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Christopher Snowbeck | (TNS) The Minnesota Star Tribune

Bobbie Putman-Bailey knows how to solve problems when it comes to medical bills and health insurance.

In one instance, upon the surprise realization her specialist doctor had gone out of network for her health plan, the 42-year-old Maple Grove, Minnesota, resident convinced the insurer to overturn coverage denials that could have cost her hundreds of dollars. The key, Putman-Bailey said, was to write an appeal that was long on details, while also agreeing to eventually switch to an in-network doctor — just not immediately, since she was beginning a new treatment at the time.

In another case, she wrangled with a specialty pharmacy to prevent billing for a shipment of the wrong medication to her house. It helped, Putman-Bailey said, that she was prompt in calling to report the problem and already had talked with the pharmacy several times about ambiguities with its online ordering system.

For consumers, the first step in all such disputes is to stay on top of billing documents, Putman-Bailey advised, and ask questions as soon as possible. She recognizes, of course, this can be easier said than done.

“It sucks because you are sick, and you’re chronically ill, and there are days when … you don’t have the energy to get up and look at things,” said Putman-Bailey, who has Crohn’s disease. “But if you wait until things show up in your mailbox, it’s almost too late.”

Getting sick in the U.S. health care system can trigger an avalanche of confusing paperwork. Here’s what you need to know about how to read a medical bill — plus those documents proclaiming “This Is Not a Bill” from health insurers — to help prevent the illness from spreading to your bank account.

Bills vs. EOBs

Two types of documents typically arrive in a patient’s mailbox and/or online portal after receiving health care services: One is a medical bill from a doctor’s office or health system, the second is an“explanation of benefits” form from your health insurer.

The insurance document, called an EOB, often arrives first. It reflects the health plan’s evaluation of the service received, including the amount of insurance coverage for the service, according to the Minnesota Council of Health Plans, a trade group for nonprofit health insurers in the state.

EOBs typically list the provider’s charge for a service. They also show the negotiated price the insurance company and provider agreed to consider full payment. And then, the form shows how the negotiated cost will split between the insurer and the patient.

Insurers typically describe this split as “cost-sharing,” which factors in deductibles and co-insurance that are key for patients to understand when shopping for a health plan.

“If there is a remaining bill, the doctor’s office directly sends you a bill for the remaining amount,” said Lucas Nesse, chief executive of the Minnesota Council of Health Plans, via email. “If the amount on the bill you receive from your doctor’s office does not match the amount on your EOB, the first step is to call your clinic to see if they have updated their bill to reflect payment from your insurance.”

Patients often notice on EOBs the contrast between the health care provider’s charge and the negotiated payment rate because the discounts can be very large.

“You can see them allow only 10% of the charge sometimes,” said Bill Foley, an insurance advocate and volunteer leader with Cancer Legal Care, a nonprofit group in Oakdale. “The spread can be tremendous.”

Once the bill comes from the doctor’s office or health system, patients should compare the amount due with the EOB to make sure they agree on the patient’s financial responsibility. When they don’t match, patients should call the health care provider and/or health insurer.

“Typically, your medical bill should not be more than what your explanation of benefits says you owe,” said Julia Dreier, the deputy commissioner of insurance at the Minnesota Department of Commerce.

Starting Oct. 1, a new state law goes into effect that lets patients request a review from their health care provider to check the accuracy of medical codes used in their billing. The law prohibits providers from making further collection efforts during this process, which culminates in a notice sent to patients within 30 days of the review’s completion.

“A medical provider will always … provide notice about whether the coding was accurate,” said Joe Schindler, vice president of finance policy and analytics at the Minnesota Hospital Association.

Comparing EOBs and medical bills can be difficult when health care providers practice “global billing” and roll all charges into one final bill, said Eric Ellsworth, director for health data strategy at Consumers’ Checkbook Health. Schindler of the Hospital Association noted patients can always ask for a more detailed bill from their health care provider.

Denials and codes

Consumer advocates say patients, in many ways, are better off relying on their online portals for billing documents rather than paper statements that arrive in the mail. That’s because a health insurer’s decision on whether to pay or deny a claim can change as more information becomes available.

Foley recommends, in fact, patients compare the bill they receive in the mail to the online version to see if that one is more current.

When there’s a balance due, the key question is: Why?

“Is it because insurance hasn’t adjudicated your claim yet?” Foley asked. “Is it because you have a legitimate out-of-pocket expense? Is it due to a denial?”

There are several types of denials, Ellsworth said. Some services just aren’t a covered benefit, he added, pointing to in-vitro fertilization as an example in a number of health plans. Sometimes there’s a limitation patients might not have appreciated, such as when an insurer will pay for cataract surgery but not some multifocal lenses.

Insurers might deny a claim because the health plan deems the service not medically necessary. Some denials result in financial responsibility for patients, Ellsworth said, while others create a financial risk for the health care provider.

The Minnesota Council of Health Plans said insurers list on the EOB a “reason code” to explain the reason for a claim’s denial. Reasons can vary from services being out of network to the lack of prior authorization from a health plan.

It’s not clear exactly how often denials happen across all types of insurance, but consumer advocates say appeals are few and far between. They worry the process of filing appeals is just too confusing and/or difficult for patients to navigate.

To appeal a denied claim, patients must navigate the language of medical coding, which is how health care providers and health insurers communicate about the services provided. Many medical bills and EOBs don’t actually include these codes, so patients must contact either their provider or health plan to understand. Patients can then use the codes and descriptions to determine whether their insurer processed their claims correctly according to their plan’s benefits.

“If there’s a balance due that you’re questioning, then it’s really important to know those codes,” Foley said. “We’ve set up this system where all of these claims are handled by computers now instead of people. So, the codes are really key. That’s the magic.”

When facing big bills for out-of-network care, patients should explore whether the federal No Surprises Act provides any help. And advocates say rather than trying to navigate all this alone, patients should seek help from a friend, family member or even government agencies.

“If someone’s stuck, I would encourage people to call us,” said Dreier of the Commerce Department.

‘I’m not trying to duck the bill’

The Minnesota Attorney General’s Office has online tips for handling medical bills and pointers for ensuring your portion is accurate. The state Commerce Department has online information about denials and appeals. Ellsworth of Consumers’ Checkbook said people in “self-insured” health plans that large employers typically run — especially those operating in multiple states — can seek help from the Employee Benefit Services Administration (EBSA) at the U.S. Department of Labor.

Some advocates refer to a book called “Never Pay the First Bill” when talking about how consumers should think about questionable medical bills. Patients often want to pay promptly, Foley said, either because they received good care or from fear of being sent to collections and suffering credit score dings.

Those are good instincts, Foley said, yet there are times when he advises consumers to let everything play out a bit before making a payment.

“The key is: Just keep the provider in the loop. Let them know that you are aware that they’ve sent you a balance-due statement but that you’re still working through the details of it,” he said. “Make sure you are staying in contact with your provider and telling them: ‘Hey, I’m not trying to duck the bill.’ That’s really an important thing.”

Putman-Bailey, the patient from Maple Grove, said to be suspicious if any medical paperwork is delayed since that can be a sign of trouble.

The Minnesota Medical Association said providers must submit claims to insurance companies within six months of the date of service, although most are quicker. Insurers generally pay claims within 30 days of receipt, the Medical Association said, and EOBs are available when claims process.

As for phone calls, Putman-Bailey said she’s learned the importance of recording the date of the conversation, the name of the customer service representative and the agent’s phone number, if possible. Another tip: When insurers assert a service is not medically necessary, Putman-Bailey asks to talk with the physician who made that decision.

The process can feel adversarial and is often emotional, Putman-Bailey said, but she always tries to stress how it’s not personal.

“I usually am saying to the person on the phone: ‘This is not about you,’” she said, “‘this is about the system.’”

©2024 The Minnesota Star Tribune. Visit at startribune.com. Distributed by Tribune Content Agency, LLC.

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Julie Appleby | (TNS) KFF Health News

Suspicions that U.S. consumers’ personal information could be accessed from India led regulators to abruptly bar two large private sector enrollment websites from accessing the Affordable Care Act marketplace in August.

New details about the suspensions come in legal filings made late Friday stemming from an effort by the two to regain access to the Obamacare marketplace before the upcoming ACA open enrollment period, which starts Nov. 1.

The Centers for Medicare & Medicaid Services wrote in a Sept. 2 letter to the companies that they were suspended after the agency identified “a serious lapse in the security posture” that could have led to marketplace data, including consumers’ personal information, being accessed from overseas.

The letter, included in the court filings, also noted that regulators will audit the two companies because they have “reasonable suspicion” that they are players in a separate problem: signing people up for Obamacare coverage — or changing their policies — without the consumers’ permission.

Whether those legal issues will be resolved before the upcoming enrollment period is an open question. Currently, the concerns raised about the companies remain allegations, with none of the legal challenges or the audit close to a ruling or conclusion.

Still, the larger issue of fraudulent ACA enrollment by rogue insurance agents seeking commissions will continue to pose a headache for regulators, with more than 200,000 complaints filed by consumers in the first six months of 2024. And it has become a political problem for the Biden administration. GOP lawmakers blamed the schemes partly on Biden-backed expanded Obamacare premium subsidies.

President Joe Biden has claimed record-breaking enrollment under the ACA as one of his administration’s major accomplishments, and regulators are looking to thwart deceptive enrollment schemes without slowing legitimate sign-ups. In recent weeks they’ve removed at least 200 agents’ access to the federal ACA marketplace, and in July began requiring, in many circumstances, that brokers participate in three-way calls with their clients and the healthcare.gov help center before changes can be finalized.

The CMS letter now adds another layer. It is the first time this year the agency has called out a company over questionable enrollments, saying it suspects “the Speridian Companies” might have “directed its employees and other agents to change Marketplace enrollees’ coverage and enroll insured and uninsured consumers without the enrollees’ consent.”

California-based Speridian Global Holdings owns the companies in question, which include enrollment platform Benefitalign and TrueCoverage, doing business as the Inshura enrollment site. It has a data center in India.

The now-suspended Benefitalign site handled at least 1.2 million applications for ACA coverage during the last open enrollment period, according to court documents, which would rank it among the largest of the private enrollment sites allowed to integrate with healthcare.gov, the federal marketplace.

Previously, CMS had said publicly only that it suspended the websites for “anomalous activity.”

The suspended companies deny any wrongdoing related to enrollment schemes. Spokesperson Catherine Riedel declined comment beyond their court filings.

In late August they filed a complaint against CMS over the suspensions in U.S. District Court for the District of Columbia, seeking a restraining order. They added to that complaint on Sept. 6, calling CMS’ suspension action “lawless.”

On Aug. 8, CMS suspended the two websites from accessing healthcare.gov information.

It did so, according to the Sept. 2 letter, over concerns that some consumer information “is processed and/or stored” in India, citing “suspicions” that the data is “being accessed from outside of the United States.”

That’s a problem, the letter says, because marketplace data must stay in the U.S. to “eliminate the possibility that foreign powers might obtain access.” Additionally, websites approved by CMS to integrate with the federal marketplace cannot transmit data outside of the U.S. or allow access from outside the country, under the terms of agreements such companies sign to get CMS approval to operate.

CMS did not spell out what consumer information might have been included, but ACA applications can contain information including a person’s name, date of birth, address, and detailed household income information.

Speridian companies were suspended, then reinstated, from the marketplace in prior years over other concerns, including problems with false Social Security Numbers submitted with some TrueCoverage ACA applications in 2018, and for a 2023 effort by Benefitalign to access the federal marketplace’s “software testing environment” from India, according to the CMS letter.

In seeking a restraining order against CMS, the companies argue that the agency’s action to suspend them now is arbitrary and capricious and violates its own regulations as well as the due process clause of the Constitution.

The filing calls the Sept. 2 CMS letter explaining the reasons for the suspensions “a post hoc justification” that includes a litany of “‘concerns,’ suspicions,’ ‘allegations.’” The filing also asserts “these intimations of violations are made without evidence of any actual violation.”

The court documents say the suspensions will prevent the companies from participating in the upcoming open enrollment period, harming them and “the thousands of brokers” and “millions of consumers who count on brokers” using those websites to sign up for ACA coverage.

The suspension remains in place, the CMS letter says, partly because its concerns have not been allayed by information provided by the companies, but also while the audit is conducted.

CMS has “reasonable suspicion, based on credible evidence it has considered,” that the companies were involved in enrolling consumers or changing their coverage without specific permission, the letter stated, noting that such allegations are included in a civil lawsuit filed by private sector lawyers in U.S. District Court for the Southern District of Florida.

The firms have previously said the allegations in the civil lawsuit are without merit.

Brokers who have used the suspended websites in the past have other options to enroll clients, including several other websites currently approved to integrate with the federal Obamacare marketplace. Consumers can also go directly to the federal or state ACA websites and enroll themselves or get assistance from call centers associated with those marketplaces.

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(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

Phil Galewitz | (TNS) KFF Health News

The proportion of Americans without health insurance remained stable in 2023, the Census Bureau reported Tuesday, close to the record low the Biden administration achieved in 2022 through expansions of public programs, including the Affordable Care Act.

About 8% of Americans were uninsured, a statistically insignificant increase of just 0.1 percentage point from a year earlier. But because of the Census survey’s methodology, the findings likely don’t capture the experience of tens of millions of Americans purged from Medicaid rolls after pandemic-era protections expired in spring 2023.

Enrollment in Medicaid, the government health program for people with low incomes and disabilities, reached its highest level in April 2023. That was just before what’s called the “unwinding,” the process states have used to disenroll people from the program after the federal government lifted a prohibition on culling enrollment.

It isn’t yet clear what effect the unwinding has had on insurance coverage, but the Census Bureau will release additional data on Thursday from a different survey that may refine the numbers.

“We are likely at a turning point,” said Leighton Ku, director of the Center for Health Policy Research at George Washington University. “We are about to change to a new season where things will be a little worse off from Medicaid unwinding.”

The Medicaid unwinding has been completed in most states, and more than 25 million people have been disenrolled, according to KFF, a health information nonprofit that includes KFF Health News. The Census report, based on surveys conducted early this year, counts people as uninsured only if they lacked insurance for all of 2023. So, for example, a person who was on Medicaid in April 2023 before the unwinding began then lost coverage and never regained it would nonetheless be counted as insured for the entire year.

Many people purged from Medicaid were successfully reenrolled in or obtained other insurance, such as Affordable Care Act marketplace or job-based coverage. Others remained uninsured.

Advocates have feared the unwinding would trigger a rise in the uninsured rate as people struggled to find alternative coverage.

But states, private health insurers, and advocates launched intense efforts to contact enrollees by phone, email, and social media to ensure they did not experience gaps in coverage.

Still, because of the way the Census Bureau reports the uninsured rate, the full impact of the unwinding won’t be known until the 2026 report.

Beyond Medicaid, several other factors boosted the number of Americans with health insurance last year, including a strong economy and near-record-low unemployment. Most Americans obtain insurance through their jobs, according to the Census, meaning that higher employment typically results in broader health coverage.

Another key factor: enhanced federal subsidies that since 2021 helped lower the cost of private coverage through Obamacare. Sign-ups on Affordable Care Act marketplaces hit a record high of 20.8 million in 2024, according to a Treasury report released Tuesday.

But that extra financial assistance is slated to expire at the end of 2025, setting up a flashpoint for whichever party controls power in Washington after the November elections. Democrats want to extend the subsidies introduced during the pandemic, while many Republicans wish to let them end.

Before Congress passed the ACA in 2010, the uninsured rate had been in double digits for decades. The rate fell steadily under President Barack Obama but reversed under President Donald Trump, only to come down again under President Joe Biden.

In addition to expanding subsidies, the Biden administration increased advertising and the number of counselors who help people sign up for plans during the open enrollment season, which Trump greatly curtailed.

Also contributing to the reduction in the number of uninsured Americans are state efforts to expand coverage to mostly low-income residents. North Carolina, for example, expanded Medicaid eligibility in December 2023, resulting in more than 500,000 additional enrollees.

Decades of research shows that expanded health coverage helps people individually and the public overall. Health insurance pays for routine care and can protect people from financial calamity because of severe injuries or illness.

People who are uninsured are more likely to delay or avoid getting health care, which can lead to relatively minor problems becoming more severe and costly to treat. Having more people covered also means more patients can pay their bills, which can improve the financial condition of hospitals and other providers.

The health insurance data released annually by the Census Bureau is considered the most accurate picture of health coverage in the United States. The state-level uninsured data it plans to release Thursday, based on a larger survey, counts people as uninsured if they say they don’t have coverage at the time they’re contacted. Thus, it likely will provide more insight into the effects of the unwinding.

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

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One of the worst parts of World War II is coming to metro Detroit this month. And it’s scheduled to keep coming into January.

Each week about 25 semi-trucks will haul low-level radioactive waste from New York to a disposal site in Wayne County’s Van Buren township.

It’s by-products from the Manhattan Project, which created the atomic bombs dropped in Japan that ended World War II.

It’s also the latest in a series of toxic material shipments sent to Michigan raising concerns among some members of Congress and other officials.

That includes Wayne County Executive Warren Evans. He says there’s a disconnect between federal agencies that regulate hazardous waste, the company that owns the Van Buren disposal site and Michigan’s government.

“It doesn’t make sense to me that we would be the location of choice so often for this toxic material.”

-Wayne County Executive Warren Evans

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Listen: Warren Evans on toxic atomic waste coming to Wayne County

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This interview has been edited for clarity and length.

Warren Evans: I don’t believe that they level with us about what they’re doing. My trust level for them is almost zero. And it doesn’t lead to good results or good communications back and forth. The only time we hear about these waste issues is when a reporter writes a story and we read about it and they become automatically defensive. I’m concerned about the lack of notice (that shipments are coming to Michigan.) That leads me to be concerned about the level of hazardous waste in the material and the amount that’s coming and how it’s being transported.

Quinn Klinefelter, WDET News: The Army Corps of Engineers has said they’re not required to notify anybody if they’re sending waste to a facility that’s allowed to take those kinds of shipments, which the one in Van Buren is. So when you say you don’t think that they’re leveling with you, what do you think needs to be changed?

WE: They said they’re not “required” to. What the heck does that mean? Does it mean there’s a prohibition about doing it? They’re hiding behind a rule that doesn’t require them to do it. But good public policy does require them to do it, them or somebody, I think. Hiding behind a rule that doesn’t make you do it just tells me the rule doesn’t make any sense and you’re not concerned about the reaction of the public’s health concerns about this. If that’s the way you feel, then I’m troubled by the whole thing.

QK: You’ve had a couple of town hall meetings about this and other toxic waste that came from the East Palestine, Ohio train derailment. What are you hearing from residents about the situations?

WE: It’s real clear that residents don’t want it here. And what we hear from the federal agencies is how safe they claim to be and what the rules and federal regulations are. That’s not what people are asking for. They are asking for clear answers about why so much of it is coming here and just how safe is it? It’s troubling to me, because the agencies are answering questions in a very bureaucratic way. “This is regulation 207 and we’re required to do that.” It’s double-speak to me. People are asking about the health concerns that they have, the health concerns that they’re afraid of in the future. They are asking for solid, honest answers. Part of that would be alleviated if there was more discussion about the actual hazardous waste, the toxicity of it, how it’s being transported and how it is being kept in the landfill. That would help people determine whether the safety valves are there or not there. When you hear the agencies talk about it, they say they have a stellar track record for keeping us safe. And every year you hear about catastrophes that occur and violations that occur at these different waste treatment places. Those two notions don’t square in my mind or the minds of anybody else that has any sense.

QK: So you still have some concerns when state environmental officials say that they’ve tested this latest waste coming from the Manhattan Project, that it’s within the limits that the site is permitted to take? And there’s only seven similar sites in the country, so you just gotta grit your teeth and bear with it?

WE: Yeah but that doesn’t really make sense. There’s a significant amount of it that’s coming and there’s certainly no legal prohibition against dividing it into some different landfills. Why does it all have to come here? Particularly since the waste is rated at a level that would allow it to go to many other landfills — and many other landfills that are closer to New York than here. They can talk all day about how this landfill provides added security. But if the waste is rated low enough that it can go just about anywhere, then why don’t you send it just about anywhere?

QK: I have heard that it was somewhat cheaper to dispose of it in landfills here as opposed to other places. Have you heard that same reasoning?

WE: Absolutely. And I think that that, in and of itself, calls for a state solution. It appears to me that there are two solutions that we ought to be working on as a community. One is, we ought to act legislatively, get our legislature to refuse to take it. In other words, change the rules about Michigan being able to take the hazardous waste. That’s why it’s coming out of New York, New York won’t take it. That’s one option. That’s a pretty drastic one, but a significant one. The other one is to raise the tipping fees such that it is not so profitable for those who want to deliver the waste here. I think both of those are solutions that bear some close scrutiny and, I think, support.

There are many states that are less populated than Michigan. Wayne County is the largest by population county in the state of Michigan. It doesn’t make sense to me that we would be the location of choice so often for this toxic material. Nobody wants it. There’s no financial advantage to the county for accepting it. The disadvantages are creating a further health care risk. And we’re already rated poorly in the state of Michigan in terms of health indicators.

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Everett LaBrash is a Children’s Miracle Child.

The son of Alex and Marianne LaBrash of Sterling Heights, he is now a year old who is continuing to reach milestones and exemplifies the healthy outcomes that are made possible through the support of the annual Feldman Automotive Children’s Miracle Celebrity Invitational presented by Corewell Health Foundation of Southeast Michigan and the Mark Wahlberg Youth Foundation.

This year’s golf outing raised $1.5 million.

All of the money garnered through sponsorship support, on site-donations and a live auction, which included an electric guitar signed by Taylor Swift, benefit Children’s Miracle Network programming at Corewell Health Children’s and patients like Everett.

Everett  came early at 24 weeks.

Being a preemie, he faced a plethora of challenges, especially lung development, which required a C-pap at birth, and a ventilator after developing pneumothorax, to regulate his oxygen and help with breathing.

During his stay at Corewell Health Beaumont Troy Hospital a team of health care professionals at Corewell Health Children’s Child Life Services provided Everett and his parents with care and compassion. Panda Warmers, Giraffe Omni Beds, and fold-out furniture for long stays were just some of the benefits that they received with the help of donations made to Corewell Health Children’s through Children’s Miracle Network Hospitals.

“Our team at Troy, honestly, they were life-changing,” Marianne LaBrash said in a video released by the hospital. “They helped us through… so much. I definitely have a couple of lifelong friends with them.”

Alex concurred.

“Everyone’s easy going,” he said. “They’d lend an ear if you needed to vent to them. Thank you doesn’t wrap it up enough.”

The Feldman Automotive Children’s Miracle Celebrity Invitational is the largest celebrity golf event in the Detroit area, where every foursome enjoys an up-close and personal celebrity pairing.

This year’s event featured more than 50 national and local celebrities, including actors Donnie Wahlberg (last year it was Mark Wahlberg), Kevin Chapman, Jamie Denton, Marion “Pooch” Hall, Jamie Hector, and Jesse Spencer. From the world of sports, Kenny Anderson, Joique Bell, Lomas Brown, Johnny Damon, Braylon Edwards, Calvin Johnson, Pepper Johnson, Frank Zombo, and dozens of others took part in the day’s activities. It’s one of those events that everyone looks forward to, players and donors alike.

The morning began with Wahlberg accepting a “putting challenge” from three Corewell Health Children’s “Miracle” children selected to represent the more than 200,000 children treated at Corewell Health Children’s each year.

“We are delighted with the incredible success of this event”, said Lamong Yoder, a registered nurse and president of Corewell Health in Southeast Michigan. “Our gratitude goes out to the many sponsors and celebrities that are the backbone of this one-of-a kind invitational. Funds raised will be used to help the children in our communities when they need it the most.”

After golf, a spirited live auction and course contests raised about $300,000 from bids on items like Taylor’s guitar donated by Bob and Connie Skandalaris, which went for $31,000, a private tour of Rick Hendrick’s Automotive Heritage Museum in Charlotte, North Carolina, hosted and donated by Jay Feldman and Rick Hendrick, a 2025 Formula 1, Monaco package donated by Nino Cutraro; an Italian villa vacation, donated by the Rugiero Family and dinner in the Celani Wine Cellar, donated by Tom and Vicki Celani.

“It was inspiring to see so many people lending their support and contributing to our cause. We are helping so many children and families with the money raised. We are already planning for next year’s event and aiming to raise even more money to continue to provide support for those families in need,” said Jay Feldman, chairman and CEO of the Feldman Automotive Group.

Supporting the fundraising event this year was its title sponsor, the Feldman Automotive Group; lead presenting sponsor Quantum Ventures of Michigan; presenting sponsors Shift Digital and Vesco Oil Corporation; and supporting sponsors including the Celani Family Foundation, CIBC, Corewell Health, The Fourth Tri Sanctuary, Aaron and Carolynn Frankel Family Foundation, Mechanical Services, NativeWahl, and Terra Capital Industries and more than 50 other generous sponsors.

Also praising the generosity shown during the invitational was Ryan Daly, president of the Corewell Health Foundation Southeast Michigan.

“Corewell Health Children’s will receive support to provide life-saving services, vital pediatric equipment, and funds for patient scholarships for families unable to afford needed care,” Daly said, while the Mark Wahlberg Youth Foundation will utilize its funds to improve the quality of life for youth across the country by providing financial resources and community support to youth services.

Organizers of the event included a dedicated committee of community members — Tom Celani, Nino Cutraro, Jay Feldman, Ken Noonan, Bob Skandalaris, and Sam Yamin.

For more information visit corewellhealth.org/childrens  or call 855-480-KIDS (5437). Children’s Miracle Network Hospitals raises funds and awareness for 170 member hospitals that provide 32 million treatments each year to kids across the U.S. and Canada.

All of the donations and money raised is used locally, to help Miracle families in nine counties throughout Southeast Michigan including Macomb, Oakland and Wayne counties.

For more information visit CMNHospitals.org.

For more than a decade, independent pharmacist Jay Patel has built a close and enduring relationship with his customers, who come to him for help in sickness and in health.

But now there are interlopers: Drug middlemen, companies known as pharmacy benefit managers (PBMs) that influence which medicines can be bought, where to buy them and at what cost.

Patel and other independent pharmacists say their businesses are threatened by the growing influence of these companies, tied to huge health care conglomerates. In a system that is opaque and complex, patients are steered to affiliated pharmacies, such as CVS and mail-order pharmacies, they say. Pharmacists face high fees and low reimbursement rates, so are unable to cover their costs.

That could put Patel — and other locally-owned pharmacists — out of business.

“I want to do what matters to the community. But how long can I sustain this?” said Patel, 48, who owns Savco Pharmacy in San Jose’s West San Carlos neighborhood. “We are at their mercy.”

The PBMs respond that critics base their conclusions on incomplete evidence. According to the trade organization Pharmaceutical Care Management Association, they protect consumers from high drug prices by negotiating for discounts, called rebates, from drug companies.

The disappearance of independent pharmacies could limit consumer choice and health care access — especially in low-income or rural communities.

On Oakland’s Telegraph Avenue, Selam Pharmacy owner Michael Gebru called PBMs “a big black box.” He said “They bill me whatever they want, and can reclaim it. That’s pretty scary. It’s a Wild West.”

In the coastal village of Point Reyes Station, tiny West Marin Pharmacy recently lost its contract with PBM company Express Scripts, used by insurer Cigna and others. Now residents covered by Cigna must get their prescriptions by mail or make a 20-mile drive to find another pharmacy.

“If any of us, our children and families are ill, suffering from fevers, vomiting, diarrhea or worse, we may be forced to drive an hour or more to San Rafael, Novato or Petaluma just to get a prescription filled,” worried pharmacy customer Christine Cordaro of Inverness Park.

PBMs were created in the 1960s as a way to process prescription drug claims. They are responsible for paying pharmacies on behalf of insurance companies, employers and the government. The three largest companies are run by CVS Health, Cigna and UnitedHealth Group, which oversee prescriptions for more than 200 million Americans.

In 2012, the year San Jose pharmacist Patel bought his modest shop, PBMs processed fewer than 50% of prescriptions.

A series of mergers in 2018 created the current system, where health care conglomerates are vertically integrated — owning the insurer, the PBM and pharmacy. The giant health insurer Aetna combined with drug retailer CVS. Another large insurer, Cigna, bought Express Scripts. UnitedHealth built its own PBM.  All three companies operate mail-order pharmacies.

“It’s like they’re taking the money from one pocket, and putting it into the other,” said Zsuzsanna Biran, pharmacist owner of West Marin Pharmacy.

Despite consumer opposition, the FTC approved the mergers.  But now there are concerns about PBMs’ economic leverage. The smaller, locally owned pharmacies feel muscled out of the market.

CVS calls the plight of independent pharmacies “overblown.”

“Contrary to much of the independent pharmacy lobby’s rhetoric, there is no crisis facing independent pharmacies,” CVS said in a statement.

“What the independent pharmacy lobby has long coveted is a world without managed pricing or the competitive pressure from PBM negotiations on behalf of payer clients and consumers,” CVS said.

According to Express Scripts, “If we didn’t provide significant value for our thousands of partners, we wouldn’t exist.”

The PBMs work by negotiating rebates on the “sticker price” of medicines. Some of these savings are shared with insurers and employers.  But a slice is kept by the PBMs. This is enormously profitable.

There is evidence of anticompetitive behavior that illegally distorts the market, hurting consumers and threatening the survival of independent pharmacies, according to new reports by the U.S. Federal Trade Commission and a House Committee on Oversight and Accountability investigation.

PBMs steer patients toward pricier drugs, with “formularies” of preferred medicines that discourage use of lower-priced alternatives, according to the reports, released last month. Because these high-priced drugs command a greater rebate, there’s more profit.

They also sometimes restrict patients’ access to mail-order deliveries, which they own. This cuts out the role of the local pharmacy.

Independent pharmacies say they’re saddled with unnecessary extra fees. When he started his business in 2012, Patel paid $15,000 to $20,000 in PBM fees; this year, his fees could surpass $110,000.

High fees and low reimbursement may discourage pharmacists from filling a prescription. If he loses money on a prescription, “I have two options,” said Patel. “Take the loss, or tell the patient that I cannot fill it.”

“With lower prescription reimbursements in one corner and higher back-end fees in the other, many community pharmacists are thinking about throwing in the towel,”  according to the National Community Pharmacists Association, which represents more than 19,400 independent U.S. pharmacies.

Nearly one-third of independent pharmacy owners may close their stores this year, it predicted.

But in Sacramento and other state capitals, lawmakers are taking a tougher look.

State Sen. Scott Wiener has authored legislation, Senate Bill 966, that would impose new rules on PBMs, better regulating the companies. It would require PBMs to be licensed with the California State Board of Pharmacy and to pass down drug rebates to consumers.

Meanwhile, Patel takes joy in things that don’t cost money — recognizing customers’ names and faces, making birthday phone calls and reminding them to be immunized. Once he provided a cane, for free, to a customer with a gimpy leg.

And there are rewards that are priceless, such as the gifts of fruit, chocolate and home-baked cookies from grateful customers.

“He’s the best,” said customer Rob Souza, picking up a prescription for an ailing wife. “He’s like a small-town pharmacist, always working things out.”

Miriam Fauzia | The Dallas Morning News (TNS)

A fentanyl vaccine developed by researchers at the University of Houston is expected to head to clinical trials sometime in the middle of next year, with the hope of being a groundbreaking solution to a deadly crisis.

The vaccine, which has shown success in animal studies, is designed to stop the highly addictive opioid from entering the brain and causing an overdose. Biopharmaceutical startup Ovax acquired the license to produce and test the vaccine in November 2023 and raised over $10 million toward that effort by June.

“We’re all incredibly excited,” said Collin Gage, the start-up’s co-founder and chief executive officer. He added that his company is starting at “ground zero,” but he is confident it will one day have a fentanyl vaccine available to the public.

That day may be a long time from now. While public health emergencies, like the COVID-19 pandemic, can accelerate a vaccine’s development, testing a new vaccine can take anywhere from five to 10 years — sometimes longer.

Meanwhile, fentanyl overdose deaths have been on the rise in Texas, from less than 80 in 2014 to nearly 2,300 in 2023, according to the Texas Department of State Health Services. The synthetic opioid — made illegally but also available by prescription — is 50 times stronger than heroin and 100 times stronger than morphine, making it the deadliest drug in the opioid crisis.

For fentanyl vaccines, adjuvants are key

The idea of creating an opioid vaccine has drawn scientific attention since the 1970s. Unlike bacteria or viruses, opioids aren’t recognized by our immune systems as foreign invaders. But the immune system can be trained to make antibodies in response to an opioid like fentanyl through a vaccine that links bits of the drug to noninfectious bits of bacteria and uses substances called adjuvants.

Adjuvants are designed to enhance immune response, and are particularly important in vaccines targeting substance use disorders. Past attempts to make these vaccines have been unsuccessful in part because the adjuvants weren’t effective enough, said Jay Evans, director of the Center for Translational Medicine at the University of Montana. Evans is also the chief scientific and strategy officer of Inimmune, a Montana-based biotech company developing and testing a variety of vaccines including ones targeting fentanyl and heroin addiction.

The adjuvant in the University of Houston’s fentanyl vaccine is an enterotoxin, a chemical produced by the bacteria Escherichia coli and modified to be noninfectious. It was first developed at Tulane University in Louisiana in the early 2000s and has been used in a variety of vaccines, said Colin Haile, a research associate professor of psychology at the University of Houston who led its fentanyl vaccine development. Haile is also an Ovax co-founder and adviser.

“It has been in 15 human clinical trials in combination with other vaccines,” he said, referring to the adjuvant used in his team’s vaccine. “There have been studies in infants where the results have been fantastic, nearly no side effects.”

Other researchers such as David Dowling and Dr. Ofer Levy, both Ovax co-founders, are using adjuvants that haven’t been tested in humans but appear to effectively enhance the immune response to vaccines targeting substance use disorders, at least based on animal studies, Dowling said.

Clinical trials littered with challenges

Phase 1 clinical trials for the University of Houston vaccine are planned to begin in the second quarter of 2025. Ovax is also in licensing negotiations with Boston Children’s Hospital for a fentanyl vaccine developed by Dowling and Levy. If those negotiations are successful, phase 1 clinical trials could begin in early 2026.

These trials will aim to establish the vaccine’s safety level, potential side effects and optimal dosage. Finding people to take part in them will be a challenge, Evans said.

“Compared to a normal infectious disease clinical trial, it will be more difficult. The FDA (Food and Drug Administration) is pretty adamant that you’re not going to test this vaccine in healthy individuals that don’t already have some sort of opioid addiction,” he said. “So we need to target patients in phase 1 who have a history of opioid use disorder, and that’s a harder population to try to recruit. It’s going to take longer; the patient population will have more adverse events because they’re drug users and they will be harder to track.”

Evans added that the stigma around addiction and drug use might make people reluctant to disclose their condition and participate in a clinical trial.

Ovax has yet to decide where it plans to run its phase 1 clinical trials, Gage said, but it has been looking at sites in Australia and the Netherlands.

“We’re also looking in the United States,” he said, “but it’s difficult to find the right patient population.”

Future clinical trials would need to determine the effectiveness of the vaccine, who would benefit the most and how long immunity would last.

Vaccines as part of the solution

Some critics of fentanyl vaccines say they pull resources from existing treatments for opioid addiction such as buprenorphine, methadone and naltrexone. Some have questioned whether people would seek out the vaccine.

“People have to say they want to be injected, and they have to choose to keep coming back for each injection or infusion,” Keith Humphreys, a Stanford University professor of psychiatry and behavioral sciences, told The Washington Post in 2023. “The vaccines do nothing to reduce craving or withdrawal or to motivate anyone to return for more care.”

For Haile, a fentanyl vaccine is not the sole solution but another weapon in the fight against the opioid crisis. He and his colleagues at the University of Houston have conducted animal studies investigating how the vaccine affects treatment with buprenorphine, a medication commonly prescribed to manage withdrawals and drug cravings. The findings have yet to be published but are “quite impressive,” Haile said, noting fentanyl vaccines could improve the effectiveness of existing treatments.

“The most important thing to keep in mind is that we’re moving as fast as we can go. … We need to get something to market as quickly as possible to address this terrible problem,” Haile said. “The ultimate goal is to protect people and save lives.”

©2024 The Dallas Morning News. Visit dallasnews.com. Distributed by Tribune Content Agency, LLC.

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For many women experiencing symptoms caused by uterine fibroids the only option for relief was a hysterectomy and that created its own kind of pain for women still wanting to have children.

Now there’s another way.

Through laparoscopic radiofrequency ablation (Lap-RFA) women have a viable and considerably less invasive option, for the treatment of uterine fibroids should they choose to seek a diagnosis and treatment.

But will they?

Dr. Jay Fisher, a Corewell Health obstetrician-gynecologist pioneering the treatment in Southeast Michigan, also known as the Acessa procedure, said up to 75 million women in the United States may experience symptoms caused by uterine fibroids, but only 1.4 million will seek care for it.

“Most of them just live with it,” Fisher said.

Once a month these women suffer a variety of symptoms such as excessive menstrual bleeding, cramping and anemia and, while a laparoscopic hysterectomy is less invasive, it still requires the surgical removal of the uterus, or womb, from a woman’s body. Plus, a lot of women are unable to take the medication (estrogen) that was typically prescribed afterwards.

Laparoscopic radiofrequency ablation (Lap-RFA) was  first used in the treatment of liver tumors uses radiofrequency energy to treat uterine fibroids.

“It’s really remarkable technology because it’s very precise, delivering (the radiofrequency) directly to the fibroid itself while not damaging any tissue around it.”

Among those who were trying to live with the symptoms caused by uterine fibroids was Balsam Goriel, 47, of Warren.

“Every other month I would be in the emergency room,” said Goriel, whose condition got so bad it required blood transfusions.

“It was exhausting,” she said. “I wouldn’t go anywhere. I barely ate. I was like a car without lights.”

Her doctor tried a procedure that has had some success but it didn’t work for her and it appeared that her only option would be a hysterectomy, which she was not ready to accept.

“I don’t like getting my periods but I think it’s like a detox for a woman,” Goriel said. “It wasn’t about having children.”

It’s then she was told about laparoscopic radiofrequency ablation (Lap-RFA), which at one time was not covered by many health insurance plans. However, in recent years data has shown that it’s not only an effective treatment medically, but also financially more cost effective.

“It’s the best thing I’ve ever done. Dr. Fisher was amazing. He worked hard to identify the right solution for me,” she said.

The renewed energy she experienced after the outpatient procedure enabled her to return to a normal life.

“I have not gone to the ER since,” she said, adding she has not had to call in sick to work as well. She is socializing, happy and robustly practicing the tenets of self-care such as walking and exercise, journaling, prioritizing water intake, a solid sleep routine and a diet rich in fruits and vegetables.

“It’s the best thing I’ve ever done,” said Goriel. “I still get cramps but it’s nothing like it used to be. Now, I just have the same discomfort as everyone else.”

For more information visit beaumont.org/services/doctors.

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Anna Claire Vollers | (TNS) Stateline.org

Helping a pregnant minor travel to get a legal abortion without parental consent is now a crime in at least two Republican-led states, prompting legal action by abortion-rights advocates and copycat legislation from conservative lawmakers in a handful of other states.

Last year, Idaho became the first state to outlaw “abortion trafficking,” which it defined as “recruiting, harboring or transporting” a pregnant minor to get an abortion or abortion medication without parental permission. In May, Tennessee enacted a similar law. And Republican lawmakers in Alabama, Mississippi and Oklahoma introduced abortion trafficking bills during their most recent legislative sessions, although those bills failed to advance before the sessions ended.

Those five states are among the 14 that enacted strict abortion bans following the U.S. Supreme Court’s June 2022 Dobbs decision, which dismantled the federal right to abortion. Now, conservative state lawmakers are pushing additional measures to try to restrict their residents from getting them in states where it remains legal.

“A lot of folks thought Dobbs was the floor and it’s really not,” said Tennessee state Rep. Aftyn Behn, a Nashville Democrat who’s challenging Tennessee’s trafficking law in court. “[Anti-abortion lawmakers] are coming for state travel and the ability to even talk about abortion.”

Abortion-rights advocates have filed lawsuits in Alabama, Idaho and Tennessee, arguing the laws are vague and violate constitutional rights to free speech and travel between states. A federal judge has temporarily blocked Idaho’s law from being enforced while the case is ongoing.

Proponents of the laws argue they’re needed to protect parental rights and to prevent other adults from persuading adolescents to get abortions.

“This is a parental rights piece of legislation,” Idaho Republican state Rep. Barbara Ehardt told Stateline. “We can’t control someone getting an abortion in Oregon. But you cannot take a child to get an abortion without the parent’s knowledge because, at least in the past, we would have called that kidnapping.”

But critics warn that abortion trafficking laws could have grave implications not only for interstate travel, but also for personal speech and communication between friends, or between children and adults they trust.

“If courts go down this road, it could change the scope of the First Amendment,” Mary Ziegler, a legal historian and law professor at the University of California, Davis School of Law, told Stateline. “It could have an effect on what else qualifies as crime-facilitating speech, and that could limit the kinds of things people can say and do online and in other contexts.”

Opponents also question whether states should be permitted to interfere in the business of other states. Criminalizing travel within an abortion-ban state to reach another state for a legal abortion would “allow prosecutors to project power across state lines,” said Ziegler.

“We haven’t seen states try to interfere in what’s happening in other states in quite the same way in a long time,” she said. “That’s why there is legal uncertainty — because we’re not talking about something where we have a lot of legal precedent.”

‘Parental rights’

Tennessee state Rep. Jason Zachary, a Knoxville Republican, defended Tennessee’s legislation as “a parental rights bill” that “reinforces a parent’s right to do what’s best for their child,” in remarks he made to the Tennessee General Assembly before the bill passed. Republican Gov. Bill Lee signed it into law in May.

The following month, Behn joined with Nashville attorney and longtime abortion access activist Rachel Welty to file a lawsuit challenging the new law.

Behn and Welty sued nearly a dozen district attorneys in Tennessee, alleging they ignored Welty’s requests to define what behavior would be deemed illegal under the new law. The Tennessee law says that abortion trafficking occurs when an adult “intentionally recruits, harbors, or transports” a pregnant minor within the state to get an abortion or an abortion-inducing drug without parental consent, “regardless of where the abortion is to be procured.”

A hearing to determine whether the court will grant a temporary injunction blocking the Tennessee law, which is currently in effect, is scheduled for Aug. 30.

After Idaho passed its law in April 2023, two advocacy groups and an attorney who works with sexual assault victims sued the state attorney general. The plaintiffs claim Idaho’s law is vague and violates the First Amendment right to free speech, as well as the right to travel freely between states. The right to interstate travel isn’t spelled out in the U.S. Constitution but it’s implied, legal experts say. The Idaho law directly applies to travel within the state, but it also notes that defendants are not immune from liability if “the abortion provider or the abortion-inducing drug provider is located in another state.”

Megan Kovacs, a board member with the Northwest Abortion Access Fund, which is a plaintiff in the case along with the Indigenous Idaho Alliance, said it is “so clearly unconstitutional to disallow people from accessing health care from within or outside their state.” Kovacs added that her group also wants to protect its volunteers from legal liability.

Neither the Idaho nor the Tennessee law exempts minors who become pregnant after being raped by a parent.

“If that person had to go to a parent who didn’t believe them or wanted to defend that family member who was the abuser, that only impedes healing even more,” said Kovacs, who has spent a decade working with survivors of domestic and sexual violence.

Ehardt, who sponsored the Idaho bill, said any adult who is told by a child about an incident of incest should call authorities rather than helping the minor obtain an abortion without parental consent.

“You have to call the police and they will be the ones to help protect the child’s safety,” she said.

The 9th U.S. Circuit Court of Appeals held a hearing in May in Seattle, and Kovacs said she expects to learn in the next few weeks whether the court will uphold the temporary injunction blocking Idaho’s law while the lawsuit rolls on.

In July 2023, a group of health care providers sued Alabama Republican Attorney General Steve Marshall and district attorneys, asking the court to prevent the state from prosecuting people who help Alabamians travel to get abortion care in states where it’s legal.

The providers filed the lawsuit in response to remarks that Marshall made on a radio show in 2022, when he suggested that some people who aid a pregnant person in planning or traveling to get an abortion in another state could be prosecuted under the state’s criminal conspiracy laws. A judge denied Marshall’s motion to dismiss the lawsuit earlier this year, and the case is ongoing.

A coordinated effort

The Tennessee and Idaho laws mirror language in model legislation that was published in 2022 by the National Right to Life Committee, which bills itself as the nation’s oldest and largest grassroots pro-life organization.

“With this model law, we [are] laying out a roadmap for the right-to-life movement so that, in a post-Roe society, we can protect many mothers and their children from the tragedy of abortion,” said Carol Tobias, president of National Right to Life Committee, in a June 2022 statement introducing the model anti-abortion law.

Anti-abortion-rights organizations, like other interest groups, have long coordinated strategies to promote their preferred legislation to state and federal lawmakers.

The Idaho and Tennessee laws focus specifically on minors, even though they comprise a small fraction of people who get abortions. Those under 19 accounted for 8.1% of abortions, and those under age 15 accounted for just 0.2% of abortions in 2021, the most recent year for which the federal Centers for Disease Control and Prevention has published data.

Kovacs and Ziegler say the bills zero in on minors’ access to abortion because policies that regulate children and teens tend to be more politically acceptable than broader restrictions that affect adults. Such bills also tend to be more likely to survive legal challenges in court.

A chilling effect

Nobody in Tennessee or Idaho has yet been prosecuted under the abortion trafficking laws, but an Idaho woman and her son were charged with kidnapping last fall for allegedly taking the son’s girlfriend, a minor, out of state to get an abortion.

One main goal of a law such as Tennessee’s, Behn believes, is to create a chilling effect so that average people are scared to help anyone who might need an abortion, for fear of breaking the law.

“These bills create an environment of suspicion, fear and misinformation,” said Behn. “But I do think we will see more aggressive district attorneys start to prosecute these cases. [The law] widens the permission structure to start prosecuting people.”

Laws criminalizing abortion travel and imposing other abortion restrictions may be designed to provoke a legal challenge, Ziegler said. With a 6-3 conservative majority, the U.S. Supreme Court might be inclined to support them.

Abortion-rights advocates argue that restrictive abortion laws end up harming even those people who live in states where abortion is still legal.

Oregon, for example, has some of the strongest abortion protection laws in the nation. And yet the strict abortion ban next door in Idaho has made it more difficult for Oregonians to access care, said Kovacs, who lives in Oregon.

Before Idaho’s ban, many people in Eastern Oregon traveled to Idaho for abortion care, she said, because its clinics were closer than Oregon’s clinics, most of which are concentrated on the western side of the state. Last year, in response to increasing abortion restrictions in other states, Oregon passed a sweeping health care omnibus bill that strengthens protections for abortion providers and explicitly allows minors to seek abortions without parental consent. It was signed into law and took effect in January.

Ziegler said it’s not hard to imagine that if abortion trafficking laws are upheld in abortion-ban states, at some point prosecutors in those states could file charges against providers in “safe” states for providing abortion help, such as mailing abortion pills.

“I think it’s not intended to just stop with the people who are in the ban states,” Ziegler said.

©2024 States Newsroom. Visit at stateline.org. Distributed by Tribune Content Agency, LLC.

Sarah Varney, KFF Health News | KFF Health News (TNS)

Ashley and Kyle were newlyweds in early 2022 and thrilled to be expecting their first child. But bleeding had plagued Ashley from the beginning of her pregnancy, and in July, at seven weeks, she began miscarrying.

The couple’s heartbreak came a few weeks after the U.S. Supreme Court overturned the federal right to abortion. In Wisconsin, their home state, an 1849 law had sprung back into effect, halting abortion care except when a pregnant woman faced death.

Insurance coverage for abortion care in the U.S. is a hodgepodge. Patients often don’t know when or if a procedure or abortion pills are covered, and the proliferation of abortion bans has exacerbated the confusion. Ashley said she got caught in that tangle of uncertainties.

Ashley’s life wasn’t in danger during the miscarriage, but the state’s abortion ban meant doctors in Wisconsin could not perform a D&E — dilation and evacuation — even during a miscarriage until the embryo died. She drove back and forth to the hospital, bleeding and taking sick time from work, until doctors could confirm that the pregnancy had ended. Only then did doctors remove the pregnancy tissue.

“The first pregnancy was the first time I had realized that something like that could affect me,” said Ashley, who asked to be identified by her middle name and her husband by his first name only. She works in a government agency alongside conservative co-workers and fears retribution for discussing her abortion care.

A year later, the 1849 abortion ban still in place in Wisconsin, Ashley was pregnant again.

“Everything was perfect. I was starting to feel kicking and movement,” she said. “It was the day I turned 20 weeks, which was a Monday. I went to work, and then I picked Kyle up from work, and I got up off the driver’s seat and there was fluid on the seat.”

The amniotic sac had broken, a condition called previable PPROM. The couple drove straight to the obstetrics triage at UnityPoint Health-Meriter Hospital, billed as the largest birthing hospital in Wisconsin. The fetus was deemed too underdeveloped to survive, and the ruptured membranes posed a serious threat of infection.

Obstetrician-gynecologists from across Wisconsin had decided that “in cases of previable PPROM, every patient should be offered termination of pregnancy due to the significant risk of ascending infection and potential sepsis and death,” said Eliza Bennett, the OB-GYN who treated Ashley.

Ashley needed an abortion to save her life.

The couple called their parents; Ashley’s mom arrived at the hospital to console them. Under the 1849 Wisconsin abortion ban, Bennett, an associate clinical professor at the University of Wisconsin School of Medicine, needed two other physicians to attest that Ashley was facing death.

But even with an arsenal of medical documentation, Ashley’s health insurer, the Federal Employees Health Benefits Program, did not cover the abortion procedure. Months later, Ashley logged in to her medical billing portal and was surprised to see that the insurer had paid for her three-night hospital stay but not the abortion.

“Every time I called insurance about my bill, I was sobbing on the phone because it was so frustrating to have to explain the situation and why I think it should be covered,” she said. “It’s making me feel like it was my fault, and I should be ashamed of it,” Ashley said.

Eventually, Ashley talked to a woman in the hospital billing department who relayed what the insurance company had said.

“She told me,” Ashley said, “quote, ‘FEP Blue does not cover any abortions whatsoever. Period. Doesn’t matter what it is. We don’t cover abortions.’”

University of Wisconsin Health, which administers billing for UnityPoint Health-Meriter hospital, confirmed this exchange.

The Federal Employees Health Benefits Program contracts with FEP Blue, or the BlueCross BlueShield Federal Employee Program, to provide health plans to federal employees. In response to an interview request, FEP Blue emailed a statement saying it “is required to comply with federal legislation which prohibits Federal Employees Health Benefits Plans from covering procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.”

Those restrictions, known as the Hyde Amendment, have been passed each year since 1976 by Congress and prohibit federal funds from covering abortion services.

In Ashley’s case, physicians had said her life was in danger, and her bill should have immediately been paid, said Alina Salganicoff, director of Women’s Health Policy at KFF, a health information nonprofit that includes KFF Health News.

What tripped up Ashley’s bill was the word “abortion” and a billing code that is insurance kryptonite, said Salganicoff.

“Right now, we’re in a situation where there is really heightened sensitivity about what is a life-threatening emergency, and when is it a life-threatening emergency,” Salganicoff said. The same chilling effect that has spooked doctors and hospitals from providing legal abortion care, she said, may also be affecting insurance coverage.

In Wisconsin, Bennett said, lack of coverage for abortion care is widespread.

“Many patients I take care of who have a pregnancy complication or, more commonly, a severe fetal anomaly, they don’t have any coverage,” Bennett said.

Recently, the bill for $1,700 disappeared from Ashley’s online bill portal. The hospital confirmed that eight months later, after multiple appeals, the insurer paid the claim. When contacted again on Aug. 7, FEP Blue responded that it would “not comment on the specifics of the health care received by individual members.”

Ashley said tangling with her insurance company and experiencing the impact of abortion restrictions on her health care, similar to other women around the country, has emboldened her.

“I’m in this now with all these people,” she said. “I feel a lot more connected to them, in a way that I didn’t as much before.”

Ashley is pregnant again, and she and her husband hope that this time their insurance will cover whatever medical care her doctor says she needs.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

Rae Ellen Bichell | (TNS) KFF Health News

GREELEY, Colo. — In early August, farmworkers gathered under a pavilion at a park here for a picnic to celebrate Farmworker Appreciation Day. One sign that this year was different from the others was the menu: Beef fajitas, tortillas, pico de gallo, chips, beans — but no chicken.

Farms in Colorado had culled millions of chickens in recent months to stem the transmission of bird flu. Organizers filled out the spread with hot dogs.

No matter the menu, some dairy workers at the event said they don’t exactly feel appreciated. They said they haven’t received any personal protective equipment beyond gloves to guard against the virus, even as they or colleagues have come down with conjunctivitis and flu-like symptoms that they fear to be bird flu.

“They should give us something more,” one dairy worker from Larimer County said in Spanish. He spoke on the condition of anonymity out of fear he’d lose his job for speaking out. “What if something happens to us? They act as if nothing is wrong.”

Agricultural health and safety experts have been trying to get the word out about how to protect against bird flu, including through bilingual videos on TikTok showing the proper way to gear up with respirators, eye protection, gloves, and coveralls. And Colorado’s health and agriculture departments have offered a free month’s supply of protective equipment to any producer who requests it.

But so far, many farms aren’t taking them up on it: According to numbers provided by the state health department in late August, fewer than 13% of the state’s dairies had requested and received such PPE.

The virus is known to infect mammals — from skunks, bears, and cows to people and house pets. It began showing up in dairy cattle in recent months, and Colorado has been in the thick of it. Ten of the 13 confirmed human cases in the U.S. this year have occurred in Colorado, where it continues to circulate among dairy cows. It isn’t a risk in cooked meat or pasteurized milk but is risky for those who come into contact with infected animals or raw milk.

Weld County, where the farmworker event was held, is one of the nation’s top milk producers, supplying enough milk each month this year to fill about 45 Olympic-size swimming pools, according to U.S. Department of Agriculture data. Neighboring counties are notable producers, too.

Concerns are growing about undiagnosed illness among farmworkers because of a lack of testing and safety precautions. One reason for concern: Bird flu and seasonal flu are capable of gene trading, so if they ended up in the same body at the same time, bird flu might end up with genes that boost its contagiousness. The virus doesn’t appear to be spreading easily between people yet. That could change, and if people aren’t being tested then health officials may be slow to notice.

Strains of seasonal flu already kill some 47,000 people in the U.S. a year. Public health officials fear the havoc a new form of the flu could wreak if it spreads among people.

The Centers for Disease Control and Prevention recommends that dairy workers don a respirator and goggles or a face shield, among other protections, whether they are working with sick animals or not.

A recent study found that not all infected cows show symptoms, so workers could be interacting with contagious animals without realizing it. Even when it is known that animals are infected, farmworkers often still have to get in close contact with them, sometimes under grueling conditions, such as during a recent heat wave when Colorado poultry workers collected hundreds of chickens by hand for culling because of the outbreak. At least six of the workers became infected with bird flu.

One dairy worker in Weld County, who spoke on the condition of anonymity for fear of losing his job, said his employer has not offered any protective equipment beyond gloves, even though he works with sick cows and raw milk.

His bosses asked the workers to separate sick cows from the others after some cows produced less milk, lost weight, and showed signs of weakness, he said. But the employer didn’t say anything about the bird flu, he said, or suggest they take any precautions for their own safety.

He said he bought protective goggles for himself at Walmart when his eyes became itchy and red earlier this summer. He recalled experiencing dizziness, headaches, and low appetite around the same time. But he self-medicated and pushed through, without missing work or going to a doctor.

“We need to protect ourselves because you never know,” he said in Spanish. “I tell my wife and son that the cows are sick, and she tells me to leave, but it will be the same wherever I go.”

He said he’d heard that his employers were unsympathetic when a colleague approached them about feeling ill. He’d even seen someone affiliated with management remove a flyer about how people can protect themselves from the bird flu and throw it in a bin.

The dairy worker in neighboring Larimer County said he, too, has had just gloves as protection, even when he has worked with sick animals — close enough for saliva to wipe off on him. He started working with them when a colleague missed work because of his flu-like symptoms: fever, headache, and red eyes.

“I only wear latex gloves,” he said. “And I see that those who work with the cows that are sick also only wear gloves.”

He said he doesn’t have time to wash his hands at work but puts on hand sanitizer before going home and takes a shower once he arrives. He has not had symptoms of infection.

Such accounts from dairy workers echo those from farmworkers in Texas, as reported by KFF Health News in July.

“Employers who are being proactive and providing PPE seem to be in the minority in most states,” said Bethany Boggess Alcauter with the National Center for Farmworker Health, a not-for-profit organization based in Texas that advocates for improving the health of farmworkers and their families. “Farmworkers are getting very little information.”

But Zach Riley, CEO of the Colorado Livestock Association, said he thinks such scenarios are the exception, not the rule.

“You would be hard-pressed to find a dairy operation that isn’t providing that PPE,” he said. Riley said dairies typically have a stockpile of PPE ready to go for situations like this and that, if they don’t, it’s easily accessed through the state. “All you have to do is ask.”

Producers are highly motivated to keep infections down, he said, because “milk is their life source.” He said he has heard from some producers that “their family members who work on the farm are doing 18-to 20-hour days just to try to stay ahead of it, so that they’re the first line between everything, to protect their employees.”

Colorado’s health department is advertising a hotline that ill dairy workers can call for help getting a flu test and medicine.

Project Protect Food Systems Workers, an organization that emerged early in the covid-19 pandemic to promote farmworker health across Colorado, is distributing PPE it received from the state so promotoras — health workers who are part of the community they serve — can distribute masks and other protections directly to workers if employers aren’t giving them out.

Promotora Tomasa Rodriguez said workers “see it as another virus, another covid, but it is because they don’t have enough information.”

She has been passing out flyers about symptoms and protective measures, but she can’t access many dairies. “And in some instances,” she said, “a lot of these workers don’t know how to read, so the flyers are not reaching them, and then the employers are not doing any kind of talks or trainings.”

The CDC’s Nirav Shah said during an Aug. 13 call with journalists that awareness about bird flu among dairy workers isn’t as high as officials would like it to be, despite months of campaigns on social media and the radio.

“There’s a road ahead of us that we still need to go down to get awareness on par with, say, what it might be in the poultry world,” he said. “We’re using every single messenger that we can.”

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KFF Health News correspondents Vanessa G. Sánchez and Amy Maxmen contributed to this report.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for their newsletters here.

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(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

Aneri Pattani and Henry Larweh and Ed Mahon, Spotlight PA | (TNS) KFF Health News

The conversation wasn’t sounding good for Kensington residents on June 20.

The Philadelphia neighborhood is a critical center of the nation’s opioid crisis, and the city had decided to spend $7.5 million in opioid settlement money to improve the quality of life there. But on that day, a Pennsylvania oversight board was about to vote on whether to reject the city’s decision.

It was a thorny issue with major implications — both for Kensington residents and people across the state, as the decision could set a precedent for what kind of spending the board would allow for years to come.

But a lot of people were shut out of the discussion.

Pennsylvania’s board doesn’t allow members of the public to speak at its meetings, a rule that sets it apart from about two dozen similar opioid councils nationwide.

“It’s another moment where folks not connected to this community are making decisions for this community, and I think that’s inappropriate,” said Bill McKinney, a Kensington resident whose nonprofit is involved in some of the city’s settlement-funded initiatives. “Those that are sort of most affected are not at the table.”

It’s one example of how the public, including people who have lost loved ones to the opioid crisis or are dealing with it daily, are routinely shut out of having a meaningful say in how this windfall can be best used to address the damage. They are eager to suggest solutions for dollars that many of them consider blood money. But a first-of-its-kind survey conducted by KFF Health News and Spotlight PA found that, in many places, their voices are systematically dismissed.

In at least 39 states and Washington, D.C., councils consisting of government officials, clinicians, law enforcement officers, and others guide decisions about how to spend settlement dollars. These powerful groups are influencing addiction policy and funding at a time when more than 100,000 Americans are dying of overdoses annually.

At least 14 of these councils — including Pennsylvania’s — routinely block members of the public from speaking at their meetings. Four of those typically conduct their meetings in secret, barring the public from even attending or observing.

The survey also found:

• The majority of councils do not make video recordings of their meetings readily available online for those who cannot attend live. Although some councils said recordings can be accessed through public records requests, at least one — Minnesota’s Opioid Epidemic Response Advisory Council — deletes its recordings after using them to create meeting minutes. (Minnesota law does not require the council to record its open meetings or post recordings online.)
• At least five states have used committees or work groups that meet in private, or have a policy for allowing such private meetings. In Pennsylvania, such work groups have become a point of contention, with victims, advocates, and even one member of the council questioning their legality. (The Pennsylvania Opioid Misuse and Addiction Abatement Trust’s administrative director said the work groups’ meetings are not required to be public. They make recommendations that the full council decides on.)

Practices that close the public out of settlement spending discussions are “unconscionable,” said Stephen Loyd, chair of Tennessee’s Opioid Abatement Council, which regularly allows public attendance and comment at its meetings. “This is the population we’re there to serve. They have to have a voice in this process.”

Different Stances on Public Comment

People directly affected by the issue are a staple of the Tennessee council’s meetings. This year, commenters have included several parents holding photos of their deceased children and choking back tears, and at least one frustrated community member.

At the June meeting in Memphis, Peter Hossler, an associate professor at Rhodes College, said he was “very angry” about how the council’s recent grant awards of $81 million seemed to shortchange the western part of the state.

Loyd called such critique “invaluable,” comparing it to the feedback he received from loved ones during his recovery journey.

“We have to be held accountable,” he told KFF Health News and Spotlight PA. “And then we have to fix it.” Hossler’s comments are changing the council’s conversation about its next round of grants, Loyd added.

Loyd believes people who have been failed by the current system know what needs to be improved “better than anybody.”

“I want to talk to the people who had medication stopped in jail and laid there and withdrew,” he said. “I want to talk to the people who got out of jail with no money, a couple of felonies hanging over their heads, three meetings they had to make that week or they’re going to be in violation of their probation, and they ain’t got a car or driver’s license.”

States cited a variety of reasons for limiting public involvement. In some, state law does not require councils to take public comment at meetings. Several officials said they’ve sought feedback in other ways. An official in New Jersey said its council held public listening sessions, but that its monthly meetings are not public.

Some officials may worry that public comment would add to meetings that already run multiple hours, but several states manage that by limiting each person’s comment to a few minutes.

For communities of color, being shut out of opioid settlement discussions can compound the negative effects not just from today’s overdose crisis but from the earlier crack cocaine epidemic. Many people considered the government’s response at that time to be ineffective and harmful.

If settlement money is used only to “build on what’s already in place, you’ve already failed,” said Philip Rutherford, an expert on substance use disorder at the National Council for Mental Wellbeing.

At a July 2023 meeting of Illinois’ settlement council, Fanya Burford-Berry said the current system doesn’t work for women of color with substance use disorder — they can risk losing custody of their children. Burford-Berry, director of the West Side Heroin/Opioid Task Force in Chicago, hopes comments like hers will prompt the council to support solutions tailored to women of color, including bringing together more organizations that already work in those communities.

“When you allow more people to be involved, and then they have an idea, and they get excited about it, then they get more people involved and the circle of healing can become larger,” she said.

‘A Retraumatizing Moment’

In Pennsylvania, the state’s 13-member opioid settlement board has the power to withhold future funding if it decides local governments spent their money inappropriately. At its June meeting, the board — which includes a state senator representing part of Kensington — voted to disapprove of Philadelphia’s use of$7.5 million for park improvements, home repairs, rent relief, and other initiatives in Kensington. (Philadelphia later appealed the rejection; the issue is pending.)

McKinney, the Kensington resident and executive director of the New Kensington Community Development Corporation, called the board’s decision “a retraumatizing moment” for residents and criticized the way they were silenced.

“I think it’s unfortunate that things were chosen to be done that way,” McKinney said.

Others have also been frustrated by Pennsylvania’s settlement council.

Gail Groves Scott, a public health policy advocate who has a child in sustained recovery from an opioid use disorder, attended a board meeting in person last year. Not allowing the public to comment at meetings, she said, prevents them from offering feedback at critical times, such as when the board is considering county spending plans or contracts for its operations.

“We could be questioning those decisions or adding information they may not be aware of,” Groves Scott said. “It’s disappointing that, despite pushback from multiple people, they have not changed.”

Some advocates say the closed sessions of work groups, which make recommendations about which programs to approve, obscure why the full board takes certain action.

Pennsylvania trust officials have defended their practices.

Briana Anderson, the trust’s administrative director, downplayed the group’s role, saying it does not make specific spending decisions on settlement money but reviews choices made by local governments. State law doesn’t require the trust to offer public comment at its meetings but the public is encouraged to participate at the local level, Anderson added.

Pennsylvania’s practices contrast sharply with the way councils operate in places like Illinois, Kentucky, and Oregon, which routinely allow public comment at both full council and smaller committee meetings. In Kentucky, the open process has allowed members of the public to weigh in on a fierce debate over funding research into ibogaine, a psychedelic drug that has shown potential to treat addiction. At least eight people spoke in favor of the drug at the council’s January meeting.

Back in Tennessee, council chair Loyd said he hopes to increase public participation by creating an advisory panel that consists primarily of people who have personally experienced addiction or their loved ones.

He also encouraged other settlement councils to embrace opportunities to hear from people in their states.

“You’ll make better decisions as a result. I can’t be convinced otherwise,” he said.

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Methodology

In June and July, reporters from KFF Health News and Spotlight PA surveyed opioid settlement councils in 39 states and Washington, D.C., to assess their general and standard practices for engaging with the public. The team also reviewed council websites, meeting minutes, agendas, and, in some cases, hours of meeting recordings. These councils have various roles, including directly deciding how to spend the money, making recommendations, or providing oversight. Although they go by different names, including advisory councils, boards, committees, and commissions, we refer to them as councils as a broad, encompassing term.

Spotlight PA is an independent, nonpartisan, and nonprofit newsroom producing investigative and public-service journalism that holds power to account and drives positive change in Pennsylvania. Sign up for its free newsletters.

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

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