But on Oct. 1 at 3 a.m., a Friday, the hospital CEO’s phone rang with an urgent call.

“My chief of nursing said, ‘Well, it looks like we got hacked,’” said , CEO of the health system based in Franklin, Indiana.

The information technology team at Johnson Memorial discovered a ransomware group had infiltrated the health system’s networks. The hackers left a ransom note on every server, demanding the hospital pay $3 million in bitcoin within a few days.

The note was signed by the “Hive,” a prominent ransomware group that has hospitals, school districts, and financial firms in over 80 countries, according to the Justice Department.

Johnson Memorial was just one victim in a rising wave of cyberattacks on U.S. hospitals. One study found that cyberattacks on the nation’s health care facilities from 2016 to 2021 — from 43 attacks to 91.

In the aftermath of a breach, the focus frequently falls on the risk of confidential patient information being exposed, but these attacks can also leave hospitals hemorrhaging millions of dollars in the months that follow, and also cause disruptions to patient care, lives at stake.

After its own attack, the staff at Johnson Memorial suddenly had to revert to low-tech ways of patient care. They relied on pen and paper for medical records and notes, and sent runners between departments to take orders and deliver test results.

A few hours after that 3 a.m. call, Dunkle was on the phone with cybersecurity experts and the FBI.

The burning question on his mind: Should his hospital pay the $3 million ransom to minimize disruptions to its operations and patient care?

Dunkle worried about levied by the Treasury Department’s Office of Foreign Assets Control against the hospital if it paid a ransom to an unknown entity that turned out to be on a sanctions list.

Dunkle also worried about possible lawsuits, because the hackers claimed they stole sensitive patient information they’d release to the “dark web” if Johnson Memorial did not pay up. Other health data breaches have led to from patients.

The Office for Civil Rights, within the Department of Health and Human Services, can also against hospitals if patient data protected by federal privacy laws is divulged.

“It was information overload,” Dunkle recalled. All the while, he had a hospital full of patients needing care and employees wondering what to do.

In the end, the hospital did not pay the ransom. Leaders decided to disconnect after the attack, assess, and then rebuild, which meant taking several critical systems offline. That upended normal operations in various departments.

The emergency department diverted ambulances with sick patients to other hospitals because the staff couldn’t access patients’ medical records. In the obstetrics unit, newborns usually wear security bracelets around their tiny legs to prevent unauthorized adults from moving the infant or leaving the unit with them. When that tracking system went dark, staff members physically guarded the unit doors.

During one delivery, nurses struggled to communicate with an Afghan refugee who came from the nearby military post to give birth. The remote translation service they typically used was inaccessible because of the cyberattack.

“Stressed-out nurses were using Google Translate to communicate with this woman in labor,” said Stacey Hummel, the maternity department manager. “It was crazy.”

Hummel said it was the hardest challenge she’s ever faced in her 24 years of experience — even worse than the covid-19 pandemic. As the cyberattack unfolded, her nursing team was praying, “Please don’t let the fetal monitors go down.”

And then they did.

The clinical staff suddenly could no longer receive digital notifications outside the labor rooms, notifications that help them monitor the vital signs of laboring women and their fetuses. That meant critical data points, like a dangerously low heart rate or high blood pressure, could go unnoticed.

“Once that happened, we had to station a nurse in every single room,” Hummel said. “So staffing was a nightmare because you had to stand there and watch the monitor.”

The hospital’s billing department was also crippled. For months afterward, they were unable to bill insurance plans to be paid in a timely fashion. An IBM report estimated that cyberattacks on hospitals per incident, excluding any ransom payment — the highest among all industries. Hospital leaders say that, for this reason, cyberattacks pose an existential threat to the viability of hospitals across the country.

Cyber insurance has become a critical part of hospital budgets, according to , national adviser for cybersecurity and risk at the .

But some institutions are finding the insurance coverage isn’t comprehensive, so even after an attack they remain on the hook for millions of dollars in damages. At the same time, insurance premiums can soar after a cyberattack.

“The government certainly could help in the space of cyber insurance, perhaps setting up a national cyber insurance fund, just like post-9/11, when folks could not obtain insurance against terrorist attacks, to help with that emergency financial aid,” Riggi said.

The federal government has taken steps to address the threat of cyberattacks against critical infrastructure, including training and awareness campaigns by the federal Cybersecurity and Infrastructure Security Agency. The FBI has taken down several ransomware groups, including the Hive, the group behind the attack on Johnson Memorial.

Today, Johnson Memorial is up and running again. But it took nearly six months to resume near-normal operations, according to the hospital’s chief operating officer, Rick Kester.

“We worked … every single day in October, every single day. And some days, 12, 14 hours,” Kester said.

The hospital is still dealing with some ongoing costs. Its revenue cycle has not fully recovered and its cyberattack insurance claim, submitted nearly two years ago, still hasn’t been paid, Dunkle said. The hospital’s annual insurance premium is up 60% since the incident.

“That is an incredible increase in cost over the last three or four years and … when your claims aren’t paid, it can be even more frustrating,” he said. “We are investing so much in cybersecurity right now that I don’t know how small hospitals will be able to afford [to operate] much longer.”

And this week, may become partly due to a cyberattack. St. Margaret’s Health in Spring Valley, Illinois, planned to close its doors June 16. Suzanne Stahl, chair of the hospital’s parent company, SMP Health, said it became impossible to continue the hospital’s operations “due to a number of factors, such as the covid-19 pandemic, the cyberattack on the computer system of St. Margaret’s Health, and a shortage of staff.”

The hospital suffered a ransomware attack in 2021 that left it unable to bill insurance, Medicaid, or Medicare for more than three months, according to Linda Burt, the hospital’s vice president of quality and community services. Burt said not being able to submit claims put the hospital in a “financial spiral.”

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“I don’t know where that number came from. I just felt like four wasn’t enough,” said Woolford, a Baltimore resident. “Six is a good number.”

Woolford, 31, was born with . The genetic disorder causes blood cells to become misshapen, which makes it harder for blood to carry oxygen and flow throughout the body. This can lead to strokes, organ damage, and frequent bouts of excruciating pain.

Sickle cell disease affects an estimated , and the of them are Black. Federal and charitable dollars dedicated to fighting sickle cell disease to what is spent to combat other, less common diseases that mostly affect white patients.

Physicians and researchers said the disease is a stark example of the health inequities that pervade the U.S. health system. A poignant expression of this, patient advocates said, is the silence around the impact that sickle cell disease has on fertility and the lack of reproductive and sexual health care for the young people living with the complex disease.

Woolford’s sickle cell complications have run the gamut. By the time she was 15, her hip joints had become so damaged that she had to have both hips replaced. She depended on frequent blood transfusions to reduce pain episodes and vascular damage, and her liver was failing.

“So many complications, infections, hospitalizations, and so by the time I graduated high school, I just felt defeated [and] depressed,” said Woolford, speaking from a hospital bed in Baltimore. She had experienced a sickle cell pain crisis a few days earlier and was receiving pain medication and intravenous fluids.

In her late teens, Woolford sought out a , a treatment that enables the sickle-shaped cells in the patient’s body to be replaced with healthy cells from a stem cell donor. The procedure comes with risks, and not everyone is eligible. It also relies on finding a compatible donor. But if it works, it can free a person from sickle cell disease forever.

Woolford couldn’t find a perfect match, so she enrolled in a clinical trial in which . As part of the bone marrow transplant, patients first receive chemotherapy, which can fertility. Woolford hesitated. After all, her ideal family included six children.

When she told her doctor about her worry, his response crushed her: “This doctor, he looked at me, and he was like, ‘Well, I’ll be honest, with all the complications you’ve already had from sickle cell, I don’t know why you’re even worried about this process making you infertile because you’re probably already infertile.’”

Even if patients don’t have the transplant, sickle cell disease can damage their bodies in ways that can affect their , according to , a pediatric endocrinologist at Nationwide Children’s Hospital in Ohio.

For women, chronic inflammation and the sickling of blood cells in the ovaries can make getting pregnant harder. For men, sickled blood can jam inside the blood vessels of the penis, causing painful, unwanted erections that last for hours. This condition, called priapism, can damage sexual function and decrease sperm count.

And it’s not just the disease. Researchers are evaluating how some widely used treatments may affect fertility — for example, by decreasing .

“It remains unclear how that translates directly to fertility outcomes but at least raises the concern that this may be an issue,” Nahata said. Even more concerning to Nahata were the results of a , which she co-authored, that showed some patients were unaware of the many fertility risks related to sickle cell disease.

Woolford said she was 19 and shocked when her doctor told her she was probably already infertile. But no one could be sure, so she held out hope that she might still undergo a procedure to before having the chemotherapy required for the bone marrow transplant.

From extensive research, she learned that egg freezing could cost more than $10,000 and that her insurance wouldn’t cover it. She couldn’t afford to do it on her own. Woolford wondered whether she could find another way to pay for egg freezing. “So I started looking into financial resources,” she said. “And I saw all these foundations [that] give away grants. But you had to have a diagnosis of cancer.”

In the end, Woolford had the transplant without freezing her eggs. She said she felt that being cured would “be a fair trade-off to give up my dream of biological children.”

Unfortunately, the partial-match transplant did not work. Woolford’s body rejected it.

“So, here I am,” she said. “I am 30, still have sickle cell disease, and I’m infertile.”

A grim thought sometimes pops into Woolford’s mind: If she had cancer instead of sickle cell disease, her dreams of having biological children might still come true.

The first description of sickle cell disease in medical literature was published . Because most sickle cell patients in the U.S. were Black, it quickly became labeled as a “Black disease.” And with that came a legacy of systemic racism that still affects patients today.

Black patients tend to have and fewer resources, said , a sickle cell disease researcher and an assistant professor of medicine at Johns Hopkins University.

Pecker said that for fertility treatment, the resources available to cancer patients differ starkly from those available to sickle cell patients. “There are any number of foundations, large and small, that help support and pay for fertility preservation for people with cancer,” Pecker said. “Those foundations actually work with fertility preservation centers to negotiate lower rates for affected people.”

Clear state that and are going through chemotherapy should be referred for fertility preservation.

Children with sickle cell disease going through transplants are exposed to chemotherapy, too, “but we don’t really have guidelines like that yet for people with sickle cell disease,” Pecker said.

It’s not a perfect comparison, she added, because the kinds of chemotherapy drugs used in pediatric cancer are different from the chemotherapies used in sickle cell treatment. But fertility preservation can be crucial when there is any risk of treatment-associated fertility impairment, Pecker said. Without clear and widely adopted clinical guidelines, sickle cell patients may not be referred to appropriate care.

Pecker said current medical practice forces sickle cell patients to make a difficult choice. “You can have treatment or you can have fertility,” she said. But in cancer care, she said, the thought is: You can have treatment and you can have fertility.

In the U.S., health insurance coverage for fertility preservation and treatment is not guaranteed and . Only 12 states have laws that mandate fertility preservation coverage for patients who undergo treatments that could imperil their ability to have biological children — usually referred to as iatrogenic treatments — like chemotherapy or radiation.

After Woolford’s transplant failed, the disease continued its assault on her body. And Woolford has had to come to terms with the impossibility of ever having a biological child. She launched a nonprofit, the , to raise awareness of fertility issues at medical conferences and among patients. A future goal is to provide financial grants to sickle cell patients struggling to pay for fertility preservation and treatments.

Most days, Woolford finds the work empowering. On other days, she admitted, it reminds her of the bleak reality that she will probably never conceive a child.

“It’s really hard because I don’t think a lot of people realize that I’m fighting for something that I didn’t have access to,” she said.

At this point, she said, it’s no longer a medical justice fight. It’s a reproductive justice one.

Reporting for this story was supported by the USC Annenberg Center for Health Journalism’s . It was produced in partnership with , , and .

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“This case has taken on, really, a life of its own way beyond what I could have foreseen,” said Talevski, a resident of Valparaiso, Indiana.

Talevski filed a lawsuit in 2019 alleging that her father’s rights were violated at a nursing home where he lived to get care for his dementia.

“He went from being able to walk and talk … to not being able to move,” Talevski said. “[The nursing facility] treated my dad like trash, like a dog. In fact, dogs are treated better than that.”

In court filings, the Talevski family claims that Gorgi Talevski was overmedicated to keep him asleep, his dementia wasn’t properly managed, and he was involuntarily transferred to different facilities hours away from the family’s home, which accelerated his decline. Her father died a year ago, in October.

the Health and Hospital Corp. of Marion County, the public health agency in Indiana that owns the nursing facility. The agency, known as HHC, declined to comment on the case but has denied any wrongdoing. In court documents, it argued that Gorgi Talevski was , which affected his care. It tried to dismiss the case, saying Talevski didn’t have the right to sue. But federal courts said the lawsuit could move forward.

So, the public health agency made an unexpected move. It took the case to the nation’s highest court and posed a sweeping question: Should people who depend on initiatives funded in part by the federal government — such as Medicaid and programs that provide services for nutrition, housing, and disabilities — be allowed to sue states when they believe their rights have been violated?

A ruling in favor of the HHC of Americans who rely on federal assistance programs would lose that right. The Supreme Court is scheduled to hear oral arguments on Nov. 8.

“The reach of an adverse decision would be catastrophic,” said , an attorney at the National Health Law Program. “It would leave these programs really standing out there without a true enforcement mechanism.”

HHC of Marion County owns and operates 78 skilled nursing facilities across Indiana in a with .

The answer to the question of whether people who depend on federal assistance programs can sue over rights violations has been settled precedent for decades, said Perkins, who has litigated numerous civil rights cases for Medicaid beneficiaries.

For that reason, she was shocked when she learned the Supreme Court had chosen to hear this case. The Supreme Court each year and they often agree to look at only 1%-2% of them.

Perkins said she sees parallels between this case and the recent Supreme Court decision that overturned the constitutional right to an abortion.

“The idea that the court would accept this case and accept that question of whether you can ever enforce these laws is of concern,” Perkins said. “The recent court decisions — Dobbs in the abortion context coming to mind — shows the court is willing to set aside precedent.”

Since the Supreme Court agreed to look at the case, at least , which provide courts information from people not directly involved in a case. Most have sided with the Talevskis — including like House Speaker Nancy Pelosi and Majority Whip James Clyburn, , , , and . Marion County HHC will be represented by , who has argued 19 cases before the Supreme Court and represented Christine Blasey Ford during the confirmation hearing of Justice Brett Kavanagh. Talevski will be represented by of Arnold & Porter. Recently, Tutt argued and won a case before the Supreme Court that safeguarded the reemployment rights of thousands of veterans and service members.

flowing from Congress to states, like Medicaid, typically come with a set of provisions or requirements that states are supposed to follow to receive and use the funds. Civil rights lawsuits are one of the primary enforcement mechanisms beneficiaries of those programs have to hold state agencies accountable if the agencies violate their rights or fail to provide entitled services.

There are other means of oversight, which supporters of the Indiana state agency’s petition tout as viable alternatives to lawsuits. One is federal monitoring by the Department of Health and Human Services. The agency can investigate and threaten to withhold funding from state programs that fail to comply with federal provisions. But this usually involves lengthy legal processes that can be counterproductive, stalling benefits to individual patients, instead of helping them.

“If [HHS] tries to turn off the money, the state could take them to court immediately and get an injunction,” arguing that the ceasing of federal funds would cause irreparable harm, said , a professor of health law and policy at George Washington University. “People [would be] left totally without their benefits, or the providers are left totally without their payments.”

say that federal oversight is far from sufficient and that civil rights lawsuits remain a crucial enforcement mechanism. Private enforcement through lawsuits is indispensable for nursing home residents, they say, especially in places like Indiana where the state owns the most nursing homes.

The former officials said in a that a decision in favor of HHC would potentially raise the risk of waste, fraud, and abuse of Medicaid funds, leading to widespread underenforcement and leaving “millions of individuals, providers, and other beneficiaries more vulnerable to violations of their statutory rights.”

, a quarter of the U.S. population, are enrolled in Medicaid. This means HHS oversees more than half a trillion dollars in spending across all states and U.S. territories — and the federal agency, the former officials argue, lacks the logistical and practical capacity to “meaningfully remedy individual violations in many cases.”

Indiana’s Attorney General, Todd Rokita, is among allies publicly supporting the state’s perspective. Rokita, in a filed along with 21 other Republican attorneys general, said civil rights lawsuits burden states and cripple them with legal expenses, just to line the pockets of attorneys rather than benefit Medicaid enrollees.

“The state has litigated 1,200 civil rights cases just in the last three years,” Rokita said in a written statement.

Legal experts told Side Effects that the number Rokita cites is highly misleading because it lumps together all civil rights lawsuits, not just those that have to do with federal entitlement programs, which are at the heart of this case.

If the Supreme Court rules in favor of HHC, lawsuits like a 2015 case that won to an expensive hepatitis C drug may not be possible in the future, said , an attorney with the advocacy group .

When states tried to cap the benefits of people with disabilities in Indiana and across the nation, have helped patients gain access to things like in-home support with day-to-day tasks, known as attendant care.

Munson has litigated similar cases. She has a disability herself, and the prospect of a Supreme Court decision in favor of Marion County terrifies her.

“I rely on Medicaid for attendant care, for wheelchair repairs,” Munson said, “and losing the ability to go to federal court if need be is very scary.”

During the , the monumental case was absent from the agenda. But when the meeting opened for public comment, state representatives, patients, and advocates seized the opportunity to voice their concerns.

They had one demand for the agency: withdraw its Supreme Court petition.

State Rep. Robin Shackleford, an Indianapolis Democrat, and others in the legislature have been vocal about their concerns. Shackleford said many of her constituents are on Medicaid and , the Department of Agriculture’s supplemental nutrition program.

“They would be horrified … if they knew the board was the driver behind removing their rights,” Shackleford said.

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After a few moments of silence, one resident asked: “How’s Dr. Bernard doing?”

“Bernard is actually in really good spirits — I mean, relatively,” Scott answered. “She has 24/7 security, has her own lawyer.”

They were talking about Dr. Caitlin Bernard, an Indiana OB-GYN who provides abortions and trains residents at the university hospital. Bernard was recently after she spoke about an abortion she provided to a 10-year-old rape victim from Ohio. Bernard was the target of false accusations made on national television by pundits and political leaders, .

The doctors interviewed for this article said that they are not speaking on behalf of their school of medicine but rather about their personal experiences during a tumultuous moment that they worry will affect the way they care for their patients.

The vitriol directed at Bernard hit home for this group of residents. She has mentored most of them for years. Many of the young doctors were certain they wanted to practice in Indiana after their training. But lately, some have been ambivalent about that prospect.

Dr. Beatrice Soderholm, a fourth-year OB-GYN resident, said watching what Bernard went through was “scary.” “I think that was part of the point for those who were putting her through that,” Soderholm said. They were trying “to scare other people out of doing the work that she does.”

In early August, Gov. Eric Holcomb, a Republican, into law, making Indiana the first state to adopt new restrictions on abortion access since the Supreme Court struck down Roe v. Wade in June. When the ban takes effect Sept. 15, medical providers who violate the law risk losing their licenses or serving up to six years in prison.

These days, Scott, the residency program director, uses some meeting time with residents to fill them in on political updates and available mental health services. She also reminds them that legal counsel is on call round-the-clock to help if they’re ever unsure about the care they should provide a patient.

“Our residents are devastated,” Scott said, holding back tears. “They signed up to provide comprehensive health care to women, and they are being told that they can’t do that.”

She expects this will “deeply impact” how Indiana hospitals recruit and retain medical professionals.

found that 27% of Indiana counties are considered maternity care deserts, with no or limited access to maternal care. The state has one of the nation’s .

Scott said new laws restricting abortion will only worsen those statistics.

Scott shared results from a recent survey of nearly 1,400 residents and fellows across all specialties at the IU School of Medicine, nearly 80% of the trainees said they were less likely to stay and practice in Indiana after the abortion ban.

Dr. Wendy Tian, a third-year resident, said she is worried about her safety. Tian grew up and went to medical school in Chicago and chose to do her residency in Indiana because the program has a strong family-planning focus. She was open to practicing in Indiana when she completed her training.

But that’s changed.

“I, for sure, don’t know if I would be able to stay in Indiana postgraduation with what’s going on,” Tian said.

Still, she feels guilty for “giving up” on Indiana’s most vulnerable patients.

Even before Roe fell, Tian said, the climate in Indiana could be hostile and frustrating for OB-GYNs. Indiana, with abortion restrictions, allows nearly all health care providers to to patients having an abortion.

“We encounter other people who we work with on a daily basis who are opposed to what we do,” Tian said. Tian said she and her colleagues have had to cancel scheduled procedures because the nurses on call were not comfortable assisting during an abortion.

Scott said the OB-GYN program at the IU School of Medicine has provided residents with comprehensive training, including on abortion care and family planning. Since miscarriages are managed the same way as first-trimester abortions, she said, the training gives residents lots of hands-on experience. “What termination procedures allow you to do is that kind of repetition and that understanding of the female anatomy and how to manage complications that may happen with miscarriages,” she said.

The ban on abortions dramatically reduces the hands-on opportunities for OB-GYN residents, and that’s a huge concern, she said.

The program is exploring ways to offer training. One option is to send residents to learn in states without abortion restrictions, but Scott said that would be a logistical nightmare. “This is not as simple as just showing up to an office and saying, ‘Can I observe?’ This includes getting a medical license for out-of-state trainees. This includes funding for travel and lodging,” Scott said. “It adds a lot to what we already do to educate future OB-GYNs.”

in the U.S. are in states where abortion is banned or likely to be banned, so there could be a surge of residents looking to go out of state to make up for lost training opportunities. The Accreditation Council for Graduate Medical Education, the body that accredits residency programs, to the graduation requirements for OB-GYN residents to account for the changing landscape.

For some of the Indiana OB-GYN residents — including Dr. Veronica Santana, a first-year resident — these political hurdles are a challenge they’re more than willing to take on. Santana is Latina, grew up in Seattle, and has been involved in community organizing since she was a teenager. One reason she chose obstetrics and gynecology was because of how the field intersects with social justice. “It’s political. It always has been, and it continues to be,” she said, “And, obviously, especially now.”

After Roe was overturned, Santana, alongside other residents and mentors, took to the streets of Indianapolis to participate in rallies in support of abortion rights.

Indiana could be the perfect battleground for Santana’s advocacy and social activism. But lately, she said, she is “very unsure” whether staying in Indiana to practice after residency makes sense, since she wants to provide the entire range of OB-GYN services.

Soderholm, who grew up in Minnesota, has felt a strong connection to patients at the county hospital in Indianapolis. She had been certain she wanted to practice in Indiana. But her family in Minnesota — where abortion — has recently questioned why she would stay in a state with such a hostile climate for OB-GYNs. “There’s been a lot of hesitation,” she said. But the patients make leaving difficult. “Sorry,” she said, starting to cry.

It’s for those patients that Soderholm decided she’ll likely stay. Other young doctors may make a different decision.

This story is part of a partnership that includes ,Ìý,Ìýand KHN.

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