Category: Medicine and Health

When College Athletes Kill Themselves, Healing the Team Becomes the Next Goal

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing “988,” or the Crisis Text Line by texting “HOME” to 741741.

In the weeks after Stanford University soccer goalie Katie Meyer, 22, died by suicide last March, her grieving teammates were inseparable even when not training.

Coaches adjusted practices to give the athletes time and space to make sense of losing their friend and team captain. They offered to cancel the spring season, but the players declined, said Melissa Charloe, who started as a Stanford assistant women’s soccer coach the day Meyer died.

“It’s hard because there’s no playbook on how to do this,” Charloe said.

No playbook exists because, until recently, it was relatively uncommon for student-athletes to die by suicide. But at least five NCAA athletes, including Meyer, ended their lives in a two-month period last year. And a 2021 NCAA poll released in May found that student-athletes say they are experiencing more mental health concerns, anxiety, and depression than they reported in surveys conducted before the covid-19 pandemic took hold in 2020.

Suicide is the second-leading cause of death on college campuses. And despite the overall rise in mental health concerns there, universities have been caught off guard when student-athletes have died by suicide. Traditionally, sports psychologists focused on mental health as it related to performance on the field. Their goal was to help athletes improve physically — jump higher, run faster — not navigate mental health crises, largely because of a misperception that college athletes were less susceptible to mental health concerns.

What little research exists about student athletes and mental health is inconsistent and inconclusive. But many experts thought athletes were insulated from risk factors such as depression and social isolation, in part because physical activity is good for mental health and athletes have a steady stream of people around them, including coaches, trainers, and teammates, said Kim Gorman, director of counseling and psychological services at Western Carolina University.

“They’re kind of used to pain — it’s not so foreign to them,” added organizational psychologist Matt Mishkind, deputy director of the Helen and Arthur E. Johnson Depression Center at the University of Colorado’s Anschutz Medical Campus.

Still, athletes face pressures that their peers in the general student population don’t, such as balancing sports, schoolwork, fears of career-ending injuries, and mistakes that can lead to ridicule that gets amplified on social media. With suicide rates in the general population on the rise and the effects of the pandemic continuing to threaten well-being, high-profile suicides highlight how to deal with the unthinkable — and how to try to prevent it from happening again.

In the wake of such suicides, schools are reevaluating the kind of mental health support they provide. Creating a safe space to talk about grief with someone who understands suicide is a critical first step, said psychologist Doreen Marshall, a vice president at the American Foundation for Suicide Prevention.

“Many professionals are good with grief, but suicide grief can be a little different,” she said, as it often involves guilt and questions about why someone would end their life.

Gina Meyer, Katie’s mother, and her husband, Steve, have developed an initiative, Katie’s Save, to ensure that all students have a trusted advocate to turn to in times of trouble. “We know that the bravest thing you can do is ask for help,” she said.

The Meyers filed a wrongful death lawsuit against Stanford in November alleging that their daughter ended her life after receiving an email from the university about disciplinary action against her. Stanford University spokesperson Dee Mostofi did not answer questions about the case, but Stanford posted a statement on its website saying the Meyers’ suit contains misleading information and the school disagrees with their allegations that it is responsible for Katie’s death.

“Like other colleges and universities across the country, Stanford has seen a sharp increase in demand for mental health counseling and other well-being resources over the last two years,” Mostofi said. “Mental health remains not only an ongoing challenge but our most urgent priority.”

After Meyer died, Stanford provided mental health counselors and a sports psychologist to her teammates, but the players said they lobbied the university to pay for Zoom sessions with a specialist, Kimberly O’Brien, a clinical social worker in the Sports Medicine Division’s Female Athlete Program at Boston Children’s Hospital.

O’Brien has professional and personal experience dealing with sports and suicide: She was an ice hockey player at Harvard in 1998 when one of the athletes in her university house died. “I wasn’t even extremely close to her, but it affected me profoundly,” she said. “There were no resources to deal with it.”

That’s changing. Colleges are trying to hire more mental health therapists to meet increasing and varied needs. Some, including Stanford and Washington State University, are working with The Jed Foundation, which provides suicide prevention programming for high school and college students. And crisis support doesn’t happen just in the student health center: Colleges are establishing campus-wide “postvention” programs to prevent suicide contagion.

After Stanford University soccer goalie Katie Meyer died by suicide in March 2022, her grieving teammates were inseparable. The coaches adjusted practice schedules and asked the team members if they wanted to cancel the season, but they wanted to keep playing. “It’s hard because there’s no playbook on how to do this,” assistant coach Melissa Charloe says. (Tyler Geivett/Stanford Athletics)

Before cross-country runner Sarah Shulze, 21, died by suicide at the University of Wisconsin-Madison in April 2022, the athletics department was expanding its professional mental health support from two staffers to six to help the school’s approximately 800 student-athletes, said David Lacocque, the department’s director of mental health and sport psychology. The department, known until eight months ago as “clinical & sport psychology,” changed its name in part because student-athletes were asking for mental health support.

In addition to scheduled appointments, the sports liaisons attend practices, team meetings, training sessions, and competitions to help normalize mental health concerns.

“Gone are the days when we sit in our office and wait for people to knock on the door and talk to us,” Lacocque said.

Student-athletes can also seek free help from the university’s mental health professionals or providers in the community under contract with the University of Wisconsin athletics department. And some women’s cross-country athletes at the school now keep an eye on their teammates when coaches aren’t around, letting the team’s liaison know if they’re concerned about someone’s mental health.

“We don’t want anyone slipping between the cracks,” said teammate Maddie Mooney. “It’s a hard time for everybody, and everybody grieves at different paces and processes things differently.”

Teammate Victoria Heiligenthal, who shared a house with Shulze, said she avoided talking to campus counselors for months after her close friend died. “I only wanted to be alone or be with my friends who really understood the situation,” she said.

Heiligenthal couldn’t bear to stay in the home where she and Shulze had lived, so the university put her and Mooney up in a hotel for a week, and then she stayed awhile at Mooney’s apartment. Once back in her own place, teammates, coaches, training staff, and psychologists checked in on her and Mooney.

But the real game changer for the two was connecting last spring with Stanford soccer players Sierra Enge and Naomi Girma (who now plays professionally). Enge reached out after seeing something Mooney posted on Instagram. Since then, the four have met via Zoom. They have also talked with O’Brien and will join her on a mental health panel at a conference in Boston in June to talk about their experiences of losing a teammate to suicide.

“It was powerful hearing the parallels,” Heiligenthal said. “It made you realize Maddie and I weren’t alone; there were others who were experiencing similar things to us.”

At the University of Wisconsin-Madison and Stanford, athletes honored their late teammates last fall by raising mental health awareness. At a major meet in October, the Wisconsin runners painted green ribbons on the course, put ribbons in race packets, and contributed to a video. At Stanford’s game against UCLA in November, spectators wore green ribbons to highlight the importance of addressing mental health issues.

Stanford won the game, handing UCLA its first loss of the season. The victory was bittersweet. A year earlier, Meyer had spearheaded the team’s first mental health awareness game.

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Journalists Delve Into Insulin Costs and Prior Authorization Policy

KHN senior correspondent Angela Hart discussed California’s contract with Civica to make lower-cost insulin on KQED’s “Forum” on March 23. She also discussed California’s potential plan to use Medicaid funding to cover up to six months of rent for low-income enrollees on KCBS’ “State of California” on March 22.

KHN South Carolina correspondent Lauren Sausser discussed prior authorization on WNHN’s “The Attitude With Arnie Arnesen” on March 21.

KHN Montana legislative fellow Keely Larson discussed Montana’s vaccine exemption legislation on the Montana Free Press’ “The Session” on March 20.

KHN Midwest correspondent Bram Sable-Smith discussed insulin costs on NPR’s “Weekend Edition Saturday” on March 18.

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Obamacare at 13: Biden and a KHN Reporter Remember

I was back in the crowded East Room of the White House on Thursday, as I was 13 years ago, this time standing under a portrait of first first lady Martha Washington, when President Joe Biden entered for a lunchtime event focused on the Affordable Care Act.

The room looked much the same as it did on March 23, 2010, when I had rushed over to the White House to witness President Barack Obama signing his historic health bill into law. I knew from that moment — standing under a portrait of President Teddy Roosevelt, who was the first chief executive to espouse a need for national health insurance — that my life as a health journalist would never be the same.

Yet, when Biden scheduled an event to commemorate the 13th anniversary of the health law, I was unsure of the need to keep commemorating its birthday.

After all, on the 13th anniversary of President Lyndon Johnson signing Medicare and Medicaid into law — July 30, 1978 — the Democratic president in the White House did not hold an event to commemorate the date when tens of millions of older Americans and lower-income people gained coverage. Then-President Jimmy Carter spent that Sunday at Camp David.

But with the ACA in 2010, after a century of debate, the U.S. health system was getting hit with a thunderbolt that would enable millions of people to gain medical coverage. The law made many changes affecting hospitals, doctors, insurers, drugmakers, and employers in an effort to live up to its lofty name by lowering costs.

Those sweeping provisions, the years spent implementing them, and efforts by Republicans and the courts to repeal or change the law have kept the Affordable Care Act in the news for even longer than I had anticipated. After 13 years, the job is still not done. North Carolina on Thursday became the 40th state to expand Medicaid under the ACA.

Biden used the health law anniversary to tout the law’s influence. He reminded his audience that Republicans still want to strip many of its benefits. He also stressed that the country has unfinished business to lower drug costs for many and expand health coverage to people who still don’t have it. Indeed, more than 2 million people are without coverage in the 10 states — highly populous Florida and Texas among them — that have yet to expand Medicaid.

Many former Obama staffers who helped get the law passed were there — including some who work in the Biden White House. (Obama was not there.) So, too, were several Democratic lawmakers who helped pass the law, including former House speaker Nancy Pelosi and former California congressman and now Health and Human Services Secretary Xavier Becerra.

“Look, 13 years ago today, we gathered in this room as President Obama signed into law the Affordable Health Care Act,” Biden began with his remarks. “Hard to believe 13 days ag- — 13 years ago. It seems like 13 days ago.”

“And I remember the three words I used at the time,” he said as many in the audience recalled the swear word he was caught whispering to Obama via a live microphone. “I thought it was. I thought it was a big deal. And I stand by the fact it was a big deal.”

Biden said that the health law has been called by many names, but that the most appropriate is Obamacare.

The law has become ingrained into the fabric of the country, Biden said. Over 40 million Americans are covered by Medicaid or online insurance marketplace plans, the highest on record, the Biden administration said Thursday. That’s a 36% increase from 2021.

But a 13th anniversary celebration? Jessica Altman, who helped implement Obamacare in the Obama administration and is now CEO of Covered California, one of the Obamacare exchanges, said it was important to take time to remind people what the American health system used to look like as well as the many challenges remaining to improve it. (Altman is the daughter of KFF’s president and CEO. KHN is an editorially independent program of KFF.)

“We still have places to go, and we still have work to do and the people in that room are excited to keep doing it,” Altman said.

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Health Providers Scramble to Keep Remaining Staff Amid Medicaid Rate Debate

Andrew Johnson lets his clients choose what music to play in the car.

As an employee of Family Outreach in Helena, Montana — an organization that assists developmentally disabled people — part of his workday involves driving around, picking up clients, and taking them to work or to run errands.

“What’s up, gangsta?” Johnson said as a client got in the car one day in March.

The pair fist-bumped and Johnson asked what type of music the client liked.

“Gangsta stuff,” came the response. Rap, mainly.

Snoop Dogg played in the background as Johnson and his client drove to McDonald’s, where Johnson helps his client work. The duo washed dishes for two hours in the back of the fast-food restaurant, where it smelled like maple syrup and sulfur.

About two weeks earlier, Johnson testified at a hearing at the Montana Capitol in support of a bill that seeks to raise health providers’ Medicaid reimbursement rates to levels aligned with the average cost of the care they provide. The bill is informed by a 2022 study that recommended benchmark rates after its authors found that Montana Medicaid providers like Family Outreach were being significantly underpaid.

“The provider rates need to be funded so people that work in this field or that work in adjacent fields can have solid ground, a place where you can build a career,” said Johnson, who makes $16.24 per hour in his position as an individual living specialist.

Republican Gov. Greg Gianforte and legislators agree that Medicaid rates need to rise; where they disagree is by how much. The proposals range from the bill Johnson testified for — Democratic Rep. Mary Caferro’s bill to raise rates to the study’s benchmarks — to Gianforte’s plan to fund 91% of that benchmark in 2024 and 86% in 2025.

Meanwhile, the Republicans leading the House Appropriations Committee, a key budget panel, are proposing an average increase of 92% for fiscal year 2024 and 97% in 2025.

Andrew Johnson says his friends think he’s crazy for deciding to work in human services. He knows he made the right career choice for himself, but he still wants to be able to afford a house in Montana someday. (Keely Larson)

Providers and leaders who work in behavioral health, developmental disability, long-term care, and family support services have attended the multiple hearings on rate adjustments, saying thanks for the proposed increases but asking for more. Many providers said the benchmark rates in the study are already outdated.

Providers across the United States say they haven’t seen significant reimbursement increases in more than a decade, according to Shawn Coughlin, president of the National Association for Behavioral Healthcare. Behavioral health can be an afterthought for policymakers, resulting in lower rates than for medical or surgical reimbursement, he said

Michael Barnett, associate professor of health policy and management at the Harvard T.H. Chan School of Public Health, said the supply of staff is inadequate to meet demand for behavioral health care across the U.S.

“And it’s not clear we’re going to meet any of that without paying people more,” Barnett said.

Some health providers have raised wages but still struggled to draw workers and keep the ones they’ve got. Family Outreach raised the wages of some direct care workers from $11 per hour to $12.20 per hour this year, and by more in places where the cost of living is higher, such as Bozeman. But even starting wages of $16 or $18 an hour aren’t attracting enough people to work there, Family Outreach Program Manager Tyler Tobol said.

“It’s a field that not a lot of people want to get into, so those that we can find, I think being able to pay a higher wage, a living wage, I think that would be the best benefit we get out of the rate increase,” Tobol said.

The organization went from 153 employees in 2020 to 128 today. The staffing shortage means employees now focus mainly on making sure clients have the basics — medications and meals — instead of providing additional community integration and activity support services.

At Florence Crittenton in Helena, where moms 18 to 35 with substance use disorders can live with their young kids while undergoing treatment, a mom entered the kitchen where women are taught life skills like learning to cook dinner. The woman told a staff member she was making juice for her child.

“This is where life happens,” said Daniel Champer, Florence Crittenton’s clinical and residential services director.

Executive Director Carrie Krepps said the organization’s two main sources of revenue are Medicaid reimbursements and fundraising. Fundraising, which used to account for 30% of revenue, now makes up between 60% and 70% of the money coming in.

“It’s the reason we’re still open,” Krepps said.

Florence Crittenton’s youth maternity wing has been closed since November 2021 due to staffing difficulties. Previously, teens ages 12-15 stayed in the apartments and received support services from Florence Crittenton. (Keely Larson)
Andrew Johnson says a lot of people with developmental disabilities go to Van’s Thriftway in Helena to get checks cashed. He describes Van’s as an inclusive grocery store. (Keely Larson)

At any given time, an average of 15 to 18 of Florence Crittenton’s 50 staff positions are vacant. If Medicaid rates don’t increase, she said, the organization will have to consider if it can continue operating the recovery home at its current capacity.

“The full rates would just barely cover where we are today,” Krepps said of raising Medicaid reimbursement rates to benchmark levels.

In 2021, Florence Crittenton closed a youth maternity home for pregnant youths and young moms ages 12 to 15, the only home in the state that took teens under 16. Krepps said Florence Crittenton didn’t take Medicaid fees there because the rates were too low.

“It’s heartbreaking,” Champer said. “It’s like clockwork on Monday morning. I come in and see the inquiries and referrals about moms who need treatment and we can’t function at full capacity because we don’t have staff.”

Dennis Sulser, the CEO of Youth Dynamics, which provides home support, case management, and community-based psychiatric rehabilitation across the state, said his organization is paying its staff more than it can afford. Even with the rate increase, he said, they’d only break even.

In the past three years, Youth Dynamics has lost 56 full-time employees. The covid-19 pandemic made people realize they could find other jobs that paid more and even allowed them to stay home, Sulser said.

Andrew Johnson transports a client from his group home to Family Outreach, where the client does janitorial work for the organization. Johnson described this client as his “soul animal,” referring to their similar taste in music. (Keely Larson)

Two years ago, the entry-level pay for Youth Dynamics was $10.70 per hour, and it now averages $13.70. Still, staffing shortages led to the closure of a group home in Boulder and one in Billings, shrinking the organization’s capacity from 80 to 64 beds statewide.

Ashley Santos, program manager for the organization’s three remaining group homes in Boulder, said she is trying to figure out how to attract enough staff to reopen the closed home there. An increase in pay supported by the provider rate increase could give her flexibility to provide extra incentives, she said.

But it’s hard to attract workers when Hardee’s has a starting wage of $18 per hour compared with Youth Dynamics’ $16, she said. And fast-food jobs don’t come with the emotional toll of working with kids who have a severe emotional disturbance diagnosis like PTSD or depression.

Back in Helena, Johnson made his last stop of the day for Family Outreach. He sat next to a client on the couch at the house where the client lives with his mom. Johnson called the number on the back of his client’s debit card to see how much money was left on it before they went out to run errands.

Johnson and the client then headed to a local supermarket. Trips like these give his client a chance to interact with other people, while his mom gets some time to herself.

“You look nice,” Johnson said to the client as they got into the car, the folksy music of Dougie Poole, the choice of Johnson’s previous client, playing in the background.

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

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Sen. Sanders Shows Fire, but Seeks Modest Goals, in His Debut Drug Hearing as Health Chair

Sen. Bernie Sanders, who rose to national prominence criticizing big business in general and the pharmaceutical industry in particular, claimed the spotlight Wednesday on what might at first seem a powerful new stage from which to advance his agenda: chairmanship of the Senate health committee.

But the hearing Sanders used to excoriate a billionaire pharmaceutical executive for raising the price of a covid-19 vaccine showed the challenges the Vermont independent faces.

Though its formal name is the Committee on Health, Education, Labor, and Pensions (HELP), the panel Sanders chairs has little if any authority over drug prices. In the Senate, most of that leverage lies with the Finance Committee, which oversees Medicaid, Medicare, and Obamacare.

As far as drug prices go, the platform Sanders commands is essentially a bully pulpit. So Sanders was left to bully his way toward results. And while some committee Republicans sympathized with his complaints, others bristled at his approach.

By the end of the hearing, seeming to acknowledge the limits of his power, the former presidential candidate was pleading with Moderna chief executive Stéphane Bancel for a relatively modest concession on vaccine pricing.

The CEO made no promises. Then again, pulpit proclamations can lead to corporate action, even if delayed and informal; in the weeks following President Joe Biden’s State of the Union call for cheaper insulin, the companies that make it drastically cut their prices.

Sanders began Wednesday’s hearing with his usual fire and brimstone.

“All over this country people are getting sicker, and in some cases dying, because they can’t afford the outrageous cost of prescription drugs, while companies make huge profits and executives become billionaires,” Sanders thundered.

Bancel had won his place in the witness chair with federal assistance. Moderna, which was founded in 2010 and had not brought a drug to market before the pandemic, received billions in government funds for research, guaranteed purchases, and expert advice to help develop and produce its successful covid vaccine. The payoff has been handsome. As of March 8, Bancel held $3 billion in Moderna stock. He also held options to buy millions of additional shares.

Government research and support are foundational to many of the expensive drugs and vaccines in use today. But Bancel made himself the perfect foil for Sanders when he announced in January that Moderna planned to increase the price of its latest covid shot from about $26 to $110 — or as much as $130.

Denouncing greed, Sanders expounded on his dream of a system in which the government fully funds drug development — and in exchange controls drug prices. “Is there another model out there where, when a lifesaving drug is made, it becomes accessible to all those who need it?” he asked. “What am I missing in thinking that it’s cruel to make a medicine that people can’t afford?’”

Sanders’ overt moralizing and harsh attacks on big business make him an outlier in the Senate, even in his own party. Yet distaste for soaring drug prices extends across the aisle. On the HELP Committee, at least, Republican politicians seem about evenly split between populist and pro-business takes on the problem, showing both the possibilities and the pitfalls that Sanders faces.

Sen. Mike Braun (R-Ind.) expressed disgust with the lack of transparency in the health care system and called Moderna’s planned price hike “preposterous.” Sen. Roger Marshall (R-Kan.) called it “outrageous.”

Sen. Rand Paul (R-Ky.), who often bucks mainstream GOP views and has expressed rancor for the biomedical establishment, claimed Bancel was downplaying vaccine injuries to make money. (Paul vastly exaggerated those risks.)

Ranking member Bill Cassidy (R-La.), who has pledged to work with Sanders, responded to the chairman’s opening remarks with both a hedge and a warning. “I’m not defending salaries or profits,” Cassidy said, but he added that he hoped the hearing’s goal wasn’t to “demonize capitalism.”

Only Sen. Mitt Romney (R-Utah), a former private equity executive, came heartily to Bancel’s defense. “If I’m an investor, I have to expect that if a product I’m backing works, I get to make an awful lot of money,” he said. “I’ve heard people say, ‘That’s corporate greed.’ Yeah, that’s how it works.”

Sanders’ idealized vision of the pharmaceutical industry is, in any case, moot. Even the Biden administration, which successfully browbeat insulin makers into drastically lowering prices in March, revealed this week it would not use “march-in” rights to lower the price of a cancer drug, Xtandi, developed with government-licensed patents.

March-in rights were established in the 1980 Bayh-Dole Act, which enabled companies to license federally funded research and use it to develop drugs. But federal courts and administrations have consistently said the government can seize a product only if the license holder has failed to make it available — not because the price is too high. The administration did, however, announce a review of whether price might be considered in future march-in decisions.

Sanders said before the hearing that he was “extremely disappointed” with the Xtandi decision. But he was ultimately realist enough to aim his bully pulpit at a lower target. Late in Wednesday’s hearing, Sanders pushed for a minimal gimme from Moderna. “Will you reconsider your decision to quadruple the price of your vaccine to the U.S. government and its agents?” he asked politely.

Bancel dodged, saying pricing was more complex now that Moderna faced an uncertain market, had to fill separate syringes with its vaccine, and needed to sell and distribute the vaccine to thousands of pharmacies, where previously the government did all that work. Later, he left open the possibility that negotiations could drive down the price paid by some government agencies or private insurers.

For all the theatrics of such hearings and the mix of opinions among the senators, interrogations of figures like Bancel may help inspire a shift in how the National Institutes of Health “does business in giving away its science to the private sector,” said Tahir Amin, co-executive director of I-MAK, a nonprofit that advocates for equitable access to medicines.

“You have to prosecute it so you at least get these public comments on record,” Amin said. Eventually, he said, this type of hearing could lead to a recognition that, ‘Hey, we need to do this.’”

Despite the HELP Committee’s lack of direct jurisdiction over drug prices, said John McDonough, a Harvard professor who was senior adviser for health reform on the HELP Committee from 2008 to 2010, Sanders “uses his position of authority and influence to draw attention to this in a way that has been helpful.”

KHN correspondent Rachana Pradhan contributed to this report.

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The Policy, and Politics, of Medicare Advantage

The Host

Medicare Advantage, the private-sector alternative to original Medicare, now enrolls nearly half of all Medicare beneficiaries. But it remains controversial because — while most of its subscribers like the extra benefits many plans provide — the program frequently costs the federal government more than if those seniors remained in the fully public program. That controversy is becoming political, as the Biden administration tries to rein in some of those payments without being accused of “cutting” Medicare.

Meanwhile, President Joe Biden has signed a bill to declassify U.S. intelligence about the possible origin of covid-19 in China. And new evidence has emerged potentially linking the virus to raccoon dogs at an animal market in Wuhan, where the virus reportedly first took hold.

This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Among the takeaways from this week’s episode:

  • The Biden administration recently changed the formula used to calculate how much the federal government pays private Medicare Advantage plans to care for patients with serious conditions, amid allegations that many of the health plans overcharge or even defraud the government. Major insurers are making no secret about how lucrative the program can be: Humana recently said it would leave the commercial insurance market and focus on government-funded programs, like its booming Medicare Advantage plans.
  • The formula change is intended to rein in excess spending on Medicare — a huge, costly program at risk of insolvency — yet it has triggered a lobbying blitz, including a vigorous letter-writing campaign in support of the popular Medicare Advantage program. On Capitol Hill, though, party leaders have not stepped up to defend private insurers as aggressively as they have in the past. But the 2024 campaign season could hear the parties trading accusations over whether Biden cut Medicare or, conversely, protected it.
  • The latest maternal mortality rates released by the Centers for Disease Control and Prevention show the problem continued to worsen during the pandemic. Many states have extended Medicaid coverage for a full year after women give birth, in an effort to improve care during that higher-risk period. But other problems limit access to postpartum care. During the pandemic, some women did not get prenatal care. And after the fall of Roe v. Wade, some states are having trouble securing providers — including one rural Idaho hospital, which announced it will stop delivering babies.
  • The federal government will soon declassify intelligence related to the origins of the covid pandemic. In the United States, the fight over what started the pandemic has largely morphed into an issue of political identity, with Republicans favoring the notion that a Chinese lab leak started the global health crisis that killed millions, while Democrats are more likely to believe it was animal transmission tied to a wet market.
  • And in drug price news, Sanofi has become the third major insulin maker (of three) to announce it will reduce the price on some of its insulin products ahead of a U.S. government policy change next year that could have cost the company.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Vice News’ “Inside the Private Group Where Parents Give Ivermectin to Kids With Autism,” by David Gilbert

Jessie Hellmann: The Washington Post’s “Senior Care Is Crushingly Expensive. Boomers Aren’t Ready,” by Christopher Rowland

Joanne Kenen: The New Yorker’s “Will the Ozempic Era Change How We Think About Being Fat and Being Thin?” by Jia Tolentino

Margot Sanger-Katz: Slate’s “You Know What? I’m Not Doing This Anymore,” by Sophie Novack

Also mentioned on this week’s podcast:

To hear all our podcasts, click here.

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

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Being ‘Socially Frail’ Comes With Health Risks for Older Adults

Consider three hypothetical women in their mid-70s, all living alone in identical economic circumstances with the same array of ailments: diabetes, arthritis, and high blood pressure.

Ms. Green stays home most of the time and sometimes goes a week without seeing people. But she’s in frequent touch by phone with friends and relatives, and she takes a virtual class with a discussion group from a nearby college.

Ms. Smith also stays home, but rarely talks to anyone. She has lost contact with friends, stopped going to church, and spends most of her time watching TV.

Ms. Johnson has a wide circle of friends and a busy schedule. She walks with neighbors regularly, volunteers at a school twice a week, goes to church, and is in close touch with her children, who don’t live nearby.

Three sets of social circumstances, three levels of risk should the women experience a fall, bout of pneumonia, or serious deterioration in health.

Of the women, Ms. Johnson would be most likely to get a ride to the doctor or a visit in the hospital, experts suggest. Several people may check on Ms. Green and arrange assistance while she recovers.

But Ms. Smith would be unlikely to get much help and more likely than the others to fare poorly if her health became challenged. She’s what some experts would call “socially vulnerable” or “socially frail.”

Social frailty is a corollary to physical frailty, a set of vulnerabilities (including weakness, exhaustion, unintentional weight loss, slowness, and low physical activity) shown to increase the risk of falls, disability, hospitalization, poor surgical outcomes, admission to a nursing home, and earlier death in older adults.

Essentially, people who are physically frail have less physiological strength and a reduced biological ability to bounce back from illness or injury.

Those who are socially frail similarly have fewer resources to draw upon, but for different reasons — they don’t have close relationships, can’t rely on others for help, aren’t active in community groups or religious organizations, or live in neighborhoods that feel unsafe, among other circumstances. Also, social frailty can entail feeling a lack of control over one’s life or being devalued by others.

Many of these factors have been linked to poor health outcomes in later life, along with so-called social determinants of health — low socioeconomic status, poor nutrition, insecure housing, and inaccessible transportation.

Social frailty assumes that each factor contributes to an older person’s vulnerability and that they interact with and build upon each other. “It’s a more complete picture of older adults’ circumstances than any one factor alone,” said Dr. Melissa Andrew, a professor of geriatric medicine at Dalhousie University in Halifax, Nova Scotia, who published one of the first social vulnerability indices for older adults in 2008.

This way of thinking about older adults’ social lives, and how they influence health outcomes, is getting new attention from experts in the U.S. and elsewhere. In February, researchers at Massachusetts General Hospital and the University of California-San Francisco published a 10-item “social frailty index” in the Proceedings of the National Academy of Sciences journal.

Using data from 8,250 adults 65 and older who participated in the national Health and Retirement Study from 2010 to 2016, the researchers found that the index helped predict an increased risk of death during the period studied in a significant number of older adults, complementing medical tools used for this purpose.

“Our goal is to help clinicians identify older patients who are socially frail and to prompt problem-solving designed to help them cope with various challenges,” said Dr. Sachin Shah, a co-author of the paper and a researcher at Massachusetts General Hospital.

“It adds dimensions of what a clinician should know about their patients beyond current screening instruments, which are focused on physical health,” said Dr. Linda Fried, an internationally known frailty researcher and dean of the Mailman School of Public Health at Columbia University.

Beyond the corridors of medicine, she said, “we need society to build solutions” to issues raised in the index — the ability of seniors to work, volunteer, and engage with other people; the safety and accessibility of neighborhoods in which they live; ageism and discrimination against older adults; and more.

Meanwhile, a team of Chinese researchers recently published a comprehensive review of social frailty in adults age 60 and older, based on results from dozens of studies with about 83,900 participants in Japan, China, Korea, and Europe. They determined that 24% of these older adults, assessed both in hospitals and in the community, were socially frail — a higher portion than those deemed physically frail (12%) or cognitively frail (9%) in separate studies. Most vulnerable were people 75 and older.

What are the implications for health care? “If someone is socially vulnerable, perhaps they’ll need more help at home while they’re recovering from surgery. Or maybe they’ll need someone outside their family circle to be an advocate for them in the hospital,” said Dr. Kenneth Covinsky, a geriatrician at UCSF and co-author of the recent Proceedings of the National Academy of Sciences article.

“I can see a social frailty index being useful in identifying older adults who need extra assistance and directing them to community resources,” said Jennifer Ailshire, an associate professor of gerontology and sociology at the University of Southern California Leonard Davis School of Gerontology.

Unlike other physicians, geriatricians regularly screen older adults for extra needs, albeit without using a well-vetted or consistent set of measures. “I’ll ask, who do you depend on most and how do you depend on them? Do they bring you food? Drive you places? Come by and check on you? Give you their time and attention?” said Dr. William Dale, the Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, a comprehensive cancer center in Duarte, California.

Depending on the patients’ answers, Dale will refer them to a social worker or help modify their plan of care. But, he cautioned, primary care physicians and specialists don’t routinely take the time to do this.

Oak Street Health, a Chicago-based chain of 169 primary care centers for older adults in 21 states and recently purchased by CVS Health, is trying to change that in its clinics, said Dr. Ali Khan, the company’s chief medical officer of value-based care strategy. At least three times a year, medical assistants, social workers, or clinicians ask patients about loneliness and social isolation, barriers to transportation, food insecurity, financial strain, housing quality and safety, access to broadband services, and utility services.

The organization combines these findings with patient-specific medical information in a “global risk assessment” that separates seniors into four tiers of risk, from very high to very low. In turn, this informs the kinds of services provided to patients, the frequency of service delivery, and individual wellness plans, which include social as well as medical priorities.

The central issue, Khan said, is “what is this patient’s ability to continue down a path of resilience in the face of a very complicated health care system?” and what Oak Street Health can do to enhance that.

What’s left out of an approach like this, however, is something crucial to older adults: whether their relationships with other people are positive or negative. That isn’t typically measured, but it’s essential in considering whether their social needs are being met, said Linda Waite, the George Herbert Mead Distinguished Service Professor of sociology at the University of Chicago and director of the National Social Life, Health, and Aging Project.

For seniors who want to think about their own social vulnerability, consider this five-item index, developed by researchers in Japan.

(1) Do you go out less frequently now than last year?

(2) Do you sometimes visit your friends?

(3) Do you feel you are helpful to friends or family?

(4) Do you live alone?

(5) Do you talk to someone every day?

Think about your answers. If you find your responses unsatisfactory, it might be time to reconsider your social circumstances and make a change.

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Legal Questions, Inquiries Intensify Around Noble Health’s Rural Missouri Hospital Closures

A year after private equity-backed Noble Health shuttered two rural Missouri hospitals, patients and former employees grapple with a broken local health system or missing out on millions in unpaid wages and benefits.

The hospitals in Audrain and Callaway counties remain closed as a slew of lawsuits and state and federal investigations grind forward.

In March, Missouri Attorney General Andrew Bailey confirmed a civil investigation. He had previously told local talk radio that there was an “ongoing” investigation into “the hospital issue.”

Bailey’s comment came weeks after the U.S. Department of Labor’s Employee Benefits Security Administration notified executives tied to Noble Health, a startup, that they had violated federal laws and asked them to pay $5.4 million to cover unpaid employee health insurance claims, according to a 13-page letter detailing “interim findings” that was obtained by KHN.

The January letter confirms KHN’s previous reporting, which was informed by employees and patients who described missing paychecks; receiving unexpected, high-dollar medical bills; and going without care, including cancer treatment. According to the letter from federal investigators, the Noble hospitals and their corporate owners collected employee contributions for medical, dental, and vision insurance in 2021 and 2022 but then failed to fund the insurance plans.

The owners and executives were “aware of the harm to participants and, in some cases, were attempting to resolve individual participant complaints,” the letter states, adding that “despite the volume and gravity of complaints and bills received,” they failed to respond.

A photo of a two-year-old boy with spina bifida in a walker.
Ryder Hagedorn was born with spina bifida. His parents have struggled to pay for specialty care since claims were denied by a health plan his mother, Marissa, was offered through her employer. She is one of several former employees of Noble Health who say they were left with substantial medical bills after the company shuttered its two rural Missouri hospitals.(Marissa Hagedorn)

‘Tomfoolery’ and Doing ‘Everybody Dirty’

Marissa Hagedorn, who worked as a hospital laboratory technician, has spent much of the past year starting a new job, caring for her 2-year-old son who was born with spina bifida, and haggling over unpaid medical bills. She told KHN the family owes at least $8,000 for son Ryder’s specialty care in St. Louis, with $6,000 of that in collections. As a Noble employee, Hagedorn said, she was told repeatedly that her employee health insurance would cover Ryder’s care. It didn’t.

Noble has “done everybody dirty,” she said. “We just would like for some responsibility to be taken by this company that didn’t feel the need to get their act together.” Hagedorn’s story of unpaid bills, which was first reported by the local newspaper, the Mexico Ledger, is common among former Noble employees a year after the hospitals closed.

A former employee of the Fulton hospital has filed a class-action lawsuit intended to represent hundreds of employees from both hospitals.

The Jan. 13 letter from federal officials called for responses by Jan. 27 from Noble corporate and hospital executives as well as Platinum Neighbors, which last April bought the hospitals and assumed all liabilities. The letter instructs executives to contact the agency “to discuss how you intend to correct these violations, fund participant claims, and achieve compliance.”

Former employees say their claims have not yet been paid. A Labor Department spokesperson, Grant Vaught, said the agency could not comment on an ongoing investigation.

Separately, the Kansas Department of Labor is reviewing Noble and Platinum’s failure to pay wages and severance to corporate employees. Agency spokesperson Becky Shaffer confirmed that hearings took place in early February on a half-dozen cases totaling more than $1 million in claims for unpaid wages and severance.

Dave Kitchens was among those who filed claims against Noble Health. Kitchens worked briefly as a contract employee and then was hired in October 2021 as a corporate controller, an accounting role in which he was responsible for financial reporting and data analytics. Kitchens provided an audio recording of his hearing to KHN and hopes to eventually get paid more than $90,000 in lost wages, benefits, and severance pay. During the hearing, Kitchens told the administrative judge: “I would just like to be paid what I’m owed.”

Kitchens, who is also named as a fiduciary on the federal investigation, said he was not on Noble’s executive team. When asked by Kansas Administrative Law Judge James Ward whether he expected Noble or the secondary buyer Platinum to pay his wages, Kitchens responded he had “no idea who was in charge.”

“I believe there was some tomfoolery,” Kitchens said.

A ‘Rabbit Hole’ of Responsibility

Noble launched in December 2019 with executives who had never run a hospital, including Donald R. Peterson, a co-founder who prior to joining Noble had been accused of Medicare fraud. Peterson settled that case without admitting wrongdoing and in August 2019 agreed to be excluded for five years from Medicare, Medicaid, and all other taxpayer-funded federal health programs, according to the Health and Human Services Office of Inspector General.

By March 2022, the hospitals had closed and Noble offered explanations on social media, including “a technology issue” and a need to “restructure their operations” to keep the hospitals financially viable. In April, Texas-based Platinum Neighbors paid $2 for the properties and all liabilities, according to the stock purchase agreement.

Despite receiving approval for nearly $20 million in federal covid-19 relief money before it closed the hospitals — funds whose use is still not fully accounted for — Noble had stopped paying its bills, according to court records. Contractors, including nursing agencies, a lab that ran covid tests and landscapers, have filed lawsuits seeking millions.

In Audrain County, where community members still hope to reopen the hospital or build a new one, county leaders filed suit for the repayment of a $1.8 million loan they made to Noble. Former Missouri state senator Jay Wasson also filed suit in September, asking for repayment of a $500,000 loan.

Two Noble Health real estate entities filed bankruptcy petitions this year. One Chapter 11 bankruptcy filing names the Fulton hospital property in Callaway County as an asset and lists nearly $4.9 million in liabilities. A third bankruptcy filing by FMC Clinic includes Noble Health as a codebtor.

In the U.S. District Court of Kansas, Central Bank of the Midwest is suing Nueterra Capital over a $9.6 million loan Noble used to buy the Audrain hospital. The bank alleges Nueterra, a private equity and venture capital firm that in 2022 included Noble as part of its portfolio, signed off as the guarantor of the loan.

Federal investigators listed nearly a dozen people or entities connected to Noble Health as fiduciaries who they say are personally responsible for paying back millions in unpaid medical claims. The letter also detailed Noble Health’s ownership for the first time. The owners included William A. Solomon with a 16.82% share, Thomas W. Carter with a 16.82% share, The Peterson Trust with a 19.63%, and NC Holdings Inc. with 46.72%.

NC Holdings is also listed on the stock sale agreement with Platinum along with several signatures including Jeremy Tasset, chief executive of Nueterra Capital.

Tasset did not respond to a request for comment for this article. In an email to KHN in March 2022, the Nueterra Capital CEO wrote, “We are a minority investor in the real estate and have nothing to do with the operations of the hospitals.” In May 2022, Tasset wrote in an email to KHN that “everything was sold (real estate included) to Platinum Neighbors, a subsidiary of Platinum Team Management.”

It is unclear who owns and controls The Peterson Trust, which federal investigators identified. Peterson, who is listed on Noble’s state registration papers as a director and in other roles, didn’t respond to requests for comment for this article. He previously told KHN that his involvement in Noble didn’t violate his exclusion, in his reading of the law.

He said he owned 3% of the company, citing guidance from the Office of Inspector General for the U.S. Department of Health and Human Services. Federal regulators may exclude companies if someone who is banned has ownership of 5% or more.

In March 2022, Peterson created Noble Health Services, which federal investigators note in their letter was “established to restructure the ownership of multiple Noble entities.” Peterson dissolved that company in July 2022, according to a Missouri business filing.

In September, Peterson posted on LinkedIn that he was “sitting in the Emirates Air lounge in Dubai” to finish up due diligence on “launching a new business.”

A 2013 OIG advisory states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.”

KHN examined the federal system meant to stop health care business owners and executives from repeatedly bilking government health programs and found that it failed to do so.

The OIG keeps a public list of people and businesses it has banned from all federal health care programs, such as Medicare and Medicaid. KHN’s review found a system devoid of oversight and rife with legal gray areas.

In the wake of KHN’s reporting, Oregon Sen. Ron Wyden, a Democrat who is the chair of the powerful Senate Finance Committee, said “it’s imperative that federal watchdogs can ensure bad actors are kept out of Medicare.” Sen. Chuck Grassley (R-Iowa) said the government needs to do more and “it’s also up to private-sector entities to do a better job checking against the exclusions list.”

“We can’t just depend on one or the other to do everything,” Grassley said.

In recent months, the Missouri hospitals appear to have been sold twice more, according to public records. Oregon-based Saint Pio of Pietrelcina notified state officials of a change of ownership in December and requested an extension of the hospital licenses, which was denied. In January, Audrain County officials, in its lawsuit, revealed another owner named Pasture Medical, which registered as a Wyoming company on Dec. 27, 2022.

“We haven’t come out of the rabbit hole on this one,” said Steve Bollin, director of the division of regulation and licensure for the Missouri Department of Health and Senior Services. Bollin’s agency, which conducts inspections and approves hospital changes in ownership, said he would support his agency doing financial reviews.

“It’s probably not a bad idea that someone takes a little bit deeper dive. We don’t have that many changes of ownership, but we would need appropriate staffing to do that, including some really good CPAs [certified public accountants].”

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Fresh Produce Is an Increasingly Popular Prescription for Chronically Ill Patients

When Mackenzie Sachs, a registered dietitian on the Blackfeet Reservation, in northwestern Montana, sees a patient experiencing high blood pressure, diabetes, or another chronic illness, her first thought isn’t necessarily to recommend medication.

Rather, if the patient doesn’t have easy access to fruit and vegetables, she’ll enroll the person in the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access to reduce their cost for healthy foods. Since 2021, Sachs has recommended a fruit-and-vegetable treatment plan to 84 patients. Increased consumption of vitamins, fiber, and minerals has improved those patients’ health, she said.

“The vouchers help me feel confident that the patients will be able to buy the foods I’m recommending they eat,” she said. “I know other dietitians don’t have that assurance.”

Sachs is one of a growing number of health providers across Montana who now have the option to write a different kind of prescription — not for pills, but for produce.

The Montana Produce Prescription Collaborative, or MTPRx, brings together several nonprofits and health care providers across Montana. Led by the Community Food & Agriculture Coalition, the initiative was recently awarded a federal grant of $500,000 to support Montana produce prescription programs throughout the state over the next three years, with the goal of reaching more than 200 people across 14 counties in the first year.

Participating partners screen patients for chronic health conditions and food access. Eligible patients receive prescriptions in the form of vouchers or coupons for fresh fruits and vegetables that can be redeemed at farmers markets, food banks, and stores. During the winter months, when many farmers markets close, MTPRx partners rely more heavily on stores, food banks, and nonprofit food organizations to get fruits and vegetables to patients.

The irony is that rural areas, where food is often grown, can also be food deserts for their residents. Katie Garfield, a researcher and clinical instructor with Harvard’s Food is Medicine project, said produce prescription programs in rural areas are less likely than others to have reliable access to produce through grocers or other retailers. A report from No Kid Hungry concluded 91% of the counties nationwide whose residents have the most difficulty accessing adequate and nutritious food are rural.

“Diet-related chronic illness is really an epidemic in the United States,” Garfield said. “Those high rates of chronic conditions are associated with huge human and economic costs. The idea of being able to bend the curve of diet-related chronic disease needs to be at the forefront of health care policy right now.”

An example of a voucher for fresh produce distributed by the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access on the Blackfeet reservation. (FAST Blackfeet)

Produce prescription programs have been around since the 1960s, when Dr. Jack Geiger opened a clinic in Mound Bayou, a small city in the Mississippi Delta. There, Dr. Geiger saw the need for “social medicine” to treat the chronic health conditions he saw, many the result of poverty. He prescribed food to families with malnourished children and paid for it out of the clinic’s pharmacy budget.

A study by the consulting firm DAISA Enterprises identified 108 produce prescription programs in the U.S., all partnered with health care facilities, that launched between 2010 and 2020, with 30% in the Northeast and 28% in the Midwest. Early results show the promise of integrating produce into a clinician-guided treatment plan, but the viability of the approach is less proven in rural communities such as many of those in Montana.

In Montana, 31,000 children do not have consistent access to food, according to the Montana Food Bank Network. Half of the state’s 56 counties are considered food deserts, where low-income residents must travel more than 10 miles to the nearest supermarket — which is one definition the U.S Department of Agriculture uses for low food access in a rural area.

Research shows long travel distances and lack of transportation are significant barriers to accessing healthy food.

“Living in an agriculturally rich community, it’s easy to assume everyone has access,” said Gretchen Boyer, executive director of Land to Hand Montana. The organization works with nearby health care system Logan Health to provide more than 100 people with regular produce allotments.

“Food and nutritional insecurity are rampant everywhere, and if you grow up in generational poverty you probably haven’t had access to fruits and vegetables at a regular rate your whole life,” Boyer said.

More than 9% of Montana adults have Type 2 diabetes and nearly 35% are pre-diabetic, according to Merry Hutton, regional director of community health investment for Providence, a health care provider that operates clinics throughout western Montana and is one of the MTPRx clinical partners.

Brittany Coburn, a family nurse practitioner at Logan Health, sees these conditions often in the population she serves, but she believes produce prescriptions have tremendous capacity to improve patients’ health.

“Real food matters and increasing fruits and veggies can reverse some forms of diabetes, eliminate elevated cholesterol, and impact blood pressure in a positive way,” she said.

Mackenzie Sachs, a registered dietitian, and Thedra Bird Rattler, a nutrition education specialist, work for FAST Blackfeet. (FAST Blackfeet)

Produce prescription programs have the potential to reduce the costs of treating chronic health conditions that overburden the broader health care system.

“If we treat food as part of health care treatment and prevention plans, we are going to get improved outcomes and reduced health care costs,” Garfield said. “If diet is driving health outcomes in the United States, then diet needs to be a centerpiece of health policy moving forward. Otherwise, it’s a missed opportunity.”

The question is, Do food prescription initiatives work? They typically lack the funding needed to foster long-term, sustainable change, and they often fail to track data that shows the relationship between increased produce consumption and improved health, according to a comprehensive survey of over 6,000 studies on such programs.

Data collection is key for MTPRx, and partners and health care providers track how participation in the program influences participants’ essential health indicators such as blood sugar, lipids, and cholesterol, organizers said.

“We really want to see these results and use them to make this more of a norm,” said Bridget McDonald, the MTPRx program director at CFAC. “We want to make the ‘food is medicine’ movement mainstream.”

Sachs acknowledged that “some conditions can’t usually be reversed,” which means some patients may need medication too.

However, MTPRx partners hope to make the case that produce prescriptions should be considered a viable clinical intervention on a larger scale.

“Together, we may be able to advocate for funding and policy change,” Sachs said.

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End of Covid Emergency Will Usher in Changes Across the US Health System

The Biden administration’s decision to end the covid-19 public health emergency in May will institute sweeping changes across the health care system that go far beyond many people having to pay more for covid tests.

In response to the pandemic, the federal government in 2020 suspended many of its rules on how care is delivered. That transformed essentially every corner of American health care — from hospitals and nursing homes to public health and treatment for people recovering from addiction.

Now, as the government prepares to reverse some of those steps, here’s a glimpse at ways patients will be affected:

Training Rules for Nursing Home Staff Get Stricter

The end of the emergency means nursing homes will have to meet higher standards for training workers.

Advocates for nursing home residents are eager to see the old, tougher training requirements reinstated, but the industry says that move could worsen staffing shortages plaguing facilities nationwide.

In the early days of the pandemic, to help nursing homes function under the virus’s onslaught, the federal government relaxed training requirements. The Centers for Medicare & Medicaid Services instituted a national policy saying nursing homes needn’t follow regulations requiring nurse aides to undergo at least 75 hours of state-approved training. Normally, a nursing home couldn’t employ aides for more than four months unless they met those requirements.

Last year, CMS decided the relaxed training rules would no longer apply nationwide, but states and facilities could ask for permission to be held to the lower standards. As of March, 17 states had such exemptions, according to CMS — Georgia, Indiana, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, New Jersey, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, and Washington — as did 356 individual nursing homes in Arizona, California, Delaware, Florida, Illinois, Iowa, Kansas, Kentucky, Michigan, Nebraska, New Hampshire, North Carolina, Ohio, Oregon, Virginia, Wisconsin, and Washington, D.C.

Nurse aides often provide the most direct and labor-intensive care for residents, including bathing and other hygiene-related tasks, feeding, monitoring vital signs, and keeping rooms clean. Research has shown that nursing homes with staffing instability maintain a lower quality of care.

Advocates for nursing home residents are pleased the training exceptions will end but fear that the quality of care could nevertheless deteriorate. That’s because CMS has signaled that, after the looser standards expire, some of the hours that nurse aides logged during the pandemic could count toward their 75 hours of required training. On-the-job experience, however, is not necessarily a sound substitute for the training workers missed, advocates argue.

Adequate training of aides is crucial so “they know what they’re doing before they provide care, for their own good as well as for the residents,” said Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy.

The American Health Care Association, the largest nursing home lobbying group, released a December survey finding that roughly 4 in 5 facilities were dealing with moderate to high levels of staff shortages.

Treatment Threatened for People Recovering From Addiction

A looming rollback of broader access to buprenorphine, an important medication for people in recovery from opioid addiction, is alarming patients and doctors.

During the public health emergency, the Drug Enforcement Administration said providers could prescribe certain controlled substances virtually or over the phone without first conducting an in-person medical evaluation. One of those drugs, buprenorphine, is an opioid that can prevent debilitating withdrawal symptoms for people trying to recover from addiction to other opioids. Research has shown using it more than halves the risk of overdose.

Amid a national epidemic of opioid addiction, if the expanded policy for buprenorphine ends, “thousands of people are going to die,” said Ryan Hampton, an activist who is in recovery.

The DEA in late February proposed regulations that would partly roll back the prescribing of controlled substances through telemedicine. A clinician could use telemedicine to order an initial 30-day supply of medications such as buprenorphine, Ambien, Valium, and Xanax, but patients would need an in-person evaluation to get a refill.

For another group of drugs, including Adderall, Ritalin, and oxycodone, the DEA proposal would institute tighter controls. Patients seeking those medications would need to see a doctor in person for an initial prescription.

David Herzberg, a historian of drugs at the University at Buffalo, said the DEA’s approach reflects a fundamental challenge in developing drug policy: meeting the needs of people who rely on a drug that can be abused without making that drug too readily available to others.

The DEA, he added, is “clearly seriously wrestling with this problem.”

Hospitals Return to Normal, Somewhat

During the pandemic, CMS has tried to limit problems that could arise if there weren’t enough health care workers to treat patients — especially before there were covid vaccines when workers were at greater risk of getting sick.

For example, CMS allowed hospitals to make broader use of nurse practitioners and physician assistants when caring for Medicare patients. And new physicians not yet credentialed to work at a particular hospital — for example, because governing bodies lacked time to conduct their reviews — could nonetheless practice there.

Other changes during the public health emergency were meant to shore up hospital capacity. Critical access hospitals, small hospitals located in rural areas, didn’t have to comply with federal rules for Medicare stating they were limited to 25 inpatient beds and patients’ stays could not exceed 96 hours, on average.

Once the emergency ends, those exceptions will disappear.

Hospitals are trying to persuade federal officials to maintain multiple covid-era policies beyond the emergency or work with Congress to change the law.

Surveillance of Infectious Diseases Splinters

The way state and local public health departments monitor the spread of disease will change after the emergency ends, because the Department of Health and Human Services won’t be able to require labs to report covid testing data.

Without a uniform, federal requirement, how states and counties track the spread of the coronavirus will vary. In addition, though hospitals will still provide covid data to the federal government, they may do so less frequently.

Public health departments are still getting their arms around the scope of the changes, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

In some ways, the end of the emergency provides public health officials an opportunity to rethink covid surveillance. Compared with the pandemic’s early days, when at-home tests were unavailable and people relied heavily on labs to determine whether they were infected, testing data from labs now reveals less about how the virus is spreading.

Public health officials don’t think “getting all test results from all lab tests is potentially the right strategy anymore,” Hamilton said. Flu surveillance provides a potential alternative model: For influenza, public health departments seek test results from a sampling of labs.

“We’re still trying to work out what’s the best, consistent strategy. And I don’t think we have that yet,” Hamilton said.

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