HELENA, Mont. — The 2021 Montana legislative session will be remembered as one of the state’s most consequential as a Republican-led legislature and governor’s office passed new laws restricting abortions, lowering taxes and regulating marijuana.
But the debate over those and other highly publicized issues may have caused other meaningful legislation related to health care to slip off the public’s radar. Here are five substantial health-related policies that emerged from the recently ended session. They include bills that Gov. Greg Gianforte has signed or is expected to sign into law.
1. The permanent expansion of telehealth
One byproduct of the covid-19 pandemic has been the widespread use of computers, tablets and smartphones for medical and behavioral health appointments instead of in-person office visits. Telehealth has particularly benefited Montana’s large rural population during the pandemic.
“A lot of Montanans are in very rural areas and often need to take extended time off work, drive long distances, find child care just so they can attend a routine health care appointment,” said state Sen. Jen Gross (D-Billings).
Gross sponsored one of two Montana bills that make permanent the expanded telehealth regulations set by emergency order at the start of the pandemic last year. The new laws redefine telehealth to include nonclinical health services, require private insurers and Medicaid to cover telehealth services and authorize state licensing boards to set rules regulating the practice.
The new laws also allow audio-only telehealth appointments, which supporters say are needed for rural areas without broadband internet coverage. An exception is that a doctor can’t certify a patient for the state’s medical marijuana program by phone without a previously established doctor-patient relationship. Telehealth by text messaging and fax alone is also still illegal.
The boom in virtual health care is being met with concern by local providers who worry that large out-of-state providers might poach patients and by regulators who see the potential for telehealth scams and fraud.
2. The weakened authority of local public health officials
Lawmakers fettered local public health officials with legislation after local health departments implemented and enforced state and federal recommendations to stop the spread of the coronavirus, such as mask mandates, limits on gathering and bans on indoor dining.
Many public health officials have faced threats and harassment over their work to enforce those covid restrictions, leading to high rates of turnover in health departments across the nation.
One measure passed by Republican-majority lawmakers ensures that any Montana public health order can be changed or repealed by elected officials, such as a county commission, and it bans officials from placing any restrictions on attending church services.
Another measure bars public health officials from issuing orders that restrict the ability of a private business to operate. There are some exceptions, such as restaurant health inspections. A third allows citizens to amend or reject public health orders by referendum, while a fourth overturned a law that penalized law enforcement officials who refused to enforce public health orders.
State lawmakers also added a provision in a bill on how to distribute the federal aid in the American Rescue Plan Act that would withhold 20% of any infrastructure grant made to a city, town or county if that local government enforces covid restrictions such as mask mandates and restaurant limits. Gianforte lifted those statewide restrictions after taking office, and the provision takes aim at local governments, like Gallatin County, that decided to keep their own restrictions.
“It’s time for us to make sure the state is open,” said Rep. Frank Garner (R-Kalispell), who backed the provision.
3. Making it more difficult to stay enrolled in Medicaid expansion
Lawmakers cut funding for the state Medicaid expansion program’s 12-month continuous eligibility provision, which has allowed people enrolled in the program to receive benefits for a full year, regardless of changes to their income.
Continuous eligibility is meant to reduce the churning of Medicaid expansion rolls as people are added and removed if their income fluctuates, such as with seasonal work.
Instead, those enrollees will be required to certify their eligibility more than once a year. Department of Public Health and Human Services spokesperson Jon Ebelt said in an email that the department has reached out to the federal Centers for Medicare & Medicaid Services for guidance on how to make the change after the pandemic emergency ends.
Nearly 98,000 Montana adults were enrolled in the Medicaid expansion program in March, according to the most recent data.
4. Anti-vaccinators make their mark
Riding a wave of opposition toward the covid vaccines, the Montana Legislature passed a bill that makes it more difficult to require workers to be vaccinated as a condition of employment. That measure received much publicity and several last-minute amendments in the session’s final days as hospitals and long-term care facilities warned it would force them to require face masks for employees and permanently ban visitors. The bill that passed “poses a significant threat to public safety,” Montana Hospital Association CEO Rich Rasmussen said.
Another consequential vaccination bill that received less attention will make it easier for parents to obtain medical exemptions for their children for vaccines required by schools. State law requires kids to be vaccinated against illnesses such as measles and pertussis to go to school, but students can be exempted for religious or medical reasons.
Previously, a physician needed to sign off on a medical exemption. The new law allows a wide range of health professionals to do so, including nurses, pharmacists, massage therapists, chiropractors and nutritionists. It also makes it more difficult for schools to share exemption data with health officials.
Some parents who testified in support of the bill during legislative hearings said they wanted a medical exemption option because their children might need that medical documentation in the future to attend college or get a job that might not accept a religious exemption.
The state health department and the American Academy of Pediatrics opposed the legislation. “This bill has the effect of making medical exemptions extremely easy to obtain in cases where they might not be warranted,” said Dr. Lauren Wilson, a pediatrician and vice president of the Montana chapter of the American Academy of Pediatrics.
5. Hearing aids for kids
Lawmakers passed a bipartisan measure that will require private insurers and the state employee health plan to cover hearing amplification devices and services for children 18 and under.
The new law won’t affect a large number of people in the state, but supporters said it will make a difference in the lives of families who spend $6,000 every three to five years on hearing aids for their children.
Kiera Kirschner of Bozeman testified before lawmakers during the session that her 2½-year-old son was born with hearing loss and has had hearing aids since he was 2 months old.
“My son did not choose to have hearing loss,” Kirschner said. “He needs hearing aids so he can grow and develop. They’re medically necessary.”
Montana is the 26th state to require such insurance coverage, and insurers said they did not oppose the measure because the total cost would not be significant.
This pandemic has been stressful for millions of children. Some have lost a loved one to covid, and many families have lost jobs, their homes and even reliable access to food. If that stress isn't buffered by caring adults, it can have lifelong consequences.
This article was published on Monday, May 10, 2021 in Kaiser Health News.
Kai Humphrey, 9, has been learning from home for more than a year. He badly misses his Washington, D.C., elementary school, along with his friends and the bustle of the classroom.
“I will be the first person ever to have every single person in the world as my friend,” he said on a recent Zoom call, his sandy-brown hair hanging down to his shoulder blades. From Kai, this kind of proclamation doesn’t feel like bragging, more like exuberant kindness.
But when Kai’s school recently invited him back, he refused. That’s because his worry list is long, topped by his fear of getting covid-19 and giving it to his 2-year-old sister, Alaina. She was born with a heart condition, Down syndrome and a fragile immune system. To her, the disease poses a mortal threat, and he is her protector, the only one who can make her giggle breathlessly.
Kai also worries about being separated from his mom, Rashida Humphrey-Wall. His biological father died in 2014, and she remains his rock, his mama bear and occasional taekwondo partner. He sometimes visits her bedside, in the middle of the night, just to check on her.
This pandemic has been stressful for millions of children like Kai. Some have lost a loved one to covid, and many families have lost jobs, their homes and even reliable access to food. If that stress isn’t buffered by caring adults, it can have lifelong consequences.
“Kids have had extended exposure to chaos, crisis and uncertainty,” said Dr. Matt Biel, a child psychiatrist at MedStar Georgetown University Hospital.
But there’s some good news for kids like Kai: Educators across the country say their top priority right now isn’t doubling down on math or reading — it’s helping students manage pandemic-driven stress.
“If kids don’t return to school and get a lot of attention paid to security, safety, predictability and reestablishing of strong, secure relationships, [they] are not gonna be able to make up ground academically,” Biel said.
Promoting Mental Wellness in the Classroom
To reestablish relationships in the classroom — and help kids cope with the stress and trauma of the past year — mental health experts say educators can start by building in time every day, for every student, in every classroom to share their feelings and learn the basics of naming and managing their emotions. Think morning circle time or, for older students, homeroom.
At Irene C. Hernandez Middle School in Chicago, teacher Lilian Sackett starts off each day by checking in with students, then diving into a short lesson on mindfulness and other social-emotional skills.
The school is in a predominantly Latino area that was hit hard by the pandemic, Sackett said. She teaches English as a second language, and she learned that many of her students’ families were dealing with a lot of stress related to job losses and illness — that’s on top of any trauma that may have predated the pandemic.
“We need to allow the students to share their experiences with the pandemic and to give them that safe space [to] talk about it,” Sackett said.
What’s more, she said, children can benefit a lot from just a few minutes each day of classwidecalm. When she found out her students love Bob Ross and his tranquil, televised painting lessons from the 1980s and ’90s, Sackett decided to work him into their morning routine.
“We watch five minutes of Bob Ross, and we watch the whole painting session within one week,” she explained. “When they’re having fun, they’re so excited — they’ll learn anything you throw at them.”
Sackett said her approach was informed by a virtual training, provided by Chicago’s Ann & Robert H. Lurie Children’s Hospital, that focused on the impacts of trauma on children.
“They mentioned a bad grade is never about a lazy kid,” she said. If a child is struggling academically, they may be dealing with really tough circumstances at home. Sackett learned that teachers can help by creating a supportive environment that fosters resilience.
Sheyla Ramirez, an eighth grader at Sackett’s school, has benefited a lot from daily check-ins with her teacher. Last fall, her family came down with covid, and her baby sister ended up hospitalized before she recovered. Sheyla’s uncle had died after testing positive for the virus months earlier. She said it was a really stressful time, especially for her sister in third grade.
“My sister was like, ‘Oh, I don’t want to die,'” Sheyla remembered. “I didn’t know what to tell her because I was in shock, too.”
School staff members routinely checked in to see if she or her family needed anything, and they offered to connect Sheyla with a school counselor. But Sheyla said the short daily lessons in mindfulness at the start of each school day — and being able to share her feelings and concerns with her teacher — were enough to help her get through.
“They’ve been doing an excellent job,” said Sheyla’s mom, Amparo Ramirez. “I’ve been telling them, ‘I’m thankful for you being here.'”
When More Serious Help Is Needed
For many kids, a little morning circle time with a caring teacher, or an occasional chat with a school counselor is all they need. And the more schools invest in promoting mental health and equipping children with social-emotional skills, the fewer children will go on to develop more serious problems, said child psychiatrist Biel.
But there will always be children who need more intensive interventions, which could involve school social workers and psychologists, when available, or a referral to a mental health professional beyond the school.
Kai has been talking regularly with a therapist through his elementary school. And he said she has helped him come up with strategies to manage his stress at home.
“I would go in my room, lay on my bed, and either watch TV or play with my toys or do something like that,” Kai said. “And then I’ll come back out when I’m more calm and happy.”
As a solo parent, Kai’s mom, Humphrey-Wall, has also had a tough year. She admitted that looking after two kids, in addition to taking on a new job, during a pandemic has been stressful. “In the beginning, I think I had depression, anxiety … anything you can think of, I probably had it.”
Biel said that kind of stress can trickle down to children.
“All of the best evidence-based practices in the world are not going to have the desired effect if that child is living in a family that’s overwhelmed by stress,” he explained.
One of the best ways to address that is to also help caregivers, like Humphrey-Wall. And that’s exactly what Kai’s school has done. Through a partnership with MedStar Georgetown Center for Wellbeing in School Environments, Kai’s school arranged for Humphrey-Wall to meet with a clinical psychologist once a week for what they call “parent wellbeing sessions.”
Without it, she said, “I don’t know what I would have done, really.”
Partnerships between schools and mental health care providers can be expensive for districts and may not be an option in rural or under-resourced areas where there simply aren’t enough child-focused services.
Biel said he’s hopeful the rise in telehealth will help. But whatever the solution, he said, schools need support as they explore their options.
“Schools can’t beg, borrow and steal from what they already have to do this,” Biel said. “We need to support schools and school systems with more resources to make this possible.”
Federal Help for Schools
For districts that want to do more, the latest covid relief package could be a big help. The American Rescue Plan contains roughly $122 billion for K-12 schools, some of which can be used to hire more counselors, social workers and psychologists. And one U.S. senator has been pushing the Biden administration to emphasize mental health as it guides districts on how to spend that money.
“Not all schools and districts are equipped to work on these complex mental and behavioral health issues and meet the unique needs of today’s students,” Sen. Catherine Cortez Masto wrote in a letter to the secretaries of the U.S. Departments of Education and Health and Human Services. “Many suffer from drastic shortages of counselors, social workers, and psychologists to work with students even under normal circumstances. They will need robust assistance from community-based service providers and the health care community.”
“This is a unique situation we’re in, hopefully a once-in-a-lifetime pandemic,” she said. “We don’t know the impact it’s going to have long term [on] our kids. But we know the short term. I’ve seen it here in southern Nevada and its devastating consequence here. So we’ve got to change that dynamic.”
In the U.S., where access to health care — especially for children’s mental health — is inequitable and inconsistent, the difficult work of identifying and tending to the mental and emotional health of this pandemic generation will fall largely on the shoulders of educators.
Programs like the one at Kai’s school, in Washington, D.C., could play a critical role in helping change that dynamic. Cortez Masto hopes the flood of federal relief dollars will help other districts create similar partnerships with child mental health providers, or find other solutions.
In the meantime, Kai and his mom are trying to figure out when Kai will return to in-person school. Humphrey-Wall said it would be good for her son to get out of the house, but Kai still fears bringing covid home. He’s talking it through with his school-based therapist, doing his best to give those worries a roundhouse kick:
“We all need to be free from this quarantine. I’m going crazy. I want to be free!” Kai shouted. He’s eager to get back to the business of making friends with the entire world.
If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en español: 1-888-628-9454; deaf and hard of hearing: dial 711, then 1-800-273-8255) or the Crisis Text Line by texting HOME to 741741.
This story is part of a reporting partnership that includes NPR, Illinois Public Media and Kaiser Health News.
Both parents had read about people who are transgender, but they were not familiar with the term nonbinary, which refers to people who don't see themselves as strictly male or female or people who move between genders.
This article was published on Friday, May 7, 2021 in Kaiser Health News.
It’s 7:30 a.m. on a school day. Two parents are racing to get their three young children dressed, fed, packed for the day, into coats and out the door when 6-year-old Hallel runs downstairs, crying.
Ari, Hallel’s father, is the first to ask “What’s wrong?”
The answer launched a journey these parents never envisioned, described by words they’d not heard and questions they never thought they’d ask. (We’re using only first names for the family members in this story due to Hallel’s age.)
The journey started with a “let’s pretend” game. Hallel’s little sister Ya’ara wanted to play “parents.” Ya’ara decides that she’ll be the mommy, and Hallel will be the daddy. Hallel protests. Ya’ara insists: Hallel is a boy, and therefore must play the daddy.
“But that doesn’t feel right,” Hallel said to Ari, between tears, “cause I’m a boy-girl.”
Shira, Hallel’s mother, said she copes well in a crisis. In that moment, she packaged the news away for later.
“I was like, ‘Well, we love you whoever you are, give me a hug,’” Shira remembered telling Hallel.
For Ari, “it felt a little bit like getting up to the top of a roller coaster, like, OK, now it’s going to begin. I don’t know exactly what’s going to happen next, but what I do know for sure is that this is happening.”
To clarify, Ari and Shira had known for some time that Hallel was not a traditional boy. If they bought action figures, Hallel preferred female characters. Hallel would watch fairy movies one day and draw dresses, then dress and act more like what they expected from a boy the next.
“For us that wasn’t a problem,” Ari said. “There’s lots of ways to be a boy and lots of ways to be a girl. But at the back of our mind it was confusing.”
When Hallel made the boy-girl announcement, Shira said the family finally had an explanation that made sense. But she wondered, “Is that an option?”
Both parents had read about people who are transgender, but they were not familiar with the term nonbinary, which refers to people who don’t see themselves as strictly male or female or people who move between genders. Hallel’s self-described status as a boy-girl seemed like it might resolve years of confusion.
“It felt really right,” said Ari. And now, three years later, “it still feels really right.”
But Hallel’s identity has triggered new worries. They surfaced one night while Shira and Hallel cuddled at bedtime. (Shira agreed to record family conversations over a period of time for this story.)
“How did you feel when you first realized that I was a boy-girl?” asked Hallel, now age 9.
Shira paused, then answered slowly: “Abba [the Hebrew word for Daddy] and I knew for a very long time before you said anything that something was a little bit different about your gender. So we were not going to force you to fit in a certain box. But I think when we first found out, we were nervous because we want things to be easy for you.”
Shira has a version of that question for Hallel.
“Can you tell me what it feels like to be a boy-girl?” she asked.
“That’s hard,” Hallel said. “I just feel like myself, and that’s it. I don’t feel that different from anybody else.”
Pronouns and Patience
Hallel asked Shira and Ari to stop using “he” and start calling Hallel “they” about a month after the boy-girl declaration.
Little sister Ya’ara has had a hard time using “they,” as have Hallel’s grandparents, some friends and teachers at Hallel’s school.
Ari, who studies linguistics, said people frequently struggle to change the pronouns they use because those words are deeply embedded in our brains; we repeat them so much more often than nouns or verbs, for example.
“We say ‘he’ or ‘she’ or ‘they’ or ‘it’ in almost every single sentence,” Ari told Hallel one morning, “so we have a lot of practice using a pronoun in one way, kind of like walking. Imagine if you had to walk in a new way, it would probably take some time, right?”
“Like walking backwards?” Hallel asked.
“That’s right,” said Ari.
Ari tries to be patient with himself and others who coded Hallel as a boy from birth and subconsciously default to “he” now when speaking about Hallel.
“However much we might want to, even when we have the intention to do something, we have the underlying linguistic machinery that is actually making the language happen,” Ari said.
Hallel has a suggestion for grandparents and others: “Refer to me as a group of people.”
“Do you remember what Grandma said to you, the way that she helps to remind herself?” Shira asked Hallel. “She thinks of God. She feels like God is very universal and not a he or she, but more a they. And so she thinks of God when she refers to you.”
With excitement, Shira showed Hallel a news story about Merriam-Webster naming “they” the dictionary company’s word of the year.
“Wow, wow,” Hallel said in between mouthfuls of waffles.
“Why wow?” Shira wanted to know.
“It’s just really new that something like that’s happening,” Hallel said.
New still, yes, but familiar to many members of Generation Z and millennials, who say they know someone who uses gender-neutral pronouns.
“Wow,” Hallel said again. “Maybe, like, next year, ‘they’ will be in the dictionary.”
“I think it is in the dictionary already,” Shira told them.
“Already?” said a wide-eyed Hallel, their voice trailing off.
Coded Clothing
Hallel likes colorful clothes, especially those with pictures of animals.
Ari estimated Hallel wears dresses about a third of the time, clothes that might be seen as boyish about a third of the time and clothes that don’t read as either gender for the remainder. Hallel’s curly blond hair flows to about midneck.
“When people first see me they think I’m a girl,” Hallel said.
Sometimes Hallel or one of their parents will correct people who make the wrong assumption, but not all the time. Explaining boy-girl, nonbinary or “they” to everyone who calls Hallel “she” in the grocery store checkout line or on the street or at a public event would be exhausting.
“I don’t blame them. It’s new,” Hallel said. “The first time, I’ll let it slide.”
Dropping Hallel at school in a dress was hard for Ari, initially.
“There was an internal squeamishness,” Ari said. “I realized it’s just because it was different and something I wasn’t used to.”
Watching Hallel has changed that.
“They have taken such pride in who they are and in telling people,” Ari said. “And Hallel’s friends have completely embraced Hallel. I’m very grateful to their families for not pulling them back because this is something new or different.”
Bathroom Schedule
Hallel said they’ve been told “about 50 times,” mostly by kids at school, that they’re in the wrong bathroom.
They have a system for deciding which bathroom to use.
“On Mondays, Thursdays and Fridays, I go into the boys’ or men’s bathroom. On Tuesday, Wednesday and Saturday, I go into the women’s bathroom. And on Sunday, I just go to whatever bathroom’s to my right,” Hallel said.
“Remember when we were in the airport in Hawaii, and I said, ‘Hallel, you’re wearing a dress. I don’t think you should be going into the men’s room even though there’s no line.’ Remember that?” Shira asked.
“Well, I really had to go,” Hallel said.
“I know,” said Shira, “but I was just nervous that you would not be protected in the bathroom.”
“But I thought all those questions became laws,” said Hallel. The family campaigned for the 2018 ballot Question 3 in Massachusetts, which passed, confirming Hallel’s right to use a bathroom aligned with their gender identity.
“We know that you’re protected in Massachusetts, but we have to do our research to understand what the protection is in other states,” Shira explained.
“Well, everyone in Hawaii is nice,” Hallel said.
Hawaii is among the states with laws that specifically protect transgender people in public accommodations.
‘Now Is Now’
In addition to legal concerns, big questions remain for Hallel and their parents.
In a few years, Hallel will begin preparing for a coming-of-age ceremony in the Jewish faith, using Hebrew, a language that doesn’t have a gender-neutral pronoun. Hallel plans what they are calling a “bart mitzvah,” combining a boy’s bar mitzvah and a girl’s bat mitzvah.
Hallel will be defining a new place for themself within Judaism as they approach puberty, a time when testosterone will deepen Hallel’s voice and make irreversible changes in the bone structure of Hallel’s face and other areas of the body.
“We’ve started to talk with Hallel a little bit,” Ari said. “Hallel very much understands that there are male bodies and female bodies, and on the basis of this conversation Hallel says they feel comfortable with having a male body. So that’s where we are right now.”
Ari and Shira are getting some help for Hallel through a program at Jewish Big Brothers Big Sisters for LGBTQ+ youth. Within the family, by the way, Hallel is a “brister” to two younger sisters, merging “brother” and “sister.”
Shira looks forward to guidance from someone who can help her understand life as a nonbinary teenager and adult.
“I am very worried about what Hallel’s future will look like,” she said. “My kid affirmed who they are, and … I decided to accept them. But what’s that going to look like when Hallel is 11, 12, 13, in adolescence? I hope it’s gonna be wonderful. I don’t know, though.”
Ari said he has a lot of confidence that Hallel will be OK, based, in part, on the culture he sees among the college students he teaches.
“My students are very comfortable with the idea that people don’t have just male and female genders, and I think that says a lot for our future,” Ari said. “I’m personally very hopeful that Hallel will live in a world where they can be who they want to be.”
Shira has heard people ask: “Why are all these kids now being trans? Or why are all these kids now being nonbinary?”
“With Hallel, this is who they envisioned themselves to be, and we just didn’t put hurdles in front of them,” she said. “That may be the case for more kids who are trans and nonbinary; their parents are just listening to them.”
Hallel has lots of projects underway with Legos, a podcast, baking and a comic book series they sometimes imagine will lead to fame and fortune. But they don’t spend much time thinking about the future.
“I’ll know it when I live it,” Hallel said. “I don’t really want to think about that stuff because now is now.”
This story is part of a partnership that includes WBUR, NPR and KHN.
The shot fired into Alan Pean's chest would extinguish his family's belief that diligent high achievers could outwit the racism that shadows the American promise.
This article was published on Monday, May 10, 2021 in Kaiser Health News.
The beer bottle that cracked over Christian Pean's head unleashed rivulets of blood that ran down his face and seeped into the soil in which Harold and Paloma Pean were growing their three boys. At the time, Christian was a confident high school student, a football player in the suburbs of McAllen, Texas, a border city at the state's southern tip where teenage boys — Hispanic, Black, white — sung along to rap songs, blaring out the N-word in careless refrain. "If you keep it up, we're going to fight," Christian warned a white boy who sang the racial epithet at a party one evening in the waning years of George W. Bush's presidency. And they did.
On that fall evening in 2005, Christian pushed and punched, his youthful ego stung to action by the warm blood on his face. A friend ushered Christian into a car and drove through the bedroom community of Mission, passing manicured golf greens, gable roofs and swimming pools, to the well-appointed home of Dr. Harold and Paloma Pean, who received their son with care and grace. At the time, even as he stitched closed the severed black skin on his son's forehead, Dr. Pean, a Haitian exile and internal medicine physician, believed his family's success in America was surely inevitable, not a choice to be made and remade by his adopted country's racist legacy.
Christian's younger brother, Alan, a popular sophomore linebacker who shunned rap music and dressed in well-heeled, preppy clothes, agitated to find the boy and fight him. "Everybody shut up and sit down," Paloma ordered. Inside her head, where thoughts roiled in her native Spanish, Paloma recalled her brother's advice when they were kids growing up in Mexico: No temas nada. Eres una chica valiente.Never be scared.You are a brave girl. She counseled restraint, empathy even. "Christian, we need to forgive. We don't know how the life of this guy is that he took that reaction." This is a country that recognizes wisdom, Paloma thought.
The Pean family's tentative truce with America's darker forces would not last long. In August 2015, when Alan was 26 and under care at a Houston hospital where he had sought treatment for bipolar delusions, off-duty police officers working as security guards would shoot him through the chest in his hospital room, then handcuff him as he lay bleeding on the floor. Alan would survive, only to be criminally charged by the Houston police.
The shot fired into Alan's chest would extinguish the Pean family's belief that diligent high achievers could outwit the racism that shadows the American promise. Equality would not be a choice left up to a trio of ambitious boys.
Nearly six years later, the Peans remain haunted by the ordeal, each of them grappling with what it means to be Black in America and their role in transforming American medicine. Christian and Dominique, the youngest Pean brother, both aspiring doctors, like their father, have joined forces with the legions of families working to expose and eradicate police brutality, even as they navigate more delicate territory cultivating careers in a largely white medical establishment.
Alan has seen his studies derailed. He remains embroiled in a lawsuit with the hospital and wavers over his responsibility to the fraternity of Black men who did not survive their own racist encounters with police.
And Paloma and Harold, torn from their Mexican and Haitian roots, look to buoy and reassure their sons, propel them to the future they have earned — even as they wonder whether the America they once revered doesn't exist.
"People don't want to admit we have racism," Paloma told me. "But Pean and me, we know the pain."
Harold Pean doesn't recall being raised Black or white. His native Haiti was fractured by schisms beyond skin color.
Harold was 13 when he, his sister and five brothers woke on a May morning in 1968 to find that their father, a prominent judge, had fled Port-au-Prince on one of the last planes to leave the island before another anti-Duvalier revolt pitched the republic into a season of executions. His father had received papers from President François Duvalier demanding he sign off on amendments to Haiti's Constitution to allow Duvalier to become president for life. Harold's father refused. Soldiers arrived at the Pean house days after his father escaped.
The Republic of Haiti was marked by Duvalier's capricious cruelty during Harold's youth, but as the son of a judge and grandnephew of a physician, he enjoyed a comfortable life in which the Pean children were expected to excel in school and pursue professional careers: engineering, medicine, science or politics. In school, the children learned of their ancestors' brave heroics, African slaves who revolted against French colonialists and established a free republic, and they saw Black men and women running fruit stands, banks, schools and the government. "I didn't experience racism as a kid," Harold remembers. "When you find racism as a kid, that makes you doubt yourself. But I never doubted myself."
Two years after Harold's father fled Haiti, his mother joined her husband in New York, leaving the Pean children in the care of relatives. In 1975, Harold and his siblings left Haiti and immigrated to New York City. New York was cold, like being inside a refrigerator, and the streets were much wider than in Haiti. His father had found a job as an elevator operator at Rockefeller Center.
At the time, Harold's older brother, Leslie, was attending medical school in Veracruz, Mexico, where tuition was cheaper than in the States, and his father urged Harold to join him. A native French speaker who knew no Spanish, Harold learned anatomy, pathology and biochemistry in a foreign tongue. And he was fluent in Spanish by the time he met María de Lourdes Ramos González, known as Paloma, on Valentine's Day 1979 at a party in Veracruz. Harold remembers the moment vividly: a vivacious young woman spilling out of a car in the parking lot, shouting her disapproval at the low-energy partygoers. "'Everybody is sitting here!'"
"They were so quiet," Paloma remembers. She pointed to the man she would eventually marry, "You! Dance with me!"
Growing up as the only girl in her parents' modest ranch in Tampico, a port city on the Gulf of Mexico, Paloma was expected to stay inside sewing, cleaning and reading while her three brothers ventured out freely. She felt loved and protected but fumed at her circumscribed life, pleading for a car for her quinceañera and pushing her father, the boss at a petroleum plant, to allow her to become a lawyer. Her father thought she should instead become a secretary, teacher or nurse. "I said, 'Why are you telling me that?' He said, 'Because you are going to get married, you are going to end up in your house. But I want you to have a career in case you don't have a good husband, you can leave.'" That good husband, Paloma understood, could be Mexican or white. She remembers her father saying, "I don't want Black or Chinese people in my family."
After earning a degree to teach elementary school, Paloma moved to Veracruz. When she was 21, her father installed her in a boarding house for women. Watched over by a prying house matron, Paloma and Harold's courtship unfolded under the guise of Harold teaching Paloma English. The couple dated for several years before Paloma told her father she wanted to get married to the handsome, young medical student. Harold had returned to New York, and Paloma was eager to join him.
Her father was skeptical. He had spent a few months in Chicago and seen America's racial unrest. "He told me, 'My daughter, I don't have any objections. He's a good man, but I'm scared for you. I'm scared for my grandkids because, let me tell you, your kids are going to be Black. And I don't know if you are ready to raise Black kids in the U.S.,'" Paloma remembers. "At that moment I didn't understand what he meant."
In the early 1980s, as Harold and Paloma started their lives together, the news from America spoke to racial divisions. The country was seized by a presidential campaign, in which the actor and former California Gov. Ronald Reagan courted segregationist Southern voters at a Mississippi fairground a few miles from where civil rights workers had been murdered in 1964. In Miami, Black residents protested after an all-white, all-male jury acquitted four white police officers who had beaten an unarmed Black motorcyclist, Arthur McDuffie, to death with their fists and nightclubs. Beaten him "like a dog" McDuffie's mother, Eula McDuffie, told reporters. Over three days of violent street protests, 18 people died, hundreds were injured, buildings burned and President Jimmy Carter called in the National Guard.
The couple lived in Queens, where Christian was born in 1987, and Harold found work while pursuing medicine. He inspected day care schools for sanitary violations. As he traveled around the city's streets, he never felt imperiled by the color of his skin. "People said there was racism, but I didn't see it." On the few occasions he noticed a police officer or shop security trailing him, he put it out of his mind, trying not to pursue the logic of what had happened. "We never talked about it in the house," he said. "We were concentrating on achieving whatever goals we had to do."
Moving with common purpose, Harold and Paloma went wherever the young doctor could find work. Caguas, Puerto Rico, where Alan was born in 1989; back to New York for Harold's residency in internal medicine at the Brooklyn Hospital Center; then Fort Pierce, Florida, where Dominique was born in 1991; and eventually to McAllen, Texas. Harold's brother, Leslie, had established his practice in Harlingen, 20 miles north of the Mexican border. Harold was comforted to have family nearby and Paloma wanted to reach her family in Mexico more easily. Still, the first hospital that recruited Harold offered an uncharitable contract; he had to cover half the costs of running the medical practice while seeing only a few patients.
Harold remembers few, if any, other Black doctors in the area. Paloma was more certain about the dearth of diversity in the medical ranks: "We were among the only Blacks in the [Rio Grande] Valley and the only [primary care] doctor." Three months into the contract, Paloma, who managed the office's finances, could see they were losing money. She pressed her husband to renegotiate. When he refused, she went to the hospital herself. "I love the Valley," she told the administrator, her optimism unimpeachable. "But I came here to work. My husband is a very good doctor and you are not paying what he deserves. If you don't pay him, we are going to move." Stunned, the administrator, who was white, agreed to her demands, and Paloma returned triumphant.
Daily life was a blur. The couple worked assiduously at the medical practice, finding allies at the hospital who applauded their diligence and, by Harold's account, rooted for their success. But race was never far from the surface. When a medical assistant at the office told Paloma that another doctor had asked her repeatedly if she was still working with "the Black doctor," Paloma fumed. At the medical center's Christmas party that year, Paloma approached the doctor. "'Are you so and so, the doctor?' I said. 'Well, I'm Paloma Pean, and I'm here just to let you know the name of my husband. My husband is Harold Pean. P-E-A-N. His last name is not Black.' And I said, 'Thank you, and nice to meet you.' He opened his eyes big, and then I left."
At home, Paloma insisted on a Catholic upbringing, and the family prayed every evening after dinner in three languages (Paloma in Spanish, Harold in French, the boys in English). Harold pushed his three boys in the ways his own parents had. "I was expecting them to be either a doctor or a professional, like my parents expected us to be professionals."
That was the period in which the three Pean boys — Christian, Alan and Dominique — tried to sort out their Blackness in a place that was almost entirely Hispanic and white. Accustomed to being surrounded by Latinos in Florida and later in McAllen, Paloma recalled her father's warnings. When the boys started nursery school, they were the only Black babies. "That's when I thought, I need to start to make them very proud of what they are."
The questions about skin color came early for Dominique, the youngest brother. His fellow kindergartners watched Paloma, a Latina, drop off her son for school in the mornings, and a cousin, who was Chinese, pick him up after the last bell. (Paloma's brother had married a Chinese woman.) "They asked me if I was adopted," Dominique remembers clearly. He told his mother, "I don't look like you." Would his father, pretty-please, pick him up at school to show the kids, once and for all that, no, he was not adopted? It was a conclusive victory. "The kids stopped bringing it up. 'OK, you're Black!'"
The boys steered in different directions, employing sports, fashion and culture to signal their preferences to the perplexed children of McAllen. "I really identified with my Hispanic side, but when people see me, they see a Black kid," remembers Dominique. He ventured to look "more Black," braiding his hair into cornrows and wearing FUBU, a line of clothing that telegraphed Black street pride. Meanwhile, Alan forged a collegiate look. He listened to "corny, white boy music" (Christian's words) and dressed in Abercrombie & Fitch.
The boys were left to their own to make sense of the off-handed remarks at school and on the football field. You're Black, you're supposed to jump farther. Do Black kids have extra muscles in their legs? You sound smart for a Black kid. You sound white. Does anyone know if the Pean brothers have big dicks?
"There was open ignorance back then," Christian remembers. The boys absorbed and repelled the remarks, protesting vigorously only when the N-word exploded in front of them. One of Alan's friends on the football team asked him, "What's up, d…igger?" replacing the N and smirking knowingly. Alan responded, "Why would you even do that?"
It never occurred to Dr. Pean to give his teenage boys "the talk," the dreaded conversation Black parents initiate to prepare their sons for police encounters. The day Christian came home, blood running down his forehead, Harold argued against pressing charges. "The chief of police was my friend, and I had a lot of police patients," Harold said. "I would meet white people or Black or Hispanic, and I never thought they would see me differently."
Where Harold was silent, Paloma was explicit. The history of African Americans amazed her. Dominique remembers his mother saying, "Being Black is beautiful. They came to the United States as slaves, and now they are doctors. That blood runs in you, and you are strong."
Of all the sons, the oldest boy, Christian, seemed the most curious about exactly what his heritage and his skin color had to do with who he was. Why hadn't his mother married a Mexican man? Why did other kids want to know if his dark skin rubbed off? Could they touch his hair? At age 6, Christian told his mother a Hispanic girl at school had called him the N-word and his mother a "wetback" as he sat in the cafeteria sipping a Capri Sun.
The racist lexicon of American youth befuddled Paloma. She asked Christian, "What does that mean?" "That word is bad," he responded.
Christian's doubts about his father's faith in American meritocracy emerged early. After he endured racist slurs and other offensive remarks at school, Christian told Harold that he felt he was treated differently "because I'm Black."
"No, Chief," his father responded, "hard work gets rewarded. It's not going to help anybody to get down on your race."
As mixed-race children, the legitimacy of the Pean brothers' Blackness trailed them into adulthood. At Georgetown University, Christian found an abundance of Black students for the first time — African Americans and immigrants from Nigeria, Ghana and the Caribbean — and unfamiliar fault lines began to emerge.
"When I was in high school, there was never Black immigrants vs. Black Americans," Christian said. But in college and later in medical school at Mount Sinai in East Harlem, Christian fielded questions from other Black students about whether scholarships for people of color should be set aside for African Americans descended from slaves, not children of Black immigrants like him.
At the Catholic University of America in Washington, D.C., Dominique was facing similar questions about his racial camp. When he joined the board of the Student Organization of Latinos, he was asked, "Are you Latino enough?"
"When I'm on the street, people see a Black man. But when I'm with my Black friends, they're like, Dom, you're not really Black," he said. The questions followed them into their personal lives: African American women berating Christian and Dominique for dating women who were not Black.
If the Pean brothers' Haitian and Mexican roots called into question their rightful membership among African Americans, the police discerned no difference. After graduating from high school in the McAllen suburbs, Alan matriculated to the University of Texas-Austin, a sprawling campus filled almost entirely with white, Hispanic and Asian students. Alan, laid-back and affable, made friends easily. It surprised him then when a security officer trailed him at a store in the mall while he shopped for jeans. "That was the moment when I was like, 'Oh, I'm Black," he said.
In August 2015, Alan Pean started the fall semester at the University of Houston where he had transferred to finish his degree in biological sciences. Within days, he began to feel agitated, and his mind slipped into a cinematic delusion in which he believed he was a stunt double for President Barack Obama. At other times, armed assassins chased him.
Alarmed by Alan's irrational Facebook posts and unable to reach him by phone, Christian called his parents, who were sitting in a darkened McAllen movie theater. He urged them to get to Houston. This was not a drill. In 2009, Alan had spent a week at a hospital for what doctors believed was bipolar disorder.
In the lucid moments between the delusions traversing his psyche, Alan knew he needed medical help. Around midnight, on Aug. 26, 2015, he drove to St. Joseph Medical Center in Houston, swerving erratically and crashing his white Lexus into other cars in the hospital parking lot. As he was hustled into the emergency room on a stretcher, Alan screamed, "I'm manic! I'm manic!"
The following morning, Paloma and Harold flew to Houston and arrived at St. Joseph Medical Center expecting to find sympathetic nurses and doctors eager to aid their troubled son. Both Harold and Christian had placed calls to the emergency department, alerting them to Alan's mental health history. Instead of finding their son being cared for as a man in the midst of a delusion, Harold and Paloma discovered doctors had not ordered a psychiatric evaluation or prescribed psychiatric medication.
Barred from seeing their son and galled by the hospital's refusal to provide psychiatric care, Harold and Paloma went to their hotel to try to rent a car so they could take Alan for treatment elsewhere. They were gone for half an hour.
In his hospital room, Alan became more agitated. He believed the oxygen tanks next to his bed controlled a spaceship and that he urgently needed to deactivate a nuclear device using the buttons on his bed. He stripped off his hospital gown and wandered into the hallway naked. A nurse called a "crisis code" and two off-duty Houston police officers, one white and one Latino, charged into Alan's room. They were unaccompanied by any nurses or doctors, and they closed the door behind them.
The officers would say later that Alan hit one of them and caused a laceration. The first officer fired a stun gun. When the electroshock failed to subdue Alan, according to officers' statements, the second officer said he feared for his safety and fired a bullet into Alan's chest, narrowly missing his heart.
Paloma and Harold arrived back at the hospital to find themselves plucked from their ordered lives and hurled into a world in which goodwill and compassion had vanished. Alan was in intensive care with a gunshot wound, and police officers were asking questions about his criminal record. (He had none.) Alan would be detained for attacking the security officers, they were told, and it was now a criminal matter.
Christian flew in from New York, Dominique from Fort Worth, and Uncle Leslie from McAllen. Inconclusive conversations with a hospital administrator strained their patience. "That's when I was told that we had to have a lawyer to see him," Leslie said, trembling even as he recounted it nearly six years later.
Paloma was bewildered that her appeals for fairness went unanswered. "I was expecting they would allow me to see my son immediately. I said, 'My son is a good boy. Let me go and see my kid, please! Please!'" She felt like a ghost, wandering the hospital unstuck in time. Suddenly, the complexions and accents of everyone around her mattered: One police officer was surely white, she thought, the other Hispanic, but maybe born in the U.S.? The nurses were Asian, perhaps Filipino?
Days later, the hospital relented, and nurses led her to a glass window. Alan lay sedated, a tube down his throat, handcuffed to the hospital bed. Paloma's chest tightened and she felt faint. "I pinched myself, and I said, 'This cannot be true.' I screamed to my Lord, 'Please hold me in your hands.'"
"That's when I really understood what my father was talking about," Paloma told me. This, she thought, is how America treats Black men.
Over the next few weeks, it became impossible to unravel what exactly had happened to Alan. Sgt. Steve Murdock, a Houston police investigator, told Christian that Alan had been out of control, picking up chairs, acting like a "Tasmanian devil." When the hospital eventually allowed the Pean family into Alan's room, Alan was groggy, his wrists and hands swollen. Standing by his bedside, Uncle Leslie asked Paloma, Harold, Dominique and Christian to hold hands and pray. A week later, Alan was transferred to a psychiatric unit, and his delusions began to lift. A few days later, he was released from the hospital.
It was pouring rain the day the Pean family left Houston. Alan insisted on driving — he always drove on family trips — and his parents and brothers, desperate for a return to normalcy, agreed. Paloma prayed on her rosary in the backseat, nestled next to Christian. Alan drove for 20 minutes until someone suggested they stop and eat. At that moment, Alan turned to his father, "Did I really just drive out of Houston with a bullet wound still in my chest? Pop, I probably shouldn't be driving." Dominique drove the last five hours home.
Back in McAllen, neighbors passed on their sympathies, dumbfounded that the Pean's "well-behaved" middle child, the son of a "respected doctor," had been shot. Just as Harold years before had sewn up the gash in Christian's head left by a racially charged fistfight, he and Christian now tended to the piercing pain in Alan's ribs and changed the dressings of his wound.
That Alan survived a gunshot to the chest meant he faced a messy legal thicket. The police charged him with two accounts of aggravated assault of a police officer and, three months after the shooting, added a third charge of reckless driving. The criminal charges shocked his family.
"At the time, I thought the police and the hospital would apologize, or go to jail," said Dominique. "If a doctor amputated the wrong leg, there would be instant changes." A lawyer for the family readied a lawsuit against the hospital and demanded the federal government investigate the hospital's practice of allowing armed security officers into patients' rooms.
The seed of injustice planted in Alan's chest took root in the Pean family.
In October 2015, two months after the shooting, Christian summoned the family from Texas to New York City to march in a #RiseUpOctober protest against police brutality. On a brisk fall day, the five Peans held hands in Washington Square Park wearing custom-made T-shirts that read, "Medicine, Not Bullets." Quentin Tarantino, the film director, had flown in from California for the event, and activist Cornel West addressed the combustive crowd. Families shouted stories of loved ones killed by police.
Harold had never protested before and stood quietly, taking in the crowds and megaphone chants. Paloma embraced the spirit of the march, kissing her sons with hurricane force as the crowd made its way through Lower Manhattan. She found common cause with mothers whose Black sons had not survived their encounters with police. "We were very lucky that my son was alive," Paloma said.
The Peans' attorney had advised Alan not to speak publicly, fearing it would torpedo the lawsuit against the Houston hospital. Christian had his own reservations; he was applying for orthopedic residency programs, a notably conservative field in which only 1.5% of orthopedic surgeons are Black. "Everything is Google-able," he told me. "I wasn't sure what people would think about me being involved in Black Lives Matter or being outspoken."
When protesters began to chant "F— the police!" Christian moved into the crowd to change its tenor. He argued briefly with a white family whose daughter had been shot in the head and killed. This isn't how we move forward, he told them. Christian wanted to summon empathy and unity. Instead, he saw around him boiling vitriol. The protest turned unruly; 11 people were arrested.
Afterward, Alan expressed shock at the crowds, so consumed with anger. Christian wondered, How many of us are out there?
Six months passed, eight months. Expectations of quick justice left the Pean family like a breath. The Houston Police Department declined to discipline the two officers who tased and shot Alan. Mark Bernard, then chief executive officer of St. Joseph hospital, told federal investigators that given the same circumstances, the officers "would not have done anything different."
A brief reprieve arrived in March 2016, when a Harris County grand jury declined to indict Alan on criminal assault charges, and the district attorney's office dropped the reckless driving charge. The family's civil lawsuit against the hospital; its corporate owner, IASIS Healthcare Corp.; Criterion Healthcare Security; the city of Houston; and the police officers dragged on, one lawyer replaced by another, draining the family checkbook.
The Peans, meanwhile, registered each new death of a Black person killed by police as if Alan were shot once more. "It was all I could think about, I had dreams about it," Dominique said. "I felt powerless." Memories stored away resurfaced, eliciting doubts about a trail of misunderstood clues and neon warnings. Dominique had been close in age to Trayvon Martin when the Florida teenager was killed in 2012. Dominique remembers thinking, "It's terrible, it's wrong, but it would never happen with me. I have nice clothes on. I'm going to get my master's and become a doctor."
Even Uncle Leslie, who each year donated generously to the Fraternal Order of Police and had brushed off the numerous times police had stopped his car, caved under the overwhelming evidence. "I never related to the police killings until it happened to us," he confessed. "Now I doubt about whether they are protecting society as a whole." He has stopped giving money to the police association.
By 2017, Christian, Alan and Dominique had reunited in New York City. For a time, they shared an apartment in East Harlem. Their industrious lives resumed in haste; young men with advanced degrees to earn, careers to forge, loves to be found, just as their parents had done at that dud of a party in Veracruz.
Primed by his own experiences, the nick on his forehead a reminder of earlier battles, Christian pressed the family to speak out. Appointed the family spokesperson, he expanded the problems that would need fixing to guarantee the safety of Black men on the streets and in hospitals: racial profiling, healthcare inequities, the dearth of Black medical students. Working at a feverish pace, he aced crushing med school exams and pressed more than 1,000 medical professionals across the country to sign a petition protesting Alan's shooting and the use of armed security guards in hospitals.
"My perspective was, we should be public about this," Christian said. "We don't have anything to hide."
He embraced activism as part of his career, even if it meant navigating orthopedic residency interviews with white surgeons who eyed his résumé with skepticism. Would he be too distracted to be a good surgeon? He delivered a speech at his medical school graduation, and wrote a textbook chapter and spoke at the Mayo Clinic on healthcare inequities. Medical school deans asked Christian to help shape their response to the deaths of Breonna Taylor and George Floyd, and friends sought out his opinion. "For many people, I'm their only Black friend," he said. Christian has told the story of Alan's shooting over and over, at physician conferences and medical schools to shine a bright light on structural racism.
Over the months we spoke, Christian, now 33, juggled long days and nights as chief resident of orthopedic trauma at Jamaica Hospital in Queens with his commitments to Physicians for Criminal Justice Reform, Orthopedic Relief Services International and academic diversity panels. He is the über-polymath, coolly cerebral in the operating room and magnetic and winning in his burgeoning career as a thought leader.
Christian's family imagines he will run for office someday, a congressman, maybe. "He's charismatic, he has good ideas," said Dominique. "He's got big plans."
Dominique, too, has tried to spread the gospel, pushing for action where he could. He led an event in 2016 at the University of North Texas in Fort Worth using Alan's story as a case study in the catastrophic collision of racism, mental health and guns in hospitals.
When he moved to New York for medical school, joining his brothers, Dominique was anxious when he spotted police officers on the street. "I would try to be more peppy or upbeat, like whistling Vivaldi." But with each death — Stephon Clark, Atatiana Jefferson, Breonna Taylor, Daniel Prude, George Floyd, Rayshard Brooks, Daunte Wright — he has come to view these offerings as pointless. "After Alan, it doesn't matter how big I smile," Dominique decided.
Now 29 and a third-year medical student at Touro College of Osteopathic Medicine in Harlem, he said, "You can have all these resources and it doesn't mean anything because of the color of your skin, because there is a system in place that works against you. It's been so many years, and we didn't get justice."
Dominique has devised a routine for each new shooting: watch the videos of Black men and women killed by police or white vigilantes and read about their cases. Then set them aside and pivot back to his studies and school where there are few other Black doctors in training.
"I can escape by doing that," he told me. "I still need to do well for myself."
For Alan, as the years passed, time took on a bendable quality. It snapped straight with purpose — a talk show appearance on "The Dr. Oz Show," presentations with his brothers at medical schools in Texas, Massachusetts and Connecticut — and then lost its shape to resignation. Survival had bought him an uneasy liberty: He feared squandering the emotional potency of his own story but remained squeamish at the prostrations demanded by daytime TV shows, the tedium of repeating his story in front of strangers, doubting whether his life's misfortune was fueling social progress or exploiting a private tragedy.
In 2017, Alan enrolled at the City University of New York to study healthcare management, digging into a blizzard of statistics about police shootings and patients in crisis, and transferred the following year to a similar program at Mount Sinai. But by last fall, Alan had settled into a personal malaise. He dropped out of Mount Sinai's program, and spent hours in his room, restless and uncertain.
"I'm still working with coming to terms with who I am, my position in the family," said Alan, 32. "Christian is an orthopedic surgeon. Dominique is in medical school." After years of pursuing various degrees (biology, healthcare management, physician assistant, public health), that might not be who he is after all.
"Inside I didn't want to do it," he said. "It translates as a failure."
"Alan goes back and forth about whether he wants to write about it or go back to his regular life," Christian said. "I see him all the time, every day, being disappointed in himself for not being more outspoken, not feeling the free will to choose what to do with this thing."
Isn't it enough that he survived?
Alan sees a therapist and takes medication for bipolar disorder. He practices yoga. When he breathes deeply, his chest tingles, most likely nerve damage from where the bullet pierced. After a great deal of thinking, he has turned to writing science fiction and posting it online. The writing comes easily, mostly stories of his delusions told with exquisite detail — people, good and bad, with him in a place "that looks like Hell."
Outside of his apartment in New York, there are few places he can find sanctuary. Even as the coronavirus emptied the streets, he walked around the city, his eyes scanning for police cars, police uniforms, each venture to the store a tactical challenge. He selects his clothes carefully. "Never before 2015 had police officers stood out to me. Now, if they are a block away, I see them. That's how real the threat is. I have to think, 'What am I wearing? Do I have my ID? Which direction am I going?'
"If I were a white person, do they ever think those things?"
Reports of new shootings stir up his own trauma, and Alan trembles at the betrayal. "Why is it so hard to register that an unarmed person should not be shot?"
COVID presented new trauma for the Pean family, and underscored the nation's racial divide. The three brothers largely were confined to their apartment. Dominique attended medical school classes online while Christian volunteered to work at Bellevue, a public hospital struggling to treat a torrent of COVID patients who were dying at a terrifying pace. Many patients spoke only Spanish, and Christian served as both physician and interpreter.
The patients coming to Bellevue were nearly all Black or Latino and poor, and Christian grew angrier each day as he saw wealthier private hospitals, including NYU Langone just a few blocks away, showered with resources. The gaping death rates between the two hospitals would prove startling: About 11% of COVID patients died at NYU Langone; at Bellevue, about 22% died. "This wasn't the kind of death I was used to," Christian said.
At the peak of the epidemic in New York, Christian video-called his dad at home in Mission, Texas, and cried, exhausted and overwhelmed. Harold and Paloma had largely shuttered their clinic after several staff members became infected, but Harold continued to see urgent cases. Knowing the dangers to front-line healthcare workers, Christian was scared for his parents. "I was worried my dad wasn't going to protect himself," he said. "And that I was going to lose one of my parents and I wasn't going to be able to say goodbye."
All that was stirring inside Christian when Minneapolis police officer Derek Chauvin callously murdered George Floyd in May 2020, sparking protests across the globe. Black Lives Matter demonstrators filled New York City's streets, and Christian and Dominique joined them. Alan did not; the lockdown and blaring ambulance sirens had left him anxious and hypervigilant, and after months indoors, he feared open spaces.
"I'm going to wait this one out," he told Christian.
On the streets, surrounded by the fury and calls for change, Christian wore his white doctor's coat, a potent symbol of solidarity. "I wanted to show that people who were on the front lines of the pandemic realized who the pandemic was affecting was reflective of the racism that led to George Floyd's death." When they returned home, Christian told Alan that the multiethnic makeup of the protesters surprised him. "I think maybe people's minds are changing," Christian said. "It was beautiful to see."
Nearly a year later, on April 20, 2021, a jury found Chauvin guilty of murder, and Christian felt a wash of relief. But in the days that followed, news coverage erupted about the fatal police shooting of a 13-year-old Latino boy in Chicago, and the death of a 16-year-old Black girl in Columbus, Ohio, also at the hands of police. The Pean family was unusually muted. "We only exchanged a few texts about it as a family," Christian said. "We said maybe things are changing, maybe not."
The Pean sons will scatter soon: Christian to Harvard University for a trauma medicine fellowship; Dominique to medical rotations at Nassau University Medical Center; and Alan to McAllen, where he will oversee the financial operations of his parents' business. It will be Alan's first time living alone. "The one semester I was almost going to live by myself I was in Houston, and I got shot. I need to do this by myself to know I can."
Watching violence unravel one of his son's lives has haunted Dr. Harold Pean — the threats to Black lives in American cities not escaped as easily as a Haitian dictator.
But Harold, 66, is reluctant to allow Alan's shooting to rewrite his American gospel; the shooting was a personal tragedy, not a transmutation of his identity. He pushes the memories from his mind when they appear and summons generosity. "Whatever the bad stuff, I keep it inside. I try to psych myself to think positively all the time," he said. "I want to see everyone like a human."
He has convinced himself that no more violence will befall his sons or, someday, his grandchildren. Still, he can no longer reconcile the tragedy of Alan's shooting with his Catholic beliefs. "If God was powerful, a lot of bad things would not have happened," he said.
"It's difficult for him to acknowledge that he's struggling," Christian said of his father. "He's a resilient person. He's never talked about the added burden of being a Black man in America."
"I think Paloma is the one keeping my brother together," Uncle Leslie told me.
But who is keeping Paloma together? To her sons, her husband, her fellow parishioners, Paloma, 63, brims with purpose. She's a fighter, an idealist. But at night, she sleeps with the phone beside her bed. When it rings, she jumps. Are you OK? In her dreams, she is often in danger. Many nights, she lies awake and talks aloud to God. "Why? For what? Tell me, Lord." (She speaks to the Lord in Spanish. "In English, I think he will not understand me!")
Paloma's activism is quietly public: her presence in the community of mostly white doctors; her motherly boasts about Christian and Dominique becoming physicians and Alan's return to McAllen; her insistence that racism is real in a part of the country where "White Lives Matter" signs abound. "I'm on a mission," she said. "I want to disarm hate."
But deep within her, that sense of purpose lives beside a fury she can't quell and a disappointment so profound it can make it hard to breathe. She wonders if God is punishing her for abandoning Mexico, and whether the U.S. soil in which she chose to grow her own family is poisoned. "Sometimes I feel like I want to leave everything," she told me. "I feel like I don't understand how people can be so selfish here in America."
They are dark thoughts that go largely unspoken, secrets kept even from her mother, age 90, who now lives with them in McAllen. Six years have passed since Alan was shot, and Paloma still has not told her mother what happened in that Houston hospital room. Nor will she ever.
"The pain I went through," Paloma said, "I don't want to give that pain to my mom."
Pamela Valfer needed multiple COVID tests after repeatedly visiting the hospital last fall to see her mother, who was being treated for cancer. Beds there were filling with COVID patients. Valfer heard the tests would be free.
So, she was surprised when the testing company billed her insurer $250 for each swab. She feared she might receive a bill herself. And that amount is toward the low end of what some hospitals and doctors have collected.
Hospitals are charging up to $650 for a simple, molecular COVID test that costs $50 or less to run, according to Medicare claims analyzed for KHN by Hospital Pricing Specialists (HPS). Charges by large health systems range from $20 to $1,419 per test, a new national survey by KFF shows. And some free-standing emergency rooms are charging more than $1,000 per test.
Authorities were saying "get tested, no one's going to be charged, and it turns out that's not true," said Valfer, a professor of visual arts who lives in Pasadena, California. "Now on the back end it's being passed onto the consumer" through high charges to insurers, she said. The insurance company passes on its higher costs to consumers in higher premiums.
As the pandemic enters its second year, no procedure has been more frequent than tests for the virus causing it. Gargantuan volume — 400 million tests and counting, for one type — combined with loose rules on prices have made the service a bonanza for hospitals and clinics, new data shows.
Lab companies have been booking record profits by charging $100 per test. Even in-network prices negotiated and paid by insurance companies often run much more than that and, according to one measure, have been rising on average in recent months.
Insurers and other payers "have no bargaining power in this game" because there is no price cap in some situations, said Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health who has studied test economics. When charges run far beyond the cost of the tests "it's predatory," she said. "It's price gouging."
The data shows that COVID tests continue to generate high charges from hospitals and clinics despite alarms raised by insurers, anecdotalreports of high prices and pushback from state regulators.
The listed charge for a basic PCR COVID test at Cedars-Sinai Medical Center in Los Angeles is $480. NewYork-Presbyterian Hospital lists $440 as the gross charge as well as the cash price. Those amounts are far above the $159 national average for the diagnostic test, which predominated during the first year of the pandemic, at more than 3,000 hospitals checked by HPS.
That's the amount billed to insurance companies, not what patients pay, Cedars spokesperson Cara Martinez said in an email.
"Patients themselves do not face any costs" for the tests, she said. "The amounts we charge [insurers] for medical care are set to cover our operating costs," capital needs and other items, she said.
Likewise at NewYork-Presbyterian, charges not covered by insurance "are not passed along to patients," the hospital said.
Many hospitals and labs follow the Medicare reimbursement rate, $100 for results within two days from high-volume tests. But there are outliers. Insurers oftentimes negotiate lower prices within their networks, although not for labs and testing options outside their purview.
Billing by hospitals and clinics from outside insurance company networks can be especially lucrative because the government requires insurers to pay their posted COVID-test price with no limit. Regulation for out-of-network vaccine charges, by contrast, is stricter. Charges for vaccines must be "reasonable," according to federal regulations, with relatively low Medicare prices as a possible guideline.
"There's a problem with the federal law" on test prices, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. "The CARES Act requires insurers to pay the full billed charge to the provider. Unless they've negotiated, their hands are tied."
But even in-network payments can be highly profitable.
Optim Medical Center in Tattnall, Georgia, part of a chain of orthopedic practices and medical centers, collects $308 per COVID test from two insurers, its price list shows. Yale New Haven Hospital collects $182 from one insurer and $173 from another.
Yale New Haven's prices resulted from existing insurer agreements addressing unspecified new procedures such as the COVID test, said Patrick McCabe, senior vice president of finance for Yale New Haven Health.
"We didn't negotiate" specifically on COVID tests, he said. "We're not trying to take advantage of a crisis here."
Officials from Optim Medical Center did not respond to queries from KHN.
Castlight Health, which provides benefits and healthcare guidance to more than 60 Fortune 500 companies, analyzed for KHN the costs of 1.1 million COVID tests billed to insurers from March 2020 through this February. The analysis found an average charge of $90, with less than 1% of bills passing any cost along to the patient. Since last March, the average cost has gone up from $63 to as high as $97 per test in December before declining to $89 in February, the most recent results available.
In some cases, hospitals and clinics have supplemented revenue from COVID tests with extra charges that go far beyond those for a simple swab.
Warren Goldstein was surprised when Austin Emergency Center, in Texas, charged him and his wife $494 upfront for two COVID tests. He was shocked when the center billed insurance $1,978 for his test, which he expected would cost $100. His insurer paid $325 for "emergency services" for him, even though there was no emergency.
"It seemed like highway robbery," said Goldstein, a New York professor who was visiting his daughter and grandchild in Texas at the time.
Austin Emergency Center has been the subject of previous reports of high COVID-test prices.
The center provides "high-quality healthcare emergency services" and "our charges are set at the price that we believe reflects this quality of care," said Heather Neale, AEC's chief operating officer. The law requires the center to examine every patient "to determine whether or not an emergency medical condition exists," she said.
Curative, the lab company that billed $250 for Valfer's PCR tests, said through a spokesperson that its operating costs are higher than those of other providers and that consumers will never be billed for charges insurance doesn't cover. Valfer's insurer paid $125 for each test, claims documents show.
Even at relatively low prices, testing companies are reaping high profits. COVID PCR tests sold for $100 apiece helped Quest Diagnostics increase revenue by 49% in the first quarter of 2021 and quadruple its profits compared with the same period a year ago.
"We are expecting … to still do quite well in terms of reimbursement in the near term," Quest CFO Mark Guinan said during a recent earnings call.
Hospitals and clinics do pay tens of thousands of dollars upfront when purchasing analyzer machines, plus costs for chemical reagents, swabs and other collection materials, maintenance, and training and compensating staff members. But the more tests completed, the more cost-effective they are, said Marlene Sautter, director of laboratory services at Premier Inc., a group purchasing organization that works with 4,000 U.S. hospitals and health systems.
A World Health Organization cost assessment of running 5,000 COVID tests on Roche and Abbott analyzers — not including that initial equipment price, labor or shipping costs — came to $17 and $21 per test, respectively.
Unlike earlier in the pandemic, lab-based PCR tests no longer dominate the market. Cheaper, rapid options can now be purchased online or in stores. In mid-April, some CVS, Walmart and Walgreens stores began selling a two-pack of Abbott Laboratories' BinaxNOW antigen test for $23.99.
Regulations require insurers to cover COVID testing administered or referred by a healthcare provider at no cost to the patient. But exceptions are made for public health surveillance and work- or school-related testing.
Claire Lemcke, who works for a Flagstaff, Arizona, nonprofit, was tested at a mall in January and received a statement from an out-of-state lab company saying that the price was $737, that it was performed out-of-network and that she would be responsible for paying. She's working with her insurer, which has already paid $400, to try to get it settled.
Sticker shock from COVID tests has gotten bad enough that Medicare set up a hotline for insurance companies to report bad actors, and states across the country are taking action.
Free-standing emergency centers across Texas, like the one Goldstein visited, have charged particularly exorbitant prices, propelling the Texas Association of Health Plans to write a formal complaint in late January. The 19-page letter details how many of these operations violate state disclosure requirements, charge over $1,000 per COVID test and add thousands more in facility fees associated with the visit.
These free-standing ERs are "among the worst offenders when it comes to price gouging, egregious billing, and providing unnecessary care and tests," the letter says.
In December, the Kansas Insurance Department investigated a lab whose cash price was listed at nearly $1,000. State legislatures in both Minnesota and Connecticut have introduced bills to crack down on price gouging since the pandemic began.
"If these astronomical costs charged by unscrupulous providers are borne by the health plans and insurers without recompense, consumers will ultimately pay more for their healthcare as health insurance costs will rise," Justin McFarland, Kansas Insurance Department's general counsel, wrote in a Dec. 16 letter.
Long before they receive a dementia diagnosis, many people start losing their ability to manage their finances and make sound decisions as their memory, organizational skills and self-control falter, studies show.
This article was published on Wednesday, May 5, 2021 in Kaiser Health News.
After Maria Turner’s minivan was totaled in an accident a dozen years ago, she grew impatient waiting for the insurance company to process the claim. One night, she saw a red pickup truck on eBay for $20,000. She thought it was just what she needed. She clicked “buy it now” and went to bed. The next morning, she got an email about arranging delivery. Only then did she remember what she’d done.
Making such a big purchase with no forethought and then forgetting about it was completely out of character for Turner, then a critical care nurse in Greenville, South Carolina. Although she was able to back out of the deal without financial consequences, the experience scared her.
“I made a joke out of it, but it really disturbed me,” Turner said.
It didn’t stop her, though. She shopped impulsively online with her credit card, buying dozens of pairs of shoes, hospital scrubs and garden gnomes. When boxes arrived, she didn’t remember ordering them.
Six years passed before Turner, now 53, got a medical explanation for her spending binges, headaches and memory lapses: Doctors told her that imaging of her brain showed all the hallmarks of chronic traumatic encephalopathy.CTE is a degenerative brain disease that in Turner’s case may be linked to the many concussions she suffered as a competitive horseback rider in her youth. Her doctors now also see evidence of Alzheimer’s disease and frontotemporal dementia, which affects the frontal and temporal lobes of the brain. These may have roots in her CTE.
Turner’s money troubles aren’t unusual among people who are beginning to experience cognitive declines. Long before they receive a dementia diagnosis, many people start losing their ability to manage their finances and make sound decisions as their memory, organizational skills and self-control falter, studies show. As people fall behind on their bills or make unwise purchases and investments, their bank balances and credit rating may take a hit.
Mental health experts say the covid pandemic may have masked such early lapses during the past year. Many older people have remained isolated from loved ones who might be the first to notice unpaid bills or unopened bank notices.
“That financial decision-making safety net may have been weakened,” said Carole Roan Gresenz, interim dean at Georgetown University’s School of Nursing and Health Studies, who co-authored a study examining the effect of early-stage Alzheimer’s disease on household finances. “We haven’t been able to visit, and while technology can provide some help, it’s not the same … as sitting next to people and reviewing their checking account with them.”
Even during times that aren’t complicated by a global health crisis, families may miss the signs that someone is struggling with finances, experts say.
“It’s not uncommon at all for us to hear that one of the first signs that families become aware of is around a person’s financial dealings,” said Beth Kallmyer, vice president for care and support at the Alzheimer’s Association.
Early in the disease, Kallmyer said, dementia robs people of the abilities they need to manage money: “executive functioning” skills like planning and problem-solving, as well as judgment, memory and the ability to understand context.
People who live alone may be the most likely to slip through the cracks, their lapses unnoticed, Kallmyer said. And many adult children may be reluctant to discuss personal finances with their parents, who often guard their independence.
About 6 million Americans are living with Alzheimer’s disease, the most common cause of dementia. Dementia is an umbrella term for a range of conditions associated with declines in mental abilities that are severe enough to interfere with daily life. There is no cure. Alzheimer’s, which killed more than 133,000 Americans in 2020, is the seventh-leading cause of death in the U.S.
Many people have mild symptoms for years before they are diagnosed. During this stage, before obvious impairment, they may make substantial errors managing their finances.
In Gresenz’s study, researchers linked data from Medicare claims between 1992 and 2014 with results from the federally funded Health and Retirement Study, which regularly surveys older adults about their finances, among other things. Her study, published in the journal Health Economics in 2019, found that during early-stage Alzheimer’s, people were up to 27% more likely than cognitively healthy people to experience a large decline in their liquid assets, such as savings and checking accounts, stocks and bonds.
Another study, published in JAMA Internal Medicinein November,linked Medicare claims data to the Federal Reserve Bank of New York/Equifax Consumer Credit Panel to track people’s credit card payments and credit scores. The study found that people with Alzheimer’s and related dementias were more likely to miss bill payments up to six years before they were diagnosed than were people who were never diagnosed. The researchers also noted that the people later diagnosed with dementia started to show subprime credit scores 2.5 years before the others.
“We went into the study thinking we might be able to see these financial indicators,” said Lauren Hersch Nicholas, an associate professor of public health at the University of Colorado, who co-authored the study. “But we were sort of surprised and dismayed to find that you really could. That means it’s sufficiently common because we’re picking it up in a sample of 80,000 people.”
For decades, Pam McElreath kept the books for the insurance agency that she and her husband, Jimmy, owned in Aberdeen, North Carolina. In the early 2000s, she started having trouble with routine tasks. She assigned the wrong billing codes to expenditures, filled in checks with the wrong year, forgot to pay the premium on her husband’s life insurance policy.
Everyone makes mistakes, right? It’s just part of aging, her friends would say.
“But it’s not like my friend that made that one mistake, one time,” saidMcElreath, 67. “Every month I was having to correct more mistakes. And I knew something was wrong.”
She was diagnosed with mild cognitive impairment in 2011, at age 56, and with early-onset Alzheimer’s two years later. In 2017, doctors changed her diagnosis to frontotemporal dementia.
Receiving a devastating diagnosis is hard enough, but learning to cope with it is also hard. Eventually both McElreath and Maria Turner put mechanisms in place to keep their finances on an even keel.
Turner, who has two adult children, lives alone. After her diagnosis, she hired a financial manager, and together they set up a system that provides Turner with a set amount of spending money every month and doesn’t allow her to make large withdrawals on impulse. She ditched her credit cards and removed eBay and Amazon from her phone.
Though not a micromanager, Turner’s financial adviser keeps an eye on her spending and questions her when something seems off.
“Did you realize you spent X?” she’ll ask, Turner said.
“And I’ll be like, ‘No, I didn’t.’ And that’s the thing. I’m aware but I’m not aware,” she added.
In 2017, Pam and Jimmy McElreath sold their insurance agency to spend more time together and moved west to Sugar Grove, in the Blue Ridge Mountains. They worked with a therapist to figure out how to ensure Pam is able to continue to do as much as possible.
These days, Pam still signs their personal checks, but now Jimmy looks them over before sending them out. The system is working so far.
“At first I was mad, and I went through this dark time,” Pam said, adding: “But the more that you come to accept your problem, the easier it is to say, ‘I need help.’”
Jimmy’s gentle approach helped. “He was so good about telling me when I did something wrong but doing it in such a kind way, not blaming me for making mistakes. We’ve been able to work it out.”
Tips for Helping a Loved One
It’s not easy to broach financial management issues with an elderly parent or other relative experiencing cognitive trouble. Ideally, you and they will have these conversations before problems develop.
As an adult child, you might mention you’ve been talking with a financial adviser about managing your own finances to ease into a conversation about what your elder is doing, said Beth Kallmyer of the Alzheimer’s Association.
Or suggest that allowing a shared financial management arrangement would eliminate the hassle of tracking and paying bills.
“Often people are open to the idea of making their lives easier,” Kallmyer said.
Whatever the approach, it’s important to plan and take steps to protect assets.
“Part and parcel of any legal or estate planning is protecting oneself in the event of incapacity,” said Jeffrey Bloom, an elder law attorney at Margolis & Bloom in the Boston area.
Specific steps depend on the family and their financial situation, but here are some to consider:
Encourage the parent in need of help to sign a financial power of attorney.
These legal documents authorize you or another person to act on a parent’s behalf in financial matters. The terms may be narrow or broad, allowing you to make all financial decisions or to perform specific duties like paying bills, making account transfers or filing taxes.
A “durable” power of attorney allows you to make decisions even if your parent becomes incapacitated. In some states, power of attorney documents are automatically considered durable.
Put assets in a trust.
A trust is a legal vehicle that can hold a range of assets and property. It can spell out how those assets are managed and distributed while people are alive or after they die.
“We do believe in the power of attorney, but we believe in the trust as an even better tool in the event of incapacity,” Bloom said.
Trusts can be tailored to a client’s concerns and provide more guidance than a power of attorney document about what money can be spent on and who has access under what circumstances, among other things.
You might be a co-trustee on major distributions, for example, or there may be rules that provide for you or others to review and be notified of any changes, Bloom said.
The Alzheimer’s Association recommends working with an attorney who specializes in trusts to ensure all laws and regulations are followed, Kallmyer said.
Have your name added as another user on a parent’s bank accounts, credit cards or other financial accounts.
This may be a convenient way to make payments or monitor activity. But a shared account can be problematic if children are sued, for example, or wish to withdraw the money for their own use.
The funds typically belong to all parties whose names are on the account. Unlike a power of attorney, the child isn’t obligated to act in a parent’s best interest.
Each of these setups may help protect a parent’s assets. But parents may not welcome what they see as interference, no matter how well meaning family members are. Typically, they can refuse to permit children’s access to their financial information or revoke permission previously granted.
Finding a balance between protecting someone and usurping their rights is hard, said Bloom. The only way to ensure financial control is to go to court to establish guardianship or conservatorship. But that is a serious step not to be taken lightly.
“You only want to do that if there’s a major risk.”
The panel recommends that all Americans select a primary care provider or be assigned one, a landmark step that could reorient how care is delivered in the nation's fragmented medical system.
This article was published on Tuesday, May 4, 2021 in Kaiser Health News.
The federal government must aggressively bolster primary care and connect more Americans with a dedicated source of care, the National Academies of Sciences, Engineering and Medicine warn in a major report that sounds the alarm about an endangered foundation of the U.S. health system.
The urgently worded report, which comes as internists, family doctors and pediatricians nationwide struggle with the economic fallout of the coronavirus pandemic, calls for a broad recognition that primary care is a "common good" akin to public education.
The authors recommend that all Americans select a primary care provider or be assigned one, a landmark step that could reorient how care is delivered in the nation's fragmented medical system.
And the report calls on major government health plans such as Medicare and Medicaid to shift money to primary care and away from the medical specialties that have long commanded the biggest fees in the U.S. system.
"High-quality primary care is the foundation of a robust healthcare system, and perhaps more importantly, it is the essential element for improving the health of the U.S. population," the report concludes. "Yet, in large part because of chronic underinvestment, primary care in the United States is slowly dying."
The report, which is advisory, does not guarantee federal action. But reports from the national academies have helped support major health initiatives over the years, such as curbing tobacco use among children and protecting patients from medical errors.
Strengthening primary care has long been seen as a critical public health need. And research dating back more than half a century shows that robust primary care systems save money, improve people's health and even save lives.
"We know that better access to primary care leads to more timely identification of problems, better management of chronic disease and better coordination of care," said Melinda Abrams, executive vice president of the Commonwealth Fund, a New York-based foundation that studies health systems around the world.
Recognizing the value of this kind of care, many nations — from wealthy democracies like the United Kingdom and the Netherlands to middle-income countries such as Costa Rica and Thailand — have deliberately constructed health systems around primary care.
And many have reaped significant rewards. Europeans with chronic illnesses such as diabetes, high blood pressure, cancer and depression reported significantly better health if they lived in a country with a robust primary care system, a group of researchers found.
For decades, experts here have called for this country to make a similar commitment.
But only about 5% of U.S. healthcare spending goes to primary care, versus an average of 14% in other wealthy nations, according to data collected by the Organization for Economic Co-operation and Development.
Other research shows that primary spending has declined in many U.S. states in recent years.
The situation grew even more dire as the pandemic forced thousands of primary care physicians — who didn't receive the government largesse showered on major medical systems — to lay off staff members or even close their doors.
Reversing this slide will require new investment, the authors of the new report conclude. But, they argue, that should yield big dividends.
"If we increase the supply of primary care, more people and more communities will be healthier, and no other part of healthcare can make this claim," said Dr. Robert Phillips, a family physician who co-chaired the committee that produced the report. Phillips also directs the Center for Professionalism and Value in Healthcare at the American Board of Family Medicine.
The report urges new initiatives to build more health centers, especially in underserved areas that are frequently home to minority communities, and to expand primary care teams, including nurse practitioners, pharmacists and mental health specialists.
And it advocates new efforts to shift away from paying physicians for every patient visit, a system that critics have long argued doesn't incentivize doctors to keep patients healthy.
Potentially most controversial, however, is the report's recommendation that Medicare and Medicaid, as well as commercial insurers and employers that provide their workers with health benefits, ask their members to declare a primary care provider. Anyone who does not, the report notes, should be assigned a provider.
"Successfully implementing high-quality primary care means everyone should have access to the 'sustained relationships' primary care offers," the report notes.
This idea of formally linking patients with a primary care office — often called empanelment — isn't new. Kaiser Permanente, consistently among the nation's best-performing health systems, has long made primary care central. (KHN is not affiliated with Kaiser Permanente.)
But the model, which was at the heart of managed-care health plans, suffered in the backlash against HMOs in the 1990s, when some health plans forced primary care providers to act as "gatekeepers" to keep patients away from costlier specialty care.
More recently, however, a growing number of experts and primary care advocates have shown that linking patients with a primary care provider need not limit access to care.
Indeed, a new generation of medical systems that rely on primary care to look after elderly Americans on Medicare with chronic medical conditions has demonstrated great success in keeping patients healthier and costs down. These "advanced primary care" systems include ChenMed, Iora Health and Oak Street Health.
"If you don't have empanelment, you don't really have continuity of care," said Dr. Tom Bodenheimer, an internist who founded the Center for Excellence in Primary Care at the University of California-San Francisco and has called for stronger primary care systems for decades.
Bodenheimer added: "We know that continuity of care is linked to everything good: better preventive care, higher patient satisfaction, better chronic care and lower costs. It is really fundamental."
Tobin's pharmacy and department store had already stocked its shelves with Easter and Mother's Day items last spring, and the staff had just placed the Christmas orders. The shop in Oconomowoc, Wisconsin, had been operating on a razor's edge as retail sales moved online and mail-order pharmacies siphoned off its patients. It was losing money on 1 out of 4 pill bottles filled, so the front of the store, where it sold clothing, cosmetics and jewelry, had been compensating for pharmacy losses for years.
"And then COVID hit," said Dave Schultz, who co-owned the store with his brother. "And that was the final straw."
The COVID-19 pandemic sank many businesses in 2020, particularly those relying on in-person sales to stay afloat. For pharmacies — especially independent pharmacies — the pandemic lockdowns exacerbated long-standing economic pressures. Many small owner-operated pharmacies adapted quickly, delivering their traditional amenities in safer ways or capitalizing on new services created by the pandemic, such as COVID testing and vaccinations. But others, like Tobin's, became casualties of the pandemic, closing their doors for good.
It's too early to quantify just how many pharmacies succumbed to COVID and assess how patients will be affected. The total number of pharmacies has declined less than 1% over the past five years, as pharmacy chains get larger while independent community pharmacies — often the last place left to fill a prescription in some small towns — go under. The Rural Policy Research Institute found that 1,231 independently owned rural pharmacies, about 16%, closed for good from 2003 to 2018, well before the pandemic pinch. And according to the Drug Channels Institute, after five years of declines, the number of urban and rural independent pharmacies dipped below 20,000 for the first time in 2020.
Revenue from COVID testing and vaccinations may help keep some independents afloat, but that comes with added costs and logistical challenges.
"Pharmacies are struggling," said Harry Lattanzio, president of PRS Pharmacy Services, a consulting firm in Latrobe, Pennsylvania. "We're getting calls from a lot more pharmacy owners that want to sell their stores. They've had enough."
Most pharmacies, he said, saw a decline in prescriptions last year as customers hesitated to visit their doctors for anything but emergencies. That drop in business also meant fewer sales of over-the-counter medicines and ancillary items sold by the stores. Meanwhile, pharmacies had to buy protective equipment to keep staffers and customers safe and beef up their technology to address the new reality.
Lattanzio said some independent pharmacies, which had always preferred the personal touch of having staff members answer the phones, have had to invest in new systems to handle thousands of calls a day from people seeking vaccines. Costs rose even as revenues dropped.
"For the most part, they lost money," Lattanzio said. "If you didn't lose money, you did something really right."
When Lattanzio opened his first pharmacy 20 years ago, he saw gross profit margins of 36%. Now independent pharmacies are fortunate to see margins of 3% to 5%, if they survive the pandemic at all. Much of that decline comes from the impact of pharmacy benefit managers, which manage commercial and public health plans' prescription drug reimbursements to pharmacies. Those PBMs, often aligned with large drugstore chains, systematically squeezed the profits out of independent pharmacies. That left many smaller chains or unaffiliated pharmacies unable to bear the added hit from the pandemic.
"I'm afraid to see the outcome," said Joe Moose, co-owner of Moose Pharmacy, a chain of seven drugstores on the outskirts of Charlotte, North Carolina. "The delay in payments, the increased cost to keep operating in the early days of this, combined with the fact that reimbursement is so poor already — COVID may be the final nail in the coffin for some of us."
Moose Pharmacy is trying to adapt. When it had to stop in-store purchases during the pandemic, the chain expanded curbside services and hired additional drivers. Home deliveries tripled. Workers ferried food, toilet paper, paper towels and shampoo to customers.
"We had to build out our website. We put in technology so that people could text us from the parking lot. It had to be HIPAA-compliant," said Moose, who owns the chain with his brother. "And keep in mind that all of that is happening at no change in reimbursement."
COVID also interrupted the medication supply chain. In normal times, the pharmacy's supply of drugs is automated, so when it dispenses medicines, replacements show up in the next day's delivery. But Moose and his staff had to resort to the old way of calling up five or six wholesalers to see who had the drugs in stock.
When COVID testing was scarce, the pharmacies taught their employees to perform rapid tests. Once vaccines arrived, Moose sought out patients who couldn't make an appointment on a smartphone, who couldn't drive to mass vaccination clinics, or who were just afraid to leave their home.
Staffers delivered vaccines to one elderly man with cancer, whose wife had died a year earlier. He and his disabled adult son didn't want to risk going out and contracting the virus.
"But he trusts us, and so we deliver medication to him probably every other week," Moose said. "So it made sense that we bring the vaccine to him."
Tripp Logan, a pharmacist in Charleston, Missouri, said one of his three pharmacies is in rural Mississippi County, which has no hospital or chain pharmacy for the 14,000 residents. There, four independent pharmacies and the county health department formed a consortium to help distribute COVID vaccines.
"It started with a group text, and the next thing you know, we're vaccinating hundreds of people a week collectively," Logan said.
Because pharmacies can make up to $70 per COVID test and $40 for each vaccination, many pharmacies are earning new revenue to offset some of the retail losses, said Owen BonDurant, president of Independent Rx Consulting in Centerville, Ohio.
"So that has brought a significant increase in profit margins for the short term," BonDurant said. "COVID has probably saved a lot of pharmacies. Because PBM pressure has been so hard, especially on some of these rural and inner-city pharmacies, a lot of them still are on the verge of going out of business."
The cash infusion from the federal Paycheck Protection Program also kept many pharmacies afloat, and allowed some to make investments that better position them for the future.
"We would have had to shut down or sell because the PBMs were brutal last year, and they killed off a lot of our friends in Wisconsin," said Dan Strause, president and chief executive officer of Hometown Pharmacy in Madison, Wisconsin. "Without the PPP, there would have been far more facing the same fate."
Some of the changes born of necessity could stick. In a recent survey by the National Community Pharmacists Association, 3 in 5 community pharmacists said they expect more pharmacies to offer point-of-care testing after the pandemic, and more than half said additional pharmacies will give immunizations.
Hashim Zaibak, CEO of Hayat Pharmacy in Milwaukee, said his pharmacy is considering testing for the flu, strep and hemoglobin A1C levels for those with diabetes, and it will continue providing vaccinations.
"Those changes are here to stay," Zaibak said.
Tobin's owners considered selling their pharmacy, but finding no buyers, they shut down for good in September. Schultz said it's unclear whether they could have survived had COVID not happened — or if the vaccine revenue might have helped. He knows of two other independent pharmacies in Wisconsin that closed in the past 18 months.
"The real crux of the matter is you're getting paid, in some cases, $60 under the cost that we end up paying for the medication," he said. "How do you justify that portion of your business?"
Oconomowoc has one independent drugstore, two grocery store pharmacies and a Walgreens to serve its 17,000 residents. But Schultz worries about many of the older, sicker customers who relied on the personalized care his pharmacy provided. One of his former pharmacists now works at a drugstore outside of town but delivers medications to some of Tobin's most vulnerable former customers on her way home.
"She just didn't think they would survive going someplace else," he said.
California's dentist and doctor lobbies say insurance companies are flush with cash after collecting premiums during the pandemic but paying fewer claims than usual — and should foot the bill.
This article was published on Wednesday, May 5, 2021 in Kaiser Health News.
SACRAMENTO — Treating patients has become more expensive during the pandemic, and doctors and dentists don't want to be on the hook for all the new costs.
For instance, the box of 100 gloves that cost $2.39 in February 2020 costs $30 now, said Dr. Judee Tippett-Whyte, president of the California Dental Association, who has a private dental practice in Stockton.
Her practice used to rely on surgical masks that cost 20 cents each but has upgraded to N95 masks at $2.50 a pop. On top of that, her office is scheduling two or three fewer patients each day to accommodate physical distancing and give staff members time to disinfect between patients, she said.
"We've sustained a lot of financial costs," Tippett-Whyte said. "We shouldn't have to bear the cost of this for ourselves."
Her argument raises a fundamental COVID question: Who should pay for pandemic expenses? Should it be healthcare providers contending with new pandemic-era protocols or insurance companies, which may pass on their additional costs to customers in the form of higher premiums?
California's dentist and doctor lobbies say insurance companies are flush with cash after collecting premiums during the pandemic but paying fewer claims than usual — and should foot the bill. The California Medical Association, which represents doctors, has sponsored legislation that would require insurers to reimburse medical and dental practices for pandemic-related expenses like personal protective equipment, disinfectant and the staff time required to screen patients for symptoms before an appointment.
A request by doctors to bill Medicaid and Medicare for supplies and other pandemic-related costs recently failed at the federal level. But in Washington state, a new law sponsored by the state doctors' lobby requires private health insurers to reimburse a portion of those costs.
Insurance trade groups have opposed both state measures.
Reimbursing the cost of nonmedical supplies isn't typically the responsibility of insurers, said Mary Ellen Grant, spokesperson for the California Association of Health Plans.
"Here we are with treatment and office levels back at pre-pandemic levels. Now they want additional payment from plans to pay for nonmedical expenses," Grant said.
The insurance industry also points out that doctors and dentists haven't had to fend for themselves when it comes to PPE and other pandemic-related expenses. Since April 2020, the U.S. Department of Health and Human Services has distributed $9.9 billion to more than 50,000 California medical providers through the Provider Relief Fund, out of $178 billion available nationally.
And more than 900,000 businesses in the "healthcare and social assistance" category — including some medical practices and dentists — have gotten Paycheck Protection Program loans from the Small Business Administration since March 2020.
A letter from insurance groups opposing California's bill points to other assistance, such as advance payments on insurance claims from the federal government and insurance plans, state-based grants and loans, and programs that distributed free PPE to some practices.
"They've gotten plenty of help from the feds to cover these costs," Grant said.
Health insurance companies saw their margins and profits skyrocket at the beginning of the pandemic when they were collecting premiums while patients put off non-urgent medical care. Those tapered off when people started returning to the doctor. Still, the nation's largest medical insurer, UnitedHealth Group, recently announced its net income for the first quarter of 2021 was 44% higher than in the same quarter last year.
Allison Hoffman, a professor who researches health policy at the University of Pennsylvania's law school, said she has little sympathy for health insurance companies that "made a fortune over the past year" by collecting premiums without paying for the typical number of treatments and doctors' visits.
"We're starting to see a kind of broader definition of what health insurance might pay for in order to keep people healthy," Hoffman said. "There's nothing like a public health emergency to shine a light on the fact that sometimes it's not a prescription drug or surgical procedure that's going to improve health."
Late last year, the American Medical Association lobbied the federal Centers for Medicare & Medicaid Services to approve a procedure code doctors could use to bill those public insurance programs for PPE, disinfecting materials, office modifications to keep people apart, and staff time spent instructing patients before their visits and checking their symptoms. Often, when federal regulators approve a new billing code for Medicare and Medicaid, private insurers start reimbursing for the corresponding costs as well.
Allowing doctors to bill for that code would help them follow infection control protocols without further cutting into revenues, the association wrote to the federal agency.
But CMS denied the request, saying it considers payment for those costs part of the payment for the rest of the appointment, according to an agency spokesperson.
In the wake of that decision, two state medical associations took up the cause themselves.
The Washington State Medical Association backed a law, which took effect April 16, that allows healthcare providers to bill state-regulated private insurance companies $6.57 when they see a patient in person — on top of billing for whatever services they provide — to cover the cost of extra PPE, staff time, and materials to conduct and transport COVID tests. The new rules last through the rest of the federally declared public health emergency.
For a law that put the state's medical association and insurance association on opposite sides of the bargaining table, it was remarkably uncontentious, said state Sen. David Frockt (D-Seattle), who introduced the bill.
California's legislation, which is still being debated, is more open-ended than Washington's.
SB 242 doesn't specify a dollar amount but would require private health plans regulated by the state to reimburse dental and medical practices for the "medically necessary" business expenses associated with a public health emergency.
The California Medical Association said physician practice revenues fell by one-third while PPE costs rose by 14% in the first six months of the pandemic, according to an October 2020 survey of its members. Of the survey respondents, 87% said they were worried about their financial viability.
"When you look at the record profits on some of these publicly traded companies and what they're showing their shareholders, this would be a drop in the bucket," association spokesperson Anthony York said of health insurers. "We're not surprised plans don't want to pay more, but ultimately this is a fight we'll have in the legislature."
The bill is intended to keep small and medium-sized practices from closing their doors in the face of rising costs, said its author, state Sen. Josh Newman (D-Fullerton). The state medical and dental associations warn that anything that adds costs and cuts into revenues could force smaller practices to close or consolidate, exacerbating physician and dentist shortages around the state.
"What I'm doing, as a legislator, is to deliberately offset some of these burdensome costs so we don't lose physicians and practices," Newman said. "It would be a shame if those communities lost access to healthcare."
Debbie Cook was in her pajamas on a summer morning in 2019 when she got a call from her son: "Something bad is wrong with Granny."
The fear in his voice told Cook it was serious. She dialed 911 immediately, knowing it could take time for an ambulance to navigate the country roads in Fentress County, Tennessee.
She got dressed and made the short drive across the family farm, over two bridges and a creek, to her mother's house. Cook prayed that one of the three ambulances covering their roughly 500-square mile county was near.
When Cook arrived, she found her mother, Lottie Crouch, in the bathroom, unable to stand or walk. Cook, a licensed practical nurse, quickly recognized the signs: lopsided face, one side of the mouth drooping.
Her mama was having a stroke.
"I was petrified," Cook recalled. She started her career working with stroke rehab patients and knew that getting the right care fast could mean life or death. Or a big difference in her mother's quality of life. Crouch was 75 and still energetic and loved doing things like firing up a kettle of soup for herself. To continue living the life Crouch knew, each step toward getting care in a rural area had to go right.
But when the paramedics arrived, one of the biggest questions was: Where would they take Crouch for care?
Across the nation, nearly 800,000 people suffer strokes each year. The issue is particularly acute across the regions of Appalachia and the Mississippi Delta, where more than 80% of counties have stroke death rates above the national average. Many of these counties also face high rates of poverty and are home to vulnerable elderly populations. They have a shortage of medical providers or have seen local hospitals shutter.
In Tennessee, 2 million people — nearly one-third of the state — are people like Crouch who live more than 45 minutes from a hospital that is stroke-certified and able to provide the most advanced care, according to a new analysis by KHN and InvestigateTV. And rates are even higher in Delta states such as Arkansas and Mississippi, where more than half of residents must drive longer than 45 minutes to those specialized stroke centers.
The analysis is part of a yearlong project called Bridging the Great Health Divide, in which KHN and Gray Television's national investigative team, InvestigateTV, are digging into health issues that have historically plagued these regions. Strokes are chief among them. Despite medical advancements in stroke care, routing patients from rural parts of Appalachia and the Delta to the appropriate facility is an intricate jigsaw puzzle.
"There's not the same one correct answer for all patients," said Dr. Raul Nogueira, an interventional neurologist at Grady Memorial Hospital in Atlanta. Where a patient should be taken for care "really depends on travel time," he said. "It's all about time."
For years, the advice for stroke patients has been to get to the nearest hospital as soon as possible. A stroke cuts off blood flow to part of the brain, and the sooner that blood flow can be restored the better. So, the idea has been to get patients to a doctor — any doctor — quickly.
But that advice is now evolving. Research shows some stroke patients benefit more from advanced procedures typically done by specialists at large medical centers. The new goal is to get patients to the right doctor at the right hospital as soon as possible.
In some cases, that means skipping the closest facility. For patients with severe strokes, in which a clot is blocking one of the brain's major arteries, the American Heart and Stroke associations recommend traveling up to an additional 30 minutes in urban areas and 60 minutes in rural areas to reach a hospital with more advanced stroke capabilities.
While that's easy enough in a city where multiple hospitals are clustered together, in rural areas like Fentress County the question of where to take a patient has become increasingly fraught.
Big Decisions, Little Time
When Lottie Crouch had her stroke, what would have been the nearest hospital, less than 20 minutes away, had closed two months earlier. It's one of 136 rural hospitals nationwide that have shuttered since 2010, including nearly three dozen across Appalachia and the Delta. That meant the closest in-state hospital for Crouch was nearly 45 minutes away by car, and medical centers with the most advanced care were more than an hour's drive. That left EMS services stretched thin trying to transport patients farther away.
Each step in the process to get someone who'd had a stroke to the right care within the right amount of time had become more complex.
The decisions along the way are rarely clear-cut, Nogueira said. If a patient has a severe stroke, they might benefit from getting to a large medical center where they can undergo surgery right away, he said. Stopping at a smaller hospital that can't perform that procedure might unnecessarily delay care.
But if the stroke is less severe, the person might benefit more from first going to a closer facility that can offer medications to break up the clot sooner, Nogueira said. Then the patient could avoid unnecessary medical bills from a long trip, anything from $500 for a ride in the back of a regular ambulance to $50,000 for a helicopter. And their family could save the time and money needed to visit them in a faraway hospital.
The problem is that first responders can't necessarily tell how severe a stroke is just by looking at someone. So, they rely on an evaluation of the patient's symptoms to make the best choice.
The gravity of these decisions weighs on Jamey Beaty, a paramedic in Fentress County, who responded to Lottie Crouch's home.
"When you're in the back of a truck and all alone and you have a patient actively dying on you, the only thing you can think about is: How can I keep this patient alive until I can get them somewhere?" Beaty said. "That's all that crosses your mind."
Anytime Beaty gets a call about a stroke, his first response is to look at the sky.
Since the local hospital closed, an air ambulance is how he quickly gets people to treatment. The day Lottie Crouch had her stroke, luckily the Tennessee sky was clear blue. Crouch was taken nearly 100 miles to a hospital in Knoxville with advanced stroke services.
Long Journeys to Advanced Care
Over the past two decades, two main treatments have advanced care for strokes caused by a blockage — the most common type of stroke in America. The first is a medication delivered through an IV to break up clots in patients' blood vessels. The medicine has to be given within 4½ hours of when symptoms start. The second is a procedure using a catheter to physically remove the clot from a patient's vessels. This treatment can be done up to 24 hours after symptoms start but is generally used only for severe strokes.
Across the country, hospitals are certified by tiers, largely based on their ability to regularly provide these treatments. Some hospitals have no certification. Among stroke-certified hospitals, the first level is acute stroke-ready hospitals, which can assess stroke patients, keep them stable and provide clot-busting medications. At the other end of the spectrum are comprehensive stroke centers, which have specialized teams of neurologists and neurosurgeons. In addition to giving the clot-busting drugs, these centers can physically remove clots.
The big question is: Which facility can and should stroke patients be taken to first to get the right care within the right time span?
In Appalachia, about 11% of residents must drive more than 45 minutes to reach any kind of stroke center, according to the KHN and InvestigateTV analysis. That proportion is even higher in the Delta, where nearly a third of residents have to drive more than 45 minutes to a stroke center. Another third of Delta residents have only basic-care stroke centers within that distance and would need to drive farther for advanced stroke surgeries.
And in the most rural parts of both these regions, people are less likely to be near an advanced-care stroke facility.
Rural and Largely African American
While reaching appropriate stroke care in time is difficult for many rural Americans, such as Crouch, who is white, the concerns are compounded for places with a large Black population.
In Sumter County, Alabama, several people interviewed — from a business owner to a college professor to the district judge — were able to name someone off the top of their heads who has had a stroke. The county is more than 70% Black, and it is one of the poorest areas of the state.
The only hospital within county lines has no stroke certification. Loretta Wilson, the CEO of Hill Hospital of Sumter County, wishes her facility could do more for stroke patients. But clot-busting medications can cost $8,000 per dose, and the hospital can't always afford to keep them on hand, she said.
Most stroke patients are taken to larger hospitals at least 30 or 40 minutes away. That can be a long and expensive journey for many residents, Wilson said.
Understanding that, Wilson focuses largely on prevention efforts. She runs a nonprofit that tackles issues like high blood pressure, obesity and diabetes, all of which increase a person's risk of stroke. Her organization partners with churches to teach people about healthy eating and exercise, and passes around blood pressure monitors so congregants can screen themselves after services.
"We have a high African American population," said Wilson, who is African American too, "and those are the ones who really need the services."
Other organizations in the county also work to educate people about heart health and when to call 911. The local college's nursing program has a scholarship aimed at bringing more medical providers to the area.
Using Telestroke to Boost Rural Care
In rural hospitals, even if doctors have access to clot-busting drugs, they may hesitate to administer them for fear of harming the patient. In rare instances — about 2% to 7% of cases — the drugs can cause bleeding in the brain.
But not using the drugs can also have consequences. A national study published in 2020 found stroke patients were less likely to receive those medications in rural hospitals than urban ones, and stroke patients were more likely to die in rural hospitals.
Telestroke programs can help bridge that gap, said Dr. Amelia Adcock, a neurologist at WVU Medicine in West Virginia and head of the system's telestroke network.
By connecting doctors from smaller, often rural, hospitals with an on-call specialist at a large medical center, the programs allow people "to share the burden of decision-making," Adcock said. And the liability.
Dr. Michael Gould is an emergency medicine doctor at the 25-bed Potomac Valley Hospital in rural northern West Virginia. His hospital is not stroke-certified and does not have a neurologist on staff. He said giving clot-busting drugs is "one of the decisions in medicine that makes me the most nervous."
But consulting with neurologists at WVU Medicine's hub about 80 miles away in Morgantown has given him more confidence, he said. Gould estimated he now administers the drugs once or twice a month.
A study of WVU Medicine's telestroke network found the number of stroke patients receiving clot-busting medications nearly doubled over the first three years of the program.
Last fall, Christopher Green was picking up groceries when he suddenly developed a severe headache and lost his peripheral vision. Green, a longtime paramedic, immediately recognized what was happening. "Oh, my God, I'm having a stroke," he remembers thinking. He was brought to Gould's hospital, and the ER staff immediately fired up the telestroke program.
Within 30 minutes, Green got drugs to break up the blockage in his vessels. "A textbook outcome," said Green, who has responded to many 911 calls for stroke.
Looking back, Green said he probably would have taken a patient in his situation to a farther hospital that was stroke-certified. But experiencing the telestroke program firsthand changed his outlook.
"Now I see that delaying that treatment 20 to 30 minutes makes a difference on whether you have a full resolution or some kind of residual effects," he said.
'What Could It Have Been?'
Back in Tennessee, Debbie Cook was grateful her mother was taken to the advanced-care stroke center in Knoxville. It allowed Lottie Crouch to get the treatment she needed so she can still lead a mostly independent life.
But there were trade-offs. The distance took a toll on the family. Cook, her sister and her daughter took turns driving nearly two hours each way to watch over Crouch in the hospital each night.
After 10 days, when Crouch was transferred to a rehab facility closer to home, the family felt a sense of relief. They could bring her meatloaf and wild blackberry dumplings for dinner. And "a lot of peppermint candy," Crouch recalled — her favorite.
Although Crouch is now healthy and at home, her 27-year-old granddaughter, Haelee Stockton, is still haunted by the possibility of what could have happened that day. If the paramedics hadn't made it in time or if bad weather had prevented the helicopter from flying, her granny might not be alive.
"What could it have been?" Stockton said. "How lucky was she? And how many people are going to get that lucky in the future?"
Aneri Pattani led the reporting and writing for this story. Hannah Recht led the data analysis and graphics. InvestigateTV's Daniela Molina contributed to this report.