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.
Recent conflicts have underlined the pressure on health care workers to provide unauthorized covid treatments, particularly in parts of the country where vaccination rates are low, government skepticism is high, and conservative leaders have championed the treatments.
This article was published on Thursday, December 2, 2021 in Kaiser Health News.
HELENA, Mont. — One Montana hospital went into lockdown and called police after a woman threatened violence because her relative was denied her request to be treated with ivermectin.
Officials of another Montana hospital accused public officials of threatening and harassing their health care workers for refusing to treat a politically connected covid-19 patient with that antiparasitic drug or hydroxychloroquine, another drug unauthorized by the Food and Drug Administration to treat covid.
And in neighboring Idaho, a medical resident said police had to be called to a hospital after a covid patient’s relative verbally abused her and threatened physical violence because she would not prescribe ivermectin or hydroxychloroquine, “drugs that are not beneficial in the treatment of covid-19,” she wrote.
These three conflicts, which occurred from September to November, underline the pressure on health care workers to provide unauthorized covid treatments, particularly in parts of the country where vaccination rates are low, government skepticism is high, and conservative leaders have championed the treatments.
“You’re going to have this from time to time, but it’s not the norm,” said Rich Rasmussen, president and CEO of the Montana Hospital Association. “The vast majority of patients are completely compliant and have good, robust conversations with their medical care team. But you’re going to have these outliers.”
Even before the pandemic, the health care and social assistance industry — which includes residential care facilities and child day care, among other services — led all U.S. industries in nonfatal workplace violence, according to the Bureau of Labor Statistics. Covid has made the problem worse, leading to hospital security upgrades, staff training and calls for increased federal regulation.
Ivermectin and other unauthorized covid treatments have become a major source of dispute in recent months. Lawsuits over hospitals’ refusals to provide ivermectin to patients have been filed in Texas, Florida, Illinois and elsewhere. The ivermectin harassment extends beyond U.S. borders to providers and public health officials worldwide, in such countries as Australia, Brazil and the United Kingdom. Even so, reports of threats of violence and harassment like those recently seen in the Northern Rocky Mountains region have been relatively rare.
Ivermectin is approved to treat parasites in animals, and low doses of the drug are approved to treat worms, head lice and certain skin conditions in humans. But the FDA has not authorized the drug to treat covid. The agency says that clinical trials are ongoing but that the current data does not show it is an effective covid treatment and taking higher-than-approved levels can lead to overdose.
Likewise, hydroxychloroquine can cause serious health problems and the drug does not help speed recovery or decrease the chance of dying of covid, according to the FDA.
In Missoula, Montana, the Community Medical Center was placed on lockdown and police were called on Nov. 17 after a woman reportedly threatened violence over how her relative was being treated, according to a Police Department statement. Nobody was arrested.
“The family member was upset the patient was not treated with ivermectin,” Lt. Eddie McLean said Tuesday.
Hospital spokesperson Megan Condra confirmed on Wednesday that the patient’s relative demanded ivermectin, but she said the patient was not there for covid, though she declined to disclose the patient’s medical issue. The main entrance of the hospital was locked to control who entered the building, Condra added, but the hospital’s formal lockdown procedures were not implemented.
The scare was reminiscent of one that happened in Idaho in September. Dr. Ashley Carvalho, who is completing her medical residency training in Boise, wrote in an op-ed in the Idaho Capital Sun that she was verbally abused and threatened with both physical violence and a lawsuit by a patient’s relative after she refused to prescribe ivermectin or hydroxychloroquine.
“My patient was struggling to breathe, but the family refused to allow me to provide care,” Carvalho wrote. “A call to the police was the only solution.”
An 82-year-old woman who was active in Montana Republican politics was admitted to St. Peter’s Health, the hospital in Helena, with covid in October. According to a November report by a special counsel appointed by state lawmakers, a family friend contacted Chief Deputy Attorney General Kris Hansen, a former Republican state senator, with multiple complaints: Hospital officials had not delivered a power-of-attorney document left by relatives for the patient to sign, she was denied her preferred medical treatment, she was cut off from her family, and the family worried hospital officials might prevent her from leaving. The patient later died.
That complaint led to the involvement of Republican Attorney General Austin Knudsen, who texted a lobbyist for the Montana Hospital Association who is also on St. Peter’s board of directors. An image of the exchange was included in the report.
“I’m about to send law enforcement in and file unlawful restraint charges,” Knudsen wrote to Mark Taylor, who responded that he would make inquiries.
“This has been going on since yesterday and I was hoping the hospital would do the right thing. But my patience is wearing thin,” the attorney general added.
A Montana Highway Patrol trooper was sent to the hospital to take the statement of the patient’s family members. Hansen also participated in a conference call with multiple health care providers in which she talked about the “legal ramifications” of withholding documents and the patient’s preferred treatment, which included ivermectin and hydroxychloroquine.
Public Service Commissioner Jennifer Fielder, a former Republican state senator, left a three-minute voicemail on a hospital line saying the patient’s friends in the Senate would not be too happy to learn of the care St. Peter’s was providing, according to the special counsel’s report.
Fielder and the patient’s daughter also cited a “right to try” law that Montana legislators passed in 2015 that allows terminally ill patients to seek experimental treatments. But a legal analysis written for the Montana Medical Association says that while the law does not require a provider to prescribe a particular medication if a patient demands it, it could give a provider legal immunity if the provider decides to prescribe the treatment, according to the Montana State News Bureau.
The report did not offer any conclusions or allegations of wrongdoing.
Hospital officials said before and after the report’s release that their health care providers were threatened and harassed when they refused to administer certain treatments for covid.
“We stand by our assertion that the involvement of public officials in clinical care is inappropriate; that individuals leveraged their official positions in an attempt to influence clinical care; and that some of the exchanges that took place were threatening or harassing,” spokesperson Katie Gallagher said in a statement.
“Further, we reviewed all medical and legal records related to this patient’s care and verified that our teams provided care in accordance with clinical best practice, hospital policy and patient rights,” Gallagher added.
The attorney general’s office did not respond to a request for comment but told the Montana Free Press in a statement that nobody at the state agency threatened anyone.
Rasmussen, the head of the Montana Hospital Association, said St. Peter’s officials have not reached out to the group for assistance. He downplayed the attorney general’s intervention in Helena, saying it often happens that people who know medical leaders or trustees will advocate on behalf of a relative or friend.
“Is this situation different? Certainly, because it’s from the attorney general,” Rasmussen said. “But I think the AG was responding to a constituent. Others would reach out to whoever they know on the hospital board.”
He added that hospitals have procedures in place that allow family members of patients to take their complaints to a supervisor or other hospital leader without resorting to threats.
Hospitals in the region that have watched the allegations of threats and harassment unfold declined to comment on their procedures to handle such conflicts.
“We respect the independent medical judgment of our providers who practice medicine consistent with approved, authorized treatment and recognized clinical standards,” said Bozeman Health spokesperson Lauren Brendel.
Tanner Gooch, a spokesperson for SCL Health Montana, which operates hospitals in Billings, Butte and Miles City, said SCL does not endorse ivermectin or other covid treatments that haven’t been approved by the FDA but doesn’t ban them, either.
“Ultimately, the treatment decisions are at the discretion of the provider,” Gooch said. “To our knowledge, no covid-19 patients have been treated with ivermectin at our hospitals.”
The number of U.S. deaths from covid-19 has surpassed 778,000. Left behind are tens of thousands of children — some orphaned — after their parents or a grandparent who cared for them died. In this report, co-produced with PBS NewsHour, KHN correspondent Sarah Varney looks at the risks these grieving children face to their well-being, both in the short and long term. No concerted government effort exists to help the estimated 140,000 children who have lost a parent — or even to identify them.
Betty Hamilton of Eastman, Georgia, took in her five grandsons, ages 4 to 10, after their father died suddenly of covid in August. They had already lost their mom in a car crash years ago. With no financial help from the government, except food stamps and Medicaid, she struggles to provide the basics: keeping them fed and clothed as they grow.
But for these kids and countless others, the unaddressed emotional needs seem the greatest risk. Stressful events can be “biologically embedded,” says one expert, and their unresolved grief and depression can haunt them for life, leaving them economically disadvantaged.
The reports from covid-19 patients are disconcerting. Only a few hours before, they were enjoying a cup of pungent coffee or the fragrance of flowers in a garden. Then, as if a switch had been flipped, those smells disappeared.
Young and old alike are affected — more than 80% to 90% of those diagnosed with the virus, according to some estimates. While most people recover in a few months, 16% take half a year or longer to do so, research has found. According to new estimates, up to 1.6 million Americans have chronic smell problems due to covid.
Seniors are especially vulnerable, experts suggest. “We know that many older adults have a compromised sense of smell to begin with. Add to that the insult of covid, and it made these problems worse,” said Dr. Jayant Pinto, a professor of surgery and specialist in sinus and nasal diseases at the University of Chicago Medical Center.
Recent data highlights the interaction between covid, advanced age and loss of smell. When Italian researchers evaluated 101 patients who’d been hospitalized for mild to moderate covid, 50 showed objective signs of smell impairment six months later. Those 65 or older were nearly twice as likely to be impaired; those 75 or older were more than 2½ times as likely.
Most people aren’t aware of the extent to which smell can be diminished in later life. More than half of 65- to 80-year-olds have some degree of smell loss, or olfactory dysfunction, as it’s known in the scientific literature. That rises to as high as 80% for those even older. People affected often report concerns about safety, less enjoyment eating and an impaired quality of life.
But because the ability to detect, identify and discriminate among odors declines gradually, most older adults — up to 75% of those with some degree of smell loss — don’t realize they’re affected.
A host of factors are believed to contribute to age-related smell loss, including a reduction in the number of olfactory sensory neurons in the nose, which are essential for detecting odors; changes in stem cells that replenish these neurons every few months; atrophy of the processing center for smell in the brain, called the olfactory bulb; and the shrinkage of brain centers closely connected with the olfactory bulb, such as the hippocampus, a region central to learning and memory.
Also, environmental toxic substances such as air pollution play a part, research shows. “Olfactory neurons in your nose are basically little pieces of your brain hanging out in the outside world,” and exposure to them over time damages those neurons and the tissues that support them, explained Pamela Dalton, a principal investigator at the Monell Chemical Senses Center, a smell and taste research institute in Philadelphia.
Still, the complex workings of the olfactory system have not been mapped in detail yet, and much remains unknown, said Dr. Sandeep Robert Datta, a professor of neurobiology at Harvard Medical School.
“We tend to think of our sense of smell as primarily aesthetic,” he said. “What’s very clear is that it’s far more important. The olfactory system plays a key role in maintaining our emotional well-being and connecting us with the world.”
Datta experienced this after having a bone marrow transplant followed by chemotherapy years ago. Unable to smell or taste food, he said, he felt “very disoriented” in his environment.
Common consequences of smell loss include a loss of appetite (without smell, taste is deeply compromised), difficulty monitoring personal hygiene, depression and an inability to detect noxious fumes. In older adults, this can lead to weight loss, malnutrition, frailty, inadequate personal care, and accidents caused by gas leaks or fires.
Jerome Pisano, 75, of Bloomington, Illinois, has been living with smell loss for five years. Repeated tests and consultations with physicians haven’t pinpointed a reason for this ailment, and sometimes he feels “hopeless,” Pisano admitted.
Before he became smell-impaired, Pisano was certified as a wine specialist. He has an 800-bottle wine cellar. “I can’t appreciate that as much as I’d like. I miss the smell of cut grass. Flowers. My wife’s cooking,” he said. “It certainly does decrease my quality of life.”
Smell loss is also associated in various research studies with a higher risk of death for older adults. One study, authored by Pinto and colleagues, found that older adults with olfactory dysfunction were nearly three times as likely to die over a period of five years as seniors whose sense of smell remained intact.
“Our sense of smell signals how our nervous system is doing and how well our brain is doing overall,” Pinto said. According to a review published earlier this year, 90% of people with early-stage Parkinson’s disease and more than 80% of people with Alzheimer’s disease have olfactory dysfunction — a symptom that can precede other symptoms by many years.
There is no treatment for smell loss associated with neurological illness or head trauma, but if someone has persistent sinus problems or allergies that cause congestion, an over-the-counter antihistamine or nasal steroid spray can help. Usually, smell returns in a few weeks.
For smell loss following a viral infection, the picture is less clear. It’s not known, yet, which viruses are associated with olfactory dysfunction, why they damage smell and what trajectory recovery takes. Covid may help shine a light on this since it has inspired a wave of research on olfaction loss around the world.
“What characteristics make people more vulnerable to a persistent loss of smell after a virus? We don’t know that, but I think we will because that research is underway and we’ve never had a cohort [of people with smell loss] this large to study,” said Dalton, of the Monell center.
Some experts recommend smell training, noting evidence of efficacy and no indication of harm. This involves sniffing four distinct scents (often eucalyptus, lemon, rose and cloves) twice a day for 30 seconds each, usually for four weeks. Sometimes the practice is combined with pictures of the items being smelled, a form of visual reinforcement.
The theory is that “practice, practice, practice” will stimulate the olfactory system, said Charles Greer, a professor of neurosurgery and neuroscience at Yale School of Medicine. Although scientific support isn’t well established, he said, he often recommends that people who think their smell is declining “get a shelf full of spices and smell them on a regular basis.”
Richard Doty, director of the University of Pennsylvania’s Smell and Taste Center, remains skeptical. He’s writing a review of smell training and notes that 20% to 30% of people with viral infections and smell loss recover in a relatively short time, whether or not they pursue this therapy.
“The main thing we recommend is avoid polluted environments and get your full complement of vitamins,” since several vitamins play an important role in maintaining the olfactory system, he said.
Americans, already weary of a pandemic nearly two years long, were dealt a new blow during the long Thanksgiving weekend: the announcement that a new coronavirus variant had emerged.
The omicron variant, officially known as B.1.1.529, surfaced in November in several southern African nations. It set off alarm bells worldwide when public health officials in South Africa saw it beginning to outcompete the previous reigning variant, delta. This suggested that omicron could eventually spread widely. Indeed, omicron has since been reported on multiple continents, likely due to international travel by people unknowingly infected.
After the emergence of omicron was announced, several nations imposed travel bans hoping to contain the virus. Whether those bans will effectively slow the spread remains unknown. “Travel bans don’t help once the horse is already out of the barn, as we’ve seen before and are seeing now,” said Tara Smith, a Kent State University epidemiologist.
Scientists caution that it’s still too early to say whether omicron will prove as dangerous as delta. Other variants that initially seemed worrisome have flamed out.
For now, here’s what we know, and don’t know, about the omicron variant.
What Is a Variant?
A variant of a virus is one that has mutated in a way that bolsters its spread or severity compared with the original strain that emerged in Wuhan, China. “RNA viruses like the coronavirus can mutate when they replicate, especially when circulating at high rates,” said Dr. Monica Gandhi, professor of medicine at the University of California-San Francisco.
Coronaviruses do not mutate as readily as influenza viruses do, but they do mutate over time. The variants generally produce the same range of symptoms as the original strain of the coronavirus. But the mutations may help the virus spread more effectively from person to person, or have an advantage in sneaking past either natural or vaccine immunity.
What Variants Were Already Circulating in the United States?
To date, public health officials have noted five “variants of concern,” plus two “variants of interest” not yet considered as worrisome. So far, no variants have emerged that fit the most worrisome of the three official categories — “variants of high consequence.”
The World Health Organization decided early this year to name the variants after Greek letters, both to simplify the discussion and to limit the stigma of having a variant named for a country.
The first four “variants of concern” — alpha, beta, gamma and delta — have been circulating in the United States for most of this year. But the most dominant variant has been delta, due to its ability to spread from person to person more quickly than other variants. For months, delta has accounted for more than 99% of coronavirus infections in the U.S.
There were no confirmed cases of omicron in the United States as of midday Nov. 29, but experts warn it’s just a matter of time. It could be in the U.S. already, merely undetected.
How Did Omicron Emerge?
Though scientists aren’t sure precisely where omicron first surfaced, it was most likely in a southern African nation.
Experts say low vaccination rates in that part of the world probably played a role in creating a favorable environment for the mutations that produced omicron. (It can be pronounced either AH-mi-crahn or OH-mi-crahn.)
“Many countries in Africa have populations with very low immunity — about 30% in South Africa are vaccinated,” Smith said. “In a largely non-immune population, the virus can sweep through, and each new person infected is a chance for the virus to mutate.”
Why Did Public Health Officials React So Urgently to Omicron?
The concern stems from the scope and nature of the new variant’s mutations. South African health officials noted 50 notable mutations, 30 of which are on the spike protein, a key structure in the virus, New York magazine reported. That’s more than previous variants have had.
“If we were looking out for mutations that do affect transmissibility, it’s got all of them,” University of Oxford evolutionary biologist Aris Katzourakis told Science magazine.
Still, what’s uncertain at this point is how effectively those mutations will work together in creating a variant that can consistently outcompete delta.
What Do We Know About Omicron’s Degree of Infectiousness?
The omicron variant is so new that scientists are just beginning to learn about its characteristics. Because of this, experts urge caution in drawing conclusions, especially from anecdotal evidence.
That said, scientists say they would not be shocked if omicron becomes as easily transmissible as delta.
“The answer is uncertain, of course, but it looks as though it will be at least as infectious as delta,” said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University School of Medicine.
One complicating factor, Schaffner said, is that the initial areas of fastest spread have been in areas of Johannesburg populated by young adults and college students, who tend to have lower vaccination rates. The vulnerability of these groups to infection may be exaggerating how rapidly omicron seems to be spreading.
What Do We Know About Whether Omicron Makes Patients Sicker?
The early evidence is somewhat conflicting, but there are signs that symptoms from omicron may not be more severe than previous variants. Dr. Angelique Coetzee, who chairs the South African Medical Association, has said that the early cases being seen among the unvaccinated are mild.
It remains to be seen, however, whether older and unhealthier patients will also see milder symptoms. Another caveat is that it may be too early in omicron’s spread to see cases that have seriously progressed.
Will Existing Vaccines Be Effective Against the Omicron Variant?
Scientists are cautiously optimistic that existing vaccines will also be effective against omicron, just as they have been against delta, at least in being able to prevent illness severe enough to require hospitalization.
Gandhi added that the immunity-providing B cells produced by the vaccines have been shown to produce antibodies against variants, and that T-cell immunity, which protects against severe disease, is robust and should not be at risk from the mutations being seen in omicron. The vaccines also produce polyclonal antibodies that work against multiple parts of the spike protein, she said. Finally, booster shots have been shown to be effective in strengthening immunity quickly.
“Most scientists believe we should still have protection against severe disease with vaccinations, and vaccination remains the mainstay of control,” Gandhi said.
Bottom line: If you haven’t been vaccinated, and especially if you haven’t had the disease yet, get vaccinated. And if you’ve already been vaccinated, get a booster.
How Long Will It Be Before We Have a Better Handle on the Threat From Omicron?
Other questions — including whether omicron makes you sicker, and whether it’s more transmissible — will take longer to answer because they require careful contact tracing and accurate diagnoses of those infected.
To better answer those questions, Smith said, “I think, at a minimum, it will take a month to get some preliminary data, and quite possibly longer to really know the fuller picture. We also won’t know about real-world experience in vaccine breakthroughs until that time.”
Can We Expect a Specific New Booster to be Developed for Omicron?
It’s unknown whether the omicron variant will require a reformulated booster. A newly formulated booster wasn’t necessary for delta, because researchers determined that the existing formulation was still effective.
That said, vaccine makers can jump in with a new booster quickly if they have to.
In the event that such a variant emerges, Pfizer and BioNTech “expect to be able to develop and produce a tailor-made vaccine against that variant” within 100 days, pending regulatory approval, a Pfizer spokesperson told The Washington Post.
Dr. Matthew Laurens, a specialist in pediatric infectious diseases at the University of Maryland School of Medicine, said he’s confident boosters could be developed and tested quickly if needed, “likely within a few months.”
What Happened to the Other Variants?
Between May 2021, when delta was named a variant of concern, and November 2021, when omicron was given the same label, two other variants were elevated to the lower “variant of interest” status: lambda from Peru and mu from Colombia. Other variants, such as one discovered in Nepal called “delta-plus,” attracted notice during that period as well. But none of these managed to outcompete delta in a consistent way, so they were never elevated to “variant of concern.”
This is the most hopeful outcome for omicron. The other variants “all had similar concerns around them, but they didn’t expand to any significant degree after the initial reporting,” Gandhi said.
Is It Reasonable to Think the U.S. Is in a Better Position to Handle Omicron Than It Was for Delta?
Experts generally agreed that the United States should be better prepared to battle omicron than it was when delta emerged earlier this year.
“We are in a much better position since we have higher rates of vaccination, the availability of boosters for everyone over 18 and vaccine eligibility down to 5 years old,” Gandhi said. “We also have higher rates of natural immunity in this country due to the delta variant’s spread since July 2021. And we have oral antiviral therapeutics on the horizon. So we have the tools to fight this new variant.”
The challenge, Schaffner said, will be to make sure Americans continue to get vaccinated and boosted, and to make use of testing and maintain safe behavior in public.
“All these tools are available,” he said. “The big question is how inclined the general public is to use these tools.”
Is the Coronavirus Going to Be Around Permanently, Like the Flu?
Experts now believe it’s unlikely that the coronavirus will either be eradicated from the globe, like smallpox has been, or even eliminated in the United States, as polio was following near-universal vaccination. The combination of rapid mutations and too-low vaccination rates make it likely that covid-19 won’t follow smallpox and polio into submission.
“This will more likely be the influenza model, where we have to track mutations annually and alter the boosters accordingly,” Schaffner said. In fact, he said, efforts to create combined coronavirus-flu shots are already underway.
A growing body of research into PTSD and service animals paved the way for President Joe Biden to sign into law the Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act.
This article was published on Tuesday, November 30, 2021 in Kaiser Health News.
It was supper time in the Whittier, California, home of Air Force veteran Danyelle Clark-Gutierrez, and eagerly awaiting a bowl of kibble and canned dog food was Lisa, a 3-year-old yellow Labrador retriever.
Her nails clicking on the kitchen floor as she danced about, Lisa looked more like an exuberant puppy than the highly trained service animal that helps Clark-Gutierrez manage the symptoms of post-traumatic stress disorder.
“Having her now, it’s like I can go anywhere,” Clark-Gutierrez said. “And, yes, if somebody did come at me, I’d have warning — I could run.”
A growing body of research into PTSD and service animals paved the way for President Joe Biden to sign into law the Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act. The legislation, enacted in August, requires the Department of Veterans Affairs to open its service dog referral program to veterans with PTSD and to launch a five-year pilot program in which veterans with PTSD train service dogs for other veterans.
Clark-Gutierrez, 33, is among the 25 percent of female veterans who have reported experiencing military sexual trauma while serving in the U.S. armed services.
Military sexual trauma, combat violence and brain injuries are some of the experiences that increase the risk that service members will develop PTSD. Symptoms include flashbacks to the traumatic event, severe anxiety, nightmares and hypervigilance — all normal reactions to experiencing or witnessing violence, according to psychologists. Someone receives a PTSD diagnosis when symptoms worsen or remain for months or years.
That’s what Clark-Gutierrez said happened to her after ongoing sexual harassment by a fellow airman escalated to a physical attack about a decade ago. A lawyer with three children, she said that to feel safe leaving her home she needed her husband by her side. After diagnosing Clark-Gutierrez with PTSD, doctors at VA hospitals prescribed a cascade of medications for her. At one point, Clark-Gutierrez said, her prescriptions added up to more than a dozen pills a day.
“I had medication, and then I had medication for the two or three side effects for each medication,” she said. “And every time they gave me a new med, they had to give me three more. I just couldn’t do it anymore. I was just getting so tired. So we started looking at other therapies.”
And that’s how she got her service dog, Lisa. Clark-Gutierrez’s husband, also an Air Force veteran, discovered the nonprofit group K9s for Warriors, which rescues dogs — many from kill shelters — and trains them to be service animals for veterans with PTSD. Lisa is one of about 700 dogs the group has paired with veterans dealing with symptoms caused by traumatic experiences.
“Now with Lisa we take bike rides, we go down to the park, we go to Home Depot,” said Clark-Gutierrez. “I go grocery shopping — normal-people things that I get to do that I didn’t get to do before Lisa.”
That comes as no surprise to Maggie O’Haire, an associate professor of human-animal interaction at Purdue University. Her research suggests that while service dogs aren’t necessarily a cure for PTSD, they do ease its symptoms. Among her published studies is one showing that veterans partnered with these dogs experience less anger and anxiety and get better sleep than those without a service dog. Another of her studies suggests that service dogs lower cortisol levels in veterans who have been traumatized.
“We actually saw patterns of that stress hormone that were more similar to healthy adults who don’t have post-traumatic stress disorder,” O’Haire said.
A congressionally mandated VA study that focuses on service dogs’ impact on veterans with PTSD and was published this year suggests that those partnered with the animals experience less suicidal ideation and more improvement to their symptoms than those without them.
Until now, the federal dog referral program — which relies on nonprofit service dog organizations to pay for the dogs and to provide them to veterans for free — required that participating veterans have a physical mobility issue, such as a lost limb, paralysis or blindness. Veterans like Clark-Gutierrez who have PTSD but no physical disability were on their own in arranging for a service dog.
The pilot program created by the new federal law will give veterans with PTSD the chance to train mental health service dogs for other veterans. It’s modeled on a program at the VA hospital in Palo Alto, California, and will be offered at five VA medical centers nationwide in partnership with accredited service dog training organizations.
“This bill is really about therapeutic, on-the-job training, or ‘training the trainer,’” said Adam Webb, a spokesperson for Sen. Thom Tillis (R-N.C.), who introduced the legislation in the Senate. “We don’t anticipate VA will start prescribing PTSD service dogs, but the data we generate from this pilot program will likely be useful in making that case in the future.”
The Congressional Budget Office estimates the pilot program will cost the VA about $19 million. The law stops short of requiring the VA to pay for the dogs. Instead, the agency will partner with accredited service dog organizations that use private money to cover the cost of adopting, training and pairing the dogs with veterans.
Still, the law represents a welcome about-face in VA policy, said Rory Diamond, CEO of K9s for Warriors.
“For the last 10 years, the VA has essentially told us that they don’t recognize service dogs as helping a veteran with post-traumatic stress,” Diamond said.
PTSD service dogs are often confused with emotional support dogs, Diamond said. The latter provide companionship and are not trained to support someone with a disability. PTSD service dogs cost about $25,000 to adopt and train, he said.
Diamond explained that the command “cover” means “the dog will sit next to the warrior, look behind them and alert them if someone comes up from behind.” The command “block” means the dog will “stand perpendicular and give them some space from whatever’s in front of them.”
Retired Army Master Sgt. David Crenshaw of Kearny, New Jersey, said his service dog, Doc, has changed his life.
“We teach in the military to have a battle buddy,” Crenshaw said. “And these service animals act as a battle buddy.”
A few months ago, Crenshaw experienced this firsthand. He had generally avoided large gatherings because persistent hypervigilance is one symptom of his combat-caused PTSD. But this summer, Doc, a pointer and Labrador mix, helped Crenshaw navigate the crowds at Disney World — a significant first for Crenshaw and his family of five.
“I was not agitated. I was not anxious. I was not upset,” said Crenshaw, 39. “It was truly, truly amazing and so much so that I didn’t even have to even stop to think about it in the moment. It just happened naturally.”
Thanks to Doc, Crenshaw said, he no longer takes PTSD drugs or self-medicates with alcohol. Clark-Gutierrez said Lisa, too, has helped her quit using alcohol and stop taking VA-prescribed medications for panic attacks, nightmares and periods of disassociation.
The dogs actually save the VA money over time, Diamond said. “Our warriors are far less likely to be on expensive prescription drugs, are far less likely to use other VA services and far more likely to go to school or go to work. So it’s a win-win-win across the board.”
Long waits for mental health treatment are a nationwide problem, with reports of patients waiting an average of five or six weeks for care in community clinics, at Department of Veterans Affairs facilities and in private offices from Maryland to Los Angeles County.
This article was published on Monday, November 29, 2021 in Kaiser Health News.
When Greta Christina fell into a deep depression five years ago, she called up her therapist in San Francisco. She’d had a great connection with the provider when she needed therapy in the past. She was delighted to learn that he was now “in network” with her insurance company, meaning she wouldn’t have to pay out-of-pocket anymore to see him.
But her excitement was short-lived. Over time, Christina’s appointments with the therapist went from every two weeks, to every four weeks, to every five or six.
“To tell somebody with serious, chronic, disabling depression that they can only see their therapist every five or six weeks is like telling somebody with a broken leg that they can only see their physical therapist every five or six weeks,” she said. “It’s not enough. It’s not even close to enough.”
Then, this summer, Christina was diagnosed with breast cancer. Everything related to her cancer care — her mammogram, biopsy, surgery appointments — happened promptly (like a “well-oiled machine,” she said), while her depression care stumbled along.
“It is a hot mess,” she said. “I need to be in therapy — I have cancer! And still nothing has changed.”
A new law signed by Gov. Gavin Newsom in October aims to fix this problem for Californians. Senate Bill 221, which passed the state legislature with a nearly unanimous vote, requires health insurers across the state to reduce wait times for mental health care to no more than 10 business days. Six other states — including Colorado, Maryland and Texas — have similar laws limiting wait times.
At Kaiser Permanente, the state’s largest insurance company, 87% of therapists said weekly appointments were not available to patients who needed them, according to a 2020 survey by the National Union of Healthcare Workers, which represents KP therapists — and was the main sponsor of the California wait times legislation.
“It just feels so unethical,” said triage therapist Brandi Plumley, referring to the typical two-month wait time she sees at Kaiser Permanente’s mental health clinic in Vallejo, east of San Francisco.
Every day, she takes multiple crisis calls from patients who have therapists assigned to them but can’t get in to see them, she said, describing the providers’ caseloads as “enormous.”
“It’s heartbreaking. And it eats on me day after day after day,” Plumley said. “What Kaiser simply needs to do is hire more clinicians.”
Kaiser Permanente says there just aren’t enough therapists out there to hire. KP is an integrated system — it is a health provider and insurance company under one umbrella — and has struggled to fill 300 job vacancies in clinical behavioral health, according to a statement from Yener Balan, the insurer’s Northern California vice president of behavioral health.
Hiring more clinicians won’t solve the problem, said Balan, who suggested that sustaining one-on-one therapy for all who want it in the future wouldn’t be possible in the current system: “We all must reimagine our approach to the existing national model of care.”
Kaiser Permanente lodged concerns about the wait times bill when it was introduced. And the trade group representing insurers in the state, the California Association of Health Plans, opposed it, saying the shortage of therapists would make meeting the two-week mandate too difficult.
“The COVID-19 pandemic has only exacerbated this workforce shortage, and demand for these services significantly increased,” said Jedd Hampton, a lobbyist for the California Association of Health Plans, in testimony during a state Senate hearing for the bill in the spring.
“Simply put, mandating increased frequency of appointments without addressing the underlying workforce shortage will not lead to increased quality of care,” Hampton said.
Lawmakers pushed back. State Sen. Scott Wiener (D-San Francisco), who authored the bill, accused insurers of overstating the shortage. State Sen. Connie Leyva (D-Chino) said that the therapeutic providers are out there but that insurers are responsible for recruiting them into their networks by paying higher rates and reducing administrative burdens.
If insurers want more young people to enter the mental health care profession, they must improve salaries and working conditions now, said state Sen. Richard Pan (D-Sacramento). (A 2016 KQED investigation uncovered multiple ways that insurers save money by keeping provider networks artificially small.)
As bipartisan support for the bill grew in Sacramento, insurers withdrew their formal opposition.
But whether other states have the political will, or the resources, to legislate a similar solution is unclear, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy in Washington, D.C. Although California may be able to force insurers to hire more therapists, she said, places like New Mexico, Montana, Wyoming, and parts of the South don’t have enough therapists at any price.
“They don’t have the providers, so you could fine the insurers as much as you want, you’re not going to be able to, in the short term, make up those wait times if they already exist,” she said.
The new California law is a solid step toward improving access to mental health care, with communities of color standing to benefit the most, said Lonnie Snowden, a professor of health policy and management at the University of California-Berkeley. African Americans, Asian Americans and Latinos face the most barriers getting into care, Snowden said, and when people of color do come in for treatment, they are more likely to drop out.
Oversight and enforcement are needed for the new rules to work, said Keith Humphreys, a psychiatry professor at Stanford University. Kaiser Permanente has data systems that can track the time between appointments, but other insurers set up contracts with therapists in private practice, who manage their own caseloads and schedules.
“Who would keep track of whether people who’ve been seen once were seen again in 10 days, when it’s hard enough just to keep track of how many providers we have and who they are seeing?” he asked.
Questions like that one will fall to state regulators, primarily the California Department of Managed Health Care. The department has fined insurers $6.9 million since 2013 for violating state standards, including a $4 million penalty against Kaiser Permanente for excessive wait times for mental health care. Previous state law required insurers to provide initial mental health care appointments within 10 days, and the new law clarifies that they must do the same for follow-up appointments.
Greta Christina, who gets her care at a Kaiser Permanente facility, said she is desperate for the new law to start working. It takes effect on July 1, 2022. Christina thought about paying out-of-pocket in the meantime, to find a therapist she could see more often. But in a cancer crisis, she said, starting over with someone new would be too hard. So she’s waiting.
“Knowing that this bill is on the horizon has been helping me hang on,” she said.
This story is part of a partnership that includes KQED, NPR and KHN.