Tag: Health Care Reform

Lawsuits Claim South Carolina Kids Underwent Unnecessary Genital Exams During Abuse Investigations

Warning: Some readers may find graphic details in this article to be offensive or disturbing.

CAMDEN, S.C. — Three ongoing federal lawsuits filed in South Carolina accuse the state of forcing boys and girls to undergo traumatic genital exams during child abuse investigations, even when no allegations of sexual abuse have been raised.

One 14-year-old plaintiff — who goes by “Jane Doe” to protect her privacy — was placed into foster care in 2021 after she disclosed to a social services caseworker that her mother had spanked her with a belt and a tree branch.

“I never, ever mentioned sexual abuse,” said Jane, who was 12 when the South Carolina Department of Social Services launched its investigation and scheduled her to undergo a forensic medical exam at a hospital in Columbia. “I felt like I was kind of getting legally abused by someone that had the permission to do it,” she told KFF Health News during an interview at her attorney’s office.

During the exam, Jane was instructed to undress and open her legs in front of medical providers she’d never met before who took photos of her genital area, touched her breasts, and placed “fingers and/or instruments” in her vagina, according to her lawsuit.

“I felt like I had no right to say no,” she told KFF Health News. “Something inside me told me that wasn’t what they were supposed to do.”

Connelly-Anne Ragley, a spokesperson for the department, would not discuss the ongoing lawsuits. Court filings show the agency denies the allegations and argues that its employees are protected by “qualified immunity,” a type of court-created rule that often shields law enforcement officers and government officials from being sued. The department also asserts that forensic exams are “standard procedure” during abuse and neglect cases.

Investigating child abuse is notoriously complex. The investigations usually involve forensic interviews, which are typically recorded and involve a professional asking questions of a child to elicit information. And they sometimes include forensic full-body medical examinations that include a visual check of the child’s private parts and are designed to be noninvasive, meaning medical tools that can break the skin or enter the body are not used.

Together, the interview and the exam are considered effective tools for gathering information and evidence from underage victims, who may be reluctant to describe or disclose how they’ve been hurt. Often, these interviews and exams are conducted at children’s advocacy centers by social workers, doctors, and nurses who are specially trained to treat young patients with sensitivity and care — and learn to read between the lines.

Federal guidelines advise that the mere suspicion of child sexual abuse should be sufficient to trigger a forensic medical exam. Even so, there’s a growing consensus in medicine that genital and pelvic exams can be embarrassing, uncomfortable, and even traumatic.

The South Carolina lawsuits — which involve children who live in different parts of the state and who were assigned to different social services caseworkers — aren’t the first to raise red flags about the potentially harmful effects of forensic medical exams on children. Since the 1990s, federal courts from New York to California have ruled that government agencies violate children’s and parents’ civil rights when the exams are conducted without a court order or parental consent.

Claims that the exams are comparable to normal pediatric checkups are “garbage,” said Donnie Cox, a civil rights attorney in Carlsbad, California.

“At the time they’re happening, they’re scary as hell and it really does traumatize children on top of the trauma of being removed from their homes,” said Cox, who has represented plaintiffs in similar lawsuits. “They’re using these kids, basically, as pieces of evidence, and you can’t do that.”

‘A Fishing Expedition’

In one South Carolina lawsuit, a 16-year-old girl claims she was subjected to painful vaginal exams against her will, even after she denied being sexually abused. She felt as if she was “being raped” during the forensic medical exam, her complaint asserts.

In another lawsuit, a couple living in the north-central part of the state allege their sons were subjected to genital and rectal exams, without the parents’ knowledge or consent, more than a month after the children had been removed from their home in 2021. Their oldest son bruised his arms on playground equipment, they contend, instigating a child abuse investigation that resulted in all three boys temporarily moving in with their grandparents. Their youngest son was 6 months old at the time.

No one alleged during the investigation that the boys had been sexually abused, the lawsuit states, and yet the boys’ “penises were held and touched by strangers” during the forensic exam and “fingers and/or instruments were placed in their anus,” the lawsuit states.

The parents, whose names KFF Health News chose to withhold to protect the identity of their children, said their middle child suffers from night terrors because of the forensic examination. The oldest doesn’t talk about what happened in the exam room, his mother said.

“Because we didn’t know” what was going to happen, she said, “nobody could prepare him.”

Attorneys Deborah and Robert Butcher of the Foster Care Abuse Law Firm, who represent plaintiffs in all three South Carolina cases, have likened these forensic medical exams to “a fishing expedition.” One lawsuit they filed against the Department of Social Services argues the agency is financially motivated to find evidence of any form of child abuse so that it qualifies for more money from the federal government.

“They’re going to use every means possible to build a case,” Robert Butcher said. He estimated “easily thousands” of children in South Carolina have been forced to get unnecessary exams during child abuse investigations in recent years — an approximation he made based on child protective services intake data.

Ragley, the Department of Social Services spokesperson, said the agency is required by state law to follow the South Carolina Child Abuse Response Protocol to determine when children should be referred for a forensic medical evaluation, which includes “a complete and thorough medical history from the child (if verbal) and caregivers and a head to toe physical examination, including the anogenital area.”

In response to a Freedom of Information Act request filed by KFF Health News, the department said it couldn’t estimate how many forensic medical exams are conducted on children of any age in South Carolina each year.

“That is not a question SCDSS can answer,” Kaitlin Stout, the agency’s manager of policy and practice standards with the Office of Strategic Planning and Innovation, replied via email. “We do not track or tally how many forensic exams are ‘ordered/conducted’ in open DSS cases and would have no way to know how many are conducted on children who are not involved with the agency.”

But children’s advocacy centers, where many of these exams are conducted, do keep track, and national data shows that about 1 in 4 child abuse victims who are served by a children’s advocacy center get a forensic medical exam, said Teresa Huizar, chief executive officer of the National Children’s Alliance, which represents nearly 1,000 children’s advocacy centers in the U.S.

These numbers don’t capture all forensic medical exams, though, which may also be conducted in emergency departments and private clinics, Huizar said.

“I would say that they tend to be under-utilized,” she said. “Often, children who would very much benefit from an exam don’t get them because there simply isn’t enough money in the public pool.”

The cost of these exams varies by location. But in Georgia, for example, a pediatric anogenital exam with a colposcope, a medical tool used for magnification, is about $280, exclusive of lab fees, according to the Georgia Crime Victims Compensation Program.

The Right to Refuse

Child welfare experts agree that forensic medical evaluations can be worthwhile outside the strict scope of child sexual abuse investigations.

South Carolina’s Child Abuse Response Protocol indicates these exams should be conducted during investigations if children have witnessed violence or been exposed to an environment where drugs are used. An overt allegation or disclosure of child sexual abuse isn’t considered a prerequisite for a forensic medical exam, said Thomas Knapp, executive director of the South Carolina Network of Children’s Advocacy Centers.

“Children are often poly-victimized, so the head-to-toe exam is intended to ensure general well-being and pick up on evidence of any form of abuse,” Knapp explained. “There are also some children where there may be no disclosure, but we have digital images of their abuse. So, disclosure is not the only precipitating reason to request an exam.”

Like Huizar, he agreed that forensic medical exams are under-utilized. In South Carolina, specifically, more than 4,500 children passed through a children’s advocacy center with a report of sexual abuse in 2023. Only about half as many had received a forensic medical exam through mid-October, Knapp said.

State rules allow the Department of Social Services to request a forensic medical evaluation without consent from a child’s parent or legal guardian. But the rules don’t address the issue of obtaining the child’s permission before proceeding with an exam. Knapp explained that children’s advocacy centers allow patients to refuse. Federal Justice Department recommendations published in 2016 explicitly advise that children should be allowed to refuse participation in all or part of the process.

“If a patient refuses, we don’t do it,” said Anne-Marie Amies Oelschlager, a pediatric and adolescent gynecologist in Seattle. Genital exams for girls should be conducted only externally, in most cases, she said, even when sexual abuse is suspected. Internal exams and Pap smears to screen for cervical cancer aren’t recommended until age 21, according to the American College of Obstetricians and Gynecologists.

“You really want to teach kids to say no,” Oelschlager said. “This is an area that’s private and if they say no, I’ve got to respect that.”

One South Carolina lawsuit contends a 16-year-old girl was visibly “terrified and emotionally upset concerning the forensic medical exam” and that she told the medical examiner to stop. The medical examiner allegedly ignored the request.

Antoinette Laskey, a Utah pediatrician and member of the American Academy of Pediatrics’ Council on Child Abuse and Neglect, had no knowledge of the South Carolina cases but explained that a child’s wishes must be respected in the exam room, where the “inherent power differential” between a doctor and patient should be recognized.

“I would never force the issue,” she said.

In 2022, Laskey co-authored a policy statement for the American Academy of Pediatrics acknowledging that children are “especially vulnerable” to being exploited in health care settings because of their age, development level, any disability, race, ethnicity, or English language proficiency. The paper cited flagrant examples of abuse inflicted by doctors like Larry Nassar, who pleaded guilty in 2017 to sexually abusing child gymnasts under the guise of legitimate medical care.

The policy statement explained that pediatricians are responsible for assessing children’s health, including their genital health, from birth through puberty. To that end, the academy advises doctors to use sensitivity and care during anogenital exams. Children should be afforded privacy when disrobing, providers should wear gloves, and doctors should obtain permission from the child by discussing the need for the examination and what it will entail.

These exams “should never be traumatic,” said Megan Lechner, chief operating officer of the International Association of Forensic Nurses, a group that trains nurses to conduct sexual assault exams on adults and children. More than anything else, they are designed “to tell the child they’re OK,” she said. “If they’re traumatic, you’re doing it wrong.”

‘A Needle in a Haystack’

And yet courts have recognized the potentially traumatic impact of these exams before. In 2019, an Alabama judge rejected a motion that would have required child victims who were raped and abused by adults to undergo court-ordered vaginal examinations. One of the prosecutors successfully argued that the exams would “victimize the children all over again,” the Montgomery Advertiser reported.

Like many victims, the children in that case had delayed reporting the abuse. Shame and fear often prevent child victims from reporting sexual abuse right away. Some wait years before disclosing they were abused — if they ever disclose the abuse at all.

Children’s advocacy centers across the U.S. investigated nearly 250,000 cases involving child sexual abuse allegations in 2022, the National Children’s Alliance reported, but historical data shows that physical evidence is present in fewer than 5% of all reported cases.

Finding proof “is a needle in the haystack,” Laskey said.

Attorney Robert Butcher said the federal lawsuits in South Carolina may eventually be consolidated for the sake of efficiency. He doubted they would be resolved this year, but said cases already decided in favor of children and their parents in other parts of the country bolster his clients’ arguments.

In 1994, for example, a federal judge in New York found that a kindergartner who had been separated from her parents during a child abuse investigation “almost certainly did, in fact, experience psychological injury” during a forensic medical exam, when she was “subjected to intrusive bodily examinations by two strangers, in a strange location, in the absence of a parent or other reassuring figure.”

More recently, a panel of federal appeals court judges in California ruled in 2018 that the County of San Diego violated the constitutional rights of a family by failing to inform the parents that their children would undergo “significantly intrusive” and “potentially painful” forensic medical exams.

“This is as traumatic for the parents as it is for the children,” said Cox, the California attorney who represented the family in that case.

Jane Doe, who filed the first of the three South Carolina lawsuits, doesn’t know what the outcome of her case will be, and she doesn’t talk about it at middle school.

“I have a couple of close friends,” she said. “I don’t tell anybody about what happened. I just want this to be an example so that never happens to another person.”

El tema del aborto ayuda a los demócratas a minimizar pérdidas en estas elecciones

Es probable que los republicanos tomen el control de una o ambas cámaras del Congreso cuando todos los votos estén contados. Pero los demócratas están celebrando el hecho de que su partido desafió las pérdidas pronosticadas para estas elecciones de medio término.

La reacción a la decisión de la Corte Suprema en junio pasado de anular 49 años de derecho al aborto aparentemente fue una de las principales razones.

Como mostraron consistentemente las encuestas pre electorales, la inflación y la economía fueron los temas de votación más importantes, citados por el 51% de los votantes en las encuestas a boca de urna realizadas por Associated Press y analizadas por encuestadores de KFF.

Pero el aborto fue el tema más importante para una cuarta parte de todos los votantes y para una tercera parte de las mujeres menores de 50 años. Las encuestas a boca de urna de NBC News indicaron que la inflación fue el principal tema para votar para un 32%, y en segundo lugar el aborto, 27%.

La pronosticada “ola roja” de republicanos derrocando a los demócratas en la Cámara y el Senado no sucedió, aunque a partir del miércoles por la mañana parecía probable que los republicanos obtuvieran el puñado de escaños que necesitaban para lograr la mayoría de la Cámara.

En el Senado, donde los republicanos solo necesitaban un asiento para tomar el control, ningún titular había perdido oficialmente, aunque los demócratas capturaron el escaño de Pennsylvania que dejó vacante el senador republicano Pat Toomey.

Aún no se habían convocado varias otras contiendas reñidas, y el control de la cámara bien podría descansar en una posible segunda vuelta en diciembre en Georgia entre el actual senador demócrata Raphael Warnock y el republicano Herschel Walker.

Entre otros problemas que enfrentaron los votantes el martes, los residentes de Dakota del Sur aprobaron una expansión de Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Se convirtió así en el séptimo estado en expandir el programa a pesar de las objeciones de su gobernador republicano y/o la legislatura estatal.

Antes, medidas similares fueron aprobadas en Idaho, Maine, Missouri, Nebraska, Oklahoma y Utah. La aprobación de Dakota del Sur reducirá a 11 el número de estados que no han ampliado el programa a personas con ingresos de hasta el 138 % de la línea de pobreza, entre ellos Texas, Florida y Georgia.

Sobre el tema del derecho al aborto, los votantes de media docena de estados de todo el espectro político mostraron su apoyo directo a través de iniciativas electorales. En la más observada de esas medidas, los votantes de Michigan aprobaron una enmienda constitucional que garantiza la libertad reproductiva, evitando así que entre en vigencia una prohibición de 1931.

Los votantes de Kentucky rechazaron por poco margen una enmienda que habría declarado en su constitución que no había derecho al aborto. Eso lo convirtió en el primer estado del sur en expresar su apoyo directo al derecho al aborto.

Se aprobaron otras preguntas sobre el derecho al aborto en Vermont y California. La medida de California, que fue aprobada con el 65% de los votos, consolidó el derecho al aborto y a la  anticoncepción.

En Montana, una medida electoral para exigir que los bebés nacidos vivos después de un intento de aborto reciban atención médica estaba perdiendo con el 80% de los votos. Este requisito ya existe en la ley federal.

Además, en varios estados clave donde la legalidad del aborto está en juego, los gobernadores y candidatos a favor del derecho al aborto derrotaron a los opositores al aborto, incluidos Pennsylvania, Wisconsin y Michigan.

El aborto también fue un tema en las elecciones de la Corte Suprema en al menos seis estados, donde los desafíos a las leyes del aborto o las interpretaciones constitucionales podrían decidir si sigue o no siendo legal.

En Kentucky, la jueza Michelle Keller estaba liderando sobre Joe Fischer, un legislador estatal republicano que patrocinó la ley de activación del aborto de Kentucky. La jueza titular de Montana, Ingrid Gustafson, derrotó a su rival, James Brown, un republicano respaldado por el gobernador republicano del estado y los líderes del partido que buscaban revertir un fallo judicial de 1999 de que la constitución estatal protege el derecho al aborto.

Pero el aborto no fue el único problema de salud en las papeletas estatales del martes.

En Arizona, una pregunta electoral para limitar el interés de la deuda médica estaba ganando fácilmente con el 60% de los votos contados. En Oregon, sin embargo, una cuestión en su mayoría inaplicable que declaraba un “derecho a la atención médica” en la constitución estatal estaba perdiendo por poco con el 64% de los votos escrutados.

En medidas más específicas, los votantes de California aprobaron la prohibición de los productos de tabaco con sabor, mientras que los votantes de Massachusetts apoyaron a los dentistas sobre las compañías de seguros al aprobar el requisito de que al menos el 83% de las primas del seguro dental se gasten en atención dental directa. Massachusetts no es el primer estado en imponer tal requisito.

En Iowa, los defensores del derecho a portar armas lograron una victoria con la fácil aprobación de una enmienda constitucional que declara que los habitantes del estado tienen “un derecho individual fundamental” a poseer y portar armas, y que cualquier restricción sobre las armas debe pasar por un “escrutinio estricto” en los tribunales. Para el miércoles por la mañana, con 97 de 99 condados reportando boletas, la enmienda tenía el respaldo del 65% de los votantes de Iowa.

Abortion Issue Helps Limit Democrats’ Losses in Midterms

Republicans are likely to take control of one or both houses of Congress when all the votes are counted, but Democrats on Wednesday were celebrating after their party defied expectations of substantial losses in the midterm election. The backlash over the Supreme Court’s decision in June to overturn 49 years of abortion rights was apparently a big reason.

Inflation and the economy proved the most important voting issue, cited as the motivation of 51% of voters in exit polls conducted by the Associated Press and analyzed by KFF pollsters. But abortion was the single-most important issue for a quarter of all voters, and for a third of women under age 50. Exit polls by NBC News placed the importance of abortion even higher, with 32% of voters saying inflation was their top voting issue and abortion ranking second at 27%.

The predicted “red wave” of Republicans toppling Democrats in the House and Senate did not happen, although as of Wednesday afternoon, it seemed likely that Republicans would gain the handful of seats they needed to take over the House majority.

In the Senate, where Republicans needed just one pickup to take control, no incumbent had officially lost, and Democrats captured the Pennsylvania seat being vacated by Republican Sen. Pat Toomey. Several other close races had yet to be called, and control of the chamber may well rest on a December runoff in Georgia between Democratic incumbent Sen. Raphael Warnock and Republican Herschel Walker. In recent decades, the party that controls the White House has generally suffered serious setbacks in congressional power in the midterms.

Among other issues facing voters Tuesday, residents of South Dakota approved an expansion of Medicaid under the Affordable Care Act. That made it the seventh state to expand the program over the objections of a Republican governor and/or state legislature. Previous successful initiatives passed in Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah. South Dakota’s approval will reduce to 11 the number of states that have not expanded the program to people with incomes up to 138% of the federal poverty level, although included in that list are the heavily populated states of Texas, Florida, and Georgia.

On the issue of abortion rights, voters in five states across the political spectrum showed direct support through ballot initiatives. In the most closely watched of those measures, Michigan voters approved a constitutional amendment guaranteeing reproductive freedom, thus preventing a ban from 1931 from taking effect.

Kentucky voters narrowly rejected an amendment that would have declared in its constitution that there was no right to abortion. That made it the first Southern state to express direct support for abortion rights.

Other abortion rights ballot questions were approved in Vermont and California. The California measure, which passed with 65% of the vote, enshrined the rights to both abortion and contraception.

In Montana, a ballot measure to require that infants born alive after attempted abortions be given medical care was losing with 80% of the votes in. Such a requirement already exists in federal law.

In addition, in several key states where the legality of abortion hangs in the balance, governors and candidates who favor abortion rights defeated anti-abortion challengers, including Pennsylvania, Wisconsin, and Michigan.

Abortion was also an issue in contested Supreme Court elections in at least six states, where challenges to abortion laws or constitutional interpretations could decide whether the procedure remains legal. One state saw party control of its high court flip: North Carolina, where a Republican challenger defeated a Democratic incumbent to give the GOP a 4-3 majority. Democratic judicial majorities appeared to be holding in Illinois and in Michigan, which holds nonpartisan judicial elections after the candidates are nominated by political parties. In Ohio, Republicans kept their majority on the high court.

In Kentucky, Justice Michelle Keller defeated challenger Joe Fischer, a Republican state legislator who sponsored Kentucky’s abortion trigger law. Montana incumbent Justice Ingrid Gustafson defeated her challenger, James Brown, a Republican endorsed by the state’s GOP governor and party leaders seeking to reverse a 1999 court ruling that the state constitution protects the right to an abortion.

Abortion was not the only health issue on state ballots Tuesday.

In Arizona, a ballot question to limit interest on medical debt won easily with 66% of the vote counted. In Oregon, however, a mostly unenforceable question declaring a “right to health care” in the state constitution was losing narrowly with 64% of the votes in.

California voters approved a ban on the sale of most flavored tobacco products while voters in Massachusetts supported dentists over insurance companies in approving a requirement that at least 83% of dental insurance premiums be spent on direct dental care. Massachusetts is the first state to impose such a requirement.

In Iowa, gun rights advocates scored a victory with easy passage of a constitutional amendment declaring that Iowans have “a fundamental individual right” to keep and bear arms, and that any restrictions on guns must stand up to “strict scrutiny” in court.

KHN’s ‘What the Health?’: ACA Open Enrollment Without the Drama

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It’s open enrollment time for Affordable Care Act health coverage. And for the first time, people are enrolling with comparatively little controversy, as most Republicans have moved on from trying to repeal the law.

On the campaign trail, meanwhile, Democrats are charging that if Republicans win majorities in the U.S. House or Senate, they will try to cut Social Security and Medicare.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Tami Luhby of CNN, and Julie Appleby of KHN.

Among the takeaways from this week’s episode:

  • There are some big changes to the ACA from years past. The Biden administration used its authority to close the “family glitch” that had prevented many families of low- and moderate-income workers from getting subsidies to purchase insurance on healthcare.gov or state marketplaces.
  • Also new this year, states are required to offer “standardized” plans with the same benefits so consumers can better compare them.
  • Another important change: For the first time, people with low incomes (under 150 percent of the federal poverty level) can enroll in ACA plans anytime, instead of only during open enrollment. This could become particularly important in 2023, as many people are likely to lose their Medicaid coverage when the Biden administration ends the covid-related public health emergency.
  • Health overall has not been as big a campaign issue as usual. With a few exceptions, most Republicans on the campaign trail seem to have moved on from vows to repeal the Affordable Care Act.
  • Abortion was expected to be the top voter concern in this year’s elections, but it seems to have been trumped in most cases by inflation and the state of the economy. At least one Democratic candidate, Michigan Gov. Gretchen Whitmer, is trying to combine the issues. She is claiming that if voters in her state approve a constitutional amendment protecting the right to abortion, businesses in states with abortion bans will be more likely to move there. It’s unclear whether this will happen, though.
  • The Justice Department this week had its first-ever win in a criminal case alleging that labor antitrust rules had been violated. A Nevada staffing agency that supplies school nurses had an agreement with a similar agency in an adjacent county not to hire nurses across the county line, in an effort to prevent the nurses from seeking higher wages.  

Also this week, Rovner interviews KHN’s Arthur Allen, who wrote the latest KNH-NPR Bill of the Month, about an old but still very expensive cancer drug. Do you have an exorbitant or baffling medical bill you’d like to share with us? You can do that here.

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

Julie Rovner: Modern Healthcare’s “Elon Musk Bought Twitter. Should Healthcare Professionals Be Worried?” by Caroline Hudson

Joanne Kenen: Mountain State Spotlight’s “Stigmatize, Blame, Then Restrict: How This West Virginia City Responded to the Opioid Epidemic,” by Ellie Heffernan

Tami Luhby: The Washington Post’s “A Psychiatry Wait List Had 880 patients; a Hospital Couldn’t Keep Up,” by Rachel Zimmerman

Julie Appleby: KHN’s “‘Fourth Trimester’ Focus Is Pushed to Prevent Maternal Deaths,” by April Dembosky

Also mentioned in this week’s episode:

Politico’s “Michigan Democrats’ Pitch to Voters: Abortion Bans Are Bad for Business,” by Alice Miranda Ollstein

Bloomberg Law’s “DOJ Notches First No-Poach Win With Staffing Firm’s Sentencing,” by Dan Papscun

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.

“Cuarto trimestre”: período clave para prevenir las muertes maternas

Durante varias semanas al año, el trabajo de la enfermera-comadrona Karen Sheffield-Abdullah es detectivesco. Con un equipo de investigadores médicos del Departamento de Salud Pública de Carolina del Norte examina los registros hospitalarios y los informes forenses de las madres que murieron después de dar a luz.

Estos comités de revisión de la mortalidad materna buscan pistas sobre lo que ha contribuido a estas muertes —recetas que nunca se recogieron, faltar a citas médicas postnatales, señales de alerta que los médicos pasaron por alto—, para averiguar cuántas podrían haberse evitado y cómo.

Los comités trabajan en 36 estados, y en la última y mayor recopilación de datos de este tipo, publicada en septiembre por los Centros para el Control y Prevención de Enfermedades (CDC), un sorprendente 84% de las muertes relacionadas con el embarazo se consideraron prevenibles.

Lo que resulta aún más alarmante para enfermeras-detectives como Sheffield-Abdullah es que el 53% de las muertes se produjeron mucho después de que las mujeres fueran dadas de alta del hospital, entre siete días y un año después del parto.

“Estamos muy centrados en el bebé”, afirma. “Una vez que el bebé está aquí, es casi como si la madre fuera descartada… Y en lo que realmente tenemos que pensar es en ese cuarto trimestre, ese tiempo después del nacimiento del bebé”.

Las condiciones de salud mental fueron la principal causa subyacente de muertes maternas entre 2017 y 2019. Las blancas no hispanas y las hispanas fueron las más propensas a morir por suicidio o sobredosis de drogas, mientras que los problemas cardíacos fueron la principal causa de muerte para las mujeres negras no hispanas.

Ambas circunstancias ocurren desproporcionadamente más tarde en el período posparto, según el informe de los CDC.

Los datos revelan múltiples deficiencias en el sistema de atención a las nuevas madres, desde los obstetras que no están adiestrados (o bien pagados) para buscar signos de problemas mentales o de adicción, hasta las pólizas que despojan a las mujeres de la cobertura médica poco después de dar a luz.

El principal problema es que el típico control postnatal de seis semanas es demasiado tarde, según Sheffield-Abdullah. En los datos de Carolina del Norte, las nuevas madres que murieron más tarde no acudieron a esta cita porque tenían que volver al trabajo o tenían otros niños pequeños, agregó.

“Tenemos que estar realmente en contacto mientras están en el hospital”, dijo Sheffield-Abdullah, y luego asegurarnos de que las pacientes reciban la atención de seguimiento adecuada “una o dos semanas después del parto”.

Otra de las recomendaciones de los CDC es más pruebas de detección de depresión y ansiedad posparto, durante todo el año posterior al parto, así como una mejor coordinación de la atención entre los servicios médicos y sociales, según David Goodman, que dirige el equipo de prevención de mortalidad materna de la División de Salud Reproductiva de los CDC, que publicó el informe.

Una crisis frecuente es que la adicción de uno de los padres se agrava tanto que los servicios de protección infantil se llevan al bebé, lo que precipita una sobredosis accidental o intencionada de la madre. Tener acceso al tratamiento y asegurarse de que las visitas a los niños se produzcan con regularidad podría ser la clave para prevenir estas muertes, apuntó Goodman.

El cambio político más importante ha sido la ampliación de la cobertura sanitaria gratuita a través de Medicaid, indicó. Hasta hace poco, la cobertura de Medicaid relacionada con el embarazo solía expirar dos meses después del parto, lo que obligaba a las mujeres a dejar de tomar medicamentos o de acudir a un terapeuta o a un médico porque no podían pagar el costo sin seguro médico.

Ahora, 36 estados han ampliado o tienen previsto ampliar la cobertura de Medicaid hasta un año completo después del parto, en parte como respuesta a los primeros trabajos de los comités de revisión de la mortalidad materna.

“Si esto no es una llamada a la acción, no sé qué es”, señaló Adrienne Griffen, directora ejecutiva de la Maternal Mental Health Leadership Alliance, una organización sin fines de lucro centrada en la política nacional. “Hace tiempo que sabemos que los problemas de salud mental son la complicación más común del embarazo y el parto. Solo que no hemos tenido la voluntad de hacer algo al respecto”.

El último estudio de los CDC de septiembre analizó 1,018 muertes en 36 estados, casi el doble de los 14 estados que participaron en el informe anterior. Los CDC están dando aún más fondos para las revisiones de la mortalidad materna, dijo Goodman, con la esperanza de captar datos más completos de más estados en el futuro.

El aumento de la concientización y la atención sobre la mortalidad materna les ha dado esperanza a activistas y médicos, especialmente por los esfuerzos para corregir las disparidades raciales: las mujeres negras tienen tres veces más probabilidades de morir por complicaciones relacionadas con el embarazo que las blancas.

Pero muchos de estos mismos partidarios de una mejor atención materna dicen estar consternados por la reciente decisión del Tribunal Supremo de Estados Unidos de erradicar el derecho federal al aborto; las restricciones en torno a la atención de la salud reproductiva, dicen, erosionarán los avances.

Desde que estados como Texas empezaron a prohibir los abortos en etapas tempranas del embarazo y a hacer menos excepciones para aquellos casos en los que la salud de la embarazada está en peligro, a algunas mujeres les resulta más difícil recibir atención de urgencia por un aborto espontáneo.

Los estados también están prohibiendo los abortos —incluso en casos de violación o incesto— en chicas jóvenes, que afrontan un riesgo mucho mayor de complicaciones o muerte por llevar un embarazo a término.

“Cada vez más el mensaje es que ‘no eres dueña de tu cuerpo’”, dijo Jameta Nicole Barlow, profesora adjunta de redacción, política y gestión sanitaria en la Universidad George Washington.

Según Barlow, esto no hará más que agravar los problemas de salud mental que experimentan las mujeres en torno al embarazo, especialmente las mujeres negras, que también se enfrentan a la larga historia intergeneracional de la esclavitud y el embarazo forzado. Sospecha que las cifras de mortalidad materna empeorarán antes de mejorar, debido a la interrelación entre la política y la psicología.

“Hasta que no abordemos lo que está ocurriendo políticamente”, dijo, “no vamos a poder ayudar a lo que está ocurriendo psicológicamente”.

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

Readers and Tweeters Take Positions on Sleep Apnea Treatment

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

On a ‘Woke’ Journalist’s Journey

I found Jay Hancock’s piece rather intriguing (“Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” Oct. 3). While I agree that positional therapy is often overlooked as a first-line treatment for obstructive sleep apnea, one has to look at this serious, life-threatening health issue in a bit more detail. First, Mr. Hancock’s diagnosis was central sleep apnea, which suggests either a neurologic and/or breathing control etiology. Sleeping on the side may prevent airway obstruction, but the underlying cause has likely not been addressed. Second, the danger here is that — a bit like hypertension, with which there are little or no perceived symptoms — a catastrophic event might occur with little or no warning. Third, it sounds as if the positional therapy in this case alleviated the condition — but as one gets older, the condition will likely worsen.

Bottom line: Why does this particular patient have this condition and what can be done to address the root cause instead of taking a symptomatic approach? My fear is that, left untreated, the patients fall asleep with a false sense of security to never wake up the next morning.

— Dr. Dave Singh, an adjunct professor in sleep medicine at Stanford University, Oakland, California

— Liz Beaulieu, Yarmouth, Maine

Finally! Jay Hancock exposed the sleep apnea medical racket. I have another treatment option: During covid, many inpatients were intubated in the prone position. I was curious about that and did some Googling. Not only does sleeping on your stomach increase lung capacity, the gravity on the throat is a natural treatment for sleep apnea. While difficult to adapt to, it’s better than a CPAP. Again, doctors don’t mention it. No money in a simple gravity solution.

— Peg Keohane, Syracuse, New York

— Stanley Morrical, San Francisco

I want to thank you for this very timely article. I have suspected there was more to the question of apnea than was being reported. As stated, it is a big industry that perpetuates the idea that everyone is affected.

The reporter’s discovery that side-sleeping is the answer is absolutely valid, as I determined long ago. The article should be widely disseminated as it is of extreme importance to millions who are falling for the hype!

— Lawrence Dee, Chino Valley, Arizona

— Robert Roy Britt, Phoenix

My mouth dropped open when I read Jay Hancock’s piece about sleep apnea. You are the harbinger of a tidal wave, my friend. The party is just getting started.

Empowered Sleep Apnea is a project we created to protect individual patients from the “conveyer belt” of the American health care system, as it’s poised to deal with tens of millions of new diagnoses of sleep apnea, which will soon be made in primary care and dental offices all over our great land, using automated, wearable technology. That time is coming within 18 months.

You suffered because there was inadequate coaching for a terribly complicated disease. Simple as that. All those who will be subjected to a cloudburst of automated diagnostics will have the same journey to make. Out of necessity, your solution was to slog through your own research to get yourself some sane direction. You empowered yourself. Good on you.

My solution was to take my life’s work as a patient-centered sleep medicine physician and turn it into something beautiful to behold, so that everyone can benefit from sane coaching. Our project hinges on patient empowerment. Our website is a nice introduction. Our podcast is also a blast that I think your readers would find very interesting.

— Dr. David E. McCarty, owner and CEO of Empowered Sleep Apnea, Boulder, Colorado

— Dr. Art Sedrakyan, New York City

As president of the American Academy of Sleep Medicine (AASM), I write to address several concerns about the recent article “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution” (Oct. 3). While I commend the author for seeking medical help for his daytime drowsiness and snoring, I fear his article may mislead readers in a way that could jeopardize not only their own health and safety but that of others as well.

The author is clearly dissatisfied with the care he received; however, using this to suggest that nearly everyone diagnosed with sleep apnea should simply treat it on their own “for free” is dangerous. Sleep apnea is a common and chronic medical condition that increases the risks for numerous physical and mental health consequences, diminished quality of life, motor vehicle crashes, and premature death.

Positional therapy (which typically requires the use of a device to maintain a side-sleeping position), though useful for some patients with sleep apnea, is not the best treatment for most patients, especially those with moderate to severe sleep apnea. Positive airway pressure (PAP) therapy is the best-supported, evidence-based treatment for sleep apnea. The most recent systematic review and meta-analysis included 80 randomized controlled trials investigating the use of PAP therapy to improve outcomes. Millions of patients with sleep apnea can attest to the life-changing — and even lifesaving — impact of PAP therapy. Treatment selection is an important decision that should be made together by a patient and their treating provider.

Furthermore, it is inappropriate for the author to use his experience as justification to malign our entire organization and our 12,000 members. AASM strongly refutes the implication that support from industry biases our clinical practice guidelines and policies. Our guidelines are based on a review of the latest research by a task force of experts who determine the strength of evidence for a given treatment. The AASM also ensures conflicts of interest are mitigated through a stringent clinical practice guideline development process. While the author claims our organization “finances its operations” with industry support, this is simply untrue. Industry support represents roughly 1% of our annual revenue and is guided by a clear policy that helps ensure transparent interactions to prevent undue influence and support public health. Likewise, the implication that our members are prescribing PAP therapy as part of a revenue-generating scheme is fallacious. The vast majority of PAP devices are sold by durable medical equipment suppliers, not by sleep centers or sleep doctors.

I hope that readers struggling to get a good night’s sleep will seek information from credible sources and talk with a trusted health care professional to determine which treatment best addresses their specific situations.

— Jennifer L. Martin, president of the American Academy of Sleep Medicine, Darien, Illinois

— Timothy Noah, Washington, D.C.

I just saw Jay Hancock’s article on my Google feed and read it, as I suffer from serious sleep apnea as well. I’ve received tailor-made mouthguards, so to speak, which appear to work rather well.

But I’ve also been reading books on breathing, starting with “Breath, the New Science of a Lost Art” by James Nestor, and then on to “The Oxygen Advantage” by Patrick McKeown. I realized I was a mouth breather and that that contributes to the apnea problem as well and have since been trying to learn to breathe through my nose at all times — thus far with mixed results, but the subject is very interesting as it pertains to a lot more than just how to get a good night’s sleep.

— Dimitri F. Frank, Málaga, Spain

— James Hughes, Savannah, Georgia

Treating Trauma — Followed by Billing Trauma

I’m an emergency physician who also works at urgent care. While I appreciate patients trying to be fiscally responsible with their choices, the urgent care did precisely the right thing in this case (Bill of the Month: “Turned Away From Urgent Care — And Toward a Big ER Bill,” Sept. 29). Urgent care can typically manage fender benders or other minor accidents, but someone whose airbags deployed and whose car rolled three times and wound up “crushed” up into a tree should always go to the emergency room. The mechanism of such accidents is very concerning and typically justifies a trauma activation and CT scans to evaluate for internal injuries. Urgent care is not equipped to handle patients if they develop life-threatening complications from a severe injury.

— Dr. William Weber, Harvard Medical School / Beth Israel Deaconess, Boston

— James Conner, Kalispell, Montana

This article is missing the perspective of a medical provider. I am a retired board-certified emergency physician with 33 years in the emergency department and more than five years in urgent care and feel the need to address the medical care differences between the ED and urgent care.

I agree with the facts of your article and don’t dispute the financial issues, problems, inequities of the broken system. But there is more to the story.

The knowledge, ability, skill, and experience of the provider are key. The location of care predisposes to the abilities of the provider but doesn’t guarantee them. You may receive excellent to below-average care depending on the provider. I have seen people die from auto accidents that were sent home from urgent care after receiving an evaluation by a general practitioner not trained in trauma. Some ED physicians miss things, but the odds are better that the ED doctor will not miss critical cases.

Conversely, you might get care from an experienced ED physician at an urgent care.

Then there are the personnel and resources provided. If it is a simple “urgent” problem, no significant difference in outcome is likely to result.

There is the dilemma. What is an emergency? This has been argued in Congress: to err on the side of not missing serious problems for which a “prudent layperson” could observe symptoms. So an emergency is what a “prudent layperson” believes it is.

Some of the urgent care centers I worked in turned away “third-party” cases but most didn’t — even within the same hospital-owned urgent care chain. An option would be to offer to pay cash, asking for the cash-upfront price. Difficult to be accurate in predicting the cost ahead of time, but an estimate is not unreasonable. Instead of a low four-figure bill, the family might have turned out to have a low three-figure bill if not referred to the hospital after the urgent care evaluation.

In my experience, I’ve never seen a patient sent from urgent care (owned by or affiliated with a hospital) to the hospital for the sole reason of the hospital billing a second charge. Many patients are sent because they need a higher level of care that isn’t available, such as hospitalization, injectable medications, specialty care, imaging, and “stat” lab work not available.

Sure, the hospital uses the urgent care as a feeder site, but the patient (or the paramedic) gets to choose which hospital to go to, if they have a preference.

Please remember that not all hospitals or urgent cares are the same. Many smaller hospitals do not have some/many specialists required to back up the emergency department. Some urgent cares use primarily general practitioners, while others use only board-certified emergency physicians, nurse practitioners, or physician assistants.

Yes, the system is broken. Per a recent webinar by the California Medical Association: In the past 50 years, the increase in the number of physicians was 2%. Administrative health care personnel increased more than 3,000%. (That includes both the provider and the payer side.)

— Dr. Mickey Kolodny, Palos Verdes Peninsula, California

— Donald Farmer, Woodinville, Washington

After 40 years as a board-certified emergency medicine physician, I believe the article by Sam Whitehead is very misleading. First of all, the patient should never have gone to an urgent care. Had she called 911 as she should have, just because of the mechanism of the crash, she would have been brought to an emergency room. The ER obviously believed two CT scans were needed, which the urgent care would not have been able to provide. The reporter did not dig into the details of the acute trauma care this patient needed — other than understating her post-accident situation, which was self-defined. The author writes as if it is strictly an insurance issue or a way for the urgent care/hospital system to gain patients.

There is no indication of this happening given that the patient needed, by protocol, Advanced Trauma and Life Support (ATLS). By EMS protocol and by malpractice case law, this patient needed a visit to a trauma center emergency room. And the bill is a totally different issue. In other words, the author totally missed the medical issues to overstate and sensationalize billing issues.

— Dr. Anthony F. Graziano, Oconomowoc, Wisconsin

— Kendra Lee, Woodbridge, Virginia

I listened to your story as retold on NPR about a young woman who had a high bill for an ER visit after a car accident. I felt that the story was editorially biased, as it mentioned nothing about the requirements for care for traumatically injured patients. It seemed to recommend visiting urgent care centers instead of emergency rooms. Although less expensive, such facilities generally should not care for patients with serious injuries. Most hospitals require board-certified emergency medicine physicians and have extensive resources whereas an urgent care doctor may not have completed a residency. The “physician expert” in the story clearly had no experience in the care of traumatically injured patients. Having such insight would lend depth to what I saw as a superficial look at a nuanced issue. Clearly the public should be better informed about cost-effective care, but an evaluation after a serious car crash is inappropriate to be sent to an urgent care.

— Dr. Christopher Goltz, Flint, Michigan

A Wealth of WISDOM

Nice article (“Genetic Tests Create Treatment Opportunities and Confusion for Breast Cancer Patients,” Sept. 21). With breast cancer awareness month upon us, I would also point out the existence of the WISDOM study funded by the National Institutes of Health, which is looking at different approaches to using genetic testing to screen women for breast cancer. Check it out at www.thewisdomstudy.org.

— Dr. Daniel Halevy, New York City

— Dr. Cee A. Davis, Winchester, Virginia

On the Birth of Obstetrics Emergency Departments

I was disappointed by your article “Baby, That Bill Is High: Private Equity ‘Gambit’ Squeezes Excessive ER Charges From Routine Births” (Oct. 13). While I recognize that medical billing is often confusing and at times even alarming to patients, I would like to share a few points that I feel were downplayed or omitted:

  • The article gives the impression that the obstetrics emergency department, or OBED, is created simply by rebranding an existing process within hospitals. The author neglects to mention that before the OBED, most hospitals did not have OB-GYN hospitalists stationed in-house 24/7 to address emergencies. Prior to the implementation of the OBED, many expectant mothers, concerned that something might be wrong, were not able to see a physician when they visited a hospital emergency room. Instead, they were transferred to the labor and delivery department to be evaluated by a nurse taking instructions over the phone from a physician. If the patient and her baby were in serious distress, it became a waiting game, with the risk escalating every minute she waited for medical attention from her doctor — or any doctor. Hundreds of thousands of life-threatening emergencies are managed each year by OB-GYN hospitalists who staff obstetrics emergency departments.
  • Reporter Rae Ellen Bichell seems to have a beef with the practice of hospitals charging for an emergency evaluation when unscheduled pregnant patients arrive at the hospital with medical complaints. Whether we like it or not, that is simply the way that health care works in America. If you show up unexpectedly at a hospital for evaluation of a health concern, you will be treated as an emergency — and you will likely receive a large bill corresponding to the unscheduled care you received.
  • The author works hard to establish or imply a causal relationship between the private equity backing of medical staffing companies and the fact that hospitals are billing patients for emergency medical services. However, hospital service providers and vendors have absolutely no control over a hospital’s billing practices. This bit about private equity seems to serve no logical purpose in this article except to make the story appear as a “whodunit,” casting private equity firms in the role of immoral shadow bosses turning a profit at the expense of unwitting expectant mothers, when in fact they play no role in establishing the billing policies that Ms. Bichell incorrectly and perhaps unfairly characterizes as “moneymaking ‘emergency’ events.”

I have dedicated my career to the development and implementation of obstetrics emergency departments in hundreds of hospitals across the U.S., but I am unaware of any hospital turning routine births into moneymaking emergency events as claimed in the title and misleading argument of this article. I stand by my statement — and my sincere belief — that having trained doctors available 24/7 on the labor-and-delivery floor has significantly enhanced the quality of care available to expectant mothers at some of the most challenging and medically consequential hours of their lives.

Thank you for considering my point of view.

— Dr. Christopher C. Swain, Charleston, South Carolina

— Adam W. Gaffney, Boston

Shooting Craps?

Online stock brokerage houses have made all cellphones into “gambling devices” years ago (“Addiction Experts Fear the Fallout if California Legalizes Sports Betting,” Oct. 5). What a load of crap that California gaming would suddenly create new cases of addiction. Stop the crap reports.

— Matt McLaughlin, Carpinteria, California

— Kristina Bas Hamilton, Sacramento, California

Measuring Fat: A Gut Check

Julie Appleby provided useful information on how modern medicine misclassifies patients’ health status through the use of the body mass index (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12). She included comments advocating the use of waist circumference (WC, by tape measure in the standing position) rather than body weight to indicate more specifically where the metabolic problems can be found. She’s on the right track, but her article might have gone further to explore alternative, more focused indicators of excess adiposity.

Anatomically, more than 90% of human body fat can be classified into three main depots: gluteo-femoral (hips, buttocks, and thighs) subcutaneous adipose tissue, abdominal subcutaneous adipose tissue, and visceral (inside the abdomen) adipose tissue. Of these three, only the visceral fat is clearly associated with cardiac and metabolic disorders. Increased gluteo-femoral subcutaneous fat has been shown repeatedly to be associated with improved health outcomes. Abdominal subcutaneous fat tends to have neutral, benign effects for most individuals.

What we need is a simple adiposity indicator that can estimate the burden of visceral fat. Three decades of research suggests that a simple measure of the supine sagittal abdominal diameter (SAD, sometimes called the “abdominal height”) predicts poor health better than the standing WC. When persons are in the supine position, their benign, abdominal subcutaneous fat falls to the sides of the midline. For this reason, variation in the SAD, rather than in the WC, is more strongly associated with the variation in visceral fat volume. The SAD/height ratio (SADHtR) is arguably even better than SAD alone. The SADHtR has been shown in the federal National Health and Nutrition Examination Survey (NHANES) to be significantly better than BMI for identifying major cardio-metabolic risk factors, i.e., insulin resistance or serum triglycerides.

There is a simple tool that researchers or clinicians can use to measure the SAD: a low-cost, portable, sliding-beam caliper. Various calipers are available, all of which are less expensive than a high-quality scale. And the calipers are easier to calibrate, too.

Choosing between the adiposity indicators SAD or WC could depend on the method’s simplicity and replicability. Especially among persons with large bellies, the reliability of the standing WC is challenged by conflicts between minimizing tension on the measuring tape and the tape’s tendency to droop unpredictably below the horizontal plane. For the SAD, both the examinee and the examiner can relax as the upper arm of the sliding-beam caliper descends just to the point where it touches the abdomen. No further judgment is required.

— Dr. Henry S. Kahn, Atlanta

— Morgan Harlan, Washington, D.C.

Revisiting the Homelessness Conundrum

To me, there is only one solution to helping our homeless get off the streets and into an environment that is safe, that will provide them with food, medical attention, and security, as well as provide them a means to regain the loss of self-esteem of so many of the homeless (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21). Our military bases could provide all the above, of course, with the permission of the Department of Defense and base commanders. I see so many efforts at trying to utilize hotels, apartment buildings, and the like, that are costing our cities, states, and federal government so much money that really is just a waste of time. We need to show our homeless that our government and all of us really care about them. We need to offer them the opportunity to settle in on a military base. They have the human resources and financial resources to really do something, and in a short period of time. These homeless could even be offered up some tasks to do on the bases. Please support this effort. Thank you for your efforts, too. I think every heart cries when we see this tragic situation on our street, and leaves us feeling helpless and hopeless for them.

— Mike Stalsby, La Jolla, California

— Arielle Kane, Washington, D.C.

KHN’s ‘What the Health?’: Looking Ahead to the Lame-Duck Session

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

When the lame-duck Congress returns to Washington after Election Day, it will face a long list of health items needing attention before the end of the year, including setting overall spending for health programs and averting a series of Medicare payment cuts to health care providers.

Meanwhile, in California, Democratic Gov. Gavin Newsom has signed a first-in-the-nation bill aimed at curbing covid-19 misinformation and disinformation by doctors.

This week’s panelists are Julie Rovner of KHN; Sandhya Raman of CQ Roll Call; Jessie Hellmann, also of CQ Roll Call; and Mary Agnes Carey of KHN.

Among the takeaways from this week’s episode:

  • When congressional lawmakers left town last week for a month of campaigning before the midterm elections, they agreed to fund the government — but only until mid-December. The election results may impact whether they reach agreements on funding for the full fiscal year when they come back.
  • Key Democratic members of the House have pledged to jettison the so-called Hyde Amendment from any spending bills, but clearly those efforts don’t have enough support to get through the Senate. The Hyde Amendment, named for Rep. Henry Hyde (R-Ill.), who died in 2007, bans federal funds from being used for most abortions.
  • Among the funding issues still to be settled by lawmakers is whether they will continue certain programs begun during the pandemic, such as allowing Medicare to cover telehealth services and whether enhanced Medicaid will continue for U.S. territories.
  • Also still awaiting a decision by Congress is a bipartisan effort to improve mental health services.
  • In response to some of the unusual treatments and theories that emerged surrounding covid, California has enacted a law that could bring more discipline for doctors who knowingly spread disinformation directly to patients. They can be reprimanded by the state medical board.
  • The issue of abortion is heating up in campaigns around the country, especially among Democrats running for Congress, governor, or attorney general. Republicans, on the other hand, are playing down the issue while they try to emphasize economic and immigration issues.
  • A new report from Ohio officials points to the surprisingly high number of girls and young teens seeking abortions. The state health department reported that among 538 children age 17 and younger who got abortions in Ohio last year, 57 were under 15.

Also this week, Rovner interviews KHN’s Sam Whitehead, who reported and wrote the latest KHN-NPR “Bill of the Month” episode about a family who tried to use urgent care to save money but ended up with a big emergency room bill, anyway. If you have an outrageous or enormous medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: NPR’s “The Ice Bucket Challenge Wasn’t Just for Social Media. It Helped Fund a New ALS Drug,” by Wynne Davis

Sandhya Raman: Mountain State Spotlight’s “As WV Officials Tout Small Reductions in Drug Overdose Deaths, Epidemic Remains at Crisis Levels,” by Allen Siegler

Jessie Hellmann: KHN’s “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” by Jay Hancock

Mary Agnes Carey: The Washington Post’s “Seniors Are Stuck Home Alone as Health Aides Flee for Higher-Paying Jobs,” by Christopher Rowland

Also mentioned in this week’s episode:

To hear all our podcasts, click here.

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

Readers and Tweeters Take a Close Look at Eye Care Traps and White Mulberry Leaf

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

— Catherine Arnst, New York City

Seeing Eye Care for What It Is

Thank you for telling the story of EyeCare Partners and others (Patients for Profit: “Private Equity Sees the Billions in Eye Care as Firms Target High-Profit Procedures,” Sept. 19. I went to EyeCare once. All I will say is I will never go back. I also went to a private-practice ophthalmologist. He should be ashamed of himself.

Unfortunately, doctors themselves are ruining their profession’s reputation. Please continue your stories to help us get at least halfway-decent care. I have no hope of it ever returning to good care.

Your story brings out one old-time fact: Patients need to know that an overly busy doctor does not necessarily mean a “good” doctor. Thank you again.

— Hazel M. White, St. Louis

— Julie Doll, Garden City, Kansas

American Herbal Products Association Weighs In on White Mulberry Leaf

The article written by Samantha Young on the untimely death of Lori McClintock, the wife of California congressman Tom McClintock, used this tragic event to challenge the robust regulation of dietary supplements by the federal government, despite there being no information in the report showing that Lori McClintock consumed white mulberry leaf as a dietary supplement (“Congressman’s Wife Died After Taking Herbal Remedy Marketed for Diabetes and Weight Loss,” Aug. 24).

White mulberry leaf is normally administered for therapeutic use in the form of a tea or powdered extract, and the leaf is also used as a food ingredient. The two most comprehensive and authoritative English language compendia of traditional Chinese medicine — “Chinese Herbal Medicine” and “Chinese Medical Herbology and Pharmacology” — do not list any significant cautions or contraindications associated with mulberry leaf use.

Most clinical trials studying white mulberry leaf report no adverse events, although some placebo-controlled studies have reported minor gastrointestinal issues — such as an upset stomach. A pooled analysis of these studies found no statistically significant difference in adverse events between participants receiving mulberry leaf and a placebo.

The scientific consensus on the safety of white mulberry leaf is also reflected in the “Botanical Safety Handbook,” maintained by the American Herbal Products Association and subject to strict standards of expert review. The contributing experts placed white mulberry leaf in the reference’s safest classification based on an extensive review of the scientific literature. This classification process included a systematic literature review covering acute, short-term, and sub-chronic toxicity studies as well as in vitro, human, and animal research. The reviewers also searched for, and did not identify, any case reports in which white mulberry leaf produced a suspected drug or dietary supplement interaction.

Lori McClintock’s death certificate and the accompanying coroner’s report identify the cause of death to be dehydration due to gastroenteritis due to adverse effects of white mulberry leaf ingestion. The coroner’s report states that “a partial plant leaf” was present in the stomach and that “portions of tablets and capsules [were not] discerned in the stomach.” A University of California-Davis botanist identified the material as white mulberry leaf and stated, “White mulberry is not toxic.”

While the death certificate declares “an autopsy with toxicology testing confirmed the cause of death,” there is no toxicology test for white mulberry, and none of the toxicology testing performed for other unrelated drugs or common toxins revealed anything linking the death to white mulberry.

The coroner’s report did not explain whether or not there was evidence of any specific product(s) the deceased might have been taking, and ultimately how a conclusion was drawn to implicate white mulberry. Without this information, it is not possible to corroborate the coroner’s findings and conclusions.

Moreover, nearly half of the article is presented as a criticism of the robust federal regulation of dietary supplements, claiming that “McClintock’s death underscores the risks of the vast, booming market of dietary supplements and herbal remedies.” The article reports that two cases of people “sickened by mulberry supplements” have been reported to the FDA since 2004 and that “[a]t least one of those cases led to hospitalization.” AHPA has reviewed the publicly available records of these two cases and notes the following significant details omitted from the article:

  • A 77-year-old woman was hospitalized in July 2008 with conditions described as including diabetes mellitus, gallbladder disorder, hypotension, myocardial infarction, renal disorder, and thrombosis; whether these conditions were preexisting is not clear in the currently available public record. This record identifies 31 dietary supplements (including a mulberry leaf product) associated with this case.
  • In the other case, a 63-year-old woman was reported as taking four products — goji berry; a combination of cinnamon extract, Gymnema sylvestre leaf, and mulberry leaf; a multivitamin; and fish oil. She was diagnosed with hypoesthesia (numbness) and was hospitalized in December 2009.

AHPA has obtained these two adverse event reports through a Freedom of Information Act request. The conclusion drawn by the KHN article that either of these reports represents an individual who was “sickened by mulberry supplements” is simply not substantiated by the FDA’s database.

Given that consumption of white mulberry leaf was unlikely to have been a direct or indirect cause of Lori McClintock’s death, the Sacramento County Coroner’s Office should seriously consider conducting additional investigations and, as appropriate, revising the death certificate.

— Michael McGuffin, president, American Herbal Products Association, Silver Spring, Maryland

— Keith Vance, Gaithersburg, Maryland

Two Ways to Cut Medical Debt

Your recent article “Upended: How Medical Debt Changed Their Lives” (Aug. 18) was very powerful and informative. Thank you very much for your efforts.

There are two reforms that would greatly relieve the financial suffering of your subjects:

1. We need a law stating that if a health insurance claim is denied, and if the patient was not aware this could happen, then the patient is not liable for the charges. Medicare has had this rule for decades. With such a rule, the providers and insurers can fight out their disputes and the patient will not be harmed.

2. Patients with large medical debts should have access to a low-cost, federally funded bankruptcy attorney. Some of your subjects seem not to have been aware of the bankruptcy option. Others made tragic mistakes like cashing in retirement accounts, when that is unnecessary in bankruptcy. Most hospitals are ready to negotiate and reduce large bills, if a halfway-aggressive attorney or consultant approaches them on a timely basis. Your subjects were, sadly, isolated and unadvised.

Thanks again for your work.

— Bob Hertz, St. Paul, Minnesota

— Lee Moss, Salt Lake City

Homelessness and Social ‘In’-Security

I read your story on the Supplemental Security Income program and the woman in the homeless shelter (“A Disability Program Promised to Lift People From Poverty. Instead, It Left Many Homeless,” Sept. 16). I lived in homeless shelters in St. Louis and Mobile, Alabama, and there is something you left out of your article: If you live in a homeless shelter, the Social Security Administration may lower your SSI benefit even more because they figure you’re not paying rent so you’re not entitled to full benefits. It did that to me when I was in Mobile. It also happened to a friend of mine in St. Louis. The agency reduced hers by $200. That’s exactly the time we need our entire benefits, so we can find a place.

— Lauralee Wiltsie, Bay Minette, Alabama

— Dennis Culhane, Philadelphia

Seniors in Need of a Lifeline

I’m a senior living in affordable housing and am so sad. Not just because I can’t afford to take care of my personal needs the way I used to, but because I feel as if no one cares about seniors anymore. I read in one of your stories it’s too expensive to stay alive (Navigating Aging: “‘It’s Becoming Too Expensive to Live’: Anxious Older Adults Try to Cope With Limited Budgets,” Sept. 7). During the height of the pandemic, people were so kind and I did have enough food to eat. Now that things are almost back to normal, people have started acting mean again. They just don’t care about us seniors. Help us.

— Barbara Little, Atlanta

— Ramsey Alwin, Washington, D.C.

Only One Side of the Story?

I listened to Dr. Elisabeth Rosenthal’s comments on CBS News this morning (Bill of the Month: “Watch: Crashing Into Surprise Ambulance Bills,” Aug. 24).

First, her comments about coverage for ground ambulances being excluded from the federal No Surprises Act, which purportedly guards against surprise medical bills. She said: “There’s some speculation that ground ambulances are revenue generators for many local fire departments.” While that may be true in rare cases, most emergency medical services that are nonprofit barely get by. Why? Because insurance companies do not pay ambulances correctly.

Have a heart attack and EMS might bill you $1,100. Insurance companies pay $400. Medicare pays around $300 for the same call. Medicaid pays $200 for the same call.

Let me put it another way: You own a restaurant. You offer a dinner for two for $100. You bill the person’s dinner insurance. It pays $40. It costs the restaurant $60 to put the meal together, including staff pay and utilities. You just lost $20 and made nothing to put back into the business. How long are you going to stay in business?

Ambulance agencies do not join insurance companies’ networks because they are offered a lower pay rate to be in-network — so why should we join?

Let me put it another way: The fire department is run by the municipality and the taxpayer pays for it. You pay approximately $600 per household in taxes for fire protection each year. So over 10 years, many taxpayers have paid $6,000 for fire protection they never used. But most municipalities do not fund EMS.

If you’re going to treat this story fairly, maybe have all the facts about EMS — not just one side of it.

And as for surprise billing, you called 911 to get a ground ambulance to come. How is the bill a surprise?

— Anthony Tucci, West Lawn, Pennsylvania

— Jon Wallner, Montgomery County, Pennsylvania

This article was very one-sided. Nonprofit ambulance services are being lumped into this mix unfairly. In addition, some states have enacted their own ground portion of the federal No Surprises Act. I have seen commercial insurance companies sticking the patient with a greater responsibility for the cost of emergency services than before the No Surprises Act and yet the insurance companies themselves now reimburse at only around 67%, when they used to pay nearly 100% of claimed charges.

In addition, more ambulance companies would join commercial insurance companies’ networks if they received fair, timely reimbursement. There are so many ground ambulance companies going out of business due to insurance company games, inappropriate denials, and lack of payment.

— Jennifer Costello, Columbus, Ohio

— Kathryn A. Phillips, San Francisco

If It’s Broken, Fix It

I’m a family practice physician. Spinning off of your Bill of the Month series, I think it would be very beneficial to publish more stories on what health care and costs look like abroad. Hospitals and providers are simply functioning within a broken system. Of course, costs are astronomical when many of the mainstays on the Fortune 500 list are insurance companies. I think people (i.e., voters) need to hear more about what health care would look like if Medicare and Medicaid were the only payers. The broken system exists, and people need to know how to work through that, but people also need to hear that there are other equally effective ways of delivering health care.

— Dr. Justin Riederer, Asheville, North Carolina

— Bill Kimler, Greenwood, South Carolina

An ‘Inherently Abusive and Ineffective’ Treatment for Autism

As a member of the autistic community (and a trained journalist myself), I am deeply disturbed by the recent article “‘So Rudderless’: A Couple’s Quest for Autism Treatment for Their Son Hits Repeated Obstacles” (July 21), by Michelle Andrews.

This article appears to be a follow-up to an article written by Andy Miller and Jenny Gold and published on March 30. Both articles uncritically promote applied behavior analysis (ABA) and falsely portray families unable to access ABA as victims of the pandemic and/or health care bureaucracy.

You should be aware that both articles taint KHN’s reputation as a reliable source for medical/health care news and information and do not meet even basic journalistic standards.

ABA is an inherently abusive and ineffective pseudoscience designed not to enhance the lives of autistic people, but rather to force us to suppress our autistic traits and perform neurotypical ones. Among the critics are survivors of ABA (Julia Bascom of the Autistic Self Advocacy Network and Amy Sequenzia of the Autistic Women & Nonbinary Network being two prominent examples). Further, for the past several years, the Department of Defense Office of Inspector General has found that ABA is largely ineffective, even by its own standards. None of this was mentioned in either article.

Your articles also did not mention the origins of ABA, including the fact that the practice was pioneered by O. Ivar Lovaas, the same man who helped pioneer gay/trans conversion therapy and was infamous for “treating” autistic children with electric shocks and corporal punishment. They also did not mention critics’ specific concerns about currently practiced ABA, including that it teaches autistic individuals that they have no right to say no and that, if they do say no, they’ll be physically and verbally bulldozed into compliance.

I also did not see any reference in your articles to the 2018 survey conducted by autistic researcher Henny Kupferstein, which found that autistic individuals exposed to ABA were 86% more likely to exhibit symptoms consistent with post-traumatic stress disorder.

The few points I’ve mentioned above barely scratch the surface regarding the controversy surrounding ABA. However, your reporters chose not to reach out to any prominent critics of ABA for a quote or to cite any of their specific concerns.

Further, your reporters didn’t reach out to a single autistic source, despite both articles being about the autistic community. Despite how the autistic community is infantilized and portrayed as incompetent by various prominent “charities,” like Autism Speaks, our community as a whole is fully capable of stating our opinions and engaging in self-determination.

I would appreciate a response to this letter. Hopefully, you realize the seriousness of this matter and intend to publish a follow-up article examining ABA’s rampant abuses.

— Matthew Zeidman, New Hyde Park, New York

— The Children and Youth With Special Health Care Needs National Research Network, Denver

Readers and Tweeters Place Value on Community Services and Life-Sustaining Care

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

A Cure for Ambulance Sticker Shock

This is a comment about your recent story on ambulance surprise bills (“The Ambulance Chased One Patient Into Collections,” July 27). In the story, three siblings were taken from an accident in three separate ambulances, then charged vastly different rates.

In Oklahoma City, we pay $3.65 a month on our water bills to fund EMSA (Emergency Medical Services Authority), a public ambulance service. If you need a ride in one, that premium covers it for anyone in your household. The payment is opt-out, so most everyone pays it. Non-water customers (like those in apartments whose rent covers utilities) can buy in, too. It might still be expensive for out-of-town visitors, however.

The EMSA premium works. You should report on it.

— Phil Crow, Oklahoma City, Oklahoma

— Dr. Richard Vaughn, St. Louis

Tough Lesson on Predatory Lenders

This essay (“The Debt Crisis That Sick Americans Can’t Avoid,” Aug. 2) compares student loan debt to medical debt but doesn’t seem to grasp how predatory the student loan industry is. For example, I have paid back close to $70,000 (more than I borrowed) and still owe $282,000.

There are thousands more in the same situation. It’s why we’re pushing for relief from the uniquely predatory and exploitive student loan debt.

— Brian Galloway, Salem, Oregon

— Ellen Fink-Samnick, Burke, Virginia

Focusing on FQHCs

This article paints a grossly inaccurate picture of federally qualified health centers (FQHCs) and their work delivering life-sustaining care to 30 million Americans (“Community Health Centers’ Big Profits Raise Questions About Federal Oversight, Aug. 15).

The piece’s conclusions are based on data representing fewer than 1% of health centers. Framing an argument on a cherry-picked handful of centers out of nearly 1,400 nationwide skews the facts.

Health centers fought on the front lines of the pandemic. Fewer people were infected with, or died from, covid-19 when a health center was nearby. Such efforts came at a cost: Most centers operate on thin margins, struggling to retain staff even while battling health crises.

Financial resilience for centers is essential because federal support has never been as certain as the challenges associated with caring for low-income communities.

The centers’ financial reserves are not secreted away but are regularly reported, available for scrutiny and subjected to annual audits. In some cases, dollars go toward site expansions, staffing, or expanded services. One lesson learned from the pandemic is that centers are the “canaries in the coal mine” of public health and require funding to nimbly adapt care. Private donations have also helped health centers stay afloat, a fact barely mentioned in KHN’s reporting.

The average health center CEO salary is far less than what this reporting on outlier centers suggests. There are far more profitable jobs in health care that do not involve fighting for every dollar to care for the underserved. For health center staff, it’s about dedication, not dollars.

KHN’s reporting amplifies misconceptions about the 340B prescription program — which has provided a crucial lifeline to uninsured and underinsured Americans who otherwise struggle to afford prescriptions. By law, all savings resulting from that program must be reinvested in patient care. As a result, health centers report vastly improved health outcomes among their patients.

Accountability is also baked into the health center model. Site visits by regulators ensure that patient care and clinical data is consistent with national standards. Additionally, health centers are governed by local boards, for which patients mostly serve as the directors.

The health center model has been quietly addressing every public health crisis for more than 50 years.

When most private-practice physicians limit or do not accept Medicaid patients, roughly half of health center patients are covered by Medicaid and would, without access to health centers, likely seek costlier emergency room services. As we continue to struggle with public health threats, health centers’ efforts to test, vaccinate and treat hard-to-reach populations deserve support and investment.

The National Association for Community Health Centers will continue to stand up for our valued health care heroes. No other health system stands as a living legacy that health care can be patient-driven, effective, and trusted stewards of federal dollars. We stand by this model.

— Rachel Gonzales-Hanson, interim president and CEO of the National Association for Community Health Centers, Bethesda, Maryland

— Bijan Salehizadeh, Washington, D.C.

Mental Health for the Incarcerated: When Hands Are Tied

I am a psychologist and the director of mental health services for a medium-sized (around 800 inmates) jail in Indiana. I have been dealing with this frustrating problem for the past five years (“When Mental Illness Leads to Dropped Charges, Patients Often Go Without Stabilizing Care,” Aug. 4). We often run into this issue when police/prosecutors fail to file charges, and we’re stuck dealing with an inmate who is psychotic and homeless with no family. The local hospitals won’t take someone on an emergency detention order, or EDO, unless the individual is verbally saying they’re suicidal. With regard to the wait for a state psychiatric bed, we’re averaging four to five months now for forensic beds, and 11 months for civil commitment beds. I’ve seen inmates serve nine months or more (including time at the hospital) for a trespassing charge.

We’re often stuck in a situation in which we have to release someone who is psychotic and the hospital won’t take them. They usually have no family to help. This is extremely dangerous, especially in the winter months when it can drop below zero (all of the warming shelters in my area have closed since covid started). Sadly, the best outcome is that the patient refuses to leave the jail lobby and is arrested for trespassing and brought right back into the building.

Anyway, I wanted to say thank you for writing this article.

William Mescall, Crown Point, Indiana

— Paul R. Gormley, Boca Raton, Florida

On Psychiatric Hospitalizations and Suicide Risk

I was disappointed to see that the author of the story “Social Media Posts Criticize the 988 Suicide Hotline for Calling Police. Here’s What You Need to Know.” (Aug. 11) implied that psychiatric hospitalization causes death by suicide in the following paragraph: “Research shows suicide rates increase drastically in the months after people are discharged from psychiatric hospitals. Those who were sent involuntarily are more likely to attempt suicide than those who chose to go, and involuntary commitments can make young people less likely to disclose their suicidal feelings in the future.”

While is it true that the period after psychiatric hospitalization is a key risk period for death by suicide, there is no causal evidence to demonstrate that the hospitalization causes death by suicide. In fact, there is an important third variable that may explain this finding: Only people who are severely ill, and often at high risk for suicide, are psychiatrically hospitalized. Indeed, for me, as a licensed psychologist, involuntary psychiatric hospitalization is a last resort for people at imminent risk of death by suicide.

You may wish to read a recent meta-analysis in which the researchers synthesized data from randomized control trials, or RCTS. RCTs are the gold standard for evaluating causality because they can rule out third-variable explanations, such as severity. Their article states: “Indeed, a small number of RCTs have examined means restriction/safety programs and acute psychiatric hospitalization. Notably, these interventions produced effects that are similar to those of more commonly studied interventions.” Overall in their meta-analysis, they did not find evidence that interventions for suicidality are iatrogenic or cause increased suicidality.

— K. Jean Forney, clinical psychologist and assistant professor at Ohio University, Athens, Ohio

— Kathy Flaherty, Middletown, Connecticut

— Frank Bednarz, Chicago

Anti-Vaccine Mandate Is Not the Same as Anti-Vaccine

An important comment regarding your article “‘My Body, My Choice’: How Vaccine Foes Co-Opted the Abortion Rallying Cry” (July 6). It is purposely deceptive. You say “anti-vaccine” activists — which is incorrect. The people gathering in Los Angeles (and elsewhere across the country) are anti-forced vaccine — not necessarily “anti-vaccine,” as your article repeatedly insists. To be against being forced to submit to an experimental medicine is not the same as being against a vaccine — or those who choose to take it. You, of course know this: No medicine is right for everyone. Why are you deliberately choosing to deceive people by your careful, not-accidental choice of words?

— Kathleen German, Nashville

— Derrick Edward Jones, Seattle