Tag: Rural Health

End of Internet Subsidy Leaves Millions Facing Telehealth Disconnect

When the clock struck midnight on May 31, more than 23 million low-income households were dropped from a federal internet subsidy program that for years had helped them get connected.

The Affordable Connectivity Program was created in 2021, in the midst of the covid-19 pandemic, to help people plug into jobs, schools and health care by reducing their internet costs by up to $75 a month.

Helping connect households was particularly important in rural America, where telehealth services are often leaned on to fill health care gaps and address provider shortages.

But that aid evaporated last month when Congress didn’t move to keep it funded.

“Internet bills for millions of Americans are increasing because Congressional Republicans failed to act,” White House spokesperson Robyn Patterson emailed me.

Some lawmakers have argued that too much of the subsidy money went to people who don’t need it. Last month, Republicans and Democrats introduced proposals to address those concerns. The ACP debate continues, with a funding measure expected to be part of the Spectrum and National Security Act of 2024, under consideration Wednesday by the Senate’s Commerce, Science and Transportation Committee.

The day before the subsidies expired, White House officials offered a consolation prize, announcing they had worked out a deal with 15 internet providers that agreed to keep offering low-cost plans. The announcement isn’t really new, though, nor as robust as a previous deal.

In 2022, the Biden administration announced that 20 companies would offer plans for $30 a month or less. AT&TVerizon and Comcast are among the players continuing to sell low-cost plans the administration says will benefit an estimated 10 million households.

Of course, low-cost plans still come with bills consumers must pay. And without the connectivity program’s monthly assistance, 77 percent of households that benefited from it will have to change plans or drop their internet connections, Jessica Rosenworcel, chair of the Federal Communications Commission, wrote in a letter to lawmakers.

“A consistent theme is that many ACP recipients are seniors on fixed incomes struggling to pay competing bills and make ends meet,” she wrote.

Those affected are people like Myrna Broncho, 69, a Shoshone-Bannock tribal member who talked with me at the Fort Hall Reservation in southeastern Idaho. She had qualified for a $75 subsidy, enough to eliminate her internet bill after she signed on last year.

Without the subsidy, she’ll have to “go back on my tight budget.” Retired and ranching, Broncho said she uses the internet for shopping, paying bills and keeping track of her health care.

Rosenworcel’s letter arguing for renewed funding for the ACP was sent to a handful of lawmakers, including Sens. Maria Cantwell (D-Wash.), who chairs the commerce committee, and Ted Cruz (R-Tex.), who has proposed greatly narrowing eligibility for the program.


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End of Pandemic Internet Subsidies Threatens a Health Care Lifeline for Rural America

FORT HALL RESERVATION, Idaho — Myrna Broncho realized just how necessary an internet connection can be after she broke her leg.

In fall 2021, the 69-year-old climbed a ladder to the top of a shed in her pasture. The roof that protects her horses and cows needed to be fixed. So, drill in hand, she pushed down.

That’s when she slipped.

Broncho said her leg snapped between a pair of ladder rungs as she fell, “and my bone was sticking out, and the only thing was holding it was my sock.”

Broncho arm-crawled back to her house to reach her phone. She hadn’t thought to take it with her because, she said, “I never really dealt with phones.”

Broncho needed nine surgeries and rehabilitation that took months. Her hospital was more than two hours away in Salt Lake City and her home internet connection was vital for her to keep track of records and appointments, as well as communicate with her medical staff.

During the covid-19 pandemic, federal lawmakers launched the Affordable Connectivity Program with the goal of connecting more people to their jobs, schools, and doctors. More than 23 million low-income households, including Broncho’s, eventually signed on. The program provided $30 monthly subsidies for internet bills, or $75 discounts in tribal or high-cost areas like Broncho’s.

Now, the ACP is out of money.

In early May, Sen. John Thune (R-S.D.) challenged an effort to continue funding the program, saying during a commerce committee hearing that the program needed to be revamped.

“As is currently designed, ACP does a poor job of directing support to those who truly need it,” Thune said, adding that too many people who already had internet access used the subsidies.

There has been a flurry of activity on Capitol Hill, with lawmakers first attempting and failing to attach funding to the must-pass Federal Aviation Administration reauthorization. Afterward, Sen. Peter Welch (D-Vt.) traveled to his home state to tell constituents in tiny White River Junction that Congress was still working toward a solution.

As the program funding dwindled, both Democrats and Republicans pushed for new legislative action with proposals trying to address concerns like the ones Thune raised.

On May 31, as the program ended, President Joe Biden’s administration continued to call on Congress to take action. Meanwhile, the administration announced that more than a dozen companies — including AT&T, Verizon, and Comcast — would offer low-cost plans to ACP enrollees, and the administration said those plans could affect as many as 10 million households.

According to a survey of participants released by the Federal Communications Commission, more than two-thirds of households had inconsistent or no internet connection before enrolling in the program.

Broncho had an internet connection before the subsidy, but on this reservation in rural southeastern Idaho, where she lives, about 40% of the 200 households enrolled in the program had no internet before the subsidy.

Nationwide, about 67% of nonurban residents reported having a broadband connection at home, compared with nearly 80% of urban residents, said John Horrigan, a national expert on technology adoption and senior fellow at the Benton Institute for Broadband & Society. Horrigan reviewed the data collected by a 2022 Census survey.

The FCC said on May 31 that ending the program will affect about 3.4 million rural and more than 300,000 households in tribal areas.

The end of federal subsidies for internet bills will mean “a lot of families who will have to make the tough choice not to have internet anymore,” said Amber Hastings, an AmeriCorps member serving the Shoshone-Bannock Tribes on the reservation. Some of the families Hastings enrolled had to agree to a plan to pay off past-due bills before joining the program. “So they were already in a tough spot,” Hastings said.

Myrna Broncho, who is standing outdoors beside a large, open field on a sunny day, points to a distant tower that connects her to an internet provider.
Myrna Broncho points to a distant tower that connects her to an internet provider. Broncho is urging Congress to continue funding the Affordable Connectivity Program, which helped her pay for internet access — whose importance increased after she broke her leg in 2021. (Sarah Jane Tribble/KFF Health News)

Matthew Rantanen, director of technology for the Southern California Tribal Chairmen’s Association, said the ACP was “extremely valuable.”

“Society has converted everything online. You cannot be in this society, as a societal member, and operate without a connection to broadband,” Rantanen said. Not being connected, he said, keeps Indigenous communities and someone like “Myrna at a disadvantage.”

Rantanen, who advises tribes nationwide about building broadband infrastructure on their land, said benefits from the ACP’s subsidies were twofold: They helped individuals get connected and encouraged providers to build infrastructure.

“You can guarantee a return on investment,” he said, explaining that the subsidies ensured customers could pay for internet service.

Since Broncho signed up for the program last year, her internet bill had been fully paid by the discount.

Broncho used the money she had previously budgeted for her internet bill to pay down credit card debt and a loan she took out to pay for the headstones of her mother and brother.

As the ACP’s funds ran low, the program distributed only partial subsidies. So, in May, Broncho received a bill for $46.70. In June, she expected to pay the full cost.

When asked if she would keep her internet connection without the subsidy, Broncho said, “I’m going to try.” Then she added, “I’m going to have to” even if it means taking a lesser service.

Broncho said she uses the internet for shopping, watching shows, banking, and health care.

The internet, Broncho said, is “a necessity.”

El problema del huevo y la gallina en la lucha contra otra pandemia de gripe

Unas pocas noticias sobre una potencial nueva pandemia de gripe es suficiente para hacer que los científicos se empiecen a desesperar por los huevos.

Se preocuparon por ellos en 2005, y en 2009, y están preocupados ahora. Es porque millones de huevos de gallina fertilizados siguen siendo el ingrediente principal para fabricar vacunas que, con suerte, protegerán a las personas contra el brote de una nueva cepa de gripe.

“Es casi cómico usar una tecnología de los años 40 para una pandemia del siglo XXI”, dijo Rick Bright, quien dirigió la Autoridad de Investigación y Desarrollo Biomédico Avanzado (BARDA) del Departamento de Salud y Servicios Humanos (HHS) durante la administración Trump.

Pero agregó que no es tan gracioso cuando la formulación actualmente almacenada contra el virus de la gripe aviar H5N1 requiere dos dosis y una cantidad asombrosa, 90 microgramos de antígeno, pero proporciona solo una inmunidad media. “Solo para Estados Unidos, se necesitarían gallinas poniendo 900,000 huevos cada día durante nueve meses”, explicó Bright.

Y eso si las gallinas no se infectan.

Un virus de la gripe aviar que se está propagando rápido ya ha diezmado a bandadas completas de aves, gatos de granero y a otros mamíferos. También se han registrado vacas infectadas en nueve estados, y al menos tres personas en Estados Unidos se infectaron, lo suficiente como para atraer la atención de la salud pública una vez más sobre el potencial de una pandemia global.

Al 30 de mayo, los únicos casos confirmados de infección humana fueron trabajadores de tambos en Texas y Michigan, quienes experimentaron irritación ocular. Dos se recuperaron rápidamente, mientras que el tercero desarrolló síntomas respiratorios y estaba siendo tratado con un medicamento antiviral en su casa.

Sin embargo, la propagación del virus entre múltiples especies en un área geográfica amplia eleva la amenaza de que más mutaciones puedan producir un virus que se propague de humano a humano a través de la transmisión aérea.

Si esto ocurre, la prevención comienza con el huevo.

Para hacer materia prima para una vacuna contra la gripe, el virus se cultiva en millones de huevos fertilizados. A veces no se desarrolla bien, o muta hasta el punto que el producto de la vacuna estimula anticuerpos que no neutralizan el virus, o el virus salvaje muta y la vacuna no puede luchar contra él.

Y siempre existe la aterradora perspectiva de que las aves salvajes puedan llevar el virus a los gallineros necesarios para la producción de vacunas.

“Una vez que esos gallos y gallinas caen, no tienes vacuna”, dijo Bright.

Desde 2009, cuando una pandemia de gripe porcina H1N1 se propagó por el mundo antes que la producción de vacunas pudiera comenzar, los investigadores y los gobiernos han estado buscando alternativas. Se han invertido miles de millones de dólares en vacunas producidas en células de mamíferos e insectos que no presentan los mismos riesgos que las vacunas que se basan en huevos.

“Todos saben que las vacunas basadas en células son mejores, más inmunogénicas y ofrecen mejor producción”, dijo Amesh Adalja, especialista en enfermedades infecciosas del Centro de Seguridad de la Salud de la Universidad Johns Hopkins. “Pero están en desventaja debido a la fuerza de la fabricación basada en huevos”.

Las empresas que fabrican las vacunas contra la gripe basadas en células, CSL Seqirus y Sanofi, también tienen miles de millones invertidos en líneas de producción basadas en huevos que no están ansiosas por reemplazar. Y es difícil culparlos, dijo Nicole Lurie, subsecretaria asistente de preparación y respuesta del HHS bajo el presidente Barack Obama, quien ahora es directora ejecutiva de CEPI, la organización global, sin fines de lucro, de lucha contra epidemias.

“La mayoría de las empresas de vacunas que respondieron a una epidemia —Ébola, Zika, covid— terminaron perdiendo mucho dinero”, dijo Lurie.

Las excepciones fueron las vacunas de ARNm creadas para el covid, aunque incluso Pfizer y Moderna han tenido que destruir cientos de millones de dosis de vacunas no deseadas a medida que disminuyó el interés público.

Pfizer y Moderna están probando vacunas contra la gripe estacional hechas con ARNm, y el gobierno está solicitando ofertas para vacunas de ARNm contra la gripe pandémica, dijo David Boucher, director de preparación para enfermedades infecciosas en la Administración para la Preparación y Respuesta Estratégica del HHS.

Bright, cuya agencia invirtió $1,000 millones en una fábrica de vacunas contra la gripe basadas en células en Holly Springs, Carolina del Norte, dijo que “de ninguna manera podemos luchar contra una pandemia de H5N1 con una vacuna basada en huevos”. Pero por ahora, hay poca opción.

BARDA ha almacenado cientos de miles de dosis de una vacuna contra una cepa del H5N1 que estimula la creación de anticuerpos que parecen neutralizar el virus que circula actualmente. Podría producir millones de dosis más de la vacuna en cuestión de semanas y hasta 100 millones de dosis en cinco meses, dijo Boucher a KFF Health News.

Pero las vacunas actualmente en la reserva nacional no coinciden perfectamente con la cepa en cuestión. Incluso con dos dosis que contienen seis veces más sustancia que las vacunas contra la gripe típicas, las vacunas almacenadas solo fueron parcialmente efectivas contra las cepas del virus que circulaban cuando se fabricaron, dijo Adalja.

Sin embargo, BARDA actualmente está apoyando dos ensayos clínicos con un virus candidato para la vacuna que “coincide bien con el que hemos encontrado en las vacas”, dijo Boucher.

Los fabricantes de vacunas contra la gripe están empezando a preparar las vacunas de este otoño, pero eventualmente el gobierno federal podría solicitar que la producción se cambie a una cepa dirigida a la pandemia.

“No tenemos la capacidad para hacer ambas cosas”, dijo Adalja.

Por ahora, la Administración para una Respuesta y Preparación Estratégica (ASPR) tiene una reserva de vacunas pandémicas a granel y ha identificado sitios de fabricación donde se podrían completar 4.8 millones de dosis sin detener la producción de la vacuna contra la gripe estacional, dijo la jefa de ASPR, Dawn O’Connell, el 22 de mayo.

En 2005, funcionarios intentaron diversificarse, alejándose de las vacunas basadas en huevos, cuando la gripe aviar afectó al mundo por primera vez, y con mayor vigor después del fiasco de 2009.

Pero “con los recursos que tenemos disponibles, obtenemos el mayor rendimiento de nuestra inversión y el mejor valor para los contribuyentes estadounidenses cuando aprovechamos la infraestructura estacional, y eso todavía se basa principalmente en huevos”, dijo Boucher.

Las empresas de vacunas contra la gripe “tienen un sistema que funciona bien en este momento para lograr sus objetivos con la fabricación de la vacuna estacional”, dijo. Y sin un incentivo financiero, “creo que estaremos aquí con huevos por un buen tiempo”.

After a Brief Pandemic Reprieve, Rural Workers Return to Life Without Paid Leave

ELKO, Nev. — When Ruby B. Sutton found out she was pregnant in late 2021, it was hard to envision how her full-time job would fit with having a newborn at home. She faced a three-hour round-trip commute to the mine site where she worked as an environmental engineer, 12-plus-hour workdays, expensive child care, and her desire to be present with her newborn.

Sutton, 32, said the minimal paid maternity leave that her employer offered didn’t seem like enough time for her body to heal from giving birth or to bond with her firstborn. Those concerns were magnified when she needed an emergency cesarean section.

“I’m a very career-driven person,” Sutton said. “It was really difficult to make that decision.”

Sutton quit her job because she felt even additional unpaid time off wouldn’t be enough. She also knew child care following maternity leave would cost a substantial portion of her salary if she returned to work.

Tens of millions of American workers face similar decisions when they need to care for themselves, a family member, or a baby. Wild variations in paid leave regulations from state to state and locally mean those choices are further complicated by financial factors. And workers in rural areas face even more challenges than those in cities, including greater distances to hospitals and fewer medical providers, exacerbating health and income disparities. Companies in rural areas may be less likely to voluntarily offer the benefit because they tend to be smaller and there are fewer employers for workers to choose from.

While a growing number of states, cities, and counties have passed paid sick leave or general paid time off laws in recent years, most states where more than 20% of the population is rural haven’t, leaving workers vulnerable. Vermont and New Mexico are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave.

Experts say the gaps in paid leave requirements mean workers in rural areas often struggle to care for themselves or loved ones while making ends meet.

“The problem is, because it’s a small percentage of the population, it’s often forgotten,” said Anne Lofaso, a professor of law at West Virginia University.

The covid-19 pandemic steered attention toward paid leave policies as millions of people contracted the virus and needed to quarantine for five to 10 days to avoid infecting co-workers. The 2020 Families First Coronavirus Response Act temporarily required employers with fewer than 500 employees and all public employers to give workers a minimum of two weeks of paid sick leave, but that requirement expired at the end of 2020.

The expiration left workers to rely on the Family and Medical Leave Act of 1993, which requires companies with 50 or more employees to provide them with up to 12 weeks of unpaid time off to care for themselves or family members. But many workers can’t afford to go that long without pay.

By March 2022, 77% of workers at private companies had paid sick leave through their employers, according to the Bureau of Labor Statistics — a small increase from 2019, when 73% of workers in private industry had it. But workers in certain industries — like construction, farming, forestry, and extraction — part-time workers, and lower-wage earners are less likely to have paid sick leave.

“Paid leave is presented as a high-cost item,” said Kate Bronfenbrenner, director of labor education research at the School of Industrial and Labor Relations at Cornell University.

But it comes with a payoff: Without it, people who feel pressure to go to work let health conditions fester and deteriorate. And, of course, infectious workers who return too early unnecessarily expose others in the workplace.

Advocates say a stronger federal policy guaranteeing and protecting paid sick and family leave would mean workers wouldn’t have to choose between pushing through illness at work or losing income or jobs.

A recent report by New America, a left-leaning think tank, argues that creating policy to ensure paid leave could boost employment numbers; reduce economic, gender, and racial disparities; and generally lift up local communities.

Support for paid sick and family leave is popular among rural Americans, according to the National Partnership for Women & Families, which found in 2020 polling that 80% of rural voters supported a permanent paid family and medical leave program, allowing people to take time off from work to care for children or other family members.

But lawmakers have been divided on creating a national policy, with opponents worrying that requiring paid leave would be too big a financial burden for small or struggling businesses.

In 2006, voters in San Francisco approved the Paid Sick Leave Ordinance, making it the first U.S. city to mandate paid sick leave. Since then, 14 states, the District of Columbia, and 20 other cities or counties have done so. Two other states, Nevada and Maine, have adopted general paid time off laws that provide time that can be used for illness.

Federal workers are offered 12 weeks of paid parental leave in the Federal Employee Paid Leave Act, adopted in October 2020. It covers more than 2 million civilian workers employed by the U.S. government, though the law must be reapproved each fiscal year and employees are not eligible until they’ve completed one year of service.

The patchwork of laws nationwide leaves workers in several mostly rural states — places like Montana, South Dakota, and West Virginia where more than 40% of residents live outside cities — without mandated paid sick and family leave.

Sutton said she “would have definitely loved” to stay at her job if she could’ve taken a longer paid maternity leave. She said she wants to return to work, but the future is unclear. She has more things to consider, like whether she and her husband want more children and when she might feel healthy enough to try for a second baby after last summer’s C-section.

Sutton recalled a friend she worked with at a gold mine years ago who left the job a few months after having a baby. “And I understand now all the things she was telling me at that time. … She was like, ‘I can’t do this,’ you know?”

Telehealth Brings Expert Sexual Assault Exams to Rural Patients

Amanda Shelley was sitting in her dentist’s waiting room when she received a call from the police. A local teenage girl had been sexually assaulted and needed an exam.

Shelley, a nurse in rural Eagle County, Colorado, went to her car and called a telehealth company to arrange an appointment with a sexual assault nurse examiner, or SANE. The nurse examiners have extensive training in how to care for assault survivors and collect evidence for possible criminal prosecution.

About an hour later, Shelley met the patient at the Colorado Mountain Medical urgent care clinic in the small town of Avon. She used a tablet to connect by video with a SANE about 2,000 miles away, in New Hampshire.

The remote nurse used the video technology to speak with the patient and guide Shelley through each step of a two-hour exam. One of those steps was a colposcopy, in which Shelley used a magnifying device to closely examine the vagina and cervix. The remote nurse saw, in real time, what Shelley could see, with the help of a video camera attached to the machine.

The service, known as “teleSANE,” is new at Shelley’s hospital. Before, sexual assault patients faced mountains of obstacles — literally — when they had to travel to a hospital in another county for care.

“We’re asking them to drive maybe over snowy passes and then [be there] three to four hours for this exam and then drive back home — it’s disheartening for them,” Shelley said. “They want to start the healing process and go home and shower.”

To avoid this scenario, teleSANE services are expanding across the country in rural, sparsely populated areas. Research shows SANE programs encourage psychological healing, provide comprehensive health care, allow for professional evidence collection, and improve the chance of a successful prosecution.

Jennifer Pierce-Weeks is CEO of the International Association of Forensic Nurses, which created the national standards and certification programs for sexual assault nurse examiners. She said every sexual assault survivor faces health consequences. Assaults can cause physical injuries, sexually transmitted infections, unwanted pregnancies, and mental health conditions that can lead to suicide attempts and drug and alcohol misuse.

“If they are cared for on the front end, all of the risks of those things can be reduced dramatically with the right intervention,” Pierce-Weeks said.

Pierce-Weeks said there’s no comprehensive national data on the number and location of health care professionals with SANE training. But she said studies show there’s a nationwide shortage, especially in rural areas.

Some rural hospitals struggle to create or maintain in-person SANE programs because of staffing and funding shortfalls, Pierce-Weeks said.

Nurse Lindee Miller holds a standard sexual assault evidence collection kit distributed by the South Dakota Department of Health. (Arielle Zionts/KHN)
Using magnification and a bright light, this colposcope device allows a health care provider to closely examine the vagina and cervix. The camera transmits a live view to a remote sexual assault nurse examiner. (Arielle Zionts/KHN)

Training costs money and takes time. If rural hospitals train nurses, they still might not have enough to provide round-the-clock coverage. And nurses in rural areas can’t practice their skills as often as those who work in busy urban hospitals.

Some hospitals without SANE programs refer sexual assault survivors elsewhere because they don’t feel qualified to help and aren’t always legally required to provide comprehensive treatment and evidence collection.

Avel eCare, based in Sioux Falls, South Dakota, has been providing telehealth services since 1993. It recently added teleSANE to its offerings.

Avel provides this service to 43 mostly rural and small-town hospitals across five states and is expanding to Indian Health Service hospitals in the Great Plains. Native Americans face high rates of sexual assault and might have to travel hours for care if they live in one of the region’s large, rural reservations.

Jen Canton, who oversees Avel’s teleSANE program, said arriving at a local hospital and being referred elsewhere can be devastating for sexual assault survivors. “You just went through what is potentially the worst moment of your life, and then you have to travel two, three hours away to another facility,” Canton said. “It takes a lot of courage to even come into the first hospital and say what happened to you and ask for help.”

Patients who receive care at hospitals without SANE programs might not receive trauma-informed care, which focuses on identifying sources of trauma, determining how those experiences may affect people’s health, and preventing the retraumatizing of patients. Emergency department staffers may not have experience with internal exams or evidence collection. They also might not know about patients’ options for involving police.

Patients who travel to a second hospital might struggle to arrange for and afford transportation or child care. Other patients don’t have the emotional bandwidth to make the trip and retell their stories.

That’s why some survivors, like Ada Sapp, don’t have an exam.

Sapp, a health care executive at Colorado Mountain Medical, was assaulted before the hospital system began its SANE program. She was shocked to learn she would need to drive 45 minutes to another county for an exam. “I didn’t feel comfortable doing that by myself,” Sapp said. “So, my husband would have had to come with me, or a friend. The logistics made it feel insurmountable.”

Sapp’s experience inspired her to help bring SANE services to Colorado Mountain Medical.

Shelley and several other of the hospital system’s nurses have SANE training but appreciate having telehealth support from the remote nurses with more experience. “We are a rural community and we’re not doing these every single day,” Shelley said. “A lot of my nurses would get really anxious before an exam because maybe they haven’t done one in a couple months.”

A remote “second set of eyes” increases the confidence of the in-person nurse and is reassuring to patients, she said.

Lindee Miller, a nurse at Avera St. Mary’s Hospital in Pierre, South Dakota, turns on the camera attached to a colposcope, a magnifying device used to closely examine the vagina and cervix. The camera transmits a live view of the exam to the remote sexual assault nurse examiner.( Arielle Zionts/KHN)

Avera St. Mary’s Hospital in Pierre, South Dakota, recently began using teleSANE. Rural towns, farms, and ranches surround this capital city, home to about 14,000 people. The nearest metropolitan area is about a three-hour drive.

Taking a break from a recent busy morning in the emergency department, nurse Lindee Miller rolled out the mobile teleSANE cart and colposcope device from Avel eCare. She pulled out a thick binder of instructions and forms and opened drawers filled with swabs, evidence tags, measuring devices, and other forensic materials.

“You’re never doing the same exam twice,” Miller said. “It’s all driven by what the patient wants to do.”

She said some patients might want only medicine to prevent pregnancy and sexually transmitted infections. Other patients opt for a head-to-toe physical exam. And some might want her to collect forensic evidence.

Federal and state laws provide funding to pay for these sexual assault exams, but some survivors are billed because of legal gaps and a lack of awareness of the rules. A proposed federal law, the No Surprises for Survivors Act, would close some of those gaps.

SANE programs, including telehealth versions aimed at rural communities, are expected to continue expanding across the country.

President Joe Biden signed a bill last year that provides $30 million to expand SANE services, especially those that use telehealth and serve rural, tribal, and other underserved communities. The law also requires the Justice Department to create a website listing the locations of the programs and grant opportunities for starting them.

Nurse Midwives Step Up to Provide Prenatal Care After Two Rural Hospitals Shutter Birthing Centers

MUSCATINE, Iowa — Bailee Tordai, who was 33 weeks into her pregnancy, barely made it to the prenatal checkup. Her clunky old Jeep couldn’t complete the 2-mile trip from her house to the University of Iowa’s outreach clinic in her southeastern Iowa hometown. It was a hot June day, and a wiring problem made the Jeep conk out in the street.

A passerby helped Tordai, 22, push her stricken vehicle off the road and into a parking lot. Then she called her stepdad for a ride to the clinic.

Jaclyn Roman, a nurse midwife, walked into the exam room. “I heard your car broke down.”

“Yup. You want to buy it? Five bucks!” Tordai joked.

Her lack of reliable transportation won’t be a laughing matter in August, when her baby is due. She will need to arrange for someone to drive her about 40 miles northwest to the University of Iowa Hospitals and Clinics in Iowa City. She can’t give birth at Muscatine’s hospital because it shuttered its birthing unit in 2020.

Roman is part of an unusual effort to minimize the harm caused by such closures. She’s one of 11 certified nurse midwives from the University of Iowa who travel regularly to Muscatine and Washington, another southeastern Iowa town where the local hospital closed its birthing unit. The university’s pilot project, which is supported by a federal grant, doesn’t aim to reopen shuttered birthing units. Instead, the midwife team helps ensure area women receive related services. Last year, it served more than 500 patients in Muscatine and Washington.

Muscatine is one of hundreds of rural areas in the U.S. where hospitals have dropped birthing services during the past two decades, often because they lack obstetricians and other specialized staff members.

Hospital industry leaders say birthing units also tend to lose money, largely because of low payments from Medicaid, the public health insurance program that covers more than 40% of births in the U.S. and an even greater share in many rural areas.

The loss of labor-and-delivery services hits especially hard for women who lack resources and time to travel for care.

Muscatine, which is on the Mississippi River, has more than 23,000 residents, making it a relatively large town by Iowa standards. But its hospital is one of 41 Iowa facilities that have closed their birthing units since 2000, according to the Iowa Department of Public Health. Most were in rural areas. Just one has reopened, and only 56 Iowa hospitals now have birthing units.

The nurse midwife team’s work includes crucial prenatal checkups. Most pregnant people are supposed to have a dozen or more such appointments before giving birth. Health care providers use the checkups to track how a pregnancy is progressing and to watch for signs of high blood pressure and other problems that can lead to premature births, stillbirths, or even maternal deaths. The midwives also advise women on how to keep themselves and their babies healthy after birth.

Karen Jefferson, director of midwifery practice for the American College of Nurse-Midwives, said the University of Iowa team’s approach is an innovative way to address needs in rural areas that have lost hospital birthing units. “How wonderful would it be to see a provider in your town, instead of driving 40 miles for your prenatal visits — especially toward the end of pregnancy, when you’re going every week,” said Jefferson, who lives in rural New York.

Midwives can provide many other types of care for women and for babies. In theory, they could even open rural birthing centers outside of hospitals, Jefferson said. But they would need to overcome concerns about financing and about the availability of surgeons to do emergency cesarean sections, which she said are rarely needed in low-risk births.

The University of Iowa midwives focus on low-risk pregnancies, referring patients with significant health issues to physician specialists in Iowa City. Often, those specialists can visit with the patients and the midwives via video conference in the small-town clinics.

The loss of a hospital obstetrics unit can make finding local maternity care harder for rural families.

Tordai can attest that if patients must travel far for prenatal appointments, they’re less likely to get to them all. If she had to go to Iowa City for each of hers, repeatedly taking three hours off from her job managing a pizza restaurant would be tough, she said. On that June day her Jeep broke down, she would have canceled her appointment.

Instead, she wound up on an exam table at the Muscatine clinic listening to her baby’s heartbeat on a monitor and watching as Roman measured her belly.

“Nice job being perfect,” the midwife told her during the checkup.

Roman asked Tordai to describe her baby’s movements. “Constant,” she replied with a smile.

Roman asked whether she planned to breastfeed. Tordai said she didn’t have much luck with her first daughter, Aspen, now 4.

“Have you thought about a breastfeeding class?” the midwife asked.

“I don’t have time for that,” Tordai replied. Roman continued to coax her, noting where a breastfeeding class is available online.

Near the end of the appointment, Tordai asked Roman whether she could schedule an induced birth at the University of Iowa hospital. The midwife told her that, in general, letting labor begin on its own is better than artificially starting it.

But there was the matter of unreliable transportation. Tordai explained that scheduling the birth would help her arrange to have her mother drive her to the hospital in Iowa City. Roman agreed that transportation is a legitimate reason and arranged for an induced labor on Aug. 10.

The University of Iowa midwife team started offering services in 2020 in a clinic about 2 miles from Trinity Muscatine hospital. The hospital is owned by UnityPoint Health, a large nonprofit hospital system that blamed a lack of available obstetricians for the closure of the Muscatine birthing unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new obstetricians to the area.

Kristy Phillipson, a UnityPoint Health spokesperson, told KHN in June that the company has continued to try to recruit physicians, including for the Muscatine hospital. Although it has not reopened the birthing unit, the company regularly sends an obstetrician and other staff members to provide prenatal care and related services, she said.

Most pregnant patients from the area who choose UnityPoint for their care wind up giving birth at the system’s hospital in Bettendorf, a 45-minute drive to the east.

The University of Iowa midwife team has no plans to open its own birthing centers. But it hopes to expand its rural clinic service to other underserved towns. To do so, the university would need to hire more nurse midwives, which could be a challenge. According to the Iowa Board of Nursing, 120 licensed nurse midwives live in the state of 3 million people.

The University of Iowa plans to address that by starting the state’s first nurse midwife training program in 2023. The master’s degree program, which will emphasize rural service, will train registered nurses to become nurse midwives. It eventually could graduate eight people per year, said Amber Goodrich, a University of Iowa midwife helping lead the effort.

Those graduates could fill gaps throughout rural areas, where even more hospitals may shutter their birthing units in the coming years.

“This crisis is going nowhere fast,” Goodrich said.