisa Berry Blackstock: I will be filing in small claims, you know, against you, and you can expect to receive a notice.

Dan: And you’re saying generally if they get that, they’ll be like, okay, I’ll take it. Is that right?

Lisa Berry Blackstock: Yes. I mean, general, they, they look, they don’t understand anything with billing other than raking people over the coals because that’s what. is generally allowed across the country.

Dan: She says a lot of the time just sending the letter is enough, but sometimes she actually has to file Now, once I’ve filed Yeah. And they’ve been served. Yeah. Oh, then they’re, they’re falling all over themselves to make it go away. Because look, they’re used to sitting in an office sending out pieces of paper saying, send us 1300 bucks, or We’ll ruin your.

and getting 1300 bucks, or maybe getting a phone call and allowing themselves to be talked down to 200 without leaving their desk, they gotta send somebody to court. That person who would go to court could make more money by just accepting this offer and moving on to the next sucker,

Especially because, according to Lisa Berry Blackstock, they’d probably lose in court anyway.

Now, this was cool, but I didn’t just wanna take one person’s word for it. I found somebody else who had actually tried this thing. Somebody with a pretty good credential.

Christopher Robertson: My name’s Christopher Robertson. I’m a professor and associate dean at the James E. Rogers College of Law

Dan: That was his job when we talked in 2019. Now he’s a professor and associate Dean at the Boston University School of Law.

Anyway, I asked him, you can make these people accept a fair offer, and he’s like,

Christopher Robertson: Yeah. Duh. You know, basic contract law, you know, the stuff we teach to first year law students every day purports to just make this a non-pro. Of course you don’t have to pay a number that the other side just invented, um, , you know, this is, this is shooting fish in a barrel from a, from a contract law perspective.

Dan: Whoa, baby. The deal is you see a doc anywhere. You sign something in the business, they call it consent to treat. It says, yeah, examine me, poke, prod, whatever, and it says, I’m gonna give you my insurance info and whatever the insurance doesn’t pay, I’ll pay. The thing I’m signing doesn’t say how much I’ll pay because nobody knows exactly what’s gonna happen at the doctor’s office or the er, wherever.

Anyway. I got a stomach ache. Maybe I ate something weird. Maybe I have an ulcer. So Robertson says, what I’m signing is what lawyers call an open price contract. You know, normally a

Christopher Robertson: contract has a price in it, right? So if you want to go buy a car, your contract to buy the car has a price that’s true of a washing machine or a, or a house.

But when there is no price in the contract, it’s called an open price contract.

Dan: The courts do not treat an open price contract as a blank check.

Christopher Robertson: If the court is gonna be called upon to enforce the contract to force someone to pay something, then the court has to figure out, well, what, what amount should I force them to pay?

It can’t be just what one side says later.

Dan: In other words, courts would. An open price contract like your agreement with a medical provider does not mean the other side just gets to bill you for whatever they want, and Miriam’s case is special. It’s got this other wrinkle, which is basically the lab said the price was 35 bucks, but if you’re late, it’s 1300.

That’s why I was so interested in this case. And Robertson says, Miriam has the law on her side there too. He says, this involves something else. They teach first year law students

Christopher Robertson: literally on the very first day of contract law

Dan: When you breach a contract, courts don’t treat that like a blank check either, and a late fee, it’s like a penalty for breaching a contract. The contract says you pay on date X. Miriam breached her contract by not paying on time. But Chris Robertson says there’s a limit to what that penalty can be, and it’s gotta have some relationship to what the breach actually cost. The. .

Christopher Robertson: So that’s a second reason. This strategy is completely legally frivolous to take a $35 charge and convert it into a thousand dollars plus.

Right. So yeah, they didn’t get their $35 check in June when they wanted it. They might get it in July. Well, that doesn’t cost them a thousand dollars. So the penalty can’t be a thousand dollars . Even if they don’t get it, it’s now September and they haven’t gotten it. It’s still not costing him a thousand dollars.

Christopher Robertson: Exactly.

Dan: So he’s like, yeah, line it up. Small claims court, that sort of thing can work. I can barely believe it’s this easy.

I’m like, wait, why don’t we do this more often??

Christopher Robertson: I mean, frankly, we shouldn’t have to. We need a systematic solution to this. Uh, you know, we are all have day jobs, you know.

Frankly, a lot of people who are dealing with medical bills surprise, surprise, are sick, right? Yeah. Um, so , they’re busy trying to get well, uh, you know, they’re trying to fight their own battles and so, you know, waging their own legal battle is, is, is a huge distraction and requires a level of attention to detail that not everyone has or should be expected to have.

So that’s why I really need more systematic solutions.

Dan: So Miriam might have had some options, but small claims court, it’s not exactly a blanket solution, especially cuz there’s also the problem of scale. I mean, it’s one thing if you’ve got a lab hawking you for a thousand bucks. What if you’ve got a whole system of hospitals trying to rake untold numbers of patients over the coals for crazy amounts? Then you’re not in small claims court anymore. Christopher Robertson has been there, like he’s gotten involved in lawsuits trying to stop hospitals from doing that sort of thing, and he. It is not pretty.

Christopher Robertson: It’s, it’s the utter, utter breakdown of law. I mean, when we tried to challenge these practices by hospitals, um, we bumped up into courts insisting that for every single charge, we affirmatively prove that the amount they made up is unreasonable. But proving that. Requires, you know, experts and accounting and economics, you could spend tens of thousands of dollars litigating every single one of these thousand dollars charges. And so that’s why you really do need either class action or a more affirmative, you know, regulatory system to police this, this bad behavior.

Dan:But in an individual situation like Miriam’s, where she’s actually healthy, she’s only got one charge to fight off. You can fight back. Get your evidence together, find out the itemized billing codes, and use a website like Fair health consumer.org to figure out what a reasonable price would be. Make an offer, put it in writing. Send it certified mail. Give ’em a deadline to accept your offer or else tell ’em you’ll file in small claims court. . And if that doesn’t make ’em play ball, actually do it. I ran all this down from Miriam and she was like,

Miriam: I wish I had known. That’s my main thing. I wish I had known that I had these other options. I would’ve totally gotten a letter, like if, even if I needed to notarize a letter, get it sent certified mail. I I’m gonna take you to a small claims court. Okay. Maybe I’ll, I’ll give you 50 bucks. That’s my, that’s my offer. Yeah. I wish I had done that.

Dan: YEP! That’s where we left things, a little more than three years ago.

I mean, we’ve followed up a little here and there:

We talked with a guy named Jeffrey Fox, who has made it… kind of a hobby to use small claims courts to stand up for his rights. So when UCLA overbilled him, he was ready.

I mean, maybe we could all use a little of his readiness to fight. Here’s how he describes conversations with their billing department.

Jeffrey Fox: One thing they always do is they always try to make it seem like their policies apply to you. They’re like, well, no, our policy is blah, blah, blah. I’m like, I don’t care. Contract law, the concepts of contract law and what I actually owe you, what a court would say, I owe you is what applies. I remember saying, okay. Well, my policy is you pay me a hundred dollars every time you say something stupid. So does that apply to you? If it does you only about 400 bucks already. Wanna keep going?

Dan: Jeffrey didn’t get paid on that improvised policy of his… but he did get a judge to make UCLA give him a refund of more than two thousand dollars. That episode was called David vs Goliath, and we’ll include a link to it wherever you’re listening.

So we’ve come back to this approach to fighting back. But I’ve been starting to think we haven’t come back to it nearly enough.

Especially since I got a note from a listener named Lauren with the heading: “I sued a hospital in small claims court and lost”

… which ended, “I feel like I won.” She wrote, “the hospital spent way more money on lawyer’s fees than the total amount of my bill.” They sent three lawyers to a preliminary hearing — and her bill wasn’t even that high.

We talked — we’ll have lots of details in our next episode — about what she had learned, and how she wanted to spread it around.

Lauren: I walked out of that thinking , do I , like, just put together a list of tips and leave it on people’s windshields that are parked outside of the er. how do I help other people do this?

If everybody that they screw stands up, they can’t afford to pay a lawyer to defend against all of those.

Dan: I mean, it’s an INTERESTING idea. Not for everybody. But maybe a few more people than have tried it so far…

We’ll pick up that idea next time.

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta. Ann Heppermann edited the original story.

Marian Wang edited this version– and it looks like Marian’s parental leave from this show, coming up any minute now, will be permanent.

Marian, I cannot believe how much I am going to miss working with you. It has been such an honor and such a joy.

Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard. Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. Sarah Ballema is our operations manager.

This season of an arm and a leg is a co production with Kaiser health news. That’s a nonprofit news service about healthcare in America, an editorially-independent program of the Kaiser family foundation.

KHN is not affiliated with Kaiser Permanente, the big healthcare outfit. They share an ancestor: The 20th century industrialist Henry J Kaiser. When he died, he left half his money to the foundation that later created Kaiser health news.

You can learn more about him and Kaiser health news at arm and a leg show dot com slash Kaiser.

Zach Dyer is senior audio producer and Tarena Lofton is audience engagement producer at KHN– they are editorial liaisons to this show.

Thanks to Public Narrative — That’s a Chicago-based group that helps journalists and non-profits tell better stories– for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about Public Narrative at www dot public narrative dot org.

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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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When the covid-19 pandemic hit, Dr. Corey Siegel was more prepared than most of his peers.

Half of Siegel’s patients — many with private insurance and Medicaid — were already using telehealth, logging onto appointments through phones or computers. “You get to meet their family members; you get to meet their pets,” Siegel said. “You see more into their lives than you do when they come to you.”

Siegel’s Medicare patients weren’t covered for telehealth visits until the pandemic drove Congress and regulators to temporarily pay for remote medical treatment just as they would in-person care.

Siegel, section chief for gastroenterology and hepatology at Dartmouth-Hitchcock Medical Center, is licensed in three states and many of his Medicare patients were frequently driving two to three hours round trip for appointments, “which isn’t a small feat,” he said.

The $1.7 trillion spending package Congress passed in December included a two-year extension of key telehealth provisions, such as coverage for Medicare beneficiaries to have phone or video medical appointments at home. But it also signaled political reluctance to make the payment changes permanent, requiring federal regulators to study how Medicare enrollees use telehealth.

The federal extension “basically just kicked the can down the road for two years,” said Julia Harris, associate director for the health program at the D.C.-based Bipartisan Policy Center think tank. At issue are questions about the value and cost of telehealth, who will benefit from its use, and whether audio and video appointments should continue to be reimbursed at the same rate as face-to-face care.

Before the pandemic, Medicare paid for only narrow uses of remote medicine, such as emergency stroke care provided at hospitals. Medicare also covered telehealth for patients in rural areas but not in their homes — patients were required to travel to a designated site such as a hospital or doctor’s office.

But the pandemic brought a “seismic change in perception” and telehealth “became a household term,” said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association.

The omnibus bill’s provisions include: paying for audio-only and home care; allowing for a variety of doctors and others, such as occupational therapists, to use telehealth; delaying in-person requirements for mental health patients; and continuing existing telehealth services for federally qualified health clinics and rural health clinics.

Telehealth use among Medicare beneficiaries grew from less than 1% before the pandemic to more than 32% in April 2020. By July 2021, the use of remote appointments retreated somewhat, settling at 13% to 17% of claims submitted, according to a fee-for-service claims analysis by McKinsey & Co.

Fears over potential fraud and the cost of expanding telehealth have made politicians hesitant, said Josh LaRosa, vice president at the Wynne Health Group, which focuses on payment and care delivery reform. The report required in the omnibus package “is really going to help to provide more clarity,” LaRosa said.

In a 2021 report, the Government Accountability Office warned that using telehealth could increase spending in Medicare and Medicaid, and historically the Congressional Budget Office has said telehealth could make it easier for people to use more health care, which would lead to more spending.

Advocates like Zebley counter that remote care doesn’t necessarily cost more. “If the priority is preventative care and expanding access, that should be taken into account when considering costs,” Zebley said, explaining that increased use of preventative care could drive down more expensive spending.

Siegel and his colleagues at Dartmouth see remote care as a tool for helping chronically ill patients receive ongoing care and preventing expensive emergency episodes. It “allows patients to not be burdened by their illnesses,” he said. “It’s critical that we keep this going.”

Some of Seigel’s work is funded by The Leona M. and Harry B. Helmsley Charitable Trust. (The Helmsley Charitable Trust also contributes to KHN.)

For the past nine months, Dartmouth Health’s telehealth visits plateaued at more than 500 per day. That’s 10% to 15% of all outpatient visits, said Katelyn Darling, director of operations for Dartmouth’s virtual care center.

“Patients like it and they want to continue doing it,” Darling said, adding that doctors — especially psychologists — like telehealth too. If Congress decides not to continue funding for remote at-home visits after 2024, Darling said, she fears patients will have to drive again for appointments that could have been handled remotely.

The same fears are worrying leaders at Sanford Health, which provides services across the Upper Midwest.

“We absolutely need those provisions to become permanent,” said Brad Schipper, president of virtual care at Sanford, which has health plan members, hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota. In addition to the provisions, Sanford is closely watching whether physicians will continue to get paid for providing care across state lines.

During the pandemic, licensing requirements in states were often relaxed to enable doctors to practice in other states and many of those requirements are set to expire at the end of the public health emergency.

Licensing requirements were not addressed in the omnibus, and to ensure telehealth access, states need to allow physicians to treat patients across state lines, said Dr. Jeremy Cauwels, Sanford Health’s chief physician. This has been particularly important in providing mental health care, he said; virtual visits now account for about 20% of Sanford’s appointments.

Sanford is based in Sioux Falls, South Dakota, and Cauwels recalled one case in which a patient lived four hours from the closest child-adolescent psychiatrist and was “on the wrong side of the border.” Because of the current licensing waivers, Cauwels said, the patient’s wait for an appointment was cut from several weeks to six days.

“We were able to get that kid seen without Mom taking a day off to drive back and forth, without a six-week delay, and we were able to do all the things virtually for that family,” Cauwels said.

Psychiatrist Dr. Sara Gibson has used telehealth for decades in rural Apache County, Arizona. “There are some people who have no access to care without telehealth,” she said. “That has to be added into the equation.”

Gibson, who is also medical director for Little Colorado Behavioral Health Centers in Arizona, said one key question for policymakers as they look ahead is not whether telehealth is better than face-to-face. It’s “telehealth vs. no care,” she 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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Near the end of his scheduled three-month stay at a rehab center outside Austin, Texas, Daniel McKegney was forced to tell his father in North Carolina that he needed more time and more money, he recently recalled.

His father had already received bills from BRC Recovery totaling about $150,000 to cover McKegney’s treatment for addiction to the powerful opioid fentanyl, according to insurance statements shared with KHN. But McKegney, 20, said he found the program “suffocating” and wasn’t happy with his care.

He was advised against the long-term use of Suboxone, a medication often recommended to treat opioid addiction, because BRC does not consider it a form of abstinence. After an initial five-day detox period last April, McKegney’s care plan mostly included a weekly therapy session and 12-step group meetings, which are free around the country.

McKegney said a BRC staffer recommended he stay a fourth month and even sat in on the call to his dad.

“They used my life and [my] father’s love for me to pull another 20 grand out of him,” said McKegney, who told KHN he began using fentanyl again after the costly stay.

BRC did not respond to specific concerns raised by McKegney. But in an emailed statement, Mandy Baker, president and chief clinical officer of BRC Healthcare, said that many of the complaints patients and former employees shared with KHN are “no longer accurate” or were related to covid safety measures.

But addiction researchers and private equity watchdogs said models like the one used by BRC — charging high patient fees without guaranteeing access to evidence-based care — are common throughout the country’s addiction treatment industry.

The model and growing demand are why addiction treatment has become increasingly attractive to private equity firms looking for big returns. And they’re banking on forecasts that predict the market will grow by $10 billion — doubling in size — by the end of the decade as drug overdose and alcohol-induced death rates mount.

“There is a lot of money to be made,” said Eileen O’Grady, research and campaign director at the Private Equity Stakeholder Project, a watchdog nonprofit that tracks private equity investment in health care, housing, and other industries. “But it’s not necessarily dovetailing with high-quality treatment.”

In 2021, 127 mergers and acquisitions took place in the behavioral health sector, which includes treatment for substance use disorders, a rebound after several years of decline, according to investment banking firm Capstone Partners. Private equity investment drove much of the activity in an industry that is highly fragmented and rapidly growing, and has historically had few guardrails to ensure patients get appropriate care.

Roughly 14,000 treatment centers dot the country. They’ve proliferated as addiction rates rise and as health insurance plans are required to offer better coverage of drug and alcohol treatment. The treatment options vary widely and are not always consistent with those recommended by the federal Substance Abuse and Mental Health Services Administration. While efforts to standardize treatment advance, industry critics say private equity groups are investing in centers with unproven practices and cutting services that, while unprofitable, might support long-term recovery.

Baker said BRC treats people who have been unsuccessful in other facilities and does so with input from both clients and their families.

Private Equity Skimps on the Known Standards

Centers that discourage or prohibit the use of Food and Drug Administration-approved medications for the treatment of substance use disorder are plentiful, but in doing so they do not align with the American Society of Addiction Medicine’s guidelines on how to manage opioid use disorder over the long term.

Suboxone, for example, combines the pain reliever buprenorphine and the opioid-reversal medication naloxone. The drug blocks an overdose while also reducing a patient’s cravings and withdrawal symptoms.

“It is inconceivable to me that an addiction treatment provider purporting to address opioid use disorder would not offer medications,” said Robert Lubran, a former federal official and chairman of the board at the Danya Institute, a nonprofit that supports states and treatment providers.

Residential inpatient facilities, where patients stay for weeks or months, have a role in addiction treatment but are often overused, said Brendan Saloner, an associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

Many patients return to drug and alcohol use after staying in inpatient settings, but studies show that the use of medications can decrease the relapse rate for certain addictions. McKegney said he now regularly takes Suboxone.

“The last three years of my life were hell,” he said.

Along with access to medications, high-quality addiction treatment usually requires long-term care, according to Shatterproof, a nonprofit focused on improving addiction treatment. And, ideally, treatment is customized to the patient. While the “Twelve Steps” program developed by Alcoholics Anonymous may help some patients, others might need different behavioral health therapies.

But, when looking for investments, private equity groups focus on profit, not necessarily how well the program is designed, said Laura Katz Olson, a political science professor at Lehigh University who wrote a book about private equity’s investment in American health care.

With health care companies, investors often cut services and trim staff costs by using fewer and less-trained workers, she said. Commonly, private equity companies buy “a place that does really excellent work, and then cut it down to bare bones,” Olson said. During his stay, McKegney said, outings to movies or a lake abruptly stopped, food went from poke bowls and pork tenderloin to chili that tasted like “dish soap,” and staff turnover was high.

Nearly three years ago, BRC landed backing from NewSpring Capital and Veronis Suhler Stevenson, two private equity firms with broad portfolios. Their holdings include a payroll processor, a bridal wear designer, and a doughnut franchise. With the fresh funds, BRC started an expansion push and bought several Tennessee treatment facilities.

NewSpring Capital and Veronis Suhler Stevenson did not respond to emails and phone calls from KHN.

High Prices and Low Overhead = Big Business

Before the sale to BRC, Nashville Recovery Center co-founder Ryan Cain said, roughly 80% of the center’s offerings were free. Anyone could drop by for 12-step meetings, to meet a sponsor, or just to play pool. But the new owners focused on a new high-end sober living program that cost thousands of dollars per month and relied on staffers who were in recovery themselves.

In 2021, Nanci Milam, 48, emptied her 401(k) retirement fund to go through the sober living program and tackle her alcohol addiction. She had been sober for only six months when she was hired as a house manager, overseeing some of the same residents she had gone through the program with. She had to handle other residents’ medications, which she said she could have abused. Milam said she was fortunate to maintain sobriety.

“I think it served their need. And I was ambitious. But it should not have happened,” said Milam, adding that she left because the company hadn’t helped her start her certification as a drug counselor as promised.

A licensing violation reported to Tennessee regulators in late 2021 involved a staffer who was later fired for having sex with a resident in a storage area. And KHN obtained a copy of a 911 call placed in August 2022 — after a resident drank half a bottle of mouthwash — during which a staffer admitted there was no nurse on-site, which some other states require.

Removing the Burden from Consumers

The regulations of treatment providers largely focus on health and safety rather than clinical guidelines. Only a handful of states, including New York and Massachusetts, require that licensed addiction treatment centers offer medication for opioid use disorder and follow other best practices.

“We have a huge issue in the field where licensing standards don’t comport with what we know to be the most effective quality-of-care standards,” said Michael Botticelli, former director of the Office of National Drug Control Policy during the Obama administration and a member of a clinical advisory board for private equity-backed Behavioral Health Group. Some organizations, including Shatterproof, guide patients toward appropriate care. The federal and state governments largely direct public funds to centers that meet clinical quality-of-care standards.

But access to treatment is limited, and desperate patients and their families often don’t know where to turn. State or federal regulators aren’t policing claims from rehab facilities, like the “99% success rate” touted by BRC.

“We cannot put the burden on patients and their families” to navigate the system, said Johns Hopkins’ Saloner. “My heart really breaks for people who have thrown thousands of their dollars at programs that are bogus.”

When her niece was ready for inpatient rehab in summer 2020, Marina said, sending her to BRC was a “knee-jerk reaction.” Marina, a physician in Southern California, requested to be identified only by her middle name to protect the privacy of her niece, who suffers from alcohol addiction.

She had researched the facility three years earlier but didn’t investigate deeper because she was worried her niece would change her mind. BRC advertised success stories on the television show “Dr. Phil” and posted affirmations on social media.

Marina agreed to BRC’s upfront cost of $30,000 a month for a three-month stay in Texas, which she paid for out-of-pocket because her niece lacked insurance. She allowed KHN to review some of her niece’s pharmacy and treatment bills.

Marina said she paid for a fourth month, but said ultimately the program didn’t help her niece, who remains “horribly sick.” She said her niece felt constant guilt and shame at rehab. Marina thought there was inadequate medical oversight, and said the program “nickeled and dimed” her for additional services, like physicians’ visits, that she thought would be included.

“It almost doesn’t matter if you are educated and intelligent,” Marina said. “When it’s your loved one, you are just desperate.”

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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Jan. 26

This week’s “KHN Health Minute” nudges listeners to have an antiviral care plan before covid hits, and looks at how medical emergencies like Damar Hamlin’s heart attack can affect NFL players’ mental health.

Jan. 19

Tune in to the “KHN Health Minute” this week to learn how your smartphone could become your doctor’s newest diagnostic tool and the importance of taking morning sickness symptoms seriously.

Jan. 12

Tune in to the “KHN Health Minute” this week to hear how noise pollution affects our health and why an optimistic outlook may help you live longer.

The KHN Health Minute is available every Thursday on CBS News Radio.

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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Mother-to-be Kathleen Founds made a routine doctor’s appointment to discuss the risks of antidepressants in pregnancy. After the visit, Founds, who relies on medication to quell the manic highs and despondent lows of bipolar disorder, learned the physician was out of network.

She received a surprise bill for $650, launching her into a maze of claim forms and hours on the phone being routed from one office to the next to dispute the charges — insurance red tape that so many Americans have encountered. A decade later, Founds captured her experience in a graphic novel, “Bipolar Bear and the Terrible, Horrible, No Good, Very Bad Health Insurance,” a richly illustrated, darkly funny fable for adults about the country’s dysfunctional health system.

The book, published in November, follows Theodore, an intelligent but angst-ridden bear, on his quest for treatment for his own manic-depressive illness. But first he must navigate the demands of the WeCare company, a shady outfit run by cigar-smoking felines who profit unfairly from a lopsided economy and a corrupt justice system, among other things. His fellow outcasts include such characters as an overeducated owl drowning in student debt and a bomb-sniffing puppy suffering from PTSD.

America is internationally known for high-quality care, for those who can afford it. A new Gallup Poll shows that a record-high proportion of Americans — 38% — postponed medical care because of high costs in 2022. Federal and state “no surprise” laws of the past few years seek to protect consumers from unexpected medical bills. But they don’t prevent expenses like high deductibles or fees hidden in the fine print of their insurance policies.

“Bipolar Bear” joins other recent works to shine a light on health inequities — part of the emerging genre of graphic medicine. It includes seminal illness narratives such as “Mom’s Cancer” by Brian Fies and nurse MK Czerwiek’s “Taking Turns: Stories from the HIV/AIDS Care Unit 371” as well as “Rx,” Rachel Lindsay’s memoirs about taking a job at a pharmaceutical company to secure insurance to cover treatment for bipolar disorder.

Descended from the underground comics of the 1960s, graphic medicine has grown into a new field of scholarship on the medium’s role in the study and delivery of health care, said Ian Williams, the Welsh physician who coined the term back in 2007. “It’s ideal for exploring subjects having to do with one’s life and well-being in an ironic and funny way,” he said.

As Founds puts it, humor is a powerful weapon against despair.

The 40-year-old mother of two teaches English at a community college in Santa Cruz County on California’s central coast. She has never taken an art class and didn’t set out to write a graphic novel. The book began as a doodle in the margins of her notebook while studying for a master’s degree in fiction writing at Syracuse University in New York. Her 2014 novel in short stories, “When Mystical Creatures Attack,” is about a teacher who suffers a nervous breakdown and communicates with her students from a psychiatric hospital.

KHN contributing reporter Rachel Scheier spoke to Founds about bringing Theodore to life. The interview has been edited for length and clarity.

Q: How did you come to write a book about a bear with bipolar disorder?

I’d been making children’s books for my little brother. They were all about angst-ridden animals: a lonely giant squid, a possum with social anxiety disorder who falls asleep whenever he’s in an awkward situation, a burro who wants to be a unicorn. My goal was to write a novel. But whenever I was too depressed to string a sentence together, I’d draw bears. Then I realized that anyone dealing with a mental health issue in this country is going to have to deal with the labyrinth of health insurance. And I thought it would be fun to depict it as an actual labyrinth with trapdoors and man-eating flowers. Once I went in that direction, it was no longer a children’s book.

Q: Was the book based on your own experience with mental illness?

Yes. I had my first major depressive episode at the end of high school, but I didn’t seek out professional help. I just sort of muddled through it. Then, when I was a sophomore at Stanford, I had my first manic episode. I had a series of realizations about the nature of the universe, and I didn’t sleep or eat very much. Then, in graduate school, I went to a clinic because I was going through a depression, and the psychiatrist asked me questions like “Was there ever a time when you had a lot of energy and didn’t feel a need to sleep?” And I said, “Oh, sure, but that was a spiritual awakening.” So, I had to reframe my life story a bit after that.

Q: But religion still has a role in your life?

I’m a Quaker. It’s something I came to through my interest in nonviolent social change. When I am severely depressed, I feel like life has no purpose. So, following a code that says life does have meaning, that we are all connected by a force of love that undergirds the universe, is something that has helped me a lot.

Q: Why animals?

People are hard to draw! Cartoon animals are a lot easier. I wasn’t interested in art in school — actually, when I started drawing was during that first manic episode. I do not recommend writing a 200-page graphic novel with no artistic training. I mean, it took 13 years, but I did finish it.

Q: Why did it take so long?

I worked on it off and on while I was writing essays and working on the beginnings of several other novels. When I finally finished it, I was so excited. I was ready to see it on bookshelves within a year. I sent it to my agent, and she wrote me a very nice email which said, “I love this. It’s very creative. But there’s no way I can sell it.” Most graphic novels for grownups are memoir — there wasn’t a clear genre. Then another agent I reached out to said, “I can’t take this on, but you should try Graphic Mundi, which had published several novels in the field of graphic medicine.”

Q: What made you want to write about health insurance?

Our system is actually killing people. We have a high suicide rate in this country, and people are not able to access mental health care. And then, when they do get help, it’s not necessarily the psychiatrist who determines the course of care; it’s the insurance company. If you go into a room of 10 Americans, five can tell you a health insurance nightmare story.

But I also wanted to explore what it means to develop a healthy lifestyle and grow a strong community and go through all this growth and healing that Bipolar Bear goes through in the story, only to have the depression come back again. What is the meaning of my journey if I find myself right back where I was before? Ultimately, there’s no answer to that question, but there is a right thing to do, which is to ask for help. We’re all saved by each other.

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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Medicare Advantage plans for seniors dodged a major financial bullet Monday as government officials gave them a reprieve for returning hundreds of millions of dollars or more in government overpayments — some dating back a decade or more.

The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.

But in a surprise action, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.

While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018. Exactly how much is not clear because audits as far back as 2011 have yet to be completed.

In late 2018, CMS officials said the agency would collect an estimated $650 million in overpayments from 90 Medicare Advantage audits conducted for 2011 through 2013, the most recent ones available. Some analysts calculated overpayments to plans of at least twice that much for the three-year period. CMS is now conducting audits for 2014 and 2015.

The estimate for the 2011-13 audits was based on an extrapolation of overpayments found in a sampling of patients at each health plan. In these reviews, auditors examine medical records to confirm whether patients had the diseases for which the government reimbursed health plans to treat.

Through the years, those audits — and others conducted by government watchdogs — have found that health plans often cannot document that they deserved extra payments for patients they said were sicker than average.

The decision to take earlier audit findings off the table means that CMS has spent tens of millions of dollars conducting audits as far back as 2011 — much more than the government will be able to recoup.

In 2018, CMS said it pays $54 million annually to conduct 30 of the audits. Without extrapolation for years 2011-17, CMS won’t come near to recouping that much.

CMS Deputy Administrator Dara Corrigan called the final rule a “commonsense approach to oversight.” Corrigan said she did not know how much money would go uncollected from years prior to 2018.

Health and Human Services Secretary Xavier Becerra said the rule takes “long overdue steps to move in the direction of accountability.”

“Going forward, this is good news. We should all be happy that they are doing that [extrapolation],” said former CMS official Ted Doolittle. But he added: “I do wish they were pushing back further [and extrapolating earlier years]. That would seem to be fair game,” he said.

David Lipschutz, an attorney with the Center for Medicare Advocacy, said he was still evaluating the rule, but noted: “It is our hope that CMS would use everything within their discretion to recoup overpayments made to Medicare Advantage plans.” He said that “it is unclear if they are using all of their authority.”

Mark Miller, who is the executive vice president of health care policy for Arnold Ventures and formerly worked at the Medicare Payment Advisory Commission, a congressional advisory board, said extrapolating errors found in medical coding have always been a part of government auditing. “It strikes me as ridiculous to run a sample and find an error rate and then only collect the sample error rate as opposed to what it presents to the entire population or pool of claims,” he said. (KHN receives funding support from Arnold Ventures.)

Last week, KHN released details of the 90 audits from 2011-2013, which were obtained through a Freedom of Information Act lawsuit. The audits found about $12 million in net overpayments for the care of 18,090 patients sampled for the three-year period.

In all, 71 of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits. CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient, the records showed.

Since 2010, the federal Centers for Medicare & Medicaid services has threatened to crack down on billing abuses in the popular health plans, which now cover more than 30 million Americans. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies including Humana, UnitedHealthcare, Centene, and CVS/Aetna.

But the industry has succeeded in opposing extrapolation of overpayments, even though the audit tool is widely used to recover overcharges in other parts of the Medicare program.

That has happened despite dozens of audits, investigations, and whistleblower lawsuits alleging that Medicare Advantage overcharges cost taxpayers billions of dollars a year.

Corrigan said Monday that CMS expected to collect $479 million from overpayments in 2018, the first year of extrapolation. Over the next decade, it could recoup $4.7 billion, she said.

Medicare Advantage plans also face potentially hundreds of millions of dollars in clawbacks from a set of unrelated audits conducted by the Health and Human Services inspector general.

The audits include an April 2021 review alleging that a Humana Medicare Advantage plan in Florida had overcharged the government by nearly $200 million in 2015.

Carolyn Kapustij, the Office of the Inspector General’s senior adviser for managed care, said the agency has conducted 17 such audits that found widespread payment errors — on average 69% for some medical diagnoses. In these cases, the health plans “did not have the necessary support [for these conditions] in the medical records, which has caused overpayments.”

“Although the MA organizations usually disagreed with us, they almost always had little disagreement with our finding that their diagnoses were not supported,” she said.

While CMS has taken years to conduct the Medicare Advantage audits, it also has faced criticism for permitting lengthy appeals that can drag on for years. These delays have drawn sharp criticism from the Government Accountability Office, the watchdog arm of Congress.

Leslie Gordon, an acting director of the GAO health team, said that until CMS speeds up the process, it “will fail to recover improper payments of hundreds of millions of dollars annually.”

KHN senior correspondent Phil Galewitz contributed to this report.

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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Brenna Kearney was seven months pregnant in December 2019 when she experienced what she thought were bad flu symptoms.

Her husband, Casey Trumble, drove her from their Chicago home to her OB-GYN’s office at Northwestern Medicine Prentice Women’s Hospital downtown. With suddenly elevated blood pressure and protein in her urine, she was diagnosed with preeclampsia, a potentially fatal but treatable pregnancy complication. Doctors admitted her to the hospital, saying she could expect to stay up to six weeks and have an induced delivery.

Then Kearney developed a bad headache and her blood platelet count plummeted, signs she was experiencing a rare, dangerous type of preeclampsia and requiring an immediate delivery by cesarean section.

Kearney’s daughter, Joey, born at 31 weeks, was placed on a ventilator and moved to the hospital’s neonatal intensive care unit. Small but healthy, she slowly began breathing on her own and eating normally. She was discharged in late January 2020, after 36 days in the NICU.

Then the bill came.

The Patient: Josephine “Joey” Trumble, now 3, was covered by her mother’s health plan through her employer, an advertising agency. For 2019, it was an Aetna plan, and for 2020, it was a plan from Blue Cross and Blue Shield of Illinois. Both policies were fully insured plans governed by Illinois laws.

Medical Service: Neonatology physician services provided in January 2020. Joey needed tube feeding and ventilator care to provide oxygen.

Service Provider: Ann & Robert H. Lurie Children’s Hospital of Chicago, whose staff physicians treated Joey at Northwestern Medicine Prentice Women’s Hospital. Ownership-wise, Lurie is independent of Northwestern Medicine, but it is physically connected to Prentice Women’s by an enclosed walkway. Lurie has a collaboration agreement with Northwestern Medicine to provide neonatology and pediatric physician services to Prentice Women’s patients.

Total Bill: Aetna paid for nearly all of Joey and her mother’s hospital and physician charges in December, while Blue Cross picked up nearly all of Joey’s hospital charges in January. Physician charges from Lurie in January totaled $14,624.55, of which the family was asked to pay $12,531.58 after payments from Blue Cross.

What Gives: It took Kearney months of calls to Blue Cross and the two hospitals to find out why Lurie billed more than $14,000 for physician services: The physicians treating her daughter at Prentice Women’s — an in-network hospital under her health plan — actually worked for a separate, out-of-network hospital.

Illinois law bars insurers from charging patients out-of-network rates for neonatal care at in-network hospitals.

Kearney said no one had told her or her husband that Lurie doctors were treating their daughter. She said the family never signed an agreement consenting to receive care from out-of-network doctors.

Though it did not happen here, many patients unknowingly sign broad financial agreements — saying they’ll pay for almost anything their insurance doesn’t cover — in the piles of paperwork they receive upon admission to a hospital. In many cases, they are simply asked to sign on a screen, without seeing the document.

Blue Cross agreed to pay Lurie the in-network rate for the doctors’ services, reducing the bill to about $12,500 — which Lurie expected the family to pay.

In November 2020, Kearney started receiving letters from ICS Collection Service, a collection agency.

“Talking to Blue Cross was impossible, and Lurie said it’s not their problem and just wanted to put us on a payment plan,” Kearney said.

Joey’s 36-day stay in the NICU happened before the federal government implemented the No Surprises Act barring surprise out-of-network billing. A state law prohibiting it, though, was in effect.

Since 2011, Illinois law has prohibited insurers from charging out-of-network rates for neonatologists, anesthesiologists, and certain other physicians when patients are treated at in-network hospitals.

Kearney said she repeatedly mentioned the law to Lurie and Blue Cross representatives, who denied knowledge of the provision.

“It definitely appears that under the 2011 law, Brenna can only be billed for in-network cost sharing,” said Kathy Mikos, a registered nurse and patient advocate with the Navocate Group in Woodridge, Illinois, who is not involved with Kearney’s case.

In December 2020, an insurance broker working for Kearney’s employer persuaded Blue Cross to pay the full out-of-network charges for the Lurie doctors, leaving the family owing $289.63 for coinsurance, which they promptly paid.

Having spent nearly the first year of her daughter’s life fighting medical bills from her birth, Kearney thought the ordeal was over.

Then, last month, she got a call from the collection agency, which again demanded payment at the full out-of-network rate for Lurie physician services provided to her daughter three years ago — the bill she believed Blue Cross had paid.

It took five hours on the phone for Kearney to piece together what had happened. Blue Cross had indeed paid the out-of-network charges in December 2020 — but, two days later, had taken back the money, ultimately paying Lurie’s doctors only the in-network rate.

A Lurie representative said Kearney and her husband still owed thousands of dollars. A Blue Cross representative suggested she set up a payment plan.

“I was at wits’ end, and I didn’t know how to fight this anymore,” Kearney said.

Lurie, Blue Cross, and Northwestern Medicine did not respond to numerous requests from KHN for comment. Lurie cited patient privacy, despite receiving a release from Kearney regarding the federal Health Insurance Portability and Accountability Act, or HIPAA, which authorized the hospital to discuss Joey’s case with KHN.

The Resolution: After KHN contacted Lurie and Blue Cross, a Lurie representative called Kearney offering to accept payment at the in-network rates after all.

Kearney said Tracy A. Spicer, manager of consolidated services at Lurie, told her Lurie has a “long-standing policy” of accepting in-network rates for Lurie physician services provided at Prentice Women’s. Spicer subsequently described it as a “long-standing courtesy,” then explained that acceptance of in-network rates was subject to “case-by-case consideration,” Kearney said.

Spicer said the family owed about $3,000 for their coinsurance share and offered to set up a payment plan.

A day later — following additional requests by KHN for comment — Spicer called Kearney and said she would remove all physician charges for her daughter’s care. Spicer did not return KHN’s call seeking comment.

“I’m certain I’m not the only person still dealing with this” kind of predicament, Kearney said.

Kearney has filed complaints with the Illinois Department of Insurance and the Illinois Attorney General’s Office. The attorney general’s office told KHN it had never enforced the 2011 law barring certain out-of-network billing.

Presented with the facts of Kearney’s case, state Sen. Ann Gillespie, who sponsored a 2022 state law expanding consumer protections against out-of-network bills, told KHN she plans to contact Lurie, Blue Cross, and Northwestern Medicine to ask about their billing arrangement and whether they are in compliance with state law.

“We’ll see if it was a pattern and whether they need to look back and see if refunds are warranted,” Gillespie said.

The attorney general’s office told KHN it will investigate Kearney’s complaint, including whether Lurie violated the state Consumer Fraud and Deceptive Business Practices Act by telling her it was extending a “courtesy” by charging her only in-network rates, when that is what the 2011 law required. The insurance department also said it would investigate the complaint.

The Takeaway: Even resourceful consumers who appear to have the law on their side, like Kearney, may find themselves in a losing, time-consuming battle with medical billing bureaucracies and facing collection actions.

Gillespie, the state senator, said Lurie, Northwestern Medicine, and Blue Cross should have known about the state law. She said patients who believe they have been improperly charged should file complaints with their state’s insurance department, which can trigger a broader investigation.

The federal No Surprises Act, which took effect last year, prohibits medical providers or insurers from billing patients for out-of-network physician charges at an in-network hospital, unless the patient formally consents to an out-of-network doctor. To be safe, patients should ask treating doctors whether they are in or out of network, even at an in-network hospital.

While the federal law offers patients new protections from out-of-network bills, many Americans still face problems from before the law took effect, said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy. Illinois is one of relatively few states that had prior laws to protect consumers.

Also, some out-of-network physicians continue to bill patients, despite the new federal protections. So know your rights. Cite the new law. And don’t write the check.

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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MILLSTADT, Ill. — It was a late Friday afternoon when a team of men approached a tiny pink casket. One wiped his brow. Another stepped away to smoke a cigarette. Then, with calloused hands, they gently lowered the child’s body into the ground.

Earlier that day, the groundskeepers at Sunset Gardens of Memory had dug the small grave up on a hill in a special section of this cemetery in a southern Illinois community across the river from St. Louis. It was for a 3-year-old girl killed by a stray bullet.

“It can be stressful sometimes,” Jasper Belt, 26, said. “We have to use little shovels.”

More than 30 years ago, Johnnie Haire and the other groundskeepers built a garden site just for children, separate from unlabeled sections of the 30-acre cemetery where they used to bury infants. They added a birdbath and bought angel figurines, carefully painting each one a hue of brown. Haire wanted the angels to be Black, like many of the children laid to rest here.

“This is ‘Baby Land,’” said Haire, 67, Sunset Gardens’ grounds supervisor, as he gestured across the area. “This is where a lot of babies are buried.”

Cemeteries like this one have long honored those who die too young. Such special burial sites exist in Gainesville, Florida; Quincy, Illinois; Owensboro, Kentucky; and beyond. They are for stillborn children and those who died of disease or accidents.

Today, a modern epidemic fills more graves than anything else: In the U.S., firearm-related injuries were the leading cause of death for children in 2020, ahead of motor vehicle crashes, according to researchers from the University of Michigan.

The men at Sunset Gardens are collecting data in their own way, too.

In 2019, Haire broke ground on a new section of the cemetery where teenagers and young adults are buried, including those killed by covid-19 and many who were victims of gun violence. It’s called the “Garden of Grace.” It’s already been used more than anyone would like.

“One time, it was just every weekend. Just a steady flow,” Haire said. “This one getting killed over here. This one getting killed over there. They fighting against each other, some rival gangs or whatever they were. So we had a lot. A lot of that.”

And 2021 was especially deadly nationwide: More than 47,000 people of all ages died from gunshot injuries, the highest U.S. toll since the early 1990s, according to the Centers for Disease Control and Prevention. This past year wasn’t as deadly nationally, though the tally is still being finalized.

The groundskeepers at Sunset Gardens have learned to watch their step in Baby Land because grieving parents drop off toys, candy, and balloons for their deceased children. “They just do things so differently in grief,” said Jocelyn Belt, 35, whose dad, William Belt Sr., 66, has worked at the cemetery since before she was born. Her brother and cousin work there, too.

The groundskeepers work quietly as families grieve. William Belt Jr., 44, said he doesn’t pry, even if he knows the family and would like to know how they’re doing.

“That’s what you learn not to do,” he said. “We let them come to us.”

But often, the men said, they are anonymous amid the rituals of grief. William Belt Jr. said he sometimes runs into those who attended the burials around town. “They don’t know my name. They’ll be like, ‘Gravedigger, you buried my mom. Man, thanks.’”

These men understand the complicated pain of losing loved ones. In the past year alone, the Belt family has experienced three deaths, including a relative who was shot and killed.

And on New Year’s Eve, William Belt Jr. himself was shot while in his truck outside a gas station convenience store.

“Nobody’s exempt,” he said, while recovering at home. “It could have been an old lady going to get some cornmeal or something like that from that store and could have got caught right in the crossfire.”

His family is thankful he’s OK. He is still grappling with his own close call, though.

“I would have probably been overtime for some of my co-workers. That’s something to think about,” Belt said. “And then they wouldn’t been able to go to my funeral ’cause they got to bury me.”

William Belt Sr. said his body froze when his son was shot. And he said he couldn’t hold back his emotions when he buried his brother and niece less than a month apart. Many of their relatives are buried at Sunset Gardens — literally by them.

“I weep,” he said. “Big difference between crying and weeping. Weeping, I’m closer to God.”

Their job is physical, emotional work done in all seasons, all weather. Injuries occur. Heartbreak is everywhere.

To hold their own hearts together, the groundskeepers often decompress as they eat lunch in a shed near the cemetery’s front office, trading stories in front of a wood-burning stove to keep warm during winter. They find joy where they can. The Belts like to fish. And the senior Belt occasionally sings the blues to soothe his soul. Parker, a long-haired cat, provides them company, too — and enjoys investigating the men’s lunches.

And they laugh when they can. William Belt Sr. still remembers his first year on the job. He wanted to be respectful, he said with a smile, even though his clients were deceased.

“‘Excuse me, coming through,’” Belt recalled saying as he walked through the cemetery. “Then I got myself together.”

Digging graves for a living wasn’t on the career list for Belt or his friend Haire. But that’s exactly what the two men have done for some 43 years — whether it’s for those who lived long, full lives or those whose young lives were cut short. They’re caretakers.

“That’s the proper name for it,” Haire said.

As he stood amid the graves on a recent day, he noted that the wooden Baby Land sign that welcomes mourners is worn. The paint on the angels is peeling, too.

“It needs touching up over there,” Haire said. “But I’ve been busy.”

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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The Host

Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special, two-part podcast, taped the week of the 50th anniversary of the decision in Roe v. Wade, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Panelists

Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories Sarah Varney KHN @sarahvarney4 Read Sarah's stories
Among the takeaways from this week’s episode:

• Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
• The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
• A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
• Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
• Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
• Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
• Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

And for extra credit, the panelists recommend their most memorable reproductive health stories from the last year:

Julie Rovner: NPR’s “Because of Texas’ Abortion Law, Her Wanted Pregnancy Became a Medical Nightmare,” by Carrie Feibel

Alice Miranda Ollstein: The New York Times Magazine’s “She Wasn’t Ready for Children. A Judge Wouldn’t Let Her Have an Abortion,” by Lizzie Presser

Sandhya Raman: ProPublica’s “’We Need to Defend This Law’: Inside an Anti-Abortion Meeting with Tennessee’s GOP Lawmakers,” by Kavitha Surana

Sarah Varney: Science Friday’s and KHN’s “Why Contraceptive Failure Rates Matter in a Post-Roe America,” by Sarah Varney

Also mentioned in this week’s podcast:

• NPR’s “Doctors Who Want to Defy Abortion Laws Say It’s Too Risky,” by Selena Simmons-Duffin
• The Columbus Dispatch’s “Suspect Indicted in Rape of 10-Year-Old Columbus Girl Who Got Indiana Abortion,” by Bethany Bruner
• Reveal’s “The Long Campaign to Turn Birth Control Into the New Abortion”
• Reuters’ “Alabama Case Over Mistaken Pregnancy Highlights Risks in a Post-Roe World,” by Hassan Kanu
• Politico’s “The Next Abortion Fight Could Be Over Wastewater Regulation,” by Alice Miranda Ollstein
• The Washington Post’s “Abortion Bans Complicate Access to Drugs for Cancer, Arthritis, Even Ulcers,” by Katie Shepherd and Frances Stead Sellers
• The Washington Post’s “A Triumphant Antiabortion Movement Begins to Deal With Its Divisions,” by Rachel Roubein and Brittany Shammas
• NBC News’ “Abortion Rights Groups Look to Build on Their Victories With New Ballot Measures,” by Adam Edelman

Credits

Francis Ying Audio Producer Emmarie Huetteman Editor
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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Mark Buck, a physician and pharmacist in Helena, Montana, said he’s been seeing more patients turn to urgent care clinics when they run out of medication. Their doctors have retired, moved away, or left the field because they burned out during the covid-19 pandemic, leaving the patients with few options to renew their prescriptions, he said.

“Access is where we’re really hurting in this state,” Buck said.

Senate Bill 112, sponsored by Republican Sen. Tom McGillvray, would address that need by expanding the limited authority Montana already gives pharmacists to prescribe medications and devices. Supporters said the measure could help fill health care gaps in rural areas in particular, while opponents worried it would give pharmacists physician-like authority without the same education.

Eleven states, including Montana, give pharmacists prescribing authority to some degree for medications such as birth control, naloxone, tobacco cessation products, preventive HIV drugs, and travel-related medications. The FDA has allowed pharmacists nationwide to prescribe the covid drug Paxlovid during the public health emergency.

According to a 2021 report by George Mason University’s Mercatus Center, there were about 228,000 primary care physicians nationwide in 2019 and more than 315,000 pharmacists in 2020. The report found that patients using Medicare visit a pharmacist twice as often as a primary care provider, and the difference is even larger in rural areas.

Pharmacists, who often work in grocery stores, “are open longer hours than most doctors’ offices, and no appointment is needed,” the authors of the Mercatus Center study wrote.

Under the bill, pharmacists could prescribe for patients who do not require a new diagnosis, for minor conditions, or in emergencies. They could not prescribe controlled substances.

During a Jan. 18 committee hearing on the bill, supporters said pharmacists also would be able to provide strep and flu tests, along with diabetic supplies.

Buck, the Helena doctor-pharmacist, said the bill wouldn’t solve the provider shortage, but it would “put a thumb in the dike that’s leaking.”

According to data from the University of Wisconsin Population Health Institute, Montana had one primary care physician per 1,210 people in 2019. Some counties have no primary care providers, but they usually have a pharmacy, said Kendall Cotton, executive director of the Frontier Institute, a public policy think tank in Montana. For example, Powder River County has no physician, he said, but a grocery store in the county seat, Broadus, has a pharmacy.

As a clinical pharmacist practitioner for 15 years, Travis Schule of Kalispell wouldn’t be much affected by the passage of SB 112. In Montana, providers like him with additional education and training already have authority to prescribe under Montana’s existing rules.

But he sees the bill’s potential to expand access to treatment in Montana. In some cases, people might have to drive three hours to see a physician, and SB 112 would allow a pharmacist to serve as a “first triage” before they travel that long distance, Schule said.

“This bill is a patient-centric bill,” Schule said. “It’s not for pharmacists. It’s for patients.”

SB 112 is modeled after a bill passed in Idaho. Tim Flynn, a pharmacist at an Albertsons grocery store in Meridian, Idaho, said the legislation lets patients be treated for minor conditions, such as urinary tract infections, when they can’t schedule a doctor’s appointment or get to an urgent care clinic.

The Montana Medical Association and the Montana chapter of the American Academy of Pediatrics oppose SB 112. They say SB 112 would fragment care, risk patient safety, and substitute pharmacists for emergency care physicians.

But Montana Medical Association CEO Jean Branscum said there was an opportunity to build on the Idaho model, by bringing pharmacists and physicians together while making sure patients get the same standard of care.

“Let’s come up with a model of care that will allow pharmacists to do more than they do now, be a part of that team, practice at the highest level, and also appreciate the value of the physicians as part of that team too,” Branscum told lawmakers at the Jan. 18 hearing.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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Today, KHN has released details of 90 previously secret government audits that reveal millions of dollars in overpayments to Medicare Advantage health plans for seniors.

The audits, which cover billings from 2011 through 2013, are the most recent financial reviews available, even though enrollment in the health plans has exploded over the past decade to over 30 million and is expected to grow further.

KHN has published the audit spreadsheets as the industry girds for a final regulation that could order health plans to return hundreds of millions, if not billions, of dollars or more in overcharges to the Treasury Department — payments dating back a decade or more. The decision by the Centers for Medicare & Medicaid Services is expected by Feb 1.

KHN obtained the long-hidden audit summaries through a three-year Freedom of Information Act lawsuit against CMS, which was settled in late September.

In November, KHN reported that the audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled. In all, 71 of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits. CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

The audit spreadsheets released today identify each health plan and summarize the findings. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies. Contract numbers for the plans indicate where the insurers were based at the time.

Since 2018, CMS officials have said they would recoup an estimated $650 million in overpayments from the 90 audits, but the final amount is far from certain.

Spencer Perlman, an analyst with Veda Partners in Bethesda, Maryland, said he believes the data released by KHN indicates the government’s clawbacks for potential overpayments could reach as high as $3 billion.

“I don’t see government forgoing those dollars,” he said.

For nearly two decades, Medicare has paid the health plans using a billing formula that pays higher monthly rates for sicker patients and less for the healthiest ones.

Yet on the rare occasions that auditors examined medical files, they often could not confirm that patients had the listed diseases, or that the conditions were as serious as the health plans claimed.

Since 2010, CMS has argued that overpayments found while sampling patient records at each health plan should be extrapolated across the membership, a practice commonly used in government audits. Doing so can multiply the overpayment demand from a few thousand dollars to hundreds of millions for a large health plan.

But the industry has managed to fend off this regulation despite dozens of audits, investigations, and whistleblower lawsuits alleging widespread billing fraud and abuse in the program that costs taxpayers billions every year.

CMS is expected to clarify what it will do with the upcoming regulation, both for collecting on past audits and those to come. CMS is currently conducting audits for 2014 and 2015.

UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding the $1,000 average in 10 of 11 audits, according to the records.

That could spell trouble for the Louisville, Kentucky-based insurer, which relies heavily on Medicare Advantage, according to Perlman. He said Humana’s liability could exceed $900 million.

Mark Taylor, Humana’s director of corporate and financial communications, had no comment on the overpayment estimates.

Commenting on the upcoming CMS rule, he said in an emailed statement: “Our primary focus will remain on our members and the potential impact any changes could have on their benefits. ... We hope CMS will join us in protecting the integrity of Medicare Advantage.”

Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.

In a conference call with reporters this week, Tim Noel, who leads UnitedHealthcare's Medicare team, said the company wants CMS to make changes in the regulation but remains “very comfortable” with what the 2011-13 audit results will show.

“Like all government programs, taxpayers and beneficiaries need to know that the Medicare Advantage program is well managed,” he said.

He said the company supports annual auditing of Medicare Advantage plans.

But Perlman said the sheer size of the program makes annual audits “completely impractical.”

These audits are “incredibly time-consuming and labor-intensive” to conduct,” he 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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California’s decision last month to cancel the results of a long-planned bidding competition among commercial health plans in its Medicaid program has some industry insiders and consumer advocates wondering whether the state can stand up to insurers and force improvements in care for millions of low-income beneficiaries.

In a backroom agreement announced in the final days of 2022, Gov. Gavin Newsom’s administration, facing lawsuits, granted concessions that allowed major insurers to claw back business they would have lost had health officials stuck with the state’s initial contract awards for managed-care plans. Oakland-based Blue Shield of California and St. Louis-based Centene Corp. — which owns Health Net, the largest commercial health plan in Medi-Cal, the state’s version of Medicaid — were among those that had aggressively challenged the initial results.

“They had this long process, and then they just sort of struck deals,” said Maya Altman, who retired a year ago after nearly 17 years as CEO of the Health Plan of San Mateo, which did not participate in the bidding. “It’s kind of weird. Not transparent — very much behind closed doors.”

It was a remarkable change of course that came four months after the state had announced its initial contract awards. The Department of Health Care Services, which oversees Medi-Cal, had spent years preparing for the bidding competition and touted it as an important means of addressing substandard care. Eight commercial Medi-Cal plans, covering around 30% of the program’s 13 million managed-care enrollees, were required to submit bids for contracts worth about $70 billion over five years.

Noncommercial, locally governed Medi-Cal plans that cover the other 70% of managed-care enrollees did not have to submit bids, but they will be required to sign the same new contract as the commercial plans, scheduled to take effect next year.

State officials said their new decision avoids uncertainty after the losing health plans — Health Net, Blue Shield of California, Community Health Group, and Aetna — threatened drawn-out legal action. It also dramatically reduces the number of Medi-Cal enrollees who will have to switch plans — from an estimated 2.3 million to about 1.2 million. And state officials said it strengthens their ability to enhance Medi-Cal through the new contracts, which will contain requirements for higher-quality care, greater transparency, and more equitable access.

Other states have faced legal disruption after they put their Medicaid contracts up for bid. In Louisiana, for example, Centene and Aetna in 2019 protested the results of a rebidding process, which led that state to nullify its awards and start over. The new results were announced nearly two years later, with Centene and Aetna among the winners.

“When you create disputes, and lawsuits, they always put some uncertainty into things,” Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, told KHN. “We feel that we ended up in a place where we achieved certainty. We have a set of [health] plans who are committed to this.”

Consumer advocates had worried that lingering uncertainty would hinder the rollout of a far-reaching nearly $12 billion, five-year Medi-Cal initiative to provide nonmedical social services that address socioeconomic factors such as homelessness and food insecurity, widely viewed as key health indicators.

Still, the state’s decision to throw out the bidding results has many patient advocates and some health plan executives questioning the value of future contract competitions and even whether health officials will effectively enforce the higher standards in the new contract.

“It would be extremely disappointing if poor-performing plans were able to litigate their way into participating in Medi-Cal,” said Abbi Coursolle, a senior attorney in the Los Angeles office of the National Health Law Program.

Tony Cava, a spokesperson for the Department of Health Care Services, said the bids submitted were still “incredibly valuable,” because they showed how the health plans intend to improve care. He said commitments made in the bids will be incorporated into the new contracts. Cava also said the department, which had not previously held a statewide bidding competition, now intends to hold one every five years.

Patient advocates and industry insiders gave the state credit for fining health plans that fell short of quality and access standards in a report issued late last year. But they also noted that several of the health plans that will continue to operate in Medi-Cal — including Molina Healthcare and Health Net — were among the lowest performers.

When the state announced its initial awards in August, Blue Shield was shut out, despite its large health care footprint statewide and its long-standing efforts to curry favor with the state’s political class. The state also said initially that it would take Los Angeles County, a huge Medi-Cal contract, away from Health Net.

Between 2018 and 2022, Blue Shield spent at least $31 million on lobbying, political donations, and other contributions, including $20 million to a state homelessness fund Newsom set up, according to a KHN analysis of filings with the secretary of state and the California Fair Political Practices Commission. Health Net parent Centene spent at least $5 million over that period, mostly on lobbying and political donations.

Under the new arrangement, Blue Shield will keep its San Diego County Medi-Cal business after initially losing it in the contract competition, though it will not get a contract in any of the other 12 counties where it bid. Its roughly 129,000 San Diego enrollees will not have to switch plans, but over 100,000 other Medi-Cal members in San Diego will still have to switch, as Health Net and Aetna exit.

In Los Angeles County, Health Net will retain its primary Medi-Cal contract, but will have to split its 1.1 million members 50-50 with Molina under a subcontract. Molina already subcontracts with Health Net in the county, but currently has only 80,000 enrollees under that arrangement.

Some observers questioned how the split can be maintained. Cava said half of new Medi-Cal enrollees in L.A. County don’t choose a plan and are assigned to one instead, according to the most recent data. These assignments will be used to help balance enrollment between Health Net and Molina, he said.

The state and the five participating health plans issued an unusual joint statement, and the plans put a positive spin on it. Centene said the state’s revised decision “is in the best interest of millions of members.” A Blue Shield executive said it was “honored to continue serving Medi-Cal beneficiaries in San Diego County.”

In an investor call this month, Molina’s CEO, Joseph Zubretsky, noted that his company’s Medi-Cal membership will double with the new agreement, though it would have tripled under the state’s initial decision. He summarized the situation for Molina as “taking three steps forward, taking one step back, and ending up being two steps ahead.”

Consumer advocates, patients, and medical professionals expressed relief that the new agreement allows Community Health Group, the largest Medi-Cal health plan in San Diego County, to keep operating there. Had the initial results held, it would have lost its contract, and its 335,000 members would have had to choose new plans.

Christine Xayalinh, a member of Community Health Group in Escondido, said the plan afforded her treatment for Type 2 diabetes and referred her to University of California-San Diego for a successful gastric bypass.

“I know some people do have concerns about their health insurance,” Xayalinh, 29, said, “but for me, it’s been a lifesaver.”

With the contract awards decided, the state’s hope of improving Medi-Cal will hinge on its ability to enforce the new contracts.

“The focus now needs to be on making sure that works,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “This is a very vulnerable population of Californians who are not getting what they need.”

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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At a meeting to simplify the nation’s covid vaccination policy, the FDA’s panel of experts could agree on only one thing: Information is woefully lacking about how often different groups of Americans need to be vaccinated. That data gap has contributed to widespread skepticism, undervaccination, and ultimately unnecessary deaths from covid-19.

The committee voted unanimously Thursday to support the FDA’s proposal for all vaccine-makers to adopt the same strain of the virus when making changes in their vaccines, and suggested they might meet in May or June to select a strain for the vaccines that would be rolled out this fall.

However, the panel members disagreed with the FDA’s proposal that everyone get at least one shot a year, saying more information was needed to make such a declaration. Several panelists noted that in recent studies, only about a third of people hospitalized with a positive covid test actually were there because of covid illness. That’s because everyone entering a hospital is tested for covid, so deaths of patients with incidental infections are counted as covid deaths even when it isn’t the cause.

The experts questioned the rationale for annual shots for everyone, given that current vaccines do not seem to protect against infection for more than a few months. Yet even a single booster seems to prevent death and hospitalization in most people, except for the very old and people with certain medical conditions.

“We need the CDC to tell us exactly who is getting hospitalized and dying of this virus — the ages, vulnerability, the type of immune compromise, and whether they were treated with antivirals. And we need immunological data to indicate who’s at risk,” said Dr. Paul Offit, director of the Vaccine Education Center and a pediatrician at Children’s Hospital of Philadelphia. “Only then can we decide who gets vaccinated with what and when.”

Offit and others have expressed frustration over the lack of clear government messaging on what the public can expect from covid vaccines. While regular boosters might be important for keeping the elderly and medically frail out of the hospital, he said, the annual boosters suggested by the FDA and the drug companies may not be necessary for everyone.

“The goal is to keep people out of the hospital,” he said. “For the vulnerable, it would be important for vaccines to keep up with circulating strains. But for the general population, we already have a vaccine that prevents hospitalization.”

Other panelists said the government needs to push research harder to get better vaccines. Pamela McGinnis, a retired official of the National Institutes of Health, said she had trouble explaining to her two young-adult sons why they promptly got sick after venturing out to bars one night only weeks after getting their bivalent booster.

“‘Think how sick you would have gotten if you weren’t fully vaccinated’ is not a great message,” she said. “I’m not sure ‘You would have landed in the hospital’ resonates with recipients of the disease.”

Members of the FDA’s advisory committee have been irked in recent months, saying the agency didn’t present them with all the data it had on the bivalent vaccine before it was released in September. And some critics have said the FDA should have instructed drug companies to include only the newer strains of the virus in the shot.

Asked about that Thursday, Jerry Weir, a senior FDA vaccine officer, said his “gut feeling” was that a vaccine matched to a single omicron strain would have performed better than the bivalent shot, which also contains the original covid strain. “But the real question is where we’re headed,” he said, “and I don’t know the answer.”

Perhaps the most important presentation Thursday was from Heather Scobie, who keeps tabs on covid at the Centers for Disease Control and Prevention. She reported that fewer than half of Americans 65 and older had gotten the latest booster, and that only two-thirds of that age group had gotten even a single booster.

Yet evidence continues to mount that it’s mostly the elderly who are at serious risk from covid. Death rates from the disease have declined in every age group except those over 75 since April, despite the uptick in new strains. Except for the very old, the death rate has hovered around 1 in 100,000 since April. Earlier in 2022, babies 6 months old and younger were hospitalized and died at relatively high rates. Vaccination levels in the 4-and-under group hover at about 10%.

While acknowledging the FDA’s desire to regularize its covid vaccine policy, panel members said it’s still too early to know for sure whether covid will surge only in the winter, like flu, respiratory syncytial virus, and other respiratory infections.

“For the next few years we may not know how often we need to make a strain change in the vaccine,” said Dr. Steven Pergam, medical director of infection prevention at the Seattle Cancer Care Alliance. Or even if people who are not in poor health or elderly need additional boosters.

One vaccine-maker represented at the meeting, Novavax, said it would need to know by the end of March which strain to include in its vaccine for fall. Companies with mRNA vaccines like Pfizer and Moderna can change their formulas faster, but their products aren’t clearly better than Novavax’s.

All three of those vaccine-makers revealed at the meeting that they are developing single-dose vials or prefilled syringes. Up to now, they’ve delivered their vaccines in multidose vials, but since the government has run out of money to buy vaccines, individual pediatricians may order them in the future. Since the vaccine must be used quickly once a vial is open, doctors are leery of wasting vaccine and losing money.

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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The Host

Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special two-part podcast, taped the week of the 50th anniversary of the Roe decision, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Panelists

Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories Sarah Varney KHN @sarahvarney4 Read Sarah's stories
Among the takeaways from this week’s episode:

• Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
• The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
• A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
• Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
• Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
• Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
• Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

Also this week, Rovner interviews Elizabeth Nash, who tracks state reproductive health policies for the Guttmacher Institute, a reproductive rights research group.

Credits

Francis Ying Audio Producer Emmarie Huetteman Editor
To hear all our podcasts, click here.

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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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The covid-19 pandemic has spurred a surge in the proportion of Californians who are dying at home rather than in a hospital or nursing home, accelerating a slow but steady rise that dates back at least two decades.

The recent upsurge in at-home deaths started in 2020, the first year of the pandemic, and the rate has continued to climb, outlasting the rigid lockdowns at hospitals and nursing homes that might help explain the initial shift. Nearly 40% of deaths in California during the first 10 months of 2022 took place at home, up from about 36% for all of 2019, according to death certificate data from the California Department of Public Health. By comparison, U.S. Centers for Disease Control and Prevention data shows that about 26% of Californians died at home in 1999, the earliest year for which data on at-home deaths is accessible in the agency’s public database.

The trend is amplified among California residents with serious chronic conditions. About 55% of Californians who died of cancer did so at home during the first 10 months of 2022, compared with 50% in 2019 and 44% in 1999. About 43% of Californians who died of Alzheimer’s disease in the first 10 months of 2022 did so at home, compared with 34% in 2019 and nearly 16% in 1999.

Nationwide, the share of deaths occurring at home also jumped in 2020, to 33%, then rose to nearly 34% in 2021. Nationwide data for 2022 is not yet available.

Covid’s early, deadly sweep across California does not in itself explain the increase in at-home death rates; the vast majority of people who have died of covid died in a hospital or nursing home. Instead, medical experts said, the surge — at least initially — appears to coincide with sweeping policy changes in hospitals and nursing homes as caregivers struggled to contain a virus both virulent and little understood.

The sweeping bans on in-person visitation in hospitals and nursing homes, even to the bedsides of dying patients, created an agonizing situation for families. Many chose to move a loved one back home. “It was devastating to have Mom in a nursing home and dying, and the only way you can see Mom is through the window,” said Barbara Karnes, a registered nurse who has written extensively about end-of-life care.

At the same time, fears of covid exposure led many people to avoid hospitals in the first years of the pandemic, in some cases neglecting treatment for other serious conditions. That, too, is thought to have contributed to the rise in at-home deaths.

Those who specialize in end-of-life care say it is no surprise the trend has continued even as visitation policies have eased. They said more people simply want to die in a comfortable, familiar place, even if it means not fighting for every second of life with medical interventions.

“Whenever I ask, ‘Where do you want to be when you breathe your last breath? Or when your heart beats its last beat?’ no one ever says, ‘Oh, I want to be in the ICU,’ or ‘Oh, I want to be in the hospital,’ or ‘I want to be in a skilled nursing facility.’ They all say, ‘I want to be at home,’” said John Tastad, coordinator for the advance care planning program at Sharp HealthCare in San Diego.

Meanwhile, the physicians who specialize in the diseases that tend to kill Americans, such as cancer and heart disease, have become more accepting of discussing home hospice as an option if the treatment alternatives likely mean painful sacrifices in quality of life.

“There's been a little bit of a culture change where maybe oncologists, pulmonologists, congestive heart failure physicians are referring patients to palliative care earlier to help with symptom management, advanced care planning,” said Dr. Pouria Kashkouli, associate medical director for hospice at UC Davis Health.

The trends have created a booming industry. In 2021, the California Department of Health Care Access and Information listed 1,692 licensed hospice agencies in its tracking database, a leap from the 175 agencies it listed in 2002.

That much growth — and the money behind it — has sometimes led to problems. A 2020 investigation by the Los Angeles Times found that fraud and quality-of-care issues were common in California’s hospice industry, a conclusion bolstered by a subsequent state audit. Gov. Gavin Newsom signed a bill in 2021 that placed a temporary moratorium on most new hospice licenses and sought to rein in questionable kickbacks to doctors and agencies.

When done correctly, though, home hospice can be a comfort to families and patients. Hospice typically lasts anywhere from a few days to a few months, and while services vary, many agencies provide regular visits from nurses, health aides, social workers, and spiritual advisers.

Most people using hospice are insured through the federal Medicare program. The amount Medicare pays varies by region but is usually around $200 to $300 a day, said Dr. Kai Romero, chief medical officer at the nonprofit Hospice by the Bay.

To find quality end-of-life care, Andrea Sankar, a professor at Wayne State University and author of “Dying at Home: A Family Guide for Caregiving,” recommends seeking out nonprofit providers and having a list of questions prepared: How often will nurses visit in person? In what circumstances do patients have access to a physician? What help will be available for a crisis in the middle of the night?

While hospice providers offer crucial guidance and support, families need to be prepared to shoulder the bulk of the caregiving. “It really takes a pretty evolved family system to be able to rally to meet all of the needs,” said Tastad at Sharp HealthCare.

Several end-of-life experts said they expect the proportion of Californians choosing to die at home to keep climbing, citing a variety of factors: Medical advances will make it easier for patients to receive pain management and other palliative care at home; telemedicine will make it easier for patients to consult doctors from home; and two powerful forces in American health care — insurance companies and the federal government — increasingly see dying at home as an affordable alternative to lengthy hospital stays.

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

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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“Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

Florida Republican Gov. Ron DeSantis, on Jan. 17, 2023, during a press conference

As he proposed to extend the state’s ban on mandates for covid vaccines and face masks, Florida Republican Gov. Ron DeSantis lobbed a flurry of criticism at President Joe Biden and “the medical establishment.”

“They were not following the science,” DeSantis said at a Jan. 17 press conference in Panama City Beach. “Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

Fewer than 11% of eligible Floridians have received an updated booster vaccine, according to the Centers for Disease Control and Prevention.

The bivalent booster, which contains components of the original covid virus and the omicron variant, is designed to provide broad protection against illness or hospitalization from those covid strains.

Research into the efficacy of the bivalent booster in preventing infection continues.

Broadly speaking, covid vaccines do not prevent infection; they prevent the virus from spreading within the body and causing severe illness, according to Johns Hopkins University. Early CDC research shows that people who got the booster were 84% less likely to be hospitalized from covid.

The data collected on the booster’s ability to curb infection is early and limited. Some clinical trials have shown that bivalent shots are no more equipped to prevent people from contracting covid than the original vaccines.

Although some people have suggested the bivalent booster offers little protection against infection, DeSantis went further. He said people who received the bivalent booster shot were more susceptible to covid than those who hadn’t.

The governor’s press office responded to PolitiFact’s inquiry about the claim, citing two articles and three studies, two of which are not yet peer-reviewed. The most recent came from the Cleveland Clinic and was discussed in an opinion article in The Wall Street Journal.

Dr. Nabin Shrestha, an infectious-disease physician and one of the study’s authors, told PolitiFact the data did not find a link between the bivalent shot and a higher risk of contracting covid. The early conclusion was the opposite of what DeSantis said: The dose is, in fact, effective in preventing infection.

DeSantis’ Conclusion Could Not Be Drawn From That Study

Cleveland Clinic researchers examined the bivalent booster’s effectiveness in preventing infection among 51,011 health care workers — some of whom had not received the booster — from September to December 2022. Pfizer and Moderna offer the bivalent booster, which the FDA authorized in August.

Over those four months, about 5% of the clinic’s employees contracted covid. The researchers then estimated that the bivalent booster was about 30% effective in reducing the likelihood of contracting the virus.

The Cleveland Clinic researchers were not trying to determine the bivalent vaccine’s effectiveness in preventing severe illness or hospitalization.

“The study wasn’t measuring the vaccine causing infection,” said Jill Roberts, a public health professor at the University of South Florida. “The study was measuring the efficacy of the bivalent vaccine in preventing infection.”

What drove coverage in outlets like The Wall Street Journal was an “unexpected” association researchers found between the number of prior vaccine doses and an increased risk of contracting covid. People with three or more doses of the vaccine had a higher chance of getting infected.

That finding quickly overshadowed the protection the bivalent shot provided. The Wall Street Journal opinion piece cited the Cleveland Clinic’s study as evidence that vaccine boosters are making “the population as a whole” more vulnerable to covid.

Andrea Pacetti, the Cleveland Clinic’s public and media relations director, told PolitiFact that the study population, whose average age was 42, is not reflective of the general public.

“The study was done in a younger, relatively healthy, health care employee population. It included no children, very few elderly individuals and likely few immunocompromised individuals,” Pacetti said. “Therefore, we urge caution in generalizing the findings to the public, which can include different populations.”

More than 50% of the health care workers participating in the clinic’s study had received three or more doses of a covid vaccine; only 12% were not vaccinated.

Dr. René Najera, an epidemiologist and director of the Center for Public Health at the College of Physicians of Philadelphia, said the Cleveland Clinic study’s outcome was unsurprising given the characteristics of the research subjects — mostly vaccinated health care workers.

If the majority of the study population received three or more doses of a covid vaccine, for instance, then it is reasonable to assume that the majority of covid cases would occur in that population.

“Those who were studied were health care workers: more likely to be exposed, more likely to be vaccinated as well,” Najera told PolitiFact. “If the study is found to be sound through peer review, its findings would only be applicable to health care workers in large settings such as the Cleveland Clinic, not the general public.”

Pacetti further emphasized that the study has not yet been peer-reviewed, and “more research is needed to either confirm or refute this finding.”

The Cleveland Clinic acknowledged that two other studies had found a similar association between the number of prior vaccine doses and an increased risk of contracting covid, though it had similar limitations.

One of the studies had not yet been peer-reviewed, and the other examined only health care employees. And even with that finding, the Cleveland Clinic’s study did not suggest the bivalent booster increased the likelihood of infection.

DeSantis’ “statement is incorrect,” Najera said. “That conclusion cannot be drawn from that study, and the authors state that it is not designed to evaluate that association.”

Our Ruling

DeSantis said, “Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

An unpublished study from the Cleveland Clinic examined the bivalent covid booster’s effectiveness in preventing infection among a group of about 50,000 health care workers.

However, one of the study’s authors told PolitiFact that the research did not find an association with the bivalent booster and a higher risk of covid. The study found that the bivalent booster is 30% effective in preventing infection from the virus.

The researchers did find that there could be an association between the number of prior vaccine doses and an increased risk of contracting covid. Still, that finding did not suggest the bivalent booster could cause infection or increase the likelihood of infection.

We rate DeSantis’ claim False.

Our Sources

Gov. Ron DeSantis’ Rumble, “Permanent Protections Against the COVID-19 Biomedical Security State,” Jan. 17, 2023

Cleveland Clinic, “Effectiveness of the Coronavirus Disease 2019 (COVID-19) Bivalent Vaccine,” accessed Jan. 19, 2023

Email interview with Bryan Griffin, press secretary for Gov. Ron DeSantis, Jan. 19, 2023

Email interview with Jill Roberts, professor of public health at the University of South Florida, Jan. 19, 2023

Email interview with Dr. René Najera, an epidemiologist and director of the Center for Public Health at the College of Physicians of Philadelphia, Jan. 19, 2023

Email interview with Andrea Pacetti, director of public and media relations for the Cleveland Clinic, Jan. 19, 2023

The Washington Post, “No, Vaccines Aren’t Making New Covid Variants Worse,” Jan. 6, 2023

U.S. Centers for Disease Control and Prevention, COVID data tracker, accessed Jan. 19, 2023

U.S. Centers for Disease Control and Prevention, “Early Estimates of Bivalent mRNA Vaccine Effectiveness in Preventing COVID-19–Associated Hospitalization,” Jan. 20, 2023

The Wall Street Journal, “Are Vaccines Fueling New Covid Variants?” Jan. 1, 2023

U.S. Food and Drug Administration, “Rumor Control,” accessed Jan. 19, 2023

The Lancet, “The Vaccinated Proportion of People With COVID-19 Needs Context,” accessed Jan. 19, 2023

Tampa Bay Times, “DeSantis Wants Ban on COVID Mask and Vaccine Mandates to Be Permanent,” Jan. 17, 2023

PolitiFact, “Why Were the Recent COVID-19 Boosters Authorized Before Human Trials Were Completed?” Sept. 13, 2022

MedRxiv, “A Bivalent Omicron-Containing Booster Vaccine Against Covid-19,” accessed Jan. 19, 2023

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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One night last month, a 9-year-old boy who had autism and talked about killing himself was among about 70 foster care children and youth under state supervision sleeping in hotels across Georgia.

Georgia’s designated health insurer for foster care, Amerigroup Community Care, had denied the boy placement in a psychiatric residential treatment facility, said Audrey Brannen, coordinator of complex care for Georgia’s child welfare agency. He stayed in a hotel for more than a month before receiving a temporary emergency placement in a foster home, she said.

The boy and the other children staying in the hotels lacked permanent placements, Brannen said, and many weren’t getting help for their complex mental and behavioral needs.

The frustration over gaps in care had gotten so bad that Candice Broce, commissioner of the Georgia Department of Human Services, sent a scathing six-page letter to the state Medicaid agency in August — signaling an unusual interagency conflict. She argued that Amerigroup, a unit of Elevance Health, isn’t being held accountable for failures in care, and that its foster care contract should not be renewed.

“Simply put, the state’s most vulnerable children cannot access the physical, mental, or behavioral health treatment they need — and deserve,” Broce wrote.

Amerigroup declined to comment on Broce’s remarks specifically, saying it had not seen her letter. But Michael Perry, an Amerigroup Georgia spokesperson, said the insurer hosts collaborative monthly meetings with state agencies to hear any concerns and will “continue to work on behalf of these vulnerable individuals to ensure they have access to the appropriate healthcare and support services they need to be successful.”

Such problems extend beyond Georgia, according to Sandy Santana, executive director of the national advocacy group Children’s Rights. While foster care grabs headlines mainly in cases of abuse or neglect — even deaths — the failures of states and insurers in providing adequate health care for these children are widespread and occur largely without public scrutiny.

“These kids cycle in and out of ERs, and others are not accessing the services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care problems. “This is an issue throughout the country.”

Nearly all children in foster care are eligible for Medicaid, the state-federal program for those with low incomes, but states decide on the delivery mechanism. Georgia is among at least 10 states that have turned to managed-care companies to deliver specialized services exclusively for foster kids and others under state supervision. At least three more — North Carolina, New Mexico, and Oklahoma — are taking similar steps. But regardless of the structure, getting timely access to care for many of these vulnerable kids is a problem, Santana said.

Obtaining mental health care for privately insured children can be a struggle too, of course, but for children in state custody, the challenge is even greater, said Dr. Lisa Zetley, a Milwaukee pediatrician and chair of the American Academy of Pediatrics’ Council on Foster Care, Adoption, and Kinship Care.

“This is a unique population,” she said. “They have experienced quite of bit of toxic stress prior to entering foster care.”

For states that use specialty managed care for these kids, transparency and oversight remain spotty and the quality of the care remains a troubling unknown, said Andy Schneider, a research professor at Georgetown University’s Center for Children and Families.

Illinois, for example, has paid more than $350 million since 2020 to insurance giant Centene Corp. to manage health coverage for more than 35,000 current and former foster care children. But last year, an investigation by the Illinois Answers Project newsroom found Centene’s YouthCare unit repeatedly failed to deliver basic medical services such as dental visits and immunizations to thousands of these kids. Federal officials are now probing allegations about the contract.

Centene said YouthCare has not been informed of any probe. In a statement, the company said Illinois Answers Project’s reporting was based on outdated information and didn’t account for its recent progress as it works “to ensure that families have the access they need to high-quality care and services.”

In some cases, child advocates say, the care kids do get is not appropriate. In Maryland, the local branch of the American Civil Liberties Union, Disability Rights Maryland, and Children’s Rights filed a lawsuit this month against the state accusing it of failing to conduct adequate oversight of psychotropic drug prescribing for children in its foster care system. As many as 34% the state’s foster children are given psychotropic drugs, court documents said, although most of them don’t have a documented psychiatric diagnosis.

In Georgia, Lisa Rager said she and her husband, Wes, know well the hurdles to obtaining services for foster kids. The suburban Atlanta couple has cared for more than 100 foster children and adopted 11 of them from state custody.

She said one child waited more than a year to see a specialist. Getting approvals for speech or occupational therapy is “a lot of trouble.”

Rager said she pays out-of-pocket for psychiatric medications for three of her children because of insurance hassles. “It’s better for me to pay cash than wait on Amerigroup,” she said.

Such problems occur often, Broce said in her letter. Amerigroup’s “narrow definition for ‘medically necessary services’ is — on its face — more restrictive than state and federal standards,” she wrote.

“Far too often, case managers and foster families are told that the next available appointment is weeks or months out,” she told the state’s Joint Appropriations Committee on Jan. 17. Broce added that her agency has formed a legal team to fight Amerigroup treatment denials.

Amerigroup’s Perry said its clinical policies are approved by the state, and follow regulatory and care guidelines.

In a recent 12-month period, Amerigroup received $178.6 million in government funds for its specialty foster care plan that serves about 32,000 Georgia children, with the large majority being foster children and kids who have been adopted from state custody. The contract is currently up for rebidding.

David Graves, a spokesperson for the Department of Community Health, which runs Medicaid in the state, said the agency would not comment on Broce’s letter because it’s part of the contract renewal process. Graves said the agency regularly monitors the quality of care that children in state custody receive. He pointed to a state report that showed Amerigroup did well on several metrics, such as use of asthma medication.

But Melissa Haberlen DeWolf, research and policy director for the nonprofit Voices for Georgia’s Children, said the majority of kids cycling through the state’s emergency departments for mental illness are in foster care.

“The caregivers we speak to are desperate for behavioral health care coordination help — finding providers and getting appointments, understanding how to manage behaviors and medication, and prevent crises, and sharing health information between providers,” she said.

To fix these problems, Zetley, the pediatrician, recommends creating a larger benefit package for foster kids, coordinating care better, and raising Medicaid reimbursement rates to attract more providers to these managed-care networks.

Contracts with managed-care companies also should be performance-based, with financial penalties if needed, said Kim Lewis, managing attorney of the National Health Law Program’s Los Angeles offices.

“Managed care is only as good as the state’s ability to manage the contract and to make sure that what they’re getting is what they are paying for,” she said. “It doesn’t work by just, you know, hoping for the best and ‘Here’s the check.’”

But in Georgia, the state has never financially penalized Amerigroup for failing to meet contractually mandated quality standards, Department of Community Health spokesperson Graves confirmed. He said the agency and Amerigroup work to resolve any issues brought to their attention.

Georgia has set up an oversight committee, with public meetings, to monitor the quality of Amerigroup’s performance. But the committee hasn’t met since August 2020, the state said last month. After KHN queries, Graves said the panel would start meeting again this year.

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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WAUKON, Iowa — Marjorie Kruger was stunned to learn last fall that she would have to leave the nursing home where she’d lived comfortably for six years.

The Good Samaritan Society facility in Postville, Iowa, would close, administrators told Kruger and 38 other residents in September. The facility joined a growing list of nursing homes being shuttered nationwide, especially in rural areas.

“The rug was taken out from under me,” said Kruger, 98. “I thought I was going to stay there the rest of my life.”

Her son found a room for her in another Good Samaritan center in Waukon, a small town 18 miles north of Postville. Kruger said the new facility is a pleasant place, but she misses her friends and longtime staffers from the old one. “We were as close as a nice family,” she said.

The Postville facility’s former residents are scattered across northeastern Iowa. Some were forced to move twice, after the first nursing home they transferred to also went out of business.

Owners say the closures largely stem from a shortage of workers, including nurses, nursing assistants, and kitchen employees.

The problem could deepen as pandemic-era government assistance dries up and care facilities struggle to compete with rising wages offered by other employers, industry leaders and analysts predict. Many care centers that have managed to remain open are keeping some beds vacant because they don’t have enough workers to responsibly care for more residents.

The pandemic brought billions of extra federal dollars to the long-term care industry, which was inundated with covid-19 infections and more than 160,000 resident deaths. Many facilities saw business decline amid lockdowns and reports of outbreaks. Staff members faced extra danger and stress.

The industry is still feeling the effects.

From February 2020 to November 2021, the number of workers in nursing homes and other care facilities dropped by 410,000 nationally, according to the federal Bureau of Labor Statistics. Staffing has rebounded only by about 103,000 since then.

In Iowa, 13 of the 15 nursing homes that closed in 2022 were in rural areas, according to the Iowa Health Care Association. “In more sparsely populated areas, it’s harder and harder to staff those facilities,” said Brent Willett, the association’s president. He noted that many rural areas have dwindling numbers of working-age adults.

The lack of open nursing home beds is marooning some patients in hospitals for weeks while social workers seek placements. More people are winding up in care facilities far from their hometowns, especially if they have dementia, obesity, or other conditions that require extra attention.

Colorado’s executive director of health care policy and financing, Kim Bimestefer, told a conference in November that the state recognizes it needs to help shore up care facilities, especially in rural areas. “We’ve had more nursing homes go bankrupt in the last year than in the last 10 years combined,” she said.

In Montana, at least 11 nursing homes — 16% of the state’s facilities — closed in 2022, the Billings Gazette reported.

Nationally, the Centers for Medicare & Medicaid Services reported recently that 129 nursing homes had closed in 2022. Mark Parkinson, president of the American Health Care Association, said the actual count was significantly higher but the federal reports tend to lag behind what’s happening on the ground.

For example, a recent KHN review showed the federal agency had tallied just one of the 11 Montana nursing home closures reported by news outlets in that state during 2022, and just eight of the 15 reported in Iowa.

Demand for long-term care is expected to climb over the next decade as the baby boom generation ages. Willett said his industry supports changing immigration laws to allow more workers from other countries. “That’s got to be part of the solution,” he said.

The nursing home in Postville, Iowa, was one of 10 care centers shuttered in the past year by the Good Samaritan Society, a large chain based in South Dakota.

“It’s an absolute last resort for us, being a nonprofit organization that would in many cases have been in these communities 50 to 75 years or more,” said Nate Schema, the company’s CEO.

The Evangelical Lutheran Good Samaritan Society, the full name of the company, is affiliated with the giant Sanford Health network and serves 12,500 clients, including residents of care facilities and people receiving services in their homes. About 70% of them live in rural areas, mainly in the Plains states and Midwest, Schema said.

Schema said many front-line workers in nursing homes found less stressful jobs after working through the worst days of the covid pandemic, when they had to wear extra protective gear and routinely get screened for infection in the face of ongoing risk.

Lori Porter, chief executive officer of the National Association of Health Care Assistants, said nursing home staffing issues have been building for years. “No one that’s been in this business is in shock over the way things are,” she said. “The pandemic put a spotlight on it.”

Porter, who has worked as a certified nursing assistant and as a nursing home administrator, said the industry should highlight how rewarding the work can be and how working as an aide can lead to a higher-paying job, including as a registered nurse.

Care industry leaders say that they have increased wages for front-line workers but that they can’t always keep up with other industries. They say that’s largely because they rely on payments from Medicaid, the government program for low-income Americans that covers the bills for more than 60% of people living in nursing homes.

In recent years, most states have increased how much their Medicaid programs pay to nursing homes, but those rates are still less than what the facilities receive from other insurers or from residents paying their own way. In Iowa, Medicaid pays nursing homes about $215 per day per resident, according to the Iowa Health Care Association. That compares with about $253 per day for people paying their own way. When nursing homes provide short-term rehabilitation for Medicare patients, they receive about $450 per day. That federal program does not cover long-term care, however.

Willett said a recent survey found that 72% of Iowa’s remaining nursing homes were freezing or limiting admissions below their capacity.

The Prairie View nursing home in Sanborn is one of them. The facility, owned by a local nonprofit, is licensed for up to 73 beds. Lately, it has been able to handle only about 48 residents, said administrator Wendy Nelson.

“We could take more patients, but we couldn’t give them the care they deserve,” she said.

Prairie View’s painful choices have included closing a 16-bed dementia care unit last year.

Nelson has worked in the industry for 22 years, including 17 at Prairie View. It never has been easy to keep nursing facilities fully staffed, she said. But the pandemic added stress, danger, and hassles.

“It drained the crud out of some people. They just said, ‘I’m done with it,’” she said.

Prairie View has repeatedly boosted pay, with certified nursing assistants now starting at $21 per hour and registered nurses at $40 per hour, Nelson said. But she’s still seeking more workers.

She realizes other rural employers also are stretched.

“I know we’re all struggling,” Nelson said. “Dairy Queen’s struggling too, but Dairy Queen can change their hours. We can’t.”

David Grabowski, a professor of health care policy at Harvard Medical School, said some of the shuttered care facilities had poor safety records. Those closures might not seem like a tragedy, especially in metro areas with plenty of other choices, he said.

“We might say, ‘Maybe that’s the market working, the way a bad restaurant or a bad hotel is closing,’” he said. But in rural areas, the closure of even a low-quality care facility can leave a hole that’s hard to fill.

For many families, the preferred alternative would be in-home care, but there’s also a shortage of workers to provide those services, he said.

The result can be prolonged hospital stays for patients who could be served instead in a care facility or by home health aides, if those services were available.

Rachel Olson, a social worker at Pocahontas Community Hospital in northwestern Iowa, said some patients wait a month or more in her hospital while she tries to find a spot for them in a nursing home once they’re stable enough to be transferred.

She said it’s particularly hard to place certain types of patients, such as those who need extra attention because they have dementia or need intravenous antibiotics.

Olson starts calling nursing homes close to the patient’s home, then tries ones farther away. She has had to place some people up to 60 miles away from their hometowns. She said families would prefer she find something closer. “But when I can’t, I can’t, you know? My hands are tied.”

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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Los compañeros de clase paran a menudo a Alma Gallegos en los bulliciosos pasillos de la secundaria Theodore Roosevelt, en el sureste de Fresno. Le preguntan a la estudiante de 17 años sobre pruebas para covid-19, la seguridad de las vacunas, y el valor de las inyecciones de refuerzo.

Alma se ganó su reputación como fuente de información fiable gracias a sus prácticas como trabajadora comunitaria de salud.

Fue una de los 35 estudiantes del condado de Fresno a los que se formó recientemente para explicar cómo las vacunas de covid ayudan a prevenir enfermedades graves, hospitalizaciones y muertes, y para animar a familiares, compañeros y miembros de la comunidad a estar al día con sus vacunas, incluidas las de refuerzo.

Cuando Alma terminó sus prácticas en octubre, ella y siete compañeros de equipo evaluaron su trabajo en un proyecto final. Los estudiantes estaban orgullosos de poder llevar a cabo este trabajo de divulgación sobre las vacunas.

Alma convenció a su familia para que se vacunara. Dijo que sus familiares, que habían recibido información sobre covid a través de las noticias en español, no creían en los riesgos hasta que murió un amigo cercano de la familia.

“Te dan ganas de saber más”, dijo Alma. “Ahora toda mi familia está vacunada, pero aprendimos por las malas”.

Organizaciones comunitarias de salud en California y en todo el país forman a adolescentes, muchos de ellos latinos, para que actúen como educadores de la salud en la escuela, en las redes sociales y en las comunidades donde persiste el miedo a la vacuna contra covid.

Según una encuesta de 2021 encargada por Voto Latino y realizada por Change Research, el 51% de los latinos no vacunados dijeron que no confiaban en la seguridad de las vacunas. La cifra se dispara hasta el 67% en el caso de aquellos cuyo idioma principal en casa es el español. Las razones más comunes para rechazar la vacuna incluyen no confiar en su eficacia y no confiar en los fabricantes de la vacuna.

Y las dudas sobre las vacunas no solo prevalecen entre los no vacunados. Aunque casi el 88% de hispanos y latinos han recibido al menos una dosis de la vacuna contra covid, pocos afirman estar al día en sus vacunas, según los Centros para el Control y la Prevención de Enfermedades (CDC).

Los CDC estiman que menos del 13% de los latinos han recibido un refuerzo bivalente, una vacuna actualizada que los funcionarios de salud pública recomiendan para proteger contra las nuevas variantes del virus.

Proveedores y activistas de salud creen que los jóvenes, como Alma, están bien posicionados para ayudar a aumentar esas cifras de vacunación, especialmente cuando ayudan a navegar por el sistema sanitario a sus familiares hispanohablantes.

“Tiene sentido que consideremos a nuestros jóvenes como educadores en materia de vacunas ante sus compañeros y familias”, afirmó el doctor Tomás Magaña, profesor del departamento de pediatría de la Universidad de California-San Francisco. “Y cuando hablamos de la comunidad latina, tenemos que pensar con seriedad y creatividad en cómo llegar a ellos”.

Algunos programas de formación utilizan modelos para estudiantes en los campus, mientras que otros enseñan a los adolescentes a abrirse camino en sus comunidades.

FACES for the Future Coalition, una organización de jóvenes con sede en Oakland, aprovecha programas en California, Nuevo México, Colorado y Michigan para convertir a los estudiantes en educadores sobre la vacuna contra covid.

Y el Health Information Project de Florida, que forma a estudiantes de primer y segundo año de secundaria para que enseñen a los de primer año sobre salud física y emocional, integra la seguridad de la vacuna contra covid en su plan de estudios.

En Fresno, el programa para jóvenes trabajadores comunitarios de la salud, llamado Promotoritos, adoptó el modelo promotoras.

Las promotoras son trabajadoras sanitarias, sin licencia, de las comunidades latinas encargadas de orientar a las personas hacia los recursos médicos y promover mejores opciones de estilo de vida. Los estudios demuestran que las promotoras son miembros de confianza de la comunidad, lo que las sitúa en una posición privilegiada para ofrecer educación y divulgación sobre las vacunas.

“Los adolescentes se comunican de forma diferente, y obtienen una gran respuesta”, afirmó Sandra Celedon, CEO de Fresno Building Healthy Communities, una de las organizaciones que ayudó a diseñar el programa de prácticas para estudiantes de 16 años o más. “Durante los eventos de divulgación, todos quieren hablar con los jóvenes”.

Los adolescentes que participan en Promotoritos son principalmente latinos, inmigrantes indocumentados, estudiantes refugiados o hijos de inmigrantes. Reciben 20 horas de formación, que incluyen estrategias de campaña en las redes sociales. Por ello, obtienen créditos escolares y el año pasado les pagaron $15 la hora.

“Nadie piensa en estos chicos como becarios”, señaló Celedon. “Así que queríamos crear una oportunidad para ellos porque sabemos que estos son los estudiantes que más se pueden beneficiar de unas prácticas remuneradas”.

El otoño pasado, Alma, que es latina, y otros tres jóvenes trabajadores comunitarios de salud distribuyeron kits de pruebas covid en negocios locales de su barrio.

Su primera parada fue Tiger Bite Bowls, un restaurante de fusión asiática. Los adolescentes hablaron con el propietario del restaurante, Chris Vang, y le preguntaron si tenía alguna duda sobre covid. Al final de la conversación, le entregaron un puñado de kits de pruebas.

“Creo que es bueno que estén concienciados y no tengan miedo de compartir sus conocimientos sobre covid”, afirmó Vang. “Voy a entregar estas pruebas a quien las necesite: clientes y empleados”.

Otro beneficio del programa: los jóvenes se familiarizan con las carreras en el campo de la salud.

California se enfrenta a una escasez generalizada de mano de obra en el sector sanitario, y los profesionales de la salud no siempre reflejan la creciente diversidad de la población del estado.

Hispanos y latinos representan el 39% de la población de California, pero son solo el 6% de los médicos del estado y el 8% de los licenciados en medicina, según un informe de la California Health Care Foundation.

Alma se unió al programa en junio después de ver un folleto en la oficina del consejero escolar. Dijo que era su forma de ayudar a evitar que otras familias perdieran a un ser querido.

Ahora está interesada en convertirse en radióloga.

“A mi edad”, añadió Alma, “esta es la manera perfecta de contribuir con mi comunidad”.

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

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

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Montana’s conservative leaders, stymied by the courts from passing laws that impose significant statewide abortion restrictions, seek to tighten the state’s Medicaid rules to make it more difficult for low-income women to receive abortions.

The Montana Department of Public Health and Human Services is proposing to define when an abortion is medically necessary, limit who can perform such services, and require preauthorization for most cases.

The push to change the regulations is borne of a belief by Republican Gov. Greg Gianforte’s administration that health providers are using existing rules that allow Medicaid reimbursements to cover abortions that aren’t medically necessary.

“Taxpayers shouldn’t foot the bill for elective abortions,” said Gianforte spokesperson Brooke Stroyke.

Medical professionals have said the term “elective abortions” can misrepresent the complex reasons someone may seek an abortion and constrain health providers from making their best clinical judgment. Laurie Sobel, associate director of Women’s Health Policy at KFF, said that appears to be the aim of the Montana proposal’s focus on defining medically necessary abortions.

“It looks like Montana’s trying to curtail abortion access under Medicaid and take the conversation of ‘medically necessary’ away from a physician and a patient,” Sobel said.

Democratic lawmakers and many health providers have said existing state rules ensure providers consider and document why an abortion is needed to protect a patient.

Democratic state Rep. Ed Stafman, who recently chaired the Children, Families, Health, and Human Services Interim Committee, said the proposed changes are unnecessary because the state already complies with federal Medicaid rules on abortion.

“It’s clear that this is part of the anti-abortion agenda,” Stafman said.

States are barred from using federal funds to pay for abortions except in cases of rape or incest, or when a woman’s life is at risk. However, states have the option of using their own money to allow reimbursements under the joint state-federal Medicaid program in other circumstances.

Montana is one of 16 states that allow the use of state Medicaid funds for abortions deemed medically necessary. A study published in 2017 in the journal Obstetrics & Gynecology found that states with Medicaid coverage of medically necessary abortions had a reduced risk of severe maternal morbidity for that population, 16% on average, compared with states without that coverage.

Montana’s proposed changes are more restrictive than the rules in many of the other states that allow medically necessary Medicaid abortions. At least nine states that use state funds to pay for Medicaid abortions don’t require health providers to report the circumstances for an abortion, according to a 2019 U.S. Government Accountability Office report on state compliance with abortion coverage rules. For example, California’s Medi-Cal program does not require any medical justification for abortions, and requires preauthorization only when the patient needs to be hospitalized.

Most of the states that permit medically necessary Medicaid abortions, including Montana, are under court orders to fund the procedure as they would other general health services for low-income people.

Montana’s coverage is tethered to a 1995 court case that determined the state’s Medicaid program was established to provide “necessary medical services” and the state can’t exclude specific services. The state’s existing eligibility rules governing when a Medicaid-funded service is medically necessary include when a pregnancy would cause suffering, pain, or a physical deformity; result in illness or infirmity; or threaten to cause or aggravate a disability.

Under the health department’s new proposal, abortions would be determined to be medically necessary only when a physician — not another type of provider — certifies a patient suffers from an illness, condition, or injury that threatens their life or has a physical or psychological condition that would be “significantly aggravated” by pregnancy.

Elsewhere, courts have rejected some states’ attempts to create a definition for medically necessary abortions apart from existing Medicaid standards as constitutional violations of equal protection. The Alaska Supreme Court struck down a 2013 state law changing the definition of a medically necessary abortion because it treated Medicaid beneficiaries who wanted an abortion differently than those seeking pregnancy-related procedures like a cesarean section. And New Mexico’s high court said in 1999 that a state rule limiting Medicaid-funded abortions applied different standards of medical necessity to men and women.

Montana opponents of the proposed changes have threatened to sue if the regulations are adopted.

The state’s Medicaid program covers more than 153,900 women. From 2011 through 2021, the program paid for 5,614 abortion procedures, which typically represents nearly a third of all abortions in the state, according to state data.

Currently in Montana, doctors, physician assistants, and advanced nurse practitioners are allowed to perform abortions. At least one Montana clinic that provides abortions to Medicaid beneficiaries is run by a nurse practitioner, All Families Healthcare’s Helen Weems, who is suing the state for trying to block nurses from performing abortions.

Medical providers make the decision of whether an abortion is medically necessary and submit a form afterward to the state health department.

The proposed change would require providers to get state approval before performing an abortion, except in emergencies, and submit supporting documents to justify the medical necessity. That preauthorization process would entail providing state officials details of patients’ medical history, such as how many pregnancies a person has had, the date of their last menstrual cycle, whether they smoke, the results of any pregnancy tests, and whether they have ever had behavioral health issues or substance use disorders.

Martha Fuller, president and CEO of Planned Parenthood of Montana, said providers already collect that information but don’t send it to the state. If they are required to do so, she said, that will have a chilling effect that may keep people from seeking help or lead them to pay for it out-of-pocket, if they can.

“Patients could feel like, ‘Oh, and everything that I tell you, it’s going to be now shared with my insurer for the purpose of them making a decision about whether or not I can have an abortion?’” Fuller said.

In Montana, a patient seeking an abortion via medication typically gets that through nurse practitioners or physician assistants instead of going through one of the few physicians who provide that care through Medicaid, Fuller said. She said Medicaid patients would see longer wait times if the new rules are put in place as they wait to see a physician. And waiting for prior authorization would add to the time in limbo.

Telehealth helps provide access amid scattered resources across the big, rural state, but Montana’s proposed changes would require a physical examination.

“Patients might have to make a more invasive procedure. They may have to travel. They have to take more time off from work,” Fuller said. “There will be patients who will decide not to seek abortion care because they cannot afford it.”

Of the 1,418 abortions covered by Montana Medicaid in 2020 and 2021, state records show, one was performed because a person’s life was in danger. The rest were performed under the broader medically necessary justification, with paperwork about those cases including a brief explanation for why the procedure was needed.

According to the state’s proposed rules, the lack of supporting documentation for the procedures leads “the department to reasonably believe that the Medicaid program is paying for abortions that are not actually medically necessary.”

In 2021, state lawmakers passed and Gianforte signed three laws restricting abortions that a court temporarily blocked. The Montana Supreme Court upheld the injunction, arguing that the state constitution’s right-to-privacy provision extends to abortion.

Gianforte and the state attorney general have called on the Montana Supreme Court to strike down the two-decade-old ruling that tied abortion to the right to privacy. Republican lawmakers also have filed a slew of abortion-related bills in the legislative session, including one proposal to exclude abortion from the state’s right-to-privacy protections.

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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Classmates often stop Alma Gallegos as she makes her way down the bustling hallways of Theodore Roosevelt High School in southeast Fresno, California. The 17-year-old senior is frequently asked by fellow students about covid-19 testing, vaccine safety, and the value of booster shots.

Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help prevent serious illness, hospitalization, and death, and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, 51% of unvaccinated Latinos said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although nearly 88% of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated fewer than 13% of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. FACES for the Future Coalition, a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the Health Information Project in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called Promotoritos, adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. Studies show that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of Fresno Building Healthy Communities, one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a widespread labor shortage in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a California Health Care Foundation report.

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

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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Sunday marked the 50th anniversary of the Supreme Court’s landmark ruling in Roe v. Wade, granting federal constitutional protection for the right to seek an abortion. Last year, a very different Supreme Court overturned Roe, erasing that federal right for women across the United States and, instead, giving individual states broad authority to regulate and restrict abortion within their borders.

In this report co-produced by PBS NewsHour, KHN senior correspondent Sarah Varney joins “PBS News Weekend” anchor John Yang to discuss how abortion opponents and supporters are taking their campaigns to the states, the impact of abortion bans on medical care for women, and the emerging conflicts over medication abortion pills.

We asked people across the country what the abrupt shift in abortion access has meant to them, and we lay out the stakes in the political battles ahead.

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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For Tammy Rainey, finding a health care provider who knows about gender-affirming care has been a challenge in the rural northern Mississippi town where she lives.

As a transgender woman, Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’”

So Rainey drives around 170 miles round trip every six months to get a supply of estrogen from a clinic in Memphis, Tennessee, to take home with her.

The obstacles Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural U.S. often face: a general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama-Birmingham.

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states to estimate that roughly 1 in 6 transgender adults in the U.S. live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, according to the Williams Institute, a nonprofit think tank at the UCLA School of Law.

One in 3 trans people in rural areas experienced discrimination by a health care provider in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. Additionally, a third of all trans individuals report having to teach their doctor about their health care needs to receive appropriate care, and 62% worry about being negatively judged by a health care provider because of their sexual orientation or gender identity, according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as all transgender adults to travel 25 to 49 miles for routine care.

In Colorado, for example, many trans people outside Denver struggle to find proper care. Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the Colorado Transgender Health Survey published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health themes in their curriculum, with half providing three or fewer classes on this topic.

Perhaps because of this, almost 77% of students from 10 medical schools in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use appropriate pronouns and trans-inclusive language.

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the organization created a four-week boot camp in 2021 for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Dr. Caroline Kirsch, director of osteopathic education at the University of Wyoming Family Medicine Residency Program-Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide experience a rise in harassment and threats. For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the target of far-right hate on social media last year. After growing pressure from Tennessee’s Republican lawmakers, the clinic paused gender-affirmation surgeries on patients younger than 18, potentially leaving many trans kids without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”

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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Thousands of anti-abortion activists descended on the National Mall in Washington, D.C., on Jan. 20 for the annual March for Life, a long-standing rally held for the first time since the Supreme Court overturned Roe v. Wade in June, rescinding a constitutional right to abortion.

In this report co-produced by PBS NewsHour, KHN senior correspondent Sarah Varney spoke with activists gathered in Washington about what this moment means for them and the future of the broader anti-abortion movement.

This year’s gathering signals a turning point for a movement that has had a singular focus for decades. With Roe now defeated, that focus is fracturing into competing priorities as the practical implications of criminalizing abortion crystallize.

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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Anti-abortion advocates are pressing for expanded abortion bans and tighter restrictions since the Supreme Court overturned the national right to abortion. But with the debate mostly deadlocked in Washington, the focus is shifting to states convening their first full legislative sessions since Roe v. Wade was overturned.

Although some state GOP lawmakers have filed bills to ban abortion pills or make it more difficult for women to travel out of state for an abortion, others seem split about what their next steps should be. Some are even considering measures to ease their states’ existing bans somewhat, particularly after Republicans’ less-than-stellar showing in the 2022 midterm elections and voters’ widespread support for abortion on state ballot measures.

Meanwhile, Democratic-led states are looking to shore up abortion protections, including Minnesota and Michigan, where Democrats sewed up legislative majorities in the November elections.

Anti-abortion groups said their goal in overturning Roe v. Wade was to turn the decision back to the states, but now they are making clear that what they want is an encompassing national abortion ban.

“Legislation at the state and federal levels should provide the most generous protections possible to life in the womb,” says the “Post-Roe Blueprint” of the anti-abortion group Students for Life.

The new Republican-led House showed its anti-abortion bona fides on its first day of formal legislating, Jan. 11, passing two pieces of anti-abortion legislation that are unlikely to become law with a Senate still controlled by Democrats and President Joe Biden in the White House.

So at the federal level, the fight is taking shape in the courts over the abortion pill mifepristone, which has been used as part of a two-drug regimen for more than two decades, and recently became the way a majority of abortions in the U.S. are conducted.

The Biden administration has moved to make mifepristone more widely available by allowing it to be distributed by pharmacies, as well as clarifying that it is legal to distribute the pills via the U.S. mail. But the conservative legal group Alliance Defending Freedom, on behalf of several anti-abortion groups, filed a federal lawsuit in Texas in November, charging that the FDA never had the authority to approve the drug in the first place.

In Texas, some lawmakers are exploring new ways to chip away at Texans’ remaining sliver of access to abortions. For example, one proposal would prevent local governments from using tax dollars to help people access abortion services out of state, while another would prohibit tax subsidies for businesses that help their local employees obtain abortions out of state.

Those measures could get lost in the shuffle of the state’s frantic 140-day, every-other-year session, if legislative leaders don’t consider them a priority. The state’s trigger law banning almost all abortions that went into effect last year “appears to be working very well,” said Joe Pojman, founder and executive director of Texas Alliance for Life, an anti-abortion group. In August 2022, three abortions were documented in the state, down from more 5,700 reported during the same month a year earlier, according to the most recent state data.

The top state House Republican said his priority is boosting support for new moms, for example, by extending postpartum Medicaid coverage to 12 months.

It’s “an opportunity for the Texas House to focus more than ever on supporting mothers and children,” said Republican House Speaker Dade Phelan.

South Dakota Gov. Kristi Noem, a Republican, struck a similar theme in a Jan. 10 speech, saying she will introduce bills to expand a program for nurses to visit new mothers at home and help state employees pay for adoptions. Previously, Noem said South Dakota needs to focus “on taking care of mothers in crisis and getting them the resources that they need for both them and their child to be successful.”

Some Texas GOP lawmakers indicated they may be open to carving out exceptions to the abortion ban in cases of rape and incest. And a Republican lawmaker plans to attempt to modify South Dakota’s ban, which allows abortions only for life-threatening pregnancies, to clarify when abortions are medically necessary.

“Part of the issue right now is that doctors and providers just don’t know what that line is,” said state Rep. Taylor Rehfeldt, a nurse who has experienced miscarriages and high-risk pregnancies herself.

Rehfeldt wants to reinstate a former law that allows abortions for pregnancies that could cause serious, irreversible physical harm to a “major bodily function.” Rehfeldt said she is also working on bills to allow abortions for people carrying non-viable fetuses, or who became pregnant after rape or incest.

Some anti-abortion activists in Georgia are pushing lawmakers to go further than the state’s ban on most abortions at about six weeks of pregnancy. They want a law to ban telehealth prescriptions of abortion pills and a state constitutional amendment declaring that an embryo or a fetus has all the legal rights of a person at any stage of development.

“Roe is out of the way,” said Zemmie Fleck, executive director of Georgia Right to Life. “There’s no more roadblock to what we can do in our state.”

Republican leaders, however, are biding their time while Georgia’s high court weighs a legal challenge of the six-week ban. “Our focus remains on the case before the Georgia Supreme Court and seeing it across the finish line,” said Andrew Isenhour, spokesperson for Republican Gov. Brian Kemp.

Abortion rights lawmakers and advocates have few options to advance their initiatives in these Republican-controlled statehouses.

A Georgia Democrat filed a bill that would make the state compensate women who are unable to terminate pregnancies because of the state’s abortion ban. State Rep. Dar’shun Kendrick acknowledged her bill likely won’t go far, but she said she hopes it keeps attention on the issue and forces GOP lawmakers to “put their money where their mouth is” in supporting families.

In Missouri, where nearly all abortions are now banned, abortion rights advocates are mulling the idea of circumventing the state’s Republican-dominated legislature by asking voters in 2024 to enshrine the right to an abortion in the state’s constitution.

But those efforts could be upended by a slew of bills filed by Republican lawmakers seeking to make it more difficult to place constitutional initiatives on the ballot, and for those measures that do make it on the ballot, by requiring the approval of at least 60% of voters for passage.

Democrats in Michigan and Minnesota are likely to use their newfound control of both legislative chambers and the governors’ office to protect abortion access. While Michigan voters already passed a ballot measure in November that enshrines the right to abortions in the state constitution, Democrats are trying to repeal a 1931 abortion law from the books.

In Illinois, Democrats in control of the legislature recently bolstered abortion protections amid increased demand from out-of-state residents. New York lawmakers this year may send voters a proposed state constitutional amendment to protect abortion, while New Jersey lawmakers decided against a similar proposal.

The November elections brought divided government to Arizona and Nevada, with Arizona now having a Democratic governor and Nevada having a Republican one. Any abortion-related bills that pass the legislatures in those states could be vetoed.

Some Republican-controlled legislatures, including those in Montana, Florida, and Alaska, also are limited in passing sweeping abortion bans because of court rulings that tie abortion access to right-to-privacy provisions in those states’ constitutions.

In Montana, a state judge blocked three anti-abortion laws passed in 2021 on that basis. State government attorneys have asked the Montana Supreme Court to reverse the precedent, and a decision is pending.

In the meantime, Republican state Sen. Keith Regier has filed a bill there seeking to exclude abortion from the state’s definition of a right to privacy. Regier said he believes an individual’s right to privacy should not apply to abortion because an unborn child also is involved.

Democratic leaders said Republicans are out of sync with the people they represent on this issue. In November, Montana voters rejected a “born alive” ballot initiative that would have required doctors to apply medical care to newborns who draw breath or have a heartbeat after a failed abortion or any other birth.

“Montanans said so clearly that they do not want government overreach in their health care decisions,” said Democratic state Rep. Alice Buckley.

KHN correspondents Renuka Rayasam and Sam Whitehead in Atlanta; Arielle Zionts in Rapid City, South Dakota; Bram Sable-Smith in St. Louis; and Katheryn Houghton in Missoula, Montana, contributed to this report.

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 Montana correspondent Katheryn Houghton discussed Montana’s radon mine health spas on Montana Public Radio’s “The Big Why” podcast on Jan. 18.

• Click here to hear Houghton on “The Big Why”
• Read Houghton’s “Covid Renews Interest in Radiation, but Docs Caution Against Pilgrimages to Radon-Filled Mines“

KHN correspondent Julie Appleby discussed this year’s open enrollment period for Affordable Care Act health plans on NPR’s “Weekend Edition Sunday” on Jan. 15.

• Click here to hear Appleby on “Weekend Edition Sunday”

KHN senior correspondent Sarah Jane Tribble discussed gaps in the government system that bans bad actors from federal health programs on America’s Heroes Group on Jan. 7.

• Click here to watch Tribble on America’s Heroes Group
• Read Tribble and Lauren Weber’s “KHN Investigation: The System Feds Rely On to Stop Repeat Health Fraud Is Broken“

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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When Buffalo Bills safety Damar Hamlin suffered cardiac arrest and collapsed on the field in the middle of the “Monday Night Football” game in Cincinnati on Jan. 2, Carrie Hastings, half a continent away, understood what she needed to do — and right away.

“I had a few guys that I sort of immediately knew I should check in on,” said Hastings, the Los Angeles Rams’ sports psychologist and mental health clinician. “A couple of spouses and significant others, too.”

Hastings’ familiarity with the Rams’ personnel, and with which players might be emotionally traumatized after watching Hamlin’s shocking medical emergency, was the product of her having spent six seasons with the club — getting to know the athletes, meeting rookies when they first arrive, and making herself a regular presence at the Rams’ facility.

Across the NFL, no such continuity of care exists. The league is working its way toward the kind of mental health support for its players, coaches, and staff in which a range of counseling is standard and readily accessible.

It was just over three years ago, in 2019, that the NFL implemented a formal program to manage its employees’ mental health needs. That came as part of a new collective bargaining agreement, after the NFL Players Association pushed hard for its creation. Among other things, the agreement mandates that each team have a licensed behavioral health clinician on staff.

But individual franchises still have great latitude in implementing that directive. Some have full-time sports psychologists; others employ clinicians part time, while a few contract with outside providers and make them available to players, Hastings said. And clinicians aren’t required to have any sports background, which some sports psychologists see as a critical flaw.

“This is a very specialized area,” said Sam Maniar, a psychologist who consults for the Cleveland Browns and formerly worked as the team’s full-time clinician. “The environment of athletics, and especially at the highest level, is something that does require specialization, and not every clinician being brought into the NFL has that.”

Hastings was a sprinter and hurdler in her undergraduate years at Notre Dame, has deep professional experience with athletes, and is listed in the U.S. Olympic & Paralympic Committee’s registry for sports psychology and mental training. She keeps her private practice a short drive from the Rams’ training facility in Agoura Hills, northwest of Los Angeles, and though technically a part-time employee, Hastings said she is at the facility three or four times a week “and basically on call 24/7 during the season.”

In that capacity, Hastings has worked to forge a foundation of trust with elite athletes who often think of a sports psychologist only in terms of getting them primed to compete.

“It’s often the case that a player comes in for something performance-related, and that opens up the door for conversations in other areas of mental health,” she said. “The relationship deepens.”

That kind of ingrained presence with teams is crucial, clinicians say, particularly as some athletes have begun to speak more openly about the mental and emotional challenges they face and have indirectly encouraged their peers to be more open to getting help.

Tennis sensation Naomi Osaka, Olympic gold medalists Simone Biles and Michael Phelps, NBA stars Kevin Love and DeMar DeRozan all have publicly discussed their mental health challenges over the past decade, and several have led campaigns to raise awareness. “I credit them for discussing their struggles and the great benefits they received by accessing some care that was available to them,” said Maniar, who runs an athletic performance center in Ohio and works with college and high school football teams beyond his relationship with the Browns.

The NFL is a difficult arena for such conversations. Players in the league are accustomed to working through all manner of pain and injury practically as a job condition, and for much of the league’s existence, its athletes essentially were trained to show no vulnerability.

The implementation of a leaguewide program, though an important milestone, hasn’t radically accelerated the pace of change. “I think the NFL is still a dinosaur in that respect,” Green Bay Packers quarterback Aaron Rodgers told The New York Times two seasons ago. “There’s a stigma around talking about feelings, struggles, and dealing with stress. There’s a lot of vernacular that seems to tag it as weakness.”

The players union has become more aggressive in addressing the issue. “NFL players are often seen as the pinnacle of masculinity, and because caring about our own mental well-being and seeking support has not historically been associated with masculinity, too many of us do not prioritize that aspect of our health,” union president JC Tretter, an eight-year NFL veteran, wrote in a 2021 blog post to players, urging them to make use of the resources available.

Hamlin’s highly unusual emergency, in which he required on-field CPR before being transported to a hospital from the Cincinnati stadium where the Bills and Bengals were playing, “really created anxiety in some players, and it triggered others,” Hastings said. In addition to contacting several players individually, she sent out a message across the Rams organization reminding the athletes, coaches, and staff she was available to talk.

“A lot of them were receptive,” Hastings said. “The elephant in the room is mortality. The players know they can be hurt, and they’ve all dealt with injuries, but this included an element over which they had no control.”

Players from the Bills and the Cincinnati Bengals stood in stunned silence as Hamlin lay on the field. Days later, Buffalo players still struggled to articulate their feelings. “The scene replays over and over in your head,” quarterback Josh Allen said during a news conference, fighting back tears. “It’s hard to describe how I felt and how my teammates felt in that moment. It’s something we’ll never forget.”

Hamlin’s subsequent progress, including his release from hospital care to convalesce at home, “will help alleviate some of the trauma the players have been undergoing,” said Dr. Joshua Norman, an Ohio State University sports psychiatrist who often works with athletes on processing emotions. “But even though they try to compartmentalize things, these players have witnessed a serious injury. Some of them will have a strong reaction.”

Dr. Claudia Reardon, a University of Wisconsin psychiatrist, said the term “vicarious trauma” applies in this case. “The original traumatic event didn’t happen to you personally, but it is experienced as traumatic to have witnessed it or learned about it,” Reardon said. Reactions range from fear and helplessness to nightmares and flashbacks, she said, and some athletes will try to avoid “people, places, or things that remind them of the trauma they witnessed.”

“I wouldn’t be surprised to see a few players retire early,” Maniar said. “And a big concern is a player going out there and playing hesitantly or in fear. That is a sure way to get hurt in a sport like football, and this is a league where the contracts are not guaranteed. You’ve heard the saying ‘NFL means not for long.’ The players feel that pressure.”

The NFL’s best chance to make big strides in its mental health coverage, clinicians say, may derive from the simple fact that it is continually drafting and developing new talent. “The younger generation is just more sophisticated about mental health, period,” said Norman. “They come to a college campus often already having established some connection with their mental health needs, through counseling or other means. They’re more open to the idea of dealing with their mental health.”

Within franchise complexes, the work goes on. Both Hastings and Maniar were hired by their NFL teams years before the league made a clinician mandatory, and both made sure they kept an office away from the practice facility for those players who weren’t comfortable seeing them at work. But lately, Hastings said, that, too, is changing.

“Players are talking about these kinds of issues with each other more often, and they’re doing so very publicly,” she said. “In many ways, we’ve been building out our mental health protocol since I was brought on in 2017.” In the NFL, it is proving a slow turn.

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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Jenna Eisenhart spent nearly six years as a licensed therapist in Colorado before deciding to move to a place with a greater need for her services. She researched rural states facing a shortage of behavioral health providers and accepted a job as a lead clinical primary therapist at Shodair Children’s Hospital in Helena, Montana, in January 2018.

But she couldn’t start her new job right away because state officials denied her application for a license to practice in Montana on the grounds that her master’s degree program required only 48 credits to complete instead of 60.

Eisenhart spent nearly $7,000 to earn 12 more credits to meet the requirement, something she acknowledged not every provider would be able, or want, to do.

“I’m coming here as a licensed therapist to provide services that Montana desperately needs and you’re saying, no, you’re educationally deficient, when that’s not actually true,” said Eisenhart, now the director of clinical services at Shodair. “It kind of made me feel unwanted.”

Eisenhart’s difficulties are an example of the problems that health professionals can have in obtaining a Montana license to practice. State lawmakers are considering proposals to make it easier for professionals with out-of-state licenses to work in Montana. The need to attract more workers is particularly acute amid a national mental health crisis and a worker shortage, both heightened by the covid-19 pandemic. But lawmakers, behavioral health advocates, and providers say the need is so great, they doubt that lowering barriers for out-of-state practitioners will be enough.

One measure, House Bill 101, sponsored by Republican Rep. Jane Gillette and drafted by the Children, Family, Health and Human Services Interim Committee, covers social workers, professional counselors, addiction counselors, marriage and family therapists, and behavioral health peer support specialists. It would let the Department of Labor & Industry automatically license those providers in Montana if they meet certain requirements, like having an active license from another state for at least a year and having proper educational credentials.

Eisenhart said if the bill had been in effect in 2018, she wouldn’t have had to jump through as many hoops to work in Montana.

Another, House Bill 152 sponsored by Republican Rep. Bill Mercer and requested by the state Department of Labor & Industry as part of Gov. Greg Gianforte’s “Red Tape Relief” initiative, aims to streamline the licensing process for all occupations regulated by the department, from nurses to real estate appraisers.

HB 152 is designed to simplify the process for licensing the more than 50 professions and 150 types of licenses under the purview of the labor department, Eric Strauss, administrator of the department’s Employment Standards Division, said in a Jan. 18 committee hearing on the bill.

Last year, the department received more than 21,300 applications for licensure across professions, and half of those were from out-of-state professionals, said Dave Cook, the department’s deputy administrator of professional licensing. Health care-related licenses had an even higher share of out-of-state applicants — 60%, he said.

HB 152 would improve license mobility by creating a standard the department uses across professions to determine whether out-of-state license holders are qualified to work in Montana, department officials said. It also would establish a timeline of 30 days for the agency to issue a license after receiving a completed application.

“This helps the engineer, psychologist, social worker, or cosmetologist who has practiced for 20 years to get licensed without being required to get additional education or take an examination,” said department spokesperson Jessica Nelson.

Though the two bills have the same aim, labor department officials criticized Gillette’s bill on behavioral health worker licensing as not going far enough to remove obstacles for out-of-state workers.

HB 101 “creates additional burdens to licensure, including requiring residency and mandating that a particular licensing examination has been taken,” Nelson wrote in an email. “These are issues that HB 152 is attempting to reform.”

Gillette said she doesn’t think her bill or Gianforte’s bill alone would solve the workforce problem in health care. To make a substantial change, Gillette said, Medicaid provider reimbursement rates need to be higher.

“It’ll do something but it’s not going to fix it by any stretch,” Gillette said, referring to streamlining the licensing process.

A study commissioned by the 2021 legislature found that Montana’s Medicaid provider rates were too low to cover the cost of many of those who work with seniors, people with disabilities, and children and adults with mental illness.

The study found that the state’s Medicaid program is now paying, on average, 85% of the actual cost of care for adult behavioral health services, for example. Gianforte’s proposed budget would boost that funding next year to 94% of costs, on average, before lowering it again to 91%. The budget proposal is before lawmakers, and, to fully fund the services, providers are asking them to raise the rates higher than the governor proposes.

Mary Windecker, executive director of the Behavioral Health Alliance of Montana, which strives to make community-based services more accessible to patients, said that her organization recommended the interim committee come up with what became HB 101 but that HB 152 goes further than they could have hoped.

Windecker said every agency that her organization represents is experiencing staffing shortages of 25% to 30%. Up to 90% of the alliance members’ income comes from Medicaid reimbursements, she said, and it’s not enough. She said speeding up the licensure process and raising the Medicaid provider rates in accordance with a study the Montana Department of Public Health and Human Services instigated are the main strategies needed to satisfy demand for behavioral health services.

“We’ve got to get people in here to work,” Windecker said. “We have a huge labor shortage and with the Medicaid reimbursement so low, we’re having a really hard time hiring people.”

According to the Board of Behavioral Health, there were 5,126 active behavioral health providers in Montana as of last April. The Montana chapter of the National Alliance on Mental Illness reported 163,000 adults in Montana have a mental health condition.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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Tune in to the first “KHN Health Minute” to hear how noise pollution affects health and why an optimistic outlook may help people live longer.

The KHN Health Minute is available every Thursday on CBS News Radio.

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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The Host

Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
While repealing the Affordable Care Act seems to have fallen off congressional Republicans’ to-do list for 2023, plans to cut Medicare and Medicaid are back. The GOP wants Democrats to agree to cut spending on both programs in exchange for a vote to prevent the government from defaulting on its debts.

Meanwhile, the nation’s health care workers — from nurses to doctors to pharmacists — are feeling the strain of caring not just for the rising number of insured patients seeking care, but also more seriously ill patients who are difficult and sometimes even violent.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Tami Luhby of CNN, and Victoria Knight of Axios.

Panelists

Joanne Kenen Johns Hopkins Bloomberg School of Public Health and Politico @JoanneKenen Read Joanne's stories Tami Luhby CNN @luhby Read Tami's stories Victoria Knight Axios @victoriaregisk Read Victoria's stories
Among the takeaways from this week’s episode:

• Conservative House Republicans are hoping to capitalize on their new legislative clout to slash government spending, as the fight over raising the debt ceiling offers a preview of possible debates this year over costly federal entitlement programs like Medicare.
• House Speaker Kevin McCarthy said Republicans will protect Medicare and Social Security, but the elevation of conservative firebrands — like the new chair of the powerful House Ways and Means Committee — raises questions about what “protecting” those programs means to Republicans.
• Record numbers of Americans enrolled for insurance coverage this year under the Affordable Care Act. Years after congressional Republicans last attempted to repeal it, the once highly controversial program also known as Obamacare appears to be following the trajectory of other established federal entitlement programs: evolving, growing, and becoming less controversial over time.
• Recent reports show that while Americans had less trouble paying for health care last year, many still delayed care due to costs. The findings highlight that being insured is not enough to keep care affordable for many Americans.
• Health care workers are growing louder in their calls for better staffing, with a nursing strike in New York City and recent reports about pharmacist burnout providing some of the latest arguments for how widespread staffing issues may be harming patient care. There is bipartisan agreement in Congress for addressing the nursing shortage, but what they would do is another question.

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

Julie Rovner: Roll Call’s “NIH Missing Top Leadership at Start of a Divided Congress,” by Ariel Cohen

Tami Luhby: CNN’s “ER on the Field: An Inside Look at How NFL Medical Teams Prepare for a Game Day Emergency,” by Nadia Kounang and Amanda Sealy

Joanne Kenen: The Atlantic’s “Don’t Fear the Handshake,” by Katherine J. Wu

Victoria Knight: The Washington Post’s “‘The Last of Us’ Zombie Fungus Is Real, and It’s Found in Health Supplements,” by Mike Hume

Also mentioned in this week’s podcast:

The New York Times’ “As France Moves to Delay Retirement, Older Workers Are in a Quandary,” by Liz Alderman

Stat’s “Congressional Medicare Advisers Warn of Higher Drug Prices, Despite New Price Negotiation,” by John Wilkerson

Credits

Francis Ying Audio producer Emmarie Huetteman Editor
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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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

U.S. Health Care Is Harmful to One’s Health

Thank you for publishing this research (“Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?” Dec. 21). I am a psychotherapist and have written about this problem in my blog. The mercenary American health care system is hypocritical in the stressful financial demands and threats it imposes on so many patients. Stress due to health care-related bankruptcy, or the threat of bankruptcy, is harmful to one’s health. A health care system that is supposed to treat illness and restore health can, in fact, cause serious illness and/or exacerbate existing medical problems. The higher levels of stress and the threat of bankruptcy that all too frequently follow needed medical care can be harmful to individuals with cardiovascular issues such as high blood pressure and heart arrhythmia, and can trigger panic attacks in those who suffer from anxiety disorders. There may be digestive issues associated with higher levels of stress, and the patient’s sleep may be adversely affected. The individual may have to cut back on essentials such as food and medications because of unpaid medical bills, aggressive calls from collection agencies, and the threat of bankruptcy.

All of this in the name of “health care” delivered by professions and organizations that proclaim the importance of beneficence, justice, and malfeasance within their respective codes of ethics. Curative stress? Therapeutic bankruptcy? The hypocrisy is palpable.

American history is replete with examples of discrimination against certain groups, including racial discrimination, the disenfranchisement of women, child labor, and others. Eventually, political measures were enacted to correct these injustices. It’s only a matter of time until the American health care system, including the pharmaceutical industry, is forced to reform itself for the sake of the men, women, and children in need of essential health care. It’s not a question of if, but when.

— Fred Medinger, Parkton, Maryland

I find this infuriating! Especially the nonprofit organizations. Hundreds of US Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds | Kaiser Health News https://t.co/87TTYPVE0P
— Jan Oldenburg ☮️ (@janoldenburg) December 21, 2022

— Jan Oldenburg, Richmond, Virginia

Thanks for the article about hospitals suing patients. I just switched health plans in New York state. Reasons: My previous insurer raised my premium over 90% last year, paid very little of my claims (leaving Medicare to pay most of the claims), and sent me to collections. This, even though I worked two full-time jobs for most of my 46 years of teaching. How do insurance companies and hospitals get away with this unethical and outrageous behavior?

— George Deshaies, Buffalo, New York

Great story by @KHNews' @NoamLevey, which found that at least 297 hospitals in MN, 56%, sue patients for unpaid medical bills. 90, or 17%, can deny patients nonemergency medical care if they have past-due bills.Mayo is one of those hospitals. See🧵https://t.co/p5dHdbZKou
— Molly Work (@mollycastlework) December 21, 2022

— Molly Work, Rochester, Minnesota

Unhappy New Year of Deductibles and Copays

Listened to a conversation between Noam N. Levey and NPR’s Ari Shapiro, regarding Levey’s article on Germany’s lack of medical debt (“What Germany’s Coal Miners Can Teach America About Medical Debt,” Dec. 14). Levey passed along the tidbit that Affordable Care Act plans purchased through state exchanges would pay a maximum out-of-pocket amount of $9,000 a year. Likely Mr. Levey knows the actual details of the ACA at least as well as I, but I had well over $20,000 in out-of-pocket expenses for my own care last year (in addition to annual premiums of over $15,000). The deductible/copay aspect of health insurance is rigged against folks who actually use their insurance. The in-network and out-of-network provider scheme is likewise designed to benefit providers as opposed to patients.

I’ve had health insurance for about 40 years, since I graduated from college. Always a plan paid for by myself, never through an employer. I’ve had my first year of using a lot of heath care services (colon cancer surgery and chemo follow-up), and the bills are quite astronomical. Still awaiting the final negotiations between Stanford Hospital and Blue Shield of California for the $97,000 bill for services for the surgery and stay in the hospital. Though my surgery was in September, the two had not resolved the bill by year-end. Now all my copays and deductibles have reset, and I’ll be back at the starting gate, dollar-wise.

We need health care payment reform.

— George McCann, Half Moon Bay, California

Tx @NoamLevey for this important comparative piece on how Germany's private healthcare system does not create #medicaldebt. We need to do better. @RIPMedicalDebt https://t.co/PoAduYljXq
— Allison Sesso (@AllisonSesso) December 14, 2022

— Allison Sesso, president and CEO of RIP Medical Debt, Long Island City, New York

Greedy to the Bone?

In orthopedics, surgery is where the money is (“More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality,” Jan. 6). Just as a private equity-controlled ophthalmology group tried to persuade me to have unnecessary cataract surgery (three other eye doctors agreed it wasn’t necessary), too many orthopedic patients can expect to be pushed to unnecessary surgeries.

— Gloria Kohut, Grand Rapids, Michigan

As #private #equity firms acquire #physician practices, the issue of non-competes and #restrictive covenants become even more relevant in #healthcare @AAOS1 @AmerMedicalAssn @JHU_HBHI @linakhanFTC @KHNews https://t.co/fTfilK4WEX
— Amit Jain, MD, MBA (@AmitJainSpine) January 8, 2023

— Dr. Amit Jain, Baltimore

The Painful Truth of the Opioid Epidemic

In a recent article, Aneri Pattani and Rae Ellen Bichell discussed disparities in the distribution of settlement funds from lawsuits against major pharmaceutical companies, especially in rural areas (“In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them,” Dec. 12).

We suggest that the merit of many of the lawsuits that led to these large settlements remains unproven. While Purdue Pharma clearly overstated the safety of prescription opioids in treating chronic pain, judges in two high-profile cases ruled in favor of the pharmaceutical companies stating that prosecutors falsely inflated the danger of opioids and noted that opioids used per FDA guidelines are safe and effective, remaining a vital means to treat chronic pain. Also, many cases involving Purdue Pharma, Johnson & Johnson, and others were settled based on expediency, rather than merit. This may have been due to the reasoning that continuing their defense against prosecutors having access to limitless public funds would lead to bankruptcy.

The primary cause of America’s overdose crisis is not physicians’ “overprescribing” opioids. Dr. Thomas Frieden, former head of the Centers for Disease Control and Prevention, noted that the rise in prescription opioids paralleled the increase in opioid deaths up to 2010, leading the CDC to create guidelines in 2016 limiting opioid use to treat chronic pain. However, cause-and-effect relationships between the legitimate use of prescription opioids and opioid deaths remain unclear. For example, the National Institute on Drug Abuse noted in 2015 that since 2000, misuse of prescription drugs preceded the use of heroin in most cases. But legitimate prescriptions by physicians to patients with chronic pain constituted only 20% of the cases leading to heroin addiction. Prescription drugs used by heroin addicts were from family members or friends in 80% of the cases leading to heroin use.

Since at least 2010, the volume of prescription opioids dropped by over 60% — yet overdose deaths have skyrocketed to over 100,000 cases in 2021. The opioid overdose death crisis is now driven mainly by illegally imported fentanyl and in part by a misguided crackdown of the Drug Enforcement Administration against physicians who legitimately prescribe opioids to chronic pain patients, forcing them to seek out street drugs.

Statistics from Michigan indicate that nearly 40% of primary care clinics will no longer see new patients for pain management. The CDC, in its 2022 updated guidelines, attempted to clarify misunderstandings, including inappropriate rapid tapering and individualizing care. However, the public health crisis of undertreated pain remains. Some states have passed intractable pain laws to restore access to opioids to chronic pain patients with a legitimate need, indicating the shortfalls of the CDC guidelines to treat pain.

— Richard A. Lawhern, Fort Mill, South Carolina, and Dr. Keith Shulman, Skokie, Illinois

Important reporting from @aneripattani and @raelnb in @KHNews: National settlements are being paid out by #opioids manufacturers, but #rural communities are often getting less funds to address the #OpioidCrisis than their urban and suburban counterparts. https://t.co/qeoXtqKfpo
— Joanne Conroy (@JoanneConroyMD) December 15, 2022

— Dr. Joanne Conroy, Lebanon, New Hampshire

We’re fighting to hold accountable the companies that helped create and fuel the opioid crisis so we can help people struggling with opioid use disorder across North Carolina and the country get resources for treatment and recovery. We need this money now to save lives.

To that end, I wanted to flag one concern about the article on rural counties and opioid funding. It looks as if the comparison and the maps about North Carolina funding by county and overdose deaths may not correlate. The reporting seems to reflect overdose deaths on a per capita basis, but funding is indicated by total dollars received.

This spreadsheet might be helpful. It ranks each North Carolina county by the amount of funds they will receive from the distributor and Johnson & Johnson settlements (as posted on www.ncopioidsettlement.org) per capita, using 2019 population figures. In per capita rankings, rural and/or less populous counties are typically receiving more funding per capita than larger counties. For example, the 10 counties receiving the most per capita funding are all rural and/or less populous counties (Wilkes, Cherokee, Burke, Columbus, Graham, Yancey, Mitchell, Clay, Swain, and Surry). Wake County, our most populous county, is ranked 80th.

It’s also important to note that the formula was developed by experts for counsel to local governments in the national opioid litigation, who represent and have duties of loyalty to both large urban and small rural local governments. It takes into account opioid use disorder in the county (the number of people with opioid use disorder divided by the total number of people nationwide with opioid use disorder), overdose deaths as a percentage of the nation’s opioid overdose deaths, and the number of opioids in the county. Click here for more information.

Indeed, one of the special masters appointed by U.S. District Judge Dan Polster in the national opioid litigation found that the national allocation model “reflects a serious effort on the part of the litigating entities that devised it to distribute the class’s recovery according to the driving force at the heart of the lawsuit — the devastation caused by this horrific epidemic.” (See Page 5 of this report of Special Master Yanni.)

You’re absolutely right that rural counties were often the earliest and hardest hit by the opioid epidemic, and it’s critical that they receive funds to help get residents the treatment and recovery resources they need. We’re hopeful that these funds, whose allocation was determined in partnership by local government counsel, will help deliver those resources.

— Nazneen Ahmed, North Carolina Attorney General’s Office, Raleigh, North Carolina

This article is a great example of equality ≠ equity regarding opioid settlement funds disbursement. Really thoughtful article by @aneripattani & @raelnb https://t.co/vRbksffwqP
— Kate Roberts, LCSW (@KateandOlive_) December 14, 2022

— Kate Roberts, Durham, North Carolina

A Holistic Approach to Strengthening the Nursing Workforce Pipeline

As we face the nation’s worst nursing shortage in decades, some regions are adopting creative solutions to fill in the gaps (“Rural Colorado Tries to Fill Health Worker Gaps With Apprenticeships,” Nov. 29). To truly solve the root of this crisis, we must look earlier in the workforce pipeline.

The entire nation currently sits in a dire situation when it comes to having an adequate number of nurses — especially rural communities. With the tripledemic of covid-19, influenza, and RSV tearing through hospitals, it’s never been more evident how vital nurses are to the functioning of our health care system. A recent McKinsey report found that we need to double the number of nurses entering the workforce every year for the next three years to meet anticipated demand. Without support from policymakers and health care leaders, we cannot meet that.

As a health care executive myself, I’ve seen firsthand how impactful apprenticeships can be because they help sustain the health care workforce pipeline. From high school students to working adults, these “earn while you learn” apprenticeships allow students to make a living while working toward their degree, and my system’s apprenticeship program has even reduced our turnover by up to 50%. It provides a framework to support a competency-based education rooted in real-life skills and hands-on training for key nursing support roles, all while team members earn an income.

Education is key to developing competent, practice-ready nurses. Not just through apprenticeships but early on in students’ educational journey, too. According to the newest data from the nation’s report card, students in most states and most demographic groups experienced the steepest declines in math and reading ever recorded. As we continue to see the devastating impact the pandemic had on young learners, it’s crucial we invest more in remediation and support, so students graduate from secondary school with a deep understanding of these core competencies and are ready to pursue nursing. A recent survey of nearly 4,000 prospective nursing students from ATI Nursing Education found that a lack of academic preparedness was the top reason for delaying or forgoing nursing school.

Without intervention now, our nursing workforce shortage will only worsen in the future. We need our leaders to face these challenges head-on and invest in a holistic approach to strengthen our nursing pipeline. There’s no time to waste.

— Natalie Jones, executive director of workforce development at WellStar Health System, Atlanta

1 solution to the staffing crisis: Apprenticeship programs put students directly into long-term care professions. Rural areas benefit the most since they have more residents who are 65 or older & fewer direct care workers to help people w/ disabilities. https://t.co/vnbHAJYWvY
— OK Health Action (@ok_action) November 30, 2022

— Oklahoma Health Action Network, Oklahoma City

Planning Major Surgery? Plan Ahead

I read Judith Graham’s good article “Weighing Risks of a Major Surgery: 7 Questions Older Americans Should Ask Their Surgeon” (Jan. 3) on CNN. Thought I should add some personal experience. At age 78, my mother had back surgery in 2016. When she was getting prepped, she was given multiple documents to sign. Once signed, she was immediately taken to surgery. There was not enough time to read any of them. In hindsight, we are certain the documents were mostly for release of liability if something goes wrong. After surgery, she had “drop foot” — total loss of use of her left foot. Never heard of it. She was told she would regain use in about six months. Never happened. She had to use a walker and still had numerous falls in which her head had hit the ground multiple times. She slowly slid into long-term “confusion” that was attributed to her falls and passed away at age 84.

My story is about my abdominal aorta aneurysm surgery in 2022 at age 62. I did not have an overnight recovery — tube taken out of my throat, catheter removed, and was immediately transferred to a room. An IV pump of saline was left on and my arm swelled up — I thought my arm was going to burst. Five days later, I was discharged. Everything seemed rushed. The only postsurgical “instructions” I received were to keep the incision clean and not to play golf, and I don’t even play golf. I recuperated at home, and after five months I still have abdominal pain that I’ll always have.

Both of our surgeries were done on a Friday. I’m certain our experiences were due to hospital staff wanting to leave early on Friday, and weekend staffers are mostly the “B” team. So, my advice is to suggest to the elderly not to have surgery scheduled on a Friday unless there is absolute urgency in choosing the date.

— Paul Lyon, Chesapeake, Virginia

Reality bites, doesn’t it.https://t.co/sHe0EV1DQG
— suzette sommer (@suzette_sommer) December 28, 2022

— Suzette Sommer, Seattle

I am writing to express my concerns over the significant misinformation in the article about what older Americans should ask their surgeon before major surgery.

Most abdominal aortic aneurysms are treated with endovascular methods. These minimally invasive procedures still require general anesthesia (with a breathing tube), but most patients have the tube removed before leaving the operating room, and many patients leave the hospital the next day with minimal functional limitations due to surgery being performed through half-inch incisions in each groin.

The “best case” surgical scenario described in your article describes open abdominal aortic aneurysm repair, which is recommended for fewer than 20% of patients requiring aortic aneurysm repairs.

In essence, you’re threatening everyone who comes in for a tuneup with an engine rebuild.

Abdominal aortic aneurysms are still undertreated in the U.S., with many patients not receiving screening recommended by Medicare since 2006. Your article misrepresents the “best case” scenario and may dissuade patients from receiving lifesaving care.

— Dr. David Nabi, Newport Beach, California

I read, with interest, Judith Graham’s article about older Americans preparing for major surgery. But you failed to mention the life-altering effects of anesthesia. My independent 82-year-old mother had a minor fall in July and broke her hip. After undergoing anesthesia, she is required to have 24/7 care as her short-term memory has been forever altered. Was there a choice not to have hip surgery? I didn’t hear one. Did anyone explain the issues that could (and often do) occur with an elderly brain due to anesthesia? No. And now we are dealing with this consequence. And what happens when you don’t have money (like most people in the U.S.) for 24/7 care? I hope you’ll consider writing about this.

— Nancy Simpson, Scottsdale, Arizona

Shouldn't more people wonder why MA plans are profitable while our own gov't MC is losing money. Only 5% of MA plans are audited yearly. Yet they are getting 8.5% increase in payment & docs (the folks taking care of the pts) are getting cut. https://t.co/UiFiiQ9wre via @khnews
— Madelaine Feldman (@MattieRheumMD) December 15, 2022

— Dr. Madelaine Feldman, New Orleans

The High Bar of Medicare Advantage Transparency

Unfortunately, KHN’s article “How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions” (Dec. 13) provided a misleading, incomplete depiction of Medicare Advantage payment.

This story focuses largely on audits that, in some cases, are more than a decade old. While KHN’s focus is on alleged “overpayment,” the same audits show that many plans were underpaid by as much as $773 per patient.

More recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars. For example, an October 2021 Milliman report concludes “the federal government pays less and gets more for its dollar in MA than in FFS,” while the Department of Health and Human Services’ fiscal year 2021 report shows that the net improper payment rate in Medicare Advantage was roughly half that of fee-for-service Medicare.

KHN’s article is right about one thing: Only a small fraction of Medicare Advantage plans are audited each year — denying policymakers and the public a fuller understanding of the program’s exceptional value to seniors and the health care system. That is why Better Medicare Alliance has called for regulators to conduct Risk Adjustment Data Validation (RADV) audits of every Medicare Advantage plan every year.

There are opportunities, as outlined in our recent policy recommendations, to further strengthen and improve Medicare Advantage’s high bar of transparency and accountability, but that effort is not well served by this misleading article.

— Mary Beth Donahue, president and CEO of the Better Medicare Alliance, Chevy Chase, Maryland

Targeting Gun Violence

I’m curious why KHN neglected to actually get into all the “meat and potatoes” regarding its report on Colorado’s red flag law (“Colorado Considers Changing Its Red Flag Law After Mass Shooting at Nightclub,” Dec. 23). Specifically, it failed to report that the suspect in this case used a “ghost gun” to execute the crime in Colorado Springs, and more importantly what impact any red flag law is going to have on a person who manufactures their own illegal firearm. Lastly, why is it the national conversation regarding the illegal use and possession of firearms curiously avoids any in-depth, substantive conversation of access to firearms by mentally ill people? Quite frankly, this is the underlying cause of illegal firearms use and no one wants to step up to the plate and address the issue at any in-depth level. It’s categorically embarrassing for American journalism.

— Steve Smith, Carbondale, Colorado

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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DECATUR, Ill. — The question came out of the blue, or so it seemed to Crossing Healthcare CEO Tanya Andricks: If you had $30 million to design an addiction treatment facility, how would you do it?

The interim sheriff of Macon County, Illinois, posed the question in 2018 as he and Andricks discussed the community’s needs. When she responded that she’d have to do some research, she was told not to take too long because the offer wouldn’t be there forever.

“I thought: ‘Oh, my God, he’s serious,’” Andricks said.

That sheriff was Howard Buffett, the philanthropist son of billionaire investor Warren Buffett. The younger Buffett ended up giving Crossing about $30 million from his charitable foundation to build an addiction treatment center in Decatur, a city with a population of just over 69,000 in the heart of Macon County.

There was a caveat, though. The donation to Crossing was a one-time gift to pay only for the buildings. It was up to Andricks and her team to find money to run the programs. And that has proven difficult.

The covid-19 pandemic upended everything mere months after the facilities opened in October 2019. An audited financial statement said the inpatient recovery center had lost $2.5 million by June 2021, and management worried about its ability to continue operating. Even so, the center remained open while other addiction treatment facilities around the country shuttered.

Now communities nationwide are preparing for an unprecedented windfall of their own for addiction treatment from a nearly $26 billion national opioid settlement and a more than $300 million expansion of a federal pilot program for mental health. The experience at Crossing offers them a model but also a warning: It will take more than a single shot of money to build a treatment program that can last.

Drug addiction wasn’t on Howard Buffett’s radar, he told KHN, until he joined the Macon County sheriff’s office as an auxiliary deputy in 2012. While the county has had some treatment resources, like a behavioral health center, it has one of the state’s higher death rates from opioid overdoses.

Buffett moved to the area in 1992 to work for food-processing giant Archer Daniels Midland. He runs a farm nearby and his Decatur-based foundation donates hundreds of millions of dollars for initiatives ranging from helping people kidnapped by Joseph Kony’s Lord’s Resistance Army in central Africa to revitalizing the cacao industry in El Salvador.

Soon after Buffett was appointed interim sheriff in 2017, he toured Crossing to learn more about local social services. The health center offers primary care, including mental health, for all ages and sees roughly 17,500 patients a year. Most Crossing patients are on Medicaid, the public health insurance for people with low incomes.

“He was impressed with what we were able to provide patients,” Andricks recalled. “I don’t think he expected the scope and size of what we do.”

Addiction treatment, though, is notoriously difficult. Evidence supports treating addiction like a chronic illness, meaning even after difficult short-term behavior changes, it requires a lifetime of management. Research suggests relapse rates can be more than 85% in the first year of recovery. So any new treatment program is likely to face headwinds.

Buffett didn’t set Crossing up for failure. In fact, he has helped fund other aspects of the organization’s work. Part of the idea behind paying for the addiction treatment buildings but not the operations, Buffett said, is to keep his foundation “creative.” If it spends all its money on the same programming every year, that means less is available to fund other work around the globe. Buffett said it’s also about sustainability.

“If Tanya can show ‘with this investment I made this work,’” Buffett said, “then other people should be making that investment.”

Crossing’s inpatient recovery center holds eight beds for medication-assisted detox, 48 beds for rehabilitation, and a cafeteria where meals are cooked with input from dietitians working with patients. An outpatient treatment center also has classrooms for continuing education, a gym with a small bowling alley, and a movie theater. Buffett insisted on the last two amenities. (“People have to feel good about getting better,” he said.)

A separate building holds 64 beds of transitional housing, and just across the street are 20 rent-controlled apartments. Buffett spent an additional $25 million on buildings at that campus for other organizations focused on housing, workforce development, and education, among other things.

“There’s a lot to like in this program,” said Dr. Bradley Stein, director of Rand Corp.’s Opioid Policy and Tools Information Center.

As positives, Stein pointed specifically to the spectrum of care offered to patients as they progress in their recovery, the use of medication-assisted treatment to help stave off physical cravings for opioids, the connection to the health center, and even the involvement of law enforcement.

Laura Cogan, a 36-year-old mother who has struggled with addiction since she was 14, is one of the patients working their way through the system.

Cogan said she was the first patient in the doors when the recovery center opened. Less than 24 hours later, she was also the first patient to walk out.

The biggest challenge with Cogan’s previous attempts at recovery, she said, was never being sure about her next steps: What was she supposed to do after getting out of detox and residential treatment?

Crossing’s approach was designed to address that by providing transitional housing, easy access to outpatient services, and educational programming.

On her third attempt, Cogan got a round of applause after completing the first three days in detox. After six days, she joined residential treatment. After a month, she moved over to transitional housing, began outpatient treatment, and started offering peer support at Crossing. She tutored other patients, taught a writing class, and helped them get on computers and fill out job applications.

Then the pandemic hit.

Like other health centers around the nation, Crossing turned its attention to providing covid testing and vaccines. Meanwhile, just about every aspect of addiction treatment became more expensive. Crossing halved the number of residential treatment beds so each room would have only one patient and converted the rooms into negative pressure chambers to reduce the risk of covid transmission.

Staffing grew harder amid a nationwide nursing shortage. The number of patients in residential treatment dropped, Andricks said, because few people wanted to live inside a facility and wear masks. It was common to have as few as 10 beds occupied on a given day. The women’s unit was temporarily closed due to lack of demand and staffing constraints.

Cogan said several other transitional housing residents left once the $1,200 pandemic stimulus checks arrived, with some resuming treatment when that money dried up. But Cogan continued. Eventually she moved into Crossing’s rent-controlled apartments, where she has been one of just a few tenants.

Without the federal Paycheck Protection Program’s $1,375,200 forgivable loan in 2020, Andricks said, the outpatient treatment program might have had to close altogether.

But momentum at the recovery center started to change last spring as covid cases tapered off, Andricks said. Hiring became easier. More patients arrived. In October, the center received a grant to use the apartments for women with a history of substance misuse who are pregnant or who have given birth within the prior year. They’ve placed six women, in addition to Cogan, there already. The inpatient recovery center now averages about 27 occupied beds a day, within striking distance of the 30 that Andricks said the inpatient center needs to survive.

Rand’s Stein suggested another measurement of a treatment program’s success: whether people in the community get into treatment when they need it. National “secret shopper” reports have found significant barriers to service, such as long wait times.

Crossing’s program quadrupled the number of residential treatment beds in Macon County, according to Andricks. In the three years since the inpatient recovery center opened, it has had over 1,300 admissions. While most patients haven’t stayed in recovery, staffers have seen a pattern of success with those like Cogan who stay on campus and become involved with recovery offerings — although Andricks estimated that’s fewer than 10% of the patients.

Cogan said she hopes Crossing doesn’t get discouraged. People are going to mess up, she said, but she’s living proof of the impact the recovery center can have.

“I’m one of the lucky ones and I don’t know why,” Cogan said, sitting on a couch in the apartment on Crossing’s campus that she shares with her 12-year-old son since regaining custody of him. “I just know that today I am. And I hope that more people get the opportunity.”

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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Promise: “I’ll not only restore Obamacare; I’ll build on it.”

In a speech on Nov. 2, 2020, then-presidential candidate Joe Biden promised, “I’ll not only restore Obamacare; I’ll build on it.”

Two years and counting since then, how is he doing in meeting that promise?

KHN has teamed up with our partners at PolitiFact to monitor 100 key promises — including this one — made by Biden during the 2020 presidential campaign. The pledges touch on issues related to improving the economy, responding to calls for racial justice, and combating climate change. On health care, they range from getting covid-19 under control and improving veterans’ health care to codifying Roe v. Wade. KHN has recently done progress checks on the administration’s pledges to lower the costs of prescription drugs and to reduce the nation’s maternal mortality rate.

Eight days into his tenure as president, Biden signed an executive order aimed at strengthening Medicaid and the Affordable Care Act, or Obamacare. A couple of months later, he signed his first major piece of legislation, the American Rescue Plan, which included provisions expanding eligibility for subsidies and increasing premium tax credits available to help low- and moderate-income Americans purchase ACA coverage.

That legislation also offered financial incentives to encourage the 12 states that had declined to expand Medicaid eligibility to do so.

The consumer subsidies were originally set to expire this year but were extended by the Inflation Reduction Act, which Biden signed into law Aug. 16, after much debate and without any Republican votes. The expanded eligibility for subsidies was also continued by this measure.

In October, the Biden administration addressed another issue in the ACA, the so-called family glitch, which prevented some people with job-based insurance from qualifying for subsidies.

Those items alone prompt “an unequivocal yes,” to the question of whether Biden has met his campaign promise, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

Joe Antos, a senior fellow at the American Enterprise Institute think tank, offered a different perspective — that the actions taken on the glitch can’t count toward Biden’s promise to “restore” the ACA. Antos said that’s because it wasn’t a glitch at all, but rather an intentional element of the original ACA put there to save the government money, and help win its passage in Congress.

“Biden was vice president when the bill was signed into law, and he supposedly supported it,” Antos said.

Corlette touted other Biden administration changes, including increased funding for consumer assistance programs that help people sign up for ACA coverage and streamlined some of the paperwork required for enrollment.

The White House issued an official recap of other actions taken as a result of the executive order, including extending the annual open enrollment period to bring in more policyholders, and allowing low-income Americans to sign up anytime.

Last year, a record 14.5 million Americans selected an ACA plan. This year’s sign-up period ended Jan. 15 in most states and, based on preliminary numbers, enrollment in 2023 will continue the upward trend.

The boost in enrollment is due, in part, to the enhanced subsidies, which lowered premiums to $10 or less a month for some low-income consumers, and eliminated a cutoff threshold, allowing some higher-income families to qualify for at least some subsidy, said Corlette.

Antos agreed that the administration has made changes that “clearly built on Obamacare and expanded spending and probably did cover more people.”

What happened with the financial incentives meant to get states to expand their Medicaid programs to include more low-income adults, particularly those at or below the poverty level who have no children? Those incentives are still there for the taking, but, so far, no states have done so.

South Dakota expanded after the rescue plan’s passage, but that was because voters approved a ballot measure, not because of the financial incentives.

“That was part of Biden’s goal, to close the coverage gap,” said Joan Alker, executive director of the Center for Children and Families at Georgetown. “We still have 11 states resisting Medicaid expansion, and that leaves a big, gaping hole in coverage in those states. But that’s not for lack of trying by the Biden administration.”

Because enrollment is up, subsidies are more available, more people are helping consumers enroll, and there are additional enticements to get states to expand Medicaid, we rate this as a Promise Kept.

Our sources:

Telephone interview with Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, Dec. 20, 2022

Telephone interview with Joseph Antos, senior fellow at the American Enterprise Institute, Jan. 5, 2023

Telephone interview with Joan Alker, executive director of the Center for Children and Families at Georgetown University, Jan. 10, 2023

Archive Today, transcript of Joe Biden campaign speech in Pittsburgh, Nov. 2, 2022

KHN, “Inflation Reduction Act Contains Important Cost-Saving Changes for Many Patients — Maybe for You,” Aug. 12, 2022

White House, Executive Order on Continuing to Strengthen Americans’ Access to Affordable, Quality Health Coverage, April 5, 2022

KFF, “Marketplace Enrollment 2014-2022,” accessed Jan. 5, 2023

KFF, “Five Things to Know About the Renewal of Extra Affordable Care Act Subsidies in the Inflation Reduction Act,” Aug. 11, 2022

KFF, “Navigating the Family Glitch Fix: Hurdles for Consumers with Employer-Sponsored Coverage,” Nov. 21, 2022

NPR, “Shopping for ACA Health Insurance? Here’s What’s New This Year,” Oct. 31, 2022

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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A new coronavirus variant is circulating, the most transmissible one yet. Hospitalizations of infected patients are rising. And older adults represent nearly 90% of U.S. deaths from covid-19 in recent months, the largest portion since the start of the pandemic.

What does that mean for people 65 and older catching covid for the first time or those experiencing a repeat infection?

The message from infectious disease experts and geriatricians is clear: Seek treatment with antiviral therapy, which remains effective against new covid variants.

The therapy of first choice, experts said, is Paxlovid, an antiviral treatment for people with mild to moderate covid at high risk of becoming seriously ill from the virus. All adults 65 and up fall in that category. If people can’t tolerate the medication — potential complications with other drugs need to be carefully evaluated by a medical provider — two alternatives are available.

“There’s lots of evidence that Paxlovid can reduce the risk of catastrophic events that can follow infection with covid in older individuals,” said Dr. Harlan Krumholz, a professor of medicine at Yale University.

Meanwhile, develop a plan for what you’ll do if you get covid. Where will you seek care? What if you can’t get in quickly to see your doctor, a common problem? You need to act fast since Paxlovid must be started no later than five days after the onset of symptoms. Will you need to adjust your medication regimen to guard against potentially dangerous drug interactions?

“The time to be figuring all this out is before you get covid,” said Dr. Allison Weinmann, an infectious-disease expert at Henry Ford Hospital in Detroit.

Being prepared proved essential when I caught covid in mid-December and went to urgent care for a prescription. Because I’m 67, with blood cancer and autoimmune illness, I’m at elevated risk of getting severely ill from the virus. But I take a blood thinner that can have life-threatening interactions with Paxlovid.

Fortunately, the urgent care center could see my electronic medical record, and a physician’s note there said it was safe for me to stop the blood thinner and get the treatment. (I’d consulted with my oncologist in advance.) So, I walked away with a Paxlovid prescription, and within a day my headaches and chills had disappeared.

Just before getting covid, I’d read an important study of nearly 45,000 patients 50 and older treated for covid between January and July 2022 at Mass General Brigham, a large Massachusetts health system. Twenty-eight percent of the patients were prescribed Paxlovid, which had received an emergency use authorization for mild to moderate covid from the FDA in December 2021; 72% were not. All were outpatients.

Unlike in other studies, most of the patients in this one had been vaccinated. Still, Paxlovid conferred a notable advantage: Those who took it were 44% less likely to be hospitalized with severe covid-related illnesses or die. Among those who’d gotten fewer than three vaccine doses, those risks were reduced by 81%.

A few months earlier, a study out of Israel had confirmed the efficacy of Paxlovid — the brand name for a combination of nirmatrelvir and ritonavir — in seniors infected with covid’s omicron strain, which arose in late 2021. (The original study establishing Paxlovid’s effectiveness had been conducted while the delta strain was prevalent and included only unvaccinated patients.) In patients 65 and older, most of whom had been vaccinated or previously had covid, hospitalizations were reduced by 73% and deaths by 79%.

Still, several factors have obstructed Paxlovid’s use among older adults, including doctors’ concerns about drug interactions and patients’ concerns about possible “rebound” infections and side effects.

Dr. Christina Mangurian, vice dean for faculty and academic affairs at the University of California-San Francisco School of Medicine, encountered several of these issues when both her parents caught covid in July, an episode she chronicled in a recent JAMA article.

First, her father, 84, was told in a virtual medical appointment by a doctor he didn’t know that he couldn’t take Paxlovid because he’s on a blood thinner — a decision later reversed by his primary care physician. Then, her mother, 78, was told, in a separate virtual appointment, to take an antibiotic, steroids, and over-the-counter medications instead of Paxlovid. Once again, her primary care doctor intervened and offered a prescription.

In both cases, Mangurian said, the doctors her parents first saw appeared to misunderstand who should get Paxlovid, and under what conditions. “This points to a major deficit in terms of how information about this therapy is being disseminated to front-line medical providers,” she told me in a phone conversation.

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, agrees. “Every day, I hear from people who are misinformed by their physicians or call-in nurse lines. Generally, they’re being told you can’t get Paxlovid until you’re seriously ill — which is just the opposite of what’s recommended. Why are we not doing more to educate the medical community?”

The potential for drug interactions with Paxlovid is a significant concern, especially in older patients with multiple medical conditions. More than 120 medications have been flagged for interactions, and each case needs to be evaluated, taking into account an individual’s conditions, as well as kidney and liver function.

The good news, experts say, is that most potential interactions can be managed, either by temporarily stopping a medication while taking Paxlovid or reducing the dose.

“It takes a little extra work, but there are resources and systems in place that can help practitioners figure out what they should do,” said Brian Isetts, a professor at the University of Minnesota College of Pharmacy.

In nursing homes, patients and families should ask to speak to consultant pharmacists if they’re told antiviral therapy isn’t recommended, Isetts suggested.

About 10% of patients can’t take Paxlovid because of potential drug interactions, according to Dr. Scott Dryden-Peterson, medical director of covid outpatient therapy for Mass General Brigham. For them, Veklury (remdesivir), an antiviral infusion therapy delivered on three consecutive days, is a good option, although sometimes difficult to arrange. Also, Lagevrio (molnupiravir), another antiviral pill, can help shorten the duration of symptoms.

Many older adults fear that after taking Paxlovid they’ll get a rebound infection — a sudden resurgence of symptoms after the virus seems to have run its course. But in the vast majority of cases “rebound is very mild and symptoms — usually runny nose, nasal congestion, and sore throat — go away in a few days,” said Dr. Rajesh Gandhi, an infectious-disease physician and professor of medicine at Harvard Medical School.

Gandhi and other physicians I spoke with said the risk of not treating covid in older adults is far greater than the risk of rebound illness.

Side effects from Paxlovid include a metallic taste in the mouth, diarrhea, nausea, and muscle aches, among others, but serious complications are uncommon. “Consistently, people are tolerating the drug really well,” said Dr. Caroline Harada, associate professor of geriatrics at the University of Alabama-Birmingham Heersink School of Medicine, “and feeling better very quickly.”

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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ELKO, Nev. — When Ruby B. Sutton found out she was pregnant in late 2021, it was hard to envision how her full-time job would fit with having a newborn at home. She faced a three-hour round-trip commute to the mine site where she worked as an environmental engineer, 12-plus-hour workdays, expensive child care, and her desire to be present with her newborn.

Sutton, 32, said the minimal paid maternity leave that her employer offered didn’t seem like enough time for her body to heal from giving birth or to bond with her firstborn. Those concerns were magnified when she needed an emergency cesarean section.

“I’m a very career-driven person,” Sutton said. “It was really difficult to make that decision.”

Sutton quit her job because she felt even additional unpaid time off wouldn’t be enough. She also knew child care following maternity leave would cost a substantial portion of her salary if she returned to work.

Tens of millions of American workers face similar decisions when they need to care for themselves, a family member, or a baby. Wild variations in paid leave regulations from state to state and locally mean those choices are further complicated by financial factors. And workers in rural areas face even more challenges than those in cities, including greater distances to hospitals and fewer medical providers, exacerbating health and income disparities. Companies in rural areas may be less likely to voluntarily offer the benefit because they tend to be smaller and there are fewer employers for workers to choose from.

While a growing number of states, cities, and counties have passed paid sick leave or general paid time off laws in recent years, most states where more than 20% of the population is rural haven’t, leaving workers vulnerable. Vermont and New Mexico are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave.

Experts say the gaps in paid leave requirements mean workers in rural areas often struggle to care for themselves or loved ones while making ends meet.

“The problem is, because it’s a small percentage of the population, it’s often forgotten,” said Anne Lofaso, a professor of law at West Virginia University.

The covid-19 pandemic steered attention toward paid leave policies as millions of people contracted the virus and needed to quarantine for five to 10 days to avoid infecting co-workers. The 2020 Families First Coronavirus Response Act temporarily required employers with fewer than 500 employees and all public employers to give workers a minimum of two weeks of paid sick leave, but that requirement expired at the end of 2020.

The expiration left workers to rely on the Family and Medical Leave Act of 1993, which requires companies with 50 or more employees to provide them with up to 12 weeks of unpaid time off to care for themselves or family members. But many workers can’t afford to go that long without pay.

By March 2022, 77% of workers at private companies had paid sick leave through their employers, according to the Bureau of Labor Statistics — a small increase from 2019, when 73% of workers in private industry had it. But workers in certain industries — like construction, farming, forestry, and extraction — part-time workers, and lower-wage earners are less likely to have paid sick leave.

“Paid leave is presented as a high-cost item,” said Kate Bronfenbrenner, director of labor education research at the School of Industrial and Labor Relations at Cornell University.

But it comes with a payoff: Without it, people who feel pressure to go to work let health conditions fester and deteriorate. And, of course, infectious workers who return too early unnecessarily expose others in the workplace.

Advocates say a stronger federal policy guaranteeing and protecting paid sick and family leave would mean workers wouldn’t have to choose between pushing through illness at work or losing income or jobs.

A recent report by New America, a left-leaning think tank, argues that creating policy to ensure paid leave could boost employment numbers; reduce economic, gender, and racial disparities; and generally lift up local communities.

Support for paid sick and family leave is popular among rural Americans, according to the National Partnership for Women & Families, which found in 2020 polling that 80% of rural voters supported a permanent paid family and medical leave program, allowing people to take time off from work to care for children or other family members.

But lawmakers have been divided on creating a national policy, with opponents worrying that requiring paid leave would be too big a financial burden for small or struggling businesses.

In 2006, voters in San Francisco approved the Paid Sick Leave Ordinance, making it the first U.S. city to mandate paid sick leave. Since then, 14 states, the District of Columbia, and 20 other cities or counties have done so. Two other states, Nevada and Maine, have adopted general paid time off laws that provide time that can be used for illness.

Federal workers are offered 12 weeks of paid parental leave in the Federal Employee Paid Leave Act, adopted in October 2020. It covers more than 2 million civilian workers employed by the U.S. government, though the law must be reapproved each fiscal year and employees are not eligible until they’ve completed one year of service.

The patchwork of laws nationwide leaves workers in several mostly rural states — places like Montana, South Dakota, and West Virginia where more than 40% of residents live outside cities — without mandated paid sick and family leave.

Sutton said she “would have definitely loved” to stay at her job if she could’ve taken a longer paid maternity leave. She said she wants to return to work, but the future is unclear. She has more things to consider, like whether she and her husband want more children and when she might feel healthy enough to try for a second baby after last summer’s C-section.

Sutton recalled a friend she worked with at a gold mine years ago who left the job a few months after having a baby. “And I understand now all the things she was telling me at that time. … She was like, ‘I can’t do this,’ you know?”

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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