The massive spending bill is the first of two likely to at least delay the so-called Medicare rebate rule released at the end of the Trump administration, which has yet to take effect.

This article was published on Thursday, August 5, 2021 in Kaiser Health News.

By Michael McAuliff

The Senate's release of its bipartisan infrastructure plan signals that lawmakers are poised to throw former President Donald Trump's belated bid to lower Medicare drug prices under the bus — not to mention trains, bridges, tunnels and broadband connections.

That's because the massive spending bill is the first of two likely to at least delay the so-called Medicare rebate rule released at the end of the Trump administration, which has yet to take effect. Congress would use the projected costs of that rule to pay for more than half a trillion dollars in new infrastructure.

What has infrastructure spending got to do with Medicare drug rebates?

Bear with us as we explain the mad logic of how Congress intends to pay for a spending program with money that doesn't really exist. Tossing Trump's reform under the steamroller to offset other costs offers a window into the convoluted process of congressional budgeting: Senators say the plan will provide billions of dollars of savings, even though the federal government has never spent a dime on the rebate rule. And it focuses attention on the intractable problem of bringing down drug prices: The rule would take money from drug industry brokers and provide refunds to consumers, which would suggest it was saving them and Medicare money. Yet budget analysts said the process would cost the government billions of dollars.

Let's start with the Medicare drug rebates.

The way things work now, pharmacy benefit managers, which are often owned by insurance companies, negotiate with drugmakers to get significant reductions on a drug's list price. They pass the bulk of that savings along to Medicare and the insurers, who can pocket some of it and use it to lower overall premiums for customers who buy drug plans in Medicare Part D.

While customers benefit from a lower premium, it doesn't mean they actually get a better price for their drugs, said Gerard Anderson, a professor of health policy at Johns Hopkins Bloomberg School of Public Health.

That's because a patient's price is not based on the rebate but on a share of the original list price of the drug. If a drug costs $100, and a patient's share is 25%, they pay $25, regardless of how big a rebate the PBM got for the insurer.

It thus serves the interest of the PBM for the drugmaker to raise prices. "When the list price goes up, your patient responsibility goes up, so the patient ends up paying more," Anderson said. "The PBM makes money because, when the list price goes up, the rebate is larger. But the patient loses, because their cost sharing is based often on the list price."

Since the PBM controls the formulary that says which drugs are covered in a given plan, Anderson and others point out, it is also in the interest of a drug company to raise list prices if it wants the PBM to give its drugs preferential treatment.

"If you've got two drugs that are available to take care of some heart disease, the PBM wants the drug that's going to pay them the most money, and the money is the difference between the list price and the actual transaction price," Anderson said. "So the higher the list price, the higher the profit margin for the PBM. So the drug company who wants their drug on the formulary has to raise their price in order to give the PBM a greater profit."

A wrinkle in federal law allows that to happen. Typically in federal contracting, if someone sets a high price to give the buyer a cut, it's considered a bribe or a kickback, and it's illegal. But the law that created the Part D drug program carved out what's known as a safe harbor to allow such deals in the hope that negotiations would lower overall costs.

The Trump administration's rule attempts to end the perverse incentive by taking the safe harbor away from the PBMs and giving the rebate to customers at the pharmacy counter. Then-Health and Human Services Secretary Alex Azar said costs would fall by about 30%.

But the effort had two major problems. First, the rule was challenged in court by the PBMs on procedural grounds. Second, the Congressional Budget Office predicted that, rather than save money, it would end up costing the federal government $177 billion over 10 years because drugmakers would be less likely to provide as many discounts, causing a spike in Medicare drug coverage premiums.

The Biden administration delayed the rule, and could scrap it, making that $177 billion cost more theoretical than real. But that's where congressional budgeting comes in.

A chief selling point of the infrastructure proposal is that it is "paid for," meaning it taps new revenue streams or ends other things that cost money so that the $550 billion in new spending in the plan doesn't add to the federal deficit.

Even though Trump's rebate rule has already been delayed and is likely to be killed, it is, at this moment, on the books. Since the infrastructure bill would delay the rule and its costs until 2026, the savings get counted as offsetting the new spending. Confused yet?

Delaying the rule, instead of killing it outright, means there's still another $130 billion on the books that can be used to offset other spending — almost certainly likely to help fund the even bigger budget reconciliation measure that Senate Democrats intend to pursue as soon as the Senate passes the bipartisan infrastructure bill.

Sen. Bill Cassidy (R-La.), who liked Trump's rule and also supports the bipartisan infrastructure bill, explained the reasoning to reporters shortly before the infrastructure legislation was released.

"The Medicare rebate rule — you know, I actually agree with the policy, but it was a $182 billion cost to the Treasury," Cassidy said, citing a slightly different figure for the savings. "And so, it's been signaled that it was going to be used for something. … Just speaking practically, if something's going to score that high, and here with a party, Democrats, that don't like it, it's going to go away, right? So that was just a good take."

The move is essentially painless in congressional budget terms, and PBMs are thrilled. They argue they do not actually profit from the rebates they negotiate in Part D and pass all the rebate cash along to Medicare and plan sponsors already.

They say their ability to negotiate those rebates is part of what makes them valuable, and the rule interferes. "That's sort of the bread and butter of the work that our companies do, and undermining the ability to provide that value is obviously a real challenge," Pharmaceutical Care Management Association CEO JC Scott said in a call with KHN and PCMA spokesperson Charles Coté.

They favor not just delaying it but spiking it completely. "From our perspective, that is the action that's needed," said Coté. "To create certainty for Part D and for beneficiaries, it should just be fully repealed."

Repealing Trump's rebate rule is not painless for people who have high drug costs, though, because, as Johns Hopkins professor Anderson explained, the 10% or so of people who would get significant rebates at the pharmacy counter would be better off.

"It helps the people that have the large bills; it harms the most the people that don't have the large bills," Anderson said.

Benefiting from Trump's rule would be drugmakers, according to the CBO data and other sources. In a statement from the Pharmaceutical Research and Manufacturers of America, the industry's lobby group, spokesperson Debra DeShong cast ending the rule as a windfall for PBMs and a cynical raid on cash meant for sick, older Americans.

"Lawmakers are threatening to gut a rule that would provide patients meaningful relief," DeShong said. "This would be an unconscionable move that robs patients of the prescription drug savings they deserve to help fill potholes and fund other infrastructure projects."

Senate lawmakers were hoping to pass the infrastructure bill by Thursday, then move quickly on the reconciliation bill, both paid for in part with the ill-fated rebate rule. The legislation would then go to the House when it returns from its August recess.

Michael McAuliff: @mmcauliff ‏

Support for breastfeeding was upended last year, when it no longer seemed safe to take a baby class at the hospital or invite a nurse into one’s home.

This article was published on Tuesday, August 3, 2021 in Kaiser Health News.

By Kate Ruder

Madison Cano knew she wanted to breastfeed her son, Theo. But breastfeeding was painful for her. The skin on her breasts was chafed and blistered last July when she returned home from the hospital. And Theo sometimes screamed during feedings.

Cano, 30, realized she needed help to get the short- and long-term health benefits of breastfeeding for moms and babies. New studies also have shown that covid-vaccinated mothers pass protective antibodies on to their newborns. However, Cano lives in Montrose in western Colorado, 60 miles away from her lactation counselor, Ali Reynolds, in Grand Junction — and it was during the thick of the pandemic.

She messaged Reynolds on Facebook and took photos and recorded videos of herself breastfeeding so Reynolds could offer advice and encouragement from afar. It worked. She no longer had pain. Cano is still breastfeeding Theo, who just turned 1.

“I don’t think I would have understood what was happening and been able to work through it without that resource,” said Cano.

Support for breastfeeding was upended last year, when it no longer seemed safe to take a baby class at the hospital or invite a nurse into one’s home. Hospitals, lactation counselors and support groups turned to virtual platforms like Zoom or phone calls. That made lactation support accessible to struggling families during the pandemic, said Danielle Harmon, executive director of the United States Lactation Consultant Association.

Today, although lactation specialists have more options to safely meet in person with families after their covid-19 vaccinations, many are choosing to continue virtual classes, keeping alive the online communities they created and relying on the technology that worked for many families. Virtual options especially help those in remote areas or those with limited transportation access, breastfeeding experts say.

Right before the pandemic, for example, Sandrine Druon typically had one or two moms attend in-person meetings she held for La Leche League of Longmont at the First Evangelical Lutheran Church or at a Ziggi’s Coffee shop. But because they could no longer meet in person, last June she launched two monthly virtual meetings. Now, an online meeting will typically include nine or 10 moms. She started an online Spanish-speaking meeting in May and parents joined from their homes in several states and even from other countries. She hopes eventually to have a mix of online and in-person meetings.

The virtual switch hasn’t worked for everyone. Harmon said the logistics of video support remain difficult, along with privacy concerns on platforms that could be hacked. Other lactation experts noted Black and Hispanic mothers are sometimes still left behind. So lactation specialists are trying to learn from the pandemic on what worked — and what didn’t — to reach all kinds of new parents.

Before the pandemic, 84% of U.S. mothers breastfed at least initially, according to 2019 data from the Centers for Disease Control and Prevention, while Colorado had a 93% rate.

The pandemic hasn’t seemed to change the picture, said Stacy Miller, Colorado’s breastfeeding coordinator for the Special Supplemental Nutrition Program for Women, Infants and Children, shorthanded as WIC. Citing state birth certificate data, Miller said preliminary breastfeeding rates among families discharged from Colorado hospitals remained similar in the first quarter of 2021 to rates from 2020 or 2019.

Throughout the pandemic, lactation specialists have tried to offer convenient options for parents. St. Joseph Hospital in Denver launched virtual breastfeeding support groups that still occur today, in addition to breastfeeding help during families’ hospital stays, said Katie Halverstadt, the hospital’s clinical nurse manager of lactation and family education.

Last year in North Carolina, experts adapted an in-person prenatal breastfeeding program to an interactive video platform in English and Spanish. A separate effort on New York’s Long Island successfully converted in-person breastfeeding support to phone and video calls in 2020.

To help support parents in Grand Junction, Colorado, Reynolds expanded her private practice, Valley Lactation, by offering virtual appointments while continuing to see some clients in their homes. That hybrid model continues today, although Reynolds said the demand for virtual or phone appointments has decreased lately as the country reopens.

Paying out-of-pocket for appointments is a hurdle her clients face, said Reynolds, but she encourages them to submit claims for telehealth or in-person visits to their health insurance companies for reimbursement. Early in the pandemic, telehealth rules were relaxed to encourage more telephone and virtual appointments — many of which have been covered by insurance.

But insurance coverage for lactation support will likely continue to be an issue independent of whether pandemic telehealth rules expire, USLCA’s Harmon said. While the Affordable Care Act mandates that insurance companies cover lactation support and supplies, such as breast pumps, Harmon said reimbursement is often spotty. Mirroring Medicaid, insurance providers often cover services only from licensed providers, she said, but just four states — Georgia, New Mexico, Oregon and Rhode Island — license lactation consultants.

Experts such as Jennifer Schindler-Ruwisch, an assistant professor at Fairfield University in Connecticut, found the pandemic may have exacerbated breastfeeding barriers for those without access to online technology or translation services, among other things. She published one of the first studies in the U.S. to examine covid’s effect on lactation services by collecting experiences from lactation support providers in Connecticut, including many working in WIC programs. For income-eligible WIC families, all breastfeeding classes, peer groups and one-on-one consultations are free.

Birdie Johnson, a doula who provides breastfeeding and other postpartum support to Black families as part of Sacred Seeds Black Doula Collective of Colorado, said virtual support groups during the pandemic also did not meet her clients’ needs for connection and interaction. Social media built communities online, particularly by normalizing breastfeeding struggles among Black parents, she said, but obstacles remained.

“Covid brought our community together and at the same time destroyed it,” Johnson said.

Black parents in the U.S. already had lower rates of breastfeeding than Asian or white parents, according to 2017 CDC data, and both Black and Hispanic parents have had lower rates of exclusively breastfeeding their babies at 6 months, which is what the American Academy of Pediatrics recommends. Socioeconomics and lack of workplace support have been found to contribute to the gap. Research also has found Black mothers are more likely than white moms to be introduced to infant formula at hospitals.

A scarcity of Black health care providers in lactation, women’s health and pediatrics is a continuing concern, Johnson said. In Colorado last year, the Colorado Breastfeeding Coalition, the Center for African American Health, Elephant Circle and Families Forward Resource Center held three training sessions for people of color to become lactation specialists, said Halverstadt, who chairs the coalition.

Jefferson County, which encompasses much of Denver’s western suburbs, is now training at least a dozen Spanish-speaking community members for lactation certification. In addition to classes, the trainees log clinical hours in breastfeeding support, sometimes during virtual meetings of a Spanish-speaking support group called Cuenta Conmigo Lactancia.

“You are more confident and more at ease with someone who knows your language, your culture and who is part of the community,” said Brenda Rodriguez, a dietitian and certified lactation consultant for Jefferson County Public Health, which reaches roughly 400 breastfeeding families each month through its WIC programs.

Angelica Pereda, a maternal and child health registered nurse, is part of that training program. Pereda, who is Hispanic and bilingual, gave birth to son Ahmias in April 2020 and struggled with breastfeeding because he could not latch on to her breasts. A lactation consultant could not come into her home during the pandemic, and she was skeptical of virtual consultations because of privacy concerns. So she pumped her breast milk and bottle-fed it to her son.

Her experience gave her newfound empathy for families, and she wants to help other Spanish-speaking parents find solutions — whether in person or virtually.

“There is just not enough breastfeeding support in general, but especially when that support is in a different language,” said Pereda.

We wanted to know whether there was any truth to the idea that the CDC was removing its test because it is faulty and cannot tell one virus from another. So we consulted several laboratory testing experts.

This article was published on Friday, July 30, 2021 in Kaiser Health News.

By Victoria Knight

Posts circulating on Facebook and Instagram claim the Centers for Disease Control and Prevention will stop using its covid-19 test because it cannot differentiate between the covid virus and flu viruses.

“CDC has just announced they will revoke the emergency use authorization of the RT-PCR tests first introduced in 2/20,” reads a July 25 post, which goes on to quote from the agency’s lab directive: “CDC encourages laboratories to consider adoption of a multiplexed method that can facilitate detection and differentiation of SARS CoV-2 and influenza viruses.” It continues: “Translation: They’ve been adding flu cases to Covid cases when using that test.”

Mike Huckabee, a former Fox News host who was also a Republican presidential candidate and governor of Arkansas, similarly claimed on Facebook that the CDC test cannot tell the difference between coronaviruses and flu viruses.

A July 24 Instagram post went further: “The FDA announced today that the CDC PCR test has failed its full review. Emergency Use Authorization has been REVOKED.”

The posts were flagged as part of Facebook’s efforts to combat false news and misinformation on its news feed. (Read more about PolitiFact’s partnership with Facebook.)

We wanted to know whether there was any truth to the idea that the CDC was removing its test because it is faulty and cannot tell one virus from another. So we consulted several laboratory testing experts.

The Real Reason for Withdrawing the EUA Request

The first Facebook post we referenced quoted from and linked to a July 21 CDC laboratory alert that informed labs that as of Dec. 31 the agency would withdraw its emergency use authorization request for the CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time Reverse Transcriptase (RT)-PCR Diagnostic Panel or, for short, the CDC 2019-nCoV RT-PCR.

It is standard practice for the Food and Drug Administration to issue temporary emergency use authorizations for tests and other medical products that have not yet undergone the FDA’s full approval process but need to be used in an emergency to diagnose, treat or prevent serious diseases.

The FDA issued the EUA for the CDC’s 2019-nCoV RT-PCR in February 2020. At that time, no other tests were available in the U.S. to determine whether someone had covid.

But it’s important to remember that what the CDC developed and submitted for its EUA request was not a tangible product but rather a protocol for how to test for covid, said Susan Whittier, a professor of pathology and cell biology at Columbia University Irving Medical Center. That means the CDC wrote out directions specifying which reagents were needed to test the laboratory samples for the presence of the covid virus. The CDC does not distribute covid tests.

“It’s not like they have a test that laboratories can purchase. We borrow their protocol and use the reagents that they say,” said Whittier, who recently retired as director of the clinical microbiology lab at Columbia. So withdrawing the EUA request just “means that protocol will no longer be available.”

In the lab alert, the CDC said it was withdrawing the EUA request because, rather than testing only for the covid virus, it wants labs to test people for multiple viruses simultaneously, using what is known as a “multiplexed method.” The CDC’s 2019-nCoV RT-PCR panel tests only for the covid virus.

“Such assays can facilitate continued testing for both influenza and SARS-CoV-2 and can save both time and resources as we head into influenza season,” noted the alert regarding the multiplexed method.

Dr. Christopher Polage, an associate professor of pathology at Duke University, said his take on the CDC’s message is that, because flu season is on the horizon, a patient might come in with respiratory symptoms that could be attributed to either covid or the flu. Laboratories need to start testing for both covid and various flu viruses.

But the lab alert does not mean the CDC’s test cannot differentiate between covid and the flu.

In fact, the CDC’s 2019-nCoV RT-PCR test was developed to look for the presence of a nucleic acid found only in the covid virus, said Kelly Wroblewski, director of infectious disease programs at the Association of Public Health Laboratories.

“It is not remotely accurate that the CDC test doesn’t differentiate between flu and SARS-CoV-2. It doesn’t detect influenza. It only detects SARS-CoV-2,” said Wroblewski. “If flu and covid are both circulating, you would be able to detect only SARS-CoV-2 and not flu.”

How the CDC’s 2019-nCoV RT-PCR test (or any other PCR test) works, Wroblewski said, is that primers, which are little bits of a genetic material, are used to identify specific viruses. In this case, the primer is built to identify a nucleic acid found only in the covid virus.

If the covid virus is present in the sample, the primer will attach to the virus’s nucleic acid and make many copies of it. A chemical in the test will then fluoresce, which the polymerase chain reaction, or PCR, machine will interpret as a positive result. If the covid virus is not present, the primer will have nothing to attach to.

When asked about the CDC withdrawing its EUA request, FDA spokesperson Jim McKinney told us PCR tests are considered the “gold standard” for covid diagnosis. He pointed us to data that illustrated the specificity and exclusivity of the CDC’s test. That data shows test results came back negative for samples that contained similar viruses, including different types of flu and other coronaviruses.

All of this means the CDC’s 2019-nCoV RT-PCR test would not erroneously detect flu viruses. Thus, the Facebook posts’ assertions that the test cannot differentiate between covid and flu are demonstrably false.

Even though the CDC is withdrawing its EUA request for this specific test, Wroblewski pointed out, it still has an EUA for a second PCR test, a multiplex one that simultaneously tests for covid and influenza types A and B.

The FDA has issued EUAs to many laboratories and testing companies for hundreds of covid tests that use the same PCR technology the CDC uses — which experts said essentially made the CDC testing protocol moot, since similar tests will still be available.

So, while it is true the CDC is withdrawing its EUA request for its test that tests solely for covid, it is not for the reasons given by the Facebook posts. The assertion that covid case counts were inflated because the test was faulty and was counting flu cases as covid cases is false.

“They didn’t withdraw the EUA because the test wasn’t working,” said Whittier. “They just wanted people to look for other viruses as well.”

Polage agreed.

“The CDC is pulling their test ‘off the market’ as a gesture to encourage labs to use tests that include reagents (primers and probes) for both SARS-CoV-2 and Influenza so providers, labs, states, and CDC will have better data this fall and winter to estimate how much of clinical influenza-like illness is due to SARS-CoV-2 and how much is due to seasonal influenza,” Polage said in an email.

Our Ruling

Social media posts claimed the CDC was revoking its emergency use authorization request for its covid test because it couldn’t differentiate between the covid virus and flu viruses. While the CDC is withdrawing its EUA request for the 2019-nCoV RT-PCR test, it is not because the test is faulty.

Rather, it’s because the agency is concerned that, with flu season approaching, patients with respiratory illness symptoms should be screened for both the flu and covid. The patients shouldn’t be tested for covid alone, because flu cases might be missed.

The statements made in these Facebook posts are not accurate. We rate this claim False.

Source List

Associated Press, “CDC Encourages Use of New Tests That Detect Both COVID-19 and the Flu,” July 27, 2021

Centers for Disease Control and Prevention, CDC’s Diagnostic Test for COVID-19 Only and Supplies, updated July 13, 2021

Centers for Disease Control and Prevention, CDC Diagnostic Tests for COVID-19, updated Aug. 5, 2020

Centers for Disease Control and Prevention, Lab Alert: Changes to CDC RT-PCR for SARS-CoV-2 Testing, July 21, 2021

Cleveland Clinic, COVID-19 and PCR Testing, accessed July 28, 2021

Email interview with Dr. Christopher Polage, associate professor of pathology at Duke University, July 26, 2021

Email statement from Jim McKinney, press officer at the Food and Drug Administration, July 27, 2021

Facebook post, Mike Huckabee, July 26, 2021

Facebook post, Robertson Family Values, July 25, 2021

FactCheck.org, “Viral Posts Misrepresent CDC Announcement on COVID-19 PCR Test,” July 26, 2021

Food and Drug Administration, Emergency Use Authorization, updated July 23, 2021

Food and Drug Administration, CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel: For Emergency Use Only — Instructions for Use, effective July 21, 2021

Food and Drug Administration, Influenza SARS-CoV-2 (Flu SC2) Multiplex Assay EUA issuance, July 2, 2020

Food and Drug Administration, In Vitro Diagnostics EUAs — Molecular Diagnostic Tests for SARS-CoV-2, updated July 26, 2021

Health Feedback, “EUA Withdrawal for CDC COVID-19 PCR Test Is Due to the Development of Newer Tests That Help Save Time and Resources, Not Because the Test Is Faulty,” July 26, 2021

Instagram post, amybeard_md, July 24, 2021

Phone interview with Susan Whittier, professor of pathology and cell biology at Columbia University Irving Medical Center, July 27, 2021

Phone interview with Kelly Wroblewski, director of infectious disease programs at the Association for Public Health Laboratories, July 27, 2021

Some pregnant women already travel an hour and a half or longer to reach the 25-bed Big Bend Regional in Alpine.

This article was published on Monday, August 2, 2021 in Kaiser Health News.

By Charlotte Huff

The message from Big Bend Regional Medical Center was stark: The only hospital in a sparsely populated region of far West Texas notified local physicians last month that because of a nursing shortage its labor and delivery unit needed to temporarily close its doors and that women in labor should instead be sent to the next closest hospital — an hour’s drive away.

That is, unless the baby’s arrival appears imminent, and the hospital’s unit is shut down at that point. In that case, a woman would deliver in the emergency room, said Dr. Jim Luecke, who has practiced 30-plus years in the area.

But that can be a tough call, he added. Luecke described his concerns for two patients, both nearing their due date, who had previously given birth, boosting the chance of a faster delivery. “They can go from 4 centimeters dilated to completely dilated within a few minutes,” said the family physician, who estimates he’s delivered 3,000 babies.

Some pregnant women already travel an hour and a half or longer to reach the 25-bed Big Bend Regional in Alpine, said Dr. Adrian Billings, another family physician who delivers babies there. “Now to divert these ambulances at least another 60 miles away, it’s asking for more deliveries to happen en route to the hospital, and potentially poor maternal or neonatal outcomes.”

Luecke can’t recall a time when the obstetrics unit at Big Bend Regional has closed.

But it’s happening in other parts of the state: Ten rural hospitals have stopped delivering babies in the past five years or so, leaving 65 out of 157 that still do, according to the Texas Organization of Rural & Community Hospitals.

Hiring and retaining rural nurses has become even more challenging amid the pandemic as nurses have been recruited to work in urban covid-19 hot spots and sometimes don’t return to their communities, said John Henderson, chief executive officer at TORCH. More recently, some Texas hospitals have offered signing bonuses of $10,000 or more as they jockey for nurses, he said. “Covid has caused a resetting of market rates and a reshuffling of nurse staffing.”

The circumstances at Big Bend Regional, which serves a 12,000-square-mile area (about the size of Maryland), illustrates the ripple effects of potentially losing obstetric services across a broader region. The hospital, owned by Quorum Health Corp., serves a swath that extends southwest to the Mexican border and includes Big Bend National Park as well as the communities of Presidio and Candelaria. The nearest hospital, the 25-bed Pecos County Memorial in Fort Stockton, is 68 miles northeast of Alpine.

As of late July, Big Bend Regional’s obstetrics services remained in flux, with the unit closed for four- and five-day stretches, said Billings. Physicians have been told that the unit would typically remain open only Monday morning through Thursday morning of each week until more nurses arrive, he said.

The staffing crisis highlights the need for more state and national efforts to train rural nurses and other clinicians, Billings added. “The big concern that I have is that, if we don’t fix this, this could be the beginning of a rural maternity care desert out here in the Big Bend.”

The hospital, which delivered 136 babies last year, said it is “working feverishly to ensure adequate staffing levels in the coming weeks,” recruiting to fill 10 nursing positions in the labor and delivery unit, according to a statement to KHN. “When our hospital is on diversion for elective OB patients, we communicate in advance with nearby emergency transport services and acute care providers to ensure continuity of care,” the statement said.

Kelly Jones of Alpine, who worried she was having contractions, couldn’t get anyone to pick up the phone for a few hours at Big Bend’s unit in mid-July. She decided to drop off her son at a friend’s house and head to the hospital.

Jones, who is nearly full term, knew the unit had been closed a few days earlier that month but didn’t realize that closures were still occurring. “I went in and said, ‘I think I’m in labor.’ They were like, ‘Well, you can’t go into labor and delivery because they’re closed. So we’re going to take you to the ER.’” In the end, medical personnel determined she wasn’t going to deliver that day and she went home.

Since the hospital first alerted doctors last month, the unit has been on diversion July 5-9, July 14-18 and then again July 22 until Sunday, July 25, according to Billings. Efforts were being made to recruit nurses from Odessa, 150 miles away, to fill in, but the outcome was uncertain, Billings said.

Luecke scheduled an induction for one patient for July 26, when her pregnancy would be at 39 weeks — a week short of full term — and the unit was scheduled to be open. “We are trying to induce them [women] on the days that they [the hospital’s unit] are open,” he said.

Jones, who is being cared for by another physician, is scheduled for induction Aug. 2, at 39 weeks. “For a while, I was not sleeping. I was really stressed. I was panicking about every scenario,” said the 30-year-old, whose pregnancy was initially considered high risk because her son had been born prematurely.

But Jones felt better once her induction date was set. And what if the baby arrives sooner and the unit is closed? She’s been told to go to the ER, to be taken from there by ambulance to the local airport and flown to Fort Stockton.

Malynda Richardson, director of emergency medical services for the town of Presidio, which sits along the Mexican border about 90 miles from Alpine, said its first responders transport more than two dozen women with pregnancy-related issues each year, most of them in labor, including an average of two who deliver en route. First responders, including paramedics, are not typically trained to assess a woman’s cervix for dilation, making it more difficult to gauge imminent delivery, she said.

Also, when responders drive an additional two to three hours round trip to reach Fort Stockton, that affects the Presidio community, which can reliably staff only one ambulance, Richardson said. “What happens when we do have that transport [of a woman in labor] and have to go to Fort Stockton and then we have somebody else down here having a heart attack and we don’t have an ambulance available?”

Rural obstetrics units require far more nurses than doctors to remain open, so diverting women elsewhere in the short term makes sense, said Dr. Tony Ogburn, who chairs the department of obstetrics and gynecology at the University of Texas Rio Grande Valley School of Medicine. “If you don’t have trained nurses there, it doesn’t matter if you have a physician that can do a C-section or do a delivery; you can’t take care of those patients safely,” he said.

Registered nurses who work in labor and delivery have completed specialized training, such as how to read a fetal heart monitor, so a nurse from the ER or another hospital unit can’t easily step in, Billings said. “It’s kind of like having a small football team or a small soccer team and not being able to pull from the bench,” he said.

Billings said he’s reached out to Dr. Michael Galloway, who chairs the department of obstetrics and gynecology at Texas Tech University Health Sciences Center in Odessa and has been helping coordinate efforts to recruit nurses from that city. But even if Odessa nurses agree to pick up some shifts at Big Bend Regional, they are likely a stopgap solution, said Billings, who questions how long they’d be willing to work so far away from home.

Luecke believes Big Bend Regional administrators are doing everything they can to improve nurse staffing. But, like Billings, he’s worried that these July temporary closures could become longer-term.

“We are hoping August will be a different situation,” Luecke said. “But it’s pretty iffy right now.”