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Telemedicine Abortions Offer Cheaper Options but May Also Undermine Critical Clinics

Fri, 09/03/2021 - 5:00am

Allison Hansen had just gone through a breakup with her boyfriend last year when she discovered she was pregnant. She already had an 8-year-old son and did not want another child.

Hansen called the Planned Parenthood facility near her home in Savannah, Georgia, to inquire about abortion services and was told the procedure would cost $500 and require four to six hours at the clinic.

Hansen didn’t have that kind of time. Her son was at home, attending school online, and needed supervision. While Googling for alternatives, she came across Carafem — a nonprofit that delivers abortion pills to a patient’s home after a telemedicine visit for $375 or less.

“It just seemed almost too good to be true,” Hansen recalled.

Patients like Hansen have benefited from a quiet but monumental shift in abortion access enabled by the covid-19 pandemic. In July 2020, in response to advocates’ concerns about the risks posed by in-person visits in a pandemic, a federal court placed on hold a long-standing FDA rule that required mifepristone — the first pill in a two-step regimen used in medical abortions — to be dispensed in clinics. After the Trump administration appealed that decision, the conservative-majority Supreme Court agreed to reinstate the rule, with Chief Justice John Roberts writing that courts should defer to government experts who set the rules. The Biden administration put the rule back on hold in April during the remaining public health emergency and said it is reviewing the agency’s restriction.

In the meantime, telemedicine abortion operations are growing in some places, although not in such states as Texas and Alabama with strict laws designed to curb or end abortions.

A new slate of digital abortion options like Just the Pill, Hey Jane, Abortion on Demand and Choix proliferated, mailing abortion pills to patients in many states after a telemedicine visit. Carafem, which had been mailing the pills to patients in Georgia before the pandemic as part of a research project, streamlined its process for patients who are eligible for medical abortions.

These services can be a lifeline for patients who haven’t hit the 10- or 11-week threshold typically used for medical abortion and who can’t get to a clinic or need a less expensive choice. But reproductive health advocates worry that telemedicine abortion options don’t reach the patients who need it the most because they live in states with laws that actively discourage abortions and have made in-clinic care harder to access. At the same time, these new options could be endangering brick-and-mortar clinics by siphoning away the first-trimester visits that make up more than 90% of abortions.

“If [clinics] lose a considerable amount of the clientele for first-trimester abortions, they might have to close, or some of them will,” said Carole Joffe, a professor focusing on reproductive health at the University of California-San Francisco and co-author of “Obstacle Course: The Everyday Struggle to Get an Abortion in America.” “Potentially, we see people needing second-trimester procedures, not to mention even later ones, with literally nowhere to go.”

Many clinics, which charge higher prices to support the costs of running a building and providing security, are closing around the country amid an avalanche of state restrictions. That is especially true of independent clinics, which perform 58% of abortions, according to the Abortion Care Network, an association of independent providers. Since 2012, the number of independent abortion clinics has dropped by 34%.

Concerns about access to abortion deepened this week when a Texas law took effect banning abortions after six weeks of pregnancy and a divided Supreme Court did not block it, at least for now. The court is also scheduled to hear a case this term on Mississippi’s 15-week abortion ban. If the justices allow either state law to stand, it would likely lead other states to further restrict abortion, forcing patients in many conservative states across the South, Midwest and West to travel for services or seek out overseas options like Aid Access, according to Mary Ziegler, a Florida State University law professor who focuses on legal issues surrounding reproductive health and sexuality.

“If you’re in New York or California or Boston, you can get abortion pills online, you can go to a clinic — there are tons of options. Whereas if you’re in a state like Alabama, you’re probably going to be worried that you can’t do any of those things,” Ziegler said.

Carafem, which operates clinics in Georgia, Illinois, Tennessee and Maryland, began mailing abortion pills to patients in Georgia in 2019 when it joined the TelAbortion Study, an ongoing project run by the reproductive health nonprofit Gynuity that received federal permission to study the safety of telemedicine abortions. Over four years, abortion providers mailed 1,390 medication packages to patients in 13 states and Washington, D.C. Researchers reported that 95% of tracked participants had a complete abortion without a procedure. They reported 10 serious adverse events, including five cases of patients needing blood transfusions, none of which could have been avoided by an in-person visit, the researchers said. Participants made 70 unplanned visits to emergency rooms or urgent care centers.

Anti-abortion advocates, however, stress that medical abortion should require in-person exams.

“Women deserve excellent health care, and excellent health care does not involve talking to someone online,” said Dr. Christina Francis, board chair of the American Association of Pro-Life Obstetricians and Gynecologists. “It involves actually being seen and being evaluated to make sure that if she’s going to make this decision, she’s an appropriate candidate to make this decision and she’s not putting herself at severe risk by taking these medications.”

Many states require in-person counseling or ultrasounds before an abortion, forcing patients to make more than one trip to a clinic. In 19 states, laws require a physician who prescribes a medical abortion to be physically present when the medication is administered.

Alabama is one of those states. “I use telemedicine all the time because I’m a full-spectrum OB-GYN,” said Dr. Sanithia Williams, an abortion provider at Alabama Women’s Center for Reproductive Alternatives in Huntsville. “But for the abortion portion of my practice, it just is completely nonexistent.”

Even in states with relatively few abortion restrictions, patients with medical risk factors, unreliable periods, unsafe living situations or pregnancies beyond 11 weeks generally can’t get care online. “There will always be a need for clinic-based health care,” said Melissa Grant, chief operations officer of Carafem. “This is not a panacea.”

On a Thursday morning in late June, Leah Coplon, a certified nurse midwife, sat down in the Augusta office of Maine Family Planning for a televisit with a patient seeking an abortion who was in her home miles away. The young patient nodded and messaged her boyfriend, telling him to go buy her menstrual pads, as Coplon ran through a detailed list of warning signs like excessive bleeding that should prompt a call to the clinic or trip to an emergency room. “This is all very rare, but I’ve got to tell you the scary things. That’s my job,” Coplon said, the blue light of the monitor reflecting off her glasses.

For uninsured patients, the out-of-pocket cost for a telemedicine visit like this is $500, about average for brick-and-mortar clinics.

Maine is among a minority of states that cover abortions under Medicaid. The state also requires private plans to cover abortion if they cover prenatal care. Yet even here, with 8% of the population uninsured, cost is the biggest barrier Coplon’s patients face, she said. To meet the needs of low-income patients, clinics like hers haven’t raised their out-of-pocket rates in years. If the price of abortion had kept pace with medical inflation, a procedure that cost $200 in 1974 would cost $2,686 today, according to a Bloomberg Businessweek calculation last year.

Maine Family Planning has 18 locations across the sprawling, mostly rural state. In 2014, it became one of the first clinics to launch a telehealth pilot program. When covid struck, providers like Coplon used existing telemedicine equipment to shift to a “no-test” protocol, bypassing ultrasounds and blood tests that research shows can be safely skipped in order to minimize contact with patients.

For many patients choosing between a clinic and an online service, cost will be a deciding factor — and that concerns Dr. Jamie Phifer, founder of Abortion on Demand, which serves patients in 20 states and Washington, D.C. Like many other digital options, Phifer’s service does not take insurance, but she worries her low out-of-pocket price — $239, or less than half of what a typical clinic charges — could put abortion clinics out of business.

“I am very worried that in-person clinics are already bearing the brunt of the challenges of abortion access,” Phifer said. “They already have to hire security and deal with protesters, and they have been on the ground working for access for 50 years, longer than I have been around.”

Phifer, who lost her job as a primary care doctor following a profile of her work on Abortion on Demand in a magazine, plans to donate 60% of the profits from her business to the Abortion Care Network to support brick-and-mortar clinics.

“I didn’t want to contribute to creating a two-tiered system,” Phifer 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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Your Covid Game Plan: Are Stadiums Safe?

Fri, 09/03/2021 - 5:00am

The college football season is kicking into high gear, the National Football League season starts Sept. 9, and the baseball pennant races are heating up. For the first time since 2019, nearly all stadiums will be fully open to fans.

In the so-called Before Times, sitting shoulder to shoulder inside a stadium with tens of thousands of boisterous spectators — after a few hours of pregame tailgating — was a highlight of many fans’ autumn. But with covid-19 cases, hospitalizations and deaths soaring from the delta variant, many fans are wondering if that is a wise idea.

KHN talked to seven health experts to get their takes.

1. Is it safe to go to a packed stadium even if you are vaccinated?

Six out of the seven public health experts that KHN spoke to from big football states were adamant in their response: No way. Not now.

“I am a die-hard sports fan,” said Jason Salemi, an associate professor of epidemiology at the University of South Florida in Tampa. “But I would not go to these events right now.”

Salemi said that with covid cases at their highest level since late January — with the seven-day average case count rising to just over 149,000 as of Monday — and hospitals filling up around the country, there is too much risk even for people who have been fully vaccinated against covid.

While outdoor events are less likely to lead to infection because the air circulation is greater, sitting within just a few feet of 10 or 20 screaming fans watching football, baseball, soccer or an auto race at a stadium reduces that safety margin, he said.

Vaccines greatly lower your risk of being hospitalized or dying from covid, but the dominance of the more transmissible delta variant is leading to increasing numbers of breakthrough infections, some of which do cause uncomfortable symptoms. Getting infected also increases the likelihood of passing the infection to unvaccinated people, who could become seriously ill.

Even some vaccinated fans — especially those who are older and frail or people with chronic medical conditions — should also realize they face higher risk from an infection. The Centers for Disease Control and Prevention does not specifically have guidance about sporting events, but it recommends that anyone attending large gatherings in areas with high numbers of covid cases should “consider wearing a mask in crowded outdoor settings and for activities with close contact” with others who are not fully vaccinated.

“A packed football stadium now is not a good idea,’’ said Dr. Olveen Carrasquillo, a professor of medicine and public health sciences at the University of Miami’s medical school. “When there’s a lot of shouting and yelling’’ without masks, “it means they’re spraying the virus.’’

Football stadiums, which are generally among the largest sporting venues in this country, are typically packed with fans cheering and high-fiving, making it impossible to physically distance from people who may be unvaccinated. Equally difficult is remaining apart from the unvaccinated in crowded concourses and restrooms.

Dr. Robert Siegel, a professor of microbiology and immunology at Stanford University, said that while the risk of dying or ending up in intensive care from covid after being vaccinated is “vanishingly small,” he would prefer to even avoid a milder case so he doesn’t have to worry about long-term consequences of the disease. “It’s not worth it to me, but if football is your life, you may have a different calculus,” he said.

2. What can I do to reduce my risk at the game?

The first line of defense is being fully vaccinated.

If unvaccinated, don’t go to the game, all seven experts strongly recommended.

Some colleges such as Louisiana State University are requiring fans to be vaccinated or to show a negative covid test to attend a game — and many players on teams are vaccinated to reduce their risk and stay in the game. But many stadiums will have no such restriction on fans.

Wear a mask except when eating or drinking.

Mask mandates vary by venue for both the NFL and college teams. Even if others around you are not wearing one, your mask will give you a level of protection from inhaling the virus. “It’s best if all parties are wearing a mask, but wearing a mask is better than not wearing a mask,” said Dr. Nasia Safdar, a specialist in infectious diseases at the University of Wisconsin School of Medicine and Public Health.

Dr. Dale Bratzler, Oklahoma University’s chief covid officer, said he would not tell vaccinated people to avoid going to football games. He does strongly advise, however, that fans consider double masking. He doesn’t plan to go to the OU games this fall, but it has nothing to do with covid. “It’s because of the traffic getting into and out of the stadium. I am fine watching at home on TV.”

If you want to protect others, consider taking a home covid test the day of the game. If the test results come back positive, or if you feel any symptoms, even a runny nose, mild headache, or cough, don’t go to a game, Safdar said.

And the experts said to pay attention to the level of covid cases in any city to which you are traveling. The incidence could be high, and that should factor into your decision about attending a game.

3. What about tailgating for hours with friends before the game?

Most of the experts agreed tailgating with a few friends outdoors is a less risky part of the football game experience. But that’s only if you know the people you are eating and drinking with are vaccinated.

“It’s also that party atmosphere, where people are generally not in a position to wear a mask and you are standing close to people,” Safdar said. “It’s still a risk.”

4. Millions of people have been attending baseball games, soccer games and other sports events all summer — without many outbreaks. Why worry now about football games?

There have been rare reports of outbreaks from major league baseball stadiums, which often pack in 40,000 fans. But that could be changing, too, because the more highly transmissible delta variant has been widespread only since July. Also, the experts said, it’s difficult to track how many fans get sick because the incubation period can last a week or more. People may not connect their illness to the game, especially if they assume outdoor activities are safe.

“Delta changed the entire equation of how we looked at the risk,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University School of Medicine in Nashville. “I do think there will be transmission’’ in stadiums.

Health experts point to the Sturgis Motorcycle Rally in South Dakota last month that has been linked to more than 100 infections.

5. Can I still get together with other vaccinated friends and family?

Even with the delta variant raging, health experts say people who are fully immunized can safely meet without masks with those they know are fully vaccinated.

“If you know with certainty that someone is vaccinated, you can safely get together for dinner and other activities,” said Dr. Joseph Gastaldo, a specialist in infectious diseases at Ohio Health, a large, multihospital system based in Columbus.

And the risk of spread can be minimized at events such as an outdoor wedding if organizers include requirements for vaccinations, wearing masks and physical distancing for vulnerable attendees, experts say.

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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Voters in Tight Recall Race Sound Off on California Gov. Newsom’s Covid Leadership

Thu, 09/02/2021 - 5:00am

Gov. Gavin Newsom’s first term in office has been defined by his response to the covid-19 pandemic, which has claimed the lives of more than 65,400 Californians.

The Democratic governor issued the first statewide stay-at-home order in the nation, and his policies kept most public school students at home last year. But his own children attended private school in person and, in a move that has haunted him since, he dined with friends and lobbyists at the ritzy French Laundry restaurant in the Napa Valley in November — even though state guidelines discouraged people from mixing with others outside their household.

More recently, Newsom has required all health care workers to get fully vaccinated by the end of the month. But he has not ordered a new statewide mask mandate, despite the deadly spread of the virus’s delta variant.

Newsom has said his policies are driven by science, but they have helped land him in an unexpectedly competitive recall election. A Public Policy Institute of California poll released Wednesday shows that about 58% of likely voters want to keep him in office. Voters, who have been mailed ballots, have until the Sept. 14 election date to return them.

Many of Newsom’s Republican rivals, including talk-radio host Larry Elder, businessman John Cox and former San Diego mayor Kevin Faulconer, are focusing their opposition on Newsom’s mask and vaccine policies.

Just how much is the pandemic playing into voters’ decisions? KHN reporters fanned out across the Golden State — visiting a fire evacuee camp in Placerville, outdoor malls in the Silicon Valley, Olvera Street in downtown Los Angeles and an urban park in Sacramento — to find out.

Placerville

In the Sierra Nevada foothills, many voters describe Newsom as a big-city elitist who issued pandemic mandates for the masses but played by his own rulebook.

“RECALL NEWSOM SAVE CALIFORNIA” signs line busy roads and plaster fences and storefronts in Placerville, home to about 11,000 people some 40 miles from California’s capital.

Even a few evacuees from the raging Caldor Fire — whose homes and livelihoods are at stake — display anti-Newsom signs on their RVs and vans at their temporary outpost in the Walmart parking lot.

The deep anger facing Newsom in El Dorado County isn’t unexpected. The area draws on Gold Rush-era independence: Several businesses flouted public health orders that required masks indoors.

“Whatever edict he put out there never applied to him,” said Denise Byer, 55, a volunteer at a wildfire evacuation site whose children missed nearly a year of in-person high school and competitive sports. “His own children went back to school. He’s an elite. He’s a hypocrite.”

That was the overwhelming sentiment at two Placerville evacuation sites, where several people commented but asked not to be identified, some for fear of workplace repercussions. Newsom “sat up on high,” said a county worker. The governor wants to impose broad mandates on Californians that should be up to the people, said an evacuee who, like other state workers, must be vaccinated or submit to weekly covid tests. Newsom “has ruled like a king,” chimed in an evacuee who didn’t know whether his home would survive the fires.

— Samantha Young

Silicon Valley

On a sunny, late-August Sunday, Palo Alto’s luxe University Avenue and San Jose’s trendy Santana Row, an outdoor shopping mall, were jammed, and the broad streets have been taken over by shopping, outdoor dining and live music. Signs occasionally reminded patrons to mask up in stores, but there was little evidence of the pandemic, and even less of the impending recall election.

Both cities are in Santa Clara County, where registered Democrats outnumber Republicans 3-to-1.

When it comes to the recall, there was only one answer: No. Obviously no. Have you seen who he’s running against?

“I’m really frustrated that the recall is even happening. The people who are running to replace him are going to undo a lot of his work and make it a lot riskier to be in California,” said Meghan Purdy, a 34-year-old product manager in Palo Alto. “I have friends in Texas, and I worry about them. I have a dad in Florida. They have horrible governors, and the fact that it could happen to us is scary.”

In a small but crowded park on Santana Row, Michael Burrows, a 56-year-old database administrator, listened to a band while a coffee line snaked around the musicians.

Newsom handled the pandemic as well as he could have, Burrows said. The recall is a waste of time, and anti-maskers and anti-vaxxers are trying to tarnish Newsom’s reputation on a national stage, he said.

“Nobody likes to wear a mask — I don’t like to wear a mask — but it’s what you have to do,” Burrows said. “You have to have an adult in the room.”

— Rachel Bluth

Los Angeles

The sound of salsa music lingered in the air as people wandered the cobblestone paths along Olvera Street in downtown Los Angeles. The historical Mexican marketplace was a ghost town of shuttered shops during the height of the pandemic, but now bustles with customers— most of them Latino.

Some had no idea about the recall election. Others said they favored the governor but wouldn’t be able to vote because they are undocumented immigrants. Most expressed support for Newsom.

Antonio Ramos, 57, and Isabel Ceja, 48, a couple from Novato, California, were visiting family in Los Angeles on Saturday. Some of their relatives have had covid, and they said they know what it’s like to worry if they will survive.

“What he’s done for the community has been beneficial,” Ramos said in Spanish. “Like getting the vaccines out to everyone and the mask mandate. It’s for the safety of everyone.”

The couple plan to vote against the recall. “I like him because he’s Catholic and does everything with transparency,” Ceja added. “He isn’t two-faced.”

Veronica Ayón, 28, a Los Angeles mother of three, disagreed. “I think he says one thing and then does another,” she said in Spanish.

Ayón isn’t vaccinated but said she always wears a mask. She is breastfeeding her baby girl and fears what a vaccine could do to her. (The Centers for Disease Control and Prevention recommend pregnant and breastfeeding women get vaccinated.)

She said she will probably vote against Newsom. “He wants to make it mandatory for kids to get vaccinated at 12,” said Ayón, whose eldest child is about to turn 12. “She’s my daughter. It’s my decision.”

— Heidi de Marco

Sacramento

In Sacramento’s Oak Park, a largely African American, inner-city neighborhood that is rapidly gentrifying, people don’t seem motivated to vote. Anti-recall signs backing Newsom pepper grassy lawns in the city’s wealthier neighborhoods, but none were visible here, though there are Black Lives Matter signs on nearly every block — a couple of them praising Dolly Parton.

Many Oak Park residents said Newsom has failed them.

“I tore up my ballot and threw it in the trash,” said 52-year-old Regina Davis, who gathered with friends at a park filled with people barbecuing and jamming to music — a Sunday tradition in the neighborhood. She backed Newsom in 2018 but said she doesn’t plan to vote, arguing that Newsom has prioritized wealthy Californians during the pandemic.

Others said they hadn’t decided whether to vote.

“He needs to step up,” said Cleo Brown, 39, who supported Newsom when he ran for governor but said she now feels let down because Newsom has not invested in day care and after-school programs that could help her and her two kids, ages 15 and 18.

Her message to Newsom: “Do something for our kids. They’re still hurting from the school shutdowns.”

Emma Patterson, 57, voted for Newsom in 2018 but said she has other things to worry about than the recall. “He needs us to show up for him, but Black families are struggling,” Patterson said.

Her apartment burned down in July, and she’s renting a room for herself and her two grandkids for $150 a week. “Voting isn’t even on my mind,” she said.

— Angela Hart

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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Minister for Seniors at Famed Church Confronts Ageism and the Shame It Brings

Thu, 09/02/2021 - 5:00am

Later life is a time of reassessment and reflection. What sense do we make of the lives we have lived? How do we come to terms with illness and death? What do we want to give to others as we grow older?

Lynn Casteel Harper, 41, has thought deeply about these and other spiritual questions. She’s the author of an acclaimed book on dementia and serves as the minister of older adults at Riverside Church in New York City, an interdenominational faith community known for its commitment to social justice. Most of the church’s 1,600 members are 65 and older.

Every Thursday from September to June, Harper runs programs for older adults that include Bible study, lunch, concerts, lectures, educational sessions and workshops or other forms of community-building. She also works with organizations throughout New York committed to dismantling ageism.

I spoke with Harper recently about the spiritual dimension of aging. Our conversation, below, has been edited for length and clarity.

Q: What does a minister of older adults do?

A large part of my job is presence and witness — being with people one-on-one in their homes, at the bedside in hospitals or nursing homes, or on the phone, these days on Zoom, and journeying with them through the critical junctures of their life.

Sometimes if people are going through really difficult experiences, especially medically, it’s easy for the story of the illness and the suffering to take over. Part of my role is to affirm the other dimensions. To say you are valuable despite your sickness and through your sickness. And to affirm that the community, the church is with you, and that doesn’t depend on your capacity or your abilities.

Q: Can you give me an example of someone who reached out to you?

I can think of one today — a congregant in her 70s who’s facing a surgery. She had a lot of fear leading up to the surgery and she felt there could be a possibility she wouldn’t make it through.

So, she invited me to her home, and we were able to spend an afternoon talking about experiences in her life, about the things that were important to her and the ways she’d like the church to be there for her in this time. And then we were able to spend some time in prayer.

Q: What kind of spiritual concerns do you find older congregants bringing to you?

One of the things, undeniably, is death and dying. I see a lot of older adults wanting to express their concerns and desires regarding that.

I can think of one woman who wanted to plan out her memorial service. It was really important for her to think about what would be special for the congregation and her family — a gift she wanted to leave behind.

I rarely encounter a fearfulness about what will happen when someone dies. It’s more about: What kind of care will I receive before I go? Who will care for me? I hear that especially from people who are aging solo. And I think the church has an opportunity to say we are a community that will continue to care for you.

Q: What other spiritual concerns regularly arise?

People are looking back on their lives and asking, “How do I make sense of the things that maybe I regret or maybe am proud or am ambivalent about? What do those experiences mean to me now and how do I want to live the rest of my life?”

We invite story sharing. For instance, we did a program where we asked people to share an important object from their home and talk about how you came to have it and why it’s important to you.

For another program, we asked, “What is a place that’s been important to you and why?” That ended up being a discussion about “thin places” — a Celtic concept — where it feels like the veil between this world and the next is very thin and where you feel a connection with the divine.

Q: Your work revolves around building community. Help me understand what that means.

That’s another theme of spirituality and aging. In middle life and earlier in life, we’re incentivized to be self-sufficient, to focus on what you can accomplish and build up in yourself. In later life, I see some of that shedding away and community becoming a really important value.

There are many types of communities. A faith community isn’t based on shared interests, like a knitting club or a sports team. It’s something deeper and wider. It’s a commitment to being with one another beyond an equal exchange — beyond your ability to pay or repay what I give to you in kind. It’s a commitment to going the extra mile with you, no matter what.

Q: How did the pandemic and spiritual concerns change or influence the nature of spiritual discussions?

Every Sunday, our congregation offers a moment of silence for the victims of covid-19. And every Sunday, we list the names of congregants who are sick and who died, not only of covid. It’s built into our practice to acknowledge sickness and death. And that became something even more needed.

As much as there was a lot of worry about isolation and our older adults, in many ways our ties with one another became stronger. I saw a tremendous amount of compassion — people extending themselves in very gracious ways. People asking, “Can I deliver groceries? Does anyone need a daily phone call? What can I do?”

Q: What about pandemic-related loss?

The grief has been heavy and will live with us for a while. I think that the ongoing work of the church now is to understand what to do in the wake of this pandemic. Because there have been multiple layers of loss — the loss of loved ones, the loss of mobility, the loss of other abilities. There have been significant changes for people, emotionally, mentally, financially or physically. Much of our work will be acknowledging that.

Q: What have you learned about aging through this work?

I’ve learned how real and pervasive ageism is. And I’ve been brought into the world of what ageism does, which is to bring shame in its wake. So that people, instead of moving toward community, if they feel like they’re compromised physically or in some other way, the temptation is to withdraw. I’m pained by that.

Q: What else have you learned?

How wildly creative and liberating aging can be. I’m around people who have all kinds of experience: all these years, all these tragedies and triumphs and everything in between. And I see them every day showing up. There’s this freedom of being without apology.

I’m so appreciative of the creativity. The honesty. And the real radical attention they pay to each other and the world around them. I’m always remarking how many of our older adults pay attention to things that I hadn’t noticed.

Q: It sounds like a form of bravery.

Yes, that’s right. Courage. The courage to almost be countercultural. To say, even if the culture tells me I don’t have a place or I don’t really matter, I’m going to live in a way that pushes back against that. And I’m really going to see myself and others around me. So they’re not invisible, even if they’re invisible in a larger cultural sense.

Those of us who aren’t of advanced age yet, we often think we’re doing a favor by being around older people and listening to their stories. I don’t see it that way at all. It’s not charity to be around older adults. I am a better person, a better minister, our church is a better place because of our older members, not despite them.

It reflects poorly that our imagination is so stunted and limited when it comes to aging — that we can’t see all the gifts that are lost, all the creativity and the care and the relationships that are lost when we don’t interact with older adults. That’s a real spiritual deficit in our society.

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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Categories: National News Content

Violación y pérdida de memoria, lo que la policía debería saber

Wed, 09/01/2021 - 9:33am

Annie Walker se despertó una mañana de 2019 con pocos recuerdos de la noche anterior. Tenía moretones en los brazos, las piernas, la muñeca y el bajo vientre.

“Pero literalmente no tenía ni idea de lo que había pasado”, dijo. “Y durante días, estuve intentando armar las piezas”.

Sabía que había ido a un bar y restaurante de Sacramento, California, con un grupo de personas, y recordaba haber bebido allí y haberse quedado a solas con el hombre que luego identificaría como su violador. Pero no mucho más.

Los recuerdos que no pudo evocar aquella primera mañana fueron apareciendo poco a poco con el paso de los días y las semanas. Entre los detalles que fueron surgiendo recordó la ropa que llevaba el hombre y la forma en que la empujó contra la barra.

Una semana después del ataque, denunció el delito al Departamento del Sheriff del condado de Sacramento.

Luego, en los días posteriores a la denuncia, surgió otra oleada de recuerdos: recordó claramente que el hombre la había violado y que tenía un arma.

“Sabía que había un arma en mi cuello, en mi espalda”, dijo. “Lo tenía claro”.

Contó que los detectives le hicieron pasar un mal rato cuando llamó para informar de que había recordado que su atacante tenía un arma. Los detectives de Sacramento asignados al caso de Walker no parecían entender por qué ella no podía recordar todos los detalles de inmediato.

“Sentí como si me estuvieran interrogando por teléfono. Preguntándome, ‘¿Por qué no recordaste lo del arma? Eso es algo muy importante'”.

Las supervivientes de agresiones sexuales dicen que las interacciones con las fuerzas del orden pueden ser tan intensas, y tan brutales, que agregan un trauma secundario. Denunciar una violación puede ser especialmente traumático cuando los agentes ponen en duda las historias de las víctimas.

Pero no tiene por qué serlo, aseguran científicos y estudiosos de la justicia penal. Si la policía comprendiera mejor lo que ocurre en el cerebro durante y después de una violación, cambiaría su forma de abordar los casos y se evitaría que las supervivientes se sientan culpables o que no se les cree.

Los científicos que estudian los traumas y la memoria afirman que es habitual que las víctimas de agresiones sexuales, así como las de otros traumas graves, sean incapaces de recordar completamente un ataque. Es posible que recuerden ciertos hechos pero no otros, o que les cueste recordar los acontecimientos en la secuencia correcta.

Exertos dicen que, cuando los policías no conocen la neurociencia del trauma, se tiende a desestimar o no creer a las víctimas que sufren lagunas de memoria.

“Existe un peligro real cuando los investigadores piden información que nunca fue codificada o que se ha perdido”, señaló el psicólogo de la Universidad de Harvard Jim Hopper. “Pueden estresar a la víctima, hacer que se sienta incomprendida, incompetente, que no quiera seguir participando en la investigación”.

Nunca detuvieron al presunto agresor de Walker. Y ella sigue frustrada por la forma en que los detectives la presionaron para que recordara detalles durante la investigación.

Ante una crisis, el cerebro suele activar su respuesta de “lucha, huida o congelación”. En estas situaciones, el “circuito de defensa” del cerebro toma el control, explicó Hopper. El córtex prefrontal, responsable de la toma de decisiones lógicas, deja de tener el control y, en su lugar, el mando lo asumen las áreas del cerebro encargadas de detectar el peligro.

“Y eso es lo que controla a las personas cuando se produce el trauma”, indicó Hopper.

Algunas personas responden “disociándose” mentalmente, o desconectándose de su yo físico. Esa respuesta de supervivencia afecta a la capacidad de asimilar lo que ocurre a su alrededor, añadió Hopper.

Los estudios sobre la memoria y el recuerdo durante un acontecimiento traumático describen dos tipos de detalles: centrales y periféricos. Los detalles centrales son los que captan nuestra atención y evocan emociones en el momento, como un lugar. Los detalles periféricos son aquellos a los que un sobreviviente puede no haber prestado atención durante la crisis, como algo que dice el agresor o si había otras personas presentes.

Los detalles centrales tienden a almacenarse de forma más fiable y durante más tiempo que los detalles periféricos.

A veces, las víctimas son incapaces de responder a lo que podría parecer una pregunta sencilla si implica un detalle periférico, como el color de la camisa del atacante. Y Hopper dijo que eso puede hacer sospechar a los agentes.

Hopper, que da testimonio legal en casos de agresión sexual, indicó que a las víctimas a menudo se les impone estándares injustos, incluso en comparación con otros sobrevivientes de traumas.

“Todos los días, en los tribunales de este país, [los abogados defensores] atacan y cuestionan la credibilidad de las víctimas de agresiones sexuales por tener el mismo tipo de recuerdos que tienen los soldados por sus experiencias de combate”, señaló Hopper.

Defensores y académicos dicen que es importante que los detectives estén abiertos a todo lo que una víctima pueda decir, sea cual sea el momento en que lo diga —incluso si esos detalles no se ofrecieron en una denuncia inicial— porque la información que proporcionan más tarde puede ser útil para resolver el crimen.

Nicole Monroe, detective de la policía de Elk Grove, un suburbio de Sacramento, dijo que ella y algunos de sus colegas han recibido educación adicional sobre la ciencia del cerebro, y esto ha cambiado la forma en que abordan los casos de agresión sexual.

Monroe les dice a las víctimas que seguirán apareciendo más recuerdos en los días, semanas e incluso meses venideros.

“Los olores volverán. Volverán las imágenes. Cuando piensen en estas cosas, llámenme y háganmelo saber”, contó Monroe. “Porque esas pequeñas cosas van a marcar la diferencia”.

Tradicionalmente, se entrena a los agentes para llevar a cabo un interrogatorio que puede implicar la extracción de detalles específicos, generalmente en orden cronológico.

“La expectativa es que alguien llega, se sienta, se supone que está lista para hablar, se supone que sabe de qué hablar”, comentó Carrie Hull, ex detective del Departamento de Policía de Ashland, en el sur de Oregon. “Te van a contar lo que les ha pasado desde el principio hasta el final. Esa es una concepción muy tradicional”.

Hull es ahora consultora de departamentos de policía, y parte de su trabajo consiste en abogar por la adopción de una técnica de entrevista forense conocida como Forensic Experiential Trauma Interviewing (FETI). La formación puede ayudar a las fuerzas del orden a aprender a hacer preguntas de forma diferente: con empatía, paciencia y una comprensión informada de cómo un cerebro traumatizado crea recuerdos y los recuerda.

La formación en esta técnica está disponible a través de un curso en línea, pero no es mandatoria para la mayoría de los departamentos de policía.

Quienes hacen el curso de Hull aprenden estrategias específicas para ayudar a alguien a resucitar un recuerdo relevante al que puede no haber tenido acceso cuando entró por primera vez en la sala de entrevistas. Hull dijo que la FETI desaconseja prácticas contraproducentes como parafrasear, cambiar las palabras de la víctima, interrumpir o dar consejos.

Hull dijo que el objetivo general de la entrevista es primero “reunir los puntos, y luego conectar los”. En otras palabras, simplemente entrevistar a la víctima sobre lo ocurrido. Las tácticas de investigación más agudas y agresivas pueden esperar.

No hay estudios que demuestren que los departamentos de policía que reciben esta formación resuelvan más casos de violación. Pero los defensores y académicos dicen que es una buena práctica que podría hacer que el trabajo con la policía sea una experiencia más positiva para las víctimas y, a la larga, ayudar a llevar a más agresores ante la justicia.

“Si por mí fuera, todos estarían haciendo esto”, expresó Dave Thomas, oficial de programas de la Asociación Internacional de Jefes de Policía.

Annie Walker sigue luchando por recuperarse de su agresión sexual, pero también se está recuperando de la forma en que la policía manejó su caso. Cree que, tanto policías como víctimas, necesitan más educación sobre el modo en que el trauma afecta a la memoria.

Dijo que, si las sobrevivientes supieran qué esperar en cuanto a los problemas de memoria, no sería tan frustrante. “Necesitan sentir que todo lo que ocurre en su mente es normal. Normal para ellas”.

Esta historia es el resultado de una asociación que incluye CapRadio, NPR y KHN.

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

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How Rape Affects Memory, and Why Police Need to Know About That Brain Science

Wed, 09/01/2021 - 5:00am

Annie Walker woke up one morning in 2019 with little recollection of the night before. She had bruises on her arms, legs, wrist and lower abdomen.

“But I literally had no idea what had happened,” she said. “And, for days, I was trying to put the pieces together.”

She knew she had gone to a Sacramento, California, bar and restaurant with a group of people, and she remembered drinking there and being left alone with the man she’d later identify as her rapist. But not much else.

Memories she couldn’t summon that first morning gradually came into focus over days and weeks, she said. The emerging details included what the man had been wearing, and the way he shoved her against the bar. One week after the attack, she reported the crime to the Sacramento County Sheriff’s Department.

Then, in the days after making the report, another wave of memories surfaced — she recalled, vividly, that the man had raped her and had a weapon.

“I knew that there was a gun at my neck, at my back,” she said. “It was just clear.”

The detectives gave her a hard time, she said, when she called to report that she had remembered that her attacker had a gun. The Sacramento detectives assigned to Walker’s case didn’t seem to understand why she couldn’t remember all the details right away.

“I felt like I was just extremely cross-examined on the phone. Like, ‘Why didn’t you remember a gun? That’s, like, a really important thing.'”

Sexual assault survivors say interactions with law enforcement can be so intense, and so unsympathetic, that they add secondary trauma. Reporting a rape can be especially traumatic when officers cast doubt on victims’ stories.

But it doesn’t have to be, say scientists and scholars of criminal justice. If police gain a deeper understanding of what’s going on in the brain during and after a rape, they can change the way they approach rape cases and avoid making survivors feel blamed or disbelieved.

Scientists who study trauma and memory say it’s common for sexual assault survivors — as well as survivors of other serious traumas — to be unable to recall an attack fully. They might remember certain facts but not others, or struggle to recall events in the correct sequence.

When law enforcement officers aren’t aware of the neuroscience of trauma, or have no training to deal with it, there’s a tendency to dismiss or disbelieve victims who experience memory gaps, according to scholars and advocates for sexual assault survivors.

“There’s a real danger when investigators are asking people for information that was never encoded or has been lost,” said Harvard University psychologist Jim Hopper. “They can stress out the victim, leave them feeling misunderstood, incompetent, not wanting to further engage with the investigation.”

Walker’s alleged perpetrator was never arrested. And she’s still frustrated with the way detectives put pressure on her to remember details during the investigation.

The Brain in Survival Mode

When confronted with a crisis, the brain often activates its “fight, flight or freeze” response. In these scenarios, the brain’s “defense circuitry” takes over, explained Hopper. The prefrontal cortex, which is responsible for logical decision-making, is no longer in control and, instead, the areas of the brain responsible for scanning for danger take charge.

“And that’s what people are running on” when trauma happens, Hopper said.

Some people respond by mentally “dissociating,” or disconnecting from their physical selves. That survival response affects the ability to absorb what’s happening around them, Hopper said.

Studies on memory and recall during a traumatic event describe two types of details: central and peripheral. Central details are those that capture our attention and evoke emotions in the moment, such as a location. Peripheral details are those that a survivor might not have been paying attention to during the crisis, such as something the perpetrator said or whether other people were present. Central details tend to be stored more reliably and for longer than peripheral details.

Every day in courtrooms around the country, [defense attorneys] attack and question the credibility of victims of sexual assault for having the same kind of memories that soldiers have for their combat experiences.

Harvard University psychologist Jim Hopper

Sometimes survivors are unable to answer what might seem like a simple question if it involves a peripheral detail like the color of the attacker’s shirt. And Hopper said that can make officers suspicious.

Hopper, who gives legal testimony in sexual assault cases, said victims are often held to unfair standards, even compared with other trauma survivors.

“Every day in courtrooms around the country, [defense attorneys] attack and question the credibility of victims of sexual assault for having the same kind of memories that soldiers have for their combat experiences,” he said.

Victim advocates and criminal justice scholars say it’s important for detectives to be open to anything a survivor might say, whenever they say it — even if those details were not available in an initial report — because the information survivors provide later can be helpful for solving the crime.

Maintaining an Open Mind

Nicole Monroe, a police detective in Elk Grove, a suburb of Sacramento, said she and some of her colleagues have gotten additional education on brain science, and it has changed the way they approach sexual assault cases.

Monroe tells victims she works with that more memories will continue to surface in the days, weeks and even months to come.

“Smells will come back. Sights will come back. When you think of these things, give me a call and let me know, so that it can be added,” Monroe said. “Because little things like that are going to make a difference.”

Traditionally, law enforcement officers are trained to conduct an interrogation that may involve drawing out specific details, usually in chronological order.

“The expectation is someone is supposed to come in, sit down, they’re supposed to be ready to talk, they’re supposed to know what to talk about,” said Carrie Hull, a former detective with the Ashland Police Department in southern Oregon. “They’re going to tell you what happened to them from the beginning, through the middle, and then the end. That is a very traditional understanding.”

Hull is now a consultant for police departments, and part of her work involves advocating for the adoption of a technique known as Forensic Experiential Trauma Interviewing, or FETI. The training can help law enforcement learn how to ask questions differently: with empathy, patience and an informed understanding of how a traumatized brain makes memories and recalls them. Training in the technique is available through an online course, but it’s not a mandatory requirement for most police departments.

People who take Hull’s course learn specific strategies for helping someone resurface a relevant memory that he or she may not have had access to when they first walked into the interview room. Hull said FETI discourages counterproductive practices such as paraphrasing, changing the victim’s words, interrupting or giving advice.

Hull said the overarching goal of trauma interviewing is to first “collect the dots, then connect the dots.” In other words, simply interview the victim about what happened. The sharper, more aggressive investigative tactics can wait.

There isn’t research proving that law enforcement departments who take this training solve more rape cases. But victim advocates and scholars said it’s a best practice that could make working with police a more positive experience for victims and, eventually, help bring more perpetrators to justice.

“If I had my way, every one of them would be doing this,” said Dave Thomas, a program officer with the International Association of Chiefs of Police.

Annie Walker is still struggling to recover from her sexual assault, but it’s complicated because she’s also healing from the way law enforcement handled her case. She said both police officers and survivors need more education on the way trauma affects memory.

She said if survivors knew what to expect in terms of memory issues, it wouldn’t be so frustrating. “They need to feel like the way that things are happening in their mind is normal. Normal for them.”

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

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

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To Quarantine or Not: The Hard Choices Schools Are Leaving to Parents and Staff

Wed, 09/01/2021 - 5:00am

On the second day of high school in Texas, Natosha Daniels’ 14-year-old daughter went all day without eating because she did not want to remove her mask.

The teen’s school has a couple of thousand students, and the cafeteria was crowded. Plus Round Rock Independent School District outside Austin didn’t require masks, so some students weren’t wearing them. Even her honors biology teacher was maskless.

Daniels said her daughter, who like her is fully vaccinated, is terrified of bringing home the virus because it could infect her 7-year-old sibling, who is too young for a shot.

“She was like, ‘Mama I’m going to pass out,’” said Daniels, a Round Rock Black Parents Association member and former assistant principal in the district.

“Every morning I wake up with knots in my chest, just like, ‘Am I making the right decision, putting myself and my child at risk for my older two to go to school?’” said Daniels, who is immunocompromised. “And my husband was like, ‘Well the option still stands for you to go get an Airbnb and move out’ with my youngest. … Do we sacrifice our savings? It’s so hard.”

After a difficult year or more of virtual learning, parents are eager to have their children back in classrooms. But even as the highly transmissible delta variant surges, school districts like Daniels’ aren’t beefing up protocols to prevent infections. Masks aren’t mandated or enforced, according to teachers, parents and officials in several states. Physical distancing is nearly impossible. To top it off, students exposed to covid may not be required to quarantine despite guidelines from the Centers for Disease Control and Prevention, risking an even more rapid spread among children, the youngest of whom aren’t yet eligible for vaccination.

The CDC advises quarantining up to 14 days for people who have had close contact with an infected person — within 6 feet for at least 15 minutes over a 24-hour period. (It exempts vaccinated people without symptoms.) This summer, the agency drafted an exception for schools: It’s not considered close contact if both the infected and exposed students “correctly and consistently” wore masks. That means an unvaccinated but masked student who was exposed wouldn’t have to quarantine.

But whether school districts follow CDC guidelines is an open question. And, in many cases, counties, states and the CDC don’t issue the same advice.

Even if districts follow CDC guidance, success hinges on whether students consistently wear masks. In Round Rock, for example, quarantine is “strongly” recommended for students and staff members who had close contact with those infected, essentially leaving it up to parents whether to take a child out of school.

“An optional quarantine just doesn’t work,” said Allison Stewart, lead epidemiologist at Williamson County and Cities Health District, which oversees 12 school districts including most Round Rock schools. When not required, “it seems that there’s only a cursory effort to actually identify contacts.” And then only “a cursory effort to quarantine.”

“There is more transmission occurring in a school setting than there is in the community right now,” Stewart said, “which is the exact opposite of what happened last year.”

The nation’s largest school districts are mostly not following the CDC’s close-contact exception for masked students, said Bree Dusseault, an analyst at the Center on Reinventing Public Education who is tracking state and district policies. The center reviewed 100 large and urban school districts and found that most of them gave students who are fully vaccinated and have close contact with an infected student an exemption from quarantine. Some require covid testing for students to return earlier than recommended, while others exempt those who’ve recently recovered from covid and, assumedly, have antibodies.

“Districts are managing on-the-ground politics,” Dusseault said. “You may find leaders relying less on scientific recommendations and data and more on local preferences” and on “what they’re hearing.”

“We know that masks aren’t perfect,” said Debra Pace, superintendent of the School District of Osceola County in Florida. Fully vaccinated people without symptoms are exempt from quarantine, but Osceola schools require any exposed students to quarantine for four to 10 days, depending on whether they showed symptoms or had a negative test.

“The delta variant is very different,” Pace said. “As much as I hate to quarantine kids, if we don’t quarantine, we risk having to shut a school down, which we absolutely don’t want to do.”

Each school’s decision about who counts as a close contact affects contact tracing, a laborious process officials use to slow the spread of disease. The CDC’s guidance curtails the number of school-based contacts for follow-up. Epidemiologists support the CDC’s approach, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists. She added that having clear consequences for not wearing masks seems to resonate with parents: Kids who don’t mask up will miss more school.

“So many parents are interested — and I think rightly so — in having their children have in-person learning,” Hamilton said.

But in Round Rock, protocols are squishy in part because state orders and guidelines conflict with federal recommendations. Only after the courts got involved did Round Rock ISD add a strong mask mandate last Thursday — a week into school and after dozens of new positive cases and hundreds of new close contacts among students were reported.

Ben Sterling, president of the local teachers union Education Round Rock, said staffers and students alike are not incentivized to follow covid rules, particularly related to quarantine. For staff members, one round of quarantine would use all 10 days of personal and sick leave they get annually. Those days roll over, but Sterling knows of teachers with health issues who haven’t banked any. “The ones who are most vulnerable are going to get hit hardest, as per usual,” he said.

Dusseault said Round Rock’s policy is unusual because it’s optional. But the district is hardly alone — neighboring Leander ISD has a similar policy. Round Rock ISD requires anyone who tests positive for covid or is a probable case to quarantine for 10 days. For close contacts, it’s merely suggested “because parents and students have a right to a free, appropriate public education under the federal law,” said Jenny LaCoste-Caputo, Round Rock ISD’s chief of public affairs and communications.

Leniency about covid safety doesn’t sit well with Natosha Daniels. “I feel sick” about it, she said. “At best, they are, like, caving to this violent group of right-wing parents and, at worst, it’s like a blatant willingness to increase our community spread.”

Quarantine isn’t required for Round Rock employees because they would have to use personal and sick leave, LaCoste-Caputo said. The board of trustees approved covid leave only for staff members who test positive.

It is also “just not having the backing of our state government,” said Amy Weir, president of the Round Rock ISD board of trustees.

The Texas legislature did not fund virtual learning, so school districts are covering the costs themselves. Weir said Round Rock ISD is paying $17.5 million to offer virtual learning for students younger than 12, who cannot get vaccinated. For older students, teachers upload handouts of curated lessons.

On the second day of classes, the middle school where Sterling teaches saw its first case. He and another teacher said the student who tested positive was sometimes maskless and around others without masks. Yet, they said, the school told the families of that child’s classmates that no one was a close contact.

The school, they said, is not requiring seating charts, which would help staff members track student movement, nor do school officials know who is vaccinated or unvaccinated, which factors into the school district’s close-contact definition. It’s all handled on the honor system.

“You’re saying, ‘Choose between going to work and quarantining your child for 10 days,’” Daniels said. “This is the world that we are in — creates these systems that leave parents with no choice.”

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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Lack of a Vaccine Mandate Becomes Competitive Advantage in Hospital Staffing Wars

Tue, 08/31/2021 - 5:00am

In the rural northeastern corner of Missouri, Scotland County Hospital has been so low on staff that it sometimes had to turn away patients amid a surge in covid-19 cases.

The national covid staffing crunch means CEO Dr. Randy Tobler has hired more travel nurses to fill the gaps. And the prices are steep — what he called “crazy” rates of $200 an hour or more, which Tobler said his small rural hospital cannot afford.

A little over 60% of his staff is fully vaccinated. Even as covid cases rise, though, a vaccine mandate is out of the question.

“If that becomes our differential advantage, we probably won’t have one until we’re forced to have one,” Tobler said. “Maybe that’s the thing that will keep nurses here.”

As of Thursday, about 39% of U.S. hospitals had announced vaccine mandates, said Colin Milligan, a spokesperson for the American Hospital Association. Across Missouri and the nation, hospitals are weighing more than patient and caregiver health in deciding whether to mandate covid vaccines for staffers.

The market for health care labor, strained by more than a year and a half of coping with the pandemic, continues to be pinched. While urban hospitals with deeper pockets for shoring up staff have implemented vaccine mandates, and may even use them as a selling point to recruit staffers and patients, their rural and regional counterparts are left with hard choices as cases surge again.

“Obviously, it’s going to be a real challenge for these small, rural hospitals to mandate a vaccine when they’re already facing such significant workforce shortages,” said Alan Morgan, head of the National Rural Health Association.

Without vaccine mandates, this could lead to a desperate cycle: Areas with fewer vaccinated residents likely have fewer vaccinated hospital workers, too, making them more likely to be hard hit by the delta variant sweeping America. In the short term, mandates might drive away some workers. But the surge could also squeeze the hospital workforce further as patients flood in and staffers take sick days.

Rural covid mortality rates were almost 70% higher on average than urban ones for the week ending Aug. 15, according to the Rural Policy Research Institute.

Despite the scientific knowledge that covid vaccinations sharply lower the risk of infection, hospitalization and death, the lack of a vaccine mandate can serve as a hospital recruiting tool. In Nebraska, the state veterans affairs’ agency prominently displays the lack of a vaccine requirement for nurses on its job site, The Associated Press reported.

It all comes back to workforce shortages, especially in more vaccine-hesitant communities, said Jacy Warrell, executive director of the Rural Health Association of Tennessee. She pointed out that some regional health care systems don’t qualify for staffing assistance from the National Guard as they have fewer than 200 beds. A potential vaccine mandate further endangers their staffing numbers, she said.

“They’re going to have to think twice about it,” Warrell said. “They’re going to have to weigh the risk and benefit there.”

The mandates are having ripple effects throughout the health care industry. The federal government has mandated that all nursing homes require covid vaccinations or risk losing Medicare and Medicaid reimbursements, and industry groups have warned that workers may jump to other health care settings. Meanwhile, Montana has banned vaccine mandates altogether, and the Montana Hospital Association has gotten one call from a health care worker interested in working in the state because of it, said spokesperson Katy Peterson.

It’s not just nurses at stake with vaccine mandates. Respiratory techs, nursing assistants, food service employees, billing staff and other health care workers are already in short supply. According to the latest KFF/The Washington Post Frontline Health Care Workers Survey, released in April, at least one-third of health care workers who assist with patient care and administrative tasks have considered leaving the workforce.

The combination of burnout and added stress of people leaving their jobs has worn down the health care workers the public often forgets about, said interventional radiology tech Joseph Brown, who works at Sutter Roseville Medical Center outside Sacramento, California.

This has a domino effect, Brown said: More of his co-workers are going on stress and medical leave as their numbers dwindle and while hospitals run out of beds. He said nurses’ aides already doing backbreaking work are suddenly forced to care for more patients.

“Explain to me how you get 15 people up to a toilet, do the vitals, change the beds, provide the care you’re supposed to provide for 15 people in an eight-hour shift and not injure yourself,” he said.

In Missouri, Tobler said his wife, Heliene, is training to be a volunteer certified medical assistant to help fill the gap in the hospital’s rural health clinic.

Tobler is waiting to see if the larger St. Louis hospitals lose staff in the coming weeks as their vaccine mandates go into effect, and what impact that could have throughout the state.

In the hard-hit southwestern corner of Missouri, CoxHealth president and CEO Steve Edwards said his health system headquartered in Springfield is upping its minimum wage to $15.25 an hour to compete for workers.

While the estimated $25 million price tag of such a salary boost will take away about half the hospital system’s bottom line, Edwards said, the investment is necessary to keep up with the competitive labor market and cushion the blow of the potential loss of staffers to the hospital’s upcoming Oct. 15 vaccine mandate.

“We’re asking people to take bedpans and work all night and do really difficult work and maybe put themselves in harm’s way,” he said. “It seems like a much harder job than some of these 9-to-5 jobs in an Amazon distribution center.”

Two of his employees died from covid. In July alone, Edwards said 500 staffers were out, predominantly due to the virus. The vaccine mandate could keep that from happening, Edwards said.

“You may have the finest neurosurgeon, but if you don’t have a registration person everything stops,” he said. “We’re all interdependent on each other.”

But California’s Brown, who is vaccinated, said he worries about his colleagues who may lose their jobs because they are unwilling to comply with vaccine mandates.

California has mandated that health care workers complete their covid vaccination shots by the end of September. The state is already seeing traveling nurses turn down assignments there because they do not want to be vaccinated, CalMatters reported.

Since the mandate applies statewide, workers cannot go work at another hospital without vaccine requirements nearby. Brown is frustrated that hospital administrators and lawmakers, who have “zero covid exposure,” are the ones making those decisions.

“Hospitals across the country posted signs that said ‘Health care heroes work here.’ Where is the reward for our heroes?” he asked. “Right now, the hospitals are telling us the reward for the heroes: ‘If you don’t get the vaccine, you’re fired.’”

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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Telehealth’s Limits: Battle Over State Lines and Licensing Threatens Patients’ Options

Tue, 08/31/2021 - 5:00am

If you live in one state, does it matter that the doctor treating you online is in another? Surprisingly, the answer is yes, and the ability to conduct certain virtual appointments may be nearing an end.

Televisits for medical care took off during the worst days of the pandemic, quickly becoming commonplace. Most states and the Centers for Medicare & Medicaid Services temporarily waived rules requiring licensed clinicians to hold a valid license in the state where their patient is located. Those restrictions don’t keep patients from visiting doctors’ offices in other states, but problems could arise if those same patients used telemedicine.

Now states are rolling back many of those pandemic workarounds.

Johns Hopkins Medicine in Baltimore, for example, recently scrambled to notify more than 1,000 Virginia patients that their telehealth appointments were “no longer feasible,” said Dr. Brian Hasselfeld, medical director of digital health and telemedicine at Johns Hopkins. Virginia is among the states where the emergency orders are expiring or being rolled back.

At least 17 states still have waivers in effect, according to a tracker maintained by the Alliance for Connected Care, a lobbying group representing insurers, tech companies and pharmacies.

As those rules end, “it risks increasing barriers” to care, said Hasselfeld. Johns Hopkins, he added, hosted more than 1 million televisits, serving more than 330,000 unique patients, since the pandemic began. About 10% of those visits were from states where Johns Hopkins does not operate facilities.

The rollbacks come amid a longer and larger debate over states’ authority around medical licensing that the pandemic — with its widespread adoption of telehealth services — has put front and center.

“Consumers don’t know about these regulations, but if you all of a sudden pull the rug out from these services, you will definitely see a consumer backlash,” said Dr. Harry Greenspun, chief medical officer for the consultancy Guidehouse.

Still, finding a way forward pits high-powered stakeholders against one another, and consumers’ input is likely to be muted.

State medical boards don’t want to cede authority, saying their power to license and discipline medical professionals boosts patient safety. Licensing is also a source of state revenue.

Providers have long been split on whether to change cross-state licensing rules. Different state requirements — along with fees — make it cumbersome and expensive for doctors, nurses and other clinicians to get licenses in multiple states, leading to calls for more flexibility. Even so, those efforts have faced pushback from within the profession, with opposition from other clinicians who fear the added competition that could come from telehealth could lead to losing patients or jobs.

“As with most things in medicine, it’s a bottom-line issue. The reason telehealth has been blocked across state lines for many years related fundamentally to physicians wanting to protect their own practices,” said Greenspun.

But the pandemic changed the equation.

Even though the initial spike in telehealth visits has eased, utilization remains 38 times higher than before the pandemic, attracting not only patients, but also venture capitalists seeking to join the hot business opportunity, according to a report from consulting firm McKinsey and Co.

Patients’ experience with televisits coupled with the growing interest by investors is focusing attention on this formerly inside-baseball issue of cross-state licensing.

Greenspun predicts consumers will ultimately drive the solution by “voting with their wallets,” aided by giant, consumer-focused retailers like Amazon and Walmart, both of which in recent months made forays into telemedicine.

In the short term, however, the focus is on both the protections and the barriers state regulations create.

“The whole challenge is to ensure maximum access to health while assuring quality,” said Barak Richman, a Duke University law professor, who said laws and policies haven’t been updated to reflect new technological realities partly because state boards want to hang onto their authority.

Patients and their doctors are getting creative, with some consumers simply driving across state lines, then making a Zoom call from their vehicle.

“It’s not ideal, but some patients say they are willing to drive a mile or two and sit in a parking lot in a private space and continue to get my care,” said Dr. Shabana Khan, director of telepsychiatry at NYU Langone Health’s department of child and adolescent psychiatry and a member of the American Psychiatric Association’s Telepsychiatry Committee. She and other practitioners ask their patients about their locations, mainly for safety reasons, but also to check that they are in-state.

Still, for some patients, driving to another state for an in-person or even a virtual appointment is not an option.

Khan worries about people whose care is interrupted by the changes, especially those reluctant to seek out new therapists or who cannot find any clinicians taking new patients.

Austin Smith hopes that doesn’t happen to him.

After initial treatment for what he calls a “weird flavor of cancer” didn’t help reduce his gastrointestinal stromal tumors, he searched out other experts, landing in a clinical trial. But it was in San Diego and the 28-year-old salesman lives in Phoenix.

Although he drives more than five hours each way every couple of months for treatment and to see his doctors, he does much of his other follow-up online. The only difference is “if I was in person, and I said I was hurting here, the doctor could poke me,” he said.

And if the rules change? He’ll make the drive. “I’ll do anything to beat this,” he said of his cancer.

But will doctors, whose patients have spent the past year or more growing comfortable with virtual visits, also be willing to take steps that could likely involve extra costs and red tape?

To get additional licenses, for instance, practitioners must submit applications in every state where their patients reside, each of which can take weeks or months to process. They must pay application fees and keep up with a range of requirements such as continuing education, which vary by state.

States say their traditional role as overseer ensures that all applicants meet educational requirements and pass background checks. They also investigate complaints and argue there’s an advantage to keeping local officials in charge.

“It’s closer to home,” said Lisa Robin, chief advocacy officer with the Federation of State Medical Boards. “There’s a remedy for residents of the state with their own state officials.”

Doctor groups such as the American Medical Association agree.

Allowing a change that doesn’t put centralized authority in a patient’s home state would raise “serious enforcement issues as states do not have interstate policing authority and cannot investigate incidents that happen in another state,” said then-AMA President-elect Jack Resneck during a congressional hearing in March.

But others want more flexibility and say it can be done safely.

Hasselfeld, at Johns Hopkins, said there is precedent for easing multistate licensing requirements. The Department of Veterans Affairs, for example, allows medical staffers who are properly licensed in at least one state to treat patients in any VA facility.

The Alliance for Connected Care and other advocates are pushing states to extend their pandemic rules. A few have done so. Arizona, for example, made permanent the rules allowing out-of-state medical providers to practice telemedicine for Arizona residents, as long as they register with the state and their home-state license is in good standing. Connecticut’s similar rules have now been stretched until June 2023.

The alliance and others also back legislation stalled in Congress that would temporarily allow medical professionals licensed in one state to treat — either in person or via televisits — patients in any other state.

Because such fixes are controversial, voluntary interstate pacts have gained attention. Several already exist: one each for nurses, doctors, physical therapists and psychologists. Proponents say they are a simple way to ensure state boards retain authority and high standards, while making it easier for licensed medical professionals to expand their geographic range.

The nurses’ compact, enacted by 37 states and Guam, allows registered nurses with a valid license in one state to have it recognized by all the others in the pact.

A different kind of model is the Interstate Physician Licensure Compact, which has been enacted by 33 states, plus the District of Columbia and Guam, and has issued more than 21,000 licenses since it began in 2017, said Robin, of the Federation of State Medical Boards.

While it speeds the paperwork process, it does not eliminate the cost of applying for licenses in each state.

The compact simplifies the process by having the applicant physician’s home state confirm his or her eligibility and perform a criminal background check. If the applicant is eligible, the home state sends a letter of qualification to the new state, which then issues a license, Robin said. Physicians must meet all rules and laws in each state, such as requirements for continuing medical education. Additionally, they cannot have a history of disciplinary actions or currently be under investigation.

“It’s a fairly high bar,” said Robin.

Such compacts — especially if they are bolstered by new legislation at the federal level — could help the advances in telehealth made during the pandemic stick around for good, expanding access to care for both mental health services and medical care across the U.S. “What’s at stake if we get this right,” said Richman at Duke, “is making sure we have an innovative marketplace that fully uses virtual technology and a regulatory system that encourages competition and quality.”

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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Delta Cutting ‘Like a Buzzsaw’ Through Oregon-California Border Counties

Tue, 08/31/2021 - 5:00am

If you live in one of the rural communities tucked into the forested hillsides along the Oregon-California border and need serious medical care, you’ll probably wind up at Asante Rogue Regional Medical Center. It serves about nine counties on either side of the border.  

It is one of three hospitals Asante owns in the region. All three ICUs are 100% full of covid patients, according to staff members.  

“We’ve had two deaths today. So, it’s a very grim, difficult time,” Dr. Michael Blumhardt, medical director of the hospital’s intensive care unit, said on a recent Tuesday in August. “The delta virus is passing through the region like a buzzsaw.”

Unlike earlier covid waves, he said, patients are in their 20s, 30s, 40s and 50s.

“We’re seeing clusters of families being admitted. We had a father and an adult daughter admitted to the intensive care unit and he passed away. Right before, I had to put the daughter on life support,” he said. 

Overall, vaccination rates in many states look pretty good. Oregon and California both have vaccination rates above the national average. But zoom in on any state, and you’ll see a checkerboard effect with huge differences among counties. In Oregon, around big-city Portland, two-thirds of all residents are fully vaccinated. But rural counties aren’t even close to that. Jackson County, on the California border, has the largest number of unvaccinated individuals in Oregon. That’s pushing hospitals to their limits. 

Blumhardt blames the current surge on the delta variant, but also a widespread rejection of the vaccine. 

“This is far more severe for this region than the prior covid waves,” he said.

Inside the Asante ICU, Chelsea Orr, a registered nurse, closely monitors patients, “just trying to keep people alive,” she said. “We’re taking care of a lot of ventilated patients here that are super sick.” 

What feels different about this stage of the pandemic, she said, is the incredible loss of life: “We’re working harder than we’ve ever worked before and still losing.” 

Down the hallway, Justin McCoy waited outside another patient’s isolation room. “I’ve been an ICU nurse for 10 years. I’ve never seen anything like this,” McCoy said. “It’s really terrible seeing these patients who can’t breathe. That is a very difficult thing to watch. It’s really terrifying for them, and it’s really difficult for us to see day in and day out.”  

Blumhardt said the vast majority of their covid patients are unvaccinated.

“We admit nine unvaccinated to every one vaccinated individual. So clearly the vaccine is protecting against hospital admission,” he said. 

Jackson County has been seeing record numbers of new covid infections. Within weeks, many of those people may need hospital care — and a new forecast from Oregon Health & Science University predicts that by Labor Day the state will face a shortfall of 400 to 500 staffed hospital beds. 

Blumhardt said smaller hospitals in Oregon are trying to transfer their sickest patients to Asante, but so far they’ve had to decline around 200 people because of lack of space.

Even though Asante has already postponed some surgeries, staffers are simply worn out, said emergency room physician Dr. Courtney Wilson. 

“I think people are frustrated,” Wilson said. “It feels discouraging that we have had a vaccine available for a really long time in this community and we have a really low vaccination rate here.”

Oregon Democratic Gov. Kate Brown recently sent National Guard troops to overwhelmed counties, to help with nonmedical tasks, including about 150 soldiers to southern Oregon. Medical leaders at Asante and another local hospital system, Providence, have asked for the state to set up a 300-bed field hospital. 

“I don’t know how we’re going to get everybody taken care of. That’s the bottom line. We’re all hands on deck at every level of the organization,” Blumhardt said. 

Residents of Jackson County are starting to respond to the crisis. The rate of new vaccinations here has grown to about twice that of the Portland area. But thousands of people still need to be vaccinated to catch up.

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

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

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Concert Venues Are Banking on Proof of Vaccines or Negative Tests to Woo Back Fans

Mon, 08/30/2021 - 5:00am

MARYLAND HEIGHTS, Mo. — Fans of the band Wilco could have reasonably interpreted frontman Jeff Tweedy singing “I Am Trying to Break Your Heart” at an Aug. 13 concert at St. Louis Music Park as the universe explaining the past year or so.

For example, 30-year-old fan Lazarus Pittman had planned to see Wilco and co-headliner Sleater-Kinney in August 2020 at the open-air venue in this suburb west of St. Louis. Then the show was postponed because of the covid-19 pandemic. Pittman got sick with the coronavirus. He quit his job as a traffic engineer in Connecticut to relocate to St. Louis for his girlfriend — only to have her break up with him before he moved.

But he still trekked from New England to Missouri in a converted minivan for the rescheduled outdoor show. “Covid’s been rough, and I’m glad things are opening up again,” he said.

Yet hours before Pittman planned to cross off the concert from his bucket list, he learned the latest wrinkle: He needed proof of vaccination or a negative covid test from the previous 48 hours to enter the concert.

The bands announced the requirements just two days earlier, sending some fans scrambling. It was the latest pivot by the concert industry, this time amid an increase in delta variant infections and lingering concerns about the recent Lollapalooza music festival in Chicago being a superspreader event.

After more than a year without live music, promoters, bands and fans are eager to keep the concerts going, but uncertainty remains over whether the vaccine or negative-test requirements actually make large concerts safe even if held outdoors.

“Absolutely not,” said Dr. Tina Tan, a specialist in pediatric infectious diseases at Northwestern University. “There is just too much covid that is circulating everywhere in the U.S.”

During the first months of summer, large outdoor venues such as Red Rocks Amphitheatre in Colorado and Ruoff Music Center in Indiana again hosted bands such as the String Cheese Incident and Phish, with sellout crowds of mostly maskless people inhaling marijuana or whatever other particles were possibly around.

Then the delta variant surge in July prompted renewed concerns about large gatherings, even at such outdoor venues.

Tan, and other doctors, warned that Lollapalooza, with an estimated 385,000 attendees from July 29 to Aug. 1, was a “recipe for disaster” even though organizers instituted a vaccine or negative-test requirement.

It turned out that Lollapalooza was not a superspreader event, at least according to Chicago Department of Public Health Commissioner Dr. Allison Arwady, who reported that only 203 attendees were diagnosed with covid.

Tan said she is skeptical of those numbers.

“We know that contact tracing on a good day is difficult, so think about a venue where you have hundreds of thousands of people,” Tan said. “That just makes contact tracing that much more difficult, and there always is a reluctance for people to say where they have been.”

But Saskia Popescu, an infectious disease expert at the University of Arizona, said she sees the Lollapalooza data as “a really good sign.” Still, an outdoor concert with the new entrance rules is not without risk, she said, particularly in states such as Missouri, where the delta variant has thrived. 

“If you are considering an event in an area that has high or substantial transmission, it’s probably not a great time for a large gathering,” Popescu said.

Recently, two of the country’s largest live music promoters, AEG Presents and Live Nation Entertainment, announced they would begin requiring vaccination cards or negative covid tests where permitted by law starting in October. But not all bands and venues are instituting such measures. And some simply are postponing shows yet again. For the second straight year, organizers canceled the annual New Orleans Jazz & Heritage Festival slated for October.

Theresa Fuesting, 55, wasn’t planning on coming to her first Wilco show, even though she had four tickets, until the bands announced the new rules.

“I still think it’s a threat even though I am vaccinated,” said Fuesting, who lives just over the river from St. Louis in Illinois.

For promoters, ensuring that people like Fuesting feel safe enough to use their tickets affects their bottom line, said Patrick Hagin, who promoted the Wilco concert and serves as a managing partner of The Pageant and Delmar Hall music venues in St. Louis. Even if the tickets are already purchased, bar and merchandise sales at the venue suffer if fans are no-shows.

“Also you worry: Is this person who purchased a ticket going to even come in the future?” said Hagin.

In non-covid times, more than 90% of ticket buyers ultimately attend, Hagin said. During the pandemic, that number has been as low as 60%.

Hagin said he is temporarily offering refunds for shows at his venues. St. Louis Music Park did not offer refunds for the Wilco concert and told fans on its Facebook page that it was instituting the requirements “based on what each show wants.” The venue operators did not answer questions for this story.

Jason Green, unable to get a refund for the Aug. 13 show, sold his two sixth-row tickets for $66 — which was $116 less than he paid for the pair in March 2020. He was concerned the venue’s new requirements weren’t enough.

“You want to wait and see if that’s a legit thing that is keeping things from being spread,” said Green, 42, who lives in St. Louis and is fully vaccinated against covid.

He skipped the concert even though he and friends in a comic book collective liked Wilco enough to name a recent comic after the band’s album “A Ghost Is Born.” The band enjoys a loyal local following: Tweedy is from Belleville, Illinois, just across the Mississippi River, and the band played its debut concert in 1994 in St. Louis.

Fuesting and Pittman took their chances.

This was many fans’ first visit to the new venue, an open-air space beneath a curved roof. It was supposed to open last year but was delayed because of the pandemic.

Fans passed through metal detectors and quickly showed their vaccine cards or test results to people sitting at tables. Out of about 2,500 attendees, the venue had to turn only four people away; one of them left, got a test and then returned, Hagin said.

“I was very encouraged just by how positive the compliance was,” he said.

Fortunately, Pittman had a photo of his vaccine card on his phone, which organizers accepted.

“It was so much fun,” said Fuesting, who wore a mask for the whole show. “I just liked the energy of the crowd. They were all just such super fans and singing along to every song.”

The band encored with their classic tune “Casino Queen,” the name of a riverboat casino in East St. Louis, Illinois.

“Casino Queen,” Tweedy sang, “my lord, you’re mean.”

So is covid. But for Pittman, who didn’t wear a mask, the show was worth the gamble. He said he was so into the music, he could push the coronavirus from his mind, at least for a bit.

“They just played all of my favorite songs, one after another,” Pittman said. “I wasn’t even thinking about it.”

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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‘My Time to Live’: Through Novel Program, Kidney Patients Get Palliative Care, Dialysis ’Til the End

Mon, 08/30/2021 - 5:00am

After a decade of living with chronic kidney disease, Vonita McGee knows her body is wearing out.

At 63, McGee undergoes dialysis sessions three times each week at a Northwest Kidney Centers site near her Burien, Washington, home to rid her blood of waste and water. She has endured the placement of more than a dozen ports, or access sites, in her arms and chest as sites became scarred and unusable. Late last month, doctors performed surgery to install yet another port near her left elbow, but no one is certain it will hold.

“Because of scar tissue, I was told this is my last viable access,” she said.

Without ongoing dialysis, McGee knows she could face death within days or weeks. But, unlike many of the nearly 500,000 U.S. patients who require dialysis, McGee said she’s had help making peace with the process.

“I know that things are coming,” she said. “I’m in awe of death, but I’m not afraid of it anymore.”

That’s largely attributed to a novel effort in Washington state that embeds palliative care within a kidney center whose clinics treat patients living with kidney disease; and then later pair dying patients with hospice care without forcing them to forgo the comfort that dialysis may still provide.

Traditional hospice services require kidney patients to abandon dialysis, a decision that hastens death, and almost inevitably comes with acute symptoms, including muscle spasms and nausea.

McGee is one of 400 patients enrolled since 2019 in a first-in-the-nation palliative care program housed at Northwest Kidney Centers, a Seattle-based operation with clinics throughout the region. The organization founded the first dialysis center in the U.S. — and the world — nearly 50 years ago.

Chronic kidney disease, or CKD, encompasses five stages, from mild damage in the organs’ functioning in stage 1 to complete kidney failure in stage 5. Most patients start preparing for dialysis — and kidney failure — in stage 4. Dialysis does not cure kidney failure. The only other option for treatment is an organ transplant.

Dialysis patients typically face distressing physical, emotional and spiritual symptoms throughout their treatment, ranging from pain, shortness of breath and intense itching to depression and panic. The symptoms can grow dire as years pass.

But only a fraction of those patients, 4% or fewer, ever receive specialized palliative care that can effectively target those issues, said Dr. Daniel Lam, the University of Washington nephrologist and palliative care expert who launched the program with the help of a two-year, $180,000 grant from the Cambia Health Foundation. Attention to palliative care in nephrology has lagged behind its use for advanced cancer, for instance.

That’s especially true for Black patients and other minorities, who are disproportionately more likely than white patients to require dialysis, but far less likely to receive quality palliative or end-of-life care.

“We’re trying to address this current and projected gap,” Lam said. “What we are doing is asking people how do they want to live their lives and what’s most important to them.”

If McGee’s condition deteriorates to the point that she has a prognosis of six months or less to live, she will then be a candidate for a related partnership between the kidney center and the nonprofit Providence Hospice of Seattle, which would allow her to continue to receive dialysis even after hospice care begins.

While the goal of both hospice and palliative care is pain and symptom relief, hospice has traditionally been regarded as comfort care without the intent to treat or cure the primary disease. The nuance with dialysis is that it is central to keeping a kidney patient’s body functioning; discontinuing it abruptly results in death within days.

“The goal of this program is to provide kind of a smooth off-ramp from curative dialysis to the end of their lives,” said Mackenzie “Mack” Daniek, who co-directs the hospice.

Most dialysis patients face a harrowing choice between continuing dialysis or receiving hospice services. That’s because the Medicare hospice benefit, which took effect in 1983, provides palliative care and support for terminally ill patients who have six months or less to live — and who agree to forgo curative or life-prolonging care.

That rigid requirement could change in the future. The Centers for Medicare & Medicaid Services has approved an experimental model that will allow concurrent care for some patients starting next year. But, for now, Medicare will not simultaneously pay for dialysis and hospice care for patients with a terminal diagnosis of kidney failure.

Hospices receive a daily per-patient rate from Medicare, typically $200 or less, and must use it to cover all services related to the terminal diagnosis. Dialysis can easily cost $250 a session, which means only the largest hospices, those with 500 or more patients, can absorb the costs of providing concurrent care. Only about 1% of the more than 4,500 hospices in the U.S. meet that mark.

The result? About a quarter of dialysis patients receive hospice care, compared with about half of the general Medicare population. And their median time spent in hospice care is about five days compared with more than 17 days for the general population. This means that dialysis patients often receive aggressive medical treatment until the very end of life, missing out on the comfort of targeted end-of-life care.

“What’s happened through the years is when a dialysis patient is ready to stop treatment, that’s when they come to hospice,” said Dr. Keith Lagnese, chief medical officer of the University of Pittsburgh Medical Center Family Hospice. “They’re forced to draw that line in the sand. Like many things in life, it’s not easy to do.”

Lagnese said the Seattle program is among the first in the U.S. to address palliative and hospice care among dialysis patients. His UPMC program, which has experimented with concurrent care, allows patients up to 10 dialysis treatments after they enter hospice care.

In the Washington state program, there’s no limit on the number of sessions a patient can receive. That helps ease the patient into the new arrangement, instead of abruptly halting the treatment they’ve been receiving, often for years.

“If they’re faced with immediately stopping, they feel like they’re falling off of a cliff,” said Lam, the program’s founder.

In McGee’s case, she’s had the benefit of palliative care for three years to help negotiate the daily struggles that come with dialysis. The care focuses on relieving the physical side effects, and emotional symptoms such as depression and anxiety. It also addresses spiritual needs, which McGee said has helped augment the comfort she finds as a member of the Baha’i religious faith.

“They provide mental support, and they inform you what you need to do to do things properly, and they’re your liaisons,” McGee said. “Basically, I was just living before without knowing the information.”

When she considers her degenerating medical condition and the possibility that it will become too difficult, even impossible, to continue dialysis long term, she said she welcomes the option to ease into the final stage of her life.

“Do I feel scared? At one point, I did,” McGee said. “But they are assuring me that my rights will be honored, they will be advocates for me when it happens. By having that support, it gives me my time to live.”

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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Journalists Give Rundown on Vaccine Mandates and FDA’s Official Approval of the Pfizer Shot

Sat, 08/28/2021 - 5:00am

KHN correspondent Rachana Pradhan discussed covid vaccine mandates and the Food and Drug Administration’s recent approval of the Pfizer-BioNTech vaccine on Newsy’s “Morning Rush” on Tuesday.

KHN Midwest correspondent Cara Anthony talked about covid vaccines on Illinois Public Media’s “The 21st Show” on Monday.

KHN chief Washington correspondent Julie Rovner discussed the FDA approval of the Pfizer vaccine on WAMU’s “1A” on Friday.

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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Beneficiarios de Medicaid se vacunan mucho menos contra covid

Fri, 08/27/2021 - 7:59am

Los beneficiarios de Medicaid se están vacunando contra covid-19 a tasas mucho más bajas que la población general, mientras los estados buscan las mejores estrategias para mejorar el acceso a las vacunas, y persuadir a quienes siguen indecisos.

Los esfuerzos de las agencias estatales de Medicaid y los planes de salud privados que la mayoría de los estados pagan para cubrir a sus residentes de bajos ingresos se han debilitado, en parte por la falta de acceso a los datos estatales sobre qué miembros están vacunados.

Los problemas reflejan la naturaleza descentralizada del programa de salud, financiado en gran parte por el gobierno federal pero administrado por los estados.

También por la dificultad de hacer llegar el mensaje a las poblaciones de Medicaid sobre la importancia de las vacunas contra covid, y los desafíos que enfrentan para obtener atención.

“Estas son algunas de las poblaciones a las que es más difícil llegar, y las que generalmente son las últimas en la fila para recibir atención médica”, dijo Craig Kennedy, director ejecutivo de Medicaid Health Plans of America, un grupo comercial.

Los afiliados a Medicaid a menudo enfrentan obstáculos para acceder a las vacunas, incluidas la preocupación por faltar al trabajo o encontrar transporte, dijo.

En California, el 49% de los afiliados de 12 años o más a Medi-Cal (el nombre de Medicaid en California) están vacunados al menos en parte, en comparación con el 74% de los californianos en general.

A diferencia de otros estados grandes, como Texas y Pennsylvania, California proporciona a sus planes de Medicaid información de los registros de vacunas, lo que puede ayudarlos a buscar a los beneficiarios no vacunados. Pero aún así, la tasa de inmunización está muy por detrás comparada con la población en general.

Según informes detallados que muestran las tasas de vacunación por condado y por plan de salud, los porcentajes varían drásticamente. En el condado de Santa Clara, donde está Silicon Valley, el 63% de los que tienen Medi-Cal han sido vacunados, frente al 38% en el vecino condado de Stanislaus.

Los planes de salud de California están trabajando con grupos comunitarios para tocar puertas en vecindarios con bajas tasas de vacunación y proporcionar vacunas en el lugar para que la gente no tenga que viajar.

Este otoño, California, que tiene el programa de Medicaid más grande del país, con casi 14 millones de personas, ofrecerá a sus planes de salud de Medi-Cal $250 millones en incentivos para vacunar a los miembros. El estado también está aportando $100 millones para tarjetas de regalo, $50 por cada beneficiarios vacunado.

En otros estados, como Kentucky y Ohio, los planes de salud están dando tarjetas de regalo de $100 a los afiliados cuando se vacunan.

Si bien más de 202 millones de estadounidenses están vacunados al menos en parte contra covid, casi el 30% de las personas mayores de 12 años siguen sin vacunarse. Las encuestas muestran que los más pobres tienen menos probabilidades de recibir una vacuna.

Más de dos tercios de los beneficiarios de Medicaid en todo el país están cubiertos por un plan de salud privado. Los estados pagan una tarifa mensual al plan por cada miembro para atender las necesidades médicas y la atención preventiva.

A nivel nacional, alrededor del 70% de los afiliados a Medicaid tienen al menos 12 años y son elegibles para las vacunas, según un análisis de KFF.

Los programas estatales de Medicaid que pueden rastrear su progreso muestran resultados modestos:

  • En Florida, el 34% de los beneficiarios de Medicaid están al menos parcialmente vacunados, en comparación con el 67% de todos los residentes de 12 años o más.
  • En Utah, el 43% de los beneficiarios de Medicaid están vacunados al menos en parte, en comparación con el 68% en todo el estado.
  • En Louisiana, el 26% de los afiliados a Medicaid están vacunados al menos en parte, en comparación con el 59% de la población estatal.
  • En Washington, DC, el 41% de los afiliados a Medicaid están vacunados al menos en parte, en comparación con el 76% de todos los residentes.

“No es fantástico”, dijo la doctora Pamela Riley, directora médica del Departamento de Finanzas de la Atención Médica de D.C., que supervisa Medicaid.

Las agencias de Medicaid en varios estados, incluidos Pennsylvania, Missouri, Nueva Jersey y Texas, dijeron que carecen de datos completos sobre las tasas de vacunación y no tienen acceso a los registros estatales que muestren quién ha sido vacunado. Los expertos en salud dicen que, sin esos datos, las campañas de vacunas de Medicaid están prácticamente moviéndose a ciegas.

“Tener datos es el primer paso para saber a quién contactar y a quién llamar, y quiénes tienen médicos y pediatras que pueden ayudar”, dijo Julia Raifman, profesora asistente de derecho, políticas y administración de salud en la Universidad de Boston.

Durante años, los programas de Medicaid han trabajado con proveedores para mejorar las tasas de vacunación entre niños y adultos. Pero ahora, necesitan más instrucciones del gobierno federal para establecer “un enfoque más claro y efectivo” para controlar a covid, dijo Raifman.

Chiquita Brooks-LaSure, administradora de los Centros de Servicios de Medicare y Medicaid (CMS), dijo que el gobierno federal está otorgando fondos adicionales a los programas estatales de Medicaid para alentar la vacunación contra covid. “También estamos alentando a los estados a recordarles a las personas inscritas en Medicaid que las vacunas son gratuitas, seguras y efectivas”, dijo a KHN en un comunicado.

“Necesitamos acceso a los registros estatales de inmunización para poder tomar decisiones informadas para vacunar a las personas no vacunadas e identificar a las que están haciendo un gran trabajo, pero todo comienza con el intercambio de datos”, dijo.

Los datos de reclamos de las agencias de Medicaid no tienen en cuenta los muchos afiliados que se vacunan en los sitios de vacunación federales y otros lugares que no requieren información de seguro.

Los funcionarios de Medicaid de California dijeron que pueden rastrear la vacunación de los beneficiarios conectándose al registro de inmunizaciones del Departamento de Salud Pública del estado, que registra las vacunas de los residentes independientemente de dónde se vacunen.

Jana Eubank, directora ejecutiva de la Asociación de Centros de Salud Comunitarios de Texas, dijo que sus clínicas estarían agradecidas de saber qué beneficiarios de Medicaid están vacunados para orientar mejor las campañas de inmunización. Tener los datos también ayudaría a los proveedores a asegurarse de que las personas reciban una dosis adicional, de refuerzo, que se recomienda este otoño.

“Tenemos bastante sentido común, pero sería muy bueno tener más detalles, ya que eso nos permitiría enfocar mejor nuestros limitados recursos”, dijo Eubank.

El Departamento de Servicios Humanos de Pennsylvania, que supervisa Medicaid, dijo que solicitó datos del registro de vacunas al departamento de salud del estado en la primavera, pero que no los ha recibido. Una vocera dijo que su agencia estaba analizando asuntos legales para salvaguardar los datos de salud personales del registro.

“Obtener datos de vacunación precisos y completos para nuestros beneficiarios de Medicaid es una prioridad, pero no podemos hacerlo basándonos únicamente en reclamos y datos ad hoc”, dijo Ali Fogarty, vocera de Medicaid de Pennsylvania.

AmeriHealth Caritas, que opera planes de salud de Medicaid en Pennsylvania, Florida y otros seis estados, demás del Distrito de Columbia, tiene aproximadamente el 25% de sus afiliados a Medicaid vacunados, dijo la doctora Andrea Gelzer, vicepresidenta senior de asuntos médicos.

AmeriHealth está trabajando con sus médicos y organizaciones comunitarias para apoyar a las clínicas de vacunas. Ha ofrecido transporte gratuito y ha puesto las vacunas a disposición de beneficiarios confinados en sus hogares.

En Louisiana, el programa Medicaid ha ofrecido bonificaciones a cinco planes de salud para estimular las vacunas. Pero hasta ahora solo uno, Aetna, ha calificado.

Richard Sánchez, director ejecutivo de CalOptima, el plan de salud de Medicaid en el condado de Orange, California, dijo que ofrecer tarjetas de regalo de Subway de $25 ayudó a aumentar las vacunas entre los miembros que viven en refugios para personas sin hogar.

A mediados de agosto, alrededor del 56% de sus afiliados elegibles estaban vacunados al menos en parte. “No estamos donde deberíamos estar y la nación no está donde debería estar”, dijo Sánchez.

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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Democrats Say Abortion Is on the Line in Recall Election. But Rolling Back Rights Wouldn’t Be Easy.

Fri, 08/27/2021 - 5:00am

SACRAMENTO, Calif. — As the election to recall California Gov. Gavin Newsom approaches, abortion-rights groups are warning that Californians’ right to an abortion is on the ballot.

Newsom, a Democrat, himself tweeted that “abortion access” is at stake.

“There’s no question that if a Republican is elected, access to abortion in California will be restricted,” Jodi Hicks, president of Planned Parenthood Affiliates of California, said at a press conference in July.

But this message is strategic and is more about firing up left-leaning voters than it is about policy, said Rob Stutzman, a Republican political strategist.

“There’s no indication from polling in this election that [abortion] is at all what Californians think this election is about,” Stutzman said. “This fits into the type of campaign that they’re running, which isn’t persuasion; it’s motivation to turn out.”

In reality, California has some of the strongest abortion protections in the country and restricting them would be difficult for a replacement governor to accomplish with only a little over a year remaining in the term, opposition from an overwhelmingly Democratic legislature — and the right to abortion enshrined in the state constitution.

Although governors can veto legislation, set budget priorities and make regulations through state agencies, only small-scale change would be possible and would almost exclusively affect women on Medi-Cal, the state’s Medicaid insurance program for low-income people.

“I don’t think abortion is going to be severely restricted in California,” said Laurie Sobel, associate director of women’s health policy for KFF. “It’s more subtle than just slashing laws that are on the books — it’s not being supportive” of progressive new laws.

Restrictions adopted by other states — such as laws that require ultrasounds before abortions or regulations that make it hard to open abortion clinics — likely wouldn’t fly in California without a friendly legislature, Sobel said.

Yet reproductive rights groups have painted Californians’ right to access abortion as threatened by the Sept. 14 recall election. Newsom appeared with Planned Parenthood leaders Wednesday night to say California’s role as an abortion-rights standard-bearer is more important than ever because other states are increasingly restricting access and the U.S. Supreme Court will decide this year whether to uphold the seminal Roe v. Wade decision, which legalized abortion nationally.

None of the four leading Republican recall candidates responded to calls and emails about their positions on abortion.

Larry Elder, a conservative radio host who is the leading replacement candidate in most polls, has been the most outspoken on the issue. He has called abortionmurder” and Roe v. Wade “one of the worst decisions that the Supreme Court ever handed down.” Businessman John Cox has called himself “pro-life” in previous campaigns, but said he prefers not to talk about social issues, and state Assembly member Kevin Kiley (R-Rocklin) has received endorsements and positive ratings from anti-abortion groups. Former San Diego mayor Kevin Faulconer has said he supports abortion rights.

Every registered voter will receive a ballot in the mail, though voters will also have in-person voting options. If Newsom is recalled in the Sept. 14 election, his replacement would take office in late October, and would serve the remaining portion of Newsom’s term, until January 2023. A replacement could run for a regular four-year term in the November 2022 election.

State law establishes a woman’s right to an abortion, generally until a fetus could survive on its own. And the state constitution includes a right to privacy that the Supreme Court of California has ruled protects abortion, even if the U.S. Supreme Court overturns Roe v. Wade. The state Supreme Court has also struck down laws that limit abortion or require parental consent. State law requires every state-regulated health plan, public or private, to cover the procedure.

Still, abortion-rights advocates argue that having a right doesn’t always mean being able to access treatment, and that an anti-abortion governor could find ways to make the procedure less accessible. Experts say there are three primary ways a replacement governor could restrict access:

  • Vetoing bills or budget items (the governor has line-item veto power over the state budget) would be one of the most direct ways. State Sen. Lena Gonzalez (D-Long Beach) introduced a bill this year to eliminate cost sharing for abortion for Medi-Cal patients, which awaits a committee hearing before heading to the Assembly for a final vote. She said she still would have introduced the measure under an anti-abortion administration, but that it would have been an “uphill battle” on every front.

Democrats, who have a supermajority in both houses of the legislature, could override a governor’s veto with a two-thirds majority in both chambers. The last time that happened was in 1980.

Susan Arnall, director of outreach and engagement at the Right to Life League, said an anti-abortion governor could help bring balance to the Capitol by vetoing “anti-life” legislation, even if lawmakers end up overriding the veto. “That at least delays things. It slows the process down, and that’s helpful,” she said.

  • Governors have broad power to change how Medi-Cal, which covers roughly half the abortions in the state, funds abortion. For instance, an anti-abortion governor could work through the Department of Health Care Services to set Medi-Cal reimbursement rates for abortion so low that no doctors could afford to perform the procedure. Or the governor could make the process of getting paid by Medi-Cal so difficult that providers wouldn’t bother. These and other bureaucratic hurdles could add up, making it harder for someone to get an abortion as quickly as they need one, said Fabiola Carrión, the National Health Law Program’s interim director of reproductive and sexual health. “This is particularly a concern with people who live in central California and rural areas” where patients must drive long distances to find a provider. “Abortion is already a time-sensitive service.”
  • At the end of the year, the Food and Drug Administration is expected to rule on whether mifepristone, a prescription drug used in medication abortions, can continue to be dispensed via telemedicine without seeing a provider in person — a service the agency approved provisionally this year. If the FDA allows the telemedicine option to continue, it will require the state to update its Medi-Cal provider manual. A new governor could install a director at the Department of Health Care Services who wouldn’t update the manual, and Medi-Cal enrollees who want medication abortion might have to see their provider in person first.

“California already has abortion deserts within our own state,” Hicks said. Even a barrier that seems small “still matters for someone trying to get services.”

Democratic consultant Rose Kapolczynski said the threat an anti-abortion governor could pose to abortion access is real, regardless of how long that person held office. Newsom’s replacement would immediately have to start running for reelection, she said, which provides the incentive to do big things in the first year.

“The Newsom team knows they need to do everything they can to motivate Democrats to mail in their ballots, and they’re talking to those voters about the issues they care most about,” Kapolczynski said. “It’s completely legitimate to talk about what happens if the recall succeeds.”

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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Medicaid Vaccination Rates Founder as States Struggle to Immunize Their Poorest Residents

Fri, 08/27/2021 - 5:00am

Medicaid enrollees are getting vaccinated against covid-19 at far lower rates than the general population as states search for the best strategies to improve access to the shots and persuade those who remain hesitant.

Efforts by state Medicaid agencies and the private health plans that most states pay to cover their low-income residents has been scattershot and hampered by a lack of access to state data about which members are immunized. The problems reflect the decentralized nature of the health program, funded largely by the federal government but managed by the states.

It also points to the difficulty in getting the message to Medicaid populations about the importance of the covid vaccines and challenges they face getting care.

“These are some of the hardest-to-reach populations and those often last in line for medical care,” said Craig Kennedy, CEO of Medicaid Health Plans of America, a trade group. Medicaid enrollees often face hurdles accessing vaccines, including worries about taking time off work or finding transportation, he said.

In California, 49% of enrollees age 12 and older in Medi-Cal (the name of Medicaid in California) are at least partly vaccinated, compared with 74% for Californians overall.

Unlike some other large states, such as Texas and Pennsylvania, California provides its Medicaid plans with information from vaccine registries, which can help them target unvaccinated enrollees. But still, the rate of immunizations lags far behind that of the general population.

According to detailed reports showing vaccination rates by county and by health plan, rates around the state vary dramatically. In Silicon Valley’s Santa Clara County, 63% of Medi-Cal members have been vaccinated, versus 38% in neighboring Stanislaus County. California health plans are working with community groups to knock on doors in neighborhoods with low vaccination rates and providing shots on the spot.

This fall, California — which has the nation’s largest Medicaid program, with nearly 14 million people — will offer its Medi-Cal health plans $250 million in incentives to vaccinate members. The state is also putting up $100 million for gift cards limited to $50 for each enrollee.

In other states — such as Kentucky and Ohio — health plans are giving $100 gift cards to members when they get vaccinated.

While more than 202 million Americans are at least partly vaccinated against covid, nearly 30% of people 12 and older remain unvaccinated. Surveys show poor people are less likely to get a shot.

More than two-thirds of Medicaid beneficiaries across the country are covered by a private health plan. States pay a monthly fee to the plan for each member to handle medical needs and preventive care.

Nationally, about 70% of Medicaid enrollees are at least 12 years old and eligible for the vaccines, according to a KFF analysis.

State Medicaid programs that can track their progress show modest results:

  • In Florida, 34% of Medicaid recipients are at least partly vaccinated, compared with 67% for all residents 12 and older.
  • In Utah, 43% of Medicaid recipients are at least partly vaccinated, compared with 68% statewide.
  • In Louisiana, 26% of Medicaid enrollees are at least partly vaccinated, compared with 59% for the state population.
  • In Washington, D.C., 41% of Medicaid enrollees are at least partly vaccinated, compared with 76% of all residents.

“We know how we are doing, and it’s not great,” said Dr. Pamela Riley, medical director of the D.C. Department of Health Care Finance, which oversees Medicaid.

Hemi Tewarson, executive director of the National Academy for State Health Policy, said she “had hoped there would not be this much of a disparity, but clearly there is.”

Medicaid agencies in several states, including Pennsylvania, Missouri, New Jersey and Texas, said they lack complete data on vaccination rates and don’t have access to state registries showing who has been immunized. Health experts say that, without that data, the Medicaid vaccine campaigns are virtually flying blind.

“Having data is step one in knowing who to reach out to and who to call and who to have doctors and pediatricians help out with,” said Julia Raifman, assistant professor of health law, policy and management at Boston University.

For years, Medicaid programs have worked with providers to improve vaccination rates among children and adults. But now, Medicaid officials need more direction from the federal government to set up “a more clear and focused and effective approach” to control covid, Raifman said.

Chiquita Brooks-LaSure, the administrator of the Centers for Medicare & Medicaid Services, said the federal government is giving extra funding to state Medicaid programs to encourage covid vaccinations. We’re also encouraging states to remind people enrolled in their state Medicaid plans that vaccines are free, safe, and effective,” she said in a statement to KHN. Kennedy, of Medicaid Health Plans of America, said the job of getting shots to Medicaid enrollees is harder when states don’t share immunization data.

“We need access to the state immunization registries so we can make informed decisions to get those unvaccinated people vaccinated and identify those doing a great job, but it all starts with data sharing,” he said.

Medicaid agencies’ claims data doesn’t account for the many enrollees who get vaccinated at federal immunization sites and other places that don’t require insurance information.

California Medicaid officials said they can track enrollee vaccination by linking to the state Department of Public Health’s immunization registry, which captures residents’ inoculations regardless of where they occur in the state.

Data as of Aug. 8 shows rural Lassen County in northeastern California with the lowest vaccination rate among Medi-Cal enrollees, at 21%, and San Francisco with the highest, at 67%.

Medicaid enrollees’ vaccination rates fall short even compared with those of other people in the same county. In San Diego County, for example, 91% of residents are at least partially vaccinated, compared with 51% of Medicaid recipients.

Jana Eubank, executive director of the Texas Association of Community Health Centers, said her clinics would be grateful to know which Medicaid recipients are vaccinated to better target immunization campaigns. Having the data would also help providers make sure people get an additional dose, often called a booster, being recommended this fall.

“We have a pretty good sense, but it would be great to have more detail, as that would allow us to be more focused with our finite resources,” Eubank said.

Pennsylvania’s Department of Human Services, which oversees Medicaid, said it requested vaccine registry data from the state health department in the spring but hasn’t received it. A health department spokesperson said her agency was working through legal issues to safeguard the registry’s personal health data.

“Getting accurate, comprehensive vaccination data for our Medicaid recipients is a priority, but we cannot do so based off claims and ad hoc data alone,” said Ali Fogarty, a Pennsylvania Medicaid spokesperson.

Dr. David Kelley, chief medical officer of the state’s Medicaid program, said the lack of immunization data hasn’t slowed the agency’s vaccination work: “We are continuing full steam ahead to get folks immunized.”

AmeriHealth Caritas, which operates Medicaid health plans in Pennsylvania, Florida and six other states and the District of Columbia, has about 25% of its Medicaid enrollees vaccinated, said Dr. Andrea Gelzer, senior vice president of medical affairs.

AmeriHealth is working with its doctors and community organizations to support vaccine clinics. It has offered free transportation and made vaccines available to homebound enrollees.

In Louisiana, the Medicaid program has offered bonuses to five health plans to spur vaccines. But so far only one, Aetna, has qualified.

Louisiana Medicaid is paying Aetna $286,000 for improving its vaccination rates by 20 percentage points from May to August, state and health plan officials said. Aetna had at least partly vaccinated 36% of its enrollees as of Aug. 16.

John Baackes, CEO of L.A. Care Health Plan, said he remains skeptical about paying people to get their shots and said it could upset enrollees who already have been vaccinated and won’t qualify for cash or a gift card. “We don’t think gift cards are going to move the needle very much,” he said.

As part of its strategy to increase vaccinations, the health plan has called members at high risk of covid complications to get them into walk-up or drive-thru immunization sites and helped homebound members get shots where they live. About half the plan’s eligible enrollees have received at least one dose.

Richard Sanchez, CEO of CalOptima, the Medicaid health plan in Orange County, California, said offering $25 Subway gift cards helped increase vaccinations among members living at homeless shelters.

As of mid-August, about 56% of its eligible enrollees were at least partly vaccinated. “We are not where we should be, and the nation is not where it should be,” Sanchez 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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Jaw Surgery Takes a $27,119 Bite out of One Man’s Budget

Fri, 08/27/2021 - 5:00am

For years, Ely Bair dealt with migraine headaches, jaw pain and high blood pressure, until a dentist recommended surgery to realign his jaw to get to the root of his health problems.

The fix would involve two surgeries over a couple of years and wearing braces on his teeth before and in between the procedures.

Bair had the first surgery, on his upper jaw, in 2018 at Swedish Medical Center, First Hill Campus in Seattle. The surgery was covered by his Premera Blue Cross plan, and Bair’s out-of-pocket hospital expense was $3,000.

He changed jobs in 2019 but still had Premera health insurance. In 2020, he had the planned surgery on his lower jaw at the same hospital where he’d been treated the first time. The surgery went well, and he spent one night in the hospital before being discharged. He was healing well and beginning to see the benefits of the surgeries.

Then the bill arrived.

The Patient: Ely Bair, 35, a quality assurance analyst. He has a Premera Blue Cross health plan through his job at a biotech firm in Seattle.

Total Bill: Swedish Medical Center billed Bair $27,119 for the second surgery in July 2020. This was Bair’s share of the negotiated rate, after the hospital took $14,310 off the charge. His insurer paid $5,000. Bair owed additional bills to the surgeon and the anesthesiologist.

Service Provider: Swedish First Hill Campus in Seattle, part of the largest nonprofit health system in the Seattle area, which is affiliated with Providence, a major Catholic health care network.

What Gives: Bair hit two maddening health system pitfalls here: He expected his new plan to behave like his previous one from the same insurer — and he expected his mouth to be treated like the rest of his body. Neither commonsense notion appears true in America’s health system.

Typically, large companies, such as Bair’s employers, “self insure,” meaning they pay their workers’ health costs but use insurance companies to maintain provider networks and handle claims. When Bair changed jobs, his insurance coverage changed even though both employers used Premera. Bair paid $3,000 for his first surgery because that was the out-of-pocket maximum under his plan from his previous employer, which covered oral and maxillofacial surgery.

Bair expected that using the same hospital and the same insurance carrier would mean his costs would be similar for part two of his treatment. Bair’s oral and maxillofacial surgeon — the same doctor who performed the first procedure — checked Bair’s benefits through his insurer’s online portal and thought it would be covered. Premera also sent his doctor confirmation agreeing that the second procedure was medically necessary.

About three months after the surgery, Bair was shocked to get the large hospital bill — about $24,000 higher than he expected.

When he called Premera, he learned his new plan had a $5,000 lifetime limit on coverage for the reconstructive jaw procedure known as orthognathic surgery, which is sometimes regarded as a dental rather than a medical intervention. His doctor said that information was not noted in Bair’s benefits when the practice reviewed them through an online portal. Premera told Bair he should have known about the limit because it was listed in his detailed, hard-copy, 86-page member-benefit booklet.

The Affordable Care Act in 2014 eliminated lifetime and annual caps on insurance coverage for categories of treatment such as prescription drugs, laboratory services and mental health care. While the ACA lists broad categories about what is considered an “essential health benefit,” each state decides which services are included in each category and the scope or duration that must be offered. Bariatric surgery, physical therapy and abortion are examples of care for which insurance coverage can vary a lot by state under this ACA provision. Orthognathic surgery is not considered an essential health benefit in Washington. It is sometimes performed for cosmetic purposes only. Also, plans sometimes regard the surgery as part of orthodontia — which frequently involves limits on coverage. But for Bair, it was a clear medical necessity.

Without an ACA requirement for orthognathic surgery, Premera and self-insured plans are allowed to provide various levels of benefits and can impose annual and lifetime caps.

Premera spokesperson Courtney Wallace said Bair transferred from a plan with his former company that did not have a lifetime maximum to a plan with a $5,000 lifetime maximum benefit.

Martine Brousse, a patient advocate and owner of AdvimedPro, which helps patients with health care billing disputes, said Bair acted appropriately by using a doctor and hospital in his health plan’s network and checking with his doctor about his insurance coverage.

She said Swedish should have told him before the surgery — which was planned weeks ahead of time — how much he would have to pay. “That is a failure on part of the hospital,” she said.

Sabrina Corlette, co-director of the Georgetown University Center on Health Insurance Reforms, said it doesn’t seem fair that his first employer covered the cost of his surgery but the second employer did not. She said the $27,000 bill seemed excessive and the $5,000 lifetime limit very low. “Essential health benefits serve a really important function, and when there are gaps or holes people can really get hurt,” she said.

Resolution: Bair’s doctor told him the hospital charge was at least three times the amount Swedish charges uninsured patients for the same surgery. Bair said Swedish offered to let him pay the bill over two years but did not make any other concessions.

Swedish would not say why it did not verify Bair’s insurance benefits before the surgery or let him know he would face an enormous bill even though he was insured.

“Hospital pricing is complex and nuanced,” Swedish officials said in a statement. Bair’s bill “was inclusive of all the care he received, which included specialized services and expertise, equipment and the operating room time. He had a jaw procedure that had a maximum benefit from his insurer of $5,000. He was billed the balance not covered by his insurer.”

The hospital system said it also has an online tool that generates estimates tailored to patients’ coverage and choice of hospital.

The online tool did not come up with anything on the term “orthognathic surgery,” however.

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Bair appealed three times to Premera to reconsider its decision to cover only $5,000 of the cost of his procedure. But the insurer rejected each one saying he had exhausted his lifetime orthognathic surgery benefit and he was responsible for any additional care. When Swedish wouldn’t lower his cost, he filed a complaint in December 2020 with the state attorney general’s office.

A few months later, Swedish reduced Bair’s bill from over $27,000 to $7,164.

“Because neither the patient nor his provider was aware of this limitation in coverage prior to the procedure, the surgeon advocated on the patient’s behalf to get the bill lowered,” the hospital told KHN in a statement.

Bair agreed to pay the lower amount. “The bill is at least a much more manageable number than the financial ruin $27,000 would have been,” he said. “I am just looking forward to closing this chapter and moving on.”

His surgeon, who helped him fight the hospital bill and limited insurance coverage, reduced his bill to $5,000 from $10,000, Bair said.

Bair said his employer, Adaptive Biotechnologies, is looking into eliminating its $5,000 lifetime limit for the procedure when it is medically necessary.

Since the surgery, Bair said he gets far fewer migraine headaches and his high blood pressure has been reduced. “I feel way more energized,” he said.

The Takeaway: When facing a planned surgery, talk to your hospital, doctor and insurer about how much of the bill you will be responsible for — and get it in writing before any procedure.

“In theory, you should be able to rely on your provider to confirm your coverage but, in practice, it is in your best interest to call your insurer yourself,” Corlette said.

Even though the ACA eliminated lifetime and annual caps on coverage, that applies only to services deemed essential in a patient’s state. Be aware that certain surgeries — like jaw surgery — lie in a gray area; insurers might not consider them a necessary medical intervention or even a medical procedure at all. Corlette said health plans should notify patients when they are closing in on lifetime or annual limits, but that doesn’t always happen.

Also, be aware that even though your insurance carrier may stay the same after switching jobs, your benefits could be quite different.

Kudos to Bair for being a proactive patient and appealing to the state attorney general — which got him a positive result.

Stephanie O’Neill contributed the audio profile with this report.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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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States Pull Back on Covid Data Even Amid Delta Surge

Fri, 08/27/2021 - 5:00am

Two state government websites in Georgia recently stopped posting updates on covid-19 cases in prisons and long-term care facilities, just as the dangerous delta variant was taking hold.

Data has been disappearing recently in other states as well.

Florida, for example, now reports covid cases, deaths and hospitalizations once a week, instead of daily, as before.

Both states, along with the rest of the South, are battling high infection rates.

Public health experts are voicing concern about the pullback of covid information. Dr. Georges Benjamin, executive director of the American Public Health Association, called the trend “not good for government and the public” because it gives the appearance of governments “hiding stuff.”

A month ago, the Georgia agency that runs state prisons stopped giving public updates on the number of new covid cases among inmates and staff members. The Department of Corrections, in explaining this decision, cited its successful vaccination rates and “a declining number of covid-19 cases among staff and inmates.”

Now, a month later, Georgia has among the highest covid infection rates in the U.S. — along with one of the lowest vaccination rates. But the corrections department hasn’t resumed posting case data on its website.

When asked by KHN about the covid situation in prisons, department spokesperson Joan Heath said Monday that it currently has 308 active cases among inmates.

“We will make a determination whether to begin reposting the daily covid dashboard over the next few weeks, if the current statewide surge is sustained,” Heath said.

Another state website, run by the Department of Public Health, no longer links to a listing of the number of covid cases among residents and staffers of nursing homes and other long-term care residences by facility. The data grid, launched early in the pandemic, gave a running total of long-term care cases and deaths from the virus.

Asked about the lack of online information, public health officials directed a reporter to another agency, the Department of Community Health, which explained that covid information on nursing homes could be found on a federal health website. But locating and navigating that link can be difficult.

“Residents and families cannot easily find this information,” said Melanie McNeil, the state’s long-term care ombudsman. “It used to be easily accessible.”

Georgia gives updates on overall numbers of covid cases, hospitalizations and deaths in the state five days a week but has recently stopped its weekend covid reporting.

Other states also have cut back their public case reporting, despite the nation being engulfed in a fourth, delta-driven covid surge.

Florida had issued daily reports on cases, deaths and hospitalizations until the rate of positive test results dropped in June. Even when caseloads soared in July and August, the state stuck with weekly reporting.

Florida has been accused of being less than transparent with covid health data. Newspapers have sued or threatened to sue the state several times for medical examiner reports, long-term care data, prison data and weekly covid reports the state received from the White House.

Florida Agriculture Commissioner Nikki Fried, a Democrat running for governor in 2022, has repeatedly questioned Republican Gov. Ron DeSantis’ decision to delay the release of public data on covid cases and has called for restoring daily reporting of covid data.

Nebraska discontinued its daily covid dashboard June 30, then recently resumed reporting, but only weekly. Iowa also reports weekly; Michigan, three days a week.

Public health experts said full information is vital for a public dealing with an emergency such as the pandemic — similar to the government reports needed during a hurricane.

“All the public health things we do are dependent on trust and transparency,” Benjamin said.

A government, when removing public data, should provide a link redirecting people to where they can get that data, he said. And if a state doesn’t have enough staff members to provide regular data, he said, that argues for investment in staff and technology.

People in prisons and long-term care facilities, living in close quarters indoors, are especially vulnerable to infectious diseases such as covid.

“They are usually hotbeds of disease,” said Amber Schmidtke, a microbiologist who tracks covid in Georgia. Family members “want to know what’s going on in there.”

Prison data has been removed or reduced in several states, according to the UCLA School of Law’s COVID Behind Bars Data Project, which tracks the spread of covid in prisons, jails and detention facilities.

The group said Alaska provides only monthly updates on covid cases in such facilities, while Florida stopped reporting new data in June.

When Georgia stopped reporting on covid in prisons, the project found, only 24% of employees reported being vaccinated. Prison workers can spread the virus inside the facilities and then in their homes and the community.

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The group reports that at least 93 incarcerated people and four staffers have died of covid in Georgia and that the state has the second-highest case fatality rate, or percentage of those with reported infections who die, among all state and federal prison systems.

“Right now, if there was a massive outbreak in prisons, there would be no way to know it,” said Hope Johnson of the COVID Behind Bars Data Project.

Recent Facebook posts point to cases at Smith State Prison in southeastern Georgia.

Heath, when asked about cases there, said Tuesday that the prison has 19 active covid cases and its transitional center has one.

Mayor Bernie Weaver of Glennville, the Tattnall County town where the prison is located, said he hasn’t been told about recent covid cases at the prison. But he noted that Tattnall itself has had a spike in cases. The county has a 26% vaccination rate, among the lowest in the state.

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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KHN’s ‘What the Health?’: Vaccine Approval Moves the Needle on Covid

Thu, 08/26/2021 - 1:45pm

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

The Food and Drug Administration gave full approval this week to the covid-19 vaccine from Pfizer and BioNTech, which will henceforth be known as “Comirnaty.” It is not clear how many vaccine-hesitant Americans will now be willing to get a jab, but the approval has prompted many public and private employers to implement mandates for their workers.

Meanwhile, the U.S. House, back early from its summer break, overcame a brief rebellion by some Democratic moderates to pass a budget resolution that starts the process for a giant social-spending measure addressing many new health benefits.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Tami Luhby of CNN and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s episode:

  • House Speaker Nancy Pelosi walked a tightrope again this week but managed to keep her caucus together to move forward an infrastructure bill and a budget resolution that will be a vehicle for a massive social-spending bill. Nonetheless, conflicts among Democrats on the size of that bill and its timing were not resolved and could spark heated battles between progressives and moderates in the next couple of months.
  • Some aspects of the health programs in the spending bill are already in danger of being ditched, including a proposal to lower the eligibility age for Medicare. Other cost-saving strategies being discussed include implementing some programs for only a limited time. Democrats hope those programs would prove popular enough for future lawmakers to extend them.
  • Some companies, including Delta Air Lines, are not mandating vaccines, but they will charge workers a higher insurance premium if they opt to not get a shot.
  • To the horror of many public health experts, some people who are refusing to get vaccinated have instead turned to a veterinary medicine, Ivermectin, that is being touted as a covid treatment or preventive on social media and by conservative broadcasters. The FDA has warned people that the drug could be dangerous, tweeting out last week: “You are not a horse. You are not a cow.”
  • Florida Gov. Ron DeSantis, who has been determined to stop mask and vaccination mandates in his state, is setting up centers for people infected with covid to get infusions of monoclonal antibody treatments, which have been shown to help covid patients. But the treatments are expensive and timing is crucial, so it’s not clear how effective these centers will be. Those treatments have only an emergency use authorization from the FDA. Coincidentally, many people hesitant to get a vaccine complained it was because the products were authorized only for emergency use.
  • The FDA is warning parents and doctors against vaccinating children under age 12. It has not yet authorized the vaccine for them, and drugmakers say these younger children may need smaller doses. Studies are underway.
  • A new law is set to take effect in Texas next week that bans abortions after six weeks and allows private citizens to sue abortion providers and even individuals who drive women to abortion clinics. If federal courts do not step in to block the law, providers in the state say they will not be able to operate.

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

Julie Rovner: The Washington Post’s “Long-Term-Care Facilities Are Using the Pandemic as a Shield, Even in Lawsuits Unrelated to Covid-19,” by Christopher Rowland

Joanne Kenen: Politico’s “Sadness and Death: Inside the VA’s State Nursing-Home Disaster,” by Joanne Kenen, Allan James Vestal and Darius Tahir

Tami Luhby: CNN’s “My Son Was Lucky to Get a Pediatric ICU Bed When He Needed One. He Shouldn’t Have Needed Luck,” by Ben Tinker

Sarah Karlin-Smith: The New Yorker’s “Costa Ricans Live Longer Than Us. What’s the Secret?” by Atul Gawande

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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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Apple, Bose and Others Pump Up the Volume on Hearing Aid Options, Filling Void Left by FDA

Thu, 08/26/2021 - 5:00am

Spurred by decades of complaints about the high cost of hearing aids, Congress passed a law in 2017 to allow over-the-counter sales, with hopes it would boost competition and lower prices.

Four years later, federal regulators have yet to issue rules to implement the law. But changes in the industry are offering consumers relief.

In August 2017, President Donald Trump signed the legislation that called for the Food and Drug Administration to issue regulations by 2020 for hearing aids that could be sold in stores without a prescription or a visit to an audiologist or other hearing specialist. That hasn’t happened yet, and President Joe Biden last month ordered the FDA to produce those rules for over-the-counter (OTC) purchases by mid-November. That means it will likely take at least until next summer for consumers to feel the direct effects of the law.

Despite the delay, consumers’ options have expanded with more hearing devices entering the market, alternative ways to get them and lower prices, particularly for the largest segment of the population with impaired hearing — those with mild to moderate hearing loss, for whom the law was intended.

Leading consumer brands Apple and Bose are offering products and several smaller companies sell aids directly to consumers, providing hearing tests and customer service online from audiologists and other hearing specialists. Even major retailers offer hearing aids directly to consumers and provide audiology services online: Walgreens stores in five Southern and Western states sell what the chain calls “FDA-registered” Lexie hearing aids for $799 a pair — far less than half the price of typical devices.

Nationally, personal sound amplification products, or PSAPs, that are smaller and customizable are now available in stores and online. These devices, which look like hearing aids and sell for a fraction of the price, amplify sounds, but some do not address other components of hearing loss, such as distortion.

“There are many more options than there were in 2017 when Trump signed the Hearing Aid Act into law,” said Nancy Williams, president of Auditory Insight, a hearing industry consulting firm in New Haven, Connecticut. “In a sense, you can say the OTC revolution is happening without the FDA, but the difficulty is it is happening more slowly than if the FDA issued its rules on time.”

The price for a pair of standard hearing aids typically ranges from $2,000 to $8,000, depending on the technology. That price includes the professional fitting fees and follow-up visits. The hearing aid industry has remained largely insulated from price competition because of consolidation among manufacturers, widespread state licensing laws that mandate sales through audiologists or other hearing professionals, and the acquisition of hearing professionals’ practices by device makers.

The federal law creates a category of hearing aids that would legally bypass state dispensing laws and enable consumers to buy aids in stores without consulting a hearing aid professional. Users would be expected to program the devices through a smartphone, and companies could offer service via phone or internet.

With an increasing number of hearing aids and PSAPs being sold directly to consumers, advocates are eager for the FDA rules to come out, because they worry about the confusion caused by the array of choices — with none having the FDA’s full seal of approval.

“The FDA delaying regulations has done more harm than good, because the direct-to-consumer market is filling the void and people are doing what they want, and we don’t know the quality of these devices,” said Barbara Kelley, executive director of the Hearing Loss Association of America, a consumer advocacy group.

The law, sponsored by Sen. Elizabeth Warren (D-Mass.), gave the FDA until August 2020 to issue regulations. Last year, after missing that deadline, FDA officials said the covid-19 pandemic had delayed the rule-making process.

Many in the hearing aid industry are concerned about the unchecked competition likely to come with allowing consumers to buy aids on their own without an evaluation by a hearing specialist.

Brandon Sawalich, CEO of Starkey, the largest U.S.-based hearing aid company, said consumers need expert assistance to test their hearing, buy an appropriate aid, properly fit it and fine-tune its settings.

“It’s not just picking up something off the shelf at your local drugstore or ordering something online and putting it in your ear and your life is going to be reconnected and you are going to hear perfectly again,” he said on a recent podcast. “It doesn’t work that way, and it’s not that easy.”

However, by avoiding professional help, more Americans likely can get hearing assistance. “The OTC and direct-to-consumer options open up avenues for those who have no other path to get hearing aids,” said Hope Lanter, a Charlotte, North Carolina, audiologist with Hear.com, a Netherlands-based online hearing aid retailer.

She expects that after the FDA issues its rules many hearing aid manufacturers will develop lower-cost, over-the-counter devices that can be obtained without an audiologist’s evaluation. She said consumers with modest hearing loss may start out with those types of aids, but later, if their hearing worsens, shift to more expensive devices that require assistance from hearing aid professionals.

“In my view, there is enough pie for everyone,” Lanter said, noting that millions of people with hearing loss are not getting any help today. More than 37 million American adults have trouble hearing, including nearly half of people over age 60. Only 1 in 4 adults who could benefit from a hearing aid have ever used one, federal health officials estimate.

Unlike most consumer electronics, hearing aids have remained expensive for decades, generating consumer complaints.

The price is concerning because Medicare and many insurers don’t cover hearing aids, though most private Medicare Advantage plans do. Only about half of state Medicaid programs cover the devices, but benefits in those states vary widely, according to data from KFF.

Industry experts predict new over-the-counter hearing aids will be priced at less than $1,000 a pair — about 25% lower than low-cost retailer Costco sells its Kirkland aids, dispensed through a hearing aid professional.

Without federal rules in place, manufacturers have largely waited to develop devices for the OTC market.

Bose chose a different path. This spring it began selling its hearing aids, which can be purchased online without a doctor visit, hearing test or prescription. Bose gained FDA clearance in 2018 after providing data showing the effectiveness of its self-fitting aids was comparable to that of similar devices fitted by a hearing professional. The Bose aids sell for $849 a pair.

Meanwhile, Apple last year integrated hearing assistance into its popular Air Pods Pro earbuds, which can be customized using settings on an iPhone. Apple is not marketing the free benefit as a hearing aid but instead as similar to a PSAP that amplifies sound to help hearing.

Several companies such as Eargo, Lively and Lexie allow consumers to buy aids online and get help from specialists to set them up remotely. As long as companies have generous return policies that enable people to try a couple of aids to see which works best, the proliferation of online options selling high-quality aids is good news for consumers, said Williams, the Connecticut hearing consultant.

Lanter said the stigma around hearing aids will be reduced as people obtain them more easily. She predicted consumers will someday buy hearing aids much as they can buy inexpensive reading eyeglasses at the drugstore today with the option to get a prescription for higher-quality glasses or ones with a more precise fit.

Michelle Arnold, an audiologist and assistant professor at the University of South Florida, said there is no evidence consumers will be harmed buying a hearing aid without seeing an audiologist, and the benefits of getting some improvement in their hearing outweigh any risks. “Will people get the maximum benefit? Maybe not, but it’s better than nothing,” 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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