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.

Here are five steps you can take to support your heart health right now.

1. Stay up to date with your medical care

Prevention and management of conditions like hypertension, high cholesterol, diabetes and weight concerns is key to preventing heart disease. Regular checkups with your physician and knowing your lab and blood pressure numbers can help you manage potential contributors that increase risk for heart disease.

2. Prioritize potassium-rich foods

Consuming foods rich in potassium can help support healthy blood flow and blood pressure management. You can boost your intake of potassium with fruit, vegetables, beans, nuts and seeds. Some of the best sources of potassium include dark green leafy vegetables, oranges, tomatoes, sweet potatoes, avocados and bananas to name a few. Include these foods every day.

3. Break bad habits

Unfortunately, some everyday habits can be detrimental for heart health. These include smoking, drinking alcohol in excess and neglecting dental care. If you are struggling with overcoming bad habits, reach out to your physician or a therapist who can help you with the tools and skills needed to achieve your goals.

4. Move your body daily

Inactivity is a major contributor to heart disease even when no other risk factors are present. Plus, not moving enough can increase other risk factors for heart disease like type 2 diabetes and obesity. Aerobic exercise like swimming, biking, brisk walking, tennis and dancing are fantastic for your heart. If it’s been a while since you’ve exercised, speak to your doctor before you resume a new exercise plan.

5. Practice gratitude and stress reduction

Having a grateful heart may just be the best medicine. According to recent studies, having a grateful mindset is associated with a decreased risk of heart disease. It seems that gratitude promotes both healthful behaviors and improves biomarkers related to cardiovascular disease risk. Journaling and meditation, for example, can help cultivate feelings of gratitude. Overall, practicing gratitude can help guard against the negative physiological consequences of life’s stresses, potentially protecting the heart.

There’s no better time than the present to consider how your everyday habits may be supporting or undermining your longer-term heart health. You can take action now to eat better, move more, stay in the know and take action to reduce your risk of cardiovascular disease.

LeeAnn Weintraub, MPH, RD is a registered dietitian, providing nutrition counseling and consulting to individuals, families and organizations. She can be reached by email at RD@halfacup.com.

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.

“The dollar store expanding is the fastest-growing retail format, and we also have seen a lot of family, independently owned grocery stores going out of business,” Lopez said.

“So we try to link the two and to find not just a statistical correlation, but also we find that indeed when the dollar store comes to the neighborhood these stores tend to go out of business as well.”

The low-priced dollar store — primarily Dollar General, Family Dollar and its subsidiary, Dollar Tree — “is the most successful type of format that is proliferating all across the United States, especially in rural areas and food deserts, which are the more underserved areas,” Lopez said.

According to the study, published in Applied Economic Perspectives and Policy, there were 35,000 dollar stores in the United States in 2019 and they were “among the few food retailers” that grew in revenue after the Great Recession of 2008-10, outperforming big box discounters and retail clubs.

Between 2000 and 2019, dollar stores opening in a neighborhood resulted in a 5.7% drop in independent grocery store sales, a 3.7% decrease in employment and a 2.3% increase in the likelihood of the grocery stores closing, according to the research.

The effects are three times more likely in rural than urban areas, the study found.

The dollar stores tend not to offer fresh produce and meats, with foodstuffs being limited to canned and boxed goods.

“In general they provide an unhealthier food assortment … and less services,” Lopez said. “They don’t have bakery, butchers, they don’t have a lot of these.”

Dollar General disputes the characterization as offering only unhealthful items and notes customers depend on the business with goods they need and can obtain nearby, as well as providing local jobs.

Lopez said the dollar stores’ business model is “low prices, low cost, low quality. … But a lot of the food that they sell is not healthy. It’s processed foods that they can store. Keeping fresh food and vegetables costs money.”

Dollar stores are not necessarily a negative, if there was not a grocery store in the area before, Lopez said.

“Public health advocates, they’re against dollar stores, but a lot of people that visit the dollar store, they prefer to have a dollar store than not to have anything at all in some areas. … But in general … we find if they are driving some of the local businesses out, then that is the negative trend.”

There is also a potential that a dollar store may be “rupturing the connection to local communities and mom and pop stores, so that trend is negative,” Lopez said. “So it’s a mixed blessing, I will say.”

Caitlin Caspi is director of food security initiatives at the UConn Rudd Center for Food Policy and Health and has researched small and non-traditional food retailers.

“Historically speaking, basically, most dollar stores don’t offer any fresh fruits and vegetables and canned fruits and vegetables are the only options for produce,” she said, though she said it appears this has changed some in recent years.

“When we’re comparing dollar stores to other small and non-traditional retailers that sell food — so that includes independent corner stores, gas marts or pharmacy chains — even among that class of stores, dollar stores were really offering the fewest healthy options of any small or non-traditional food retailer,” she said.

The issue is that dollar stores don’t have the infrastructure for refrigeration, sourcing and supply for fresh foods, Caspi said, so they can’t offer those foods at a volume to be profitable.

“That’s going to have consequences for people’s diet quality, because we know that fresh fruits and vegetables is a cornerstone of a healthy diet and recommended in all of the U.S. dietary guidelines,” Caspi said. “It seems like for a long time, historically, they didn’t have the mechanism in place to be sourcing and supplying these foods at their stores.”

Most food sold at dollar stores is “energy dense and nutrient poor,” Caspi said, such as sugar-sweetened beverages and candy. She said the median amount spent on food at such stores is $2.89, with the food containing 1,200 calories, “and more than half of that energy was from added sugar. So this doesn’t paint a picture of a retailer that’s providing a staple.”

While the daily caloric intake is generally 2,000 a day for women and 2,500 for men, Caspi said the statistic is “reflecting the fact that this isn’t maybe where people are doing major grocery shopping. … So these are food retailers, but what is being purchased is not the cornerstone of a healthy meal or diet,” she said.

‘Affordable access to goods’

A Dollar General spokeswoman issued a statement via email:

“With approximately 75 percent of Americans within five miles of a DG store, thousands of our customers rely on us for convenient and affordable access to everyday household essentials. We also believe our mission of Serving Others and our intense customer focus differentiate Dollar General from other seemingly similar retailers,” she said.

“In a wide variety of communities across the country, our neighborhood general stores operate alongside local grocers and business owners to collectively meet customers’ needs. While we are not a grocery store, every Dollar General store offers components of a nutritious meal including canned and frozen vegetables, canned fruits, proteins, grains, dairy, and more,” she said. “Additionally, we’ve worked with a registered dietitian and nutritionist to create Better For You recipes to help our customers create healthier meals from products sourced primarily from our stores.”

“We believe each new store represents positive economic impact through the increased affordable access to goods; new jobs and career growth opportunities; the ability for nonprofits, schools and libraries to apply for DGLF grants and the generation of local tax revenue that can be reinvested into the community.”

Family Dollar also was asked to comment for this story.

The suit, filed by Delray Beach, Florida, resident Harvey Sultzer in U.S. District Court in West Palm Beach, claims that Intuitive Surgical Inc. failed to warn his wife, Sandra Sultzer, of issues that would have caused her to forego use of the company’s da Vinci surgical robot for her procedure in September 2021.

The company also failed to safely design its product “so that stray electrical energy would not burn the insides of patients without the knowledge or control of the operating surgeons,” and failed to properly train surgeons how to use the device, the lawsuit says.

The lawsuit notes that the da Vinci robot is a multi-armed surgical device, introduced in 1999, that’s controlled remotely by surgeons with help of an onboard camera. The instruments include forceps, scissors, scalpels and other surgical tools.

Intuitve Surgical did not immediately respond to an email sent to its corporate communications department seeking comment about the lawsuit. Because the lawsuit was filed on Tuesday, no defense attorney is listed.

The company’s financial reports, filed to the Securities and Exchange Commission, mention an undisclosed number of pending lawsuits and state that the company disputes the allegations.

The Sultzer lawsuit alleges Intuitive Surgical sells the instruments to hospitals that have no experience in robotic surgery but relies on the company to train its surgeons how to use them.

Most of the instruments that the robot uses are disposable or can only be used for a limited number of procedures before they have to be replaced, the suit says. As a result, the company relies on volume of surgeries to make much of its income, it says.

When Sandra Sultzer underwent surgery to treat her colon cancer at Baptist Health Boca Raton Regional Hospital, she experienced “thermal injury (to her) small intestine, causing a perforation which required subsequent medical intervention and caused physical and emotional injury, and ultimately her death,” the lawsuit claims.

The suit says that Sandra Sultzer’s injury and death was not an isolated incident involving the da Vinci device. Currently, Intuitive Surgical is named as a defendant in about 93 product liability lawsuits, the suit says.

Among “thousands of injury and defect reports” received by the company about the device, “the most dangerous injuries arose from burns to internal organs caused by the discharge of electricity, caused by the robot’s instruments inside the patient,” the lawsuit says.

In 2013, the Food and Drug Administration conducted an investigation into injury reports and sent a warning letter to the manufacturer concluding that it had “concealed information from the FDA, secretly recalled defective parts, and ignored known injuries to patients in its design process of critical da Vinci instruments,” the lawsuit cited.

The FDA requires manufacturers, distributors and user facilities to report adverse events involving medical devices to a database it calls MAUDE, for About Manufacturer and User Facility Device Experience.

In March 2013, Intuitive Surgical issued a statement saying it revised its reporting practices to the database, and the change would increase the number of events in the serious injury category. It also noted that the most common type of malfunction report involved broken instrument cables that could be easily replaced.

Of hundreds of complaints received between July 2009 and December 2011, the “vast majority” concerned a rubber sleeve placed on the end of certain da Vinci instruments that were designed as an insulating device to prevent electricity from radiating out, the suit says.

But the sleeves had cracks or slits that prevented the sleeves from properly insulating the metal instruments and allowed electricity or sparks to escape — or arc, the suit says.

“Because the arcing usually occurred outside of the surgeon’s camera field of vision, blood vessels and organs were burned without the medical team’s knowledge,” the complaint states.

Intuitive Surgical’s most recent annual report filed with the SEC describes a global operation that has developed and improved a large offering of products since introducing the da Vinci surgical system in 1999.

A long list of clinical applications stem from the company’s focus on five specialties — general surgery, urologic surgery, gynecologic surgery, cardiothoracic surgery, and head and neck surgery. Key procedures include hernia repair, colon and rectal procedures, cholecystectomy, bariatric surgery, hysterectomy, and lobectomy, among others.

The company also focuses on minimal invasive biopsies in the lung.

Through Dec. 31, the company was providing service for 8,606 da Vinci surgical systems, including 5,111 in the United States, which were used to perform 2,286,000 surgical procedures in 2023, according to Intuitive Surgical’s 2023 financial report, filed to the Securities and Exchange Commission.

The financial report describes “a number of” product liability lawsuits filed in various state and federal courts.

“The plaintiffs generally allege that they or a family member underwent surgical procedures that utilized the da Vinci surgical system and sustained a variety of personal injuries and, in some cases, death as a result of such surgery,” the company said.

Allegations in the lawsuits include that plaintiffs’ injuries resulted from purported defects in the system and/or failure of the company to provide adequate training resources to surgeons, the financial report said. “The cases further allege that the company failed to adequately disclose and/or misrepresented the potential risks and/or benefits” of the system, the report said.

“The company disputes these allegations and is defending against these claims,” the SEC filing says.

In 2018, NBC News posted a report about Intuitive Surgical and the da Vinci device.

The story focused on an Iowa woman who said she sustained a burn to her ureter and damage to her colon during hysterectomy procedure involving a da Vinci device in 2015 and said her prognosis called for a permanent colostomy. The report noted that the woman sued Intuitive Surgical in 2017 but later voluntarily withdrew the lawsuit.

NBC News said it spoke to more than a dozen patients who say they were burned or otherwise injured during surgery involving the device.

In a statement to NBC News in 2018, Intuitive Surgical said its mission “is to help surgeons safely and effectively improve patient outcomes and decrease surgical variability.” It added, “While any surgery regardless of modality carries risk, the best evidence of the safety and efficacy of robotic-assisted surgery can be found in the more than 15,000 peer-reviewed scientific publications that are fully grounded in scientific method and that, in aggregate, support the safety and efficacy of our systems.”

The NBC News story said that more than 20,000 adverse events had been filed to the FDA’s MAUDE database over the past 10 years related to the da Vinci robot.

Of those, nearly 17,000 were classified as device malfunctions. More than 2,000 involved injuries and 274 were categorized as deaths, the network reported.

In 2023, the number of adverse events related to the da Vinci device filed in the database totaled 3,098, the South Florida Sun Sentinel found.

Ron Hurtibise covers business and consumer issues for the South Florida Sun Sentinel. He can be reached by phone at 954-356-4071, on Twitter @ronhurtibise or by email at rhurtibise@sunsentinel.com.

Cervical cancer is the only cancer that is vaccine-preventable and curable, but the United States is lagging in its efforts to meet the World Health Organization’s 2030 targets to effectively eliminate the disease.

A mix of low vaccination uptake — just 61.7% of U.S. teenage girls were up to date on their HPV vaccine doses in 2022, according to a Centers for Disease Control and Prevention survey — combined with health equity issues have hobbled U.S. efforts to end the disease.

The combination can be deadly: Though cervical cancer is now preventable and treatable, roughly 11,500 new cases are reported in the U.S. each year and roughly 4,000 women die of the disease, according to CDC data.

Alarmed by the increase, the Biden administration last week announced a handful of measures aimed at fighting the disease, including a new initiative to lower rates of cervical cancer by allowing for Americans to test for human papillomavirus, or HPV, which causes most cervical cancer, at home.

The new program, called the Self-collection for HPV Testing to Improve Cervical Cancer Prevention, will launch in the second quarter of this year.

The initiative will be a clinical trial network to gather data on the self-collection method of HPV, to prevent cervical cancer.

If the method is determined viable, it could dramatically increase uptake of cervical cancer screening.

Heather White, executive director of TogetHER for Health, an organization that works to eliminate cervical cancer globally, said the Biden administration’s self-sampling initiative could be “a real game changer” for U.S. efforts to stem HPV, because it’ll help get more screenings to women in rural areas and those who may otherwise have issues accessing the health care system.

“That’s a major milestone to be able to turn the regulatory corner,” she said of potential approval of the HPV self-sampling kits. “And I think that’s really where you’ll start to see a sea change in terms of screening uptake.”

Equity issues

Health equity and vaccine access issues have plagued the HPV vaccination effort in the U.S., so much so that cervical cancer incidence and deaths are on the rise among low-income women in rural areas, according to a new study led by researchers from the University of Texas MD Anderson Cancer Center, published in the International Journal of Cancer.

The rise in cases comes despite a longtime solution: In 2006, the Food and Drug Administration approved Gardasil, an HPV vaccine developed by Merck and Co. Inc., and CDC advisers recommended the shot in 2007.

The shot has proven highly effective: A study published last week in the Journal of the National Cancer Institute found no cervical cancer cases detected in women born between 1988 and 1996 who received the HPV vaccine when they were adolescents.

In the decades following the introduction of cervical cancer screening tools in the U.S., cancer rates decreased. But these interventions have occurred less frequently in rural areas of the country lacking access to care, according to the MD Anderson study. This is hitting non-Hispanic white women in low-income counties particularly hard, as this group has seen a 4.4 percent increase in cervical cancer occurrences since 2007.

Black women saw the largest increase in cervical cancer deaths, at 2.9% annually since 2013, even though cancer incidence in this group is declining.

White, of TogetHER for Health, said her home state of Alabama has experienced the disparity firsthand.

The state lacks health care providers in many areas and women might have to wait months to get an appointment for a screening. Couple that with a lack of awareness about the disease and many women end up skipping appointments.

Alabama’s HPV vaccination rates track slightly lower than national averages so the state’s public health department recently launched a 10-year plan to up vaccination rates to 80% by 2033.

Reaching vaccine-hesitant Alabamans will require many of the tools state health departments utilized during the COVID-19 pandemic: health education and meeting people where they are.

“We’ve had a challenge, certainly in this country for many years around misinformation, disinformation, related to the HPV vaccine. And I think of course that is compounded by vaccine hesitancy, which has certainly been exacerbated by COVID,” White said.

Capitol Hill push

Congress, meanwhile, is due to reauthorize a key cancer detection program that helps low-income Americans gain access to timely breast and cervical cancer screening, diagnostic and treatment services.

Sens. Tammy Baldwin, D-Wis., and Susan Collins, R-Maine, introduced a bill to reauthorize the cervical cancer detection program for fiscal years 2024 to 2028. The measure, as approved by the Senate Health, Education, Labor and Pensions Committee last month would fund the program at $275 million per year, an increase from current levels of $235.5 million a year.

A Baldwin staffer said the two senators, who are both lead appropriators, are trying to attach that measure to an upcoming spending bill. But nothing is set yet.

The National Breast and Cervical Cancer Early Detection Program was first authorized by Congress in 1990.

Global efforts

The United States’ efforts mirror international ones: The World Health Organization aims to eliminate cervical cancer globally in the next century. It has asked participating countries to set ambitious targets to meet by 2030.

Among them: All countries must maintain an incidence rate of or below 4 cases per 100,0000 women, which means vaccinating 90% of young girls with the HPV vaccine by age 15, screening 70% of adult women by age 35 to 45 and treating 90% of women with pre-cancer.

Those efforts, too, are lagging. Cervical cancer is the fourth-most common cancer globally, with an estimated 604,000 cases reported every year. The disease is typically caused by Human Papillomavirus, or HPV, a relatively common sexually transmitted virus.

“At the end of 2022 only about 21% of women globally had coverage with a single dose of the HPV vaccine,” said Pavani Ram, chief of child health and immunization at the U.S. Agency for International Development, at an event at the White House last week. “That’s a long way away from the 2030 target of 90%-plus that we need to be at in order to achieve cervical cancer elimination goals.”

©2024 CQ-Roll Call, Inc., All Rights Reserved. Visit cqrollcall.com. Distributed by Tribune Content Agency, LLC.

Gabriel Henao fled Colombia to escape a guerrilla group who, he said, twice threatened to kill him. After some time in Mexico, he arrived in Colorado in July 2022, settling in Fort Collins.

His severe stomach pain started when he was in Mexico, he said. It was debilitating and left him bedridden for days at a time. The pain continued to plague Henao in the United States, but he said he didn’t make enough money cleaning houses to pay for health insurance.

Colorado did not offer Medicaid coverage to residents living in the country without legal status such as Henao, or to immigrants in the mandatory five-year waiting period after receiving their green cards. Without coverage, Henao couldn’t get a proper checkup, he said, let alone a diagnosis or treatment for his stomach pain.

That changed at the beginning of January, when Henao received care through Colorado’s OmniSalud program, which provides health care coverage to low-income immigrants in the country without documentation. When the program started accepting enrollments in 2022 it covered 10,000 people without requiring them to pay premiums, and this year Colorado expanded the number of zero-premium slots to 11,000.

Alianza NORCO, a nonprofit organization that supports immigrants in northern Colorado with legal and other resources, is helping Henao acclimate to the U.S. and assisted with his application to the OmniSalud program.

“I started to get really scared, nervous, anxious because I didn’t have money to care for my health,” said Henao, 44, a father of three who owned a clothing warehouse in Colombia. He has applied for asylum, saying his life was in danger in his native country.

Now, after undergoing an appendectomy a few weeks ago, “I feel excellent,” he said in Spanish through a translator provided by the Colorado Immigrant Rights Coalition.

Colorado is one of a growing number of Democratic-dominated states that are extending health care coverage to a limited number of immigrants who otherwise wouldn’t be eligible for public insurance because of their legal status.

Supporters say such programs save money in the long run, because insured people are more likely to receive treatment for chronic conditions and get preventive care, thereby avoiding expensive medical crises that end up costing taxpayers and raising premiums for the insured. But as more states face budget crunches, critics object to spending millions to insure people who are living here without authorization.

Meanwhile, the flood of migrants at the U.S.-Mexico border figures to be a major issue in the presidential campaign. And recently, nine Democratic governors sent a letter to the Biden administration and congressional leaders urging them to solve the “humanitarian crisis” of “the sustained arrival of individuals seeking asylum and requiring shelter and assistance.”

The Colorado program serves immigrants, regardless of their legal status, who have an income of less than $22,000 a year for an individual or less than $45,000 for a family of four. The state filled its 11,000 available slots in two days. The program costs the state an estimated$73 million annually, according to the Colorado Division of Insurance.

“For some people, it’s the first time that anyone in their family has been able to have health care, which is a huge, life-changing advancement,” said Raquel Lane-Arellano, communications manager for the Colorado Immigrant Rights Coalition. “They’re not just seeking emergency care. They’re able to go get preventative care.”

Covering more people

Advocates say the pandemic, and the health disparities it revealed, prompted state efforts to provide coverage to more people, regardless of their immigration status.

“It’s a very exciting trend that we are monitoring very closely. Some of the work on this has been decades long,” said Tanya Broder, senior staff attorney at the National Immigration Law Center. “But the recognition of the value of investing in health care for all really increased during the height of the pandemic, when states recognized that our health is interconnected, and it makes sense to protect the health of everyone in the community in order to protect public health.”

California, Oregon and Washington state also offer health care coverage to people of all ages who have incomes below a certain level, regardless of their immigration status. Minnesota will do so starting in 2025.

In addition, at least 24 states and Washington, D.C., now offer coverage to pregnant immigrant women who are in the five-year waiting period to qualify for Medicaid, according to an analysis by KFF, a health care policy research organization. Meanwhile, seven states— California, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island and Washington — use state dollars or money from the state-federal Children’s Health Insurance Program, known as CHIP, to offer coverage for a year postpartum regardless of immigration status, according to KFF.

Starting in March, Michigan will eliminate the five-year waiting period for Medicaid for children and pregnant women. The change will result in coverage for up to 4,000 children and about 5,500 women, most of them Hispanic, said Simon Marshall-Shah, senior policy analyst for the Michigan League for Public Policy. Michigan will spend about $6.4 million on the program, but federal matching funds will bring the total to$26.4 million.

And in January, a new law went into effect in California offering Medicaid coverage to adults ages 26 to 49 regardless of immigration status.

California rolled out its health care coverage for immigrants in phases. In 2020, the state expanded its Medicaid program, which it calls Medi-Cal, to young adult immigrants ages 19 to 25, modeling the Young Adult Expansion program after a previous one for children under 19.

“This expansion comes out of our state general fund, meaning there isn’t like a new tax or a new funding source that we have to raise for this expansion,” said Sarah Dar, California Immigrant Policy Center’s policy director. Since emergency room visits are costly to both individuals and hospital systems, creating programs that expand access to primary health care coverage “makes good fiscal sense,” she said.

Pushback on efforts

But critics say California can’t afford the expansion amid the state’s mounting budget deficit. Republican state Sen. Brian Jones, who is the minority leader, released a statement in January urging Democratic Gov. Gavin Newsom to enact an 18-month freeze on the program.

“In the midst of a significant budget deficit, hospitals shutting down, and a massive influx of migrants illegally crossing our open border, now is not the time to be expanding this costly government program,” Jones wrote. “Our priority should be safeguarding critical services and core functionalities.”

In Nevada, Republicans blocked efforts to expand Medicaid to immigrants without documentation last year, saying the proposal would be too costly. During a March floor debate, Republican state Sen. Robin Titus, who is also a physician, said she worried about adding thousands more to the Medicaid rolls when the state already struggles with a lack of enough health practitioners.

“You’re diluting an even more diluted system. So, in the long run, it might hurt everyone,” she said. “How do you solve that access to care when you already don’t have enough of us?”

However, Republican-dominated Utah in January began enrolling kids in a new state-funded children’s health insurance program that covers immigrant children without documentation. The bipartisan bill signed by Utah Republican Gov. Spencer Cox last March allocated $4.5 million toward the program.

Critics say immigrants who are living in the United States illegally burden the system without contributing to it. But even unauthorized workers have payroll taxes deducted from their paychecks, and they pay sales taxes on their purchases. Immigrants without legal status pay property taxes on their homes or indirectly as renters, and at least half file income tax returns.

Those taxes help support public insurance programs such as Medicaid and Medicare, research shows. An analysis published in 2022 in the American Medical Association’s JAMA Network Open by researchers from Boston University, Harvard Medical School and others found immigrants here without legal permission pay an estimated $51.9 billion more into the health care system than the cost of their care.

Ultimately, “it’s about values,” said Dar, of the California Immigrant Policy Center. “We want our communities to be healthy. … It costs much less to just get preventative care, get regular checkups, get on insulin; if you need it, get on a statin, if you’ve got blood pressure issues. Those things are actually far, far cheaper than expensive life-saving procedures and tests.”

Starting in January in Washington state, immigrants without documentation and recipients of Deferred Action for Childhood Arrivals, which delays deportation of immigrants who came to the U.S. as children, are allowed to shop for health plans through the state’s exchange marketplace. Those making $36,450 or less can qualify for state aid to help them cover premiums.

In July, the state also will launch a new Medicaid program that will cover poorer residents ages 19 and older, though there will a spending cap.

Dr. Leo Sergio Morales, who co-directs the University of Washington’s Latino Center For Health, noted that certain treatments and procedures, such as transplants, are especially costly and increasingly inaccessible for the uninsured.

“Transplants can be life-saving,” Morales said, “[and] people have to be able to afford the medications and treatment that follows the transplant — so, a lifetime of immunosuppression.”

States are also grappling with budget constraints. Illinois, for example, last November paused new enrollments for its health care coverage program for noncitizens 42 and older.

Colorado’s OmniSalud now provides zero-premium coverage to 11,000 people, but the state has about 200,000 immigrants who are in the country without authorization, Colorado Immigrant Rights Coalition’s Lane-Arellano noted. “The biggest thing we want to see is the program continuing to expand,” she said. “This is very much that ‘all ships rise’ kind of situation.”

“There are economic reasons and sound data that prove preventative care saves the state of the economy and families in the long run,” she added. “It hurts families, and it hurts our entire community, our economy, when people get sick or are forced into medical debt.”

Henao hopes more states create programs like OmniSalud.

“It will be positive for all communities if immigrants who are arriving are able to get the support that they need, are able to get the ability to work, have access to health insurance,” he said. “Medical care is costly in this country.”

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.

“It’s been hard for all of us,” said Esqueda. “We are just keeping our heads up and leaning on each other. Our focus is my health and leaving everything in God’s hands. Prayer is what gets us through.”

The Green Chile Cantina, which offers a blend of American and Mexican cuisine, had only been open for about five months before disaster struck. On the morning of Sunday, Jan. 21, Esqueda got a call that a fire had broken out in the kitchen and destroyed the restaurant.

The kitchen and prep kitchen were completely burned out, the ceiling in the pizza kitchen collapsed and there were six holes in the roof with the rest of the ceiling collapsing, Esqueda said. There was also water damage from a broken pipe in the kitchen, which leaked into the dining area.

The fire was knocked down in about 25 minutes and caused an estimated $400,000 in damage, Orange County Fire Authority Captian Greg Barta said at the time. Fire investigators told Esqueda the cause was likely electrical, but the investigation on the source is still ongoing, she said.

The restaurant, Esqueda said, is a total loss.

“They say that the rebuild is going to take at least a year,” said Esqueda. “We are not sure what the future holds, and we are still ironing out all of the details in regards to the building.”

“Everything is messed up and destroyed, it’s all going to have to be rebuilt.”

Due to the fire, Esqueda’s 27 employees have had to find other work or go on unemployment, she said.

Esqueda was already struggling to balance the demands of keeping her business operational while prioritizing her health needs at the time of the fire. Just days before Green Chile Cantina opened its doors for the first time in August, Esqueda was given a diagnosis of stage three follicular helper T-cell lymphoma.

Now, Esqueda has had to delay medical appointments because of the chaos of the fire’s aftermath.

Right after the fire occurred, Esqueda said her phone was “ringing off the hook” from her insurance adjuster, fire officials, news agencies and community members wanting updates. She’s also diabetic, and with her sugar levels so inconsistent of late, she’s had to push PET scans as well, she said.

“I have lots to take care of, and the stress has been so high,” said Esqueda. “I am trying to not overdo it and trying to get rest when I can.”

As she considers what’s next for her Mission Viejo restaurant, Esqueda says she needs to make her health a priority — and the community is rallying behind her.

A fundraiser organized by Esqueda’s family and friends had already been in the works to help Esqueda with her mounting medical bills. But after the fire, it turned into support for the restaurant as well.

“This fundraiser was just meant to be a small thing for the family,” said Valorie Green, a long-time friend and previous owner of the restaurant. “But it blew up with all the news around the fire.”

The event took place in the Green Chile Cantina parking lot on Saturday, Jan. 27. Community members donated gift baskets full of goodies and services to be raffled off or bid on while others sold drinks and food, all to benefit the Esquedas. Close to 50 classic cars and hot rods were also on display for attendees to view.

The city of Mission Viejo assisted with the fundraiser, providing traffic control and portable toilets.

The turnout was “huge and successful,” said Esqueda.

“Mission Viejo really showed up, and there was great community support,” said Esqueda. “Restaurant regulars showed up, and they were so supportive.”

Esqueda and her husband, Tony Esqueda, purchased the Mission Viejo location from Green earlier this year. Seeing this happen to the restaurant that was once hers has been “overwhelming,” Green said.

“It’s difficult for my husband and me since this has been our second home since January 2000,” said Valorie Green. “We were in there often, even after the Esquedas took over because we know many of the patrons. People are coming forward to give support, and it shows what a wonderful community Mission Viejo is and the goodness of people.”

A GoFundMe was created by the Mission Viejo Chamber of Commerce in the fire’s aftermath. Esqueda said all proceeds will go toward her medical costs as well as provide anywhere from nine to 12 months of income for the employees who are now out of work while the restaurant is being rebuilt.

As of Friday, Feb. 2, more than $7,200 has been raised for the fundraiser’s $25,000 goal.

Esqueda said the best way to support her business and family at this time is to visit Green Chile Cantina’s La Habra location, located at 2050 W Whittier Blvd., and try a stuffed sopaipilla.

Staff writer Mona Darwish contributed to this report.