Should insurers pay the same reimbursement rate for 'audio-only' visits as when a patient is sitting in a doctor’s office?
This article was published on Wednesday, December 8, 2021 in Kaiser Health News.
By Julie Appleby
Maybe this has happened to you recently: Your doctor telephoned to check in with you, chatting for 11 to 20 minutes, perhaps answering a question you contacted her office with, or asking how you’re responding to a medication change.
For that, your doctor got paid about $27 if you are on Medicare — maybe a bit more if you have private insurance.
Behind those calls is a four-digit “virtual check-in” billing code created during the pandemic, for phone conversations lasting just within that range, which has drawn outsize interest from physician groups.
It’s part of a much bigger, increasingly heated debate: Should insurers pay for “audio-only” visits? And, if they do, should they pay the same reimbursement rate as when a patient is sitting in a doctor’s office, as has been allowed during the pandemic?
Cutting off or reducing audio-only payments could lead providers to sharply curtail telehealth services, warn some physician groups and other experts. Other stakeholders, including employers who pay for health coverage, fear payment parity for audio-only telehealth visits could lead to overbilling. Will it lead, for example, to a flood of unneeded follow-up calls?
Robert Berenson, an Institute Fellow at the Urban Institute, who has spent much of his career studying payment methods, said if insurers pay too little, doctors — now accustomed to the reimbursement — might no longer make the follow-up calls they might have made for free pre-pandemic.
But, he added, “if you pay what they want, parity with in-person, you’ll have a run on the treasury. The right policy is somewhere in between.”
Medicare billing codes, while a dull and arcane topic, draw keen interest from doctors, hospitals, therapists and others because they are the basis for health care charges in the United States. Medicare’s verdict serves as a benchmark and guide for private insurers in setting their own payment policies.
Thousands of codes exist, describing every possible type of treatment. Without a code, there can be no payment. The creation of codes and Medicare’s determination of a reimbursement amount, designed to reflect the amount of work involved, prompt ferocious lobbying by the business interests involved. The American Medical Association derives a chunk of revenue from owning the rights to a specific set of physician billing codes. Other codes are developed by dental groups, as well as the Centers for Medicare & Medicaid Services or state Medicaid agencies.
The idea of a “virtual check-in” code began before the pandemic, in 2019, when Medicare included it to cover five- to 10-minute telephone calls for doctors to respond to established patients. It pays about $14.
When the pandemic hit, Congress and the Trump administration opened the door wider to telehealth, temporarily lifting restrictions — mainly those limiting such services to rural areas.
Meanwhile, CMS this year added a billing code for longer “virtual check-ins” — 11- to 20-minute calls — with payment set at about $27 a pop, with the patient contributing 20% in copayment. Such calls are meant to determine whether a patient needs to come in or otherwise have a longer evaluation visit, or if their health concern can simply be handled over the phone.
And physicians argue that allowing payments for audio-only care is a positive step for them and for their patients.
“I take care of patients who drive from two or three hours away and live in places without broadband access,” said Dr. Jack Resneck Jr., a dermatologist and president-elect of the American Medical Association. “For these patients, it’s important to have a backup when the video option doesn’t’ work.”
Still, the focus on telephone-only care has raised concerns.
“Here’s an invitation to convert every five-minute call into an 11- to 20-minute call,” said Berenson.
The Medicare code allows “other qualified health professionals,” such as physician assistants or nurse practitioners, to bill for such calls. Private insurers would set their own rules about whether non-physicians can bill for follow-up calls. It’s not clear how much of a revenue stream dedicating such staff members to make these short, telephone check-ins would create for a medical practice.
To avoid overuse, CMS did set rules: The code can’t be used if the call takes place within seven days of an evaluation visit, either in person or through telemedicine. Nor can a doctor bill for the call if he or she determines the patient needs to come in right away.
When the health emergency ends, however, so do most audio-only payments. The emergency is expected to last at least through the end of the year. Congress or, possibly, CMS could change the rules on audio-only payments, and much more lobbying is expected.
While the virtual check-in codes have been made permanent, physician groups are lobbying for Medicare to retain a host of other telephone-only-visit codes created during the pandemic, including several that allow physicians to bill for telephone-only visits in which the doctor potentially diagnoses a patient’s condition and sets up a treatment plan.
For those, considered “evaluation and management” audio visits, Medicare during the public health emergency has paid about $55 for a five- to 10-minute call and $89 for one that runs 11 to 20 minutes — the same as for an in-office visit.
“Whether we see patients in house, by video or by phone, we need the same coding” and the same payments, because a similar amount of work is involved, said Dr. Ada Stewart, the board chair for the American Academy of Family Physicians.
Many patients like the concept of telehealth, according to Suzanne Delbanco, executive director of Catalyst for Payment Reform, a group representing employers who want payment methods for health care to be overhauled. And, for some patients, it’s the easiest way to see a doctor, especially for those who live far from urban areas or are unable to take time off work or away from home.
But, she said, employers “don’t want to get locked into paying more for it than they have in past, or as much as other [in-person] visits when it’s not truly the same value to the patient.”
Ad campaign says parts of the legislation would have 'serious unintended consequences' for cancer patients.
This article was published on Wednesday, December 8, 2021 in Kaiser Health News.
By Julie Appleby
“An independent analysis shows that payments for cancer care will be slashed by close to 45% causing cancer clinics to close and massively raising your healthcare costs”
A radio ad sponsored by the Community Oncology Alliance, Nov. 29.
An advertisement from the Community Oncology Alliance, part of a $1.6 million campaign running both on radio airwaves and in print, attacks a proposal in the Democratic-backed Build Back Better package approved by the House last month and now headed to the Senate.
The ads, which started on Nov. 29 and are set to run through Dec. 12, say parts of the legislation would have “serious unintended consequences” for cancer patients — specifically, that “an independent analysis shows that payments for cancer care will be slashed by close to 45%, causing cancer clinics to close and massively raising your healthcare costs.” The alliance is an advocacy and lobbying organization representing physicians and clinics involved with cancer care.
The Build Back Better plan is the Biden administration’s legislative proposal that includes an array of provisions, from plans to curb prescription drug costs to expansion of Medicare coverage. The provision targeted by the alliance’s ad would empower the federal government to negotiate prices for a small set of yet unnamed expensive drugs, including cancer treatments, with the aim of lowering prices, an important campaign promise issued by both President Joe Biden and numerous congressional Democrats.
That got us wondering: Would the plan really result in reduced payments for cancer care and higher health care costs, as the ads claim?
Because drug pricing and negotiations — as well as the Senate action on the proposal — are such hot news, we took a closer look.
The experts we talked to expressed no doubt that certain provisions of the Build Back Better proposal, if passed into law, would reduce some payments to oncology offices. But we found that the advertisement leaves out key details about the scope of those cuts, an omission that could mislead people who hear or see the ads.
About That Cut
The oncologists’ ad is just one of many ads in recent weeks seeking to sway opinions as Congress considers legislation that would allow Medicare to negotiate drug prices, something it currently cannot do.
At the root of the ad’s claim is the way Medicare pays for drugs administered in doctors’ offices. These payments are particularly important to some specialists, including oncologists. Lower prices paid by the government for these drugs also result in less administrative revenue for physician offices.
Oncologists and other specialists provide injections or infusions in a medical office, covered by Part B of Medicare. Medicare reimburses physicians for the cost of the drug based on its average sales price, plus a 6% “add-on” payment, which is meant to cover the cost of overhead, staffing and the effort that goes into purchasing the drug. (Pre-pandemic, those payments were reduced to 4.3% under a complicated budget sequester process but were reinstated at the higher level for the duration of the health emergency.)
The percentage-based payment formula has the unintended consequence of incentivizing expensive drugs over lower-cost options: A 6% add-on to a $10,000 drug translates to a lot more money than for a $1,000 drug.
The Build Back Better Act, as passed by the House, would have Medicare negotiate prices for a small number of high-priced drugs, including those used by oncologists under Part B, starting in 2025. At first, only 10 drugs would be selected, rising to 20 in 2028.
There would be an upper limit on price, called the Maximum Fair Price, which is expected to be lower than average sales prices. That would save Medicare and taxpayers money on those drugs.
Patients, too, might save money because their copays are set as a percentage of the cost of the drug. Oncologists would still get a 6% add-on fee for overhead and administration, but that 6% would be on a lower price, hence the decrease in revenue that concerns the doctors.
What the Oncologists Say
We reached out to the Community Oncology Alliance to ask about the ad’s assertions that payments for cancer care would be cut by 45%. It provided a number of reports, including one it commissioned by consulting firm Avalere Health, that calculated the possible revenue loss, and a separate study that tracks mergers, acquisitions, closures and financial matters affecting oncology practices.
For its report, Avalere chose 10 drugs it thought were likely to make the administration’s list, then calculated the likely negotiated price and the resulting add-on payments.
While it varies by specialty, the overall average reduction in add-on revenue would be 39% for those specific 10 drugs, with physician offices seeing a 44.2% drop, and hospitals seeing a 36% decline, said Milena Sullivan, a principal with the health policy team at Avalere and the report’s lead author.
But the wording in the ad — “payments for cancer care will be slashed by close to 45%” — glosses over the specifics of that finding. It seems to suggest overall revenue for community cancer clinics would be cut 45%, whereas the reduction identified in the study affects only a segment of their revenue: the add-on payments for some such drugs that clinics and physicians provide.
“They commissioned an analysis that did not look at the total impact on community oncology practice finances. They looked just at drugs affected, which wildly inflates impact,” said Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center and an expert on drug costs.
Without details on what percentage of a practice’s revenue comes from the add-on payments for a specific set of drugs that has yet to be defined, “we don’t know how much this is going to reduce oncologists’ income,” said Paul Van de Water, a senior fellow in health care policy at the Center on Budget and Policy Priorities.
Ted Okon, executive director for the alliance, defended the wording, saying, “You can only say so much in an ad.”
“Those are the biggest drugs out there,” Okon said. “If you take a hit of 42.9% on 70% of your practice, or even 60%, you are dead in the water.”
However, the alliance didn’t have specific data on the overall percentage of revenue that the add-on payments represent.
Will Cancer Clinics Close?
Okon argues that the revenue hit will be substantial enough that it would lead some practices to close, others to merge and still others to be sold to hospitals. The new maximum prices in Medicare would also affect how private insurers calculate their payments, he said, possibly adding to the revenue woes.
Already, financial pressures have led to closures, mergers or financial difficulty for more than 1,700 community practices over the past 12 years, shifting a portion of cancer care “from independent practice settings to hospitals,” he said.
He thinks that reduces patient choice and could also lead to higher costs for Medicare and patients, because they then seek care at hospitals, which are more expensive.
Joseph Antos, a senior fellow at the American Enterprise Institute, expressed doubts. He said that the Avalere analysis looks correct and that practices will lose a chunk of revenue from add-on payments.
“The impact would be pretty substantial,” he said. “But that doesn’t mean this business about clinics closing is right.”
Our Ruling
The advertisement says an independent analysis shows that under the Build Back Better bill as it’s currently written, “payments for cancer care will be slashed by close to 45% causing cancer clinics to close and massively raising your healthcare costs.”
The advertisement leaves out important context about the analysis.
For one, the cuts it cites are to an unspecified portion of oncologists’ revenue, the add-on revenue for administering certain drugs. Secondly, it isn’t yet known which drugs will be affected. The cuts may well prove substantial for some practices, particularly those that use a lot of the treatments ultimately selected for price negotiation.
As to closures, even without this change, some clinics will face financial stress leading to mergers, or sales to hospitals, mirroring what is happening in other sectors of the health industry.
The argument that fewer clinics could lead more patients to get cancer care in hospitals — at higher costs to them, to Medicare and to private insurers — is economically plausible. But lower cancer drug costs in Medicare would mean savings for patients, since the program limits copayment amounts for patients who don’t have supplemental insurance to cover those costs.
Rais Vohra, MD, interim health officer for Fresno County Department of Public Health, spoke with KHN’s Jenny Gold about the "why" behind the persistent surges and the toll on Fresno’s health care system.
This article was published on Tuesday, December 7, 2021 in Kaiser Health News.
Dr. Rais Vohra has impeccable timing. He stepped into his role as interim health officer of Fresno County just months before the start of the covid-19 pandemic. Almost immediately, he found himself navigating the treacherous tensions between public health messaging and a skeptical population in a hub of industrial agriculture that is also one of the most politically conservative regions of California.
First came the anti-mask protests, amplified by vows from the county sheriff that her deputies would refuse to enforce the state’s mask mandate. Next was the vocal resentment of covid-related business restrictions. Cap that off with roiling distrust of the new covid vaccines and a large migrant farmworker population with long-standing challenges accessing health care. Little surprise, then, that as of Dec. 3, about 55% of Fresno County residents were fully vaccinated, nearly 10 percentage points lower than the statewide average. In some rural pockets of the county, fewer than 40% of residents are fully vaccinated.
For almost two years, Vohra and the rest of the county’s health care system have struggled to keep up with what has felt like an unrelenting series of covid surges. The current wave has overwhelmed area hospitals, with emergency rooms so packed that ambulances line up for hours waiting to offload patients. Nearly 160,000 cases of covid have been recorded, and more than 2,200 residents have died.
Fresno County stretches over 6,000 square miles and includes the city of Fresno — the Central Valley’s urban core — as well as vast expanses of farmland. The county is home to about 1 million residents, a little more than half of whom are Latino.
Vohra, who is also a professor of clinical emergency medicine at UCSF-Fresno, spoke with KHN’s Jenny Gold about the “why” behind the persistent surges and the toll on Fresno’s health care system. The conversation has been edited for length and clarity.
Q: Fresno County’s covid hospitalization rate is four times what Los Angeles County is seeing and eight times San Francisco’s rate. Why?
The whole state experienced a surge in the fall. And when the surge resolved in the rest of the state, unfortunately our numbers did not come down. We plateaued. We may be having another surge this winter, so not to be able to recover our resources and give people time to debrief and think about how to prepare for the next one is obviously very concerning.
Our vaccination rates are not where we need them to be. The amount of masking that we have is definitely lower, and we weren’t able to get a mask mandate. We also have a lot of essential workers. A remote worker who can “Zoom in” is very different from someone who works at Foster Farms, who has to show up and doesn’t have any time off left. Every little thing is connected to every other little thing.
Q: Why does the county’s vaccination rate continue to lag behind rates in much of the state?
There are some people who are still struggling with access, and we’re absolutely trying to address that. Then there are other people who are just not accepting the science, and I don’t know how to get those folks to buy in. I think that the emotion comes first and the reasoning comes later.
Is it disappointing? Yeah, it is. Are we trying to do the right thing and improve that rate? Of course we are.
But when you look at all the things that we’ve been hearing, sometimes I’m pleasantly surprised. A million doses of vaccine have been given. If you told me a year ago we were going to get that done in less than a year, I would not have believed it.
Q: Fresno’s hospital network is struggling to absorb the covid patient load and has pleaded with other counties to take patients. Are you getting help?
We have only seven acute care hospitals here in Fresno County. We probably need twice that many to serve the population. They’re always running at a very high capacity, sometimes over 100% of what they’re licensed for. And so this covid surge really was very challenging.
You would think that given all of our informatics technology, we would have a way to share the burden and transfer people. But that’s not how the system is designed. We had a great conversation with our state partners and all the other hospitals to talk about this, and I’m hoping that something materializes. But these are not easy questions to answer.
In addition to just the logistical issues of finding an open bed and an EMS [emergency medical services] transportation vehicle with the right people able to manage a critically ill patient over hundreds of miles, you also have to have patients consenting. And, it turns out, patients and their families actually resist if you tell them, “Your family member is going to get great care, but it’ll be 100 or 200 miles away.”
Q: When you said Fresno needs twice as many hospitals, did you mean in covid times or normal times?
Non-covid times. We have such a shortage of clinicians and we have such a shortage of nurses that it’s really hard to meet the needs of the patients. The population has grown a lot faster than the hospitals.
Rural hospitals are actually limiting their services, not adding new ones, and that’s just part of a much larger and more tragic story about the health care landscape.
Q: As health officer in Fresno County, you’re operating at a point of natural tension amid the anti-mask and anti-vaccination sentiments. How have you been navigating that?
It’s been very interesting, very humbling and also very instructive. It actually makes us have to be very sure about the recommendations we’re making, because we know they’re going to get scrutinized.
Sometimes we’re disappointed. For example, we really tried hard to get a mask mandate when we saw that the fall surge was impending. And, unfortunately, our county just did not want to embrace that. People were just ready to be done, and to bring it back was not even an option.
Q: I imagine the public health staff and health care providers are exhausted. What are you seeing?
There’s an element of exhaustion and fatigue that I’ve never seen in my colleagues before the pandemic came along. In the early days, we all talked about health care heroes, and even though it was scary and surreal, we had a lot of adrenaline. But that ran out a long time ago. Now people are just managing as best they can.
In the hospitals, many people are really just fed up with a lot of this anti-vaccination sentiment. Because they’re the ones taking care of the people who get sick. It is very sad to see and to live through. What it does, though, is bond people in a way that only severe trauma can. At this point, if you’re still going into work every day, despite your exhaustion, it’s because you really love the team that you’re working with. I certainly see that in our health department.
Q: Your wife, Dr. Stacy Sawtelle Vohra, is an emergency physician at Community Regional Medical Center in Fresno, so also on the covid front lines. What has been the toll on your family?
Whenever there’s high transmission in our community, that affects us personally, too, and people have to take time off of work to take care of relatives or get checked out. We’ve had our kids tested because they came down with the sniffles. And you have to keep a kid out of school when they get their test. Living through that, you understand that if I wasn’t able to do my meetings from home, this would become just an impossibility. We haven’t created good solutions for our communities, especially for parents who have to work and don’t have good child care options.
We’re both fortunate that we have employers that are understanding and flexible. We have two young children who are 4 and 7, and their biggest priority was to make sure that the Elf on the Shelf showed up today. For better or worse, we’re good compartmentalizers, and we just leave all that stuff at the office or in the emergency department. And when we’re home, we’re a family. We just hope to give them as normal a childhood as they can have during this really challenging time.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Covid ravaged communities across the United States and laid bare how marginalized populations lose out in the scrum for public health dollars and specific populations were left vulnerable.
This article was published on Tuesday, December 7, 2021 in Kaiser Health News.
The ferocity of the covid-19 pandemic did what Black Pittsburgh — communities that make up a quarter of the city’s population — thought impossible. It shook the norms.
Black researchers, medical professionals and allies knew that people of color, even before covid, experienced bias in public health policy. As the deadly virus emerged, data analysts from Carnegie Mellon and the University of Pittsburgh, foundation directors, epidemiologists and others pooled their talents to configure databases from unwieldy state data to chart covid cases.
Their work documented yet another life-threatening disparity between white and Black Pittsburgh: People of color were at higher risk of catching the deadly virus and at higher risk of severe disease and death from that infection.
More than 100 weeks after advocates began pinging and ringing one another to warn of the virus’ spread, these volunteers are the backbone of the Black Equity Coalition, a grassroots collaboration that scrapes government data and shares community health intel.
About a dozen members of its data team of 60 meet twice weekly to study hospitalization rates and employment statistics. Social media advisers turned health equity into a buzzy online effort, with videos and weekly Facebook town halls, to encourage vaccinations. Local ministries are consulted, and volunteers take surveys at pop-up clinics, sponsored by other groups, at barbershops and hair salons. Elected lawmakers seek its counsel.
“We came together because we were concerned about saving lives,” said Tiffany Gary-Webb, associate dean for diversity and inclusion at the University of Pittsburgh, who oversees the data effort. “It evolved, with us realizing we can do more than address covid.”
Covid ravaged communities across the United States — more than 787,000 Americans have died, including Colin Powell, the first Black secretary of state and a decorated Army general — and laid bare how marginalized populations lose out in the scrum for public health dollars and specific populations were left vulnerable.
Months before the pandemic began, the Rev. Ricky Burgess led the Pittsburgh City Council to declare racism a public health crisis.
“Institutional racism is for real,” the councilman said in a recent interview. “You are talking about generational disproportional investment and generational disproportional treatment. And it impacts all that you see.”
The covid pandemic proved how structural inequities have been missed or ignored, Burgess said.
“I’ve lost friends, family and a lot of church members. My son had covid. For me it’s personal,” he said. “I knew immediately it would have a disproportionate effect.”
Using county data, the Black Equity researchers found a sobering racial gap in the Pittsburgh area: Black residents of Allegheny County saw disproportionate hospitalization rates — and were more likely to land in the ICU or on a ventilator — in the pandemic. Weekly hospitalization rates were higher during surges of infection in April, July and December 2020 and again in March and October 2021. Deaths, too, were disproportionate but fluctuated after December 2020.
For much of the pandemic, death rates were higher for African Americans than for other racial groups, the coalition said.
‘It’s All a Shade of Bad’
Kellie Ware has long considered health inequity a deadly problem. She graduated from Pittsburgh public schools, left for law school in Boston, and months before covid began its global assault she was working in her hometown mayor’s office as an equity and diversity policy analyst.
Ware was at her desk in late 2019 when her phone started ringing. A damning report, compiled by university sociologists and the city’s gender commission, had yet again detailed glaring disparities.
The blandly titled report, “Pittsburgh’s Inequality Across Gender and Race,” jolted emotions in the city of 303,000 people — and underscored how health disparities track with income.
Among the findings: Black people in Pittsburgh earned far less than their white neighbors and suffered far worse from disease. For every dollar white men earned, the report found, Black women earned 54 cents, making them five times as likely to live in poverty as white men.
With notably higher cardiovascular disease and cancer rates, Black residents’ life expectancy was about eight years less than white Pittsburghers’.
The report sparked a furor, which Ware met with perspective shaped over years away from the former steel town. “The report was factual,” Ware said, “but I know this: There’s not a ton of places where it’s great to be a Black woman. Those earnings? It’s 54 cents to a dollar for women in Pittsburgh. It’s 68 cents nationally. It’s all a shade of bad.”
The first signs of the pandemic supercharged Ware and others. As covid devastated New York in March 2020, Karen Abrams, a program officer at the Heinz Endowments, a foundation in Pittsburgh that spends $70 million a year on community programs, began connecting the dots in texts and calls with nonprofits, business owners and university researchers.
Covid spread quickly in dense multi-generational households and in Black neighborhoods in Chicago, Washington, New Orleans and Detroit. Abrams was among the advocates in Pennsylvania who watched county and state health systems race to prepare and who feared that Black residents would be underserved.
In Philadelphia, early on in the pandemic, volunteer doctors in mobile units began distributing protective equipment and covid tests in Black neighborhoods. In Pittsburgh, Abrams asked tech-minded allies to document the reality of covid infection in Pittsburgh. “We intuitively knew what was happening,” she said. “But without that data, we couldn’t target our attention and know who needed the help most.”
Within days, volunteers were on daylong rounds of video calls and appealing to county and state bureaucrats for more race-based statistics to bolster their research.
Fred Brown, president of the nonprofit Forbes Funds, and Mark Lewis, who heads the nonprofit Poise Foundation, were stalwarts of a “huddle,” a core of longtime advocates who eventually founded the coalition.
Brown emphasized pulling labor statistics to show that the essential workers keeping the city running — among them nursing homes aides and home care staff — were overwhelmingly Black or Latino.
Mapping covid testing centers and analyzing data proved sobering, he said. It turned out that the people most likely to be tested lived in Pittsburgh’s predominately white neighborhoods. Largely employed in tech, academia and finance, they could easily adapt to lockdowns. They had round-the-clock internet at home and could afford food deliveries to limit the chance of infection. Later, they could access vaccines quicker.
“The communities that had the most tests were the affluent ones,” Brown said. And those with the fewest “were the most resilient, the people who had to go out there and work.”
Lewis, a certified public accountant who spent years as a corporate auditor, focused on standards. County and state health professionals worked mightily to control the spread of covid but didn’t always gather data to ensure fairness in distribution, he said. “We realized that, as testing was done, it was not being recorded by race,” Lewis said. “Why? A lot of the issue was — at the state and the local level — there was no requirement to collect it.”
Gary-Webb said researchers had a sense of where the inequities would be found because they knew the neighborhoods. They first layered in percentages of Black families in poverty as well as data on the locations of federally qualified health centers to advise health authorities on where and when to increase testing.
University and nonprofit researchers found anomalies as they worked. For instance, race was noted on some testing data, with patients designated as Black, white or, inexplicably, unknown. The “unknowns” were a significant percentage. So researchers began layering additional census, labor and ZIP code data, to identify neighborhoods, even streets, at risk.
The ZIP code data took months to shake loose from state databases, largely because government software was slow in the fast-moving pandemic and government data was not updated regularly or formatted in ways that could be easily shared.
Their efforts paid off: The group was able to winnow down Allegheny County records that omit race to 12% of positive covid cases; 37% of statewide records are missing race details, the coalition reported.
Robert Gradeck, who manages the Western Pennsylvania Regional Data Center, a nonprofit data collaborative, said covid should play a lasting role in improving public health reporting. “We kept thinking: What can we learn from this?” Gradeck said. “It’s not that you can’t answer questions. But you can answer only part of them.”
Among the top recommendations to health authorities: adopt software practices to ensure that race and other demographic data must be entered into electronic records. And then refine how to share data among counties, states, research institutions and the public.
The coalition attracted support in monthly calls with state Health Secretary Rachel Levine, recently sworn in as a four-star admiral in charge of the U.S. Public Health Service Commissioned Corps, which responds to health crises on behalf of the federal government.
“I thought what they did was critically important,” Levine said, noting that officials recognized the coalition’s research as revelatory. With “a diverse group of professionals, they were able to use and collect data in a very effective way.”
Their early research found the covid rate among Black people in Allegheny County, which encompasses Pittsburgh, was three times the rate of white people. Hospitalizations among Black people have been as high as seven times the rate of whites, according to “Missing Our Shot,” the coalition’s 2021 report.
A Vaccine Clinic Campaign Stop
Ed Gainey, a state legislator from Pittsburgh, was among the first politicians to say African Americans in his hometown were missing out on covid protections. Last month, Gainey was elected the city’s first Black mayor, after winning a primary, within months of the murder of George Floyd, that pointed to inequities in health care and policing.
A Democrat who worked for two Pittsburgh mayors, Gainey admits he and other Black elected officials were somewhat ill-equipped in the first weeks of the pandemic.
"I fought hard to get the vaccine into the community last year, but I really didn't know the language — the health language — to be able to get it," Gainey said during an interview at a pop-up vaccine clinic in the city.
Vaccinations have risen because of community efforts, he said, but children are still a source of worry. Gainey, who grew up in a low-income housing complex, said he understands when some youngsters shrug when asked about covid risks. “But I will tell you I know this: If you can make a kid believe in Santa Claus, you can make them believe in the vaccine. And you know, I understand some of the young kids’ reluctance. I didn’t grow up going to the doctor regularly either,” he said. “I came from the same kind of environment.”
As the 2019 report made clear, many of the benefits of Pittsburgh’s tech-based economy — a vaunted “ed-and-meds” renewal against the industrial decline of the 1980s — still was largely bypassing African Americans.
The first year of covid was an iterative process of trying to stay ahead of the virus. Gary-Webb, who earned a doctorate from Johns Hopkins’ public health school, said it was also a time for Black residents to be heard about what they knew and saw in their neighborhoods.
The coalition, sustained by thousands of volunteer hours, attracted some funding earlier this year, notably for outreach and to pay for running datasets. Last month, the Poise Foundation was approved for a three-year, $6.99 million grant, federal money to be administered by the state health department to support an array of health partnerships in the region and, notably, to improve covid vaccine uptake in ZIP code areas the Black Equity Coalition identified as vulnerable. Among its goals: demographic messaging, data analysis on covid testing and education outreach in dozens of counties.
Gary-Webb counts herself among a group of “boomerang” Pittsburghers who have lived other places — in her case, Baltimore, New York and Philadelphia — and covid has helped them recalibrate how Black residents can participate in public health.
As she put it: “The health planners were saying, ‘Help us get out the message.’ We said, ‘No, we are not just getting out the message. We want to be talking about equity at the same time.’”
The Centers for Disease Control and Prevention has recommended that everyone 18 and older get a covid booster shot, revising its narrower guidance that only people 50 and up "should" get a shot while younger adults could choose whether or not to do so.
This article was published on Friday, December 3, 2021 in Kaiser Health News.
As more indoor venues require proof of vaccination for entrance and with winter — as well as omicron, a new covid variant — looming, scientists and public health officials are debating when it will be time to change the definition of “fully vaccinated” to include a booster shot.
It’s been more than six months since many Americans finished their vaccination course against covid; statistically, their immunity is waning.
At the same time, cases of infections with the omicron variant have been reported in at least five states, as of Friday. Omicron is distinguished by at least 50 mutations, some of which appear to be associated with increased transmissibility. The World Health Organization dubbed it a variant of concern on Nov. 26.
The Centers for Disease Control and Prevention has recommended that everyone 18 and older get a covid booster shot, revising its narrower guidance that only people 50 and up “should” get a shot while younger adults could choose whether or not to do so. Scientists assume the additional shots will offer significant protection from the new variant, though they do not know for certain how much.
Dr. Anthony Fauci, chief medical adviser to President Joe Biden, during a White House press briefing Wednesday was unequivocal in advising the public. “Get boosted now,” Fauci said, adding urgency to the current federal guidance. About a quarter of U.S. adults have received additional vaccine doses.
“The definition of ‘fully vaccinated’ has not changed. That’s, you know, after your second dose of a Pfizer or Moderna vaccine, after your single dose of a Johnson & Johnson vaccine,” said the CDC’s director, Dr. Rochelle Walensky, during Tuesday’s White House briefing on covid. “We are absolutely encouraging those who are eligible for a boost six months after those mRNA doses to get your boost. But we are not changing the definition of ‘fully vaccinated’ right now.” A booster is recommended two months after receiving the J&J shot.
But that, she noted, could change: “As that science evolves, we will look at whether we need to update our definition of ‘fully vaccinated.’”
Still, the Democratic governors of Connecticut and New Mexico are sending a different signal in their states, as are some countries — such as Israel, which arguably has been the most aggressive nation in its approach. Some scientists point out that many vaccines involve three doses over six months for robust long-term protection, such as the shot against hepatitis. So “fully vaccinated” may need to include shot No. 3 to be considered a full course.
“In my view, if you were vaccinated more than six months ago, you’re not fully vaccinated,” Connecticut Gov. Ned Lamont said Nov. 18 during a press briefing. He was encouraging everyone to get boosted at that time, even before the federal government authorized extra shots for everyone.
New Mexico Gov. Michelle Lujan Grisham had a similar response in mid-November, saying she defined “fully vaccinated” as receiving three shots of the mRNA type. She also opened up booster eligibility to all of her state residents before the CDC and Food and Drug Administration did.
What do the varying views on the evolving science mean for vaccine requirements imposed on travelers, or by schools or workplaces? And what about businesses that have required patrons to provide proof of vaccination?
Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Pennsylvania, said the CDC’s stronger recommendation for everyone to get boosted signals to him that a booster is now part of the vaccine regimen. Yet Offit, who is also a member of the FDA’s vaccine advisory committee, wrote a joint op-ed this week in which he and two other scientists argued that boosters were not yet needed for everyone and that healthy young people should wait to see whether an omicron-specific booster might be needed.
“I think when the CDC said they are recommending a third dose, they just made the statement that this is a three-dose vaccine series,” Offit told KHN. “And, frankly, I think it’s going to throw a wrench into mandates.”
Yet to be determined is whether restaurants or other places of business will look more closely at vaccine cards for the booster.
Dr. Georges Benjamin, executive director of the American Public Health Association, said it’s too early to say. “For now, businesses should stay focused on current guidelines,” he said.
Dr. Marc Siegel, an associate professor of medicine at the George Washington School of Medicine and Health Sciences, said the question of whether you are fully vaccinated with just two doses or need a booster is a question of semantics. Covid immunity level is the more important issue.
Siegel said he thinks more suitable terminology would be to call someone “appropriately” or “adequately” vaccinated against covid rather than “fully” vaccinated, since it’s possible that more boosters could be needed in the future — making “full vaccination” a moving target.
But, as with so many aspects of the pandemic, ambiguity prevails — both in federal guidance on the definition of “fully vaccinated” and in entrance policies, which vary by state, school and business.
Right now, businesses don’t appear to be checking for boosters, but that could change. So, it may be wise to first check the requirements — lest patrons present a two-shot vaccine passport, only to be turned away as inadequately protected.
In contrast to a surgical abortion, which usually takes place in a clinic, a medication abortion involves two pills, taken 48 hours apart, that manipulate the hormones to end a pregnancy.
This article was published on Monday, December 6, 2021 in Kaiser Health News.
Texas already had the most restrictive abortion laws in the U.S. — and they just got tougher. On Wednesday, a new law took effect that adds penalties of jail time and a fine of up to $10,000 for anyone who prescribes pills for medication abortions through telehealth or the mail.
Texas bans all abortions after cardiac activity can be detected in the embryo, which typically occurs about six weeks into pregnancy — often before people realize they’re pregnant. Medication abortions via telehealth or mail were already illegal in Texas, and the new criminal penalties took effect on the day the Supreme Court heard arguments in a Mississippi case that ultimately could overturn Roe v. Wade, the landmark 1973 ruling that established a constitutional right to abortion.
In contrast to a surgical abortion, which usually takes place in a clinic, a medication abortion involves two pills, taken 48 hours apart, that manipulate the hormones to end a pregnancy. Many people prefer this process early in a pregnancy because the pills can be taken at home. The Food and Drug Administration approved the drugs in 2000, and the procedure is effective up to 10 weeks into a pregnancy.
Texas is not the only state that restricts medication abortion and telehealth. This year alone, five other states have passed laws against sending abortion pills through the mail, said Elizabeth Nash, a state policy analyst with the Guttmacher Institute.
“It’s a squeeze play on abortion,” she said.
Nash said this crackdown is partially a response to the pandemic, which propelled interest in medication abortions.
“We saw the increase and, really, sort of the coming out of telehealth as part of medical practice,” she said.
Texas’ new law, known as SB 4, also narrows the legal window for medication abortion to the first seven weeks of pregnancy. State legislators passed this new law on Sept. 17 during a special session — more than two weeks after the other abortion law, often called the “six-week ban,” took effect on Sept. 1. Attempts to halt that law as groups challenge it in court have failed.
“We already have the most extreme abortion ban in the U.S. and yet our legislature made it a priority to add this additional abortion restriction,” said Sarah Wheat, chief external affairs officer with Planned Parenthood of Greater Texas.
Because of the six-week ban, the new limits on medication abortions won’t have an immediate impact. “Most people at this stage of a pregnancy are already banned from accessing abortion in Texas,” Wheat said.
But the new law could significantly affect future access to abortion.
By criminalizing the use of telehealth and mail-order prescriptions to acquire abortion pills, the state seeks to forestall a possible workaround to the shrinking number of reproductive health clinics in Texas.
Already, many Texans live hundreds of miles from the nearest clinic offering abortion services. Advocates have promoted the use of telehealth for medication abortions in places where clinics are few and far between, and some states experimented with greater telehealth flexibility — including for abortion pills — during the pandemic shutdowns.
The new law “is creating additional fear and additional stigma for people who may be seeking access to medication abortion,” Wheat said.
Anti-abortion groups in Texas hailed SB 4 as a victory — an important second step, after the six-week ban, in their efforts to curtail all access to the procedure in the state.
John Seago, legislative director for Texas Right to Life, said his group wanted to ensure that law enforcement officials could prosecute people who skirt the state’s strict limits by administering medication abortions.
“This piece is really important for this period but also moving into the future, when we see even after [Roe v. Wade] we have organizations and individuals advertising that they will mail abortion-inducing drugs,” he said.
Nash of the Guttmacher Institute said that in some states it has become easier for people to obtain medication abortions through telehealth services.
Seago said he wants to make sure that doesn’t happen in Texas.
“This is going to be a future public policy issue around abortion, no matter what happens to Roe v. Wade,” he said.
So far, no lawsuit has challenged Texas’ law restricting access to abortion pills. Mounting a legal challenge to halt the law is complicated because Texans already are effectively prohibited from all abortions after six weeks. Finding legal standing to sue would likely be difficult for any Texas plaintiff.
Ultimately, Wheat said, Texas’ latest law is a sign of what could happen elsewhere. She said it shows there is no end to efforts aimed at making abortions harder to get.
“Take note of Texas, because what you see is that our politicians, they do not quit, and they can find endless ways to add fear, intimidation and restrictions,” Wheat said.
This story is part of a partnership that includes KUT, NPR and KHN.
The most important part of the new law, advocates say, is the shortening of the waiting period.
This article was published on Friday, December 3, 2021 in Kaiser Health News.
By Bernard J. Wolfson
During her three-year battle with breast cancer, my wife, Leslie, graciously endured multiple rounds of horrifically toxic treatment to eke out more time with our two young children.
But after 18 cancer-free months, the disease returned with a vengeance in June 2003. It fractured her bones and invaded her spinal canal, bathing her brain in malignancy.
During the final six months, as she lay on her home hospice bed in constant pain, attached to a morphine drip around-the-clock while losing her eyesight and withering to a skeleton, the idea of ending her suffering by ending her life didn’t even enter into our conversations.
I’ve been thinking a lot about those bleak days while looking into California’s End of Life Option Act, which allows terminally ill patients with a life expectancy of less than six months to end their lives by taking medications prescribed by a physician.
In October, Gov. Gavin Newsom signed a revised version of the law, extending it to January 2031 and loosening some restrictions in the 2015 version that proponents say have become barriers to dying people who wish to avail themselves of the law.
The original law, which remains in effect until Jan. 1, contains numerous safeguards meant to ensure that patients are not being coerced by family members who view them as a burden or a potential financial bonanza.
Under the current law, patients who want to die must make two oral requests for the medications at least 15 days apart. They also must request the drugs in writing, and two doctors must agree the patients are legally eligible. After receiving the medications, patients must confirm their intention to die by signing a form 48 hours before ingesting them.
The patients must take the drugs without assistance, either by swallowing them in a drink or pushing a plunger attached to an IV or a feeding tube. And physicians can decline to prescribe the death-inducing drugs.
After the law had been in effect for a while, its proponents and practitioners concluded that some safeguards made the option unavailable to certain patients.
Some patients were so sick they died during the 15 days they were required to wait between their first and second requests for the medications. Others were too weak or disoriented to sign the final attestation.
The revised law reduces the 15-day waiting period to just two days and eliminates the final attestation.
It also requires health care facilities to post their aid-in-dying policies online. Doctors who decline to prescribe the drugs — whether on principle or because they don’t feel qualified — are obliged to document the patient’s request and transfer the record to any other doctor the patient designates.
The most important part of the new law, advocates say, is the shortening of the waiting period.
Dr. Chandana Banerjee, an assistant clinical professor specializing in palliative medicine at City of Hope National Medical Center in Duarte, California, says she’s seen many patients who were afraid to broach the subject of their own death until they were very close to the end.
“By the time they made that first request and then had to wait for those 15 days, they either became completely nondecisional or went into a coma or passed away,” Banerjee says.
Amanda Villegas, 30, of Ontario, California, became an outspoken advocate for updating the law after watching her husband, Chris, die an agonizing death from metastatic bladder cancer in 2019.
When the couple asked about the possibility of a physician-assisted death, Villegas says, staff at the Seventh-day Adventist hospital where Chris was being treated told them, inaccurately, that it was illegal. When he finally made a request for death-inducing drugs, it was too late: He died before the 15-day waiting period was up.
The new law “will open doors for people who might … experience the same roadblocks,” Villegas says. “When you are dying, the last thing you need is to go through bureaucratic barriers to access peace.”
Medical aid in dying straddles the same political fault line as abortion and has long been opposed by many religious institutions and anti-abortion groups. It has also encountered resistance from some disability rights organizations that claim it belittles the lives of those who are physically dependent on others.
“We object to the whole idea of a state providing a vehicle for people to kill themselves,” says Alexandra Snyder, CEO of the Life Legal Defense Foundation, an anti-abortion nonprofit law firm. The 15-day waiting period, she says, provided an important cooling-off period for patients to reflect on a decision that is irreversible. “Now, any safeguards that were in the law are gone.”
Proponents of the law say they haven’t seen evidence that a patient’s decision to take the life-ending medications has ever been anything other than voluntary.
Though neither version of the law requires a medical professional to be present when a patient takes the drugs, medical standards encourage professional participation in the dying process, says Dr. Lonny Shavelson, chair of the American Clinicians Academy on Medical Aid in Dying. The drugs should be kept at the pharmacy until the patient is ready to ingest them, he says — though that doesn’t always happen.
From the time the aid-in-dying law took effect in June 2016 through Dec. 31, 2020, just under two-thirds of the 2,858 people who received prescriptions actually took the medications and died, according to the most recent data from the California Department of Public Health. The rest died before they could take the drugs or found other ways to manage their pain and emotional distress.
Most major commercial health plans — including Kaiser Permanente, Anthem Blue Cross, Blue Shield of California and Health Net — cover aid-in-dying drugs and the related doctor visits, as does Medi-Cal, the government-run health insurance program for people with low incomes.
However, more than 60% of those who take the drugs are on Medicare, which does not cover them. Effective life-ending drug combinations are available for as little as $400.
If you are contemplating aid in dying, here are some resources to learn more about it:
Compassion & Choices, 1-800-247-7421 or www.compassionandchoices.org
The California Department of Public Health, www.cdph.ca.gov (click “programs”)
The American Clinicians Academy on Medical Aid in Dying, www.acamaid.org
End of Life Choices California, www.endoflifechoicesca.org or 1-760-636-8009
Talk to your doctor sooner rather than later if you are considering medically assisted death, in case you’ll need to seek a different physician’s help. If your doctor agrees to help, the law requires that he or she discuss other end-of-life options with you, including hospice and palliative care.
Whatever choice a patient makes, being more open about our mortality is important, says state Sen. Susan Eggman (D-Stockton), the author of the revised aid-in-dying law.
“We should all have more conversations about life and death and what we want and don’t want and what is a peaceful death,” she says. “We are all going to die.”
Leslie and I had plenty of those conversations, until the cancer ultimately robbed her of her mind.
In her final months, she would often sink into a semiconscious state, far out of our reach for days on end. Then, just when we thought she wasn’t coming back, she would suddenly open her eyes and ask for the children. She’d get into her wheelchair and join us at the dinner table.
Those periods, which we called “awakenings,” were a source of great comfort to everyone who loved Leslie — but especially to the kids, who were relieved and overjoyed to have their mommy back.
Though I’ll never know for sure, I suspect Leslie would not have wanted to foreclose on such moments.
The experience of the newly eligible in those two states has differed dramatically.
This article was published on Friday, December 3, 2021 in Kaiser Health News.
By Bram Sable-Smith
Temp worker James Dickerson applied for Medicaid because it will be cheaper than his current health plan. Home health aide Sharon Coleman looks forward to having coverage that will cover a hospital stay. Incoming medical student Danielle Gaddis no longer worries a trip to the doctor will leave her in debt.
All three are among the roughly 490,000 people newly eligible for Medicaid after Oklahoma and Missouri voters in 2020 approved expanding the federal-state public health insurance program for people with low incomes. In both states, people who earn up to 138% of the federal poverty level — about $18,000 per year for an individual — can now get the free coverage even if they don’t have disabilities.
But the experience of the newly eligible in those two states — an estimated 215,000 people in Oklahoma and 275,000 in Missouri — has differed dramatically. Oklahoma has enrolled over 210,000 people, while Missouri has enrolled fewer than 20,000.
The difference comes down to the approaches taken by the two states, both of which are Republican-led and resisted expanding Medicaid for years.
Once Oklahoma voters approved the expansion, it was quickly embraced: The legislature appropriated $164 million in the state budget to fund it. Applications opened this June, one month before the program began, and within a month, 113,000 people had been approved.
In August, Oklahoma Secretary of Health and Mental Health Kevin Corbett told state lawmakers about one of those enrollees: a 62-year-old woman able to schedule appointments with a doctor and dentist for the first time in 20 years.
“Truly life-changing,” Corbett said. “We feel very good about what we’re being able to do.”
Other states that expanded Medicaid in recent years saw enrollment swell in the first month. Louisiana’s combined Medicaid and Children’s Health Insurance Program rolls grew by over 255,000; Virginia’s increased by almost 184,000; Idaho added about 45,500 enrollees, roughly half of the anticipated number of newly eligible people; and Montana added over 23,000, 51% of its expected total. Missouri, on the other hand, has enrolled only about 7% of newly eligible people in Medicaid.
“You can expand Medicaid on the books, but there are a lot of ways that you can throw up barriers to keep people from getting enrolled,” said Sidney Watson, director of the Center for Health Law Studies at Saint Louis University.
Expansion has been a slog in Missouri. The legislature refused to fund the voter-approved program, prompting Republican Gov. Mike Parson to announce in May that the state would “withdraw” its expansion plan. Then, in August, a judge ordered the state to start accepting applications, which it did. But Missouri could not begin processing them until Oct. 1.
That whiplash means many newly qualified Missourians are likely unaware they could be covered by Medicaid, according to University of Missouri-Kansas City law professor Ann Marie Marciarille.
Marciarille said that the state has a responsibility to get the word out about the program and that Missouri has done little more than what was legally required by the August court order. The critique has been echoed by others.
Heather Dolce, a spokesperson for the Missouri Department of Social Services, which oversees Medicaid, said the department had publicized the Medicaid expansion by updating its website, emailing participants in its family support programs and posting on social media. The department’s Facebook and Twitter accounts show a handful of posts about the expansion, including twotweets posted the day after the publication of a KCUR article that noted the state’s outreach efforts had been slow.
In Missouri, without robust advertising by the state, much of the outreach has fallen to clinics like Affinia Healthcare in St. Louis. James Dickerson saw a flyer about the Medicaid expansion on the front door of an Affinia clinic when he went to see a doctor about an ear infection.
The 59-year-old, who works various jobs through a temp agency, was eager to sign up. He had a good experience with Medicaid in 2014 when he was covered while getting spinal surgery for a workplace injury.
At Affinia, Dickerson met with a certified application counselor, Sunni Johnson, who within about five minutes got all the information she needed to send in his application. Most clinics like this have specialists who can help patients enroll in health insurance and other assistance programs.
By federal law, Missouri is required to determine whether an applicant is eligible for the program within 45 days. But Michelle Davis Reed, the lead eligibility and enrollment coordinator at Northwest Health Services, based in St. Joseph, Missouri, said in November that some applications she had filed in August were still not processed.
Dolce said the state had 32,000 Medicaid applications pending as of Nov. 17. She did not respond directly to a question about the number of staffers processing the applications but said overtime was being used.
In Oklahoma, 144,000 of the 210,000 Medicaid expansion enrollees previously lacked insurance. The remainder were enrolled when the state evaluated whether people who had applied to other benefit programs were also now eligible for Medicaid.
One Missouri program that could be a candidate for such reprocessing is Gateway to Better Health, a temporary insurance program that Sharon Coleman uses in St. Louis. Gateway covers about 16,000 residents of the city of St. Louis and St. Louis County who earn up to 100% of the federal poverty level.
Angela Brown, CEO of the St. Louis Regional Health Commission, which administers Gateway, said she believes that at least 90% of its participants would qualify for Medicaid under expansion but that bureaucratic hurdles made encouraging patients to sign up for Medicaid directly simpler than the process necessary to move them into a new system. Gateway sent a text message to Coleman and other recipients urging them to apply.
After getting the alert, Coleman, 60, who provides in-home care to older adults, went to Affinia specifically to enroll in Medicaid. She has high blood pressure, but her health is otherwise good — she said she hasn’t been to a hospital since her son was born 40 years ago. Coleman was relieved to know that if she had to go now, her bills would be covered by Medicaid. Gateway covers only primary, specialty and urgent care.
“I can go to the emergency room now and not worry about them sending me bills I can’t pay,” Coleman said after visiting with Johnson, the enrollment specialist.
In Oklahoma, 26-year-old Danielle Gaddis had been uninsured for two years. She was reluctant to see a doctor during that time, fearing the medical bills. So she was thankful to be enrolled in Oklahoma’s Medicaid program when she got sick recently. Like Dickerson and Coleman, Gaddis applied for Medicaid with the help of a specialist at a health clinic, Mary Mahoney Memorial Health Center in Oklahoma City.
“Because of covid, a cold could be the end of the world, so you freak out,” said Gaddis, who will start medical school in August after deferring for a year.
Gaddis said she’s keeping the experience of being uninsured front of mind as she begins her medical training.
“No one should ever have to worry about, ‘How long am I going to have to ride this out before I go to see what’s wrong?’” Gaddis said. “That’s how things get worse.”
While growing up in the ’90s in Johnson County, Kansas, in a suburb of Kansas City, I had a friend, Kevin Aaron, who was a dedicated environmentalist.
To strangers, Kevin appeared to be a laid-back punk-rock music fan with a dry and slightly mischievous sense of humor, but those of us who knew him best saw his passion for sustainability blossom during high school.
In his barbecue-obsessed part of the country, he became the rare vegetarian, driven by witnessing large-scale meat production’s damage to the environment. As he grew into a young man, he eagerly researched and then adopted alternative practices — like driving a hybrid car — that he thought might reduce carbon emissions, if only by tiny measures.
In the early 2000s, Kevin was living in the Bay Area and preparing for a career in climate advocacy, enrolled in a master’s program in city and regional planning while studying for a law degree.
During his graduate studies, he became overwhelmed by a sense of hopelessness about the climate. He died by suicide in 2003, at age 27. Kevin had been living with a feeling that his efforts — combined with those of other environmental activists — just wouldn’t be enough to turn the tide on global warming. It added to the depression he was already struggling with, said his mother, Sami Aaron.
The loss of Kevin remains a shock for me, and for others who cared about him — especially his mother, who has become increasingly involved in environmental advocacy.
Aaron often turns to nature for comfort, and she picked a former Superfund site in Olathe, Kansas, that has been converted to a flower-filled sanctuary as the spot for us to talk about her son. She said that the more deeply Kevin became involved in environmental activism, the more his thinking about the future turned pessimistic — his mind and mood overtaken by despairing thoughts, like an invasive species.
“There was one little seed that was planted where he couldn’t then quit thinking about it,” she said.
After Kevin died, Aaron found some solace in yoga and meditation, but continued to see her grief as a private struggle — until a few years ago, when she met some environmentalists in the Flint Hills of Kansas who also struggled with mental health issues.
Aaron wanted to teach them the coping strategies she had learned after her son’s death, so she created a Kansas City-based nonprofit, the Resilient Activist. The organization’s website explains that Kevin’s death occurred “when eco-anxiety (fear about the ecology of the planet) and solastalgia (grief over loss of beloved places in nature) combined with his own inner demons and he took his own life.” The Resilient Activist offers mental health resources, community-building programs, consulting and other psychological resources for the environmental community.
“We need activists who have the resilience to see us through these difficult times,” Aaron said. “That’s what I wanted to give. It’s like, what would have helped him and others like him.”
In eastern Kansas, the college town of Lawrence is steeped in environmental activism and, on Aug. 31, dozens of protesters gathered before the start of a city meeting, chanting slogans and carrying signs: “Time Is Running Out!” As the evening rush-hour traffic roared past, activists demanded Lawrence leaders follow through on their sustainability pledges.
Many of the protesters were University of Kansas students, like undergraduate Marc Veloz. He moved to Lawrence from Texas, where he became concerned about how flooding was disproportionately affecting communities of color in Dallas. He said taking part in local activism helps get him through what he calls “dark days.”
“There are those days that I just have to lean on the little wins we’ve had to keep me going,” Veloz said. “Because I know that being in that space of despair and anger and sadness, it isn’t sustainable.”
Another student, Kai Hamilton, grew up in the Kansas farming town of Hesston. She recalled that even though her neighbors suffered droughts year after year, the words “climate change” were never said out loud.
“I have vivid memories of being alone in my room in high school and just being so overwhelmed and deeply sad about my lack of control over it and also the lack of action in the world,” Hamilton said.
Another protester, Agustina Carvallo Vazquez, came to KU from Paraguay, where she said she witnessed destructive and exploitative agricultural practices. She planned to study economics and music but started focusing on environmental activism after she grew frustrated by the inaction she found in the United States.
Some amount of anxiety is a natural response to climate change, said Susan Clayton, a professor of psychology at the College of Wooster and a board member of the American Psychological Association. She said getting involved in activism or environmental groups can help relieve feelings of helplessness, but, paradoxically, advocacy carries the risk added stress — sometimes leading to a diagnosis of mental illness.
Clayton said that anxiety crosses the line to becoming a true concern when it causes activists to turn away or give up on the problem.
“We have to find that common ground, where we can accept that there are some really serious things going on, but it doesn’t lead us to despair,” Clayton said.
For decades, though, many environmentalists resisted prioritizing their own mental health.
In 2018, Greenpeace International signaled a shift when it launched a major study on why so many of its activists were working themselves past their healthy limits. Agustin Maggio, a campaign manager for Greenpeace, explains that many local volunteers and leaders had bought into a kind of “martyr culture.”
“Burning yourself out is almost like a badge of honor,” Maggio said.
Greenpeace and other leading environmental groups, including the Sierra Club, have begun urging volunteers and staff members to take breaks, unplug or even limit the scope of their activism for the sake of mental health.
Ward Lyles, an associate professor of urban planning at the University of Kansas and an environmental activist since the ’90s, said he has changed the way he talks with students about the climate.
“When I first started, I thought it was my job to scare people into action,” Lyles said.
Now, Lyles said, he recognizes that students enter his classes already terrified about what’s happening to the planet — and desperate to do something about it. In class, Lyles welcomes discussions about environmental anxiety and grief, so that emerging activists understand they are not alone in having those feelings.
“In classes where you acknowledge this is hard — this is hard work to do, but we’re here to support each other — then it’s really amazing to watch students come together and talk about finding solutions,” Lyles said.
During the pandemic, Sami Aaron has been leading yoga and meditations to help activists relax and reduce narrow, negative thinking patterns that feed anxiety and depression. Reaching a sustainable future, Aaron explained, will require people to remain optimistic and open to new possibilities.
The goal is “to kind of shift you out of that fight-or-flight mode,” she said. “So that now you’re in a place where you have all different ways of thinking. You have all other options for what can happen and what you can do.”
This story is from a partnership that includes NPR, KCUR and KHN.
It appears possible — even likely — that a majority of the Supreme Court could vote to turn the thorny question of whether to allow abortion and under what circumstances back to individual states.
This article was published on Thursday, December 2, 2021 in Kaiser Health News.
A newly conservative Supreme Court on Wednesday heard the most serious legal challenge in a generation to a woman’s right to obtain an abortion. And judging from the questions asked by the justices, it appeared possible — even likely — that a majority of them could vote to turn the thorny question of whether to allow abortion and under what circumstances back to individual states.
In recent years, the high court has been asked to decide not whether states can ban the procedure entirely but whether state regulations prior to viability represent an “undue burden” on a patient seeking an abortion. In 2007, for example, in Gonzales v. Carhart, the court ruled that Congress could ban a specific abortion method, dubbed “partial-birth abortion.” But in 2016, the court also ruled in Whole Woman’s Health v. Hellerstedt that Texas went too far in requiring abortion clinics to meet health standards equivalent to those for outpatient surgical facilities and requiring doctors who perform abortions to hold hospital admitting privileges.
Not since 1992 has the court squarely faced the question of whether to retain Roe and Casey’s central holding: that there is a constitutional right to abortion prior to viability. But in accepting the Mississippi case for argument last spring, the court specifically said it intended to address the question of “whether all pre-viability prohibitions on elective abortion are unconstitutional.”
Mississippi Solicitor General Scott Stewart, however, did not spend his time before the justices trying to persuade the court merely to uphold his state’s ban while leaving the broader right to abortion intact. Rather, he argued for overturning both Roe and Casey. Roe, he said, “is an egregiously wrong decision that has inflicted tremendous wrong on our country and will continue to do so … unless and until this court overrules it.”
One can never really tell what the justices will do from the oral arguments, but Stewart’s comments seemed to gain sympathy from the six conservative justices. “Why should this court be the arbiter rather than Congress, state legislatures and the people,” asked Justice Brett Kavanaugh. “Why is that not the right answer?”
Those on the other side argued back. “For a state to take control of a woman’s body … is a fundamental deprivation of her liberty,” said Julie Rikelman of the Center for Reproductive Rights, the lead attorney for the last remaining abortion clinic in Mississippi.
Rikelman was buttressed by U.S. Solicitor General Elizabeth Prelogar, who told the justices that overruling Roe and Casey “would be an unprecedented contraction of individual rights.”
The conservative justices also trained many questions on the issue of why viability of the fetus is a proper standard for setting a limit on abortions.
Mississippi’s Stewart argued that viability “is not tethered to anything in the Constitution. It’s a quintessentially political line.”
Justice Sonia Sotomayor, however, was quick to respond. “How is your interest anything other than a religious view?” she asked Stewart. “The issue of when life begins has been debated since the beginning of time.”
And Prelogar specifically declined to set a cutoff date for states to ban abortion other than viability. “I don’t think there’s any line that could be more principled than viability,” she told Justice Neil Gorsuch.
Still, court watchers say the mere act of accepting the case suggests that the conservative supermajority of justices intends to overrule or at least change Roe in a major way.
“For the Supreme Court to take this case and presumably uphold the law, the justices will either have to say Mississippi is within its rights to do this because there’s no right to choose abortion at all or because viability as a dividing line doesn’t make sense,” said Mary Ziegler, a Florida State University law professor, in the Nov. 23 episode of KHN’s “What the Health?” podcast. “So that means, in essence, the court is either going to have to overrule Roe entirely or transform what Roe means in order to side with Mississippi. And either of those things would be a huge deal.”
In fact, should Roe be overturned, more than half the states are likely to ban abortion almost immediately, according to the Guttmacher Institute, an abortion-rights research group. Nine states have bans still on the books from when Roe was decided; a dozen states have “trigger” laws that would ban abortion if Roe falls; and several other states have various other bans that have passed but are not in force due to Roe’s existence.
That’s exactly what anti-abortion forces seem to be hoping for. “Mississippi’s law, if upheld, brings us much closer to where we ought to be,” said Marjorie Dannenfelser, president of the Susan B. Anthony List, which funds anti-abortion candidates for public office. “This is America’s chance to step back from the brink of madness after all these long years. To turn the page on Roe’s onerous chapter and begin a more humane era — one where every child and every mother is safe under the mantle of law.”
The arguments Wednesday came just a month after the court took up arguments in two cases involving a Texas law, known as SB 8, that bans abortion after fetal cardiac activity can be detected, at about six weeks into pregnancy. Those arguments, however, focused not on the question of whether the Texas ban is unconstitutional, but on whether either the abortion providers or the federal government can challenge it in court.
The arguments last month focused on an unusual mechanism designed to prevent federal courts from blocking the law. State officials have no role in ensuring that the ban is obeyed; rather, the law leaves enforcement to the public, by authorizing civil lawsuits against not just anyone who performs an abortion, but anyone who “aids and abets” the performance of an abortion, which could include those who drive patients to an abortion clinic or counsel them. People who bring those suits and win would be guaranteed damages of at least $10,000.
A decision in the Mississippi case is not expected until summer. The Texas decision, however, could come anytime because the law is currently in effect.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.