Tag: Public Health

Readers Slam Hospital Monopolies and Blame the Feds for Understaffed Nursing Homes

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.

Why Hospital Monopolies Are a Bad Idea

I recently read the article about Ballad Health by Brett Kelman and Samantha Liss regarding the Mountain States Health Alliance and Wellmont Health System merging to create Ballad Health, upon state approval (“These Appalachia Hospitals Made Big Promises to Gain a Monopoly. They’re Failing to Deliver,” Sept. 29). Well, it was approved, and here is another reason that monopolies are a bad idea. My husband is a teacher in Tennessee, and it complicated our open enrollment selections for 2024 insurance. We have used BlueCross BlueShield of Tennessee, a widely selected insurer in our state. We were sent notification that Ballad Health and BCBST were in negotiations and that there was a high probability that Ballad will soon be an out-of-network provider for those with BCBST plans. Luckily, the school district offers Cigna insurance as well, but not all providers accept that insurance (as I said, BCBST is a huge insurer in this area).

Please explain to me how it is OK for a monopoly to decide not to be in-network with any health plans. They should be required to be in-network with any insurer from this area. I find this very upsetting. I shouldn’t have to worry that if a catastrophic event were to happen that my insurance coverage would be reduced to 60%-40% from 80%-20%, all because my only option for emergency care (Ballad) chose not to negotiate with the largest insurance provider in my area. Just food for thought.

— Kimberly Ensor, Johnson City, Tennessee

On X, formerly known as Twitter, a user whose tagline is “a one-woman wrecking ball” had this to say about nursing home worker shortages:

— Ashley Thomas, Cleveland, Ohio

The Crisis of Understaffed Nursing Homes

I wanted to thank you for providing a platform for discussion of nursing home staffing (“Exclusive: CMS Study Sabotages Efforts to Bolster Nursing Home Staffing, Advocates Say,” Aug. 29). As a nursing student entering my final semester at SUNY Downstate, I have seen firsthand the destitute conditions of understaffed nursing homes. Staffing ratios are abysmal and, as I see it, the only solution for the well-being of nursing home residents is a responsible staff-to-resident ratio.

I wholeheartedly agreed with the sentiment of the article: The Abt Associates study was a shameful attempt to undermine the movement toward standardized staffing ratios at nursing homes. People become residents at nursing homes for many reasons, but the fact is they are there, above all, because they need specialized care, which these homes need nurses to provide — services such as ventilator care, tube feedings, medication, continuous monitoring, and frequent interventions to prevent pressure injuries, and so much more. There is something terribly wrong when nursing homes cannot provide the services that define them, especially when families and residents depend on them to do so.

I do think there were some missed opportunities in the article. For example, Jordan Rau writes that “immobile residents are not repositioned in bed, causing bedsores that can lead to infection.” While this statement is true, it is rather vague. Infections are a life-threatening risk associated with pressure injuries, but the sores themselves are grotesque and painful, a point I think should have been included to emphasize the injustice of allowing pressure injuries to develop and worsen. Health care workers should make every effort to prevent them. And nurses should understand their roles as advocates in being a voice for patients who are unable to speak for themselves.

It’s easy for the public to imagine the residents of nursing homes as homogenous and stereotypical elderly people who have been forgotten as they became burdensome, which is not only false, but actively harmful and agist. People of all ages and backgrounds live in nursing homes, and their needs are as diverse as they are themselves. The only universal commonality they have is that they live in nursing homes and need respect, dignity, care, and an adequate number of nurses and staff to protect these needs.

— Tara L. Clark, Freeport, New York

A union activist who supports a national single-payer health system also weighed in on X:

— Kay Tillow, Louisville, Kentucky

Avoiding Financial Ruin for Aging Elders

As Jordan Rau and Reed Abelson identify (“Facing Financial Ruin as Costs Soar for Elder Care,” Nov. 14), too many of today’s older adults are falling through the cracks. They may struggle with daily activities and declining health but don’t necessarily need 24/7 nursing home care.

Within the patchwork of long-term care, the Program of All-Inclusive Care for the Elderly is underutilized. PACE offers integrated care through its campus-based model, where participants can receive comprehensive, coordinated medical care and social services in a combined Medical Clinic and Day Center, while also receiving at-home support with essential tasks like dressing, bathing, and eating.

This care is free to our dually eligible participants who are never saddled with copays, out-of-pocket costs, or deductibles. PACE has saved states thousands annually per participant. Further, participants are grateful to stay at home and remain engaged with family and friends.

PACE acts as a critical safety net for low-income seniors, so they and their families aren’t forced into financial ruin. For those not Medicaid-eligible, it costs less than the nursing home alternative.

To close our system’s gaps and lower spending, programs like PACE need to become a more prominent part of the discussion. Policymakers should expand access to PACE services so more people can benefit from this successful model of senior care.

— Richard Fish, CEO of One Senior Care, Erie, Pennsylvania

JoAnne Dyer echoed the dire warning about the draining cost of long-term care in an X post:

— JoAnne Dyer, Seattle

More Power to Suzanne Somers

Age 76 is pretty long to fight an aggressive, metastatic breast cancer without chemotherapy (“Suzanne Somers’ Legacy Tainted by Celebrity Medical Misinformation,” Oct. 18). I’d say Suzanne Somers proved her point! None of us lives forever. I got a lumpectomy in 2015 and refused tamoxifen. Chemotherapy wasn’t needed. I refuse mammograms and gynecology. I am doing well. I found Ms. Somers’ book on cancer, called “Knockout,” very informative. I didn’t buy into the supplements angle, but it empowered me in my own fight, when there were no answers, to ask questions and research. Quality of life is more important.

— Kerry McCracken, Milan, Illinois

A Las Vegas reader reacted on X to the same article published by the Los Angeles Times, one of KFF Health News’ media partners:

— Grant David Gillham, Las Vegas

Over-the-Counter Narcan a Big Leap for Humankind

Thank you for sharing your article highlighting barriers to accessing Narcan (“Narcan, Now Available Without a Prescription, Can Still Be Hard to Get,” Oct. 11). While some experts have questioned the significance of making Narcan available over the counter, I firmly believe this development is a major milestone in our ongoing battle against opioid-related fatalities.

One may argue that this change is merely a “tiny, tiny baby step” and not deserving of applause; however, I would contend that every positive change, no matter how small or late in the game, is a vital part of a larger solution. Making Narcan available without a prescription is a tangible acknowledgment of the urgency of the opioid crisis and a recognition of the need for swift, accessible interventions.

Narcan’s OTC status can help reduce the stigma surrounding opioid overdose and encourage open conversations about addiction and harm reduction. It sends a message that saving lives is a priority, and it encourages individuals to be prepared to act in emergencies.

Still, there are certainly challenges related to affordability of OTC Narcan. While $45 isn’t an ideal price tag, community groups, first responders, state and local governments, and harm reduction groups — many of whom may purchase Narcan in bulk — can buy Narcan for a cheaper price, $41 per two-dose carton.

It is also important to continue educating pharmacists on the use of Narcan. Only 19 states require that pharmacists complete a training course prior to dispensing naloxone in any capacity. All pharmacists, especially those located in areas with high rates of opioid deaths, need to be firmly equipped with the necessary information on administering Narcan to be a trusted source among the public. Provider education is a key steppingstone to improving access.

Narcan’s OTC availability represents a positive shift in our approach to combating opioid overdoses, and it is a step that deserves acknowledgment and support. Let us not underestimate the impact of this change and continue working toward a future where every person has access to the tools they need to prevent opioid-related fatalities.

— Sana Imam, master’s student at George Washington University, Washington, D.C.

The HIV Prevention Trials Network chimed in on X:

A ‘Hit Piece’ on Rival Hospital Systems

I recently read your article of a couple of years ago comparing for-profit versus nonprofit medical schools (“Montana Med School Clash Revives For-Profit Vs. Nonprofit Flap,” June 7, 2021). I am an anesthesiologist with 24 years of experience, and almost every health care institution or hospital has become for-profit. In fact, most anesthesiology groups are managed by corporations like NorthStar Anesthesia, U.S. Anesthesia Partners, etc. Hospitals have merged into gigantic multibillion-dollar corporations like Ascension, Universal Health Services, HCA Healthcare, and CHI Health.

So why is it so bad to have a for-profit medical school, exactly? Almost every aspect of modern health care has become for-profit, and those nonprofit institutions have colluded with larger systems to shut down smaller hospitals. So this clearly is a “hit piece” on the for-profit educational system by their competitor, Touro College and University System.

I am one of the few doctors truly trained in a nonprofit — called the U.S. Army, where I did my residency in anesthesiology at Brooke Army Medical Center. This is quite an uninformed and unreasonable article, especially given the state of the corporate health care industry that is pervasive in our country. When I left the military for private practice, I could not believe what was being passed for elective surgery outside the military.

So let’s not get the pot and kettle confused here. Calling out a for-profit medical school in an era dominated by large multibillion-dollar health care corporations is certainly the pot calling the kettle black. And the rural Montana area is just as much of a deserving area for any medical school — for-profit or nonprofit — as the rural state of West Virginia, where I practice.

— Lance R. Hoover, Morgantown, West Virginia

Medicare Cuts Harm Seniors’ Access to Physical Therapy Care

It’s disheartening to hear stories of physical therapists who are increasingly struggling to afford their training and cost of living while facing lower pay (“Back Pain? Bum Knee? Be Prepared to Wait for a Physical Therapist,” Nov. 28). No one should have to give up their dream of being a physical therapist because they worry the pay is unsustainable — especially at a time when many patients already have limited access to therapy care.

Unfortunately, that’s the reality for many — especially since the Centers for Medicare & Medicaid Services recently finalized yet another year of steep payment cuts to physical, occupational, and speech therapy in its recently released Medicare Physician Fee Schedule Final Rule for CY 2024.

CMS’ final rule includes a troubling pay cut of at least 3.4% to therapy providers in 2024. But in some geographic regions, that cut could be as high as over 4% because of the highly technical formula CMS uses to determine reimbursement. Not only will this cut weaken the pipeline of new physical therapists entering the field, but it will also put significant financial strain on physical therapists currently practicing, hurting retention, and potentially leading to practice closings, which all negatively impact patient access to physical therapy.

Physical therapy care is a critically important non-pharmacological treatment option for our nation’s aging population. It helps patients manage pain, improve mobility, and protect their independence, while avoiding reliance on powerful painkillers and preventing potentially deadly falls. It even saves CMS money: On average, Medicare spending for beneficiaries who receive physical therapy as the first treatment option is 75% lower than the total average spending for Medicare patients who undergo surgery first.

Though it’s disappointing that CMS did not listen to the patient and provider communities when finalizing yet more cuts, there’s still time for Congress to act. I urge our lawmakers on Capitol Hill to work together and swiftly reverse the serious cuts in the new rule to help stabilize our nation’s health care system and expand access to physical therapy care for patients.

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

Grassroots College Networks Distribute Emergency Contraceptives on Campus

Limya Harvey and Cydney Mumford set up a folding table a few times a month on the University of Texas-San Antonio campus to give away kits containing emergency contraceptives, condoms, and lube, or menstrual products like tampons and pads. They typically bring 50 of each type of kit, and after just an hour or two everything is gone.

The 19-year-old sophomores — Harvey is enrolled at UTSA and Mumford at Northeast Lakeview College — founded the organization Black Book Sex Ed last spring. Their mission is to educate students and others in need about sexual health and connect them with free services and products packaged into kits they distribute on campus, in the community, and through their website.

“Both of us grew up rather lower-income,” Mumford said, “so there’s a soft spot as it relates to people who say, ‘Oh, I just don’t have it right now.’ That’s part of the reason we started doing this.”

Harvey and Mumford aren’t alone. A growing number of students on college campuses nationwide are stepping in to provide other students with free or low-cost emergency contraceptives, birth control, and menstrual products.

They are also pushing back against threats to their reproductive freedom since the U.S. Supreme Court’s Dobbs decision last year, which eliminated federal abortion protections.

Although emergency contraceptives are legal in every state, some policymakers worry that in states that ban or severely restrict abortion, access to emergency contraceptives and other types of birth control may erode because of people failing to distinguish between drugs that prevent pregnancy and medications used for abortions.

“Our requests for help have quadrupled since Dobbs,” said Kelly Cleland, the executive director of the American Society for Emergency Contraception, which provides toolkits and technical assistance to help students develop what are becoming known as peer-to-peer distribution networks. Those student networks provide emergency contraceptives and bring vending machines to their campuses that carry the medications and other personal health care products. The organization has worked with students at more than 200 campuses.

Many types of emergency contraceptive pills are available over the counter and without age restrictions. Students who distribute them are generally not putting themselves at legal risk, especially if they ensure the products are in their original packaging and haven’t expired and refrain from providing medical advice, Cleland said. It’s like giving a friend a Tylenol, one advocate explained.

“It’s really growing and a really interesting new route for people to get what they need in trusted ways, especially in Texas and other states where there are repercussions from the Dobbs decision,” said Mara Gandal-Powers, director of birth control access at the National Women’s Law Center.

Like those of many student groups, Harvey and Mumford’s kits contain products — emergency contraceptive pills, tampons, lube, etc. — donated by nonprofits and companies. Black Book Sex Ed accepts financial donations as well and uses the money to buy items at big-box stores.

The University of Texas-San Antonio didn’t respond to requests for comment.

Across the country, at Bowie State University in Maryland, a graduate student took a different approach to improving student access to contraceptives.

What started as a class project last year for Jakeya Johnson’s master’s degree program in public administration and policy, eventually became state law.

Starting next year, the measure will require many Maryland public colleges to provide round-the-clock access to emergency contraception and develop a comprehensive plan to ensure students have access to all FDA-approved forms of birth control, plus abortion services.

As part of her project, Johnson, 28, started researching the availability of reproductive health care at Bowie State, and she quickly learned that options were somewhat limited. When she called the health center, she was told that emergency contraception was available only to students who went through counseling first and that, while the college prescribed birth control, there was no pharmacy on campus where students could fill their prescriptions. She proposed that the school install a vending machine stocked with emergency contraceptives, condoms, pregnancy tests, and other sexual health products. But college officials told her they didn’t have money for the machines. Her research showed that students at other colleges in Maryland faced similar roadblocks.

So, Johnson approached state Delegate Ariana Kelly, now a state senator, about introducing a bill that would require schools to provide access to emergency contraceptives and other contraceptive services.

The bill, which was signed in May, requires the schools to provide the services by August 2024.

“There was definitely some pushback” from conservative legislators during the process, Johnson said. Although the final bill didn’t include requirements for transportation services or school reporting that Johnson wanted, she was heartened by the amount of support the bill received from parents and students.

In the spring, Johnson received a public service fellowship from the University System of Maryland that has enabled her to work with her student health center to develop a blueprint for Bowie State that other schools can follow, she said.

“It’s something that in 2023 we shouldn’t have to be fighting for,” she said.” We should already have it.”

“The legislation was confirmation and affirmation of the direction we were headed anyway,” said Michele Richardson, director of the Henry Wise Wellness Center at Bowie State. She noted that the school is in the process of bringing to campus wellness vending machines, which will be installed by August.

But increasing access is more challenging elsewhere.

At Loyola University Chicago, a Jesuit college, members of the organization Students for Reproductive Justice aren’t permitted to host events on campus or reserve space in meeting rooms. The Loyola for Life group, which opposes abortion, faces no such restrictions.

While Loyola “welcomes an open exchange of ideas,” only registered student organizations that are “congruent with our values as a Jesuit, Catholic institution” can submit activity requests or reserve space on campus, said Matthew McDermott, a spokesperson for the university.

Oral contraceptives are provided only to students who need them for reasons unrelated to preventing pregnancy, and resident advisers are not permitted to distribute condoms or other forms of birth control.

“That’s where Students for Reproductive Justice comes in,” said Andi Beaudouin, 21, who for the past two years has overseen the group’s distribution of free emergency contraception. “We were like, ‘If the university isn’t going to do it then we will.’ Everyone deserves this and we don’t need to feel embarrassed or hesitant about getting the resources that we need.”

Beaudouin and other volunteers take orders for emergency contraception by email. They package pills with two pregnancy tests and some pads and liners in case of bleeding and hand off the kits to students either on campus or nearby. In the past two years, they’ve filled orders for more than 100 kits.

When the Supreme Court ruled in Dobbs, the number of requests skyrocketed, Beaudouin said. The group posted on Instagram pleading with students not to stockpile pills, because its supplies were very limited.

“People understood, but I felt really bad about it,” they said. (Beaudouin uses the pronoun they.)

Beaudouin doesn’t think university officials know that the reproductive health group distributes emergency contraceptives on campus. And Loyola for Life has picketed their off-campus condom distribution events, but it has gotten better since the reproductive health group asked them to stop, Beaudouin said.

Loyola for Life didn’t respond to a request for comment.

The national anti-abortion group Students for Life of America wouldn’t object to students distributing free pregnancy tests and menstrual products, said Kate Maloney, manager of the group’s Campaign for Abortion Free Cities. But they would object to distribution of emergency contraception, which they claim is an abortion-causing drug.

Still, the reproductive justice groups shouldn’t be prohibited from operating on campus, Maloney said. “We’re not going to say whether a group should be denied the right to exist,” she said, “because that has happened a lot to us.”

Watch and Listen: Opioid Settlement Case Triggers Protests Outside the High Court

[embedded content]

The Supreme Court heard a case this week about who could claim bankruptcy protection from civil lawsuits. The case stems from the opioid epidemic and lawsuits brought by state and local governments against the companies that made, sold, or distributed prescription painkillers — in this instance, Purdue Pharma, which marketed OxyContin.

The company filed for bankruptcy and agreed to pay settlements to governments, as well as individual victims of the opioid crisis. That bankruptcy provided Purdue Pharma liability protection from future civil cases about opioids. The family behind this company, the Sacklers, did not seek bankruptcy but requested the same liability protections.

Family members have offered to pay $6 billion from their personal fortune into the settlement, but only if they’re given immunity. It’s this stipulation that the Department of Justice opposes.

KFF Health News senior correspondent Aneri Pattani went to the site of the protests outside the Supreme Court building and talked to advocates and people affected by the opioid crisis to get their take on the case. She also was interviewed on WBUR’s “Here & Now.”

Explosive DeSantis-Newsom Debate Reflects Nation’s Culture Wars

Fox News officially titled it “The Great Red vs. Blue State Debate.” But the faceoff quickly turned into a full-out political brawl between Gavin Newsom, California’s Democratic governor who isn’t running for president; and Ron DeSantis, the Florida Republican governor who is, and is not gaining ground against former President Donald Trump in voter polls.

The event was held in Alpharetta, Georgia, aired on Fox News, and moderated by Sean Hannity. Our PolitiFact partners examined the two state officials’ wide-ranging statements. You can read the full coverage here.

Newsom has relished taunting DeSantis on social media and Fox News and, earlier this year, he invited DeSantis to debate — arguing that the red-state policies DeSantis has passed are stripping Americans of their freedoms. DeSantis counters that he is the stronger defender of freedom, and has blasted California as “the petri dish for American leftism” and argues that “everything [President Joe] Biden is doing, they would accelerate.”

True to the event’s billing, the nation’s culture wars were front and center on the debate stage. DeSantis portrayed California as a failed state with rampant crime and homelessness led by an “elite” politician too liberal for the rest of the country. “They have failed because of his leftist ideology,” DeSantis said.

Newsom shot back, playing up California’s immense economy and describing his state as one without peer. He expressed his commitment to Biden’s reelection. He also called out DeSantis for his covid-19 policies, saying more Floridians died of covid due to his more relaxed public health rules: “Tens of thousands of people lost their lives and for what, Ron?”

Abortion was a clear flashpoint. Newsom defended California’s strong abortion protections and attacked DeSantis, alleging he “criminalizes” women and doctors. He also suggested that if DeSantis became president, he would further roll back abortion rights nationwide. Newsom, asked by Hannity if he would sign a law banning abortion later in pregnancy, argued that such cases are extremely rare.

“I trust the mother and her doctor to make that decision,” he said.

The two also sparred over book bans, parental rights, and policies regarding the LGBTQ+ community.

DeSantis criticized Newsom on California’s growing homelessness, which he said contributed to the “destruction of qualify of life” in the state.

Newsom pointed out that the crisis has been brewing for decades. He noted, though, that under his leadership, billions of dollars in taxpayer money has been directed toward countering homelessness. He also boasted about the state’s investments in mental health and addiction programs.

“The difference is I’m the first governor in California history to take this head-on,” Newsom said, arguing that under his policies 68,000 people have been moved off the streets and into shelter or housing.

Here are the health-related claims PolitiFact examined:

Covid-19 Lockdowns

Newsom borrowed a page from Trump’s playbook by misleadingly portraying DeSantis as a lockdown leader. Newsom’s comments focused on DeSantis’ actions in the pandemic’s first few weeks, when nearly all governors operated in lockstep. Newsom omits that DeSantis reopened earlier than most governors in spring 2020.

“You passed an emergency declaration before the state of California did,” Newsom said. “You closed down your beaches, your bars, your restaurants. It is a fact.”

Many local governments closed beaches for a limited time, but DeSantis did not close them statewide.

DeSantis issued an executive order on March 17, 2020, directing Floridians to “limit their gatherings” at beaches to no more than 10 people and to “support beach closures at the discretion of local authorities.”

He also ordered beaches in Broward and Palm Beach counties to close for 11 days, following recommendations from local officials and the Centers for Disease Control and Prevention. The governor’s refusal to close most beaches to spring break crowds drew heavy criticism and litigation.

Newsom was on firmer ground in his claim about closing bars. DeSantis ordered all bars and nightclubs closed for 30 days. Restaurants did not close. His March 17 order said restaurants were limited to 50% customer capacity and had to separate seating by 6 feet.

Governors nationwide issued multiple orders in March 2020 in response to the pandemic. DeSantis issued an order March 1 to establish covid response protocol and direct a public health emergency. On March 4, Newsom declared a state of emergency to help California prepare for the pandemic.

Florida’s Abortion Limits and DeSantis’ Abortion Survivor Story

As Hannity pressed Newsom on whether he supported any abortion restrictions, Newsom attacked Florida’s abortion laws.

“He signed a bill banning any exceptions for rape and incest,” Newsom said of DeSantis. “And then he said it didn’t go far enough and decided to sign a six-week ban … that criminalizes women and criminalizes doctors.”

DeSantis signed legislation in 2022 that outlawed abortions after 15 weeks of pregnancy. It does not make exceptions for cases of incest, rape or human trafficking but includes an exception for a mother’s life.

DeSantis signed a stricter bill in April that bans abortions after six weeks of pregnancy. Whether the law takes effect hinges on how the Florida Supreme Court rules in a lawsuit against the current 15-week ban. The 2023 law does contain exceptions, including to save a pregnant woman’s life or in cases of fatal fetal anomalies. Abortions for pregnancies involving rape, incest, or human trafficking would be allowed until 15 weeks of pregnancy if a woman has documentation such as a restraining order, police report, or medical record.

The law penalizes physicians, but whether it also criminalizes women is less clear, so we have rated a similar claim Half True. The law says that anyone who “actively participates in” an abortion commits a third-degree felony, which opens the door to prosecutors charging women, but we don’t yet know whether they will or how courts would respond to such charges. DeSantis has also said that he doesn’t want women prosecuted, only doctors.

Defending the law, DeSantis repeated an anecdote from the first GOP presidential debate about a Floridian named Penny Hopper. Miriam “Penny” Hopper is a real person, and an anti-abortion activist. Some of the details about her birth story have been called into question.

Hopper said she survived an abortion attempt in Florida in 1955. Her claim has been featured by anti-abortion groups and used to support what abortion opponents call “born alive” bills in state legislatures, which aim to protect infants who survive abortions, even though there are federal laws for that purpose.

In interviews, Hopper has said she had been delivered around 23 weeks of gestation after her mother went to a hospital in Wauchula, Florida, while experiencing bleeding. Hopper said the doctor induced labor, and she was born at 1 pound, 11 ounces, and that the doctor told staff to discard her “dead or alive.” She said her grandmother found her the next day on the hospital porch in a bedpan. Then, Hopper said, a nurse volunteered to take her to a larger hospital that was about 40 miles away.

That a baby born at 23 weeks could survive overnight without medical attention in 1955 is medically dubious, experts said. From the 1950s through 1980, “newborn death was virtually ensured” for infants born at or before 24 weeks of gestation, the American College of Obstetrics and Gynecology says on its website.

The Washington Post also reported that contemporaneous newspaper accounts offer a different scenario at the hospital, and said the staff spent days keeping her alive before arranging a police escort to rush her to another hospital.

‘Forever Chemicals’ Found in Freshwater Fish, Yet Most States Don’t Warn Residents

Bill Eisenman has always fished.

“Growing up, we ate whatever we caught — catfish, carp, freshwater drum,” he said. “That was the only real source of fish in our diet as a family, and we ate a lot of it.”

Today, a branch of the Rouge River runs through Eisenman’s property in a suburb north of Detroit. But in recent years, he has been wary about a group of chemicals known as PFAS, also referred to as “forever chemicals,” which don’t break down quickly in the environment and accumulate in soil, water, fish, and our bodies.

The chemicals have spewed from manufacturing plants and landfills into local ecosystems, polluting surface water and groundwater, and the wildlife living there. And hundreds of military bases have been pinpointed as sources of PFAS chemicals leaching into nearby communities.

Researchers, anglers, and environmental activists nationwide worry about the staggering amount of PFAS found in freshwater fish. At least 17 states have issued PFAS-related fish consumption advisories, KFF Health News found, with some warning residents not to eat any fish caught in particular lakes or rivers because of dangerous levels of forever chemicals.

With no federal guidance, what is considered safe to eat varies significantly among states, most of which provide no regulation.

[embedded content]

Eating a single serving of freshwater fish can be the equivalent of drinking water contaminated with high levels of PFAS for a month, according to a recent study from the Environmental Working Group, a research and advocacy organization that tracks PFAS. It’s an unsettling revelation, especially for rural, Indigenous, and low-income communities that depend on subsistence fishing. Fish remain a large part of cultural dishes, as well as an otherwise healthy source of protein and omega-3s.

“PFAS in freshwater fish is at such a concentration that for anyone consuming, even infrequently, it would likely be their major source of exposure over the course of the year,” said David Andrews, a co-author of the study and researcher at EWG. “We’re talking thousands of times higher than what’s typically seen in drinking water.”

Dianne Kopec, a researcher and faculty fellow at the University of Maine who studies PFAS and mercury in wildlife, warned that eating fish with high concentrations of PFAS may be more harmful than mercury, which long ago was found to be a neurotoxin most damaging to a developing fetus. The minimal risk level — an estimate of how much a person can eat, drink, or breathe daily without “detectable risk” to health — for PFOS, a common PFAS chemical, is 50 times as low as for methylmercury, the form of mercury that accumulates in fish, according to the federal Agency for Toxic Substances and Disease Registry. But she emphasized, “They’re both really nasty.”

Just like mercury, PFAS bioaccumulate up the food chain, so bigger fish, like largemouth bass, generally contain more chemicals than smaller fish. Mercury is more widespread in Maine, but Kopec said PFAS levels near contamination sources are concerningly high.

‘Fishing Is a Way of Life’

The Ecology Center, an environmental group in Michigan, educates anglers about consumption advisories and related health impacts. But Erica Bloom, its toxics campaign director, noted that for many people out on the river, “fishing is a way of life.”

Eisenman participated in an Ecology Center community-based study published this year, which tested fish from Michigan’s Huron and Rouge rivers for PFAS that poured out from auto and other industry contamination. Across 15 sites, anglers caught 100 fish samples from a dozen species, and what they found scared him.

“There were no sites that registered zero,” said Eisenman, noting that some had significantly higher levels of chemicals than others. “You need to make a value judgment. I’m going to still eat fish, but I don’t know if that’s a good thing.”

Last year, the National Academies of Sciences, Engineering, and Medicine published a sweeping federally funded report that associated PFAS exposure with health effects like decreased response to vaccines, cancer, and low birth weight.

There are thousands of PFAS, or perfluoroalkyl and polyfluoroalkyl substances, many of them used to make both household and industrial products stain-resistant or nonstick. They’re in fire-retardant foam used for decades by fire departments and the military, as well as in cookware, water-repellent clothing, carpets, food wrappers, and other consumer goods.

In late October, the EPA added hundreds of PFAS compounds to its list of “chemicals of special concern.” This will require manufacturers to report the presence of those PFAS chemicals in their products — even in small amounts or in mixtures — starting Jan. 1.

Sparse Testing Leaves Blind Spots

About 200 miles north of Detroit, in rural Oscoda, Michigan, state officials have warned against eating fish or deer caught or killed near the former Wurtsmith Air Force Base because of PFAS contamination.

“We have a 9-mile stretch of river system in which the state determined way back in 2012 that it wasn’t safe to even eat a single fish,” said Tony Spaniola, an advocate for communities affected by PFAS. He owns a home across a lake from the shuttered military site.

In Alaska, several lakes are designated catch and release only because of PFAS contamination from firefighting foam. A study by the U.S. Geological Survey and Pennsylvania Department of Environmental Protection released in August led to a warning to avoid eating fish from the Neshaminy Creek watershed.

Nationwide, use of firefighting foam and other PFAS-loaded products by the Department of Defense alone has led to the contamination of at least 359 military bases and communities that need to be cleaned up, with an additional 248 still under investigation as of June.

But many lakes and streams haven’t been tested for PFAS contamination, and researchers worry far more sites hold fish laced with high levels of PFAS.

Federal efforts to curb PFAS exposure have focused mostly on drinking water. Earlier this year, the EPA proposed the nation’s first PFAS drinking water standards, which would limit contamination from six types of chemicals, with levels for the two most common compounds, PFOA and PFOS, set at 4 parts per trillion.

But the EWG researchers found that one serving of fish can be equivalent to a month’s worth of drinking water contaminated with 48 parts per trillion of PFOS.

Store-bought fish caught in the ocean, like imported Atlantic salmon and canned chunk tuna, appear to have lower PFAS levels, according to FDA research.

A biomonitoring project focused on the San Francisco Bay Area’s Asian and Pacific Islander community measured PFAS levels in the blood and found higher amounts of the compounds compared with national levels. The researchers also surveyed participants about their fish consumption and found that 56% of those who ate locally caught fish did so at least once a month.

Eating a fish’s fillet is often recommended, as it accumulates fewer chemicals than organs or eggs, but many participants reported eating other parts of the fish, too.

California is one of many states with no fish consumption advisories in place for PFAS. Jay Davis, senior scientist at the San Francisco Estuary Institute, said that’s in part because of “limited monitoring dollars” and a priority on legacy chemicals like PCBs as well as mercury left over in particularly high concentrations from gold and mercury mining.

Wesley Smith, a senior toxicologist with California’s Office of Environmental Health Hazard Assessment, said the state is reviewing the latest scientific literature but needs more data to develop an advisory that is “neither too restrictive nor too permissive.”

States like New Hampshire, Washington, Maine, and New Jersey have some of the most protective guidance, while other states, such as Maryland and Michigan, lag when it comes to designating fish unsafe to eat.

Advisory levels for at-risk groups — such as children and women of childbearing age — are usually lower, while “do not eat” thresholds for the general population range from 25.7 parts per billion in New Hampshire to 300 ppb in Michigan, 408 ppb in Maryland, and 800 ppb in Alabama.

“That’s wicked outdated to have levels that high and consider that safe for folks to eat,” said Kopec, the University of Maine researcher.

Though it is no longer made in the U.S., PFOS remains the most commonly found — and tested for — PFAS chemical in fish today.

The primary maker of PFOS, 3M, announced it would begin phasing the chemical out in 2000. This year, the company said it would pay at least $10.3 billion to settle a class-action lawsuit brought by public water system operators. But in July, attorneys general from 22 states asked the court to reject the settlement, saying it was insufficient to cover the damages.

The military first documented health concerns surrounding PFAS chemicals in the 1970s yet continued to use firefighting foam made with them. Mandated by Congress, the Defense Department was required to stop buying retardant containing PFAS by Oct. 1 and phase it out altogether by 2024. A recently published study linked testicular cancer among military personnel to PFOS.

Tackling Pollution at the Source

Pat Elder, an activist and director of the environmental advocacy group Military Poisons, has tested water for PFAS up and down the East Coast, including in Piscataway Creek, which drains from Joint Base Andrews, the home of Air Force One.

In 2021, after testing fish from Piscataway Creek, Maryland officials released the state’s sole PFAS fish consumption advisory to date. But Elder worries Maryland has not gone far enough to protect its residents.

“People eat the fish from this creek, and it creates an acute health hazard that no one seems to be paying attention to,” Elder said.

Since then, Maryland’s Department of the Environment has conducted more fish monitoring in water bodies near potential PFAS sources, as well as at spots regularly used by subsistence anglers, said spokesperson Jay Apperson. He added that the state plans to put out more advisories based on the results, though declined to give a timeline or share the locations.

Part of the challenge of getting the word out and setting location-specific consumption advisories is that contamination levels vary significantly from lake to lake, as well as species to species, said Brandon Reid, a toxicologist and the manager of Michigan’s Eat Safe Fish program.

Michigan set its screening values for fish consumption advisories in 2014, and the state is in the process of updating them within the next year, Reid said.

But to see the chemicals dip to healthier levels, the pollution needs to stop, too. There is hope: Andrews, the EWG researcher, compared EPA fish sample data from five years apart and found about a 30% drop on average in PFAS contamination.

Bloom has watched this cycle happen in the Huron River in southeastern Michigan, where PFAS chemicals upstream seeped into the water from a chrome plating facility. While the levels of PFAS in the water have slowly gone down, the chemicals remain, she said.

“It’s very, very hard to completely clean up the entire river,” Bloom said. “If we don’t tackle it at the source, we’re going to just keep having to spend taxpayer money to clean it up and deal with fish advisories.”

Desantis, Newsom to Tangle Over Hot-Button Health Issues

Florida’s Republican presidential hopeful, Ron DeSantis,and Democratic firebrand Gavin Newsom of California square off today in a contest of governors that can best be described as the debate to determine ¿quién es más macho? — who is more manly — about protecting your freedoms. 

Both men have led their respective states since 2019, and they’ve lately been engaged in an escalating feud. While Newsom isn’t running for president himself — yet — he’s a key surrogate for President Biden. Fox News is playing up the faceoff, which it’ll host, as “The Great Red Vs. Blue State Debate.” 

The debate promises to put America’s culture wars front-and-center. Abortion. Homelessness. Transgender health care. The coronavirus pandemic response. Health coverage for undocumented immigrants. Even drag shows, DEI and Disney’s First Amendment rights.

Though conservative TV host Sean Hannity is moderating the 90-minute showdown in Alpharetta, Ga., seemingly a home-field advantage for DeSantis, Newsom is relishing the confrontation after goading Florida’s governor into going head-to-head. 

Both men use each other’s states as punching bags. DeSantis portrays Newsom as too liberal for America, presiding over a failed state where homelessness and crime are rampant, citizens are forced to mask up and get vaccinated, and access to abortion and public assistance like Medicaid is too easy, breaking society morally and financially.

In a fundraising video for his presidential campaign, DeSantis called California “the petri dish for American leftism,” adding that “everything Biden is doing — they would accelerate and they would cause this country to collapse. That is not the future that we need. Florida shows a model for revival, a model based on freedom.”

Newsom has blasted DeSantis as a “small pathetic man” and argues that small-d democracy itself is at stake in the presidential election. His political operation paid for an ad on Florida’s airwaves this year in which Newsom told Sunshine State residents: “Freedom — it’s under attack in your state.”

He has knocked DeSantis’s education policies that restrict teaching gender and sexuality to schoolchildren as well as laws the Florida governor pushed through the legislature banning abortion after six weeks and limiting gender transition-related health care. 

“Your Republican leaders, they’re banning books, making it harder to vote, restricting speech in classrooms,” Newsom said in his ad. “Even criminalizing women and doctors. Join us in California, where we still believe in freedom.”

Newsom’s health and education policies are largely the opposite of DeSantis’s. He’s expanded access to gender-affirming care for children and adults, and is expanding Medicaid beginning Jan. 1 to cover lower-income undocumented immigrants. Backed by the Democratic-controlled state legislature, Newsom led an effort in 2022 to enshrine the right to abortion in the state constitution, and he’s fought to block local school districts from restricting access to certain books.

While DeSantis directs resources to the presidential campaign, where he’s struggling to maintain his second-place standing in the GOP primary behind front-runner Donald Trump, Newsom struck again this month with another Florida ad buy, this time centered on reproductive health and abortion access. 

The ad alleges that DeSantis has criminalized doctors and women seeking an abortion after six weeks and argues that they could be arrested “by order of Governor Ron DeSantis.”

Both men face a monumental test in their debate. Newsom must demonstrate his loyalty to Biden, the Democratic Party leader and the actual candidate next November, while scoring points against DeSantis.

DeSantis, a wooden public speaker who struggles to connect with his audiences, has faced some criticism in Republican circles for a lackluster campaign. He’s got to persuade GOP voters that he’s a formidable option to Trump, without any major gaffes. 

The proxy battle could shape not only next year’s presidential contest, but the 2028 field of White House contenders as well.

One other hot-button issue we’re watching for is homelessness, considering nearly one-third of all homeless Americans live in California. Expect DeSantis to hammer Newsom over Californians fleeing for cheaper living elsewhere — including to Florida. Newsom, meanwhile, will play up the unprecedented investment he’s spearheaded to combat the humanitarian crisis (without clear results as of yet).

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

‘Forever Chemicals’ in Thousands of Private Wells Near Military Sites, Study Finds

Water tests show nearly 3,000 private wells located near 63 active and former U.S. military bases are contaminated with “forever chemicals” at levels higher than what federal regulators consider safe for drinking.

According to the Environmental Working Group, a Washington, D.C.-based nonprofit that analyzed Department of Defense testing data, 2,805 wells spread across 29 states were contaminated with at least one of two types of per- and polyfluoroalkyl substances, or PFAS, above 4 parts per trillion, a limit proposed earlier this year by the Environmental Protection Agency. That new drinking water standard is expected to take effect by the end of the year.

But contamination in those wells was lower than the 70 parts per trillion threshold the Pentagon uses to trigger remediation.

EWG researchers said they did not know how many people rely on the wells for drinking, cooking, and bathing, but the 76 tested locations represent just a fraction of the private wells near 714 current or former military sites spread across the U.S. According to EWG, Texas had nearly a third of the contaminated wells, with 909. Researchers recorded clusters of tainted wells in both urban and rural areas, from Riverside County and Sacramento in California to Rapid City, South Dakota, and Helena, Montana.

“They are going to have to test more bases,” said Jared Hayes, a senior policy analyst with EWG, in an interview with KFF Health News. “Those 2,805 are going to be a small number when they start testing drinking water wells near every single base.”

Defense Department officials are investigating hundreds of current and former domestic U.S. military installations and communities that surround them to determine whether their soil, groundwater, or drinking water is contaminated with PFAS chemicals.

The Defense Department is a major contributor of PFAS pollution nationwide — the result of spills, dumping, or use of industrial solvents, firefighting foam, and other substances that contain what have been dubbed forever chemicals because they do not break down in the environment and can accumulate in the human body.

Exposure to PFAS has been associated with health problems such as decreased response to vaccines, some types of cancer, low birth weight, and high blood pressure during pregnancy, according to a report published last year by the National Academies of Sciences, Engineering, and Medicine.

A study published this year linked testicular cancer in military personnel to exposure to PFOS, the main type of PFAS chemical used in firefighting foam.

In July, a U.S. Geological Survey study estimated that at least 45% of U.S. tap water contains at least one type of PFAS chemical.

USGS researchers tested 716 locations nationwide and found the forever chemicals more frequently in samples that were collected near urban areas and potential sources of PFAS like military installations, airports, industrial sites, and wastewater treatment plants, according to Kelly Smalling, a USGS research chemist and lead author of the study.

“We knew we would find PFAS in tap water,” she told KFF Health News in July. “But what was really interesting was the similarities between the private wells and the public supply.”

Drinking water sources near military installations that test above 70 parts per trillion draw immediate action from the Defense Department. Those responses include providing alternate drinking water sources, treatment, or water filtration systems.

Below that threshold, federal officials leave it up to homeowners to weigh and mitigate the health risks of contamination, Hayes said.

“It’s unclear what, if anything, these private individuals are being advised,” Hayes said. “If DoD is saying that 70 parts per trillion is the level they are going to provide clean water … the understanding would be if it’s below that, it must be fine.”

The Pentagon bases its 70 parts per trillion standard for PFOS and PFOA chemicals on a 2016 health advisory issued by the EPA. Officials have said they’re waiting for the new federal standard to go into effect before changing Defense Department parameters.

The Department of Defense did not respond by publication deadline to questions about EWG’s findings, or how it will address the new EPA limits.

While EWG’s examination found that thousands of wells contained PFAS at levels above the new EPA standard, but below the military’s 70 ppt threshold for action, it also learned that the Defense Department had found 1,800 private wells that registered higher than 70 ppt and had provided mitigation services to the owners of those wells.

Hayes said the combined levels of PFOS and PFOA in some wells were as high as 10,000 ppt.

Hayes said it’s unclear how long people near those military sites have been drinking contaminated water. “Chances are it’s been years, decades,” he said.

Federal law requires public water systems to be monitored regularly for pollutants, but private wells have no similar requirements. Hayes recommended that people who live near any current or former military installations and use a well for their drinking water have their water tested and use a filter designed specifically to remove PFAS.

According to the DoD’s PFAS remediation website, as part of its ongoing investigation and remediation effort, it has closed contaminated wells, installed new water sources, and treated drinking water on military bases. According to DoD, it is working to “to ensure no one on-base is exposed to PFOS or PFOA in drinking water above 70ppt.”

“Addressing DoD’s PFAS releases is at the core of the Department’s commitment to protect the health and safety of its Service members, their families, the DoD civilian workforce, and the communities in which DoD serves,” Pentagon officials said on the site.

KFF Health News’ Hannah Norman contributed to this report.

GOP Presidential Hopefuls Use Trump’s Covid Record to Court Vaccine Skeptics

Former President Donald Trump often seems proud to advertise his administration’s record on speedily developing covid-19 vaccines.

On the campaign trail to win another term in the White House, though, he also has knocked the use of those very vaccines. In October, for example, he unleashed a barrage of social media attacks on Ron DeSantis’ pandemic record by reposting claims that the Florida governor — who is running against him in the Republican presidential primaries — was too active in vaccinating Sunshine State residents.

In a further twist, Trump simultaneously circulated an MSNBC article suggesting DeSantis wasn’t vaccinating his constituents enough.

Trump’s tap dance — touting Operation Warp Speed’s success at developing vaccines while criticizing vaccine use — is emblematic of how pandemic politics are intensifying broader vaccine politics. Republican presidential candidates currently trailing the former president in polls are contorting their messaging to court the party’s vaccine-skeptical voters. No one embraces, without qualification, the utility of a public health measure that has saved millions of lives.

Like Trump, even the more establishment candidates can’t seem to avoid embracing the anti-vaccine leanings of the party’s base. Take Nikki Haley, who formerly served as governor of South Carolina and ambassador to the United Nations and has been rising in the polls. In the waning days of the Trump administration, she was pro-vaccine. But by the end of November 2021, in an interview with the Christian Broadcasting Network, she repeated dubious anti-vaccine claims: for instance, that the vaccine could undermine a woman’s fertility. (Studies consistently show no effect.)

The GOP has gained the allegiance of “a minority of people who feel very strongly about the safety of vaccines,” Robert Blendon, a Harvard professor of public health, told KFF Health News. Presidential candidates are trying to use this sensibility as “a cultural issue” to signal distrust in scientists, other experts, and government authority in general, he said.

The resulting dynamic carries the risk of reaching beyond the current election cycle to affect public health policy in years to come, leading to lower rates among schoolchildren and seniors of vaccinations that protect them from measles, shingles, and HPV. Even as candidates try to weaponize this rhetoric, they’ve had little luck in changing the former president’s front-runner status.

A recent KFF survey of adults about their plans to get vaccinated against the flu, respiratory syncytial virus, known as RSV, and covid found that partisanship remains a key predictor of how people view vaccines. Confidence in the safety of the updated covid vaccines split sharply along party lines, with more than 8 in 10 Democrats saying they trust the new shots, compared with 1 in 3 Republicans.

But unease about covid or the vaccines is not Republican primary voters’ top issue — Blendon said concerns around the border, crime, and inflation are — and it’s not clear vaccine-focused attacks hurt Trump.

“I didn’t like his response to covid,” says an Iowa business owner featured in a critical ad from a well-funded political action committee that questioned Trump’s handling of the pandemic. “I thought he probably got led a little bit by the bureaucrats,” he says, hitting Trump on his bragging about the development of the vaccine and contrasting Trump unfavorably with certain governors the man in the ad thought performed better against covid. (Images of DeSantis, otherwise unnamed, flash by.)

The result? The ad “produced a backlash” and, when audience-tested with focus groups, improved the former president’s support, according to a memo summarizing the political action committee’s attempts to dent the front-runner.

Candidates nonetheless are trying to make hay, acknowledged Joe Grogan, who led the Domestic Policy Council during the Trump administration. But “I think people have a lot of other targets for ire about the pandemic.”

“Trump is not at the top of the list for Republican primary voters,” Grogan said. “He’s not on Page 2. Or 3, or 4. It begins with the media, the public health bureaucracy, or Big Tech companies.”

Voters have strong, yet divided and sometimes inconsistent, opinions. Some, like Joshua Sharff, 48, of Chesapeake, Virginia, are opposed to the covid vaccines and to candidates who support the shots as safe and effective. Sharff describes himself as a conservative voter who intends to support the Republican nominee for president. Though he’s vaccinated, he said, “If you’re a governor or a president and you tell me that I have to take a vaccine that has not been tried, that has not been tested, and ignores the science, that’s a problem for me. You’re taking away my freedoms as an American citizen.”

These positions have led Sharff away from Trump — and toward DeSantis, who has promoted anti-vaccine and anti-public health positions in his quest for the nomination.

Trump “pushed the vaccine very hard and recently came out, when he began to get pushback on it, that it was somebody else’s fault,” Sharff said. “That’s not true.”

Other Republican voters said the vaccine is not key to their vote.

“It will not sway my vote one way or another,” said Kimberly Hunt, 59, of Melville, Tennessee.

In chasing these voters, some candidates are distancing themselves from initial, pro-vaccine positions to embrace outspoken views against the shot. Vivek Ramaswamy, a biotech entrepreneur, started out as a vaccine cheerleader. But then he flipped, coming out against vaccine mandates and saying this summer that he regretted getting vaccinated. (His wife, a doctor, said she had no regrets.)

The most vocal of all is DeSantis.

Appearing on the right-leaning “PBD Podcast” on Oct. 30, DeSantis attacked Trump and “the corrupt medical swamp in D.C.” for overselling a vaccine that, despite the initial federal guidance, could not prevent infection or transmission of covid. The Centers for Disease Control and Prevention recommends the vaccine for anyone 6 months and older to protect against serious illness.

Though he initially encouraged people to get vaccinated in early 2021, DeSantis pivoted months later, banning vaccine passports for businesses and government entities, and later approving legislation prohibiting vaccine mandates in the state. That fall, he also appointed a new Florida surgeon general, physician Joseph Ladapo, whose guidance on covid vaccines contradicts CDC recommendations. DeSantis formed a Public Health Integrity Committee to assess, and generally dispute, federal health recommendations.

When the CDC released new vaccine guidance in September, Florida responded with its own advisory casting doubt on the safety of the boosters.

This anti-vaccine positioning hasn’t helped DeSantis. He has been losing support nationally and is generally polling third behind Haley and Trump in New Hampshire, a key early primary state. He headlined a “medical freedom” town hall in Manchester on Nov. 1 with Ladapo as a special guest.

Among the candidates remaining, DeSantis may be the most famous convert to the politics of anti-vaccination, but, with this subject, Haley has more experience.

In the 2021 CBN interview, she said “mandates are not what America does.” But the forceful declaration is merely the end of an ambivalent record, and, for critics, demonstrates her willingness to get in sync with the demands of the GOP base. As a state legislator, she supported 2007 legislation that included a mandate for HPV vaccines before voting against it; and later, as governor, she vetoed an effort to promote those vaccinations.

Bakari Sellers — now a commentator on CNN, but at the time a lawmaker who spearheaded that bill — told KFF Health News, “That’s the biggest Nikki Haley issue that there is: She kind of has her finger in the air.”

The issue of vaccines may affect the general election: Even as Trump defends his vaccine record, it’s nevertheless clear he has support from the anti-vaccine crowd. An analysis by Politico, for example, found overlap among donors to independent presidential candidate Robert F. Kennedy Jr., who is staunchly opposed to vaccines, and Trump.

The willingness among politicians to assail what’s traditionally looked on as a foundational achievement of public health is likely to lead to turbulence for doctors themselves. Allison Ferris, a primary care physician and an associate professor at Florida Atlantic University, said people should be listening to their doctors and not to presidential candidates about whether to take the new covid vaccines. But that message is hard to deliver in the current climate.

“It is a tricky position to be in,” said Ferris, who co-authored recently released guidance advising doctors to counsel patients that frequent covid vaccination will likely become a necessity.

Medicaid’s ‘Unwinding’ Can Be Especially Perilous for Disabled People

Earlier this year, Beverly Likens thought she’d done everything she needed to do to keep her Medicaid. Then came an unwelcome surprise: Ahead of surgery to treat chronic bleeding, the hospital said her insurance was inactive, jeopardizing her procedure.

Likens had just been diagnosed with severe anemia and given a blood transfusion at the emergency room. “I was just ready to fall to pieces,” she said. The Kentucky resident, 48 at the time, experienced a coverage gap that she and a lawyer who tried to help say never should have happened. 

The situation highlights a complication with what’s known as the Medicaid “unwinding.” States are reviewing the eligibility of millions of Americans who remained enrolled in the safety-net health program through the pandemic — but the process has been messy and caused chaos all over the country, as KFF Health News has reported.

In part, that’s because people are being asked to reapply when they shouldn’t need to, or outright dropped when they still qualify. According to consumer advocates and legal aid attorneys, some states aren’t following federal rules that require them to consider all the ways people might qualify for Medicaid before concluding that they’re ineligible and terminating their coverage. That’s what happened to Likens.

Before she lost her coverage, Likens qualified for Medicaid because she had Supplemental Security Income, a program for people with little to no income or assets who are blind, disabled or at least 65 years old. After she lost her SSI benefits in the spring because she had assets whose cash value exceeded federal limits, Kentucky’s Medicaid agency sent a notice in April that she’d automatically lose her health coverage but could reapply.

The state didn’t assess whether Likens qualified another way. She did: Even without SSI, her income was low enough. And when she tried to reapply herself, she experienced technical issues with Kentucky’s enrollment system — another common problem around the country.

“There undoubtedly are people who are eligible in another category, but they’re falling through the cracks,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Medicaid eligibility is complicated. Often, someone who qualifies initially for one reason can remain eligible even when their life circumstances change, as long as their income remains below certain thresholds. But those income thresholds can vary — both state by state and even within a single state.

At least 11.1 million people have been disenrolled from Medicaid this year, as of Monday, according to KFF’s unwinding tracker, while 20.7 million had their coverage renewed. During the pandemic, when states were banned from disenrolling people, Medicaid enrollment grew by 22.6 million, data from the Centers for Medicare and Medicaid Services shows. 

Certain Medicaid beneficiaries are more likely to run into problems maintaining enrollment, said Jennifer Tolbert, associate director of KFF’s program on Medicaid and the uninsured. They include pregnant women whose eligibility for the program would change after delivery, kids who age out of eligibility or someone who had been receiving disability benefits but isn’t anymore — like Likens. There were 7.7 million SSI recipients as of 2021, according to the Social Security Administration.

But if a state’s Medicaid eligibility system works correctly, it “should automatically” assess all the ways an applicant may qualify, Tolbert said. “It should be built into the system.”

Likens, who doesn’t have children and isn’t working, was eventually reinstated and had her surgery. But she knows that other people aren’t as fortunate. “We are entitled to health care,” she said.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

‘Everybody in This Community Has a Gun’: How Oakland Lost Its Grip on Gun Violence

OAKLAND, Calif. — The red-tipped bullet pierces skin and melts into it, Javier Velasquez Lopez explains. The green-tipped bullet penetrates armored vests. And the hollow-tipped bullet expands as it tears through bodies.

At 19, Velasquez Lopez knows a lot about ammunition because many of his friends own guns, he said. They carry to defend themselves in East Oakland, where metal bars protect shop windows and churches stand behind tall, chain-link fences.

Some people even hide AR-15-style assault weapons down their pants legs, he said.

“It doesn’t feel safe. Wherever you’re at, you’re always anxious,” said Velasquez Lopez, who dreams of leaving the city where he was born. “You’re always wondering what’s going to happen.”

Last year, two gunmen in ski masks stormed his high school, killing a school district carpenter and injuring five other adults, including two students.

Oakland won acclaim just a few years ago as a national model for gun violence prevention, in part by bringing police and community groups together to target the small number of people suspected of driving the gun violence.

Then, in 2020, the covid-19 pandemic shut down schools, businesses, and critical social services nationwide, leaving many low-income people isolated and desperate — facing the loss of their jobs, homes, or both. The same year, police murdered George Floyd, a Black man in Minneapolis, which released pent-up fury over racial discrimination by law enforcement, education, and other institutions — sparking nationwide protests and calls to cut police funding.

In the midst of this racial reckoning and facing the threats of an unknown and deadly virus, Americans bought even more guns, forcing some cities, such as Raleigh, North Carolina; Chicago; New York City; and Oakland, to confront a new wave of violent crime.

“There was emotional damage. There was physical damage,” said James Jackson, CEO of Alameda Health System, whose Wilma Chan Highland Hospital Campus, a regional trauma center in Oakland, treated 502 gunshot victims last year, compared with 283 in 2019. “And I think some of this violence that we’re seeing is a manifestation of the damage that people experienced.”

A man stands beside and looks out a large sunny window. He wears glasses and a blazer over his collared shirt.
James Jackson, CEO of the Alameda Health System, says Wilma Chan Highland Hospital Campus in Oakland, California, has an opportunity to help break the cycle of violence, in part by helping patients get preventive care instead of waiting for an emergency. The hospital also hosts a weekly farmers market so patients and community members can buy fresh produce.(Shelby Knowles for KFF Health News)

Jackson is among a growing chorus of health experts who describe gun violence as a public health crisis that disproportionately affects Black and Hispanic residents in poor neighborhoods, the very people who disproportionately struggle with Type 2 diabetes and other preventable health conditions. Covid further eviscerated these communities, Jackson added.

While the pandemic has retreated, gun violence has not. Oaklanders, many of whom take pride in the ethnic diversity of their city, are overwhelmingly upset about the rise in violent crime — the shootings, thefts, and other street crimes. At town halls, City Council meetings, and protests, a broad cross-section of residents say they no longer feel safe.

Programs that worked a few years ago don’t seem to be making a dent now. City leaders are spending millions to hire more police officers and fund dozens of community initiatives, such as placing violence prevention teams at high schools to steer kids away from guns and crime.

Yet gun ownership in America is at a historic high, even in California, which gun control advocates say has the strictest gun laws in the country. More than 1 million Californians bought a gun during the first year of the pandemic, according to the latest data from the state attorney general.

As Alameda County District Attorney Pamela Price told an audience at a September town hall in East Oakland: “We are in a unique, crazy time where everybody in this community has a gun.”

The Streets of Oakland

Oakland’s flatlands southeast of downtown are the backdrop of most of the city’s shootings and murders.

The area stands in stark contrast to the extreme wealth of the millionaire homes that dot the Oakland Hills and the immaculate, flower-lined streets of downtown. The city’s revived waterfront, named after famed author and local hero Jack London, draws tourists to trendy restaurants.

The city center of Oakland, California, sparkles with flower-lined streets, trendy lunch spots, and brand-name hotels. (Samantha Young/KFF Health News)
A few miles away lies a different side of Oakland: homeless encampments, litter-strewn streets, and fenced-in buildings in neighborhoods beset by poverty and gun violence. (Samantha Young/KFF Health News)

On a Saturday night in August, Shawn Upshaw drove through the flatlands along International Boulevard, past the prostitutes who gather on nearly every corner for at least a mile, and into “hot spots,” where someone is shot nearly every weekend, he said.

“When I grew up, women and kids would get a pass. They wouldn’t get caught in the crossfire,” said Upshaw, 52, who was born and raised in Oakland. “But now women and kids get it, too.”

Upshaw works as a violence interrupter for the city’s Department of Violence Prevention, which coordinates with the police department and community organizations in a program called Ceasefire.

When there’s a shooting, the police department alerts Upshaw on his phone and he heads to the scene. He doesn’t wear a police uniform. He’s a civilian in street clothes: jeans and a black zip-up jacket. It makes him more approachable, he said, and he’s not there to place blame, but rather to offer help and services to survivors and bystanders.

The goal, he said, is to stop a retaliatory shooting by a rival gang or grieving family member.

Shawn Upshaw (center) says he was called to be a violence interrupter after he heard the gunshots that killed his neighbor’s child in the street more than a decade ago. He vowed he would do everything he could to stop gun violence.(Samantha Young/KFF Health News)

Police also use crime data to approach people with gang affiliations or long criminal records who are likely to use a gun in a crime — or be shot. Community groups follow up with offers of job training, education, meals, and more.

“We tell them they’re on our radar and try to get them to recognize there are alternatives to street violence,” said Oakland Police Department Capt. Trevelyon Jones, head of Ceasefire. “We give them a safe way of backing out of a conflict while maintaining their street honor.”

Every Thursday at police headquarters, officers convene a “shooting review.” They team up with representatives from community groups to make house calls to victims and their relatives.

After the program launched in 2012, Oakland’s homicides plummeted and were down 39% in 2019, according to a report commissioned by the Oakland Police Department.

Then covid hit.

“You had primary care that became an issue. You had housing that became an issue. You had employment that became an issue,” said Maury Nation, an associate professor at Vanderbilt University. “It created a surplus of the people who fit that highest risk group, and that overwhelms something like Ceasefire.”

With ever-rising housing prices in Oakland and across California, homeless encampments have multiplied on sidewalks and under freeway bypasses. The city is also bracing for the loss of jobs and civic pride if the Oakland Athletics baseball team relocates after April 2024, following departures by the NBA’s Golden State Warriors in 2019 and the NFL’s Raiders in 2020.

“Housing, food insecurity, not having jobs that pay wages for folks, all can lead to violence and mental health issues,” said Sabrina Valadez-Rios, who works at the Freedom Community Clinic in Oakland and teaches a high school class for students who have experienced gun violence. Her father was fatally shot outside their Oakland home when she was a child. “We need to teach kids how to deal with trauma. Violence is not going to stop in Oakland.”

Homicides in Oakland climbed to 123 people in 2021, police reports show, dipping slightly to 120 last year. Police have tallied 108 homicides as of Nov. 12 this year. Neither the police department nor the city provided statistics on how many of those killings involved firearms, despite repeated requests from KFF Health News.

Experts also blame the rise in killings in Oakland and other American cities on the prevalence of gun ownership in the U.S., which has more guns than people. For all the pandemic disruption worldwide, homicide rates didn’t go up in countries with strict gun laws, said Thomas Abt, director of the Center for the Study and Practice of Violence Reduction at the University of Maryland.

“We saw gun violence, homicides, shootings spike up all around the country. And interestingly, it did not happen internationally,” Abt said. “The pandemic did not lead to more violence in other nations.”

Cedrick Emerson leads regular anti-gun walks through East Oakland, California. Emerson, a violence interrupter with Faith in Action East Bay, visits shooting victims in the hospital or their homes, as part of a partnership with police to prevent retaliatory attacks. (Shelby Knowles for KFF Health News)

Unrest in Oakland

Oakland residents are angry. One by one, business owners, community organizers, church leaders, and teenagers have stood at town halls and City Council meetings this year with an alarming message: They no longer feel safe anywhere in their city — at any time.

“It’s not just a small number of people in the evening or nighttime. This is all hours, day and night,” said Noha Aboelata, founder of the Roots Community Health Center in Oakland. “Someone’s over here pushing a stroller and someone’s getting shot right next to them.”

One morning in early April, automatic gunfire erupted outside a Roots clinic. Patients and staff members dropped to the ground and took cover. After the shooting stopped, medical assistants and a doctor gave first aid to a man in his 20s who had been shot six times.

Everyone is blaming someone or something else for the bloodshed.

People walk past a church. Some wear reflective vests and some carry signs that read "Live in Peace" and "Peace is an Oakland value".
 (Shelby Knowles for KFF Health News)
Nearly every Friday, Faith in Action leads a “Ceasefire” walk through an East Oakland, California, neighborhood to protest gun violence. (Shelby Knowles for KFF Health News)
Passing cars honked and drivers cheered during an August Ceasefire walk. (Shelby Knowles for KFF Health News)

Business owners have had enough. In September, Target announced it would close nine stores in four states, including in Oakland because of organized retail theft; the famed Vietnamese restaurant Le Cheval shut its doors after 38 years, partly blaming car break-ins and other criminal activity for depressing its business; and more than 200 business owners staged an hours-long strike to protest the rise in crime.

The leadership of the local NAACP, the nation’s oldest civil rights organization, made headlines this summer when it said Oakland was seeing a “heyday” for criminals, and pointed to the area’s “failed leadership” and “movement to defund the police.”

“It feels like there’s a dark cloud over Oakland,” said Cynthia Adams, head of the local chapter, which has called on the city to hire 250 more police officers.

Price, a progressive elected last year, already faces a recall effort, in part because she rejects blanket enhanced sentences for gangs and weapons charges, and has declined to charge youths as adults.

The new mayor, Sheng Thao, was criticized for firing the police chief for misconduct and breaking a campaign promise to double funding at the city’s Department of Violence Prevention. In her first State of the City address last month, Thao described the surge in crime as “totally and completely unacceptable,” and acknowledged that Oaklanders are hurting and scared. She said the city has expanded police foot patrols and funded six new police academies, as well as boosted funding for violence prevention and affordable housing.

“Not a day goes by where I don’t wish I could just wave a magic wand and silence the gunfire,” Thao said.

Many in the community, including Valadez-Rios, advocate for broader investment in Oakland’s poorest neighborhoods over more law enforcement.

On the left, a large piece of paper hangs from a wall. It reads "What are the solutions you believe can prevent and intervene violence?" and 18 pastel sticky notes are attached beneath. On the right are close-ups of the sticky notes, with notes like "Employment, Education, Housing, Income 4-all."
Oakland, California, residents at an August town hall meeting argued that gun violence can be resolved only if the community invests in social services, especially within low-income neighborhoods that have been disproportionately affected by violence and poverty. (Samantha Young/KFF Health News)

City councils, states, and the federal government are putting their faith in violence prevention programs, in some cases bankrolling them from nontraditional sources, such as the state-federal Medicaid health insurance program for low-income people.

Last month, California’s Democratic Gov. Gavin Newsom approved an 11% state tax on guns and ammunition, and $75 million of the revenue annually is expected to go to violence prevention programs.

Although these programs are growing in popularity, it is unclear how successful they are. In some cases, proven programs that involve law enforcement, such as Ceasefire, were cut back or shelved after George Floyd was murdered, said Abt, the Maryland researcher.

“The intense opposition to law enforcement means that the city was unwilling to use a portion of the tools that have been proven,” Abt said. “It’s good to work on preventing youth violence, but the vast majority of serious violence is perpetrated by adults.”

Not a day goes by where I don’t wish I could just wave a magic wand and silence the gunfire.

Oakland Mayor Sheng Thao

A Focus on Schools

Kentrell Killens, interim chief at the Oakland Department of Violence Prevention, acknowledges that young adults drive Oakland’s gun violence, not high school kids. But, he said, shootings on the streets affect children. Of the 171 homicides in 2019 and 2020, 4% of victims were 17 or under, while 59% were ages 18 to 34, according to the Oakland Police Department.

The number of children injured in nonfatal shootings is also worrisome, he said. Roughly 6% of victims and 14% of suspects in nonfatal shootings were 17 or younger in 2019 and 2020.

Kiki Reitano, an educator with the Family Violence Law Center, creates a safe, calming space for students at Fremont High School to talk about healthy relationships, setting boundaries, and sexual abuse. (Samantha Young/KFF Health News)

“We’ve seen the impact of violence on young people and how they have to make decisions around what roles they want to play,” said Killens, who spent a decade as a case manager working with schoolkids.

By being in the schools, “we can deal with the conflicts” that could spill into the community, he added.

At Fremont High School, Principal Nidya Baez has welcomed a three-person team to her campus to confront gun violence. One caseworker focuses on gun violence and another on sexual assaults and healthy relationships. The third is a social worker who connects students and their families to services.

They are part of a $2 million city pilot program created after the Oakland School Board eliminated school-based police in 2020 — about one month after George Floyd was killed and after a nine-year push by community activists to kick police out of schools.

“We’ve been at a lot of funerals, unfortunately, for gang-related stuff or targeting of kids, wrong-place-wrong-time kind of thing,” said Baez, whose father was shot and injured on his ice cream truck when she was a child.

Colorful posters with sobering messages about dating-related violence, depression, substance misuse, rumors, and youth violence hang in Kiki Reitano’s office.(Samantha Young/KFF Health News)

When Francisco “Cisco” Cisneros, a violence interrupter from the nonprofit group Communities United for Restorative Youth Justice, arrived at Fremont in January, students were wary, he said. Many still are. Students are hard-wired not to share information — not to be a “snitch” — or open up about themselves or their home life, especially to an adult, Cisneros said. And they don’t want to talk to fellow students from another network, group, or gang.

“If we catch them at an early age, right now, we can change that mindset,” said Cisneros, who was born and raised in Oakland.

Francisco “Cisco” Cisneros establishes relationships with students at Fremont High School as part of a city program to reduce gun violence. Many students in East Oakland, California, are affiliated with a gang or group, he says, and lingering trauma from gun violence goes back generations. (Samantha Young/KFF Health News)

Cisneros pulls from his past to build a rapport with students. This summer, for example, when he overheard a student chatting on the phone to an uncle in jail, Cisneros asked about him. It turns out Cisneros and the boy’s uncle had grown up in the same neighborhood.

That was enough to begin a relationship between Cisneros and the student, “J,” who declined to be identified by his full name for fear of retribution. The 16-year-old credits Cisneros, whom he describes as “like a dad,” with keeping him engaged in school and employed with summer jobs — away from trouble. Still, he regularly worries about making a wrong move.

“You could do one thing and you could end up in a situation where your life is at risk,” J said in Cisneros’ office. “You go from being in school one day to being in a very bad, sticky situation.”

The program is underway in seven high schools, and Cisneros believes he has helped prevent a handful of conflicts from escalating into gun violence.

A Better Life

A young man wearing a vest with the words "Alameda Health System" on it stands outside of a building and looks at the camera.
Javier Velasquez Lopez interned at Wilma Chan Highland Hospital Campus after gunmen stormed his East Oakland High School last year. Velasquez Lopez says many people he knows own guns because Oakland doesn’t feel safe to them.(Samantha Young/KFF Health News)

After his school counselor was shot at Rudsdale High School in September 2022, Velasquez Lopez heard that the man and other victims were treated at nearby Highland Hospital.

“Seeing him get hurt, he obviously needed medical attention,” Velasquez Lopez said. “That made it obvious I could help my community if I were to be a nurse to help people that live around my area.”

When a recruiter from the Alameda Health System came to campus to promote a six-week internship at Highland Hospital, Velasquez Lopez applied. It was, he said, a dramatic step for a student who had never cared about school or sought vocational training.

Over the summer, he volunteered in the emergency room, learned how to take a patient’s vitals, watched blood transfusions, and translated for Spanish-speaking patients.

Velasquez Lopez, who graduated this year, is now looking for ways to get a nursing degree. The cost of college is out of reach at the moment, but he knows he doesn’t want to stay in a city where you can easily buy a gun for $1,000 — or half that, if it’s been used in a crime.

Velasquez Lopez said he has bigger goals for himself.

Young people in East Oakland “always feel like we’re trapped in that community, and we can’t get out,” he said. “But I feel like we still have a chance to change our lives.”

A person holds a sign that reads "Live In Piece" and has the image of a handgun behind a general prohibition sign. They stand behind a streetlight pole beside a road.
(Shelby Knowles for KFF Health News)

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.