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“Cuarto trimestre”: período clave para prevenir las muertes maternas

Durante varias semanas al año, el trabajo de la enfermera-comadrona Karen Sheffield-Abdullah es detectivesco. Con un equipo de investigadores médicos del Departamento de Salud Pública de Carolina del Norte examina los registros hospitalarios y los informes forenses de las madres que murieron después de dar a luz.

Estos comités de revisión de la mortalidad materna buscan pistas sobre lo que ha contribuido a estas muertes —recetas que nunca se recogieron, faltar a citas médicas postnatales, señales de alerta que los médicos pasaron por alto—, para averiguar cuántas podrían haberse evitado y cómo.

Los comités trabajan en 36 estados, y en la última y mayor recopilación de datos de este tipo, publicada en septiembre por los Centros para el Control y Prevención de Enfermedades (CDC), un sorprendente 84% de las muertes relacionadas con el embarazo se consideraron prevenibles.

Lo que resulta aún más alarmante para enfermeras-detectives como Sheffield-Abdullah es que el 53% de las muertes se produjeron mucho después de que las mujeres fueran dadas de alta del hospital, entre siete días y un año después del parto.

“Estamos muy centrados en el bebé”, afirma. “Una vez que el bebé está aquí, es casi como si la madre fuera descartada… Y en lo que realmente tenemos que pensar es en ese cuarto trimestre, ese tiempo después del nacimiento del bebé”.

Las condiciones de salud mental fueron la principal causa subyacente de muertes maternas entre 2017 y 2019. Las blancas no hispanas y las hispanas fueron las más propensas a morir por suicidio o sobredosis de drogas, mientras que los problemas cardíacos fueron la principal causa de muerte para las mujeres negras no hispanas.

Ambas circunstancias ocurren desproporcionadamente más tarde en el período posparto, según el informe de los CDC.

Los datos revelan múltiples deficiencias en el sistema de atención a las nuevas madres, desde los obstetras que no están adiestrados (o bien pagados) para buscar signos de problemas mentales o de adicción, hasta las pólizas que despojan a las mujeres de la cobertura médica poco después de dar a luz.

El principal problema es que el típico control postnatal de seis semanas es demasiado tarde, según Sheffield-Abdullah. En los datos de Carolina del Norte, las nuevas madres que murieron más tarde no acudieron a esta cita porque tenían que volver al trabajo o tenían otros niños pequeños, agregó.

“Tenemos que estar realmente en contacto mientras están en el hospital”, dijo Sheffield-Abdullah, y luego asegurarnos de que las pacientes reciban la atención de seguimiento adecuada “una o dos semanas después del parto”.

Otra de las recomendaciones de los CDC es más pruebas de detección de depresión y ansiedad posparto, durante todo el año posterior al parto, así como una mejor coordinación de la atención entre los servicios médicos y sociales, según David Goodman, que dirige el equipo de prevención de mortalidad materna de la División de Salud Reproductiva de los CDC, que publicó el informe.

Una crisis frecuente es que la adicción de uno de los padres se agrava tanto que los servicios de protección infantil se llevan al bebé, lo que precipita una sobredosis accidental o intencionada de la madre. Tener acceso al tratamiento y asegurarse de que las visitas a los niños se produzcan con regularidad podría ser la clave para prevenir estas muertes, apuntó Goodman.

El cambio político más importante ha sido la ampliación de la cobertura sanitaria gratuita a través de Medicaid, indicó. Hasta hace poco, la cobertura de Medicaid relacionada con el embarazo solía expirar dos meses después del parto, lo que obligaba a las mujeres a dejar de tomar medicamentos o de acudir a un terapeuta o a un médico porque no podían pagar el costo sin seguro médico.

Ahora, 36 estados han ampliado o tienen previsto ampliar la cobertura de Medicaid hasta un año completo después del parto, en parte como respuesta a los primeros trabajos de los comités de revisión de la mortalidad materna.

“Si esto no es una llamada a la acción, no sé qué es”, señaló Adrienne Griffen, directora ejecutiva de la Maternal Mental Health Leadership Alliance, una organización sin fines de lucro centrada en la política nacional. “Hace tiempo que sabemos que los problemas de salud mental son la complicación más común del embarazo y el parto. Solo que no hemos tenido la voluntad de hacer algo al respecto”.

El último estudio de los CDC de septiembre analizó 1,018 muertes en 36 estados, casi el doble de los 14 estados que participaron en el informe anterior. Los CDC están dando aún más fondos para las revisiones de la mortalidad materna, dijo Goodman, con la esperanza de captar datos más completos de más estados en el futuro.

El aumento de la concientización y la atención sobre la mortalidad materna les ha dado esperanza a activistas y médicos, especialmente por los esfuerzos para corregir las disparidades raciales: las mujeres negras tienen tres veces más probabilidades de morir por complicaciones relacionadas con el embarazo que las blancas.

Pero muchos de estos mismos partidarios de una mejor atención materna dicen estar consternados por la reciente decisión del Tribunal Supremo de Estados Unidos de erradicar el derecho federal al aborto; las restricciones en torno a la atención de la salud reproductiva, dicen, erosionarán los avances.

Desde que estados como Texas empezaron a prohibir los abortos en etapas tempranas del embarazo y a hacer menos excepciones para aquellos casos en los que la salud de la embarazada está en peligro, a algunas mujeres les resulta más difícil recibir atención de urgencia por un aborto espontáneo.

Los estados también están prohibiendo los abortos —incluso en casos de violación o incesto— en chicas jóvenes, que afrontan un riesgo mucho mayor de complicaciones o muerte por llevar un embarazo a término.

“Cada vez más el mensaje es que ‘no eres dueña de tu cuerpo'”, dijo Jameta Nicole Barlow, profesora adjunta de redacción, política y gestión sanitaria en la Universidad George Washington.

Según Barlow, esto no hará más que agravar los problemas de salud mental que experimentan las mujeres en torno al embarazo, especialmente las mujeres negras, que también se enfrentan a la larga historia intergeneracional de la esclavitud y el embarazo forzado. Sospecha que las cifras de mortalidad materna empeorarán antes de mejorar, debido a la interrelación entre la política y la psicología.

“Hasta que no abordemos lo que está ocurriendo políticamente”, dijo, “no vamos a poder ayudar a lo que está ocurriendo psicológicamente”.

Esta historia es parte de una alianza que incluye a KQED, NPR, y KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Readers Boo Medical Debt and Viral Threats in Winning Halloween Haikus

You did it again, readers! We received more than three dozen Halloween haiku submissions in KHN’s fourth annual Halloween haiku contest. Our expert panel of judges took the ghastly challenge of choosing the best head-on … or off. Here’s the winner, which was recited by Julie Rovner on last week’s “What the Health?” podcast, plus a sampling of finalists illustrated by Oona Tempest. The judges’ favorites drew inspiration from real-life viral outbreaks and the burden of haunting medical bills. Keep an eye on KHN’s social media accounts (Twitter, Instagram, and Facebook) for more of our favorites. Enjoy!

1st Place

Covid, Ebola,Monkeypox, seasonal flu —Who needs Halloween?

— Paul Hughes-Cromwick

Inspiration: 24/7 ghosts, goblins, and pathogens

2nd Place

Surprise billing curbs,Like the famed headless horseman,Remain incomplete.

— Michael L. Millenson

Inspiration: “How to Avoid Surprise Bills — And the Pitfalls in the New Law“

3rd Place

Ghastly, grotesque, sick!You mask up to trick-or-treat,But not for covid?

— Micki Jackson

Inspiration: The ongoing mask-or-not masquerade

While Halloween may be coming to an end, KHN reporting continues year-round. Send us your haikus at any time for possible inclusion in our Morning Briefing: https://khn.org/contact-haiku/

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Pese al consejo de Katie Couric, médicos dicen que las ecografías de seno pueden no ser necesarias

Cuando Katie Couric compartió la noticia de su diagnóstico de cáncer de mama, la ex presentadora del programa Today de NBC dijo que veía este nuevo reto de salud como un momento para animar a la gente a hacerse pruebas de detección de cáncer.

“Por favor, háganse su mamografía anual”, escribió en su página web el mes pasado. “Pero igual de importante, averigüen si necesitan pruebas adicionales”.

En el ensayo, Couric, de 65 años, explicaba que, como tiene senos densos, se hace una prueba de ultrasonido además de la mamografía todos los años para detectar el cáncer de seno. La ecografía mamaria, también llamada sonograma, utiliza ondas sonoras para tomar imágenes del tejido mamario.

A veces puede identificar tumores malignos que son difíciles de detectar en una mamografía en mujeres con pechos densos, que significa tener una alta proporción de tejido fibroso y glándulas, y menos tejido graso.

Couric, que se sometió a una colonoscopía en vivo en televisión después de que su primer esposo muriera de cáncer de colon, y que perdió a una hermana por cáncer de páncreas, lleva mucho tiempo abogando por mejores opciones de detección.

Expertos en cáncer de seno aplaudieron a Couric por llamar la atención sobre la densidad mamaria como factor de riesgo de cáncer. Pero no coinciden con su defensa de las pruebas complementarias.

“No tenemos pruebas de que la revisión auxiliar reduzca la mortalidad por cáncer de mama o mejore la calidad de vida”, dijo la doctora Carol Mangione, profesora de medicina y salud pública de UCLA que preside el Grupo de Trabajo de Servicios Preventivos de Estados Unidos, un grupo de expertos médicos que hace recomendaciones sobre servicios preventivos tras sopesar beneficios y daños.

Couric no respondió al pedido de comentarios.

Además de la mamografía anual, algunas mujeres con mamas densas se hacen una ecografía o una resonancia magnética para tratar de identificar las células cancerosas que no se detectan en la mamografía. En la mamografía, el tejido fibroso denso aparece de color blanco y hace más difícil ver un cáncer, que también se ve blanco. El tejido mamario graso, que aparece oscuro en la mamografía, no oculta los cánceres de mama.

Dado que la tomosíntesis digital de las mamas, o mamografía en 3D, está cada vez más extendida, un número creciente de mujeres se hace esta prueba de chequeo en lugar de la mamografía estándar en 2D.

La mamografía 3D reduce el número de falsos positivos y parece identificar más cánceres en algunas mujeres con mamas densas, aunque se desconoce el impacto en la mortalidad.

El grupo de trabajo da una calificación de “I” a la ecografía para las mujeres con mamas densas cuyos resultados de la mamografía no indican ningún problema. Esto significa que la evidencia actual es insuficiente para evaluar si los beneficios superan los daños del examen adicional.

Uno de los principales efectos nocivos que preocupa a los investigadores son los falsos positivos.

Las imágenes complementarias en mujeres que no tienen un riesgo elevado de padecer cáncer de mama pueden identificar posibles puntos problemáticos, lo que puede dar lugar a pruebas de seguimiento, como biopsias, que son invasivas y suelen aumentar el temor de las pacientes al cáncer. Pero la investigación ha descubierto que muy a menudo estos resultados resultan ser falsas alarmas.

Si 1,000 mujeres con senos densos se someten a una ecografía tras una mamografía negativa, la ecografía identificará entre dos y tres cánceres, según los estudios. Pero las imágenes adicionales también identificarán hasta 117 problemas potenciales que llevan a visitas y pruebas de seguimiento, pero que finalmente se determinan como falsos positivos.

“Por un lado, queremos hacer todo lo posible para mejorar la detección”, dijo la doctora Sharon Mass, ginecóloga y obstetra en Morristown, New Jersey, y ex presidenta de la sección de New Jersey del Colegio Americano de Obstetras y Ginecólogos. “Pero, por otro lado, hay muchos costos y angustia emocional” asociados a los resultados falsos positivos.

El grupo profesional no recomienda la revisión suplementaria para las mujeres con senos densos que no tienen ningún factor de riesgo adicional de cáncer.

Muchos otros grupos profesionales tienen una posición similar.

“Recomendamos tener una conversación con un proveedor de atención médica, y que las pacientes entiendan si sus senos son densos”, dijo Mass. “Pero no recomendamos que todo el mundo se haga la prueba”.

En particular, para aproximadamente el 8% de las mujeres que tienen senos extremadamente densos, vale la pena tener una conversación con un médico sobre la detección adicional, dijo Mass.

Del mismo modo, para las mujeres con senos densos que tienen factores de riesgo adicionales para el cáncer de mama, como antecedentes familiares de la enfermedad o un historial personal de biopsias de mama para comprobar los cánceres sospechosos, la ecografía puede tener sentido, dijo.

Las mamas densas son relativamente comunes. En Estados Unidos, se calcula que el 43% de las mujeres mayores de 40 años tiene mamas consideradas densas o extremadamente densas. Además de dificultar la interpretación de las mamografías, las mujeres con mamas densas tienen hasta el doble de probabilidades de desarrollar cáncer de mama que las mujeres con senos de densidad media, según las investigaciones.

Estudios han demostrado que las mamografías reducen la mortalidad por cáncer de seno. Sin embargo, aunque parece intuitivo que un mayor número de pruebas mejore las probabilidades de vencer al cáncer, las investigaciones no han demostrado que las mujeres tengan menos probabilidades de morir de cáncer de mama si se hacen una ecografía o una resonancia magnética suplementaria tras un resultado negativo de la mamografía.

Treinta y ocho estados y el Distrito de Columbia tienen leyes que exigen que se notifique a las pacientes sobre la densidad mamaria después de una mamografía, aunque no todas ordenan que se informe a las mujeres sobre su propia situación. Algunos estados exigen que las aseguradoras cubran las pruebas complementarias.

En 2019, la Administración de Alimentos y Medicamentos (FDA) propuso que la información sobre la densidad mamaria se incorporara a las cartas que reciben las pacientes después de una mamografía. Esa regla aún no se ha concretado, pero la agencia indicó a los legisladores que espera emitirla a más tardar a principios de 2023.

Las pruebas de imagen complementarias pueden ser caras si el plan de salud no las cubre. Una ecografía puede costar $250, mientras que un MRI puede salir $1,084 si se paga del propio bolsillo, según la Brem Foundation to Defeat Breast Cancer.

La diputada Rosa DeLauro (demócrata de Connecticut) tuiteó que está trabajando en un proyecto de ley con Couric que cubriría los MRI y las ecografías para las mujeres con mamas densas.

Algunos médicos recomiendan otras medidas que pueden ser más eficaces que las pruebas adicionales para las mujeres con senos densos que quieren reducir su riesgo de cáncer de mama.

“Si realmente quieres ayudarte a tí misma, pierde peso”, dijo la doctora Karla Kerlikowske, profesora de medicina y epidemiología/bioestadística de la Universidad de California-San Francisco, que ha desarrollado calculadoras para ayudar a las personas a evaluar su riesgo de cáncer de mama. “Modera su consumo de alcohol y evita la sustitución hormonal a largo plazo. Son cosas que puedes controlar”.

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Ambulance Company to Halt Some Rides in Southern California, Citing Low Medicaid Rates

For 23 years, the private ambulance industry in California had gone without an increase in the base rate the state pays it to transport Medicaid enrollees. At the start of the year, it asked the state legislature to more than triple the rate, from around $110 to $350 per ride. The request went unheeded.

In September, American Medical Response, the largest U.S. provider of ambulance services, announced it had “made the difficult decision” to end nonemergency transports in Los Angeles County and blamed the state for having one of the lowest Medicaid reimbursement rates in the country. “What’s more,” the company, which sold for $2.4 billion in 2017 to private equity firm KKR, said, “we are not subsidized by taxpayer funds like public agencies, and almost 80% of our patients pay nothing or below cost for our services.”

The company, which also cited high operational costs, said its nonemergency division in that area was on track to lose $3.5 million in 2022.

The California Department of Health Care Services, which administers the state’s Medicaid program for low-income people, known as Medi-Cal, did not contest that the base rate hasn’t increased since 1999, but said that reimbursements have increased through add-on payments for supplemental costs and emergency rides.

In its initial announcement, AMR mentioned the phaseout of nonemergency services only in L.A. County. However, the company told KHN that it would stop servicing five hospitals in Orange County in addition to seven hospitals in L.A. County.

Jason Sorrick, vice president of government affairs at KKR-owned Global Medical Response, which is now AMR’s parent company, said AMR would exit over the next six months and shift vehicles and as many of the 170 crew members as possible to its core emergency services.

AMR’s pullout equates to a loss of 28,000 nonemergency transports a year and could create a predicament for the hospitals that contracted with the company. L.A. County said it does not track the total number of nonemergency rides provided by ambulances in the county, while Orange County wasn’t immediately able to share its figure.

Although ambulances are typically associated with 911 calls, many are used to transport frail or vulnerable patients between health care facilities. A patient may need to go to a rehabilitation facility after hip surgery, or someone who attempted suicide may need to be moved from an emergency room to a psychiatric facility. Such transfers, known as interfacility transports, enable hospitals to free up beds and maintain patient access.

There isn’t consensus on what the impact of AMR’s pullout will be. The state told KHN that it will review and address access issues on a “targeted basis” if it becomes aware of any. Patient advocates said it’s too early to draw conclusions about the effect on patients, particularly those covered by Medi-Cal. The California Ambulance Association flagged concerns that companies are already stretched thin by staffing and vehicle shortages.

Though the two counties and the insurers that serve their Medi-Cal populations did not express immediate concern about AMR’s decision, some hospitals may have trouble dealing with the loss.

“Halting these services will undoubtedly impact hospitals’ ability to efficiently manage” the flow of patients from arrival to discharge, said Adam Blackstone, senior vice president of communications for the Hospital Association of Southern California.

AMR said its pullout will primarily affect Providence, a Catholic health system operating in several states, including California. It did not respond to a request for comment.

AMR now also attributes its exit to avoiding a labor dispute. Sorrick said that because of Medi-Cal’s rates, AMR could not staff both emergency and nonemergency ambulances and raise wages for unionized emergency staffers who were threatening to strike. So it shuttered its lower-priority nonemergency division, which wasn’t unionized. It planned to use the savings to increase wages for emergency staff members.

Michael Diaz, an EMT and president of the International Association of EMTs and Paramedics Local 77, which represents 350 EMTs and paramedics for AMR emergency services in L.A. County, confirmed that AMR’s announcement came the day before the union planned to march in protest for higher wages.

Diaz, whose national union had joined the industry in lobbying the California legislature for higher rates, said AMR’s announcement could also have been politically motivated. “They’re sending a message,” he said.

So far, it’s unclear whether elected officials have noticed the pullout. Leaders of legislative budget committees declined to comment or did not respond to inquiries.

Medi-Cal spending on all medical transportation services totaled about $975 million in fiscal year 2021-22, according to data from the Department of Health Care Services.

The department said Medi-Cal’s insurers are ultimately responsible for maintaining an adequate network of medical transportation providers and noted that the insurers are allowed to pay above the base rate. The ambulance industry said it’s uncommon for insurers to pay more.

Jimmy Pierson, president of the California Ambulance Association, said other ambulance companies usually pick up the slack when one exits a market. But he warned that competitors may not be able to cover all of AMR’s nonemergency ambulance rides this time, given unprecedented labor and supply shortages — including two-year waits for new ambulances — and rising Medi-Cal enrollment and inflation. A recent national survey found that EMTs turned over at an annual rate of 36%.

“How are you going to find 170 employees in a labor shortage?” Pierson asked. “How will you find those ambulances?”

Ambulance companies said that hiring and retention have been battered by low wages, burnout, and lasting effects of EMT school closures during the pandemic — and that low Medi-Cal reimbursements make paying EMTs competitive salaries difficult.

A few other companies in the state have already shut down or scaled back services, Pierson added. In 2016, AMR ended nonemergency and emergency services in Tulare County, a region in the Central Valley with one of the highest shares of residents on Medi-Cal.

Sorrick said AMR believes enough companies provide nonemergency transports to absorb the volume.

Chad Druten, president of the Los Angeles County Ambulance Association, said the county has approximately 1,200 licensed private ambulances operated by about 35 companies, most of which are small to medium-sized and focus on nonemergency transports. A few large companies, including AMR, cover emergency calls.

Melissa Harris, who owns AmbuServe Ambulance Service in L.A. County, said she plans to compete for small portions of AMR’s contracts, focusing on the ones with fewer Medi-Cal patients. Harris said she loses money on every Medi-Cal-covered transport and can’t easily buy and staff new ambulances. If she wins any contracts, she will likely have to “trade” away her existing contracts that serve the highest portions of Medi-Cal patients.

The consequences of that, Harris said, would hit underserved patients the hardest.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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KHN’s ‘What the Health?’: Voters Will Get Their Say on Multiple Health Issues

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

Voters in several states will be asked to vote on ballot questions related to abortion, but it’s not the only health issue that will be decided on Election Day. Other ballot proposals will ask voters whether they want to curb interest on medical debt (Arizona), expand Medicaid (South Dakota), or make health care a right under the state constitution (Oregon).

Meanwhile, plaintiffs in a suit charging that the Affordable Care Act’s requirement to provide preventive medication against HIV are expanding their scope. Now they want the judge to rule that all preventive benefits under the health law are unconstitutional.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Jessie Hellmann of CQ Roll Call, and Victoria Knight of Axios.

Among the takeaways from this week’s episode:

The South Dakota ballot measure is the latest effort by health care advocates in conservative states to get a Medicaid expansion despite resistance from state officials. South Dakota’s governor and state legislature have refused to make the move. In recent years, voters in several of those states, including Idaho, Missouri, and Utah, have pushed the expansion forward over officials’ objections through voter initiatives.
Arizona’s unique ballot measure would limit interest rates on medical debt, among other things. It’s a bit of an under-the-radar issue, but if Arizona passes the measure, it could spur other states to try similar initiatives.
A handful of states will also be voting on abortion issues. In Kentucky, the legislature has put forward a constitutional amendment that says abortion rights aren’t protected by the state constitution and that government funding for abortions is not required. Voters in another red state, Kansas, surprised political pundits last summer when they overwhelmingly voted to maintain the right to abortion access, so the Kentucky results will be watched closely. If voters disapprove of the measure, it would be the first Southern state where voters have turned against the tide of legislation seeking to restrict abortion.
On the other hand, two reliably blue states — California and Vermont — are asking voters to enshrine a right to abortion in the states’ constitutions. Debate on the ballot measures, however, has raised the question of whether fetal viability should be a standard for when an abortion can’t be performed. Neither the groups supporting wide access for abortion rights nor those opposing abortion have said they are comfortable making a decision on abortion by using a viability standard.
In Washington, D.C., news, the Department of Defense’s announcement that it would pay travel expenses and provide leave for servicemembers seeking abortions out of state is likely to rile Republicans on Capitol Hill. It could also make the final negotiations tense over a defense spending bill that needs to be settled before the end of the year. The tone of those talks will likely depend on the election results next month.
The suit in federal court in Texas challenging the ACA’s preventive care mandates continues to grow. Judge Reed O’Connor has already ruled that the plaintiffs’ religious views should exempt them from having to provide some preventive care, including certain HIV drugs. It may yet take months to realize the implications of the case, but the plaintiffs have asked the judge to strike down all the preventive care provisions and to make the ruling applicable across the country. If that happens, the case will undoubtedly be appealed.
Studies out this week show that the covid-19 pandemic had a nasty aftereffect for children: Test scores have dropped around the country. And an analysis by The Washington Post found that the covid death rate among white Americans is now higher than among Black residents. These data points add to concerns this fall as public health officials face difficulty encouraging people to get the latest covid booster, let alone their flu shot.

Also this week, Rovner interviews Sandra Alvarez, writer, director, and co-producer of the documentary “InHospitable,” which looks at the growing market power of nonprofit hospitals and how well they serve their patients and their communities.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Washington Post’s “An Autistic Teen Needed Mental Health Help. He Spent Weeks in an ER Instead,” by William Wan

Alice Miranda Ollstein: CBS News’ “U.S. Offers Flu Shots to Migrants in Border Custody, Reversing Long-Standing Policy,” by Camilo Montoya-Galvez

Victoria Knight: Stat’s “Inside Michelle McMurry-Heath’s Departure From BIO: Firings, Internal Clashes, and a Pivotal Job Review,” by Rachel Cohrs

Jessie Hellmann: KHN’s “Hospitals Said They Lost Money on Medicare Patients. Some Made Millions, a State Report Finds,” by Fred Clasen-Kelly

Also mentioned in this week’s episode:

The Washington Post’s “Whites Now More Likely to Die From Covid Than Blacks: Why the Pandemic Shifted,” by Akilah Johnson and Dan Keating

Bloomberg Law’s “Law Firm Calls Out Ex-EEOC Counsel’s Note on Abortion Travel,” by Rebecca Rainey and J. Edward Moreno

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

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How Private Equity Is Investing in Health Care: A Video Primer

In the past decade, private equity has moved aggressively into health care, gobbling up physician practices and even entire hospitals. But what exactly is private equity? And what does its involvement mean for patients and for the American health care system? KHN explains.

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Hospitals Said They Lost Money on Medicare Patients. Some Made Millions, a State Report Finds.

CHARLOTTE, N.C. — Atrium Health, the largest hospital system in North Carolina, has declared publicly that in 2019 it provided $640 million in services to Medicare patients that were never paid for, by far the largest “community benefit” it provided that year.

Like other nonprofit hospitals around the nation, Atrium logs losses on the federal health insurance program for seniors and people with disabilities as a community benefit to satisfy legal requirements for federal, state, and local tax breaks.

But for the same year that Atrium’s website says it recorded the $640 million loss on Medicare, the hospital system claimed $82 million in profits from Medicare and an additional $37.2 million in profits from Medicare Advantage in a federally required financial document, according to a report released Oct. 25 by the North Carolina state treasurer’s office.

The lack of clarity about whether health systems like Atrium gain or lose money treating Medicare recipients reflects how loosely the federal government regulates the way hospitals calculate their community benefits.

As a result, the analysis of North Carolina hospitals’ financial data concluded, what taxpayers get from local nonprofit hospitals in return for tax exemptions worth billions of dollars a year is unclear.

“There is no transparency, no accountability, and no oversight,” said North Carolina State Treasurer Dale Folwell, a Republican who is critical of Atrium and other hospitals’ business practices. “With the hospital cartel, it is always profits over people.”

Atrium did not make officials available for an interview. In a statement, spokesperson Dan Fogleman said the hospital system reported $85 million in services to Medicare patients that weren’t paid for in its most recent cost report to the Centers for Medicare & Medicaid Services.

“And, as labor, equipment, supplies and inflation continue to drive health care costs higher, the gap between Medicare payments and costs incurred to deliver the quality care we provide has grown in the post-Covid inflationary environment,” Fogleman said.

More than half of the hospitals in the United States are nonprofits or government-run. The federal government requires them to operate emergency rooms open to all patients regardless of their ability to pay, accept patients insured by Medicare, and use surplus funds to improve facilities and patient care to demonstrate they are giving back to the community.

Even though their tax-exempt status is based on charitable acts, nonprofit hospital systems sat on more than $283 billion in assets from stocks, hedge funds, venture capital, and private equity and other investments in 2019, according to a 2021 KHN analysis of IRS filings.

The hospital systems used most of that to produce income and classified only $19 billion, or about 7% of their total investments, as principally devoted to their nonprofit missions, the analysis found.

The new North Carolina report describes how hospitals’ self-reported Medicare profit margins differed from the financial picture they provided to the public through IRS records, annual reports, and community benefit documents.

Although most hospitals have complained of significant Medicare losses, the analysis of data from more than 100 North Carolina hospitals found that most made profits on Medicare from 2015 to 2020.

IRS audits are supposed to protect the public from fraud and abuse, but the system has major gaps, said health economists and federal watchdog groups.

Federal law requires the IRS to review community benefit activities at least once every three years. Yet the agency did not “have a well-documented process to ensure that those activities are being reviewed,” said a 2020 report from the Government Accountability Office.

In response to GAO recommendations, IRS leaders updated the system last year to help ensure the agency could identify cases in which hospitals were suspected of not meeting requirements.

The IRS referred nearly 1,000 hospitals nationwide to its audit division for violations of the Affordable Care Act from 2015 to 2019, but the IRS could not identify if they were related to community benefits, the GAO said.

The tax agency has no authority to determine what activities hospitals must perform to comply with the law, the GAO said. An analysis of IRS data found 30 hospitals that reported no spending on community benefits in 2016, “indicating potential noncompliance,” the report said.

“Perhaps this is the result of the IRS being underfunded,” said Vivian Ho, a health economics professor at Rice University in Houston, who worked on the North Carolina report. “They don’t have the resources to reconsider what information they should seek.”

It is critical that the government collects accurate information from hospitals because the data affects all patients, Ho said.

Federal law forbids IRS employees from discussing tax information submitted to the agency by people or organizations, IRS spokesperson Anthony Burke said in response to questions about how effectively the government monitors hospitals.

Hospitals have long used what they report as losses on Medicare to justify charging patients with private insurance higher prices. According to a study released in 2021 by the Rand Corp., a nonprofit research organization, hospitals across the nation charge private insurers more than what they receive from Medicare for the same services.

In the Affordable Care Act, federal lawmakers mandated that to maintain their tax-exempt status, nonprofit hospitals must conduct a community health needs assessment, maintain a written financial assistance policy, set billing and collections limits, and set a limit on charges.

In written responses to KHN, the North Carolina Healthcare Association, which lobbies on behalf of hospitals, said hospitals provided $1.2 billion in charity care in 2020. It added that those community benefits can include a lot of different activities, such as covering the gap between how much a procedure costs and what a provider is reimbursed, volunteering by staff, and paying for medical outreach programs.

“Providing care to vulnerable populations is part of their nonprofit mission,” the statement said.

Atrium spends millions of dollars per year to provide care to people who need behavioral health care “but have no safety net — even from the state,” the association said.

Fogleman, the Atrium spokesperson, said an advisory commission has consistently told Congress that Medicare payments do not cover the full costs of services at most hospitals, including Atrium’s.

In North Carolina, large hospital systems received $1.8 billion in tax breaks in 2020, according to the state treasurer’s office.

The same year, lobbyists for North Carolina hospitals reported collectively losing $3.1 billion on Medicare, according to the office’s report. Other data shows they made $87 million in profit.

From 2015 to 2020, the report concludes, 35 hospitals posted profits from Medicare each year.

Other hospitals listed in the report did not respond to requests for comment.

The American Hospital Association contends that the federal government reimburses providers significantly less than it costs to care for Medicare recipients. Unlike private insurers, the federal government does not negotiate prices with hospitals. Medicare bases the amount it pays on hospitals’ locations, labor costs, and other factors.

Melinda Hatton, the association’s general counsel, said in a statement that “underpayments” totaled more than $75 billion in 2020. “These data show that few, if any, hospitals break even much less make a profit on the basis of Medicare payments,” she said.

But Glenn Melnick, a health economics and finance professor at the University of Southern California who reviewed the North Carolina data, said no one is certain how nonprofit hospitals are calculating their numbers.

“The nonprofit hospital systems are getting so big, we need greater transparency,” Melnick said. “Health care is amazingly expensive, and it will bankrupt us if we don’t get it under control.”

Nonprofit hospitals receive significantly more in tax breaks than they spend on community investment or charity care, according to a report released this year by the Lown Institute, a think tank in Needham, Massachusetts.

Using 2019 data from the IRS, researchers found that out of 275 hospital systems across the country, 227 spent less on community investments or charity care than they got in tax breaks. The deficit totaled more than $18 billion, the report said.

Leah Kane is a senior attorney for consumer protection at the Charlotte Center for Legal Advocacy, a nonprofit that provides civil legal assistance to people who cannot afford an attorney. She said her agency receives calls from people who were not offered charity care from hospitals.

She said her group is worried that hospitals are offering charity care to uninsured patients but not to other people, like the underinsured, who don’t have the income to pay thousands of dollars for treatment not covered by their insurance plans.

“People are angry and stressed out,” Kane said. “They don’t know what this [debt] will mean for their lives.”

KHN correspondent Aneri Pattani contributed to this report.

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A Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill

If Dr. Bhavin Shah was on his own, he said, he probably would have paid the bill for his broken arm. The 47-year-old physician from suburban Chicago incurred surprisingly steep charges after landing in an emergency room on New Year’s Day 2021. He’d hit an icy patch while skiing with his kids in Wisconsin.

The $10,563.49 in initial ER charges from a Froedtert South hospital in Pleasant Prairie, Wisconsin, seemed high considering he basically got only an exam, X-rays, pain relief, and an arm splint. His insurer negotiated the cost down to $7,922.62 — but, with Shah owing $250 for his deductible and 40% of the remaining charges, his bill of $3,319.05 still felt like too much. However, he thought, who was he to question the hospital’s billing department?

Shah’s wife, on the other hand, is highly qualified to question such charges. Sunita Kalsariya, 45, is the office manager of her husband’s medical practice, a job that includes overseeing billing. She took one look at the hospital charges and decided to investigate further.

Kalsariya had no way of knowing then that she was embarking on a crusade that would take over a year, send their bill to debt collections, lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

Froedtert South did not respond to multiple requests for comment on the case.

Here’s how Kalsariya reduced her family’s bill:

Tip 1: Start Early

Even before you know you’ll be challenging a bill, Kalsariya said, you should ask the hospital both for more information and to pause the billing process. The sooner you do that, the more time you’ll have to track down the details you need to contest a bill — and possibly reset the clock before it is sent to collections.

“Even in our case, we waited until the second bill,” Kalsariya said. “Start acting with the first bill.”

Tip 2: Get an Itemized Bill

Hospitals often have their own internal billing codes, so it’s important to ask for an itemized bill that lists “current procedural terminology” billing codes (CPT codes, for short), which are standardized across the country.

Depending on the medical procedure, Kalsariya said, a bill could contain an overwhelming number of line items that are hard to understand. She suggested focusing on the items that stand out, such as those with the highest price tag.

Kalsariya said it took months to get a bill that included CPT codes for her husband’s ER trip. Once she did, one item jumped out: $6,961.75 for CPT code 24505 — treating a fractured humerus without making an incision.

Shah didn’t remember having that treatment at Froedtert South. What he did recall was having his arm splinted in a comfortable position and making plans to have surgery the next day at a hospital in the Chicagoland area unaffiliated with Froedtert South. He returned home that night, caught maybe a couple of hours of sleep while propped up by pillows in an almost-seated position, then had a successful surgery.

Tip 3: Compare Your Charges With Those at Other Hospitals

Since January 2021, all hospitals have been required to make their prices publicly available, although some do so in a way that is difficult to find. Still, Kalsariya was able to find the prices that other hospitals in Wisconsin and beyond charged for the same procedure. They ranged from $201 in Boise, Idaho, to $1,300 in Madison, Wisconsin, she said, but all were fractions of the nearly $7,000 that Froedtert South charged.

The website fairhealthconsumer.org has a tool that allows consumers to search for typical patient expenses for procedures in their area. The website estimates that the out-of-network cost for the procedure Shah underwent, within the hospital’s ZIP code, would be $3,863; in network, it would be $1,707. Medicare also has an online tool to find national average patient expenses searchable by CPT code. The total cost for that procedure is listed at $1,892, with Medicare paying $1,514 and the patient on the hook for $378.

Tip 4: Challenge Your Charges

Armed with the information that Froedtert South was seemingly charging more than others for the bone realignment, the couple tried appealing directly to the hospital with no luck.

“The charges incurred on your date of service were both reasonable and within the range usually charged by similar healthcare providers in the area,” the hospital’s response letter read. “Moreover, your insurance company, United Healthcare Choice-Golden Rule, entered into a long-term agreement with Froedtert South knowing the charges for its various services.”

The couple sent two complaints to their insurer asking how it could allow itself to be charged such a high amount, but response letters said the claim was processed correctly.

“We expect our in-network providers to bill appropriately for their services,” UnitedHealthcare spokesperson Maria Gordon Shydlo wrote in an email to KHN. “We paid the claim under the terms of Mr. Shah’s benefit plan based on the information we received from the provider.”

Fed up, Kalsariya filed a complaint with the Illinois attorney general’s office. After going back and forth, she eventually was told her husband could apply for the hospital’s financial assistance program to reduce his bill. But Kalsariya said they didn’t need financial assistance. They could afford $3,319.05. This, she said, was about the principle of the thing — she felt they were being egregiously overcharged.

Tip 5: Request Your Medical Records

Getting Shah’s medical records proved to be another challenge. Kalsariya said her attempt to access the records on the hospital’s website didn’t work, so instead the couple was required to send hospital officials a form to release the records.

“They wouldn’t even accept fax or email,” Kalsariya said. “They needed it mailed, specifically, and it had to be notarized.”

It almost didn’t seem worth the hassle to them. But when a KHN reporter responded to the family’s request for help investigating Shah’s hospital bill, the couple decided to send in the form to accurately document their saga.

When the records arrived, they showed the splinting that Shah remembered but not the treatment that was driving up his bill. They appealed the bill to Froedtert South once more in May 2022, this time noting the discrepancy between the charges and the medical records.

Tip 6: Tell Collections You Are Disputing the Bill

Shah had received a letter from a debt collector, which Kalsariya said came in November 2021, over his unpaid medical bill. She asked the hospital to pull the bill from collections because the dispute was unresolved, which she said it did.

Informing a collections agency that a bill is in dispute can help protect a patient’s credit score. That wasn’t an issue with Shah’s bill from the hospital because the hospital pulled it back after Kalsariya’s call.

How It All Ended

After the couple asked the hospital about the discrepancy with the procedure, Shah received a letter from the hospital dated May 27 of this year, saying it had reviewed the records and discovered the bill was inappropriately coded: The hospital should have used the code for a splint, not a treatment. A month later, Shah got a new bill with a patient balance of $1,214.91 — $2,100 less than the original balance.

Kalsariya still thought the bill seemed high and that the hospital seemed unapologetic about charging for a procedure that was never performed.

But the couple paid the new, smaller bill, and their saga was finally over. Her advice to other patients? When you get a bill, look into it before paying.

“I know it’s time-consuming. It is really taxing on our minds to do this,” Kalsariya said. “But if everybody makes that effort, then they have to be transparent.”

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For the Houma People, Displacement Looms With Every Storm

For generations, Thomas Dardar Jr.’s family has lived on a small bayou island off the coast of Louisiana called Isle de Jean Charles. Environmental changes, rising seawaters, and storms have dramatically changed the island. Home to members of the United Houma Nation, the island is now about 320 acres, a sliver of the more than 22,000 acres it was in the mid-20th century.

Massive hurricanes, including Katrina and Ida, have raked the area. Relief efforts struggled to meet the devastation caused in 2005 by Hurricane Katrina, which killed more than 1,800 people along the Gulf Coast, swept away coastal land, and caused more than $100 billion in damage. The island’s only road to the mainland is often impassable because of strong winds and rising water. Encroaching water has made growing food difficult.

Now, just a small number of citizens live on Isle de Jean Charles, Dardar said. “We’re losing land here in Louisiana — used to say a football field every 90 minutes,” said Dardar, a former chief of the United Houma Nation, which has about 17,000 members. “Now it’s quicker than that.”

In 2016, Louisiana’s state government received a federal grant to help resettle island residents, among them the Houma. Some people do not want to move. For many others, moving is a hardship.

Displaced by the loss of land, infrastructure, and cultural heritage along Louisiana’s southern coast, members of the United Houma Nation are among those in the region most vulnerable to climate change and its repercussions on health. Health advocates fear the consequences could be worse for Indigenous people, who experience higher rates of diabetes, heart disease, and certain other health problems than white people.

The Houma Nation is not recognized by the federal government as a tribe, but a 2015 change to federal standards could ease barriers to federal status for the tribe, more than 35 years after its initial application.

That recognition would allow the Houma to work directly with the federal government rather than through intermediaries to secure resources, said Lanor Curole, a member of the Houma Nation who oversees its day-to-day operations. Direct communication with federal officials during an emergency can save precious time in delivering critical relief to communities like the Houma, she said.

“Our people are on that front line, but we don’t have a seat at that table,” she said.

In 2010, when the Deepwater Horizon oil spill released at least 4 million barrels of oil into the Gulf of Mexico, the incident wreaked havoc on the Houma people. It polluted the region, destroyed ecosystems, threatened commercial fishing, and exposed people to toxic substances known to cause cancer. But after that environmental disaster, BP, the company using the drilling rig, wasn’t required to pay damages directly to the Houma because the tribe isn’t one of the 574 recognized by the federal government.

For federal recognition, tribes must prove they meet several criteria, including that their members descend from a historical tribe and that they are a distinct community. Dan Lewerenz, a law professor at the University of North Dakota, said the lack of federal recognition means the government does not see the Houma as a self-governing sovereign entity.

Houma leaders said the community’s status has become a barrier to getting support to tackle climate emergencies. Meanwhile, the Chitimacha, a federally recognized tribe in the region, partnered with the federal government in 2016 to develop an adaptation plan to address climate pressures.

Serious health concerns associated with climate change include water-borne infections like E. coli and diseases transmitted by mosquitoes like dengue and West Nile virus, problems that plague communities inundated with water.

The Houma are not eligible for care through the Indian Health Service, winnowing the already slim options in the region. According to a 2010 community needs assessment conducted by the tribe, more than half of Houma members have cardiovascular disease.

Health researchers and social scientists link the health inequities among Indigenous peoples to intergenerational traumas, with younger generations exhibiting poor health outcomes connected to their ancestors’ experiences. The historical traumas experienced by Native people in the U.S. include genocide and displacement.

In the vulnerable communities along the coast, people often don’t have the extra cash needed to rebuild after a storm, putting them at risk of losing their homes. The cost of repairing infrastructure can be astronomical, forcing some people to move elsewhere and leaving already resource-poor communities further choked off from necessities like schools and doctors.

“There are very few grocery stores on the bayous,” said Shanondora Billiot, who studies the effects of environmental changes on the health of Indigenous people in Louisiana. “Many people have to drive 30 to 45 minutes to get to the closest grocery store with fresh fruit, fresh vegetables because many people can no longer grow those vegetables on their soil.”

Billiot’s research on the Houma Nation found that repeated exposure to environmental disasters has taken a toll on people’s mental health, and she noticed a “sadness” among some members that she compared to symptoms of post-traumatic stress disorder. “Climate change interrupts the expression of culture and the protective factors that culture and identity have on health,” Billiot said.

Jobs are scarce, and the cost of flood insurance — a requirement in coastal areas — is so high that some people can no longer afford their homes. Pricey flood insurance premiums helped push Curole from her home in Golden Meadow, Louisiana. “I was going to spend just as much per month in insurance than I was going to spend in a house note,” she said. “And I couldn’t afford that.”

In August 2021, Hurricane Ida, a Category 4 hurricane with 150 mph winds, made landfall just 20 miles south of Golden Meadow. Almost 16 years to the day after Hurricane Katrina, Ida caused tremendous damage, overwhelming preparations and relief efforts.

For coastal residents like the Houma, every year could bring the next big storm, and with the acceleration of climate change, it is increasingly likely that it will. Hurricane season typically peaks in September and October, according to the National Oceanic and Atmospheric Administration.

“They roll up their sleeves and build, rebuild, and help their neighbors, and start over essentially,” said Billiot. “And they’re deemed resilient for it. However, citizens have talked about, ‘I don’t want to have to be resilient.’”

This article includes reporting from Taylor Cook, Zach Dyer, and Dr. Céline Gounder that first aired in the “Climate Displacement, Cultural Resilience” episode of the “American Diagnosis” podcast.

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Labor Tries City-by-City Push in California for $25 Minimum Wage at Private Medical Facilities

A class of health care facility support staff, including nursing assistants, security guards, and janitors, has worked alongside doctors and nurses throughout the covid-19 pandemic keeping patients and medical buildings safe and clean. It’s an unassuming line of work that some people consider a calling.

Tony Ramirez, 39, a critical care technician at Garfield Medical Center in Monterey Park, California, finds more fulfillment in helping people in need than he once did editing technical documents for Disneyland. Before the pandemic, he would reposition and bathe patients and sometimes monitor their vital signs. After covid struck, he took on more duties, providing CPR or grabbing medications during an emergency, placing leads to monitor heart rhythms, and conducting post-mortem work. “We started doing that,” Ramirez said, “because of the influx of covid patients running very ill and in very intense situations.”

Through it all, his $19.40-an-hour pay hasn’t changed.

In Southern California, one labor union is trying to help by pushing for a $25 minimum wage at private hospitals, psychiatric facilities, and dialysis clinics. The Service Employees International Union-United Healthcare Workers West, which represents roughly 100,000 health care workers in California, says a raise would help the providers retain workers who could land comparable positions at Amazon or fast-food restaurants amid labor shortages. It would also allow Ramirez to give up one of the three jobs he works just to make rent.

What began as a 10-city campaign by the union has been winnowed to November ballot measures in just two cities in Los Angeles County, reflecting expensive political jockeying between labor and industry. And the $25 minimum wage isn’t the only campaign being waged by SEIU-UHW this cycle — the union is also trying for the third time to get dialysis industry reforms passed.

A ballot issue committee called the California Association of Hospitals and Health Systems — with funding from Kaiser Permanente of Northern California, Adventist Health, Cedars-Sinai, Dignity Health, and other hospitals and health systems — opposes a $25 minimum wage because it raises costs for private, but not public, hospitals and health care facilities. Opponents have latched on to this disparity by calling it the “unequal pay measure.” An analysis commissioned by the California Hospital Association estimated that the change would raise costs for private facilities by $392 million a year, a 6.9% increase, across the 10 cities.

“No one in hospitals and no one in health care is opposed to a living wage,” said George Greene, president and CEO of the Hospital Association of Southern California. “But we believe that this should be a statewide conversation that is measured and thoughtful.”

Earlier this year, city councils in Los Angeles, Downey, Monterey Park, and Long Beach adopted similar $25 minimum wage ordinances for health workers, but they were challenged by hospitals and health facilities, which pushed the issue to the ballot in 2024. Meanwhile, the union dropped its effort in Anaheim and failed to gather enough signatures in Culver City, Lynwood, or Baldwin Park to get a minimum wage measure on the fall ballot. As a result, only voters in Inglewood and Duarte will cast their votes — on Measure HC and Measure J, respectively — this November.

Spending on the fight over the minimum wage proposals in Southern California has reached nearly $22 million. According to state campaign finance filings, SEIU-UHW has spent nearly $11 million across all 10 cities. Hospitals and health facilities have also spent almost $11 million to defeat minimum wage proposals.

Unions have long agitated for across-the-board minimum wage increases. In 2016, labor played a key role in successfully lobbying then-Gov. Jerry Brown to make California the first state to set a $15 minimum wage, a graduated measure that as of this year applies to all employers with 26 or more workers. About 40 local governments set their own minimum wages above the state minimum. The federal minimum wage remains $7.25.

SEIU-UHW contemplated a statewide scope, as well as the current piecemeal strategy of targeting cities in and around Los Angeles. “At first we were looking at city by city,” said the union’s political director, Suzanne Jimenez. “And then a conversation around doing it statewide came up but ultimately didn’t move forward.”

That’s partly because a deal to set a statewide minimum wage at public and private hospitals fell apart at the end of the last legislative session, and wins like that are harder to pull off than they once were, said Bill Sokol, a labor lawyer who has worked with SEIU-UHW.

“It’s not about what we wish we could do, but about where can we win,” Sokol said. “The answer is in one city at a time.”

Union leaders said they targeted cities where internal polling showed support among residents. Jimenez said the proposal has majority support in Inglewood but Duarte is too small to sample. The measures need a majority vote in each city to pass, and if that happens, they will take effect 30 days after the results are certified.

Should the approach prove successful in Los Angeles County, the union will consider taking the proposal to other parts of the state, including the Inland Empire and Sacramento, Jimenez said. That could eventually build momentum for statewide change.

If voters in Inglewood and Duarte pass the $25 minimum wage, the effect would be limited. Workers at state- and county-run medical facilities aren’t covered by city ordinances, so the local measures wouldn’t apply. That means it excludes workers who do the same jobs at public hospitals, clinics, and health care facilities.

In Inglewood, the measure would apply only to Centinela Hospital Medical Center and several for-profit dialysis clinics. In Duarte, it would apply to City of Hope, a private cancer hospital.

Many labor economists agree that something must improve for this workforce: They need higher wages and better work conditions. But that comes at a cost to the health system, said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco.

“In the end, who ends up paying for that? Consumers do,” Spetz said. “Maybe you’ll cut into the profit margins of a publicly traded company a little bit, but the reality is those companies have been pretty good at figuring out how to keep their revenues and profitability up.”

Still, the union says a $25 minimum wage would help members of the lowest-paid sector of the health care workforce, who are disproportionately women, immigrants, and people of color.

Andrew Kelly, assistant professor of public health at Cal State East Bay, said raising wages at one facility could have a cascade effect because surrounding facilities would then need to raise wages to compete.

Currently, a living wage in L.A. County for a single adult with no children is $21.89 hourly, or a little more than $45,500 a year, according to a tool from the Massachusetts Institute of Technology. Occupations like “healthcare support” generally pay around $33,000 annually in the county, according to the same tool.

Come Election Day, most Southern California health workers will have to watch from the sideline.

In Monterey Park, where Ramirez works, the city council approved the $25 minimum wage, but opponents got the vote invalidated by arguing that the council lacked a quorum at the time. The council ended up placing the question on the ballot in 2024, two years from now. Ramirez said that new hires at his medical center start at $15.30 an hour doing the dirtiest jobs in the hospital and that five workers have left his department this year.

“It’s disheartening, I’m not going to lie,” Ramirez said. “These elected officials know what’s going on.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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KHN’s ‘What the Health?’: Biden Hits the Road to Sell Democrats’ Record

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As Links to MS Deepen, Researchers Accelerate Efforts to Develop an Epstein-Barr Vaccine

Maybe you’ve never heard of the Epstein-Barr virus. But it knows all about you.

Chances are, it’s living inside you right now. About 95% of American adults are infected sometime in their lives. And once infected, the virus stays with you.

Most viruses, such as influenza, just come and go. A healthy immune system attacks them, kills them, and prevents them from sickening you again. Epstein-Barr and its cousins, including the viruses that cause chickenpox and herpes, can hibernate inside your cells for decades.

This viral family has “evolved with us for millions of years,” said Blossom Damania, a virologist at the University of North Carolina-Chapel Hill. “They know all your body’s secrets.”

Although childhood Epstein-Barr infections are typically mild, exposure in teens and young adults can lead to infectious mononucleosis, a weeks-long illness that sickens 125,000 Americans a year, causing sore throats, swollen glands, and extreme fatigue. And while Epstein-Barr spends most of its time sleeping, it can reawaken during times of stress or when the immune system is off its game. Those reactivations are linked to a long list of serious health conditions, including several types of cancer and autoimmune diseases.

Scientists have spent years trying to develop vaccines against Epstein-Barr, or EBV. But recently several leaps in medical research have provided more urgency to the quest — and more hope for success. In just the past year, two experimental vaccine efforts have made it to human clinical trials.

What’s changed?

First, the Epstein-Barr virus has been shown to present an even greater threat. New research firmly links it to multiple sclerosis, or MS, a potentially disabling chronic disease that afflicts more than 900,000 Americans and 2.8 million people worldwide.

The journal Science in January published results from a landmark 20-year study of 10 million military personnel that offers the strongest evidence yet that Epstein-Barr can trigger MS. The new study found that people infected with Epstein-Barr are 32 times as likely as people not infected to develop MS.

And shedding new light on the mechanisms that could explain that correlation, a separate group of scientists published a study in Nature describing how the virus can cause an autoimmune reaction that leads to MS. The disease, which usually strikes between ages 20 and 40, disrupts communication between the brain and other parts of the body and is often marked by recurring episodes of extreme fatigue, blurred vision, muscle weakness, and difficulty with balance and coordination. At its worst, MS can lead to impaired speech and paralysis.

Amplifying that newfound urgency, several new studies suggest that reactivation of the Epstein-Barr virus also is involved with some cases of long covid, a little-understood condition in which patients experience lingering symptoms that often resemble mononucleosis.

And just as crucial to the momentum: Advances in vaccine science spurred by the pandemic, including the mRNA technology used in some covid vaccines, could accelerate development of other vaccines, including ones against Epstein-Barr, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine. Hotez co-created a low-cost, patent-free covid vaccine called Corbevax.

Some researchers question the need for a vaccine that targets a disease like MS that, while debilitating, remains relatively rare.

Eliminating Epstein-Barr would require vaccinating all healthy children even though their risk of developing cancer or multiple sclerosis is small, said Dr. Ralph Horwitz, a professor at the Lewis Katz School of Medicine at Temple University.

Before exposing children to the potential risks of a new vaccine, he said, scientists need to answer basic questions about MS. For example, why does a virus that affects nearly everyone cause disease in a small fraction? And what roles do stress and other environmental conditions play in that equation?

The answer appears to be that Epstein-Barr is “necessary but not sufficient” to cause disease, said immunologist Bruce Bebo, executive vice president for research at the National MS Society, adding that the virus “may be the first in a string of dominoes.”

Hotez said researchers could continue to probe the mysteries surrounding Epstein-Barr and MS even as the vaccine efforts proceed. Further study is required to understand which populations might benefit most from a vaccine, and once more is known, Hotez said, such a vaccine possibly could be used in patients found to be at highest risk, such as organ transplant recipients, rather than administered universally to all young people.

“Now that we know that Epstein-Barr is very tightly linked to MS, we could save a lot of lives if we develop the vaccine now,” Damania said, “rather than wait 10 years” until every question is answered.

Moderna and the National Institute of Allergy and Infectious Diseases launched separate clinical trials of Epstein-Barr vaccines over the past year. Epstein-Barr vaccines also are in early stages of testing at Opko Health, a Miami-based biotech company; Seattle’s Fred Hutchinson Cancer Center; and California’s City of Hope National Medical Center.

Scientists have sought to develop vaccines against Epstein-Barr for decades only to be thwarted by the complexities of the virus. Epstein-Barr “is a master of evading the immune system,” said Dr. Jessica Durkee-Shock, a clinical immunologist and principal investigator for NIAID’s trial.

Both MS and the cancers linked to Epstein-Barr develop many years after people are infected. So a trial designed to learn whether a vaccine can prevent these diseases would take decades and a lot of money.

Moderna researchers initially are focusing on a goal more easily measured: the prevention of mononucleosis, which doubles the risk of multiple sclerosis. Mono develops only a month or so after people are infected with Epstein-Barr, so scientists won’t have to wait as long for results.

Mono can be incredibly disruptive on its own, keeping students out of class and military recruits out of training for weeks. In about 10% of cases, the crippling fatigue lasts six months or more. In 1% of cases, patients develop complications, including hepatitis and neurological problems.

For now, the clinical trials for Epstein-Barr immunizations are enrolling only adults. “In the future, the perfect vaccine would be given to a small child,” Durkee-Shock said. “And it would protect them their whole life, and prevent them from getting mono or any other complication from the Epstein-Barr virus.”

The NIAID vaccine, being tested for safety in 40 volunteers, is built around ferritin, an iron-storage protein that can be manipulated to display a key viral protein to the immune system. Like a cartoon Transformer, the ferritin nanoparticle self-assembles into what looks like a “little iron soccer ball,” Durkee-Shock said. “This approach, in which many copies of the EBV protein are displayed on a single particle, has proved successful for other vaccines, including the HPV and hepatitis B vaccine.”

Moderna’s experimental vaccine, being tested in about 270 people, works more like the company’s covid shot. Both deliver snippets of a virus’s genetic information in molecules called mRNA inside a lipid nanoparticle, or tiny bubble of fat. Moderna, which has dozens of mRNA vaccines in development, hopes to learn from each and apply those lessons to Epstein-Barr, said Sumana Chandramouli, senior director and research program leader for infectious diseases at Moderna.

“What the covid vaccine has shown us is that the mRNA technology is well tolerated, very safe, and highly efficacious,” Chandramouli said.

But mRNA vaccines have limitations.

Although they have saved millions of lives during the covid pandemic, the antibody levels generated in response to the mRNA vaccines wane after a few months. It’s possible this rapid loss of antibodies is related specifically to the coronavirus and its rapidly evolving new strains, Hotez said. But if waning immunity is inherent in the mRNA technology, that could seriously limit future vaccines.

Designing vaccines against Epstein-Barr is also more complicated than for covid. The Epstein-Barr virus and other herpesviruses are comparatively huge, four to five times as large as SARS-CoV-2, the coronavirus that causes covid. And while the coronavirus uses just one protein to infect human cells, the Epstein-Barr virus uses many, four of which are included in the Moderna vaccine.

Earlier experimental Epstein-Barr vaccines targeting one viral protein lowered the rate of infectious mononucleosis but failed to prevent viral infection. Targeting multiple viral proteins may be more effective at preventing infection, said Damania, the UNC virologist.

“If you close one door, the other door is still open,” Damania said. “You have to block infection in all cell types to have a successful vaccine that prevents future infections.”

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Centene Gave Thousands to Georgia Leaders’ Campaigns While Facing Medicaid Overbilling Questions

A health insurance giant that has paid out more than $485 million in legal settlements with states over pharmacy billing allegations has also been a major donor to Georgia’s Republican Gov. Brian Kemp and Attorney General Chris Carr, according to campaign finance records.

St. Louis-based Centene Corp. said Monday in a statement that it’s working to settle Medicaid billing issues with Georgia and eight other states, beyond the 13 states it has already agreed to pay. In the public agreements so far, state attorney general offices have been involved in setting the agreements’ terms and have announced the settlement amounts.

According to Carr’s campaign filings, Centene-related donations included spending around an event for him in late August. Carr’s campaign did not respond to requests for comment on the donations. Kemp’s campaign declined to comment.

Centene is the parent company of Peach State Health Plan, which delivers managed-care services to about 1 million low-income Georgians enrolled in Medicaid and PeachCare for Kids. It is one of three companies that typically receive more than $4 billion, combined, from the state annually to run the public health insurance programs.

Centene has settled with 13 states over allegations the conglomerate overbilled state Medicaid programs for prescription drug services. It has paid a total of at least $489 million to 10 states, with the other three not yet publicly announced, KHN has reported.

A spokesperson for Carr’s office said Friday that it was waiting for direction from the state Department of Community Health, or DCH, Georgia’s Medicaid agency, before the state pursues a settlement with Centene. “The state is aware of other settlements in other states involving Centene, and the Law Department understands that DCH is conducting a review of its relevant information,” Kara Richardson said. “Once DCH comes to a decision, the Law Department stands ready to provide legal representation in any potential settlement negotiation or litigation.”

A spokesperson for the Community Health Department, David Graves, told The Atlanta Journal-Constitution on Monday that the agency “can confirm that we will be thoughtful and intentional with our approach in a way that ensures the taxpayers of Georgia are best protected.” The governor’s office did not respond directly to questions about possible settlement negotiations.

Centene is the national leader in Medicaid managed care, with more than 15 million members. The company earns about two-thirds of its revenue from Medicaid, which is jointly funded by state and federal taxpayers.

In many states, insurance companies such as Centene also administer Medicaid enrollees’ prescription medications through what is called a pharmacy benefit manager. These benefit managers act as middlemen between drugmakers and health insurers and as intermediaries between health plans and pharmacies. In some cases, Centene acted as both the Medicaid managed-care provider and the pharmacy benefit manager for those plans.

The company, in a statement on Monday, said that it donates to candidates of both parties and is generally supportive of incumbents: “As a member of the healthcare community, we work with elected representatives to help improve quality of care and access to services for the communities we serve.”

Kemp’s reelection campaign has received more than $100,000 in contributions from Centene, its subsidiaries, and its employees since 2018, according to state campaign records, with heavy giving after the first publicly announced settlements, with Ohio and Mississippi in 2021.

Most of the more than $70,000 in Centene-related giving to Carr’s campaign this year came from company executives, including $10,000 from CEO Sarah London. Carr’s campaign also got $6,000 from Centene general counsel Chris Koster, a former Missouri attorney general who has signed pharmacy billing settlements on behalf of the company.

Much of the Centene-related donations to Carr’s campaign occurred in late August, according to the campaign records. They include $3,097 for a venue rental Aug. 26 and catering costs of $3,000 on Aug. 24. The latter was paid by Kelly Layton, wife of Centene President Brent Layton, a former staffer at the Georgia insurance department. Five out-of-state Centene employees donated a total of $13,000 during that three-day period.

In previously announced settlements, Centene has not admitted any wrongdoing. Centene set aside $1.25 billion in 2021 to resolve the pharmacy benefit manager settlements in “affected states,” according to a July filing with the U.S. Securities and Exchange Commission that did not specify how many states were involved.

In January, Wade Rakes, president and CEO of Centene subsidiary Peach State Health Plan, alerted Community Health officials that the company, after an analysis of its pharmacy cost reporting, “may have a remittance obligation” to the state Medicaid program, according to an email obtained by KHN through a public records request.

William Perry, founder of Georgia Ethics Watchdogs, pointed out that nothing in state law bars Kemp or Carr from accepting donations from companies like Centene that do business with the state. “They’ll sit there and say they’ve done nothing unethical under the law, but if you come from an ethically moral position, it’s horrible,” he said. “It’s bad optics, and it just really makes me sick.”

The campaign of Carr’s Democratic opponent in the November election, Jen Jordan, criticized the attorney general for accepting the Centene contributions to his campaign. A Centene subsidiary donated $1,500 to Jordan in 2019, when she was running for reelection to the Georgia Senate, but the conglomerate doesn’t appear to have given to her campaign this cycle.

“This is yet another example of how Chris Carr prioritizes special interests over the people of Georgia, and the culture of corruption that characterizes the current office of the attorney general,” said Caroline Korba, a spokesperson for Jordan. “Our attorney general should not be bought and sold.”

A Centene subsidiary gave a total of $6,600 to Stacey Abrams, the Democrat running against Kemp, in three separate donations since 2015, the last coming in October 2018, during Abrams’ previous campaign for governor.

Maya T. Prabhu is a state government reporter for The Atlanta Journal-Constitution.

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