California will prioritize the homeless under an experiment to move Medi-Cal beyond traditional care delivery and into the realm of social services.

This article was published on Wednesday, September 8, 2021 in Kaiser Health News.

By Angela Hart   

OAKLAND, Calif. — Living unmedicated with schizophrenia and bipolar disorder, Eugenia Hunter has a hard time recalling how long she's been staying in the tent she calls home at the bustling intersection of San Pablo Avenue and Martin Luther King Jr. Way in Oakland's hip Uptown neighborhood. Craft coffee shops and weed dispensaries are plentiful here and one-bedroom apartments push $3,000 per month.

"At least the rats aren't all over me in here," the 59-year-old Oakland native said on a bright August afternoon, stretching her arm to grab the zipper to her front door. It was hot inside and the stench of wildfire smoke hung in the air. Still, after sleeping on a nearby bench for the better part of a year, she felt safer here, Hunter explained as she rolled a joint she'd use to ease the pain from also living with what she said is untreated pancreatic cancer.

Hunter has been hospitalized repeatedly, including once last summer after she overdosed on alcohol and lay unconscious on a sidewalk until someone stopped to help. But she is reluctant to see a doctor or use Medi-Cal, California's health insurance program for low-income and disabled people, largely because it would force her to leave her tent.

"My stuff keeps on getting taken when I'm not around and, besides, I'm waiting until I got a place to live to start taking my medication again," Hunter said, tearing up. "I can't get anything right out here."

Hunter's long and complex list of ailments, combined with her mistrust of the healthcare system, make her an incredibly difficult and expensive patient to treat. But she is exactly the kind of person California intends to prioritize under an ambitious experiment to move Medi-Cal beyond traditional doctor visits and hospital stays into the realm of social services. Under the program, vulnerable patients like Hunter will be assigned a personal care manager to coordinate their healthcare treatments and daily needs like paying bills and buying groceries. And they will receive services that aren't typically covered by health insurance plans, such as getting security deposits paid, receiving deliveries of fruits and vegetables, and having toxic mold removed from homes to reduce asthma flare-ups.

Over the next five years, California is plowing nearly $6 billion in state and federal money into the plan, which will target just a sliver of the 14 million low-income Californians enrolled in Medi-Cal: homeless people or those at risk of losing their homes; heavy users of hospital emergency rooms; children and seniors with complicated physical and mental health conditions; and people in — or at risk of landing in — expensive institutions like jails, nursing homes or mental health crisis centers.

Gov. Gavin Newsom is trumpeting the first-in-the-nation initiative as the centerpiece of his ambitious healthcare agenda — and vows it will help fix the mental health and addiction crisis on the streets and get people into housing, all while saving taxpayer money. His top healthcare advisers have even cast it as an antidote to California's worsening homelessness crisis.

But the first-term Democrat, who faces a Sept. 14 recall election, is making a risky bet. California does not have the evidence to prove this approach will work statewide, nor the workforce or infrastructure to make it happen on such a large scale.

Critics also fear the program will do nothing to improve care for the millions of other Medi-Cal enrollees who won't get help from this initiative. Medi-Cal has been slammed for failing to provide basic services, including vaccinations for kids, timely appointments for rural residents and adequate mental health treatment for Californians in crisis. Yet the managed-care insurance companies responsible for most enrollees' health will nonetheless be given massive new power as they implement this experiment. The insurers will decide which services to offer and which high-needs patients to target, likely creating disparities across regions and further contributing to an unequal system of care in California.

"This will leave a lot of people behind," said Linda Nguy, a policy advocate at the Western Center on Law & Poverty.

"We haven't seen health plans excel in even providing basic preventative services to healthy people," she said. "I mean, do your basic job first. How can they be expected to successfully take on these additional responsibilities for people with very high health needs?"

This revolution in Medi-Cal's scope and mission is taking place alongside a parallel initiative to hold insurance companies more accountable for providing quality healthcare. State health officials are forcing Medi-Cal managed-care plans to reapply and meet stricter standards if they want to continue doing business in the program. Together, these initiatives will fundamentally reinvent the biggest Medicaid program in the country, which serves about one-third of the state population at a cost of $124 billion this fiscal year.

If California's experiment succeeds, other states will likely follow, national Medicaid experts say. But if the richest state in the country can't pull off better health outcomes and cost savings, the movement to put health insurers into the business of social work will falter.

When Newsom signed the "California Advancing and Innovating Medi-Cal" initiative into law in late July — "CalAIM" for short — he celebrated it as a "once-in-a-generation opportunity to completely transform the Medicaid system in California." He declined an interview request.

Beginning next year, public and private managed healthcare plans will pick high-need Medi-Cal enrollees to receive nontraditional services from among 14 broad categories, including housing and food benefits, addiction care and home repairs.

The approach is known as "whole person care," and insurers will be required to assign patients a personal care manager to help them navigate the system. Insurers will receive incentive payments to offer new services and boost provider networks and, over time, the program will expand to more people and services. For instance, members of Native American tribes will eventually be eligible to receive treatment for substance misuse from natural healers, and inmates will be enrolled in Medi-Cal automatically upon release.

The insurers — currently 25 are participating — will focus most intensely on developing housing programs to combat the state's worsening homelessness epidemic. The state was home to at least 162,000 homeless people in 2020, a 6.8% increase since Newsom took office in 2019.

Jacey Cooper, the state's Medicaid director, said all Medi-Cal members will eventually be eligible for housing services. Initially, though, they will be available only to the costliest patients. State Medi-Cal expenditure data shows that 1% of Medi-Cal enrollees, many of the homeless patients who frequently land in hospitals, account for a staggering 21% of overall spending. And 5% account for 44% of the budget.

"You really need to focus on your top 1% to 5% of utilizers — that's your most vulnerable," Cooper said. "If you generally focus on that group, you will be able to yield better health outcomes for those individuals and, ultimately, cost savings."

State officials do not have a savings estimate for the program, nor a projection of how many people will be enrolled.

The plan, Cooper said, builds on more than 25 successful regional experiments underway since 2016. From Los Angeles to rural Shasta, big and small counties have provided vulnerable Medi-Cal patients with different services based on their communities' needs, from job placement services to providing a safe place for a homeless person to get sober.

Cooper highlighted interim data from the experiments that showed patients hospitalized due to mental illness were more likely to receive follow-up care, obtain treatment for substance abuse, avoid hospitalizations and emergency department visits, and see improvements in chronic diseases like diabetes.

She argued that data — even though it is not comprehensive — is enough to prove the initiative will work on a statewide scale.

However, studies of similar programs elsewhere have yielded mixed results. New York provided housing services to high-cost Medicaid enrollees with chronic diseases and mental health and substance use disorders and found major reductions in hospital admissions and emergency department visits between 2012 and 2017, and saw a 15% reduction in Medicaid spending.

In Camden, New Jersey, an early test of the "whole person care" approach provided expensive Medicaid patients with intensive care coordination, but not nontraditional services. A study concluded in 2020 that it hadn't lowered hospital readmissions — and thus didn't save healthcare dollars.

"We found we just couldn't help people with housing as quickly as they needed help," said Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers. "Many of these clients have bad credit, they may have a record, and they're still using. Those are huge challenges."

California may find success where the coalition hadn't because it will offer social services, she said, which the coalition has also started doing.

But it will take time. California will have five years to prove to the federal government it can save money and improve healthcare quality. Insurers will be required to track health outcomes and savings, and can boost services over time or drop programs that don't work.

So far, the regional experiments have failed to serve low-income Black and Latino residents, according to the interim assessments conducted by Nadereh Pourat, director of the UCLA Center for Health Policy Research. She concluded that they have primarily benefited white, English-speaking, middle-aged men.

Cooper said the statewide initiative will tackle "systemic racism," initially as it targets homeless people, who are disproportionately Black.

Consider Eugenia Hunter, who is African American, and whose many untreated mental and physical illnesses, intertwined with her addictions, mean it will take a herculean effort — and cost — to get her off the street.

Hunter has been homeless for at least three years. Or maybe it's five; her mental illness clouds her memory, and she erupts in anger when pressed for details. She eases her frustration sometimes with sleep, sometimes by smoking crystal meth.

A stack of unopened health insurance letters sat beside Hunter one evening in late August. Her eyes were glassy when she struggled to remember when she received a cancer diagnosis — if she ever did at all.

Health insurers will not be required to offer social services to patients like Hunter because federal law requires nontraditional Medicaid services to be optional. But California is enticing insurers with bigger payouts and higher state rankings.

"We are asking the plans and providers to stretch. We're asking them to reform," Cooper said.

The state is urging insurers to start with the roughly 130,500 Medi-Cal patients already enrolled in the local experiments. To prepare, they are cobbling together networks of nonprofits and social service organizations to provide food, housing and other services — much as they do with doctors and hospitals contracted to deliver medical care.

Services will vary by insurer and region. The Inland Empire Health Plan, for example, will offer some patients home repairs that reduce asthma triggers, such as mold removal and installing air filters. But Partnership HealthPlan of California will not offer those benefits in its wildfire-prone Northern California region because it doesn't have an adequate network of organizations equipped to provide those services.

In interviews with nearly all of California's Medi-Cal managed-care plans, executives said they support the dual goals of helping patients get healthier while saving money, but "it is a lot to take on," said Richard Sanchez, CEO of CalOptima, which serves Orange County and will start modestly, primarily with housing services. "The last thing I want to do is make promises that we can do all these things and not come through."

Nearly all the health plans will offer housing services right away, focusing on three categories of aid: helping enrollees secure housing and rent subsidies; providing temporary rent and security deposit payments; and helping tenants stay housed, like intervening with a landlord if a patient misses rent.

Partnership HealthPlan, which serves 616,000 Medi-Cal patients in 14 Northern California counties, will prioritize its most at-risk enrollees with housing services, food deliveries and a "homemaker" benefit to help them cook dinner, do laundry and pay bills.

"It's a great deal of money for a small number of members and, frankly, there's no guarantee it's going to work," said Dr. Robert Moore, the plan's chief medical officer. "We are building something extraordinarily ambitious quickly, without the infrastructure in place to make it successful."

Even if offering new services costs more money than it saves, it's a worthwhile investment, said John Baackes, CEO of L.A. Care Health Plan, the largest Medi-Cal plan, which serves more than 2 million patients in Los Angeles County.

"When somebody has congestive heart failure, their diet should be structured around alleviating that chronic condition," he said, explaining his plan to offer patients healthful food. "What are we going to do — let them eat ramen noodles for the rest of their lives?"

In Alameda County, two plans are available to serve Hunter. The Alameda Alliance for Health, a public insurer established by the county, and Anthem Blue Cross, a private insurance company, will expand housing services.

"People like Eugenia Hunter are exactly who we want to serve, and we're prepared to go out and help her," said Scott Coffin, CEO of the Alameda Alliance, who is also on a local street medicine team.

But they'd have to find her first — chaos and homeless encampment sweeps force her to move her tent frequently. And then they'd have to win her trust.

In one moment, Hunter angrily described how health plans have tried to enroll her in services, but she declined, mistrustful of their motives. In the next moment, fighting back voices in her head, she said she desperately wants care.

"Someone is going to help me?" she asked. "All I want to do is pay my rent and succeed."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Angela Hart: ahart@kff.org, @ahartreports

Mississippi has one of the highest per capita infection rates in the nation and one of the lowest vaccination rates.

This article was published on Tuesday, September 7, 2021 in Kaiser Health News.

By Sarah Varney September 7, 2021

The Allie Henderson who stepped out of her mother's car to a driveway full of cheering friends and family holding "Welcome Home" signs was a wisp of her former self.

After 10 days in the hospital with a near-fatal case of COVID inflammatory syndrome, the then-13-year-old softball phenom and beloved, straight-A student was lethargic and frail and braced herself against the car's door frame.

But six months later, as the highly contagious delta variant swarms Mississippi, the state has one of the highest per capita infection rates in the nation and one of the lowest vaccination rates. In Hinds County, where the Hendersons live, the vaccination rate is 45%, well below the national average of 53%, as of last week. Some of Allie's closest friends and family remain unvaccinated.

"I feel like it hasn't been tested enough," said Erin Acey, 16, of the vaccine. Erin is a cousin of Allie's who lives a block away and grew up playing whiffle ball with Allie in the backyard.

Erin's parents are also not vaccinated, nor is another cousin, Cara McClure, 23, a hairstylist in nearby Clinton who is suspicious of conflicting information she's heard about the vaccine.

"I try not to watch the news. I get it from Facebook," said McClure. "I really try not to talk about it at work because it's like politics: You don't talk about politics at work."Bottom of Form

The gravity of Allie's condition last winter became clear when the prayer requests went out, months before vaccines were widely available.

Congregations across the area in Crystal Springs, Hazelhurst, Wesson and Georgetown prayed for Allie; teachers at her small, independent Christian school in Gallman, Copiah Academy, prayed before class.

Allie's grandmother texted Wayne Hall, the pastor at Jackson First, where the Hendersons have been regular parishioners. Allie was a fixture in the Children's Ministry, a vivacious child always in the middle of the action, and the Hendersons are an admired family of go-getters. "Please pray," the text said. "Allie is in the hospital."

"When the request went out, it was all hands on deck," said Hall, who hunts with Allie's dad, Brook. He said his own prayers: "We believe in God to heal her body and are praying for Mom and Dad, who are walking through this, because there are a lot of unknowns."

Allie had felt crummy at school on a Monday in late January but still managed to play in a basketball game that evening. A few days later, she was doubled over with stomach pain and no remedy — Tylenol, Motrin, baths — would break her 104-degree fever. LeAnn Henderson, Allie's mother, asked her best friend, Caroline Young, a nurse and fellow softball mom, "Why can't we get this fever to go away?"

At the emergency room, Allie tested negative for COVID, strep and influenza, and doctors settled on removing her inflamed appendix. But soon after the surgery, her fever spiked again, her blood pressure and oxygen levels dropped, her eyes were eerily bloodshot, her hands splotchy.

"Allie was so weak, she was talking about giving up," said LeAnn.

An ambulance whisked Allie to Children's of Mississippi, a hospital in Jackson with a pediatric intensive care unit where doctors diagnosed her with multisystem inflammatory syndrome in children. MIS-C, as it is known, appears to affect children two to eight weeks after an asymptomatic or mild COVID-19 infection. A blood test found COVID antibodies, and Allie began receiving steroids, blood pressure medication and intravenous antibiotics to fight the syndrome.

McClure, who often styled Allie's hair and took her to the local waterpark, video chatted with her cousin. "She looked tired, drained, her face was white," said McClure. Already thin, Allie was losing weight. At the hair salon, McClure tried to keep the unfolding family crisis away from clients already spooked by the pandemic. Her co-workers would see her crying between appointments.

Outside the hospital windows, friends and family stood on the grass and held up signs that Allie could see from her room. There was an endless stream of food deliveries for the family: Chick-fil-A, chili from Wendy's, seafood pasta from Biaggi's.

"Everybody in Allie's world knew about this — softball, school, church — it was on our doorstep," said LeAnn. "People had known adults who had gotten sick and been in the hospital, but not sick like Allie. I think it was like, 'Wow, this is real and this happened to her.' They know how strong and athletic [she is]. She's a power hitter.

At Copiah Academy, Allie's absence registered with growing fear. "Parents began to get scared," said Rita Henley, a school administrator. The school had taken precautions, sanitizing classrooms, requiring students to wear masks and to physically distance. Students who tested positive for COVID and those who shared classrooms or sports teams had to quarantine at home. "Some of the parents embraced it and some didn't," said Henley. "It reflected the differences in opinion that we have right now in our country."

As Allie came in and out of consciousness at the hospital, she fretted about her grades and missing the remainder of basketball season and the upcoming softball season.

"Allie is a very aggressive athlete, always ready to practice and play hard," said Caroline Young, LeAnn's friend whose daughter plays on the same travel softball team as Allie. "That was the most poignant thing about the illness — we saw a really strong teammate become weak."

On Feb. 7, LeAnn drove her daughter home to the cheers and open arms of a loving gaggle of friends and family. "I started crying, she started crying, everyone started crying," said Allie's cousin Erin.

LeAnn shared her family's ordeal with a local television station. "I immediately went to the media and said, 'This is something else COVID can do. This happened to my 13-year-old. We need to look out for this.'"

Allie returned to school for a few hours each day and grew stronger. On occasion, she was overcome by seizures, passing out once in the bathroom at home and once on her way to her bedroom. One night, Allie woke and couldn't feel her legs. "I was screaming," LeAnn said, whose usual unflappable disposition had finally caved. By spring break, in mid-March, after neurology appointments and brain scans and heart scans, Allie started coming back to herself. She and her family got the vaccines when they became available.

At school, the questions overwhelmed her. "We had a little joke. I said I had a bad haircut and couldn't come to school," Allie said. But she didn't feel the urge to proselytize about the dangers of COVID. "I don't like to go public about personal stuff."

She suited up for a softball scrimmage and could barely hoist the bat above her shoulder. "It was very difficult because I couldn't do what I could do before," said Allie. She told her mom, "I just suck at this." The crowd of softball dads teared up when Allie tried to swing the bat. "It's amazing that she's out there," LeAnn said they told her.

Students returned to Copiah Academy in early August. Masks are not required, nor is the COVID vaccine for those eligible. "Our internal conversation is that we do not feel we can require the vaccine unless the state requires it," said Henley. But "because of Allie, people — without question — know that this is a real thing."

Still, the shifting nature of the pandemic — the arrival of the delta variant, the news that vaccinated people can spread COVID — has brewed confusion. "I truly think that we see too much back-and-forth on the news. I think it hurts people," said Henley, who is vaccinated. "People don't know what to believe."

Federal health officials say millions of Americans have been safely vaccinated, and vaccination reduces the risk of severe complications from COVID.

Pastor Hall is reluctant to direct his parishioners to get vaccinated. "We believe in healing, we believe in the power of God, and we also know God gives wisdom," he said. "If the CDC is saying things we need to abide by, we need to really listen." He added, "Allie's story has helped a lot of people really understand, 'Hey, this is not a pick-and-choose kind of deal. It can hit home anywhere.'"

At the hair salon in Clinton, McClure shares more openly now about her cousin's illness with her clients. "I'll say my little cousin had it and we get to talking about it," said McClure. But she doesn't push it. "When clients come in, we want it to be about them. We ask, 'Are you going on vacation?' We focus on them to make them feel good."

But she notices those around her have dropped their guard. "They take everything for granted. 'Oh, we're good. We're fine. We don't have to sanitize,'" she said. "Even now at the salon we try to make people sanitize, and they're like, 'Ugh.'"

McClure had a mild COVID infection last Thanksgiving — headache and nausea — but it passed. Even now, she's in no rush to get vaccinated. "Even with the vaccine, you can still get it. Every day I feel like something about it is changing, there's a new strand," she said.

Erin, Allie's 16-year-old cousin, isn't sure when — or if — she'll get vaccinated. She's nervous about the side effects and wants to wait and see. In her view, the pandemic has "died down" and she's unfamiliar with the delta variant. "I'd rather read about it and see it myself," she said.

"I know she has a different perspective," Allie said about her cousin Erin. "I would have a different perspective if it hadn't happened to me. I just know some people are like, 'My body, my choice.' Everything these days is about politics and nobody likes to be wrong. It's very confusing for my part. I want people to get vaccinated because I know what it feels like."

Some of her closest friends have gotten the vaccine. Was it because of what happened to her? Allie responded, "Yes, ma'am."

Sarah Varney: svarney@kff.org, @SarahVarney4

Nonprofit Carafem delivers abortion pills to a patient's home after a telemedicine visit for $375 or less.

This article was published on Friday, September 3, 2021 in Kaiser Health News.

By Amy Littlefield  

Allison Hansen had just gone through a breakup with her boyfriend last year when she discovered she was pregnant. She already had an 8-year-old son and did not want another child.

Hansen called the Planned Parenthood facility near her home in Savannah, Georgia, to inquire about abortion services and was told the procedure would cost $500 and require four to six hours at the clinic.

Hansen didn't have that kind of time. Her son was at home, attending school online, and needed supervision. While Googling for alternatives, she came across Carafem — a nonprofit that delivers abortion pills to a patient's home after a telemedicine visit for $375 or less.

"It just seemed almost too good to be true," Hansen recalled.

Patients like Hansen have benefited from a quiet but monumental shift in abortion access enabled by the COVID-19 pandemic. In July 2020, in response to advocates' concerns about the risks posed by in-person visits in a pandemic, a federal court placed on hold a long-standing FDA rule that required mifepristone — the first pill in a two-step regimen used in medical abortions — to be dispensed in clinics. After the Trump administration appealed that decision, the conservative-majority Supreme Court agreed to reinstate the rule, with Chief Justice John Roberts writing that courts should defer to government experts who set the rules. The Biden administration put the rule back on hold in April during the remaining public health emergency and said it is reviewing the agency's restriction.

In the meantime, telemedicine abortion operations are growing in some places, although not in such states as Texas and Alabama with strict laws designed to curb or end abortions.

A new slate of digital abortion options like Just the Pill, Hey Jane, Abortion on Demand and Choix proliferated, mailing abortion pills to patients in many states after a telemedicine visit. Carafem, which had been mailing the pills to patients in Georgia before the pandemic as part of a research project, streamlined its process for patients who are eligible for medical abortions.

These services can be a lifeline for patients who haven't hit the 10- or 11-week threshold typically used for medical abortion and who can't get to a clinic or need a less expensive choice. But reproductive health advocates worry that telemedicine abortion options don't reach the patients who need it the most because they live in states with laws that actively discourage abortions and have made in-clinic care harder to access. At the same time, these new options could be endangering brick-and-mortar clinics by siphoning away the first-trimester visits that make up more than 90% of abortions.

"If [clinics] lose a considerable amount of the clientele for first-trimester abortions, they might have to close, or some of them will," said Carole Joffe, a professor focusing on reproductive health at the University of California-San Francisco and co-author of "Obstacle Course: The Everyday Struggle to Get an Abortion in America." "Potentially, we see people needing second-trimester procedures, not to mention even later ones, with literally nowhere to go."

Many clinics, which charge higher prices to support the costs of running a building and providing security, are closing around the country amid an avalanche of state restrictions. That is especially true of independent clinics, which perform 58% of abortions, according to the Abortion Care Network, an association of independent providers. Since 2012, the number of independent abortion clinics has dropped by 34%.

Concerns about access to abortion deepened this week when a Texas law took effect banning abortions after six weeks of pregnancy and a divided Supreme Court did not block it, at least for now. The court is also scheduled to hear a case this term on Mississippi's 15-week abortion ban. If the justices allow either state law to stand, it would likely lead other states to further restrict abortion, forcing patients in many conservative states across the South, Midwest and West to travel for services or seek out overseas options like Aid Access, according to Mary Ziegler, a Florida State University law professor who focuses on legal issues surrounding reproductive health and sexuality.

"If you're in New York or California or Boston, you can get abortion pills online, you can go to a clinic — there are tons of options. Whereas if you're in a state like Alabama, you're probably going to be worried that you can't do any of those things," Ziegler said.

Carafem, which operates clinics in Georgia, Illinois, Tennessee and Maryland, began mailing abortion pills to patients in Georgia in 2019 when it joined the TelAbortion Study, an ongoing project run by the reproductive health nonprofit Gynuity that received federal permission to study the safety of telemedicine abortions. Over four years, abortion providers mailed 1,390 medication packages to patients in 13 states and Washington, D.C. Researchers reported that 95% of tracked participants had a complete abortion without a procedure. They reported 10 serious adverse events, including five cases of patients needing blood transfusions, none of which could have been avoided by an in-person visit, the researchers said. Participants made 70 unplanned visits to emergency rooms or urgent care centers.

Anti-abortion advocates, however, stress that medical abortion should require in-person exams.

"Women deserve excellent healthcare, and excellent healthcare does not involve talking to someone online," said Dr. Christina Francis, board chair of the American Association of Pro-Life Obstetricians and Gynecologists. "It involves actually being seen and being evaluated to make sure that if she's going to make this decision, she's an appropriate candidate to make this decision and she's not putting herself at severe risk by taking these medications."

Many states require in-person counseling or ultrasounds before an abortion, forcing patients to make more than one trip to a clinic. In 19 states, laws require a physician who prescribes a medical abortion to be physically present when the medication is administered.

Alabama is one of those states. "I use telemedicine all the time because I'm a full-spectrum OB-GYN," said Dr. Sanithia Williams, an abortion provider at Alabama Women's Center for Reproductive Alternatives in Huntsville. "But for the abortion portion of my practice, it just is completely nonexistent."

Even in states with relatively few abortion restrictions, patients with medical risk factors, unreliable periods, unsafe living situations or pregnancies beyond 11 weeks generally can't get care online. "There will always be a need for clinic-based healthcare," said Melissa Grant, chief operations officer of Carafem. "This is not a panacea."

On a Thursday morning in late June, Leah Coplon, a certified nurse midwife, sat down in the Augusta office of Maine Family Planning for a televisit with a patient seeking an abortion who was in her home miles away. The young patient nodded and messaged her boyfriend, telling him to go buy her menstrual pads, as Coplon ran through a detailed list of warning signs like excessive bleeding that should prompt a call to the clinic or trip to an emergency room. "This is all very rare, but I've got to tell you the scary things. That's my job," Coplon said, the blue light of the monitor reflecting off her glasses.

For uninsured patients, the out-of-pocket cost for a telemedicine visit like this is $500, about average for brick-and-mortar clinics.

Maine is among a minority of states that cover abortions under Medicaid. The state also requires private plans to cover abortion if they cover prenatal care. Yet even here, with 8% of the population uninsured, cost is the biggest barrier Coplon's patients face, she said. To meet the needs of low-income patients, clinics like hers haven't raised their out-of-pocket rates in years. If the price of abortion had kept pace with medical inflation, a procedure that cost $200 in 1974 would cost $2,686 today, according to a Bloomberg Businessweek calculation last year.

Maine Family Planning has 18 locations across the sprawling, mostly rural state. In 2014, it became one of the first clinics to launch a telehealth pilot program. When COVID struck, providers like Coplon used existing telemedicine equipment to shift to a "no-test" protocol, bypassing ultrasounds and blood tests that research shows can be safely skipped in order to minimize contact with patients.

For many patients choosing between a clinic and an online service, cost will be a deciding factor — and that concerns Dr. Jamie Phifer, founder of Abortion on Demand, which serves patients in 20 states and Washington, D.C. Like many other digital options, Phifer's service does not take insurance, but she worries her low out-of-pocket price — $239, or less than half of what a typical clinic charges — could put abortion clinics out of business.

"I am very worried that in-person clinics are already bearing the brunt of the challenges of abortion access," Phifer said. "They already have to hire security and deal with protesters, and they have been on the ground working for access for 50 years, longer than I have been around."

Phifer, who lost her job as a primary care doctor following a profile of her work on Abortion on Demand in a magazine, plans to donate 60% of the profits from her business to the Abortion Care Network to support brick-and-mortar clinics.

"I didn't want to contribute to creating a two-tiered system," Phifer said.

States are rolling back many pandemic workarounds.

This article was published on Tuesday, August 31, 2021 in Kaiser Health News.

By Julie Appleby  

If you live in one state, does it matter that the doctor treating you online is in another? Surprisingly, the answer is yes, and the ability to conduct certain virtual appointments may be nearing an end.  

Televisits for medical care took off during the worst days of the pandemic, quickly becoming commonplace. Most states and the Centers for Medicare & Medicaid Services temporarily waived rules requiring licensed clinicians to hold a valid license in the state where their patient is located. Those restrictions don't keep patients from visiting doctors' offices in other states, but problems could arise if those same patients used telemedicine.

Now states are rolling back many of those pandemic workarounds.

Johns Hopkins Medicine in Baltimore, for example, recently scrambled to notify more than 1,000 Virginia patients that their telehealth appointments were "no longer feasible," said Dr. Brian Hasselfeld, medical director of digital health and telemedicine at Johns Hopkins. Virginia is among the states where the emergency orders are expiring or being rolled back.

At least 17 states still have waivers in effect, according to a tracker maintained by the Alliance for Connected Care, a lobbying group representing insurers, tech companies and pharmacies.

As those rules end, "it risks increasing barriers" to care, said Hasselfeld. Johns Hopkins, he added, hosted more than 1 million televisits, serving more than 330,000 unique patients, since the pandemic began. About 10% of those visits were from states where Johns Hopkins does not operate facilities.

The rollbacks come amid a longer and larger debate over states' authority around medical licensing that the pandemic — with its widespread adoption of telehealth services — has put front and center.

"Consumers don't know about these regulations, but if you all of a sudden pull the rug out from these services, you will definitely see a consumer backlash," said Dr. Harry Greenspun, chief medical officer for the consultancy Guidehouse.

Still, finding a way forward pits high-powered stakeholders against one another, and consumers' input is likely to be muted.

State medical boards don't want to cede authority, saying their power to license and discipline medical professionals boosts patient safety. Licensing is also a source of state revenue.

Providers have long been split on whether to change cross-state licensing rules. Different state requirements — along with fees — make it cumbersome and expensive for doctors, nurses and other clinicians to get licenses in multiple states, leading to calls for more flexibility. Even so, those efforts have faced pushback from within the profession, with opposition from other clinicians who fear the added competition that could come from telehealth could lead to losing patients or jobs.

"As with most things in medicine, it's a bottom-line issue. The reason telehealth has been blocked across state lines for many years related fundamentally to physicians wanting to protect their own practices," said Greenspun.

But the pandemic changed the equation.

Even though the initial spike in telehealth visits has eased, utilization remains 38 times higher than before the pandemic, attracting not only patients, but also venture capitalists seeking to join the hot business opportunity, according to a report from consulting firm McKinsey and Co.

Patients' experience with televisits coupled with the growing interest by investors is focusing attention on this formerly inside-baseball issue of cross-state licensing.

Greenspun predicts consumers will ultimately drive the solution by "voting with their wallets," aided by giant, consumer-focused retailers like Amazon and Walmart, both of which in recent months made forays into telemedicine.

In the short term, however, the focus is on both the protections and the barriers state regulations create.

"The whole challenge is to ensure maximum access to health while assuring quality," said Barak Richman, a Duke University law professor, who said laws and policies haven't been updated to reflect new technological realities partly because state boards want to hang onto their authority.

Patients and their doctors are getting creative, with some consumers simply driving across state lines, then making a Zoom call from their vehicle.

"It's not ideal, but some patients say they are willing to drive a mile or two and sit in a parking lot in a private space and continue to get my care," said Dr. Shabana Khan, director of telepsychiatry at NYU Langone Health's department of child and adolescent psychiatry and a member of the American Psychiatric Association's Telepsychiatry Committee. She and other practitioners ask their patients about their locations, mainly for safety reasons, but also to check that they are in-state.

Still, for some patients, driving to another state for an in-person or even a virtual appointment is not an option.

Khan worries about people whose care is interrupted by the changes, especially those reluctant to seek out new therapists or who cannot find any clinicians taking new patients.

Austin Smith hopes that doesn't happen to him.

After initial treatment for what he calls a "weird flavor of cancer" didn't help reduce his gastrointestinal stromal tumors, he searched out other experts, landing in a clinical trial. But it was in San Diego and the 28-year-old salesman lives in Phoenix.

Although he drives more than five hours each way every couple of months for treatment and to see his doctors, he does much of his other follow-up online. The only difference is "if I was in person, and I said I was hurting here, the doctor could poke me," he said.

And if the rules change? He'll make the drive. "I'll do anything to beat this," he said of his cancer.

But will doctors, whose patients have spent the past year or more growing comfortable with virtual visits, also be willing to take steps that could likely involve extra costs and red tape?

To get additional licenses, for instance, practitioners must submit applications in every state where their patients reside, each of which can take weeks or months to process. They must pay application fees and keep up with a range of requirements such as continuing education, which vary by state.

States say their traditional role as overseer ensures that all applicants meet educational requirements and pass background checks. They also investigate complaints and argue there's an advantage to keeping local officials in charge.

"It's closer to home," said Lisa Robin, chief advocacy officer with the Federation of State Medical Boards. "There's a remedy for residents of the state with their own state officials."

Doctor groups such as the American Medical Association agree.

Allowing a change that doesn't put centralized authority in a patient's home state would raise "serious enforcement issues as states do not have interstate policing authority and cannot investigate incidents that happen in another state," said then-AMA President-elect Jack Resneck during a congressional hearing in March.

But others want more flexibility and say it can be done safely.

Hasselfeld, at Johns Hopkins, said there is precedent for easing multistate licensing requirements. The Department of Veterans Affairs, for example, allows medical staffers who are properly licensed in at least one state to treat patients in any VA facility.

The Alliance for Connected Care and other advocates are pushing states to extend their pandemic rules. A few have done so. Arizona, for example, made permanent the rules allowing out-of-state medical providers to practice telemedicine for Arizona residents, as long as they register with the state and their home-state license is in good standing. Connecticut's similar rules have now been stretched until June 2023.

The alliance and others also back legislation stalled in Congress that would temporarily allow medical professionals licensed in one state to treat — either in person or via televisits — patients in any other state.

Because such fixes are controversial, voluntary interstate pacts have gained attention. Several already exist: one each for nurses, doctors, physical therapists and psychologists. Proponents say they are a simple way to ensure state boards retain authority and high standards, while making it easier for licensed medical professionals to expand their geographic range.

The nurses' compact, enacted by 37 states and Guam, allows registered nurses with a valid license in one state to have it recognized by all the others in the pact.

A different kind of model is the Interstate Physician Licensure Compact, which has been enacted by 33 states, plus the District of Columbia and Guam, and has issued more than 21,000 licenses since it began in 2017, said Robin, of the Federation of State Medical Boards.

While it speeds the paperwork process, it does not eliminate the cost of applying for licenses in each state.

The compact simplifies the process by having the applicant physician's home state confirm his or her eligibility and perform a criminal background check. If the applicant is eligible, the home state sends a letter of qualification to the new state, which then issues a license, Robin said. Physicians must meet all rules and laws in each state, such as requirements for continuing medical education. Additionally, they cannot have a history of disciplinary actions or currently be under investigation.

"It's a fairly high bar," said Robin.

Such compacts — especially if they are bolstered by new legislation at the federal level — could help the advances in telehealth made during the pandemic stick around for good, expanding access to care for both mental health services and medical care across the U.S. "What's at stake if we get this right," said Richman at Duke, "is making sure we have an innovative marketplace that fully uses virtual technology and a regulatory system that encourages competition and quality."

Julie Appleby: jappleby@kff.org, @Julie_Appleby