Goodlow, a member of the Lower Brule Sioux Tribe, said she’s lost six friends and acquaintances to suicide, two to car crashes, and one to appendicitis. Four of her relatives died in their 30s or 40s, from causes such as liver failure and covid-19, she said. And she recently lost a 1-year-old nephew.

“Most Native American kids and young people lose their friends at a young age,” said Goodlow, who is considering becoming a mental health therapist to help her community. “So, I’d say we’re basically used to it, but it hurts worse every time we lose someone.”

Native Americans tend to die much earlier than white Americans. Their median age at death was 14 years younger, according to an analysis of 2018-21 data from the Centers for Disease Control and Prevention

The disparity is even greater in Goodlow’s home state. Indigenous South Dakotans who died between 2017 and 2021 had a median age of 58 — 22 years younger than white South Dakotans,

Donald Warne, a physician who is co-director of the Johns Hopkins Center for Indigenous Health and a member of the Oglala Sioux Tribe, can rattle off the most common medical conditions and accidents killing Native Americans.

But what’s ultimately behind this low life expectancy, agree Warne and many other experts on Indigenous health, are social and economic forces. They argue that in addition to bolstering medical care and fully funding the Indian Health Service — which provides health care to Native Americans — there needs to be a greater investment in case management, parenting classes, and home visits.

“It’s almost blasphemy for a physician to say,” but “the answer to addressing these things is not hiring more doctors and nurses,” Warne said. “The answer is having more community-based preventions.”

The Indian Health Service funds of these programs, including initiatives, and efforts to increase access to fresh produce and traditional foods.

and state Medicaid programs, including South Dakota’s, are such services. But insurers don’t pay for all the services and aren’t reaching everyone who qualifies, according to Warne and the .

Warne pointed to , a program developed by the Johns Hopkins center to improve health outcomes for Indigenous mothers and children.

Chelsea Randall, the director of maternal and child health at the Great Plains Tribal Leaders’ Health Board, said community health workers educate Native pregnant women and connect them with resources during home visits.

“We can be with them throughout their pregnancy and be supportive and be the advocate for them,” said Randall, whose organization runs Family Spirit programs across seven reservations in the Dakotas, and in Rapid City, South Dakota.

The community health workers help families until children turn 3, teaching parenting skills, family planning, drug abuse prevention, and stress management. They can also integrate the tribe’s culture by, for example, using their language or birthing traditions.

The health board funds Family Spirit through a grant from the federal Health Resources and Services Administration, Randall said. Community health workers, she said, use some of that money to provide child car seats and to teach parents how to properly install them to counter high rates of fatal crashes.

Other causes of early Native American deaths include homicide, drug overdoses, and chronic diseases, such as diabetes, Warne said. Native Americans also suffer a disproportionate number of infant and maternal deaths.

The crisis is evident in the obituaries from the Sioux Funeral Home, which mostly serves Lakota people from the Pine Ridge Reservation and surrounding area. The funeral home’s posts obituaries for older adults, but also for many infants, toddlers, teenagers, young adults, and middle-aged residents.

Misty Merrival, who works at the funeral home, blames poor living conditions. Some community members struggle to find healthy food or afford heat in the winter, she said. They may live in homes with broken windows or that are crowded with extended family members. Some neighborhoods are strewn with trash, including intravenous needles and broken bottles.

Seeing all these premature deaths has inspired Merrival to keep herself and her teenage daughter healthy by abstaining from drugs and driving safely. They also talk every day about how they’re feeling, as a suicide-prevention strategy.

“We’ve made a promise to each other that we wouldn’t leave each other like that,” Merrival said.

live in small towns or on poor, rural reservations. But rurality alone doesn’t explain the gap in life expectancy. For example, white people in rural Montana live 17 years longer, on average, than Native Americans in the state, reported by Lee Enterprises newspapers.

Many Indigenous people also face racism or personal trauma from child or sexual abuse and exposure to drugs or violence, Warne said. Some also deal with generational trauma from that broke up families and tried to suppress Native American culture.

Even when programs are available, they’re not always accessible.

Families without strong internet connections can’t easily make video appointments. Some lack cars or gas money to travel to clinics, and public transportation options are limited.

Randall, the health board official, is pregnant and facing her own transportation struggles.

It’s a three-hour round trip between her home in the town of Pine Ridge and her prenatal appointments in Rapid City. Randall has had to cancel several appointments when family members couldn’t lend their cars.

Goodlow, the 20-year-old who has lost several loved ones, lives with seven other people in her mother’s two-bedroom house along a gravel road. Their tiny community on the Pine Ridge Reservation has homes and ranches but no stores.

Goodlow attended several suicide-prevention presentations in high school. But the programs haven’t stopped the deaths. One friend recently killed herself after enduring the losses of her son, mother, best friend, and a niece and nephew.

A month later, another friend died from a burst appendix at age 17, Goodlow said. The next day, Goodlow woke up to find one of her grandmother’s parakeets had died. That afternoon, she watched one of her dogs die after having seizures.

“I thought it was like some sign,” Goodlow said. “I started crying and then I started thinking, ‘Why is this happening to me?’”

Warne said the overall conditions on some reservations can create despair. But those same reservations, including Pine Ridge, also contain flourishing art scenes and language and cultural revitalization programs. And

Warne said federal, state, and tribal governments need to work together to improve life expectancy. He encourages tribes to negotiate contracts allowing them to manage their own health care facilities with federal dollars because that can open funding streams not available to the Indian Health Service.

Katrina Fuller is the health director at Siċaŋġu Co, a nonprofit group on the Rosebud Reservation in South Dakota. Fuller, a member of the Rosebud Sioux Tribe, said the organization works toward “wicozani,” or the good way of life, which encompasses the physical, emotional, cultural, and financial health of the community.

Siċaŋġu Co programs include bison restoration, youth development, a Lakota language immersion school, financial education, and food sovereignty initiatives.

“Some people out here that are struggling, they have dreams, too. They just need the resources, the training, even the moral support,” Fuller said. “I had one person in our health coaching class tell me they just really needed someone to believe in them, that they could do it.”

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Abortion remains legal in the conservative stronghold because of a 25-year-old that protected it under the right to privacy included in the state’s constitution.

So far, most efforts by Montana’s Republican governor and GOP-led legislature to overcome that obstacle have gone nowhere. Montana courts have blocked multiple laws that would have restricted abortion.

It’s “a very daunting hurdle for those who would seek to undermine abortion access,” said Kal Munis, an assistant professor of political science at Utah Valley University and expert on politics in Montana, his home state.

Munis said to outlaw abortion, voters would need to amend the state constitution or elect Supreme Court justices willing to reverse precedent.

But it is abortion rights advocates who have jumped on the chance to amend the state constitution. A legal fight is brewing over proposed for the November election that would add abortion protections to the constitution.

Meanwhile, two open state Supreme Court seats are up for election, and some of the candidates are signaling that abortion access will be a campaign issue.

Voters have to be thinking about the future of abortion from “multiple fronts,” said Martha Fuller, CEO of Planned Parenthood Advocates of Montana, which is suing to block several anti-abortion laws, backing the proposed constitutional amendment, and monitoring the Supreme Court races.

Montana anti-abortion advocates celebrated when Republican Gov. Greg Gianforte was elected in 2020 after 16 years of Democratic governors and, since 2011, vetoes of anti-abortion laws passed by the Republican-controlled legislature.

From their opponents’ perspective, that change left the courts as the last line of defense of abortion rights, one they are focused on protecting.

Munis and Jessi Bennion, who teaches political science at Montana State University, said abortion rights groups in Montana have momentum after the U.S. Supreme Court’s 2022 reversal of Roe v. Wade.

That decision resulted in by the issue and a . Montanans, for example, rejected a measure that would have required doctors to provide medical care after premature births and failed abortions, which opponents said was already the law.

For now, Montanans may have abortions any time before fetal viability, which under Montana code is “presumed” to be about 24 weeks into a pregnancy. Patients can go to one of six providers in the state or make a telehealth appointment and receive pills in the mail.

That makes Montana the most abortion-friendly state in the largely between Minnesota and the Pacific Northwest.

Montana is sandwiched between Idaho and the Dakotas, which severely restrict abortion. To the south is Wyoming, where abortion pills are available through telehealth, but lawmakers there have passed a bill that the only clinic in the state that provides in-person abortions, depending on what action Republican Gov. Mark Gordon takes. Abortion is legal in Canada, Montana’s northern neighbor, but Americans need a passport to travel there.

An attempt to further cement abortion rights in Montana is facing an obstacle. Republican Attorney General Austin Knudsen the proposed abortion rights constitutional amendment as being legally insufficient, which prompted the campaign behind the initiative . The State Supreme Court will now decide if initiative organizers may proceed with gathering signatures.

Analysts and Montana leaders — including some Republicans — think there’s a good chance voters will approve the constitutional amendment if it appears on the ballot.

“We’re a Republican state, but there’s always historically been a kind of a libertarian streak in it,” said Steve Fitzpatrick, an attorney and the majority leader in the Montana Senate. “It’s not unusual to see Republicans winning up and down the ballot and then seeing something like marijuana be legalized at the same time.”

Abortion will also be an undercurrent in two state Supreme Court races. Chief Justice Mike McGrath and Justice Dirk Sandefur, who both ruled against efforts to unravel the state’s abortion protections, decided not to seek reelection.

Judges don’t run as Democrats or Republicans, but Supreme Court elections have in recent years.

Given the recent election wins by abortion rights advocates after Roe v. Wade was overturned, conservatives may choose not to make abortion a campaign issue for these judicial races, according to Munis.

Focusing on abortion “would be a strategic blunder given that they have so many other things that they could talk about instead,” he said.

But the candidates who are viewed as more liberal have strongly signaled their desire to protect abortion rights.

State judges Katherine Bidegaray and Dan Wilson are running for Sandefur’s seat on the high court.

During a campaign event, Bidegaray said she would defend Montanans’ constitutional right to privacy and stand up to “unprecedented attacks” on women’s rights, .

Wilson and his campaign did not respond to phone and email messages from Ģ��ӰԺ Health News.

In the race for chief justice, former federal magistrate judge Jerry Lynch, who is running against Cory Swanson, a county prosecutor backed by Republicans, has been more direct than Bidegaray.

Montanans must be “free from government interference, especially when it comes to reproductive rights,” Lynch , according to the Montana Free Press.

Lynch’s candidacy has triggered some early opposition spending. Montanans for Fair Judiciary, a conservative group, sent mailers calling Lynch a “liberal trial lawyer,” the outlet reported.

Swanson told Ģ��ӰԺ Health News that judges shouldn’t decide how they would rule on abortion or any other topic until a case is before the court.

Fuller said Planned Parenthood Advocates of Montana has not yet decided how it will get involved in the Supreme Court races but that it likely will.

“If people are not paying attention to who is making these decisions and who is winning these judicial races, we could lose that ability to have that backstop,” she said.

Regardless of whom voters choose to seat on the court, any change in this election is unlikely to immediately swing a majority of the seven-member court to overturn the 1999 ruling protecting abortion access, according to Bennion.

In Iowa, conservatives were a state Supreme Court precedent similar to Montana’s after more Republican-appointed justices joined the bench.

In Montana, the abortion issue is playing out more quickly in the state’s lower courts.

In February, a state court that would have restricted abortion, including a ban on the procedure after 20 weeks of pregnancy. Last year, another state judge several anti-abortion measures including a ban on the most common abortion procedure used in the second trimester of pregnancy.

Frustrated by the courts, Republican officials have also used the executive branch to try to restrict abortions. The Gianforte administration implemented a rule to reduce Medicaid-funded abortions by defining when an abortion is medically necessary, limiting who can perform them, and requiring preauthorization for most cases.

But that rule and a new state law that mirrors it have also been temporarily blocked by a judge. Knudsen has appealed those injunctions, as well as the judge’s ruling from February, to the Montana Supreme Court.

And this month, the high court as the state attempts to overturn a judicial block of a 2013 law requiring parental consent before a minor may have an abortion.

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It’s an example of how states are responding to the national controversy over what exceptions to abortion bans actually mean. Critics point to reports of women developing dangerous complications after hospitals in states with strict abortion laws refused to terminate their pregnancies.

South Dakota legislators are moving a bill that would direct the state Department of Health to work with the attorney general and health and legal experts to create educational material, including a video, and publish it on its website.

The legislation is the first of its kind in the country, according to Susan B. Anthony Pro-Life America, an anti-abortion group.

the video would explain how South Dakota law defines abortion. Republican Rep. Taylor Rehfeldt, who introduced the bill, said treatments for miscarriages or an ectopic pregnancy —when a fertilized egg implants outside the uterus — do not count as abortions, and therefore are allowed.

The video would also discuss conditions that can threaten the life or health of a pregnant woman, and the criteria that providers might use to decide the best course of treatment. Rehfeldt said she expects the video to address when these medical conditions may need to be treated with an abortion, including how sick a patient needs to become.

Rehfeldt, a nurse anesthetist with a personal history of high-risk pregnancies, said she introduced the bill after hearing from health care providers who want guidance about the state’s abortion law.

“They said that they were confused and not sure when they can intervene,” Rehfeldt said. “I think it’s important that we provide that clarification because we all want moms to be taken care of.”

South Dakota has one of the nation’s strictest laws, unless they’re needed to save the life of a woman. There are no exceptions for preventing serious injury to the mother or in cases of fatal fetal anomalies, rape, or incest. Providing an illegal abortion is a felony that can be punished with two years in prison.

The state also has high rates of and mortality, . Some South Dakota women have already been harmed because of the law after they were denied or received delayed abortions, according to Amy Kelley, an obstetrician and gynecologist in Sioux Falls.

Rehfeldt is confident her bill will pass the Republican-controlled legislature because the proposal has support from the governor’s office, health department, one of the state’s largest hospital systems, and state and national anti-abortion groups.

Anti-abortion advocates support the bill even though some groups, such as the Charlotte Lozier Institute, say exceptions to abortion bans are already clear. state laws use language such as “reasonable medical judgment,” terms that hospitals should understand since such standards are often used in malpractice cases.

“Abortion activists have spread the dangerous lie that pregnant women in states with pro-life laws cannot receive emergency care,” Kelsey Pritchard, a South Dakota-based official with Susan B. Anthony Pro-Life America — which is affiliated with the Lozier Institute — said in a news release. “This patently false allegation that is used to justify the abortion industry’s agenda for no limits on abortion is putting women’s lives in danger.”

But abortion rights advocates say many doctors are afraid to provide critical care because of vaguely worded exceptions to abortion bans. Many say the only way to protect providers and their patients’ health is to repeal bans.

Nisha Verma is an OB-GYN in Georgia, where abortion is generally banned once fetal cardiac activity can be detected, typically around six weeks. Verma, who has provided abortions, is also a spokesperson for the American College of Obstetricians and Gynecologists.

“I understand the desire to grasp for anything that helps us provide care for our patients,” Verma said. But “there’s no way that you can create a video that talks about any type of inclusive list of conditions where you can and can’t provide care.”

Several other states have tried to clarify exceptions to their bans, but the South Dakota bill is the most comprehensive, Pritchard said.

In Oklahoma, the attorney general’s office sent on the subject to prosecutors and police. It said doctors should have “substantial leeway” to provide lifesaving abortions, and don’t need to wait until a patient is “septic, bleeding profusely, or otherwise close to death.” The memo also says doctors should be prosecuted only if there’s evidence of criminal intent or a pattern of similar behavior.

Kentucky’s attorney general on the topic; Louisiana’s health department listing “medically futile” fetal conditions that can legally justify an abortion. Texas lawmakers for doctors who end ectopic pregnancies or pregnancies of patients whose water breaks too early for the fetus to survive. The legislation does not use the word “abortion,” and as they were passing it.

Texas’ Supreme Court, lawmakers, and several pro- and anti-abortion rights advocates the state’s medical board for more guidance. The board as to whether it will do so, according to the health care publication Stat.

Abortion rights supporters are divided about the value of supplying guidance on exceptions to the abortion law.

“I wish we weren’t having this conversation,” said South Dakota Rep. Oren Lesmeister, a Democrat. “I wish we wouldn’t have had the trigger law” that banned most abortions.

But given that the law does exist, Lesmeister decided to co-sponsor and vote for the bill in hopes it will help doctors and their patients.

Critics of the legislation include the ACLU of South Dakota, the regional Planned Parenthood organization, and the Justice through Empowerment Network, a South Dakota abortion fund.

Verma and Kelley, the obstetricians, said laws, videos, and other guidance can’t capture the complexity of when an abortion may be necessary.

For example, conditions that aren’t fatal on their own can become deadly when combined with other complications, they said. Then there’s the question of when situations become life-threatening, which can happen quickly in obstetrics.

“There’s not a line in the sand where someone goes from being totally fine to acutely dying,” Verma said.

Verma and Kelley said doctors use their own expertise but also take their patients’ views into account when responding to life-threatening situations. That’s because one patient who learns they have a 25% risk of dying might decide against continuing their pregnancy, while another might view it as a risk worth taking, they said.

Some patients are willing to die if it means their baby will live, Kelley said, and “we honor their choice even if we don’t always think that that’s the right choice.”

Rehfeldt said she understands the concerns outlined by Verma and Kelley. But she said her bill would give doctors and hospital attorneys confidence to distinguish between legal and illegal procedures.

“If you have an interpretation that’s coming from collaboration with the attorney general, as well as the pertinent medical professionals, as well as the current governor’s office, I don’t see how you would be worried about being charged with a crime,” Rehfeldt said.

Kelley said it’s difficult to feel assured by any abortion-related guidance from South Dakota government officials when it feels as if they don’t trust doctors. For example, she said, lawmakers to share information with patients that can be opinionated and misleading.

“So, it’s really hard for them to then say, ‘Oh, but trust us, you won’t get in trouble with this law, we’ll go with your judgment,’” Kelley said.

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These sparsely populated communities can have trouble sustaining ambulance services, if small patient volumes and low reimbursements rates don’t cover operating costs.

They also struggle with staffing. Most medics across the country are paid, but are based in rural areas. However, their ranks are aging, and the younger generation isn’t showing enough interest in volunteering.  

Why do ambulance deserts matter? Even though rural Americans, they have. They have a higher risk of dying from certain diseases, like strokes and cancer, and are more than twice as likely to suffer accidental deaths, such as fatal car crashes and opioid overdoses.

And they’re way more likely to get gored by bison.

“What does Chuck Norris say? ‘Always expect the unexpected.’ Well, I didn’t do that. I didn’t expect the unexpected,” South Dakota rancher Jim Lutter told me.��

Bill, a 3-year-old bison Lutter had always considered docile, attacked him last December, inflicting a 4-inch-deep puncture wound, a fractured collar bone, 16 broken ribs and a partially torn off scalp. Lutter benefited from a technology showing up in a smattering of ambulance services nationwide: video telehealth.

Ed Konechne, a volunteer medic, treated Lutter with the help of Katie DeJong, an emergency medicine physician who watched and spoke with Konechne and Lutter inside the ambulance from 140 miles away in a Sioux Falls office building.��

“I firmly believe that Jim had the best care anyone has ever received in the back of a basic life-support ambulance,” the medic told me.  

The video technology, Konechne said, lets him focus 100 percent of his time on his patients.��

Just as rural Americans can live far from ambulance bases, they can also face long drives to the nearest hospital, which are .��

So during Lutter’s ambulance ride, DeJong made sure the rancher would get help as soon as possible by arranging a helicopter transport and telling the receiving hospital how to prepare.  

The technology doesn’t directly address the financial and staffing strains that lead to ambulance deserts. But by improving treatment, speeding up care and handling logistics, the remote provider may help rural medics reach their next patient more quickly.  

DeJong thinks the technology could also help with recruitment: people in rural areas might be more interested in volunteering as emergency medical technicians if they know they’ll have remote backup.

Ambulance-based telehealth programs recently launched in parts of ���Ի� , but South Dakota officials say appears to be the nation’s only statewide effort. It’s funded with $2.7 million in state and federal pandemic relief money, state officials said.

But when funding dries up, ambulance services that want to continue using the technology will need to foot the bill. An official with South Dakota’s contractor, Avel eCare, says there is “not a standard cost” for its service.

Another to address ambulance deserts is to declare EMS an “essential service,” like police and fire departments, so states or municipalities have to fund them. include creating new reimbursement models and for the federal government to offer grants to designated ambulance deserts.

Lutter was fortunate. And bison gorings, thankfully, are uncommon. But more deaths in rural America could be prevented if ambulances and emergency departments were more accessible.

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GANN VALLEY, S.D. — Rural medics who rescued rancher Jim Lutter after he was gored by a bison didn’t have much experience handling such severe wounds.

But the medics did have a doctor looking over their shoulders inside the ambulance as they rushed Lutter to a hospital.

The emergency medicine physician sat 140 miles away in a Sioux Falls, South Dakota, office building. She participated in the treatment via a video system recently installed in the ambulance.

“I firmly believe that Jim had the best care anyone has ever received in the back of a basic life support ambulance,” said Ed Konechne, a volunteer emergency medical technician with the Kimball Ambulance District.

The ambulance service received its video system through an initiative from the South Dakota Department of Health. The project, , helps medics across the state, especially in rural areas.

Telehealth became commonplace in clinics and patients’ homes during the covid-19 pandemic emergency, and the technology is starting to spread to ambulances. Similar programs recently launched in regions of and , but South Dakota officials say their partnership with Avel eCare — a Sioux Falls-based telehealth company — appears to be the nation’s only statewide effort.

Lutter, 67, and his wife, Cindy, are among the 12 residents of Gann Valley, a town just east of the Missouri River in central South Dakota. They operate a hunting lodge and ranch, where they raise more than 1,000 bison.

Last December, Lutter went to check on a sick bison calf. The animal was in the same pen as Bill, a 3-year-old bull that was like a family pet.

“We raised him from a tiny little calf, and I always told everybody he thinks I’m his mother. He just followed me everywhere,” Lutter recalled. Lutter climbed into the pen and saw Bill calmly walk toward him.

“What does Chuck Norris say? ‘Always expect the unexpected.’ Well, I didn’t do that. I didn’t expect the unexpected,” he said.

The bison suddenly hooked Lutter with his horns, repeatedly tossed him in the air, and then gored him in the groin. Lutter thought he was going to die but somehow escaped the pen and found himself on the ground, bleeding heavily.

“The red snow was just growing,” he said.

Lutter couldn’t reach his cellphone to call 911. But he managed to climb into a front-end loader, similar to a tractor, and drove a few miles to the house of his brother Lloyd.

Jim Lutter’s pain didn’t kick in until his brother pulled him out of the loader and into a minivan. Lloyd called 911 and began driving toward the ambulance base, about 18 miles away.

Rural ambulance services like the one in Kimball are difficult to sustain because insurance reimbursements from small patient volumes often aren’t enough to cover operating costs. And they’re largely staffed by dwindling ranks of aging volunteers.

That’s left 84% of rural counties in the U.S. with at least one “ambulance desert,” where people live more than 25 minutes from an ambulance station, by the Maine Rural Health Research Center.

Konechne, the volunteer medic, was working his regular job as a hardware store manager when a dispatcher came onto his portable radio with a call for help. He hustled two blocks to the Kimball fire station and hopped into the back of an ambulance, which another medic drove toward Gann Valley.

Lloyd Lutter and the ambulance driver both pulled over on the side of the country road once they saw each other coming from opposite directions.

“I opened the side door of the van where Jim was and just saw the look on his face,” Konechne said. “It’s a look I’ll never forget.”

Rural medics often have less training and experience than their urban counterparts, Konechne said. Speaking with a more experienced provider via video gives him peace of mind, especially in uncommon situations. Konechne said the Kimball ambulance service sees only about three patients a year with injuries as bad as Jim Lutter’s.

Katie DeJong was the emergency medicine physician at Avel eCare’s telehealth center who took the ambulance crew’s video call.

“What? A bison did what?” DeJong remembers thinking.

After speaking with the medics and viewing Lutter’s injuries, she realized the rancher had life-threatening injuries, especially to his airway. One of Lutter’s lungs had collapsed and his chest cavity was filled with air and blood.

DeJong called the emergency department at the hospital in Wessington Springs — 25 miles from Gann Valley — to let its staff know how to prepare. Get ready to insert a chest tube to clear the area around his lungs, she instructed. Get the X-ray machine ready. And have blood on standby in case Lutter needed a transfusion.

DeJong also arranged for a helicopter to fly Lutter from the rural hospital to a Sioux Falls medical center, where trauma specialists could treat his wounds.

Konechne said he was able to devote 100% of his time to Lutter since DeJong took care of taking notes, recording vital signs, and communicating with the hospitals.

Nurse practitioner Sara Cashman was working at the emergency department in Wessington Springs when she received the video call from DeJong.

“It was nice to have that warning so we could all mentally prepare,” Cashman said. “We could have the supplies that we needed ready, versus having to assess when the patient got there.”

A doctor inserted a tube into Lutter’s chest to drain the blood and air around his lungs. Medics then loaded him into the helicopter, which flew him to the Sioux Falls hospital where he was rushed into surgery. Lutter had a fractured collarbone, 16 broken ribs, a partially torn-off scalp, and a 4-inch-deep hole near his groin.

The rancher stayed in the hospital for about a week and compared his painful wound-packing regimen near his groin to the process of loading an old-fashioned rifle.

“That’s exactly what it was. Like packing a muzzleloader and you take a rod, let’s poke that in there,” Lutter said. “That was just a lot of fun.”

The video technology that helped save Lutter had only recently been installed in the ambulance after Telemedicine in Motion launched in fall 2022. The program is financed with $2.7 million from state funds and federal pandemic stimulus money.

The funding pays for Avel eCare employees to provide and install video equipment and teach medics how to use it. The company also employs remote health care professionals who are available 24/7.

So far, 75 of South Dakota’s 122 ambulance services have installed the technology, and an additional 18 plan to do so. The system has been used about 700 times so far.

Avel’s contract ends in April, but the company hopes the state will extend Telemedicine in Motion into a third year. Once the state funding ends, ambulance services will need to decide if they want to start paying for the video service on their own. Patients wouldn’t be charged extra for the video calls, said Jessica Gaikowski, a spokesperson for Avel eCare.

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Gatewood is now set to be part of the first graduating class at Oklahoma State University’s College of Osteopathic Medicine at the Cherokee Nation. Leaders say the physician training program is the only one on a Native American reservation and affiliated with a tribal government.

“This is the school that is everything that I need to be successful,” said Gatewood, a member of the Choctaw Nation who also has Cherokee and Chickasaw ancestry. “Literally, the campus, the curriculum, the staff — everything was built and hired and prepared and planned for you.”

The program in Tahlequah, the capital of the Cherokee Nation, aims to increase the number of Cherokee and other Indigenous physicians. It’s also focused on expanding the number of doctors from all backgrounds who serve rural or tribal communities.

Natasha Bray, an osteopathic physician and dean of the program, said most medical schools teach about barriers that can make it difficult for rural or Indigenous patients to get care and improve their health.

But she said students in Tahlequah get to see these barriers firsthand by studying on the Cherokee Reservation and doing rotations in tiny communities and within facilities run by the federal Indian Health Service.

“Unless you are living in that community, you’re part of that community, you’re seeing patients from that community — you can’t begin to understand what those barriers to care are,” said Bray, who is not Native American.

For example, Bray knows that one town on the reservation is a 50-minute drive to the nearest delivery room, and that some patients trying to eat healthier live far from supermarkets and settle for convenience store food.

Rural America of health care providers. The Indian Health Service, which serves Indigenous patients in mostly rural areas, has also .

Rural residents make up about 14% of the U.S. population but fewer than 5% of incoming medical students, of 2017 data. Native Americans are 3% of the population but represented only 0.2% of those accepted to medical school for the 2018-19 school year, .

Gatewood, 34, who grew up in a city between the Chickasaw Reservation and Oklahoma City, first attended medical school at the University of Missouri. She said it was a great program, but it didn’t match her learning style. And with few Native American students, it left her feeling disconnected from her culture.

She ended up leaving after three semesters. Gatewood went on to become a nurse and earned a master’s degree in public health.

Then, in 2019, six years after dropping out of the Missouri medical school, Gatewood learned about Oklahoma State’s new campus in Tahlequah. She decided to once more pursue her dream of becoming a doctor. After taking classes in Oklahoma, she’s now getting hands-on experience through a family medicine rotation in Baltimore.

Half the 202 medical students in Tahlequah are from rural areas, and nearly a quarter are Native American. Most of the Indigenous students are from Oklahoma tribes. Others come from tribes outside the state, including from Alaska and New Mexico.

Tahlequah has about 16,800 residents. It’s more than an hour east of Tulsa, home to Oklahoma State’s other osteopathic medicine campus.

Osteopathic physicians, or DOs, attend separate medical schools from allopathic doctors, or MDs. The schools have similar curricula, but osteopathic colleges also teach how to ease patient discomfort through physical manipulation of muscles and bones. Osteopathic schools graduate more students who decide to work in primary care and in rural areas.

The Cherokee Reservation spreads across roughly 7,000 square miles in eastern Oklahoma. It’s home to about 150,000 Cherokee citizens, most of whom live in rural areas, said Principal Chief Chuck Hoskin Jr. Hoskin grew up in a small town that was once served by a doctor who traveled across the reservation, treating patients in a recreational vehicle.

The Cherokee Nation now operates 10 hospitals and clinics to ensure that all citizens live within a 30-minute drive of care. Hoskin said this means the reservation has better access to health care than much of rural America.

“There are not many communities in this country in which you would see that sort of investment,” he said.

Still, access to care remains challenging for some rural residents on the reservation, Bray said. The reservation has significant poverty, and some people lack cars or cell or internet service. Cherokee residents have high rates of diabetes, obesity, addiction, and heart disease, Bray said.

The Cherokee Nation spent $40 million of its own revenue — including from casinos and federal contracts — to construct the college building on its medical campus, which includes a hospital and outpatient center. The tribe is responsible for maintenance, while Oklahoma State pays for the faculty and equipment.

The college building features large windows, Cherokee symbols etched into concrete, and orange accents — a shoutout to the university’s colors. Inside, signs are written in both English and Cherokee.

On a recent afternoon, students practiced osteopathic manipulative therapy on one another inside a classroom. Down the hall in a simulation center, lifelike patient models lay with their mouths agape on hospital beds.

Next door at the hospital, medical student Mackenzie Hattabaugh checked on Chyna Chupco, who was recovering after giving birth to her first baby. Hattabaugh asked Chupco questions to make sure she was reaching recovery milestones and not showing signs of complications. She also felt Chupco’s uterus to make sure it was healing properly.

Hattabaugh, who is not Native American, grew up in Muldrow, a town of about 3,300 on the reservation. The 24-year-old said the town sometimes had a doctor but never a hospital or urgent care clinic.

“I would like to go back to around my hometown and perhaps be a staple in my community, to become a physician and provide people health care who usually have to drive 30 minutes or more to get it,” said Hattabaugh, a first-generation college student.

Students said studying at the Tahlequah campus prepares them to work in tribal and rural areas in ways that might not be possible at other medical schools.

Charlee Dawson, a 27-year-old medical student and citizen of the Cherokee Nation, said rotations within the Indian Health Service help students understand how the system’s care and complex billing procedures differ from those of other health facilities.

The program helps students understand what health problems are more common among Native Americans, Gatewood said. She said her previous medical school taught students about the high rate of diabetes among Black patients, but not the rate for Native Americans, which is

The students also said they’ve learned to ask Indigenous patients not just what pharmaceutical drugs and supplements they’re taking, but also whether they’re using traditional medications or working with a healer.

Native Americans have long received inadequate, discriminatory, and unethical health care. Children died of infectious disease outbreaks . The Indian Health Service in the 1960s and ’70s. Today, the agency remains .

This has led some Indigenous people to mistrust the health care system. But several of the Tahlequah students said they’ve bonded with patients who share similar backgrounds.

“It really comforts patients to know that someone like them is taking care of them,” said Caitlin Cosby, a member of the Choctaw Nation.

Cosby, 24, said she once had a patient who asked, “‘Are you Native?’ And I said, ‘I am!’”

The patient told Cosby he was proud of her.

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Gebel, a mother of two, went to her primary care doctor in Juneau, Alaska, who referred her for testing, she said.

Her 9-month-old was asleep in her arms when she got the results.

“I got the call from my primary care nurse telling me it was cancer. And I remember I just sat there for probably at least another half an hour or so and cried,” Gebel said.

Juneau, the state capital, has about 31,700 residents, who are served by the city-owned Bartlett Regional Hospital. But Gebel said she has several friends who have also had cancer, all of whom recommended she seek treatment out of town because they felt bigger cities would have better care.

She opted for treatment in Seattle, the closest major American city to Alaska. She underwent surgery at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she said she selected because it offers a lower-dose chemotherapy.

During chemo, she learned she had stage 4 breast cancer, she said.

Commuting to Seattle for chemo every week — nonstop flights that lasted as long as two hours and 45 minutes — became tiring. So Gebel began treatment at Bartlett Regional Hospital after her Seattle doctor taught hospital staffers there how to administer her chemo regimen.

Then the bill came.

The Patient: Emily Gebel, 37, insured through her husband’s employer by Premera Blue Cross. She was previously covered by Moda Health.

Medical Service: One round of metronomic chemotherapy, which involves regular infusions at lower but more frequent doses and over a longer period than traditional chemotherapy.

Service Provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The hospital is a tax-exempt facility owned by the city and borough of Juneau, though most of its revenue comes from the services it provides, according to hospital officials. Lifespring is a stand-alone, doctor-owned cancer clinic in Seattle.

Total Bill: The prices for Gebel’s chemo infusions at Bartlett Regional Hospital varied week to week. A hospital bill showed one infusion in July was listed at $5,077.28 — more than three times the price for a similar mix of drugs at the Seattle clinic, $1,611.24.

What Gives: In the United States, the price for the same medical service can vary based on where it is received. And for those living in remote areas like Alaska, the price difference can put care further out of reach.

Gebel’s firsthand experience with this disparity began after her husband, Jered, requested a cost estimate from Bartlett Regional Hospital. It said Gebel’s chemo would cost around $7,500 per weekly infusion, more than 4½ times what she had been charged in Seattle.

“The email came through with the bill estimate, and it’s like, ‘Oh my goodness, this has to be wrong,” Jered said.

Jered said Emily had met her annual out-of-pocket maximum, meaning her insurance would cover the costs of her treatment, but from the start, the disparity just bothered him.

When Emily received a bill for a few rounds of her weekly chemo treatments, it showed the hospital charged more than triple what the Seattle clinic did for a round of chemo, asking higher prices for every related service and medication she received that week.

The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle clinic. One of the drugs cost $714, more than three times the price at the clinic.

It was even the tiniest things: The hospital charged $19.15 for Benadryl, about 22 times the clinic’s price of 87 cents.

Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not reply to requests for comment.

Sam Muse, the hospital’s former chief financial officer, , said Bartlett Regional Hospital officials determined prices by looking at average wholesale prices and what other facilities in the region charge. Muse said the hospital had to account for high operating costs.

“Anything that we charge certainly has to take into consideration … the cost of just supplying health care in a rural setting like Juneau,” Muse said. “We’re not accessible by road at all, only ferry or plane.”

Juneau’s isolated geography makes reaching many resources a challenge. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged between Canada, the Pacific Ocean, and Glacier Bay National Park & Preserve. Neither Anchorage nor Vancouver, its nearest major cities, is close by.

The hospital — the only one in the city and largest in the panhandle — treats a small number of cancer patients, at least a few hundred last year, Muse said. Its two oncologists live outside the city and fly into Juneau six times a month, said Erin Hardin, a hospital spokesperson.

Bartlett spent nearly $11 million last year to pay and fly in nurses, doctors, and other staffers who live outside the city, Muse said.

We’re “trying to find that happy medium between keeping care here and and how do we do that in a sustainable way for the long term,” Muse said.

Even though research shows Alaskans and less often than many Americans, they had the health care expenditures per capita in 2020.

“Alaska is special in that it’s small, it’s remote, therefore it’s more expensive,” said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied health care costs in Alaska when he taught there.

Guettabi said hospitals often need to to recruit doctors and nurses willing to live in Alaska, which has a than that of most states.

Towns or entire regions may have few specialists and only one hospital, creating a dearth of competition that may drive up costs, Guettabi said. It’s also more expensive to ship items there, including medical supplies.

But Alaska’s costs are higher even when taking all those factors into account, Guettabi said. In Anchorage, for instance, prices for medical items from 1991 through 2017 than prices overall.

Alaska also has a unique policy that may be increasing prices. Its “80th percentile rule” was enacted in 2004 to limit the amount of money patients pay when treated by providers outside their health insurers’ network. But like many experiments meant to rein in costs, the rule has instead been increasing health care spending,

“Critics think the rule may be adding to that soaring spending, partly because over time providers could increase their charges — and insurance payments would have to keep pace,” the study noted.

The Resolution: Emily received a bill from the hospital in September, more than five months after beginning treatment there.

It said Emily owed about $3,100 even though a previous explanation of benefits said she’d met her out-of-pocket limit.

Jered said he contacted hospital billing officials, who discovered that a medicine had been incorrectly coded and told Jered that Emily’s charge was zero.

“We know how hard it is to pay these ridiculous medical bills,” Jered said. “If I’m able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows, maybe eventually health care prices can come down.”

Emily said she’s glad Jered knows how to handle the financial aspects of her care. Like many Americans, she could have just paid or ignored the incorrect bills, risking being sent to collections.

“I can’t imagine the amount of time I would have to spend on it while juggling parenting and also dealing with completing treatment, going through the sickness that goes along with that, and just generally feeling very run down,” she said.

The Takeaway: Alaska government officials, nonprofits, and experts have suggested methods to lower the cost of health care. The state is considering and , which emphasizes paying providers based on health outcomes.

But what should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out prices at a health care system in a state next door.

In any case, get ready to advocate for yourself.

Jered learned about medical billing by following the Bill of the Month series and reading “Never Pay the First Bill,” a book by Marshall Allen, a former ProPublica reporter.

Request itemized bills and make sure the codes match the services you received, Jered said. Note any prices that seem outrageous. If you have concerns, arrange an in-person meeting with an official in the provider’s finance department. If that’s not possible, a phone call is better than email. Make sure to document all conversations, so you have a record.

Come prepared with your documents and evidence, including the rate paid by Medicare, the federal insurance system for those 65 and older. Ask the official to explain the reasons for the codes and pricing before contesting anything. You can sometimes negotiate high-priced services down. And remember that the person you’re speaking with isn’t to blame for your health care costs.

“Don’t come at them angry, don’t come at them as viewing them as the enemy — because they’re not,” Jered said. “They are working within the same broken system.”

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“I was like, ‘Oh my gosh, no!’” Hodge recalled while sitting in an exam room on a July afternoon, waiting to see the physician, Terry Vester. “Well, I’m happy for the retirement part, but that’s my favorite doctor, so I’m crying on the inside.”

Hodge, a 29-year-old customer service representative, has been seeing Vester for nine years. She had come to check in on her diabetes management and to ask for anti-nausea medication in preparation for a cruise.

LaFayette — pronounced “luh-FAY-it” by most residents — and surrounding Chambers County face of disease and chronic illness. Yet Terry Vester and her husband, Al, are the only primary care doctors in the town of 2,700 residents, surrounded by farms and other small communities.

The Vesters are in their late 60s and would like to retire soon. Terry Vester wants to spend more time with her grandson and aging parents. But she can’t imagine abandoning her patients, some of whom she has cared for since they were born.

“There are people here that still need in-town doctors,” said Vester, who sometimes visits patients in their homes. “So we want to stay here to take care of them until someone else is here to take care of them.”

Terry Vester’s worry — leaving her town with no doctors — is already reality across much of rural America, where but to turn to.

LaFayette, in east-central Alabama near the border with Georgia, is a 30-minute drive to the nearest sizable city, the college town of Auburn. Its lush, wooded neighborhoods include elegant, restored homes with wraparound porches and massive lawns. But the town also has formerly grand houses that have fallen into disrepair, plus mobile homes and public housing.

The town’s is much lower than the state’s and country’s. Black residents — who make up 70% of the population — are than white residents. They are also more likely to attend the public high school, whose student body is and which is with a majority-white school in another community.

The Vesters have worked in LaFayette since the early 1980s and saw the local hospital close in 1988. The nearest emergency room is now in another town 20 minutes away along a rolling road. So are the nearest urgent care clinic and pediatrician’s office.

To fill that void, residents turn to the one place in LaFayette where medical professionals are always on the clock: the city fire department, staffed with full-time firefighters and emergency medics.

Fire Chief Jim Doody worked for 13 years as the fire chief at Bagram Airfield in Afghanistan. He arrived in LaFayette in 2020, just as the county was about to be hit by covid-19 outbreaks in Alabama.

Doody said most of the station’s ambulance runs are for nonemergency situations. Other calls involve urgent issues that could have been headed off if patients had better access to preventive care.

People from LaFayette regularly walk or drive themselves to the fire station to ask for help, Doody said. The station has a makeshift exam area within its small entryway, containing a bench, defibrillator machine, and cabinet filled with medical supplies.

Firefighter Tanner Hill said people often arrive with concerns about fatigue, blood sugar levels, breathing difficulties, or heart trouble. He recalled helping a man who walked into the station after getting hit by a car.

“He was just like, ‘Hey, I just got run over.’ And I was like, ‘Oh, OK, well, let me check you out.’ And sure enough, he got run over,” Hill said.

Hill determined the man’s leg was broken and sent him by ambulance to the nearest hospital.

This de facto walk-in clinic option isn’t available in most other rural areas, where emergency medical services are often run by volunteers who aren’t posted at a station all day, Doody said. But he’s noticed fewer LaFayette residents relying on the fire department since a new telehealth service arrived in town.

Rickey Whitlow was recently driving in LaFayette when he saw a sign touting the new option.

The 61-year-old was intrigued. He parked his car and walked into a new health center that also houses an OnMed Care Station, a large booth stocked with a video screen and high-tech health monitoring equipment.

Whitlow was scheduled for his monthly diabetes checkup with physician Al Vester in a few weeks. But his feet felt like they were burning, and he needed relief now.

Whitlow stepped into the telehealth kiosk, pressed a button, and saw a nurse practitioner appear on a large vertical video screen positioned at eye level. After consulting with the provider, he left the free appointment with a prescription for a cream to relieve his foot pain.

OnMed patients use an automated blood pressure cuff and other devices to collect their vital signs, and the data is sent to the provider treating them from a distance. Patients can also hold a stethoscope to their chest to transmit the sounds of their heart and lungs. A special camera captures internal temperatures, which can be used to diagnose infections. A hand-held camera lets providers examine problems such as rashes, irritated eyes, and swollen throats. In some states, the stations can dispense medications.

OnMed, a Florida-based company, has another kiosk in rural Texas and hopes to open several dozen more in various states next year. The company wants to keep its services free for patients, with funding from universities, health systems, nonprofits, and insurance companies.

The kiosks can stay open on evenings and weekends and are much cheaper to operate than brick-and-mortar doctor’s offices, said CEO Tom Vanderheyden. They also make telehealth available to rural residents whose home internet connections are too weak for video appointments.

LaFayette’s OnMed kiosk is part of a new health center inside a building that has seen several medical facilities come and go.

The is operated by Auburn University, whose students and faculty travel there to host vaccination and diagnostic clinics, such as speech and hearing exams. They also offer health education events on topics such as healthy eating and maternal health.

The university plans to bring similar centers and OnMed kiosks to other rural Alabama towns.

Vester, the longtime primary care physician, is excited about the new health care resources in LaFayette. But she said it’s still important to have doctors in town.

“You know everyone, or you have a connection with someone,” Vester said.

Vester’s statement rang true during recent appointments as she asked about her patients’ lives and relatives.

“Deep breath,” Vester instructed as she placed a stethoscope on Hodge’s chest.  “Are you still at home with your mother? Is she doing good?”

“Yes, she’s doing very well,” Hodge said.

Earlier that day, Vester treated a patient who had throat pain and difficultly speaking after surviving a choking incident. During the appointment, the patient mentioned an upcoming funeral.

Vester knew about the funeral. It was for a woman she once treated.

“I see her daughters and then their children, and they have children — so that’s four generations right there,” Vester said. “And so, you sort of know the whole story, you know the context.”

Vester plans to reach out to Alabama medical schools to let them know she’s looking for doctors to take over for her and her husband. But she said not everyone wants to live in rural areas like LaFayette.

The doctor hopes some of the Auburn students will want to serve in LaFayette after seeing what it’s like working at the new health center. She said it’s nice to live in a small, quiet town that’s relatively close to larger cities, and to run an independent clinic rather than work for a larger health system.

Vester said the charm of LaFayette and its residents is also a selling point.

“All they have to do is pretty much come here and spend a day and go through what we do, and I think they would enjoy it,” she said.

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During the covid-19 public health emergency, the Drug Enforcement Administration allowed doctors and other health care providers to prescribe controlled medicine during telehealth appointments without examining the patient in person. The emergency declaration ended May 13, and in February, the agency that would require providers to see patients at least once in person before prescribing many of those drugs during telehealth visits.

include many stimulants, sedatives, opioid painkillers, and anabolic steroids.

Regulators said they — which don’t require an in-person appointment — until November 11 after receiving more than 38,000 comments on the proposed changes, a record amount of feedback. They also said patients who receive controlled medications from prescribers they’ve never met in person will have until November 11, 2024, to come into compliance with the agency’s future rules.

The discuss the potential effects on a variety of patients, including people being treated for mental health disorders, opioid addiction, or attention-deficit/hyperactivity disorder. Thousands of commenters also mentioned possible impacts on rural patients.

Opponents wrote that health care providers, not a law enforcement agency, should decide which patients need in-person appointments. They said the rules would make it difficult for some patients to receive care.

Other commenters called for exemptions for specific medications and conditions.

Supporters wrote that the proposal would balance the goals of increasing access to health care and helping prevent medication misuse.

Zola Coogan, 85, lives in Washington, Maine, a town of about 1,600 residents northeast of Portland. Coogan has volunteered with hospice patients and said it’s important for very sick and terminally ill people in rural areas to have access to opioids to ease their pain. But she said it can be hard to see a doctor in person if they lack transportation or are too debilitated to travel.

Coogan said she supports the DEA’s proposed rules because of a provision that could help patients who can’t travel to meet their telehealth prescriber. Instead, they could visit a local health care provider, who then could write to the telehealth prescriber. But she said accessing controlled medications would still be difficult for some rural residents.

“It could end up being a very sticky wicket” for some patients to access care, she said. “It’s not going to be easy, but it sounds like it’s doable.”

Some health care providers may hesitate to offer those referrals, said Stefan Kertesz, a physician and professor at the University of Alabama at Birmingham whose expertise includes addiction treatment. Kertesz said the proposed referral process is confusing and would require burdensome record-keeping.

Ateev Mehrotra, a physician and Harvard professor who has studied telehealth in rural areas, said different controlled drugs come with different risks. But overall, he finds the proposed rules too restrictive. He’s worried people who started receiving telehealth prescriptions during the pandemic would be cut off from medicine that helps them.

Mehrotra said he hasn’t seen clear evidence that every patient needs an in-person appointment before receiving controlled medicine through telehealth. He said it’s also not clear whether providers are less likely to write inappropriate prescriptions after in-person appointments than after telehealth ones.

Mehrotra described the proposed rules as “a situation where there’s not a clear benefit, but there are substantial harms for at least some patients,” including many in rural areas.

Beverly Jordan, a family practice doctor in Alabama and a member of the state medical board, supports the proposed rule, as well as that requires annual in-person appointments for patients who receive controlled medications. Jordan prescribes such medications, including to rural patients who travel to her clinic in the small city of Enterprise.

“I think that once-a-year hurdle is probably not too big for anybody to be able to overcome, and is really a good part of patient safety,” Jordan said.

Jordan said it’s important for health care practitioners to physically examine patients to see if the exam matches how the patients describe their symptoms and whether they need any other kind of treatment.

Jordan said that, at the beginning of the pandemic, she couldn’t even view most telehealth patients on her computer. Three-fourths of her appointments were over the phone, because many rural patients have poor internet service that doesn’t support online video.

The proposed federal rules also have a special allowance for buprenorphine, which is used to treat opioid use disorder, and for most categories of non-narcotic controlled substances, such as testosterone, ketamine, and Xanax.

Providers could prescribe 30 days’ worth of these medications after telehealth appointments before requiring patients to have an in-person appointment to extend the prescription. Tribal health care practitioners would from the proposed regulations, as would Department of Veterans Affairs providers in emergency situations.

Many people who work in health care were surprised by the proposed rules, Kertesz said. He said they expected the DEA to let prescribers apply for special permission to provide controlled medicine without in-person appointments. Congress ordered the agency to create in 2008, but it has not done so.

Agency officials said creating a version of that program for rural patients but decided against it.

Denise Holiman disagrees with the proposed regulations. Holiman, who lives on a farm outside Centralia, Missouri, used to experience postmenopausal symptoms, including forgetfulness and insomnia. The 50-year-old now feels back to normal after being prescribed estrogen and testosterone by a Florida-based telehealth provider. Holiman said she doesn’t think she should have to go see her telehealth provider in person to maintain her prescriptions.

“I would have to get on a plane to go to Florida. I’m not going to do that,” she said. “If the government forces me to do that, that’s wrong.”

Holiman said her primary care doctor doesn’t prescribe injectable hormones and that she shouldn’t have to find another in-person prescriber to make a referral to her Florida provider.

Holiman is one of thousands of patients who shared their opinions with the DEA. The agency also received comments from advocacy, health care, and professional groups, such as the American Medical Association.

The physicians’ organization said the in-person rule for most categories of controlled medication. Even telehealth prescriptions for drugs with a higher risk of misuse, such as Adderall and oxycodone, should be exempt when medically necessary, the group said.

already have laws that are stricter than the DEA’s proposed rules. Amelia Burgess said Alabama’s annual exam requirement, which went into effect last summer, burdened some patients. The Minnesota doctor works at Bicycle Health, a telehealth company that prescribes buprenorphine.

Burgess said hundreds of the company’s patients in Alabama couldn’t switch to in-state prescribers because many weren’t taking new patients, were too far away, or were more expensive than the telehealth service. So Burgess and her co-workers flew to Alabama and set up a clinic at a hotel in Birmingham. About 250 patients showed up, with some rural patients driving from five hours away.

Critics of the federal proposal are lobbying for exemptions for medications that can be difficult to obtain due to a lack of specialists in rural areas.

Many of the public comments focus on the importance of telehealth-based buprenorphine treatment in rural areas, including in jails and prisons.

Rural areas also have shortages of mental health providers who can prescribe controlled substances for anxiety, depression, and ADHD. Patients across the country who use opioids for chronic pain have trouble finding prescribers.

It also can be difficult to find rural providers who prescribe testosterone, a controlled drug often taken by transgender men and people with various medical conditions, such as menopause. Controlled medications are also used to treat seizures, sleep disorders, and other conditions.

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“I’d probably not be able to work that much because I’d be tired but couldn’t fall asleep,” he said.

Murray’s mother is paying $1,548 more than usual in health insurance premiums over three months to make sure he can afford his sleeping pills, other medication, lab work, and doctors’ appointments.

Murray had to scramble to find an insurance option after he was surprised to lose his Medicaid coverage on April 1 — even though he will likely requalify July 1.

Due to a convoluted situation in South Dakota and North Carolina, Murray isn’t the only person who will experience this whiplash in Medicaid coverage.

Medicaid is the joint federal and state health insurance program for people with low incomes or disabilities. During the national covid-19 public health emergency, states were barred from removing people from the program even if they no longer qualified.

This rule has now ended, and states can redetermine whether Medicaid participants still qualify. The federal government Americans will lose coverage under Medicaid or the Children’s Health Insurance Program because they no longer qualify or because of paperwork issues.

But as South Dakota and North Carolina remove participants from Medicaid, the states also plan to add people to the program. That’s because South Dakota voters and recently approved Medicaid expansion, which will increase the number of people eligible for the program.

“It would have been great if they would have kept people on until the expansion, so you’re not kicking so many people off,” said Kathy Murray, Jonathon’s mother.

South Dakota could have tried to prevent participants from temporarily losing Medicaid coverage, according to several health policy experts.

State officials are “saying federal regulations mean that they have to kick people off before expansion, and that’s just not right,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. “They absolutely could be structuring this in a way that those people didn’t experience a loss in coverage.”

Lucy Dagneau, head of Medicaid campaigns for the American Cancer Society Cancer Action Network, agreed. South Dakota and North Carolina “can’t actually stop the process of the unwinding. However, they have flexibility in terms of how they batch the enrollees,” she said.

Alker and Dagneau said states don’t have to start the unwinding process right away, and when they do, they could delay reviewing enrollees who are likely to requalify under expansion.

South Dakotans and North Carolinians who want to avoid a gap in health care coverage can apply for private insurance, which could be subsidized under the Affordable Care Act. They could then reapply for Medicaid once applications for expansion coverage begin. But if they wind up uninsured during the gap period, they might avoid seeking treatment or face expensive bills.

South Dakota is that began culling April 1, the earliest date possible. Its Medicaid expansion goes into effect July 1. About 16,000 South Dakotans were disenrolled in April, but more than 1,700 of them will requalify under expansion, .

North Carolina will begin disenrolling people who are no longer eligible for Medicaid on July 1. The state has not set a timeline for Medicaid expansion, but it’s expected to occur within the unwinding period, which lasts through May 2024.

Jay Ludlam, deputy secretary of North Carolina’s Medicaid program, said the uncertain timing makes it difficult to avoid temporarily disenrolling people. Ludlam said about 300,000 North Carolinians are expected to be removed from Medicaid during the unwinding. He estimated one-third of them will requalify after expansion.

Kathy Murray added Jonathon to her workplace insurance plan, which will more than double her premiums over the intervening months. She said she won’t be able to pay some other bills during this time, but her son can’t go without health care.

She said South Dakota’s approach seems inefficient, since state workers will have to disenroll and reenroll some people within a short period. “It’s creating a lot of work for the state workers because they’re going to send out paperwork and requalify everybody,” she said.

Matt Althoff, secretary of the South Dakota Department of Social Services, said that the agency’s unwinding plan is “based on compliance with CMS rules, limitations of the technology used to support South Dakota Medicaid, and the overall impact to customers.”

The agency wrote in a that it was working closely with the federal Centers for Medicare & Medicaid Services “to explore waivers and flexibilities during the period of the unwinding prior to expansion and will continue to do so.”

Althoff did not respond when asked by Ģ��ӰԺ Health News whether the state had discussions with the federal agency about avoiding temporary disenrollments. Sara Lonardo, press secretary for CMS, said the agency could not comment on whether it had any related conversations with South Dakota or North Carolina officials.

Although South Dakota won’t prevent people likely to requalify for Medicaid from temporarily losing coverage, it is taking steps to make sure they know to reapply.

The state is screening people who no longer qualify for Medicaid under the current rules to see if they would requalify after Medicaid expansion. If so, they should be sent letters .

Since 2014, the Affordable Care Act has allowed states to offer Medicaid coverage to more people, with the federal government paying 90% of the costs. All but .

South Dakota adults currently qualify for Medicaid if they have a certified disability or have children and incomes up to 46% of the federal poverty level. That translates to $13,800 for a family of four.

Jonathon Murray qualified for Medicaid as a child. But he became an adult during the public health emergency and thus no longer qualifies.

Medicaid expansion will allow adults, with or without children, to enroll in the program if they earn up to 138% of the federal poverty level, or $20,120 for a single adult. Murray’s income as a part-time restaurant cook and dishwasher should allow him to requalify and begin receiving Medicaid coverage on July 1.

Get Covered South Dakota helps people understand and apply for health care insurance. So far, everyone the organization has assisted after being disenrolled from Medicaid has qualified for subsidized private plans under the Affordable Care Act’s marketplace, according to program manager Penny Kelley. For people with low incomes, the subsidies can cover most or all of their premiums.

South Dakota Voices for Peace, a nonprofit agency, is assisting people with the Medicaid unwinding and expansion process. Carla Graciano, its outreach coordinator, said many people are confused about the unwinding process after not having to worry about health coverage for more than three years during the public health emergency.

“We have heard concerns about people potentially losing their medical coverage,” Graciano said. “It puts a lot of people under stress.”

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