Tagged Public Health

House Democrats Foreshadow Possible Subpoena With Letters To Barr About DOJ’s Decision Not To Defend Health Law

In letters to Attorney General William Barr and White House Counsel Pat Cipollone, five House chairmen say they’ve been asking since April 8 for documents connected to the decision to stop defending the constitutionality of the Affordable Care Act, as well as testimony from four key officials involved in the effort.

Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?

FORT SCOTT, Kan. — A slight drizzle had begun in the gray December sky outside Community Christian Church as Reta Baker, president of the local hospital, stepped through the doors to join a weekly morning coffee organized by Fort Scott’s chamber of commerce.

The town manager was there, along with the franchisee of the local McDonald’s, an insurance agency owner and the receptionist from the big auto sales lot. Baker, who grew up on a farm south of town, knew them all.

Still, she paused in the doorway with her chin up to take in the scene. Then, lowering her voice, she admitted: “Nobody talked to me after the announcement.”

Just a few months before, Baker — joining with the hospital’s owner, St. Louis-based Mercy — announced the 132-year-old hospital would close. Baker carefully orchestrated face-to-face meetings with doctors, nurses, city leaders and staff members in the final days of September and on Oct. 1. Afterward, she sent written notices to the staff and local newspaper.

For the 7,800 people of Fort Scott, about 90 miles south of Kansas City, the hospital’s closure was a loss they never imagined possible, sparking anger and fear.

Reta Baker, president of Mercy Hospital, began as a staff nurse in 1981 and “has been here ever since.” The hospital closed at the end of 2018.(Christopher Smith for KHN)

“Babies are going to be dying,” said longtime resident Darlene Doherty, who was at the coffee. “This is a disaster.”

Bourbon County Sheriff Bill Martin stopped before leaving the gathering to say the closure has “a dark side.” And Dusty Drake, the lead minister at Community Christian Church, diplomatically said people have “lots of questions,” adding that members of his congregation will lose their jobs.

Yet, even as this town deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small communities like this one need a traditional hospital at all? And, if not, what health care do they need?

Sisters of Mercy nuns first opened Fort Scott’s 10-bed frontier hospital in 1886 — a time when traveling 30 miles to see a doctor was unfathomable and when most medical treatments were so primitive they could be dispensed almost anywhere.

Now, driving the four-lane highway north to Kansas City or crossing the state line to Joplin, Mo., is a day trip that includes shopping and a stop at your favorite restaurant. The bigger hospitals there offer the latest sophisticated treatments and equipment.

Visitors to Mercy Hospital Fort Scott would pass a tall white cross as they drove down a winding driveway before arriving at the front door. Sisters of Mercy nuns founded the hospital in 1886, and the newest building, constructed in 2002, honors that Roman Catholic faith with various fixtures and stained-glass windows.(Christopher Smith for KHN)

Mercy flew its flags at half-staff in December in honor of former President George H.W. Bush, who died Nov. 30. (Christopher Smith for KHN)

And when patients here get sick, many simply go elsewhere. An average of nine patients stayed in Mercy Hospital Fort Scott’s more than 40 beds each day from July 2017 through June 2018. And these numbers are not uncommon: Forty-five Kansas hospitals report an average daily census of fewer than two patients.

James Cosgrove, who directed a recent U.S. Government Accountability Office study about rural hospital closures, said the nation needs a better understanding of what the closures mean to the health of people in rural America, where the burden of disease — from diabetes to cancer — is often greater than in urban areas.

What happens when a 70-year-old grandfather falls on ice and must choose between staying home and driving to the closest emergency department, 30 miles away? Where does the sheriff’s deputy who picks up an injured suspect take his charge for medical clearance before going to jail? And how does a young mother whose toddler fell against the coffee table and now has a gaping head wound cope?

There is also the economic question of how the hospital closure will affect the town’s demographic makeup since, as is often the case in rural America, Fort Scott’s hospital is a primary source of well-paying jobs and attracts professionals to the community.

The GAO plans to complete a follow-up study later this year on the fallout from rural hospital closures. “We want to know more,” Cosgrove said. The report was originally requested in 2017 by then-Sen. Claire McCaskill (D-Mo.) and then-Rep. Tim Walz (D-Minn.), and has been picked up by Sen. Gary Peters (D-Mich.). Here in Fort Scott, the questions are being answered — painfully — in real time.

At the end of December, Mercy closed Fort Scott’s hospital but decided to keep the building open to lease portions to house an emergency department, outpatient clinic and other services.

Mercy Hospital Fort Scott joined a growing list of more than 100 rural hospitals that have closed nationwide since 2010, according to data from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. How the town copes is a window into what comes next.

An empty operating room at the closed hospital(Christopher Smith for KHN)

Unused hospital equipment is stored for shipment to other hospitals in the nonprofit Mercy health system.(Christopher Smith for KHN)

While some parts of the building are still in use, vast, empty halls and workstations abound at Mercy’s closed Fort Scott hospital. (Christopher Smith for KHN)

‘We Were Naive’

Over time, Mercy became so much a part of the community that parents expected to see the hospital’s ambulance standing guard at the high school’s Friday night football games.

Mercy’s name was seemingly everywhere, actively promoting population health initiatives by working with the school district to lower children’s obesity rates as well as local employers on diabetes prevention and healthy eating programs — worthy but, often, not revenue generators for the hospital.

“You cannot take for granted that your hospital is as committed to your community as you are,” said Fort Scott City Manager Dave Martin. “We were naive.”

Indeed, in 2002 when Mercy decided to build the then-69-bed hospital, residents raised $1 million out of their own pockets for construction. Another million was given by residents to the hospital’s foundation for upgrading and replacing the hospital’s equipment.

“Nobody donated to Mercy just for it to be Mercy’s,” said Bill Brittain, a former city and county commissioner. The point was to have a hospital for Fort Scott.

Today Mercy is a major health care conglomerate, with more than 40 acute care and specialty hospitals, as well as 900 physician practices and outpatient facilities. Fort Scott is the second Kansas hospital Mercy has closed.

Tom Mathews, vice president of finance for Mercy’s southwestern Missouri and Kansas region, said Fort Scott’s steady decline in patients, combined with lack of reimbursement — as well as the increasing cost of expenses such as drugs and salaries — “created an unsustainable situation for the ministry.”

But Fort Scott is a place that needs health care: One out of every four children in Bourbon County live in poverty. People die much younger here than the rest of the state and rates for teen births, adult smoking, unemployment and violent crime are all higher in Bourbon County than the state average, according to data collected by the Kansas Health Institute and the Robert Wood Johnson Foundation. Ten percent of Bourbon County’s more than 14,000 residents, about half of whom live in Fort Scott, lack health insurance. Kansas is one of 14 states that have not expanded Medicaid under the Affordable Care Act and, while many factors cause a rural closing, the GAO report found states that had expanded Medicaid had fewer closures.

Dr. Katrina Burke checks Randall Phillips during an exam at Mercy Hospital in Fort Scott, Kan., in December. “Up in the city, a lot of doctors don’t do everything like we do,” Burke says of the variety of patients she sees as a family practice doctor who also delivers babies. (Christopher Smith for KHN)

Burke, a family practice physician, also delivered babies at Mercy Hospital before it closed. “A lot of my moms are single moms … they don’t have good resources to even get to their OB appointment,” says Burke, who adds that she’s worried about how her patients will get to another hospital 30 miles away when it’s time for the baby to come. Burke delivered 85 babies last year. (Christopher Smith for KHN)

The GAO report also found that residents of rural areas generally have lower household incomes than their counterparts in bigger cities, and are more likely to have limitations because of chronic health conditions, like high blood pressure, diabetes or obesity, that affect their daily activities.

The county’s premature birth rate is also higher than the 9.9% nationwide, a number that worries Dr. Katrina Burke, a local family care doctor who also delivers babies. “Some of my patients don’t have cars,” she said, “or they have one car and their husband or boyfriend is out working with the car.”

By nearly any social and economic measure, southeastern Kansas is “arguably the most troubled part of the entire state,” said Dr. Gianfranco Pezzino, senior fellow at the Kansas Health Institute. While the health needs are great, it’s not clear how to pay for them.

Health Care’s ‘Very Startling’ Evolution

Reta Baker describes the farm she grew up on, south of town, as “a little wide place in the road.” She applied to the Mercy school of nursing in 1974, left after getting married and came back in 1981 to take a job as staff nurse at the hospital. She has been here ever since,” 37 years — the past decade as the hospital president.

It has been “very startling” to watch the way health care has evolved, Baker said. Patients once stayed in the hospital for weeks after surgery and now, she said, “they come in and they have their gallbladder out and go home the same day.”

With that, payments and reimbursement practices from government and health insurers changed too, valuing procedures rather than time spent in the hospital. Rural hospitals nationwide have struggled under that formula, the GAO report found.

Acknowledging the challenge, the federal government established some programs to help hospitals that serve poorer populations survive: Through a program called 340B, some hospitals get reduced prices on expensive drugs. Rural hospitals that qualified for a “critical access” designation because of their remote locations got higher payments for some long stays. About 3,000 hospitals nationwide get federal “disproportionate share payments” to reflect the fact that their patients tend to have poor or no insurance.

Fort Scott took part in the 340B discount drug program as well as the disproportionate share payments. But, though Baker tried, it could not gain critical access status.

When Medicare reimbursement dropped 2% because of sequestration after the Budget Control Act of 2011, it proved traumatic, since the federal insurer was a major source of income and, for many rural hospitals, the best payer.

Then, in 2013, when the federal government began financially penalizing most hospitals for having too many patients returning within 30 days, hospitals like Fort Scott’s lost thousands of dollars in one year. It contributed to Fort Scott’s “financial fall,” Baker said.

Baker did her best to set things right. To reduce the number of bounce-back admissions, patients would get a call from the physician’s office within 72 hours of their hospital stay to schedule an office visit within two weeks. “We worked really, really hard,” Baker said. Five years ago, the number of patients returning to Fort Scott’s hospital was 21%; in 2018 it was 5.5%.

Meanwhile, patients were also “out-migrating” and choosing to go to Ascension Via Christi in Pittsburg — which is two times larger than Fort Scott — because it offered cardiology and orthopedic services, Baker said. Patients also frequently drove 90 miles north to the Kansas City area for specialty care and the children’s hospital.

“Anybody who is having a big surgery done, a bowel resection or a mastectomy, they want to go where people do it all the time,” Baker said. Mercy’s Fort Scott hospital had no cardiologists and only two surgeons doing less complicated procedures, such as hernia repair or removing an appendix.

Last year, only 13% of the people in Bourbon County and the surrounding area who needed hospital care chose to stay in Fort Scott, according to industry data shared by Baker.

There were no patients in the hospital’s beds during one weekend in December, Baker said, adding: “I look at the report every day. It bounces between zero and seven.” The hospital employed 500 to 600 people a decade ago, but by the time the closure was announced fewer than 300 were left.

Fort Scott City Manager Dave Martin stands in the middle of the city’s historical main street, which connects to one of the first military outposts built in the United States. Martin, who feels angry at Mercy for abandoning the community, says, “We really thought that we had a relationship.”(Christopher Smith for KHN)

That logic — the financial need — for the closing didn’t sit well with residents, and Mercy executives knew it. They knew in June they would be closing Fort Scott but waited until October to announce it to the staff and the city. City Manager Martin responded by quickly assembling a health task force, insisting it was “critical” to send the right message about the closure.

Relations between Mercy and the city grew so tense that attorneys were needed just to talk to Mercy. In all, Fort Scott had spent more than $7,500 on Mercy Closure Project legal fees by the end of 2018, according to city records.

Will Fort Scott Sink With No Mercy?

When Darlene Doherty graduated from Fort Scott High School in 1962, there were two things to do in town: “Work at Mercy or work at Western Insurance.” The insurance company, though, was sold in the 1980s, and the employer disappeared, along with nearly a thousand jobs.

Yet, even as the community’s population slowly declined, Martin and other community leaders have kept Fort Scott vibrant. There’s the new Smallville CrossFit studio, which Martin attends; a new microbrewery; two new gas stations; a Sleep Inn hotel, an assisted living center; and a Dairy Queen franchise. And the McDonald’s that opened in 2012 just completed renovation.

The town’s largest employer, Peerless Architectural Windows and Doors, which provides about 400 jobs, bought 25 more acres and plans to expand. There’s state money promised to expand local highways, and Fort Scott has applied for federal grants to expand its airport.

Baker and some of the physicians on Mercy’s staff have been busy trying to ensure that essential health care services survive, too.

Baker found buyers for the hospital’s hospice, home health services and primary care clinics so they could continue operating.

Burke, the family care doctor, signed on to be part of the Community Health Center of Southeast Kansas, a federally qualified nonprofit that is taking over four health clinics operated by Mercy Hospital Fort Scott. She will have to deliver babies in Pittsburg, which is nearly 30 miles away on a mostly two-lane highway that has construction workers slowing traffic as they work to expand it to four lanes.

Burke said her practice is full, and she wants her patients to be taken care of: “If we don’t do it, who’s going to?”

Mercy donated its ambulances and transferred emergency medical staff to the county and city.

And, in a tense, last-minute save, Baker negotiated a two-year deal with Ascension Via Christi hospital in Pittsburg to operate the emergency department — which was closed for two weeks in February before reopening under the new management.

But she knows that too may be just a patch. If no buyer is found, Mercy will close the building by 2021.

This is the first installment in KHN’s year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium.

Newsom Changes Course On Plan To Pay For Immigrant Health Coverage

Gov. Gavin Newsom’s administration Friday reversed course on his plan to divert public health dollars from several counties to help provide health coverage to young adults who are in the country illegally.

The administration heeded the alarm sounded by Sacramento, Placer, Santa Barbara and Stanislaus counties, which had warned that the governor’s plan would compromise their ability to cope with surging rates of sexually transmitted diseases and, in some cases, measles outbreaks.

“The Administration has subsequently reevaluated this proposal due to the potential negative impacts to public health activities in these counties,” Vivek Viswanathan, chief deputy director of the state Department of Finance, wrote in a letter Friday to the chairs of the state Assembly and Senate Budget Committees.

Sacramento County, for example, estimates it would have lost roughly $7.5 million  that goes toward operating its STD clinic and paying communicable disease investigators. It warned that without the money, it would have to close the STD clinic and cut its own health services for undocumented immigrants of all ages.

“The public health dollars being restored make a big difference particularly at a time we have measles,” Dr. Peter Beilenson, Sacramento County Health Services Director, told California Healthline Friday. “We’re thrilled. It’s a great thing for the patients that we’re serving.”

This year, there have been 44 confirmed cases of measles in California as of May 8, three of them in Sacramento County. Public health officials also are struggling to address record rates of sexually transmitted diseases, with more than 300,000 cases of gonorrhea, chlamydia and syphilis reported in California in 2017.

On Thursday, when Newsom unveiled his revised budget — one that still included the plan to divert money from the four counties — he announced it would cost less to cover young adult unauthorized immigrants next year than previously estimated.

Because the state would have to delay the implementation date by six months to address IT issues, he said, it would cost $98 million to cover them in 2019-20, a significant drop from his original forecast of $260 million. The number of people expected to enroll also has dropped from 138,000 to 106,000.

The lower cost estimate means the administration won’t need to divert money from those four counties. What it does need, it will take from a special state budget reserve fund, said Department of Finance spokesman H.D. Palmer.

Newsom still plans to divert state money from 35 mostly small and rural counties, funds that currently pay for health services for uninsured residents, including undocumented immigrants, Palmer said.

Those counties participate in something called the County Medical Services Program, which has a $300 million budget surplus, Newsom noted at his budget briefing Thursday.

“That’s more than enough to address their issues,” Newsom said.

He also noted that his budget includes $40 million to combat infectious diseases.

Legislators are crafting their own budget proposals and have held dozens of hearings examining Newsom’s plan. The governor and lawmakers have until June 15 to negotiate a final budget, so it’s not yet clear which proposals will be included.

Placer County, which has reported three measles cases this year, praised Newsom’s change of heart.

“I appreciate the governor listening to some of the potential impacts it could have on public health and realizing that, in this time in California, we need to be making investments,” said Jeff Brown, director of Placer County’s Health and Human Services Department.

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

Racing To Get Ahead Of An Outbreak: Experts Project What Cities Could Be The Next To Be Hit By Measles

The cities at the top of the list? Chicago, Los Angeles and Miami. A similar analysis, which uses statistics on nonmedical exemptions and international airport hubs, from last year proved to be surprisingly accurate. Meanwhile, there’s been little movement on tightening exemptions at the state level despite the sweeping measles outbreak. Advocates say that the vocal antivaccination movement is to blame.

Untangling The Inflammatory Rhetoric Around Abortion Bills In Georgia, Alabama

The abortion bills are not simple, especially Georgia’s, which experts say sends you “down a rabbit hole” and that you “have to be a lawyer to understand.” But fear and confusion over the measures has distorted some of the facts of the bills. Meanwhile, the legislation is part of a wave a similar restrictive measures under consideration throughout the south and Midwest.

Opioid Litigation Divides Sackler Family Over How To Respond To Charges It Bears Responsibility For Deadly Epidemic

As communities seek billions in settlements, the family that owns OxyContin-maker Purdue Pharma is reportedly growing uneasy about defense tactics and charges of misleading marketing. Other news on the drug epidemic looks at a new CDC report on cocaine and meth deaths and unethical practices by a Delaware physician.

State Highlights: Washington Health Spending Law For Native American Groups Called Promising; Citing Abuses, 5 More Former Ohio State Students File Lawsuit Against Team Doctor

Media outlets report on news from Washington, Ohio, Illinois, Maryland, Connecticut, Arizona, Georgia, California, New York, Minnesota, North Carolina, Utah, New Hampshire, Massachusetts, Iowa and Arkansas.

As Many As Two-Thirds Of Older Americans Will Need Long-Term Care But Won’t Be Able To Afford It

Nearly 15 million middle-income adults will be hit the hardest, according to an analysis in Health Affairs, because they won’t quality for Medicaid or subsidized housing. Other public health news focuses on maternal death rates, the impact of boys’ early sexual initiation, a skin disorder on genitals, unidentified patients, snake bites, good gossip, organ donations and tick information.

44 States Sue Pharma Companies Over Alleged Conspiracy To Inflate Generic Drug Prices By As Much As 1,000%

In court documents, the state prosecutors lay out a brazen price-fixing scheme involving more than a dozen generic drug companies, including Teva, Pfizer, Novartis and Mylan. A key element of the scheme was an agreement among competitors to cooperate on pricing so each company could maintain a “fair share” of the generic drug markets, the complaint alleges.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! As if those sky-high medical bills weren’t bad enough, apparently California teachers also must pay substitutes to cover for them — even while undergoing treatment for breast cancer.

Which is the perfect segue into what you may have missed this week (almost like I planned it).

President Donald Trump waded into the turf wars among doctors, hospitals and insurers Thursday when he called for an end to surprise medical bills. The issue has been gaining attention across the country as stories about $48,512 cat bites and $109,000 heart attacks resonate with voters who are sick of paying an arm, a leg and a mortgage for health care even when they have insurance.

It’s not exactly a controversial issue — it’s listed as a top concern among voters, and lawmakers are lining up in droves to sign their names to any potential legislation. But, as is often the case with health care costs, the devil’s in the details. The costs don’t just disappear because the president doesn’t want patients to have to pay them. Physician groups tend to favor arbitration, while insurers argue that method is flawed because it still relies on bill charges. Instead, the industry wants set prices, with rates in line with what they would consider reasonable for the procedures. Each side hates the other’s opinion. So … good luck to the lawmakers who have to balance those two big interest groups!

The New York Times: Trump Said He Wanted to Work With Democrats on Surprise Medical Bills. Then He Attacked Democrats.

(FWIW: Two stories of the patients who were featured at the White House event were previously highlighted in KHN and NPR’s “Bill of the Month” series. Check them out here.)

Kicking off a veritable blitz of bills, House Democrats voted on legislation that would ban the Trump administration from granting states waivers for health law regulations. Over the next couple of weeks, Dems are expected to go hard on their campaign promises to shore up the bruised and battered health law. Some of the topics of those bills: short-term “junk insurance” plans, outreach funding, “reinsurance” payments, drug rebates and more.

The New York Times: With Insurance Bill Passage, House Democrats Begin Health Care Blitz

Speaking of waivers, Tennessee is set to ask for one to shift its Medicaid program into a block grant model. Block grants — aka Republicans’ longtime dream system — as an idea have a long history riddled with controversy and criticism, and the request, if granted, is all but certain to draw a court challenge. Now the question is: How far is CMS ready to go in pushing the envelope on Medicaid changes? Especially when other waivers are getting knocked down left and right in court?

Modern Healthcare: Tennessee Will Test CMS’ Willingness to Block-Grant Medicaid

Meanwhile, the Trump administration is proposing a change to the formula to calculate poverty. That may seem fairly dry, but since government assistance (like Medicaid and food stamps) is tied to that line, millions could lose health care coverage and/or have to go hungry.

The New York Times: Trump Administration Seeks to Redefine Formula for Calculating Poverty

Pharma companies are going to start to have to include list prices in their TV ads under a new rule that’s central to the Trump administration’s war on high drug costs. While most people think, in general, it’s a good step, many doubt it will accomplish much. It’s not as if sick consumers can then go negotiate a different price, as they would with cars.

As Ben Wakana, the executive director of Patients for Affordable Drug Prices, told NPR: “Drug companies have been shamed about their price increases for years. They appear to be completely comfortable with the shame as long as it is bringing them in the billions of dollars a year that they make from their outrageous prices.”

NPR: New Rule for Drugmakers: Disclose Drugs’ List Prices in TV Ads

Drug prices were a hot topic this week (and most weeks, amiright?), with the Senate Finance Committee holding a hearing on the idea of setting an international price index. Other countries set lower prices and “we look like chumps,” said Sen. John Kennedy (R-La.).

Modern Healthcare: GOP Senators Warn Drug Price Controls Could Come

And, yup, there’s still more news: Despite HHS Secretary Alex Azar’s concerns about safety, Trump backed Florida’s plan to import drugs from other countries. The kicker here: Florida will surely be a battleground state in the 2020 election, and drug prices routinely top voters’ list of concerns. The potential for a winning talking point is huge.

The Associated Press: Trump Backs Fla. Plan to Import Lower-Cost Meds From Abroad

In somewhat tangential news, Gilead announced it will donate its drug that reduces the risk of HIV transmission for up to 200,000 people a year. The price of the life-changing medication has long been a barrier to the goal of ending HIV transmissions, and many advocates were thrilled with the decision. Still, others were disappointed, saying that will cover only a fifth of what the country needs.

The Associated Press: Drugmaker Will Donate Meds for US Push to End HIV Epidemic

But everyone was cheering a new study out of Europe. Out of nearly 1,000 gay male couples where one partner had HIV and was taking antiretroviral drugs, there were zero cases of HIV transmission even without the use of condoms.

Reuters: AIDS Drugs Prevent Sexual Transmission of HIV in Gay Men

Fed up with the strategy to slowly chip away at abortion rights, Alabama lawmakers are poised to go all in. The legislation (which was almost up for a vote this week, but was delayed because of a ruckus over rape and incest amendments) would effectively ban all abortions and criminalize the act of performing the procedure. The supporters of the bill aren’t being coy at all about their intention: They want to challenge Roe v. Wade with a simple, “clean bill” on the legality of abortions.

The New York Times: As States Race to Limit Abortions, Alabama Goes Further, Seeking to Outlaw Most of Them

And over in Georgia, abortion rights advocates have one message to Republican Gov. Brian Kemp, who just signed a heartbeat bill: “We will see you, sir, in court.”

The Associated Press: Opponents of Georgia Abortion Ban Promise Court Challenge

On a sad note: Legendary New York Times reporter Robert Pear passed away this week from complications of a stroke. Although I did not have the pleasure of meeting or working with him, his byline became a familiar friend of mine. He has shaped my world for the past several years with the stories he continuously broke. It is a loss for journalism, for health care and for the people he helped through the light he shined on Washington.

His last story is a perfect example of that: looking at legislation that carried promises of helping people with preexisting conditions but failed to live up to them.

The New York Times: Robert Pear, Who Covered Washington for 45 Years, Dies at 69

The New York Times: Republicans Offer Health Care Bills to Protect Patients (and Themselves)

In the miscellaneous files of the week:

• Traditionally, HHS has received, on average, one complaint related to “conscience” violations from health care workers per year. Last year, that rose to 343. What on earth happened? (Hint: It does not mean the problem actually worsened.)

NPR: Why Are Health Care Workers’ Religious and Moral Conscience Complaints Rising?

• It might seem like the anti-vaccination movement is a new phenomenon spurred on by social media, but there’s a long history of resistance in the country. And it’s not as random as it might appear at first. Usually, it’s tied to time periods that are marked by great resentment toward government.

Los Angeles Times: Why the Measles Outbreak Has Roots in Today’s Political Polarization

• Stories about student heroes stopping mass shooters and dying in the process highlight just how grim our reality has become as young people find themselves thrust into violence.

The New York Times: Colorado School Shooting Victim Died Trying to Stop the Gunman

• Not only is the United States’ maternal mortality rate abysmal, a new study finds that many of those deaths — 60%! — are preventable. What’s more, African American and American Indian/Alaska Native women are three times more likely to die from pregnancy and childbirth than white women.

USA Today: Pregnancy and Childbirth Deaths Are Largely Preventable, CDC Says

• Beneath the bright, tantalizing promises of the stem cell industry (targeted at the most desperate patients) festers a dark underbelly of greed and profit.

ProPublica: The Birth-Tissue Profiteers

Have a great weekend, and remember, as National Nurses Week wraps up, to hug (or otherwise appropriately thank) the nurses in your life. Their job can be quite tough.

Experts Want States To Pump The Brakes On Labeling Porn A Public Health Crisis

Some experts argue that state resolutions to label pornography as a public health risk create a stigma for marginalized groups like LGBTQ people and miss a key piece of the puzzle by leaving out calls for more robust sex education for teens. In other public health news: gonorrhea, anxiety, Huntington’s disease, sex after menopause, school shootings, children’s safety and more.

Warren Hopes Opioid Message Will Reach Through Partisan Hostility In Ohio And West Virginia, Both Hit Hard By Crisis

Sen. Elizabeth Warren (D-Mass.) announced a plan this week that would funnel $100 billion toward combatting the opioid epidemic. She’s on the road to talk about it, stopping in states that have been deeply impacted by the drug crisis. In other news: a Trump administration official talks about boosting funding; prescription opioid use plummets; spending on the epidemic sky-rockets; and more.

Much Of Public Officials’ Attention Has Focused On Jewish Community, But Vaccination Resistance Spreads Far Beyond It

The majority of the dozens of New York City schools that had less than 90 percent of their children vaccinated for measles in the last school year were not ultra-Orthodox Jewish. Meanwhile, a look into history shows that vaccination resistance is nothing new in the U.S., and it tends to be tied tumultuous times of social upheaval and distrust in our institutions.

State Bans Pesticide Linked To Developmental Problems

California will ban the use of a widely used pesticide in the face of “mounting evidence” that it causes developmental problems in children, state officials announced Wednesday.

Several studies have linked prenatal exposure of chlorpyrifos to lower birth weights, lower IQs, attention deficit hyperactivity disorder and autism symptoms in children.

The chemical is mostly used on crops — including citrus, almonds and grapes — but is also applied on golf courses and in other non-agricultural settings.

The ban “is needed to prevent the significant harm this pesticide causes children, farm workers and vulnerable communities,” Jared Blumenfeld, secretary of the California Environmental Protection Agency (CalEPA), said in a statement.

California’s ban comes as federal regulators fight to keep the chemical on the market.

Almost two decades ago, the U.S. Environmental Protection Agency, which regulates pesticides at the federal level, prohibited the sale of chlorpyrifos for residential use.

But under the Trump administration, the agency rejected a proposal to ban its use altogether, ignoring the recommendations of its own scientists. It continues to defend the use of chlorpyrifos in court.

Some states aren’t waiting for the federal government to act, California Healthline reported last month. The New York legislature last week sent a proposed ban to Democratic Gov. Andrew Cuomo for consideration. A bill in the California legislature to ban chlorpyrifos was pending at the time of the CalEPA’s announcement. Oregon and Connecticut lawmakers also are considering bans.

Hawaii was the first state to enact a state ban last year.

“Because the science is pretty clear that this a dangerous chemical, it’s long past time to get it off the market,” said Virginia Ruiz, director of occupational and environmental health at the Washington, D.C.-based nonprofit Farmworker Justice. “There’s momentum now, and people and policymakers are becoming better educated about chlorpyrifos.”

Chlorpyrifos can be inhaled during application and as it drifts into nearby areas or ingested as residue on food. People also can be exposed through drinking water if their wells have been contaminated by it.

Globally, several companies make chlorpyrifos products. In the U.S., the most recognized brand names are Dursban and Lorsban, manufactured by Corteva Agriscience, formerly known as Dow AgroSciences.

Corteva Agriscience did not respond to requests for comment.

California citrus growers are among the groups that oppose the ban. They worry that eliminating chlorpyrifos could result in disease outbreaks among their fruit trees.

Casey Creamer, president of California Citrus Mutual, pointed to the Asian citrus psyllid, a tiny insect that feeds on citrus leaves that can transmit a disease known as Huanglongbing, or citrus greening, as one risk.

“The impacts are potentially significant,” he said. If farmers “don’t have the tools to effectively manage the psyllid, people are going to switch out or stop growing citrus.”

Implementing the ban in California could take up to two years as the state wades through the administrative process and tries to find safer options, CalEPA said in its announcement.

On Thursday, Democratic Gov. Gavin Newsom is expected to propose $5.7 million as part of his 2019-20 budget to support the transition to “safer, more sustainable alternatives,” the announcement said.

The agency added that its decision to ban chlorpyrifos “follows mounting evidence … that the pesticide causes serious health effects in children and other sensitive populations,” even at low levels of exposure.

The California Farm Bureau Federation warned that food may get pricier as a result of the ban, leaving state residents more dependent on produce grown in states with less stringent regulations.

“Protecting our food supply, rural economy and the many jobs that depend on California agriculture will require state agencies to be open-minded and realistic in evaluating ways to fight pests and plant diseases,” said Jamie Johansson, the federation’s president.

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

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Needle Exchanges Find New Champions Among Republicans

Once repellent to conservative politicians, needle exchanges are now being endorsed and legalized in Republican-controlled states.

At least four legislatures have considered bills to allow hypodermic needle exchanges, and two states, Georgia and Idaho, made them legal this year. In each of these states, the House and Senate are controlled by Republicans and the governor is a Republican.

Florida, Missouri, Iowa and Arizona have introduced bills this legislative session that would allow needle exchanges in their state. The measures were all sponsored or co-sponsored by Republicans.

As much as this has been a series of victories for public health officials who see how needle exchanges — also called syringe exchanges — stymie the spread of blood-transmitted diseases, it has been a triumph of public health policy research. For years, research has shown the benefit of needle exchanges, but now that the opioid epidemic and infectious diseases have affected their own communities, lawmakers are listening.

“The reality is maybe 10 or 15 years ago this wasn’t where Georgia was,” said Republican state Rep. Houston Gaines, the sponsor for Georgia’s needle-exchange law. “But the medical and science community has shown that this works. My hope is as Republicans, we can always be willing to embrace programs and ideas if they’re proven to work.”

Republicans have not always held this mindset.

Needle-exchange programs, pioneered in Amsterdam in 1983, allow individuals to get sterile needles free of charge and safely dispose of dirty needles and syringes used for drug injection. The programs have been proved to reduce the risk of getting and transmitting HIV, viral hepatitis and other bloodborne infections through sharing needles.

Syringe exchange programs also give public health officials an opportunity to offer educational and medical services, such as referrals to substance use disorder programs and HIV or hepatitis testing.

Currently, 28 states and the District of Columbia allow needle exchanges.

In 1988, Tacoma, Wash., established the nation’s first exchange program and with it came Republican opposition. North Carolina Republican Sen. Jesse Helms led Congress in banning the use of federal funds for needle-exchange programs that year. An ultra-conservative, Helms said allowing needle exchanges was the same as the government saying, “It’s not only all right to use drugs, but we’ll give you the needles.”

Despite the federal government refusing to fund research on the exchange programs, public health evidence of their effectiveness started to stack up, as did the number of states allowing the programs.

Multiple studies found that exchanges reduced the spread of hepatitis B, hepatitis C and HIV. These programs could also be cost-effective; a 2014 study found that for every dollar invested in expanding a needle exchange, $6 could be saved in HIV treatment. Other research found that going to an exchange program led drug users to enroll in substance abuse treatment programs.

The tipping point for many Republicans, however, came in a 2015 HIV outbreak related to the injection-drug epidemic in Scott County, Ind., a strong GOP state. In a matter of months, more than 150 people were newly diagnosed with HIV in a rural county with 24,000 residents.

Mike Pence, then the governor and now the vice president, was initially opposed to needle-exchange programs. Two months after the HIV outbreak was detected, Pence declared a public health emergency and allowed a limited needle exchange in Scott County.

Pence’s White House staff did not respond to several requests for comment.

Asal Sayas, director of government affairs at amfAR, the Foundation for AIDS Research, said this was a critical moment for Republicans with rural constituents. “A lot of communities realized they were also vulnerable and had situations similar to Scott County, where there was minimal HIV care and no syringe exchange,” said Sayas.

The syringe exchange in Scott County was effective, and it had a ripple effect.

An analysis by amfAR found that after Scott County’s needle-exchange program, the number of exchange programs across the country spiked. The organization’s most recent count is at 320.

Other Republican-leaning states also passed legislation allowing needle exchanges — Kentucky and Ohio in 2015, North Carolina in 2016 and Louisiana, North Dakota, Tennessee and Virginia in 2017.

Though critics said Pence waited too long to implement the program, the move has been hailed by conservative state lawmakers who in the ensuing years began supporting needle-exchange programs.

Attitudes among Republicans on the federal level are also shifting.

In December 2015, three congressional Republicans from states hit hard by the opioid crisis, Sen. Shelley Moore Capito of West Virginia and Senate Majority Leader Mitch McConnell and Rep. Hal Rogers, both of Kentucky, inserted language into an omnibus spending bill that partially repealed the federal funding ban. That provision allows federal dollars to be used for operating needle-exchange program operations, just not for the drug-injection devices themselves.

Following President Donald Trump’s recent announcement that he wants to end the HIV epidemic, Secretary of Health and Human Services Alex Azar expressed his support for needle exchanges. “Syringe-services programs aren’t necessarily the first thing that comes to mind when you think about a Republican health secretary, but we’re in a battle between sickness and health, between life and death,” Azar said at the National HIV Prevention Conference in Washington in March. “The public health evidence for targeted interventions here is strong.”

AmfAR’s Sayas said it’s important to remember how effective needle exchanges could be in achieving Trump’s HIV goals. “The administration’s plan targets 48 counties with high HIV diagnoses and seven states with a high rural burden of HIV,” said Sayas. “In six of those seven rural states, needle exchanges are illegal. If we’re serious about wanting this plan to work, we need to consider that.”

Despite the movement among some Republicans to accept needle exchanges, 13 states still have laws that make them illegal. All of those have Republican governors and Republican-majority legislatures, except for Kansas, which has a Democratic governor.

Nine states have either no law that prohibits syringe programs or only locally permitted needle exchanges, which means that it is up to each city or county to decide whether to operate needle exchanges.

In states that have given localities control of needle-exchange programs, there has been some movement to shut down the programs. Charleston, W.Va., suspended its needle exchange in 2018 after law enforcement officers complained about needles littering the streets and the mayor joined the opposition. Two programs in Indiana shut down in 2017 because of local opposition, although one has since reopened through a nonprofit health center.

Republican Rep. Ed Clere was one of the authors of Indiana’s needle-exchange legislation. He said local control of the needle exchanges often means decisions now play out among local conservative lawmakers.

“I don’t want you to think that I don’t like local approval. It’s just the way the approval process works, it just tends to be very political,” Clere said in an interview. “The people who make the decision, the commissioners, don’t have medical or research background. Instead of talking about the research evidence, the discussion ends up being about needles on playgrounds or drug use, which is just not useful.”