Tag: Mental Health

Health Care Workers Push for Their Own Confidential Mental Health Treatment

States are redefining when medical professionals can get mental health treatment without risking notifying the boards that regulate their licenses.

Too often, health care workers wait to seek counseling or addiction treatment, causing their work and patient care to suffer, said Jean Branscum, CEO of the Montana Medical Association, an industry group representing doctors.

“They’ve invested so much time in their career,” Branscum said. “To have anything jeopardize that is a big worry on their mind.”

Montana, like other states, has a recovery program for health professionals who have a substance use disorder or mental illness. However, medical associations say such programs often come with invasive monitoring, even for voluntary care. And gray areas about when a mental illness should become public breeds fear that seeking care jeopardizes a medical career.

Montana is among the states looking to boost confidential care for health professionals as long as they’re not deemed a danger to themselves or patients. In recent years, at least a dozen states have considered or created confidential wellness programs to offer clinicians help early on for career burnout or mental health issues. States have also reworked medical licensing questions to avoid scrutiny for providers who need mental health treatment. The changes are modeled after Virginia legislation from 2020.

During a legislative committee meeting last month, advocates for Montana medical professionals asked state lawmakers to follow Virginia’s lead. They say the goal is twofold: to get clinicians treatment before patients are at risk and to curtail the workforce burnout that’s partly fueled by untreated stress.

Montana’s existing medical monitoring program, the Montana Recovery Program, is run by the global company Maximus. Montana’s professional advocates had backed another nonprofit to run Montana’s program, which didn’t win the state contract.

The Montana Recovery Program declined a request for an interview, instead referring KFF Health News to the Montana Department of Labor & Industry, which oversees the state’s medical licensing boards. Department staffers didn’t comment by deadline.

In a Medscape survey released this year, 20% of physicians said they felt depressed, with job burnout as a leading factor. The majority said confiding in other doctors wasn’t practical. Some said they might not tell anyone about their depression out of fear people would doubt their abilities, or that their employer or medical board could find out.

Health professionals are leaving their jobs. They’re retiring early, reducing work hours, or switching careers. That further dwindles patients’ care options when there already aren’t enough providers to go around. The federal government estimates 74 million people live in an area without enough primary care services due to a workforce shortage.

Aiming to ensure patient safety, state medical boards can suspend or revoke clinicians’ rights to practice medicine if substance use or psychological disorders impair their work. Those cases are rare. One study found roughly 4,400 actions against the licenses of U.S. physicians for either substance use or psychological impairment from 2004 to 2020.

Nonetheless, workforce advocates say disclosure requirements cause some health professionals to dodge questions about mental health histories on licensing and insurance forms or forgo care altogether. They’re worried divulging any weakness will signal they shouldn’t practice medicine.

The mental health questions health workers are asked vary by state and profession. For example, nurses in Montana renewing their license are asked if they have any psychological condition or substance use that limited their ability to practice “with reasonable skill and safety” in the previous six months. Along with being asked about substance use on the job, doctors are required to say whether they’ve experienced a mental condition that “might adversely affect any aspect of your ability to perform.”

“When I see that question on my renewal, do I have to report that I was depressed because I was going through a really tough divorce?” Branscum cited as an example of workers’ uncertainty. “You know, my life is turned upside down now. Am I obligated to report that?”

A “yes” wouldn’t immediately result in licensing problems. Those who do report mental health troubles would be flagged by state workers as a potential concern. They could end up before the board’s same screening panel that recommends whether to revoke a license, or be referred to long-term monitoring with regular screening.

Additionally, health professionals are required to report when other clinicians show unprofessionalism or have potential issues that affect performance. Branscum said medical professionals worry that what they say in a counseling session could be flagged for licensing boards, or that a co-worker may make a report if they seem depressed at work.

Bob Sise, a Montana addiction psychiatrist and co-founder of the nonprofit 406 Recovery, told state lawmakers that job stressors are playing into workers’ mental health challenges, such as long shifts and heavy patient loads. And with the rising cost of health care, physicians feel they’re sacrificing their commitment to healing as they routinely substitute optimal treatment for lesser care that patients can afford.

Sise said his practice now has roughly 20 health professionals as patients.

“They were able to access care before it was too late,” Sise said. “But they’re the exception.”

In Virginia, doctors, nurses, physician assistants, pharmacists, and students can join the state’s SafeHaven program. Melina Davis, CEO of the Medical Society of Virginia, said the service offers counseling and peer coaching with staffers available to answer a call 24/7.

“If you only have a moment at 2 a.m., or that’s when you had the chance to first process the death of a patient, then you can talk to somebody,” Davis said.

Those in the program are assured that those conversations are privileged and can’t be used in lawsuits. This year, the state is considering adding medical diagnoses under the program’s confidential protections.

States that have followed suit have slight variations, but most create a “safe haven” with two types of wellness and reporting systems. Those who seek out care before they’re impaired at work have broad privacy protections. The other defines a disciplinary track and monitoring system for those who pose a risk to themselves or others. Indiana and South Dakota followed Virginia’s lead in 2021.

States are also narrowing the time frame that licensing boards can ask about mental illness history. The American Medical Association has encouraged states to require health care workers to disclose current physical or mental health conditions, not past diagnoses.

Last year, Georgia updated its license renewal form to ask doctors if any current condition “for which you are not being appropriately treated” affects their ability to practice medicine. That update replaces a request for seven years of mental health history.

Even outside the “safe haven” framework, some states are grappling with how to grant doctors privacy while guaranteeing patient safety.

The Medical Board of California is creating a program to treat and monitor doctors with alcohol and drug illnesses. But patients’ advocates have argued too much privacy, even for voluntary treatment, could risk consumers’ well-being. They told the state medical board that patients have a right to know if their doctor has an addiction.

Davis said states should debate how to balance physicians’ privacy and patients’ safety.

“We in medical professions are supposed to be saving lives,” she said. “Where’s the line where that starts to fall off, where their personal situation could affect that? And how does the system know?”

According to the Montana Recovery Program website, it’s not a program of discipline but instead one “of support, monitoring, and accountability.” Participants may self-refer to the program or be referred by their licensing board.

Branscum, with the Montana Medical Association, said the state’s monitoring program is needed for cases in which an illness impairs a clinician’s work. But she wants that form of treatment to become the exception.

Vicky Byrd, CEO of the Montana Nurses Association, said nurses don’t tend to join the program until they’re forced to in order to keep their license. That leaves many nurses struggling in silence until untreated illness shows up in their work, she said.

“Let’s get them taken care of before it has to go on their license,” Byrd said.

Because after that point, she said, it’s hard to recover.

Pandemic Stress, Gangs, and Utter Fear Fueled a Rise in Teen Shootings

Diego never imagined he’d carry a gun.

Not as a child, when shots were fired outside his Chicago-area home. Not at age 12, when one of his friends was gunned down.

Diego’s mind changed at 14, when he and his friends were getting ready to walk to midnight Mass for the feast of Our Lady of Guadalupe. But instead of hymns, Diego heard gunfire, and then screaming. A gang member shot two people, including one of Diego’s friends, who was hit nine times.

“My friend was bleeding out,” said Diego, who asked KHN not to use his last name to protect his safety and privacy. As his friend lay on the ground, “he was choking on his own blood.”

The attack left Diego’s friend paralyzed from the waist down. And it left Diego, one of a growing number of teens who witness gun violence, traumatized and afraid to go outside without a gun.

Research shows that adolescents exposed to gun violence are twice as likely as others to perpetrate a serious violent crime within two years, perpetuating a cycle that can be hard to interrupt.

Diego asked his friends for help finding a handgun and — in a country supersaturated with firearms — they had no trouble procuring one, which they gave him free.

“I felt safer with the gun,” said Diego, now 21. “I hoped I wouldn’t use it.”

For two years, Diego kept the gun only as a deterrent. When he finally pulled the trigger, it changed his life forever.

Disturbing Trends

The news media focuses heavily on mass shootings and the mental state of the people who commit them. But there is a far larger epidemic of gun violence — particularly among Black, Hispanic, and Native American youth — ensnaring some kids not even old enough to get a driver’s license.

Research shows that chronic exposure to trauma can change the way a child’s brain develops. Trauma also can play a central role in explaining why some young people look to guns for protection and wind up using them against their peers.

The number of children under 18 who killed someone with a firearm jumped from 836 in 2019 to 1,150 in 2020.

In New York City, the number of young people who killed someone with a gun more than doubled, rising from 48 juvenile offenders in 2019 to 124 in 2022, according to data from the city’s police department.

Youth gun violence increased more modestly in other cities; in many places, the number of teen gun homicides rose in 2020 but has since fallen closer to pre-pandemic levels.

Researchers who analyze crime statistics stress that teens are not driving the overall rise in gun violence, which has increased across all ages. In 2020, 7.5% of homicide arrests involved children under 18, a slightly smaller share than in previous years.

Local leaders have struggled with the best way to respond to teen shootings.

A handful of communities — including Pittsburgh; Fulton County, Georgia; and Prince George’s County, Maryland — have debated or implemented youth curfews to curb teen violence. What’s not in dispute: More people ages 1 to 19 die by gun violence than by any other cause.

A Lifetime of Limits

The devastating toll of gun violence shows up in emergency rooms every day.

At the UChicago Medicine trauma center, the number of gunshot wounds in children under 16 has doubled in the past six years, said Dr. Selwyn Rogers, the center’s founding director. The youngest victim was 2. “You hear the mother wail, or the brother say, ‘It’s not true,’” said Rogers, who works with local youth as the hospital’s executive vice president for community health engagement. “You have to be present in that moment, but then walk out the door and deal with it all over again.”

Dr. Selwyn Rogers sits on a chair in a hospital lobby. He wears a white doctor's coat and looks directly at the camera. The room is sunny and spacious.
Dr. Selwyn Rogers is the founding director of UChicago Medicine’s trauma center. In the past six years, the trauma center has seen the number of gunshot wounds in children under 16 double.(UChicago Medicine)

In recent years, the justice system has struggled to balance the need for public safety with compassion for kids, based on research that shows a young person’s brain doesn’t fully mature until age 25. Most young offenders “age out” of criminal or violent behavior around the same time, as they develop more self-control and long-range thinking skills.

Yet teens accused of shootings are often charged as adults, which means they face harsher punishments than kids charged as juveniles, said Josh Rovner, director of youth justice at the Sentencing Project, which advocates for justice system reform.

About 53,000 juveniles in 2019 were charged as adults, which can have serious health repercussions. These teens are more likely to be victimized while incarcerated, Rovner said, and to be arrested again after release.

Young people can spend much of their lives in a poverty-imposed lockdown, never venturing far beyond their neighborhoods, learning little about opportunities that exist in the wider world, Rogers said. Millions of American children — particularly Black, Hispanic, and Native American kids — live in environments plagued by poverty, violence, and drug use.

The covid-19 pandemic amplified all those problems, from unemployment to food and housing insecurity.

Although no one can say with certainty what spurred the surge in shootings in 2020, research has long linked hopelessness and lack of trust in police — which increased after the murder of George Floyd that year — to an increased risk of community violence. Gun sales soared 64% from 2019 to 2020, while many violence prevention programs shut down.

One of the most serious losses children faced during the pandemic was the closure of schools — institutions that might provide the only stabilizing force in their young lives — for a year or more in many places.

“The pandemic just turned up the fire under the pot,” said Elise White, deputy director of research at the nonprofit Center for Justice Innovation, which works with communities and justice systems. “Looking back, it’s easy to underplay now just how uncertain that time [during the pandemic] felt. The more that people feel uncertain, the more they feel there’s no safety around them, the more likely they are to carry weapons.”

Of course, most children who experience hardship never break the law. Multiple studies have found that most gun violence is perpetrated by a relatively small number of people.

The presence of even one supportive adult can protect children from becoming involved with crime, said Dr. Abdullah Pratt, a UChicago Medicine emergency physician who lost his brother to gun violence.

Pratt also lost four friends to gun violence during the pandemic. All four died in his emergency room; one was the son of a hospital nurse.

Although Pratt grew up in a part of Chicago where street gangs were common, he benefited from the support of loving parents and strong role models, such as teachers and football coaches. Pratt was also protected by his older brother, who looked out for him and made sure gangs left the future doctor alone.

“Everything I’ve been able to accomplish,” Pratt said, “is because someone helped me.”

Growing Up in a ‘War Zone’

Diego had no adults at home to help him feel safe.

His parents were often violent. Once, in a drunken rage, Diego’s father grabbed him by the leg and swung him around the room, Diego said, and his mother once threw a toaster at his father.

At age 12, Diego’s efforts to help the family pay overdue bills — by selling marijuana and stealing from unlocked cars and apartments — led his father to throw him out of the house.

At 13, Diego joined a gang made up of neighborhood kids. Gang members — who recounted similar stories about leaving the house to escape abuse — gave him food and a place to stay. “We were like a family,” Diego said. When the kids were hungry, and there was no food at home, “we’d go to a gas station together to steal some breakfast.”

Dr. Abdullah Pratt stands at a reception desk in a medical building. He wears a white doctor's coat and gently smiles at the camera.
Dr. Abdullah Pratt is a UChicago Medicine emergency physician who lost his brother to gun violence. Pratt says the presence of even one supportive adult can protect children from becoming involved with crime.(UChicago Medicine)

But Diego, who was smaller than most of the others, lived in fear. At 16, Diego weighed only 100 pounds. Bigger boys bullied and beat him up. And his successful hustle — selling stolen merchandise on the street for cash — got the attention of rival gang members, who threatened to rob him.

Children who experience chronic violence can develop a “war zone mentality,” becoming hypervigilant to threats, sometimes sensing danger where it doesn’t exist, said James Garbarino, an emeritus professor of psychology at Cornell University and Loyola University-Chicago. Kids who live with constant fear are more likely to look to firearms or gangs for protection. They can be triggered to take preemptive action — such as firing a gun without thinking — against a perceived threat.

“Their bodies are constantly ready for a fight,” said Gianna Tran, deputy executive director of the East Bay Asian Youth Center in Oakland, California, which works with young people living in poverty, trauma, and neglect.

Unlike mass shooters, who buy guns and ammunition because they’re intent on murder, most teen violence is not premeditated, Garbarino said.

In surveys, most young people who carry guns — including gang members — say they do so out of fear or to deter attacks, rather than perpetrate them. But fear of community violence, both from rivals and the police, can stoke an urban arms race, in which kids feel that only the foolish walk around without a weapon.

“Fundamentally, violence is a contagious disease,” said Dr. Gary Slutkin, founder of Cure Violence Global, which works to prevent community violence.

Although a small number of teens become hardened and remorseless, Pratt said, he sees far more shootings caused by “poor conflict resolution” and teenage impulsivity rather than a desire to kill.

Indeed, firearms and an immature teenage brain are a dangerous mix, Garbarino said. Alcohol and drugs can magnify the risk. When confronted with a potentially life-or-death situation, kids may act without thinking.

When Diego was 16, he was walking a girl to school and they were approached by three boys, including a gang member who, using obscene and threatening language, asked if Diego was also in a gang. Diego said he tried to walk past the boys, one of whom appeared to have a gun.

“I didn’t know how to fire a gun,” Diego said. “I just wanted them to get away.”

In news accounts of the shooting, witnesses said they heard five gunshots. “The only thing I remember is the sound of the shots,” Diego said. “Everything else was going in slow motion.”

Diego had shot two of the boys in the legs. The girl ran one way, and he ran another. Police arrested Diego at home a few hours later. He was tried as an adult, convicted of two counts of attempted homicide, and sentenced to 12 years.

A Second Chance

In the past two decades, the justice system has made major changes in the way it treats children.

Youth arrests for violent crime plummeted 67% from 2006 to 2020, and 40 states have made it harder to charge minors as adults. States also are adopting alternatives to incarceration, such as group homes that allow teens to remain in their communities, while providing treatment to help them change their behavior.

Because Diego was 17 when he was sentenced, he was sent to a juvenile facility, where he received therapy for the first time.

Diego finished high school while behind bars and went on to earn an associate’s degree from a community college. He and other young inmates went on field trips to theaters and the aquarium — places he had never been. The detention center director asked Diego to accompany her to events about juvenile justice reform, where he was invited to tell his story.

Those were eye-opening experiences for Diego, who realized he had seen very little of Chicago, even though he had spent his life there.

“Growing up, the only thing you see is your community,” said Diego, who was released after four years in detention, when the governor commuted his sentence. “You assume that is what the whole world is like.”

KHN data editor Holly K. Hacker and researcher Megan Kalata contributed to this report.

Readers and Tweeters Urgently Plea for a Proper ‘Role’ Call in the ER

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.

How Physician Assistants and Nurse Practitioners Enhance Health Care

The story of one patient’s ER experience does not at all capture the complexities of an emergency department serving the needs of a stochastic patient population.

Given the reach of KHN, it is disappointing to read stories that inch closer to tabloid-level reporting (“Doctors Are Disappearing From Emergency Rooms as Hospitals Look to Cut Costs,” Feb. 13).

Having spent most of my career working in and operationalizing emergency departments, I can assure you that there are plenty of opportunities to optimize the delivery of care and reduce unnecessary waste and cost while maintaining excellent outcomes. The salient point that you make “it’s all about the money” is too simplistic given the complexities.

Advanced practice providers (APPs) collectively describe nurse practitioners (NPs), physician assistants (PAs), certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs). The term “midlevel practitioner” is outdated.

The archaic paternalistic approach to health care has long been overdue for change. Post-pandemic, it is critical to pivot from “the way it has always been done,” and that includes embracing new models of care.

Physicians and APPs provide excellent care to their patients and operate with different scopes of practice, training, and licensure. Therefore, most of us find working together in team-based models to be highly effective in ensuring that patients see the right care provider for the right health problem.

I found this reporting to be superficial and even offensive to nurse practitioners, like myself, who provide just as high quality care to patients as our physician colleagues.

I welcome the opportunity for dialogue about the value of nurse practitioners and physician assistants.

— Cindi Warburton, Spokane, Washington

— Mark Williams, Sacramento, California

I heard your NPR-partnered story on emergency rooms being managed by private equity and using fewer doctors and more nurse practitioners and physician assistants as midlevel practitioners.

But I prefer midlevel practitioners and medical residents, if their skills are relevant to me. They tend to be more careful in telling me what I should know and in entering records.

The professionally senior doctors (by years of experience and specialty, but I don’t know about board certification) tend to use record-keeping to support higher insurance reimbursement and then they don’t seem to believe what anyone else writes in the records, or don’t bother looking. Furthermore, they’re less likely to tell me what circumstances should prompt me to seek out a doctor or an ER, but if anything goes so wrong or becomes so advanced that I need even more care, they’re happy to provide it.

Doctors often categorically object to nurse practitioners, and state regulations reflect that.

— Nick Levinson, Brooklyn, New York

The recent KHN article “Doctors Are Disappearing From Emergency Rooms as Hospitals Look to Cut Costs” failed to address a critical consideration in the complexities of health care delivery today: the challenge of providing care to patients when they need it at a time when demand for care is on the rise, and the health care workforce is experiencing staggering levels of decline.

Today, 99 million Americans lack adequate access to primary care. By 2026, there will be a shortage of up to 3.2 million health care workers. As a physician associate/physician assistant for more than 20 years, I am kept up at night because of this perfect storm on the horizon — worried for my patients and their ability to access the care they need. Timely access to a trusted and qualified health care provider is never more pressing than during an emergency, when patients are at their most vulnerable, and delay in care can be a matter of life or death.

There is no easy answer to this impending workforce crisis, but one thing is clear: We can meet patient needs only if every member of today’s health care team is respected for the contributions they bring and can practice to the fullest extent of their education and training.

The fact is, without PAs, patients’ access to care would suffer. PAs account for more than 500 million patient visits each year. For many patients, PAs serve as primary care providers. And in some communities, PAs are the only health care providers. Let’s not lose sight of the countless stories we have all read in the media about community hospitals and clinics closing.

This article failed to take into account any research that shows the value and quality of PA-delivered care. For example, a 2021 study published by PLOS ONE looked at 39 studies across North America, Europe, and Africa between 1977 and 2021. In 33 of the 39 studies, researchers found care provided by a PA was comparable or better than care delivered by a physician. In 74% of the studies, resource and labor costs were lower when care was delivered by a PA versus a physician.

The quality of PA-delivered care can also be seen when looking at the ratio of liability claims. The ratio of claims to PAs averaged one claim for every 550 PAs. Compare this to the physician ratio, which averaged 1 claim for every 80 physicians.

Hiring PAs to practice in emergency medicine is not about “replacing” physicians, nor does it diminish the quality of care. Utilizing PAs in emergency medicine is about equipping health care teams with a wide range of highly educated and trained clinicians who can work together to ensure patients get the safe, high-quality care they need.

Let us stay focused on the reason why PAs, nurse practitioners, and physicians went into medicine in the first place: to care for people! Patient-centered, team-based care is about every single one of us contributing our knowledge, experience, and expertise to ensure the best outcomes for patients.

— Jennifer M. Orozco, American Academy of Physician Associates president and board chair, Chicago

— Whitney Schmucker, New York City

KHN should not be using the term “midlevel providers.” It’s a derogatory term used by doctors to belittle advanced practice providers (nurse practitioners and physician associates).

— Danielle Franklin, Minneapolis

— Gregg Gonsalves, New Haven, Connecticut

Nurse practitioners are essential providers in our nation’s current and future health care system. In an effort to highlight concerns related to health facility ownership models, the recent article “Doctors Are Disappearing From Emergency Rooms as Hospitals Look to Cut Costs” incorrectly represents the care provided by NPs in emergency rooms.

In fact, a recent study examining advanced practice providers (APPs), including NPs, in the ER found increasing APP coverage had no impact on flow, safety, or patient experiences in the emergency department. Additional research concluded that after controlling for patient severity and complexity, APPs diagnostic testing and hospitalization rates did not differ from physicians in patients presenting to the emergency department with chest and abdominal pain.

Prepared at the master’s or doctoral level, NPs provide primary, acute, chronic, and specialty care to patients of all ages and backgrounds. NPs practice in nearly every health care setting including hospitals, clinics, Veterans Health Administration and Indian Health Service facilities, emergency rooms, urgent care sites, private physician or NP practices, skilled nursing facilities and nursing facilities, schools, colleges and universities, retail clinics, public health departments, nurse-managed clinics, homeless clinics, and home health care settings. Collectively, NPs deliver high-quality care in more than 1 billion patient visits each year.

Grounded in 50 years of research and evidence-based practice, NPs deliver high-quality care, consistent with their physician counterparts. Results from a study of over 800,000 patients at 530 Veterans Affairs facilities found that patients assigned to NP primary care providers were less likely to utilize additional services, had no difference in costs, and experienced similar chronic disease management compared with physician-assigned patients. Furthermore, a comprehensive summary of studies examining NP quality of care from the American Enterprise Institute underscores the benefits of NP-led care.

Today, NPs represent 355,000 solutions to our nation’s health care needs. Patients deserve access to these high-quality health care providers wherever they seek care.

— April N. Kapu, president of the American Association of Nurse Practitioners, Austin, Texas

— Dr. Sarabeth Broder-Fingert, Boston

Ophthalmologists and Optometrists Aren’t Interchangeable

Increasing Americans’ access to care is critical. However, loosening the scope of practice for certain types of care can be counterproductive and potentially risky for patients (“Montana Considers Allowing Physician Assistants to Practice Independently,” Feb.10).

A small handful of states, for example, have loosened scope-of-practice laws for laser eye surgery, which, if done incorrectly, could lead to serious complications that can damage a person’s vision. Over the course of their medical school education, internships, and residencies, ophthalmologists must complete thousands of hours of training before being allowed to perform laser eye surgeries on their own.

Unfortunately, some states permit optometrists, who are not medical doctors, to perform laser eye surgeries as long as they complete a 16- to 32-hour course. As one might expect, the likelihood of a patient needing additional surgery is significantly higher — more than double — when initial surgeries are performed by an optometrist instead of an ophthalmologist. It is little wonder, then, why states like California have successfully blocked efforts to loosen the scope of practice for laser eye surgery.

Despite the potential risks, and no evidence of documented access issues, the Department of Veterans Affairs updated its community care guidelines last year to allow optometrists in this small number of states to perform laser eye surgery on veterans in community care settings. Worse still, the VA is developing its National Standards of Practice, which many fear would let optometrists in VA facilities nationwide perform laser eye surgery on America’s veterans. To defend our veterans and prevent them from suffering adverse outcomes, it is critical for the VA to maintain patient protections that ensure only medical doctors with the requisite education and training can perform invasive eye surgeries.

Ophthalmologists and optometrists both play important roles in a patient’s collaborative care team, but their duties and skill sets are not interchangeable. Loosening the scope of practice for laser eye surgeries will not serve patients well. Our veterans defended us; now the VA must protect them.

— Dr. Daniel J. Briceland, president of the American Academy of Ophthalmology, Sun City West, Arizona

— David Johnson, Chicago

We were disappointed that the article by Keely Larson about Montana’s consideration of a change in physician assistant regulation failed to note that the vast majority of research on the quality of care provided by physician assistants and nurse practitioners demonstrates that they have similar quality of care to physicians when practicing in their area of expertise. There are numerous literature reviews published in peer-reviewed journals on this topic, which should have been noted in the story. The author selected a single working paper that focuses on quality of care in emergency departments in a single health system (the Department of Veterans Affairs) that is not representative of the settings in which most physician assistants and nurse practitioners work. The individual cited, Dr. Yiqun Chen, extrapolated her working paper to the entire profession of physician assistants (who were not included in her study), which is a significant overreach.

We are accustomed to KHN stories being well researched and balanced. This story missed the mark and does not reflect well on the quality KHN aims to achieve.

— Joanne Spetz, Janet Coffman, and Ulrike Muench, the University of California-San Francisco

— Dr. Mehmet Oz, Bryn Athyn, Pennsylvania

At the Crux of Nursing Home Staffing Crunch: Compensation

I doubt it is possible to staff nursing facilities with qualified and caring staff when the compensation is quite poor and the work environment is very challenging (“Wave of Rural Nursing Home Closures Grows Amid Staffing Crunch,” Jan. 25). It is more a system problem than a staffing problem and will not get “fixed” without some serious changes.

— Dr. Jack Page, Durham, North Carolina

— Benjy Renton, Washington, D.C.

Participating in the Mental Illness Stigma

I wonder what is behind the pressure to persuade us to say there is a stigma to mental health issues (“Public Health Agencies Turn to Locals to Extend Reach Into Immigrant Communities,” Feb. 10)? I wonder why we so easily comply?

— Harold A. Maio, retired mental health editor, Fort Myers, Florida

— Andrzej Klimczuk, Bialystok, Poland

Remote Fitness Must Not Replace the Value of Physical Therapy

If we’ve learned anything in recent years, it’s how vital technology is in allowing us to stay connected virtually, especially when it comes to health care. However, the online world cannot safely and adequately replace everything.

The recent article “Rural Seniors Benefit From Pandemic-Driven Remote Fitness Boom” (Jan.17) details how many older Americans living in rural areas rely on virtual fitness classes to remain physically active. While this is an important and effective option for some seniors, remote fitness classes cannot and should not replace clinically directed physical therapy.

Physical therapy helps patients remain strong and independent by managing pain, preventing injury, and improving mobility, flexibility, and balance under the supervision of a professionally trained physical therapist. It’s especially important at a time when senior deaths from falls are on the rise. Evidence shows that when seniors underwent an exercise intervention from a trained health care professional, it lowered their risk of a fall by 31%.

Not only is it effective in rehabilitating patients, but it is also an affordable, lower-cost alternative to invasive surgeries and pharmacological treatments, saving our health care system millions. And now, with the emergence of remote therapeutic monitoring, physical therapists can more easily reach patients in rural communities to ensure they are reaching their clinical goals through safe, at-home therapy exercises.

Physical therapists undergo years of education and training to provide the best, safest care for their patients. And while I applaud seniors for embracing online fitness classes and staying active, I also encourage them to recognize when clinically supervised physical therapy is needed to protect their safety and health.

— Nikesh Patel, executive director of the Alliance for Physical Therapy Quality and Innovation (APTQI), Washington, D.C.

— Eric Weinhandl, Victoria, Minnesota

Tallying Bad Pennies

Did Your Health Plan Rip Off Medicare?” (Jan. 27) was a highly misleading article. On a per-enrollee per-year basis, over- and under-payments amounted to literally pennies. If you must pile on, focus on the few bad apples.

— Jon M. Kingsdale, Boston

— Inger Burnett-Zeigler, Chicago

How Much Did They Know and When Did They Know It?

Great story by Harris Meyer about Prentice and Lurie hospitals (“A Baby Spent 36 Days in an In-Network NICU. Why Did the Hospital Next Door Send a Bill?” Jan. 30). I was practicing as an anesthesiologist in Illinois in 2011 when the bill became law banning out-of-network balance billing for hospital-based docs. Of course we knew about the advent of the law: We had to enter into contracts to be in network, contracts that materially reduced all our doctors’ incomes!

It is impossible for me to believe that a professional operating a billing service in 2020 for Ann & Robert H. Lurie Children’s Hospital of Chicago didn’t know about this 2011 law. I don’t believe them for a moment.

Thanks for the great article.

— Ron Meyer, Wilmette, Illinois

— Regina Phelps, San Francisco

Leaving a Bad Taste in My Mouth

In every article I’ve read about Paxlovid, including yours (“What Older Americans Need to Know About Taking Paxlovid,” Dec. 18), not one mentions the horrible metallic taste these pills have. I was prescribed Paxlovid after contracting covid-19. I’m 71 years old. It’s beyond my reasoning that in this day and age a pharmaceutical manufacturer can’t put a neutral coating on the pills. This awful taste stays with you day and night for the five days of use. I even had a friend who had to stop taking them as she was losing sleep over the horrible taste. My reference to friends is: “It’s like sucking on a wrench.” I’m sure this issue isn’t confined to us seniors, but it would be nice to read some recognition of a problem with this medication.

By the way, my workaround, which definitely helps but is hardly a solution, is to swallow the pills down with a swig of cranberry juice.

— Don Dugan, Brookfield, Wisconsin

— Olav Mitchell Underdal, Irvine, California

Admiration for Abortion Doulas

I admire and respect individuals willing to provide aid and comfort to others who are going through either the traditional birth process or a hard decision to end a pregnancy (“In North Carolina, More People Are Training to Support Patients Through an Abortion,” Jan. 5). Kudos to news groups for increasing awareness of individuals and organizations providing valuable services for their fellow citizens.

— Michael Walker, Black Mountain, North Carolina

— Dr. Darrell Gray II, Owings Mills, Maryland

Thinking Outside the Traditional Medicine Box

Katheryn Houghton missed out on sharing info on traditional methods, especially acupuncture (“Why People Who Experience Severe Nausea During Pregnancy Often Go Untreated,” Jan. 13). Also ginger, as in ginger tea, and peppermint. Peppermint oil (sniffed) or tea. I am an advocate for people with cancer.

— Ann Fonfa, founder of the Annie Appleseed Project, Delray Beach, Florida

— Catherine Arnst, New York City

A Cartoon Blooper?

The “Gender reveal?” political cartoon (Feb. 14) was confusing, unfunny, and inaccurate. How is this “political”? (It isn’t.) What makes gender reveals funny? (They’re not.) Most importantly, such reveals — an anachronistic cultural tradition that should be done away with anyway — are “sex reveals,” not “gender reveals.” (Biology is based on anatomy at birth, while gender is self-determined later in life and is fluid over time.) Even sex reveals are problematic, as they assume two biological sexes. (Some estimates indicate nearly 2% of individuals are born intersex, with their sexual anatomy not fitting into categories of either female or male.)

With anti-trans and anti-drag queen legislation being proposed and codified seemingly daily, now is not the time to poke fun at, nor inaccurately represent, the construct of gender. (It’s never the time.)

— Steff Du Bois, licensed clinical psychologist, Chicago

Keeping Marijuana Candy Away From Children

As an emergency room doctor, I was disappointed by the recent “KHN Health Minute” story trivializing a growing public health risk by suggesting parents “lock up their marijuana gummies” to avoid poisoning their children (“Listen to the Latest ‘KHN Health Minute,’” Feb. 16).

For background on why I, and other doctors, are concerned, I encourage you to read “Marijuana Candy: Poisoning and Lack of Protection for Children.”

— Dr. Roneet Lev, San Diego

— Halee Fischer-Wright, Denver

A Suggestion for Extra-Credit Reading

In response to the recent “What the Health?” podcast episode “As US Bumps Against Debt Ceiling, Medicare Becomes a Bargaining Chip” (Jan. 19), please have Julie Rovner read Stephanie Kelton’s book “The Deficit Myth.” She needs to understand why taxes pay for nothing. I consider Kelton’s book the most important on economics and how government budgets and financing work in the modern world.

— Mark Schaffer, Las Vegas

— Iqbal Atcha, Hanover Park, Illinois

Investing in ‘Practice-Ready’ Nurses to Bolster Workforce

The Connecticut Center for Nursing Workforce Inc. has created a best-practice plan to address these issues (“Senators Say Health Worker Shortages Ripe for Bipartisan Compromise,” Feb. 17). As nursing is the largest health care workforce role and a critical infrastructure within the state, nurses are a significant contributor to the fiscal, physical, and mental health of Connecticut, and a profession that can provide economic stability to its workers and families. Over 10,000 qualified nursing students were denied admission to registered nursing programs in 2021 due to full-time and part-time faculty shortages, lack of student clinical placements, and capacity of capstone experiences in specialty areas.

To produce “practice-ready” nurses, investment needs to be made in increasing the number of nursing faculty lines, both full-time (classroom) and part-time (clinical) experiences, simulation capacity and expertise, operations staff, and transition to practice resources.

Today, this is more challenging than ever, due to the impact of covid-19 on our nursing workforce, the natural attrition of our older nurses, early departure of new nurses causing a severe nursing shortage in the state, and the cost of “travel” nurses that is crippling the budgets of our health care facilities and not sustainable over the long term.

Nursing schools are competing for the same nursing human capital as our practice settings yet offer 30% less compensation for faculty roles as compared to clinical practice roles.

As a solution, it is critical to:

  1. Engage nursing schools to identify the demand for full-time and part-time faculty lines and staff.
  2. Develop a nurse faculty marketing campaign for associate, baccalaureate, accelerated registered nurse programs, and master’s degree in nursing programs for both full-time and part-time roles.
  3. Capitalize on the expertise of clinical nurses for the role of part-time clinical nurse faculty.
  4. Engage health care facilities to determine current nurse vacancies, future staffing needs, and onboarding/“transition to practice” gaps to best inform educational institutions as to the programs needed to be continued, expanded, or dissolved; thereby, maximizing education capacity, resources, faculty, and staff.

— Marcia Proto, executive director for the Connecticut Center for Nursing Workforce Inc., North Haven, Connecticut

— RJ Connelly III, Pawtucket, Rhode Island

Missing Pieces in the Covid Data Puzzle

It is misinformation to state that covid-19 deaths were counted when the opposite was true, and deaths were underreported due to political reasons, and reasons of expediency (“FDA Experts Are Still Puzzled Over Who Should Get Which Covid Shots and When,”) Jan. 27. For example, my father-in-law tested positive for covid before entering the hospital, and then repeatedly tested positive for covid while in the hospital so that he could not be released, and he died in the hospital, and covid was not listed as a cause of death on his death certificate. I have reason to believe that my own father died of covid in May 2020, during an election year, and covid was not listed as a cause of death on his death certificate. These men were not merely statistics, but left behind families who are still in turmoil and grief.

In public, people should wear masks all the time regardless of vaccination status, but, at the same time, be updated on vaccinations and boosters, and, at the same time, socially distance, and, at the same time, wash hands frequently and thoroughly. While all these measures should be taken simultaneously, everyone wearing masks is the easiest way to monitor compliance, and eliminates problems in determining someone else’s vaccination status, or determining whether the efficacy of their vaccines may have waned, or in determining whether they tested positive for covid, and failed to quarantine.

When, previously, the science was that vaccines and booster efficacy waned after three to six months, it should not be touted now to get the vaccine or booster only once a year.

The goal post should never have been moved to merely keeping people out of the hospital, but the goal should be to prevent people contracting covid, and to eradicate this scourge once and for all.

— Edward H. Bonacci Jr., Apex, North Carolina

Senators Have Mental Health Crises, Too

The Host

Both Republicans and Democrats in Congress reacted with compassion to the news that Sen. John Fetterman (D-Pa.) has checked himself into Walter Reed National Military Medical Center for treatment of clinical depression. The reaction is a far cry from what it would have been 20 or even 10 years ago, as more politicians from both parties are willing to admit they are humans with human frailties.

Meanwhile, former South Carolina governor and GOP presidential candidate Nikki Haley is pushing “competency” tests for politicians over age 75. She has not specified, however, who would determine what the test should include and who would decide if politicians pass or fail.

This week’s panelists are Julie Rovner of KHN, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Roubein of The Washington Post.

Among the takeaways from this week’s episode:

  • Acknowledging a mental health disorder could spell doom for a politician’s career in the past, but rather than raising questions about his fitness to serve, Sen. John Fetterman’s decision to make his depression diagnosis and treatment public raises the possibility that personal experiences with the health system could make lawmakers better representatives.
  • In Medicare news, Sen. Rick Scott (R-Fla.) dropped Medicare and Social Security from his proposal to require that every federal program be specifically renewed every five years. Scott’s plan has been hammered by Democrats after President Joe Biden criticized it this month in his State of the Union address.
  • Medicare is not politically “untouchable,” though. Two Biden administration proposals seek to rein in the high cost of the popular Medicare Advantage program. Those are already proving controversial as well, particularly among Medicare beneficiaries who like the additional benefits that often come with the private-sector plans.
  • New studies on the effectiveness of ivermectin and mask use are drawing attention to pandemic preparedness. The study of ivermectin revealed that the drug is not effective against the covid-19 virus even in higher doses, raising the question about how far researchers must go to convince skeptics fed misinformation about using the drug to treat covid. Also, a new analysis of studies on mask use leaned on pre-pandemic studies, potentially undermining mask recommendations for future health crises.
  • On the abortion front, abortion rights supporters in Ohio are pushing for a ballot measure enshrining access to the procedure in its state constitution, while a lawyer in Florida is making an unusual “personhood” argument to advocate for a pregnant woman to be released from jail.

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

Julie Rovner: Stat’s “Current Treatments for Cramps Aren’t Cutting It. Why Aren’t There Better Options,” by Calli McMurray

Joanne Kenen: The Atlantic’s “Eagles Are Falling, Bears Are Going Blind,” by Katherine J. Wu

Rachel Roubein: The Washington Post’s “Her Baby Has a Deadly Diagnosis. Her Florida Doctors Refused an Abortion,” by Frances Stead Sellers

Sarah Karlin-Smith: DCist’s “Locals Who Don’t Speak English Need Medical Translators, but Some Say They Don’t Always Get the Service,” by Amanda Michelle Gomez and Hector Alejandro Arzate

Also mentioned in this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on SpotifyApple PodcastsStitcherPocket Casts, or wherever you listen to podcasts.

The Kids Are Not OK

The Host

Teen girls “are experiencing record high levels of violence, sadness, and suicide risk,” according to a new survey from the Centers for Disease Control and Prevention. In 2021, according to the survey, nearly 3 in 5 U.S. teen girls reported feeling “persistently sad or hopeless.”

Meanwhile, a conservative judge in Texas has delayed his ruling in a case that could ban a key drug used in medication abortion. A group of anti-abortion doctors is suing to challenge the FDA’s approval decades ago of the abortion pill mifepristone.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Sandhya Raman of CQ Roll Call.

Among the takeaways from this week’s episode:

  • American teenagers reported record rates of sadness in 2021, with especially high levels of depression in girls and teens identifying as LGBTQ+, according to a startling CDC report. Sexual violence, mass shootings, cyberbullying, and climate change are among the intensifying problems plaguing young people.
  • New polling shows more Americans are dissatisfied with abortion policy than ever before, as a U.S. district court judge in Texas makes a last call for arguments on the fate of mifepristone. The case is undermining confidence in continued access to the drug, and many providers are discussing using only misoprostol for medication abortions. Misoprostol is used with mifepristone in the current two-drug regimen but is safe and effective, though slightly less so, when used on its own.
  • There are big holes in federal health privacy protections, and some companies that provide health care, like mental health services, exploit those loopholes to sell personal, identifying information about their customers. And this week, Republican Gov. Glenn Youngkin of Virginia blocked a state law that would have banned search warrants for data collected by menstrual tracking apps.
  • California plans to manufacture insulin, directly taking on high prices for the diabetes drug. While other states have expressed interest in following suit, it will likely be up to wealthy, populous California to prove the concept.

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

Julie Rovner: NPR’s “Is the Deadly Fungi Pandemic in ‘The Last of Us’ Actually Possible?” by Michaeleen Doucleff

Alice Ollstein: The New York Times’ “Childbirth Is Deadlier for Black Families Even When They’re Rich, Expansive Study Finds,” by Claire Cain Miller, Sarah Kliff, and Larry Buchanan; interactive produced by Larry Buchanan and Shannon Lin

Joanne Kenen: NPR’s “In Tennessee, a Medicaid Mix-Up Could Land You on a ‘Most Wanted’ List,” by Blake Farmer

Sandhya Raman: Bloomberg Businessweek’s “Zantac’s Maker Kept Quiet About Cancer Risks for 40 Years,” by Anna Edney, Susan Berfield, and Jef Feeley

Also mentioned in this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on SpotifyApple PodcastsStitcherPocket Casts, or wherever you listen to podcasts.

Journalists Probe Problems in Providing Care for Foster Kids and Propping Up Addiction Treatment

KHN senior editor Andy Miller discussed the problems with Georgia’s foster care system on Georgia Public Broadcasting’s “Lawmakers” on Jan. 26.

KHN Midwest correspondent Bram Sable-Smith discussed Howard Buffett’s $30 million donation for a recovery center on KMOX’s “Total Information A.M.” on Jan. 25.

Montana Lawmakers Seek More Information About Governor’s HEART Fund

A fund championed by Gov. Greg Gianforte to fill gaps in Montana’s substance use and behavioral health treatment programs has spent $5.2 million since last year as the state waits for an additional $19 million in federal funding.

Now, the Republican governor wants to put more state money into the Healing and Ending Addiction Through Recovery and Treatment initiative, but lawmakers and mental health advocates are asking for more accountability and clarity on how the money is spent.

Republican Rep. Jennifer Carlson, chair of the Human Services Committee of the Montana House of Representatives, said her committee has heard bill proposals seeking to use HEART money for child care and suicide prevention programs, among others. She is sponsoring a bill to increase HEART initiative reporting requirements.

“You really have to think, is that what that money is for, or is that just what’s convenient?” said Carlson.

Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness, said a lot of questions have been floating around about the initiative this legislative session.

“Nobody really knows exactly how this is being spent or the process of how to get it,” Kuntz said.

The legislature passed Gianforte’s HEART initiative soon after he took office. It uses revenue primarily from recreational marijuana taxes for the state’s $6 million annual share to be distributed to programs dedicated to treating substance use and mental health disorders.

A federal match would bring the fund total to $25 million, but the state is waiting for full approval of its Medicaid waiver application from the Centers for Medicare & Medicaid Services. The federal agency approved part of the waiver last year.

“Until CMS approves the full HEART waiver, the state is limited in what we can do,” said Jon Ebelt, spokesperson for the state Department of Public Health and Human Services.

The health department submits a report to CMS four times a year. Department officials did not respond to a request by KHN for the latest report. The department is supposed to receive reports from tribal nations on how their funds were used. It didn’t specify whether it had received any.

Carlson’s House Bill 310 would require the department to report HEART initiative spending to the Children, Families, Health, and Human Services Interim Committee each year. That reporting would allow lawmakers to know what the money had already been used for, and if there might be a better way to spend it, Carlson said.

When Gianforte introduced the HEART initiative during his 2021 State of the State speech, he said it was designed to give directly to local communities, which know their own needs best.

“This is not bigger government,” the governor said at the time.

The HEART money is distributed through grants and Medicaid-funded services. Of the $5.2 million distributed since 2022, $1.5 million has gone to Medicaid for services like inpatient and residential chemical dependency services, Ebelt said.

Eight Indigenous tribal nations have received $1 million covering fiscal year 2022, the first year of the fund, and 2023, the current fiscal year, which ends June 30. Those grants went toward substance use prevention; mental health promotion; mental health crisis, treatment, and recovery services; and tobacco cessation and prevention.

Seven county detention centers received a total of $2.7 million in HEART money through a competitive grant process to provide behavioral health services at those facilities.

Missoula County hired a therapist, jail care coordinator, and mental health transport officer with its share. Gallatin County hired a counselor and two social workers, and Lewis and Clark County hired a therapist, case manager, and education and transport manager.

Jackie Kerry Lemon, program and facilities director at the Gallatin County Detention Center, said the money had to be used for mental health and addiction services. “Our population is often in crisis when they come to us, so having that ability to have a therapist see them really does help with their anxiety and their needs at a good time,” Kerry Lemon said.

Democratic Rep. Mary Caferro said the HEART money could go toward increases in the Medicaid rates paid to health care providers, which a state study found fall short of the cost of care, or mobile crisis response teams, which the health department intends to provide as a Medicaid service.

Caferro is sponsoring a bill on behalf of the National Alliance on Mental Illness to add youth suicide prevention to the list of programs eligible for HEART funding.

Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said the HEART fund initially was meant to support tribes and county jails, and only recently did it start funding community substance use and mental health programs, after last year’s partial Medicaid waiver approval.

That allowed larger substance use disorder treatment centers (more than 17 beds) to receive Medicaid reimbursement for short-term stays at institutions for mental illness, like Rimrock in Billings and the Badlands Treatment Center in Glendive.

From July 2022 to January 2023, Ebelt said, 276 Medicaid recipients were treated in Rimrock and Badlands. A facility in Clinton, the Recovery Centers of Montana, opened in December and will be licensed for 55 additional beds able to serve patients with the new Medicaid benefit, Ebelt said. Gianforte proposed in his state budget to increase the amount going into the HEART fund by changing the funding formula from $6 million a year to 11% of Montana’s annual recreational marijuana tax revenue.

The Behavioral Health Alliance recommended that change, but, as with many of the health-related proposals in this legislative session, a major factor in the HEART initiative’s success will be whether Medicaid provider rates are raised enough, Windecker said. If provider rates aren’t funded at the full cost of care, people won’t be available to provide the care the initiative promises, she said.

The committee that meets to determine the health department’s budget will hear a presentation about the HEART initiative on Feb. 9.

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.

Florida Leaders Misrepresented Research Before Ban on Gender-Affirming Care

Behind Florida’s decision to block clinical services for transgender adolescents is a talking point — repeated by the state’s governor and top medical authorities — that most cases of gender incongruence fade over time.

The Florida Board of Medicine voted Nov. 4 to approve a rule that barred physicians from performing surgical procedures on minors to alter “primary or secondary sexual characteristics” and from prescribing them medication to suppress puberty and hormones. The rule included an exception for patients who were already receiving those treatments. 

Two days later, Florida’s Republican governor, Ron DeSantis, said gender-affirming care is “an example of ideology overtaking the practice of medicine,” touting that he worked with the board to take a stand against it. 

“Over 80% of the dysphoria amongst teenagers resolves itself by the time they become older,” DeSantis said during a Nov. 6 campaign event. “So why are you mutilating their body parts?”

Earlier in the year, the Florida Department of Health used the statistic as it advised against medical transitioning for minors. The department’s April memo said that “80% of those seeking clinical care will lose their desire to identify with the non-birth sex.” 

Dr. Hector Vila, a Tampa anesthesiologist and member of the governor-appointed board, said he supported the rule because a “significant percentage” of transgender children will return to their assigned sex.

PolitiFact consulted with experts and data to determine whether gender incongruence will “resolve itself” for a large cohort of teenagers.

Those experts said Florida mischaracterized a statistic linked to an academic review from 2016. What’s more, one of the researchers whose work is cited as the statistic’s source has said the data he consulted is not “optimal” and can lead to “wrong inferences.”

The public comment period for the rule ended Dec. 5.

The 80% figure comes from a 2016 paper published in the International Review of Psychiatry.

Dutch health psychologist Thomas Steensma and Italian psychologist Jiska Ristori examined past studies on gender dysphoria, which describes the distress people may experience because of a discrepancy between their gender identity and the sex assigned to them at birth.

Not all transgender people experience or are diagnosed with gender dysphoria. Gender dysphoria diagnoses focus on gender identity-related psychological distress, not gender identity itself.

The researchers wanted to know whether people who experienced gender dysphoria as children still had it later in life. They looked at the outcomes for children involved with 10 studies conducted from 1968 to 2012 in the U.S., Canada, and the Netherlands.

Their review of the studies said they showed that gender dysphoric feelings went away for 85% of children “around or after puberty” — while acknowledging several limitations.

“There may be a number of arguments to nuance this high percentage of desistence,” the review read. “The lower persistence rates in the earlier studies, compared to the more recent studies after 2000, may be the result of the inclusion of less extreme cases in the earlier studies than in later studies.”

In other contexts, “desistence” can refer to an apparent end of gender variance and a return to an identity that aligns with the sex assigned at birth. In the paper, the researchers meant the lifting of dysphoric feelings.

Other experts mentioned concerns with the methodology of studies cited in the paper.

Dr. Kristin Dayton, a pediatric endocrinologist, said the studies had a small share of children assigned female at birth — and are thus not representative samples of the population. Eight of the 10 studies examined only children assigned male at birth.

At least six of the studies were conducted before the American Psychiatric Association developed a formal diagnosis for gender dysphoria in children. Some of the 10 studies did not include children who were referred to the studies by medical professionals.

1987 study, for instance, used advertisements to recruit children. Only 30% of the children examined had “frequently” stated a desire to be a girl. Experts said most of the children in that study wouldn’t have met the current criteria for gender dysphoria.

The diagnostic criteria for the condition include a “marked incongruence” between one’s experienced gender and assigned sex at birth lasting at least six months and a “strong desire to be of the other gender or an insistence that one is the other gender.”

Florida’s Department of Health and Board of Medicine misrepresented the review’s conclusion by stating 80% of children will “lose the desire” to identify with a sex not assigned at birth.

The 80% figure in the review did not reference children’s gender identities; it centered on the persistence and desistence of gender dysphoria in adulthood. Steensma later wrote that “using the term desistence in this way does not imply anything about the identity of the desisters.”

Although the review noted the studies found that gender dysphoria in childhood is “strongly associated” with a “lesbian, gay, or bisexual outcome,” it did not say what percentage of people studied stopped identifying as transgender.

“The 80% statistic, used by the Florida Department of Health and the state’s leadership, is categorically false,” Dr. Meredithe McNamara, an assistant professor of pediatrics at the Yale School of Medicine, told PolitiFact. “After a close read of the scholarship cited by the state, the state’s conclusion simply cannot be drawn in good faith.”

Steensma, who did not respond to PolitiFact’s requests for an interview, has responded to criticism from colleagues about how his research is used to discourage social and medical affirmation for gender diverse adolescents. 

“We want to stress that we do not consider the methodology used in our studies as optimal … or that the terminology used in our communications is always ideal,” Steensma wrote in 2018. “As shown, it may lead to confusion and wrong inferences.” 

McNamara also said that Florida’s reliance on a 2016 paper is a “glaring problem” because the state neglected to consider about six years of new research.

study published in July, for instance, sought to develop an estimate of transgender children who later stop identifying with a gender that is incongruent with their assigned sex. It evaluated 300 transgender children over five years. To participate in the study, children must have already begun social transitioning, which often involves changing names, haircuts, and pronouns. 

Researchers from Princeton University’s TransYouth Project followed up with participants in person and online. At the end of the five years, 94% of participants still identified as transgender.

“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.

KHN’s ‘What the Health?’: Voters Will Get Their Say on Multiple Health Issues

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Voters in several states will be asked to vote on ballot questions related to abortion, but it’s not the only health issue that will be decided on Election Day. Other ballot proposals will ask voters whether they want to curb interest on medical debt (Arizona), expand Medicaid (South Dakota), or make health care a right under the state constitution (Oregon).

Meanwhile, plaintiffs in a suit charging that the Affordable Care Act’s requirement to provide preventive medication against HIV are expanding their scope. Now they want the judge to rule that all preventive benefits under the health law are unconstitutional.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Jessie Hellmann of CQ Roll Call, and Victoria Knight of Axios.

Among the takeaways from this week’s episode:

  • The South Dakota ballot measure is the latest effort by health care advocates in conservative states to get a Medicaid expansion despite resistance from state officials. South Dakota’s governor and state legislature have refused to make the move. In recent years, voters in several of those states, including Idaho, Missouri, and Utah, have pushed the expansion forward over officials’ objections through voter initiatives.
  • Arizona’s unique ballot measure would limit interest rates on medical debt, among other things. It’s a bit of an under-the-radar issue, but if Arizona passes the measure, it could spur other states to try similar initiatives.
  • A handful of states will also be voting on abortion issues. In Kentucky, the legislature has put forward a constitutional amendment that says abortion rights aren’t protected by the state constitution and that government funding for abortions is not required. Voters in another red state, Kansas, surprised political pundits last summer when they overwhelmingly voted to maintain the right to abortion access, so the Kentucky results will be watched closely. If voters disapprove of the measure, it would be the first Southern state where voters have turned against the tide of legislation seeking to restrict abortion.
  • On the other hand, two reliably blue states — California and Vermont — are asking voters to enshrine a right to abortion in the states’ constitutions. Debate on the ballot measures, however, has raised the question of whether fetal viability should be a standard for when an abortion can’t be performed. Neither the groups supporting wide access for abortion rights nor those opposing abortion have said they are comfortable making a decision on abortion by using a viability standard.
  • In Washington, D.C., news, the Department of Defense’s announcement that it would pay travel expenses and provide leave for servicemembers seeking abortions out of state is likely to rile Republicans on Capitol Hill. It could also make the final negotiations tense over a defense spending bill that needs to be settled before the end of the year. The tone of those talks will likely depend on the election results next month.
  • The suit in federal court in Texas challenging the ACA’s preventive care mandates continues to grow. Judge Reed O’Connor has already ruled that the plaintiffs’ religious views should exempt them from having to provide some preventive care, including certain HIV drugs. It may yet take months to realize the implications of the case, but the plaintiffs have asked the judge to strike down all the preventive care provisions and to make the ruling applicable across the country. If that happens, the case will undoubtedly be appealed.
  • Studies out this week show that the covid-19 pandemic had a nasty aftereffect for children: Test scores have dropped around the country. And an analysis by The Washington Post found that the covid death rate among white Americans is now higher than among Black residents. These data points add to concerns this fall as public health officials face difficulty encouraging people to get the latest covid booster, let alone their flu shot.

Also this week, Rovner interviews Sandra Alvarez, writer, director, and co-producer of the documentary “InHospitable,” which looks at the growing market power of nonprofit hospitals and how well they serve their patients and their communities.

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

Julie Rovner: The Washington Post’s “An Autistic Teen Needed Mental Health Help. He Spent Weeks in an ER Instead,” by William Wan

Alice Miranda Ollstein: CBS News’ “U.S. Offers Flu Shots to Migrants in Border Custody, Reversing Long-Standing Policy,” by Camilo Montoya-Galvez

Victoria Knight: Stat’s “Inside Michelle McMurry-Heath’s Departure From BIO: Firings, Internal Clashes, and a Pivotal Job Review,” by Rachel Cohrs

Jessie Hellmann: KHN’s “Hospitals Said They Lost Money on Medicare Patients. Some Made Millions, a State Report Finds,” by Fred Clasen-Kelly

Also mentioned in this week’s episode:

The Washington Post’s “Whites Now More Likely to Die From Covid Than Blacks: Why the Pandemic Shifted,” by Akilah Johnson and Dan Keating

Bloomberg Law’s “Law Firm Calls Out Ex-EEOC Counsel’s Note on Abortion Travel,” by Rebecca Rainey and J. Edward Moreno

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