In December, a mom on Long Island, New York, watched her young daughter get onto a school bus, then had to jump out of the way when a car came speeding past on the shoulder. That same month in Minnesota, a child leaving his school bus had to run to avoid being hit by a pickup truck.

Drivers nationwide continue to barrel illegally past stopped school buses, endangering children and caregivers — and sometimes worse. But some states have found it hard to enforce relatively new laws allowing on-board bus camera systems that record the violations.

Recent deaths during school bus stops include those of a parent and student in separate Texas crashes last year and of a high school student in Pennsylvania in 2022. They highlight continued careless driving around school buses despite flashing stop signs and obvious camera lenses. The recklessness may be part of a pattern of more aggressive driving noted by authorities that has caused more traffic deaths despite fewer miles driven overall since the beginning of the COVID-19 pandemic.

A survey of school bus drivers last year, conducted by the National Association of State Directors of Pupil Transportation Services, estimated 242,000 vehicles illegally passed school buses in a single day. That was up from the 232,000 estimate for 2019. That year, seven states passed laws to allow automatic camera surveillance to catch suspected violators.

Almost half of states have such laws now. Massachusetts and Oregon considered, but didn’t pass, similar legislation last year. A school bus camera program in Bridgeport, Connecticut, was held up last year amid debates in the state legislature over the size of fines and their impact on low-income communities.

But there are several reasons why enforcement might not have been as effective as intended.

Some safety authorities object to new camera laws that reduced fines and excluded license points and other more punitive actions allowed when the same violations are caught in person by law enforcement. Legislatures may have softened school bus penalties to gain consensus among skeptical lawmakers, authorities say.

Some states also are struggling with the limitations of cameras when it comes to enforcing laws requiring evidence police officers can see in person but cameras might not catch. The cameras might not show school bus markings mentioned in the law or whether students are actively getting on or off buses. Another technical issue: School bus cameras have flagged cars on different streets or in lanes separated by medians, where they’re not legally required to stop.

How it works

Typically, the automatic cameras are engaged when a bus driver turns on a flashing stop sign, triggering a computer program that detects violations and sends them to reviewers to check before mailing a violation notice. But the cameras can’t capture everything.

On New York’s Long Island, a state appeals court threw out a $250 ticket in November, saying evidence from bus cameras isn’t enough to prove a violation. Judges on the court said the camera did not establish that the school bus had correct markings or that it was actively picking up or dropping off passengers at the time of the ticket. That decision could endanger $25 million in annual fines from one county alone if other tickets are struck down.

In Pittsburgh, a district court judge told Stateline he dismisses most cases based on school bus cameras for insufficient evidence from the cameras.

Judge James Motznik said he also objects to the way Pennsylvania’s law, like most state laws allowing automatic camera evidence to identify bus-passing violations, undermines a traffic law that’s more punitive. The camera violations are issued as “civil complaints” with a lower fine and no loss of license points as required by the original traffic law against passing a stopped school bus.

“It was sold as a deterrent to enhance public safety,” Motznik said. “But it’s actually less of a deterrent. If a police officer witnessed this, there’d be a $500 fine, a license suspension, points toward losing your license. A camera sees the same thing, it’s $300 and goodbye.”

State legislatures sometimes have used less-punitive fines, without license points or suspensions, as a bargaining chip to reach agreement on camera enforcement such as school bus cameras, said Russ Martin, senior director of policy and government relations for the Governors Highway Safety Association.

“The thought was like, ‘We can make this more accepted by the public.’” Martin said. “But there’s another side to it. In some ways the points are more important than the fines for the worst violators — it means you can’t just pay your way out.”

Pennsylvania’s law on school bus cameras was updated last year partly to allow a lower-cost way for motorists to contest tickets, using a state hearing officer in a free process instead of a court that requires filing fees, said Jennifer Kuntch, a spokesperson for the state transportation department. Pittsburgh schools recorded more than 9,000 violations since the bus camera program began in July, the district announced last month.

On Long Island, the appeals court decision against the red-light camera evidence endangers not only Suffolk County’s program, which receives the $25 million in fine revenue a year, but also nearby Nassau County, where a class-action lawsuit is underway on behalf of 132,000 drivers with similar fines.

The appeals court ruling was vexing for local governments, said Paul Sabatino, an attorney and former Suffolk County legislative counsel. Cameras are a necessary part of enforcing the law against passing stopped school buses, he said.

“You can’t allow people to endanger children like that, and you can’t call out the National Guard to watch every school bus at every stop,” Sabatino said.

Many school districts use contractors such as Virginia-based BusPatrol, which claims 90% of the market for school bus cameras, with some competition from others such as RedSpeed USA and American Bus Video. The companies may include school bus stop-arm cameras within a package of other automated traffic enforcement.

Justin Meyers, president of BusPatrol, said the company already has addressed evidence questions in New York state by adding to its “evidence packets” the school bus markings and maps showing the bus is on an established route. Suffolk County is the company’s biggest customer, and BusPatrol has made a $40 million investment in equipping school buses there, Meyers said in an interview. It also operates in Pittsburgh.

The company uses computer algorithms and artificial intelligence to detect violations, which are then screened for accuracy by a BusPatrol employee before going to local law enforcement for a final decision on whether to issue a violation notice, Meyers said.

Few statistics available

There are few statistics on the extent of deaths and injuries from passing stopped school buses. Pennsylvania reviewed crash records at Stateline’s request and said 12 such crashes occurred in 2022 and 13 in 2021, with one death in each year — one a student, one a parent — and 23 injuries across both years. Those figures include a crash that killed a 16-year-old high school student in November 2022 as she was trying to board a school bus in York County.

Across the country, the National Highway Traffic Safety Administration found 53 fatalities, half of them school-age children, between 2000 and 2021 in accidents involving illegal passing of a school bus, according to an analysis requested by Stateline.

In Minnesota, school districts can apply for state funds to install school bus cameras. The Edina school district sought money last year after an “alarming” increase in bus-passing violations reported by bus drivers, along with two injuries to students, according to a press account in the local Sun Current newspaper. The district won $105,000 for cameras, a cost of about $4,000 per bus, and in January reported drivers had been ticketed for 70% of passing violations noticed by bus drivers, up from 5% without cameras.

In one of the Texas fatalities last year, a woman helping her child onto a bus in Upshur County was killed by a vehicle passing the bus, Sgt. Adam Albritton, a spokesperson for the state Department of Public Safety, told Stateline. The crash was reported, a driver was charged with manslaughter, and police are reviewing footage from a video camera on the bus for evidence, Albritton said.

Texas was an early adopter of video cameras to catch school bus passing violations, commissioning a 2008 study on such cameras. The state did not include school bus cameras in its ban on automated traffic enforcement in 2019. Not all school districts participate, but Austin, Dallas and San Antonio are among those that do.

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

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

House Republicans last year were the least unified party bloc on legislation in more than four decades, CQ Roll Call’s annual Vote Studies analysis of congressional data found.

And that’s the case even without the multiple ballots it took to pick a speaker at two different points in the year, though those fights were certainly symptomatic.

The data show Republicans had only a 63.7 percent success rate on “party unity votes” or roll calls on bills, amendments and resolutions in which majorities of the two parties were on opposite sides of roll call votes. The metric ignores votes where both parties were overwhelmingly for or against a bill to identify cases where a member’s vote had the most potential to tip the scales one way or another.

The last time a majority party lost more unity votes was when Democrats presided in 1982, the second year of President Ronald Reagan’s first term, and prevailed just 63.5 percent of the time.

‘Stymied’ by hard-liners

There are parallels between 1982 and 2023, notes Princeton University politics professor Frances Lee. In both cases, the House was controlled by the party that did not control the Senate and the White House.

But, Lee explained, “A key difference between the 1982 Democrats and the 2023 Republicans is that the 2023 Republicans have been repeatedly stymied by a hard-line bloc, whereas the 1982 Democrats had to contend with a swing moderate/conservative contingent who wanted to work with the Reagan White House.”

In this Congress, spending fights have been an ongoing flashpoint within the GOP majority, and divisions reached a head with the historic Oct. 3 ouster of California’s Kevin McCarthy from the speaker’s chair after a faction moved to punish him for calling a vote on a short-term spending extension to prevent a government shutdown.

In 2023, many of the party unity votes that drove down the GOP’s success rate came on floor amendments to appropriations bills. Those votes included a slew of salary reduction amendments aimed at individual executive branch employees, as well as broader efforts to reduce funding for federal programs.

Of the 515 House party unity votes, 54 of them (more than 10 percent) were on measures to reduce salaries for officials ranging from the White House press secretary to the acting administrator of the National Highway Traffic Safety Administration.

Those votes tended to follow a pattern, with all Democrats present voting “no” and between 45 and 75 Republicans crossing over to join the opposition.

“The American people should not be forced to pay the salary of an individual who dispenses bold-faced lies to the American people,” Rep. Claudia Tenney, R-N.Y., said during floor debate in November after seeking to reduce the salary of White House Press Secretary Karine Jean-Pierre to $1.

Like others, that amendment was not adopted, with the final tally being 165-257.

Seven of the votes came on amendments to reduce appropriations for regional commissions funded through the Energy and Water Development spending bill.

The commissions, like the Denali Commission in Alaska and the Appalachian Regional Commission, are favorite agencies of some lawmakers who see them as providing economic development funding and services to their constituents.

Rep. Scott Perry, R-Pa., offered separate amendments to reduce funding for several of the commissions and faced similar defeats in each case, running up the score in terms of party unity votes. All told, the House took seven roll call votes on amendments to reduce commission funding that all proved unsuccessful for the GOP position.

The data show, therefore, that one concession McCarthy made to the most conservative faction in the caucus helped drive down the unity rate.

Leaders usually do not call for votes they know will not pass, but McCarthy agreed to a much more robust amendment process on spending bills than Democrats and even some of his GOP predecessors allowed when they had the majority. The change led to conservative members being able to force amendment votes that had no chance of success.

Speakers of the recent past, in contrast, would routinely consider appropriations measures under more restrictive rules and closed processes.

Rules defeated

Arguably, the most significant losses for Republicans, however, came on rules themselves. Rules votes, which set the framework for how long debate can take and what amendments are allowed, effectively give the majority its power to set the agenda. They traditionally get near-unanimous support from the ruling party, even if members plan to vote later against the underlying legislation. Until July 2023, no rule had been defeated on the House floor since November of 2002.

Two of the year’s most significant successful House votes completely divided the majority party, with Republican unity rates slightly above 50 percent against the December measure that expelled Rep. George Santos, R-N.Y., and a September vote on Ukraine security assistance.

Republicans started the year with a 222-213 majority, meaning leaders could afford to lose only four GOP votes and still prevail if every Democrat voted “no.” That was the same split then-Speaker Nancy Pelosi had in 2022, however, when Democrats won 91.4 percent of party unity votes that year, their lowest majority win rate since 2010.

“House Republicans have contended with similar difficulties under other recent leaders dating back at least to Boehner,” Lee said in an email, referring to GOP Speaker John Boehner who held the gavel from 2011 through 2015. “Their problems were more severe in 2023 given the party’s narrow margin of control and hard-liners’ newfound willingness to withhold support for the party’s procedural control of the House.”

Senate trend continues

Senate unity rates for 2023 were more in line with recent trends. Roughly 81 percent of the roll call votes cast in 2023 were unity votes, with the majority Democrats prevailing 91.5 percent of the time. Most of the unity votes were on nominations or on procedural votes to set them up, meaning essentially duplicate votes boosted the average. All told, 208 of the 284 Senate unity votes in 2023 were on nominations.

Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Lindsey Graham of South Carolina were the only three Republicans to vote the opposite way from most their GOP colleagues more than 100 times, with Collins leading the way at 186.

All three are senior appropriators, but the bulk of the votes in question were nominations. For instance, of the 124 times that Graham broke, 119 (96 percent) were on nominations.

The results have been basically the same since Senate Majority Leader Charles E. Schumer of New York started setting the agenda in 2021, operating with the narrowest of margins.

Twelve of the 24 times that Senate Republicans prevailed on party unity votes came on votes related to overturning regulations adopted by the executive branch or the District of Columbia municipal government. These measures were able to get up-or-down votes because they were not subject to the 60-vote threshold normally needed to end debate on legislation. But they were also subject to President Joe Biden’s veto, which he used nine times and was not overriden.

©2024 CQ-Roll Call, Inc. Visit at rollcall.com. Distributed by Tribune Content Agency, LLC.

Physician groups and other advocates for overhauling the Medicare payment system will lose three of their biggest Capitol Hill supporters to retirement next year, raising questions about next steps for long-term changes to the Medicare payment program.

Republican Reps. Larry Bucshon of Indiana, Michael C. Burgess of Texas and Brad Wenstrup of Ohio, all members of the GOP Doctors Caucus, have been vocal in pushing for changes to the way Medicare pays physicians.

The current system has been fraught with controversy, with doctors complaining their rates don’t keep up with inflation and with requirements that payments be budget-neutral, resulting in cuts to doctor pay. Meanwhile, a near decadelong push to embrace value-based care has not panned out.

Burgess, Bucshon and Wenstrup, who are all doctors, have become well-known on Capitol Hill for translating wonky Medicare policies and communicating the needs of fellow physicians to their colleagues, carving out a particular niche issue in Medicare physician payments. Burgess and Wenstrup co-chair the GOP Doctors Caucus with Rep. Greg Murphy, R-N.C.

“They’ll really be missed,” said Margaret C. Tracci, chair of the advocacy council at the Society for Vascular Surgery.

Burgess, who came to Congress in 2003, is a former chair of the House Energy and Commerce Health Subcommittee, and Bucshon currently is the vice chair. They, along with Wenstrup, who came to Congress in 2013, owned or worked in private practice and came to the job with experience of not just treating patients but running small businesses and working with Medicare.

Tracci said their experience helped them translate the “very complex issue” of Medicare payment, easing the burden for doctors pressed to explain the complications of the payment system to laymen. “It really creates a lot more work for physicians and for physician advocacy groups to climb that hill again of trying to translate what the needs are,” Tracci said.

But now, the lawmakers’ retirements might leave a long-term overhaul unfinished, with Congress instead pursuing other priorities and distracted by an election year.

“It’s going to be hard, but I think we’re just going to try and lay some of the groundwork,” Bucshon said, referring to hoped-for changes to the Medicare Access and CHIP Reauthorization Act of 2015, commonly called MACRA, which aimed to stabilize physician payments and reward quality instead of volume.

The road to MACRA

Bucshon came to Congress in 2011, when doctors were fighting a similar Medicare payment problem: the sustainable growth rate, which also resulted in cuts to physician pay year after year, with Congress stepping in on an ad hoc basis to avert those cuts.

Viewing those short-term fixes as ultimately unworkable, Burgess led the effort to get Congress to pass MACRA, which repealed the sustainable growth rate formula while providing new frameworks to shift payments toward value instead of volume.

But it hasn’t quite worked out that way, doctors say.

The new law’s budget neutrality requirement has typically meant that pay increases for one specialty, like primary care doctors, have resulted in cuts to others.

Since 2020, Congress has stepped in to avert cuts triggered by the law’s budget neutrality requirements. But lawmakers haven’t acted on the issue this year, and cuts took effect Jan. 1.

“MACRA, in many respects, has outlived its usefulness,” said Susan Dentzer, president and CEO of America’s Physician Groups. “It was very important at the time and got us out of a rut that the system was in around a prior formula for setting payments. But it [MACRA] was enacted in 2015 and it’s been 10 years.”

While Bucshon, Burgess and Wenstrup are pushing for short-term fixes to the most recent cuts in the next spending package, the prospects for long-term change are murky.

Other options

One bill, sponsored by Rep. Mariannette Miller-Meeks, R-Iowa, and co-sponsored by Burgess, Wenstrup and Bucshon, would lift the budget neutrality threshold from $20 million to $53 million per year.

Currently, if the fee schedule increases spending by more than $20 million, cuts are triggered. Raising the threshold would provide more breathing room in the fee schedule, but the American Medical Association has pushed for a $100 million at least, paired with other changes.

“These are significant steps and the urgency cannot be overstated,” Burgess said on the House floor last month, referring to the legislation.

But floor action is unclear at this point. Negotiators are working on including some kind of “doc fix” in the spending package due in March. Broader, long-term changes will take time.

“It’s clear that we need to do some reforms to MACRA, and we clearly need to change the physician fee schedule, but it’ll be hard,” Bucshon said.

Bucshon also co-sponsors a bill, sponsored by Rep. Raul Ruiz, D-Calif., that would require that physician payment updates be tied to inflation, a concept also supported by AMA and other physician groups. That bill hasn’t received committee consideration.

“There used to be a greater opportunity for them [retiring members] to get something on their way out the door,” said Rodney Whitlock, vice president at McDermott+Consulting and a former GOP aide. “I’m not too certain that I’m as big of a believer in that as I used to be, but once you decide you won’t be here, you fight like hell to get something done on the way out, and I wouldn’t expect any less of these guys.”

Other problems

Also among disappointing aspects of the 2015 law, doctors say, are the pathways it set up for doctors to be graded and paid for delivering value-based care.

Nearly 10 years after the bill’s passage, the committee that advises Congress on Medicare policy has recommended that one of those pathways, the Merit-based Incentive Payment System, should be eliminated because it imposes a significant reporting burden on providers, exempts more physicians than will participate and results in small bonuses for those who do.

Meanwhile, participation in the other pathway, alternative payment models, and the savings it was intended to generate haven’t been as high as was originally hoped.

Physician practices had complained that the models available were not applicable to them. One of the main types of models, accountable care organizations, worked best for integrated health systems and not small independent practices, doctors say.

Those problems are harder to fix. And the loss of institutional knowledge from lawmakers like Burgess, who helped draft the law and knows in depth how it works and what was intended, is not a small thing, said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association.

“The comprehensive fix to what we’re dealing with — the aftermath of MACRA reform — would be helped by many of the physicians in Congress that unfortunately are retiring this year,” he said.

©2024 CQ-Roll Call, Inc. Visit at rollcall.com. Distributed by Tribune Content Agency, LLC.

Each fall, millions of hunters across North America make their way into forests and grasslands to kill deer. Over the winter, people chow down on the venison steaks, sausage, and burgers made from the animals.

These hunters, however, are not just on the front lines of an American tradition. Infectious disease researchers say they are also on the front lines of what could be a serious threat to public health: chronic wasting disease.

The neurological disease, which is contagious, rapidly spreading, and always fatal, is caused by misfolded proteins called prions. It currently is known to infect only members of the cervid family — elk, deer, reindeer, caribou, and moose.

Animal disease scientists are alarmed about the rapid spread of CWD in deer. Recent research shows that the barrier to a spillover into humans is less formidable than previously believed and that the prions causing the disease may be evolving to become more able to infect humans.

A response to the threat is ramping up. In 2023, a coalition of researchers began “working on a major initiative, bringing together 68 different global experts on various aspects of CWD to really look at what are the challenges ahead should we see a spillover into humans and food production,” said Michael Osterholm, an expert in infectious disease at the University of Minnesota and a leading authority on CWD.

“The bottom-line message is we are quite unprepared,” Osterholm said. “If we saw a spillover right now, we would be in free fall. There are no contingency plans for what to do or how to follow up.”

The team of experts is planning for a potential outbreak, focusing on public health surveillance, lab capacity, prion disease diagnostics, surveillance of livestock and wildlife, risk communication, and education and outreach.

Despite the concern, tens of thousands of infected animals have been eaten by people in recent years, yet there have been no known human cases of the disease.

They think, “I am not going to worry about it because it hasn’t jumped the species barrier,” Rinella said. “That would change dramatically if a hunter got CWD.”

Other prion diseases, such as bovine spongiform encephalopathy, also known as mad cow disease, and Creutzfeldt-Jakob disease, have affected humans. Mad cow claimed the lives of more than 200 people, mostly in the United Kingdom and France. Some experts believe Parkinson’s and Alzheimer’s also may be caused by prions.

First discovered in Colorado in captive deer in 1967, CWD has since spread widely. It has been found in animals in at least 32 states, four Canadian provinces, and four other foreign countries. It was recently found for the first time in Yellowstone National Park.

Prions behave very differently than viruses and bacteria and are virtually impossible to eradicate. Matthew Dunfee, director of the Chronic Wasting Disease Alliance, said experts call it a “disease from outer space.”

Symptoms are gruesome. The brain deteriorates to a spongy consistency. Sometimes nicknamed “zombie deer disease,” the condition makes infected animals stumble, drool, and stare blankly before they die. There is no treatment or vaccine. And it is extremely difficult to eradicate, whether with disinfectants or with high heat — it even survives autoclaving, or medical sterilization.

Cooking doesn’t kill prions, said Osterholm. Unfortunately, he said, “cooking concentrates the prions. It makes it even more likely” people will consume them, he said.

Though CWD is not known to have passed to humans or domestic animals, experts are very concerned about both possibilities, which Osterholm’s group just received more than $1.5 million in funding to study. CWD can infect more parts of an animal’s body than other prion diseases like mad cow, which could make it more likely to spread to people who eat venison — if it can jump to humans.

Researchers estimate that between 7,000 and 15,000 infected animals are unknowingly consumed by hunter families annually, a number that increases every year as the disease spreads across the continent. While testing of wild game for CWD is available, it’s cumbersome and the tests are not widely used in many places.

A major problem with determining whether CWD has affected humans is that it has a long latency. People who consume prions may not contract the resulting disease until many years later — so, if someone fell sick, there might not be an apparent connection to having eaten deer.

Prions are extremely persistent in the environment. They can remain in the ground for many years and even be taken up by plants.

Because the most likely route for spillover is through people who eat venison, quick testing of deer and other cervid carcasses is where prevention is focused. Right now, a hunter may drive a deer to a check station and have a lymph node sample sent to a lab. It can be a week or more before results come in, so most hunters skip it.

Montana, for example, is famous for its deer hunting. CWD was first detected in the wild there in 2017 and now has spread across much of the state. Despite warnings and free testing, Montana wildlife officials have not seen much concern among hunters. “We have not seen a decrease in deer hunting because of this,” said Brian Wakeling, game management bureau chief for the Montana Department of Fish, Wildlife & Parks. In 2022 Montana hunters killed nearly 88,000 deer. Just 5,941 samples were taken, and 253 of those tested positive.

Experts believe a rapid test would greatly increase the number of animals tested and help prevent spillover.

Because of the importance of deer to Indigenous people, several tribal nations in Minnesota are working with experts at the University of Minnesota to come up with ways to monitor and manage the disease. “The threat and potential for the spread of CWD on any of our three reservations has the ability to negatively impact Ojibwe culture and traditions of deer hunting providing venison for our membership,” said Doug McArthur, a tribal biologist for the White Earth Nation, in a statement announcing the program. (The other groups referenced are the Leech Lake Band of Ojibwe and Red Lake Band of Chippewa.) “Tribes must be ready with a plan to manage and mitigate the effects of CWD … to ensure that the time-honored and culturally significant practice of harvesting deer is maintained for future generations.”

Peter Larsen is an assistant professor in the College of Veterinary Medicine at the University of Minnesota and co-director of the Minnesota Center for Prion Research and Outreach. The center was formed to study numerous aspects of prions as part of the push to get ahead of possible spillover. “Our mission is to learn everything we can about not just CWD but other prionlike diseases, including Parkinson’s and Alzheimer’s disease,” he said. “We are studying the biology and ecology” of the misfolded protein, he said. “How do prions move within the environment? How can we help mitigate risk and improve animal health and welfare?”

Part of that mission is new technology to make testing faster and easier. Researchers have developed a way for hunters to do their own testing, though it can take weeks for results. There’s hope for, within the next two years, a test that will reduce the wait time to three to four hours.

“With all the doom and gloom around CWD, we have real solutions that can help us fight this disease in new ways,” said Larsen. “There’s some optimism.”

(KFF Health News, formerly known as Kaiser Health News (KHN), 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.

Expressing undying love for your sweetheart on Valentine’s Day doesn’t cost any money, but nearly everything else does. Some 53% of Americans planned to celebrate Valentine’s Day in 2024, bringing the expected holiday spending total to $25.8 billion, according to the National Retail Federation’s 2024 Valentine’s Day Spending Survey.

While there’s nothing wrong with showering someone you love with gifts, it’s still possible to celebrate this wonderful holiday on a budget. Below, we’ll explore some steps savvy consumers can take to keep their expenses under control.

1. Plan ahead

Valentine’s Day is all about love — but it’s also about sweets, flowers and fine dining. Last year, OpenTable reported Saturday, Feb. 12, as the single biggest dining day of the year, with more than 50% of Valentine’s Day reservations booked by Feb. 7— and dining out exceeding pre-pandemic levels.

For 2024, lovebirds may want to plan for Saturday, Feb. 10 — and get reservations for that candlelit dinner as soon as possible, especially for top restaurants. You might want to use the same approach for buying gifts as well. Shop well in advance to make sure you get what you want and avoid overspending at the last minute.

2. Celebrate at home

For Valentine’s Day 2024, Americans are expected to spend 8.1% more than last year on restaurants and dining, according to the U.S. Bureau of Labor Statistics. To avoid the high cost of a night out, consider cooking a romantic dinner together. This can be a fun and intimate experience (as long as you know your way around the kitchen). Heck, meal-kit company HelloFresh reports that 42% of their respondents prefer a home-cooked meal on Valentine’s Day.

Whether you dine in or dine out, there are ways to reduce your financial burden. For instance, you may want to consider using one of the top credit cards for dining out or buying groceries — like the American Express® Gold Card or the Capital One SavorOne Cash Rewards Credit Card — to earn rewards on your food purchases.

Additionally, many credit cards offer their own dining programs to help you save or earn rewards (such as Capital One Dining), or partner offers on meal-kit, grocery or dining services. For example, the Chase Sapphire Preferred® Card comes with partner bonuses for Instacart+ and Gopuff, along with other food-related perks.

3. Get creative with gift ideas

Along with Valentine’s Day cards — first produced by Hallmark back in 1913 — it’s become customary for lovers to gift each other candy and flowers (usually roses).

According to the NRF, candy (57%), greeting cards (40%) and flowers (39%) are expected to be the most popular gifts for Valentine’s Day in 2024. And let’s not forget that 22% of NRF respondents chose to gift jewelry.

As you can see, Valentine’s Day can be pricey, especially if you choose more than one present for your loved one. To get more creative with your gift ideas, it may help to think of flowers other than roses. Not only are roses pricey, but they don’t last long. And they aren’t the only flowers suitable for Valentine’s Day, according to the Society of American Florists. Alternatives to consider include tulips, daisies and lilies, many of which may be cheaper than roses.

If you’re looking to cut back on Valentine’s Day costs, consider creating your own gift rather than buying one. You can find many inexpensive DIY ideas and kits available — like candle-making kits, cookie kits and embroidery portraits — that are thoughtful and won’t break your wallet.

4. Redeem your credit card rewards

You don’t earn credit card rewards for sport — rather, redeeming rewards is like a valuable rebate on your spending. And yet many people have unused rewards year after year. A 2021 Bankrate survey found that a third of rewards card holders never redeemed rewards in the previous year. If a penny saved is a penny earned, then failure to cut your expenses by using rewards is no better than leaving money on the table.

In some cases, hoarding rewards makes sense. For example, some people might want to accumulate more rewards for a specific reward, like an award flight or hotel room. This strategy is not without risks, however. Travel providers regularly devalue their loyalty programs, and your favorite travel currency may simply not be the same next year or at some point in the future.

If you’re not interested in redeeming your rewards for travel on Valentine’s Day, you might want to consider redeeming your rewards for gifts. For example, your credit card may allow you to redeem your rewards for gift cards, or you could put a new card’s welcome bonus toward a gift for a loved one. Also, make sure to check out your credit card’s limited-time-offer program — like Amex Offers or Chase Offers — for deals you can earn by shopping with select merchants.

5. Take advantage of gift cards

Gift cards can make a great Valentine’s Day present, as long as the object of your affection loves the merchant (and gift cards). However, be sure they don’t neglect using them — gift cards are easy to lose or forget about. Nearly half of U.S. adults (47%) had at least one unused gift card, voucher or store credit, according to a 2023 Bankrate survey, with an average value of $187 per person.

If you have any unused gift cards from over the holidays, you may want to consider using them to buy a gift for a loved one.

6. Set a budget and stick to it

There’s nothing wrong with pampering the person you love with gifts, as long as you know what you can afford and don’t go over your budget. Whether you intend to spend $60 or $1,000 on Valentine’s Day, make an itemized gift list and stay on track with your finances. Valentine’s Day might be the most romantic holiday of the year, but there is nothing romantic about going into debt for overshopping. Be realistic about what you can and can’t afford — and stick to your budget.

The bottom line

Valentine’s Day can be an expensive holiday, but you don’t have to spend a lot to impress your loved one — especially if you plan ahead, stick to a budget and think of some creative Valentine’s Day ideas. If you’re looking to save money, you may want to exchange thoughtful, homemade gifts rather than expensive gifts. Or try a low-key couples activity, like cooking dinner together at home. On the other hand, if there’s a new restaurant you’ve wanted to try, you just might want to use this occasion to check it off your gustatory list.

Key takeaways

•This Valentine’s Day, romance doesn’t have to break the bank — in fact, there are ways to celebrate the day that can fit any budget.

•Celebrating in creative ways at home can make it easier to save money on the holiday, but so can being savvy with your credit cards.

•Whether you want to go out for a lavish dinner or trade off your favorite candy at home with your loved one, don’t forget to plan ahead — reservations will fill up quickly, and sales won’t last forever.

(Visit Bankrate online at bankrate.com.)

©2024 Bankrate.com. Distributed by Tribune Content Agency, LLC.

SAN DIEGO — The pop-pop-pop of gunfire cracked just as the rain started to fall in grisly synchronicity. Then the screams began.

Within moments, civilians lay strewn across the ground, some lifeless, others writhing in pain. Blood flowed in streams that pooled with the rainwater on the muddying ground littered with shell casings.

Three gunmen quickly opened fire on a San Diego County Sheriff’s Department armored BearCat truck arriving in response. It crawled along an alleyway. Half a dozen SWAT members pointed rifles into open doorways or fired back from behind corners.

One assailant, wearing black gloves and a graying black beard, stood on a third-floor apartment balcony and, as deputies came closer, threw a Molotov cocktail at two white cars parked below. The explosion sent a blast of heat and sound, its boom punctuated by the gunman’s AK-47.

“Help me!” bellowed a man rolling on the ground, blood shooting from his severed leg. Another man groaned next to him, hidden by smoke billowing around the cars.

It seemed like something out of an action movie. And, in a way, it was.

The rounds were blanks, the Molotov cocktail wasn’t lit, the smoke came from a machine. The explosion was controlled, the victims and gunmen were actors, and the blood was fake. However, the deputies, firefighters and doctors from across the region were real.

They were in the middle of a simulation on a Saturday afternoon in mid-January in a commercial lot on the north end of San Diego, conducted by Strategic Operations, a local company run by former Hollywood producers and military combat veterans.

First responders and law enforcement agents have for decades used simulations to train for mass casualty events such as shootings or natural disasters, especially after the Columbine school shooting in 1999. But in recent years, as mass shootings have become increasingly common in the United States, the simulations have become more and more realistic. Now they feature visceral sound effects, trained actors, pyrotechnics and even virtual reality. The trainings also have become more and more expensive for public agencies.

But hyper-realistic simulations are essential for learning how to respond to an active shooter, triage mass casualties and coordinate among departments in a chaotic environment, said Sgt. Colin Hebeler, who works in the Infrastructure Security Group within the San Diego County Sheriff’s Department. The department has two facilities where deputies go through similar simulation training.

“If we can provide these trainings that are as close to the real-life event as possible, you will actually induce that same kind of stress and the reaction that you might have during a real-life incident,” he told Stateline.

Stop the killing, stop the dying

Training has evolved in Hebeler’s 16 years in the department, expanding well beyond both the classroom and limited simulations that involved plastic pieces that looked like guns and shouts of “Bang, bang.” Although expensive, simulated mass shootings are far more intense, realistic and frequent now, he said.

“If it does happen, we’re going to be prepared,” Hebeler added. “We don’t want this to be one of those catastrophic events that comes out on the news, and everyone says, ‘Well, the law enforcement messed up.’”

Law enforcement agencies continue to face public scrutiny over how they respond to mass shooting events — highlighted by last month’s scathing report from the U.S. Department of Justice on the response to the 2022 school shooting in Uvalde, Texas, that left 21 people dead, all but two of them elementary school children.

First responders are trained to focus on two things in a mass shooting event: Stop the killing and stop the dying. By waiting 77 minutes outside the fourth grade classrooms where the active shooter was before confronting and killing him, Uvalde law enforcement failed to follow protocols and that cost lives, the federal report found.

Uvalde showed “layer upon layer upon layer of failures,” said Jaclyn Schildkraut, executive director of the Regional Gun Violence Research Consortium at New York’s Rockefeller Institute of Government. Simulations highlight the sights, sounds and smells of an active shooter event in a controlled environment so the failures seen in Uvalde don’t occur, she said.

“It doesn’t matter if you’re the first officer or by yourself or there’s 20 of you, you go in and you stop the shooter, and then you start trying to help the people who’ve been injured,” she said.

“Simulations are really about acclimating you to what you might encounter on that given day, so that you are able to maintain that focus and subsequently your safety as best as possible.”

But she wanted to be clear about one point: This kind of training should never be used in schools among children. It is far too traumatic.

Simulation’s increased use

Seventeen miles east of downtown Raleigh, North Carolina, Wake Technical Community College is building a 60,000-square-foot facility with an 8-acre driving pad that is dedicated to reality-based simulation training for police, fire and emergency medical workers.

From the outside, observers wouldn’t realize the massive gray complex is full of buildings and streets, with spaces designed to mimic the commercial, jail, residential and school spaces first responders would experience in their communities. Trainees can drive into the facility, pull up to a specific location inside and respond to the simulated event — a school shooting, for example, or a fire inside a supermarket.

During mass shooting simulations, trainees will experience the disaster through all their senses: It could smell like smoke, there might be flashing lights and sirens, role players may act as screaming victims or use simulated munitions filled with paint. The $60 million facility, which is slated to open this spring, was funded by a bond that Wake County voters approved in 2018.

For officers, simulation training is much more effective than shooting at a line of paper targets, or simply going over shoot/don’t-shoot scenarios, said Jamie Wicker, provost of public safety education at Wake Tech. Training for mass shooting events has developed over many years with the help of veterans who served in Afghanistan and Iraq, she added.

“It’s one thing to describe chaos. It’s completely different to experience chaos,” said Wicker, who has been in law enforcement for more than 20 years, in part as a trainer. “This is managed chaos.”

This approach has been backed up by researchers who have studied the effectiveness of simulation training for first responders.

When officers respond to a mass shooting, they’re running, maybe up a flight of stairs or while carrying people. They will see victims who are injured or dead. They will be worried about the shooter’s location. Meanwhile, parents may be rushing to the scene, along with additional first responders from agencies across the region who might not have interacted with one another before.

While an increased heart rate can produce positive reactions such as adrenaline and sharpened senses, it can quickly turn negative, leading to tunnel vision, auditory exclusion or impaired judgment, Dolly said.

“You want to, at some level, induce that in a training environment,” he said. “It conditions the officer to inoculate them from being overwhelmed by all that when the time comes.”

For the past decade, federal law enforcement has viewed the Advanced Law Enforcement Rapid Response Training Center, known commonly as the ALERRT Center, as the national standard for active shooting simulation training. Hundreds of thousands of police officers have received training from the center, which was formed in the wake of Columbine and has been housed at Texas State University since 2002.

Funded by a line item in the Texas state budget and federal grants, ALERRT is mandated to train 80,000 Texas officers every two years at its facility in San Marcos — a city between Austin and San Antonio. But center experts also go to all 50 states to spread their training, going to schools during breaks and to businesses, at no cost to trainees or their agencies.

Sometimes they use local drama students to play victims, wearing makeup and moulage, simulating a wound. “They love it,” said Larry Balding, external resources director with the center.

For the training, ALERRT likes long hallways and T intersections — stress points for law enforcement responding to an active shooter. Beyond learning how to stop the shooter, trainees focus on getting victims to an operating table. Gunshot victims only have around 30 minutes before it’s too late, said Balding, who used to be in the fire service.

“Nobody will ever be 100% ready,” he said. “But if you can get a new officer, get him trained, trying to get the mindset right, that’s what we want to do.”

When asked where simulation training is heading in the field of first responders, Balding didn’t hesitate: virtual reality.

Training in the virtual world

The floor of the San Diego Convention Center was filled with lifelike mannequins — bleeding, blinking, moving and able to be poked and prodded and to respond to questions. Some were even pregnant, with a baby ready to squirm out when prompted.

Among the 140 health care presenters last month at a conference organized by the Society for Simulation in Healthcare, a membership nonprofit that seeks to promote simulation training to reduce errors in medical care, were companies that want to take the industry in a whole new direction with virtual reality.

Whether first responders use Oculus headsets to learn how to interact with patients in an emergency room or use lifesaving tools at the scene of a shooting, localities are turning more to virtual reality training for first responders, said Dr. Barry Issenberg, president of the society.

“It’s the reduction of errors, safer care, safer way of training,” said Issenberg, who is also the director of the Gordon Center for Simulation and Innovation in Medical Education at the University of Miami. “What we’re doing is not just a cool idea, but ultimately going to make an impact for their constituents.”

The society worked with the Hollywood-style facility, which organized the simulation for the San Diego County Sheriff’s Department and other local first responders who participated the day before. Around 100 visiting academics and health care workers in town for a conference were among the onlookers.

While researchers have found in several studies that virtual reality can add some benefits to health care training, there is still some skepticism.

Dolly, at the National Policing Institute, sees “some promise” with virtual reality for training police officers. It can be a cost-effective alternative to in-person simulations and can help officers train in shoot/don’t-shoot scenarios.

However, he does see limitations with not being able to run around and experience viscerally the confusion of a mass shooting, which can be fully felt with an in-person simulation.

Back at the San Diego shooting simulation, screams still pierced the air.

Gunfire continued for another minute, as the seven deputies dashed from room to room in the complex of buildings. They killed the shooters, then carried some of the wounded down flights of stairs.

After the shots finally stopped, the screams of victims were nearly drowned out by the wail of ambulance sirens.

Firefighters and emergency medical technicians rushed bloodied victims in stretchers to nearby pop-up emergency and operating rooms, where Navy doctors tried to keep their footing on floors slippery with blood and worked to close victims’ wounds.

Wearing blue scrubs and shoe coverings, doctors turned victims on their side and searched for exit wounds. One demanded O negative blood.

An hour after the first shots rang out, the simulation ended. The first responders gathered in the ER in a semicircle. An instructor quieted the room, asked for the beeping heart monitors to be shut off and turned to the participants.

“So, what did we learn?”

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

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

There are people who love to give travel advice, and then there are Distinguished Travel Hackers. They are road warriors who love to share their high-end hacks, tips and off-the-wall experiences.

David Alwadish is one of them. He is the founder and chief executive officer of ItsEasy, which specializes in expediting travel-related paperwork such as passports and visas. The company has processed over 2 million such documents in more than four decades, and it’s authorized by the U.S. State Department to provide passport services to the public for a fee. It can also pre-review applications to ensure they won’t be rejected at the last moment and intervene if issues arise.

The 67-year-old executive commutes between two homes, one in Great Neck, New York, and the other in Boca Raton, Florida, which influences his airline of choice. “I travel so much on JetBlue, because they have the latest flights to get me to Boca Raton. I can leave my office late and make their last flight,” he says.

His schedule — back and forth to Florida every other week or so — means he racks up around 60,000 miles per year, and more if he and his wife and two sons venture overseas on a trip or two.

Alwadish has a go-to gadget when he’s heading anywhere cold. The durable, double-duty Ocoopa Hand Warmer is a little cheat. It’s great for keeping my hands warm on the go. I love to take it with me on cold weather trips. In 2015 I had a (heart) valve replacement, and since then, I get a little chilly. With three temperature settings, it can be tailored to your specific needs, whether you’re outdoors in the cold or indoors in a chilly environment. Because it’s rechargeable, you don’t need disposable hand warmers, making this an environmentally friendly choice.

The best way to score a better seat on a plane?

I’m absolutely the last one onto a plane. All those people doing this barbaric dance of rushing to board — it’s as if they want to get to Florida before me, but, of course, they’re not going to. I just sit there, waiting, and then board the plane after all of them. I might be in a middle seat at the back of the plane, but if you’re the last one on, you can see which other seats are open once they’ve closed the boarding doors, say, an aisle closer to the front. If you know no one’s behind you, you can take that instead. Walk down last, and you’re able to check out everybody’s seat.

Want to save on your 3-1-1 liquid allowance?

Try this hack. Portable soap sheets are a must-have for me. My wife brought them to me, because she wants me to have Purell — to not get COVID or get sick again — but I don’t like having bottles in my hands. These are more TSA-friendly, since you don’t have to use up any of your liquid allocation in a carry-on for them. They’re easy to fit in my pocket.

Where to find a friendly, live resource on any destination

Browse or join expat Facebook groups in your destination for local travel advice and insights. I went to South Korea a while back to try to get Samsung to do something with a patent I have, and I studied the expat groups. They told me to go to Seoul’s market district, which is open 24 hours a day pretty much, for food—kimchi for breakfast, rice cakes all day long. It’s better to use those groups than Google, because you can ask the questions you might have when you land but of someone who’s already done it. It’s a preview of what your experience might be: real people, real questions, real timely things. And Facebook is a lot friendlier than, say, Twitter.

This simple garment eases social interactions

I usually wear my FBI hat to travel. I got it in Washington. I think there’s no doubt that it makes people look and wonder. And when they’re wondering, they err on the side of respect. I’m looking at everybody, and they’re looking back at me very carefully. Listen, I walked on to the plane one time, and I couldn’t believe it. The lovely flight attendant said, “Thank you for all you do.” And so, what else was I going to say? I just said, “You’re welcome. And the same thing to you. I think we both have very responsible positions, and you should not be second-rated for what you do.”

A simple advice for making friends while traveling solo

The first trip I took on my own was to Acapulco, Mexico, a long time ago — I was in my 20s. I went because I was a jilted lover, and I was feeling sorry for myself. I just decided to jump on a plane and go. I learned a lot about myself on that trip. And I met so many people by myself. One hundred percent without question the best way to meet people is to focus on other solo travelers. They’re the ones who’ll want to meet someone too.

What to check when picking the smartest time to fly

We all know how busy the airport of departure is going to be, but Google when your destination will be busy, too, to avoid landing congestion: Heathrow is busiest after 10 a.m., for example. The reality of traveling and then coming back is not easy. When I was in Lisbon recently, so many planes just landed at Lisbon during a certain time, and it was daunting — getting on buses to get to the terminal. It was hours of checking in and checking out.

Lean into the social spaces on a train

Even if you’re not traveling in a group of four, take the four-top on a train, with the table. Don’t shy away from sharing that space on a regional train or Acela. I had to go to Washington (D.C.), with my attorney, and we sat there. Right across from me was this gentleman who works for McKinsey who travels almost nonstop. He took my card, because he loved the fact that I could help him with passports. We had a great time, and it was all because of the setup on the Acela, like four people around a kitchen table, which meant you couldn’t help but not talk. We didn’t stop talking for three-and-a-half hours.

___

©2024 Bloomberg L.P. Visit bloomberg.com. Distributed by Tribune Content Agency, LLC.

HUNTSVILLE, Ala. — Help at Home employed nearly 800 caregivers scattered across every county in Alabama, helping 1,100 older and disabled clients with activities such as bathing, housework and meal preparation.

And then suddenly, it was gone.

Alabama’s largest provider of home care services said it abruptly left the state last fall because the state’s “reimbursement and regulatory environment” made it difficult to recruit and retain enough workers, according to Kristen Trenaman, the company’s vice president of public relations. Its departure sent state agencies scrambling to find new caregivers for the people who relied on it.

Help at Home’s departure from Alabama “had a significant effect,” according to Debra Davis, deputy commissioner for the Alabama Department of Senior Services. Davis said her agency worked with former Help at Home clients to find replacements on the fly.

Help at Home, owned by private equity firms Centerbridge Partners and Vistria Group, continues to provide in-home and community-based care in a dozen other states, with 49,000 caregivers and 66,000 monthly clients. It’s been aggressively expanding outside Alabama, acquiring home care companies and posting thousands of job openings on its website. Neither firm responded to Stateline’s request for comment.

Proponents of private equity investment in health care say the infusion of capital helps smaller companies expand into new markets, streamline their costs and pay for new technology.

But critics point to Help at Home’s departure from Alabama as a cautionary tale for what can happen when states that spend little on health care rely on private equity-owned providers to care for their most vulnerable residents.

Private equity-owned health care companies are focused on generating robust profits for investors. Typically, they want to cut costs, increase cash flow, use debt to fund expansion and then sell within a few years for maximum profit. In health care, critics say, that business model can diminish the quality of care, increase costs and narrow access for patients — particularly in more lightly regulated industries such as home care and hospice care.

“We leave a lot to the whims of the market and allow private players to dictate access to and quality of health care, and the case of Help at Home is a great example of that,” said Mary Bugbee, senior research and campaign coordinator for health care at the Private Equity Stakeholder Project, a research and advocacy group.

“At the end of the day it’s about money, and if we don’t have guardrails in our policies to prevent these pullouts, they’re going to keep happening.”

And while much of that negative attention has focused on hospitals and nursing homes, many private equity firms also have turned their sights to the lucrative and less regulated home health care industry.

“There are favorable demographic trends in the aging population that’s only going to keep getting older,” Ankeet Patel, a vice president at private equity firm Shore Capital Partners, told the audience at the Home Health Care News Capital + Strategy Conference in April 2023. “Pair that with home-based settings being cost-effective and the preferred setting for people that receive care, and that creates a lot of opportunity.”

Around 10,000 baby boomers turn 65 every day. By 2030, 1 in 5 Americans will be over age 65, the largest share in U.S. history. That’s tens of millions of people who will need care in the coming years, and most older adults say they would prefer to age in their homes, rather than in a nursing home, for as long as possible.

As long-term care for older adults moves away from nursing homes and toward home care, private equity is following close behind.

Increasing demand

Home care can mean a variety of things. Home health is often the term for more skilled care provided by licensed nurses and therapists, including wound care and medication management. Personal home care typically refers to nonclinical services from professional aides, such as help bathing and dressing, or performing household chores that might include cleaning, cooking and laundry.

It’s not just aging consumers who prefer home care to nursing homes: Insurance payers like it too. For both public and private insurance, It’s a potential cost-saver for people who don’t need round-the-clock supervision.

Monthly costs for in-home care average about $5,000 for 40+ hours per week, compared with $8,000-$9,000 at a nursing home, according to the most recent Cost of Care Survey from insurance company Genworth. The survey is cited by agencies including the U.S. Department of Health and Human Services.

But costs vary widely from state to state. In Mississippi, in-home care averages around $3,800 monthly, while a private room in a nursing home is nearly twice that, about $7,300 per month. In Massachusetts, in-home care is nearly $6,000 monthly while a private nursing home room is more than $13,500 a month.

For those who need 24/7 care, home health is far less economical, averaging around $19,000 per month, more than twice the cost of a private room in a nursing home.

A 2019 analysis of Medicare claims found total costs 90 days after an emergency department visit were lower for patients treated at home versus those treated in the hospital. The home health patients also had lower hospital readmissions.

As consumer demand increases and insurance giants such as Humana and UnitedHealth Group wade into the market with their own home health agencies, private equity continues to gobble up smaller home health companies, consolidating them into regional networks. From 2018 to 2019, private equity was involved in nearly half of home health care industry deals.

Piling on debt

Private equity firms typically aim to acquire a company and boost profits before selling it within five to seven years. They often purchase companies with borrowed money, using the company’s assets as collateral for the loans.

Help at Home’s private equity owners, Centerbridge Partners and Vistria Group, partially funded their 2020 purchase of the company by loading it with $745 million in debt. Now, Help at Home — and not its private equity owners — must pay off the debt and interest, which can leave it less able to turn a healthy profit in a state such as Alabama with low Medicaid reimbursement rates.

Piling debt onto a company to finance additional purchases or to pay investors a dividend is a private equity hallmark. The industry tends to use debt more recklessly than publicly traded companies that must be more transparent about their financials, said Bugbee, of the Private Equity Stakeholder Project. Plus, there’s an attitude of high risk, high reward.

A private equity-owned company struggling under high debt payments might make the business decision to unload its services in one state while expanding in a state that can better help the business stay afloat, Bugbee said.

Extra debt can leave a company more financially vulnerable and more likely to look for less-profitable service lines to cut, said Michael Fenne, senior coordinator for health care at the Private Equity Stakeholder Project.

“This is a good example of the extent that private equity can shape the health care landscape in a state,” Fenne said of Help at Home’s abrupt departure from Alabama. “They can do that in different ways; sometimes it’s cutting staff, sometimes it’s shedding real estate.

“What stood out about this situation is that they went beyond any of those more mitigated measures toward a complete removal from the state.”

A high percentage of Help at Home’s revenue came from Medicare and Medicaid, leaving it vulnerable to regulatory changes and state budget challenges, according to a 2022 report from Moody’s Investors Service, a credit rating agency.

“It’s possible [for a business] to make money from Medicaid, even from low reimbursement rates, but if you have a business that’s saddled with debt it’s going to be a lot harder to do that,” Bugbee said.

Trenaman, of Help at Home, told Stateline that the decision to exit Alabama wasn’t made lightly.

“We take our responsibility to provide the safest, in-home personal care services to our clients very seriously,” she said in an email. “Taking that responsibility into account, we believe we had no choice but to make that very difficult decision not to renew our annual contracts effective September 30, 2023.”

Alabama’s Medicaid policies for in-home care made it difficult to hire and retain employees, she said, “and we have not been able to overcome these challenges in the state of Alabama.”

Alabama is one of 10 states that has not accepted federal funding to expand eligibility for Medicaid coverage to people making up to 133% of the federal poverty level. The state has some of the stingiest income-based eligibility requirements in the country.

Help at Home also operates in Florida, Georgia and Mississippi, none of which has expanded Medicaid. In the year or so before its Alabama exit, Help at Home purchased home care companies in Georgia, Indiana, New York, Ohio and Pennsylvania. As of late January, it had about 2,700 open jobs on its website, most of them for caregivers.

But Alabama does have especially low Medicaid reimbursement rates for home care services. The state reported paying home health agencies just$27 per day for each Medicaid client receiving care, according to KFF, a health policy research organization, though it did not share its rates for in-home personal care. Its home health reimbursement is the lowest daily rate for home health agencies out of the 26 states that reported their numbers to KFF.

Texas and Wyoming, which also have not expanded Medicaid, reimburse home health agencies about $181 and $58 per visit or per day, respectively.

“Medicaid and a state’s failure to expand it is definitely a valid reason a business might struggle,” said Bugbee. “But there are analogous examples of private equity-owned health care companies that will pull out of some states and not others because at the end of the day, it’s about their bottom line.”

Potential for regulation

Since private equity functions similarly across the health care sphere, state and federal laws that were spurred by private equity’s involvement in hospital systems and other health care sectors also could work for home health agencies.

Last year, 24 states enacted laws related to health system consolidation and competition, according to the National Conference of State Legislatures, an advisory think tank for lawmakers.

“The change of ownership [of companies owned or being acquired by private equity] is a window of time that regulators can use to really look into a business and who’s acquiring it,” Bugbee said. “If they do their due diligence, it can go a long way toward protecting patients and workers.”

Improving transparency, requiring certain health care staff-to-patient ratios and boosting wages for health care workers can also help protect patients and communities.

This year California will begin enforcing a 2022 law that requires health care providers to notify the state of major financial transactions, including mergers and acquisitions. In January, New York increased minimum wages for home health care workers to $17.55-$18.55, depending on the region. Those wages will continue to rise annually through 2026.

Efforts to enact new rules often lag a few years behind, as policymakers want to see evidence of harm to workers or patients before enacting changes.

“But after watching private equity investments play out in health care for decades,” Bugbee said, “we do know enough about how private equity typically operates that there are still ways regulators and policymakers can be proactive.”

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

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

Chloe Bell is a case manager at the National Abortion Federation. She spends her days helping people cover the cost of an abortion and, increasingly, the interstate travel many of them need to get the procedure.

“What price did they quote you?” Bell asked a woman from New Jersey who had called the organization’s hotline seeking money to pay for an abortion. Her appointment was the next day.

“They quoted me $500,” said the woman, who was five weeks pregnant when she spoke to Bell in November. She gave permission for a journalist to listen to the call on the condition that she not be named.

“We can definitely help,” Bell told her. “We can cover the cost of the procedure. You just tell them you have a pledge from the NAF.”

Bell is one of a growing network of workers who help people seeking abortions understand what’s legal, where they can travel for care, and how to get there.

These “navigators” can often recite from memory the names and locations of clinics throughout their region that offer abortion services at a given point in a pregnancy. Often, they can then name the hotel closest to the clinic. And some are so familiar with the most common airports for connecting flights that they can help patients find their next departure gate in real time.

State abortion laws have always varied, so helping people access legal abortion services isn’t new, but the amount of travel needed to get care has risen sharply.

In the first six months of 2023, nearly 1 in 5 abortion patients traveled out of state to get care, compared with 1 in 10 in 2020, according to an analysis by the Guttmacher Institute, a national nonprofit that supports abortion rights. That increase in travel, even for early-pregnancy abortions, has sparked a corresponding rise in the need for case managers like Bell.

Most callers are like the woman from New Jersey — people in the early stages of a pregnancy who can’t afford the $500 cost of a medication abortion. But with elective abortion banned almost entirely in 14 states and after six weeks in two more, the logistics of ending a pregnancy at any stage have become more complicated.

“People are being forced later into pregnancies to access care” because of the difficulty of arranging travel over long distances and the chilling effect of the bans, said Brittany Fonteno, president of the NAF, a nonprofit professional organization of clinics that provide abortions. “It increases the cost of care and has a devastating impact on people.”

After hanging up with the woman from New Jersey, Bell told a woman from Georgia that she likely wouldn’t need to pay the $4,800 bill for her 24-week abortion. Half the money would come from the National Abortion Federation and Bell would contact local organizations that have their own abortion access funds to find the rest. Once the money was sorted, the woman told Bell she couldn’t decide whether she should drive more than 14 hours to Washington, D.C., for her care or buy a plane ticket. Her appointment was the following week.

“I was looking at flights, but most of them won’t be there at the time that I need to be there,” she told Bell, a former librarian who talks to as many as 40 callers a day. The Georgia woman said she had $1,200 saved for the trip. Because of the length of a second-trimester abortion procedure, she would likely have to stay in Washington for three nights.

“Sometimes we can help with travel,” Bell told the Georgia caller. “Book the flight and hotel to see if the $1,200 covers those things, also meals and ride-shares from airport to hotel. Factoring in all of those expenses, if you feel like $1,200 doesn’t cover that, reach back out to me immediately.”

Since July 2022, NAF case managers like Bell have helped patients pay for nearly three times the number of hotel rooms and plane, train, and bus tickets each month as they did before the Supreme Court overturned Roe v. Wade, which had recognized a constitutional right to abortion. The most requests for financial assistance have come from people in Texas, Georgia, Florida, and Alabama — populous states with strict abortion laws. Calls are also longer and more involved. The nonprofit now spends $200,000 a month (up from $30,000 a month before Texas instituted a six-week-ban in 2021) and is still not meeting the need, Fonteno said.

In 2020, Fonteno’s organization employed about 30 full-time hotline operators. That number rose when Texas passed its six-week ban. And since the Dobbs decision overturning Roe, the line has employed 45 to 55 people, said Melissa Fowler, the NAF’s chief program officer.

Other reproductive health organizations — at the local, regional, and national levels — have also added staff like Bell. Planned Parenthood affiliates, including some in states with full bans, now employ 98 people known as patient navigators. Most were hired after Dobbs, said Danika Severino Wynn, vice president of abortion access for Planned Parenthood Federation of America. She estimates 127,000 people have relied on these navigators since July 2021.

Planned Parenthood Columbia Willamette in Portland, Oregon, has hired three abortion patient navigators since Roe was overturned, according to spokesperson Sam West. Abortion is legal in Oregon, with no restrictions, but that doesn’t mean everyone has equal access to services. One of the new navigators speaks Spanish and focuses on the rural parts of the state, where services are sparse.

The clinic declined a request for a journalist to listen in on calls with its navigators, citing patient privacy. The two other navigators focus on helping callers who are from out of state (usually Idaho), are younger than 15, or are in their second trimester.

Lawyers contacted for this story who are familiar with current state laws said patient navigators are unlikely to be at legal risk for their work helping people connect with abortion services, though it could matter which state they are sitting in when they offer help. For example, an Idaho law stating that adults in Idaho are not allowed to “recruit” minors to get an abortion could apply to navigators if they answered the phone in Idaho. That law, along with many others in states with bans, is being challenged in court.

Back at her desk in Georgia, Bell took a call from a 20-year-old woman in North Carolina named Deshelle, who was seeking financial support for a second-trimester abortion. Deshelle talked with KFF Health News a few days later, speaking on the condition that only her middle name be used, to protect her privacy.

On the day Deshelle became pregnant, it was legal to get an abortion in North Carolina at up to 20 weeks of pregnancy. About six weeks later, when she discovered she was pregnant, she went to a nearby clinic to have a medication abortion. She went to the first appointment to fill out paperwork. She was required by state law to wait 72 hours before returning to get the abortion pills. She was also given an ultrasound she didn’t want. The image of the embryo rattled her and she skipped the second appointment.

By the time Deshelle decided again to go ahead with an abortion, she was nearly 15 weeks pregnant and the North Carolina law had changed. By July 1, nearly all abortions after 12 weeks were banned. She would have to go out of state.

With the help of NAF navigators, Deshelle made an appointment at a clinic in Virginia, where a 15-week abortion is legal. Her mother drove but did not support Deshelle’s decision to end the pregnancy. Then there were protesters. By the time Deshelle got inside, she was crying. She met with a provider but decided once again not to go through with the abortion.

None of that came up on her call with Bell in November. By that time, Deshelle was 26 weeks pregnant. It was her second time calling the hotline and her third time trying to get an abortion. She just wanted to know if she could still get financial assistance. The cost of her care had escalated from about $500 when she could have gotten a medication abortion to $6,500 for a multiday abortion procedure.

Bell took her cue from Deshelle and stayed focused on logistics. She approved funding to cover half the cost of the procedure and secured a donation to cover the rest. She confirmed that Deshelle had a place to stay and the required companion to go to the clinic with her each day. Then they hung up. The rest of the journey was Deshelle’s alone.

“This isn’t what I want, but I think it’s the best choice for me,” Deshelle said from just outside the waiting room on the first day of the procedure. She read aloud from a pamphlet about the medications she’d be given and the timing of it all. Then her name was called.

A week later, after it was all over, she still felt she’d done the right thing.

“You literally have to be really strong to abort your baby and be OK,” she said she’d tell anyone else in her situation, “and you also have to be really strong to be a single mom.”

(KFF Health News, formerly known as Kaiser Health News (KHN), 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.

As Black History Month 2024 unfolds, it’s time to celebrate and explore some of the most compelling Black art exhibits that not only showcase talent but are pivotal in understanding the cultural narrative that spans continents. From contemporary canvases to historical statements, these exhibits promise to wield the power to move, educate and inspire.

Get ready to be challenged, inspired and transformed as you witness the talent and rich narratives through Black art waiting to be discovered in each of the five cities below.

New York City: Metropolitan Museum of Art (“Met”)

The Harlem Renaissance and Transatlantic Modernism

This highly anticipated exhibit will showcase a redefinition of the Harlem Renaissance at the prestigious Met. This groundbreaking exhibition shatters conventional narratives, showcasing how this vital movement wasn’t just a local phenomenon but a key player in the global dialogue of modern art and culture. Prepare to be dazzled by iconic works, discover lesser-known gems, and delve into the transatlantic artistic exchanges that fueled this vibrant era.

Runs through July.

Chicago: Museum of Science and Industry

Black Creativity Juried Art Exhibition

Head to the Windy City for a vibrant explosion of contemporary creativity. This juried exhibition of Black art promises visitors an array of artistic voices. The artwork will showcase diverse themes and mediums by emerging and established Black artists. From thought-provoking installations to soul-stirring paintings, prepare to be surprised, challenged, and moved by the sheer scope of talent on display.

Runs through April 21.

Williamsburg, Virginia: Jamestown Settlement and the American Revolution Museum at Yorktown

Black Artist Showcase

Step into the heart of American history and explore the often-overlooked narratives of Black artists in Williamsburg. This exhibition presents Black artwork that spans centuries, from poignant colonial-era artifacts to powerful contemporary pieces. Engage with the complex legacies of slavery, freedom, and resistance through the lens of art, gaining a deeper understanding of the Black experience in America.

Runs through February.

Detroit: Cranbrook Art Museum

Skilled Labor: Black Realism in Detroit

Take a visit to Motor City and Immerse yourself in the unique artistic movement of Detroit Black Realism at the Cranbrook Art Museum. Explore works that celebrate the dignity and humanity of working-class Black communities, showcasing the everyday struggles and triumphs of ordinary Black people. From gritty cityscapes to intimate portraits, these powerful art pieces will challenge stereotypes and reveal the beauty and resilience found in everyday life.

Runs through March 3.

Houston: The Museum of Fine Arts

Multiplicity: Blackness in Contemporary American Collage

Touch down in H-Town and get ready to have your perceptions of collage disrupted! This innovative exhibition delves into the creative world of contemporary Black artists who utilize this dynamic medium to explore identity, history, and the complexities of the Black experience. Witness intricate narratives layered into vibrant assemblages, playful deconstructions of stereotypes, and powerful social commentary – all through the captivating lens of collage.

Runs through May 12.

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Admire the art, but also engage. Make an effort to participate in conversations, workshops and community events that align with these exhibitions and connect with artists, fellow art lovers and local communities. Your experience will truly be immersive and transformative.

©2024 Northstar Travel Media, LLC. Visit at travelpulse.com. Distributed by Tribune Content Agency, LLC.