If you are looking for good news about the state of the American Health Care System, you need not read any further than the first clipping.
If you can tolerate the truth - read this posting to the end.
- SPC
A chance to send a message on universal health care
By David Jolly - Ellsworth American -
In addition to the eight state ballot
questions this November, residents of the town of Penobscot will have
their own referendum to consider: “Shall the citizens of Penobscot call
on the Maine Legislature to create a publicly funded health-care plan
that provides every Maine resident with comprehensive medical care?”
I
am a resident of Penobscot and board member with Maine AllCare, a
statewide nonprofit that advocates for universal health care here in
Maine and across the country. I asked the town’s Select Board to put the
referendum on November’s ballot, and the board agreed. If the Penobscot
referendum succeeds, Maine AllCare intends to launch similar
initiatives in other towns across the state, with the goal of
demonstrating to state legislators that there is widespread support for a
publicly funded system of universal health care in Maine.
Despite
the Affordable Care Act and Medicaid expansion, over 75,000 Mainers are
still uninsured. And hundreds of thousands more are underinsured — that
is, they have insurance but still can’t afford health care because
their plans come with significant co-pays and deductibles as high as
$10,000 per year. Consequently, far too many Mainers go without care,
and far too many are saddled with medical debt — the number one cause of
bankruptcy in the United States.
With
publicly funded health care we would no longer have people forgoing
care they need because they can’t afford it. We would treat health care
as a public good less driven by profit. We already handle other common
needs this way, such as education, roads and highways and fire
protection — services that everyone requires, supports, and should have a
right to. (Unlike these other public goods, however, in the system that
Maine AllCare proposes, health care would be publicly funded but still
privately provided.)
There
are a number of paths to universal health care that are financially
sound and distribute benefits fairly to all. Most of these paths would
eliminate the current system of employment-based private health
insurance (which is where more than half of all insured people currently
get their coverage). This system places huge financial and
administrative burdens on employers. It puts small businesses that can’t
afford to offer health insurance as a benefit at a disadvantage in
recruiting good workers. In addition, the need to maintain insurance
coverage makes many employees reluctant to change jobs or start their
own businesses.
Employment-based
private health insurance is also the source of massive waste in health
care, and eliminating this waste would provide more than enough money to
provide good coverage for all those who currently lack it, both
uninsured and underinsured. First and foremost, this waste comes from
the high administrative costs of private health insurance. According to
the Kaiser Family Foundation, the cost for administering Medicare is
about 2 percent of operating expenses; estimates of the comparable
figure for private insurance range from 12 to 18 percent. Other sources
of waste include corporate profit-making and uncontrolled prices.
In
2018, Maine AllCare contracted with the Maine Center for Economic
Policy to analyze the economic impact of publicly funded universal
health care in Maine. That study concluded that a public plan it
envisioned could decrease yearly health care spending in Maine by $1.5
billion. Under this plan, universal health care would be supported by
taxes and premiums. There would be no co-pays or deductibles, and what
people paid in taxes and premiums would be pegged to income. Everyone
would pay their fair share, and 80 percent of families and individuals
would see an increase in household income because of savings in
insurance and out-of-pocket health costs. (A summary of the study is
available on our website, maineallcare.org)
No
health care system is perfect, but almost every other developed country
has managed to implement a plan for universal care, and on average
they’ve done so at less than half of what the U.S. spends per person on
health care. We are the richest nation in the world; our country could
have universal care as well — if we had the political will to make it
happen. Unfortunately, comprehensive reform of health care is unlikely
any time soon at the federal level. But change is possible at the state
level. Maine AllCare wants our state legislators to make that happen
here. That’s why we hope the people of Penobscot will vote yes on this
referendum, and why we ask all Maine residents to work with us for
high-quality, affordable health care for all.
David
Jolly is a member of the Maine AllCare board. He taught public health
policy at North Carolina Central University for more than a dozen years.
‘Get the right cases to the supreme court’: inside Charles Koch’s network
Billionaire’s web of rightwing groups works to bring cases to court that could undermine core functionings of the US government
by Ed Pilkington and Nick Surgey - The Guardian - October 26, 2023
The Koch network, a web of rightwing groups cultivated by billionaire
businessman Charles Koch and his late brother David Koch, is
spearheading the attack on federal agencies and government regulations
that dominates the US supreme court agenda this term.
The
network has been working behind the scenes to bring cases before the
court that, if successful, could undermine many of the core functionings
of the US government. At least two of the biggest cases to be
considered by the justices this term have been spurred by groups
bankrolled and coordinated within the Koch universe.
Footage
of an internal panel discussion between senior operatives from Koch
entities held in the summer of 2022 reveals that the network has been
quietly planning the current assault on the “administrative state”. The
groups are seeking to exploit the supreme court’s new six-to-three
rightwing majority secured by Donald Trump to dismantle vital executive powers.
Regulatory
controls in their sights include environmental standards to combat
pollution and the climate crisis, consumer protections against predatory
lenders, and safeguards for workers’ rights. At stake is what the Strict Scrutiny podcast has called “the future of government as we know it”.
The footage, which is made public here for the first time, was obtained by the investigative watchdog Documented
and shared with the Guardian. During the 37-minute panel discussion,
legal strategists with several Koch-related groups expressed excitement
that the new hard-right supreme court supermajority has created the
potential for a concerted attack on the functions of federal agencies.
Jorge
Lima, an economic policy strategist at the Koch network’s central
coordinating group, Stand Together, said that the new composition of the
court amounted to a huge “landscape opportunity, particularly on the
administrative state. We’re doubling down on this strategy.”
Lima added: “Every dog has its day, and it’s a big day for the administrative state.”
Casey
Mattox, a legal strategist at the main Koch advocacy group, Americans
for Prosperity, argued that the supreme court was now “primed for a real
change in the law” on federal regulations which he said amounted to a
“paradigm shift”. Mattox said: “That’s why we are partnering with
organizations that can get the right cases to the supreme court.”
The
effort appears to have born fruit. Two of the most significant cases
before the court in the 2023-24 term, brought with the backing of
Koch-linked organizations, attempt to rein back the government’s power
to impose regulations on corporations.
The prominence of the cases
underlines how the libertarian empire created by the Kochs is still a
force to be reckoned with within US politics. Since David Koch’s death
in 2019, and the Koch network’s decision to come out in opposition to Trump ahead of next year’s presidential election, the network has receded from public attention.
But the scope of Charles Koch’s reach remains formidable, as was demonstrated earlier this month when the 87-year-old told Forbes
that he had given $4.3bn of his Koch Industries stock to Believe in
People, a newly-created group named after his book of the same title. He
has transferred a further $975m to another new entity, CCKc4, which
carries the initials of his son Chase Koch.
The massive combined
$5.3bn in donations, one of the largest acts of giving to non-profits in
US history, will ensure that the Koch influence will continue to push
the US to the right for years to come. Undermining government
regulations is central to those ambitions.
Lisa Graves, the executive director of the progressive watchdog True North Research
who is a long-time Koch watcher, said that Charles Koch has shown a
“fundamental hostility to government regulation” since his early
political writings in the 1960s. “This is the through-line of his
career. His business operations have a substantial self-interest in
assailing regulations that impede his profits.”
Koch Industries is
a conglomerate of energy and chemicals companies that stand to benefit
if controls on pollution, workers’ rights and other aspects of public
governance are rolled back. The firm is the second largest
privately-owned company in the US.
Among the big administrative state cases that the justices will be considering this term is Loper Bright Enterprises v Raimondo, which seeks to overturn a 40-year precedent set by the supreme court itself. Known as Chevron,
the ruling allows federal agencies the flexibility to reasonably
interpret laws without interference from the courts as they regulate
critical parts of public life, such as the environment and public
safety.
Experts have warned that if Chevron is struck down, it
could be a recipe for legal and administrative chaos. “We are talking
about rules that protect us in so many ways – truckers who are too tired
to drive on the highway, unsafe workplaces, and pollution of our water
and the air we breathe,” Graves said.
The case was nominally
brought by a New Jersey herring fishing company that objected to being
charged by a federal agency that monitors its catch to prevent
over-fishing. Behind the challenge is a conservative group called Cause of Action, which is intricately tied to the Koch network.
The chair of Cause of Action’s board, Brian Menckes, is general counsel of the Charles Koch Foundation. Cause of Action’s executive director, James Valvo, who is acting as one of the fishing company’s lawyers in the case, is the former head of policy of Americans for Prosperity.
A second lawyer representing the company, Eric Bolinder, holds dual roles as a counsel for Cause of Action and Americans for Prosperity.
In 2021 Cause of Action’s entire income of $375,000 came from Stand Together, the Koch network’s coordinating group, Bloomberg reported. The groups are also physically close: Cause of Action and Americans for Prosperity not only share the same address in Arlington, Virginia, they occupy the same office – suite 700.
Bolinder
was one of the panel speakers at the 2022 Koch discussion on the
administrative state. He framed the plan to use the supreme court to
launch a legal attack on regulatory government as a states’ rights
issue.
“As the federal government grabs more and more power,
particularly to the regulatory state, the states become less and less
important,” he said.
The Guardian contacted Stand Together and Cause of Action for comment. Cause of Action did not immediately reply.
Gretchen
Reiter, Stand Together spokesman, said that the Loper Bright case was
seeking “to restore one of the core tenets of our democracy: that
Congress, not the administrative agency, makes the laws. Cause of Action
Institute – which filed the lawsuit in 2020 – is representing
family-run fishing companies that the federal government is forcing to
pay a tax that Congress never authorized, and that violates our
constitution’s separation of powers.”
Last week, the supreme court
accepted a second case also challenging the Chevron precedent, which
has now been consolidated with the fishermen’s petition. Relentless v Department of Commerce was also filed by a group with intimate connections to the Koch network, the New Civil Liberties Alliance (NCLA).
The
organization, which claims to “protect constitutional freedoms from
violations by the administrative state”, was founded in 2017 with seed
money from the Charles Koch Foundation. Over five years, it has received
more than $5m from the Koch network.
NCLA’s president, Mark Chenoweth, previously served as in-house counsel for Koch Industries.
NCLA submitted an amicus brief last week supporting another major challenge to regulatory agencies that will be heard by the supreme court this term. Securities and Exchange Commission (SEC) v Jarkesy
threatens to gut the enforcement power of the SEC by curtailing its
ability to fast-track cases of securities fraud through its own in-house
administrative law judges.
A ruling against the SEC could
drastically reduce the ability of numerous government agencies to
enforce environmental and other standards.
The footage of the Koch
panel discussion obtained by Documented reveals that the NCLA has been
secretly lobbying for the Jarkesy case to reach the supreme court.
Mattox said that “NCLA brought a lot of value to that case”.
He
went on: “You won’t see them actually directly litigating on that case,
but they’ve done a lot of work behind the scenes, and that speaks to the
way that our community adds value here, because when we partner with
people we look for results, not necessarily for headlines and
attention-grabbing.”
There is a further twist to the issue of Koch influence on the supreme court’s docket this term. Last month, ProPublica revealed
as part of its expose of ethical breaches by some justices, that the
right-leaning Clarence Thomas had attended at least two Koch donor
events where funds were raised to forward the Koch network’s mission –
which includes bringing cases before the court.
The attack on the
administrative state is central to the work of Americans for Prosperity,
which boasts of its years-long campaign to challenge what it calls the
“out-of-control regulatory environment imposed by Washington”. It
organizes bus tours around the country, directly relating “red tape” on
energy infrastructure projects to the high cost of fuel at the pump.
This has taken place while oil and gas giants such as Exxon, BP and Shell have posted record profits,
and the world has increasingly felt the impact of climate change.
Americans for Prosperity calls itself “the nation’s premier grassroots
organization”, but according to an independent audit report from 2021,
94% of the $112m in cash it received that year came from just two
donors.
This article was produced in partnership with Documented, an investigative watchdog and journalism project.Nick Surgey is Documented’s executive director
Nurse’s furious takedown of American healthcare system goes viral: ‘Treating people like literal garbage’
‘It is virtually impossible to be a ethical healthcare worker in this extremely unethical healthcare system,’ Lex Hinkley said
Kelly Rissman - The Independent - September 11, 2023
A nurse has gone viral on TikTok for her tirade against the “unethical” American healthcare system.
In a video posted on TikTok, 27-year-old San Diego-based nurse Lex Hinkley, laid out some of her qualms with the healthcare system.
“It
is virtually impossible to be an ethical healthcare worker in this
extremely unethical healthcare system,” she began. “The amount of times
I’ve had to discharge patients back to situations where I knew they
weren’t going to be able to take care of themselves, but I had no other
options, is truly too hard to even give a number to.
“If my career as a healthcare worker has done anything to my
worldview or life, it has simply radicalised me further than anyone
could believe.”
Ms Hinkley, who has said she has been a nurse for
four years and worked in seven states, said ”there is no way shape or
form that we improve our society as a whole without completely
dismantling for-profit healthcare.”
To demonstrate how for-profit
healthcare companies value making money more than patients’ wellbeing,
she shared a heartbreaking tale. She pointed to a recent example in
Louisville, Kentucky where hospitals have been scrutinised for leaving
“leaving patients outside on f***ing sidewalks” rather than being placed
inside the shelters.
The nurse was referring to a local hospital employee’s complaint made to a local news outlet, WAVE.
The employee reported seeing security dumping an elderly woman just
outside of the hospital, throwing her out of her wheelchair onto the
sidewalk. This prompted the outlet to investigate further.
A reporter began filming what was going on outside of the hospital,
and eventually saw another patient being dumped from the hospital
grounds—on a cold December day— allegedly because she was homeless and
asked to leave despite being there for diabetes and COPD treatment.
“In
order to understand what could potentially lead to a situation like
this, we need to know two things,” Ms Hinkley said. One, the nurse
detailed, is the Emergency Medical Treatment and Labor Act (EMTALA), a
federal law that states “that anyone who has an emergency must be
treated or stabilized, regardless of their insurance status or ability
to pay,” according to the American College of Emergency Physicians.
“Patient dumping,” as the upsetting practice is called, has long been an issue. The AMA Journal of Ethics
even wrote about it in 2009, underscoring “EMTALA’s inability to curb
denial of treatment,” due to the law’s ambiguity and lack of
enforcement. It’s unclear if these are the same problems that lead to
patient dumping in 2023.
The second thing, Ms Hinkley explained, is “when you defund social
programs”—like senior care, psychiatric care, or homeless shelters —
people end “up in the ER.”
“When you defund the safety nets that
our society needs to prevent people from beginning a crisis, a downward
spiral, they end up in the ER and simply put, ER workers and hospital
workers are already at their f***ing wit’s end,” she continued.
“We cannot act as a catch all for every single issue in society, and
yet, we are here we are doing it. And at the very f***ing same time,
treating people like literal f***ing garbage should never f***ing
happen.”
The 27-year-old added that while medical professionals
have no options, she placed blame on the executives. “The only way to
fix situations as unethical and disgusting as this from happening is to
fund solutions. We need to fund proper safety nets for our society,” she
said.
“In this country, if you lose your job, you lose your
health insurance, you potentially lose all of your income, which means
you’re not going to be able to pay rent,” Ms Hinkley added.
“Well,
then what happens if you get sick? Do you see what I’m saying? We don’t
have safety nets for our poor in this country,” the nurse added. “We
have a greased chute, and at the very bottom of that greased chute of
poverty is a trip to your local emergency room because everything ends
up in the ER and then we have nowhere to place people.”
She said
ER employees have “to answer for all of these executives…who have
privately funded their own bank accounts instead of publicly funding our
communities.”
Ms Hinkley added that the solutions are there but
come with a cost. “And we as a society have said that we’re A-okay with
400 people having 70 per cent of the nation’s wealth while our community
members get treated like this,” she said.
Social media users praised the nurse’s rant.
One wrote, “This is why so many of us healthcare workers are leaving the field. We just can’t take it anymore.”
Another
commented, “Can’t agree more. I’m so morally distressed and burnt out. I
left the ER [because] of the emotional turmoil it caused in me.”
Having a harder time accessing health care? You’re not alone – and it’s making us sicker
by Joe Lawlor - Portland Press Herald - October 23, 2023
Jessica Rogers has tried for two years to find a mental health
counselor who can take her on as a new patient. But she continues to
struggle on her own with the grief that followed her adult son’s death
in 2020.
“It’s been pretty much impossible,” said Rogers, of Augusta. “I ended
up giving up. Every place I called had a long wait list or weren’t
accepting patients.”
Sara Kinrade, of Naples, can’t schedule a dentist appointment for her
5-year-old son, even though she knows he has a cavity. It’s maddening
to know he’s in pain and that there’s not much she can do.
“I have called every dentist within 50 miles, and I can’t get him in,” Kinrade said. “I’m just so frustrated I canscream. It makes me feel like I’m a bad parent.”
Alex Petrovich, of Woodstock, said that despite many efforts, he
can’t get in to see a mental health therapist, and he knows it’s holding
him back.
“It’s like I can see the finish line, and I know what needs to
happen, but I’m stuck,” the 27-year-old said. “I can’t take that first
step forward to get better.”
Maine is experiencing a crisis in access to health care services.
While a record number of Mainers now have health insurance, many are
finding it difficult or impossible to get help from a broad range of
providers – primary care doctors, medical specialists, mental health counselors,
dentists. It can take months – even more than a year – to get an
appointment with a health professional, frustrated patients told the
Portland Press Herald.
While the severity of the problem may vary, other states also are
struggling with access. The U.S. will need 4.2 million additional health
care workers to meet the demand over the next five years, according to
Kaiser Permanente, a national managed-care organization.
The reasons for constricted access to health care are myriad, but
experts say the pandemic worsened access in two significant ways. People
delayed care during the early years of the pandemic, and as
restrictions were relaxed, patients flooded the health care system
seeking services for untreated or chronic health problems. Meanwhile,
the health care workforce shrank during the pandemic, leaving fewer
health care professionals to see an increasing number of sicker
patients.
Maine’s population also has grown – by slightly
under 2% since 2021 – outpacing the rest of New England. Maine’s
population had only grown 2.6% from 2010 to 2020. The population
increase is driven by people moving to Maine since the pandemic,
including an influx of people from other states and the immigrant
population.
Delayed care leads to sicker patients with more complex conditions, research shows.
More people will need hospitalization to treat mental health crises,
for example, when they may not have reached a breaking point had they
been seeing counselors. And what could have been an easily managed
chronic illness can grow serious if left untreated – hypertension, for
instance, developing into a significant heart condition.
Petrovich’s wife, Roxy Kai-Petrovich, said she’s been trying to get a primary care doctor for more than a year,
ever since her doctor moved away. Her physician had been a convenient
15-minute drive away, a rarity in rural Maine. She has chronic
conditions, including attention-deficit/hyperactivity disorder and
migraines, and she’s had a difficult time managing them without a
doctor.
“Every place I call, there’s such a long wait list with no end in
sight, or they say they’re completely full and don’t even have a
waitlist,” Kai-Petrovich said.
Kristin Jackson, of Brunswick, said it took about 10 months to get an
appointment with a dermatologist so she could properly diagnose and
treat a skin rash. And trying to schedule a preventive colonoscopy
screening is also a monthslong process that she is still in the middle
of trying to navigate.
“It’s just really frustrating. America is an advanced country with a
supposedly advanced health care system. It can make you feel really
helpless,” Jackson said.
Medical professionals say they understand the frustration and sympathize.
“Every new patient we see tells us, ‘I’m so glad we’re here. I waited
so long to get here.’ It really breaks my heart,” said Dr. Brigitte
Salembier, a primary care doctor with MaineHealth in Westbrook.
Dr. Andy Mueller, CEO of MaineHealth, the largest health care
provider in Maine and the parent organization of Maine Medical Center in
Portland, said everyone is feeling the strain, from health
professionals to patients.
“There’s not enough availability compared to demand,” Mueller said.
“We have patients seeking care, and we know they are having difficulty
finding it. We are still dealing with a lot of deferred care from the
pandemic.”
Glenda Dwyer, vice president of clinical operations and chief access
officer for Northern Light Health, said bottlenecks delaying care cause a
host of problems in the health care system, so solving the access
problem is paramount.
“If we don’t get people in through the gate, they just get sicker and sicker,” Dwyer said.
WORKFORCE SHRINKS
While the uninsured rate in Maine declined from 8% in 2019 to 5.7% in
2021 – the most recent data available – having insurance coverage does
not guarantee being able to get a doctor’s appointment.
Experts say the global pandemic continues to reverberate through the
health care industry, exacerbating what already had been a persistent
access problem, especially in rural areas of Maine.
The ability to see a health care provider historically has varied in
Maine depending on whether patients were in rural, suburban or urban
parts of the state, and whether they were covered by MaineCare, Medicare
or private insurance. But patients around the state are now struggling
to find care.
Statewide labor statistics tell part of the story. Maine’s health
care practitioner workforce is significantly leaner than before the
pandemic.
As with workers in many other sectors, health care professionals
retired early or left the workforce for other careers faster than they
could be replaced. The stress and strain of caring for patients during
the peak of the pandemic added to the exodus. And now a shortage of
staff across the health system may be causing more to leave. Between 40%
and 70% of health care workers say they feel burned out, according to
national data.
Workforce numbers vary widely in the many sectors of health care, but
the number of health care practitioners – which includes doctors,
nurses and numerous other medical positions – has declined overall.
In 2019, the year before the pandemic began, Maine’s health care
practitioner workforce totaled 42,390, according to the U.S. Bureau of
Labor Statistics, a peak after several years of mostly slow and steady
growth. By last year, the number had declined to 41,110.
Because the state’s population grew during the period – a trend also
fueled by the pandemic – the decline was more significant on a per
capita basis, with 67.32 practitioners per 1,000 population in 2022, the
lowest level in more than a decade.
The decline was evident in key areas, such as primary care, where
demand for services is especially strong. The number of family medicine
doctors in Maine decreased from 710 in 2019 to 580 in 2022. Nurse
practitioners declined in number from 1,380 in 2019 to 1,300 in 2022,
while the pool of physician assistants fell from 840 in 2019 to 770 in
2022.
The number of registered nurses increased slightly, from 14,490 in
2019 to 14,610 in 2022, in part a result of aggressive efforts to build
the nurse workforce. But there is still a shortage of nurses compared to
the need, especially in hospitals, health officials have said.
Workforce gaps are often filled by expensive traveling nurses, straining
hospital budgets.
DEMAND CLIMBS
At the same time the state’s workforce declined, demand for services climbed.
People put off seeking care for health issues during the early years
of the pandemic. Then demand exploded. And patients now tend to have
more complex problems because they went a long time without screenings
or treatment, health professionals say.
Patients who are now coming in for primary care or specialized
services have greater needs in large part because their untreated
chronic conditions have become more severe. Fifteen-minute consultations
take twice as long. Each patient takes longer to care for.
The situation is especially critical in mental health.
“We are having a mental health crisis in this country,”
said Jayne Van Bramer, president and CEO of Sweetser, a Maine mental
health provider. “We have high levels of suicide, anxiety and
depression, especially in our youth. But we have a waiting list at
Sweetser of over 2,000 people.”
Van Bramer said Maine’s reimbursement levels under MaineCare are too
low and the state needs to step in and fix the system. MaineCare is the
state’s name for Medicaid, a state-administered program funded with
state and federal dollars.
“We pay our therapists much less than in any state I’ve worked,
including Oklahoma,” said Van Bramer, who also worked in New York.
Without care, patients who otherwise might be stable end up in crisis in hospital emergency departments.
“When a person goes to the ER, that’s far more expensive for the
system than paying mental health therapists,” Van Bramer said. “We are
being penny wise and pound foolish.”
Dr. John Campbell, senior physician executive at Northern Light
Acadia Hospital in Bangor, said it’s not just the increased ER crisis
care. Some in need of help self-medicate with alcohol and drugs.
“We’re not anywhere near as effective as we could be,” he said.
DENTAL CARE
Dental care is also facing staff shortages and overwhelming demand,
said Kalie Hess, associate director of the Partnership for Children’s
Oral Health, andboth those with private insurance and MaineCare are affected.
“Access is definitely a problem. There are fewer providers to serve
more people,” Hess said. “We definitely still need more dentists and
more hygienists.”
Dental disease is the most prevalent chronic disease in childhood, andpreventive care is key, she said: “It’s really horrible the number of kids in Maine who are not getting any preventive care.”
In 2019, Maine had 590 dentists, according to the U.S. Bureau of
Labor Statistics. That total dipped to 521 in 2021 before rebounding to
560.
But in 2022, Maine created a new adult MaineCare dental benefit
covering about 200,000 Mainers, many of whom had gone decades without
care.
That’s created a crushing demand, only made worse because not all
dentists accept MaineCare, in part because reimbursement rates are
lower.
Kinrade, whose 5-year-old son has a cavity that needs care, said their MaineCare insurance doesn’t help.
“Some of these waiting lists go into 2025,” she said. “He’s not going to even have the same teeth by then.”
LACK OF ACCESS HARD TO MEASURE
Workforce statistics gathered by the health care industry and state and federal governments tell only part of the story.
The number of primary care physicians in Maine per capita is one of
the highest in the country, for instance, even with the dip since the
pandemic.
But the numbers don’t reflect how the need haschanged
since the pandemic, with patients requiring more care and time. Maine
also has the highest median age in the nation – 45 – and older patients
typically have more health problems and take longer to treat. And doctor
totals don’t take into account other health care workers – physician
assistants, nurse practitioners, front-office staff – who are essential
to making a practice run smoothly.
Meanwhile, there is no comprehensive data to track wait times for
medical appointments around the state and therefore no way to measure
the unmet demand or to compare Maine’s access crisis to other states.
MaineHealth is in the middle of updating the way it tracks how long
it takes to get in to see a doctor, said spokesman John Porter.
Dwyer, of Northern Light Health, said their health system does not
have a statistic that shows, over time, the changes in wait times for
patients, but access has definitely been a problem.
In Northern Light’s service area, which includes Bangor, Portland,
and many parts of northern and Down East Maine, Dwyer said, there are 37
vacancies for advanced practitioners in primary care – doctors, nurse
practitioners and physician assistants. That number has sometimes been
as high as 50.
Before the pandemic, vacancies would typically be in the 15-20 range, she said.
Some data points to the demand for mental health care. A
comprehensive report by the nonprofit Mental Health America found that
when looking justat “access to care” including
therapists per capita, Maine ranks 11th among the states. But when
looking at a number of factors, such as unmet mental health needs and
prevalence of substance use disorder, Maine’s ranking plummets to 31st.
SEARCH FOR SOLUTIONS
Maine’s health care systems are trying to increase efficiency by various means:changing
how patients are scheduled, expanding telehealth, assigning patients to
teams of providers instead of just one doctor, increasing the number of
graduates in health care and providing incentives for them to stay in
Maine. The University of New England, MaineHealth, Northern Light and
others have expanded student enrollment in various health care fields in
Maine recently, including nursing, primary care, dentistry and other
health care fields.
Telehealth, which boomed as a pandemic necessity, is now being used
for some of the simpler health needs, such as medication management,
that used to require in-person appointments.
More MaineHealth practices are using a team-based approach. Salembier
works on a care team with Caitlin Costigan, a nurse practitioner. They
manage 1,800 patients and give them care based on needs. Some patients
may just need to see a nurse or have a telehealth consultation, they
said.
Costigan said in specialty care practitioners can consult
“econsultants,” apps linking physicians in specialty areas, such as
dermatology. Primary care doctors used to often have to call specialists
with questions and wait for responses, which could take time if the
specialists and primary care doctors were booked up with appointments.
But the apps’ doctors focus solely on responding to queries from other
doctors.
Mueller, the MaineHealth CEO, said there are some common sense ways
to improve efficiency, such as streamlining responses to patients’
online messages to their doctors. A doctor doesn’t need to respond to
all of them, and MaineHealth now funnels some questions to others,
including nurses and front-office staff.
Hess, of the Partnership for Children’s Oral Health, said they are
looking for ways to provide baseline care when dentists aren’t
available, such as in-school clinics where hygienists can provide
cleanings and fluoride coatings.
Northern Light, Dwyer said, is trying to reduce patient no-shows by
10% with increased communication with patients to ensure they show up to
appointments.
In all health care sectors, suggestions of ways to help fix the
access problems include increasing MaineCare and Medicaid reimbursement
rates, loan forgiveness for college graduates in health fields and
increasing the number of college graduates in health fields including
mental health, primary care and dentistry.
Northern Light Acadia Hospital in Bangor is starting a postgraduate
residency program to help boost the number of psychiatrists in Maine,
said Dr. John Campbell, senior physician executive. The number of
psychiatrists practicing in Maine fell from 220 in 2015 to 110 in 2020.
And with the average age of Maine psychiatrists at 55, many will soon be
retiring.
With four residents per class, the Northern Light program will have
16 residents in four years, Campbell said, helping alleviate shortages.
He said it’s hard to know how many psychiatrists will remain in Maine
after completing their residencies, but typically it’s about half.
Van Bramer said Sweetser has also expanded non-clinical mental health
care, such as peer support and call lines that allow people to discuss
their challenges anonymously. Sweetser also has a system in place to
call and check in on the people on its waitlist – and it refers some to
outside services.
Lindy Graham, CEO and founder of Wellspace, a Portland- and
Yarmouth-based outpatient mental health clinic, said Wellspace is always
working at improving patients’ access by “shortening the time between
when they reach out to us and get an appointment.”
The new Wellspace@Work program, she said, provides mental health
services to workers at companies, which gives people faster access.
“When people are in a place of distress and it takes enormous hoops
for them to jump through to get to a clinician, that’s really
traumatic,” Graham said. “At a time when someone needs help, it should
be a seamless process.”
Jessica Rogers, whose 23-year-old son Hunter died of a fentanyl
overdose in October 2020, said the fight to find a mental health
counselor has been exhausting and painful.
“It’s a lot of effort just to be told no,” she said. “I called
Augusta, Portland, Bath, Brunswick. Every place I called, they said,
‘Try back in a few months.’ No one was even taking names for a waiting
list.
Shortage of pharmacists leaving Maine customers in peril
Walkouts at some pharmacies in other states are fueling concerns in Maine, where store closures are already a problem.
by Emily Bader - The Maine Monitor - October 22, 2023
With pharmacists around the country walking off the job or
threatening to do so, Maine pharmacies have experienced sudden closures,
infrequent hours and frustration from customers who say they’re
unreliable.
Over the past several weeks, employees at Walgreens and CVS, the
nation’s two largest pharmacy chains, staged walkouts or did not show up
for work to protest what organizers told The Washington Post are
conditions that threaten the safety of employees and patients.
The walkouts show pharmacists feel “safety is so compromised that
it’s actually better to not open the pharmacy,” than to open it, said
Emily Dornblaser, a founding faculty member of the University of New
England School of Pharmacy and director of interprofessional education.
“They just can’t meet the needs of the people that need them. And in
doing so, they’re potentially putting other people at risk.”
There have been no reports of walkouts at Maine pharmacies as of
Friday, but national organizers told CNBC that Walgreens walkouts are
scheduled for Oct. 30 to Nov. 1. It is unclear whether any Maine
pharmacists will participate.
Meanwhile, at least eight Walgreens have closed since 2020.
There is a shortage of pharmacists in Maine and nationwide,
Dornblaser said. It started in the mid-2000s, when a shortage prompted a
number of pharmacy school openings. But then the 2008 recession hit,
and pharmacists who may have otherwise retired continued to work, she
said.
Starting about six years ago, Maine finally met the demand for
pharmacists – and then some. Jobs became more competitive, wages
dropped, and so did applications to pharmacy schools.
In the fall of 2018, UNE School of Pharmacy reported 273 students
enrolled in its Doctor of Pharmacy program, according to data from the
university. By the fall of 2022, enrollment had dropped to 116 students,
a nearly 60% decrease over five years.
Maine’s only other pharmacy school, at Husson University in Bangor, admits 65 students per year, according to its website.
“Right in the middle of that, then, is a pandemic,” Dorblaser said.
Complicating the equation is that pharmacists are doing a lot more than filling prescriptions.
“We’ve definitely seen a lot more added to our plate:
testing, delivery of vaccines. We’re right now in the introduction
phase of the 23-24 COVID vaccine, along with our flu vaccine, along with
the (respiratory syncytial virus) vaccine,” said Steve Maki, president
of the Maine Pharmacy Association.
“So, I mean, there’s a lot of additional services and things that
three years ago weren’t even on our radar of, ‘Oh my gosh, this is now
something we have to adjust for and we have to plan for.’”
Maki, who has been a pharmacist since 1996 and opened Spruce Mountain
Pharmacy in Jay in 2009, said the pharmacy landscape “seems like it
changes right before our eyes.”
“Three years ago, pharmacists weren’t even considered as providers in the state,” he said, referencing a bill passed
during the 130th Legislature that amended wording to the Maine Pharmacy
Act to add that a pharmacist is a “provider of healthcare services,”
but did not effectively change what pharmacists do.
The additional responsibilities led to “substantial burnout,” Dornblaser said.
Compounding that, wages for pharmacy technicians, who provide
critical support by counting and filling pills, stocking shelves, giving
immunizations and assisting customers, have remained low for years,
Dornblaser said.
The average hourly wage for a pharmacy technician in May 2022 was
$18.12, according to the Bureau of Labor Statistics. Dornblaser said
during the pandemic-induced workforce shortage in other industries, she
often heard of techs lured from pharmacies for better-paying jobs.
“You had people who had really a large amount of responsibility in
the job in terms of keeping people safe, who weren’t compensated nearly
as much as somebody working at … a McDonald’s,” she said.
Not only are pharmacists overworked and pharmacies understaffed, but
there are fewer brick-and-mortar locations for people to get
prescriptions filled.
Since 2020, Walgreens has closed locations in Auburn, Bangor, Fort
Fairfield, Guilford, Millinocket, Newport, Pittsfield and Portland,
according to pharmacy board licensing records that were confirmed by a
Walgreens spokesperson.
Walgreens, CVS and Rite-Aid, which had already closed hundreds of
stores nationwide before the pandemic, have since announced hundreds
more closures.
Walgreens announced in June it would close 150 stores and in 2021, CVS said it would close 900 stores by next year.
Rite-Aid, which closed its Maine locations by early 2018,
announced earlier this month it filed for bankruptcy and will close
hundreds of stores.
In rural areas, inconsistent hours, staff shortages and closures mean
residents can’t depend on their local pharmacy to get their medications
– if they even have a pharmacy near them.
Peter McCormick spends his summers on Campobello Island, just over
the bridge from Lubec, in Canada. When he’s there, he transfers his
prescriptions from a Walgreens pharmacy near his primary residence in
Vermont to the one closest to his summer home, 40 miles away in Machias.
One Friday last summer, he received a notification two prescriptions
were ready for pickup and made the 50-minute drive to Machias. When he
got there, he said, the pharmacy was closed. A clerk told him, “We don’t
have enough pharmacists,” and he could try the Calais Walgreens an hour
away.
“A woman standing nearby said to me, ‘Don’t bother going to Calais
because the Walgreens there is closed, too,’ ” McCormick said.
“Thankfully I had enough medication to get me to Monday, but the
episode caused me an unnecessary three-hour round trip and would have
been a much bigger problem if I hadn’t ordered my refills somewhat
early. Overall, very disappointing,” he said.
Last month, Walgreens signed a consent agreement with
the Maine Board of Pharmacy that said the chain’s Machias and Calais
locations closed without notification and did not meet the state
requirement that pharmacies are open for at least 40 hours per week on
multiple occasions. It agreed to pay a $10,500 fine.
“There are times when we must adjust or reduce pharmacy operating
hours, or temporarily close a store, as we work to balance staffing and
resources in the market to best meet customer demand. When this occurs,
we make every effort to minimize disruption for patients and customers
by selecting days with the lowest prescription demand to ensure that
there is a nearby pharmacy to meet immediate prescription needs,”
Walgreens spokesperson Kris Lathan said in an email.
“We also provide patients as much advance notice as possible through
signage, automated phone calls, updates to our online scheduler, and
adjustments in refills,” she said, but did not respond to specific
questions from The Maine Monitor about the penalties, store closures or
walkouts.
Lance Keen of Cooper said those stores are a “mess,” with “sporadic closures and can’t be relied on.”
He, too, experienced an incident where he ran out of a prescription
and was unable to get it refilled in a timely manner, causing him
“physical distress.”
With his usual pharmacy being 20 miles away, Keen said he has to be
more attentive to when he needs to send in refill requests. He has also
started to get his prescriptions delivered through Express Scripts, a
prescription benefit manager that offers home delivery.
Mail order services offer convenience and consistency, especially for
people in rural areas, like McCormick or Keen in Washington County, but
Dornblaser worries an overreliance on them is a missed opportunity to
develop “that community relationship.”
“Often it’s the pharmacist that you sort of casually mention
something to and they can sort of say, ‘You know, that sounds like
this,’ or, ‘You should go get that checked out,’ ” she said.
They can catch potential drug interactions, administer vaccines or
serve as an easily accessible healthcare professional to answer
questions.
The possibility of more closures worries her.
“We are a very rural state and, you know, having access to a
healthcare provider can be such a lifeline for people,” Dornblaser said.
“And the loss of a pharmacist or a pharmacy in a community has a pretty
big impact overall.”
Stabbed. Kicked. Spit On. Violence in American Hospitals Is Out of Control.
Video by Roland Kielman and Ryan Mercer Text by Helen Ouyang - NYT - October 24, 2023
Crushing chest pain, an itch that festers into torment, an
inconsolable baby, no place to sleep at 3 a.m., an ankle twisted on a
jog, a fentanyl overdose, a car crash, the need to tell someone, “I feel
sad and lonely.” The only place that tends to this kaleidoscope of
needs is the emergency room, its doors perpetually open to all.
It’s
what I love — fiercely, unwaveringly — about emergency medicine. It’s
why I and other doctors pursued it as a specialty: to provide a safety
net. For many, we may be the first health care workers they meet at
their most dismal hour. But it’s also what makes our workplace so
dangerous, more than ever, and jeopardizes the emergency care that
everyone receives.
Last year one of my patients was on the phone,
lamenting about how long he had been in the emergency room. He had
already waited several hours to get a CT scan. Medications he was
supposed to be given were repeatedly delayed. I heard his voice rise and
fall, with each swell more expansive than the one before. When I turned
to look at him, he yelled a racial epithet before hurling a desktop
computer into the area where doctors and nurses sit. A seasoned nurse
ducked. As I pushed an intern and medical student out of the way, he
charged at us with a steel tray. Thankfully, no one was injured.
In a 2022 American College of Emergency Physicians survey
of E.R. doctors, 55 percent said they had been physically assaulted,
almost all by patients, with a third of those resulting in injuries.
Eighty-five percent had been seriously threatened by patients. The risks
can be even higher for E.R. nurses, with over 70 percent reporting they
had sustained physical assaults at work. I don’t know anyone who works
in the E.R. who hasn’t suffered some form of violence there. The health
workers at the University of Vermont Health Network in the video above
share examples of this.
“People, appropriately so, feel
that the safety net should always be there, no matter what, and should
serve its purpose of not letting people fall through the cracks,” Dr.
Aisha Terry, the president of the American College of Emergency
Physicians, told me. But it’s this tenet at the heart of emergency
medicine that also allows it to be exploited. “Whether intentionally or
unintentionally, those factors have resulted in us becoming more
vulnerable to violence.”
In the E.R., there’s a certain level of
resignation that violence is just part of the job, like getting
bloodstains on our shoes. We have come to endure racist, sexist and
homophobic slurs, choosing silence over confrontation, to fulfill our
duty to care for human life. After all, we pledge to hold our patients’
well-being above all else.
In some sense, violence in the E.R. is
stark evidence of society’s broader neglect: a medical system in which
mental health beds are scarce, primary care remains elusive and
prescription costs soar; a shelter network that’s buckling; a country
where parents may not make enough to feed their children. All of this
can lead to intolerable overcrowding and interminable waiting in the
E.R., which can rupture into frustration, anger and incivility.
Even before the Covid pandemic, the trajectory was troubling. The U.S. Bureau of Labor Statistics reports
that the rate of injuries from workplace violence against health care
workers grew by nearly two-thirds from 2011 to 2018. The pandemic
worsened the situation, cracking society wide open and exposing its
systemic failures. During the pandemic, more than 40 percent of American
adults reported high psychological distress, which may contribute to
outbursts. It has also sown profound mistrust between patients and
medical professionals.
The repercussions of this are being felt.
Only 15 percent of surveyed hospital nurses said they would continue in
the same job in one year; a third of nurses said they had considered
exiting the profession because of the pandemic. The burnout rate among
E.R. doctors climbed to 65 percent, the highest rate among all
specialties. When employees leave, those who remain face terribly
short-staffed workplaces. Or employees meet a revolving door of new
colleagues, making it impossible to understand one another’s strengths
or compensate for one another’s shortcomings — to become a team. This
can worsen outcomes for patients.
Organizations and
lawmakers are starting to address violence against health care workers.
The Joint Commission, a group that accredits hospitals, added workplace violence
regulations last year. This year Virginia became the first state to
pass a law requiring that all emergency departments keep a security
officer on site around the clock. Federal legislation is also in
progress: If passed, the Workplace Violence Prevention for Health Care
and Social Service Workers Act would mandate health employers to adopt
plans to prevent workplace violence. Another bill, the Safety From
Violence for Healthcare Employees Act, modeled on protections in the
airline industry, would create federal criminal penalties for people who
assault health care workers.
Health care, though, is not the same
as air transportation. Because of the Emergency Medical Treatment and
Labor Act, in place since 1986, every person who goes to an E.R. for
treatment must be medically examined and assessed. Hospitals don’t
create no-fly lists, akin to airlines, nor should they. A patient can be
aggressive and also be seriously ill. Patients struggling with mental
illness, addiction or delirium may have violent episodes but also need
compassionate care.
Federal and state laws are necessary as
backstops, permitting warning signs to be posted, so that everyone knows
a boundary exists that will be enforced. But hospital administrators
also need to prioritize their staff members’ safety. Hospital systems
have added electronic flags to the charts of patients who threatened or
assaulted staff members in the past. Currently, these flags are put in
by providers to warn one another and don’t go beyond individual charts.
This is a starting point, but more must be done.
Simple
confidential reporting systems that encourage employees to formally
record these incidents in detail for further review, as they would with
any medication error, should be instituted. Hospital administrators need
to then perform thorough dissections of the events to diagnose what
went wrong, applying the same rigor as they would to clinical mistakes,
and intervene with specific remedies — whether it’s bolstering security
in certain areas or equipping staff members with personal panic buttons.
Some health care workers have already taken matters into their own
hands by undergoing self-defense training, even looking into wearing
body armor.
What has stayed with me most is not the near miss of a
thrown computer or a slur a patient used but a medical student saying
to me after he witnessed a violent episode, “I learned today that I
don’t want to go into emergency medicine.” The field is seeing a steep
decline in applicants. Who will tend to waiting patients? What will
happen when society’s safety net withers away?
Standing
up to end violence against health care workers does not mean taking
care away from anyone. Instead, it promises to make care better for
everyone.
Roland Kielman is a communications specialist
with the University of Vermont Health Network, where he focuses on
storytelling and corporate communications. Ryan Mercer is a
communications specialist with the University of Vermont Health Network
where he focuses on multimedia storytelling. Helen Ouyang (@drhelenouyang) is a physician, an associate professor at Columbia University and a contributing writer for The New York Times Magazine.
Opinion | Open Enrollment Reminds Us How Easy It Is to Lose Health Insurance in America
Danielle Ofri - NYT - October 25, 2023
A few days before New Year’s Eve, an
unfamiliar health insurance card for me arrived in the mail. I assumed
there must have been an error and called the human resources department
of the medical center where I’m employed as a doctor.
“No,” the
representative replied, “it’s not a mistake. You didn’t enroll this
year, so you automatically got put on the basic plan.”
“That’s … that’s impossible,” I stammered. “I’ve always signed up my family for the same health plan.”
“I’m sorry, Dr. Ofri,” the representative said, rechecking her records, “but you didn’t enroll this year.”
Could
that be? Could I have somehow forgotten? Or missed the notification?
“But don’t worry,” she said. “We’ve put you on the basic plan.”
“OK,” I said, starting to relax and thinking out loud. “I guess my kids will get to meet some new doctors.”
But
the representative did not match my tone. “I’m sorry, but the basic
plan is just for the employee,” she said, “not your family.”
That’s
when a coil of disbelief clamped my heart to a standstill. My spouse
and children would be left without health insurance? The panicked
questions quickly percolated: What about their ongoing medical
treatments? What about their medications? What if someone got hit by a
car, or got cancer? There’s hardly a more devastating feeling for a
parent than to realize that you haven’t adequately provided for your
family.
Swirling in panic, I hardly heard anything else the
representative said. There was something about referring my case to a
supervisor, but it was a holiday week, so many employees were on
vacation. All I could think about was that in a few days it would be the
new year, and my family would be uncovered. I felt tears creep into the
corners of my eyes as I realized that I had jeopardized my family’s
health. All, it seemed, from missing the email notifications.
The
smaller question of my oversight turned out to be easily answered. My
work inbox is teeming with dross; legitimate emails disappear in the sea
of junk mail. We’ve been encouraged to clean up our inboxes using
various tools, and one of the spam filters I enabled had apparently
inadvertently swept up all the emails from H.R.
“But didn’t you know
that October is open-enrollment month?” the representative had
chastened me; I work in health care, after all. Well, yes, but there’s
life and work and children and my patients. I must have assumed I’d
already done it.
The larger question was why this could occur so
easily. Why is the American health insurance system set up in a manner
that a slip of the mind or a bureaucratic hiccup can render people
uninsured?
As I thought about it some more, I was struck by a
question that I’d never thought about before: Why do Americans have to
“remember” to get health insurance every year? We don’t ask citizens to
remember to enroll with the fire department every year, or to remember
to sign up for electricity service or water. Yet with health insurance,
we’ve set up an unwieldy mechanism where millions of people have to opt
in every year or do without. (While some companies automatically
re-enroll employees with their prior year’s selections, this is by no
means universal.)
During the Covid-19 pandemic, the federal
government forbade states from removing anyone from Medicaid. This
so-called continuous enrollment resulted in coverage for an additional 23 million Americans and brought the nation’s uninsured rate down to a historic low of 8 percent.
Once the public health emergency ended this year, however, states were
free to resume culling the rolls, and more than nine million people have
been disenrolled to date. This has tragic human consequences, as medical treatments and preventive care are abruptly amputated.
The
stated reason for this bureaucratic merry-go-round is that eligibility
must be ascertained every year so as not to allot services to someone
who doesn’t qualify. But the process of determining eligibility is
highly flawed. Only some of disenrolled Medicaid patients, for example,
are truly ineligible; according to KFF, a health policy research
organization, the majority of people (more than 90 percent in some
states) were disenrolled for “procedural reasons,” such as missed
deadlines, paperwork issues or outdated contact information. Many of
these people are actually eligible for insurance, but lose coverage
because of the byzantine logistics. And even beyond the pandemic related
“unwinding,” some people on Medicaid face multiple disenrollments and
re-enrollments if their income fluctuates, such as with seasonal work or
gig jobs.
The net effect is that we require an enormous chunk of
the U.S. population to continually re-enroll for health insurance. The
inefficiency of this is staggering; we require tens of millions of
people to prove eligibility over and over again to catch the few who
might no longer be eligible. Beyond pure inefficiency, it’s also
inhumane, leading to worse medical outcomes, plus higher costs.
A
simpler solution would be to flip the script. After an initial
eligibility assessment, people would stay with the same insurance plan
unless they opt out, request a change or are ineligible for genuine —
not procedural — reasons. For employer-based health insurance, this
would be relatively simple, as most ineligibility stems from no longer
working at the company, something that employers surely know. For
everyone else, health insurance would auto-renew each year the same way
it already does for the plans on the Affordable Care Act exchanges. This
would be far simpler than having every person redo the paperwork every
single year.
For Medicaid, the income eligibility requirement adds
a layer of complexity, but there are nevertheless ways to reduce the
hoop jumping. For starters, every recipient should be granted a full year of continuous coverage
after enrolling to eliminate the wasteful short-term upheavals. But the
simpler and more humane option would be to keep the continuous coverage
we adopted during the pandemic, and only disenroll people if I.R.S. and
other data sources demonstrate sustained higher income or insurance
from another job. Random audits — as we do for taxes — can help ensure
compliance.
Will there be errors? Of course. Some people will stay
insured when they are no longer eligible. But our current system offers
a crueler and more expensive type of error: mistakenly kicking off
eligible people.
My own experience of jeopardizing my
family’s insurance because of an errant spam filter drove home the
harrowing point. Our health insurance system is capricious, and it takes
little to upend people’s lives. For me, it took endless phone calls to
fix the problem and a miserable week in which I was convinced that I’d
failed my family. For millions of Americans, the system is simply
unnavigable.
Of course, none of this would be necessary if the
only requirement for getting insurance was — as it is in most countries —
being born. Instead, Americans are forced to live within an illogical
patchwork of plans and regulations that so easily allows people to fall
through the cracks.
Faced with abortion bans, doctors beg hospitals for help with key decisions
by Caroline Kitchener and Dan Diamond - Washington Post - October 28, 2023
Vague state laws, and a lack of guidance on how to interpret them,
have led to some patients being denied care until they are critically
ill
Amelia
Huntsberger pulled up a list of the top administrators at her northern
Idaho hospital, anxious last fall to confirm she could treat a patient
with a potentially life-threatening pregnancy complication.
But it was a Friday afternoon — and no one was picking up.
Huntsberger said she called six administrators before she finally got ahold of someone, her patient awaiting helpa few rooms away. When she askedwhether she could terminate a pregnancy underIdaho’s
new abortion ban — which allows doctors to perform an abortion only if
they deem it “necessary to prevent the death of the pregnant woman” —
the OB/GYN said the decision was punted back to her.
“You know the laws, Amelia,” Huntsberger recalled the administrator saying. “You know what to do.”
If she made the wrong decision, the doctor knew she could face up to five years in prison.
While the more than two dozen abortion bans enacted since the fall of Roe v. Wade
all include some kind of exception for the mother’s life, the laws use
ambiguous language, with many permitting abortions in a “medical
emergency” without offering a concrete definition of that term. Prompted
by numerous prominent cases in which women became critically ill after
being turned away from hospitals, the issue has spawned debate in state
legislatures, several high-profile lawsuits and a standoff with Biden administration officials who say the procedure should be covered by emergency care laws.
But
behind that public controversy is a little-known struggle between
doctors making life-or-death decisions at great personal risk and
hospital administrators navigating untested legal terrain, political
pressure from antiabortion lawmakers, and fears of lost funding, a
Washington Post investigation found. Instaffmeetings,
phone calls and tense, months-long email exchanges, many doctors have
repeatedly sought guidance on how to interpret the medical exceptions in
their states’ abortion bans, only to be given directives from hospital
officials that are as vague as the laws themselves.
“I
just worry that without more guidance, our patients are in danger and
providers are in a dangerous place as well,” Lindsey Finch,then
an OB/GYN resident at Jackson Health System in Miami, wrote in a July
2022 email obtained by The Post. “It just does not feel safe and I am
concerned.”
Confiding
in a colleague, another OB/GYN practicing at Jackson Health, Ian
Bishop, said he had tried unsuccessfully to get his hospital to “plan
for the upcoming changes” in Florida’s abortion law, according to
another email reviewed by The Post, expressing concern that the hospital
“does not want to create a policy or guidelines, thus leaving those who
perform abortions vulnerable and not the institution.”
A
spokesperson for Jackson Health System, Lidia Amoretti, said the
hospital “complies with Florida law and follows a policy that ensures
pregnancy terminations are performed in compliance with state and
federal regulations.” Finch and Bishop did not respond to requests for
comment.
This report on an overlooked aftershock of the fall of Roe
is based on interviews with 26 doctors, lawyers and hospital
administrators in antiabortion states, as well as documents gathered
from public records requests to 50 of the largest public hospitals in
states with abortion bans.
The
Post review found that many hospitals have failed to provide specific
guidance or policies to help doctors navigate high-stakes decisions over
how to interpret new abortion bans — leading to situations where
patients are denied care until they are on the brink of permanent injury
or death.
Of
the 37 hospitals that responded to The Post’s requests, documents
provided by 28 institutions revealed they offered guidance that was
virtually identical to the language of the abortion ban, or no guidance
at all. While many doctors were told to reach out to lawyers or hospital
leaders to solicit advice on a case-by-case basis,some said
they were unable to reach those people when confronted with emergency
situations after hours — provided with only office phone numbers or, in
one instance, an email address.
Just nine of the hospitals that responded to The Post produced records showingthat
they had provided doctors with guidance on how to interpret their state
laws’ medical exceptions — often with carefully crafted answers that
advised physicians to take a cautious approach.
At
the University of Arkansas for Medical Sciences (UAMS) Medical Center,
for example, officials opted for a narrow interpretation of the medical
exception in Arkansas’ abortion law, which allows doctors to perform an
abortion to “save the life of a pregnant woman in a medical emergency.”
The hospital issued June 2022 guidance that forbids abortions in certain
cases, according to records, even though some hospitals in states with
similar bans permit the procedure in identical situations. Stephen
Mette, who was chief executive officer for the Arkansas hospital before
stepping down in September 2022, said the staff made that decision
because they feared retribution from the state’s antiabortion
legislators.
“You
won’t find a document saying [it], but the leaders at UAMS were
perennially afraid of funding cuts,” said Mette, adding that legislators
routinely threatened to withdraw funding from the hospital. “I have no
doubt it was subliminally or actually was overtly influencing the
conservatism in the guidelines.”
UAMS
officials disputed Mette’s account. The attorney who crafted the
guidance said she was “not influenced by any political pressure,” Leslie
Taylor, a spokesperson for the hospital, wrote in an email.
While
abortion laws specifically target the individuals involved in
performing an abortion, the potential legal risk for hospitals is
unclear. More than a dozen hospitals and their state and national
associations declined to answer questions from The Post about their
abortion policies, with officials privately citing fears of slashed
funding or other retaliation from lawmakers.
“Everyone
just wants to be off the radar right now — and not invite the ire of
the state attorney general,” said Ellie Schilling, a lawyer in Louisiana
who supports abortion rights and has consulted with hospitals on how to
interpret new abortion laws.
In
a handful of cases, the Post review found, some hospitals have crafted
clear and robust guidance — or even formalized policies — that permit
their physicians to treat considerably more conditions than others. Such
efforts, doctors say, have likely saved patients’ lives.
But
even those hospitals are often reluctant to put their policies in
writing or discuss them widely, according to several people who helped
craft those policies. Hospital leaders quietly circulate lists of
situations in which they feel their doctors can legally perform
abortions, often including life-threatening pregnancy complications many
doctors would not feel comfortable treating without an institutional
green light.
Adding
to the pressure on hospitals, according to lawyers and experts, is that
they are caught between the contradictory demands of state abortion
bans and the Biden administration’s use of the Emergency Medical
Treatment and Labor Act, or EMTALA — the federal rule requiring
hospitals to treat emergency medical conditions, or risk being
blacklisted from Medicaid, Medicare and other federal programs that
provide hospitals much of their funding.
Biden
officials have repeatedly insisted that the nearly four-decade-old law
takes precedence over state abortion bans. But several federal judges —
all Trump appointees — have rebuffed those arguments, and said the White
House is attempting to justify abortions by twisting rules that were
meant to help low-income patients access emergency health care.
In
northern Idaho, Huntsberger said she watched other hospitals in her
state develop detailed policies on the issue, forming working groups and
offering 24/7 legal support to doctors. She became increasingly
frustrated by the lack of guidance offered by her own hospital, she
said, and administrators who did not seem to fully understand the law.
“It
was profoundly disturbing that I was supposed to be taking advice from
someone who didn’t seem to have read every single line,” said
Huntsberger, stressing that she does not speak for the hospital.
Officials
from the Sandpoint, Idaho-based hospital where she worked, Bonner
General Health, said the hospital empowers medical professionals “to
make evidence-based decisions regarding care and treatment of their
patients.”
“Unfortunately,
one of the drivers of medical decision-making regarding women’s health
in Idaho is the fear of litigation and that’s not something Bonner
General Health can control,” Sandy Brower, the hospital’s director of
quality and risk management, wrote in an email.
By March 2023, Huntsberger — one of only a handful of OB/GYNs in northern Idaho —had decided she could not continue working under the abortion ban.
She now practices in Oregon.
GOP seeks to avoid a ‘gaping exception’
Many
hospitals have resisted providing abortions for decades, with some
allowing the procedure only to save the life of the mother or for fatal
fetal anomalies. At religiously affiliated hospitals,
those policies stemmed from a long-standing moral opposition to
abortion; elsewhere, doctors said hospitals restricted abortions to
placate lawmakers responsible for their funding.
But
those policies were far easier to navigate than the abortion bans,
doctors said, because they could typically refer patients to abortion
clinics in the area. Doctors deciding whether to perform an abortion in a
hospital setting were also far less fearful, they added — worried only
about censure from their employer, rather than jail time.
Medical
exceptions have long been a point of tension within the antiabortion
movement, with some conservatives concerned that doctors may interpret
the exceptions too broadly, offering abortions for conditions
antiabortion advocates view as not sufficiently life-threatening, said
Mary Ziegler, a law professor at the University of California at Davis
who specializes in abortion.
When
former Florida state senator Kelli Stargel (R) began drafting Florida’s
15-week abortion ban with her Republican colleagues in the fall of
2021, she said they talked at length about whether to allow an exception
for the mother’s health, in addition to the exception for the mother’s
life.
“We
had a big discussion,” recalled Stargel, who is no longer in the
legislature. “Is health strong enough? Is mental health considered
health? Is inconvenience considered health?”
They
ultimately decided they did not want to offer a “gaping exception”
available to anyone, Stargel said — drafting a law that allowed
abortions only to “save the pregnant woman’s life” or“avert a serious risk of substantial and irreversible physical impairment of a major bodily function.”
Then came a series of cases, widely covered in the news media, in which women with life-threatening complicationswereturned away from hospitals because of new abortion bans.
While
antiabortion lawmakers like Stargel were initially hesitant to offer a
broad medical exception, some now say their laws allow doctors to treat a
wider range of medical conditions than has been generally understood.
On
the Florida Senate floor this spring, nearly a year after the state’s
15-week abortion ban took effect, Sen. Erin Grall (R) assured her
colleagues that doctors could legally treat patients who experienced
pre-viable PPROM, a relatively common life-threatening condition where a
woman’s water breaks before the fetus can survive on its own. Grall
said the problem was not the laws themselves but the doctors who are
playing “games and politics” by willfully misinterpreting them — a claim
doctors say is inaccurate and deeply insulting.
Several states, including Texas and Tennessee,
have recently passed new laws to clarify their medical exceptions,
designed to allow doctors to treat ectopic pregnancies, a
life-threatening condition where a fetus grows outside of the uterus,
among other conditions. Texas’s law, which took effect Sept. 1, also
permits doctors to treat patients with pre-viablePPROM.
But
even the new laws are hard to trust, several doctors and hospital
lawyers said. The Texas law, for example, is worded in a way that
technically leaves doctors liable but provides a path for them to prove
their innocence in court. Instead of including an explicit exception for
ectopic pregnancies and pre-viable PPROM, the law instead outlines
situations where doctors could make an “affirmative defense” that shows
they performed the procedure for a true medical emergency.
“That
law is not as great as a lot of people think it is,” said Marc Hearron,
senior counsel at the Center for Reproductive Rights. “They still need
to go to court to defend themselves. It just adds to the confusion.”
Hospitals fear liability in untested legal landscape
Speaking
at a regional conference for OB/GYNs in August 2022, Rachel Rapkin was
determined to convince over 50 of her fellow doctors that their
hospitals had power. Rapkin told the group gathered at the Orlando
Ritz-Carlton what she’d learned in the two months since the Supreme
Court overturned Roe v. Wade — and how doctors at her hospital, Tampa General, had quietly forged a path forward.
Then, Rapkin said, she asked her colleagues to put down their phones: The next slide, she said, should not be photographed.
“This
is what we are doing,” Rapkin recalled saying. She gestured to a list
of more than a dozen life-threatening pregnancy complications and severe
fetal abnormalitiesfor which doctors often offer an abortion —
but that many in the audience assumed they could no longer treat as they
once did, given Florida’s new abortion law.
“You should be doing these things — at a minimum,” said Rapkin.
Rapkin’s
colleagues at Tampa General had already tried reaching out to other
hospitals in the region, including Jackson Health System in Miami, where
physicians had previously exchanged emails expressing concern about a
lack of hospital guidance. As one Tampa doctor wrote in a June 2022
email to several Florida OB/GYNs, including one in Miami, “it may be
helpful if [our institutions] were aligned in policy and which
conditions we considered lethal.”
But
records show that Jackson Health took a very different approach,
drafting a policy that simply mirrors the language of Florida’s abortion
ban and without offering further guidance for doctors on how to
interpret the law’s medical exception.
Today,
Tampa General continues to be known as the only major hospital in the
region that will offer abortions for many pregnancy complications,
according to several doctors licensed in Florida.Rapkin recently moved to New Zealand in part because of Florida’s abortion laws,and, she said, her fear that a future Congress might pass a national ban.
Amanda
Bevis, a spokesperson for Tampa General, said the guidelines and list
of conditions Rapkin discussed are considered “educational tools,” not a
formal hospital policy.
“Public records prove that the procedure is extremely rare at this hospital(less
than 0.2% of pregnant patients over the last year), and when it does
occur, it is medically necessary and well within the confines of the
law,” she wrote in an email.
At one hospital in Texas, the lawyer charged with helping to crafttheir
institution’s policy said each new abortion ban triggered a new round
of weekly meetings to hash out how doctors should interpret the laws’
medical exceptions. The lawyer and their colleagues carefully studied
the language in the laws, they said, even reviewing discussions held in
committee to try to parse the legislative intent. Ultimately, they
settled on a narrow interpretation that “sticks to the most restrictive
language in the statute,” the lawyer said.
“We
do not take those risks, we just don’t. We’re a tax-supported
organization,” said the lawyer, speaking on the condition of anonymity
to discuss sensitive internal deliberations. “I think it’s so new and
untested that lawyers don’t know how to interpret it.”
Some
doctors worry that a written list of approved conditions could backfire
— even one like the list at Tampa General, which Rapkin said is
explicitly not comprehensive and focuses on the most common pregnancy
complications that arise.
After
some debate, the American College of Obstetricians and Gynecologists
decided not to create its own list of conditions its leaders consider to
be medical emergencies, said Christopher Zahn, the group’sinterim chief executive.
“The
problem when you get into creating a list is that there are so many
aspects that need to be individualized,” said Zahn. “Creating a list
like that creates more risk and more danger.”
But
many doctors interviewed for this story stressed that some limited
degree of specificity would be useful, even if hospitals just issue
guidelines that permit ending a pregnancy for one or two of the most
common complications, like pre-viable PPROM.
As
Rapkin was creating guidance for Tampa General, she spoke with her
county prosecutor, Andrew Warren, to make sure she and her colleagues
would not be charged, she recalled.
“I
knew we’d be doing more abortions at Tampa General than at any other
hospital,” said Rapkin. “So I wanted to make sure everything I’m doing
was in accordance with state law.”
Warren assured Rapkin that she had nothing to worry about,so long as doctors exercised reasonable medical judgment, Rapkinand Warren said. (Bevis, the Tampa General spokesperson, said the hospital did not collaborate with Warren to create a policy.)
Several months later, Gov. Ron DeSantis (R) suspended Warren from the elected post he’d held for six years, citing his public statements about abortion and appointing a conservative to the position.
Rapkin decided not to meet with Warren’s successor,Susan Lopez, who did not respond to a request for comment.
“I was really scared,” Rapkin said. “I really didn’t want to be on her radar.”
Caught between state and federal law
Seeking
protection against state bans, some doctors have urged their hospitals
to invoke EMTALA, the 1986 federal law that Biden officials insist
requires hospitals to provide abortions when physicians say so.
Idaho
has emerged as a flash point: The federal government sued the state
last year, arguing that its strict abortion ban did not provide enough
leeway for physicians to perform abortions in emergency situations.
Idaho officials are currently barred from prosecuting physicians as the
Ninth Circuit Court of Appeals considers the case, and local doctors
said they are closely tracking the implications.
“EMTALA
has been tremendously helpful for us in clarifying our legal
obligations,” said an OB/GYN at an Idaho hospital, who spoke on the
condition of anonymity to discuss internal hospital deliberations.
The
OB/GYN recounted a medical episode earlier this year in which a woman
came into the emergency room after her water broke long before the fetus
was viable, asking to be induced immediately. The woman was at high
risk for infection or hemorrhage, and there was virtually no chance that
her baby would make it to term — but, the OB/GYN said, the guidance
shared by hospital leaders did not allow the doctors to end the
pregnancy until the patient developed an infection the next morning.
“It bothered us all night long,” said the OB/GYN. “We were dragging our feet, waiting for something to happen.”
The
case prompted the doctor to continue to press hospital lawyers to
permit abortions in similar situations, eventually warning them that
their guidance on the abortion ban was “placing our hospital at risk for
EMTALA violations,” according to emails provided to The Post. Hospital
lawyers later agreed to change their guidance, said the OB/GYN, who then
emailed the revised guidelines to colleagues in their department in
May. “If the patient desires immediate delivery, our EMTALA obligation
is to offer it to her,” the doctor wrote in the guidance shared with
other doctors.
The
Biden administration earlier this year announced investigations into
two hospitals in Missouri and Kansas for failing to provide treatment to
a pregnant patient who presented with PPROM at 18 weeks of pregnancy.
Federal officials also are privately reviewing dozens of reports of
potential EMTALA violations, said four people with knowledge of those
cases. Federal officials declined to comment on the number of cases
under investigation, but confirmed that they are reviewing multiple
reports related to abortion bans.
But
it is unclear whether Biden officials’ interpretation of EMTALA will
stand, as conservative states and antiabortion groups argue the White
House has twisted the law from its original purpose of ensuring
hospitals treat patients who need emergency care but can’t pay for it.
“We’re
not going to allow left-wing bureaucrats in Washington to transform our
hospitals and emergency rooms into walk-in abortion clinics, and the
decision last night proves what we knew all along: The law is on our
side,” Texas Attorney General Ken Paxton (R) said last year, after his
state won an injunction over the Biden administration’s guidance. The
case is now pending at the Fifth Circuit Court of Appeals.
If
a Republican wins the 2024 presidential election, a new administration
could also argue that the federal emergency-care law does not apply to
abortion; a playbook being circulated by the conservative Heritage
Foundation calls for the next president to immediately reverse the
“distorted pro-abortion ‘interpretations’” of the law.
Some
supporters of abortion rights said that the White House hasn’t gone far
enough, calling for the Biden administration to sue more states with
bans and take other steps to clarify the legallandscape.Schilling,
the Louisiana lawyer who’s worked with hospitals facing abortion bans,
said that the Biden administration’s decision to highlight the federal
emergency-care law “doesn’t actually help hospitals or doctors”
determine how to proceed when faced with many abortion complications.
“It
just puts them on notice that you may either be violating state law and
get thrown in jail or you may be violating federal law and … could get
sued,” Schilling said.
Huntsberger,
the OB/GYN who left Idaho for Oregon, said she had been so attuned to
EMTALA as a potential counterweight that she helped organize a series of
local webinars to emphasize the federal law.
“We realized people were so focused on state laws, and they were neglecting EMTALA,” said Huntsberger.
Many
hospitals seemed receptive, said Huntsberger — and some facilities
eventually updated their policies. But not every institution made the
same choice.
“At my own hospital,” Huntsberger added, “nothing changed.”
