PRESQUE ISLE, Maine — Outside the Mi’kmaq Nation’s health department sits a dome-shaped tent, built by hand from saplings and covered in black canvas. It’s one of several sweat lodges on the tribe’s land, but this one is dedicated to helping people recover from addiction.

Up to 10 people enter the lodge at once. Fire-heated stones — called grandmothers and grandfathers, for the spirits they represent — are brought inside. Water is splashed on the stones, and the lodge fills with steam. It feels like a sauna, but hotter. The air is thicker, and it’s dark. People pray and sing songs. When they leave the lodge, it is said, they reemerge from the mother’s womb. Cleansed. Reborn.

The experience can be “a vital tool” in healing, said Katie Espling, health director for the roughly 2,000-member tribe.

She said patients in recovery have requested sweat lodges for years as a cultural element to complement the counseling and medications the tribe’s health department . But insurance doesn’t cover sweat ceremonies, so, until now, the department couldn’t afford to provide them.

In the past year, the Mi’kmaq Nation received more than $150,000 from settlements with companies that made or sold prescription painkillers and were accused of exacerbating the overdose crisis. A third of that money was spent on the sweat lodge.

Health care companies are more than $1.5 billion to hundreds of tribes over 15 years. This windfall is similar to settlements that many of the same companies are paying to state governments, which total about $50 billion.

To some people, the lower payout for tribes corresponds to their smaller population. But some tribal citizens point out that the overdose crisis has had a disproportionate effect on their communities. Native Americans had the highest overdose death rates of any racial group each year from 2020 to 2022. And federal officials say those statistics were likely undercounted by about 34% because Native Americans’ race is often misclassified on death certificates.

Still, many tribal leaders are grateful for the settlements and the unique way the money can be spent: Unlike the state payments, money sent to tribes can be used for — anything from sweat lodges and smudging ceremonies to basketmaking and programs that teach tribal languages.

“To have these dollars to do that, it’s really been a gift,” said Espling of the Mi'kmaq tribe. “This is going to absolutely be fundamental to our patients’ well-being” because connecting with their culture is “where they’ll really find the deepest healing.”

Public health experts say the underlying cause of addiction in many tribal communities is intergenerational trauma, resulting from centuries of brutal treatment, including broken treaties, land theft, and a government-funded boarding school system that sought to erase the tribes’ languages and cultures. Along with a long-running lack of investment in the Indian Health Service, these factors have led to lower life expectancy and higher rates of addiction, suicide, and chronic diseases.

Using settlement money to connect tribal citizens with their traditions and reinvigorate pride in their culture can be a powerful healing tool, said , a researcher with the Johns Hopkins Center for Indigenous Health and a member of the Haida Nation. She for how tribes can consider spending settlement money.

Medley said that having respect for those traditional elements outlined explicitly in the settlements is “really groundbreaking.”

‘A Drop in the Bucket’

Of the 574 federally recognized tribes, more than 300 have received payments so far, totaling more than $371 million, according to , one of three court-appointed directors overseeing the tribal settlements.

Although that sounds like a large sum, it pales in comparison with what the addiction crisis has cost tribes. There are also hundreds of tribes that are excluded from the payments because they aren’t federally recognized.

“These abatement funds are like a drop in the bucket compared to what they’ve spent, compared to what they anticipate spending,” said , a lawyer who represented several tribes in the opioid litigation and a citizen of the Passamaquoddy Tribe. “Abatement is a cheap term when we’re talking about a crisis that is still engulfing and devastating communities.”

Even leaders of the Navajo Nation — the largest federally recognized tribe in the United States, which has received $63 million so far — said the settlements can’t match the magnitude of the crisis.

“It’ll do a little dent, but it will only go so far,” said Kim Russell, executive director of the Navajo Department of Health.

The Navajo Nation is trying to stretch the money by using it to improve its overall health system. Officials plan to use the payouts to hire more coding and billing employees for tribe-operated hospitals and clinics. Those workers would help ensure reimbursements keep flowing to the health systems and would help sustain and expand services, including addiction treatment and prevention, Russell said.

Navajo leaders also want to hire more clinicians specializing in substance use treatment, as well as primary care doctors, nurses, and epidemiologists.

“Building buildings is not what we want” from the opioid settlement funds, Russell said. “We’re nation-building.”

High Stakes for Small Tribes

Smaller nations like the Poarch Band of Creek Indians in southern Alabama are also strategizing to make settlement money go further.

For the tribe of roughly 2,900 members, that has meant investing $500,000 — most of what it has received so far — into a statistical modeling platform that its creators say will simulate the opioid crisis, predict which programs will save the most lives, and help local officials decide the most effective use of future settlement cash.

Some recovery advocates have questioned the model’s value, but the tribe’s vice chairman, , said it would provide the data and evidence needed to choose among efforts competing for resources, such as recovery housing or peer support specialists. The tribe wants to do both, but realistically, it will have to prioritize.

“If we can have this model and we put the necessary funds to it and have the support, it'll work for us,” McGhee said. “I just feel it in my gut.”

The stakes are high. In smaller communities, each death affects the whole tribe, McGhee said. The loss of one leader marks decades of lost knowledge. The passing of a speaker means further erosion of the Native language.

For Keesha Frye, who oversees the Poarch Band of Creek Indians’ tribal court and the sober living facility, using settlement money effectively is personal. “It means a lot to me to get this community well because this is where I live and this is where my family lives,” she said.

Erik Lamoreau in Maine also brings personal ties to this work. More than a decade ago, he sold drugs on Mi’kmaq lands to support his own addiction.

“I did harm in this community and it was really important for me to come back and try to right some of those wrongs,” Lamoreau said.

Today, he works for the tribe as a peer recovery coordinator, a new role created with the opioid settlement funds. He uses his experience to connect with others and help them with recovery — whether that means giving someone a ride to court, working on their résumé, exercising together at the gym, or hosting a cribbage club, where people play the card game and socialize without alcohol or drugs.

Beginning this month, Lamoreau’s work will also involve connecting clients who seek cultural elements of recovery to the new sweat lodge service — an effort he finds promising.

“The more in tune you are with your culture — no matter what culture that is — it connects you to something bigger,” Lamoreau said. “And that’s really what we look at when we’re in recovery, when we talk about spiritual connection. It’s something bigger than you.”

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Have you or someone you know with disabilities unexpectedly lost Medicaid benefits since April 2023? Tell us about it .

She received coverage through Florida’s Medicaid program until it abruptly stopped at the end of March, she said.

“Every day the anxiety builds,” said Saa, who lost her home health aide for 11 days, starting April 1, despite being eligible. The state has since restored Saa’s home health aide service, but during the gap she leaned on her mother and her 23- and 15-year-old daughters, while struggling to regain her Medicaid benefits.

“It’s just so much to worry about,” she said. “This is a health care system that’s supposed to help.”

Medicaid’s home and community-based services are designed to help people like Saa, who have disabilities and need help with everyday activities, stay out of a nursing facility. But people are losing benefits with little or no notice, getting bad advice when they call for information, and facing major disruptions in care while they wait for the issue to get sorted out, according to attorneys and advocates who are hearing from patients.

In , , and ., the National Health Law Program, a nonprofit that advocates for low-income and underserved people, has filed civil rights complaints with two federal agencies alleging discrimination against people with disabilities. The group has not filed a lawsuit in Florida, though its attorneys say they’ve heard of many of the same problems there.

Attorneys nationwide say the special needs of disabled people were not prioritized as states began to review eligibility for Medicaid enrollees after a pandemic-era mandate for coverage expired in March 2023.

“Instead of monitoring and ensuring that people with disabilities could make their way through the process, they sort of treated them like everyone else with Medicaid,” said , a senior attorney for the National Health Law Program. Federal law puts an “obligation on states to make sure people with disabilities don’t get missed.”

At least 21 million people nationwide have been disenrolled from Medicaid since states began eligibility redeterminations in spring 2023, according to a .

The unwinding, as it’s known, is an immense undertaking, Edwards said, and some states did not take extra steps to set up a special telephone line for those with disabilities, for example, so people could renew their coverage or contact a case manager.

As states prepared for the unwinding, the Centers for Medicare & Medicaid Services, the federal agency that regulates Medicaid, that they must give people with disabilities the help they need to benefit from the program, including specialized communications for people who are deaf or blind.

The Florida Department of Children and Families, which verifies eligibility for the state’s Medicaid program, has a specialized team that processes applications for home health services, said , the department’s communications director.

People with disabilities disenrolled from Medicaid services were “properly noticed and either did not respond timely or no longer met financial eligibility requirements,” McManus said, noting that people “would have been contacted by us up to 13 times via phone, mail, email, and text before processing their disenrollment.”

Allison Pellegrin of Ormond Beach, Florida, who lives with her sister Rhea Whitaker, who is blind and cognitively disabled, said that never happened for her family.

“They just cut off the benefits without a call, without a letter or anything stating that the benefits would be terminating,” Pellegrin said. Her sister’s home health aide, whom she had used every day for nearly eight years, stopped service for 12 days. “If I’m getting everything else in the mail,” she said, “it seems weird that after 13 times I wouldn’t have received one of them.”

Pellegrin, 58, a sales manager who gets health insurance through her employer, took time off from work to care for Whitaker, 56, who was disabled by a severe brain injury in 2006.

Medicaid reviews have been complicated, in part, by the fact that eligibility works differently for home health services than for general coverage, based on that give states more flexibility to determine financial eligibility. Income limits for home health services are higher, for instance, and assets are counted differently.

In Texas, a parent in a household of three would be limited to earning no more than $344 a month to qualify for Medicaid. And most adults with a disability can qualify without a dependent child and be eligible for Medicaid home health services with an income of up to $2,800 a month.

The state was not taking that into consideration, said , a supervising attorney for community integration at Disability Rights Texas, a nonprofit advocacy group.

Even a brief lapse in Medicaid home health services can fracture relationships that took years to build.

“It may be very difficult for that person who lost that attendant to find another attendant,” Anstee said, because of workforce shortages for attendants and nurses and high demand.

Nearly all states have a waiting list for home health services. About were on waiting lists in 2023, most of them with intellectual and developmental disabilities, according to Ģ��ӰԺ data.

Daniel Tsai, a deputy administrator at CMS, said the agency is committed to ensuring that people with disabilities receiving home health services “can renew their Medicaid coverage with as little red tape as possible.”

CMS this year for states to monitor Medicaid home health services. For example, CMS will now track how long it takes for people who need home health care to receive the services and will require states to track how long people are on waitlists.

Staff turnover and vacancies at local Medicaid agencies have contributed to backlogs, according to focused on civil rights.

The District of Columbia’s Medicaid agency requires that case managers help people with disabilities complete renewals. However, a complaint says, case managers are the only ones who can help enrollees complete eligibility reviews and, sometimes, they don’t do their jobs.

Advocates for Medicaid enrollees have also complained to the Federal Trade Commission about developed by Deloitte, a global consulting firm that contracts with about two dozen states to design, implement, or operate automated benefits systems.

Ģ��ӰԺ Health News found that multiple audits of Colorado’s eligibility system, managed by Deloitte, uncovered errors in notices sent to enrollees. A 2023 review by the Colorado Office of the State Auditor found that 90% of sampled notices contained problems, some of which violate the state’s Medicaid rules. The audit blamed “flaws in system design” for populating notices with incorrect dates.

Deloitte declined to comment on specific state issues.

In March, Colorado officials paused disenrollment for people on Medicaid who received home health services, which includes people with disabilities, after a “system update” led to in February.

Another common problem is people being told to reapply, which immediately cuts off their benefits, instead of appealing the cancellation, which would ensure their coverage while the claim is investigated, said attorney , founder of the Florida Health Justice Project.

“What they’re being advised to do is not appropriate. The best way to protect their legal rights,” Harmatz said, “is to file an appeal.”

But some disabled people are worried about having to repay the cost of their care.

Saa, who lives in Davie, Florida, received a letter shortly before her benefits were cut that said she “may be responsible to repay any benefits” if she lost her appeal.

The state should presume such people are still eligible and preserve their coverage, Harmatz said, because income and assets for most beneficiaries are not going to increase significantly and their conditions are not likely to improve.

The Florida Department of Children and Families would not say how many people with disabilities had lost Medicaid home health services.

But in Miami-Dade, Florida’s most populous county, the , a nonprofit that helps older and disabled people apply for Medicaid, saw requests for help jump from 58 in March to 146 in April, said , the organization’s director of its Aging and Disability Resources Center.

“So many people are calling us,” she said.

States are not tracking the numbers, so “the impact is not clear,” Edwards said. “It’s a really complicated struggle.”

Saa filed an appeal March 29 after learning from her social worker that her benefits would expire at the end of the month. She went to the agency but couldn’t stand in a line that was 100 people deep. Calls to the state’s Medicaid eligibility review agency were fruitless, she said.

“When they finally connected me to a customer service representative, she was literally just reading the same explanation letter that I’ve read,” Saa said. “I did everything in my power.”

Saa canceled her home health aide. She lives on limited Social Security disability income and said she could not afford to pay for the care.

On April 10, she received a letter from the state saying her Medicaid had been reinstated, but she later learned that her plan did not cover home health care.

The following day, Saa said, advocates put her in touch with a point person at Florida’s Medicaid agency who restored her benefits. A home health aide showed up April 12. Saa said she’s thankful but feels anxious about the future.

“The toughest part of that period is knowing that that can happen at any time,” she said, “and not because of anything I did wrong.”

Have you or someone you know with disabilities unexpectedly lost Medicaid benefits since April 2023? Tell Ģ��ӰԺ Health News about it .

Ģ��ӰԺ Health News correspondents Samantha Liss and Rachana Pradhan contributed to this report.

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“The guy was up there screaming and squirming. Then the cab caught on fire,” Trammell says. “I couldn’t move him. He burned to death right there in my arms.”

Memories of that gruesome death and other traumatic incidents he had witnessed as a firefighter in Mountain View, California, didn’t seem to bother Trammell for the first seven years after he retired in 2015. But then he started crying a lot, drinking heavily, and losing sleep. At first, he didn’t understand why, but he would later come to suspect he was suffering from post-traumatic stress disorder.

After therapy failed to improve his mental well-being, he heard about the potential benefits of psychedelic drugs to help first responders with PTSD.

Last July, Trammell went on a retreat in Puerto Vallarta, Mexico, organized by , a nonprofit that advocates the use of psychedelics and other alternative medicines to help first responders. He took psilocybin mushrooms and, the next day, another psychedelic derived from the toxic secretions of the . The experience, he says, produced an existential shift in the way he thinks of the terrible things he saw as a firefighter.

“All that trauma and all that crap I saw and dealt with, it’s all very temporary and everything goes back into the universe as energy,” Trammell says.

has shown that psychedelics have the potential to produce lasting relief from depression, anxiety, PTSD, addiction, and other mental health conditions. Many universities around the United States have programs researching psychedelics. But experts warn that these powerful drugs are not for everybody, especially those with a history of psychosis or cardiovascular problems.

Most psychedelic drugs are prohibited under federal law, but California may soon join of local and state governments allowing their use.

working its way through the California Legislature, would allow the therapeutic use of psilocybin; mescaline; MDMA, the active ingredient in ecstasy; and dimethyltryptamine, the , a plant-based psychoactive tea. The drugs could be purchased and ingested in approved locations under the supervision of facilitators, who would undergo training and be licensed by a new state board. The facilitators would need a professional health credential to qualify.

The bill, co-sponsored by Sen. Scott Wiener (D-San Francisco), Assembly member Marie Waldron (R-San Diego), and several other lawmakers, follows last year’s unsuccessful effort to decriminalize certain psychedelics for personal use. Gov. Gavin Newsom, a Democrat, , though he extolled psychedelics as “an exciting frontier” and asked for new legislation with “regulated treatment guidelines.”

Wiener says the new bill was drafted with Newsom’s request in mind. It is supported by some veterans and first responder groups and opposed by numerous law enforcement agencies.

One potential roadblock is the state’s budget deficit, pegged at between and . Newsom and legislative leaders may choose not to launch a new initiative when they are cutting existing programs. “That is something we’ll certainly grapple with,” Wiener says.

The legislation, which is making its way through committees, would require the new board to begin accepting facilitator license applications in April 2026. The system would look somewhat like the one in Oregon, which allows the use of psilocybin mushrooms under the guidance of state-licensed facilitators at psilocybin service centers. And like Oregon, California would not allow for the personal use or possession of psychedelics; the drugs would have to be purchased and consumed at the authorized locations.

Colorado, following the passage of a ballot initiative in 2022, is creating a system of regulated “healing centers,” where people will be able to legally consume psilocybin mushrooms and some other psychedelics under the supervision of licensed facilitators. Colorado’s law allows for the personal use and possession of a handful of psychedelics.

In California, the cities of Oakland, San Francisco, Berkeley, Santa Cruz, and Arcata have effectively decriminalized many psychedelics, as have other cities around the United States, including Ann Arbor, Michigan; Cambridge, Massachusetts; Detroit; Minneapolis; Seattle; and Washington, D.C.

Psychedelics such as psilocybin, ayahuasca, and peyote have been by Indigenous populations in Latin America and the current-day United States. And some non-Indigenous groups use these substances in a spiritual way.

The , with locations in San Francisco and Oakland, considers psilocybin mushrooms, also known as magic mushrooms, a sacrament. “Mushrooms affect the border between this world and the next, and allow people to connect to their soul,” says Dave Hodges, founder and pastor of the church.

Hodges was behind an unsuccessful attempt to get an initiative on the California ballot this year that would have decriminalized the possession and use of mushrooms. He hopes it will qualify for the 2026 ballot.

The pending California legislation is rooted in studies showing psychedelics can be powerful agents in mental health treatment.

Charles Grob, a psychiatry professor at the University of California-Los Angeles School of Medicine who has researched psychedelics for nearly 40 years, led that found synthetic psilocybin could help reduce end-of-life anxiety in patients with advanced-stage cancer.

Grob says MDMA is good for couples counseling because it facilitates communication and puts people in touch with their feelings. And he conducted research in Brazil that showed ayahuasca used in a religious context helped people overcome alcoholism.

But Grob warns that the unsupervised use of psychedelics can be dangerous and says people should undergo mental and medical health screenings before ingesting them. “There are cases of people going off the rails. It’s a small minority, but it can happen, and when it does happen it can be very frightening,” Grob says.

Ken Finn, past president of the American Board of Pain Medicine, says that psychedelics have a number of side effects, including elevated blood pressure, high heart rate, and vomiting, and that they can trigger “persistent psychosis” in a small minority of users. Legal drugs also pose risks, he says, “but we have much better guardrails on things like prescriptions and over-the-counter medications.” He also worries about product contamination and says manufacturers would need to be tightly regulated.

Another potential problem is health equity. Since insurance would not cover these sessions, at least initially, they would likely attract people with disposable income. A supervised psilocybin journey in Oregon, for example, can cost more than $2,500.

Many people who have experienced psychedelics corroborate the research results. Ben Kramer, a former Marine who served in Afghanistan and now works as a psilocybin facilitator in Beaverton, Oregon, says a high-dose mushroom session altered his worldview.

“I relived the first time I was ever shot at in Afghanistan,” he says. “I was there. I had this overwhelming love and compassion for the guy who was shooting at me, who was fighting for what he believed in, just like I was.”

Another characteristic of psychedelic therapy is that just a few sessions can potentially produce lasting results.

Trammell, the retired firefighter, hasn’t taken psychedelics since that retreat in Mexico 10 months ago. “I just felt like I kind of got what I needed,” he says. “I’ve been fine ever since.”

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In a recent , Kunce accuses Hawley of jeopardizing reproductive care, including in vitro fertilization. Staring straight into the camera, with tears in her eyes, a Missouri mom identified only as Jessica recounts how she struggled for years to conceive.

“Now there are efforts to ban IVF, and Josh Hawley got them started,” Jessica says. “I want Josh Hawley to look me in the eye and tell me that I can’t have the child that I deserve.”

Never mind that IVF is legal in Missouri, or that Hawley has said he supports limited access to abortion as a “pro-life” Republican. In key races across the country, Democrats are branding their Republican rivals as threats to women’s health after a broad erosion of reproductive rights since the Supreme Court struck down Roe v. Wade, including near-total state abortion bans, efforts to restrict medication abortion, and a court ruling that limited IVF in Alabama.

On top of the messaging campaigns, Democrats hope ballot measures to guarantee abortion rights in as many as 13 states — including Missouri, Arizona, and Florida — will help boost turnout in their favor.

The issue puts the GOP on the defensive, said , an election analyst at the University of Virginia.

“I don’t really think Republicans have found a great way to respond to it yet,” he said.

Abortion is such a salient issue in Arizona, for example, that election analysts say a U.S. House seat occupied by Republican is now .

Hawley appears in less peril, for now. He holds a wide lead in polls, though Kunce outraised him in the most recent quarter, raking in $2.25 million in donations compared with the incumbent’s $846,000, according to campaign finance reports. Still, Hawley’s war chest is more than twice the size of Kunce’s.

Kunce, a Marine veteran and antitrust advocate, said he likes his odds.

“I just don’t think we’re gonna lose,” he told Ģ��ӰԺ Health News. “Missourians want freedom and the ability to control their own lives.”

Hawley’s campaign declined to comment. He has backed a federal ban on abortion after 15 weeks and has said he supports exceptions for rape and incest and to protect the lives of pregnant women. Missouri’s state ban is near total, with no exceptions for rape or incest.

“This is Josh Hawley’s life’s mission. It’s his family’s business,” Kunce said, a nod to , the senator’s wife, a lawyer who argued before the Supreme Court in March on behalf of activists who sought to limit access to the abortion pill mifepristone.

State abortion rights have won out everywhere they’ve been on the ballot since the end of Roe in 2022, including in Republican-led Kentucky and Ohio.

An abortion rights ballot initiative is also expected in Montana, where a Republican challenge to Democrat could decide control of the Senate.

On a late-April Saturday along historic Main Street in St. Charles, Missouri, people holding makeshift clipboards fashioned from yard signs from past elections invited locals strolling brick sidewalks to sign a petition to get the initiative on Missouri ballots. Nearby, diners enjoyed lunch on a patio tucked under a canopy of trees in this affluent St. Louis suburb.

Missouri was the first state to ban abortion after Roe fell; it is outlawed except in “cases of medical emergency.” The measure would add the right to abortion to the state constitution.

Larry Bax, 65, of St. Charles County, said he votes Republican most of the time but signed the ballot measure petition along with his wife, Debbie Bax, 66.

“We were never single-issue voters. Never in our life,” he said. “This has made us single-issue because this is so wrong.”

They won’t vote for Hawley this fall, they said, but are unsure if they’ll support the Democratic nominee.

Jim Seidel, 64, who lives in Wright City, 50 miles west of St. Louis, also signed the petition. He said he believes Missourians deserve the opportunity to vote on the issue.

“I’ve been a Republican all my life until just recently,” Seidel said. “It’s just gone really wacky.”

He plans to vote for Kunce in November if he wins the Democratic primary in August, as seems likely. Seidel previously voted for a few Democrats, including Bill Clinton and Claire McCaskill, whom Hawley unseated as senator six years ago.

“Most of the time,” he added, Hawley is “strongly in the wrong camp.”

Over about two hours in conservative St. Charles, Ģ��ӰԺ Health News observed only one person actively declining to sign the petition. The woman told the volunteers she and her family opposed abortion rights and quickly walked away. The Catholic Church has discouraged voters from signing. At St. Joseph Parish in a nearby suburb, for example, a sign flashed: “Decline to Sign Reproductive Health Petition!”

The ballot measure organizers turned in more than twice the required number of signatures May 3, though, and now await certification from the secretary of state’s office.

Larry Bax’s concern goes beyond abortion and the ballot measure in Missouri. He worries about more governmental limits on reproductive care, such as on IVF or birth control. “How much further can that reach extend?” he said. Kunce is banking on enough voters feeling like Bax and Seidel to get an upset similar to the one that occurred in 2012 for the same seat — also over abortion. McCaskill defeated Republican Todd Akin that year, largely because of his infamous response when asked about abortion: “If it’s a legitimate rape, the female body has ways to try to shut that whole thing down.”

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Blum turned to programs mostly in states where abortion access — and, by extension, abortion training — is likely to remain protected, like California, Colorado, and New Mexico. Arizona has enacted a law banning most abortions after 15 weeks.

“I would really like to have all the training possible,” she said, “so of course that would have still been a limitation.”

In June, she will start her residency at Swedish Cherry Hill hospital in Seattle.

According to new statistics from the Association of American Medical Colleges, for the second year in a row, students graduating from U.S. medical schools were less likely to apply this year for residency positions in states with abortion bans and other significant abortion restrictions.

Since the Supreme Court in 2022 overturned the constitutional right to an abortion, state fights over abortion access have created plenty of uncertainty for pregnant patients and their doctors. But that uncertainty has also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers.

Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. — a preliminary copy of which was exclusively reviewed by Ģ��ӰԺ Health News before its public release — found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2%, compared with a 0.6% drop in states where abortion remains legal.

Notably, the AAMC’s findings illuminate the broader problems abortion bans can create for a state’s medical community, particularly in an era of provider shortages: The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties.

“It should be concerning for states with severe restrictions on reproductive rights that so many new physicians — across specialties — are choosing to apply to other states for training instead,” wrote Atul Grover, executive director of the AAMC’s Research and Action Institute.

The AAMC analysis found the number of applicants to OB-GYN residency programs in abortion ban states dropped by 6.7%, compared with a 0.4% increase in states where abortion remains legal. For internal medicine, the drop observed in abortion ban states was over five times as much as in states where abortion is legal.

In its analysis, the AAMC said an ongoing decline in interest in ban states among new doctors ultimately “may negatively affect access to care in those states.”

Jack Resneck Jr., immediate past president of the American Medical Association, said the data demonstrates yet another consequence of the post-Roe v. Wade era.

The AAMC analysis notes that even in states with abortion bans, residency programs are filling their positions — mostly because there are more graduating medical students in the U.S. and abroad than there are residency slots.

Still, Resneck said, “we’re extraordinarily worried.” For example, physicians without adequate abortion training may not be able to manage miscarriages, ectopic pregnancies, or potential complications such as infection or hemorrhaging that could stem from pregnancy loss.

Those who work with students and residents say their observations support the AAMC’s findings. “People don’t want to go to a place where evidence-based practice and human rights in general are curtailed,” said Beverly Gray, an associate professor of obstetrics and gynecology at Duke University School of Medicine.

Abortion in North Carolina is banned in nearly all cases after 12 weeks. Women who experience unexpected complications or discover their baby has potentially fatal birth defects later in pregnancy may not be able to receive care there.

Gray said she worries that even though Duke is a highly sought training destination for medical residents, the abortion ban “impacts whether we have the best and brightest coming to North Carolina.”

Rohini Kousalya Siva will start her obstetrics and gynecology residency at MedStar Washington Hospital Center in Washington, D.C., this year. She said she did not consider programs in states that have banned or severely restricted abortion, applying instead to programs in Maryland, New Hampshire, New York, and Washington, D.C.

“We’re physicians,” said Kousalya Siva, who attended medical school in Virginia and was previously president of the American Medical Student Association. “We’re supposed to be giving the best evidence-based care to our patients, and we can’t do that if we haven’t been given abortion training.”

Another consideration: Most graduating medical students are in their 20s, “the age when people are starting to think about putting down roots and starting families,” said Gray, who added that she is noticing many more students ask about politics during their residency interviews.

And because most young doctors make their careers in the state where they do their residencies, “people don’t feel safe potentially having their own pregnancies living in those states” with severe restrictions, said Debra Stulberg, chair of the Department of Family Medicine at the University of Chicago.

Stulberg and others worry that this self-selection away from states with abortion restrictions will exacerbate the shortages of physicians in rural and underserved areas.

“The geographic misalignment between where the needs are and where people are choosing to go is really problematic,” she said. “We don’t need people further concentrating in urban areas where there’s already good access.”

After attending medical school in Tennessee, which has adopted one of the most sweeping abortion bans in the nation, Hannah Light-Olson will start her OB-GYN residency at the University of California-San Francisco this summer.

It was not an easy decision, she said. “I feel some guilt and sadness leaving a situation where I feel like I could be of some help,” she said. “I feel deeply indebted to the program that trained me, and to the patients of Tennessee.”

Light-Olson said some of her fellow students applied to programs in abortion ban states “because they think we need pro-choice providers in restrictive states now more than ever.” In fact, she said, she also applied to programs in ban states when she was confident the program had a way to provide abortion training.

“I felt like there was no perfect, 100% guarantee; we’ve seen how fast things can change,” she said. “I don’t feel particularly confident that California and New York aren’t going to be under threat, too.”

As a condition of a scholarship she received for medical school, Blum said, she will have to return to Arizona to practice, and it is unclear what abortion access will look like then. But she is worried about long-term impacts.

“Residents, if they can’t get the training in the state, then they’re probably less likely to settle down and work in the state as well,” she said.

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Fighting the problem presents tension for the administration: how to thwart the bad actors without affecting ACA sign-ups.

Complaints about these unauthorized changes — which can cause affected policyholders to lose access to medical care, pay higher deductibles, or even incur surprise tax bills — rose sharply in recent months, according to brokers who contacted Ģ��ӰԺ Health News and federal workers who asked not to be identified.

Ronnell Nolan, president and CEO of the trade association Health Agents for America, said her group has suggested to the Centers for Medicare & Medicaid Services that it add two-factor authentication to healthcare.gov or send text alerts to consumers if an agent tries to access their accounts. But the agency told her it doesn’t always have up-to-date contact information.

“We’ve given them a whole host of ideas,” she said. “They say, ‘Be careful what you wish for.’ But we don’t mind going an extra step if you can stop this fraud and abuse, because clients are being hurt.”

Some consumers are pursued when they respond to misleading social media marketing ads promising government subsidies, but most have no idea how they fell victim to plan-switching. Problems seem concentrated in the 32 states using the federal exchange.

CMS about unauthorized ACA plan switches and enrollments in the first quarter of 2024, according to the agency.

The problem is big enough that CMS says it’s working on technological and regulatory solutions. Affected consumers and agents have filed a civil lawsuit in federal district court in Florida against private-sector firms allegedly involved in unauthorized switching schemes.

Biden has pushed hard to make permanent the enhanced subsidies first put in place during the covid pandemic that, along with other steps including increased federal funding for outreach, helped fuel the strong enrollment growth. Biden for the ACA with the stance of former President Donald Trump, who supported attempts to repeal most of the law and presided over funding cuts and declining enrollment.

Most proposed solutions to the rogue-agent problem involve making it more difficult for agents to access policyholder information or requiring wider use of identity questions tied to enrollees’ credit history. The latter could be stumbling blocks for low-income people or those with limited financial records, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

“That is the knife edge the administration has to walk,” said Corlette, “protecting consumers from fraudulent behavior while at the same time making sure there aren’t too many barriers.”

Jeff Wu, acting director of the Center for Consumer Information & Insurance Oversight, said in a statement that the agency is evaluating options on such factors as how effective they would be, their impact on consumers’ ability to enroll, and how fast they could be implemented.

The agency is also working closely, he wrote, with insurance companies, state insurance departments, and law enforcement “so that agents violating CMS rules or committing fraud face consequences.” And it is reaching out to states that run their own ACA markets for ideas.

That’s because Washington, D.C., and the 18 states that run their own ACA marketplaces have reported far fewer complaints about unauthorized enrollment and plan-switching. Most include layers of security in addition to those the federal marketplace has in place — some use two-factor authentication — before agents can access policyholder information.

California, for example, allows consumers to designate an agent and to “log in and add or remove an agent at will,” said Robert Kingston, interim director of outreach and sales for Covered California, the state’s ACA marketplace. The state can also send consumers a one-time passcode to share with an agent of their choice. Consumers in Colorado and Pennsylvania can similarly designate specific agents to access their accounts.

By contrast, agents can more easily access policyholder information when using private-sector websites that link them to the federal ACA market — all they need is a person’s name, date of birth, and state of residence — to enroll them or switch their coverage.

of such “enhanced direct enrollment” websites run by private companies, which are designed to make it easier and faster for agents certified to offer insurance through healthcare.gov.

last June requiring agents to get written or recorded consent from clients before enrolling them or changing their coverage, but brokers say they’re rarely asked to produce the documentation. If CMS makes changes to healthcare.gov — such as adding passcodes, as California has — it would need to require all alternative-enrollment partners to do the same.

The largest is San Francisco-based HealthSherpa, which assisted 52% of active enrollments nationally for this year, said CEO George Kalogeropoulos.

The company has a 10-person fraud investigation team, he said, which has seen “a significant spike in concerns about unauthorized switching.” They report problems to state insurance departments, insurance carriers, and federal regulators “and refer consumers to advocates on our team to make sure their plans are corrected.”

Solutions must be “targeted,” he said. “The issue with some of the solutions proposed is it negatively impacts the ability of all consumers to get enrolled.”

Most people who sign up for ACA plans are aided by agents or platforms like HealthSherpa, rather than doing it themselves or seeking help from nonprofit organizations. Brokers don’t charge consumers; instead, they receive commissions from insurers participating in state and federal marketplaces for each person they enroll in a plan.

While California officials say their additional layers of authentication have not noticeably affected enrollment numbers, the state’s recent enrollment growth than in states served by healthcare.gov.

Still, Covered California’s Kingston pointed to a decreased number of uninsured people in the state. In 2014, when much of the ACA was implemented, 12.5% of Californians were uninsured, , according to data compiled by Ģ��ӰԺ. That year, the share of people uninsured nationwide was 8%.

Corlette said insurers have a role to play, as do states and CMS.

“Are there algorithms that can say, ‘This is a broker with outlier behavior’?” Insurance companies could then withhold commissions “until they can figure it out,” she said.

Kelley Schultz, vice president of commercial policy at AHIP, the trade association for large insurance companies, said sharing more information from the government marketplace about which policies are being switched could help insurers spot patterns.

CMS could also set limits on plan switches, as there is generally no legitimate need for multiple changes in a given month, Schultz said.

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A menagerie of other animals have been infected by H5N1, and at least one person in Texas. But what scientists fear most is if the virus were to spread efficiently from person to person. That hasn’t happened and might not. Shah said the CDC considers the H5N1 outbreak “a low risk to the general public at this time.”

Viruses evolve and outbreaks can shift quickly. “As with any major outbreak, this is moving at the speed of a bullet train,” Shah said. “What we’ll be talking about is a snapshot of that fast-moving train.” What he means is that what’s known about the H5N1 bird flu today will undoubtedly change.

With that in mind, Ģ��ӰԺ Health News explains what you need to know now.

Q: Who gets the bird flu?

Mainly birds. Over the past few years, however, the H5N1 bird flu virus has from birds into mammals around the world. The growing list of more than 50 species includes seals, goats, skunks, cats, and wild bush dogs at a zoo in the United Kingdom. At least died in outbreaks of H5N1 bird flu in South America last year.

What makes the current outbreak in cattle unusual is that it’s spreading rapidly from cow to cow, whereas the other cases — except for the sea lion infections — appear limited. Researchers because genetic sequences of the H5N1 viruses drawn from cattle this year were nearly identical to one another.

The cattle outbreak is also concerning because the country has been caught off guard. Researchers suggest it originally spilled over from birds into cows late last year in Texas, and has since spread among many more cows than have been tested. “Our analyses show this has been circulating in cows for four months or so, under our noses,” said Michael Worobey, an evolutionary biologist at the University of Arizona in Tucson.

Q: Is this the start of the next pandemic?

Not yet. But it’s a thought worth considering because a bird flu pandemic would be a nightmare. More than infected by older strains of H5N1 bird flu viruses from 2003 to 2016 died. Even if death rates turn out to be less severe for the H5N1 strain currently circulating in cattle, repercussions could involve loads of sick people and hospitals too overwhelmed to handle other medical emergencies.

Although at least one person has been infected with H5N1 this year, the virus can’t lead to a pandemic in its current state. To achieve that horrible status, a pathogen needs to sicken many people on multiple continents. And to do that, the H5N1 virus would need to infect a ton of people. That won’t happen through occasional spillovers of the virus from farm animals into people. Rather, the virus must acquire mutations for it to spread from person to person, like the seasonal flu, as a respiratory infection transmitted largely through the air as people cough, sneeze, and breathe. As we learned in the depths of covid-19, airborne viruses are hard to stop.

That hasn’t happened yet. However, H5N1 viruses now have plenty of chances to evolve as they replicate within thousands of cows. Like all viruses, they mutate as they replicate, and mutations that improve the virus’s survival are passed to the next generation. And because cows are mammals, the viruses could be getting better at thriving within cells that are closer to ours than birds’.

The evolution of a pandemic-ready bird flu virus could be aided by a sort of superpower possessed by many viruses. Namely, they sometimes swap their genes with other strains in a process called reassortment. In a study published in 2009, Worobey and other of the H1N1 “swine flu” pandemic to events in which different viruses causing the swine flu, bird flu, and human flu mixed and matched their genes within pigs that they were simultaneously infecting. Pigs need not be involved this time around, Worobey warned.

Q: Will a pandemic start if a person drinks virus-contaminated milk?

Not yet. Cow’s milk, as well as powdered milk and infant formula, sold in stores is considered safe because the law requires all milk sold commercially to be pasteurized. That process of heating milk at high temperatures kills bacteria, viruses, and other teeny organisms. Tests have identified fragments of H5N1 viruses in milk from grocery stores but confirm that the virus bits are dead and, therefore, harmless.

Unpasteurized “raw” milk, however, has been shown to contain living H5N1 viruses, which is why the FDA and other health authorities strongly advise people not to drink it. Doing so could cause a person to become seriously ill or worse. But even then, a pandemic is unlikely to be sparked because the virus — in its current form — does not spread efficiently from person to person, as the seasonal flu does.

Q: What should be done?

A lot! Because of a lack of surveillance, the U.S. Department of Agriculture and other agencies have allowed the H5N1 bird flu to spread under the radar in cattle. To get a handle on the situation, the all lactating dairy cattle to be tested before farmers move them to other states, and the outcomes of the tests to be reported.

But just as restricting covid tests to international travelers in early 2020 allowed the coronavirus to spread undetected, testing only cows that move across state lines would miss plenty of cases.

Such limited testing won’t reveal how the virus is spreading among cattle — information desperately needed so farmers can stop it. A leading hypothesis is that viruses are being transferred from one cow to the next through the machines used to milk them.

To boost testing, Fred Gingrich, executive director of a nonprofit organization for farm veterinarians, the American Association of Bovine Practitioners, said the government should offer funds to cattle farmers who report cases so that they have an incentive to test. Barring that, he said, reporting just adds reputational damage atop financial loss.

“These outbreaks have a significant economic impact,” Gingrich said. “Farmers lose about 20% of their milk production in an outbreak because animals quit eating, produce less milk, and some of that milk is abnormal and then can’t be sold.”

The government has made the H5N1 tests free for farmers, Gingrich added, but they haven’t budgeted money for veterinarians who must sample the cows, transport samples, and file paperwork. “Tests are the least expensive part,” he said.

If testing on farms remains elusive, evolutionary virologists can still learn a lot by analyzing genomic sequences from H5N1 viruses sampled from cattle. The differences between sequences tell a story about where and when the current outbreak began, the path it travels, and whether the viruses are acquiring mutations that pose a threat to people. Yet this vital research has been hampered by the USDA’s slow and incomplete posting of genetic data, Worobey said.

The government should also help poultry farmers prevent H5N1 outbreaks since those kill many birds and pose a constant threat of spillover, said Maurice Pitesky, an avian disease specialist at the University of California-Davis.

Waterfowl like ducks and geese are the usual sources of outbreaks on poultry farms, and researchers can detect their proximity using and other technologies. By zeroing in on zones of potential spillover, farmers can target their attention. That can mean routine surveillance to detect early signs of infections in poultry, using water cannons to shoo away migrating flocks, relocating farm animals, or temporarily ushering them into barns. “We should be spending on prevention,” Pitesky said.

Q: OK it’s not a pandemic, but what could happen to people who get this year’s H5N1 bird flu?

No one really knows. Only one person in Texas has been diagnosed with the disease this year, in April. worked closely with dairy cows, and had a mild case with an eye infection. The CDC found out about them because of its surveillance process. Clinics are supposed to alert state health departments when they diagnose farmworkers with the flu, using tests that detect influenza viruses, broadly. State health departments then confirm the test, and if it’s positive, they send a person’s sample to a CDC laboratory, where it is checked for the H5N1 virus, specifically. “Thus far we have received 23,” Shah said. “All but one of those was negative.”

State health department officials are also monitoring around 150 people, he said, who have spent time around cattle. They’re checking in with these farmworkers via phone calls, text messages, or in-person visits to see if they develop symptoms. And if that happens, they’ll be tested.

Another way to assess farmworkers would be to check their blood for antibodies against the H5N1 bird flu virus; a positive result would indicate they might have been unknowingly infected. But Shah said health officials are not yet doing this work.

“The fact that we’re four months in and haven’t done this isn’t a good sign,” Worobey said. “I’m not super worried about a pandemic at the moment, but we should start acting like we don’t want it to happen.”

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Since then, mandatory reporting laws have expanded nationally to include more types of maltreatment — including neglect, which now accounts for most reports — and have increased the number of professions required to report. In some states, are required to report what they suspect may be abuse or neglect.

But now there are efforts in Colorado and other states to roll back these laws, saying the result has been too many unfounded reports, and that they disproportionately harm families that are poor, Black, or Indigenous, or have members with disabilities.

“There’s a long, depressing history based on the approach that our primary response to a struggling family is reporting,” said Mical Raz, a physician and historian at the University of Rochester in New York. “There’s now a wealth of evidence that demonstrates that more reporting is not associated with better outcomes for children.”

Stephanie Villafuerte, Colorado’s child protection ombudsman, oversees a task force to reexamine the state’s mandatory reporting laws. She said the group is seeking to balance a need to report legitimate cases of abuse and neglect with a desire to weed out inappropriate reports.

“This is designed to help individuals who are disproportionately impacted,” Villafuerte said. “I’m hoping it’s the combination of these efforts that could make a difference.”

Some critics worry that changes to the law could result in missed cases of abuse. Medical and child care workers on the task force have expressed concern about legal liability. While it’s rare for people to be criminally charged for failure to report, they can also face civil liability or professional repercussions, including threats to their licenses.

Being reported to child protective services is becoming increasingly common. More than 1 in 3 children in the United States will be the subject of a child abuse and neglect investigation by the time they turn 18, according to the most frequently cited estimate, a funded by the Department of Health and Human Services’ Children’s Bureau.

Black and Native American families, poor families, and or with disabilities experience even more oversight. Research has found that, among these groups, parents are more likely to lose parental rights and children are more likely to wind up in foster care.

In an of investigations, no abuse or neglect is substantiated. Nonetheless, researchers who study describe them as terrifying and isolating.

In Colorado, the number of child abuse and neglect reports has increased 42% in the past decade and reached a record 117,762 last year, according to . Roughly 100,000 other calls to the hotline weren’t counted as reports because they were requests for information or were about matters like child support or adult protection, said officials from the Colorado Department of Human Services.

The increase in reports can be traced to a policy of encouraging a broad array of professionals — including school and medical staff, therapists, coaches, clergy members, firefighters, veterinarians, dentists, and social workers — to call a hotline whenever they have a concern.

These calls don’t reflect a surge in mistreatment. More than two-thirds of the reports received by agencies in Colorado don’t meet the threshold for investigation. Of the children whose cases are assessed, 21% are found to have experienced abuse or neglect. The actual has not risen over the past decade.

While studies do not demonstrate that mandatory reporting laws keep children safe, the Colorado task force , there is evidence of harm. “Mandatory reporting disproportionately impacts families of color” — initiating contact between child protection services and families who routinely do not present concerns of abuse or neglect, the task force said.

The task force said it is analyzing whether better screening might mitigate “the disproportionate impact of mandatory reporting on under-resourced communities, communities of color and persons with disabilities.”

The task force pointed out that the only way to report concerns about a child is with a formal report to a hotline. Yet many of those calls are not to report abuse at all but rather attempts to connect children and families with resources like food or housing assistance.

Hotline callers may mean to help, but the families who are the subjects of mistaken reports of abuse and neglect rarely see it that way.

That includes Meighen Lovelace, a rural Colorado resident who asked Ģ��ӰԺ Health News not to disclose their hometown for fear of attracting unwanted attention from local officials. For Lovelace’s daughter, who is neurodivergent and has physical disabilities, the reports started when she entered preschool at age 4 in 2015. The teachers and medical providers making the reports frequently suggested that the county human services agency could assist Lovelace’s family. But the investigations that followed were invasive and traumatic.

“Our biggest looming fear is, ‘Are you going to take our children away?’” said Lovelace, who is an advocate for the Colorado Cross-Disability Coalition, an organization that lobbies for the civil rights of people with disabilities. “We’re afraid to ask for help. It’s keeping us from entering services because of the fear of child welfare.”

State and county human services officials said they could not comment on specific cases.

The Colorado task force plans to suggest clarifying the definitions of abuse and neglect under the state’s mandatory reporting statute. Mandatory reporters should not “make a report solely due to a family/child’s race, class or gender,” nor because of inadequate housing, furnishings, income or clothing. Also, there should not be a report based solely on the “disability status of the minor, parent or guardian,” according to the group’s draft recommendation.

The task force plans to recommend additional training for mandatory reporters, help for professionals who are deciding whether to make a call, and an alternative phone number, or “warmline,” for cases in which callers believe a family needs material assistance, rather than surveillance.

Critics say such changes could leave more children vulnerable to unreported abuse.

“I’m concerned about adding systems such as the warmline, that kids who are in real danger are going to slip through the cracks and not be helped,” said Hollynd Hoskins, an attorney who represents victims of child abuse. Hoskins has sued professionals who fail to report their suspicions.

The Colorado task force includes health and education officials, prosecutors, victim advocates, county child welfare representatives and attorneys, as well as five people who have experience in the child welfare system. It intends to finalize its recommendations by early next year in the hope that state legislators will consider policy changes in 2025. Implementation of any new laws could take several years.

Colorado is one of several states — including and — that have recently considered changes to restrain, rather than expand, reporting of abuse. In New York City, teachers are being trained to before making a report, while New York state to help connect families with resources like housing and child care. In California, a state aimed at shifting “mandated reporting to community supporting” is planning recommendations .

Among those advocating for change are people with experience in the child welfare system. They include , who leads the Denver-based MJCF Coalition, which advocates for the abolition of mandatory reporting along with the rest of the child welfare system, citing its damage to Black, Native American, and Latino communities.

“Mandatory reporting is another form of keeping us policed and surveillanced by whiteness,” said Jihad, who as a child was taken from the care of a loving parent and placed temporarily into the foster system. Reform isn’t enough, she said. “We know what we need, and it’s usually funding and resources.”

Some of these resources — like affordable housing and child care — don’t exist at a level sufficient for all the Colorado families that need them, Jihad said.

Other services are out there, but it’s a matter of finding them. Lovelace said the reports ebbed after the family got the help it needed, in the form of a Medicaid waiver that paid for specialized care for their daughter’s disabilities. Their daughter is now in seventh grade and doing well.

None of the caseworkers who visited the family ever mentioned the waiver, Lovelace said. “I really think they didn’t know about it.”

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