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As Syphilis Invades Rural America, A Fraying Health Safety Net Is Failing To Stop It

When Karolyn Schrage first heard about the “dominoes gang” in the health clinic she runs in Joplin, Mo., she assumed it had to do with pizza.

Turns out it was a group of men in their 60s and 70s who held a standing game night — which included sex with one another. They showed up at her clinic infected with syphilis.

That has become Schrage’s new normal. Pregnant women, young men and teens are all part of the rapidly growing number of syphilis patients coming to the Choices Medical Services clinic in the rural southwestern corner of the state. She can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves.

Public health officials say rural counties across the Midwest and West are becoming the new battleground. While syphilis is still concentrated in cities such as San Francisco, Atlanta and Las Vegas, its continued spread into places like Missouri, Iowa, Kansas and Oklahoma creates a new set of challenges. Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views toward homosexuality and nonmarital sex.

In Missouri, the total number of syphilis patients has more than quadrupled since 2012 — jumping from 425 to 1,896 cases last year — according to a Kaiser Health News analysis of new state health data. Almost half of those are outside the major population centers and typical STD hot spots of Kansas City, St. Louis and its adjacent county. Syphilis cases surged at least eightfold during that period in the rest of the state.

At Choices Medical Services, Schrage has watched the caseload grow from five cases to 32 in the first quarter of 2019 alone compared with the same period last year. “I’ve not seen anything like it in my history of doing sexual health care,” she said.

Back in 1999, the Centers for Disease Control and Prevention had a plan to eradicate the sexually transmitted disease that totaled over 35,000 cases nationwide that year. While syphilis can cause permanent neurological damage, blindness or even death, it is both treatable and curable. By focusing on the epicenters clustered primarily throughout the South, California and in major urban areas, the plan seemed within reach.

Instead, U.S. cases topped 101,500 in 2017 and are continuing to rise along with other sexually transmitted diseases. Syphilis is back in part because of increasing drug use, but health officials are losing the fight because of a combination of cuts in national and state health funding and crumbling public health infrastructure.

“It really is astounding to me that in the modern Western world we are dealing with the epidemic that was almost eradicated,” said Schrage.

Grappling With The Jump

Craig Highfill, who directs Missouri’s field prevention efforts for the Bureau of HIV, STD and Hepatitis, has horror stories about how syphilis can be misunderstood.

“Oh, no, honey, only hookers get syphilis,” he said one rural doctor told a patient who asked if she had the STD after spotting a lesion.

In small towns, younger patients fear that their local doctor — who may also be their Sunday school teacher or basketball coach — may call their parents. Others don’t want to risk the receptionist at their doctor’s office gossiping about their diagnosis.

Some men haven’t told family members they’re having sex with other men. And still more have no idea their partner may have cheated on them — and their doctors don’t want to ask, according to Highfill.

It’s even hard to expect providers who haven’t seen a case of syphilis in their lifetime to automatically recognize the hallmarks of what is often called the “great imitator,” Highfill said. Syphilis can manifest differently among patients, but frequently shows up for a few weeks as lesions or rashes — often dismissed by doctors who aren’t expecting to see the disease.

Since 2000, the current syphilis epidemic was most prevalent among men having sex with men. Starting in 2013, public health officials began seeing an alarming jump in the number of women contracting syphilis, which is particularly disturbing considering the deadly effects of congenital syphilis — when the disease is passed from a pregnant woman to her fetus. That can cause miscarriage, stillbirth or birth deformities.

Among those rising numbers of women contracting syphilis and the men who were their partners, self-reported use of methamphetamines, heroin or other intravenous drugs continues to grow, according to the CDC. Public health officials suggest that increased drug use — which can result in a pattern of risky sex or trading sex for drugs — worsens the outbreaks.

That perilous trend is playing out particularly in rural Missouri, argues Dr. Hilary Reno, an assistant professor of medicine at Washington University School of Medicine in St. Louis who is researching syphilis transmission and drug use in the state. Tracking cases from 2015 through June 2018, she found that more than half of patients outside of the major metropolitan areas of Kansas City and St. Louis reported using drugs.

Less Money, More Problems

Federal funding for STD prevention has stayed relatively flat since 2003, with $157.3 million allocated for fiscal year 2018. But that amounts to a nearly 40% decrease in purchasing power over that time, according to the National Coalition of STD Directors.

In Missouri, CDC annual funding has been cut by over $354,000 from 2012 to 2018 — a 17% decrease even as the number of cases quadrupled, Highfill said.

Iowa, too, has seen its STD funding cut by $82,000 over the past decade, according to Iowa Department of Health’s STD program manager George Walton.

“It is very difficult to get ahead of an epidemic when case counts are steadily — sometimes rapidly — increasing and your resources are at best stagnant,” Walton said. “It just becomes overwhelming.”

Highfill bemoaned that legislatures in Texas, Oregon and New York have all allocated state money to raise awareness or provide transportation to local clinics. Missouri has not allocated anything.

Schrage says she can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves.(Bruce Stidham for KHN)

A New Playing Field

In the digital age, fighting syphilis is much harder for public health responders, said Rebekah Horowitz, a senior program analyst on HIV, STDs and viral hepatitis at the National Association of County and City Health Officials.

The increased use of anonymous apps gives people greater access to more sexual partners, she said. Tracking down those partners is now much harder than camping out at the local bar in town.

“We can’t get inside of Grindr and do our traditional public health efforts,” she said.

That’s not to say Highfill’s department hasn’t tried. It has engineered a series of educational ads on Instagram, Grindr and Facebook displaying messages such as “Knowledge looks good on you.”

Highfill would love to do more — if Missouri had the money.

Public health clinics nationwide have also had to limit hours, reduce screening and increase fees that can reach $400. And some run by health departments across the country have been forced to close — at least 21 in 2012 alone, according to CDC data.

In Missouri, restrictions on Planned Parenthood’s Medicaid reimbursements that were passed last year in the legislature, and are again under debate, mean the nonprofit organization cannot be reimbursed for STD treatment for some patients.

That is another crack in the already failing public health infrastructure, said Reno, the Washington University professor who also serves as the medical director of the St. Louis County Sexual Health Clinic.

“We have a system that’s not even treading water,” she said. “We are the ship that is listing to the side.”

What you need to know about syphilis:

  • Syphilis is a bacterial infection spread through oral, vaginal and anal sex. It is treatable and curable with antibiotics.
  • Syphilis causes sores that are usually painless but can spread the bacterium to other people. It can also be passed from an infected pregnant woman to her fetus, risking miscarriage, stillbirth or birth deformities. The second phase of the disease can cause a skin rash, swollen lymph nodes and fever. Final stages of the disease can cause permanent neurological damage, blindness or death.
  • Despite a Centers for Disease Control and Prevention plan in 1999 to eradicate the disease, infectious syphilis cases have skyrocketed in recent years, jumping 76% nationally from 2013 to 2017.
  • A combination of cuts in national and state funding, crumbling public health infrastructure, greater mobility, continued stigma and increasing drug use is driving the uptick.
  • The best way to prevent syphilis among those who are sexually active is to use latex condoms or dental dams during sex.

Watch: ACA’s Future And ‘Medicare-For-All’ Front And Center As Candidates Line Up For 2020

Julie Rovner, KHN’s chief Washington correspondent, joined C-SPAN host Bill Scanlan Tuesday morning on “Washington Journal” to discuss how health care is playing out in the current political debate. They talked about the Republican-sponsored lawsuit to overturn the Affordable Care Act and the backing by many Democratic candidates of a “Medicare-for-all” health plan, and took questions from viewers about a wide variety of health issues. The video is available on the C-SPAN website.

Rovner also was on NPR’s “Weekend Edition Saturday” with host Scott Simon to talk about Sen. Bernie Sander’s “Medicare-for-all” proposal. That is available on the NPR website.

Watch: ACA’s Future And ‘Medicare-For-All’ Front And Center As Candidates Line Up For 2020

Julie Rovner, KHN’s chief Washington correspondent, joined C-SPAN host Bill Scanlan Tuesday morning on “Washington Journal” to discuss how health care is playing out in the current political debate. They talked about the Republican-sponsored lawsuit to overturn the Affordable Care Act and the backing by many Democratic candidates of a “Medicare-for-all” health plan, and took questions from viewers about a wide variety of health issues. The video is available on the C-SPAN website.

Rovner also was on NPR’s “Weekend Edition Saturday” with host Scott Simon to talk about Sen. Bernie Sander’s “Medicare-for-all” proposal. That is available on the NPR website.

Heavy Rains, End Of Drought Could Help Keep West Nile Virus Subdued — For Now

The end of California’s drought, announced last month amid one of the rainiest winters in memory, could offer a surprising benefit: reduced transmission of the mosquito-borne West Nile virus.

Longer term, however, more severe droughts associated with climate change could contribute to an increase in the number of infections in the state and nationally.

Drought is the most important weather-related factor that affects the rate of West Nile infection, researchers say. Even though mosquito eggs need water to hatch, dry conditions tend to spur greater transmission of the virus.

“Ironically, when we have drought conditions, that does seem to amplify the West Nile virus transmission cycle,” said Vicki Kramer, chief of the Vector-Borne Disease Section at the California Department of Public Health.

West Nile is transmitted between mosquitoes and birds, and people can become infected if bitten by an infected mosquito. The illness is rarely transmitted from one person to another. According to one theory, when drought forces mosquitoes and birds into closer proximity around the few remaining sources of water, it increases the chance of infection.

Some researchers think another explanation for the link between drought and West Nile transmission could be that dry conditions tax birds’ immune systems, leaving them more vulnerable to infection.

In 2015, amid California’s worst drought in over 500 years, the number of severe West Nile infections — known as “neuroinvasive” cases — hit their highest level since the state began tracking the virus. Then, as the dry conditions eased, the number declined by 75% over the next three years, despite an uptick in 2017.

Researchers say neuroinvasive West Nile virus — cases accompanied by meningitis, encephalitis or a type of acute paralysis — is the best measure for comparing the prevalence of the virus from year to year. The total number of cases is a less reliable indicator, because people with only mild symptoms — the vast majority — are more likely to get tested in years when public concern about the disease is running high.

Fewer than 1% of those infected suffer severe symptoms.

Scientists and public health officials say that while drought plays a significant role in increasing the rate of infection, other factors — especially the extent of human immunity — are also important and can cut the other way, making it hard to predict infection rates from year to year. More people have immunity following years with high infection rates, and that can help reduce the number of new infections.

Last year, 10 people died in California from complications of West Nile virus, down from 44 in 2017.

Numerous states have higher rates of West Nile infection than California, according to data from the Centers for Disease Control and Prevention. The states with the highest rates of West Nile virus last year were Montana, North Dakota, South Dakota, Nebraska, Iowa and Mississippi.

Nationally, the number of severe West Nile cases in the U.S. increased slightly last year to 1,594, with 137 deaths.

Scientists fear that, in the long term, drought driven by climate change could generate much higher rates of West Nile infection around the country.

“Predictions suggest that on average there will be quite a bit more cases of West Nile virus nationally, and in high drought years it could be about three times as high as the current average,” said Marm Kilpatrick, a disease ecologist at the University of California-Santa Cruz and co-author of a 2017 research paper published by the journal Proceedings of the Royal Society B: Biological Sciences.

Jeremy Wittie, president of the Mosquito and Vector Control Association of California, noted that changes in the number of West Nile virus cases vary by region. Despite an overall drop in West Nile last year, a few places, including Sacramento, saw a higher number of cases.

State health officials and vector-control agencies monitor West Nile activity closely, with periodic testing of “sentinel chickens,” dead birds and mosquito samples, which are tracked and published on the state’s West Nile virus portal at westnile.ca.gov. California residents can report dead birds to the state’s West Nile monitoring program via the same site. Testing them provides a key indicator for public health officials tracking West Nile activity.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Podcast: KHN’s ‘What The Health’: Still More ‘Medicare-For-All’

Vermont Sen. Bernie Sanders, a presidential candidate, unveiled the 2019 version of his “Medicare-for-all” bill this week. But even more than two decades after first proposing a single-payer plan for the U.S., Sanders still has not proposed a way to finance such a major undertaking.

Congress continued to pursue its examination of high prescription drug prices this week by calling to testify both insulin makers and the drug “middlemen” known as pharmacy benefit managers.

And Idaho is following Utah in trying to scale back an expansion of Medicaid under the Affordable Care Act approved by voters last November.

This week’s panelists are Julie Rovner of Kaiser Health News, Sarah Kliff of Vox.com, Margot Sanger-Katz of The New York Times and Paige Winfield Cunningham of The Washington Post.

Also, Rovner interviews Ceci Connolly, president and CEO of the Alliance of Community Health Plans.

Among the takeaways from this week’s podcast:

  • “Medicare-for-all” was in the spotlight again this week with the release of Sanders’ bill, which is co-sponsored by four of the five other Senate Democrats running for president. Still, neither Sanders nor any other candidates — or their proposals — focus on how to pay for it. Experts differ on how much expanding Medicare would cost. But, whether it’s moving around money already being spent or raising new taxes, expanding Medicare to more people would result in winners and losers, a key political factor going forward.
  • Both parties face internal divisions over health care, revolving around whether to create something new or stick with the status quo. Within the GOP, the split is between Republicans who point to years of unsuccessful efforts to repeal and maybe replace the ACA and want to move on to other things, and others — including some in the White House — who are continuing the push. Democrats’ division is between those who back House Speaker Nancy Pelosi’s call to strengthen and improve the ACA and those who back various efforts to create a Medicare-for-all system.
  • The GOP is playing both offense and defense on the ACA. Leaders say they want to be the party of health care and protect people with preexisting medical conditions, even as the Justice Department is officially backing a court ruling in Texas that would invalidate the entire law, including those protections.
  • There was lots of talk but little action on drug prices at hearings before Congress. Lawmakers heard from drug companies and pharmacy benefit managers, but are no closer to answering the question about what to do about high drug prices. While there may be incremental changes that can be adopted, few expect legislation that would fundamentally change business practices, intellectual property rights or the ability for Medicare to negotiate drug prices.
  • Action in the Utah and Idaho legislatures around Medicaid expansion show that even successful ballot initiatives to expand the program can be changed by lawmakers in ways voters may not have expected. In both state capitols, elected officials reduced the number of people eligible for expansion below what voters approved.

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

Julie Rovner: The New York Times’ “Would ‘Medicare for All’ Save Billions or Cost Billions?” By Josh Katz, Kevin Quealy and Margot Sanger-Katz

Sarah Kliff: Politico’s “Public Option Hits a Wall in Blue States,” by Rachana Pradhan and Dan Goldberg

Margot Sanger-Katz: Politico’s “Obamacare Fight Obscures America’s Real Health Care Crisis: Money,” by Joanne Kenen

Paige Winfield Cunningham: STAT News’ “Amazon Alexa Is Now HIPAA-Compliant. Tech Giant Says Health Data Can Now Be Accessed Securely,” by Casey Ross

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Exemptions Surge As Parents And Doctors Do ‘Hail Mary’ Around Vaccine Laws

SAN JOSE, Calif. — At two public charter schools in the Sonoma wine country town of Sebastopol, more than half the kindergartners received medical exemptions from state-required vaccines last school year. The cities of Berkeley, Santa Cruz, Nevada City, Arcata and Sausalito all had schools in which more than 30% of the kindergartners had been granted such medical exemptions.

Nearly three years ago, with infectious disease rates ticking up, California enacted a fiercely contested law barring parents from citing personal or religious beliefs to avoid vaccinating their children. Children could be exempted only on medical grounds, if the shots were harmful to health.

Yet today, many of the schools that had the highest rates of unvaccinated students before the new measure continue to hold that alarming distinction. That’s because parents have found end runs around the new law requiring vaccinations. And they have done so, often, with the cooperation of doctors — some not even pediatricians. One prolific exemption provider is a psychiatrist who runs an anti-aging clinic.

Doctors in California have broad authority to grant medical exemptions to vaccination, and to decide the grounds for doing so. Some are wielding that power liberally and sometimes for cash: signing dozens — even hundreds — of exemptions for children in far-off communities.

“It’s sort of the Hail Mary of the vaccine refusers who are trying to circumvent SB 277,” the California Senate bill signed into law by Gov. Jerry Brown in 2015, said Dr. Brian Prystowsky, a Santa Rosa pediatrician. “It’s really scary stuff. We have pockets in our community that are just waiting for measles to rip through their schools.”

The number of California children granted medical exemptions from vaccinations has tripled in the past two years.

Across the nation, 2019 is shaping up to be one of the worst years for U.S. measles cases in a quarter-century, with major outbreaks in New York, Texas and Washington state, and new cases reported in 12 more states, including California. California’s experience underlines how hard it is to get parents to comply with vaccination laws meant to protect public safety when a small but adamant population of families and physicians seems determined to resist.

When Senate Bill 277 took effect in 2016, California became the third state, after Mississippi and West Virginia, to ban vaccine exemptions based on personal or religious beliefs for public and private school students. (The ban does not apply to students who are home-schooled.)

In the two subsequent years, SB 277 improved overall child vaccination rates: The percentage of fully vaccinated kindergartners rose from 92.9% in the 2015-16 school year to 95.1% in 2017-18.

But those gains stalled last year due to the dramatic rise in medical exemptions: More than 4,000 kindergartners received these exemptions in the 2017-18 school year. Though the number is still relatively small, many are concentrated in a handful of schools, leaving those classrooms extremely vulnerable to serious outbreaks.

Based on widely accepted federal guidelines, vaccine exemptions for medical reasons should be exceedingly rare. They’re typically reserved for children who are allergic to vaccine components, who have had a previous reaction to a vaccine, or whose immune systems are compromised, including kids being treated for cancer. Run-of-the-mill allergies and asthma aren’t reasons to delay or avoid vaccines, according to the U.S. Centers for Disease Control and Prevention. Neither is autism.

Before California’s immunization law took effect, just a fraction of 1% of the state’s schoolchildren had medical exemptions. By last school year, 105 schools, scattered across the state, reported that 10% or more of their kindergartners had been granted medical exemptions. In 31 of those schools, 20% or more of the kindergartners had medical exemptions.

(Story continues below.)

Seesawing Exemptions
As of July 2016, California no longer allows parents to exempt their children from state-required vaccinations based on personal beliefs. Many of the same schools that once had the highest percentage of students with personal belief exemptions now lead the state in student medical exemptions.

The spike in medical exemptions is taking place amid a politically tinged, often rancorous national conversation over vaccines and personal liberty as measles resurges in the U.S. and worldwide. At least 387 cases of measles had been reported nationwide through March 28, according to the CDC. In California, 16 cases had been reported, two of them requiring hospitalization.

The problem in California, state officials say, is how the immunization law was structured. It removed the ability of parents to cite “personal belief” as a reason for exempting their children from vaccine requirements in day care and schools. Exemptions now must be authorized by a licensed physician who provides a written statement citing a medical condition that indicates immunization “is not considered safe.”

But the law does not specify the conditions that qualify a student for a medical exemption, nor does it require physicians to follow federal guidelines.

The wording has led to a kind of gray market in which parents share names of “vaccine-friendly” doctors by word of mouth or in closed Facebook groups. And some of those doctors are granting children blanket exemptions — for all time and all vaccines — citing a range of conditions not supported by federal guidelines, such as a family history of eczema or arthritis.

Amid growing concerns about suspect exemptions, the California Department of Public Health recently launched a review of schools with “biologically unlikely” numbers of medical exemptions, said the agency’s director, Dr. Karen Smith. Doctors who have written questionable exemptions will be referred to the Medical Board of California for possible investigation.

The medical board, which licenses doctors, has the authority to levy sanctions if physicians have not followed standard medical practice in examining patients or documenting specific reasons for an exemption.

In recent years, however, the board has sanctioned only one doctor for inappropriately writing a medical vaccine exemption in a case that made headlines. Since 2013, the board has received 106 complaints about potentially improper vaccine exemptions, including nine so far this year, said spokesman Carlos Villatoro.

One pending case involves Dr. Ron Kennedy, who was trained as a psychiatrist and now runs an anti-aging clinic in Santa Rosa.

Medical board investigators took the unusual step of subpoenaing 12 school districts for student medical records after receiving complaints that Kennedy was writing inappropriate  exemptions. They found that Kennedy had written at least 50 exemptions, using nearly identical form letters, for students in multiple communities, including Santa Rosa, Fremont and Fort Bragg, saying that immunizations were “contraindicated” for a catchall list of conditions including lupus, learning disability, food allergies and “detoxification impairment.”

Dr. Dean Blumberg, chief of pediatric infectious diseases at UC Davis Children’s Hospital and the medical board’s expert witness, said that the exemptions issued by Kennedy appear to have been provided “without an appropriate evaluation,” according to court documents.

Kennedy has refused to respond to the board’s subpoenas seeking the medical records of three of his patients, according to court documents. The board has yet to file a formal accusation against Kennedy, and he continues to practice.

Like Kennedy, many of the doctors granting unorthodox exemptions cite their belief in parental rights or reference concerns not supported by conventional medical science. Kennedy is suing the medical board and its parent agency, the California Department of Consumer Affairs, saying the state did not have the legal right to subpoena school districts for his patients’ medical records without first informing him so he could challenge the action in court. The case is ongoing.

Kennedy declined comment to Kaiser Health News. “I don’t want to be out in the open,” he said in a brief phone exchange. “I’ve got to go. I’ve got a business to run.”

In Monterey, Dr. Douglas Hulstedt is known as the doctor to see for families seeking medical exemptions. In a brief phone interview, he said he was worried about being targeted by the state medical board. “I have stuck my neck way out there just talking with you,” he said. Hulstedt does not give exemptions to every child he examines, he said, but does believe vaccines can cause autism — a fringe viewpoint that has been debunked by multiple studies.

In March, the online publication Voice of San Diego highlighted doctors who write medical exemptions, including one physician who had written more than a third of the 486 student medical exemptions in the San Diego Unified School District. District officials had compiled a list of such exemptions and the doctors who provided them.

State Sen. Richard Pan (D-Sacramento), a pediatrician who sponsored California’s vaccine law, has been a vocal critic of doctors he says are skirting the intent of the legislation by handing out “fake” exemptions. Last month, he introduced follow-up legislation that would require the state health department to sign off on medical exemptions. The department also would have the authority to revoke exemptions found to be inconsistent with CDC guidelines.

“We cannot allow a small number of unethical physicians to put our children back at risk,” Pan said. “It’s time to stop fake medical exemptions and the doctors who are selling them.”

California Healthline digital reporter Harriet Blair Rowan and California politics correspondent Samantha Young contributed to this report.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Podcast: KHN’s ‘What The Health’ The GOP’s Health Reform Whiplash

President Donald Trump last week insisted that Republicans would move this year to “repeal and replace” the Affordable Care Act. Or possibly not. Senate Majority Leader Mitch McConnell made it clear the GOP Senate did not plan to spend time on the effort as long as the House is controlled by Democrats. So, the president changed his tune. At least for the moment.

Meanwhile, states with legislatures and governors that oppose abortion are racing to pass abortion bans and get them to the Supreme Court, where, they hope, the new majority there will overturn or scale back the current right to abortion.

This week’s panelists are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Anna Edney of Bloomberg News and Alice Miranda Ollstein of Politico.

Also, Rovner interviews KHN’s Paula Andalo, who wrote the latest “Bill of the Month” feature about a very expensive knee brace.

If you have an exorbitant or inexplicable medical bill you’d like to submit for our series, you can do that here.

Among the takeaways from this week’s podcast:

  • Although Trump’s political base may support his actions to undermine the entire federal health law, Republican lawmakers are flummoxed. They are hesitant to take up the cause because Democrats used the issue so effectively against Republicans in last fall’s election. They also know that many Republicans like key provisions of the health law, such as its closing of the doughnut hole in the Medicare drug benefit, letting adult children stay on parents’ plans up to the age of 26 and protecting people with preexisting conditions.
  • The unveiling this week of a new Democratic health initiative — Medicare X — signals an increasing push by party moderates to move away from progressives’ call to dramatically reshape American health care with a “Medicare-for-all” system. Medicare X is a much smaller initiative that would allow some people to buy in to the Medicare system, but it would be rolled out gradually over a number of years.
  • In other ACA news, a federal judge struck down the administration’s regulations allowing small businesses to join association health plans, saying it was an end run to avoid the health law. Thousands of people could be affected by the decision, and Labor Secretary Alex Acosta said he will decide by the end of the May whether to appeal.
  • Anti-abortion activists in many states are pushing new laws to test whether the retirement last summer of Justice Anthony Kennedy has left the Supreme Court more willing to turn back the Roe v. Wade decision. Among the types of cases going forward are state laws that would ban abortions once a fetal heartbeat could be determined, which often happens about six weeks into a pregnancy or before many women even know they are pregnant.
  • Despite a stiff rejection last week by a federal judge who overturned the Trump administration’s permission for work requirements in the Medicaid expansion approved in Arkansas and Kentucky, federal officials said that Utah could go forward with a plan to start work requirements as part of a partial expansion. Supporters of the ACA insist that expansion should be for anyone earning up to 138% of the federal poverty level. But the issue is tough for Democrats, some of whom say a partial expansion is better than none.

Ask Us Anything!

Do you have a health policy question you’d like the panelists to answer? You can send it to whatthehealth@kff.org. Please include where you’re from and how to pronounce your name.

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

Julie Rovner: Vox.com’s “The Doctor’s Strike That Nearly Killed Canada’s Medicare-for-All Plan, Explained,” by Sarah Kliff

Rebecca Adams: CQ Roll Call’s “Legal Challenges Are Threatening Trump Administration Changes to the ACA,” by Sandhya Raman

Anna Edney: The Baltimore Sun’s “Baltimore Mayor Pugh to Take Leave of Absence in Midst of ‘Healthy Holly’ Book Controversy” by Ian Duncan and Yvonne Wenger

Alice Miranda Ollstein: The New York Times’ “Rituals of Honor in Hospital Hallways,” by Dr. Tim Lahey

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.