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When Mackenzie Sachs, a registered dietitian on the Blackfeet Reservation, in northwestern Montana, sees a patient experiencing high blood pressure, diabetes, or another chronic illness, her first thought isn’t necessarily to recommend medication.
Rather, if the patient doesn’t have easy access to fruit and vegetables, she’ll enroll the person in the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access to reduce their cost for healthy foods. Since 2021, Sachs has recommended a fruit-and-vegetable treatment plan to 84 patients. Increased consumption of vitamins, fiber, and minerals has improved those patients’ health, she said.
“The vouchers help me feel confident that the patients will be able to buy the foods I’m recommending they eat,” she said. “I know other dietitians don’t have that assurance.”
Sachs is one of a growing number of health providers across Montana who now have the option to write a different kind of prescription — not for pills, but for produce.
The Montana Produce Prescription Collaborative, or MTPRx, brings together several nonprofits and health care providers across Montana. Led by the Community Food & Agriculture Coalition, the initiative was recently awarded a federal grant of $500,000 to support Montana produce prescription programs throughout the state over the next three years, with the goal of reaching more than 200 people across 14 counties in the first year.
Participating partners screen patients for chronic health conditions and food access. Eligible patients receive prescriptions in the form of vouchers or coupons for fresh fruits and vegetables that can be redeemed at farmers markets, food banks, and stores. During the winter months, when many farmers markets close, MTPRx partners rely more heavily on stores, food banks, and nonprofit food organizations to get fruits and vegetables to patients.
The irony is that rural areas, where food is often grown, can also be food deserts for their residents. Katie Garfield, a researcher and clinical instructor with Harvard’s Food is Medicine project, said produce prescription programs in rural areas are less likely than others to have reliable access to produce through grocers or other retailers. A report from No Kid Hungry concluded 91% of the counties nationwide whose residents have the most difficulty accessing adequate and nutritious food are rural.
“Diet-related chronic illness is really an epidemic in the United States,” Garfield said. “Those high rates of chronic conditions are associated with huge human and economic costs. The idea of being able to bend the curve of diet-related chronic disease needs to be at the forefront of health care policy right now.”
An example of a voucher for fresh produce distributed by the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access on the Blackfeet reservation. (FAST Blackfeet)
Produce prescription programs have been around since the 1960s, when Dr. Jack Geiger opened a clinic in Mound Bayou, a small city in the Mississippi Delta. There, Dr. Geiger saw the need for “social medicine” to treat the chronic health conditions he saw, many the result of poverty. He prescribed food to families with malnourished children and paid for it out of the clinic’s pharmacy budget.
A study by the consulting firm DAISA Enterprises identified 108 produce prescription programs in the U.S., all partnered with health care facilities, that launched between 2010 and 2020, with 30% in the Northeast and 28% in the Midwest. Early results show the promise of integrating produce into a clinician-guided treatment plan, but the viability of the approach is less proven in rural communities such as many of those in Montana.
In Montana, 31,000 children do not have consistent access to food, according to the Montana Food Bank Network. Half of the state’s 56 counties are considered food deserts, where low-income residents must travel more than 10 miles to the nearest supermarket — which is one definition the U.S Department of Agriculture uses for low food access in a rural area.
Research shows long travel distances and lack of transportation are significant barriers to accessing healthy food.
“Living in an agriculturally rich community, it’s easy to assume everyone has access,” said Gretchen Boyer, executive director of Land to Hand Montana. The organization works with nearby health care system Logan Health to provide more than 100 people with regular produce allotments.
“Food and nutritional insecurity are rampant everywhere, and if you grow up in generational poverty you probably haven’t had access to fruits and vegetables at a regular rate your whole life,” Boyer said.
More than 9% of Montana adults have Type 2 diabetes and nearly 35% are pre-diabetic, according to Merry Hutton, regional director of community health investment for Providence, a health care provider that operates clinics throughout western Montana and is one of the MTPRx clinical partners.
Brittany Coburn, a family nurse practitioner at Logan Health, sees these conditions often in the population she serves, but she believes produce prescriptions have tremendous capacity to improve patients’ health.
“Real food matters and increasing fruits and veggies can reverse some forms of diabetes, eliminate elevated cholesterol, and impact blood pressure in a positive way,” she said.
Mackenzie Sachs, a registered dietitian, and Thedra Bird Rattler, a nutrition education specialist, work for FAST Blackfeet. (FAST Blackfeet)
Produce prescription programs have the potential to reduce the costs of treating chronic health conditions that overburden the broader health care system.
“If we treat food as part of health care treatment and prevention plans, we are going to get improved outcomes and reduced health care costs,” Garfield said. “If diet is driving health outcomes in the United States, then diet needs to be a centerpiece of health policy moving forward. Otherwise, it’s a missed opportunity.”
The question is, Do food prescription initiatives work? They typically lack the funding needed to foster long-term, sustainable change, and they often fail to track data that shows the relationship between increased produce consumption and improved health, according to a comprehensive survey of over 6,000 studies on such programs.
Data collection is key for MTPRx, and partners and health care providers track how participation in the program influences participants’ essential health indicators such as blood sugar, lipids, and cholesterol, organizers said.
“We really want to see these results and use them to make this more of a norm,” said Bridget McDonald, the MTPRx program director at CFAC. “We want to make the ‘food is medicine’ movement mainstream.”
Sachs acknowledged that “some conditions can’t usually be reversed,” which means some patients may need medication too.
However, MTPRx partners hope to make the case that produce prescriptions should be considered a viable clinical intervention on a larger scale.
“Together, we may be able to advocate for funding and policy change,” Sachs said.
El segundo embarazo de Tamara Etienne estuvo lleno de riesgos y preocupaciones desde el principio, exacerbado porque ya había sufrido un aborto espontáneo.
Como maestra de tercer grado en una escuela pública del condado de Miami-Dade, pasaba todo el día parada. Le pesaban las preocupaciones financieras, incluso teniendo seguro de salud y algo de licencia paga.
Y, como mujer negra, toda una vida de racismo la volvió desconfiada de las reacciones impredecibles en la vida diaria. Estaba agotada por el trato despectivo y desigual en el trabajo. Justamente el tipo de estrés que puede liberar cortisol, que, según estudios, aumenta el riesgo de parto prematuro.
“Lo experimento todo el tiempo, no camino sola, o lo hago con alguien a quien debo proteger. Sí, el nivel de cortisol en mi cuerpo es incontable”, expresó.
A los dos meses de embarazo, las náuseas implacables cesaron de repente. “Empecé a sentir que mis síntomas de embarazo estaban desapareciendo”, dijo. Entonces comenzó un extraño dolor de espalda.
Etienne y su esposo corrieron a la sala de emergencias, donde confirmaron que corría un grave riesgo de aborto espontáneo. Una cascada de intervenciones médicas —inyecciones de progesterona, monitoreo fetal en el hogar y reposo en cama— salvó a la niña, que nació a las 37 semanas.
Aproximadamente uno de cada 10 nacimientos vivos en 2021 ocurrió antes de las 37 semanas de gestación, según un informe de March of Dimes publicado en 2022. En comparación, investigaciones recientes citan tasas de nacimientos prematuros del 7,4% en Inglaterra y Gales, del 6% en Francia y del 5,8% en Suecia.
En su informe, March of Dimes encontró que las tasas de nacimientos prematuros aumentaron en casi todos los estados de 2020 a 2021. Vermont, con una tasa del 8%, tuvo la calificación más alta del país: una “A-”. Los resultados más sombríos se concentraron en los estados del sur, que obtuvieron calificaciones equivalentes a una “F”, con tasas de nacimientos prematuros del 11,5% o más.
Mississippi (15 %), Louisiana (13,5 %) y Alabama (13,1 %) fueron los estados con peor desempeño. El informe encontró que, en 2021, el 10,9% de los nacidos vivos en Florida fueron partos prematuros, por lo que obtuvo una “D”.
Desde que la Corte Suprema anulara Roe vs. Wade, muchos especialistas temen que la incidencia de nacimientos prematuros se dispare. El aborto ahora está prohibido en al menos 13 estados y estrictamente restringido en otros 12: los estados que restringen el aborto tienen menos proveedores de atención materna, según un reciente análisis de Commonwealth Fund.
Eso incluye Florida, donde los legisladores republicanos han promulgado leyes contra el aborto, incluida la prohibición de realizarlo después de las 15 semanas de gestación.
Florida es uno de los estados menos generosos cuando se trata de seguro médico público. Aproximadamente una de cada 6 mujeres en edad fértil no tiene seguro, lo que dificulta mantener un embarazo saludable. Las mujeres de Florida tienen el doble de probabilidades de morir por causas relacionadas con el embarazo y el parto que las de California.
“Me quita el sueño”, dijo la doctora Elvire Jacques, especialista en medicina materno-fetal del Memorial Hospital en Miramar, Florida.
Jacques explicó que las causas de los partos prematuros son variadas. Alrededor del 25% se inducen médicamente, por condiciones como la preeclampsia. Pero la investigación sugiere que muchos más tendrían sus raíces en una misteriosa constelación de condiciones fisiológicas.
“Es muy difícil identificar que una paciente tendrá un parto prematuro”, dijo Jacques. “Pero sí puedes identificar los factores estresantes en sus embarazos”.
Los médicos dicen que aproximadamente la mitad de todos los nacimientos prematuros debido a factores sociales, económicos y ambientales, y al acceso inadecuado a la atención médica prenatal, se pueden prevenir.
En el Memorial Hospital en Miramar, parte de un gran sistema de atención médica pública, Jacques recibe embarazos de alto riesgo referidos por otros obstetras del sur de Florida.
En la primera cita les pregunta: ¿Con quién vives? ¿Donde duermes? ¿Tienes adicciones? ¿Dónde trabajas? “Si no supiera que trabajan en una fábrica paradas cómo les podría recomendar que usaran medias de compresión para prevenir coágulos de sangre?”.
Jacques instó al gerente de una tienda a que permitiera a su empleada embarazada trabajar sentada. Persuadió a un imán para que le concediera a una futura mamá con diabetes un aplazamiento del ayuno religioso.
Debido a que la diabetes es un factor de riesgo importante, a menudo habla con los pacientes sobre cómo comer de manera saludable. Les pregunta: “De los alimentos que estamos discutiendo, ¿cuál crees que puedes pagar?”.
El acceso a una atención asequible separa a Florida de estados como California y Massachusetts, que tienen licencia familiar paga y bajas tasas de residentes sin seguro; y a Estados Unidos de otros países, dicen expertos en políticas de salud.
En países con atención médica socializada, “las mujeres no tienen que preocuparse por el costo financiero de la atención”, apuntó la doctora Delisa Skeete-Henry, jefa del departamento de obstetricia y ginecología de Broward Health en Fort Lauderdale. Y tienen licencias por maternidad pagas.
Sin embargo, a medida que aumentan los nacimientos prematuros en Estados Unidos, la riqueza no garantiza mejores resultados.
Nuevas investigaciones revelan que, sorprendentemente, en todos los niveles de ingresos, las mujeres negras y sus bebés experimentan resultados de parto mucho peores que sus contrapartes blancas. En otras palabras, todos los recursos que ofrece la riqueza no protegen a las mujeres negras ni a sus bebés de complicaciones prematuras, según el estudio, publicado por la Oficina Nacional de Investigación Económica.
Jamarah Amani es testigo de esto como directora ejecutiva de Southern Birth Justice Network y defensora de la atención de parteras y doulas en el sur de Florida. A medida que evalúa nuevos pacientes, busca pistas sobre los riesgos de nacimiento en los antecedentes familiares, análisis de laboratorio y ecografías. Y se centra en el estrés relacionado con el trabajo, las relaciones, la comida, la familia y el racismo.
“Las mujeres negras que trabajan en ambientes de alto estrés, incluso si no tienen problemas económicos, pueden enfrentar un parto prematuro”, dijo.
Recientemente, cuando una paciente mostró signos de trabajo de parto prematuro, Amani descubrió que su factura de electricidad estaba vencida, y que la empresa amenazaba con cortar el servicio. Amani encontró una organización que pagó la deuda.
De los seis embarazos de Tamara Etienne, dos terminaron en aborto espontáneo y cuatro fueron de riesgo de parto prematuro. Harta de la avalancha de intervenciones médicas, encontró una doula y una partera locales que la ayudaron en el nacimiento de sus dos hijos más pequeños.
“Pudieron guiarme a través de formas saludables y naturales para mitigar todas esas complicaciones”, dijo.
Sus propias experiencias con el embarazo dejaron un profundo impacto en Etienne. Desde entonces, ella misma se ha convertido en una doula.
Tamara Etienne’s second pregnancy was freighted with risk and worry from its earliest days — exacerbated by a first pregnancy that had ended in miscarriage.
A third-grade teacher at an overcrowded Miami-Dade County public school, she spent harried days on her feet. Financial worries weighed heavy, even with health insurance and some paid time off through her job.
“I’m experiencing it every day, not walking alone, walking with someone I have to protect,” she said. “So the level of cortisol in my body when I’m pregnant? Immeasurable.”
Two months into the pregnancy, the unrelenting nausea suddenly stopped. “I started to feel like my pregnancy symptoms were going away,” she said. Then strange back pain started.
Etienne and her husband rushed to an emergency room, where a doctor confirmed she was at grave risk for a miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home, and bed rest while she took months off work — saved the child, who was born at 37 weeks.
Women in the U.S. are more likely to deliver their babies prematurely than those in most developed countries. It’s a distinction that coincides with high rates of maternal and infant death, billions of dollars in intensive care costs, and often lifelong disabilities for the children who survive.
About 1 in 10 live births in 2021 occurred before 37 weeks of gestation, according to a March of Dimes report released last year. By comparison, research in recent years has cited preterm birth rates of 7.4% in England and Wales, 6% in France, and 5.8% in Sweden.
In its 2022 report card, the March of Dimes found the preterm birth rates increased in nearly every U.S. state from 2020 to 2021. Vermont, with a rate of 8%, merited the nation’s highest grade: an “A-.” The grimmest outcomes were concentrated in the Southern states, which largely earned “F” ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%), and Alabama (13.1%) were the worst performers. The March of Dimes report found 10.9% of live births in Florida were delivered preterm in 2021, earning the state a “D” rating.
That includes Florida, where Etienne lives, and where Republican lawmakers have enacted a series of anti-abortion laws, including a ban on abortion after 15 weeks of gestation. Florida is one of the least generous states when it comes to public health insurance. About 1 in 6 women of childbearing age in Florida are uninsured, making it more difficult to begin a healthy pregnancy. Women are twice as likely to die from pregnancy and childbirth-related causes in Florida than in California.
“I lose sleep over this,” said Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “It’s hard to say, I expect [better birth outcomes] when I’m not investing anything from the beginning.”
***
The causes of preterm births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions like preeclampsia, a pregnancy-related hypertensive disorder. But research suggests that far more early births are thought to be rooted in a mysterious constellation of physiological conditions.
“It’s very hard to identify that a patient will automatically have a preterm birth,” Jacques said. “But you can definitely identify stressors for their pregnancies.”
Physicians say that roughly half of all preterm births are preventable, caused by social, economic, and environmental factors, as well as inadequate access to prenatal health care. Risk factors include conditions such as diabetes and obesity, as well as more-hidden issues like stress or even dehydration.
At Memorial Hospital in Miramar, part of a large public health care system, Jacques takes on high-risk pregnancies referred from other OB-GYNs in South Florida.
When meeting a patient for the first time she asks: Who else is in your household? Where do you sleep? Do you have substance abuse issues? Where do you work? “If you don’t know that your patient works in a factory [standing] on an assembly line,” she said, “then how are you going to tell her to wear compression socks because that may help her prevent blood clots?”
Jacques has urged a store manager to let her pregnant patient sit while working. She persuaded an imam to grant a mom-to-be with diabetes a reprieve from religious fasting.
Because diabetes is a major risk factor, she often talks with patients about eating healthfully. For those who eat fast food, she asks them to try cooking at home. Instead of, “Can you pay for food?” she asks, “Of the foods we’re discussing, which one do you think you can afford?”
Access to affordable care separates Florida from states like California and Massachusetts — which have paid family leave and low rates of uninsured residents — and separates the U.S. from other countries, health policy experts say.
In countries with socialized health care, “women don’t have to worry about the financial cost of care,” said Dr. Delisa Skeete-Henry, chair of the obstetrics and gynecology department at Broward Health in Fort Lauderdale. “A lot of places have paid leave, [and pregnant patients] don’t have to worry about not being at work.”
Yet, as preterm births rise in the U.S., wealth does not ensure better pregnancy outcomes.
Startling new research shows that at every U.S. income level, Black women and their infants experience far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth do not protect Black women or their babies from preterm complications, according to the study, published by the National Bureau of Economic Research.
Jamarah Amani has seen this firsthand as executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. As she evaluates new clients, she looks for clues about birth risks in a patient’s family history, lab work, and ultrasounds. She homes in quickly on stress related to work, relationships, food, family, and racism.
“I find Black women working in high-stress environments, even if they are not financially struggling, can face preterm birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching, and walking.
Recently, when a patient showed signs of preterm labor, Amani discovered that her electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the debt.
Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened by preterm labor. Fed up with the onslaught of medical interventions, she found a local doula and midwife who helped guide her through the birth of her two youngest children.
“They were able to walk me through healthy, natural ways to mitigate all of those complications,” she said.
Her own pregnancy experiences left a profound impact on Etienne. She has since become a fertility doula herself.
No lo pensó cuando niño, o durante un tiroteo fuera de su casa en el área de Chicago. Tampoco a los 12 años, cuando uno de sus amigos fue baleado.
La mente de Diego cambió a los 14, cuando él y sus amigos estaban listos para ir a la vigilia de Nuestra Señora de Guadalupe. Esa noche, en lugar de cánticos religiosos, escuchó disparos y gritos. Un pandillero le había disparado a dos personas, una de ellas un amigo suyo, quien recibió nueve balazos.
“Mi amigo se estaba desangrando”, dijo Diego, quien le pidió a KHN no utilizar su apellido para proteger su seguridad y privacidad. Mientras su amigo yacía en el suelo, “se estaba ahogando en su propia sangre”.
Investigaciones muestran que los adolescentes expuestos a la violencia armada tienen el doble de probabilidades que otros de cometer un delito violento grave dentro de los dos años luego del trauma, lo que perpetúa un ciclo difícil de romper.
Diego pidió ayuda a sus amigos para tener una pistola y, en un país sobrecargado con armas de fuego, no tuvieron problemas para conseguirle una, que le dieron gratis.
“Me sentí más seguro con el arma”, dijo Diego, que ahora tiene 21 años. “Esperaba no usarla”.
Durante dos años, Diego mantuvo el arma solo como elemento de disuasión. Cuando finalmente apretó el gatillo, cambió su vida para siempre.
Tendencias inquietantes
Los medios de comunicación se centran en gran medida en los tiroteos masivos y el estado mental de las personas que los cometen.
Estudios muestran que la exposición crónica al trauma puede cambiar la forma en que se desarrolla el cerebro de un niño. El trauma también puede desempeñar un papel central en la explicación de por qué algunos jóvenes buscan protección en las armas y terminan usándolas contra sus compañeros.
La cantidad de niños menores de 18 años que mataron a alguien con un arma de fuego aumentó de 836 en 2019 a 1,150 en 2020.
En la ciudad de Nueva York, la cantidad de jóvenes que mataron a alguien con un arma aumentó más del doble, pasando de 48 delincuentes juveniles en 2019 a 124 en 2022, según datos del departamento de policía de la ciudad.
La violencia armada juvenil aumentó más modestamente en otras ciudades; en muchos lugares, la cantidad de homicidios de adolescentes con armas de fuego subió en 2020, pero desde entonces se ha acercado a los niveles previos a la pandemia.
Investigadores que analizan las estadísticas del crimen enfatizan que los adolescentes no están impulsando el aumento general de la violencia armada, que ha aumentado en todas las edades. En 2020, el 7,5% de los arrestos por homicidio involucraron a menores de 18 años, una proporción ligeramente menor que en años anteriores.
A líderes locales les cuesta encontrar la mejor manera de responder a los tiroteos adolescentes.
Un puñado de comunidades, incluidas Pittsburgh; el condado de Fulton, en Georgia; y el condado de Prince George, en Maryland, han debatido o implementado toques de queda juveniles para frenar la violencia adolescente. Lo que no está en discusión: más personas de 1 a 19 años mueren por violencia armada que por cualquier otra causa.
Una vida de límites
El número devastador de la violencia armada se revela a diario en las salas de emergencia.
En el centro de trauma de UChicago Medicine, la cantidad de heridas de bala en menores de 16 años se ha duplicado en los últimos seis años, dijo el doctor Selwyn Rogers, director fundador del centro. La víctima más joven tenía 2 años.
“Escuchas a la madre gemir o al hermano decir: ‘No es cierto’”, dijo Rogers, quien trabaja con jóvenes locales como vicepresidente ejecutivo del hospital para salud comunitaria. “Tienes que estar presente en ese momento, pero luego salir por la puerta y lidiar con todo de nuevo”.
En los últimos años, el sistema judicial ha luchado por equilibrar la necesidad de seguridad pública con la compasión por los menores, según investigaciones que muestran que el cerebro de una persona joven no madura por completo hasta los 25 años.
La mayoría de los delincuentes jóvenes “superan la edad” del comportamiento delictivo o violento casi al mismo tiempo, a medida que desarrollan más autocontrol y habilidades de pensamiento de largo alcance.
El doctor Selwyn Rogers es el director fundador del centro de medicina del trauma de UChicago. En los últimos seis años, ha visto duplicarse el número de heridas de bala en menores de 16.(UChicago Medicine)
Sin embargo, los adolescentes acusados de tiroteos a menudo son enjuiciados como adultos, lo que significa que enfrentan castigos más severos, dijo Josh Rovner, director de justicia juvenil en Sentencing Project, que aboga por la reforma del sistema judicial.
En 2019, aproximadamente 53,000 menores fueron acusados como adultos, lo que puede tener graves repercusiones para la salud. Estos adolescentes tienen más probabilidades de ser victimizados mientras están presos, dijo Rovner, y de ser arrestados nuevamente después de quedar libres.
Los jóvenes pueden pasar gran parte de sus vidas en un “aislamiento” impuesto por la pobreza, sin aventurarse más allá de sus vecindarios, aprendiendo poco sobre las oportunidades que existen en el resto del mundo, dijo Rogers. Millones de niños estadounidenses, en particular niños negros no hispanos, latinos y nativos americanos, viven en entornos plagados de pobreza, violencia y consumo de drogas.
Aunque nadie puede decir con certeza qué provocó el aumento de tiroteos en 2020, la investigación ha relacionado durante mucho tiempo la desesperanza y la falta de confianza en la policía, que aumentó después del asesinato de George Floyd ese año, con un mayor riesgo de violencia comunitaria.
Las ventas de armas se dispararon un 64% entre 2019 y 2020, mientras que se cancelaron muchos programas de prevención de la violencia.
Una de las pérdidas más graves que enfrentaron los niños durante la pandemia fue el cierre de las escuelas durante un año o más, justamente las instituciones que proporcionan tal vez la única fuerza estabilizadora en sus jóvenes vidas.
“La pandemia encendió el fuego debajo de la olla”, dijo Elise White, subdirectora de investigación Center for Justice Innovation, un entidad sin fines de lucro que trabaja con comunidades y sistemas de justicia. “Mirando hacia atrás, es fácil restar importancia ahora a lo incierto que se sintió ese momento [de la pandemia]. Cuanto más insegura se sienta la gente, cuanto más sientan que no hay seguridad a su alrededor, más probable es que porten armas”.
Por supuesto, la mayoría de los niños que experimentan dificultades nunca infringen la ley. Múltiples estudios han encontrado que la mayor parte de la violencia armada es perpetrada por un número relativamente pequeño de personas.
Incluso la presencia de un adulto solidario puede proteger a los niños de involucrarse en la delincuencia, explicó el doctor Abdullah Pratt, médico de emergencias de UChicago Medicine que perdió a su hermano por la violencia con armas de fuego.
Pratt también perdió a cuatro amigos por la violencia con armas durante la pandemia. Los cuatro murieron en su sala de emergencias; uno era el hijo de una enfermera del hospital.
Aunque Pratt creció en una parte de Chicago donde las pandillas callejeras eran comunes, se benefició del apoyo de padres amorosos y fuertes modelos a seguir, como maestros y entrenadores de fútbol americano. A Pratt también lo protegió su hermano mayor, quien lo cuidaba y se aseguraba de que las pandillas dejaran en paz al futuro médico.
“Todo lo que he podido lograr”, dijo Pratt, “es porque alguien me ayudó”.
Crecer en una “zona de guerra”
Diego no tenía adultos en casa que lo ayudaran a sentirse seguro.
A menudo, sus propios padres eran violentos. Una vez, en un ataque de ira por la borrachera, su padre lo agarró por la pierna y lo zarandeó por la habitación, contó Diego; y su madre una vez le arrojó una tostadora a su padre.
A los 12 años, los esfuerzos de Diego para ayudar a la familia a pagar las facturas atrasadas —vendiendo marihuana, y robando autos y apartamentos— llevaron a su padre a echarlo de la casa.
A los 13 años, Diego se unió a una pandilla del barrio. Los pandilleros, que contaron historias similares sobre huir del hogar para escapar del abuso, le dieron comida y un lugar para quedarse. “Éramos como una familia”, dijo Diego. Cuando tenían hambre y no había comida en casa, “íbamos juntos a una gasolinera a robar algo de desayuno”.
Pero Diego, que era más pequeño que la mayoría de los demás, vivía con miedo. A los 16, pesaba solo 100 libras. Los chicos más grandes lo intimidaban y lo golpeaban. Y su exitosa actividad, vender mercadería robada en la calle por dinero en efectivo, llamó la atención de pandilleros rivales, quienes amenazaron con robarle.
Los niños que experimentan violencia crónica pueden desarrollar una “mentalidad de zona de guerra”, volviéndose hipervigilantes ante las amenazas, a veces sintiendo peligro donde no existe, dijo James Garbarino, profesor emérito de psicología en la Universidad de Cornell y la Universidad de Loyola-Chicago.
Los niños que viven con miedo constante tienen más probabilidades de buscar protección en las armas de fuego o en las pandillas. Se puede activar para que tomen medidas preventivas, como disparar un arma sin pensar, contra lo que perciben como una amenaza.
El doctor Abdullah Pratt es un médico de emergencias de UChicago Medicine, quien perdió su hermano por la violencia con armas de fuego. Dice que la presencia de un adulto que apoye puede proteger a un menor del criminal.(UChicago Medicine)
“Sus cuerpos están constantemente listos para pelear”, dijo Gianna Tran, subdirectora ejecutiva del East Bay Asian Youth Center en Oakland, California, que trabaja con jóvenes en riesgo.
A diferencia de los perpetradores de tiroteos masivos, que compran armas y municiones porque tienen la intención de asesinar, la mayor parte de la violencia adolescente no es premeditada, dijo Garbarino.
En las encuestas, la mayoría de los jóvenes que portan armas, incluidos los pandilleros, dicen que lo hacen por miedo o para disuadir ataques, en lugar de perpetrarlos. Pero el miedo a la violencia comunitaria, tanto de los rivales como de la policía, puede avivar una carrera armamentista urbana, en la que los menores sienten que solo los tontos no portan armas.
“Fundamentalmente, la violencia es una enfermedad contagiosa”, dijo el doctor Gary Slutkin, fundador de Cure Violence Global, que trabaja para prevenir la violencia comunitaria.
Aunque un pequeño número de adolescentes se vuelven duros y despiadados, Pratt dijo que ve muchos más tiroteos causados por la “pobre resolución de un conflicto” y la impulsividad de los adolescentes en lugar de un deseo de matar.
De hecho, las armas de fuego y un cerebro adolescente inmaduro son una mezcla peligrosa, enfatizó Garbarino. El alcohol y las drogas pueden aumentar el riesgo. Cuando se enfrentan a una situación potencialmente de vida o muerte, pueden actuar sin pensar.
Cuando Diego tenía 16 años, estaba acompañando a una niña a la escuela y se les acercaron tres jóvenes, incluido un pandillero, quien, usando un lenguaje obsceno y amenazante, le preguntó a Diego si también estaba en una pandilla. Diego dijo que trató de pasar de largo, y uno de ellos parecía tener un arma.
“No sabía cómo disparar un arma”, dijo Diego. “Solo quería que huyeran”.
En las noticias sobre el tiroteo, testigos dijeron que escucharon cinco disparos. “Lo único que recuerdo es el sonido de los disparos”, dijo Diego. “Todo lo demás fue en cámara lenta”.
Diego había disparado a dos de los muchachos en las piernas. La niña corrió por un lado y él por otro. La policía lo arrestó en su casa unas horas después. Fue juzgado como adulto, condenado por dos cargos de intento de homicidio y sentenciado a 12 años.
Una segunda oportunidad
En las últimas dos décadas, el sistema judicial ha realizado cambios importantes en la forma en que trata a los niños.
Los estados también están adoptando alternativas a la cárcel, como hogares grupales que permiten a los adolescentes permanecer en sus comunidades, al tiempo que brindan tratamiento para ayudarlos a cambiar su conducta.
Debido a que Diego tenía 17 años cuando fue sentenciado, fue enviado a un centro de menores, donde recibió terapia por primera vez.
Diego terminó la escuela secundaria mientras estaba tras las rejas, y obtuvo un título de un colegio comunitario. Con otros jóvenes reclusos fue de excursión a teatros y al acuario, lugares en los que nunca había estado. La directora del centro de detención le pidió que la acompañara a eventos sobre la reforma de la justicia juvenil, donde lo invitaron a contar su historia.
Para Diego, esas fueron experiencias reveladoras: se dio cuenta de que había visto muy poco de Chicago, a pesar de que había pasado su vida allí.
“Mientras estás creciendo, lo único que ves es a tu comunidad”, dijo Diego, quien fue liberado después de cuatro años, cuando el gobernador conmutó su sentencia. “Asumes que el mundo entero es así”.
La editora de datos de KHN Holly K. Hacker y la investigadora Megan Kalata contribuyeron con este informe.
Not as a child, when shots were fired outside his Chicago-area home. Not at age 12, when one of his friends was gunned down.
Diego’s mind changed at 14, when he and his friends were getting ready to walk to midnight Mass for the feast of Our Lady of Guadalupe. But instead of hymns, Diego heard gunfire, and then screaming. A gang member shot two people, including one of Diego’s friends, who was hit nine times.
“My friend was bleeding out,” said Diego, who asked KHN not to use his last name to protect his safety and privacy. As his friend lay on the ground, “he was choking on his own blood.”
The attack left Diego’s friend paralyzed from the waist down. And it left Diego, one of a growing number of teens who witness gun violence, traumatized and afraid to go outside without a gun.
Research shows that adolescents exposed to gun violence are twice as likely as others to perpetrate a serious violent crime within two years, perpetuating a cycle that can be hard to interrupt.
Diego asked his friends for help finding a handgun and — in a country supersaturated with firearms — they had no trouble procuring one, which they gave him free.
“I felt safer with the gun,” said Diego, now 21. “I hoped I wouldn’t use it.”
For two years, Diego kept the gun only as a deterrent. When he finally pulled the trigger, it changed his life forever.
Disturbing Trends
The news media focuses heavily on mass shootings and the mental state of the people who commit them. But there is a far larger epidemic of gun violence — particularly among Black, Hispanic, and Native American youth — ensnaring some kids not even old enough to get a driver’s license.
Research shows that chronic exposure to trauma can change the way a child’s brain develops. Trauma also can play a central role in explaining why some young people look to guns for protection and wind up using them against their peers.
In New York City, the number of young people who killed someone with a gun more than doubled, rising from 48 juvenile offenders in 2019 to 124 in 2022, according to data from the city’s police department.
Youth gun violence increased more modestly in other cities; in many places, the number of teen gun homicides rose in 2020 but has since fallen closer to pre-pandemic levels.
The devastating toll of gun violence shows up in emergency rooms every day.
At the UChicago Medicine trauma center, the number of gunshot wounds in children under 16 has doubled in the past six years, said Dr. Selwyn Rogers, the center’s founding director. The youngest victim was 2. “You hear the mother wail, or the brother say, ‘It’s not true,’” said Rogers, who works with local youth as the hospital’s executive vice president for community health engagement. “You have to be present in that moment, but then walk out the door and deal with it all over again.”
Dr. Selwyn Rogers is the founding director of UChicago Medicine’s trauma center. In the past six years, the trauma center has seen the number of gunshot wounds in children under 16 double.(UChicago Medicine)
In recent years, the justice system has struggled to balance the need for public safety with compassion for kids, based on research that shows a young person’s brain doesn’t fully mature until age 25. Most young offenders “age out” of criminal or violent behavior around the same time, as they develop more self-control and long-range thinking skills.
Yet teens accused of shootings are often charged as adults, which means they face harsher punishments than kids charged as juveniles, said Josh Rovner, director of youth justice at the Sentencing Project, which advocates for justice system reform.
About 53,000 juveniles in 2019 were charged as adults, which can have serious health repercussions. These teens are more likely to be victimized while incarcerated, Rovner said, and to be arrested again after release.
Young people can spend much of their lives in a poverty-imposed lockdown, never venturing far beyond their neighborhoods, learning little about opportunities that exist in the wider world, Rogers said. Millions of American children — particularly Black, Hispanic, and Native American kids — live in environments plagued by poverty, violence, and drug use.
Although no one can say with certainty what spurred the surge in shootings in 2020, research has long linked hopelessness and lack of trust in police — which increased after the murder of George Floyd that year — to an increased risk of community violence. Gun sales soared 64% from 2019 to 2020, while many violence prevention programs shut down.
One of the most serious losses children faced during the pandemic was the closure of schools — institutions that might provide the only stabilizing force in their young lives — for a year or more in many places.
“The pandemic just turned up the fire under the pot,” said Elise White, deputy director of research at the nonprofit Center for Justice Innovation, which works with communities and justice systems. “Looking back, it’s easy to underplay now just how uncertain that time [during the pandemic] felt. The more that people feel uncertain, the more they feel there’s no safety around them, the more likely they are to carry weapons.”
Of course, most children who experience hardship never break the law. Multiple studies have found that most gun violence is perpetrated by a relatively small number of people.
The presence of even one supportive adult can protect children from becoming involved with crime, said Dr. Abdullah Pratt, a UChicago Medicine emergency physician who lost his brother to gun violence.
Pratt also lost four friends to gun violence during the pandemic. All four died in his emergency room; one was the son of a hospital nurse.
Although Pratt grew up in a part of Chicago where street gangs were common, he benefited from the support of loving parents and strong role models, such as teachers and football coaches. Pratt was also protected by his older brother, who looked out for him and made sure gangs left the future doctor alone.
“Everything I’ve been able to accomplish,” Pratt said, “is because someone helped me.”
Growing Up in a ‘War Zone’
Diego had no adults at home to help him feel safe.
His parents were often violent. Once, in a drunken rage, Diego’s father grabbed him by the leg and swung him around the room, Diego said, and his mother once threw a toaster at his father.
At age 12, Diego’s efforts to help the family pay overdue bills — by selling marijuana and stealing from unlocked cars and apartments — led his father to throw him out of the house.
At 13, Diego joined a gang made up of neighborhood kids. Gang members — who recounted similar stories about leaving the house to escape abuse — gave him food and a place to stay. “We were like a family,” Diego said. When the kids were hungry, and there was no food at home, “we’d go to a gas station together to steal some breakfast.”
Dr. Abdullah Pratt is a UChicago Medicine emergency physician who lost his brother to gun violence. Pratt says the presence of even one supportive adult can protect children from becoming involved with crime.(UChicago Medicine)
But Diego, who was smaller than most of the others, lived in fear. At 16, Diego weighed only 100 pounds. Bigger boys bullied and beat him up. And his successful hustle — selling stolen merchandise on the street for cash — got the attention of rival gang members, who threatened to rob him.
Children who experience chronic violence can develop a “war zone mentality,” becoming hypervigilant to threats, sometimes sensing danger where it doesn’t exist, said James Garbarino, an emeritus professor of psychology at Cornell University and Loyola University-Chicago. Kids who live with constant fear are more likely to look to firearms or gangs for protection. They can be triggered to take preemptive action — such as firing a gun without thinking — against a perceived threat.
“Their bodies are constantly ready for a fight,” said Gianna Tran, deputy executive director of the East Bay Asian Youth Center in Oakland, California, which works with young people living in poverty, trauma, and neglect.
Unlike mass shooters, who buy guns and ammunition because they’re intent on murder, most teen violence is not premeditated, Garbarino said.
In surveys, most young people who carry guns — including gang members — say they do so out of fear or to deter attacks, rather than perpetrate them. But fear of community violence, both from rivals and the police, can stoke an urban arms race, in which kids feel that only the foolish walk around without a weapon.
“Fundamentally, violence is a contagious disease,” said Dr. Gary Slutkin, founder of Cure Violence Global, which works to prevent community violence.
Although a small number of teens become hardened and remorseless, Pratt said, he sees far more shootings caused by “poor conflict resolution” and teenage impulsivity rather than a desire to kill.
Indeed, firearms and an immature teenage brain are a dangerous mix, Garbarino said. Alcohol and drugs can magnify the risk. When confronted with a potentially life-or-death situation, kids may act without thinking.
When Diego was 16, he was walking a girl to school and they were approached by three boys, including a gang member who, using obscene and threatening language, asked if Diego was also in a gang. Diego said he tried to walk past the boys, one of whom appeared to have a gun.
“I didn’t know how to fire a gun,” Diego said. “I just wanted them to get away.”
In news accounts of the shooting, witnesses said they heard five gunshots. “The only thing I remember is the sound of the shots,” Diego said. “Everything else was going in slow motion.”
Diego had shot two of the boys in the legs. The girl ran one way, and he ran another. Police arrested Diego at home a few hours later. He was tried as an adult, convicted of two counts of attempted homicide, and sentenced to 12 years.
A Second Chance
In the past two decades, the justice system has made major changes in the way it treats children.
Youth arrests for violent crime plummeted 67% from 2006 to 2020, and 40 states have made it harder to charge minors as adults. States also are adopting alternatives to incarceration, such as group homes that allow teens to remain in their communities, while providing treatment to help them change their behavior.
Because Diego was 17 when he was sentenced, he was sent to a juvenile facility, where he received therapy for the first time.
Diego finished high school while behind bars and went on to earn an associate’s degree from a community college. He and other young inmates went on field trips to theaters and the aquarium — places he had never been. The detention center director asked Diego to accompany her to events about juvenile justice reform, where he was invited to tell his story.
Those were eye-opening experiences for Diego, who realized he had seen very little of Chicago, even though he had spent his life there.
“Growing up, the only thing you see is your community,” said Diego, who was released after four years in detention, when the governor commuted his sentence. “You assume that is what the whole world is like.”
KHN data editor Holly K. Hacker and researcher Megan Kalata contributed to this report.
Not as a child, when shots were fired outside his Chicago-area home. Not at age 12, when one of his friends was gunned down.
Diego’s mind changed at 14, when he and his friends were getting ready to walk to midnight Mass for the feast of Our Lady of Guadalupe. But instead of hymns, Diego heard gunfire, and then screaming. A gang member shot two people, including one of Diego’s friends, who was hit nine times.
“My friend was bleeding out,” said Diego, who asked KHN not to use his last name to protect his safety and privacy. As his friend lay on the ground, “he was choking on his own blood.”
The attack left Diego’s friend paralyzed from the waist down. And it left Diego, one of a growing number of teens who witness gun violence, traumatized and afraid to go outside without a gun.
Research shows that adolescents exposed to gun violence are twice as likely as others to perpetrate a serious violent crime within two years, perpetuating a cycle that can be hard to interrupt.
Diego asked his friends for help finding a handgun and — in a country supersaturated with firearms — they had no trouble procuring one, which they gave him free.
“I felt safer with the gun,” said Diego, now 21. “I hoped I wouldn’t use it.”
For two years, Diego kept the gun only as a deterrent. When he finally pulled the trigger, it changed his life forever.
Disturbing Trends
The news media focuses heavily on mass shootings and the mental state of the people who commit them. But there is a far larger epidemic of gun violence — particularly among Black, Hispanic, and Native American youth — ensnaring some kids not even old enough to get a driver’s license.
Research shows that chronic exposure to trauma can change the way a child’s brain develops. Trauma also can play a central role in explaining why some young people look to guns for protection and wind up using them against their peers.
In New York City, the number of young people who killed someone with a gun more than doubled, rising from 48 juvenile offenders in 2019 to 124 in 2022, according to data from the city’s police department.
Youth gun violence increased more modestly in other cities; in many places, the number of teen gun homicides rose in 2020 but has since fallen closer to pre-pandemic levels.
The devastating toll of gun violence shows up in emergency rooms every day.
At the UChicago Medicine trauma center, the number of gunshot wounds in children under 16 has doubled in the past six years, said Dr. Selwyn Rogers, the center’s founding director. The youngest victim was 2. “You hear the mother wail, or the brother say, ‘It’s not true,’” said Rogers, who works with local youth as the hospital’s executive vice president for community health engagement. “You have to be present in that moment, but then walk out the door and deal with it all over again.”
Dr. Selwyn Rogers is the founding director of UChicago Medicine’s trauma center. In the past six years, the trauma center has seen the number of gunshot wounds in children under 16 double.(UChicago Medicine)
In recent years, the justice system has struggled to balance the need for public safety with compassion for kids, based on research that shows a young person’s brain doesn’t fully mature until age 25. Most young offenders “age out” of criminal or violent behavior around the same time, as they develop more self-control and long-range thinking skills.
Yet teens accused of shootings are often charged as adults, which means they face harsher punishments than kids charged as juveniles, said Josh Rovner, director of youth justice at the Sentencing Project, which advocates for justice system reform.
About 53,000 juveniles in 2019 were charged as adults, which can have serious health repercussions. These teens are more likely to be victimized while incarcerated, Rovner said, and to be arrested again after release.
Young people can spend much of their lives in a poverty-imposed lockdown, never venturing far beyond their neighborhoods, learning little about opportunities that exist in the wider world, Rogers said. Millions of American children — particularly Black, Hispanic, and Native American kids — live in environments plagued by poverty, violence, and drug use.
Although no one can say with certainty what spurred the surge in shootings in 2020, research has long linked hopelessness and lack of trust in police — which increased after the murder of George Floyd that year — to an increased risk of community violence. Gun sales soared 64% from 2019 to 2020, while many violence prevention programs shut down.
One of the most serious losses children faced during the pandemic was the closure of schools — institutions that might provide the only stabilizing force in their young lives — for a year or more in many places.
“The pandemic just turned up the fire under the pot,” said Elise White, deputy director of research at the nonprofit Center for Justice Innovation, which works with communities and justice systems. “Looking back, it’s easy to underplay now just how uncertain that time [during the pandemic] felt. The more that people feel uncertain, the more they feel there’s no safety around them, the more likely they are to carry weapons.”
Of course, most children who experience hardship never break the law. Multiple studies have found that most gun violence is perpetrated by a relatively small number of people.
The presence of even one supportive adult can protect children from becoming involved with crime, said Dr. Abdullah Pratt, a UChicago Medicine emergency physician who lost his brother to gun violence.
Pratt also lost four friends to gun violence during the pandemic. All four died in his emergency room; one was the son of a hospital nurse.
Although Pratt grew up in a part of Chicago where street gangs were common, he benefited from the support of loving parents and strong role models, such as teachers and football coaches. Pratt was also protected by his older brother, who looked out for him and made sure gangs left the future doctor alone.
“Everything I’ve been able to accomplish,” Pratt said, “is because someone helped me.”
Growing Up in a ‘War Zone’
Diego had no adults at home to help him feel safe.
His parents were often violent. Once, in a drunken rage, Diego’s father grabbed him by the leg and swung him around the room, Diego said, and his mother once threw a toaster at his father.
At age 12, Diego’s efforts to help the family pay overdue bills — by selling marijuana and stealing from unlocked cars and apartments — led his father to throw him out of the house.
At 13, Diego joined a gang made up of neighborhood kids. Gang members — who recounted similar stories about leaving the house to escape abuse — gave him food and a place to stay. “We were like a family,” Diego said. When the kids were hungry, and there was no food at home, “we’d go to a gas station together to steal some breakfast.”
Dr. Abdullah Pratt is a UChicago Medicine emergency physician who lost his brother to gun violence. Pratt says the presence of even one supportive adult can protect children from becoming involved with crime.(UChicago Medicine)
But Diego, who was smaller than most of the others, lived in fear. At 16, Diego weighed only 100 pounds. Bigger boys bullied and beat him up. And his successful hustle — selling stolen merchandise on the street for cash — got the attention of rival gang members, who threatened to rob him.
Children who experience chronic violence can develop a “war zone mentality,” becoming hypervigilant to threats, sometimes sensing danger where it doesn’t exist, said James Garbarino, an emeritus professor of psychology at Cornell University and Loyola University-Chicago. Kids who live with constant fear are more likely to look to firearms or gangs for protection. They can be triggered to take preemptive action — such as firing a gun without thinking — against a perceived threat.
“Their bodies are constantly ready for a fight,” said Gianna Tran, deputy executive director of the East Bay Asian Youth Center in Oakland, California, which works with young people living in poverty, trauma, and neglect.
Unlike mass shooters, who buy guns and ammunition because they’re intent on murder, most teen violence is not premeditated, Garbarino said.
In surveys, most young people who carry guns — including gang members — say they do so out of fear or to deter attacks, rather than perpetrate them. But fear of community violence, both from rivals and the police, can stoke an urban arms race, in which kids feel that only the foolish walk around without a weapon.
“Fundamentally, violence is a contagious disease,” said Dr. Gary Slutkin, founder of Cure Violence Global, which works to prevent community violence.
Although a small number of teens become hardened and remorseless, Pratt said, he sees far more shootings caused by “poor conflict resolution” and teenage impulsivity rather than a desire to kill.
Indeed, firearms and an immature teenage brain are a dangerous mix, Garbarino said. Alcohol and drugs can magnify the risk. When confronted with a potentially life-or-death situation, kids may act without thinking.
When Diego was 16, he was walking a girl to school and they were approached by three boys, including a gang member who, using obscene and threatening language, asked if Diego was also in a gang. Diego said he tried to walk past the boys, one of whom appeared to have a gun.
“I didn’t know how to fire a gun,” Diego said. “I just wanted them to get away.”
In news accounts of the shooting, witnesses said they heard five gunshots. “The only thing I remember is the sound of the shots,” Diego said. “Everything else was going in slow motion.”
Diego had shot two of the boys in the legs. The girl ran one way, and he ran another. Police arrested Diego at home a few hours later. He was tried as an adult, convicted of two counts of attempted homicide, and sentenced to 12 years.
A Second Chance
In the past two decades, the justice system has made major changes in the way it treats children.
Youth arrests for violent crime plummeted 67% from 2006 to 2020, and 40 states have made it harder to charge minors as adults. States also are adopting alternatives to incarceration, such as group homes that allow teens to remain in their communities, while providing treatment to help them change their behavior.
Because Diego was 17 when he was sentenced, he was sent to a juvenile facility, where he received therapy for the first time.
Diego finished high school while behind bars and went on to earn an associate’s degree from a community college. He and other young inmates went on field trips to theaters and the aquarium — places he had never been. The detention center director asked Diego to accompany her to events about juvenile justice reform, where he was invited to tell his story.
Those were eye-opening experiences for Diego, who realized he had seen very little of Chicago, even though he had spent his life there.
“Growing up, the only thing you see is your community,” said Diego, who was released after four years in detention, when the governor commuted his sentence. “You assume that is what the whole world is like.”
KHN data editor Holly K. Hacker and researcher Megan Kalata contributed to this report.
When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.
As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.
But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.
“On at least four or five occasions, she called me up, hysterical,” Roux said.
Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.
Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”
Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.
Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.
Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.
So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.
“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”
In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.
Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.
“Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”
Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.
Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.
In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.
Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.
Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.
Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.
The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.
“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”
Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.
Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.
It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.
“I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”
Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.
“It’s a terrible system,” she said.
A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.
Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.
Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.
When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.
“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.
When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.
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JACKSON, Miss. — Two years ago, after an emergency cesarean section at a Mississippi hospital, Sherika Trader was denied a tubal ligation. Trader, now 33, was told that to have her tubes tied, she had to have a second child or a husband’s permission, even though she wasn’t married.
Jasymin Shepherd had heavy menstrual cycles because of a birth control pill prescribed after the birth of her son 13 years ago. The symptoms continued even after she stopped taking the medication. Last year, a doctor in Jackson responded by offering Shepherd, 33, a hysterectomy, which she didn’t want.
The experiences left the women feeling as though providers acted like “robots,” or, worse, they felt stereotyped. Black women already face major barriers to accessing health care, including provider shortages and racial bias rooted in the medical system.
But with contraceptive care, which deals with deeply personal patient preferences, they must also contend with providers who dismiss their concerns. Decisions about whether — or when — to have a baby and how to prevent pregnancy are not as standardized as care for other conditions. Yet providers hand out prescriptions or recommendations while disregarding a patient’s specific circumstances, Shepherd said.
Late last year, the White House made new recommendations for a federal program that provides funding for free contraceptives, wellness exams, and certain cancer screenings. Health officials want to regain the trust of patients like Trader and Shepherd, who feel as though their doctors don’t always listen to them. The goal of the Title X program, which distributes grants to states and other groups for family planning, is to let patients dictate the care they want, said Jessica Marcella, who is the deputy assistant secretary for population affairs at the U.S. Department of Health and Human Services and oversees the Title X program.
“Our belief, and that of the family planning field, is that it is essential that you respect the interests, needs, and values of a client,” she said. Providers shouldn’t force patients to take a birth control method because it’s more effective, she said, or deny them a particular method because they think a patient might want more kids.
“What we don’t want is a provider to create trauma or do unintentional harm,” Marcella said.
In Mississippi, efforts to implement that approach have started with a change in who gets to administer the Title X funds, taking that responsibility from the state and giving it to a four-year-old Jackson-based nonprofit named Converge. The Biden administration’s decision this year to give Converge the $4.5 million grant marks the first time in four decades that Mississippi’s health department hasn’t won the federal family-planning grant.
Converge doesn’t offer family planning services. Instead, the group provides funding to a network of clinics statewide, organizes provider training, helps clinics navigate technology challenges, and keeps them stocked with supplies. For example, when a provider was having trouble printing out a survey that patients took about their contraception preferences, Converge co-founder and co-director Jamie Bardwell shipped the clinic a wireless printer.
Jamie Bardwell (left) and Danielle Lampton co-founded Converge, a nonprofit that administers federal family-planning funds in Mississippi through a grant it won earlier this year.(Nico Hopkins)
But across the South, the attempt to change the culture of family planning care faces old and new obstacles. Some are deeply rooted in the medical system, such as the bias long faced by Black women and other women of color. In addition, contraception care is limited in the conservative South, and the Supreme Court’s June decision to overturn Roe v. Wade has led to the curtailing of abortion access across much of the region.
Black women often feel disrespected and dismissed by their providers, said Kelsey Holt, an associate professor of family and community medicine at the University of California-San Francisco. She co-authored a 2022 study in the journal Contraception in which dozens of Black women in Mississippi were interviewed about their experiences getting contraceptives.
Women told researchers that they struggled to get appointments, faced long wait times, and had to put up with condescending behavior. Many of the women said providers didn’t inform them about alternatives to the contraceptive Depo-Provera, a progestin shot administered once every three months, despite the known side effects and the availability of other, more appropriate options.
Trying to undo decades of such damage — and overhaul how providers deliver family planning care — became even more difficult after the Supreme Court decision and the closure of abortion clinics across the South. Suddenly, women in Mississippi, Alabama, and about a dozen other states could no longer get abortions.
“A major service has been cut off,” said Usha Ranji, associate director for women’s health policy at KFF. Title X funds cannot be used — and have never been used — to pay for abortions. But, she said, clinics can no longer present abortion as an option, hampering their ability to provide comprehensive counseling, a key requirement of the Title X program.
Many Mississippians can’t afford to travel across state lines to terminate an unwanted pregnancy. In 2020, 84% of Title X clients in the U.S. had incomes at or below 200% of the federal poverty level, and 39% were uninsured. Even women in Mississippi with the means to travel will face hurdles in nearby states, like Georgia and Florida, where abortion is not fully banned but access has been scaled back.
Even before the Supreme Court decision, access to family planning care in Mississippi came with hurdles and judgment.
In 2017, when Mia, who didn’t want her last name used for fear of legal and social repercussions, became pregnant for the second time, she called the local health department in Hattiesburg for advice on obtaining an abortion. She had a daughter and wasn’t financially or mentally prepared to have another child. The health department contact sent Mia to a faith-based, anti-abortion center.
“I felt judged,” Mia said about the call. Eventually, she terminated the pregnancy in Jackson, about 90 miles away, at the state’s sole abortion clinic, which closed in July. “Ultimately, I did what was best for me,” said Mia, who went on to have a son several years after the abortion.
The loss of abortion care in Mississippi puts more pressure on family planning providers to win the trust of their patients, said Danielle Lampton, who also co-founded Converge. Patient-centered care is the “bedrock of what we do,” Lampton said.
Both Trader and Shepherd serve on Converge’s patient experience council and receive occasional stipends for providing their perspectives to the nonprofit.
Providers shouldn’t force or pressure low-income patients to use long-term contraception, such as an intrauterine device, to safeguard against pregnancy, said Dr. Christine Dehlendorf, a family physician and researcher at UCSF, who is advising Converge.
Wyconda Thomas, a family nurse practitioner, opened a clinic four years ago in Gunnison, Mississippi, a town of only a few hundred people. Thomas lets patients’ life circumstances, their history, and their needs determine what type of contraception she prescribes.(Haleigh Brooke Thomas McGee)
Pressuring Black women to use IUDs, implants, and other long-term contraception is reminiscent of a history in which Black women were sterilized against their consent, she said. Even today, studies show that providers are more likely to pressure women of color to limit the size of their families and recommend IUDs to them. These women also have a harder time getting a provider to remove the devices and getting insurance to cover the removal cost, Dehlendorf said.
Too often, Wyconda Thomas, a family nurse practitioner near the Arkansas border, meets patients who are skeptical of birth control because of a bad experience. Many of her patients continued Depo-Provera shots even after they gained an unsafe amount of weight — a known side effect — because they weren’t offered other options.
Even if patients come in for another reason, Thomas talks to them about family planning “every chance I get,” she said. Four years ago, Thomas opened the Healthy Living Family Medical Center in Gunnison, a 300-person town that is 80% Black. The clinic receives Title X funds through Converge. Still, Thomas doesn’t force contraception on patients — she respects their decision to forgo a pill, patch, or implant.
But Title X funds help Thomas stock a variety of contraception methods so patients don’t have to worry about driving to a separate pharmacy.
“My job for them is to get them to understand that there are more methods and there’s no method at all,” Thomas said. “And that’s a whole visit by itself.”
