What kinds of rehab therapy might I need?

Physical therapy helps patients improve their strength, stability, and movement and reduce pain, usually through targeted exercises. Some physical therapists specialize in neurological, cardiovascular, or orthopedic issues. There are also geriatric and pediatric specialists. Occupational therapy focuses on specific activities (referred to as “occupations”), often ones that require fine motor skills, like brushing teeth, cutting food with a knife, and getting dressed. Speech and language therapy help people communicate. Some patients may need respiratory therapy if they have trouble breathing or need to be weaned from a ventilator.

Will insurance cover rehab?

Medicare, health insurers, workers’ compensation, and Medicaid plans in some states cover rehab therapy, but plans may refuse to pay for certain settings and may limit the amount of therapy you receive. Some insurers may require preauthorization, and some may terminate coverage if you’re not improving. Private insurers often place annual limits on outpatient therapy. Traditional Medicare is generally the least restrictive, while private Medicare Advantage plans may monitor progress closely and limit where patients can obtain therapy.

Should I seek inpatient rehabilitation?

Patients who still need nursing or a doctor’s care but can tolerate three hours of therapy five days a week may qualify for admission to a specialized rehab hospital or to a unit within a general hospital. Patients usually need at least two of the main types of rehab therapy: physical, occupational, or speech. Stays average around 12 days.

How do I choose?

Look for a place that is skilled in treating people with your diagnosis; many inpatient hospitals list specialties on their websites. People with complex or severe medical conditions may want a rehab hospital connected to an academic medical center at the vanguard of new treatments, even if it’s a plane ride away.

“You’ll see youngish patients with these life-changing, fairly catastrophic injuries,” like spinal cord damage, travel to another state for treatment, said Cheri Blauwet, chief medical officer of Spaulding Rehabilitation in Boston, one of the federal government has praised for cutting-edge work.

But there are advantages in selecting a hospital close to family and friends who can help after you are discharged. Therapists can help train at-home caregivers.

How do I find rehab hospitals?

The discharge planner or caseworker at the acute care hospital should provide options. You can search for inpatient rehabilitation facilities by location or name through . There you can see how many patients the rehab hospital has treated with your condition 鈥� the more the better. You can search by specialty through the , a trade group that lists its members.

Find out what specialized technologies a hospital has, like driving simulators 鈥� a car or truck that enable a patient to practice getting in and out of a vehicle 鈥� or a kitchen table with utensils to practice making a meal.

How can I be confident a rehab hospital is reliable?

It’s not easy: Medicare doesn’t analyze staffing levels or post on its website results of safety inspections as it does for nursing homes. You can ask your state public health agency or the hospital to provide inspection reports for the last three years. Such reports can be technical, but you should get the gist. If the report says an “immediate jeopardy” was called, that means inspectors identified safety problems that put patients in danger.

The rate of patients readmitted to a general hospital for a potentially preventable reason is a key safety measure. Overall, for-profit rehabs have higher readmission rates than nonprofits do, but there are some with lower readmission rates and some with higher ones. You may not have a nearby choice: There are fewer than 400 rehab hospitals, and most general hospitals don’t have a rehab unit.

You can find a hospital’s readmission rates under Care Compare’s quality section. Rates lower than the national average are better.

Another measure of quality is how often patients are functional enough to go home after finishing rehab rather than to a nursing home, hospital, or health care institution. That measure is called “discharge to community” and is listed under Care Compare’s quality section. Rates higher than the national average are better.

Look for reviews of the hospital on Yelp and other sites. Ask if the patient will see the same therapist most days or a rotating cast of characters. Ask if the therapists have board certifications earned after intensive training to treat a patient’s particular condition.

Visit if possible, and don’t look only at the rooms in the hospital where therapy exercises take place. Injuries often occur in the 21 hours when a patient is not in therapy, but in his or her room or another part of the building. Infections, falls, bedsores, and medication errors are risks. If possible, observe whether nurses promptly respond to call lights, seem overloaded with too many patients, or are apathetically playing on their phones. Ask current patients and their family members if they are satisfied with the care.

What if I can’t handle three hours of therapy a day?

A nursing home that provides rehab might be appropriate for patients who don’t need the supervision of a doctor but aren’t ready to go home. The facilities generally provide round-the-clock nursing care. The amount of rehab varies based on the patient. There are more than 14,500 skilled nursing facilities in the United States, 12 times as many as hospitals offering rehab, so a nursing home may be the only option near you.

You can look for them through Medicare’s Care Compare website. (Read our previous guide to finding a good, well-staffed to know how to assess the overall staffing.)

What if patients are too frail even for a nursing home?

They might need a long-term care hospital. Those specialize in patients who are in comas, on ventilators, and have acute medical conditions that require the presence of a physician. Patients stay at least four weeks, and some are there for months. Care Compare . There are fewer than 350 such hospitals.

I’m strong enough to go home. How do I receive therapy?

Many rehab hospitals offer outpatient therapy. You also can go to a clinic, or a therapist can come to you. You can hire a home health agency or find a therapist who takes your insurance and makes house calls. Your doctor or hospital may give you referrals. On Care Compare, whether they offer physical, occupational, or speech therapy. You can search for board-certified therapists on .

While undergoing rehab, patients sometimes move from hospital to nursing facility to home, often at the insistence of their insurers. Alice Bell, a senior specialist at the APTA, said patients should try to limit the number of transitions, for their own safety.

“Every time a patient moves from one setting to another,” she said, “they’re in a higher risk zone.”

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La fisioterapia, la terapia ocupacional y la terapia del habla se ofrecen en diversos entornos: hospitales, residencias de adultos mayores, clínicas y a domicilio.

Es fundamental encontrar una opción segura y de alta calidad con profesionales con experiencia en el tratamiento de tu afección.

驴Qué tipos de terapia de rehabilitación podría necesitar?

La fisioterapia ayuda a los pacientes a mejorar su fuerza, estabilidad y movimiento, y a reducir el dolor, generalmente a través de ejercicios específicos.

Algunos fisioterapeutas se especializan en problemas neurológicos, cardiovasculares u ortopédicos. También hay especialistas en geriatría y pediatría. La terapia ocupacional se centra en actividades específicas (llamadas “ocupaciones”), que suelen requerir habilidades motoras finas, como cepillarse los dientes, cortar alimentos con un cuchillo o vestirse.

La terapia del habla y del lenguaje ayuda a las personas a comunicarse. Algunos pacientes pueden necesitar terapia respiratoria si tienen dificultad para respirar o necesitan que se les retire el respirador.

驴Los seguros cubren las sesiones de rehabilitación?

Medicare, las aseguradoras de salud, la compensación laboral y los planes de Medicaid en algunos estados cubren las terapias de rehabilitación, pero los planes pueden negarse a pagar en ciertos entornos y limitar la cantidad de sesiones.

Algunas aseguradoras pueden pedir una preautorización y otras cancelar la cobertura si no se mejora. Las aseguradoras privadas suelen establecer límites anuales para la terapia ambulatoria.

El Medicare tradicional suele ser el menos restrictivo, mientras que los planes privados Medicare Advantage pueden supervisar de cerca el progreso y limitar los lugares en dónde los pacientes pueden recibir terapia.

驴Debería buscar rehabilitación hospitalaria?

Los pacientes que aún necesitan atención médica o de enfermería, pero que pueden tolerar tres horas de terapia cinco días a la semana, podrían calificar para ser admitidos en un hospital de rehabilitación especializado o en una unidad que funcione dentro de un hospital general.

Los pacientes suelen necesitar al menos dos de los principales tipos de terapia de rehabilitación: fisioterapia, terapia ocupacional o terapia del habla. Las estadías duran un promedio unos 12 días.

驴Cómo elijo?

Busca un centro especializado en el tratamiento de personas con tu diagnóstico; muchos hospitales enumeran las especialidades en sus sitios de internet. Las personas con afecciones médicas complejas o graves podrían preferir un hospital de rehabilitación conectado a un centro médico académico a la vanguardia de los nuevos tratamientos, incluso si está a un vuelo de distancia.

“Verás a pacientes jóvenes con lesiones catastróficas”, como daño de la médula espinal, viajando a otro estado para recibir tratamiento, dijo Cheri Blauwet, directora médica de Spaulding Rehabilitation en Boston, uno de los que el gobierno federal ha elogiado por su trabajo de avanzada.

Sin embargo, elegir un hospital cerca de familiares y amigos que puedan ayudar después del alta tiene sus ventajas. Los terapeutas pueden ayudar a capacitar a los que serán cuidadores en casa.

驴Cómo encuentro hospitales de rehabilitación?

El planificador de altas o el trabajador social del hospital de agudos debería ofrecerte opciones. Puedes buscar centros de rehabilitación para pacientes internados por ubicación o nombre en el . Allí puedes ver cuántos pacientes con tu misma afección ha tratado ese hospital; cuantos más, mejor.

Puedes buscar por especialidad a través de la , un grupo comercial que publica una lista de sus miembros.

Averig眉a qué tecnologías especializadas tiene un hospital, como simuladores de manejo (un auto o camión que permite al paciente practicar subir y bajar de un vehículo) o una mesa de cocina con utensilios para practicar cocinar.

驴Cómo puedo saber si un hospital de rehabilitación es confiable?

No es fácil: Medicare no analiza al personal ni publica en su sitio de internet los resultados de las inspecciones de seguridad como sí lo hace con las residencias de adultos mayores. Puedes pedir a la agencia de salud pública de tu estado o al hospital que te proporcionen informes de inspección de los últimos tres años. Estos informes pueden ser técnicos, pero te ayudarán a comprender lo esencial. Si el informe indica que se declaró un “riesgo inmediato”, significa que los inspectores identificaron problemas de seguridad que ponen en peligro a los pacientes.

La tasa de pacientes readmitidos en un hospital general por una razón potencialmente prevenible es una medida de seguridad clave. En general, los centros de rehabilitación con fines de lucro tienen tasas de readmisión más altas que los que son sin fines de lucro, pero hay algunos con tasas de readmisión más bajas y otros con tasas más altas. Puede que no tengas otra opción cerca: hay menos de 400 hospitales de rehabilitación y la mayoría de los hospitales generales no cuentan con una unidad de rehabilitación.

Puedes encontrar las tasas de readmisión de un hospital en la sección de calidad de Care Compare. Las tasas inferiores al promedio nacional son mejores.

Otra medida de calidad es la frecuencia con la que los pacientes son lo suficientemente funcionales como para irse a casa después de terminar la rehabilitación en lugar de ir a una residencia de adultos mayores, un hospital o una institución médica. Esta medida se denomina “alta a la comunidad” y se encuentra en la sección de calidad de Care Compare. Las tasas superiores al promedio nacional son mejores.

Busca reseñas del hospital en Yelp y otros sitios web. Pregunta si los pacientes ven al mismo terapeuta casi todos los días o no. Y si tienen certificaciones en la especialidad que necesitas.

Si es posible, visita el hospital y observa cómo opera. Si es posible, observa si las enfermeras responden rápido a las luces de llamada, si parecen estar sobrecargadas con demasiados pacientes o están mirando sus celulares. Pregunta a los pacientes actuales y a sus familiares si están satisfechos con la atención.

驴Qué pasa si no puedo tolerar tres horas de terapia al día?

Una residencia de personas mayores que ofrece rehabilitación podría ser adecuada para pacientes que no necesitan la supervisión de un médico, pero que no están listos para irse a casa. Las instalaciones generalmente brindan atención de enfermería las 24 horas. La duración de la rehabilitación varía según el paciente. Hay más de 14.500 centros de enfermería especializada en el país, 12 veces más que los hospitales que ofrecen rehabilitación, por lo que una de estas residencias podría ser tu mejor opción.

Puedes buscarlas a través del sitio web Care Compare de Medicare.

驴Qué sucede si los pacientes son demasiado frágiles incluso para una residencia de adultos mayores?

Podrían necesitar un hospital de cuidados de largo plazo. Estos se especializan en pacientes en coma, con respiradores y con afecciones médicas agudas que requieren la presencia de un médico. Los pacientes permanecen allí al menos cuatro semanas, y algunos meses. Care Compare te ayuda a buscar. Hay menos de 350 hospitales de este tipo.

Si tengo la fuerza suficiente para ir a casa. 驴Cómo recibo terapia?

Muchos hospitales de rehabilitación ofrecen terapia ambulatoria. También puedes ir a una clínica o un terapeuta puede ir a tu domicilio. Puedes contratar una agencia de atención médica a domicilio o encontrar un terapeuta que reciba tu seguro y haga visitas a domicilio.

Tu médico u hospital podría derivarte a otros profesionales. En Care Compare, las agencias de atención médica a domicilio indican si ofrecen fisioterapia, terapia ocupacional o terapia del habla. Puedes buscar terapeutas certificados en el sitio web de la Asociación Americana de Fisioterapia (APTA).

Durante la rehabilitación, los pacientes a veces se trasladan del hospital a un centro de enfermería y luego a su hogar, a menudo por insistencia de sus aseguradoras. Alice Bell, especialista senior de la APTA, señaló que los pacientes deberían intentar limitar el número de traslados, por su propia seguridad.

“Cada vez que un paciente cambia de un entorno a otro se encuentra en una zona de mayor riesgo”, afirmó.

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“He just gave her The Look 鈥� under his bushy eyebrows 鈥� and said, 鈥榃hat, are we getting married?’” recalled Smith, who had a good laugh, she said. Her father was then 92, a retired county planner and a World War II veteran; macular degeneration had reduced the quality of his vision, and he used a walker to get around, but he remained cognitively sharp.

“He wouldn’t normally get too frosty with people,” Smith said. “But he did have the sense that he was a grown-up and he wasn’t always treated like one.”

People understand almost intuitively what “elderspeak” means. “It’s communication to older adults that sounds like baby talk,” said Clarissa Shaw, a dementia care researcher at the University of Iowa College of Nursing and a co-author of that helps researchers document its use.

“It arises from an ageist assumption of frailty, incompetence, and dependence.”

Its elements include inappropriate endearments. “Elderspeak can be controlling, kind of bossy, so to soften that message there’s 鈥榟oney,’ 鈥榙earie,’ 鈥榮weetie,’” said Kristine Williams, a nurse gerontologist at the University of Kansas School of Nursing and another co-author of the article.

“We have negative stereotypes of older adults, so we change the way we talk.”

Or caregivers may resort to plural pronouns: Are we ready to take our bath? There, the implication “is that the person’s not able to act as an individual,” Williams said. “Hopefully, I’m not taking the bath with you.”

Sometimes, elderspeakers employ a louder volume, shorter sentences, or simple words intoned slowly. Or they may adopt an exaggerated, singsong vocal quality more suited to preschoolers, along with words like “potty” or “jammies.”

With what are known as tag questions 鈥� It’s time for you to eat lunch now, right? 鈥� “You’re asking them a question but you’re not letting them respond,” Williams explained. “You’re telling them how to respond.”

Studies in nursing homes show how commonplace such speech is. When Williams, Shaw, and their team analyzed video recordings of 80 interactions between staff and residents with dementia, they found that .

“Most of elderspeak is well intended. People are trying to show they care,” Williams said. “They don’t realize the negative messages that come through.”

For example, among nursing home residents with dementia, between exposure to elderspeak and behaviors collectively known as resistance to care.

“People can turn away or cry or say no,” Williams explained. “They may clench their mouths shut when you’re trying to feed them.” Sometimes, they push caregivers away or strike them.

She and her team developed a training program called CHAT, for Changing Talk: three hourlong sessions that include videos of communication between staff members and patients, intended to reduce elderspeak.

It worked. Before the training, in 13 nursing homes in Kansas and Missouri, almost 35% of the time spent in interactions consisted of elderspeak; that share dropped to about 20% afterward.

Furthermore, resistant behaviors accounted for almost 36% of the time spent in encounters; after training, that proportion fell to about 20%.

A study conducted in a Midwestern hospital, again among patients with dementia, found behavior.

What’s more, CHAT training in nursing homes was associated with . Though the results did not reach statistical significance, due in part to the small sample size, the research team deemed them “clinically significant.”

“Many of these medications have a black box warning from the FDA,” Williams said of the drugs. “It’s risky to use them in frail, older adults” because of their side effects.

Now, Williams, Shaw, and their colleagues have streamlined the CHAT training and adapted it for online use. They are examining its effects in about 200 nursing homes nationwide.

Even without formal training programs, individuals and institutions can combat elderspeak. Kathleen Carmody, owner of Senior Matters Home Health Care and Consulting in Columbus, Ohio, cautions her aides to address clients as Mr. or Mrs. or Ms., “unless or until they say, 鈥楶lease call me Betty.’”

In long-term care, however, families and residents may worry that correcting the way staff members speak could create antagonism.

A few years ago, Carol Fahy was fuming about the way aides at an assisted living facility in suburban Cleveland treated her mother, who was blind and had become increasingly dependent in her 80s.

Calling her “sweetie” and “honey babe,” the staff “would hover and coo, and they put her hair up in two pigtails on top of her head, like you would with a toddler,” said Fahy, a psychologist in Kaneohe, Hawaii.

Although she recognized the aides’ agreeable intentions, “there’s a falseness about it,” she said. “It doesn’t make someone feel good. It’s actually alienating.”

Fahy considered discussing her objections with the aides, but “I didn’t want them to retaliate.” Eventually, for several reasons, she moved her mother to another facility.

Yet objecting to elderspeak need not become adversarial, Shaw said. Residents and patients 鈥� and people who encounter elderspeak elsewhere, because it’s hardly limited to health care settings 鈥� can politely explain how they prefer to be spoken to and what they want to be called.

Cultural differences also come into play. Felipe Agudelo, who teaches health communications at Boston University, pointed out that in certain contexts a diminutive or term of endearment “doesn’t come from underestimating your intellectual ability. It’s a term of affection.”

He emigrated from Colombia, where his 80-year-old mother takes no offense when a doctor or health care worker asks her to “tómese la pastillita” (take this little pill) or “mueva la manito” (move the little hand).

That’s customary, and “she feels she’s talking to someone who cares,” Agudelo said.

“Come to a place of negotiation,” he advised. “It doesn’t have to be challenging. The patient has the right to say, 鈥業 don’t like your talking to me that way.’”

In return, the worker “should acknowledge that the recipient may not come from the same cultural background,” he said. That person can respond, “This is the way I usually talk, but I can change it.”

Lisa Greim, 65, a retired writer in Arvada, Colorado, pushed back against elderspeak recently when she enrolled in Medicare drug coverage.

Suddenly, she recounted in an email, a mail-order pharmacy began calling almost daily because she hadn’t filled a prescription as expected.

These “gently condescending” callers, apparently reading from a script, all said, “It’s hard to remember to take our meds, isn’t it?” 鈥� as if they were swallowing pills together with Greim.

Annoyed by their presumption, and their follow-up question about how frequently she forgot her medications, Greim informed them that having stocked up earlier, she had a sufficient supply, thanks. She would reorder when she needed more.

Then, “I asked them to stop calling,” she said. “And they did.”

The New Old Age is produced through a partnership with .

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Her mother, Jackie Hourigan, widowed and developing memory problems at 82, too often was still in bed when her children came to see her midmorning.

“She wasn’t being toileted, so her pants would be soaked,” said Peters, 69, a retired nurse-practitioner in Bloomington, Minnesota. “They didn’t give her water. They didn’t get her up for meals.” Her mother dwindled to 94 pounds.

Most ominously, Peters said, “we noticed bruises on her arm that we couldn’t account for.” Complaints to administrators 鈥� in person, by phone, and by email 鈥� brought “tons of excuses.”

So Peters bought an inexpensive camera at Best Buy. She and her sisters installed it atop the refrigerator in her mother’s apartment, worrying that the facility might evict her if the staff noticed it.

Monitoring from an app on their phones, the family saw Hourigan going hours without being changed. They saw and heard an aide loudly berating her and handling her roughly as she helped her dress.

They watched as another aide awakened her for breakfast and left the room even though Hourigan was unable to open the heavy apartment door and go to the dining room. “It was traumatic to learn that we were right,” Peters said.

After filing a police report and a lawsuit, and after her mother’s 2014 death, Peters in 2016 helped found , which lobbied for a state law permitting cameras in residents’ rooms in nursing homes and assisted living facilities. Minnesota in 2019.

Though they remain a contentious subject, cameras in care facilities are gaining ground. By 2020, eight states had joined Minnesota in enacting laws allowing them, : Illinois, Kansas, Louisiana, Missouri, New Mexico, Oklahoma, Texas, and Washington.

The legislative pace has picked up since, with nine more states enacting laws: Connecticut, North Dakota, South Dakota, Nevada, Ohio, Rhode Island, Utah, Virginia, and Wyoming. Legislation is pending in several others.

California and Maryland have adopted guidelines, not laws. The state governments in New Jersey and Wisconsin will lend cameras to families concerned about loved ones’ safety.

But bills have also gone down to defeat, most recently in Arizona. For the second year, passed the House of Representatives overwhelmingly but, in March, failed to get a floor vote in the state Senate.

“My temperature is a little high right now,” said state Rep. Quang Nguyen, a Republican who is the bill’s primary sponsor and plans to reintroduce it. He blamed opposition from industry groups, which in Arizona included LeadingAge, which represents nonprofit aging services providers, for the bill’s failure to pass.

The American Health Care Association, whose members are mostly for-profit long-term care providers, doesn’t take a national position on cameras. But its local affiliate also opposed the bill.

“These people voting no should be called out in public and told, 鈥榊ou don’t care about the elderly population,’” Nguyen said.

A few camera laws cover only nursing homes, but the majority include assisted living facilities. Most mandate that the resident (and roommates, if any) provide written consent. Some call for signs alerting staffers and visitors that their interactions may be recorded.

The laws often prohibit tampering with cameras or retaliating against residents who use them, and include “some talk about who has access to the footage and whether it can be used in litigation,” added Lori Smetanka, executive director of the National Consumer Voice.

It’s unclear how seriously facilities take these laws. Several relatives interviewed for this article reported that administrators told them cameras weren’t permitted, then never mentioned the issue again. Cameras placed in the room remained.

Why the legislative surge? During the covid-19 pandemic, families were locked out of facilities for months, Smetanka pointed out. “People want eyes on their loved ones.”

Changes in technology probably also contributed, as Americans became more familiar and comfortable with video chatting and virtual assistants. Cameras have become nearly ubiquitous 鈥� in public spaces, in workplaces, in police cars and on officers’ uniforms, in people’s pockets.

Initially, the push for cameras reflected fears about loved ones’ safety. Kari Shaw’s family, for instance, had already been who stole her mother’s prescribed pain medications.

So when Shaw, who lives in San Diego, and her sisters moved their mother into assisted living in Maple Grove, Minnesota, they immediately installed a motion-activated camera in her apartment.

Their mother, 91, has severe physical disabilities and uses a wheelchair. “Why wait for something to happen?” Shaw said.

In particular, “people with dementia are at high risk,” added Eilon Caspi, a gerontologist and researcher of elder mistreatment. “And they may not be capable of reporting incidents or recalling details.”

More recently, however, families are using cameras simply to stay in touch.

Anne Swardson, who lives in Virginia and in France, uses an Echo Show, an Alexa-enabled device by Amazon, for video visits with her mother, 96, in memory care in Fort Collins, Colorado. “She’s incapable of touching any buttons, but this screen just comes on,” Swardson said.

Art Siegel and his brothers were struggling to talk to their mother, who, at 101, is in assisted living in Florida; her portable phone frequently died because she forgot to charge it. “It was worrying,” said Siegel, who lives in San Francisco and had to call the facility and ask the staff to check on her.

Now, with an old-fashioned phone installed next to her favorite chair and a camera trained on the chair, they know when she’s available to talk.

As continues, a central question remains unanswered: Do they bolster the quality of care? “There’s zero research cited to back up these bills,” said Clara Berridge, a gerontologist at the University of Washington who听

“Do cameras actually deter abuse and neglect? Does it cause a facility to change its policies or improve?”

Both camera opponents and supporters cite concerns about residents’ privacy and dignity in a setting where they are being helped to wash, dress, and use the bathroom.

“Consider, too, the importance of ensuring privacy during visits related to spiritual, legal, financial, or other personal issues,” Lisa Sanders, a spokesperson for LeadingAge, said in a statement.

Though cameras can be turned off, it’s probably impractical to expect residents or a stretched-thin staff to do so.

Moreover, surveillance can treat those staff members as “suspects who have to be deterred from bad behavior,” Berridge said. She has seen facilities installing cameras in all residents’ rooms: “Everyone is living under surveillance. Is that what we want for our elders and our future selves?”

Ultimately, experts said, even when cameras detect problems, they can’t substitute for improved care that would prevent them 鈥� an effort that will require engagement from families, better staffing, training and monitoring by facilities, and more active federal and state oversight.

“I think of cameras as a symptom, not a solution,” Berridge said. “It’s a band-aid that can distract from the harder problem of how we provide quality long-term care.”

The New Old Age is produced through a partnership with .

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Josephine, 16, has been diagnosed with , severe autism, severe obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder, among other conditions, which will require constant assistance and supervision for the rest of her life.

Ortiz, 25, is Josephine’s caregiver. A Venezuelan immigrant, Ortiz helps Josephine eat, bathe, and perform other daily tasks that the teen cannot do alone at her home in West Orange, New Jersey. Over the past 2陆 years, Ortiz said, she has developed an instinct for spotting potential triggers before they escalate. She closes doors and peels barcode stickers off apples to ease Josephine’s anxiety.

But Ortiz’s ability to work in the U.S. has been thrown into doubt by the Trump administration, which to the temporary protected status program for some Venezuelans on April 7. On March 31, a federal judge , giving the administration a week to appeal. If the termination goes through, Ortiz would have to leave the country or risk detention and deportation.

“Our family would be gutted beyond belief,” said Krysta Senek, Josephine’s mother, who has been trying to win a reprieve for Ortiz.

Americans depend on many such foreign-born workers to help care for family members who are older, injured, or disabled and cannot care for themselves. Nearly 6 million people receive personal care in a private home or a group home, and about 2 million people use these services in a nursing home or other long-term care institution, according to a .

Increasingly, the workers who provide that care are immigrants such as Ortiz. The foreign-born share of nursing home workers rose three percentage points from 2007 to 2021, to about 18%, according to an by the Baker Institute for Public Policy at Rice University in Houston.

And foreign-born workers make up a high share of other direct care providers. More than 40% of home health aides, 28% of personal care workers, and 21% of nursing assistants were foreign-born in 2022, compared with 18% of workers overall that year, according to .

That workforce is in jeopardy amid an immigration crackdown President Donald Trump launched on his first day back in office. He signed executive orders that without a court hearing, , and more recently for nationals of Cuba, Haiti, Nicaragua, and Venezuela.

In to deport Venezuelans and attempting to for others, the Trump administration has sparked fear that even those who have followed the nation’s immigration rules could be targeted.

“There's just a general anxiety about what this could all mean, even if somebody is here legally,” said , president of LeadingAge, a nonprofit representing more than 5,000 nursing homes, assisted living facilities, and other services for aging patients. “There's concern about unfair targeting, unfair activity that could just create trauma, even if they don't ultimately end up being deported, and that's disruptive to a health care environment.”

Shutting down pathways for immigrants to work in the United States, Smith Sloan said, also means many other foreign workers may go instead to countries where they are welcomed and needed.

“We are in competition for the same pool of workers,” she said.

Growing Demand as Labor Pool Likely To Shrink

Demand for caregivers is predicted to surge in the U.S. as the youngest baby boomers reach retirement age, with the need for home health and personal care aides over a decade, according to the Bureau of Labor Statistics. Those 820,000 additional positions represent the most of any occupation. The need for also is projected to grow, by about 65,000 positions.

Caregiving is often low-paying and physically demanding work that doesn’t attract enough native-born Americans. The median pay ranges from about to a year, according to the Bureau of Labor Statistics.

Nursing homes, assisted living facilities, and home health agencies have long struggled with high turnover rates and staffing shortages, Smith Sloan said, and they now fear that Trump’s immigration policies will choke off a key source of workers, leaving many older and disabled Americans without someone to help them eat, dress, and perform daily activities.

With the Trump administration , which runs programs supporting older adults and people with disabilities, and Congress considering deep cuts to Medicaid, the largest payer for long-term care in the nation, the president’s anti-immigration policies are creating “a perfect storm” for a sector that has not recovered from the covid-19 pandemic, said , an executive vice president of the Service Employees International Union, which represents nursing facility workers and home health aides.

The relationships caregivers build with their clients can take years to develop, Frane said, and replacements are already hard to find.

In September, LeadingAge to help the industry meet staffing needs by raising caps on work-related immigration visas, expanding refugee status to more people, and allowing immigrants to test for professional licenses in their native language, among other recommendations.

But, Smith Sloan said, “There's not a lot of appetite for our message right now.”

The White House did not respond to questions about how the administration would address the need for workers in long-term care. Spokesperson Kush Desai said the president was given “a resounding mandate from the American people to enforce our immigration laws and put Americans first” while building on the “progress made during the first Trump presidency to bolster our healthcare workforce and increase healthcare affordability.”

Refugees Fill Nursing Home Jobs in Wisconsin

Until Trump suspended the refugee resettlement program, some nursing homes in Wisconsin had partnered with local churches and job placement programs to hire foreign-born workers, said Robin Wolzenburg, a senior vice president for LeadingAge Wisconsin.

Many work in food service and housekeeping, roles that free up nurses and nursing assistants to work directly with patients. Wolzenburg said many immigrants are interested in direct care roles but take on ancillary roles because they cannot speak English fluently or lack U.S. certification.

Through a partnership with the Wisconsin health department and local schools, Wolzenburg said, nursing homes have begun to offer training in English, Spanish, and Hmong for immigrant workers to become direct care professionals. Wolzenburg said the group planned to roll out training in Swahili soon for Congolese women in the state.

Over the past 2陆 years, she said, the partnership helped Wisconsin nursing homes fill more than two dozen jobs. Because refugee admissions are suspended, Wolzenburg said, resettlement agencies aren’t taking on new candidates and have paused job placements to nursing homes.

Many older and disabled immigrants who are permanent residents rely on foreign-born caregivers who speak their native language and know their customs. Frane with the SEIU noted that many members of San Francisco’s large Chinese American community want their aging parents to be cared for at home, preferably by someone who can speak the language.

“In California alone, we have members who speak 12 different languages,” Frane said. “That skill translates into a kind of care and connection with consumers that will be very difficult to replicate if the supply of immigrant caregivers is diminished.”

The Ecosystem a Caregiver Supports

Caregiving is the kind of work that makes other work possible, Frane said. Without outside caregivers, the lives of the patient and their loved ones become more difficult logistically and economically.

“Think of it like pulling out a Jenga stick from a Jenga pile, and the thing starts to topple,” she said.

Thanks to the one-on-one care from Ortiz, Josephine has learned to communicate when she’s hungry or needs help. She now picks up her clothes and is learning to do her own hair. With her anxiety more under control, the violent meltdowns that once marked her weeks have become far less frequent, Ortiz said.

“We live in Josephine’s world,” Ortiz said in Spanish. “I try to help her find her voice and communicate her feelings.”

Ortiz moved to New Jersey from Venezuela in 2022 as part of an au pair program that connects foreign-born workers with people who are older or children with disabilities who need a caregiver at home. Fearing political unrest and crime in her home country, she got temporary protected status when her visa expired last year to keep her authorization to work in the United States and stay with Josephine.

Losing Ortiz would upend Josephine’s progress, Senek said. The teen would lose not only a caregiver, but also a sister and her best friend. The emotional impact would be devastating.

“You have no way to explain to her, 鈥極h, Alanys is being kicked out of the country, and she can't come back,’” she said.

It’s not just Josephine: Senek and her husband depend on Ortiz so they can work full-time jobs and take care of themselves and their marriage. “She's not just an au pair,” Senek said.

The family has called its congressional representatives for help. Even a relative who voted for Trump sent a letter to the president asking him to reconsider his decision.

In the March 31 court decision, U.S. District Judge Edward Chen wrote that canceling the protection could “inflict irreparable harm on hundreds of thousands of persons whose lives, families, and livelihoods will be severely disrupted.”

鈥楧oing the Work That Their Own People Don’t Want To Do’

News of immigration dragnets that sweep up and are causing a lot of stress, even for those who have followed the rules, said Nelly Prieto, 62, who cares for an 88-year-old man with Alzheimer’s disease and a man in his 30s with Down syndrome in Yakima County, Washington.

Born in Mexico, she immigrated to the United States at age 12 and became a U.S. citizen under authorized by President Ronald Reagan that made any immigrant who entered the country before 1982 eligible for amnesty. So, she’s not worried for herself. But, she said, some of her co-workers working under are very afraid.

“It kills me to see them when they talk to me about things like that, the fear in their faces,” she said. “They even have letters, notarized letters, ready in case something like that happens, saying where their kids can go.”

Foreign-born home health workers feel they are contributing a valuable service to American society by caring for its most vulnerable, Prieto said. But their efforts are overshadowed by rhetoric and policies that make immigrants feel as if they don’t belong.

“If they cannot appreciate our work, if they cannot appreciate us taking care of their own parents, their own grandparents, their own children, then what else do they want?” she said. “We’re only doing the work that their own people don’t want to do.”

In New Jersey, Ortiz said life has not been the same since she received the news that her TPS authorization was slated to end soon. When she walks outside, she fears that immigration agents will detain her just because she’s from Venezuela.

She’s become extra cautious, always carrying proof that she’s authorized to work and live in the U.S.

Ortiz worries that she’ll end up in a detention center. But even if the U.S. now feels less welcoming, she said, going back to Venezuela is not a safe option.

“I might not mean anything to someone who supports deportations,” Ortiz said. “I know I'm important to three people who need me."

This article was produced by 麻豆女优 Health News, which publishes , an editorially independent service of the .听

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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Josephine tiene 16 años y ha sido diagnosticada con , autismo severo, trastorno obsesivo-compulsivo grave y trastorno por déficit de atención con hiperactividad, entre otras afecciones. Todo esto significa que necesitará asistencia y acompañamiento constantes toda su vida.

Ortiz, de 25 años, es la cuidadora de Josephine. Esta inmigrante venezolana la ayuda a comer, bañarse y hacer tareas diarias que la adolescente no puede hacer sola en su casa en West Orange, Nueva Jersey.

Ortiz cuenta que, en los últimos dos años y medio, ha desarrollado un instinto que le permite detectar posibles factores desencadenantes de las crisis antes de que se agudicen. Por ejemplo, cierra las puertas y les quita las etiquetas de códigos de barras a las manzanas para reducir la ansiedad de Josephine.

Sin embargo, la posibilidad de trabajar en Estados Unidos puede estar en peligro para Ortiz. La administración Trump al programa de Estatus de Protección Temporal (TPS) para algunos venezolanos a partir del 7 de abril. El 31 de marzo, un juez federal , dando a la administración una semana para apelar.

Si el programa se suspende, Ortiz tendrá que abandonar el país o arriesgarse a ser detenida y deportada.

“Nuestra familia quedaría devastada más allá de lo imaginable”, afirma Krysta Senek, la madre de Josephine, quien ha estado buscando un indulto para Ortiz.

Los estadounidenses dependen de muchos trabajadores nacidos en el extranjero para cuidar a sus familiares mayores, lesionados o discapacitados que no pueden valerse por sí mismos.

Según un análisis de la , casi 6 millones de personas reciben atención personal en un hogar privado o en una residencia grupal, y alrededor de 2 millones utilizan estos servicios en residencias para personas mayores u otras instituciones de cuidado a largo plazo.

Cada vez con más frecuencia, estos cuidadores son inmigrantes como Ortiz. En los centros de cuidados para adultos mayores, la proporción de trabajadores nacidos en el extranjero aumentó tres puntos porcentuales entre 2007 y 2021, hasta alcanzar aproximadamente el 18%, según un del Instituto Baker de Política Pública de la Universidad Rice, en Houston.

Además, los trabajadores nacidos en el extranjero representan una gran parte de otros proveedores de cuidados directos.

En 2022, más del 40% de los asistentes de salud a domicilio, el 28% de los trabajadores de cuidado personal y el 21% de los asistentes de enfermería habían nacido en el extranjero, un número superior al 18% de extranjeros en el total de la economía ese año, según datos de

Esa fuerza laboral está en riesgo como consecuencia de la ofensiva contra los inmigrantes que Donald Trump lanzó en el primer día de su segunda administración.

El presidente firmó órdenes ejecutivas que en los que se pueden decidir las deportaciones sin audiencia judicial, de los refugiados y, más recientemente, para ciudadanos de Cuba, Haití, Nicaragua y Venezuela.

para deportar a venezolanos e intentando de otros, la administración Trump ha generado temor incluso entre aquellos que han seguido las reglas de inmigración del país.

"Hay una ansiedad general sobre lo que esto podría significar, incluso si alguien está aquí legalmente", dijo presidenta de LeadingAge, una organización sin fines de lucro que representa a más de 5.000 residencias, hogares de cuidados asistidos y otros servicios para adultos mayores.

“Existe preocupación por la persecución injusta, por acciones que pueden ser traumáticas incluso si finalmente esas personas no terminan siendo deportadas. Pero toda esa situación, ya de por sí, altera el entorno de atención de salud”.

Según explicó Smith Sloan, cerrar las vías legales para que los inmigrantes trabajen en Estados Unidos también implica que muchos optarán por irse a países donde sí son bienvenidos y necesarios.

“Estamos compitiendo por el mismo grupo de trabajadores”, afirmó.

Más demanda, menos trabajadores

Se prevé que la demanda de trabajadores que realizan tareas de cuidado aumente considerablemente en el país, a medida que los baby boomers más jóvenes lleguen a la edad de su jubilación.

Según las proyecciones de la Oficina de Estadísticas Laborales, la necesidad de asistentes de salud y de cuidado personal a domicilio crecerá hasta cerca del en el transcurso de la próxima década.

Esos 820.000 puestos adicionales representan el mayor aumento entre todas las actividades laborales. También se proyecta un de auxiliares de enfermería y camilleros, con un incremento de alrededor de 65.000 puestos.

El trabajo de cuidado suele ser mal remunerado y físicamente exigente, por lo que en general no atrae a suficientes estadounidenses nativos. El salario medio oscila, según la misma Oficina, entre y anuales.

Los hogares para adultos mayores, las residencias geriátricas con asistencia y las agencias de atención domiciliaria han lidiado durante mucho tiempo con altas tasas de rotación de personal y escasez de empleados, señaló Smith Sloan.

Ahora, además, temen que las políticas migratorias de Trump corten una fuente clave de trabajadores, dejando a muchas personas de edad avanzada, o con discapacidades, sin alguien que las ayude a comer, a vestirse y a realizar sus actividades cotidianas.

Con el gobierno de Trump reorganizando la 鈥攅ncargada de los programas que apoyan a adultos mayores y personas con discapacidades鈥� y el Congreso considerando recortes radicales a Medicaid (el mayor financiador de cuidados a largo plazo en el país), las políticas antiinmigración del presidente están generando “la tormenta perfecta” para un sector que aún no se ha recuperado de la pandemia de covid-19, opinó , vicepresidenta ejecutiva del Sindicato Internacional de Empleados de Servicios, que representa a estos trabajadores.

Frane señaló que la relación que los cuidadores construyen con sus pacientes puede tardar años en desarrollarse, y que hoy ya es muy complicado encontrar personas que los reemplacen.

En septiembre, la organización LeadingAge hizo para que ayudara a la industria a cubrir sus necesidades de personal. Le propuso, entre otras recomendaciones, que aumentara los cupos de visas de inmigración relacionadas con estos trabajos, ampliara el estatus de refugiado a más personas y permitiera que los inmigrantes rindieran los exámenes de certificación profesional en su idioma nativo.

Pero, agregó Smith Sloan, “en este momento no hay mucho interés en nuestro mensaje”.

La Casa Blanca no respondió a las preguntas sobre cómo la administración abordaría la necesidad de aumentar el número de trabajadores en el sector de cuidados a largo plazo.

El vocero Kush Desai declaró que el presidente recibió “un mandato contundente del pueblo estadounidense para hacer cumplir nuestras leyes migratorias y poner a los estadounidenses en primer lugar”, al tiempo que -dijo- continúa con “los avances logrados durante la primera presidencia de Trump para fortalecer al personal del sector salud y hacer que la atención médica sea más accesible”.

En Wisconsin, refugiados trabajan con adultos mayores

Hasta que Trump suspendió el programa de reasentamiento de refugiados, en Wisconsin algunas residencias de adultos mayores se habían asociado con iglesias locales y programas de inserción laboral para contratar trabajadores nacidos en el extranjero, explicó Robin Wolzenburg, vicepresidente senior de LeadingAge Wisconsin.

Muchas de estas personas trabajan en el servicio de comidas y en la limpieza, funciones que liberan a las enfermeras y auxiliares de enfermería para que puedan atender directamente a los pacientes.

Sin embargo, Wolzenburg agregó que muchos inmigrantes están interesados en asumir funciones de atención directa, pero que se emplean en funciones auxiliares porque no hablan inglés con fluidez o no tienen una certificación válida estadounidense.

Wolzenburg contó que, a través de una asociación con el departamento de salud de Wisconsin y las escuelas locales, los hogares de adultos mayores han comenzado a ofrecer formación en inglés, español y hmong para que los trabajadores inmigrantes puedan convertirse en profesionales de atención directa.

Dijo también que el grupo planeaba impartir pronto una capacitación en swahili para las mujeres congoleñas que viven en el estado.

En los últimos dos años y medio, esta colaboración ayudó a los centros de cuidados para personas mayores de Wisconsin a cubrir más de una veintena de puestos de trabajo, dijo.

Sin embargo, Wolzenburg explicó que, por la suspensión de las admisiones de refugiados, las agencias de reasentamiento no están incorporando nuevos candidatos y han puesto una pausa a la incorporación de estos trabajadores.

Muchos inmigrantes mayores o que tienen alguna discapacidad, y a la vez son residentes permanentes, dependen de cuidadores nacidos en el extranjero que hablen su idioma y conozcan sus costumbres.

Frane, del sindicato SEIU, señaló que muchos miembros de la numerosa comunidad chino-estadounidense de San Francisco quieren que sus padres mayores reciban atención en casa, preferiblemente de alguien que hable su mismo idioma.

“Solo en California, tenemos miembros del sindicato que hablan 12 lenguas diferentes, dijo Frane. Esa habilidad se traduce en una calidad de atención y una conexión con los usuarios que será muy difícil de replicar si disminuye la cantidad de cuidadores inmigrantes”.

El ecosistema que depende del trabajo de un cuidador

Las tareas de cuidado son el tipo de trabajo que permite que otros trabajos sean posibles, sostuvo Frane. Sin cuidadores externos, la vida de los pacientes y de sus seres queridos se vuelve más difícil desde el punto de vista logístico y económico.

“Es como sacar el pilar que sostiene todo lo demás: el sistema entero tambalea”, agregó.

Gracias a la atención personalizada de Ortiz, Josephine ha aprendido a comunicar cuando tiene hambre o necesita ayuda. Ahora recoge su ropa y está comenzando a peinarse sola. Como su ansiedad está más controlada, las crisis violentas que antes solían repetirse semana tras semana se han vuelto mucho menos frecuentes, dijo Ortiz.

"Vivimos en el mundo de Josephine", explica Ortiz en español. "Intento ayudarla a encontrar su voz y a expresar sus sentimientos".

Ortiz llegó a Nueva Jersey desde Venezuela en 2022 a través de un programa de Au Pair para conectar trabajadores nacidos en el extranjero con personas mayores o niños con discapacidades que necesitan cuidados en su hogar.

Temerosa de la inestabilidad política y la inseguridad en su país, cuando su visa expiró obtuvo el TPS el año pasado. Quería seguir trabajando en Estados Unidos, y quedarse con Josephine.

Perder a Ortiz sería un golpe devastador para el progreso de Josephine, aseguró Senek. La adolescente no solo se quedaría sin su cuidadora, sino también sin una hermana y su mejor amiga. El impacto emocional sería enorme.

"Nosotros no tenemos ninguna manera de explicarle a Josephine que Alanys está siendo expulsada del país y que no puede volver'", dijo Senek.

No se trata solo de Josephine: Senek y su esposo también dependen de Ortiz para poder trabajar a tiempo completo y cuidar de sí mismos y de su matrimonio. “Ella no es solo una Au Pair”, dijo Senek.

La familia ha contactado a sus representantes en el Congreso en busca de ayuda. Incluso un familiar que votó por Trump le envió una carta al presidente pidiéndole que reconsiderara su decisión.

En el fallo judicial del 31 de marzo, el juez federal Edward Chen escribió que cancelar esta protección podría “ocasionar un daño irreparable a cientos de miles de personas cuyas vidas, familias y medios de subsistencia se verán gravemente afectados”.

“Solo estamos haciendo el trabajo que su propia gente no quiere hacer”

Las noticias sobre redadas migratorias que detienen incluso a y las están generando mucho estrés, incluso entre quienes han seguido todas las reglas, comentó Nelly Prieto, de 62 años, quien cuida a un hombre de 88 con Alzheimer y a otro de unos 30 con síndrome de Down en el condado de Yakima, Washington.

Nacida en México, Prieto emigró a Estados Unidos a los 12 años y se convirtió en ciudadana estadounidense en virtud de impulsada por el presidente Ronald Reagan que ofrecía amnistía a cualquier inmigrante que hubiera entrado en el país antes de 1982. Así que ella no está preocupada por sí misma. Pero, dijo, algunos de sus compañeros de trabajo con tienen mucho miedo.

“Me parte el alma verlos cuando me hablan de estas cosas, el miedo en sus rostros”, dijo. “Incluso tienen preparadas cartas firmadas ante un notario diciendo con quién deben quedarse sus hijos, por si algo llega a pasar”.

Los trabajadores de salud a domicilio que nacieron en el extranjero sienten que están contribuyendo con un servicio valioso a la sociedad estadounidense al cuidar de sus miembros más vulnerables, dijo Prieto. Pero sus esfuerzos se ven ensombrecidos por los discursos y las políticas que hacen que los inmigrantes se sientan como si fueran ajenos al país.

“Si no pueden apreciar nuestro trabajo, si no pueden apreciar que cuidemos de sus propios padres, de sus propios abuelos, de sus propios hijos, entonces, 驴qué más quieren?”, dijo. “Solo estamos haciendo el trabajo que su propia gente no quiere hacer”.

En Nueva Jersey, Ortiz contó que su vida no ha sido la misma desde que recibió la noticia de que su permiso bajo el TPS está por terminar. Cada vez que sale a la calle, teme que agentes de inmigración la detengan solo por ser venezolana.

Se ha vuelto mucho más precavida: siempre lleva consigo documentos que prueban que tiene autorización para vivir y trabajar en Estados Unidos.

Ortiz teme terminar en un centro de detención. Aunque Estados Unidos ahora no es un lugar acogedor, consideró que regresar a Venezuela no es una opción segura.

“Puede que yo no signifique nada para alguien que apoya las deportaciones”, dijo Ortiz. “Pero sé que soy importante para tres personas que me necesitan”.

Esta historia fue producida por , que publica听, un servicio editorialmente independiente de la听.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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With the 2024 election campaign in its final days, House Speaker Mike Johnson this week floated “massive” health care reform if former President Donald Trump wins 鈥� changes that are also dependent, of course, on whether Republicans control Congress next year.

Meanwhile, new reporting uncovers more maternal deaths under state abortion bans, plus at least one case in which a woman was jailed after a miscarriage. Plus, other investigations are shining a light on a reality of American health care, regardless of who wins on Tuesday: the consequences of health industry profiteering.

This week’s panelists are Emmarie Huetteman of 麻豆女优 Health News, Lauren Weber of The Washington Post, Shefali Luthra of The 19th, and Jessie Hellmann of CQ Roll Call.

Panelists

Among the takeaways from this week’s episode:

• Trump has called for reopening the fight over the Affordable Care Act, and given enough votes in Congress, Johnson suggested this week that he’s ready to back the former president’s play. To be sure, the Jan. 1, 2026, expiration of enhanced ACA premium subsidies will put the health law back on the agenda 鈥� though given the law’s popularity, changes may be a hard sell even to some Republicans.
• Trump also unveiled his own proposal to address the long-term care crisis: a tax credit for family caregivers. His plan follows Vice President Kamala Harris’ proposal weeks ago to create a new Medicare benefit that pays for home health care.
• New reporting is out this week on women suffering miscarriages being denied reproductive health care 鈥� or even being charged with manslaughter and incarcerated. While many abortion opponents say they have no intention of harming or punishing women, the consequences of overturning Roe v. Wade are coming into clearer focus.

Also this week, 麻豆女优 Health News’ Julie Rovner interviews Irving Washington, a senior vice president at 麻豆女优 and the executive director of its Health Misinformation and Trust Initiative.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Emmarie Huetteman: 麻豆女优 Health News’ “鈥楧reamers’ Can Enroll in ACA Plans This Year 鈥� But a Court Challenge Could Get in the Way,” by Julie Appleby.

Lauren Weber: The New York Times’ “,” by Walt Bogdanich and Carson Kessler.

Shefali Luthra: NBC News’ “,” by Aria Bendix.

Jessie Hellmann: ProPublica’s “,” by T. Christian Miller, ProPublica; Patrick Rucker, The Capitol Forum; and David Armstrong, ProPublica.

Also mentioned on this week’s podcast:

• 麻豆女优 Health News’ “Ghosts, Ghouls, and Ghastly Drug Prices in Winning Halloween Haikus.”
• ProPublica’s “,” by Cassandra Jaramillo and Kavitha Surana.
• The Washington Post’s “,” by Caroline Kitchener.
• The 19th’s “,” by Shefali Luthra.
• The New York Times’ “,” by Chris Hamby.
• 麻豆女优’s , a program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]听

Emmarie Huetteman: Hello and welcome back to “What the Health?” I’m Emmarie Huetteman, a senior editor for 麻豆女优 Health News and the regular editor on this podcast. I’m filling in for Julie Rovner this week, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 31, at 10 a.m. Happy Halloween. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go.听

Today, we’re joined via video conference by Shefali Luthra of The 19th.听

Shefali Luthra: Hello.听

Huetteman: Lauren Weber of The Washington Post.听

Lauren Weber: Hello, hello.听

Huetteman: And Jessie Hellmann of CQ Roll Call.听

Jessie Hellmann: Happy Halloween.听

Huetteman: Later in this episode, we’ll have Julie’s interview with Irving Washington. Irving is our 麻豆女优 colleague who is senior vice president and executive director of the Health Misinformation and Trust initiative, and he joined us this week to talk about the election. We’ll also have the winner of 麻豆女优 Health News’ Halloween Health Haiku contest. But first, this week’s news. We are this close to the end of campaign 2024 and health care is making a bit of an unexpected resurgence. During a campaign event this week, House Speaker Mike Johnson said that there would be massive health care changes if former President Donald Trump is elected, including “no Obamacare.” Here’s what Johnson said:听

“The ACA is so deeply ingrained, we need massive reform to make this work, and we got a lot of ideas on how to do that.” OK, as a reminder, Trump has called for reopening the ACA fight and he has made no promises to preserve Medicaid, which, by the way, pays medical bills for about 1 in 5 Americans. Now, for the reality check for the Republicans to make big changes, it wouldn’t be enough for Trump to win. Republicans would also need to hold the House and win control of the Senate next week.听

Let’s put that aside, though, to talk about appetite here. Do we really think that Republicans would go after the Affordable Care Act again? It worked so well for them.听

Hellmann: I don’t know if I envision another repeal-and-replace fiasco, but there is an opening for them in 2025. There are enhanced premium tax credits that expire. Those were done through the Inflation Reduction Act, and I see it very unlikely that Republicans would be willing to go along and extend those again. I think that’s going to be a big fight, but it obviously depends who wins the House and the Senate. Right now, it looks like Democrats might retake the House and Republicans will regain the Senate, so maybe there will be some kind of negotiation there, but it has such a high price tag that it just seems like it would be a really messy fight. But as far as just repealing the ACA, I don’t think they want to open that can of worms again.听

Huetteman: Absolutely. I’m wondering has much changed since Sen. [John] McCain’s famous thumbs down in 2017 ended the last effort?听

Luthra: People are more used to having the ACA. It has only gotten more and more entrenched in our system. One thing that I was really struck by is, this isn’t the first time in the campaign that a prominent Republican has talked about repealing the ACA. We had that kerfuffle earlier this cycle with JD Vance, who talked about, essentially, getting rid of protections for preexisting conditions, with the change in risk pools, and the backlash was pretty swift, and it just seems, from watching and seeing what the political reality has been, that if it was difficult to get the ACA repealed last time and it did not work, it will only be harder because people have grown just so much more accustomed to these benefits. I personally can’t remember having health care without the ACA, and a lot of people who are younger than a certain age probably feel the same way.听

Huetteman: Absolutely. I was noting, actually, in my notes, Mike Johnson himself voted for repeal in 2017, but his office, when he was asked after those comments this week, didn’t elaborate when asked whether he also supports extending the ACA subsidies expiring next year. Seems likely that that’s not on his agenda, if I had to guess, especially based on this sort of talk.听

Weber: I think this is a question of are they saying the quiet part out loud or are they walking this back because it doesn’t poll particularly well right before the election happens? To some extent, this is a little bit of a wait-and-see game here.听

Huetteman: I think you’re absolutely right, Lauren. Moving on to the next issue, talking about the election coming up next week. A few weeks ago, Vice President Kamala Harris suggested a way to address the long-term care crisis in this country. Her plan would add a new Medicare benefit to pay for home health care. Then this week, Trump countered with his own idea. His proposal is to give a tax credit to family caregivers. Here’s the thing, though: There’s a pretty big difference between having Medicare pay for a home health care worker and cutting a family caregiver’s tax bill. But do these policy differences matter to voters at this point in the race?听

Weber: I think you’re having Trump throw something at the wall because Harris tapped into something powerful, which is that there are a lot of Americans that are home health care aides. We have seen so much caregiving that goes on around this country without much notice or favor and that drives a lot of our health care costs. So I think the fact that you had the Trump campaign throw out anything at all speaks to how important this issue is to everyday Americans and remains to be seen which would be a better deal for these folks. Often, home care aides are not working, so their tax bill is different because they’re taking care of family members. But we also have to see what happens if Trump has been thought to potentially cut some forms of Medicaid, which also pays for a lot of home care aides. There’s a lot of unknown there, but there’s a lot of dollars that go into this, and a lot of Americans that feel very strongly about it. So I’m not surprised to see his campaign try to match in some way what Harris had suggested.听

Luthra: I think the other point that’s worth noting also is, from a politics perspective, there is a question of voter trust as well, and we know from decades of polling that voters largely do trust Democrats more on issues of health policy because it’s the party that has been more invested in trying to expand benefits and trying to reform the health care system and has really devoted much of its intellectual thought to this area in a way that Republicans really haven’t. Obviously, there’s not a one-to-one between home care specifically 鈥� versus other times of types of health care, but I do think that we should take a critical eye and see do voters react to this even in an abstract way with the same kind of credibility that they might to a Democrat just with that history in mind.听

Huetteman: That’s a great point. I hate to move on so quickly, but it’s time for Washington’s favorite parlor game. Let’s play “Guess Who?” 鈥� as in guess who might fill the key health jobs in the next administration. There’s one we talked about a little bit last week, but if Trump is elected, he says that he has promised Robert F. Kennedy [Jr.] free rein over both health and food policy. Here’s what Trump said about RFK Jr. during his rally at Madison Square Garden this week. “I’m going to let him go wild on health. I’m going to let him go wild on the food. I’m going to let him go wild on the medicines.” Do we know what Trump’s saying here and who else could play a major role in the next Trump administration? Lauren, what do you have to add?听

Weber: I think it’s important to note that, just last night Trump’s co-chair of his transition team got on CNN and said some version of vaccines are linked to autism, which is patently false as we all know on this panel. I think it’s important to note that RFK, in any sort of health care rule, would be quite alarming to many public health professionals who call vaccination “the bedrock of public health advancement” over the last couple decades. As we look at what’s brewing in Trump Camp, some names that have come to mind are Casey and Calley Means have been floated out as folks that could be in the Trump administration.听

You’re seeing some chatter around a fair variety of folks from before and after. I think some of it remains to be seen, but Trump is blatantly saying that he will give RFK some role in picking these people, and a lot of the people I talk to, the sources I talk to are very alarmed by what that could mean. As I said earlier in this podcast, the Trump campaign is saying the quiet part out loud. They’ve pitched the MAHA [Make America Healthy Again] movement as more about ultra-processed foods and some of these other things. But when you have top campaign officials saying, “Actually, we do have questions about vaccines,” it’s hard to look past RFK’s vast record of anti-vaccine activism.听

Huetteman: By MAHA, of course, we mean the “Make America Healthy Again” effort.听

Weber: Yes, and I will point out know RFK recently tweeted about MAHA that he would “bring sunshine back to the FDA.” He would promote ivermectin, stem cell research, a variety of things that many members of the medical community are alarmed by.听

Huetteman: Including, in fact, Trump’s own surgeon general, who made his own comments this week about RFK potentially being in the next administration, his comments were that RFK’s influence could make people less willing to get vaccines, which could impact “our nation’s health, our nation’s economy, and our global security.” That’s pretty big words from someone who served under the last Trump administration about the next one.听

Luthra: I think that gets at something quite interesting when we think about who might be doing health policy under a Trump administration, which is, in the previous administration, that picking those people was a job largely outsourced to Mike Pence. Mike Pence is obviously not on the ticket anymore, so that leaves more of an opening and I don’t think we necessarily know who will be filling that role. Does JD Vance necessarily get a larger role in picking some of the people who might influence health policy? That could have a lot of implications because he’s also quite socially conservative and the Health and Human Services Department does have real power over issues like abortion, family planning, a lot of these areas that have been very influential in shaping how voters feel about this election and where JD Vance has changed his views a number of times.听

Huetteman: Those are good points. Absolutely. Moving on now to abortion. Speaking of abortion, in terms of the election, we’re having more stories coming out about the effects of the new abortion environment here in this country. You may remember the outcry in September after ProPublica told the stories of two women who died in Georgia because they couldn’t get care under the state’s abortion ban. ProPublica is back this week with out of Texas attributable to its ban, one of which happened just two days after the state’s “heartbeat law” took effect in 2021. These are wrenching stories, but are they having an impact on voters?听

Luthra: I don’t know. I think we’ve already seen a pretty meaningful shift in how voters think about abortion in the past couple of years because they have heard so many stories about people suffering devastating health consequences, even short of death. One thing that I was really struck by that ProPublica pointed out in this piece, which is just gutting to read and which we saw reinforced by the reaction from anti-abortion interest groups yesterday, is that there isn’t necessarily a reaction from Republicans and from people who oppose abortion to acknowledge the role that abortion laws play in harming people’s health, and in these cases in people’s deaths. Susan B. Anthony List [Susan B. Anthony Pro-Life America], a prominent anti-abortion group, said that the real problem here is not the laws, but rather that doctors don’t understand how to make use of the exceptions in these laws and that the fault lies with doctors.听

ProPublica spoke to many, many doctors across the country. Many of us who cover this have also spoken to many doctors across the country, and it’s just very clear that the exceptions as written in these laws are quite unworkable. There just isn’t enough clarity for people to know that they can provide care until it is too late, and in the case like this, it was too late before people could intervene. But I remain skeptical that without broad sustained outcry, we will see this change how abortion opponents and the Republican Party talk about abortion as a policy issue.听

Huetteman: I’d love to talk a little bit more about how anti-abortion folks are talking about this issue. Here’s that came out this week from The Washington Post about a woman who suffered a miscarriage and ended up in prison charged with manslaughter. This was in Nevada, which doesn’t even have an abortion ban. Her conviction was set aside by a judge and she was released, but the woman is still in legal jeopardy because the prosecutor hasn’t dropped the charges and hasn’t decided whether he will or not. Many abortion opponents say they have no intention of punishing women who have abortions. We’re talking about doctors being potentially punished for performing abortions, but we’re still seeing women punished as a result of their pregnancy outcomes. Why is that?听

Luthra: That prosecution and the story is just phenomenal and absolutely worth reading. That prosecution actually happened before Roe v. Wade was even overturned and it made use of very old anti-abortion laws, and it highlighted something that I think is really important, which is that there has been a history of criminalizing people for pregnancy outcomes, even independently of the abortion bans that have swept the country in the past two years, and that comes from a lot of factors, but it is something that we are seeing become potentially more common in the post-Dobbs landscape, and there’s a real divide in the anti-abortion movement, whether they will eventually go after pregnant people in a more systematic way. The reason they haven’t is because of the politics, because it is just so unpopular to say we are going to specifically go after people who are pregnant as opposed to their doctors.听

But I think cases like this Nevada case and cases like others that we have seen arise around the country, including in Texas, underscore that there is some appetite for this in some corners of the anti-abortion movement, and it is something that could gain traction and gain prominence if abortion opponents make a calculus that the political trade-offs are worth it or are no longer as salient as they have been.听

Huetteman: Shefali, you’ve done some great reporting on this, and I’d like to talk a little bit more about that, actually. So first off, in last week’s extra-credits segment, Julie talked about anti-abortion crisis pregnancy centers. These centers offer free pregnancy tests, ultrasounds, and counseling while trying to convince people not to have an abortion. Shefali, you have a about how these centers are getting more involved in electoral politics. Can you tell us more about that?听

Luthra: I thought this was very interesting and I looked at these anti-abortion/crisis pregnancy centers in the states where abortion is on the ballot and I saw a good number of them have been making themselves more of a presence on the campaign trail and legally most of them are 501(c)(3) nonprofits, so they can’t endorse a specific candidate, but what they are doing is trying to share what they say is information about how these ballot measures would affect them. But what they’re sharing often contains a good amount of misleading or inflammatory language, arguing the classic Republican talking points, “These abortion measures would allow abortion up until the point of birth and beyond,” which, in most cases, isn’t true because a lot of these measures actually would only protect abortion up until fetal viability.听

But what we’re seeing is part of a larger effort. Heartbeat International, one of the big crisis pregnancy/anti-abortion center organizations, actually had a session earlier this year teaching their members how can you become more involved in politics while also maintaining your tax-exempt status. And they’re talking through these organizations what kind of strategies might be appropriate in part because they do see abortion being a continuing political issue, and they want to use these centers as part of their toolbox. They’re something that they think can be very effective because people don’t know what they are necessarily. They might look at them and see, that’s my local pregnancy center. They give free ultrasounds, they give pregnancy tests, and I trust them without realizing that they actually have a very clear political agenda.听

Huetteman: Absolutely. In many cases, these are the only options that may be available to you for pregnancy care at this point. Isn’t that right?听

Luthra: Exactly. They are very affordable because they provide for pregnancy tests and free ultrasounds, and they are not regulated as medical centers. They vastly outnumber abortion clinics, especially obviously in states with abortion bans. I have spoken to a lot of people who say, “This is my only option because I can’t afford to go to a doctor’s office to find out how far along I am, even if I know I don’t want to be pregnant.” As a result, they’ll go to these places not necessarily knowing what they are or even knowing what they are and are given inaccurate information, can be, in some cases, deliberately misled about their pregnancy outcome and options, and their medical data is at jeopardy as well.听

Huetteman: Thanks for your reporting on that. We’ll be talking about that more, I’m sure. Shifting gears, while we’ve all had our eyes on the election, President Joe Biden is still in charge of the executive branch and the Biden administration is still doing health policy things. Just in the past week, the administration put out new rules requiring insurance to pay for the new over-the-counter birth control pill, as well as some forms of prescription contraception. Separately, the administration also put out a plan to help track and ease shortages of cancer drugs for kids.听

I know we spend a lot of time talking about things politicians promise to do, but we don’t always take note when they actually follow through on these promises, particularly if they’re not controversial. I wanted to make note of that this week. Now, finally this week, here’s something that’s likely to continue no matter who is elected president or who controls Congress next year. I’m talking about profiteering in health care. This week, we have two more investigations digging into profit-seeking middlemen. The first is about how a data firm called MultiPlan determines how much insurers should pay out-of-network providers while charging fees that sometimes exceed the payments themselves. But the other investigation is about another for-profit company called EviCore. Jessie, this story is your extra credit this week. Why don’t you tell us about it now?听

Hellmann: This story [“,” by T. Christian Miller, ProPublica; Patrick Rucker, The Capitol Forum; and David Armstrong, ProPublica] looks at EviCore by Evernorth, which is hired by insurance companies to process prior authorization requests. As we’re seeing more of in health care, they use an algorithm that’s backed by AI to help make these decisions, and there has just been a lot of complaints from patients and doctors about what they see as unfair denials. But what I thought was really interesting about this story is it takes a peek behind the curtain of how this specific algorithm actually works. It has something called a dial, which they can scale up or scale down depending on how many denials they’re trying to get, which obviously can result in more money for the insurance company.听

While this algorithm can’t reject a prior authorization request, it does flag requests that have to be approved by a doctor who works for this company, who can reject those requests. I thought it was just an interesting look at 鈥� we talk all the time about prior authorization and how it impacts patients and doctors who are tired of the red tape and all the bureaucratic work that they have to do to get care to patients. But I think in the past few years, we’ve been learning more about how these systems are actually structured. I think this is a really good look at that.听

Huetteman: Definitely. The thing these businesses have in common is that they’re in the business of saving someone money, but that someone is rarely the patient. Is anyone looking into what this is doing to our health care system, having such a focus on profit as part of the system that we use to care for people when they’re sick and dying? Is this good for patients?听

Weber: I think that’s how you get the name of this podcast, right? I think that’s how you come up with the name of this podcast. I think a lot of reporters out here are looking into that, in general. I think that’s why how policy is a beat that we all like to cover because it crosses so many sectors of both real pain and suffering that people feel, and whether that’s in their pocketbooks or medically when dealing with the health care system.听

Huetteman: Absolutely, that’s true. Thank you, Lauren. OK, folks, that’s this week’s news. Now, we’ll play Julie’s interview with 麻豆女优’s Irving Washington. Then we’ll come back and do the rest of our extra credits and read this year’s Halloween Haiku winner.听

Julie Rovner: I am so pleased to welcome to the podcast Irving Washington, 麻豆女优 senior vice president and executive director of 麻豆女优’s newest program launched this summer, our initiative on Health Misinformation and Trust. Irving, welcome to, “What the Health?”听

Irving Washington: Hi. Julie. Glad to be here.听

Rovner: So why don’t you start by telling us what the Health Misinformation and Trust initiative is and what you do?听

Washington: Sure, happy to. So the Health Misinformation and Trust is a new program that you mentioned at 麻豆女优. The short of it is, it’s really designed to help people understand all the complexities and what’s going on with health misinformation and trust. As you know, we’ve always had health misinformation, it’s been around. And 麻豆女优 has been in the business for health misinformation for quite a while. But this new program will bring all of our work together at 麻豆女优. And then we’re also launching new products like the 麻豆女优 Health Misinformation Monitor, which helps people track what misinformation and narratives are happening within the country.听

Rovner: And what are some examples of the kinds of health misinformation that you’re trying to bring to light?听

Washington: There’s all kinds of examples. Everything from, we had earlier issues around, if you’ve seen on social media, the miracle cures, those things that you see on TikTok, to issues that are happening right now in the elections, whether that be reproductive health, gender-affirming care, and, of course, vaccines and covid-19.听

Rovner: Why are we seeing so very much health misinformation right now, and so little trust in expertise? I mean, this all predates Donald Trump, and it predates covid, and yet it seems to be more than ever.听

Washington: It does seem like we do see that more these days. However, I like to remind people, as you just also said, we’ve been in the business, or had health misinformation, for quite a while. Misinformation in general. I like to think of the, remember the tabloids from several years ago or just anything 鈥� think about not even written information, but if your family had something that was passed down and this is supposed to cure this. So we’ve had misinformation for a while. Obviously, there’s been a few things that have changed, which makes the appearance of it spreading more and actually spreading more. Social media, for example, spreads misinformation much quicker. It also prioritizes engagement. And then you also mentioned the trust in institutions, organizations, that’s been an ongoing trend that I think we’ve seen over the last decade as well, too. So those two things combined, I think, puts us at the moment that we’re in now.听

Rovner: So if former President Trump wins a second term, he’s promised Robert F. Kennedy Jr., who is a longtime purveyor of health misinformation, what he calls free rein in health policy. What could that mean?听

Washington: That could mean a lot of things. It could mean that many of the systems and resources that we rely on to make sure we’re getting accurate and proper information may disappear. It also could mean that the things that we consider verifiable, factual information that we see from our public health institutions and government, that might be in jeopardy now, or that may or may not be a trustworthy source.听

Rovner: How do you determine what’s misinformation and what’s not? I’m old enough I used to look things up in the encyclopedia. You can’t really do that anymore.听

Washington: Well, I will tell you, it is much, much more complex these days. I have used the advice of anyone now, and you almost have to consider yourself a detective when you’re looking at information, particularly on social media. And by that, that just means doing extra checks to make sure that you’re confirming what you’re looking at is correct. There are a number of things people can do, a couple of them, and also how you can sort of see if this is misinformation. One thing to look out for is if data is cherry-picked. So if you see one particular data point, but it leaves out the broader context of, say, a study, that’s usually a signal it might be misinformation. Also look out for sensational language. Anything that plays on an emotional appeal, I like to think, just do a check on if you feel yourself getting agitated by this, and just double-check to make sure that it’s something that is factual information as well.听

And then of course, I’d say the last thing is just look at who is sharing that information. Is it an expert? Is it someone who just read something in the book? And even with doctors, you’d have to look at, is this in their expertise? One thing I’ve often said is, do you want your cardiologist to give you brain surgery, even though they’re both doctors, right? So you have to look at all those things.听

Rovner: So what’s the role of AI in health misinformation? It can be both good and bad here, right?听

Washington: That is certainly true. AI is fascinating, I’ll say at this point. And you’re totally right, it can be good and bad. We’ve looked at that from a couple of angles. Our polling shows that more people are turning to that to get their health information. Not a large number, but it is growing. The other thing that we looked at too, and this wasn’t formal research, we just did one experiment with one staffer, and over a period of eight months, we looked at 10 health misinformation false claims. And we asked the three major chatbots if this was misinformation or not. And Julie, those answers changed over a course of eight months. One instance it said it was, the other instance says it was a developing topic. Sometimes they would quote their resources, like the CDC [Centers for Disease Control and Prevention] or the WHO [World Health Organization], the other times they wouldn’t.听

So it was an evolving process as each system got updated as to what the AI chatbot said. So it’s important for people to think about. That might be a first source, like you could Google something in the same way to get an idea of something, but you should always verify with your primary care provider.听

Rovner: So what should we tell kids and relatives and people who we sort of see purveying misinformation about how they can perhaps better educate themselves?听

Washington: As much as possible. This is a big task to ask, but I do ask this request of folks is, you yourself try to be a trusted messenger. We know that trusted messengers work, so as much as possible, share factual information, no judgment on someone else’s belief or what they’re saying, but share factual information that you know. And I think the other thing that you can do is have productive conversations with people, again, if you personally know them, have those productive conversations with people, if you see that them spreading misinformation. One of the things about misinformation, in particular, sometimes people don’t know they’re spreading misinformation. So you also can just start there by helping to inform people. And then after that, when you know there’s clear misinformation, I think we all have a role in this information ecosystem that we’re in. We all can help put out quality and correct information.听

Rovner: We’re coming up on the holiday season, Thanksgiving and Christmas, and times when families who perhaps have different views about things get together. Any good advice for sort of gently explaining to some of your friends and family why some of the information they have might not be exactly correct?听

Washington: Well, oddly enough, Julie, that might be my dinner table. I can tell you what I may do this upcoming holiday. One, you want to make sure that you are listening. I think where people sometimes perhaps are too quick to share factual information and they want to get this point across, particularly on family members, you really want to take time to listen and understand where someone is getting their information from, who they are getting it from, and why they are choosing to believe. Once you get that information, I think you can then decide how do you want to approach some of those conversations. They could be, again, providing more factual information to counter that. They could be just getting the person to ask questions about the information that they’re receiving. Some conversations 鈥� if you can just end with them questioning somewhat where they’re getting information from, that might be a way to help people understand 鈥� better factual information.听

Rovner: Last question: If people want to sign up to get the 麻豆女优 Health Misinformation Monitor, how can they do that?听

Washington: They can do that by going to kff.org. You will see our Health Misinformation and Trust landing page, and you can sign up and subscribe at the bottom.听

Rovner: Irving Washington, thank you so much for joining us. I hope we can call on you again soon.听

Washington: Happy to be here, Julie, and do this. Thank you.听

Huetteman: OK. We’re back. And it’s time for our extra-credit segment. That’s where we each recognize a story we read this week that we think you should read too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. All right, Jessie’s already done hers. Shefali, why don’t you go next?听

Luthra: Mine’s from NBC News. It is by Aria Bendix, and the headline is “.” The story is excellent. It is absolutely worth reading. It follows a couple of families in Illinois who gave birth and ended up with, as the headline would imply, thousands of dollars in medical debt. And the family in the lede, they made too much money to qualify for Medicaid. They had this health care plan that was a grandfathered plan, so had very high out-of-pocket limits, and so as a result, they had this tremendous amount of expenses that they had to pay after she gave birth to twins who were born prematurely, who required NICU care. And, even worse, were born right at the end of the year. Right when her health plan reset, and she suddenly had to go through a new effort to hit her out-of-pocket limit.听

The story is really, really smart because it takes a problem that is familiar and makes it feel new. Something that we don’t talk about enough. The loopholes that exist in the Affordable Care Act that can still leave medical debt as such a problem. It puts a real human face to this, and the end, the end is really devastating. You talk to this mother, Jessica, and she is talking about all of the medical expenses that she’s trying to forgo, if she can, whether that is for her own health or for her children’s health because she is just really scared of incurring another medical bill and being surprised yet again by more debt that she and her family really can’t afford. It’s absolutely worth your time, especially as we think so much about what it means to get pregnant and to give birth and the challenges that exist for people who do that in our country.听

Huetteman: That’s a great point. It is heartbreaking to think that people who are going through something as routine as childbirth are being subject to things like rationing care in order to make sure they can afford their medical bills. Well, all right. Lauren, how about you go next?听

Weber: I have a piece from the New York Times titled “,” written by Walt Bogdanich and Carson Kessler, and it’s pretty horrifying. Basically, there was a drug trial for an Alzheimer’s drug that the volunteers that answered the call to do it had a gene that would make them more predisposed to have Alzheimer’s, but that gene also meant that it could make them more likely to have brain bleeds that interact with this drug. They took a genetic test to see whether they had this gene that would go this way and then the drugmaker didn’t tell them that it could cause a higher risk of brain bleeds for these people.听

It’s just a very horrifying story about lack of disclosure and, especially in a field like Alzheimer’s, where often people that feel like they are taking part in these trials maybe are worried about the devastating impacts of the disease. Many of us, I’m sure on this podcast and all those listening, have had personal experiences with how devastating that can be. Holding that over someone but not giving them the full knowledge of what they could be signing up for, there was at least one patient that died, many others that had brain hemorrhages that were preventable with the proper disclosure. Great reporting by The New York Times.听

Huetteman: Absolutely. Thanks for talking about it for us. My story this week is from 麻豆女优 Health News and it’s by Julie Appleby. The headline is “鈥楧reamers’ Can Enroll in ACA Plans This Year 鈥� But a Court Challenge Could Get in the Way.” ACA open enrollment season opens Nov. 1 and, for the first time, so-called Dreamers will be eligible to enroll. As a reminder, the term Dreamers refers to people who were brought to the United States without immigration paperwork when they were kids and who have since qualified for federal protections because they meet certain requirements. Those include that they were in school or had graduated or that they had served in the military. Anyway, a Biden administration rule that came out earlier this year says that Dreamers, as “lawfully present individuals,” are eligible for ACA coverage, and, potentially, the premium subsidies to pay for it. But 19 states are challenging the rule in federal court.听

Those states say the rule will put more strain on the system and it’ll encourage people to remain in the United States without permanent legal authorization. A ruling could come at any time with several possible outcomes, including a potential hold on the Biden administration’s rule. We’ll be keeping an eye on this one.听

Before we go, I have the privilege of reading the winner of this year’s Halloween Health Haiku contest. The winning entry was written by Crystal Decker, and it goes like this.听

Vampires don’t scare me.听听

Empty blood shelves, now that’s fear.听听

Roll up, save a life.听

You can find the winner and the runners-up and some fabulous illustrations by my 麻豆女优 Health News colleague Oona Zenda on our website at kffhealthnews.org, and we’ll post the link in our show notes. That’s all the time we have this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and to Stephanie Stapleton, our editor this week. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, and you can still find me lurking on X. I’m . Jessie?听

Hellmann: I am on Twitter .听

Huetteman: Shefali?听

Luthra: I am .听

Huetteman: And Lauren?听

Luthra: I’m .听

Huetteman: Julie will be back next week. Until then, be healthy.听

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But did you know older adults are increasingly at, too?

In fact, from 2021 to 2022, adults over 65 saw the听听鈥斕�10 percent听鈥� in overdose death rates across all age groups.

Yet their addiction care needs are often overlooked, even in places teeming with medical staff, such as long-term care facilities that primarily serve older patients. My colleague听Aneri Pattani听and I dug into the issue.

One study estimated that older adults were听听in 2022 to receive any type of care for opioid use disorder. They were also unlikely to receive medications such as buprenorphine and methadone 鈥� considered the treatment gold standard.

When people think of who actively uses drugs, “they don’t want to think about grandma, they don’t think about grandpa, and they certainly don’t want to think about what could be happening at a nursing home,” said听A. Toni Young, executive director of听Community Education Group, a nonprofit that advocates on substance use policy.

But Young’s organization, along with more than听50听other advocacy groups, is working to bring the issue front and center. In听听shared exclusively with 麻豆女优 Health News and the Health Brief, the coalition is urging the听Centers for Medicare and Medicaid Services听to ensure older patients get the help they need.

“Many Americans living in residential care facilities may not be in a position to effectively advocate for their own medical interests,” the letter says. “They must be able to trust you to hold their facility operators accountable to uphold the law.”

Facilities that receive Medicaid and Medicare payments are required to abide by federal laws, including the Americans With Disabilities Act and the Fair Housing Act. The laws bar discrimination due to current or past addiction and mandate appropriate medical care, including听.

“However, without enforcement, the law is just words,” the letter notes.

To change that, the letter writers urge CMS to “undertake a systematic education, investigation, and enforcement effort, covering all categories of residential care facilities that you oversee.”

In a statement to 麻豆女优 Health News, CMS said its听, released this year, require nursing facilities to ensure they have the staffing and resources to care for patients with serious mental illness or substance use disorder. The agency directs facilities to have care plans in place to “prevent adverse events, such as an overdose.” It has also partnered with other federal agencies to听听to boost nursing home care for patients with addiction and mental health concerns.

The agency did not directly address how such guidelines would be enforced.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.

Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.

This week’s panelists are Julie Rovner of 麻豆女优 Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.

Panelists

Among the takeaways from this week’s episode:

• Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
• Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
• Abortion continues to be the biggest health policy issue of 2024, as Republican candidates 鈥� in what seems to be a replay of 2022 鈥� try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
• The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
• The 2024 麻豆女优 annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.

Also this week, excerpts from a 麻豆女优 lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: 麻豆女优 Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.

Shefali Luthra: The 19th’s “,” by Mel Leonor Barclay.

Jessie Hellmann: The Assembly’s “,” by Carli Brosseau.

Joanne Kenen: The New York Times’ “,” by Kate Morgan.

Also mentioned on this week’s podcast:

• The New York Times’ “,” by Michael D. Shear.
• The Miami Herald’s “” by Claire Healy and Ana Ceballos.
• 麻豆女优’s “.”

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]听

Julie Rovner: Hello, and welcome back to “What the Health.” I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, October 10th, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go.听

Today we are joined via teleconference by Shefali Luthra of The 19th.听

Shefali Luthra: Hello.听

Rovner: Jesse Hellmann of CQ Roll Call.听

Jessie Hellmann: Hi there.听

Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing and Politico magazine.听

Joanne Kenen: Hi everybody.听

Rovner: Later in this episode, we’ll have some excerpts from the Newsmaker lunch we had here at 麻豆女优 this week with Mark Cuban 鈥� “Shark Tank” star, part-owner of the Dallas Mavericks NBA team, and, for the purposes of our discussion, co-founder of the industry-disrupting pharmaceutical company Cost Plus Drugs. But first, this week’s news.听

We’re going to start this week with Vice President [Kamala] Harris, who’s been making the media rounds on women-focused podcasts and TV shows like “The View.” To go along with that, she’s released a proposal to expand Medicare to include home-based long-term care, to be paid for in part by expanding the number of drugs whose price Medicare can negotiate. Sounds simple and really popular. Why has no one else ever proposed something like that? she asks, knowing full well the answer. Joanne, tell us!听

Kenen: As the one full-fledged member of the sandwich generation here, who has lived the experience of being a family caregiver while raising children and working full time, long-term care is the unfulfillable, extremely expensive, but incredibly important missing link in our health care system. We do not have a system for long-term care, and people do not realize that. Many people think Medicare will, in fact, cover it, where Medicare covers it in a very limited, short-term basis. So the estimates of what families spend both in terms of lost work hours and what they put out-of-pockets is in, I think it’s something like $400 billion. It’s extraordinarily high. But the reason it’s been hard to fix is it’s extraordinarily expensive. And although Harris put out a plan to pay for this, that plan is going to have to be vetted by economists and budget scorers and skeptical Republicans. And probably some skeptical Democrats. It’s really expensive. It’s really hard to do. Julie has covered this for years, too. It’s just鈥斕�

Rovner: I would say this is where I get to say one of my favorite things, which is that I started covering health care in 1986, and in 1986 my first big feature was: Why don’t we have a long-term care policy in this country? Thirty-eight years later, and we still don’t, and not that people have not tried. There, in fact, was a long-term-care-in-the-home piece of the Affordable Care Act that passed Congress, and HHS [the Department of Health and Human Services] discovered that they could not implement it in the way it was written, because only the people who would’ve needed it would’ve signed up for it. It would’ve been too expensive. And there it went. So this is the continuing promise of something that everybody agrees that we need and nobody has ever been able to figure out how to do. Shefali, I see you nodding here.听

Luthra: I mean, I’m just thinking again about the pay-fors in here, which are largely the savings from Medicare negotiating drug prices. And what Harris says in her plan is that they’re going to get more savings by expanding the list of drugs that get lower prices. But that also feels very politically suspect when we have already heard congressional Republicans say that they would like to weaken some of those drug negotiation price provisions. And we also know that Democrats, even if they win the presidency, are not likely to have Congress. It really takes me back to 2020, when we are just talking about ideas that Democrats would love to do if they had full power of Congress, while all of us in Washington kind of know that that is just not going to happen.听

Rovner: Yes, I love that one of the pay-fors for this is cutting Medicare fraud. It’s like, where have we heard that before? Oh, yes. In every Medicare proposal for the last 45 years.听

Kenen: And it also involves closing some kind of international tax loopholes, and that also sounds easy on paper, and nothing with taxes is ever easy. The Democrats probably are not going to have the Senate. Nobody really knows about the House. It looks like the Democrats may have a narrow edge in that, but we’re going to have more years of gridlock unless something really changes politically, like something extraordinary changes politically. The Republicans are not going to give a President Harris, if she is in fact President Harris, her wish list on a golden platter. On the other hand there’s need for this.听

Rovner: But in fairness, this is what the campaign is for.听

Kenen: Right. There is a need for something on long-term care.听

Rovner: And everybody’s complaining: Well, what would she do? What would she do if she was elected? Well, here’s something she said she would do if she could, if she was elected. Well, meanwhile, former President [Donald] Trump has apparently abandoned a proposal that he made during his first term to require drugmakers to lower their prices for Medicare to no more than they charge in other developed countries where their prices are government-regulated. Is Trump going soft on the drug industry? Trump has been, what, the Republican, I think, who’s been most hostile towards the drug industry until now.听

Hellmann: I would say maybe. I think the “most favored nation” proposal is something that the pharmaceutical industry has feared even more than the Democrats’ Medicare negotiation program. And it’s something that Trump really pursued in his first term but wasn’t able to get done. In such a tight race, I think he’s really worried about angering pharmaceutical companies, especially after they were just kind of dealt this loss with Medicare price negotiation. And if he does win reelection, he’s going to be kind of limited in his ability to weaken that program. It’s going to be hard to repeal it. It’s extremely popular, and he may be able to weaken it.听

Rovner: “It” meaning price negotiation, not the “most favored nations” prices.听

Hellmann: Yeah. It’s going to be really hard to repeal that, and he may be able to weaken it through the negotiation process with drug companies. It’s definitely an interesting turn.听

Rovner: Joanne, you want to add something?听

Kenen: Trump rhetorically was very harsh on the drug companies right around the time of his inauguration. I think it was the week before, if I remember correctly. Said a lot of very tough stuff on drugs. Put out a list of something like dozens of potential steps. The drug companies have lots of allies in both parties, and more in one than the other, but they have allies on the Hill, and nothing revolutionary happened on drug pricing under Trump.听

Rovner: And his HHS secretary was a former drug company executive.听

Kenen: Yes, Eli Lilly. So we also pointed out here that former President Trump is not consistent in policy proposals. He says one thing, and then he says another thing, and it’s very hard to know where he’s going to come down. So Trump and drug pricing is an open question.听

Rovner: Yes, we will see. All right, well, moving on. Drug prices and Medicare aside, the biggest health issue of Campaign 2024 continues to be abortion and other reproductive health issues. And it’s not just Trump trying to back away from his anti-abortion record. We’ve had a spate of stories over the past week or so of Republicans running for the House, the Senate, and governorships who are trying to literally reinvent themselves as, if not actually supportive of abortion rights, at least anti abortion bans. And that includes Republicans who have not just voted for and advocated for bans but who have been outspokenly supportive of the anti-abortion effort, people like North Carolina Republican gubernatorial candidate Mark Robinson, New Hampshire Republican gubernatorial candidate and former U.S. Senator Kelly Ayotte, along with former Michigan Republican representative and now Senate candidate Mike Rogers. Donald Trump has gotten away repeatedly, as Joanne just said, with changing his positions, even on hot-button issues like abortion. Are these candidates going to be able to get away with doing the same thing, Shefali?听

Luthra: I think it’s just so much tougher when your name is not Donald Trump. And that’s because we know from focus group after focus group, and survey after survey, that voters kind of give Trump more leeway on abortion. Especially independent voters will look at him and say, Well, I don’t think he actually opposes abortion, because I’m sure he’s paid for them. And they don’t have that same grace that they give to Republican lawmakers and Republican candidates, because the party has a bad brand on abortion at large, and Trump is seen as this kind of maverick figure. But voters know that Republicans have a history of opposing abortion, of supporting restrictions.听

When you look at surveys, when you talk to voters, what they say is, Well, I don’t trust Republicans to represent my interests on this issue, because they largely support access. And one thing that I do think is really interesting is, once again, what we’re seeing is kind of a repeat of the 2022 elections when we saw some very brazen efforts by Republican candidates for the House and Senate try and scrub references to abortion and to fetal personhood from their websites. And it didn’t work, because people have eyes and people have memories, and, also, campaigns have access to the internet archive and are able to show people that, even a few weeks ago, Republican candidates were saying something very different from what they are saying now. I don’t think Mark Robinson can really escape from his relatively recent and very public comments about abortion.听

Rovner: Well, on the other hand, there’s some things that don’t change. Republican vice presidential candidate last week that if Trump is elected again, their administration would cut off funding to Planned Parenthood because, he said, and I quote, “We don’t think that taxpayers should fund late-term abortions.” Notwithstanding, of course, that even before the overturn of Roe, less than half of all Planned Parenthoods even performed abortions and almost none of those who did perform them later in pregnancy. Is it fair to say that Vance’s anti-abortion slip is showing?听

Luthra: I think it might be. And I will say, Julie, when I saw that he said that, I could hear you in my head just yelling about the Hyde Amendment, because we know that Planned Parenthood does not use taxpayer money to pay for abortions. But we also know that JD Vance has seen that he and his ticket are kind of in a tough corner talking about abortion. He has said many times, We need to rebrand 鈥� he’s very honest about that, at least 鈥� and trying to focus instead on this nonmedical term of “late term” abortions.听

It’s a gamble. It’s hoping that voters will be more sympathetic to that because they’ll think, Oh, well, that sounds very extreme. And they’re trying to shift back who is seen as credible and who is not, by focusing on something that historically was less popular. But again, it’s again tricky because when we look at the polling, voters’ understanding of abortion has shifted and they are now more likely to understand that when you have an abortion later in pregnancy, it is often for very medically complex reasons. And someone very high-profile who recently said that is Melania Trump in her new memoir, talking about how she supports abortion at all stages of pregnancy because often these are very heart-wrenching cases and not sort of the murder that Republicans have tried to characterize them as.听

Rovner: I think you’re right. I think this is the continuation of the 2022 campaign, except that we’ve had so many more women come forward. We’ve seen actual cases. It used to be anti-abortion forces would say, Oh, well, this never happened. I mean, these are wrenching, awful things that happened to a lot of these patients with pregnancy complications late in pregnancy. And it is, I know, because I’ve talked to them. It’s very hard to get them to talk publicly, because then they get trolled. Why should they step forward?听

Well, now we’ve seen a lot of these women stepping forward. So we now see a public that knows that this happens, because they’re hearing from the people that it’s happened to and they’re hearing from their doctors. I do know also from the polling that there are people who are going to vote in these 10 states where abortion is on the ballot. Many of them are going to vote for abortion access and then turn around and vote for Republicans who support restrictions, because they’re Republicans. It may or may not be their most important issue, but I still think it’s a big question mark where that happens and how it shakes out. Joanne, did you want to add something?听

Kenen: You’re seeing two competing things at the same time. You have a number of Republicans trying to moderate their stance or at least sound like they’re moderating their stance. At the same time, you also have the whole, where the Republican Party is on abortion has shifted to the right. They are talking about personhood at the moment of conception, the embryo 鈥� which is, scientifically put, a small ball of cells still at that point 鈥� that they actually have the same legal rights as any other post-birth person.听

So that’s become a fairly common view in the Republican Party, as opposed to something that just five or six years ago was seen as the fringe. And Trump is going around saying that Democrats allow babies to be executed after birth, which is not true. And they’re particularly saying this is true in Minnesota because of [Gov.] Tim Walz, and some voters must believe it, right? Because they keep saying it. So you have this trend that Shefali just described and that you’ve described, Julie, about this sort of attempting to win back trust, as Vance said. And it sounded more moderate, and at the same time as you’re hearing this rhetoric about personhood and execution. So I don’t think the Republicans have yet solved their own whiplash post-Roe.听

Rovner: Meanwhile, the abortion debate is getting mired in the free-speech debate. In Florida, Republican governor Ron DeSantis against TV stations airing an ad in support of the ballot measure that would overturn the state’s six-week abortion ban. That has in turn triggered a rebuke from the head of the Federal Communications Commission warning that political speech is still protected here in the United States. Shefali, this is really kind of out there, isn’t it?听

Luthra: It’s just so fascinating, and it’s really part of a bigger effort by Ron DeSantis to try and leverage anything that he can politically or, frankly, in his capacity as head of the state to try and weaken the campaign for the ballot measure. They have used the health department in other ways to try and send out material suggesting that the campaign’s talking points, which are largely focused on the futility of exceptions to the abortion ban, they’re trying to argue that that is misinformation, and that’s not true. And they’re using the state health department to make that argument, which is something we don’t really see very often, because usually health departments are supposed to be nonpartisan. And what I will say is, in this case, at least to your point, Julie, the FCC has weighed in and said: You can’t do this. You can’t stop a TV station from airing a political ad that was bought and paid for. And the ads haven’t stopped showing at this point. I just heard from family yesterday in Florida who are seeing the ads in question on their TV, and it’s still鈥斕�

Rovner: And I will post a link to the ad just so you can see it. It’s about a woman who’s pregnant and had cancer and needed cancer treatment and needed to terminate the pregnancy in order to get the cancer treatment. It said that the exception would not allow her to, which the state says isn’t true and which is clearly one of these things that is debatable. That’s why we’re having a political debate.听

Luthra: Exactly. And one thing that I think is worth adding in here is, I mean, this really intense effort from Governor DeSantis and his administration comes at a time when already this ballot measure faces probably the toughest fight of any abortion rights measure. And we have seen abortion rights win again and again at the ballot, but in Florida you need 60% to pass. And if you look across the country at every abortion rights measure that has been voted on since Roe v. Wade was overturned, only two have cleared 60, and they are in California and they are in Vermont. So these more conservative-leaning states, and Florida is one of them, it’s just, it’s really, really hard to see how you get to that number. And we even saw this week there’s polling that suggests that the campaign has a lot of work to do if they’re hoping to clear that threshold.听

Rovner: And, of course, now they have two hurricanes to deal with, which we will deal with in a few minutes. But first, the Supreme Court is back in session here in Washington, and even though there’s no big abortion case on its official docket as of now this term, the court quickly declined to hear two cases on its first day back, one involving whether the abortion ban in Texas can override the federal emergency treatment law that’s supposed to guarantee abortion access in medical emergencies threatening the pregnant woman’s life or health. The court also declined to overrule the Alabama Supreme Court’s ruling that frozen embryos can be considered legally as unborn children. That’s what Joanne was just talking about. Where do these two decisions leave us? Neither one actually resolved either of these questions, right?听

Luthra: I mean, the EMTALA [Emergency Medical Treatment and Labor Act] question is still ongoing, not because of the Texas case but because of the Idaho case that is asking very similar questions that we’ve talked about previously on this podcast. And the end of last term, the court kicked that back down to the lower courts to continue making its way through. We anticipate it will eventually come back to the Supreme Court. So this is a question that we will, in fact, be hearing on at some point.听

Rovner: Although, the irony here is that in Idaho, the ban is on hold because there was a court stay. And in Texas, the ban is not on hold, even though we’re talking about exactly the same question: Does the federal law overrule the state’s ban?听

Luthra: And what that kind of highlights 鈥� right? 鈥� is just how much access to abortion, even under states with similar laws or legislatures, really does depend on so many factors, including what circuit court you fall into or the makeup of your state Supreme Court and how judges are appointed or whether they are elected. There is just so much at play that makes access so variable. And I think the other thing that one could speculate that maybe the court didn’t want headlines around reproductive health so soon into an election, but it’s not as if this is an issue that they’re going to be avoiding in the medium- or long-term future. These are questions that are just too pressing, and they will be coming back to the Supreme Court in some form.听

Rovner: Yes, I would say in the IVF [in vitro fertilization] case, they simply basically said, Go away for now. Right?听

Luthra: Yeah. And, I mean, right now in Alabama, people are largely able to get IVF because of the state law that was passed, even if it didn’t touch the substance of that state court’s ruling. This is something, for now, people can sort of think is maybe uninterrupted, even as we all know that the ideological and political groundwork is being laid for a much longer and more intense fight over this.听

Rovner: Well, remember back last week when we predicted that the judge’s decision overturning Georgia’s six-week ban was unlikely to be the last word? Well, sure enough, the Georgia Supreme Court this week overturned the immediate overturning of the ban, which officially went back into effect on Monday. Like these other cases, this one continues, right?听

Luthra: Yes, this continues. The Georgia case continued for a while, and it just sort of underscores again what we’ve been talking about, just how much access really changes back and forth. And I was talking to an abortion clinic provider who has clinics in North Carolina and Georgia. She literally found out about the decision both times and changed her plans for the next day because I texted her asking her for comment. And providers and patients are being tasked with keeping up with so much. And it’s just very, very difficult, because Georgia also has a 24-hour waiting period for abortions, which means that every time the decision around access has changed 鈥� and we know it very well could change again as this case progresses 鈥� people will have to scramble very quickly. And in Georgia, they have also been trying to do that on top of navigating the fallout of a hurricane.听

Rovner: Yeah. And as we pointed out a couple of weeks ago when the court overturned the North Dakota ban, there are no abortion providers left in North Dakota. Now that there’s no ban, it’s only in theory that abortion is now once again allowed in North Dakota. Well, before we leave abortion for this week, we have two new studies showing how abortion bans are impacting the health care workforce. In one survey, more than half of oncologists, cancer doctors, who were completing their fellowships, so people ready to go into practice, said they would consider the impact of abortion restrictions in their decisions about where to set up their practice. And a third said abortion restrictions hindered their ability to provide care.听

Meanwhile, in Texas by the consulting group Manatt Health found “a significant majority of practicing OB/GYN physicians 鈥� believe that the Texas abortion laws have inhibited their ability to provide highest-quality and medically necessary care to their patients,” and that many have already made or are considering making changes to their practice that would “reduce the availability of OB/GYN care in the state.” What’s the anti-abortion reaction to this growing body of evidence that abortion bans are having deleterious effects on the availability of other kinds of health care, too? I mean, I was particularly taken by the oncologists, the idea that you might not be able to get cancer care because cancer doctors are worried about treating pregnant women with cancer.听

Luthra: They’re blaming the doctors. And we saw this in Texas when the Zurawski case was argued and women patients and doctors in the state said that they had not been able to get essential, lifesaving medical care because of the state’s abortion ban and lack of clarity around what was actually permitted. And the state argued, and we have heard this talking point again and again, that actually the doctors are just not willing to do the hard work of practicing medicine and trying to interpret, Well, obviously this qualifies. That’s something we’ve seen in the Florida arguments. They say: Our exceptions are so clear, and if you aren’t able to navigate these exceptions, well, that’s your problem, because you are being risk-averse, and patients should really take this up with their doctors, who are just irresponsible.听

Rovner: Yes, this is obviously an issue that’s going to continue. Well, moving on. The cost of health care continues to grow, which is not really news, but this week we have more hard evidence, courtesy of my 麻豆女优 colleagues via the annual , which finds the average family premium rose 7% this year to $25,572, with workers contributing an average of $6,296 towards that cost. And that’s with a distinct minority of firms covering two very popular but very expensive medical interventions, GLP-1 [glucagon-like peptide-1] drugs for obesity and IVF, which we’ve just been talking about. Anything else in this survey jump out at anybody?听

Hellmann: I mean, that’s just a massive amount of money. And the employer is really paying the majority of that, but that doesn’t mean it doesn’t have an impact on people. That means it’s going to limit how much your wages go up. And something I thought of when I read this study is these lawsuits that we’re beginning to see, accusing employers of not doing enough to make sure that they’re limiting health care costs. They’re not playing enough of a role in what their benefits look like. They’re kind of outsourcing this to consultants. And so when you look at this data and you see $25,000 they’re spending per year per family on health care premiums, you wonder, what are they doing?听

Health care, yes, it’s obviously very expensive, but you just kind of question, what role are employers actually playing in trying to drive down health care costs? Are they just taking what they get from consultants? And another thing that kind of stood out to me from this is, I think it’s said in there, employers are having a hard time lately of passing these costs on to employees, which is really interesting. It’s because of the tight labor market. But obviously health care is still very expensive for employees 鈥� $6,000 a year in premiums for family coverage is not a small amount of money. So employers are just continuing to absorb that, and it does really impact everyone.听

Rovner: It’s funny. Before the Affordable Care Act, it was employers who were sort of driving the, You must do something about the cost of health care, because inflation was so fast. And then, of course, we saw health care inflation, at least, slow down for several years. Now it’s picking up again. Are we going to see employers sort of getting back into this jumping up and down and saying, “We’ve got to do something about health care costs”?听

Hellmann: I feel like we are seeing more of that. You’re beginning to hear more from employers about it. I don’t know. It’s just such a hard issue to solve, and I’ve seen more and more interest from Congress about this, but they really struggle to regulate the commercial market. So 鈥μ�

Rovner: Yes, as we talk about at length every week. But it’s still important, and they will still go for it. Well, finally, this week in health misinformation. Let us talk about hurricanes 鈥� the public health misinformation that’s being spread both about Hurricane Helene that hit the Southeast two weeks ago, and Hurricane Milton that’s exiting Florida even as we are taping this morning. President [Joe] Biden addressed the press yesterday from the White House, calling out former President Trump by name along with Georgia Republican congresswoman Marjorie Taylor Greene for spreading deliberate misinformation that’s not just undermining efforts at storm relief but actually putting people in more danger. Now, I remember Hurricane Katrina and all the criticism that was heaped, mostly deservedly, on George W. Bush and his administration, but I don’t remember deliberate misinformation like this. I mean, Joanne, have you ever seen anything like this? You lived in Florida for a while.听

Kenen: I went through Andrew, and there’s always a certain 鈥� there’s confusion and chaos after a big storm. But there’s a difference between stuff being wrong that can be corrected and stuff being intentionally said that then in this sort of divided, suspicious, two-realities world we’re now living in, that’s being repeated and perpetuated and amplified. It damages public health. It damages people economically trying to recover from this disastrous storm or in some cases storms. I don’t know how many people actually believe that Marjorie Taylor asserted that the Democrats are controlling the weather and sending storms to suppress Republican voters. She still has a following, right? But other things 鈥μ�

Rovner: She still gets reelected.听

Kenen: 鈥� being told that if you go to FEMA [the Federal Emergency Management Agency] for help, your property will be confiscated and taken away from you. I mean, that’s all over the place, and it’s not true. Even a number of Republican lawmakers in the affected states have been on social media and making statements on local TV and whatever, saying: This is not true. Please, FEMA is there to help you. Let’s get through this. Stop the lies. A number of Republicans have actually been quite blunt about the misinformation coming from their colleagues and urging their constituents to seek and take the help that’s available.听

This is the public health crisis. We don’t know how many people have been killed. I don’t think we have an accurate total final count from Helene, and we sure don’t have from Milton. I mean, the people did seem to take this storm seriously and evacuated, but it also spawned something like three dozen tornadoes in places where people hadn’t been told, there’s normally no need to evacuate. There’s flooding. It’s a devastating storm. So when people are flooding, power outages, electricity, hard to get access to health care, you can’t refrigerate your insulin. All these鈥斕�

Rovner: Toxic floodwaters, I mean, the one thing 鈥μ�

Kenen: Toxic, yeah.听

Rovner: 鈥� we know about hurricanes is that they’re more dangerous in the aftermath than during the actual storm in terms of public health.听

Kenen: Right. This is a life-threatening public health emergency to really millions of people. And misinformation, not just getting something wrong and then trying to correct it, but intentional disinformation, is something we haven’t seen before in a natural disaster. And we’re only going to have more natural disasters. And it was really 鈥� I mean, Julie, you already pointed this out 鈥� but it was really unusual how precise Biden was yesterday in , and I believe at two different times yesterday. So I heard one, but I think I read about what I think was the second one really saying, laying it at his feet that this is harming people.听

Rovner: Yeah, like I said, I remember Katrina vividly, and that was obviously a really devastating storm. I do also remember Democrats and Republicans, even while they were criticizing the federal government reaction to it, not spreading things that were obviously untrue. All right. Well, that is the news for this week. Now we will play a segment from our Newsmaker interview with Mark Cuban, and then we will be back with our extra credits.听

On Tuesday, October 8th, Mark Cuban met with a group of reporters for a Newsmaker lunch at 麻豆女优’s offices in Washington, D.C. Cuban, a billionaire best known as a panelist on the ABC TV show “Shark Tank,” has taken an interest in health policy in the past several years. He’s been consulting with the campaign of Vice President Harris, although he says he’s definitely not interested in a government post if she wins. Cuban started out talking about how, as he sees it, the biggest problem with drug prices in the U.S. is that no one knows what anyone else is paying.听

Mark Cuban: I mean, when I talk to corporations and I’ve tried to explain to them how they’re getting ripped off, the biggest of the biggest said, Well, so-and-so PBM [pharmacy benefit manager] is passing through all of their rebates to us.听

And I’m like: Does that include the subsidiary in Scotland or Japan? Is that where the other one is?听

I don’t know.听

And it doesn’t. By definition, you’re passing through all the rebates with the company you contracted with, but they’re not passing through all the rebates that they get or that they’re keeping in their subsidiary. And so, yeah, I truly, truly believe from there everybody can argue about the best way. Where do you use artificial intelligence? Where do you do this? What’s the EHR [electronic health record? What’s this? We can all argue about best practices there. But without a foundation of information that’s available to everybody, the market’s not efficient and there’s no place to go.听

Rovner: He says his online generic drug marketplace, costplusdrugs.com, is already addressing that problem.听

Cuban: The crazy thing about costplusdrugs.com, the greatest impact we had wasn’t the markup we chose or the way we approach it. It’s publishing our price list. That changed the game more than anything. So when you saw the FTC [Federal Trade Commission] go after the PBMs, they used a lot of our pricing for all the non-insulin stuff. When you saw these articles written by the Times and others, or even better yet, there was research from Vanderbilt, I think it was, that says nine oncology drugs, if they were purchased by Medicare through Cost Plus, would save $3.6 billion. These 15, whatever drugs would save six-point-whatever billion. All because we published our price list, people are starting to realize that things are really out of whack. And so that’s why I put the emphasis on transparency, because whether it’s inside of government or inside companies that self-insure, in particular, they’re going to be able to see. The number one rule of health care contracts, particularly PBM contracts, is you can’t talk about PBM contracts.听

Rovner: Cuban also says that more transparency can address problems in the rest of the health care system, not just for drug prices. Here’s how he responded to a question I asked describing his next big plan for health care.听

We’ve had, obviously, issues with the system being run by the government not very efficiently and being run by the private sector not very efficiently.听

Cuban: Very efficiently, yeah.听

Rovner: And right now we seem to have this sort of working at cross-purposes. If you could design a system from the ground up, which would you let do it? The government or鈥斕�

Cuban: I don’t think that’s really the issue. I think the issue is a lack of transparency. And you see that in any organization. The more communication and the more the culture is open and transparent, the more people hold each other responsible. And I think you get fiefdoms in private industry and you get fiefdoms in government, as well, because they know that if no one can see the results of their work, it doesn’t matter. I can say my deal was the best and I did the best and our outcomes are the best, but there’s no way to question it. And so talking to the Harris campaign, it’s like if you introduce transparency, even to the point of requiring PBMs and insurers to publish their contracts publicly, then you start to introduce an efficient market. And once you have an efficient market, then people are better able to make decisions and then you can hold them more accountable.听

And I think that’s going to spill over beyond pharm. We’re working on 鈥� it’s not a company 鈥� but we’re working on something called Cost Plus Wellness, where we’re eating our own dog food. And it’s not a company that’s going to be a for-profit or even a nonprofit, for that matter, just for the lives that I cover for my companies, that we self-insure. We’re doing direct contracting with providers, and we’re going to publish those contracts. And part and parcel to that is going through the 鈥� and I apologize if I’m stumbling here. I haven’t slept in two days, so bear with me. But going through the hierarchy of care and following the money, if you think about when we talk to CFOs and CEOs of providers, one of the things that was stunning to me that I never imagined is the relationship between deductibles for self-insured companies and payers, and the risk associated with collecting those deductibles to providers.听

And I think people don’t really realize the connection there. So whoever does Ann’s care [麻豆女优 Chief Communications Officer Ann DeFabio, who was present] 鈥� well, Kaiser’s a little bit different, but let’s just say you’re employed at The Washington Post or whoever and you have a $2,500 deductible. And something happens. Your kid breaks their leg and goes to the hospital, and you’re out of market, and it’s out of network. Well, whatever hospital you go to there, you might give your insurance card, but you’re responsible for that first $2,500. And that provider, depending on where it’s located, might have collection 鈥� bad debt, rather 鈥� of 50% or more.听

So what does that mean in terms of how they have to set their pricing? Obviously, that pricing goes up. So there’s literally a relationship between, particularly on pharmacy, if my company takes a bigger rebate, which in turn means I have a higher deductible because there’s less responsibility for the PBM-slash-insurance company. My higher deductible also means that my sickest employees are the ones paying that deductible, because they’re the ones that have to use it. And my older employees who have ongoing health issues and have chronic illnesses and need medication, they’re paying higher copays. But when they have to go to the hospital with that same deductible, because I took more of a rebate, the hospital is taking more of a credit risk for me. That’s insane. That makes absolutely no sense.听

And so what I’ve said is as part of our wellness program and what we’re doing to 鈥� Project Alpo is what we call it, eating our own dog food. What I’ve said is, we’ve gone to the providers and said: Look, we know you’re taking this deductible risk. We’ll pay you cash to eliminate that. But wait, there’s more. We also know that when you go through a typical insurer, even if it’s a self-insured employer using that insurer and you’re just using the insurance company not for insurance services but as a TPA [third-party administrator], the TPA still plays games with the provider, and they underpay them all the time.听

And so what happens as a result of the underpayment is that provider has to have offices and offices full of administrative assistants and lawyers, and they have to not only pay for those people, but they have the associated overhead and burden and the time. And then talking to them, to a big hospital system, they said that’s about 2% of their revenue. So because of that, that’s 2%. Then, wait, there’s more. You have the pre-ops, and you have the TPAs who fight you on the pre-ops. But the downstream economic impacts are enormous because, first, the doctor has to ask for the pre-op. That’s eating doctor’s time, and so they see fewer patients. And then not only does the doctor have to deal with them, they go to HR at the company who self-insures and says, Wait, my employee can’t come to work, because their child is sick, and you won’t approve this process or, whatever, this procedure, because it has to go through this pre-op.听

Or if it’s on medications, it’s you want to go through the step-up process or you want to go through a different utilization because you get more rebates. All these pieces are intertwined, and we don’t look at it holistically. And so what we’re saying with Cost Plus Wellness is, we’re going to do this all in a cash basis. We’re going to trust doctors so that we’re not going to go through a pre-op. Now we’ll trust but verify. So as we go through our population and we look at all of our claims, because we’ll own all of our claims, we’re going to look to see if there are repetitive issues with somebody who’s just trying to 鈥攖here’s lots of back surgeries or there’s lots of this or there’s lots of that 鈥� to see if somebody’s abusing us. And because there’s no deductible, we pay it, and we pay it right when the procedure happens or right when the medication is prescribed. Because of all that, we want Medicare pricing. Nobody’s saying no. And in some cases I’m getting lower than Medicare pricing for primary care stuff.听

Rovner: OK, we are back. Now it’s time for our extra credits. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We will include the links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week.听

Kenen: There was a fascinating story in The New York Times by Kate Morgan. The headline was “” So I knew nothing about this, and it was so interesting. Placentas have amazing healing properties for wound care, burns, infections, pain control, regenerating skin tissue, just many, many things. And it’s been well known for years, and it’s not widely used. This is a story specifically about a really severe burn victim in a gas explosion and how her face was totally restored. We don’t use this, partly because placenta 鈥� every childbirth, there’s a placenta. There are lots of them around. There’s I think three and a half million births a year, or that’s the estimate I read in the Times. One of the reasons they weren’t being used is, during the AIDS crisis, there was some development toward using them, and then the AIDS crisis, there was a fear of contamination and spreading the virus, and it stopped decades later.听

We have a lot more ways of detecting, controlling, figuring out whether something’s contaminated by AIDS or whether a patient has been exposed. It is being used again on a limited basis after C-sections, but it seems to have pretty astonishing 鈥� think about all the wound care for just diabetes. I’m not a scientist, but I just looked at the story and said, it seems like a lot of people could be healed quicker and more safely and earlier if this was developed. They’re thrown away now. They’re sent to hospital waste incinerators and biohazard waste. They’re garbage, and they’re actually medicine.听

Rovner: Definitely a scientist’s cool story. Shefali.听

Luthra: My story is from my brilliant colleague Mel Leonor Barclay. The headline is “,” and as part of this really tremendous series that she has running this week, looking at how Latinas as a much more influential and growingly influential voter group could shape gun violence, abortion rights, and housing. And in this story, which I really love, she went to Arizona and spent time talking to folks on all sides of the issue to better understand how Latinas are affected by abortion rights and also how they’ll be voting on this.听

And she really challenges the narrative that has existed for so long, which is that Latinas are largely Catholic, largely more conservative on abortion. And she finds something much more complex, which is that actually polls really show that a large share of Latina voters in Arizona and similar states support abortion rights and will be voting in favor of measures like the Arizona constitutional amendment. But at the same time, there are real divides within the community, and people talk about their faith in a different way and how it connects their stance on abortion. They talk about their relationships with family in different ways, and I think it just underscores how rarely Latina voters are treated with real nuance and care and thoughtfulness when talking about something as complex as abortion and abortion politics. And I really love the way that she approaches this piece.听

Rovner: It was a super-interesting story. Jesse.听

Hellmann: My story is from The Assembly. It’s an outlet in North Carolina. It’s called “.” Some assisted living facilities have been without power and water since the hurricane hit. Several facilities had to evacuate residents, and the story just kind of gets into how North Carolina has more lax rules around emergency preparedness. While they do require nursing homes be prepared to provide backup power, the same requirements don’t apply to assisted living facilities. And it’s because there’s been industry pushback against that because of the cost. But as we see some more of these extreme weather events, it seems like something has to be done. We cannot just allow vulnerable people living in these facilities to go hours and hours without power and water. And I saw that there was a facility where they evacuated dozens of people who had dementia, and that’s just something that’s really upsetting and traumatizing for people.听

Rovner: Yeah, once again, now we are seeing these extreme weather events in places that, unlike Florida and Texas, are not set up and used to extreme weather events. And it is something I think that a lot of people are starting to think about. Well, my story this week is from our 麻豆女优 Health News public health project called Health Beat, and it’s called “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly. And it’s one of those stories you never really think about until it’s pointed out that in areas, particularly those that had been redlined, in particular, the lack of safety infrastructure that most of us take for granted 鈥� crosswalks, sidewalks, traffic lights are not really there. And that’s a public health crisis of its own, and it’s one that rarely gets addressed, and it’s a really infuriating but a really good story.听

All right, that is our show. Next week, for my birthday, we’re doing a live election preview show here at 麻豆女优 in D.C., because I have a slightly warped idea of fun. And you’re all invited to join us. I will put a link to the RSVP in the show notes. I am promised there will be cake.听

As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me for the moment at X. I’m . Joanne, where are you?听

Kenen: sometimes on Twitter and on Threads.

Rovner: Jessie.

Hellmann: on Twitter.

Rovner: Shefali.

Luthra: on Twitter.

Rovner: We will be back in your feed next week. Until then, be healthy.

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It was the latest in a drumbeat of health issues that she traces to the first months of 2020, when dozens of veterans died at the Soldiers’ Home in Holyoke, in one of the country’s at a long-term nursing facility. Ragoonanan has worked at the home for nearly 30 years. Now, she said, the sights, sounds, and smells there trigger her trauma. Among her ailments, she lists panic attacks, brain fog, and other symptoms of post-traumatic stress disorder, .

Scrutiny of the outbreak prompted the state to change the facility’s name to the , replace its leadership, sponsor a of the premises, and agree to a $56 million settlement for veterans and families. But the front-line caregivers have received little relief as they grapple with the outbreak’s toll.

“I am retraumatized all the time,” Ragoonanan said, sitting on her back porch before her evening shift. “How am I supposed to move forward?”

Covid killed more than 3,600 U.S. health care workers in the first year of the pandemic. It left many more with physical and mental illnesses 鈥� and a gutting sense of abandonment.

What workers experienced has been detailed in state investigations, surveys of nurses, and published studies. These found that many health care workers weren’t given masks in 2020. Many got covid and worked while sick. More than a dozen lawsuits filed on behalf of residents or workers at nursing facilities detail such experiences. And others allege that accommodations weren’t made for workers facing depression and PTSD triggered by their pandemic duties. Some of the lawsuits have been dismissed, and others are pending.

Health care workers and unions reported risky conditions to state and federal agencies. But the federal Occupational Safety and Health Administration had fewer inspectors in 2020 to investigate complaints than at any point in a half-century. It investigated only about that were filed officially, and just 4% of more than 16,000 informal reports made by phone or email.

Nursing assistants, health aides, and other lower-wage health care workers were particularly vulnerable during outbreaks, and many remain burdened now. About 80% of lower-wage workers who provide are women, and these workers are more likely to be immigrants, to be people of color, and to live in poverty than doctors or nurses.

Some of these a person’s covid risk. They also help explain why these workers had limited power to avoid or protest hazardous conditions, said Eric Frumin, formerly the safety and health director for the Strategic Organizing Center, a coalition of labor unions.

He also cited decreasing membership in unions, which negotiate for higher wages and safer workplaces. One-third of the U.S. labor force was , but the level has fallen to 10% in recent years.

Like essential workers in meatpacking plants and warehouses, nursing assistants were at risk because of their status, Frumin said: “The powerlessness of workers in this country condemns them to be treated as disposable.”

In interviews, essential workers in various industries told 麻豆女优 Health News they felt duped by a system that asked them to risk their lives in the nation’s moment of need but that now offers little assistance for harm incurred in the line of duty.

“The state doesn’t care. The justice system doesn’t care. Nobody cares,” Ragoonanan said. “All of us have to go right back to work where this started, so that’s a double whammy.”

鈥楢 War Zone’

The plight of health care workers is a problem for the United States as the population ages and the threat of future pandemics looms. called their burnout “an urgent public health issue” leading to diminished care for patients. That’s on top of a predicted shortage of more than 3.2 million lower-wage health care workers by 2026, according to the .

The veterans home in Holyoke illustrates how labor conditions can jeopardize the health of employees. The facility is not unique, but its situation has been vividly described in a state investigative report and in a report from a joint oversight committee of the Massachusetts Legislature.

The Soldiers’ Home made headlines in March 2020 when got a tip about refrigerator trucks packed with the bodies of dead veterans outside the facility. About 80 residents died within a few months.

The placed blame on the home’s leadership, starting with Superintendent Bennett Walsh. “Mr. Walsh and his team created close to an optimal environment for the spread of COVID-19,” the report said. He resigned under pressure at the end of 2020.

Investigators said that “at least 80 staff members” tested positive for covid, citing “at least in part” the management’s “failure to provide and require the use of proper protective equipment,” even restricting the use of masks. They included a disciplinary letter sent to one nursing assistant who had donned a mask as he cared for a sick veteran overnight in March. “Your actions are disruptive, extremely inappropriate,” it said.

To avoid hiring more caretakers, the home’s leadership combined infected and uninfected veterans in the same unit, fueling the spread of the virus, the report found. It said veterans didn’t receive sufficient hydration or pain-relief drugs as they approached death, and it included testimonies from employees who described the situation as “total pandemonium,” “a nightmare,” and “a war zone.”

Because his wife was immunocompromised, Walsh didn’t enter the care units during this period, according to his lawyer’s statement in a deposition obtained by 麻豆女优 Health News. “He never observed the merged unit,” it said.

In contrast, nursing assistants told 麻豆女优 Health News that they worked overtime, even with covid, because they were afraid of being fired if they stayed home. “I kept telling my supervisor, 鈥業 am very, very sick,’” said Sophia Darkowaa, a nursing assistant who said she now suffers from PTSD and symptoms of long covid. “I had like four people die in my arms while I was sick.”

Nursing assistants recounted how overwhelmed and devastated they felt by the pace of death among veterans whom they had known for years 鈥� years of helping them dress, shave, and shower, and of listening to their memories of war.

“They were in pain. They were hollering. They were calling on God for help,” Ragoonanan said. “They were vomiting, their teeth showing. They’re pooping on themselves, pooping on your shoes.”

Nursing assistant Kwesi Ablordeppey said the veterans were like family to him. “One night I put five of them in body bags,” he said. “That will never leave my mind.”

Four years have passed, but he said he still has trouble sleeping and sometimes cries in his bedroom after work. “I wipe the tears away so that my kids don’t know.”

High Demands, Low Autonomy

A third of health care workers reported symptoms of PTSD related to the pandemic, according to covering 24,000 workers worldwide. The disorder predisposes people to dementia and Alzheimer’s. It can lead to substance use and self-harm.

Since covid began, Laura van Dernoot Lipsky, director of the Trauma Stewardship Institute, has been inundated by emails from health care workers considering suicide. “More than I have ever received in my career,” she said. Their cries for help have not diminished, she said, because trauma often creeps up long after the acute emergency has quieted.

Another factor contributing to these workers’ trauma is “moral injury,” a term first applied to soldiers who experienced intense guilt after carrying out orders that betrayed their values. It became common among in the pandemic who weren’t given ample resources to provide care.

“Folks who don’t make as much money in health care deal with high job demands and low autonomy at work, both of which make their positions even more stressful,” said Rachel Hoopsick, a public health researcher at the University of Illinois at Urbana-Champaign. “They also have fewer resources to cope with that stress,” she added.

People in lower income brackets have to mental health treatment. And health care workers with less education and financial security are less able to take extended time off, to relocate for jobs elsewhere, or to shift careers to avoid retriggering their traumas.

Such memories can feel as intense as the original event. “If there’s not a change in circumstances, it can be really, really, really hard for the brain and nervous system to recalibrate,” van Dernoot Lipsky said. Rather than focusing on self-care alone, she pushes for policies to ensure adequate staffing at health facilities and accommodations for mental health issues.

In 2021, Massachusetts legislators acknowledged the plight of the Soldiers’ Home residents and staff in a joint saying the events would “impact their well-being for many years.”

But only veterans have received compensation. “Their sacrifices for our freedom should never be forgotten or taken for granted,” the state’s veterans services director, Jon Santiago, said at an event announcing a memorial for veterans who died in the Soldiers’ Home outbreak. The state’s $56 million settlement followed a class-action lawsuit brought by about 80 veterans who were sickened by covid and a roughly equal number of families of veterans who died.

The state’s attorney general also brought criminal charges against Walsh and the home’s former medical director, David Clinton, in connection with their handling of the crisis. The two averted a trial and possible jail time this March by changing their not-guilty pleas, instead acknowledging that the facts of the case were sufficient to warrant a guilty finding.

An attorney representing Walsh and Clinton, Michael Jennings, declined to comment on queries from 麻豆女优 Health News. He instead referred to legal proceedings in March, in which Jennings argued that “many nursing homes proved inadequate in the nascent days of the pandemic” and that “criminalizing blame will do nothing to prevent further tragedy.”

Nursing assistants sued the home’s leadership, too. The lawsuit alleged that, in addition to their symptoms of long covid, what the aides witnessed “left them emotionally traumatized, and they continue to suffer from post-traumatic stress disorder.”

The case was dismissed before trial, with courts ruling that the caretakers could have simply left their jobs. “Plaintiff could have resigned his employment at any time,” Judge Mark Mastroianni wrote, referring to Ablordeppey, the nursing assistants’ named representative in the case.

But the choice was never that simple, said Erica Brody, a lawyer who represented the nursing assistants. “What makes this so heartbreaking is that they couldn’t have quit, because they needed this job to provide for their families.”

鈥楬elp Us To Retire’

Brody didn’t know of any cases in which staff at long-term nursing facilities successfully held their employers accountable for labor conditions in covid outbreaks that left them with mental and physical ailments. 麻豆女优 Health News pored through lawsuits and called about a dozen lawyers but could not identify any such cases in which workers prevailed.

A Massachusetts chapter of the Service Employees International Union, SEIU Local 888, is looking outside the justice system for help. It has pushed for a bill 鈥� proposed last year by Judith García, a Democratic state representative 鈥� to allow workers at the state veterans home in Holyoke, along with its sister facility in Chelsea, to receive their retirement benefits five to 10 years earlier than usual. The bill’s fate will be decided in December.

Retirement benefits for Massachusetts state employees amount to 80% of a person’s salary. Workers qualify at different times, depending on the job. Police officers get theirs at age 55. Nursing assistants qualify once the sum of their time working at a government facility and their age comes to around 100 years. The state stalls the clock if these workers take off more than their allotted days for sickness or vacation.

Several nursing assistants at the Holyoke veterans home exceeded their allotments because of long-lasting covid symptoms, post-traumatic stress, and, in Ragoonanan’s case, a brain aneurysm. Even five years would make a difference, Ragoonanan said, because, at age 56, she fears her life is being shortened. “Help us to retire,” she said, staring at the slippers covering her swollen feet. “We have bad PTSD. We’re crying, contemplating suicide.”

I got my funeral dress out because the way everybody was dying, I knew I was going to die.

Debra Ragoonanan

Certain careers are linked with shorter life spans. Similarly, economists have shown that, on average, people with lower incomes in the United States than those with more. Nearly 60% of long-term care workers are among the bottom earners in the country, paid less than $30,000 鈥� or about $15 per hour 鈥� in 2018, according to analyses by the Department of and , a health policy research, polling, and news organization that includes 麻豆女优 Health News.

Fair pay was among the solutions listed in the surgeon general’s report on burnout. Another was “hazard compensation during public health emergencies.”

If employers offer disability benefits, that generally entails a pay cut. Nursing assistants at the Holyoke veterans home said it would halve their wages, a loss they couldn’t afford.

“Low-wage workers are in an impossible position, because they’re scraping by with their full salaries,” said John Magner, SEIU Local 888’s legal director.

Despite some public displays of gratitude for health care workers early in the pandemic, essential workers haven’t received the financial support given to veterans or to emergency personnel who risked their lives to save others in the aftermath of 9/11. Talk show host Jon Stewart, for example, has lobbied for this group for over a decade, successfully pushing Congress to compensate them for their sacrifices.

“People need to understand how high the stakes are,” van Dernoot Lipsky said. “It’s so important that society doesn’t put this on individual workers and then walk away.”

Healthbeat is a nonprofit newsroom covering public health published by and . Sign up for its newsletters .

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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