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.”

Bryan Keller's health insurance covered much of the cost of his visit to the CityMD clinic. But it didn't cover the physician who stitched his forehead.

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

By Rachana Pradhan

It was a Sunday morning in late November when Bryan Keller hopped on a bike for a routine ride to pick up his groceries, cruising with ease in a relatively empty New York City.

The surprises came fast and hard: a fall that sent his head into the pavement and left him bleeding profusely and in shock, a trip to an urgent care clinic for five stitches and then a $1,039.50 bill.

Keller's health insurance covered much of the cost of his visit to the CityMD clinic on Manhattan's Lower East Side. But it didn't cover the physician who arrived to stitch his forehead ― an out-of-network plastic surgeon with a Park Avenue office.

"The people at CityMD just said [this] sort of thing is covered as part of an emergency procedure," said Keller, a regular cyclist who's lived in New York City for three decades. Even in post-accident "delirium," he said, he asked several times whether the stitches would be covered by his health insurance because it struck him as unusual that a plastic surgeon would do them.

"It really irked me that, it's this classic thing you hear in this country all the time," Keller said. "When you do all the right things, ask all the right questions and you're still hit with a large bill because of some weird technicality that there's absolutely no way for you to understand when you're in the moment."

Under a law Congress passed last year, many surprise medical bills will be banned starting in January. Patients with private insurance will be protected against unexpected charges for emergency out-of-network care, for treatment by out-of-network providers at in-network facilities and for transport in an air ambulance. But one gray area: visits to urgent care clinics, which have proliferated in recent years as patients seek speed and convenience over waiting hours at an emergency room or weeks to get a regular doctor's appointment. There are roughly 10,500 urgent care centers in the U.S., according to the Urgent Care Association, which lobbies on their behalf.

Urgent care clinics were not explicitly addressed in the No Surprises Act, but Keller's experience underscores patients' predicament ― insurers often try to steer patients to urgent care and away from costly emergency rooms, but individuals could still get hit with large bills in the process. The Biden administration has expressed an interest in prohibiting surprise bills in those clinics, which may treat serious conditions but not life-threatening injuries and illnesses.

In July, several federal agencies issued interim regulations that largely would not protect patients from surprise urgent care bills. Regulation varies significantly across states, and data is scarce on how common surprise bills are in those facilities. Before the surprise billing rules are finalized, the Department of Health and Human Services and three other federal agencies have asked for information on issues such as the frequency of such bills at urgent care facilities and how health insurers contract with the clinics.

The current regulatory gap, if left untouched before the new law takes effect in January, is one that healthcare experts say could leave patients at risk.

"There's a real interesting question about whether it should apply to the extent that people perceive these as places to go for an emergency," said Jack Hoadley, research professor emeritus for Georgetown University's McCourt School of Public Policy.

CityMD, which was founded by doctors in 2010 and merged with the large medical practice Summit Medical Group in 2019, operates a massive chain of urgent care clinics in New York and New Jersey. Most of its physicians are emergency doctors. The combined enterprise created Summit Health, which is backed by private equity with investments from well-known firms Warburg Pincus ― which acquired CityMD in 2017 ― and Consonance Capital Partners.

Matt Gove, chief marketing officer of Summit Health, confirmed that the plastic surgeon who treated Keller ― Dr. Michael Wolfeld ― has an agreement with the company that allows him to see patients at certain CityMD clinics. Though he was unable to comment on the specifics of Keller's situation, he said, CityMD's "normal procedure" is to "make the patient aware that this is available to them and that they can then make the choice as to whether or not it's important to them to be seen by a plastic surgeon."

"This is a patient choice," Gove said. "We certainly don't require that a patient be seen by Dr. Wolfeld or any other provider."

But Keller said it was never put to him as an option. "It was framed to me as 'This is how we do things,'" he said. "In order to have a preference I would have to know that there is an alternative." Wolfeld did not respond to a request for comment.

"It really irked me that, it's this classic   

Last month the Biden administration proposed prohibiting surprise bills at urgent care centers licensed to perform emergency procedures, essentially treating them as free-standing emergency rooms. Some states, like Arizona, allow urgent care centers to provide emergency services, but they then are considered free-standing ERs, a spokesperson for the state Department of Health Services said. But urgent care centers aren't licensed as healthcare facilities in most states, let alone encouraged to provide emergency services, according to healthcare advocates that have tracked the issue and have pushed for greater government oversight of the industry.

New York, where Keller lives, doesn't consistently regulate urgent care providers, requiring licenses for some companies but not for CityMD clinics.

Regardless of what's prescribed in state regulations, what's considered an "emergency" versus "urgent" can vary by patient. That potentially creates confusion about whether patients would be protected from certain kinds of out-of-network bills if they show up at an urgent care facility for an acute illness or injury.

KHN also found that the urgent care clinic where Keller was treated describes several of its services as emergency care even though many are not meant to treat emergency conditions as envisioned in federal law. For example, the clinic characterizes physical exams, flu shots and vaccinations as emergency medical services. Under federal law, an emergency medical condition is defined as one where the absence of immediate medical attention could seriously jeopardize a patient's health.

Summit Health spokesperson Gove said the use of the term "emergency" is meant to be "patient-facing and patient-centric, and not having to do with miscategorizing or misrepresenting the nature of the services we provide."

The provider is "just making it clear to people that when you have something you need done quickly, which you might call personally an emergency, we're here to do that." CityMD has never marketed itself as an emergency room designed to treat all emergency conditions, Gove said.

Lou Ellen Horwitz, CEO of the Urgent Care Association, said urgent care clinics are akin to private doctor practices rather than an emergency room or hospital facility that would be subject to broad bans on surprising billing. She said that, even as urgent care clinics grow more common, there's "no data" to suggest consumer confusion about what they treat.

The association would oppose any federal push to classify these clinics as something akin to independent emergency departments, Horwitz said. Indeed, she said, such a move "contradicts" their very purpose: to treat non-life-threatening injuries and illnesses.

"The standard practice of the industry as well is that we don't hold ourselves out to be emergency departments," she said. "The likelihood of this being misunderstood is very low."

Nationwide, under the Biden administration's interim regulations, patients needing care for nonemergencies will not be protected if treated by an out-of-network provider at an in-network urgent care facility, according to healthcare experts. "You don't have protections if it turns out the doctor or the physician assistant was out of network," Hoadley said.

A March report from Community Catalyst, a Boston-based healthcare advocacy organization focused on consumer issues, and the National Health Law Program, a civil rights advocacy group, found that fewer than 10 states issue facility licenses for urgent care clinics. Those licenses give state officials greater leeway to set standards for care, staffing levels, inspections or price transparency, but could also make care more expensive by increasing providers' expenses.

Without being licensed as a healthcare facility ― something that exists for hospitals, ambulatory surgery centers and critical access hospitals ― urgent care clinics are generally treated as private physician practices subject to less regulation. "They're really flying under the radar now in many cases," said Lois Uttley, director of the Women's Health Program at Community Catalyst.

Horwitz, however, said the clinics should not be lumped in with those providers because their operations are fundamentally different.

Unlike hospitals and other practices that include facility fees in their charges to patients, "we don't charge or receive payments as a facility," she said.

In the midst of an injury, however, making such distinctions can be difficult. Keller said his motivation in going to urgent care was to get his wounds treated quickly instead of waiting hours in an ER, amid a spike in COVID-19 cases that would presage the country's deadly winter. He had also been to that particular CityMD clinic for a COVID test, so he knew it accepted his insurance.

Keller hadn't been wearing a helmet the day of his accident, caused by trying to prevent a bag of groceries from falling off his bike. With a bleeding forehead and banged-up knees and wrists ― Keller brushed a parked car and went off the bike himself ― he was given a tetanus shot and had elevated blood pressure from the shock of the accident. Still, in that moment, he thought it was odd that a plastic surgeon was being called in to give him a handful of stitches, he said.

"It sounds expensive and it sounds like something optional," he said. "I said, 'OK, is this going to be covered?' And they said, 'Oh, yeah, they should be covered. He does this, he comes here all the time.'"

In New York, CityMD is not subject to facility licensure requirements because it's considered a private physician practice, said Jeffrey Hammond, a spokesperson for the New York State Department of Health. As a result, rather than more sweeping regulations that would govern the practices of urgent care clinics, state health officials oversee individual practitioners and investigate complaints related to misconduct.

On its website for the location Keller visited, CityMD advertised many of the services it provides as "emergency medical services." They include physical exams, vaccinations, pediatric care, lab tests, X-rays, and treatment for sore throats and ear infections.

"Just stop by the CityMD walk-in clinic located on 138 Delancey St. between Norfolk and Suffolk St, where quick, reliable, emergency care service is available 365 days a year," the website reads.

About six weeks after receiving his stitches, Keller said, he went to the same plastic surgeon to get them removed. His health insurer, Aetna, has denied an appeal to fully cover the cost.

"It's so clear that getting stitches for a wound, for an open bleeding wound, is an emergency procedure to the normal world," Keller said.

As for his forehead, eight months later, Keller still has a visible scar.

Starting in August, the state plans to begin measuring the levels of disease-fighting antibodies in the blood of vaccinated nursing home residents.

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

By Phil Galewitz

West Virginia raced ahead of the country last winter to get people in nursing homes vaccinated against COVID-19, but with cases and hospitalizations on the rise again, state officials want to know whether immunity levels are falling for residents who had their shots.

Starting in August, the state plans to begin measuring the levels of disease-fighting antibodies in the blood of vaccinated nursing home residents, which could help indicate whether they need a booster shot. The process will be voluntary and the data will be shared with federal health agencies evaluating the need for boosters.

Some experts question the strategy, particularly since the federal government has not yet authorized the extra shots.

COVID cases in West Virginia and nationally have more than tripled in the past month. Much of that surge is blamed on the delta variant, a highly contagious form of the virus sweeping the country. In June, about 10% of hospitalized COVID patients in West Virginia and 12% of COVID deaths were among fully vaccinated people, said Dr. Clay Marsh, executive dean for health sciences at West Virginia University and the state's coronavirus response coordinator. Nationally, about 3% of hospitalizations and 1% of deaths in July have been among people vaccinated for COVID.

Still, deaths attributed to COVID remain very rare in West Virginia, which is averaging two fatalities a day. Hospitalizations have risen from 65 COVID patients on July 1 to 133 as of July 28, according to state data.

"In West Virginia, we were very aggressive in vaccinating our long-term care population, but we now worry and are paying more attention about whether we have sufficient immunity in those fully vaccinated," said Marsh, often referred to as the state's coronavirus czar.

The question of the need for a booster has gained much attention lately. On Thursday, Israel announced plans to start providing booster shots this weekend to adults over 60 years old who have received their second shot at least five months earlier. The decision comes a day after the release of a paper by executives at Pfizer, one of the companies producing a vaccine, that shows a slight dip in efficacy against any symptomatic cases of COVID four months after immunization is completed. The paper, which has not been peer-reviewed, predicted that a third shot could boost disease-fighting antibodies many times higher than the level achieved from a two-shot regimen.

Pfizer said it plans to seek Food and Drug Administration authorization for a booster shot by mid-August.

Some health experts cautioned that information on antibody levels may not be helpful.

Dr. Michael Wasserman, a California geriatrician and member of the California vaccine advisory committee, said lower antibody levels don't automatically mean less immunity. "The fact that antibodies are going down is normal and it doesn't mean that those people are not immune to the virus," he said.

Antibodies do decrease over time, "but that doesn't tell us if you're exposed to COVID whether your body will move into gear and produce more. … The question of whether antibodies are a marker of adequate immunity is one we have not answered yet," Wasserman said.

West Virginia officials say their nursing home antibody testing could help FDA and other regulators evaluate the need for boosters.

"We want to gather this information and, pending what we find, work with Centers for Disease Control and Prevention and the Food and Drug Administration on an appropriate response," said Marsh. "This is a complicated issue as antibodies are not the only defense against COVID."

An antibody test will be used to measure levels against what was expected after immunization and whether it is a high-enough level to neutralize the delta variant, he said.

The state will also look at breakthrough infections and how many vaccinated people have ended up hospitalized or dead.

The state's nursing home industry supports the initiative, although officials say they've seen no increase in vaccinated COVID residents getting sick. "Our goal is to advance knowledge and information that exists about the vaccines," said Marty Wright, CEO of the West Virginia Healthcare Association, which represents nursing homes. He said antibody testing will offer one indicator of how well vaccines are still working.

Dr. David Wohl, professor of medicine and director of the vaccine clinics at the University of North Carolina School of Medicine, pointed out that even if the West Virginia initiative shows antibody levels have dropped, states can't provide booster shots until the federal government authorizes them. "You do not do a test unless there is something you can do with the information that you get from the test," he said.

Wohl said he anticipates that booster shots are likely to be needed eventually and that higher-risk populations — such as those who are immunocompromised or those in nursing homes — would likely be first to get them.

Dr. Mark Roberts, professor and former chair of the health policy and management department at the University of Pittsburgh Graduate School of Public Health, said immunity protection is much more complicated than just the level of antibodies. "It looks like protection from the vaccine wanes, but we don't know exactly how fast, and if protection wanes it may still protect people from getting sick and dying," he said.

Wasserman said a bigger question is whether officials are seeing more breakthrough infections in nursing homes and whether unvaccinated staff members are to blame.

"I argued strongly against vaccine mandates when the vaccine came out, but I am in favor of them now" for nursing home workers, Wasserman said.

California requires unvaccinated nursing home staffers to be tested regularly, requiring them to wear N95s. West Virginia requires all nursing home employees to get vaccinated or face twice-a-week testing.

In a joint statement in July, the FDA, the CDC and the National Institutes of Health said the government is analyzing laboratory data, clinical trial data and other data — which can include data from specific pharmaceutical companies — as they evaluate the need for booster shots.

"We continue to review any new data as it becomes available and will keep the public informed. We are prepared for booster doses if and when the science demonstrates that they are needed."

In a press call with reporters, state health officials in Maine, Louisiana and Delaware on Thursday said they are paying attention to the booster shot issue and waiting for CDC guidance, but it's not their top priority.

"Right now our focus is getting folks first doses, not third doses," said Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention.

"There will be a time for booster shots, but there are still folks who do not have a first dose and that is where our team is focused," said Shah, also president of the Association of State and Territorial Health Officials.

KHN senior correspondents Jenny Gold and Markian Hawryluk contributed to this story.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

This article was published on Thursday, July 29, 2021 in Kaiser Health News.

By Katheryn Houghton

BOULDER, Mont. — Twice a year, Brian Tichenor makes the 1,200-mile drive each way from his home in Kansas to a defunct uranium mine in Montana, where he takes an elevator 85 feet below the surface to sit amid radioactive radon gas to ease the pain from his chronic eye condition.

"I found it like I think a lot of people do," said Tichenor, 67. "It's a point of desperation with conventional treatment."

While radon is commonly known as a hazardous gas removed from basements, people in pain travel to Montana and pay to breathe, drink and bathe in its radioactive particles. The travelers view the radon exposure as low-dose radiation therapy for a long list of health issues. But the Environmental Protection Agency and the World Health Organization, among others, blame the gas as the second-leading cause of lung cancer. Although cancer doctors use radiation as a front-line treatment to destroy dangerous cells, its role in the U.S. in low doses for other ailments is disputed. The pandemic has recharged that debate as clinical trials across the world test whether low doses of radiation can help treat COVID-19 patients.

But radon gas isn't the same radiation U.S. doctors use, radiation experts caution. Radon is just one of the radioactive chemical elements and, because it's a gas, it can be inhaled, making it particularly dangerous. Sitting in a radon-filled room and targeted radiation treatment in a medical facility are as different as "chalk and cheese," said Brian Marples, a professor of radiation oncology at the University of Rochester.

"In clinical therapy, we know exactly what the dose is, we know exactly where it's going," he said.

Marples said much of the argument for radon's therapeutic use relies on historical reports, unlike evidence-based research on clinical radiation. Still, some radiation experts are split on what level of radon should be deemed dangerous and whether it could have positive health effects.

Another concern: The radon treatment in the mines is largely unregulated. The Montana Department of Public Health and Human Services doesn't have the authority to permit or license the mines, though department spokesperson Jon Ebelt said the adverse health risk from exposure is well known. The EPA also doesn't have the power to mandate limits on radon.

Nonetheless, each year travelers head to western Montana, where four inactive mines flush with radon are within 11 miles of one another near the rural communities of Basin and Boulder. Day passes range from $7 to $15. The gas naturally forms when radioactive elements in the mountains' bedrock decay.

Outside the Merry Widow Health Mine, a billboard-like banner announces "Fountain of Youth. FEEL YOUNG AGAIN!" Inside its tunnels, water seeps from the rock walls. Those who want full immersion can slip into a clawfoot tub filled with radon-tainted water. People soak their feet and hands in water or simply sit and work on a puzzle. On a bench sits a printout of a Forbes article on clinical trials that show low-dose radiation could be a treatment for COVID-19.

To owner Chang Kim, 69, his business is a mission, especially for those with chronic medical conditions such as arthritis or diabetes. Those who swear by radon therapy say that, in low doses, a little stress on the body triggers the immune system to readapt and reduces inflammation.

"The people coming to the mines, they're not stupid," Kim said. "People's lives are made better by them."

He learned about the mines 14 years ago when he and his wife, Veronica Kim, lived in Seattle and a connective tissue disease crumpled Veronica's hands and feet. Traditional medicine wasn't working. After two sessions a year in the mines ever since, Veronica smiles when she shows her hands.

"They're not deformed anymore," she said, adding she's been able to cut down on her use of meloxicam, a medication to reduce pain and swelling.

Tichenor said going to a mine with radon over six years has been one of the few things to calm his scleritis, a disorder that causes pain he describes as ice picks stabbing his eyes. As for its potential danger, he said radon treatment is just like any medication: Too much can cause harm.

He and other radon users point to European countries such as Germany, where the therapy may be controversial but doctors still can prescribe radon treatments for various conditions that insurance may even cover.

In the U.S., the EPA maintains that no level of radon exposure is risk-free even though everyone encounters the element in their lives. The agency notes radon is responsible for about 21,000 lung cancer deaths every year. It recommends that homeowners with radon levels of 4 picocuries per liter or more should add a radon-reduction system. By contrast, the owners of Montana's oldest radon therapy mine, Free Enterprise Radon Health Mine, said their mine averages around 1,700.

Monique Mandali said the federal guidelines are "a bunch of baloney." Mandali lives in Helena, about 40 minutes from the mines, and tries to fit in three sessions at Free Enterprise a year — 25 hours of exposure spread out over 10 days for arthritis in her back.

"People say, 'Well, you know, but you could get lung cancer.' And I respond, 'I'm 74. Who cares at this point?'" she said. "I'd rather take my chances with radon in terms of living with arthritis than with other Western medication."

Antone Brooks, formerly a U.S. Department of Energy scientist who studied low-dose radiation, is among those who believe the federal government's no-level-of-radon-exposure stance goes too far. He pointed to research that indicates low doses of radiation potentially turn on pathways within bodies that could be protective. Though what's considered a "low dose" depends on who's talking.

"If you want to go into a radon mine twice a year, I'd say, OK, that's not too much," he said. "If you want to live down there, I'd say that's too much."

In the early 1900s, before antibiotics were popularized, small doses of radiation were used to treat pneumonia with reports it relieved respiratory symptoms. Since then, fear has largely kept the therapeutic potential of low-dose radiation untapped, said Dr. Mohammad Khan, an associate professor with the Winship Cancer Institute at Emory University. But amid the pandemic, healthcare providers struggling to find treatments as hospital patients lie dying have been giving clinical radiation another look.

So far, the trials Khan has led show that patients who received targeted low-dose radiation to their lungs got off oxygen and out of the hospital sooner than those without the treatment. Khan said more research is necessary, but it could eventually expand clinical radiation's role for other illnesses.

"Some people think all radiation is the same thing, that all radiation is like the Hiroshima, Nagasaki bombs, but that's clearly not the case," Khan said. "If you put radiation in the hands of the experts and the right people — we use it wisely, we use it carefully — that balances risk and benefits."

The logo for Free Enterprise Radon Health Mine is a miner skipping with crutches in the air. Roughly 70 years ago, a woman said her bursitis disappeared after visiting the mine several times. Thousands of others followed suit.

"We believe in it," said Leah Lewis, who co-owns the mine with her husband, Ryan Lewis, and has relied on it to help treat her Crohn's disease.

The couple live on-site and grew up in Boulder, going into the tunnels just as their 5-year-old daughter does now. Her husband's great-grandfather owned the mine, and the business has been in the family ever since.

"Not one person has come back and said they've gotten lung cancer here," Ryan Lewis said. "If they did, they would shut us down so fast."

Aside from a billboard outside Helena, the family doesn't really advertise the business. Clients tend to find them. Like many companies, Ryan Lewis said, Free Enterprise took a hit last year as people canceled plans because of the pandemic. Before that, he said, the business broke about even, adding that radon can be "a hard sell."

But he said the family of cattle ranchers plans to keep it running as long as it doesn't cost them money.

"The land is an investment, and we want to keep it in the family," he said. "And there are a lot of people who use this, and there's some responsibility there."

Katheryn Houghton: khoughton@kff.org, @K_Hought