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Feds to Nix Work Requirements in Montana Medicaid Expansion Program

Thu, 08/05/2021 - 5:00am

Federal health officials will likely reject Montana’s request to include work requirements for beneficiaries of its Medicaid expansion program, which insures 100,000 low-income Montana adults, state officials said.

Three years after the Trump administration encouraged states to require proof that adult enrollees are working a certain number of hours or looking for work as a condition of receiving Medicaid expansion benefits, the Centers for Medicare & Medicaid Services has reversed course under Democratic President Joe Biden.

“CMS has communicated to [the Montana Department of Public Health and Human Services] that a five-year extension of the Medicaid expansion waiver will not include work/community engagement requirements,” health officials wrote in a Medicaid waiver amendment application out for public review.

It’s unclear what that means for the future of the Montana program. In 2019, Montana lawmakers approved extending the 2015 program — the Supreme Court made the Medicaid expansion provision in the Affordable Care Act optional for states — as long as it included work requirements. Those requirements were a key condition for the moderate Republicans who joined Democratic lawmakers to muster enough votes to pass the 2019 bill over the objections of conservative GOP legislators.

The state’s position officially remains that it wants “to condition Medicaid coverage on compliance with work/community engagement requirements,” according to the amendment application. If state negotiators are proposing an alternative, they have not disclosed it.

If CMS does not approve the waiver with the work or community engagement requirements, the state health department will operate Medicaid expansion according to what is approved and await legislative review of the program, said department spokesperson Jon Ebelt.

The Montana Medicaid expansion program is scheduled to end in 2025 if the legislature doesn’t renew it. State lawmakers meet every other year, giving them the 2023 and 2025 sessions to consider changes to the popular program, which enrolls 10% of the state’s population.

Meanwhile, Republican-led lawmakers and Republican Gov. Greg Gianforte’s administration have supported other measures designed to trim the Medicaid expansion rolls and defray costs, including raising the premiums some enrollees pay and ending a provision that allows 12 months of continuous eligibility regardless of changes in income. Those proposals are also pending federal approval, and it was in the state’s application for the 12-month continuous eligibility waiver that the status of the work requirement negotiations was disclosed.

In June, the number of Montanans enrolled in the expansion program passed 100,000 for the first time in its 5½-year history. The program provides health insurance coverage to adults who earn up to 138% of the federal poverty level, which is $26,500 for a family of four.

The negotiations between state and federal health officials involve what’s called a Section 1115 waiver amendment application to CMS, which is made when a state Medicaid program seeks to deviate from federal requirements. CMS’ deadline for acting on the application, originally submitted in 2019, was extended to Dec. 31, 2021, because of the covid-19 pandemic.

The Trump administration approved work requirement waivers in 12 other states, though no states are implementing those requirements, either because of the pandemic or lawsuits, according to research by KFF. (KHN is an editorially independent program of KFF.)

Since Biden took office, CMS has withdrawn the Trump administration’s approval of work requirement waivers in Arizona, Arkansas, Indiana, Michigan, New Hampshire and Wisconsin.

Asked to comment about the Montana negotiations, CMS officials said Medicaid is a lifeline for millions of Americans who would be put at risk by work requirements.

“The pandemic and uncertainty surrounding its long-term social, health, and economic effects exacerbate the risks associated with tying Medicaid eligibility to requirements that have been demonstrated to result in significant coverage losses and substantial harm to beneficiaries,” an unattributed CMS statement said.

Montana health department officials said in their waiver application that they expect negotiations with CMS to be finalized in the fall and the Medicaid waiver to be extended for five years starting in January. That Jan. 1, 2027, end date of the waiver, presumably without work requirements, would be subject to the state’s own 2025 sunset.

The 2019 state law granting a six-year extension to the Medicaid expansion included the condition that work and community engagement be part of it. The law states beneficiaries must work at least 80 hours each month or be engaged in a job search or volunteer work, unless they are exempt for specific reasons, such as pregnancy, disability or mental illness.

State Rep. Ed Buttrey (R-Great Falls), who sponsored both the 2019 bill and the 2015 bill that created the original Montana Medicaid expansion program, said lawmakers added the 2025 sunset so that they could assess and revise the program, if needed.

“So in a couple sessions we’ll have to take another look at the program and the federal rules and find out how things are performing and how we want to move forward.” Buttrey said.

He defended work requirements, saying the goal of Medicaid expansion has always been to create a healthy workforce to improve Montana’s economy.

State Rep. Mary Caferro (D-Helena) said work requirements can cause unnecessary hurdles for people who qualify for the Medicaid expansion program. She said that 7 in 10 Montanans who gained Medicaid coverage under the expansion are already working and that the rest can’t for various reasons, such as they are caregivers, have an illness or are going to school.

“Work requirements don’t make sense for our particular population,” Caferro said.

The disclosure of the ongoing work requirement negotiations was made in an application that seeks to eliminate 12-month continuous eligibility for Medicaid expansion beneficiaries plus a separate group of Medicaid beneficiaries with severe disabling mental illnesses.

Currently, those people are enrolled in the Medicaid expansion program for a full year regardless of changes in income or assets. The proposed change, included in the state budget passed by lawmakers earlier this year, would kick enrollees out of the program if their income rises — even if only temporarily because of a one-time payment or seasonal work.

The state also proposes increasing premium payments for certain expansion beneficiaries to up to 4% of their household income in the same waiver application that proposes work requirements.

Buttrey said the goal was to offset the costs of Medicaid so that the people benefiting from it bore some of the costs, and hopes CMS will approve the proposal.

The public comment period for the state’s waiver applications is open until Aug. 31. A legislative committee is scheduled to meet Tuesday to review the proposals.

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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Providence-KP Team Up to Attract Patients in California’s Growing High Desert Region

Thu, 08/05/2021 - 5:00am

A plan by Providence and Kaiser Permanente to build a new medical center in the High Desert region of California is the latest example of leading hospital chains seeking market advantage.

They intend to spend up to $1 billion to build a hospital in Victorville, a city of about 123,000 that sits 85 miles northeast of Los Angeles. The site is only 11 miles from a hospital Providence already owns, and plans to close, in the adjoining city of Apple Valley. The new site is next to Interstate 15, a major artery that cuts across a swath of the Mojave Desert and through the San Bernardino Mountains toward the more populous cities of Fontana, Riverside and San Bernardino. That location should help ratchet up market share in an area whose population has skyrocketed over the past four decades. Victorville’s population has nearly doubled since 2000.

The unusual pairing of very different health care giants — a Catholic chain and an HMO-only model — will result in a facility available to both systems’ patients. But Kaiser Permanente members won’t be able to get certain reproductive services, including abortion, at the hospital because of Providence’s Roman Catholic affiliation.

According to a filing with the state, the new hospital will be fully functional by 2028. KP will contribute 30% of the capital to build it, and Providence 70%. Providence and KP hope to win state approval for their plan and sign a definitive agreement by year’s end.

The new facility will help the partners take on their two main Victorville competitors — Desert Valley Hospital, owned by Prime Healthcare Services, and Victor Valley Global Medical Center, owned by KPC Health. Prime is a large national health care system, though not as large as Providence, which is the nation’s 10th-largest. Kaiser Permanente, which is both an insurer and a provider, has 39 hospitals and 724 medical offices across eight states and Washington, D.C. (KHN is not affiliated with Kaiser Permanente.)

A key part of the plan is for Renton, Washington-based Providence to close its 65-year-old St. Mary Medical Center in Apple Valley. It says costly upgrades required under looming state earthquake mandates don’t make economic sense.

“Retrofitting the current hospital would cost close to the same amount as building the new hospital, but you’d have to do it while operating the hospital,” said Erik Wexler, president of Providence South, which includes the group’s operations in California, Texas and New Mexico.

The seismic mandates require that by 2030 all hospital buildings used for patient care be capable of functioning in the aftermath of a major earthquake. The California Hospital Association, the industry’s main lobbying group, and seven other hospital advocacy groups are trying to persuade state lawmakers to soften the law. They warn it would cost California hospitals over $100 billion and force many to close.

The costs of meeting seismic safety codes have also factored into the business decisions of other California hospitals.

In December 2017, Pacific Alliance Medical Center in Los Angeles closed, citing the financial burden of seismic retrofitting. Sutter Health has said it will shut its Alta Bates hospital in Berkeley by 2030 because meeting the state seismic standards would not be cost-effective.

But the Providence-KP deal is as much about competition as it is about earthquake readiness. Even if hospital lobbyists persuade state lawmakers to soften the requirements, there’s no turning back on the project, Wexler said.

Though Providence has 51 hospitals in seven states, associating with KP can burnish its credentials. KP, for its part, would get a local hospital where its approximately 110,000 members in the region can go for more than just emergency care.

That makes the deal advantageous for KP members. At present, they can use St. Mary, Desert Valley or Victor Valley Global for emergency services. But for any nonemergency hospital care, they must travel to the nearest KP hospital, 40 miles away in Fontana.

If the proposal goes through, they will have a hospital for almost all their needs much closer to home, said Bill Caswell, a senior vice president at Kaiser Permanente.

That means reduced spending on emergency care for KP members at other hospitals in Victorville — including the one owned by Prime Healthcare, with which KP has a history of mutual hostility.

And having a local hospital could help KP increase its membership in the High Desert, said Kevin Holloran, who oversees financial analysis of nonprofit hospitals at Fitch Ratings, which provides credit ratings and research for investors.

Some employers and individuals prefer KP but are put off by its lack of a nearby hospital, so they sign up with other large insurance companies such as Blue Shield of California, Anthem Blue Cross, Cigna or Aetna, Holloran said. Having a Kaiser Permanente-affiliated hospital in their community might persuade them to switch, which could ultimately draw business away from Prime, KPC and even Providence-affiliated physicians, he said.

Kaiser Permanente has affiliations with 12 other hospitals across California allowing its members full access.

KP doctors will be full-fledged members of the medical staff at the new hospital, but it will be operated by Providence, which follows Catholic health care directives that prohibit abortions, insertion of birth control devices and certain other forms of reproductive care. The KP doctors will be bound by those directives while working in the hospital.

Providence is currently embroiled in a legal battle with Orange County’s Hoag Hospital, one of its affiliates, in part over allegations by Hoag that Providence illegally restricts reproductive care for Hoag patients.

Unlike Hoag, KP can accommodate its members’ reproductive health care needs at its existing facilities, including medical offices in Victorville and nearby Hesperia and its Fontana hospital, Caswell said.

The Providence-KP plan is unsettling to many residents of Apple Valley, a town a little more than half the size of Victorville. St. Mary is the town’s biggest employer and has been around since 1956. The new hospital would be Victorville’s third, while Apple Valley would be left with none.

“My main concern is that the people in Apple Valley would have to go quite a bit farther for a hospital,” said Yvonne Spallino, an 85-year-old Apple Valley resident. “Why don’t they build one over here? Why is it over there?”

Scott Nassif, a member of the Apple Valley Town Council who sits on the board of the St. Mary Medical Center Foundation, said many people in Apple Valley felt blindsided by the news their hospital would close.

“We worked so hard to have that hospital. The original developers of Apple Valley donated the land for it. Residents have financially supported it, and all of a sudden, ‘Poof — thank you, but we’re moving,’” said Nassif. “Everybody is still a little bit in shock.”

The loss of nearby emergency care would hurt Apple Valley residents the most, Nassif said. Eleven miles doesn’t sound like much, but it can take more than a half-hour to get to the site of the new hospital if traffic is heavy, he said.

Nassif, who lives close to St. Mary, is keenly aware of that time factor. One night in 2016, he began having severe chest pains and was rushed to the emergency room. “Basically, when I got there, I was on my way out,” he said. “If I’d had to go anywhere else, I probably wouldn’t be around.”

There has been talk of converting St. Mary to an emergency care-only facility. At present, state law does not allow standalone emergency rooms, but there is a move afoot to modify that law.

If such a law were to pass, Wexler said, Providence would consider an ER at the Apple Valley site, but he added, “We can’t commit to doing it.”

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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Análisis: ¿No quieres una vacuna? Prepárate para pagar más por tu seguro de salud

Wed, 08/04/2021 - 5:14pm

La tasa de vacunación contra covid-19 en Estados Unidos es de alrededor del 60% desde los 12 años en adelante. Esto no es suficiente para alcanzar la llamada inmunidad colectiva, y en estados como Missouri, donde varios condados tienen tasas de vacunación inferiores al 25%, los hospitales están abrumados por brotes graves de la variante delta, que es más contagiosa.

Los que se resisten a las vacunas ofrecen todo tipo de razones para rechazar las dosis gratuitas y para ignorar los esfuerzos de vacunación. Las campañas que instan a los estadounidenses a vacunarse por su salud, por sus abuelos, por sus vecinos, o por obtener donas gratis no han funcionado. Los estados incluso han realizado loterías con la posibilidad de ganar millones o una beca universitaria.

Así y todo, todavía hay un gran número de personas no vacunadas. Los gobiernos federales, estatales y municipales, así como las empresas privadas, continúan evitando en gran medida los mandatos para sus empleados por temor a que provoquen una reacción violenta.

Entonces, ¿qué tal un argumento económico? Vacúnate contra covid para proteger tu billetera.

Ser hospitalizado con covid en los Estados Unidos generalmente genera facturas enormes. Los casos presentados por los mismos pacientes de covid al proyecto “Bill of the Month” de NPR-Kaiser Health News incluyen una factura de $17,000 por una breve estadía en un hospital en Marietta, Georgia (reducida a aproximadamente $4,000 para un paciente sin seguro bajo una política de “atención de caridad”).

También una cuenta de $104,000 por una hospitalización de 14 días en Miami para un hombre sin seguro; y una factura de posiblemente cientos de miles por una estadía de dos semanas en el hospital, algunos de esos días con ventilador, para un turista extranjero en Hawaii cuyo seguro médico de viaje tenía una claúsula de “exclusión pandémica”.

A pesar de que las compañías de seguros negocian precios más bajos y cubren gran parte del costo de la atención, una factura de bolsillo de más de $1,000 por un deducible, más copagos y posiblemente alguna atención fuera de la red, debería ser un incentivo bastante aterrador.

En 2020, antes de las vacunas contra covid, la mayoría de las principales aseguradoras privadas renunciaron a los pagos de los pacientes, desde el coseguro hasta los deducibles, por el tratamiento de covid. Pero muchas, si no la mayoría, han permitido que esa política caduque. Aetna, por ejemplo, puso fin a esa política el 28 de febrero; UnitedHealthcare comenzó a revertir sus exenciones a fines del año pasado y las terminó a fines de marzo.

Más del 97% de los pacientes hospitalizados el mes pasado no estaban vacunados. Aunque las vacunas no necesariamente evitarán que contraiga el coronavirus, son muy efectivas para asegurarle que tendrá un caso más leve y se mantendrá fuera del hospital.

Por esta razón, existe una lógica detrás de la reversión de la exención de las aseguradoras: ¿Por qué los pacientes deberían mantenerse financieramente ilesos de lo que ahora es una hospitalización prevenible, gracias a una vacuna que el gobierno pagó y puso a disposición de forma gratuita? Ahora se encuentra en muchas farmacias, está apareciendo en áreas de descanso de las carreteras y en las paradas de autobús, y se puede entregar y administrar en casa en algunas partes del país.

Una sociedad más severa podría imponer duras penas a las personas que se niegan a vacunarse y contraen el virus. Recientemente, la Liga Nacional de Fútbol (NFL) decretó que los equipos perderán un juego si ocurre un brote de covid entre jugadores no vacunados, y los jugadores de ninguno de los equipos recibirán pago.

Pero las aseguradoras podrían intentar hacer más, como penalizar a los no vacunados. Y hay un precedente. Algunas pólizas ya no cubren el tratamiento necesario por lo que las compañías de seguros consideran conductas de riesgo, como el buceo y escalar muros de piedra.

La Ley de Cuidado de Salud a Bajo Precio (ACA) permite a las aseguradoras cobrar a los fumadores hasta un 50% más de lo que pagan los no fumadores por algunos planes de salud. Muchos estados siguen ese protocolo, aunque la mayoría de los planes basados ​​en empleadores no lo hacen.

En 49 estados, las personas descubiertas conduciendo sin seguro de automóvil enfrentan multas, confiscación de su automóvil, pérdida de su licencia e incluso cárcel. Y los conductores imprudentes pagan más por el seguro.

La lógica detrás de las pólizas es que el comportamiento de los que no cumplen con las reglas puede dañar a otros y cuesta a la sociedad mucho dinero.

Si una persona decide no vacunarse y desarrolla un caso grave de covid, no solo está exponiendo a otros en su lugar de trabajo o vecindarios; las decenas o cientos de miles gastados en su atención podrían significar primas más altas para otros que estén en su mismo plan el próximo año.

Es más, los brotes en regiones con poca vacunación podrían ayudar a generar más variantes resistentes a las vacunas que afectan a todos.

Sí, a menudo cubrimos a las personas cuyos hábitos pueden haber contribuido a su enfermedad; el seguro paga regularmente la rehabilitación de drogas y alcohol y el tratamiento del cáncer para los fumadores.

Algunas aseguradoras privadas están ofreciendo a las personas que se vacunan un crédito para sus primas médicas o tarjetas de regalo y premios de sorteos, según America’s Health Insurance Plans, una organización de la industria.

Tal vez sería más fácil si la Administración de Alimentos y Medicamentos otorgara la aprobación total a las vacunas, en lugar de la autorización de uso de emergencia actual. Aun así, los planes financiados por los contribuyentes como Medicaid y Medicare deben tratar a todos por igual y enfrentarían un largo proceso para obtener exenciones federales para experimentar con incentivos, según Larry Levitt, vicepresidente ejecutivo de KFF.

Encuestas de KFF muestran que los incentivos tienen un valor limitado, de todos modos. Muchos de los que rechazan la vacuna dicen que recibirán las dosis solo si sus empleadores lo requieren

Pero, ¿y si el costo financiero de no vacunarse fuera demasiado alto? Si los pacientes pensaran en el precio que podrían tener que pagar por su propia atención, tal vez reconsiderarían permanecer desprotegidos.

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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“Sabiduría y miedo” llevan al 90% de los adultos mayores de EE.UU. a vacunarse contra covid

Wed, 08/04/2021 - 7:42am

En medio del último aumento de casos de covid-19 y hospitalizaciones, Estados Unidos alcanzó el martes 3 de agosto un hito que algunos pensaban que era inalcanzable: el 90% de las personas de 65 años o más están al menos parcialmente vacunadas contra la enfermedad.

Esto es más de 49 millones de adultos mayores vacunados.

En general, el 70% de todos los adultos (de 18 años y más) han sido vacunados, al menos en parte, y casi el 68% de las personas mayores de 12.

“Esto realmente demuestra que nuestros mayores son más sabios que el resto”, dijo el doctor David Wohl, profesor en la división de enfermedades infecciosas y director de las clínicas de vacunación en la Escuela de Medicina de la Universidad de Carolina del Norte.

Wohl dijo que las inclinaciones políticas que han sesgado las tasas de vacunación en todo el país han tenido un impacto mucho menor en los adultos mayores. “La amenaza de covid-19 ha sido tan real para los mayores de 65 años que trasciende muchos de los otros problemas que complican la vacunación”, dijo. “La sabiduría y el miedo realmente han llevado a tasas de inmunización impresionantes”.

La pandemia ha sido especialmente cruel para los adultos mayores. Casi el 80% de las muertes ocurrieron entre personas de 65 años y más. Los hogares y otras instalaciones de atención a largo plazo se vieron muy afectadas, y muchos prohibieron la entrada a familiares y otros visitantes, lo que aisló a los residentes.

Incluso los adultos mayores que viven en sus propias casas tuvieron que aislarse de familiares y amigos para protegerse del coronavirus. Por eso, cuando las vacunas estuvieron disponibles en diciembre, muchos estados se enfocaron primero en las personas mayores.

Ese esfuerzo ha tenido éxito, aunque las tasas varían entre estados. Hawaii, Pennsylvania y Vermont ya vacunaron a más del 99% de sus adultos mayores, mientras que West Virginia ocupa el último lugar, con el 78%.

En Connecticut, el 96% de las personas de 65 años o más están vacunadas contra covid. “No pensé que llegaríamos tan alto, y estoy realmente satisfecho”, dijo el doctor Thomas Balcezak, director médico de Yale New Haven Health. “Pero hasta que todos estén vacunados, las personas mayores todavía corren algún riesgo, aunque su riesgo de enfermedad grave o muerte es mucho menor”.

Agregó que los adultos mayores escucharon claramente el mensaje de que estaban en peligro por covid y que la vacuna podría ayudar. “Pero decir que las personas mayores corren el mayor riesgo es un arma de doble filo en términos de mensaje”, dijo Balcezak. “Puede darles a los adultos jóvenes una falsa sensación de seguridad”.

Entre los cinco hospitales del sistema de salud de Yale tuvieron 57 pacientes covid al lunes 2 de agosto, dijo. Por el contrario, en abril de 2020, cuando el virus se estaba afianzando en todo el país, el sistema tenía alrededor de 850 pacientes con covid.

Otro factor en el impulso exitoso para inocular a los adultos mayores es que han estado más expuestos a las vacunas, dijo Wohl. Por lo general, los médicos aconsejan a las personas mayores que se vacunen contra la gripe, la neumonía, el herpes zóster y otras enfermedades que son especialmente peligrosas para ellos.

Y es probable que muchos recuerden haber recibido la vacuna contra la polio cuando salió por primera vez en la década de 1950.

“Este no es su primer encuentro con las vacunas”, dijo Wohl.

En contraste, es posible que muchos adultos jóvenes no hayan sido vacunados en varias décadas desde que recibieron sus vacunas obligatorias antes de la escuela primaria, dijo.

La vacilación entre algunos adultos jóvenes no vacunados parece sólida. Una encuesta de KFF publicada el miércoles 4 encontró que el 53% de los adultos no vacunados creen que las vacunas representan un riesgo mayor para su salud que covid mismo.

Solo alrededor de una cuarta parte de los que aún no han recibido una vacuna dijeron que probablemente se vacunarán para fin de año, según la encuesta de 1,517 adultos realizada entre el 15 y el 27 de julio.

Sobre la vacunación de los adultos mayores, Jen Kates, vicepresidenta senior de KFF dijo que “es un hito increíblemente significativo, dado el devastador impacto de covid-19 en este grupo”.

Agregó que “alcanzar este objetivo es probablemente una combinación de varias cosas clave. Primero, las personas mayores estaban asustadas: vieron el impacto en su grupo. En segundo lugar, fueron el primer grupo al que se dirigió la distribución de la vacuna contra covid-19. Y tercero, el impulso para vacunar a las personas mayores provino de todos los sectores, republicanos y demócratas, nacionales, estatales y locales. Este fue un esfuerzo concertado a un nivel que no hemos visto para la mayoría de los otros grupos de población”.

El doctor Mark Roberts, profesor y ex presidente del Departamento de Política y Gestión de la Salud de la Escuela de Graduados de Salud Pública de la Universidad de Pittsburgh, advirtió que el éxito del impulso de vacunación entre las personas mayores no significa que otros en este grupo de edad puedan volverse complacientes y creer que están protegidos a través de la inmunidad colectiva.

“La inmunidad colectiva es un fenómeno local”, dijo. “Si las personas que te rodean no están vacunadas en tu burbuja local, no has alcanzado la inmunidad colectiva”.

Funcionarios de AARP, que ha estado llevando a cabo una campaña de educación para vacunar a los adultos mayores, dijeron que el umbral del 90% marca una gran victoria, pero enfatizaron que la campaña no ha terminado.

“Esta es una verdadera historia de éxito en la distribución de vacunas”, dijo Bill Walsh, vicepresidente de comunicación de AARP, quien dirige los esfuerzos de la organización sobre covid. “El 90% es una gran cifra, pero queremos que todos se vacunen”.

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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‘Wisdom and Fear’ Lead 90% of U.S. Seniors to Covid Vaccines

Wed, 08/04/2021 - 5:05am

Amid the latest surge in covid-19 cases and hospitalizations, the United States on Tuesday hit a milestone that some thought was unattainable: 90% of people 65 and older are at least partly vaccinated against the disease.

That’s more than 49 million seniors vaccinated. Overall, 70% of adults have been inoculated, at least partly, and nearly 68% of people over 12.

“This really shows our elders are wiser than the rest of us,” said Dr. David Wohl, professor of medicine in the division of infectious diseases and director of the vaccine clinics at the University of North Carolina School of Medicine.

Wohl said political leanings that have skewed vaccination rates across the country have had much less of an impact on older adults. “The threat of covid-19 is so real for those 65 and over that it transcends many of the other issues that are complicating vaccination rates,” he said. “Wisdom and fear have really led to impressive immunization rates.”

The pandemic has been especially vicious to older adults. Nearly 80% of deaths have been among people age 65 and up. Nursing homes and other long-term care facilities were hit hard, and many banned family members and other visitors from entering, isolating residents. Even older adults living at home often kept their distance from family and friends as they sought to avoid the coronavirus. So when vaccines became available in December, many states targeted seniors first.

That effort has proved successful, although rates vary among states. Hawaii, Pennsylvania and Vermont vaccinated more than 99% of their seniors, while West Virginia ranks last with 78%.

In Connecticut, 96% of people 65 and older are vaccinated against covid. “I didn’t think we would get that high, and I am really pleased about it,” said Dr. Thomas Balcezak, chief medical officer at Yale New Haven Health. “But until everyone is vaccinated, older folks are still at some risk, though their risk of severe disease or death is much less.”

He said older adults clearly heard the message that they were in danger from covid and the vaccine could help. “But saying older folks are at highest risk was a double-edged sword” in terms of messaging, said Balcezak. “That’s because younger adults heard that and it may have given them a wrong sense of security.”

The Yale health system’s five hospitals had 57 covid patients as of Monday, he said. In contrast, in April 2020, as the virus was taking hold across the country, the system had about 850 covid patients.

Another factor in the successful push to inoculate older adults is that they have been exposed to vaccines more than younger adults, said Wohl. Seniors typically are counseled by doctors to get immunizations for flu, pneumonia, shingles and other diseases that are especially risky for them. And many likely remember getting the polio vaccine when it first came out in the 1950s.

“This is not their first vaccine rodeo,” Wohl said.

In contrast, many younger adults may not have been vaccinated in several decades since getting their mandatory immunizations before grade school, he said.

The hesitancy among some unvaccinated younger adults appears stiff. A KFF survey released Wednesday found 53% of unvaccinated adults believe the vaccines pose a bigger risk to their health than covid. Only about a quarter of those who have not yet received a shot said they will likely get immunized by the end of the year, according to the survey of 1,517 adults conducted July 15-27. The margin of error is plus or minus 3 percentage points.

“This is an incredibly significant milestone, given how devastating the impacts of covid-19 were on seniors,” said Jen Kates, a senior vice president at KFF. “Reaching this goal is likely a function of a few key things. First, seniors were scared — they saw the impact on their cohort. Second, seniors were the first group to be targeted for covid-19 vaccine distribution. And third, the push to vaccinate seniors came from all sides, Republican and Democrat, national, state and local. This was a concerted effort at a level we have not seen for most other population groups.”

Dr. Mark Roberts, professor and former chair of the Department of Health Policy and Management at the University of Pittsburgh Graduate School of Public Health, cautioned that the success of the vaccination push among seniors doesn’t mean others in this age group can grow complacent and think they are protected via herd immunity.

“Herd immunity is a local phenomenon,” he said. “If people around you are not vaccinated in your local bubble, you have not reached herd immunity.”

Officials at AARP, which has been running an education campaign to get older adults vaccinated, said the 90% threshold marks a major victory, but the campaign is not over.

“This is a real success story in vaccine distribution,” said Bill Walsh, vice president of communication, who is leading the organization's efforts on covid. “Ninety percent is a great figure, but we want everyone to get vaccinated.”

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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Analysis: Don’t Want a Vaccine? Be Prepared to Pay More for Insurance.

Wed, 08/04/2021 - 5:00am

America’s covid-19 vaccination rate is around 60% for ages 12 and up. That’s not enough to reach so-called herd immunity, and in states like Missouri — where a number of counties have vaccination rates under 25% — hospitals are overwhelmed by serious outbreaks of the more contagious delta variant.

The vaccine resisters offer all kinds of reasons for refusing the free shots and for ignoring efforts to nudge them to get inoculated. Campaigns urging Americans to get vaccinated for their health, for their grandparents, for their neighbors, or to get free doughnuts or a free joint haven’t done the trick. States have even held lotteries with a chance to win millions or a college scholarship.

And yet there are still huge numbers of unvaccinated people. Federal, state and municipal governments as well as private businesses continue to largely avoid mandates for their employees out of fears they will provoke a backlash.

So, how about an economic argument? Get a covid shot to protect your wallet.

Getting hospitalized with covid in the United States typically generates huge bills. Those submitted by covid patients to the NPR-Kaiser Health News “Bill of the Month” project include a $17,000 bill for a brief hospital stay in Marietta, Georgia (reduced to about $4,000 for an uninsured patient under a “charity care” policy); a $104,000 bill for a 14-day hospitalization in Miami for an uninsured man; and a bill for possibly hundreds of thousands for a two-week hospital stay — some of it on a ventilator — for a foreign tourist in Hawaii whose travel health insurance contained a “pandemic exclusion.”

Even though insurance companies negotiate lower prices and cover much of the cost of care, an over $1,000 out-of-pocket bill for a deductible — plus more for copays and possibly some out-of-network care — should be a pretty scary incentive.

In 2020, before covid vaccines, most major private insurers waived patient payments — from coinsurance to deductibles — for covid treatment. But many if not most have allowed that policy to lapse. Aetna, for example, ended that policy Feb. 28; UnitedHealthcare began rolling back its waivers late last year and ended them by the end of March.

More than 97% of hospitalized patients last month were unvaccinated. Though the vaccines will not necessarily prevent you from catching the coronavirus, they are highly effective at assuring you will have a milder case and are kept out of the hospital.

For this reason, there’s logic behind insurers’ waiver rollback: Why should patients be kept financially unharmed from what is now a preventable hospitalization, thanks to a vaccine that the government paid for and made available free of charge? It is now in many drugstores, it’s popping up at highway rest stops and bus stops, and it can be delivered and administered at home in parts of the country.

A harsher society might impose tough penalties on people who refuse vaccinations and contract the virus. Recently, the National Football League decreed that teams will forfeit a game canceled because of a covid outbreak among unvaccinated players — and neither team’s players will be paid.

But insurers could try to do more, like penalizing the unvaccinated. And there is precedent. Already, some policies won’t cover treatment necessitated by what insurance companies deem risky behavior, such as scuba diving and rock climbing.

The Affordable Care Act allows insurers to charge smokers up to 50% more than what nonsmokers pay for some health plans. Four-fifths of states follow that protocol, though most employer-based plans do not do so. In 49 states, people caught driving without auto insurance face fines, confiscation of their car, loss of their license and even jail. And reckless drivers pay more for insurance.

The logic behind the policies is that the offenders’ behavior can hurt others and costs society a lot of money. If a person decides not to get vaccinated and contracts a bad case of covid, they are not only exposing others in their workplace or neighborhoods; the tens or hundreds of thousands spent on their care could mean higher premiums for others as well in their insurance plans next year. What’s more, outbreaks in low-vaccination regions could help breed more vaccine-resistant variants that affect everyone.

Yes, we often cover people whose habits may have contributed to their illness — insurance regularly pays for drug and alcohol rehab and cancer treatment for smokers.

That’s one reason, perhaps, that insurers too have so far favored carrots, not sticks, to get people vaccinated. Some private insurers are offering people who get vaccinated a credit toward their medical premiums, or gift cards and sweepstakes prizes, according to America’s Health Insurance Plans, an industry organization.

Tough love might be easier if the Food and Drug Administration gives vaccines full approval, rather than the current emergency use authorization. Even so, taxpayer-financed plans like Medicaid and Medicare must treat everyone the same and would encounter a lengthy process to secure federal waivers to experiment with incentives, according to Larry Levitt, executive vice president of KFF, a nonprofit focusing on health issues. (Kaiser Health News, where Rosenthal is editor-in-chief, is one program under KFF.) These programs cannot charge different rates to different patients in a state.

KFF polling shows such incentives are of limited value, anyway. Many holdouts say they will be vaccinated only if required to do so by their employers.

But what if the financial cost of not getting vaccinated were just too high? If patients thought about the price they might need to pay for their own care, maybe they would reconsider remaining unprotected.

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

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New Moms Latched On to Remote Breastfeeding Help. Will Demand Wane as Pandemic Fades?

Tue, 08/03/2021 - 5:00am

Madison Cano knew she wanted to breastfeed her son, Theo. But breastfeeding was painful for her. The skin on her breasts was chafed and blistered last July when she returned home from the hospital. And Theo sometimes screamed during feedings.

Cano, 30, realized she needed help to get the short- and long-term health benefits of breastfeeding for moms and babies. New studies also have shown that covid-vaccinated mothers pass protective antibodies on to their newborns. However, Cano lives in Montrose in western Colorado, 60 miles away from her lactation counselor, Ali Reynolds, in Grand Junction — and it was during the thick of the pandemic.

She messaged Reynolds on Facebook and took photos and recorded videos of herself breastfeeding so Reynolds could offer advice and encouragement from afar. It worked. She no longer had pain. Cano is still breastfeeding Theo, who just turned 1.

“I don’t think I would have understood what was happening and been able to work through it without that resource,” said Cano.

Support for breastfeeding was upended last year, when it no longer seemed safe to take a baby class at the hospital or invite a nurse into one’s home. Hospitals, lactation counselors and support groups turned to virtual platforms like Zoom or phone calls. That made lactation support accessible to struggling families during the pandemic, said Danielle Harmon, executive director of the United States Lactation Consultant Association.

Today, although lactation specialists have more options to safely meet in person with families after their covid-19 vaccinations, many are choosing to continue virtual classes, keeping alive the online communities they created and relying on the technology that worked for many families. Virtual options especially help those in remote areas or those with limited transportation access, breastfeeding experts say.

Right before the pandemic, for example, Sandrine Druon typically had one or two moms attend in-person meetings she held for La Leche League of Longmont at the First Evangelical Lutheran Church or at a Ziggi’s Coffee shop. But because they could no longer meet in person, last June she launched two monthly virtual meetings. Now, an online meeting will typically include nine or 10 moms. She started an online Spanish-speaking meeting in May and parents joined from their homes in several states and even from other countries. She hopes eventually to have a mix of online and in-person meetings.

The virtual switch hasn’t worked for everyone. Harmon said the logistics of video support remain difficult, along with privacy concerns on platforms that could be hacked. Other lactation experts noted Black and Hispanic mothers are sometimes still left behind. So lactation specialists are trying to learn from the pandemic on what worked — and what didn’t — to reach all kinds of new parents.

Before the pandemic, 84% of U.S. mothers breastfed at least initially, according to 2019 data from the Centers for Disease Control and Prevention, while Colorado had a 93% rate.

The pandemic hasn’t seemed to change the picture, said Stacy Miller, Colorado’s breastfeeding coordinator for the Special Supplemental Nutrition Program for Women, Infants and Children, shorthanded as WIC. Citing state birth certificate data, Miller said preliminary breastfeeding rates among families discharged from Colorado hospitals remained similar in the first quarter of 2021 to rates from 2020 or 2019.

Throughout the pandemic, lactation specialists have tried to offer convenient options for parents. St. Joseph Hospital in Denver launched virtual breastfeeding support groups that still occur today, in addition to breastfeeding help during families’ hospital stays, said Katie Halverstadt, the hospital’s clinical nurse manager of lactation and family education.

Last year in North Carolina, experts adapted an in-person prenatal breastfeeding program to an interactive video platform in English and Spanish. A separate effort on New York’s Long Island successfully converted in-person breastfeeding support to phone and video calls in 2020.

To help support parents in Grand Junction, Colorado, Reynolds expanded her private practice, Valley Lactation, by offering virtual appointments while continuing to see some clients in their homes. That hybrid model continues today, although Reynolds said the demand for virtual or phone appointments has decreased lately as the country reopens.

Paying out-of-pocket for appointments is a hurdle her clients face, said Reynolds, but she encourages them to submit claims for telehealth or in-person visits to their health insurance companies for reimbursement. Early in the pandemic, telehealth rules were relaxed to encourage more telephone and virtual appointments — many of which have been covered by insurance.

But insurance coverage for lactation support will likely continue to be an issue independent of whether pandemic telehealth rules expire, USLCA’s Harmon said. While the Affordable Care Act mandates that insurance companies cover lactation support and supplies, such as breast pumps, Harmon said reimbursement is often spotty. Mirroring Medicaid, insurance providers often cover services only from licensed providers, she said, but just four states — Georgia, New Mexico, Oregon and Rhode Island — license lactation consultants.

Experts such as Jennifer Schindler-Ruwisch, an assistant professor at Fairfield University in Connecticut, found the pandemic may have exacerbated breastfeeding barriers for those without access to online technology or translation services, among other things. She published one of the first studies in the U.S. to examine covid’s effect on lactation services by collecting experiences from lactation support providers in Connecticut, including many working in WIC programs. For income-eligible WIC families, all breastfeeding classes, peer groups and one-on-one consultations are free.

Birdie Johnson, a doula who provides breastfeeding and other postpartum support to Black families as part of Sacred Seeds Black Doula Collective of Colorado, said virtual support groups during the pandemic also did not meet her clients’ needs for connection and interaction. Social media built communities online, particularly by normalizing breastfeeding struggles among Black parents, she said, but obstacles remained.

“Covid brought our community together and at the same time destroyed it,” Johnson said.

Black parents in the U.S. already had lower rates of breastfeeding than Asian or white parents, according to 2017 CDC data, and both Black and Hispanic parents have had lower rates of exclusively breastfeeding their babies at 6 months, which is what the American Academy of Pediatrics recommends. Socioeconomics and lack of workplace support have been found to contribute to the gap. Research also has found Black mothers are more likely than white moms to be introduced to infant formula at hospitals.

A scarcity of Black health care providers in lactation, women’s health and pediatrics is a continuing concern, Johnson said. In Colorado last year, the Colorado Breastfeeding Coalition, the Center for African American Health, Elephant Circle and Families Forward Resource Center held three training sessions for people of color to become lactation specialists, said Halverstadt, who chairs the coalition.

Jefferson County, which encompasses much of Denver’s western suburbs, is now training at least a dozen Spanish-speaking community members for lactation certification. In addition to classes, the trainees log clinical hours in breastfeeding support, sometimes during virtual meetings of a Spanish-speaking support group called Cuenta Conmigo Lactancia.

“You are more confident and more at ease with someone who knows your language, your culture and who is part of the community,” said Brenda Rodriguez, a dietitian and certified lactation consultant for Jefferson County Public Health, which reaches roughly 400 breastfeeding families each month through its WIC programs.

Angelica Pereda, a maternal and child health registered nurse, is part of that training program. Pereda, who is Hispanic and bilingual, gave birth to son Ahmias in April 2020 and struggled with breastfeeding because he could not latch on to her breasts. A lactation consultant could not come into her home during the pandemic, and she was skeptical of virtual consultations because of privacy concerns. So she pumped her breast milk and bottle-fed it to her son.

Her experience gave her newfound empathy for families, and she wants to help other Spanish-speaking parents find solutions — whether in person or virtually.

“There is just not enough breastfeeding support in general, but especially when that support is in a different language,” said Pereda.

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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Long Drives, Air Travel, Exhausting Waits: What Abortion Requires in the South

Tue, 08/03/2021 - 5:00am

MEMPHIS, Tenn. — Just a quick walk through the parking lot of Choices-Memphis Center for Reproductive Health in this legendary music mecca speaks volumes about access to abortion in the American South. Parked alongside the polished SUVs and weathered sedans with Tennessee license plates are cars from Mississippi, Arkansas, Florida and, on many days, Alabama, Georgia and Texas.

Choices is one of two abortion clinics in the Memphis metro area, with a population of 1.3 million. While that might seem a surprisingly limited number of options for women seeking a commonplace medical procedure, it represents a wealth of access compared with Mississippi, which has one abortion clinic for the entire state of 3 million people.

A tsunami of restrictive abortion regulations enacted by Republican-led legislatures and governors across the South have sent women who want or need an early end to a pregnancy fleeing in all directions, making long drives or plane trips across state lines to find safe, professional services. For many women, that also requires taking time off work, arranging child care and finding transportation and lodging, sharply increasing the anxiety, expense and logistical complications of what is often a profoundly difficult moment in a woman’s life.

“Especially for women coming from long distances, child care is the biggest thing,” said Sue Burbano, a patient educator and financial assistance coordinator at Choices. “They’re coming all the way from Oxford, Mississippi, or Jackson. This is a three-day ordeal. I can just see how exhausted they are.”

The long drives and wait times could soon spread to other states, as the U.S. Supreme Court prepares this fall to consider a Mississippi ban on nearly all abortions after 15 weeks of pregnancy, with no allowances for cases of rape or incest. Under a law enacted in 2018 by the Republican-led legislature, a woman could obtain a legal abortion only if the pregnancy threatens her life or would cause an “irreversible impairment of a major bodily function.”

Mississippi’s ban was promptly challenged by abortion rights activists and put on hold as a series of lower courts have deemed it unconstitutional under the Supreme Court’s landmark Roe v. Wade decision. That 1973 ruling, in concert with subsequent federal case law, forbids states from banning abortions before “fetal viability,” the point at which a fetus can survive outside the womb, or about 24 weeks into pregnancy.

Tennessee, Texas, Mississippi and several other states have since passed laws that would ban abortions after six weeks. That legislation is also on hold pending legal review.

Groups opposed to abortion rights have cheered the court’s decision to hear the Mississippi case, believing the addition of Justice Amy Coney Barrett gives the court’s conservative bloc enough votes to overturn Roe, or at least vastly expand the authority of individual states to restrict abortion.

But, for supporters of reproductive rights, anything but a firm rejection of the Mississippi ban raises the specter of an even larger expanse of abortion service deserts. Abortion could quickly become illegal in 21 states — including nearly the entire South, the Dakotas and other stretches of the Midwest — should the court rescind the principle that a woman’s right to privacy protects pregnancy decisions.

“If we end up with any kind of decision that goes back to being a states’ rights issue, the entire South is in a very bad way,” said Jennifer Pepper, executive director of Choices in Memphis.

The decades-long strategy by conservative white evangelical Christians to chip away at abortion access state by state has flourished in the South, where hard-right Republicans hold a decisive advantage in state legislatures and nearly all executive chambers.

Though details vary by state, the rules governing abortion providers tend to hit similar notes. Among them are requirements that women seeking abortions, even via an abortion pill, submit to invasive vaginal ultrasounds; mandatory waiting periods of 48 hours between the initial consultation with a provider and the abortion; and complex rules for licensing physicians and technicians and disposing of fetal remains. Some states insist that abortion providers require women to listen to a fetal heartbeat; other providers have been unable to obtain admitting privileges at local hospitals.

“Everything is hard down here,” said Pepper.

The rules also have made some doctors reluctant to perform the procedure. While obstetricians and gynecologists in California, New York, Illinois and elsewhere routinely perform abortions at their medical offices — the same practices where they care for women through pregnancy and delivery — their peers in many Southern states who perform more than a small number of abortions a year must register their practices as abortion clinics. None has done so.

Texas offers an example of how targeted legislation can disrupt a patient’s search for medical care. In 2012, 762 Texans went out of state for abortions, according to researchers at the University of Texas-Austin. Two years later, after then-Gov. Rick Perry signed into law the nation’s most restrictive abortion bill, shuttering about half the state’s abortion facilities, 1,673 women left Texas to seek services. In 2016, 1,800 did so.

Similarly, in March 2020, as the coronavirus pandemic took hold, Gov. Greg Abbott issued an order prohibiting all abortions unless the woman’s life was in danger, deeming the procedure “not medically necessary.” The month before the order, about 150 Texans went out of state to seek abortion services. In March and April, with the order in effect, nearly 950 women sought care outside Texas.

There can also be an unsettling stigma in some parts of the South.

Vikki Brown, 33, who works in education in New Orleans, said she initially tried to end her pregnancy in Louisiana, calling her gynecologist for advice, and was told by a receptionist that she was “disgusted” by the request.

She sought out the lone abortion clinic operating in New Orleans but found it besieged with both protesters and patients. “I knew but didn’t understand how difficult it was to get care,” said Brown, who moved to Louisiana in 2010 from New York City. “The clinic was absolutely full. People were sitting on the floor. It was swamped.” It took her six hours to get an ultrasound, which cost $150, she said.

A friend in Washington, D.C., counseled Brown that “it didn’t have to be like that” and the pair researched clinics in the nation’s capital. She flew to Washington, where she was able to get an abortion the same day and for less than it would have cost her in New Orleans, even including airfare.

“No protesters, no waiting period,” she said. “It was a wildly different experience.”

Atlanta, a Southern transportation hub, has also become a key piece in the frayed quilt of abortion care in the region.

Kwajelyn Jackson, executive director of Feminist Women’s Health Center in Atlanta, said the clinic regularly sees patients from other states, including Alabama, Tennessee, Kentucky and the Carolinas.

These visits often involve long drives or flights, but rarely overnight stays because the state-mandated 24-hour waiting period can begin with a phone consultation rather than an in-person visit. Georgia has many of the same laws other states employ to make clinical operations more burdensome — requirements to cremate fetal remains, for instance, and that abortion providers adhere to the onerous building standards set for outpatient surgical centers — but its urban clinics so far have weathered the strategies.

Jackson said staffers at her clinic are aware of its role as a refuge. “We’ve had patients who were able to get a ride from Alabama, but they weren’t able to get a ride home,” she said. “We had to help them find a ride home. It is so much simpler to go 3 or 4 miles from your home and sleep in your bed at night. That is a luxury that so many of our patients can’t enjoy.”

Many women embarking on a search for a safe abortion are also confronting serious expenses. State Medicaid programs in the South do not pay for abortions, and many private insurers refuse to cover the procedure. In addition, the longer a woman’s abortion is delayed, the more expensive the procedure becomes.

Becca Turchanik, a 32-year-old account manager for a robotics company in Nashville, Tennessee, drove four hours to Atlanta for her abortion in 2019. “We got an appointment in Georgia because that was the only place that had appointments,” she said.

Turchanik said her employer’s health insurance would not cover abortion, and the cost of gas, food, medications and the procedure itself totaled $1,100. Her solution? Take on debt. “I took out a Speedy Cash loan,” she said.

Turchanik had a contraceptive implant when she learned she was six weeks pregnant. She said she was in an unhealthy relationship with a man she discovered to be dishonest, and she decided to end her pregnancy.

“I wish I had a child, but I’m glad it wasn’t his child,” she said. “I have accomplished so much since my abortion. I’m going to make my life better.”

But the emotions of the ordeal have stayed with her. She’s angry that she had to call around from state to state in a panic, and that she was unable to have her abortion close to home, with friends to comfort her.

Others turn to nonprofit groups for financial and logistical support for bus and plane tickets, hotels, child care and medical bills, including the National Abortion Federation, which operates a hotline to help women find providers. Last year, the federation received 100,000 calls from women seeking information, said its president, the Very Rev. Katherine Hancock Ragsdale.

Access Reproductive Care-Southeast, an abortion fund based in Atlanta, has trained over 130 volunteers who pick women up at bus stations, host them at their homes and provide child care. A study published this year in the International Journal of Environmental Research and Public Health examined 10,000 cases of women seeking assistance from ARC-Southeast: 81% were Black, 77% were uninsured or publicly insured, 77% had at least one child, and 58% identified as Christian.

“It’s amazing to see the scope of the people we work with,” said Oriaku Njoku, ARC-Southeast’s co-founder. “The post-Roe reality that y’all are afraid of is the lived reality for folks today in the South.”

A Texas law targets precisely this kind of help, allowing such organizations or individuals to be sued by anyone in the state for helping a woman get an abortion. It could go into effect Sept. 1, though abortion rights advocates are suing to stop the new law.

Despite the controversy surrounding abortion, Choices makes no effort to hide its mission. The modern lime-green building announces itself to its Memphis neighborhood, and the waiting room is artfully decorated, offering services beyond abortion, including delivery of babies and midwifery.

Like other clinics in the South, Choices has to abide by state laws that many abortion supporters find onerous and intrusive, including performing transvaginal ultrasounds and showing the women seeking abortions images from those ultrasounds.

Nonetheless, the clinic is booked full most days with patients from almost all of the eight states that touch Tennessee, a slender handsaw-shaped state that stretches across much of the Deep South. And Katy Deaton, a nurse at the facility, said few women change their minds.

“They’ve put a lot of thought into this hard decision already,” she said. “I don’t think it changes the fact that they’re getting an abortion. But it definitely makes their life harder.”

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

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A Health Care Giant Sold Off Dozens of Hospitals — But Continued Suing Patients

Tue, 08/03/2021 - 5:00am

Tennova Healthcare-Lebanon doesn’t exist anymore as a hospital. But it still sued Hope Cantwell.

A knock came on the door of Cantwell’s Nashville, Tennessee, apartment early this year. She said she hadn’t been vaccinated against covid-19 yet and wasn’t answering the door to strangers. So she didn’t.

But then several more attempts came over the course of a week. Eventually she masked up and opened. A legal assistant served her a lawsuit; she was summoned to appear in court.

“I couldn’t believe someone — someone? a corporation? a company? — was doing this during a pandemic,” Cantwell said.

It started with a hospital visit in May 2019.

Cantwell was admitted for a short stay at Tennova Healthcare-Lebanon, owned at the time by Community Health Systems, a publicly traded company headquartered in Franklin, Tennessee. Her insurance covered most of the stay, but it still left her with $2,700 to pay.

Nearly a year later, she was in a financial position to start chipping away at the bill. She went online to pay but couldn’t find the hospital or its payment portal.

Cantwell did a little Googling and noticed Vanderbilt University Medical Center bought the 245-bed facility around the time of her stay. It’s called Vanderbilt Wilson County Hospital now.

Then the pandemic hit. She was furloughed from work for three months. And soon after, a letter arrived. A law firm representing the former hospital owner demanded payment and threatened to take her to court. She wasn’t sure what to do, since she couldn’t come up with all the cash. She was in a holding pattern until the knock on the door from the legal assistant.

Pandemic Push

A WPLN News investigation found Tennova Healthcare-Lebanon sued more than 1,000 patients, including Cantwell, over the past two years across multiple counties after striking a deal to be sold. And hundreds of those suits were filed during the pandemic, at a time when many companies have backed away from taking patients to court over unpaid medical debt. The state of New York banned the practice.

Community Health Systems is on the tail end of a corporate downsizing that shrank the company from more than 200 hospitals to 84. The sell-off helped stabilize the company after it took on massive debt during a period of rapid growth that briefly gave Community Health Systems more hospitals than any other chain in the country.

But now many of those institutions are like zombie hospitals — little more than a legal entity still taking patients to court even after being sold to new owners that don’t sue over medical bills.

When her summons arrived, panic set in for Cantwell.

“My mind went immediately to the stimulus payments,” she said. “‘At least I have a way to take care of this now.'”

When her final pandemic stimulus money dropped into her bank account, Cantwell said, she sent it straight to the company that had sued her, even though she almost felt like the victim of a scam. She wondered if she really owed all the money or if she qualified for financial assistance since she lost income during the pandemic.

But lawsuits are a rich man’s game. She couldn’t justify trying to find an attorney or fighting a big for-profit company that would pursue her for $2,700.

“I don’t have the resources and emotional and mental capacity to handle anything more than just kind of rolling over and handing over whatever amount of money they would be happy with,” she said.

Community Health Systems’ Debt Problem

Court records indicate Community Health Systems stepped up filing lawsuits against patients in 2015 at the same time its stock price plummeted over concerns about its outsize corporate debt.

Aside from a hospital fire sale, Community Health Systems also aggressively went after patients. And the company didn’t let the pandemic slow that plan, even though it received more than $700 million from the federal government in covid relief money.

A spokesperson for HCA Healthcare, the largest for-profit hospital chain in the country, said its hospitals do not sue patients over unpaid medical debt — during the pandemic or otherwise. The Nashville-based corporation returned all its covid relief funds.

An investigation by CNN found Community Health Systems sued at least 19,000 patients during the pandemic, though the number is likely an undercount given the lawsuits filed on behalf of its former hospitals.

Like Tennova Healthcare-Lebanon, two other Community Health Systems hospitals in Tennessee also continued taking patients to court after selling to Vanderbilt more recently. Community Health Systems held on to its debt in the deals with Vanderbilt and continues to pursue patients who owe it money.

Vanderbilt University Medical Center spokesperson John Howser said Vanderbilt does not sue patients to collect on medical debt.

“Community Health Systems and its subsidiary Tennova Healthcare is a private company that is not owned or operated by Vanderbilt University Medical Center,” Howser wrote in a statement. “As such, VUMC is not involved in these lawsuits.”

Vanderbilt University Medical Center does help run a Community Health Systems-owned hospital in Clarksville, Tennessee, that continues to sue patients, but Howser noted Community Health Systems has the controlling interest.

“The thing is, these aren’t rich people who don’t want to pay their bills,” said Christi Walsh, a nurse practitioner who directs clinical research at Johns Hopkins University. Her team focuses on hospitals suing patients and pressures them to stop. “I’ve been on the ground in the courthouses. These are people who don’t have the money to pay it.”

In Wilson County, Tennessee, a husband and wife were both sued by Tennova Healthcare-Lebanon. He works in a distribution center that shut down for months during the pandemic. She cared for their foster kids and delivered meals with DoorDash, telling WPLN News they were too busy to make their court date.

The problem is, not showing up to face a debt in court can allow a company to take a cut of someone’s paycheck. It also wrecks a person’s financial credit, and the stress can lead to health problems.

‘It Threatens the Public Trust’

Walsh’s team researched the most litigious hospitals in Texas from 2018 to 2020. The top five were all affiliated with Community Health Systems. And the most lawsuits were filed by South Texas Regional Medical Center, which was sold to HCA in 2017. But South Texas Regional Medical Center continued to sue patients.

Marty Makary, a surgeon at Johns Hopkins who wrote a book about health care billing called “The Price We Pay,” said most hospitals have changed tactics. Suing their patients doesn’t make them tons of money after attorney and court fees, and it hurts their brand. But he said Community Health Systems has not expressed such concern.

“Community Health Systems, in all of our research of hospital pricing and billing practices, stands out as an aggressive institution that uniformly, across the country, engages in very aggressive predatory billing — suing patients in court to garnish their wages,” he said.

Even if Community Health Systems is willing to take a hit to its reputation, Makary said, patients think of the health system as a whole. And they’ll think twice next time they need to go to the doctor.

“It threatens the public trust in our community institutions. And medical institutions are supposed to be above those games,” he said.

In a statement to WPLN News, a Community Health Systems spokesperson said the company used its covid relief money to pay for pandemic expenses and make up for lost revenue. In January, the company said it will take patients to court only if they make at least twice the federal poverty level — or about $53,000 annually for a family of four.

“We continually evaluate modifications to our collection practices to support patients who struggle to pay their hospital bills,” spokesperson Rebecca Pitt said.

The policy change is meant to be retroactive. The company will withdraw litigation for anyone who qualifies, Pitt said. Patients who owe Community Health Systems and its former hospitals money are being made aware of the new policy in legal correspondence and can call 800-755-5152 to begin the process to drop a lawsuit, she said.

This story is from a reporting partnership that includes WPLN, 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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Why is the South the Epicenter of Anti-Abortion Fervor?

Tue, 08/03/2021 - 5:00am

Not so long ago, laws governing abortion in Massachusetts and Rhode Island were far more restrictive than those in the Deep South, as state legislators throughout New England regularly banned the procedure, no matter the circumstances, during the 1960s and ’70s.

Nowadays, however, the American South represents a hub of anti-abortion fervor, home to a series of laws and regulations that have eroded Roe v. Wade, as liberal states in the Northeast and elsewhere have enacted laws to codify that landmark 1973 Supreme Court decision.

How that regional reversal came to pass touches on demographic and ideological shifts, as well as a political environment in which few governors or state legislators anywhere claim to be moderates on the issue.

More than anything, the switch can be traced to religion, and how Christian faiths have in some cases become as polarized on the issue of abortion as the views of elected officials who rely on votes of the religious faithful.

Q: Why was famously liberal New England so opposed to abortion?

Two words: The pope.

Daniel Williams, author of “God’s Own Party: The Making of the Christian Right” and “Defenders of the Unborn: The Pro-Life Movement Before Roe v. Wade,” said that in the early 1970s the strongest opposition to abortion came not from Southern evangelicals but from states with strong Catholic ties in the Northeast.

Even as states like Connecticut and Maine were passing bans, states that were home to large populations of more conservative religious denominations allowed women to safely end pregnancies in cases of rape, incest, fetal deformities and when a woman’s life was at risk.

North Carolina was one of the first states to allow for limited legal access to abortion in 1967. Georgia followed in 1968, and South Carolina and Arkansas in 1970. In Texas, a poll taken in 1970 by the Baptist Standard, the periodical of the Baptist convention, found that 90% of its readers — largely pastors and deacons — believed Texas’ abortion laws were too harsh.

Religious scholars say white evangelical Protestants did not support unfettered abortion rights, but without a strong theology about when human life begins, less restrictive abortion laws were not a moral threat. Evangelicals viewed abortion as a Catholic cause.

“The general view among Southern evangelicals in the 1960s and early 1970s was that abortion was ethically problematic,” said Williams, who serves as a professor of history at the University of West Georgia. “But there was no firm biblical support for the Catholic claim that human life began at conception.”

Q: So, why did the South — and Southern evangelicals — change their minds?

One could say it started offshore: In March 1970, Hawaii became the first state to decriminalize abortion, though the law applied only to state residents. Later that year, New York, then led by a Republican governor, Nelson Rockefeller, and a Republican-dominated legislature, went further, allowing women from any state to receive abortion care.

In 1972, some 200,000 women had legal abortions in New York, and 3 of 5 were from out of state. That alarmed many Southerners, who feared that the procedure was being used — and abused — by unmarried women.

“Many of the Baptists in Texas might have thought if a married woman experienced problems with a pregnancy” she should have the option of a safe, legal abortion, said Williams. “They were not envisioning there would be 200,000. This was clearly not a limited procedure in a small number of instances.”

Q: Was it just abortion that worried evangelicals?

Aversion to women’s rights was not limited to reproductive issues: Disaffected by the sexual revolution and the feminist movement, Christian conservative leaders campaigned against the Equal Rights Amendment. They also battled to protect the tax-exempt status of racially segregated private schools and pushed to ban gay teachers from public schools and restore classroom prayer.

As opposition to abortion among Catholic voters and lawmakers eased, white evangelicals and fundamentalists grew more strident on the issue. By the late 1970s, white evangelicals had fully embraced the position that legal abortion was an assault on moral values. As biblicists, committed to the text of the Bible, evangelical leaders found new meaning in certain verses they believed gave credence to prenatal life.

“The connection these conservative evangelicals saw was that when Americans drifted away from God in public life, a change in gender roles came in,” said Williams. “Christianity was being replaced by secular, humanistic, sexual ethics, and Roe v. Wade became the symbol for all of that.”

Q: What role did politics play in the shift?

A major one.

While Catholics are fairly dispersed around the country, white evangelicals are heavily concentrated in Southern states, where true believers often also hold elected office, and thus the power to make laws, said Andrew Lewis, associate professor of political science at the University of Cincinnati.

Mary Ziegler, a professor at Florida State University College of Law and author of “Abortion and the Law in America: Roe v. Wade to the Present,” describes a trifecta that reinforced abortion opposition in the South. “There are a lot of white evangelicals, a lot of Republicans and a lot of gerrymandered swing states,” she said.

The acceleration of state-level abortion restrictions arose from grassroots conservative activists and socially conservative state legislators, not from national Republican Party strategists. “Once the Republican Party took over the South, it did so largely through the efforts of the Christian Coalition” of America, said Williams.

And that connection between white evangelicals and the GOP intensified as the decades passed: By 2009, white evangelicals made up 35% of the Republican Party.

Q: Where does it all stand now?

Nearly 50 years after the U.S. Supreme Court legalized abortion, the South is the most fervently anti-abortion region in the country. And year after year, Southern legislatures have outdone one another, passing ever more restrictive measures on abortion care and criminal punishment to those who provide it. For instance, a 99-year prison sentence for doctors who perform abortions in Alabama. A ban on nearly all abortions after 15 weeks of pregnancy in Mississippi and six weeks in Texas. Rape crisis counselors are subject to lawsuits from private citizens if a woman chooses to end her pregnancy.

Few of these laws have taken effect. Most have been struck down or frozen by the courts and, until last month, the Supreme Court declined to consider many of them. But state legislators, often acting without guidance from national anti-abortion organizations, have continued to introduce anti-abortion bills at a fevered pace. And with the Supreme Court’s rightward shift, many in the movement sense their moment has arrived.

The Democratic Party in the South “generally doesn’t fight” abortion restrictions, Williams said. The party, which counts on the support of Black and Hispanic voters, tends to focus on other priorities, he said. “There is much greater interest in talking about health care and jobs.”

And while many voters, even conservative ones, have shifted to the left on issues like gay rights, Williams said, younger evangelicals are more likely than their parents to oppose abortion.

“The Republican Party has a lot of staying power in Georgia and Alabama and across much of the South for the foreseeable future,” Williams 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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Restoring a Sense of Belonging: The Unsung Importance of Casual Relationships for Older Adults

Mon, 08/02/2021 - 5:00am

In May, Vincent Keenan traveled from Chicago to Charlottesville, Virginia, for a wedding — his first trip out of town since the start of the pandemic.

“Hi there!” he called out to customers at a gas station where he’d stopped on his way to the airport. “How’s your day going?” he said he asked the Transportation Security Administration agent who checked his ID. “Isn’t this wonderful?” he exclaimed to guests at the wedding, most of whom were strangers.

“I was striking up conversations with people I didn’t know everywhere I went,” said Keenan, 65, who retired in December as chief executive officer of the Illinois Academy of Family Physicians. “Even if they just grunted at me, it was a great day.”

It wasn’t only close friends Keenan missed seeing during 15 months of staying home and trying to avoid covid-19. It was also dozens of casual acquaintances and people he ran into at social events, restaurants, church and other venues.

These relationships with people we hardly know or know only superficially are called “weak ties” — a broad and amorphous group that can include anyone from your neighbors or your pharmacist to members of your book group or fellow volunteers at a school.

Like Keenan, who admitted he’s an unabashed extrovert, many older adults are renewing these connections with pleasure after losing touch during the pandemic.

Casual relationships have several benefits, according to researchers who’ve studied them. These ties can cultivate a sense of belonging, provide bursts of positive energy, motivate us to engage in activities, and expose us to new information and opportunities — all without the emotional challenges that often attend close relationships with family and friends.

Multiple studies have found that older adults with a broad array of “weak” as well as “close” ties enjoy better physical and psychological well-being and live longer than people with narrower, less diverse social networks. Also, older adults with broad, diverse social networks have more opportunities to develop new relationships when cherished friends or family members move away or die.

“Feeling connected to other people, not just the people who are closest to you, turns out to be incredibly important,” said Gillian Sandstrom, a senior lecturer in the department of psychology at the University of Essex in England.

Sandstrom’s research has found that people who talk to more acquaintances daily tend to be happier than people who have fewer of these interactions. Even talking to strangers makes people feel less lonely and more trusting, she has discovered.

Claire Lomax, 76, of Oakland, California, who’s unmarried, has made a practice of chatting with strangers all her life. Among her greatest pleasures in recent years was volunteering at the Oakland Police Department, where she would ask patrol officers about their families or what was happening at the station.

“I never wanted a man of my own, but I like to be around them,” she explained. “So, I got to have my guy buzz without any complications, and I felt recognized and appreciated,” Lomax told me. Since becoming fully vaccinated, she’s volunteering in person at the police stations again — a deep source of satisfaction.

Even people who describe themselves as introverts enjoy the positivity that casual interactions can engender.

“In fact, people are more likely to have purely positive experiences with weak ties” because emotional complications are absent, said Katherine Fiori, a prominent researcher and chair of the psychology department at Adelphi University in Garden City, New York.

Lynn Eggers, 75, a retired psychologist in Minneapolis, loved going to coffee shops and the gym before covid hit. “In both places, you can be in a group and alone,” she told me. “You can choose to talk to someone or not. But you feel you’re part of the community.”

At a light-rail station, Eggers would strike up conversations with strangers: two police officers who told her about growing up in Somalia, a working-class Texan whose daughter won a scholarship to Harvard, a young Vietnamese woman whose parents worried she was abandoning her culture.

When Eggers stopped taking public transportation for fear of covid, she missed “getting these glimpses into other ways of seeing the world.” Instead, she started chatting with neighbors in daily walks around her neighborhood — another way to feel connected.

Many people may have found that neighbors, mail carriers and delivery people became more important during the pandemic — simply because they were around when others were not, said Karen Fingerman, a professor of human ecology at the University of Texas-Austin. As pandemic restrictions lift, “the key is to get out in daily life again” and reengage with a variety of people and activities, she recommended.

Helen Bartos, 69, a retired clinical psychologist, lives in a condominium community in Rochester, New York. “With covid, a whole group of us started getting together outside,” she told me. “We’d bring out chairs and drinks, wear masks, and sit around and talk. It was very bonding. All of these people are neighbors; now I would call some of them friends.”

Ellie Mixter-Keller, 66, of Milwaukee, turned to social gatherings sponsored by the activity group Meetup six years ago after a divorce disrupted her life. “It was my salvation. It exposed me to a bunch of new people who I didn’t have to date or have to dinner,” she said. Now that she’s fully vaccinated, she’s busy almost every night of the week attending Meetup events and informal get-togethers arranged by people she’s met.

In some cases, varying views of covid vaccines have made casual interactions more difficult. Patty Beemer, 61, of Hermosa Beach, California, used to go swing-dancing two or three times a week before the pandemic. “It’d be 20 seconds of chitchat and just dance” before all those events were canceled, she said.

In the past several months, however, the swing-dance community in and around Los Angeles has split, with some events requiring proof of vaccination and others open to everyone.

“Before, everyone danced with everyone, without really thinking about it. Now, I don’t know if it’s going to be like that. I’m not sure how much mixing is going to happen,” Beemer said. “And that sense of shared humanity, which is so meaningful to all of us, may be harder to find.”

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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At Urgent Care, He Got 5 Stitches and a Big Surprise: A Plastic Surgeon’s Bill for $1,040

Mon, 08/02/2021 - 5:00am

It was a Sunday morning in late November when Bryan Keller hopped on a bike for a routine ride to pick up his groceries, cruising with ease in a relatively empty New York City.

The surprises came fast and hard: a fall that sent his head into the pavement and left him bleeding profusely and in shock, a trip to an urgent care clinic for five stitches and then a $1,039.50 bill.

Keller’s health insurance covered much of the cost of his visit to the CityMD clinic on Manhattan’s Lower East Side. But it didn’t cover the physician who arrived to stitch his forehead ― an out-of-network plastic surgeon with a Park Avenue office.

“The people at CityMD just said [this] sort of thing is covered as part of an emergency procedure,” said Keller, a regular cyclist who’s lived in New York City for three decades. Even in post-accident “delirium,” he said, he asked several times whether the stitches would be covered by his health insurance because it struck him as unusual that a plastic surgeon would do them.

“It really irked me that, it’s this classic thing you hear in this country all the time,” Keller said. “When you do all the right things, ask all the right questions and you’re still hit with a large bill because of some weird technicality that there’s absolutely no way for you to understand when you’re in the moment.”

Under a law Congress passed last year, many surprise medical bills will be banned starting in January. Patients with private insurance will be protected against unexpected charges for emergency out-of-network care, for treatment by out-of-network providers at in-network facilities and for transport in an air ambulance. But one gray area: visits to urgent care clinics, which have proliferated in recent years as patients seek speed and convenience over waiting hours at an emergency room or weeks to get a regular doctor’s appointment. There are roughly 10,500 urgent care centers in the U.S., according to the Urgent Care Association, which lobbies on their behalf.

Urgent care clinics were not explicitly addressed in the No Surprises Act, but Keller’s experience underscores patients’ predicament ― insurers often try to steer patients to urgent care and away from costly emergency rooms, but individuals could still get hit with large bills in the process. The Biden administration has expressed an interest in prohibiting surprise bills in those clinics, which may treat serious conditions but not life-threatening injuries and illnesses.

In July, several federal agencies issued interim regulations that largely would not protect patients from surprise urgent care bills. Regulation varies significantly across states, and data is scarce on how common surprise bills are in those facilities. Before the surprise billing rules are finalized, the Department of Health and Human Services and three other federal agencies have asked for information on issues such as the frequency of such bills at urgent care facilities and how health insurers contract with the clinics.

The current regulatory gap, if left untouched before the new law takes effect in January, is one that health care experts say could leave patients at risk.

“There’s a real interesting question about whether it should apply to the extent that people perceive these as places to go for an emergency,” said Jack Hoadley, research professor emeritus for Georgetown University’s McCourt School of Public Policy.

CityMD, which was founded by doctors in 2010 and merged with the large medical practice Summit Medical Group in 2019, operates a massive chain of urgent care clinics in New York and New Jersey. Most of its physicians are emergency doctors. The combined enterprise created Summit Health, which is backed by private equity with investments from well-known firms Warburg Pincus ― which acquired CityMD in 2017 ― and Consonance Capital Partners.

Matt Gove, chief marketing officer of Summit Health, confirmed that the plastic surgeon who treated Keller ― Dr. Michael Wolfeld ― has an agreement with the company that allows him to see patients at certain CityMD clinics. Though he was unable to comment on the specifics of Keller’s situation, he said, CityMD’s “normal procedure” is to “make the patient aware that this is available to them and that they can then make the choice as to whether or not it’s important to them to be seen by a plastic surgeon.”

“This is a patient choice,” Gove said. “We certainly don’t require that a patient be seen by Dr. Wolfeld or any other provider.”

But Keller said it was never put to him as an option. “It was framed to me as ‘This is how we do things,’” he said. “In order to have a preference I would have to know that there is an alternative.” Wolfeld did not respond to a request for comment.

Last month the Biden administration proposed prohibiting surprise bills at urgent care centers licensed to perform emergency procedures, essentially treating them as free-standing emergency rooms. Some states, like Arizona, allow urgent care centers to provide emergency services, but they then are considered free-standing ERs, a spokesperson for the state Department of Health Services said. But urgent care centers aren’t licensed as health care facilities in most states, let alone encouraged to provide emergency services, according to health care advocates that have tracked the issue and have pushed for greater government oversight of the industry.

New York, where Keller lives, doesn’t consistently regulate urgent care providers, requiring licenses for some companies but not for CityMD clinics.

Regardless of what’s prescribed in state regulations, what’s considered an “emergency” versus “urgent” can vary by patient. That potentially creates confusion about whether patients would be protected from certain kinds of out-of-network bills if they show up at an urgent care facility for an acute illness or injury.

KHN also found that the urgent care clinic where Keller was treated describes several of its services as emergency care even though many are not meant to treat emergency conditions as envisioned in federal law. For example, the clinic characterizes physical exams, flu shots and vaccinations as emergency medical services. Under federal law, an emergency medical condition is defined as one where the absence of immediate medical attention could seriously jeopardize a patient’s health.

Summit Health spokesperson Gove said the use of the term “emergency” is meant to be “patient-facing and patient-centric, and not having to do with miscategorizing or misrepresenting the nature of the services we provide.”

The provider is “just making it clear to people that when you have something you need done quickly, which you might call personally an emergency, we’re here to do that.” CityMD has never marketed itself as an emergency room designed to treat all emergency conditions, Gove said.

Lou Ellen Horwitz, CEO of the Urgent Care Association, said urgent care clinics are akin to private doctor practices rather than an emergency room or hospital facility that would be subject to broad bans on surprising billing. She said that, even as urgent care clinics grow more common, there’s “no data” to suggest consumer confusion about what they treat.

The association would oppose any federal push to classify these clinics as something akin to independent emergency departments, Horwitz said. Indeed, she said, such a move “contradicts” their very purpose: to treat non-life-threatening injuries and illnesses.

“The standard practice of the industry as well is that we don’t hold ourselves out to be emergency departments,” she said. “The likelihood of this being misunderstood is very low.”

Nationwide, under the Biden administration’s interim regulations, patients needing care for nonemergencies will not be protected if treated by an out-of-network provider at an in-network urgent care facility, according to health care experts. “You don’t have protections if it turns out the doctor or the physician assistant was out of network,” Hoadley said.

A March report from Community Catalyst, a Boston-based health care advocacy organization focused on consumer issues, and the National Health Law Program, a civil rights advocacy group, found that fewer than 10 states issue facility licenses for urgent care clinics. Those licenses give state officials greater leeway to set standards for care, staffing levels, inspections or price transparency, but could also make care more expensive by increasing providers’ expenses.

Without being licensed as a health care facility ― something that exists for hospitals, ambulatory surgery centers and critical access hospitals ― urgent care clinics are generally treated as private physician practices subject to less regulation. “They’re really flying under the radar now in many cases,” said Lois Uttley, director of the Women’s Health Program at Community Catalyst.

Horwitz, however, said the clinics should not be lumped in with those providers because their operations are fundamentally different.

Unlike hospitals and other practices that include facility fees in their charges to patients, “we don’t charge or receive payments as a facility,” she said.

In the midst of an injury, however, making such distinctions can be difficult. Keller said his motivation in going to urgent care was to get his wounds treated quickly instead of waiting hours in an ER, amid a spike in covid-19 cases that would presage the country’s deadly winter. He had also been to that particular CityMD clinic for a covid test, so he knew it accepted his insurance.

Keller hadn’t been wearing a helmet the day of his accident, caused by trying to prevent a bag of groceries from falling off his bike. With a bleeding forehead and banged-up knees and wrists ― Keller brushed a parked car and went off the bike himself ― he was given a tetanus shot and had elevated blood pressure from the shock of the accident. Still, in that moment, he thought it was odd that a plastic surgeon was being called in to give him a handful of stitches, he said.

“It sounds expensive and it sounds like something optional,” he said. “I said, ‘OK, is this going to be covered?’ And they said, ‘Oh, yeah, they should be covered. He does this, he comes here all the time.’”

In New York, CityMD is not subject to facility licensure requirements because it’s considered a private physician practice, said Jeffrey Hammond, a spokesperson for the New York State Department of Health. As a result, rather than more sweeping regulations that would govern the practices of urgent care clinics, state health officials oversee individual practitioners and investigate complaints related to misconduct.

On its website for the location Keller visited, CityMD advertised many of the services it provides as “emergency medical services.” They include physical exams, vaccinations, pediatric care, lab tests, X-rays, and treatment for sore throats and ear infections.

“Just stop by the CityMD walk-in clinic located on 138 Delancey St. between Norfolk and Suffolk St, where quick, reliable, emergency care service is available 365 days a year,” the website reads.

About six weeks after receiving his stitches, Keller said, he went to the same plastic surgeon to get them removed. His health insurer, Aetna, has denied an appeal to fully cover the cost.

“It’s so clear that getting stitches for a wound, for an open bleeding wound, is an emergency procedure to the normal world,” Keller said.

As for his forehead, eight months later, Keller still has a visible scar.

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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12,000 Square Miles Without Obstetrics? It’s a Possibility in West Texas

Mon, 08/02/2021 - 5:00am

The message from Big Bend Regional Medical Center was stark: The only hospital in a sparsely populated region of far West Texas notified local physicians last month that because of a nursing shortage its labor and delivery unit needed to temporarily close its doors and that women in labor should instead be sent to the next closest hospital — an hour’s drive away.

That is, unless the baby’s arrival appears imminent, and the hospital’s unit is shut down at that point. In that case, a woman would deliver in the emergency room, said Dr. Jim Luecke, who has practiced 30-plus years in the area.

But that can be a tough call, he added. Luecke described his concerns for two patients, both nearing their due date, who had previously given birth, boosting the chance of a faster delivery. “They can go from 4 centimeters dilated to completely dilated within a few minutes,” said the family physician, who estimates he’s delivered 3,000 babies.

Some pregnant women already travel an hour and a half or longer to reach the 25-bed Big Bend Regional in Alpine, said Dr. Adrian Billings, another family physician who delivers babies there. “Now to divert these ambulances at least another 60 miles away, it’s asking for more deliveries to happen en route to the hospital, and potentially poor maternal or neonatal outcomes.”

Luecke can’t recall a time when the obstetrics unit at Big Bend Regional has closed.

But it’s happening in other parts of the state: Ten rural hospitals have stopped delivering babies in the past five years or so, leaving 65 out of 157 that still do, according to the Texas Organization of Rural & Community Hospitals.

Hiring and retaining rural nurses has become even more challenging amid the pandemic as nurses have been recruited to work in urban covid-19 hot spots and sometimes don’t return to their communities, said John Henderson, chief executive officer at TORCH. More recently, some Texas hospitals have offered signing bonuses of $10,000 or more as they jockey for nurses, he said. “Covid has caused a resetting of market rates and a reshuffling of nurse staffing.”

The circumstances at Big Bend Regional, which serves a 12,000-square-mile area (about the size of Maryland), illustrates the ripple effects of potentially losing obstetric services across a broader region. The hospital, owned by Quorum Health Corp., serves a swath that extends southwest to the Mexican border and includes Big Bend National Park as well as the communities of Presidio and Candelaria. The nearest hospital, the 25-bed Pecos County Memorial in Fort Stockton, is 68 miles northeast of Alpine.

As of late July, Big Bend Regional’s obstetrics services remained in flux, with the unit closed for four- and five-day stretches, said Billings. Physicians have been told that the unit would typically remain open only Monday morning through Thursday morning of each week until more nurses arrive, he said.

The staffing crisis highlights the need for more state and national efforts to train rural nurses and other clinicians, Billings added. “The big concern that I have is that, if we don’t fix this, this could be the beginning of a rural maternity care desert out here in the Big Bend.”

The hospital, which delivered 136 babies last year, said it is “working feverishly to ensure adequate staffing levels in the coming weeks,” recruiting to fill 10 nursing positions in the labor and delivery unit, according to a statement to KHN. “When our hospital is on diversion for elective OB patients, we communicate in advance with nearby emergency transport services and acute care providers to ensure continuity of care,” the statement said.

Kelly Jones of Alpine, who worried she was having contractions, couldn’t get anyone to pick up the phone for a few hours at Big Bend’s unit in mid-July. She decided to drop off her son at a friend’s house and head to the hospital.

Jones, who is nearly full term, knew the unit had been closed a few days earlier that month but didn’t realize that closures were still occurring. “I went in and said, ‘I think I’m in labor.’ They were like, ‘Well, you can’t go into labor and delivery because they’re closed. So we’re going to take you to the ER.’” In the end, medical personnel determined she wasn’t going to deliver that day and she went home.

Since the hospital first alerted doctors last month, the unit has been on diversion July 5-9, July 14-18 and then again July 22 until Sunday, July 25, according to Billings. Efforts were being made to recruit nurses from Odessa, 150 miles away, to fill in, but the outcome was uncertain, Billings said.

Luecke scheduled an induction for one patient for July 26, when her pregnancy would be at 39 weeks — a week short of full term — and the unit was scheduled to be open. “We are trying to induce them [women] on the days that they [the hospital’s unit] are open,” he said.

Jones, who is being cared for by another physician, is scheduled for induction Aug. 2, at 39 weeks. “For a while, I was not sleeping. I was really stressed. I was panicking about every scenario,” said the 30-year-old, whose pregnancy was initially considered high risk because her son had been born prematurely.

But Jones felt better once her induction date was set. And what if the baby arrives sooner and the unit is closed? She’s been told to go to the ER, to be taken from there by ambulance to the local airport and flown to Fort Stockton.

Malynda Richardson, director of emergency medical services for the town of Presidio, which sits along the Mexican border about 90 miles from Alpine, said its first responders transport more than two dozen women with pregnancy-related issues each year, most of them in labor, including an average of two who deliver en route. First responders, including paramedics, are not typically trained to assess a woman’s cervix for dilation, making it more difficult to gauge imminent delivery, she said.

Also, when responders drive an additional two to three hours round trip to reach Fort Stockton, that affects the Presidio community, which can reliably staff only one ambulance, Richardson said. “What happens when we do have that transport [of a woman in labor] and have to go to Fort Stockton and then we have somebody else down here having a heart attack and we don’t have an ambulance available?”

Rural obstetrics units require far more nurses than doctors to remain open, so diverting women elsewhere in the short term makes sense, said Dr. Tony Ogburn, who chairs the department of obstetrics and gynecology at the University of Texas Rio Grande Valley School of Medicine. “If you don’t have trained nurses there, it doesn’t matter if you have a physician that can do a C-section or do a delivery; you can’t take care of those patients safely,” he said.

Registered nurses who work in labor and delivery have completed specialized training, such as how to read a fetal heart monitor, so a nurse from the ER or another hospital unit can’t easily step in, Billings said. “It’s kind of like having a small football team or a small soccer team and not being able to pull from the bench,” he said.

Billings said he’s reached out to Dr. Michael Galloway, who chairs the department of obstetrics and gynecology at Texas Tech University Health Sciences Center in Odessa and has been helping coordinate efforts to recruit nurses from that city. But even if Odessa nurses agree to pick up some shifts at Big Bend Regional, they are likely a stopgap solution, said Billings, who questions how long they’d be willing to work so far away from home.

Luecke believes Big Bend Regional administrators are doing everything they can to improve nurse staffing. But, like Billings, he’s worried that these July temporary closures could become longer-term.

“We are hoping August will be a different situation,” Luecke said. “But it’s pretty iffy right now.”

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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