DYING, ILLNESS, AND AGING WITH GRACE - Managing your health, pain, medications, and health care costs

Services below are leads, not endorsements. I haven't personally experienced or evaluated them or gathered reports from people who have. I've just collected information, to get you started. Ask whatever medical institution you are receiving treatment from what they can recommend locally.
Charity CareTransportation Assistance ProgramsDiscounted Lodging for Patients and Caregivers

See also (under drugs and medication): Prescription/medication assistance and patient advocate programs

Charity Care

• Charity care policy at one hospital (Sibley, Johns Hopkins system)
• Can I Get Charity Care Benefits to Pay for My Hospital Bill? (Northwest Justice Project, Washington Law Help)
• Why hospital charity care requires more intensive coverage (Joseph Burns, Covering Health, Association of Health Care Journalists, 9-30-22) Multiple reports published this week show why health care journalists need to spend more time covering the charity care that nonprofit hospitals are required to deliver to patients but mostly fail to do so. Each report cited outlines how the nation's health care system so often fails to deliver equitable care to low-income Americans.
---Comparison of US Hospital Charity Care Policies Before vs After Onset of the COVID-19 Pandemic (JAMA)
---They Were Entitled to Free Care. Hospitals Hounded Them to Pay. (Jessica Silver-Greenberg and Katie Thomas, NY Times 9-24-22) Part 1 of a series: Profits Over Patients
---How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits (Part 2 of Profits Over Patients) Profiting from 340B drug program
---Most U.S. nonprofit hospitals neglect community investment obligation, analysis reveals (Lown Institute press release, 7-11-21)
---Will Nonprofit Hospitals Have to Defend Their Tax Exemptions Next? (Nonprofit Quarterly, 2017)

• What Is Charity Care in Health Care? (Karen Axelton, Experian, 12-15-21) Explains how hospital charity programs work and how one gets charity care. Links to U.S. organizations that can help pay for medical bills for specific conditions as well as to patient assistance programs.
• How to Crush Medical Debt: 5 Tips for Using Hospital Charity Care (Emily Pisacreta, Kaiser Health News, 10-15-21) 'What if a law passed but no one enforced it? That’s essentially what has happened with one small but helpful rule about hospitals and financial assistance for medical bills. The Affordable Care Act, the health law also known as Obamacare, requires nonprofit hospitals to make financial assistance available to low-income patients and post those policies online. Across the U.S., more than half of hospitals are nonprofit — and in some states all or nearly all hospitals are nonprofit. But many people who qualify for financial assistance — or “charity care,” as it is sometimes known — never apply.'
• Top tips for using charity care to crush medical debt (Emily Pisacreta, An Arm and a Leg Show) Info you may also see on the viral TikTok video.

• Dollar For, a nonprofit group that helps patients secure charity care. Fill out form to determine if you are eligible. See this practical Dollar For Twitter thread (4-10-21) on what steps to take to to determine if your medical bill is likely to be forgiven by your hospital based on the hospital's financial assistance policy, your household size, and your household income.
• Debtors' Rights: Dealing with Collection Agencies (Northwest Justice Project, Washington Law Help)

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Transportation Assistance

Emergency medical transportation is ambulance services for emergency medical conditions.

Non-emergency medical transportation (NEMT) is transport for people who need assistance getting to and from medical appointments.

• How to Find Non-Emergency Patient Transportation (Samantha Smith, Patients Rising, 7-12-21)
• Transportation: What Caregivers Need to Know (AARP, 1-17-20) How to help your loved one get around when you can't provide a ride

• ACC Medlink Long distance medical transport services
• Air Care Alliance (nationwide volunteers)
• Air Charity Network
• Angel Flight Pilots arrange free air transportation for any legitimate, charitable, medically related need (not just cancer).
• Angel Med Flight (worldwide air ambulance)
• Corporate Angel Network (CAN). Cancer patients fly free in empty seats on corporate jets.
• Flying Angels (non-emergency medical transport anywhere in the world)
• Long Distance Medical Transportation (Medical Transport Services)
• Medicare: Non-Emergency Medical Transportation (NEMT) (Centers for Medicare and Medicaid Services). Links and a fact sheet
• Mercy Medical Angels Removes the barrier to long-distance medical care with transportation on the ground and in the air.
• Miracle Flights Provides financial assistance so seriously ill children can receive proper medical care and get second opinions
• Mobility Managers: Transportation Coordinators for Older Adults, People with Disabilities, Veterans, and Other Members of the Riding Public (M. Douglas Birnie and James J. McLary, AARP Public Policy Institute). About policy, rather than practical tips for people who need a lift, but possibly useful in the long run.
• MyModivcare
• Road to Recovery. Providing rides to cancer patients. 24/7 Lifeline 800.227.2345 (live chat). Less active because of Covid See also Travel support for cancer patients

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Discounted Lodging for Patients and Caregivers

• Hope Lodge (American Cancer Society Patient Lodging Programs)
• Healthcare Hospitality Networks Check to see if there is an HHN member providing affordable lodging and support near your healthcare system provider
• Joe's House lists cancer treatment centers and hospitals across the country with nearby lodging facilities that offer a discount.
• Discounted Medical Lodging for Patients and Caregivers (Jim Sliney Jr, Editor, Patients Rising, 10-5-2020) Details about The Healthcare Hospitality Network, Ronald McDonald House, Hope Lodge (American Cancer Society), Joe's House, Hotel Keys of HopeSM program, Woodspring Suites.
• SON Foundation
• Airbnb (for everyone)

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MANAGING PAIN

Managing ordinary (not chronic) pain
Managing chronic pain
Managing pain medications

Practical tips for easing specific types of pain
Organizations associated with pain management and relief
The medical use of marijuana

Managing ordinary (not chronic) pain

• Pain (MedlinePlus)
• Words Matter When Talking About Pain With Your Doctor (Patti Neighmond, Shots, Morning Edition, NPR, 7-23-18) Rating pain on a numerical scale (1 to 10) may be too simplistic. "Treating by numbers" may not get patients the most effective treatment for their particular pain. For chronic pain, being clear can help clinicians choose the right mix of therapies or medications to allow you to stay as active as possible. And staying active can help manage chronic pain. A few alternatives. "Jeter typically asks patients to compare their current pain to the worst pain they ever had, such as childbirth or kidney stones."
• See full separate section on Managing chronic pain
• Treatments for Pain (PainScience.com) An index of science-based, opinionated reviews about what works for pain, what doesn’t, and why, including Exercise, Massage therapy, Chiropractic, M edications and supplements, Tools, gadgets, and hardware, Hydrotherapy, Injections, surgeries (mostly minor surgeries), and other procedures, Energy medicine & "subtle" therapies, Mind-body and psychology, Consumer tips, advocacy & anti-quackery activism
• Needle Pain Is a Big Problem for Kids. One California Doctor Has a Plan. (April Dembosky, KQED and KFF Health News, 3-20-24) Pain management research suggests that needle pokes may be children’s biggest source of pain in the health care system. The problem isn’t confined to childhood vaccinations either. Simple steps clinicians and parents can follow:
    Apply an over-the-counter lidocaine, which is a numbing cream, 30 minutes before a shot.
    Breastfeed babies, or give them a pacifier dipped in sugar water, to comfort them while they’re getting a shot.
    Use distractions like teddy bears, pinwheels, or bubbles to divert attention away from the needle.
    Don’t pin kids down on an exam table. Parents should hold children in their laps instead.
• A comprehensive guide to the new science of treating lower back pain (Julia Belluz, Show Me the Evidence series, Vox, 12-12-17) A review of 80-plus studies upends the conventional wisdom. Did you know that "Moving is probably the most important thing you can do for back pain"? or why exercise is helpful? What about spinal manipulation by chiropractors? massage? acupuncture? And which medications might help without causing addiction? Study up--a good overview.
• A World Without Pain (Ariel Levy, New Yorker, 1-6-2020) Joanne Cameron, a seventy-two-year-old retired teacher who lives in the Scottish Highlands, has never experienced the extremes of rage, dread, grief, anxiety, or fear. “I see stress,” she continued, “and I’ve seen pain, what it does, but I’m talking about an abstract thing.” In sharp contrast to her near-inability to feel awful, Cameron has an expansive capacity for positive emotions. Scientists are studying her and others like her, to see what they can learn.
• Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery by Cathryn Jakobson Ramin
• Pain Relief: What You Need to Know (Consumer Reports, 4-28-16) 125 million people are in pain, spending some $300 billion on pills, pot, procedures, and natural ‘cures’ to find relief, but are they worth it?
• Pain Management: Which Treatment Is Right for You? (Consumer Reports, 4-28-16)
• You’re wrong. Pain is not a vital sign. (Miles Gart, KevinMD, 5-15-17) Vital signs are clinical measurements, specifically: pulse rate, temperature, respiration rate and blood pressure, that indicate the state of a patient’s essential body functions. After years of exaggeration, misinformation and a national epidemic of opioid and heroin abuse, the nation is finally coming to terms with the fact that pain is not the fifth vital sign. As a result of equating pain as a vital sign, medical practitioners must come up with a reliable and effective treatment if and when a patient subjectively rates their pain high on the scale.
• Try This Instead of Drugs to Treat Neck and Shoulder Pain (CR, 4-28-16) Strengthening weak neck muscles with exercise and applying heat can alleviate the pain
• How to Get Rid of Lower Back Pain (Consumer Reports, 4-28-16) If you don't feel better after four weeks, see a doctor because it could be another condition, like osteoporosis
• Best Ways to Treat Joint Pain (CR, 4-28-16) Stiff or swollen joints can result in pain, especially first thing in the morning and after resting. Here's what you can do to ease it.
• Is Supercooling the Body an Effective Therapy? (Dina Fine Maron, Scientific American, 10-31-16) The market for cryotherapy "devices is beginning to burgeon in the U.S., with sports teams snapping them up to condition their players, and spas and wellness centers installing them for clients looking to relax, lose weight and fight signs of aging....Yet the science behind these devices is decidedly lackluster. In July the U.S. Food and Drug Administration issued a warning stating that there is no evidence these technologies help to ease muscle aches, insomnia or anxiety or provide any other medical benefit. Instead, it said, they may cause frostbite, burns, eye damage or even asphyxiation. In a statement to Scientific American the agency added, 'The FDA has not approved or cleared any whole-body cryotherapy devices, and we do not have the necessary evidence to substantiate any medical claims being made for these devices.'”
• Tension Headache Treatment and Prevention (CR, 4-28-16) A few simple steps like drinking water and doing neck exercises can relieve your pain
• Speak Up: What You Should Know about Pain Management (Joint Commission)
• When Pain Remains (Jerome Groopman, New Yorker, 10-10-05) What should patients do when doctors can't figure out how to diagnose or treat reflex sympathetic dystrophy (RSD), reclassified in 1994 as complex regional pain syndrome (CRPS), the hallmark of which is excruciating pain.
• When Pain Remains: Q & A (sidebar to the Groopman piece on CRPS). What should patients do when doctors can’t figure out how to treat their suffering?
• Neuroplastix Change the Brain; Relieve the Pain; Transform the Person. Read the book free online.
• The disturbing reason some African American patients may be undertreated for pain (Sandhya Somashekhar, Wash Post) African Americans are routinely under-treated for their pain compared with whites, according to research. Whites are more likely than blacks to be prescribed strong pain medications for equivalent ailments. Unconscious stereotypes about African Americans likely contribute to this problem, as well as physicians' difficulty empathizing with patients whose experiences differ from theirs.
• Ways to Reduce Pain Naturally
• Who Has a Right to Pain Relief? (Rebecca Davis O'Brien, The Atlantic, 8-18-14). The legal, medical, and pharmaceutical industries have all struggled to locate the line between analgesia and drug abuse.
• Keith Wailoo on the politicization of pain (Book TV, C-Span, 3-3-15) Professor Keith Wailoo talked about his book, Pain: A Political History, about the politicization of treating pain in the U.S. since the 1950s. How do we decide who is or is not (really) in pain and how to treat that pain. Is chronic pain a disability that should be compensated? Are we exercising compassion in treating pain or creating a generation of dependents. It's the judges, not the doctors and not the scientists, who make significant decisions about pain. (Listen, watch, or read transcript.) A "well-rounded discussion of the politics of pain and pain relief in post WW II America." Wailoo examines how pain has defined the line between liberals and conservatives from just after World War II to the present. From disabling pain to end-of-life pain to fetal pain, the battle over whose pain is real and whose pain deserves relief has created stark ideological divisions at the bedside, in politics, and in the courts -- and the interests and arguments of media, politicians, and medical professionals often work against the voice of the individual suffering pain. What about managing pain in end-of-life care?

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Managing pain medications

Especially over-the-counter drugs like acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn) or diclofinac gel.

• Pain Medications (Web MD)

Practical information, clearly and succinctly presented.

Over-the-counter (OTC) pain relievers include:
---Acetaminophen (Tylenol)
---Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn) or diclofinac gel.
Both acetaminophen and NSAIDs reduce fever and relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). And so on, including possible side effects.

Prescription medications include
---Corticosteroids (e.g., prednisone, prednisolone, and methylprednisolone)
---Opioids
---Antidepressants
---Anticonvulsants (anti-seizure medications)
---Nonsteroidal anti-inflammatory drugs (NSAIDs)
---Lidocaine patches

• What's the Difference Between Tylenol, Advil and Aleve? All three medications can help alleviate a child's discomfort, but the active ingredient in each drug is different. In Tylenol, it's acetaminophen; in Advil and Motrin, it's ibuprofen; and in Aleve, it is naproxen. Read about the differences between them and administer the right dose!
• How Much Advil Is Too Much? (Melinda Wenner Moyer, Well, NY Times, 2-13-24) Ibuprofen — which is also sold under brand names like Advil, Motrin, and Nuprin — can be a blessing for those with aches and pains, but overdoing it poses serious risks, especially for those with kidney or stomach issues. Adults and children 12 years and older are "advised to take one (or two, if needed) 200-milligram tablets, caplets or gel caplets every four to six hours while symptoms persist. And those taking the drug should not exceed 1,200 milligrams (or six pills) in 24 hours."

But doctors sometimes prescribe ibuprofen in much higher dosages, up to 3,200 milligrams a day for a short period "because the anti-inflammatory effects are better at higher doses," so it can be hard to say how much is too much. Be careful not to accidentally take more than intended. “I have patients who don’t know that Advil and generic ibuprofen are the same, so then they might take both,” says physician Sarah Ruff. And "regular ibuprofen use among people with headache disorders (such as migraines) can cause rebound headaches, for reasons doctors don’t completely understand." If you use these drugs often, do try to read this full article.

• 6 Medications That Can Harm Your Hearing (Michelle Crouch, AARP, 9-23-22) More than 600 drugs have been linked to hearing loss and tinnitus, including over-the-counter pain relievers. Research indicates that over-the-counter pain relievers such as aspirin, acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil and Motrin, which are widely available without a prescription, can contribute to both hearing loss and tinnitus, especially if they're used for two or more days per week.

Another study found that among adults who already had hearing loss, NSAID use was associated with a 45 percent higher risk of progression of their hearing loss. Fortunately, frequent use of low-dose aspirin (100 mg or less) has not been linked to hearing-related side effects. Many older adults take a low dose of the drug daily to prevent cardiovascular disease.

Other medications sometimes linked to hearing loss and tinnitus:

---a class of antibiotics called aminoglycosides;

---loop diuretics (such as Lasix (furosemide), Bumex (bumetanide) and Demadex (torsemide), powerful medications that are used to treat high blood pressure and fluid retention due to heart failure, liver disease or kidney disease);

---platinum-based chemotherapy drugs such as cisplatin and carboplatin;

---long-term (20-year) hormone therapy for treating menopausal symptoms; and

---long-term use of quinine, chloroquine and hydroxychloroquine (used to treat malaria and sometimes prescribed for autoimmune diseases such as Lupus).

• The Ibuprofen Debate Reveals the Danger of Covid-19 Rumors (Maryn McKenna, Wired, 3-16-2020) An online furor over whether it’s safe to use the fever reducer reveals how people are sharing incomplete—and sometimes bad—information. Fevers feel like an unpleasant side effect of infection, but they actually represent the body’s strategic response: Higher internal temperature slows viral replication. When possible, Zhong says, we should resist the temptation to chase the drugs we take for fever with more drugs if the fever doesn’t go down. “If the choice is to stay uncomfortable or take an overdose that might cause liver damage,” Zhong says, “the liver damage will be much worse.”
• Ibuprofen vs Aleve vs Turmeric vs Tylenol. Pharmacist Chris Compares (YouTube video) Physical therapists Bob Schrupp and Brad Heineck talk to Pharmacist Chris. In this episode they discuss the differences and advantages of Ibuprofen vs Aleve vs Turmeric vs. Tylenol.

• Acetaminophen Is the Best Pain Reliever for Heart Patients (Orly Avitzur, Consumer Reports, 6-19-16) "Tylenol is a good choice for those needing relief from the physical pain caused by osteoarthritis in the joints or from headache pain and who also have heart troubles such as high blood pressure, heart failure, heart attacks, chest pain due to narrowed coronary arteries (angina), or stroke. Using acetaminophen is a much safer bet than most over-the-counter pain relievers like ibuprofen (Advil and generic) and naproxen (Aleve and generic)....That’s because acetaminophen is unlike other common, over-the-counter pain medications, like ibuprofen and naproxen, which can aggravate high blood pressure, and in turn raise a person's risk of having a heart attack."
• Pain Relievers: Understanding Your OTC Options (FamilyDoctor.org)

But, be aware of TYLENOL TOXICITY.

Pills or medicine labeled acetaminophen, "Tylenol," or "aspirin-free pain relief" may all contain acetaminophen. Combining such drugs is like taking poison: it may kill you or irreversibly damage your liver.
• Acetaminophen Is Leading Cause of Acute Liver Failure (Neil Osterweil, MedPage Today, 11-30-05)
• Paracetamol poisoning (acetaminophen poisoning, Wikipedia entry)
• Acetaminophen poisoning: an update for the intensivist (Paul I Dargan and Alison L Jones, Critical Care, 2002)

• MedShadow Independent health journalism that makes available information on the side effects of medicines and lower risk alternatives in order to improve quality of life for all. Prescription meds are the 4th leading cause of death in America. See Female Disruptors: Suzanne Robotti has shaken up transparency about side effects (Akemi Sue Fisher, Authority magazine, 2-17-19) Robotti founded MedShadow in 2012 after two major health issues drove her to become engaged in patient advocacy. "I'm passionate about teaching the public about dangerous side effects of medicines because I was personally affected twice."
• Some patients say Prednisone, a commonly prescribed steroid, triggered mania and suicidal ideation. I should know — it happened to me. (Julia Métraux, Insider, 7-30-22) While mood swings are a known side effect, some patients say they experienced much worse. They say prednisone made them manic and suicidal. Some had to check into the ER.

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Managing pain medications

• Addictive Pain Medication: How to Protect Yourself (Theresa Carr, CR, 4-28-16) Many painkillers can be highly addictive.
• Chronic Pain Medicines (FamilyDoctor.org).
• Home medication safety guide–how to keep kids and pets safe (Singlecare)
• How OxyContin's Pain Relief Built 'A World Of Hurt' WHYY's Fresh Air interviews Barry Meier, author of A World of Hurt: Fixing Pain Medicine's Biggest Mistake (Kindle single)
• Substance Abuse and Recovery (another full section on this website)
• Addiction to opioids and psychoactive drugs

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Practical tips for easing or preventing specific pain (including some back pain)

• Home remedies for alleviating sciatica pain (McNees blog, 4-2-16) The piriformis muscle is a small muscle located deep in the buttock (behind the gluteus maximus). It starts at the lower spine and connects to the upper surface of each femur (thighbone). It helps to rotate the hip and turn the leg and foot outward. It sits under deep layers of fat and muscle in your buttock, so if you sit a lot and don't move around, those muscles get compressed. Get up from that chair and move around more! Meanwhile, some suggested remedies.
• Lost Art Of Bending Over: How Other Cultures Spare Their Spines (Michaeleen Doucleff, Shots, Morning Edition, NPR, 2-26-18) Audio and transcript, illustrated. Bend at the hips, not the waist. "It's called hip hinging," McGill says. "And I've spent my career trying to prove it's a better way of bending than what we do." What to do: Stretch the hamstrings.
• To Fix That Pain in Your Back, You Might Have to Change the Way You Sit (Michaeleen Doucleff, Goats and Soda, Morning Edition, NPR, 8-3-18) Orthopedic surgeon Nomi Khan says we should sit less and sit better. Sitting in a C-shape, over time, can cause disk degeneration. Or one side of a disk can start to bulge.
Pull your tail out so it can wag. 'To figure out how to shift your pelvis into a healthier position, Jenn Sherer says to imagine for a minute you have a tail. If we were designed like dogs, the tail would be right at the base of your spine. "When you sit with a C shape in your spine, you're sitting on this tail," Sherer says. "It's kind of like a dog with its tail between its legs, who is scared and frightened." To straighten out the C shape, "we need to position the pelvis in a way that this tail could wag." See About Noelle Perez-Christiaens (Spinefulness).
• Spinefulness: Heal Your Back, Straighten Your Spine by Jean Couch. Posture, stretching -- runners, pay attention. Position your bones so your bones (not your muscles) absorb your body weight. She's still getting straighter at 79. (Her colleague at the Balance Center, Jenn Sherer, says "What she once perceived as aging isn't aging, but chronic tightness ignored until it becomes pain."
• Could Artificial Intelligence solve your back pain and slouching posture? (KCRA 3 Deirdre Fitzpatrick talks to entrepreneur Richard Gray and to the legendary Jean Couch about how software (an app) on your computer can help you sit at your desk and correct your posture. Slouch and an app pops up to correct you. The key problem isn't the chair; it's the sedentary behavior, the amount you are sitting. Listen till Jean Couch comes on to get the principles. Sitting rigidly isn't the answer. To change your posture -- lift your butt off the chair a couple of inches, then bend at your hip socket (at the top of your leg). Move the bottom of your butt way back into the corner of the chair. And then relax. We have an industrialized workforce, office bound. Not enough moving around.
• The Parisian Yoga Witch Who Healed My Back (Abigail Rasminsky, Racked, 7-22-15) In which she writes about Noelle Perez-Christiaens, who developed "d'Aplomb" in her studio in Paris, based on her Yoga studies with yoga guru BKS Iyengar (how to be "on the axis").
• Can't Get Comfortable In Your Chair? Here's What You Can Do (Michaeleen Doucleff interviews Jean Couch on Shots, Morning Edition, NPR, 9-24-18) Most chairs are too deep and too soft, says Couch. There are two tricks: #1: Sit on the front edge. Sit on the front hard part of the chair. Forget about the backrest. Be careful about how you position your legs. Your knee should be below the hip socket. Thats what happens when you're floating in space (when the muscles are most relaxed). #2 Build a perch. Use a jacket or a pillow. Elevate your back with a wedge-shaped pillow (dense). Great for using in the car. See Couch's book, which has helped many, many people: The Runner's Yoga Book: A Balanced Approach to Fitness by Jean Couch. Do not carry all your weight in your muscles.
• NASA Standards Inform Comfortable Car Seats (NASA, 2013) Because Nissan had observed that a person’s posture appeared to play a direct role in how physically tired he or she became while driving, the company decided to use NASA’s NBP as a benchmark for a comfortable, balanced posture, with the intention of lessening fatigue on a person’s body.
• How to Cope with Pain website (pain management skills) Breathing Exercises
• Living With, and Managing, Chronic Pain: A Patient’s Story (Sarah M. Whitman, MD and Beth Thorp, Practical Pain Management) When a patient is living with chronic pain, they don't necessarily look sick. They may be putting on a brave face, but really hurting inside. Learn how one patient learned to live a full life despite chronic pain.

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Managing back pain

• Vox reporter describes deep dive into medical studies on back pain (Tara Haelle, Covering Health, AHCJ, 12-5-17) Two years ago Vox began a new feature section called Show Me the Evidence. In each piece, the reporter reviews several dozen recent studies on a specific question with the goal of summarizing the consensus of the evidence on that issue.
• A comprehensive guide to the new science of treating lower back pain (Julia Belluz, Vox, 8-4-17) A review of 80-plus studies upends the conventional wisdom. Part of Vox's Show Me the Evidence series. "Low back pain is the second most common cause of disability in the US, but the most popular treatments out there--spine surgery, opioid painkillers, stereoid injections--are unhelpful for most people , or even downright harmful. The evidence increasingly supports a range of exercise programs and alternative therapies, such as massage and yoga, that can help people alleviate the soreness in their backs.
• We're Treating Low Back Pain All Wrong (MedPage Today, 4-14-23) Many medical diagnostic and treatment approaches -- early imaging, surgical consults, corticosteroid injections, prescription opioids and NSAIDsopens in a new tab or window -- may actually increase the number of patients who transition from acute to chronic pain. Recommended first line treatments include non-pharmacological approaches such as exercise, education, self-care options, spinal manipulation, acupuncture, and massage. The ACP guideline in particular calls for patients and clinicians to consider the use of non-pharmacological treatment approaches for low back pain before trying prescription medications.
• You’re sitting wrong — and your back knows it. (Mary Halton , Idea-TED.com, 6-22-2020) On Esther Gokhale's TEDxStanford Talk. And here’s how to sit instead: Find your primal posture and sit without back pain (Esther Cokhale demonstrates "stretch sitting" on YouTube, 8-3-2012) See also Use Your Core to Do Your Chore (also part of The Gokhale Method) and Using your inner corset Chapter 5 from her book 8 Steps to a Pain-Free Back: Natural Posture Solutions for Pain in the Back, Neck, Shoulder, Hip, Knee, and Foot.

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• Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery by Cathryn Jakobson Ramin. Jakobson Ramin shatters assumptions about surgery, chiropractic methods, physical therapy, spinal injections, and painkillers, and addresses evidence-based rehabilitation options—showing, in detail, how to avoid therapeutic dead ends, while saving money, time, and considerable anguish. Listen to Cathryn Jakobson Ramin on the ‘Crooked’ Back Pain Industry (Eric Westervelt interviews Ramin on Forum, KQED, 5-22-17). She pulls back the curtain on the back pain industry and provides strategies for navigating the plethora of treatment options. Exercise is very important (strengthen the weak muscles, stretch the tight muscles). Long-term visits to chiropractors aren't the answer (one or two sessions could be helpful but let them nowhere near your neck). You need well-developed glutes and thighs. Yoga, yes, but not competitive yoga, where you are pushed to do more than you are capable of doing; you want a many-years-experienced yoga teacher (not just someone who is "certified"): she recommends Iyengar and Viniyoga Practice. See Ramin's guide to resources.New Pathways to Overcome Chronic Back Pain (listen to podcast of back surgeon David Hanscom, author of Back in Control: A spine surgeon's roadmap out of chronic pain, on Show 972 of "The People's Pharmacy"). "According to Dr. David Hanscom, a leading spine surgeon, back pain can be overcome, but surgery is frequently NOT the best choice. People with chronic back pain may need to overcome their anger and anxiety and use an integrated approach to build new neural pathways that circumvent the pain. Some of the best tactics include finding a way to play as well as a way to confront anger and find forgiveness." From Goodreads: "Steve tells his compelling story of a 30-year battle with pain and ultimate healing after discovering Dr. Sarno's work. After Steve healed he began receiving hundreds of emails, calls, and letters, asking for his help--too many to respond to, so he decided to write his experience down in a book." See the Goodreads comments on book. "This is a more readable book than Sarno's, says one reader.
• Why Does Chronic Pain Hurt So Much? (Kieran Setiya, The Atlantic, 11-1-22) The condition of chronic pelvic pain is not well understood, and there is no reliable treatment. "I am able to function pretty well; sleep deprivation is the worst of it....If you can treat pain as a series of self-contained episodes, you can diminish its power."
• The Enduring Mystery of Pain Measurement (John Walsh, The Atlantic, 1-10-17) “We always thought of it as acute pain that just goes on and on—and if chronic pain is just a continuation of acute pain, let’s fix the thing that caused the acute and the chronic should go away. That has spectacularly failed. Now we think of chronic pain as a shift to another place, with different mechanisms, such as changes in genetic expression, chemical release, neurophysiology and wiring. We’ve got all these completely new ways of thinking about chronic pain. That’s the paradigm shift in the pain field.”
• Dr. John Sarno on healing lower mid-back pain, sciatica, psoas pain.(Basically, "It's all in your head." That is, he says that's often true AFTER you have ruled out physical problems. Your brain protects you from negative emotions by referring them to your back.) Or read his book: Healing Back Pain: The Mind-Body Connection A lot of people seem to have been helped by this book. Goodreads: " John Sarno, MD, at the NYU School of Medicine discovered in the 1970s that back pain was not coming from the things seen on the imaging, such as herniated discs, arthritis, stenosis, scoliosis, etc. Pain was coming from oxygen reduction through the autonomic nervous system due to elevated tension levels, but had been errantly linked to the "normal abnormalities" seen on MRIs and X-rays. Most physicians refused to believe his findings even though his success rate in healing the most troublesome of pain-cases was well above theirs. Dr. Sarno labeled the disorder TMS, or tension myoneural syndrome, currently being called The Mindbody Syndrome." (From a review of Hanscom's book).
•How a Crazy Old French Woman Cured My Chronic Back Pain — and Healed My Soul (Abigail Rasminsky, Lenny, 1-19-18). Listen to it being read aloud un-tucked. In regular-people lingo: the butt had to stick out. From this base, the spine could elongate up naturally. Any pain caused by a herniated disk would be alleviated with this freed-up space between the vertebrae." See also Dance Me to the End of Love (Abigail Rasminsky, Longreads, 1-8-18) "It was a small moment — an ordinary moment. Pain. We felt it all the time. But this was more: sharper, crippling — an ax slammed into my lower back." A young professional dancer keeps dancing through the pain, as so many dancers do. A story about dance, injury, chronic pain, and identity. "Anyone who has lived with chronic pain, however, knows how impossible it is to ignore your body. To live in pain is to live with the terrorizing feeling that you cannot get out of your body. That no matter where you go, or what you do, you will never outrun the pain, it will follow you everywhere — to dinner, to the movies, to work, to bed, into all your relationships, into the next day and the next and the next. You can distract yourself with friends or booze or TV, but that only works for a short time, if at all. It is the sensation of not being able to escape that is so unbearable." An earlier piece on the same woman/process: I'm Off to See the Wizard.

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Managing chronic pain

“If we know that pain and suffering can be alleviated, and we do nothing about it, then we ourselves become the tormentors.” ~ Primo Levi

"Pain is always new to the sufferer, but loses its originality for those around him. Everyone will get used to it except me."~Alphonse Daudet, in his account of living with syphilis, In the Land of Pain

• Sarah Bigham, who suffers pain resulting from several chronic diseases, writes "I found these three books incredibly useful when I was at my sickest and I recommend them for anyone dealing with painful conditions:
---A Nation in Pain by Judy Foreman
---You Are Not Your Pain by Vidyamala Burch and Danny Penman (which introduces meditation for chronic pain)
---Survival Lessons by Alice Hoffman ((slim nonfiction by a novelist who is a breast cancer survivor) Sarah's own book is Kind Chemist Wife: Musings at 3 a.m.
• It Doesn’t Hurt, It Hurts All the Time (Jess Zimmerman, Catapult, 8-11-2020) What if we thought of emotional trauma the way we do physical: as a wide class of wounds whose healing is unpredictable, whose scars take different forms? How being attacked by a dog in Jess's case led to deeper trauma and "agoraphobia...a fear born of having a panic attack outside of your home....My fear of going outside, I think, was more like the opposite of a fear, the buffering negative space around it . . . a protective nothingness, a shutdown."
• Pain Woman Takes Your Keys, and Other Essays from a Nervous System by Sonya Huber. Readers' comments: "Not only do we get the power of her experience, she is well-read in the field of pain. I added several books to my to-be-read list to explore others' experiences with pain more deeply."

"Sonya Huber takes something so raw, so wild and misunderstood and unchained as pain and turns it into something beautiful, familiar, and human."
• The Acute to Chronic Pain Transition (ACTION) Program (Lady Davis Institute for Medical Research) Complete a survey regarding the transition from acute to chronic Temporomandibular Disorder (or TMD), a type of facial pain, to see if you qualify to participate in a study.
• Beyond pills and shots: Pain patients seek other options (Felice J. Freyer, Boston Globe, 12-30-16). Part of an invaluable series, specific titles for which can be found here (read 5-piece limit for free): Boston Globe series on chronic pain. See, for example, Doctors are cutting opioids, even if it harms patients (Freyer, 1-3-17) as well as other stories on opioids, and When Chronic Pain Is a Child's Companion, among several important stories.

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• When Does Pain Treatment Become Palliative Care Treatment? (Thomas F. Kline and Carolyn D. Concia, Medium, 6-20-18) Pain care becomes palliative care when three criteria are met:
--- The underlying disease has no cure.
--- There is a likelihood that the disease may shorten lifespan.
--- Symptomatic treatment has a high probability of improving the quality of life.
Kline and Concia explain the CDC guidelines for prescribing pain relief when those conditions are met.
• Types of Pain (Practical Pain Management)
• On the other hand, according to Paul Burke, Pain and Palliative Doctors Compared (Globe1234.com), more pain is treated by "pain management" doctors than by palliative care doctors or teams. There is more on board exams about non-drug treatment of pain, and about pain assessment and diagnostic testing, for pain management doctors than there is for palliative care doctors. The board exam for palliative care doctors has more on communication and end of life issues than does the board exam for palliative care doctors, and the boards for both have similar amounts on psychological, legal, and ethical issues, says Burke.
• Steep Climb in Benzodiazepine Prescribing by Primary Care Doctors (Rhitu Chatterjee, Shots, NPR, 1-25-19) The percentage of outpatient medical visits that led to a benzodiazepine prescription doubled from 2003 to 2015, according to a study published Friday. And about half those prescriptions came from primary care physicians. This class of drugs includes the commonly used medications Valium, Ativan and Xanax. While benzodiazepines are mostly prescribed for anxiety, insomnia and seizures, the study found that the biggest rise in prescriptions during this time period was for back pain and other types of chronic pain. Benzodiazepines are best for short-term use, but long-term use of these drugs has also risen (50% from 2005 to 2015). Long-term use of the drugs can cause physical dependence, addiction and death from overdose.
• Severe Pain in Veterans: The Effect of Age and Sex, and Comparisons With the General Population (RL Nahin, J. Pain, March 2017) Prevalence of severe pain, defined as that which occurs "most days" or "every day" and bothers the individual "a lot," is strikingly more common in veterans than in members of the general population, particularly in veterans who served during recent conflicts. Additional assistance may be necessary to help veterans cope with their pain. See also Help for Veterans Struggling with Addiction (Denver Recovery Center) "Veterans who experience combat injuries may return home and be unable to find suitable work and thus have lower incomes, be unable to support themselves or their families, face increased health care costs, and may turn to alcohol or drugs to deal with the pain when traditional medicine is not able to help."

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• Treating pain in older adults takes more than painkillers (Michele Munz, St. Louis Post-Dispatch, 5-9-17) About 50% of older adults living on their own and 75% to 85% of those in care facilities suffer from chronic or persistent pain. Pain goes largely untreated in this population because many assume it’s a natural part of aging and don’t know it can be treated, experts say, or they believe it will lead to expensive tests or more medications. Pain management in older adults has to extend beyond painkillers, writes Munz. That's where integrative medicine comes in.
• Beyond pills and shots: Pain patients seek other options (Felice J. Freyer, Boston Globe, 12-30-16). Part of a series on chronic pain.
• What is TN? (Facial Pain Association). "Trigeminal neuralgia (TN) is considered to be one of the most painful afflictions known to medical practice. TN is a disorder of the fifth cranial (trigeminal) nerve. The typical or “classic” form of the disorder (called TN1) causes extreme, sporadic, sudden burning or shock-like facial pain in the areas of the face where the branches of the nerve are distributed – lips, eyes, nose, scalp, forehead, upper jaw, and lower jaw. The pain episodes last from a few seconds to as long as two minutes. These attacks can occur in quick succession or in volleys lasting as long as two hours. The “atypical” form of the disorder (called TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than TN1. Both forms of pain may occur in the same person, sometimes at the same time."

• Pain for Women, Pain for Men (Proto magazine, Massachusetts General Hospital, Clinical Research, 8-10-17) Males and females experience pain differently—and appear to process it differently, too. Why has it taken so long for science to find out?

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• Chronic Pain Patients Angry Over ‘Opioid Contracts’ (Shawn Radcliffe, Healthline, 5-2-18) More patients with chronic pain are being asked to agree to random urine drug screens, pill counts, and other conditions before they’re prescribed opioids. Many concerns, little evidence that the contracts are effective.
• 6 Ways to Take Control of Your Pain (Judy Foreman, AARP, Feb/March 2015) Are you one of the 100 million Americans who suffer from chronic pain? Breakthrough research and innovative treatments offer hope. Strategy 1: Don't let the pain start. 2: Figure out exactly what type of pain you have. 3: Know that it's real. 4: Treat it right away. 5: Try non-drug treatments first. 6: Take the right drugs for your pain.
• Opioids and Paternalism (David Brown, American Scholar, Autumn 2017) "If the use of opioids for chronic pain were just making the practice of medicine less rewarding, the problem would be tolerable. But it’s changing the country, creating a new underclass in the United States, no less real (or less fraught with the potential for controversy) than the black underclass whose existence has been so central to American history of the past half century. The new underclass, mostly white, is distributed widely, with hot spots—Appalachia, rural New England, and surprisingly, far-northern California. Like those in the black underclass, members of the new underclass usually have no more than a high school education and suffer high unemployment....For some patients with chronic pain, opioids are the answer. But for most, treatment must begin with the doctor saying no. This needn’t be done callously, and people in pain don’t have to be left with nothing. Many things help a little—nonnarcotic drugs, acupuncture, transcutaneous electrical nerve stimulation (TENS), yoga, massage, exercise. Time and sympathy from a doctor, nurse, therapist, or coach are just as important as any of these treatments. The journey back from opioid drugs—or through the land of chronic pain without them—should not be taken alone."/a>
• Sickle Cell Patients Suffer Discrimination, Poor Care — And Shorter Lives (Jenny Gold, KHN, 11-6-17) About 100,000 people in the United States have sickle cell disease, and most of them are African-American. In 1994, life expectancy for sickle cell patients was 42 for men and 48 for women. By 2005, life expectancy had dipped to 38 for men and 42 for women. Sickle cell disease is “a microcosm of how issues of race, ethnicity and identity come into conflict with issues of health care,” said Keith Wailoo, a professor at Princeton University, and author of Sickle Cell Disease — A History of Progress and Peril (Keith Wailoo, New England Journal of Medicine, 3-2-17) Studies have found that sickle cell patients have to wait up to 50 percent longer for help in the emergency department than other pain patients. The opioid crisis has made things even worse, Vichinsky added, as patients in terrible pain are likely to be seen as drug seekers with addiction problems rather than patients in need.
• Home remedies for alleviating sciatica pain (McNees blog, 4-2-16) The piriformis muscle is a small muscle located deep in the buttock (behind the gluteus maximus). It starts at the lower spine and connects to the upper surface of each femur (thighbone). It helps to rotate the hip and turn the leg and foot outward. It sits under deep layers of fat and muscle in your buttock, so if you sit a lot and don't move around, those muscles get compressed. Get up from that chair and move around more! Meanwhile, here are some suggested remedies.

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• How well-intentioned doctors helped create the opioid epidemic (The Impact, Vox, 11-7-17) The policies that created the opioid epidemic.
• Opioids often aren't a great way to treat chronic pain. So … what is? ( The Impact, Vox, 11-13-17) A doctor, Jane Ballantyne, helps her chronic pain patients with pain acceptance; a chronic pain patient named Kristin Geiger has embraced pain acceptance — and is actually trying to wean herself off of opioids right now; and a patient named Sam Merrill is really skeptical that he can replace his opioid prescription with physical therapy and meditation — or “just live” with his crippling pain. A pain patient weaning herself off opioids, a pain patient who can't imagine his life without them, and the future of pain treatment.
• Healthcare Hashtag Project, a free open platform for patients, caregivers, advocates, doctors and other providers that connects them to relevant conversations and communities. Thousands of patients talk about diseases weekly in "chats" on Twitter.
• Giving Chronic Pain a Medical Platform of Its Own (Tara Parker-Pope, Well, NY Times, 7-18-11) What doctors don't know about chronic pain. “Having pain that is not treated is like having diabetes that’s not treated,” said Ms. Thernstrom, who suffers from spinal stenosis and a form of arthritis in the neck. “It gets worse over time.”
• Hurting All Over (Jerome Groopman, New Yorker, 11-13-2000) With so many people in so much pain, how could fibromyalgia not be a disease?
• Biofeedback: A High-Tech Weapon Against Migraines (Sue Russell, Healthymagination 7-18-11)
• Migraine Treatment, Prevention & Relief (CR, 4-28-16) Tips on how to treat—and even prevent—this common type of pain.
• Can laser light therapy actually cure pain? (Jeff Wilser, Input, 2-6-2020) What studies say about a treatment called photobiomodulation (PBM), aka “low-level laser therapy,” aka red-light therapy. With photobiomodulation, you climb into a pod and get bathed in low-wavelength light — between 650 and 850 nanometers, which avoids the harmful UV rays — for around 15 minutes at a time.
• Chronic Lyme and other tick-born diseases ("When the doctor gets sick, the journey is double-edged," by Pamela Weintraub, Psychology Today, in 3 parts)
• Pains (Janice Lynne Schuster and the Pain Project). Many articles, including
--An Unwelcome Guest: Living with Chronic Pain (Schuster, Disruptive Women in Health Care, 12-15-14)
--Draft of the National Pain Strategy has been published to the Federal Register (PAINS Project, 4-2-15) the National Institute of Neurological Disorders and Stroke (NINDS) Office of Pain Policy today published a notice soliciting public comment on the draft National Pain Strategy.
--In pain? (Some resources. Janice Lynne Schuster's site.)
• Complex regional pain syndrome (CRPS, Mayo Clinic staff)
• Complex Regional Pain Syndrome fact sheet (National Institute of Neurological Disorders and Stroke
• Chronic back pain
• Dancing with Pain (one approach to pain relief)
• For Grace. Resources for Women in Pain.

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• Living With Pain That Just Won’t Go Away (Jane E. Brody, NY Times, 11-6-07)
• Quality of Life Scale , a measure of function for people with pain (pdf, American Chronic Pain Association)
• The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering by Melanie Thernstrom
• The Permanent Pain Cure: The Breakthrough Way to Heal Your Muscle and Joint Pain for Good by Ming Chew with Stephanie Golden
• Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education, 2011) Significant advances have been made in understanding the basic mechanisms of nociception and pain but that much remains to be learned. Data and knowledge gaps in pain research remain that have prevented such research advances from being translated into safe and effective therapies.
• Reflex Sympathetic Dystrophy Syndrome Association (RSDSA), promotes public and professional awareness of Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD)
• The Psychology of Pain: It’s Not What You Think (Stan Goldberg's interesting and informative essay)
• Chronic pain not only hurts, it also causes isolation and depression. But there’s hope. (Rachel Noble Benner, Wash Post, 1-12-15)
• One in 3 women could potentially be spared chronic pain after breast cancer surgery (Medical Press, 2-25-15)
• Here’s What’s Wrong With How US Doctors Respond to Painkiller Misuse(Maia Szalavitz, Substance.com, 1-13-15).
• New Report Details Uphill Battle to Solve the U.S.'s Pain Problem (Bob Roehr, Scientific American, 7-1-11) The Institute of Medicine reveals a "blueprint" for relieving Americans' pervasive chronic pain.
• Opioid Misuse In Chronic Pain Patients Is Around 25%, New Study Shows (CJ Arlotta, Forbes, 4-1-15)
• Opioids: addiction, overdose, treatment, and recovery (addiction to heroin, cocaine, crack, and other illegal and addictive painkillers--and addictive prescription drugs) In section on Substance Abuse.
• Culprits in the opioid crisis. In section on Substance Abuse.
• Opioid addiction treatment with a dark side In section on Substance Abuse.
• Overdoses (and reversing overdoses) In section on Substance Abuse.
• Managing ordinary (not chronic) pain

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Organizations associated with pain management and relief

• ‘Injections, Injections, Injections’: Troubling Questions Follow Closure of Sprawling California Pain Clinic Chain (Anna Maria Barry-Jester and Jenny Gold, California Healthline, 2-22-22) Last spring, Lags Medical Centers, a sprawling chain of pain clinics serving more than 20,000 patients in California, abruptly shuttered amid a cloaked state investigation into “credible allegations of fraud.” Tens of thousands of patients were left scrambling for care, most of them low-income Californians covered by state and federal insurance programs. Many have struggled for access to their medical records and to find doctors who would renew long-standing opioid prescriptions. Interviews with former patients and employees, and KHN analyses of reams of documents, "suggest the clinics operated based on a markedly high-volume and unorthodox approach to pain management. This includes regularly performing skin biopsies that industry experts describe as out of the norm for pain specialists, as well as notably high rates of other sometimes painful procedures, including nerve ablations and high-end urine tests that screen for an extensive list of drugs." Such procedures generated millions of dollars in insurer payments by Medicare and Medi-Cal.
• How does one choose narrative strategy? One biographer’s experience (Gabriella Marie Kelly-Davies, Australian Journal of Biography and History, No. 8, 2024) "After two decades of ricocheting from neurologist to neurologist and with escalating migraine attacks, my general practitioner referred me to the pain medicine specialist Dr Michael J. Cousins at Royal North Shore Hospital in Sydney. He greeted me in the pain clinic’s crowded waiting room." During her visits to the pain clinic, diagnosed with and treated for occipital neuralgia, she learns from Cousins’s colleagues that he had led the pain world in the late 1980s as president of the International Association for the Study of Pain. He also established two internationally acclaimed pain centres in Australia. While figuring out how to tell Cousins's story (in Breaking through the Pain Barrier: The Extraordinary Life of Dr Michael J. Cousins), Kelly-Davis reports on what she learns at the "pain centre". At his suggestion she joins a multidisciplinary pain management program involving stretching and carefully paced exercise, meditation and psychological techniques. ‘It’ll teach you how to turn down the volume of pain signals racing through your nervous system’, he explains.
• American Pain Society forced to close due to opioid scandal (Elizabeth Gourd, The Lancet, 5-31-19)
• Four Pain Management Clinics Under Investigation for Fraud Closed Abruptly (Lee H. Little, Total Health Law, 5-14-19) Four Tennessee clinics, formerly affiliated with PainMD and rebranded as Rinova, closed last week. Federal authorities alleged that PainMD and its parent company inflated profits by providing patients with unnecessary injections to be paid by federal health insurance programs.

• Academy of Integrative Pain Management (was American Academy of Pain Management)
• American Academy of Pain Medicine
• American Board of Pain Medicine (ABPM)
• American Chronic Pain Association . Among other resources provided, information about Conditions, A to Z and a free downloadable PDF, ACPA Resource Guide to Chronic Pain Medication and Treatment
• American Fibromyalgia Syndrome Association (AFSA)
• American Pain Society
• American Society/of Interventional/Pain Physicians (ASIPP)
• American Society of Regional Anesthesia and Pain Medicine (ASRA)
• The Facial Pain Association (FPA) (support for those with trigeminal neuralgia and other neuropathic facial pain conditions). Among publications available from FPA: Striking Back : The Trigeminal Neuralgia and Face Pain Handbook by George Weigel and Kenneth E. Casey (to be updated this year)
• Pain Association. Resources include a list of conditions characterized by pain and A Consumer Guide to Pain Medication and Treatment
• National Fibryomyalgia & Chronic Pain Association (NFMCPA)
• Pain Relief Network (where chronic pain patients, doctors, and supporters can be heard)
• Partners Again Pain (addressing untreated and undertreated pain in America)
• Pain management forum (MedHelp)
• Patients Like Me (sorted by conditions)
• U.S. Pain Foundation

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Dental care and oral health:

What you should (and probably don't) know

• Better understanding of ‘mouth microbes’ may improve oral health treatments (Mary Otto, Covering Health, AHCJ, 8-9-19) It is more productive to think about the community of organisms that live in the mouth than it is to think about the single microbe that causes disease. They help each other survive and prosper. One research team has concluded that a fungus in the plaque of children with early childhood caries accelerates the progress of the disease by working in concert with the matrix- and acid-making bacteria. “Bacteria by itself can cause tooth decay,” Koo tells News in Health. “But when fungus is there it boosts up the entire machinery.” Watch for practical developments based on this research.
• Always Floss Before Brushing (Better Report)"Flossing helps clear the gaps between your teeth before you use toothpaste, encouraging greater fluoride retention. By flossing first, you loosen food, plaque, and bacteria between your teeth, which makes removing those particles easier for your toothbrush." Flossing loosens up the debris and plaque on your teeth, so you get a closer brush. If you brush before flossing you're missing all the gaps food blocks off. Offers good instructions on best flossing techniques.
• Does Medicare cover dental care? What beneficiaries need to know (Liz Seegert, Fortune Well, 6-21-23) Traditional Medicare does not cover dental care, with very few and limited exceptions. Currently, regular care like cleanings and fillings, and services like dentures or extractions, are the responsibility of beneficiaries. Your Medicare Supplement Plan (Medigap) won’t cover dental care either. "If you’re willing to switch to a Medicare Advantage plan, most do cover routine dental services, such as checkups or cleanings, although it can be challenging to find in-network providers. These plans often have high deductibles ($1,000 or more), annual caps, and high co-insurance for certain procedures." Seegert provides a useful list of other options for dental care, according to the Medicare Rights Center.
• Is It Better to Brush Your Teeth Before Breakfast or After? (Hannah Seo, NY Times, 11-1-22) Persuasive reasons for either choice but probably best is the brushing habit that will make you most likely to brush your teeth consistently.
•
• Teeth: A User's Manual (Aja Drain, NPR, 2-27-23) Transcript. Takeaways: Finding a dentist is more than just picking from a list. You're on the hunt for a good oral health team. Get specific about your fears, and then you can talk about them with your oral health team. Although few, there are options for dental care with limited funds or no insurance.

Clean teeth are all about technique, not products. Health and aesthetic are not the same thing.

     Best time to brush your teeth: In the morning, before breakfast. Spending more time brushing – up to four minutes each time you brush – leads to cleaner teeth [because you] can more effectively clean our teeth and get those hard-to-reach places.
     "Mark and Alicia recommend a soft, high-quality toothbrush you should be replacing every 4 to 6 weeks, some non-nylon floss, a tongue scraper and a low-abrasive toothpaste. And funny enough, toothpaste can be helpful but is playing a smaller role than you'd expect in actually cleaning your teeth...Toothpaste is about 10% of the equation. It's the mechanical work of the floss and the brush that is most important."
      "If you're brushing after a meal that produces an acid attack in the mouth - could be coffee because it's acidic in nature to begin with - you're scraping away a lot of enamel. So for anyone that's eating junk or candy or having a soda or even having coffee or a glass of wine, wait for at least 30 minutes. Let the pH in the mouth stabilize. Let the tooth, the outer layer of the tooth stabilize and then brush."
• Dental health articles (Harvard Health Publishing) Worth a look.
• Oral health: A window to your overall health (Mayo Clinic) Learn how the health of your mouth, teeth and gums can affect your general health.
• Articles on dental health (Everyday Health
• The Tooth Divide: Beauty, Class and the Story of Dentistry (Sarah Jaffe, NY Times, 3-23-17) Review of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America by Mary Otto. "The dividing line between the classes might be starkest between those who spend thousands of dollars on a gleaming smile and those who suffer and even die from preventable tooth decay....Otto’s book begins and ends with the story of Deamonte Driver, a 12-year-old Maryland boy who died of an infection caused by one decaying tooth, and the system that failed him. In pointing out the flaws in that system, Otto takes us back through the history of dentistry and shows us how the dental profession evolved, separately from the rest of health care, into a mostly private industry that revolves almost entirely around one’s ability to pay. In other words, all of the problems with health care in America exist in the dental system, but exponentially more so....dental care is still associated in our minds with cosmetic practices, with beauty and privilege. It is simultaneously frivolous, a luxury for those who can waste money, and a personal responsibility that one is harshly judged for neglecting. In this context, “Teeth” becomes more than an exploration of a two-tiered system — it is a call for sweeping, radical change.
• Surprisingly Little Evidence for the Accepted Wisdom About Teeth (Aaron E. Carroll, The New Health Care, NY Times, 8-29-16) There’s good evidence that brushing twice a day with fluoride toothpaste is a good idea, especially with a powered toothbrush. For children, there’s good evidence that the use of fluoride varnish or sealants can be a powerful tool to prevent cavities. The rest? It’s debatable; we don't have good studies. With flossing, which is cheap and easy, it still might be worth doing. And fluoride is important.
• What dentists wish you knew
• CDC study suggests many kids using excess toothpaste (Mary Otto, Covering Health, AHCJ, 2-28-19) "Young children, whose reflexes are not fully developed, may accidentally swallow toothpaste. The ingestion of too much fluoride while the permanent teeth are developing can result in dental fluorosis, a mottling, pitting or discoloration of the enamel. The CDC recommends that children up to the age of 3 use a smear of fluoride toothpaste no larger than a grain of rice; children between the ages of 3 and 6 are advised to limit themselves to a pea-sized portion."
•Reporter explains how he wove data, human stories into compelling series on dental deaths (Mary Otto, Health Journalism, AHCJ, 1-13-16) In a seven-part Dallas Morning News investigative series, Deadly Dentistry, Brooks Egerton set out to offer what he has described as a look “into dentistry’s netherworld, where professionals take chances with patients’ lives and the government largely tolerates it.” Egerton raises questions about how many dental injuries and deaths may be going unreported across the country – and how dentists who are disciplined for patient safety failures find it easy to move on and keep working.
• 2020’s States with the Best & Worst Dental Health (Adam McCann, WalletHub, 2-6-2020) How does your state rank? You may be surprised. report card also breaks out ratings for some specific indicators including tobacco and soda consumption rates, dentists per capita and toothlessness among elders.
• HealthyPeople.gov Oral Health objectives
• Don't Toss the Floss (NIH, 11-16) The Benefits of Daily Cleaning Between Teeth.
• Tooth Wisdom Find affordable dental care.See also Healthcare Resources for Oral Health and Where to find affordable dental care (a state-by-state guide, also from Tooth Wisdom)
• Toothbrushes Buying Guide (Consumer Reports, online)
• Basic Dental Care: An Overview (Web MD)
• Where to find affordable dental care (by state) (Teeth Wisdom). Helpful blog posts, such as Root Decay and Denture Information for Caregivers. Plus other resources, such as Why you may have dry mouth (especially seniors)
• Dental patients face years of debt, inflated bills with ‘out-of-pocket’ credit cards (Manuela Tobias, Sacramento Bee, 12-9-19) Legal aid organizations report that low-income Californians are particularly at risk of falling into debt traps with medical credit cards because of ongoing struggles with the state insurance system. Advocates say the terms of medical credit cards are too complicated for most people to understand. They are particularly confusing in high-pressure situations, like the moments of excruciating pain leading up to important dental procedures. If consumers do not fully understand the terms or fall behind on payments, they can end up facing inflated bills and crippling dental debts. See story behind the story: How one reporter explored the impact of medical credit cards on dental debt (Mary Otto, Covering Health, AHCJ, 4-24-2020)
• Study documents disparities that contribute to late diagnosis of oral cancer (Mary Otto, Covering Health, AHCJ, 1-7-2020) "Research has long shown that Americans from minority groups and those with a lower socioeconomic status are less likely to get routine dental visits than patients who are white and more affluent. A new study finds that even when minorities or those who are poorer and less educated do receive oral health services, they are less likely to receive oral cancer (OC)screenings that could lead an early diagnosis. The findings come at a time when oral cancer, which disproportionately burdens poorer, less-educated and minority patients, is on the rise, according to federal data."
• Vermont moving forward on creating dental therapist training program (Mary Otto, Covering Health, AHCJ, 12-11-19) "States across the country are moving ahead with laws aimed at putting dental therapists to work. Legislators and health advocates hope the mid-level provider model will serve as a cost-effective way of getting dental care to historically underserved communities across the U.S.
"Often compared to physicians’ assistants or nurse practitioners in the medical world, dental therapists receive technical training in a range of routine preventive and restorative procedures and work as part of dentist-headed teams. But the model continues to face opposition from state and national dental societies, who have long contended that only dentists are qualified to drill and extract teeth....In 2009, Minnesota became the first state government to authorize the use of dental therapists; Vermont, Maine, Michigan, Connecticut, New Mexico and Nevada have since followed suit and other states are considering legislation."
• Here Come the Dental Therapists (Barbara Mantel, Rural Health Quarterly, 9-20-19) More states are passing laws to extend their use, but can opposition from dental societies be overcome?
• Problems With Dental Fillings (Medicine Net)
• Why neglecting your teeth could be seriously bad for your health (Linda Geddes, The Guardian, 7-19-15) It’s no secret that a lackadaisical approach to dental care leads to fillings and gum disease, but the latest evidence suggests it could also cause diabetes, heart disease and cancer.
• Often lost in health care debate, lack of dental insurance impacts millions (Yesenia Amaro and Nicole A Hayden, USC Center for Health Journalism News Collaborative, 6-20-19) Untreated dental problems can lead to other health complications and higher medical costs. A 2014 study showed that when adult Medicaid recipients had preventive dental care, medical costs for seven chronic health conditions, such as diabetes and coronary heart disease, were lower by 31% to 67%. The connection between oral and overall health seems to stem largely from bacteria and germs located in the mouth that can spread to other parts of the body and cause diseases.
• White paper calls for more attention to endodontic oral care (Mary Otto, Covering Health, AHCJ, 6-14-19) new white paper from the Geneva-based FDI World Dental Federation aims to dispel the fear surrounding such procedures and highlight the tooth-saving potential of endodontics; which is the care and treatment of the soft tissues within and around the teeth.... Untreated tooth decay impacts more than one-third of the people suffering from disease....Endodontic procedures range from pulp capping, which protects still-vital tissues within a damaged tooth to root canal treatment, in which diseased pulp is removed and the roots inside the tooth are cleaned, shaped and sealed. The placing of a crown restores the functionality of the tooth."
• Gum disease and the connection to heart disease (Robert H. Shmerling, Harvard Medical School, April 2018)
• Passage of Dental Health Act a rare act of bipartisanship (Mary Otto, Covering Health, AHCJ, 12-4-18) The Action for Dental Health Act of 2018 is a heartening acknowledgment by federal legislators of the need to respond to the long-unmet dental needs of millions of Americans. In a rare show of bipartisanship, Congress last week passed legislation that amends the Public Health Service Act to enable more groups and organizations to qualify for federal grants that develop programs and expand access to oral health education and care in states and tribal areas.
• 2018’s States with the Best & Worst Dental Health (WalletHub, 2-1-18)
• The Rise and Impending Fall of the Dental Cavity (Cremieux Recueil, 4-9-24) Cavities are a communicable disease, and if you’re among the 90% of Americans who’s ever had one, you probably got them from your mother. High-fluoride toothpaste prevents caries, with some qualifiers about potential fluorosis risk for the young. Powered toothbrushes outperform manual ones. Chlorhexidine mouthwash might be good for gingival health and is certainly good for plaque buildup.
• Drilling Down on Dental Coverage and Costs for Medicare Beneficiaries (Meredith Freed, Tricia Neuman, and Gretchen Jacobson, Kaiser Family Foundation, 3-13-19) Almost two-thirds of Medicare beneficiaries do not have dental coverage and many go without needed care, a new KFF analysis finds. Medicare does not cover routine preventive dental care or more expensive dental services that are often needed by older adults. Lack of dental care can lead to delayed diagnosis of serious health conditions, preventable infections and complications, chronic pain, and costly emergency room visits. Untreated oral health problems can lead to serious health complications. Having no natural teeth can cause nutritional deficiencies and related health problems. Untreated caries (cavities) and periodontal (gum) disease can exacerbate certain diseases, such as diabetes and cardiovascular disease, and lead to chronic pain, infections, and loss of teeth. Lack of routine dental care can also delay diagnosis of conditions, which can lead to potentially preventable complications, high-cost emergency department visits, and adverse outcomes. Medicare, the national health insurance program for about 60 million older adults and younger beneficiaries with disabilities, does not cover routine dental care, and the majority of people on Medicare have no dental coverage at all. Limited or no dental insurance coverage can result in relatively high out-of-pocket costs for some and foregone oral health care for others. This brief reviews the state of oral health for people on Medicare. It describes the consequences of foregoing dental care, current sources of dental coverage, use of dental services, and related out-of-pocket spending.
• Do Medicaid and Medicare Offer Dental Insurance? (Area Dentist) People with Medicare and Medicaid may also choose to purchase stand-alone dental insurance without affecting their health benefits.
• ‘Physicians of the Mouth’? Dentists Absorb the Medical Billing Drill (David Tuller, California Healthline, 9-21-18) On a recent Friday morning, more than 30 dentists and dental staffers gathered in a conference room to learn an arcane new skill: how to bill medical insurers. Pacing back and forth, the Florida dentist leading the two-day course advised the participants to stop thinking of themselves as tooth technicians and reposition themselves as “physicians of the mouth.” "The reason is simple: Medical insurance is generally much more generous in its coverage than dental insurance. Unlike medical coverage, dental insurance is mostly geared to the healthy — something many people don’t realize until they experience serious oral problems and get socked with unexpected costs. Standard dental insurance covers cleanings, fillings and other routine care. But major work like a crown or a bridge is often covered only at 50 percent and implants generally aren’t covered at all. And dental insurance is usually capped at $1,000 or $1,500 per year."
• Confusion Leaves Low-Income Children In Health Care Limbo (Jocelyn Wiener, California Healthline, 9-10-18) Tania Alvarado’s 13-year-old daughter doesn’t smile much anymore. She doesn’t want anyone to see her front teeth, which are so crowded they’re nearly growing atop one another. The crowding makes it painful to eat; it also embarrasses her. “Am I going to get those braces this year?” the Los Angeles eighth-grader asks her mom, again and again. Alvarado always answers her the same way: “It’s still not happening.” For two years, dentists have told Alvarado that her daughter needs braces. They’ve also told her that because the girl has Medi-Cal — the government insurance program for low-income Californians — braces aren’t covered. Legal aid attorneys say the dentists are wrong. Under federal law, children are eligible for a wide array of services, but confused providers and health plans often look only at the state’s narrow range of approved services for adults, and mistakenly apply those rules to kids. “They’re being denied care that they’re entitled to,” she said. “That’s the bottom line.”
• NY program highlights challenge of providing dental care to patients with disabilities (Mary Otto, Covering Health, AHCJ, 4-11-18) A bill recently signed into law by Arizona Gov. Doug Ducey opens the way for dental therapists to begin providing services in tribal health centers, safety net clinics and other public health settings across the state. Diverse supporters of the change ranged from health advocacy groups and tribal organizations to the libertarian Goldwater Institute, which issued the report, "The Reform That Can Increase Dental Access and Affordability in Arizona." Minnesota was the first state to authorize the licensing of dental therapists and Compromise Would Use Dental Therapists to Expand Access to Oral Health Care in Mass. (Matt Murphy, WBUR, Boston). The American Dental Association says the major problem with disparities in access to health care is the lack of reasonable Medicaid reimbursement, not dental workforce issues--concluding that the therapist model would drive down the cost and price of dental care and the income of dentists while doing little to increase the use of dental services.
• Abrupt end to Oregon legislative session leaves dental therapist bill in the lurch (Mary Otto, Covering Health, 3-17-2020) "Oregon is one of a dozen states that have approved measures allowing the practice of dental therapy in some capacity. More states are considering the use of dental therapists. The model, which has been employed for decades in other countries, has been championed by public health leaders a cost-effective way of expanding care to long-underserved communities and populations. An estimated 56 million Americans live in federally-designated dental health provider shortage areas."
• New research highlights gulf between primary care, dental care (Mary Otto, Covering Health, AHCJ, 11-29-18) "A pediatrician sees a child with untreated tooth decay, but doubts a dentist will be available in the child’s community. The pediatrician does not write a referral. A dentist notices a patient’s suspicious oral lesion, but fails to follow up. Care is delayed. A pregnant woman with an infected tooth is advised to seek dental care but has no regular oral health provider. She ends up in an emergency room where her underlying dental problem remains unresolved. Physicians and dentists fail to collaborate or even to communicate. Patients suffer; the most vulnerable often get lost in the divide. Knitting the systems together will require serious work on many levels. But the effort is necessary to ensure better health outcomes, according to a discussion paper, newly published by the National Academy of Medicine.
• Dentists under pressure to drill ‘healthy teeth’ for profit, former insiders allege (David Heath, USA Today, Mark Greenblatt and Aysha Bagchi, Newsy, 3-19-2020) A reporting team's in-depth investigation into a growing dental chain offers a troubling chronicle of dentists under pressure to meet revenue targets and patient allegations of overtreatment. "Reporters spent more than a year examining the inner workings of North American Dental Group. The Pittsburgh-based chain represents "a new trend of dental offices bought by private-equity investors and turned into revenue-generating machines," their project explained. Johannah Lancaster's son, Gregory, now 9, received seven root canals at a dental clinic when he was 3. The dentist never took X-rays and Gregory later had to have four of the teeth pulled."
• Painful Mistakes (Arthur Kane, Las Vegas Review-Journal, 10-28-19) Six-part series. (1) Injured Patients Claim Botched Dental Work. Why didn’t the board revoke licenses? (2) Patients reveal the impact of failed dental work. (3) Dental board benefiting itself, not patients, records show. (4) Longtime dental feud sparks state investigation. (5) This patient complained. The dental board filed a restraining order against him. (6) Two videos: How to check your dentist’s background. How to file a complaint against a Nevada dentist.
• Nevada is not the only state with dental oversight problems (William Heisel, Investigating Health, 1-2-2020) Problems in your state? Check out your state dental board.

• Journal roundtable explores practices to reduce anesthesia-related deaths in pediatric dentistry (Mary Otto, Covering Health, AHCJ, 12-14-17) "Tooth decay remains the most prevalent chronic health problem of children in the United States. Since the late 1980s, roughly one in four U.S. children have had tooth decay, a rate that has remained relatively stable over the decades, according to a new study based on extensive federal data....“Although it is laudable that more younger children are receiving dental treatment for caries, what we would really like to see is more children remaining caries-free through childhood,” Bruce Dye, the study’s lead author. Parents and caregivers should begin getting routine dental care for babies by their first birthday.
• Refugees face special challenges in maintaining oral health (Mary Otto, Covering Health, AHCJ, 11-21-18)
• Report: Pregnant women have harder time obtaining dental care, regardless of income (Mary Otto, Covering Health, AHCJ, 11-19-18)
• New report lays out challenges in expanding practice of dental hygienists (Mary Otto, Covering Health, AHCJ, 10-25-18) See More such stories by Mary Otto.
• UI dental school to turn away new Medicaid patients because of low payments, confusing rules (Tony Leys, Des Moines Register, 6-28-18)
• The Unmet Need for Dental Care (one of many articles on AHCJ's excellent long page on topics related to oral health)
• Efforts to expand use of dental therapists making progress (Mary Otto, Covering Health, AHCJ, 9-17-19) Connecticut has joined a growing list of states embracing dental providers as a way to expand access to care. Under the new law dental therapists must practice under the supervision of a dentist and only in public health settings,” she wrote. Dental hygienists registered to practice in the state must receive 18 months of additional training to become dental therapists. As in other states that have passed such legislation, backers of the model in Connecticut say that dental therapists will provide a cost-effective way to increase the availability of dental services among publicly-insured and uninsured patients, and in rural and minority communities where dentists are often scarce.
• Unlikely coalition expands use of dental therapists in Arizona (Mary Otto, Covering Health, AHCJ, 7-12-18)
• How Dental Inequality Hurts Americans (Austin Frakt, The Upshot, NY Times, 2-19-18) Lack of dental care through Medicaid not only harms people’s health, but has negative economic implications as well. Not being able to see a dentist is related to a range of health problems. It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most.
• ‘AGGA’ Inventor Testifies His Dental Device Was Not Meant for TMJ or Sleep Apnea (Brett Kelman, KFF Health News, and Anna Werner, CBS News, 12-22-23) At least 23 patients, some of whom described being desperate for relief from sleep apnea or temporomandibular joint disorder (TMJ), have sued Steve Galella in recent years claiming that the AGGA damaged their mouths and, in some cases, caused tooth loss. The Tennessee dentist has said under oath that he never taught dentists to use the device for those ailments — contradicting video footage of him telling dentists how to use it. Steve Galella, the inventor of the Anterior Growth Guidance Appliance, or “AGGA,” has said in court depositions that his device had been used on about 10,000 patients, and that he trained many dentists to use the AGGA in classes around the U.S. and overseas.
• New guidelines may encourage use of low-cost, painless dental treatment (Mary Otto, Covering Health, AHCJ, 11-20-17) "A treatment that offers a painless, minimally-invasive alternative to drilling and filling teeth has gotten a boost from a prominent children’s dental organization....The product, which is painted onto decayed lesions, contains fluoride, which helps remineralize the damaged tooth, and silver, which kills the bacteria that drive decay. SDF has been used for decades in Japan, but has only recently attracted the attention of U.S. health care providers. n 2014, SDF was cleared by the U.S. Food and Drug Administration to be marketed as a treatment for dental sensitivity in adults. Now, some U.S. dentists have begun using the material as an off-label restorative material."
• Treating Pain Is Not Enough: Why States’ Emergency-Only Dental Benefits Fall Short (Cheryl Fish-Parcham, Families USA, July 2018) States have great latitude to determine the scope of dental benefits that they will cover for adults through their Medicaid programs. While some states cover comprehensive benefits, others cover emergency dental care only or none at all. These states all cover limited services to address severe pain, generally including extractions. Finding appropriate care providers for emergency-only dental services can be difficult. State Medicaid programs end up paying for expensive hospital emergency department visits when appropriate dental services are not available. And most do not provide restorative care nor cleanings that would address underlying disease. When Medicaid does not cover an oral health care need, there are few other resources for low-income adults to get that need met.
• Dearth of dentistry: Reporter explores how state's economic health affects its oral health (Mary Otto, Covering Health, AHCJ, 11-14-17) In this Q&A, Caleb Slinkard, editor of the Norman Transcript, who has overseen his paper’s 15-member newsroom for the past two years, offers insights into his “Dearth of Dentistry” package. He reflects upon what oral health can tell us about economic health and how budget decisions have influenced the availability of benefits, providers and fluoridated water in the state. He also shares tips that might help fellow journalists take a similar look at oral health access in their own communities.
• How bad teeth and a lack of dental care can lead to discrimination and poverty (Manuela Tobias, Fresno Bee, 10-16-19)
• Maggie Clark’s Two Million Kids series for the Sarasota Herald-Tribune has 'explored many facets of the state’s troubled Medicaid program: a dearth of preventive and specialty care in many communities, problems faced by providers and a decade-long legal battle to reform the system. In a recent installment, Clark focused upon the shortage of oral health care services for Florida’s poor children....Clark looked at how the state’s chronic shortage of Medicaid dental care has affected young Floridians. She delved into how the system got so bad and described how evolving reform efforts, driven by the settlement of a decade-long lawsuit, might improve it....inaccurate provider lists offered to beneficiaries by their Medicaid dental plans further complicated an already difficult search for care, the newspaper found.

“For Medicaid-enrolled kids, dental care is an entitlement in federal law,” Scott Tomar, chairman of the Department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry, told Clark. “The current system is neither adequately funded or user friendly. It seems like it was designed to create as many barriers to utilization for parents, kids and dentists, as possible.”' Poor kids end up in emergency rooms when their dental problems become bad enough, but ER does not provide adequate dental care there. (Hat tip to AHCJ, Covering Health).
• Kentucky reporter shares insights on covering cuts to Medicaid dental coverage (Mary Otto Q&A with reporter Will Wright, who wrote about Kentucky Gov. Matt Bevin’s July decision to cut dental and vision benefits for about 460,000 state Medicaid beneficiaries: Appointments at this Kentucky dental clinic down by half after Bevin’s Medicaid cuts (Lexington Herald-Leader, 7-10-18)
• Top 10 Facts Your Dentist Wants You to Know (Tammy Davenport, VeryWell, 10-6-16) Useful information; annoying ads slow down the reading experience.
• Dentists keep dying of this lung disease. The CDC can’t figure out why. (Cleve R. Wootson Jr., WashPost, 3-10-18) "It’s estimated that about 200,000 people in the United States have Idiopathic Pulmonary Fibrosis (IPF) at any one time.But the common denominator of a small group of patients at a Virginia clinic over a 15-year period is worrying the Centers for Disease Control and Prevention: Eight were dentists; a ninth was a dental technician."
• When Dental Surgery Lands A Patient in a World of Everlasting Regret (Dianna Wray, Houston Press, 8-9-16) It seems there are few rules governing dental surgery and its outcomes in Texas.
• HHS targets oral care gaps in ‘health infrastructure’ awards (Mary Otto, Covering Health, 10-4-19) "More than $85 million in new federal awards will help health care centers from Aniak, Alaska, to Miami Gardens, Fla., increase access to dental care in their communities. The awards of up to $300,000 each will enable 298 federally funded clinics to start or expand oral health care services. The money will be used to buy and install dental and X-ray equipment, train staff, renovate facilities and purchase mobile dental units."
• Tip sheet, series provide template for investigating Medicaid dental care for children (Mary Otto, Covering Health, Association for Health Care Journalists, 9-19-16)
• Medicaid Adult Dental Benefits: An Overview (fact sheet from the Center for Health Care Strategies)
• Dentist Participation in Medicaid or CHIP (by state, by gender, by age) (Health Policy Institute, American Dental Association)
• Dental Benefits and Medicaid
• Microbes in Dental Plaque Are More Like Relatives in Soil Than on the Tongue (Alison Caldwell, press release, University of Chicago Medicine and Marine Biological Laboratory, 12-16-2020) Study suggests plaque may have been a “stepping stone” for microbes into the body.

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Dealing with rape and sexual assault and abuse

• National Resources for Sexual Assault Survivors and Their Loved Ones (RAINN--Rape, Abuse & Incest National Network--the nation's largest anti-sexual violence organization) An important list of resources, with links. "Every 73 seconds, an American is sexually assaulted. And every 9 minutes, that victim is a child."

National sexual assault helpline: Call 800.656.HOPE
• Safe Horizon Rape and Sexual Assault: It Is Not Your Fault.Need help? Call our 24-hour hotline (llámenos para ayudarle) 1-800-621-HOPE (4673). If you are in immediate danger, call 911.
• On the Night Shift With a Sexual Assault Nurse Examiner (Katheryn Houghton, KFF, 5-8-23) "These nights on duty are Towarnicki’s second job. She’s on call once a week and a weekend a month. A survivor may need protection against sexually transmitted infections, medicine to avoid getting pregnant, or evidence collected to prosecute their attacker. Or all the above. When her phone rings, it’s typically in the middle of the night."
• What is sexual assault? (RAINN) "Rape is a form of sexual assault, but not all sexual assault is rape....The majority of perpetrators are someone known to the victim. Approximately eight out of 10 sexual assaults are committed by someone known to the victim, such as in the case of intimate partner sexual violence or acquaintance rape." RAINN answers questions about what is sexual assault, rape, and force.
• There needs to be a better approach to victims of sexual violence (Anonymous, KevinMD, 12-20-2020) A nurse raped by her massage therapist is shocked by how difficult it was to report the rape. 'I've poured over articles on why rape kits are not more commonplace in OB/GYN offices and family medicine clinics. I never realized that for anyone who has the courage to admit sexual assault, they will then be told, “thanks for telling us, now go somewhere else.” ...Fears of litigation hinder these providers from helping in situations like mine.'
• Angry Catholics Wanted to Burn the Church. He Came to Save It. In a cold, remote corner of northern Quebec, a sexual abuse scandal pushed a church to the edge. The Rev. Gérard Tsatselam, from Cameroon, must comfort the afflicted to bring it back. A solid story with amazing photographs of a part of Canada we rarely see.

• Take It Down Having nudes online is scary, but there is hope to get it taken down. This service is one step you can take to help remove online nude, partially nude, or sexually explicit photos and videos taken before you were 18.
---Meta announces new updates to help teens on its platforms combat sextortion (Aisha Malik, TechCrunch, 2-6-24) Meta has expanded availability of Take It Down, an online tool it helps finance that is run by the National Center for Missing and Exploited Children (NCMEC). Take It Down is designed to help young people under 18 years old prevent intimate images of themselves from spreading online. The company also updated its Sextortion hub with new guidance and is launching a global campaign to raise awareness about sextortion.
---Meta backs a new system that allows minors to stop their intimate images from being posted online (Sarah Perez, TechCrunch, 2-27-23)
• 94 Women Allege a Utah Doctor Sexually Assaulted Them. Here’s Why a Judge Threw Out Their Case. (Jessica Miller, The Salt Lake Tribune and ProPublica, 2-22-23) When dozens of women sued their OB-GYN for sexual assault, a judge said the case falls under the state’s medical malpractice law. As the women appeal, lawmakers are asking whether that law should be changed. See also
---Breach of Trust: Utah’s Troubled Handling of Sexual Assaults (ProPublica,
---A Utah Therapist Built a Reputation for Helping Gay Latter-day Saints. These Men Say He Sexually Abused Them. (ProPublica, April 2023)
---Utah’s Secretive Medical Malpractice Panels Make It Even Harder to Sue Providers (ProPublica, April 2023)
---Help ProPublica and The Salt Lake Tribune Investigate Sexual Assault in Utah (ProPublica, April 2023)

• My Brother Sexually Abused Me. Do I Tell His Children? (Kwame Anthony Appiah, The Ethicist newsletter, NY Times, 4-7-23). See also My Dysfunctional Brother Was Abused. How Do I Acknowledge His Past? (7-16-19)
• The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk MD, who exposes the tremendous power of our relationships both to hurt and to heal—and offers new hope for reclaiming lives.

     “Essential reading for anyone interested in understanding and treating traumatic stress and the scope of its impact on society.” —Alexander McFarlane, Director of the Centre for Traumatic Stress Studies. A pioneering researcher transforms our understanding of trauma and offers a bold new paradigm for healing in this New York Times bestseller.
• New California Law: Docs Who Sexually Abuse Patients Can't Get Their Licenses Back (Cheryl Clark, MedPage Today, 9-27-22) Statute bars medical board from restoring licenses revoked from sex offenders
• When You Experience Sexual Harassment at Work (Valeriya Safronova, NY Times, 11-10-17) "It can be perpetrated by anyone — a manager, a colleague, a client. The perpetrator or the recipient may be male or female. It does not need to occur inside the office. Your employer could still be responsible for investigating the incident and handling it appropriately....Whatever you plan to do, keep notes and evidence. Make sure all of your attempts at reporting the abuse to your employer are documented. “Write down everything and put everything in writing. You don’t just go and talk to H.R.” Make sure you’re aware of statutes of limitations.
• #MeToo Called for an Overhaul. Are Workplaces Really Changing? (Jodi Kantor, NY Times, 3-23-18) Harassment has flourished in part because structures intended to address it are broken: weak laws that fail to protect women, corporate policies that are narrowly drawn and secret settlements that silence women about abuses. “The reality is, the problem is systemic, and we have to address it at a systemic level.”
• Liberty University agrees to unprecedented $14 million fine for failing to disclose crime data (AP, WTOP, 3-5-24) "Liberty University has agreed to pay an unprecedented $14 million fine for the Christian school’s failure to disclose information about crimes on its campus and for its treatment of sexual assault survivors, the U.S. Department of Education announced Tuesday.
      "The fine is by far the largest ever levied under the Clery Act, a law that requires colleges and universities that receive federal funding to collect data on campus crime and notify students of threats. Schools must disseminate an annual security report that includes crime reports and information on efforts to improve campus safety. Federal investigators found that many victims of sexual crimes were fearful of reporting their incidents because of fear of reprisal.
      “In fact, over the course of this review period, several sexual assault victims were punished for violating the student code of conduct known as ‘The Liberty Way,’ while their assailants were left unpunished,” according to the settlement agreement."
• “The Liberty Way”: How Liberty University Discourages and Dismisses Students’ Reports of Sexual Assaults (Hannah Dreyfus, ProPublica, 10-24-21) The school founded by evangelist Jerry Falwell ignored reports of rape and threatened to punish accusers for breaking its moral code, say former students. An official who says he was fired for raising concerns calls it a “conspiracy of silence.”
• 'After 50 Years of Sexual Assault Shame, I'm Finally Reclaiming My Voice' (Court Stroud, Newsweek,4-15-21) "It's always bothered me why, out of all of the individuals on the subway, that guy chose me. I now understand it's not because I boarded from a part of town where lots of LGBTQ folks lived or because he could tell I'm a gay man. The answer is simpler: The perpetrator tested me. When I didn't react by screaming or fighting, my silence led him to believe he could continue his assault."
• A Long and Elusive Fight for Justice (Barry Siegel, Los Angeles Times, 11-26-96) The story of a case involving a doctor in Idaho accused by dozens of women of groping them and of the difficulty of prosecuting such a case (or finding a prosecutor willing to do so), partly because friends of the accused rise up against the victims and the prosecution, unable to accept that their friend/family member would do such a thing. You need a strong and courageous prosecutor and victims willing to testify and get negative reactions for doing so.
• He was my high school journalism teacher. Then I investigated his relationships with teenage girls. (Matt Drange, Business Insider, 5-16-22) A California high school protected a star journalism teacher who abused his power to sexually pursue students, reporter Matt Drange found after spending five years re-examining the educator who taught him to be a journalist. "Despite numerous red flags, school and district officials repeatedly missed opportunities to put a stop to Burgess' behavior. Time and again, these adults failed to investigate disturbing stories and reports of sexual abuse that arose throughout his career. Burgess has not been charged with a crime, and school officials won't say whether they ever notified law enforcement of his relationships with teenage girls."
• MARTA brushed off her sexual harassment complaints. Now it settles with her for $575K (Johnny Edwards, The Atlanta Journal-Constitution, 3-2-21) The case was spotlighted in an AJC investigation that found nearly all harassment claims were rejected.

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• Covering sexual abuse, assault, harassment, trauma (Journalism, Writers and Editors)
• Telling your story can be powerful and healing. That's why they founded this nonprofit. (Simone Scully, Upworthy) Mirror Memoirs has created an audio archive of BIPOC LGBTQI+ child sexual abuse survivors sharing their stories of survival and resilience that includes stories from 60 survivors across 50 states. They plan to record another 15 stories, specifically of transgender and nonbinary people who survived child sexual abuse in a sport-related setting, with their partner organization, Athlete Ally. See also Tory Burch's Empowered Women.
• “Who Is This Monster?” (Catherine Rentz, ProPublica, 5-20-21) She went undercover to catch a rapist. Two decades later, she finally got her chance. See also
• “You Save as Long as You Have To” (Catherine Rentz, 5-22-21) Distressed by authorities’ poor treatment of rape victims and destruction of evidence, one doctor became a DNA archivist long before we had the technology to test it. For potentially hundreds of survivors, his faith in science is paying off.
• The Rape Kit’s Secret History (Pagan Kennedy, New York Times, 6-17-2020) This is the story of the woman who forced the police to start treating sexual assault like a crime. In the early days of forensic science, the 19th century, rape exams sought primarily to test the virtue of women; they began as a system for men to decide what they felt about the victim. Even in the 1970s, police officers wielded absolute power in the situation; they told the story; they assigned blame. Marty Goddard saw that the only fix for this dysfunctional system would be incontrovertible scientific proof, the same kind used in a robbery or attempted murder. She realized she had to find a mechanism that would protect the evidence from a system that was designed to destroy it. She saw that no one had bothered to tell the nurses and doctors how to collect evidence properly. A fascinating story. "When it comes to sexual assault, there are many inventions I can think of that help men get away with it — from the date-rape drug to “stalkerware” software. More striking is how few inventions, how little technology and design, has been devoted to keeping women safe." ...The rape-kit idea was presented to the public as a collaboration between the state attorney’s office and the police department, with men running both sides...and little credit given to the women who had pushed for reform. Ms. Goddard agreed to this, Ms. Gehrie said, because she saw that it was the only way to make the rape kit happen." ...But DNA testing was expensive. Compounding that problem was the sheer success of the rape kit system: Victims now felt encouraged to report their assaults and submit to exams, which meant that police departments were flooded with evidence. And so, just as the rape-kit system began to succeed, police departments strangled it. They began hiding away thousands of untested rape kits deemed too expensive to process." Do read the whole story.

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• What it’s like to experience the 2016 election as both a conservative and a sex abuse survivor(Nancy French, Washington Examiner, 10-21-16) "Some found out about the abuse several years later, but nothing changed. The preacher was too valuable to confront?...My party — which should’ve been a place of a certain set of values — now shelters an abuser [Trump]. I’m thinking of this when the GOP presses against me and asks me to close my eyes just one more time."
• Addressing Rape in Four Minutes or Less: Dating App Reps Left Unprepared to Respond to Assault Victims ( Brian Edwards, Elizabeth Naismith Picciani, Sarah Spicer and Keith Cousins, Columbia Journalism Investigations, ProPublica, 5-17-21) At OkCupid and other dating apps, moderators are expected to resolve customer claims of sexual assault in minutes — and with no special training.
• Sexual assault (WomensHealth.gov) "Sexual assault is any type of sexual activity or contact that you do not consent to. Sexual assault can happen through physical force or threats of force or if the attacker gave the victim drugs or alcohol as part of the assault. Sexual assault includes rape and sexual coercion. In the United States, one in three women has experienced some type of sexual violence.1 If you have been sexually assaulted, it is not your fault, regardless of the circumstances." Answers to many questions about sexual assault.
• An Unbelievable Story of Rape (T. Christian Miller, ProPublica and Ken Armstrong, The Marshall Project, 12-16-15) An investigative piece. Marie’s case led to changes in practices and culture.

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• Unheard (Adriana Gallardo , Nadia Sussman and Agnes Chang, ProPublica , and Kyle Hopkins and Michelle Theriault Boots, Anchorage Daily News, 6-1-2020) Alaska has the highest rate of sexual assault in the nation. Yet it is a secret so steeped into everyday life that discussing it disrupts the norm. These women and men did not choose to be violated, but they now choose to speak about what happened. Hundreds of survivors have shared their stories.
• Sexual assault and rape on U.S. college campuses: Research roundup (Kristina Mastropasqua, Journalist's Resource, 9-22-15) The Rape, Abuse and Incest National Network (RAINN) provided the White House with an extensive list of recommendations urging “the task force to remain focused on the true cause of the problem,” pointing out that rape is “not caused by cultural factors but by the conscious decisions of a small percentage of the community to commit a violent crime.” In fact, RAINN points out that research suggests 90% of rapes at colleges are perpetrated by 3% of college men — indicating a real issue of repeat offenders.
• What Experts Know About Men Who Rape (Heather Murphy, NY Times, 10-30-17)
• Why Don't Police Catch Serial Rapists? An Epidemic of Disbelief (Barbara Bradley Hagerty, The Atlantic, Aug.2019) What new research reveals about rape kits, and why police fail to catch serial rapists. Police officers continue to reflexively disbelieve women who say they've been raped. But in 49 out of every 50 rape cases, the alleged assailant goes free—often, we now know, to assault again. Previously, officers didn't bother to test rape kits in so-called acquaintance-rape cases, instances in which the victim knew the assailant. But some of these men are likely repeat offenders; testing their DNA can help solve other cases. When kits go untested, sexual predators can flourish.

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• Why the Backlog Exists (End the Backlog) The backlog of untested rape kits represents the failure of the criminal justice system to take sexual assault seriously, prioritize the testing of rape kits, protect survivors, and hold offenders accountable. Here are key factors contributing to creation of the backlog.
• When Abuse Victims Commit Crimes (Victoria Law, The Atlantic, 5-21-19) New laws in New York and elsewhere could keep women out of prison for crimes against their abusers.
• How Brett Kavanaugh Got the Last Laugh (Megan Garber, The Atlantic, 9-19) Far beyond the news it breaks, The Education of Brett Kavanaugh is a reminder that many Americans still doubt the seriousness of sexual-misconduct allegations. Essay and book by the Times reporters Robin Pogrebin and Kate Kelly.
• The Dueling Data on Campus Rape (Dana Goldstein, Justice Lab, The Marshall Project, 12-11-14) Some of the research issues that account for divergent statistics.
• What a New Survey Can — and Can’t — Tell Us About Campus Sexual Assault (Jesse Singal, Science of Us, New York Magazine, 5-20-15) As Dana Goldstein explained, above, "two different approaches to estimating the rate of rape on campus, both conducted by professionally trained researchers, led to results — 0.6 percent versus the famous “one in five” figure often cited in these discussions — separated by a chasm."

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• The Truth Could Set Them Free (Steven Yoder, Reason, 3-1-2020) Jesus Padilla, an Atascadero psychologist, was four years into a study of ex-offenders classified as "sexually violent predators" (SVPs) who had been released on technical grounds. That designation let them civilly commit them to Atascadero, much the way people with mental health issues can be locked up when they are deemed a threat to themselves or others. Padilla explained that of the 93 ex-offenders he and a colleague had tracked, just six had been rearrested for an alleged sexual crime after about five years in the community. That amounts to an astonishingly low rearrest rate of 6.5 percent. (A 2018 study by the federal Bureau of Justice Statistics found that 49 percent of all state prisoners were arrested again for the same type of offense within five years of their release.) Why did California destroy this research into a group of people it says are dangerous enough to be locked up indefinitely?
• ICE Detention Center Says It’s Not Responsible for Staff's Sexual Abuse of Detainees (Victoria López and Sandra Park, ACLU, 11-6-18) The Prison Rape Elimination Act was passed by Congress in 2003 to protect against sexual assault in prisons and jails across the country. It took the Department of Homeland Security until 2014 to finalize regulations implementing PREA. Immigrants in detention are put at serious risk for sexual violence while they are detained because officials are not doing enough to detect and respond to incidents of sexual abuse. The Trump administration continues to aggressively target immigrants and asylum seekers by stripping away legal protections, ramping up enforcement, and expanding immigration detention.
• ‘An Entire Community Got Together to Rape a Child’: India Recoils at Girl’s Assault (Kai Schultz and Suhasini Raj, NY times, 7-18-18) In the gated community in Chennai, India, a group of men took turns raping an 11-year-old girl.
• Here Are All the Public Figures Who’ve Been Accused of Sexual Misconduct After Harvey Weinstein (Samantha Cooney, Time, 3-27-19)
• Harvey Weinstein’s Last Campaign (Ken Auletta, New Yorker, 5-30-22) How the Hollywood producer lost control of the story during his criminal trial in New York. “Although this is a first conviction, it is not a first offense,” said Justice Burke, at the end of the trial. 'As it happened, on March 6th, Vance had submitted to the court a report detailing dozens of additional instances in which Weinstein had allegedly sexually assaulted women. Now Burke said that he had looked at the “evidence before me of other incidents . . . all of which are legitimate considerations for sentence.” He sentenced Weinstein to twenty years for criminal sexual assault and three years for third-degree rape.' Now he faces a similar trial in Los Angeles.
• She Stayed Silent When a Producer Turned Sexual Predator Went After a Friend (Elisabeth Egan, NY Times, 8-14-22) In her new novel, “Complicit,” Winnie M Li explores the collateral damage of assault on both victims and witnesses. A woman looks back on a brief, shining stint in the movie industry and reckons with regrettable decisions she made in the name of ambition.
• All the Other Harvey Weinsteins (Molly Ringwald, New Yorker, 10-17-17) We all seem to have a Harvey story, each one a little different but with essentially the same nauseating pattern and theme. Women were bullied, cajoled, manipulated, and worse, and then punished.

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• ‘Where there is more rape culture in the press, there is more rape’ (Denise-Marie Ordway, Dart Center, 9-7-18) 'Rape occurs more often in communities where the news media reflects “rape culture” — the tone of the coverage and word choices can be interpreted as showing empathy for the accused and blame for victims, according to a new study published in the Quarterly Journal of Political Science.'
• Jesuits identify 33 Alaska clergy and volunteers ‘credibly accused’ of sexually abusing children (Kyle Hopkins, Anchorage Daily News, 12-26-18) Created by Jesuits West, a Dec. 7 report puts names, places and dates to generations of sexual abuse inflicted by ordained priests, church volunteers and employees in 35 villages and cities across Alaska. Many of the offender priests were assigned by the church to tiny Alaska communities, prompting accusations that remote villages here became dumping grounds for predators. Jesuit leaders have denied that the order used Alaska as a hiding place for pedophile clergy. See also Lawless (5-16-19) At least one in three Alaska villages has no local law enforcement. Sexual abuse runs rampant, public safety resources are scarce, and Gov. Mike Dunleavy wants to cut the budget.
• The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse by Ellen Bass & Laura Davis. Although the effects of child sexual abuse are long-term and severe, healing is possible.

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The medical use of cannabis

(and/or marijuana, psychedelics)

• Healing with Cannabis: The Evolution of the Endocannabinoid System and How Cannabinoids Help Relieve PTSD, Pain, MS, Anxiety, and More by Cheryl Pellerin. Cannabis, approved for medical use in at least 35 states, is also available without a prescription in 11 states, Washington DC, and 2 US territories.
• The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research (press release, National Academies of Sciences, Engineering, and Medicine, 1-12-17) A once-over-lightly summary of what the evidence supports (ranging from their therapeutic effects to their risks for causing certain cancers, diseases, mental health disorders, and injuries). Download the report free or read online here.

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• Is the hype about CBD, or cannabidiol, real? (Steven Petrow, WaPo, 1-4-19) CBD, or cannabidiol, is most commonly extracted from hemp, but it can also come from marijuana plants, which is why it is sometimes confused with its trippy chemical cousin THC. Unlike CBD, THC produces a high when smoked or eaten....In my small North Carolina town, a flier at the local convenience store exhorts me to “experience the phenomenon” of CBD products, promising it can provide “relief from” diabetes, alcoholism, schizophrenia, back and knee pain, and other conditions....

"I am now taking a CBD tincture daily. After all the hype, I wanted to see whether it might have a positive impact on my lifelong struggle against depression....Despite the growing popularity of CBD, the science supporting the claims remains pretty slim at this point. So why so much interest in a substance researchers still know so little about? I’d say hype, hope and big bucks....With scant regulation, consumers should be skeptical. The source matters, too, since heavy metals or other contaminants have been found in some hemp grown in China or Eastern Europe.

“People who are buying [CBD products] on Amazon, or at their local health food store, are really working without a [safety] net,” says Michael Backes, author of Cannabis Pharmacy: The Practical Guide to Medical Marijuana. One study found that nearly 70 percent of CBD products they analyzed were mislabeled, overlabeled (containing significantly more than the label indicates), or underlabeled (not giving you a dose large enough to achieve any potential therapeutic effect" or containing "THC in amounts that could make you intoxicated or impaired"). Rigorous studies are needed to prove--or disprove--the anecdotal information about CBD.
• Is CBD Helpful, or Just Hype? (Richard A. Friedman, NY Times, 12-26-18) Let’s see what the research says before pouring it into our tea and rubbing it all over our bodies.
• DCRx: The DC Center for Rational Prescribing runs a Continuing Medical Education program on Medical Cannabis for Pain, among other topics, with excellent resources online, including slides and video of presentations, Q&A etc. There is an option to click for non-CME access for the general public.
• The Medical Use of Marijuana v. The Use of Marijuana for Medical Purposes (Bradley Steinman, American Bar Association)
• Cannabis for Elders: A Precarious State (Liana Aghajanian, The Atlantic, 7-22-13)

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• The Complete Guide to Medical Marijuana for Elders (National Council for Aging Care)
• It’s time to legalize marijuana at the federal level (Rep. Joe Kennedy III, STAT, 11-20-18) State-level legalization on marijuana has created a patchwork of laws. We need strong, clear, and fair federal guidelines on marijuana. Our federal policy on marijuana is badly broken, benefiting neither the elderly man suffering from cancer whom marijuana may help nor the young woman prone to substance use disorder whom it may harm. The patchwork of inconsistent state laws compounds the dysfunction. Our federal government has ceded its responsibility — and authority — to thoughtfully regulate marijuana. As long as marijuana remains regulated by the Controlled Substances Act, the federal government is barred from rectifying these failures or acting with any oversight authority as states move ahead with reform at record pace. So a broken, patchwork system flourishes in our country today with no federal guardrails — like the ones we have for alcohol and tobacco — to protect public health and safety and ensure equal justice.
• My Personal Experiences with the Medical Marijuana Business and the Opioid Epidemic (David Meerman Scott, Healthcare in America, 1-4-17) Marijuana is a safer alternative to opioids for pain relief, but you have to jump through hoops to qualify for medical marijuana. A business story that may prove helpful.
• Weed (Sanjay Gupta's documentary on medical marijuana)
• Marijuana stops child's severe seizures (Saundra Young, CNN, 8-7-13) Much good background information.

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• To Save Her Daughter, This Mom Became a Medical Marijuana Pioneer On a Facebook group of parents across the world with children with an incurable genetic disorder called CDKL5, one mother in the U.S. described giving her daughter cannabis-based medicines to mitigate the epileptic fits that are a symptom of the disorder. After figuring out the practical aspects of using such medicine for her daughter's condition, a mother in Brazil took on Brazil’s tangled legal system to become the first person in the country’s history with permission to grow cannabis for medicinal purposes. Other Brazilians, mostly parents of children with degenerative diseases, are forced to seek out expensive medical marijuana in clandestine fashion, risking punitive jail sentences if they are caught. The NGO Support for Patients and Research for Medicinal Marijuana (APEPI) pushes for advances in legalization and research permissions.
• Medical marijuana (Mayo Clinic) Despite a federal ban, many states allow use of medical marijuana to treat pain, nausea and other symptoms. Is medical marijuana legal under federal law in the U.S.? When is medical marijuana appropriate?
• Marijuana as Medicine (Drug Facts, National Institute on Drug Abuse, April 2017) The term medical marijuana refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions. The U.S. Food and Drug Administration (FDA) has not recognized or approved the marijuana plant as medicine. However, scientific study of the chemicals in marijuana, called cannabinoids, has led to two FDA-approved medications that contain cannabinoid chemicals in pill form. Continued research may lead to more medications. Because the marijuana plant contains chemicals that may help treat a range of illnesses and symptoms, many people argue that it should be legal for medical purposes. In fact, a growing number of states have legalized marijuana for medical use.
• News about Marijuana and Medical Marijuana, including commentary and archival articles published in The New York Times

RESEARCH ON MEDICAL MARIJUANA
• Many links here were posted as background Stories from the panel "Medical ramifications of legal marijuana", from a conference of the Association of Health Care Journalists (accessible only to members). As one member stated, "It's important to differentiate between oral THC, which is an FDA approved medication (dronabinol), and 'medical marijuana,' which if you're talking Colorado-style is just the smoked plant."
• Taking a science-informed approach to medical marijuana (Nora D. Volkow, director of the National Institute on Drug Abuse, Alcoholism & Drug Abuse Weekly, 4-27-15) "There is solid evidence that the main psychoactive ingredient in marijuana, THC, is effective at controlling nausea and boosting appetite. There is also some preliminary evidence that THC or related cannabinoid compounds such as cannabidiol (CBD) may also have uses in treating autoimmune diseases, inflammation, pain, seizures and psychiatric disorders, including substance use disorders. Despite claims of marijuana’s usefulness in treating post-traumatic stress disorder, supporting data is minimal, and studies have not investigated whether symptoms may worsen after treatment is discontinued." There is less support for some other claims of marijuana's health benefits, and "As public approval for medical marijuana grows, we need to ensure that our policy decisions are science-based and not swayed by the enthusiastic claims made widely in the media or on the Internet."

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• Gupta: 'I am doubling down' on medical marijuana (Sanjay Gupta, CNN, 3-6-14) Apologizing for having previously spoken against marijuana use, Gupta writes about "emerging science that not only shows and proves what marijuana can do for the body but provides better insights into the mechanisms of marijuana in the brain, helping us better understand a plant whose benefits have been documented for thousands of years. This journey is also about a Draconian system where politics overrides science and patients are caught in the middle."
• Weed (Sanjay Gupta's documentary on medical marijuana)
• America's Weed Rush , an investigation of marijuana legalization in America, is the 2015 project of the Carnegie-Knight News21 program, a national multimedia investigative reporting project produced by the nation’s top journalism students and graduates. 27 journalism students from 19 universities traveled through half the country to report on the politics, regulation and science behind the nation’s marijuana movement. Topics addressed: The science: Is marijuana safe? Medical marijuana: the demand for it.. Recreational marijuana--the push to regulate it. Money: the business and the complications therefrom. Law enforcement: How marijuana is pushing the limits of legality. Marijuana politics: Critics call legalization of marijuana out of control.
• Center for Medical Cannabis Research (CMCR) (best academic resource on medical marijuana; established by the California legislature to answer the question "Does marijuana have therapeutic value? Run by Igor Grant
• California pot research backs therapeutic claims (Peter Hecht, Sacramento Bee, 7-12-12) Three years after California voters passed the nation's first medical marijuana law in 1996, the legislature in 1999 approved funding for the nation's first sustained modern medical research for pot. University of California medical researchers slipped an ingredient in chili peppers beneath the skin of marijuana smokers to see if pot could relieve acute pain. It could – at certain doses....State-funded studies – costing $8.7 million – found pot may offer broad benefits for pain from nerve damage from injuries, HIV, strokes and other conditions....Igor Grant said he worries about a lack of standardization for medical marijuana. He suggests people buying pot at dispensaries – offering products far more potent than used in state research – is akin "to going to a flea market for an antibiotic."

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• Marijuana stops child's severe seizures (Saundra Young, CNN, 8-7-13) Good background information.
• Cannabis Science (My Chronic Relief) “Cannabis is the single most versatile herbal remedy, and the most useful plant on Earth. No other single plant contains as wide a range of medically active herbal constituents.”~Dr. Ethan Russo, Neurologist, Botanist and Cannabis Expert – Cannabinoid Research Institute (Google Russo's name for more stories)
• The Ad Block (Ed Mahon, Spotlight PA, 5-22) Pennsylvania lawmakers allow doctors to approve patients for medical cannabis but ban them from advertising that power, giving an advantage to largely unregulated certification businesses that stand to rake in millions of dollars each year. With millions of dollars at stake, companies are blanketing Pennsylvania with ads about how to get a medical marijuana card. But if doctors do the same, they risk their license.
• Cannabis for migraine treatment: the once and future prescription? An historical and scientific review (Ethan Russo, Pain, 1-26-98)
• No, legalizing medical marijuana doesn’t lead to crime, according to actual crime stats (Emily Badger, Washington Post, 3-26-14)
• Secondhand Marijuana Smoke (Marijuana and Public Health, CDC) Answers many frequently asked questions, including questions about marijuana's effects on general health.
• Seniors and Pot (stories from The Cannabist, the Denver Post's website on all things pot, from laws to research to strains of weed)

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• Suicide rates fall when states legalize medical marijuana, says new study ( Scot Kersgaard, Colorado Independent, 2-24-12)
• Why Medical Marijuana Laws Reduce Traffic Deaths (Maia Szalavitz, Time, 12-2-11)
• Efficacy and safety of medical cannabinoids in older subjects: a systematic review. (GA van den Elsen and others, Ageing Res Rev, Epub 2014 Feb 5) " The studies showed no efficacy on dyskinesia, breathlessness and chemotherapy induced nausea and vomiting. Two studies showed that THC might be useful in treatment of anorexia and behavioral symptoms in dementia. Adverse events were more common during cannabinoid treatment compared to the control treatment, and were most frequently sedation like symptoms. Although trials studying medical cannabinoids included older subjects, there is a lack of evidence of its use specifically in older patients. Adequately powered trials are needed to assess the efficacy and safety of cannabinoids in older subjects, as the potential symptomatic benefit is especially attractive in this age group." To access this and other articles about seniors and medical marijuana, see PubMed.

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• Teen Marijuana Use May Show No Effect On Brain Tissue, Unlike Alcohol, Study Finds (Kathleen Miles, Washington Post, 12-23-12)
• Graduation rates up in Colorado, South High leads Denver school gains (Denver Post, 1-23-14)
Am posting the following here only because I found no more logical place, and it's interesting:
• ‘It’s not medical’: Oregon wrestles with how to offer psychedelics outside the health care system (Olivia Goldhill, STAT, 3-10-22) Starting in 2023, Oregon will be the first state with widely legalized psychedelics. Technically, the state didn’t approve psychedelic therapy, though the program is often interpreted as such. Ballot Measure 109, which passed in November 2020, gave the Oregon Health Authority (OHA) the job of overseeing magic mushroom consumption at “service centers,” in the presence of “licensed facilitators.”

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HOSPITALS AND HOSPITALIZATION
WHAT YOU NEED TO KNOW

What you need to know about hospitals and surgeons
Ratings and report cards about U.S. hospitals
Informative articles and books about hospitals and hospital ratings
Managing hospitalization and after
Hospitals and hospital systems: issues within the industry

What you need to know about hospitals

• What Is Hospital Observation Status? (Elizabeth Davis, RN, VeryWell Health, 10-9-19) When you check into a hospital you are usually assigned either observation status or inpatient status. If the hospital assigns observation status, you will pay more because you'll pay outpatient prices (even if a service is precisely the same as if you were inpatient status). If you're in the hospital less than three days, you're likely to be considered observation status, so cheer if you're told you've just reached inpatient status as your health insurance and Medicare will pick up more of the tab.
• Medicare's Challenging Relationship with Hospitals (Globe1234.com) Important information.
• How to Look Up Prices at Your Hospital, if They Exist (Sarah Kliff, The Upshot, NY Times, 8-22-21) Start with a web search. Consider a third-party tool. Expect frustration.
• Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why. (Sarah Kliff and Josh Katz, The Upshot, NY Times, 8-22-21) Scroll down for "Prices for a drug that prevents rabies."

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• Hospitals’ Trauma Care Prices Differed Wildly In 2023: Study (Morning Briefing, KFF Health News, 4-17-24) A new study found prices were so unpredictable between hospitals that some insured patients needing trauma care even ended up with more bills than uninsured people did. Stat, meanwhile, covers tech startups who are making money out of hospital price transparency rules.
• Hospital Prices Must Now Be Transparent. For Many Consumers, They’re Still Anyone’s Guess. (Julie Appleby, NPR and KHN, 7-2-21) Long hidden, huge variations in pricing for procedures such as a colonoscopy are supposed to be available in stark black and white under a Trump administration price transparency rule that took effect at the start of this year. It requires hospitals to post a range of actual prices — everything from the rates they offer cash-paying customers to costs negotiated with insurers. Many have complied. But a sizable minority have not and some hospitals bury the data deep on their websites or have not included all the categories of prices required, according to industry analysts. Appleby suggests how to find the prices (for example, doing a search for "hospital transparency" and the name of a hospital to find their price disclosure page). And check out Turquoise Health:
• State of hospital price transparency (with interactive maps!) (Chris Severn, Turquoise Health, 3-31-21) Let's dive in to the pricing data from 2000+ hospitals. What is the state of compliance with the January 1st price transparency rule?
• Data on Hospitals Paul Burke's excellent Data on Hospitals (Globe1234.info)
• Cost Reports by Fiscal Year (Research statistics, Centers for Medicare & Medicaid Services, CMS.gov)
• How Rich Investors, Not Doctors, Profit From Marking Up ER Bills (Isaac Arnsdorf, ProPublica, 6-12-20) TeamHealth, a medical staffing firm owned by private-equity giant Blackstone, charges multiples more than the cost of ER care. All the money left over after covering costs goes to the company, not the doctors who treated the patients. See also This Doctors Group Is Owned by a Private Equity Firm and Repeatedly Sued the Poor Until We Called Them (Wendi C. Thomas, MLK50: Justice Through Journalism, with Maya Miller, Beena Raghavendran and Doris Burke, Profiting from the Poor: Inside Memphis' Debt Machine, ProPublica, 11-27-19) After the Blackstone Group acquired one of the nation’s largest physician staffing firms in 2017, low-income patients faced far more aggressive debt collection lawsuits. They only stopped after ProPublica and MLK50 asked about it.

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• Revealing the secret prices insurers pay can save health care (Marty Makary and Ge Bai, STAT News, 5-2-19) "Insurers and hospitals keep the prices they negotiate confidential. Insurers then sell these secret pricing deals to employers, who are also contractually bound to keep them secret. In the process, hospitals have become seasoned veterans in playing the sometimes absurd price markup-discount game that creates mirages of generous discounts.This game gives hospitals a profit margin they can control. It also allows some hospitals to appear charitable when they offer a 20% discount to an out-of-network patient even though the bill may be marked up by 500%....If real prices were disclosed, we would see the same fierce competition that now dominates the airline industry change the business of medicine.The absence of real prices also fuels the problem of price gouging and predatory billing."

• Diagnosis: Debt “Diagnosis: Debt” is a reporting partnership between Kaiser Health News (KHN) and NPR (Shots) exploring the scale, impact, and causes of medical debt in America. An investigation of more than 500 U.S. hospitals show that many use aggressive practices to collect on unpaid medical bills. More than two-thirds have
---Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours? (Noam N. Levey, KHN, 12-22)
• Sick and struggling to pay, 100 million people in the U.S. live with medical debt (Noam Levey, NPR, 6-16-22) The U.S. health system now produces debt on a mass scale, a new investigation shows. Patients face gut-wrenching sacrifices.
---'Medical cost-sharing' plan left this pastor on the hook for much of a $160,000 bill (Shots/KHN, 1-9-23) Instead of health insurance, the Rev. Jeff King had signed up for an alternative that left members of the plan to share the costs of health care. That meant lower premiums, but a huge hospital bill.'
---Many U.S. hospitals sue patients for debts or threaten their credit. Does yours? (KHN, 1-12-22) An examination of billing policies and practices at more than 500 hospitals across the country shows widespread reliance on aggressive collection tactics.
---Lessons from Germany to help solve the U.S. medical debt crisis (Shots, NPR, 12-14-22) "Germany, like the U.S., has a largely private health care system that relies on private doctors and private insurers. Like Americans, many Germans enroll in a health plan through work, splitting the cost with their employer. But Germany has long done something the U.S. does not: It strictly limits how much patients have to pay out of their own pockets for a trip to the doctor, the hospital or the pharmacy."
---From Her View in Knoxville, the Health System Is ‘Not Designed for Poor People’ (KHN, 12-21-22) Monica Reed was the first in her family to own a home and has lived “a frugal kind of life.” Cancer treatment left her with almost $10,000 in debt, pushing her to the edge financially.
---An Air Force Career Held up Because of Debt Owed for Medical Bills * (Aneri Pattani, KHN, 12-21-22) “If you need people to be there for the country and to fight for the country, why would you hold them up for a medical bill?” ---
Readers and Tweeters Diagnose Greed and Chronic Pain Within US Health Care System (Kaiser Health News, 1-19-23)
---Her Credit Was Ruined by Medical Debt. She’s Been Turned Away From Doctors, Jobs, and Loans(Aneri Pattani, KHN, 12-21-22) When Penelope Wingard’s cancer went into remission, she lost her Medicaid coverage in North Carolina. Without insurance, the debts piled up for her follow-up care. She doesn’t think she’ll ever get ahead of it.
---How Banks and Private Equity Cash In When Patients Can’t Pay Their Medical Bills Hospitals strike deals with financing companies, generating profits for lenders, and more debt for patients.
---Knoxville’s Black Community Endured Deeply Rooted Racism. Now There Is Medical Debt. (Noam N. Levey, KHN, 10-28-22)
---Kids’ Mental Health Care Leaves Parents in Debt and in the Shadows (Yuki Noguchi, NPR News, 10-19-22)

Readers and Tweeters Diagnose Greed and Chronic Pain Within US Health Care System (KFF Health News, 1-18-23)

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• Hospital obstetrics on chopping block as facilities pare costs (Arielle Dreher, Axios, 1-17-23)

• Ratings for hospitals, surgical centers, doctors, surgeons, home health agencies, nursing homes (blog post)
• State Laws Ban Surprise Medical Bills. She Got One for $227K And Fought Back. Even With Insurance, She Faced $227K In Medical Bills. What It Took To Get Answers. (JoNel Aleccia, KHN, 3-22-19) The first surprise was the massive heart attack, which struck as Debbie Moehnke waited in a Vancouver, Wash., medical clinic last summer. “She had an appointment because her feet were swollen real bad,” said Larry Moehnke, her husband. “But she got in there and it was like, ‘I can’t breathe, I can’t breathe!’” Her life suddenly at risk, the 59-year-old was rushed by ambulance, first to a local hospital, where she was stabilized, and then, the next day, to Oregon Health & Science University across the river in Portland for urgent cardiac care....
• UVA Doctors Decry Aggressive Billing Practices By Their Own Hospital (Jay Hancock, KHN, 11-23-19) A Kaiser Health News report in September showed that UVA sued 36,000 patients over six years for more than $100 million, seizing wages and savings and even pushing families into bankruptcy. Over six years, the [Virginia] state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds. Like many physicians who work at U.S. medical centers, the UVA doctors said they had little idea how aggressively the hospital where they practice was billing and pursuing their patients for payment. Court data analyzed by KHN showed that UVA Health was suing about 100 of its employees every year. See also ‘UVA Has Ruined Us’: Health System Sues Thousands Of Patients, Seizing Paychecks And Claiming Homes (Jay Hancock and Elizabeth Lucas, KHN, 9-10-19)
• Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next? (Sarah Jane Tribble, KHN, 5-14-19) A former nurses station sits empty at the closed Mercy Hospital in Fort Scott, Kan., with the message: “Gone but not forgotten.” After depending on the local hospital for more than a century, Fort Scott residents now are trying to cope with life without it. After depending on the local hospital for more than a century, Fort Scott residents now are trying to cope with life without it.
• Hospital Financial Analysis: True Cost of Healthcare (David Belk MD, True Cost of Healthcare). What do the carefully researched numbers reveal? "The revenue for any health insurance company is tied directly to its expenses. In other words, the more a health insurance company spends each year, the more revenue they can earn (through premium increases the next year). Therefore, the last thing any health insurance company would want is for their overall expenses to drop. If their expenses were to drop, they couldn’t justify raising (or even maintaining) the amount they charge policy holders in premiums. That would be a disaster for them.
Since hospital utilization has been declining overall, it would be hard for private health insurance companies to continue to show an increase in their costs each year unless they deliberately overpaid hospitals, so that’s exactly what they do. Hospitals don’t mind being overpaid, so they’re not complaining. Since hospital bills always show enormous discounts from the insurance companies (due to persistent over-billing) most people wouldn’t suspect what the insurance companies are really doing. This way, both sides can work together to profit from our ignorance."

RATINGS AND REPORT CARDS ON U.S. HOSPITALS, DOCTORS, AND HEALTH CARE RESOURCES

• Citizens for Patient Safety Links to relevant organizations around the country and other resources. "A conversation can change an outcome. A conversation can change a life."
• Dollars for Docs (Mike Tigas, Ryann Grochowski Jones, Charles Ornstein, and Lena Groeger, ProPublica, 6-28-18 and they do update) Pharmaceutical and medical device companies are required by law to release details of their payments to a variety of doctors and U.S. teaching hospitals for promotional talks, research and consulting, among other categories. Use this tool (Find surgeons and hospitals near your location) to search for general payments (excluding research and ownership interests) made from August 2013 to December 2016. Has your doctor received drug or device company money?
• Globe1234 (researcher Paul Burke's site, which summarizes information (mostly from Medicare) about doctors and hospitals. Worth exploring. If you click on an article--for example, Medicare's Challenging Relationship with Hospitals--along right side of page you can see links to other topics covered. See in particular Hospital Quality and Incentives and Doctors' Quality and Incentives .
• Health Grades (ratings for physicians)
• Guidestar (a major source of information on nonprofit organizations, including nonprofit hospitals)
• Health Watch USA (an invaluable resource: a nonprofit patient advocacy organization that promotes healthcare value, transparency, and quality--spend time exploring its website)

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• Hospital Compare (Centers for Medicare & Medicaid Services, a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients) Start by choosing three local hospitals to compare. See caveats about this site at Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes (a blog post on this site).
• HospitalFinances.org ("Bringing transparency to nonprofit hospital finances"--Association of Health Care Journalists). The site includes details of Form 990 filings made by nonprofit hospitals and systems to the U.S. Internal Revenue Service. It does not include for-profit or government-owned hospitals.
• Hospital Infections (Association of Health Care Journalists: "Bringing transparency to federal inspections.") Search hospital inspections. Links to many other resources (some only for members of AHCJ).
• Hospital Ratings and Reports (The Leapfrog Group) How transparency is driving leaps forward in hospital care in this country. Hospitals across the country demonstrate their commitment to transparency and quality improvement through the voluntary Leapfrog Hospital Survey.
• U.S. News Best Hospitals

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• Leapfrog Hospital Safety Grade How safe is your hospital? Check this database to learn what grade it earned. See also
---Reports on Hospital and ASC Performance (Each year, The Leapfrog Group asks every adult and free-standing pediatric general acute-care hospital and Ambulatory Surgery Center in the U.S. to voluntarily complete the Leapfrog Hospital Survey and the Leapfrog ASC Survey.)
---Patient Experience During the Pandemic (three reports: Outpatient Surgical Care, Adult Inpatient Care, Pediatric Care)
---Room for Better Safety at Surgery Centers, Survey Finds (Joyce Frieden, MedPage Today, 10-22-19) Leapfrog Group finds gaps in board certification, hand hygiene monitoring.
• Medicare Compare search pages
---Dialysis Compare
---Home Health Compare
---Hospital Compare
---Inpatient Rehabilitation Facility Compare
---Long-Term Care Hospital Compare
---Medicare Plan Finder
---Nursing Home Compare
---Physician Compare
• Medicare Provider Utilization and Payment Data (CMS.gov--Centers for Medicare and Medicaid Services). CMS has released a series of publicly available data files that summarize the utilization and payments for procedures, services, and prescription drugs provided to Medicare beneficiaries by specific inpatient and outpatient hospitals, physicians, and other suppliers.

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• The Never Events Collaborative (The Patient Safety Network of the Agency for Healthcare Research and Quality).
• Never Events The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur. Over time, the term's use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. Since the initial never event list was developed in 2002, it has been revised multiple times, and now consists of 29 "serious reportable events" grouped into 7 categories:
Surgical or procedural events
Patient protection events

Care management events

Environmental events

Product or device events
Radiologic events

Criminal events.

Publica's database provides summary data for nonprofit tax returns and PDFs of full Form 990 documents, including those for most nonprofit hospitals.ronmental evets
• Open Payments (Openpaymentsdata.cms.gov) The Open Payments Search Tool is used to search payments made by drug and medical device companies to physicians and teaching hospitals.
• Nonprofit Explorer. Pro Publica's database provides summary data for nonprofit tax returns and PDFs of full Form 990 documents, including those for most nonprofit hospitals.

• Quality Check Search and compare hospitals that have received a gold seal of approval by The Joint Commission, which oversees the accreditation and certification of nearly 21,000 healthcare organizations and programs in the U.S.
• Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes (links to various rating systems and ratings--invaluable information, available publicly--be a smart patient and check things out!)
• Surgeon Scorecard (Sisi Wei, Olga Pierce and Marshall Allen, ProPublica, 7-15-15) Guided by experts, ProPublica calculated death and complication rates for surgeons performing one of eight elective procedures in Medicare, carefully adjusting for differences in patient health, age and hospital quality. Use this database to know more about a surgeon before your operation.

INFORMATIVE ARTICLES AND BOOKS ABOUT HOSPITALS AND HOSPITAL ISSUES

• Diagnosis: Debt “Diagnosis: Debt” is a reporting partnership between Kaiser Health News (KHN) and NPR (Shots) exploring the scale, impact, and causes of medical debt in America. An investigation of more than 500 U.S. hospitals show that many use aggressive practices to collect on unpaid medical bills. More than two-thirds have
---Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours? (Noam N. Levey, KHN, 12-22)
• Sick and struggling to pay, 100 million people in the U.S. live with medical debt (Noam Levey, NPR, 6-16-22) The U.S. health system now produces debt on a mass scale, a new investigation shows. Patients face gut-wrenching sacrifices.
---'Medical cost-sharing' plan left this pastor on the hook for much of a $160,000 bill (Shots/KHN, 1-9-23) Instead of health insurance, the Rev. Jeff King had signed up for an alternative that left members of the plan to share the costs of health care. That meant lower premiums, but a huge hospital bill.'
---Many U.S. hospitals sue patients for debts or threaten their credit. Does yours? (KHN, 1-12-22) An examination of billing policies and practices at more than 500 hospitals across the country shows widespread reliance on aggressive collection tactics.
---Lessons from Germany to help solve the U.S. medical debt crisis (Shots, NPR, 12-14-22) "Germany, like the U.S., has a largely private health care system that relies on private doctors and private insurers. Like Americans, many Germans enroll in a health plan through work, splitting the cost with their employer. But Germany has long done something the U.S. does not: It strictly limits how much patients have to pay out of their own pockets for a trip to the doctor, the hospital or the pharmacy."
---From Her View in Knoxville, the Health System Is ‘Not Designed for Poor People’ (KHN, 12-21-22) Monica Reed was the first in her family to own a home and has lived “a frugal kind of life.” Cancer treatment left her with almost $10,000 in debt, pushing her to the edge financially.
---An Air Force Career Held up Because of Debt Owed for Medical Bills * (Aneri Pattani, KHN, 12-21-22) “If you need people to be there for the country and to fight for the country, why would you hold them up for a medical bill?” ---
Readers and Tweeters Diagnose Greed and Chronic Pain Within US Health Care System (Kaiser Health News, 1-19-23)
---Her Credit Was Ruined by Medical Debt. She’s Been Turned Away From Doctors, Jobs, and Loans (Aneri Pattani, KHN, 12-21-22) When Penelope Wingard’s cancer went into remission, she lost her Medicaid coverage in North Carolina. Without insurance, the debts piled up for her follow-up care. She doesn’t think she’ll ever get ahead of it.

---How Banks and Private Equity Cash In When Patients Can’t Pay Their Medical Bills Hospitals strike deals with financing companies, generating profits for lenders, and more debt for patients.
---Knoxville’s Black Community Endured Deeply Rooted Racism. Now There Is Medical Debt. (Noam N. Levey, KHN, 10-28-22)
---Kids’ Mental Health Care Leaves Parents in Debt and in the Shadows (Yuki Noguchi, NPR News, 10-19-22)

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• Hospital obstetrics on chopping block as facilities pare costs (Arielle Dreher, Axios, 1-17-23)

• When Hospitals Merge to Save Money, Patients Often Pay More (Reed Abelson, NY Times, 11-4-18) The nation’s hospitals have been merging at a rapid pace for a decade....The hospitals have argued that consolidation benefits consumers with cheaper prices from coordinated services and other savings. But an analysis conducted for The New York Times shows the opposite to be true in many cases. The mergers have essentially banished competition and raised prices for hospital admissions in most cases...The analysis showed that the price of an average hospital stay soared, with prices in most areas going up between 11 percent and 54 percent in the years afterward, according to researchers from the Nicholas C. Petris Center at the University of California, Berkeley. The new research confirms growing skepticism among consumer health groups and lawmakers about the enormous clout of the hospital groups. While most political attention has focused on increased drug prices and the Affordable Care Act, state and federal officials are beginning to look more closely at how hospital mergers are affecting spiraling health care costs."
• Emergency rooms are monopolies. Patients pay the price. (Sarah Kliff, Vox, 12-4-17) New data shows how emergency rooms take advantage of their market share, at the expense of their patients.

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• Healthcare Associated Infections (Neverevents.org) Learn about MRSA, C.Diff infections, CLABSI infections, CAUTI infections, VAP infections, prevention of infection events.
• Hospitals find asthma hot spots more profitable to neglect than fix (Jay Hancock, Rachel Bluth of Kaiser Health News and Daniel Trielli of Capital News Service, Washington Post, 12-4-17) Baltimore paramedic crews make more asthma-related visits per capita in 21223 than anywhere else in the city, according to fire department records. It is the second-most-common Zip code among patients hospitalized for asthma, which, when addressed properly, should never require emergency visits or hospitalization. This neighborhood in southwest Baltimore is in the shadow of prestigious medical centers — Johns Hopkins, whose researchers are international experts on asthma prevention, and the University of Maryland Medical Center (UMMC). Both receive massive tax breaks in return for providing “community benefit,” a poorly defined federal requirement that they serve their neighborhoods. But like hospitals across the country, the institutions have done little to address the root causes of asthma. The perverse incentives of the health-care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.
• How Much Hospitals Charge For the Same Procedures (New York Times)

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• How to Choose a Hospital (Joel Keehn, Consumer Reports, 3-30-17)
• 60 things to know about the hospital industry | 2016 (Becker's Hospital Review, 1-14-16)
• Lawsuit accuses HCA hospital of covering up medical error that led to patient's death (Megan Knowles, Becker's Hospital Review, 6-21-18) A good website to explore if you're digging deep for information.
• Maximizing Infection Protection in the Next Decade: Defining the Unacceptable (Thomas R. Frieden, Infection Control and Hospital Epidemiology, Oct. 2011) Thomas R. Frieden, Director of the CDC, has stated “Evidence indicates that, with focused efforts, these once formidable infections can be greatly reduced in number, leading to a new normal for healthcare-associated infections as rare, unacceptable events."
• The Problem With Satisfied Patients (Alexandra Robbins, The Atlantic, 4-17-15) A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.
• Overuse of healthcare. See The Treatment Trap: How the Overuse of Medical Care is Wrecking Your Health and What You Can Do to Prevent It by Rosemary Gibson and Janardan Prasad Singh

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• What journalists should know about hospital ratings (Liz Seegert, Covering Health, Association of Health Care Journalists, 6-24-16) "Journalists should take hospital ratings with a healthy dose of skepticism, according to experts at a recent AHCJ New York chapter event. Simply looking at an institution’s overall rating is just the start. Reporting that without understanding what’s being rated and how 'success' is measured does a disservice to your audience."
What Makes A Good Surgeon? What Makes A Good Hospital? (Norman Bauman, Veins1.com, 9-10-07). Basically you get the best results in a hospital that does a lot of a particular procedure, and at that hospital, you get the best results with a surgeon who specializes in that procedure.
• Why Hospitals Need to Share Heart Surgery Success Rates (Catherine Roberts, Consumer Reports, 4-6-17) Consumers deserve full transparency about the performance of the hospitals they choose.
• Why Markets Can't Cure Health Care (Paul Krugman, NY Times, 7-25-09)
• Why Not the Best? (WNTB) Select and compare hospitals by region, health system, size, ownership, or type. Explore performance variation among different hospital groupings - by size, ownership, or type. Compare regions: Explore aggregate performance and population health in U.S. counties, hospital referral regions, and states. These data are Medicare/Medicaid discharges only.
• Yale-New Haven Hospital U.S. News ranking remains high but dips slightly (Ed Stannard, New Haven Register, 7-21-15) 'In addition to the complex care procedures, U.S. News rated the nation’s hospitals in five “common care” procedures that most hospitals perform, whether they are trauma centers like Yale-New Haven or less specialized hospitals. While it ranks high in specialties such as diabetes and gynecology, Yale-New Haven is rated average in heart bypass, hip replacement and heart failure and below average in knee replacement and chronic obstructive pulmonary disease. “Yale did not distinguish itself,” Harder said. “It was average or below average in each of those areas.”
---Best Hospitals for Adult Cancer (U.S. News & World Report)
---Best Hospitals for Adult Cardiology & Heart Surgery (U.S. News & World Report)
---Best Children's Hospitals 2015-16 (U.S. News & World Report)
---Best Hospitals for Adult Neurology & Neurosurgery

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Urgent care and emergency care: what you should know (they are not the same)

When is each appropriate?

Section on Emergency Care follows section on Urgent Care

URGENT CARE
• It’s Called an Urgent Care Emergency Center — But Which Is It? (Renuka Rayasam, KFF Health News, 6-24-24) Parkland’s Urgent Care Emergency Center is what’s called a freestanding emergency department. The number of freestanding emergency rooms in the United States grew tenfold from 2001 to 2016, drawing attention for sending patients eye-popping bills. Most states allow them to operate, either by regulation or lack thereof. Some states, including Texas, have taken steps to regulate the centers, such as requiring posted notices identifying the facility as a freestanding emergency department.

Urgent care centers are a more familiar option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER. But the difference between an urgent care clinic and a freestanding emergency room can be tough to discern. Putting the term “urgent” in the clinic’s name while charging emergency room prices is “disingenuous,” but happens often. Ask questions!
• There's a lot about price-gouging in the emergency room (ER) departments of hospitals. My own experience with a stand-alone Urgent Care facility was more positive. In 2013 I wasn't feeling well for several days, and my doctor was out of town when I called on day 3 to report a fever of 105.9. His assistant said to take a tepid bath--with no follow-up. On day 5 a neighbor took me to an Urgent Care facility on Rockville Pike, the doctor there examined me briefly and then called an ambulance, which rushed me to a hospital. That facility provided faster triage than I would have gotten at an ER, and I suspect arriving in an ambulance got me into a hospital room faster than walking in the door would have.

(I was hospitalized for four weeks total (with a break in the middle) with sepsis, from a urinary tract infection for which the only symptoms I was aware of were the high fever and a vague "not feeling well." As you age, you may no longer experience the normal symptoms of a urinary tract infection (UTI), one of the surprises of aging.)

So I had a positive experience with Urgent Care getting me to a hospital. But there are clearly problems in some systems.

• Urgent Care Versus the ER: A Pediatrician Offers Tips on Making the Right Choice (Johns Hopkins Medicine) To ER or not: "Sparing yourself and your child an unnecessary trip to the ER is not just a matter of convenience. A visit to the ER can expose your already sick kid to the ubiquitous hospital germs and other infections carried by fellow ER visitors. In addition, ER care generally more expensive than care received elsewhere. And because emergency departments are, by definition, designed to care for the sickest patients first, those with less severe illnesses are bound to have longer waits."

• How Urgent Is ‘Urgent’ Healthcare? (Ashley Rodriguez, Medium, 11-9-15)

As walk-in urgent care centers spread, so do questions about their expertise. As a marketing tool, the phrase 'urgent care' is luring patients with an implicit promise of fast treatment. They sound like places promising the kind of medical attention offered at emergency rooms. The reality is that these facilities face much less oversight, and many are not required to have emergency rooms. That is triggering a growing debate in state governments and among health care policy experts over how to regulate urgent care centers.

"Unlike emergency rooms, urgent care centers can decide whom they want to treat.They can accept those with insurance or patients who can pay up front. They can turn away patients who cannot pay....they typically refer patients with severe traumas and life-threatening conditions to an emergency room....In New York... there are no rules specifically regulating medical standards at urgent care centers, though there are plenty covering emergency rooms."
• It’s Called an Urgent Care Emergency Center — But Which Is It? ( Renuka Rayasam, Bill of the Month, KFF Health, 6-24-24)The number of freestanding emergency rooms in the United States grew tenfold from 2001 to 2016, drawing attention for sending patients eye-popping bills. Most states allow them to operate, either by regulation or lack thereof. Some states, including Texas, have taken steps to regulate the centers, such as requiring posted notices identifying the facility as a freestanding emergency department.
Urgent care centers are a more familiar option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER. But the difference between an urgent care clinic and a freestanding emergency room can be tough to discern.

• The Decision of Where to Seek Care Is Complicated by the Multitude of Options (Sam Whitehead, KHN, 1-11-23) “We’ve created this labyrinth health care system that is functioning to maximize profit,” Donovan said. “It does that by creating an ambiguous system that’s difficult to navigate, that’s constantly shoving more costs on the patients.” But revenue-driven and risk-averse operators of sites that act as alternatives to hospital emergency rooms have little incentive to make the process easier for patients.

The proliferation of care options — particularly urgent care centers and free-standing emergency departments — can make the head spin. Facilities have little incentive to clear up the confusion of where to go. But for patients, the wrong choice can mean big bills and possibly poor health outcomes.

Urgent care clinics can provide quicker access to cheaper care.

Free-standing emergency departments, on the other hand, tend to charge considerably higher prices for similar services. Free-standing emergency departments are often staffed by doctors with emergency medicine training. Many free-standing emergency departments don’t offer trauma services or have operating rooms onsite, even as they saddle patients with large bills. Federal law requires emergency departments at Medicare-participating hospitals to care for anyone who shows up. But the lack of clear guidelines on enforcement of the law sometimes stops emergency department doctors from redirecting patients to more appropriate facilities, physicians said. The law doesn’t apply to urgent care clinics and applies inconsistently to free-standing emergency departments.

• Can't Get In to See Your Doctor? Many Patients Turn to Urgent Care (Patti Neighmond, Shots, Morning Edition, NPR, 3-17-16) For many people, the centers have become a bridge between the primary care doctor's office and the hospital emergency room. Urgent care is not meant for life-threatening emergencies, such as a heart attack, stroke or major trauma, doctors say. But it is designed to treat problems considered serious enough to be seen that day — conditions like a cut finger, a sprained ankle, severe sore throat, or the sort of infection 25-year-old Dominique Page recently experienced.
• A Quicker Trip to the Doctor, for Minor Ailments (Ann Carrns, Your Money, NY Times, 12-19-13) “Typically, co-payments are more than an office visit but less than an emergency room visit.” Questions to ask.

• They were turned away from urgent care. The reason? Their car insurance (Sam Whitehead, Bill of the Month, NPR and KHN, 9-29-22) It's a pretty standard policy for urgent care centers not to treat injuries that result from car crashes, even minor ones. Urgent care centers aren't governed by the same laws as emergency rooms so they can be more selective about who they treat. Sometimes their reasons are financial, not clinical.
"Generally, as a rule, urgent care facilities do not take care of car accident victims regardless of the extent of their injuries, because it is going to go through that auto insurance claims process before the provider gets paid," she says. Urgent care centers often operate on thin margins and can't wait months and months for an auto insurance company to pay out a claim. "Unfortunately" people tend to learn about such policies when they show up expecting care.
"Horwitz dismisses the idea that a health system might push people in car wrecks from urgent care centers to emergency rooms to make more money off them. Still, auto insurance generally pays more than health insurance for the same services."

• 25 Things to Know About Urgent Care (Becker's Hospital Review, 8-19-13)

• Race Is On to Profit From Rise of Urgent Care (Julie Creswell, Business Day, NY Times, 7-9-14)

EMERGENCY CARE: A Broken System? And who should pay?

Managing medical bills: hospital, emergency rooms (ER),
urgent care, and "extras"

• Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why. (Sarah Kliff and Josh Katz, The Upshot, NY Times, 8-22-21) The price for an M.R.I. at Mass General is …
$1,019 with a Cigna plan.
$3,101 with an Aetna plan.
$3,809 with a Humana plan.

At the University of Mississippi Medical Center, a colonoscopy costs ...
$1,463 with a Cigna plan.

$2,144 with an Aetna plan.
$782 with no insurance at all.

”Hospitals charge patients wildly different amounts for the same basic services: procedures as simple as an X-ray or a pregnancy test.... major health insurers — some of the world’s largest companies, with billions in annual profits — negotiate surprisingly unfavorable rates for their customers. In many cases, insured patients are getting prices that are higher than they would if they pretended to have no coverage at all.

Do read the article
• Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win by investigative journalist Marshall Allen. Everything you need to know to deal with health insurance companies and health care providers, explaining what to do when faced with an invoice for out-of-pocket expenses. Says one reader "It is not only about purposeful fraud, it is also about purposeful incompetence on the part of those in healthcare facilities for creating and submitting the claims."
• Your Go-To Guide to Decode Medical Bills (Bill of the month, KHN, 7-25-19) KHN's pro tips for navigating surprise medical bills. Why you MUST understand these terms and what they imply about out-of-pocket costs (click thru on right side of box to get each explanation): Observation Status (Read this one for sure!), Ombudsman, Out-of-Network, Outpatient Clinic, Outpatient Services, Surprise Medical Bills, Triage, Urgent Care Provider, Balance Billing, Chargemaster, Coinsurance, Copay, Emergency Department or Emergency Room, Explanation of Benefits (EOB), Hospital, Inpatient Services ("just because you're lying on a hospital ward, in a hospital bed, doesn't mean you've been admitted"), Itemized Bill.
• He went to get medication for ADHD. MercyOne charged him nearly $1,500 in facility fees (Lee Rood, Des Moines Register, AOL, 3-11-24) When the 35-year-old father of six finally got bills for those visits, he said, he thought surely there’d been a mistake. Cigna Healthcare paid all but $20 of the $150 doctor bill for each visit, but Grabill was told he was personally responsible for paying $488.78 in hospital facility fees to MercyOne for each visit. For all three visits, the amount due was $1,466.34.

Facility fees have become a big reason why consumers are finding it increasingly difficult to pay their medical bills. The fees can far exceed those for the care itself and often aren’t covered by insurance. Especially vulnerable are those who need to meet high deductibles before insurance starts to cover some of the bill.

A federal rule that went into effect in January 2021 requires all hospitals operating in the United States to provide clear, accessible pricing information online about the items and services they provide. But getting hospitals to comply with that rule, which is poorly enforced, has been an issue across the country, numerous media outlets have reported.

How to Fight Facility Fees

Before you see a new provider, ask your insurer if it covers facility fees. If so, ask what portion of those fees will be covered and how much you will be responsible for paying.

When your doctor refers you to a new provider or specialist, ask whether the provider is hospital-owned or works for the same hospital health system.

When you make an appointment, ask whether you will be charged a facility fee.
• Wide variations in health care providers’ charges raise questions about the right rate (Joseph Burns, Covering Health, AHCJ, 9-2-2020) A report from the Pioneer Institute in Boston showed that Massachusetts consumers could have saved $22 million in 2015 if they got health care from lower-cost providers instead of from the highest-priced health care providers. In "Analysis of Spending on Shoppable Services in Massachusetts," researchers wrote that consumers could have saved $116.6 million if the savings were adjusted for inflation over four years. The researchers analyzed what providers charged in 2015 for 16 shoppable services, such as elective or non-emergent surgery.''
• Think drug costs are bad? Try hospital prices (Bob Herman, Axios, 7-25-18) Several pharmaceutical companies have recently said they'll delay some of their price increases, under pressure from the Trump administration. But hospitals have made no such concessions, even though they make up a much larger share of total health care spending.
• The Part of the ‘Free Britney’ Saga That Could Happen to Anyone (Christopher Magoon, KHN, 9-29-21) "When Britney Spears last went before a judge, she bristled as she told of being forced into psychiatric care that cost her $60,000 a month. Though the pop star’s circumstances in a financial conservatorship are unusual, every year hundreds of thousands of other psychiatric patients also receive involuntary care, and many are stuck with the bill.... While hospitals sometimes absorb the cost, patients can be left with ruined credit, endless collection calls and additional mistrust of the mental health care system. In cases in which a hospital chooses to sue, patients can even be incarcerated for not showing up in court."

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• An Unexplained Injury Discovered After Eye Surgery. What Should Happen Next? (Fred Clasen-Kelly, KHN, 11-29-22) Patients injured during a procedure can ask for a rebate or seek to have insurance copays waived, Caplan said. They can also file a complaint with a state medical board to try to find out what happened and whether professional standards were violated. Medical care is often unpredictable, but if an avoidable injury happens, the patient should not necessarily have to pay for that to be remedied.
• Bitter Pill: Why Medical Bills Are Killing Us (Stephen Brill, Time magazine, 3-4-13). See full story and sidebars, including Tips for Lowering Your Medical Bill.) Note that it's an old story.
• Readers and Tweeters Decry Medical Billing Errors, Price-Gouging, and Barriers to Benefits (Letters to the Editors, KHN, 11-28-22) A periodic feature. We welcome all comments and will publish a selection.
• Why An ER Visit Can Cost So Much — Even For Those With Health Insurance (Fresh Air, 3-3-19) Terry Gross interviews Vox reporter Sarah Kliff, who spent over a year reading thousands of ER bills and investigating the reasons behind the costs, including hidden fees, overpriced supplies and out-of-network doctors.
• About 1 in 6 Emergency Visits and Hospital Stays Had At Least One Out-of-Network Charge in 2017 The risk of getting a surprise medical bill is much greater in some states. For instance, emergency care visits were more likely to result in at least one out-of-network charge in Texas, New Mexico, New York, California and Kansas, and less likely in Minnesota, South Dakota, Nebraska, Alabama and Mississippi. See more on this topic under Pulling back the curtain on surprise medical bills and under and Examples of outrageous medical bills.
• It’s Not Just Hospitals That Sue Patients Who Can’t Pay (Blake Farmer, Nashville Public Radio and KHN, 2-21-2020) "Nashville General Hospital is a safety-net facility funded by the Tennessee capital city. For a patient without insurance, this is supposed to be the best place to go in a city with many hospitals. But for the uninsured, it may have been the worst choice in 2019. Its emergency room was taking more patients to court for unpaid medical bills than any other hospital or practice in town....What’s surprising to Mandy Pellegrin, who has researched medical billing in Tennessee at the nonpartisan Sycamore Institute, is that it was all happening at Nashville General — where treating uninsured patients is part of the hospital’s mission." Not a good way to encourage the poor to seek health care when they need it.

• Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why? (Michelle Andrews, Bill of the Month, KHN and NPR, 3-31-22) Colonoscopies can be classified as for screening or for diagnosis. How they are classified makes all the difference for patients’ out-of-pocket costs. Screening generally incurs no cost to patients under the ACA; diagnosis can generate bills. The Centers for Medicare & Medicaid Services has clarified repeatedly that under the preventive services provisions of the ACA, removal of a polyp during a screening colonoscopy is considered an integral part of the procedure and should not change patients’ cost-sharing obligations.
• A good alternative to having a colonoscopy? Maybe not (David Lazarus, LA Times, 8-21-14) There are few medical tests with as high a squirm factor as colonoscopies. Some of the alternative tests coming up have a high rate of false positives, so you end up getting the colonoscopy anyway, but they're being marketed directly to consumers, so they're getting customers.

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• Bad Bedside Manna: Bank Loans Signed in the Hospital Leave Patients Vulnerable (Shefali Luthra, KHN, 2-21-18) Hospitals are increasingly offering “patient-financing” strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills. Private doctors’ offices and surgery centers have long offered such no- or low-interest financing for procedures not covered by insurance, but promoting bank loans at hospitals and, particularly, emergency rooms raises concerns, experts say. "Low-income patients without insurance likely will not need loans to finance large bills, because they should quality for aid from the hospital, or be treated as charity care, Napier said." Read the full article before you get to an ER, so you won't be misled to accept one of these loans. The "cost estimates provided — likely based on a hospital’s list price — may be far higher than the negotiated rate ultimately paid by most insurers." Mark Rukavina, an expert in medical debt and billing, says, “If you pay zero percent interest on a seriously inflated charge, it’s not a good deal.
• Why journalists should go beyond surprise bills and report on narrow networks — especially in rural America (Kellie Schmitt, Remaking Health Care, Center for Health Journalism, 1-22-2020) The costly experience of paying out of pocket isn’t uncommon for people who have insurance but may not understand their network’s limitations until an accident or sudden health problem arises, says Simon Haeder has studied narrow health insurance networks for years. The problem is especially troublesome in rural America, regions already plagued with a sicker and poorer population, less public transport and the devastating toll of the opioid crisis.

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Pulling Back the Curtain on Surprise Medical Bills

The red roses are ready
The champagne is still chilling.
I love you more than private equity
Loves surprise medical billing.

~Joshua Israel on KHN

• ‘An Arm and a Leg’: Know Your ‘No Surprises’ Rights (Dan Weissmann, KHN, 2-2-22) Listen or read the transcript. The No Surprises Act is a new law that protects patients from one of the worst experiences the U.S. health care system has to offer — surprise out-of-network hospital bills. That’s when a person gets hit with a bill from an out-of-network provider at an in-network hospital. Under the new law, if a person visits an in-network hospital and is seen by an out-of-network provider, that provider and the insurer have to work it out for themselves. Patients are only on the hook for what they would’ve paid an in-network provider. That’s a big deal.

To be safe, patients should ask treating doctors whether they are in or out of network, even at an in-network hospital. The federal No Surprises Act, which took effect in 2022, prohibits medical providers or insurers from billing patients for out-of-network physician charges at an in-network hospital, unless the patient formally consents to an out-of-network doctor. Even resourceful consumers who appear to have the law on their side may find themselves in a losing, time-consuming battle with medical billing bureaucracies and facing collection actions.
• Here's what the new ban on surprise medical billing means for you (Julie Appleby, Shots, NPR, 12-30-21) The No Surprises Act (2021) generally forbids insurers from passing along bills from doctors and hospitals that are not covered under a patient's plan — such bills have often left patients to pay hundreds to tens of thousands of dollars in outstanding fees. Instead, the new law requires health care providers and insurers to work out a deal between themselves. Read the details!
• How to Avoid Surprise Bills — And the Pitfalls in the New Law (Dan Weissmann, KHN, 3-16-22) Patients are no longer required to pay for out-of-network care given without their consent when they receive treatment at hospitals covered by their health insurance since a federal law took effect at the start of this year. But you need to be aware of the law's protections! Studies have shown that about 1 in 5 emergency room visits result in a surprise bill. Surprise bills frequently come from emergency room doctors and anesthesiologists, among others — specialists who are often outside a patient’s insurance network and not chosen by the patient. Under the new law, instead of leaving the patient with an unexpected bill that insurance will not cover, the law says, the insurance company and the health care provider must work out how the bill gets paid.
• Know your (new) rights under the No Surprises Act… (Dan Weissmann, First Aid Kit, 1-19-22) The No Surprises Act addresses a widespread scam called “surprise bills.”

1. The No Surprises Act pretty much only applies to hospitals. Anywhere else you go, you’re out of luck.

2. Beware the “Surprise Billing Protection Form.” If you sign it, you’re actually consenting to be treated by out-of-network providers and to pay their rates. Which could be sky-high.

3. What to do if you're being screwed with. (In ER and forced to sign a form.)

4. Put this number in your phone: 1-800-985-3059. It’s the federal hotline for reporting violations of the No Surprises Act.

5. Don’t just ask “Do you take my insurance?” Ask “Are you in my insurance plan’s network?” 6. Oh, also: Ambulances. They're not covered.

7. Finally: Watch the mail. Watch for a bunch of statements from your insurance company called an Explanation of Benefits, or EOB for short. Anything on a bill is supposed to also show up on those EOBs — which are supposed to “explain” what your insurance is paying and what you’re on the hook for. Your goal is to verify nobody’s charging you more than your insurance thinks you’re responsible for.
• Bill of the Month This crowdsourced investigation by Kaiser Health News and NPR dissects and explains your medical bills every month in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Study the examples to learn what to watch for.

• An $18,000 biopsy? Paying cash might have been cheaper than using her insurance (Lauren Sausser, Shots, NPR and KHN, 8-23-22) After a mammogram confirmed the lump needed further investigation, Yuengling scheduled a breast biopsy. The hospital's online "Patient Payment Estimator" showed that an uninsured patient would owe about $1,400 for the procedure. The good news: She didn't have cancer. The bad news: She owed roughly $5,000, of an $18,000 bill. It's not uncommon for uninsured patients — or any patient willing to pay a cash price — to be charged far less for a procedure than patients with health insurance. For the nearly 30% of American workers with high-deductible plans, like Yuengling, using insurance can lead to a far bigger expense than if they had been uninsured or just pulled out a credit card to pay in advance. She could have saved a significant amount of money by opting to undergo the procedure in a different hospital.
•5 Ways You Might Still Get a Surprise Medical Bill (Lisa R. Gill, Consumer Reports, 2-10-22) Even with the No Surprises Act and its consumer protections now in effect, you can still get an unexpected bill. There are some gray areas and Gill discusses what to do about them: "balance billing" (when a patient receives a medical service from a doctor or in a facility not in their insurer’s network, as can happen in emergency situations, or when you are hospitalized, and are asked to pay out of pocket for it); many urgent care centers; retail centers (usually located in drugstores or supermarkets); birthing centers, hospice facilities, and addiction treatment centers; and ground ambulances (read the distinction). "The new law does protect you against surprise medical bills if you require an air ambulance—both via airplane or helicopter—the cost of which can be in the tens of thousands of dollars."
• Another lobbying battle looms on surprise medical bills (Kerry Dooley Young, Covering Health, AHCJ, 10-4-21) The unveiling of a new federal rule last week to prevent “surprise” medical bills is worth covering on its own merit. The expected lobbying battle about this rule also could provide a good news peg for digging into one of the key debates about what’s causing the cost of health care to continue its rise in the U.S. At the heart of recent battles over surprise bills is the question of how much insurers should pay for out-of-network medical care.
The Biden administration’s rule leans toward using payment rates already established within insurers’ networks in resolving disputes about out-of-network care. That approach drew praise from America’s Health Insurance Plans, a trade group for medical insurers. It said the new rule reflected “a strong commitment to consumer affordability and lower health care spending.” In the view of the American Medical Association (AMA), though, the rule is an “an undeserved gift to the insurance industry.” Lawmakers faced significant pressure to address surprise medical bills, due in large part to the reporting of journalists including Sarah Kliff of The New York Times and the contributors to the “Bill of the Month” series from Kaiser Health News and NPR.
• No Surprises: Understand your rights against surprise medical bills (CMS.gov newsroom, 1-3-22) (Centers for Medicare & Medicaid Services) The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

Listen to Know Your ‘No Surprises’ Rights (Dan Weissmann, An Arm and a Leg podcast, 2-2-22) or read the transcript, "Meet your new rights under the No Surprises Act." A new federal law called the No Surprises Act protects us against what's been one of the most outrageous experiences our health care system has to offer." Any health care provider you see -- not just in a hospital, but anywhere-- owes you a good-faith estimate of what you'd be expected to pay. If their bill is more than 400 bucks over that good faith estimate? "That's their problem. You've gotta pay the estimated cost plus 400 bucks, but they've gotta eat the rest." The new law doesn't cover everything -- for example, it doesn't cover the cost of ambulances. The question to ask everyone: Are you in my insurance network? Do not sign a waiver (called a "Surprise Billing Protection Form"). The federal hotline number to call to report a violation: 1-800-985-3059.
• Explainer: Federal independent dispute resolution process for surprise medical bills (Krutika Amin, Karen Pollitz, Kaye Pestaina, and Cynthia Cox, Peterson-KFF Health System Tracker, 2-21-23) Long, detailed, and not easy reading. The No Surprises Act independent dispute resolution process generally encourages plans and providers to resolve payment disputes outside of the IDR arbitration process, while at the same time protecting patients, though early experience shows the number of arbitrated disputes has been higher than expected. The federal independent dispute resolution process has the potential to put downward pressure on prices, particularly among providers charging extremely high prices. The Congressional Budget Office (CBO) had estimated a premium decrease of between 0.5% and 1% as a result of the No Surprises Act. Thus far, health plans are generally not estimating an impact of this law on 2023 premiums.
• “The Golden Age of Older Rectums” (for investors) (5-26-22). Listen to An Arm and a Leg documentary or read the transcript. "Private equity investors have made their way into many areas of our lives. Now, they’re at the gastroenterologist’s —and lots of other medical specialists, too. We learned why these doctors are selling their practices to private equity, and what it could mean for your health care and your bills....

     "Surprise billing is not an accident. It is a business model for private equity companies. When you go to the hospital, there are staffing companies figuring out how to make sure the hospital has the number of doctors it needs every day there are private equity firms that have been purchasing up those staffing companies and those private equity companies have figured out that, you know, lo and behold, a surprise out of network bill is. Bigger than an in-network bill." The biggest add-on will be a "facility fee," which is "like a cover charge, usually from a hospital, basically just for walking in. They can be wildly-expensive -- hundreds or even thousands of dollars -- and they take a lot of folks by surprise."
• An $80,000 Tab for Newborns Lays Out a Loophole in the New Law to Curb Surprise Bills (Jay Hancock, KHN, 2-23-22) "About 1 in 5 emergency room visits are at facilities that are out of network for the patient’s insurance, research has shown. The No Surprises Act requires insurers to cover non-network emergency treatment with the same patient cost sharing as in-network care. It also prohibits hospitals from billing patients extra.
    "But if the insurer denies that the care was for an emergency or doesn’t obtain documentation to prove it, the claim can still be rejected and the patient left on the hook.
     “That’s a coding issue we see a lot,” said Kirksey, especially “if the person didn’t literally check in through the emergency room.”
• Hospital Price Transparency (CMS.gov) Starting January 1, 2021, each hospital operating in the United States will be required to provide clear, accessible pricing information online about the items and services they provide in two ways:
---As a comprehensive machine-readable file with all items and services.
---In a display of shoppable services in a consumer-friendly format.

The following articles are about incidents that happened before the No Surprises Act:

• He Bought Health Insurance for Emergencies. Then He Fell Into a $33,601 Trap. (Jenny Deam, ProPublica, 5-8-21) Since the Trump administration deregulated the health insurance industry, there’s been an explosion of short-term plans that leave patients with surprise bills and providers with huge revenue. Cory Dowd did not understand the extent to which insurers could offer plans that looked like a great deal but were stuffed with fine print that allowed companies to deny payment for routine medical events (or pre-existing conditions). Not bound by the strict coverage rules of the Affordable Care Act, the short-term plans that Dowd signed up for have been dubbed “junk insurance” by consumer advocates and health policy experts.
• After Accident, Patient Crashes Into $700,000 Bill for Spine Surgery (Julie Appleby, Bill of the Month, 4-22-21) Generous personal injury coverage on your car policy may not be enough to cover medical bills. Patients can get financially blindsided when auto insurance and health insurance policies differ.Mark Gottlieb’s life changed after a devastating car accident. He had smashed teeth, four damaged vertebrae and surgery on his spine ― which led to medical bills that exhausted the personal injury coverage in his auto insurance.
• College Tuition Sparked a Mental Health Crisis. Then the Hefty Hospital Bill Arrived. (Jordan Rau, KHN, 2-26-21) Singh found herself beset by a double whammy of bills from two of the costliest kinds of institutions in America — colleges and hospitals — both with prices that inexorably rise faster than inflation. If you have trouble paying a bill, call the hospital and ask for a copy of its financial assistance policy and the application to request your bill be discounted or excused.

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• The Knee Surgeon Was In-Network. The Surgical Assistant Wasn't, and Billed $1,167 (Markian Hawryluk, Bill of the Month, All Things Considered, NPR, 7-22-2020) A college student’s bill for outpatient knee surgery is a whopper — $96K — but the most mysterious part is a separate $1,167 charge from a health care provider she didn’t even know was in the operating room. Ever Heard of a Surgical Assistant? Meet a New Boost to Your Medical Bills (KHN) "Surgeons generally decide when they need surgical assistants, although the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and cannot bill. Meniscus repair is on the list of allowed procedures."
• How to Avoid Surprise Medical Bills (Darcy Lewis, AARP, 8-8-19) Before a planned procedure, ask what the doctor charges, and call both your insurer and the medical office to verify that the treatment is covered and the doctor or facility is in your health plan's network. And other preventive steps.
• Hit with an Unexpectedly High Medical Bill, Here's How a Savvy Patient Fought Back (Anna Almendrala, Bill of the Month, KHN and Shots/NPR, 10-29-2020) Diagnosed with uterine polyps, Tiffany Qiu was told by the hospital where she was having the polyps removed that she had to pay only 20% coinsurance — $1,656.10 —if she had the procedure at Palomar Medical Center in Poway, California, about 38 miles south of where Qiu lives.As she handed over her credit card, she confirmed one more time that this would be her total patient responsibility, barring complications. The surgery was over in less than 30 minutes, and she walked out of the hospital with her husband, feeling perfectly fine. Then the bill came. Lesson learned: Get promises in writing — before the day of surgery. Make sure the offer is explicit about which services are included and what might count as a complication. Ask whether you’ll have to pay upfront. Initial estimated bills can be full of asterisks and “weasel words,” said Akshay Gupta, co-founder of CoPatient, a medical bill review and patient advocacy company.
• A Survival Guide to Surprise Medical Bills (AARP, 2019) How to spot errors, fight out-of-network charges and lessen the stress of health care debt.
• What Causes Surprise Medical Bills? (Fran Kritz, AARP, 8-8-19) Out-of-network charges and undetected errors can drive up your health care costs. According to one study, 'about 1 in 7 patients using an in-network hospital was nevertheless billed by an out-of-network medical provider, a practice known as "balance billing." Anesthesiology, emergency treatment and lab services were among the most common causes of these unexpected bills. Medical providers in your health plan’s network cannot collect more than the rate negotiated by your insurance company. A non-network provider can, and often will, charge its full price. Many plans will still pay some of that bill, based on what the insurer considers the customary fee for a procedure. The out-of-network doctor or facility might then bill you for the remaining balance.' Other causes of surprise bills: Out-of-pocket costs, billing errors, billing fraud, medical identity theft.

• Paying Till It Hurts In her series on the cost of health care, Elisabeth Rosenthal interviews patients, physicians, economists, hospital and industry officials to examine the high price of health care. Buy her book: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back . And read the series here--including the readers' comments (from both patients and doctors).
• Part 1: Colonoscopy: A case study in high costs The $2.7 Trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures (Elisabeth Rosenthal, Health, NY Times, 6-1-13) While the American medical system is famous for expensive drugs and heroic care at the end of life, a more significant factor in the nation’s annual health care bill may be the high price tag of ordinary services.
• Part 2. Pregnancy: Cash on delivery. American Way of Birth, Costliest in the World (Elisabeth Rosenthal, Health, NY Times, 6-30-13). Cash on delivery.
• Part 3. Joint replacement: A trip abroad. In Need of a New Hip, but Priced Out of the U.S. (Elisabeth Rosenthal, NY Times, 8-3-13)
• Part 4. Prescriptions. No room to negotiate. The Soaring Cost of a Simple Breath (Elisabeth Rosenthal, NY Times, 10-12-13)
• Part 5. E.R. Visit As Hospital Prices Soar, a Stitch Tops $500 (Elisabeth Rosenthal, NY Times, 12-2-13)
• First Person: A Healthcare Reporter Who Asks Questions for a Living Can’t Get a Straight Answer on Her Own Care (Liz Carey, Daily Yonder, 7-19-21) Healthcare reporter Liz Carey has a tenacious spirit, 20 years of journalism experience, and lots of formal education. Her folder of information on her hip-replacement procedure is covered with notes and a coffee cup.If she can’t get an answer to how her insurance will handle a medical procedure, what chance do the rest of us have? "
• Surprise billing: Why consumers with medical insurance still may face major health care expenses (Kerry Dooley Young, Journalist's Resource, 6-16-2020) Young examines the topic in the context of emergency room visits, air ambulance services, elective surgeries and more. In one study, researchers found that 22% of the emergency room visits they examined involved out-of-network physicians, even though 99.4% of visits were to in-network hospitals. Sidebar: 7 tips for journalists reporting on surprise medical bills (6-22-2020) Read full article for the details behind the tips on this tipsheet: Find out what your state has done or tried to do to address surprise medical bills. Don’t overstate the findings of academic research. Pay attention to how lobbying influences the political debate about surprise billing. Interview doctors and executives for hospitals and insurance plans. Be realistic about the political battles in Congress surrounding surprise billing. Crowdsource your audience to find people who have experienced surprise billing. Keep your Kaisers straight.

Young is also the source for several additional links:
• Balancing the Bills – Policy Solutions to Address Surprise Billing (Alliance for Health Policy, 7-15-19) Listen to this 90-minute recording of its July 2019 panel discussion on surprise medical billing, supplemented by this list of experts on the topic.
• Everything You Need to Know About Surprise Billing (Brookings Institute)
• Protecting Patients from Surprise Medical Bills (Center on Health Insurance Reforms, Georgetown University)
• Visualizing Health Policy: US Statistics on Surprise Medical Billing (Kaiser Family Foundation infographic, 2-11-2020)

All that courtesy of Young and the Alliance for Health Policy.
• More Patients Are Getting Hit With Surprise Medical Bills, And the Price Tags Are Going Up, Too (KHN, 8-13-19) A study finds that over 42% of patients hospitalized or treated in an emergency room received surprise bills in 2016. “Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals,” the researchers concluded.
• Doctors Push Back As Congress Takes Aim At Surprise Medical Bills (Rachana Pradhan, Morning Edition, NPR, 2-12-2020) As doctors, hospitals and insurers lobby and sponsor TV and internet ads to protect their own bottom line, patients have no lobbyists. Fixing this is ultimately a fight between doctors and insurers over rate-setting and reimbursement. But as more patients balk at surprise bills, lawmakers are under pressure to protect patients. "Little has been as powerful in shaping surprise billing legislation as the clout of hospitals and their doctors, many of whom are, in fact, employed by private equity-backed companies and armed with years of experience shaping surprise billing legislation at the state level."

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• Pulling Back Curtain on Hospital Prices Adds New Wrinkle in Cost Control (Elisabeth Rosenthal, KHN, 1-28-19) For the moment, these lists won’t seem very useful to the average patient....Think of them as raw material to be mined for billing transparency and patient rights. For years, these prices have been a tightly guarded industrial secret....hospitals set prices crazy high so they can tout their generous discounts (while insurers tout their negotiating prowess).... Although making chargemaster pricing public will not, by itself, reform our high-priced medical system, it is an important first step. Maybe, just maybe, a hospital will think twice before charging a $6,000 “operating room fee” for a routine colonoscopy if its competitor down the street is listing its price at $1,000. Making this information public should bring list prices more in line with what is actually paid by an insurer, a far better measure of value....As a next step, regulators should insist that these prices be easily accessible on hospitals’ home pages.
• Your Go-To Guide to Decode Medical Bills (Bill of the month, KHN, 7-25-19) KHN's pro tips for navigating surprise medical bills. Why you MUST understand these terms and what they imply about out-of-pocket costs (click thru on right side of box to get each explanation): Observation Status (Read this one for sure!), Ombudsman, Out-of-Network, Outpatient Clinic, Outpatient Services, Surprise Medical Bills, Triage, Urgent Care Provider, Balance Billing, Chargemaster, Coinsurance, Copay, Emergency Department or Emergency Room, Explanation of Benefits (EOB), Hospital, Inpatient Services ("just because you're lying on a hospital ward, in a hospital bed, doesn't mean you've been admitted"), Itemized Bill.
• An examination of surprise medical bills and proposals to protect consumers from them (Karen Pollitz, Matthew Rae, Gary Claxton, Cynthia Cox and Larry Levitt Kaiser Family Foundation issue brief, 6-20-19) In roughly 1 of every 6 emergency room visits and inpatient hospital stays in 2017, patients came home with at least one out-of-network medical bill, a new KFF analysis finds. More specifically, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge, leaving patients at risk for surprise medical bills. The analysis also finds the incidence of such charges varied greatly by state, for both emergency visits and hospital stays.
• As Hospitals Post Sticker Prices Online, Most Patients Will Remain Befuddled (Julie Appleby and Barbara Feder Ostrov, KHN, 1-4-19) To figure out what, for example, a trip to the emergency room might cost, a patient would have to locate and piece together the price for each component of their visit — the particular blood tests, the particular medicines dispensed, the facility fee and the physician’s charge, and more. “I don’t think it’s very helpful,” said Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management. “There are about 30,000 different items on a chargemaster file. As a patient, you don’t know which ones you will use.” And there’s this: Other than the uninsured and people who are out-of-network, few actually pay full charges. Even when consumers do locate the lists, they might be stymied by seemingly incomprehensible abbreviations. Nevertheless, some experts say that merely making the charges public shines a light on the often very high — and widely varying — prices set by facilities.

• The problem is the prices (Sarah Kliff, Vox, 10-16-17) Opaque and sky high bills are breaking Americans — and our health care system.

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HOW TO CHALLENGE EXCESSIVE MEDICAL BILLS

• A Guide On How To Fight Your Outrageous Hospital Bill (And Win) Gemma Hartley On Assignment for HuffPost, 8-4-17 Document everything. (Watch the video, too.) "I also did a bit of sleuthing and found that putting in a higher entry level, known as upcoding, can drastically hike up ER bills. While I didn’t realize it at the time, it’s illegal." "Had I known to use the word “upcoding” in my first conversation with the billing department, I might have saved hours spent on the phone. Fortunately, I kept careful records, which gave me the upper hand, but I shouldn’t have spent two years of stressful fighting when they were so clearly in the wrong."

• Outrageous ER Charges: Don't Let Hospital Bills Break the Bank (Nick Tate, NewsMax, 6-9-17) Negotiate costs before receiving care. Don’t pay for ER care right away, or automatically.
• 10 Ways to Deal with an Expensive Emergency Room Bill (Gary Foreman, USNews, 8-16-12)
• How to Negotiate for Lower Medical Bills (Dan Weissmann, ‘An Arm and a Leg’, KHN, 8-24-22) Negotiating medical bills is often possible. It sounds hard — and it can be — but what if we got it down to a science? Mapped out all the moves ahead of time? Jared Walker and his team at the nonprofit Dollar For are running a big experiment to see whether they can do just that.
• 8 Things You Should Know About Challenging A Medical Bill (Kate Ashford, Forbes, 8-15-14)
• 4 Medical Bill Myths That Can Cost You Dearly (Gerri Detweiler, Credit.com, 3-7-12)
Myth 1: As long as I am making payments on a medical bill, it can’t be sent to collections.
Myth 2: I have to be notified before a medical bill is turned over for collections.
Myth 3: Medical collection accounts are treated differently than other types of collection accounts when credit scores are calculated.
Myth 4: To clean up my credit, I need to pay off medical collection accounts.

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PROTECTING PATIENTS FROM WRONGFUL MEDICAL BILLING

• Do Consumers Benefit When Hospitals Post Sticker Prices Online? (Julie Appleby, Here and Now, NPR and KHN, 1-11-19) The new rule took effect Jan. 1 but, for consumers seeking hospital price information, using it to find answers may be like searching for a needle in a haystack.
• New Medicare Advantage Tool to Lower Drug Prices Puts Crimp in Patients’ Choices (Susan Jaffe, KHN, 9-17-18) Starting in 2019, Medicare Advantage plans will be able to add restrictions on expensive, injectable drugs administered by doctors to treat cancer, rheumatoid arthritis, macular degeneration and other serious diseases. Under the new rules, these private Medicare insurance plans could require patients to try cheaper drugs first. If those are not effective, then the patients could receive the more expensive medication prescribed by their doctors.
• Senators Unveil Legislation to Protect Patients Against Surprise Medical Bills (Rachel Bluth, KHN, 9-19-18) With frustration growing among Americans who are being charged exorbitant prices for medical treatment, a bipartisan group of senators Tuesday unveiled a plan to protect patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks. The draft legislation, which sponsors said is designed to prevent medical bankruptcies, targets three key consumer concerns:
---Treatment for an emergency by a doctor who is not part of the patient’s insurance network at a hospital that is also outside that network.
---Treatment by an out-of-network doctor or other provider at a hospital that is in the patient’s insurance network.
---Mandated notification to emergency patients, once they are stabilized, that they could run up excess charges if they are in an out-of-network hospital.
• The bipartisan plan to end surprise ER bills, explained (Sarah Kliff, Vox, 9-21-18) The Cassidy-McCaskill proposal essentially bars out-of-network providers from billing patients directly. Instead, they would have to seek payment from the health insurer, who would be required to pay a price similar to local market rates.
• National Health Care Fraud Foundation (NHCFF) A private-public partnership against health care fraud.
• Sessions announces "largest health care fraud takedown" in U.S. history (John Bat, CBS News, 7-13-17)
• Selected Cases (U.S. Dept. of Justice) Cases involving ambulance services, billing firms, clinics, Defective Pricing and Buy America Act Violations: Drugs and Supplies, durable medical equipment suppliers, group homes, home health services, home infusion therapy, hospitals, insurance companies, laboratory services, lymphedema pumps, HHS IG and the FBI: Nursing homes, pharmaceutical and pharmaceutical firms, physicians and other practitioners, psychiatrists, psychiatric hospitals, and mental health services, staged automobile accidents/workers compensation fraud, miscellaneous.

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Charity Care and Medical Assistance

• How to Obtain Charity Care (Ashley Hall, Verywell Health, 9-27-21) Hall explains various options for the uninsured (emergency rooms, federally qualified health centers, other free and sliding scale clinics, temporary free clinics, charity care) and explains broadly how to access them.
• Charity care policy at one hospital (Sibley, Johns Hopkins system)
• Can I Get Charity Care Benefits to Pay for My Hospital Bill? (Northwest Justice Project, Washington Law Help)
• What Is Charity Care in Health Care? (Karen Axelton, Experian, 12-15-21) Explains how hospital charity programs work and how one gets charity care. Links to U.S. organizations that can help pay for medical bills for specific conditions as well as to patient assistance programs.
• Find a Pharmaceutical Assistance Program for the drugs you take (Medicare) Some pharmaceutical companies offer programs to help pay for prescriptions for people in a Medicare Drug Plan (Part D)
• Medicine Assistance Tool PhRMA’s search engine designed to help patients, caregivers and health care providers learn more about the resources available through the various biopharmaceutical industry programs.<
• How to Crush Medical Debt: 5 Tips for Using Hospital Charity Care (Emily Pisacreta, Kaiser Health News, 10-15-21) 'What if a law passed but no one enforced it? That’s essentially what has happened with one small but helpful rule about hospitals and financial assistance for medical bills. The Affordable Care Act, the health law also known as Obamacare, requires nonprofit hospitals to make financial assistance available to low-income patients and post those policies online. Across the U.S., more than half of hospitals are nonprofit — and in some states all or nearly all hospitals are nonprofit. But many people who qualify for financial assistance — or “charity care,” as it is sometimes known — never apply.'
• Top tips for using charity care to crush medical debt (Emily Pisacreta, An Arm and a Leg Show) Info you may also see on the viral TikTok video. See also Dollar For thread (ThreadReader, 4-10-21) on what it has learned about crushing medical bills.
• Debtors' Rights: Dealing with Collection Agencies (Northwest Justice Project, Washington Law Help)

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MANAGING HEALTH CARE AND HEALTH CARE COSTS

Essential medical links for patients, families, caregivers
Online-resources for patients/consumers/patient advocates/caregivers
Patients sharing info about health care
Basic healthcare explanations: How things (in the body) work
Dental care: What you should know
Improving health with yoga
Infectious diseases, Understanding, treating, and controlling
How healthcare professionals train, think, and act (a booklist)
Medical reference shelf
Making wise medical choices
Private screening tests
Shopping for vitamins and supplements
Telemedicine and virtual medical visits
Your gut microbiome

Bill of the Month and Other Outrageous Medical Bills

• Bill of the Month (Kaiser Health News and NPR) This crowdsourced investigative series dissects and explains your medical bills every month to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. See, for example:
---It’s Called an Urgent Care Emergency Center — But Which Is It? (Renuka Rayasam, KFF Health News, 6-24-24) Parkland’s Urgent Care Emergency Center is what’s called a freestanding emergency department. The number of freestanding emergency rooms in the United States grew tenfold from 2001 to 2016, drawing attention for sending patients eye-popping bills. Urgent care centers are a more familiar option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER.
---Her Hearing Implant Was Preapproved. Nonetheless, She Got $139,000 Bills for Months. (Elisabeth Rosenthal, , KFF Health News, 7-17-24)

"Providers and insurers often have disagreements over how a bill is submitted or coded, and as they work through them (or don’t), the patient is left holding the bag, facing sometimes huge bills.

   "The Takeaway: It’s not uncommon for an insurer to delay paying a claim until it receives an itemized bill; providers sometimes get creative with billing codes to increase revenue, and studies show that more than half of hospital bills contain errors. But studies also suggest insurers are wont to drag their feet, niggling over coding and charges — and, in doing so, delaying reimbursement and holding on to the cash.
   "What’s a patient to do? First step: Don’t pay the bill (aside from a copay or coinsurance) for care or services preapproved by insurance. Call the health care provider and explain they should take up their bill with the insurer.
    "Second, ask the provider to send an itemized bill with all billing codes used, then review it for errors. As the patient, you would know that you never had an MRI, for example. Your insurer wouldn’t."
---Out for Blood? For Routine Lab Work, the Hospital Billed Her $2,400 (Rachana Pradhan, 11-21-23) Beware of getting your blood drawn at a hospital.
---He Fell Ill on a Cruise. Before He Boarded the Rescue Boat, They Handed Him the Bill. (Bram Sable-Smith, 5-22-24)
---Sign Here? Financial Agreements May Leave Doctors in the Driver’s Seat (Katheryn Houghton, 4-30-24)
---The Colonoscopies Were Free. But the ‘Surgical Trays’ Came With $600 Price Tags. (Samantha Liss, 1-25-24) By law, preventive services — including routine colonoscopies — are available at zero cost to patients. But...
---When a Quick Telehealth Visit Yields Multiple Surprises Beyond a Big Bill (Darius Tahir, 12-19-23) The doctor was affiliated with Mount Sinai’s health system, though where the bill came from was unclear. The insurer said the telehealth visit was deemed an out-of-network service — a charge Greenblatt said the digital service didn’t do a great job of warning her about. It came as a surprise. “In my mind, if all my doctors are ‘in-insurance,’ why would they pair me with someone who was ‘out-of-insurance’?” she asked. And the hospital system tried its best to make contesting the charge difficult, she said.
---When That Supposedly Free Annual Physical Generates a Bill (Julie Appleby, 10-30-23) "Not all care that may be provided during a wellness visit counts as no-cost preventive care under federal guidelines. If a health issue arises during a checkup that prompts discussion or treatment — say, an unusual mole or heart palpitations — that consult can be billed separately, and the patient may owe a copayment or deductible charge for that part of the visit. Read the whole article before your next annual physical!
---A Mom’s $97,000 Question: How Was Her Baby’s Air-Ambulance Ride Not Medically Necessary? (Molly Castle Work, Bill of the Month, KFF Health News, 3-25-24) Read this in advance, so you know what to say and do at the time you need to make decisions and act.
---He Returned to the US for His Daughter’s Wedding. He Left With a $42,000 Hospital Bill. (Sarah Jane Tribble, KFF Health News, 5-23-23) After emergency surgery, an American expatriate with Swiss insurance now carries the baggage of a five-figure bill. Costs for medical care in the U.S. can be two to three times the rates in other developed countries, so foreigners and expats with good insurance in their home countries need travel insurance to protect themselves from "crazy prices."
---Personal Medical Debt in Los Angeles County Tops $2.6 Billion, Report Finds (Molly Castle Work, KFF Health News, 6-7-23) Medical debt is a leading public health problem, researchers say. Despite the county’s ongoing expansion of health coverage, the prevalence of medical debt remained unchanged from 2017 to 2021.
---Many People Living in the ‘Diabetes Belt’ Are Plagued With Medical Debt (Robert Benincasa, NPR and Nick McMillan, NPR, 5-30-23) The “Diabetes Belt,” as defined by the Centers for Disease Control and Prevention, comprises 644 mostly Southern counties where diabetes rates are high. Of those counties, KFF Health News and NPR found, more than half also have high levels of medical debt.
---Your Money or Your Life: Patient on $50,000-a-Week Cancer Drug Fears Leaving Behind Huge Medical Debt (Fred Schulte, KHN, 2-14-23) After several rounds of treatment for a rare eye cancer (uveal melanoma) — weekly drug infusions that could cost nearly $50,000 each — Paul Davis learned Medicare had abruptly stopped paying the bills, partly because of a misfiling. Cancer drug prices “are outrageous,” said Dr. Hagop Kantarjian, who chairs the Department of Leukemia at MD Anderson Cancer Center in Texas. Kantarjian said the prices manufacturers charge for cancer drugs have soared from less than $10,000 annually in the late 1990s to more than $200,000 annually today. And that’s not even the full cost. No ordinary person can handle the price of these drugs, argues Patients for Affordable Drugs
---They were turned away from urgent care. The reason? Their car insurance (Sam Whitehead, Bill of the Month, NPR and KHN, 9-29-22) It's a pretty standard policy for urgent care centers not to treat injuries that result from car crashes, even minor ones. Urgent care centers aren't governed by the same laws as emergency rooms so they can be more selective about who they treat. Sometimes their reasons are financial, not clinical. "Generally, as a rule, they do not take care of car accident victims regardless of the extent of their injuries, because it is going to go through that auto insurance claims process before the provider gets paid," she says. Urgent care centers often operate on thin margins and can't wait months and months for an auto insurance company to pay out a claim. "Unfortunately" people tend to learn about such policies when they show up expecting care.
        "Horwitz dismisses the idea that a health system might push people in car wrecks from urgent care centers to emergency rooms to make more money off them. Still, auto insurance generally pays more than health insurance for the same services."
---$38,398 for a Single Shot of a Very Old Cancer Drug (Arthur Allen, 10-26-22) In the United Kingdom, where health care is generally free and Takeda sells the drug Lupron Depot under the name Prostap, all physicians can purchase a three-month dose for about $260. Yet hospital systems like Chicago Medicine can and typically do charge lavishly for such services, to enhance revenue. Lupron Depot’s ongoing popularity among medical providers: Doctors and hospitals can earn tens of thousands of dollars each visit by marking up its price and administration fees — as they did with Hinds. If they merely write a prescription for a drug that can be taken at home, they earn nothing. After the second shot, in August 2021, a pharmacist told him he could instead receive the pill. After the second shot, a pharmacist told him he could instead receive the pill. His doctor prescribed three months’ worth of Orgovyx last November, for which he paid $216 and the insurer paid over $6,000. Tip 1:If you are prescribed an infusion or injection, ask your physician if there are cheaper oral medications to treat your condition. Also, many drugs that are given by injection — ones that are given “subcutaneously,” rather than into a muscle — can be administered by a patient at home, avoiding hefty administration fees. Drugs like Dupixent for eczema fall into this category. Tip 2: If you’re about to get an injection, infusion, or procedure done in a hospital system, ask ahead of time for an estimate of what you will owe. ---Turned Away From Urgent Care — And Toward a Big ER Bill (Sam Whitehead, 9-29-22) Remember that urgent care centers aren’t governed by the same laws as emergency rooms and they can be more selective about who they treat. Sometimes their reasons are financial, not clinical. “‘We don’t take third-party insurance,’” said the receptionist at Atrium Health's urgent care center, referring them to the nearby hospital emergency room, owned by the same hospital system. See more Bill of the Month stories.
• Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why? (Michelle Andrews, Bill of the Month, KHN, 5-31-22) The Affordable Care Act made preventive health care such as mammograms and colonoscopies free of charge to patients without cost sharing. But there is wiggle room about when a procedure was done for screening purposes, versus for a diagnosis. And often the doctors and hospitals are the ones who decide when those categories shift and a patient can be charged — but those decisions often are debatable.

More than 40% of people over 50 have precancerous polyps in the colon. Someone whose cancer risk is above average may face higher bills and not be protected by the law. Having a family history of colon cancer or a personal history of polyps raises someone’s risk profile, and insurers and providers could impose charges based on that. In addition, getting a screening colonoscopy sooner than the recommended 10-year interval could open someone up to cost-sharing charges. If you have had a polyp removed, your category may be changed from screening to preventive.

Before getting an elective procedure like a cancer screening, it’s always a good idea to try to suss out any coverage minefields, Howard said. Remind your provider that the government’s interpretation of the ACA requires that colonoscopies be regarded as a screening even if a polyp is removed. “Contact the insurer prior to the colonoscopy and say, ‘Hey, I just want to understand what the coverage limitations are and what my out-of-pocket costs might be,’” Howard said. Billing from an anesthesiologist — who merely delivers a dose of sedative — can also become an issue in screening colonoscopies. Ask whether the anesthesiologist is in-network. Be aware that doctors and hospitals are required to give good faith estimates of patients’ expected costs before planned procedures under the No Surprises Act. If you're signing up for a colonoscopy, read this article first!

---They May Owe Nothing — Half-Million-Dollar Dialysis Bill Canceled (Jenny Gold, Bill of the Month, KHN, 7-28-19) "A 50-year-old personal trainer, Sov was diagnosed with kidney failure in January and sent for dialysis at a Fresenius clinic 70 miles from his home in rural Plains, Mont. A few days later, Sov and Jessica learned that the clinic was out-of-network and that they would be required to pay whatever their insurer didn’t cover. Their insurer, Allegiance, paid $16,241.73, about twice what Medicare would have paid. Fresenius billed the couple the unpaid balance of $524,600.17 — an amount that is more than the typical cost of a kidney transplant.... Fresenius spokesman Brad Puffer said that the Valentines should always have been treated as in-network patients because their insurer, Allegiance, is a subsidiary of Cigna, which has a contract with the dialysis company. Under this contract, Fresenius would have been paid a higher rate than what Allegiance paid. The Valentines, he said, were caught in the middle of a contract dispute between the companies."
---Jaw Surgery Takes a $27,119 Bite out of One Man’s Budget(Phil Galewitz, KHN, 8-27-21) For years, Ely Bair dealt with migraine headaches, jaw pain and high blood pressure, until a dentist recommended surgery to realign his jaw to get to the root of his health problems. The fix would involve two surgeries over a couple of years and wearing braces on his teeth before and in between the procedures. The first surgery was covered by his Premera Blue Cross plan, and Bair’s out-of-pocket hospital expense was $3,000. He changed jobs in 2019 but still had Premera health insurance. In 2020, he had the planned surgery on his lower jaw at the same hospital where he’d been treated the first time. Swedish Medical Center billed Bair $27,119 for the second surgery in July 2020. His carrier was the same but his coverage was not as good with the second job.

The Takeaway: "When facing a planned surgery, talk to your hospital, doctor and insurer about how much of the bill you will be responsible for — and get it in writing before any procedure. Be aware that certain surgeries — like jaw surgery — lie in a gray area; insurers might not consider them a necessary medical intervention or even a medical procedure at all. Be aware that even though your insurance carrier may stay the same after switching jobs, your benefits could be quite different. Health plans should notify patients when they are closing in on lifetime or annual limits, but that doesn’t always happen.

---How ERs Fail Patients With Addiction: One Patient’s Tragic Death (Aneri Pattani, KHN, 7-15-21) "Nonprofit hospitals are required by the federal government to have financial assistance policies, which lower or eliminate bills for people without the resources to pay. Often called charity care, this assistance is a condition for nonprofit hospitals to maintain their tax-exempt status. But “nonprofits are actually doing less charity care than for-profits”...That’s in part because they have wide leeway to determine who qualifies and often don’t tell patients they may be eligible, despite federal requirements that nonprofit hospitals “widely publicize” their financial assistance policies, including on billing statements and in “conspicuous public displays” in the hospital. One study found that only 50% of hospitals regularly notified patients about eligibility for charity care before initiating debt collection."

---Nothing to Sneeze At: The $2,659 Bill to Pluck Doll’s Shoe from Child’s Nostril (Markian Hawryluk, Bill of the Month, KHN, 11-26-19) Three-year-old Lucy Branson put matching Polly Pocket doll's shoes up her nose. With tweezers, they got one shoe out, then took her to a Las Vegas urgent care center, where "a doctor was able to remove the shoe in less than a second, as Michael recalled it, with a longer set of forceps. The doctor typically finds Tic Tac mints up there, he told them." Lucy’s insured through her father’s high-deductible plan with UnitedHealthcare. Total Bill: $2,658.98, consisting of a $1,732 hospital bill and a $926.98 physician bill, which the physician agreed to reduce by half if paid within 20 days. Dignity Health declined to explain how it arrived at the $1,732 total for the ER visit.

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---Her Genetic Test Revealed A Microscopic Problem — And a Jumbo Price Tag (Liz Szabo, KHN, 3-31-20) Michelle Kuppersmith’s doctor suspected she had a rare blood disorder called essential thrombocythemia, which can lead to blood clots, strokes and, in rare cases, leukemia. Her doctor suggested a bone marrow biopsy, in which a large needle is used to suck out a sample of the spongy tissue at the center of the patient’s hip bone. Doctors examine the bone marrow under a microscope and analyze the DNA. She learned that all she needed to do for now is take a daily low-dose aspirin. Then she got a notice saying her insurer refused to pay for the genetic analysis, leaving her responsible for a $2,400 payment. In a fast-evolving field with lots of money at stake, tests that a doctor or lab may regard as state-of-the-art an insurer might view as experimental. Worse still, many of the commercial labs that perform the novel tests are out-of-network, as was Genoptix.
---Grief Grew into a Mental Health Crisis and a $21,634 Hospital Bill(Laura Ungar, Bill of the Month, KHN, 10-31-19) Arline Feilen’s husband died in 2013, followed by her father three years later. After her mom passed away earlier this year, she “crumbled,” she says. Her mental health crisis landed her in the hospital for five nights, but her health insurance, an individual insurance plan purchased on the open market, didn’t cover mental health. This is one type of plan that the Obama administration curtailed but is now permitted, since the Trump administration gave the go-ahead for sales of plans previously considered inadequate coverage. She was left with a bill of $21,634.
---First Kidney Failure, Then a $540,842 Bill for Dialysis (Jenny Gold, Bill of the Month, KHN, 7-25-19) Sovereign Valentine, a personal trainer in Plains, Mont., needs dialysis for his end-stage renal disease. When he first started dialysis treatments, Fresenius Kidney Care clinic in Missoula charged $13,867.74 per session, or about 59 times the $235 Medicare pays for a dialysis session. As the dominant providers of dialysis care in the U.S., Fresenius and DaVita together form what health economists call a “duopoly.” They can demand extraordinary prices for the lifesaving treatment they dispense — especially when they are not in a patient’s network. A 1973 law allows all patients with end-stage renal disease like Sov to join Medicare, even if they’re younger than 65 — but only after a 90-day waiting period. During that time, patients are extremely vulnerable, medically and financially. Before finding a dialysis clinic in their insurance network, the Valentines were charged more than half a million dollars for 14 weeks of the treatment.

---Her Biopsy Report Was Benign. But the Bill Is a Spot of Contention. (Cara Anthony, KHN, 9-30-19) As a contractor for Ford Motor Co., Brianna Snitchlerhad a United Healthcare insurance plan. When Snitchler scheduled the biopsy, no one told her that Henry Ford Health System would also charge her a $2,170 facility fee. All told, her bills for the care she received related to the biopsy left her on the hook for $3,357.52, with her insurance paying $974. The way hospitals calculate facility fees is “a black box,” said Ted Doolittle, with the Office of the Healthcare Advocate for Connecticut, a state that has put a spotlight on the issue. A representative at Henry Ford told her on the phone that the hospital isn’t “legally required” to inform patients of fees ahead of time.

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---Estimate for Cost of Hernia Surgery Misses the Mark (Rachel Bluth, Bill of the Month, Shots, NPR, 8-29-19) Wolfgang Balzer did his research and got an estimate. The hospital told him the normal billed rate was $10,333.16, but that Cigna, his insurer, had negotiated a discount to $6,995.56, meaning his 20% patient share would be $1,399.11. The surgeon's office quoted a normal rate of $1,675, but the Cigna discounted rate was just $469, meaning his copayment would be about $94. Balzers were billed $2,304.51, much more than they'd budgeted for. It is a good idea to get an estimate in advance for health care, if your condition is not an emergency. But it is important to know that an estimate can be way off — and your provider probably is not legally required to honor it.

---Which Was Worse: The Bachelor Party Hangover or the Hangover from the ER Bill? (Markian Hawryluk, KHN, 9-19-19) While free-standing ERs maintain they can’t survive on rates paid by Medicare and Medicaid, data suggests they are profit-seeking engines built primarily in high-income ZIP codes. “It’s because they’ve figured out that they can get away with it,” said economist Vivian Ho. In this case, a bachelor's visit for rehydration was billed at $12,460 (more than twice the cost of the wedding), negotiated down to $2,593 for the bachelor, after insurance. A nurse drew blood, started an IV, and gave him two bags of saline and a dose of Zofran, an anti-nausea medication.

---A Year After Spinal Surgery, A $94,031 Bill Feels Like a Back-Breaker (Jon Hamilton, NPR News, 6-17-19) A service called neuromonitoring can cut the risk of nerve damage during delicate surgery. But some patients are receiving large and unexpected bills for the service.

--Summer Bummer: A Young Camper’s $142,938 Snakebite (Carmen Heredia Rodriguez, 4-30-19) The snake struck a 9-year-old hiker at dusk on a nature trail. The outrageous bills struck her parents a few weeks later.

---Hospital Charges $4,700 For A Fainting Spell (Phil Galewitz, 1-28-19) A lot of tests ruled out serious underlying conditions. The trip to the ER cost him his whole deductible.

Go here and here for more KHN/NPR Bill of the Month stories

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• For journalists: Pulitzer finalists explain how to use court documents to cover hospitals’ predatory billing practices (Joseph Burns, Covering Health, AHCJ, 8-5-2020) Advice from two Kaiser Health News journalists — senior correspondent Jay Hancock and data editor Elizabeth Lucas — who were Pulitzer Prize finalists this year for their reporting on predatory billing practices, Here are links to their Kaiser Health News stories:
---‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and claiming homes
---Virginia governor and UVA vow to revamp practice of suing patients as CEO exits
---UVA to cut back on lawsuits against patients
---VCU Health will halt patient lawsuits, boost aid in wake of KHN investigation
---Sen. Grassley questions UVA health on findings from KHN investigation
---As UVA scales back lawsuits, pain for past patients persists
---UVA doctors decry aggressive billing practices by their own hospital
---Hospital group mum as members pursue patients with lawsuits and debt collectors
Journalists: It's worth joining the Association of Health Care Journalists to get their tip sheets, available to AHCJ members only, including this one: Pulitzer finalists outline tips for covering abusive hospital billing and collection practices.

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• How to Negotiate for Lower Medical Bills (Dan Weissmann, ‘An Arm and a Leg’, KHN, 8-24-22) Negotiating medical bills is often possible. It sounds hard — and it can be — but what if we got it down to a science? Mapped out all the moves ahead of time? Jared Walker and his team at the nonprofit Dollar For are running a big experiment to see whether they can do just that.
• I started collecting ER bills. The American Hospital Association started warning its members. (Sarah Kliff, Vox, 10-26-17) These prices are often kept secret. Vox is trying to change that. For more stories about the kinds of surprise medical bills you could get, go to The Big Picture and Case Studies (some outrageous examples).
• How they did it: Reporters find dire problems with Texas’ Medicaid system (Chloe Reichel, Journalist's Resource, 3-7-19) Journalists reveal failures of Texas' managed care system through public records requests, statewide door-knocking efforts and data analysis. The move to shift Texas’ Medicaid program from a state-run system to a managed care system was intended to cut costs and improve the coordination of sick Texans’ care. Instead, it cost the state billions while patients lost access to critical care, journalists J. David McSwane and Andrew Chavez discovered in their “Pain and Profit” multi-part investigation for the Dallas Morning News. ("Your tax money may not help poor, sick Texans get well, but it definitely helps health care companies get rich.")
• A Denver-area hospital sued a patient for nearly $230,000 over her surgery bill. A jury said not so fast. (Christopher N. Osher, Denver Post, 6-29-18) Back surgery patient French said she was told by hospital officials prior to surgery that after her insurance kicked in, she would owe just $1,336, of which she immediately paid $1,000. The jury decided that under the hospital contract she signed, French should only have to pay “the reasonable value of the goods and services provided to her.” Evidence submitted during the trial showed that 13 spinal-implant materials installed in French during her spinal-fusion surgeries cost the hospital $31,665.05. The hospital had turned around and charged French $197,640 for those implants, a markup of more than 500 percent, the evidence showed.The jury affirmed in its judgment that it did not believe the hospital’s bill had been reasonable. "What bothered me is they say they are a nonprofit hospital, but how much profit did they need to make?” French said in a recent interview.

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• Why a simple, lifesaving rabies shot can cost $10,000 in America (Sarah Kliff, Vox, 2-7-18) Untreated rabies is always fatal — but key drugs leave families with thousands in medical debt. In England, the drug to treat rabies exposure costs $1,600. Here, hospitals charge $10,000. ERs typically are the only locations where patients can find the lifesaving treatment. And they charge significant “facility fees” to anyone who walks through their doors to seek treatment — including patients seeking a rabies vaccine.
• How ER Bills Can Balloon By As Much As $50K For ‘Trauma Response’ (Jenny Gold and Sarah Kliff, Vox and KHN, 7-2-18) On the first morning of Jang Yeo Im’s vacation to San Francisco in 2016, her 8-month-old son, Park Jeong Whan, fell off the bed in the family’s hotel room and hit his head. There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital (SFGH). Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for a visit lasting three hours and 22 minutes, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” also known as “a trauma response fee” (charged for activating the trauma response team). If the patient arrives and does not require at least 30 minutes of critical care, the trauma center is supposed to downgrade the fee to a regular emergency room visit and bill at a lower rate, but many do not do so. “Some hospitals are turning this into a cash cow on the backs of patients.” Unfortunately, outside of Medicare and state hospitals, regulators have little sway over how much is charged. And at public hospitals, such fees may be a way to balance government budgets.

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• An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay (Sarah Kliff, Vox, 1-29-18) Anthem's emergency room coverage denials are inappropriate. Their new insurance policy expects patients to diagnose themselves. These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them. The Anthem policy has so far rolled out in four states: Georgia, Indiana, Missouri, and Kentucky.
• Chronically Ill, Traumatically Billed: The $123,019 for 2 Multiple Sclerosis Treatments (Jay Hancock, a crowdsourced investigation by KHN and NPR, 11-28-18) Shereese Hickson’s multiple sclerosis was flaring again. Spasms in her legs and other symptoms were getting worse. This summer, a doctor switched her to Ocrevus, a Genentech drug approved in 2017 that delayed progression of the disease in clinical trials better than an older medicine did. Such medicines have become increasingly expensive as a group, priced in many cases at well over $80,000 a year. Hospitals delivering the drugs often take a cut by upcharging the drug or adding hefty fees for the infusion clinic. Even in a world of soaring drug prices, multiple sclerosis medicines stand out. Because her MS has left her too disabled to work, she is now on Medicare; she also has Medicaid for backup. No one told Shereese Hickson she qualified for financial assistance to cover her portion of a $123,019 bill ($3,620) until she called the hospital. Also, watch: Why Infusion Drugs Come With Sticker Shock (CBS This Morning). Kaiser Health News Editor-in-Chief Elisabeth Rosenthal discusses this “Bill of the Month” installment.
• 5 Most Common Medical Billing and Coding Errors (Bethany Nock, Ease the Way blog, Gebauer.com, 5-11-17)
• The problem is the prices (Sarah Kliff, Vox, 10-16-17) Health care prices in America are high — and they are secret. Vox looked into Anthem’s practice of denying emergency room visits as part of a year-long project on emergency room billing. It relies on a database of readers’ own emergency room bills. Hospitals keep ER fees secret. Share your bill to help change that. (share your bill with Sarah Kliff at Vox)

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Managing hospitalization and after

• Medicare’s Physician Compare tool lets you know whether your doctor accepts Medicare and takes assignment.
• What You Need to Know When You Go to the Hospital: Before, During, After (Caring Collaborative, Transition Network, 2011)
• How Medicare Stole My Mother’s Health and Life Savings (Cat Stone, Covey Club) My very independent mom was aging right. Until she checked into the hospital. When a doctor at the hospital told her that she had to sign the paperwork or leave, she signed. She told us that she was doing so well after the fracture that the hospital was just keeping her “under observation” and that she was relieved not to be “admitted.” So my mother accidentally signed away her future because the papers she initialed said she understood Medicare’s special rule: that patients “under observation” do not qualify for skilled nursing care.
• Aunt Bertha, an online database and easy-to-use search tool that makes it easy to find need-based social service programs related to needs for food, health care, housing, education, and employment programs. “There’s almost a paralysis of choice, there’s so many choices,” says Aunt Bertha's founder, Erine Gray, a trim, young programmer who studied economics and computer science as an undergraduate and has a master’s degree from the LBJ School of Public Affairs. “People just can’t find stuff. They end up getting scared and intimidated. Agencies are bad at creating their own websites.” (‘Aunt Bertha’ site helps those in need find aid (Omar Gallagha, Austin American-Statesman).
• Need a Walker or Wheelchair? How to Find a Free Medical Equipment Loan Program Near You (Kristen Gerencher, GoodRx Health, 8-26-22) Medical equipment loan programs let you borrow walkers, wheelchairs, shower chairs, and even hospital beds and computer devices for free.
• Hospital Tips for Seniors and Family Caregivers (Senior Providers Network, 6-12-18)
• Taken For A Ride? Ambulances Stick Patients With Surprise Bills (Melissa Bailey, KHN, 11-27-17) Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting 21 states to pass laws protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states. Patients usually choose to go to the doctor, but they are vulnerable when they call 911 — or get into an ambulance. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911. Today, ambulances are increasingly run by private companies and venture capital firms. e police or a bystander called 911. Forty years ago, most ambulances were free for patients, provided by volunteers or town fire departments using taxpayer money. The core of the problem is that ambulance and private insurance companies often can’t agree on a fair price, so the ambulance service doesn’t join the insurance network. The KHN review of complaints revealed two common scenarios leaving patients in debt: First, patients get in an ambulance after a 911 call. Second, an ambulance transfers them between hospitals. Most complaints reviewed by Kaiser Health News did not appear to involve fraudulent charges. Instead, patients got caught in a system in which ambulance services can legally charge thousands of dollars for a single trip — even when the trip starts at an in-network hospital. Patients do have the right to refuse an ambulance ride, as long as they are over 18 and mentally capable.
• Why American medicine still runs on fax machines (Sarah Kliff, Vox, 1-12-18) It's time to face the fax. The clinic has digitized its own patient data. But its electronic system can’t connect with other clinics’ records. So when doctors want to retrieve records from another office — an ultrasound for a pregnant patient, for example — they have to turn to the fax. So they use a Rube Goldberg-esque analog method for sharing data: Print out pages of one record, fax it, and then scan those pages into the other digital system. By one private firm’s estimate, the fax accounts for about 75 percent of all medical communication. It frustrates doctors, nurses, researchers, and entire hospitals, but a solution is evasive. Obama tried to force the health sector to go digital. But he didn’t make the systems talk. “Medical records generally come by fax. Sometimes they're mailed. They almost never come by any other route.”
• Advance directives, POLSTs, living wills, health care (medical) proxies. In brief (but there is a whole section here): The health care proxy part of the advance directive designates the person who has the authority to make medical treatment decisions for you should you be unable to (say, you've been in an accident and are in a coma). The living will (identifies the types of treatment you do and do not want at the end of your life-- stating your wishes about life-sustaining medical treatment if you are terminally ill, permanently unconscious, or in the end-stage of a fatal illness. The living will part of the advance directive expresses your wishes but it is NOT a medical order. Before you undergo a procedure or surgery it may be even more important to be sure your medical team has a copy of your MOLST, or POLST. The POLST form (aka MOLST, POST, MOST, ETC.) is a medical order--that's the one they're supposed to obey in a medical emergency or a life-threatening situation. Go here for a fuller explanation and links to places where you can get forms for these documents.
• Canadian hospital takes action to prevent delirium (CBC Player, 3-19-18) The Hamilton Health Sciences Centre is taking action to try and prevent delirium before the condition takes hold of the patient. It's being done using a program developed in the U.S. called the Hospital Elder Life Program (HELP). Each year in Canada, 200,000 people who go to hospital may experience delirium, a serious disturbance in mental ability that can leave them confused and frightened
• Hospital Elder Life Program (HELP) for Prevention of Delirium A comprehensive patient-care program that ensures optimal care for older adults in the hospital. HELP prevents delirium (a sudden state of confusion or change in mental state) and loss of functioning.
• Hearing loss patients at higher risk of hospital readmission (Ankur Banerjee, Reuters, 10-24-18) Hard-of-hearing hospital patients who have trouble communicating with medical personnel are more likely to end up back in the hospital within 30 days, compared to patients who don’t have trouble hearing, a U.S. study suggests. And hearing loss is common in older patients.
• Slammed with a Huge ER Bill from an Out-of-Network Doctor or Hospital? Now What? (Sandra Levy, HealthLine, 10-22-14) An increasing number of insured patients are stunned when they receive humongous bills from hospital emergency rooms and “contracted” physicians that are out of their insurance network. You assume, when you go to an in-network hospital, that everyone treating you is in-network ... There is a tiny paragraph [on admission forms] that says, ‘We may use outside doctors that are not part of your network and you are responsible..’ 'Pat Palmer, founder and CEO of Medical Recovery Services, told Healthline that in the past year and a half, she’s seen an increase in hospital ERs using the services of “contracted physicians” or “traveling docs,” as well as outside labs and radiology services. These doctors and services are contracted by the hospital, but they are out of a patient’s insurance network.' Palmer advised patients to inform the ER personnel, and write on the admission form, that you want to be notified of any provider that is not part of your insurance program, or not in-network. When negotiating with the provider, inform them that you never engaged their services directly; someone else engaged their services on your behalf, said Palmer. “Unless they have a signed document from you that you are agreeing to pay them anything they asked for, you want the bill adjusted to what the insurance is allowing,” said Palmer. Read this very practical piece in full!
My friend Ina suggests writing this on any form you sign: "Notwithstanding any other provisions contained herein it is hereby stipulated the patient or other person signing this document is not responsible for any costs, fees or other charges not covered by patient’s insurance policies. Patient will only pay co-payment amounts when approved by patient’s insurance policy companies."
• How To Fight For Yourself At The Hospital — And Avoid Readmission (Judith Graham, Kaiser Health News, 9-1-16) This new column explains what older adults and their families can do to avoid hospital readmission. Kaiser Health News columnist Judith Graham writes: "Everything initially went well with Barbara Charnes’ surgery to fix a troublesome ankle. But after leaving the hospital, the 83-year-old soon found herself in a bad way. Dazed by a bad response to anesthesia, the Denver resident stopped eating and drinking. Within days, she was dangerously weak, almost entirely immobile and alarmingly apathetic. “I didn’t see a way forward; I thought I was going to die, and I was OK with that,” Charnes remembered, thinking back to that awful time in the spring of 2015. Her distraught husband didn’t know what to do until a long-time friend — a neurologist — insisted that Charnes return to the hospital."
• We are in danger of hospitals no longer being safe havens (Andrea Lauffer, Kevin MD, 11-7-18) Unfortunately, there are more security measures found in concert halls, stadiums, and hotels than provided in many hospitals. If we truly want to do no harm, we must work to stop an opportunity for harm to occur.
• When You Need a Home Health Aide (Orly Avitzur, Consumer Reports)
• Diagnosis: Unprepared (KHN) Hospitals can be hazardous places for elderly patients, who are at increased risk of falling, drug-induced injury and confusion. But as the nation’s senior population grows, many facilities are ill-equipped to address their unique needs. Kaiser Health News visited hospitals around the country, reviewed data and interviewed dozens of patients, family members and health providers to document the extent of the problem and highlight possible solutions.
Read the stories in this series:
• Elderly Hospital Patients Arrive Sick, Often Leave Disabled (Anna Gorman, KHN, 8-9-16)
• Geriatric ERs Reduce Stress, Medical Risks For Elderly Patients (Anna Gorman, KHN, 8-23-16) Geriatric emergency rooms, which are slowly spreading across the country, provide seniors with more expertise from physicians, nurses and others trained specifically to diagnose and care for the elderly, researchers said.
• Elderly Patients In The Hospital Need To Keep Moving (Anna Gorman, KHN, 8-16-16) “People walk in the door of a hospital and think it’s OK to stay in a bed. It’s not,” said Middlebrooks. The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don’t fall, often leave them in their beds. The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion. Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.
• ‘America’s Other Drug Problem’: Copious Prescriptions For Hospitalized Elderly (Anna Gorman, Kaiser Health News, 8-30-16)

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Hospitals and hospital systems: issues within the industry

• Too Big To Fail? Now It’s 'Too Big To Hack' (KFF Health News' 'What the Health?', 4-18-24) Congress this week had the chance to formally air grievances over the cascading consequences of the Change Healthcare cyberattack, and lawmakers from both major parties agreed on one culprit: consolidation in health care. Plus, about a year after states began stripping people from their Medicaid rolls, a new survey shows nearly a quarter of adults who were disenrolled are now uninsured. Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post join KFF Health News’ Mary Agnes Carey to discuss these stories and more.
• A Doctor’s Love Letter to ‘The People’s Hospital’ (An Arm and a Leg, KFF and NPR, Season 9, Episode 4, 4-3-23) Could a charity hospital founded by a crusading Dutch playwright, a group of Quakers, and a judge working undercover become a model for the U.S. health care system? In this episode of the podcast “An Arm and a Leg,” host Dan Weissmann speaks with Dr. Ricardo Nuila to find out. Click on transcript to read.
• He Thinks His Wife Died in an Understaffed Hospital. Now He’s Trying to Change the Industry. (Kate Wells, Michigan Public Radio, NPR and KFF Health New, 4-19-24) Nurses are telling lawmakers that there are not enough of them working in hospitals and that it risks patients’ lives. California and Oregon legally limit the number of patients under a nurse’s care. Other states trying to do the same were blocked by the hospital industry. Now patients’ relatives are joining the fight.
• Elderly Hospital Patients Arrive Sick, Often Leave Disabled (Anna Gorman, KFF Health News, 8-9-16 "The older you are, the worse the hospital is for you," said Ken Covinsky, a physician and researcher at the University of California, San Francisco division of geriatrics. “A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more.” Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles.
• Designing smart hospitals of the future (Karen Blum, Covering Health, AHCJ, 3-31-22) Looking at facility design can give journalists a sense of where new hospital construction is headed and provide ideas for feature stories. Among features mentioned:
---badges care providers wear that wirelessly transmit their photos and positions to the patient’s digital board;
---an integrated pillow speaker, through which patients can use voice commands to call for a nurse; control the room’s lighting, window shades and temperature; turn on or off privacy glass on side of the room facing the hallway, and work the television or play music;
---smart patient rooms wired for cameras and voice-controlled functions;
---robots playing a role in operating rooms, food prep areas, and possibly later to labs or other locations;
---grab-and-go stations for prepared food with barcode technology through which employees can check out using Apple Pay or swipe their badge for a deduction on their paycheck;
---a Care Hotel model (at Mayo Clinic) to offer patients an environment outside of the hospital where they can receive both in-person and virtual care following a low-risk surgery or procedure;
---a private lounge for patients in the local airport; and so on.
• 'Not an Easy Villain': Documentary Tackles Healthcare's Big Hospital Problem (Sophie Putka, MedPage Today, 10-6-22) InHospitable, a new documentary about nonprofit hospitals, follows the lives of three patients and their families as they get caught between two feuding healthcare giants in Pittsburgh -- the University of Pittsburgh Medical Center (UPMC) and Highmark Health -- when UPMC announced it would stop accepting Highmark Health's insurance in a business move.

"This situation is a microcosm of the larger problem with the U.S. healthcare system: most hospitals are nonprofit, but still operate like big businesses. They generate enormous revenues. Instead of those profits going to stockholders, like a for-profit company, or to significant charities, money is poured back into the hospitals themselves, allowing them to expand rapidly and inflate executive pay without paying taxes locally. These nonprofit giants, InHospitable argues, can make whole communities dependent on them, but without accountability to taxpayers, employees, or their patients."
• Covering the reasons why hospitals struggle to retain nurses (Kerry Dooley Young, Covering Health, AHCJ, 10-4-22) “One thing that came up again and again and again is that nurses are hindered in their work by unsafe nurse staffing, by short staffing in hospitals,” Sarah DiGregorio (author of the forthcoming book Taking Care: The Revolutionary Story of Nursing) told AHCJ. "Working conditions, which had never been ideal in the first place — because of a lack of support staff and high patient-to-staff ratios, among other factors — have dramatically deteriorated. Nurses have been asked to work to the edge of their abilities; they fear for patient safety.”
• Bounties and Bonuses Leave Small Hospitals Behind in Staffing Wars ( Bram Sable-Smith, KHN, 2-7-22) A hospital in Wisconsin sued to keep seven employees from taking jobs with a competitor. A health system in South Dakota is offering nurses $40,000 signing bonuses. Facilities with fewer resources are finding it difficult or impossible to compete for health care workers.
• 3 reasons to cover new laws on hospital billing and medical debt (Joseph Burns, Covering Health, AHCJ, 2-16-22) A good explanation of the issues and many links to excellent additional reporting.
• The Part of the ‘Free Britney’ Saga That Could Happen to Anyone (Christopher Magoon, KHN, 9-29-21) "When Britney Spears last went before a judge, she bristled as she told of being forced into psychiatric care that cost her $60,000 a month. Though the pop star’s circumstances in a financial conservatorship are unusual, every year hundreds of thousands of other psychiatric patients also receive involuntary care, and many are stuck with the bill.... While hospitals sometimes absorb the cost, patients can be left with ruined credit, endless collection calls and additional mistrust of the mental health care system. In cases in which a hospital chooses to sue, patients can even be incarcerated for not showing up in court."
• Hospitals Accused Of Paying Doctors Large Kickbacks In Quest For Patients (Jordan Rau, KHN, 5-31-19) Hospitals are eager to get particular specialists on staff because they bring in business that can be highly profitable. But those efforts, if they involve unusually high salaries or other enticements, can violate federal anti-kickback laws.
• Hollowed-Out Public Health System Faces More Cuts Amid Virus (Lauren Weber and Laura Ungar and Michelle R. Smith, The Associated Press and Hannah Recht and Anna Maria Barry-Jester, KHN, 7-1-2020) The U.S. public health system has been starved for decades and lacks the resources necessary to confront the worst health crisis in a century.
• No Mercy (Where It Hurts podcast, Kaiser Health Network) Exploring what happens when the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium. Each season “Where It Hurts” takes you to an overlooked part of the country to explore cracks in the American health system that leave people frustrated — and without the care they need. For Season One host and investigative reporter Sarah Jane Tribble returns home to southeastern Kansas to document the fallout when a small town loses its only hospital.
• The Intolerable Fragility of American Hospitals (Libby Watson, New Republic, 4-30-2020) The coronavirus pandemic has exposed the frail and unequal nature of our public health system. It doesn’t have to be this way. "In general, hospitals charge private insurers about twice what they can get from Medicare, but it can be higher—four times more expensive or even more. Meanwhile, Medicare and Medicaid rates are lower than hospitals' operating costs....Even accepting this claim at face value—that hospitals must soak private insurance and any uninsured patients who get caught up in the machine, in order to survive—there's no reason why a single-payer system would have to preserve this apparent underpayment from Medicare."
• A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack (Chad Terhune, KHN, 8-27-18) The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before. The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, believing he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him. And then the bills came.

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• Hospitals Check To See If Patients Are Donor-Worthy — Not Their Organs, But Pockets (Phil Galewitz, KHN, 1-18-19) Nonprofit hospitals across the United States are seeking donations from the people who rely on them most: their patients. Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.Those who seem promising targets for fundraising may receive a visit from a hospital executive in their rooms, as well as extra amenities like a bathrobe or a nicer waiting area for their families.
• Texas fines Humana for out-of-network anesthesiology bills (Harris Meyer, Modern Healthcare, 10-11-18) In an unusual enforcement action against an insurer for out-of-network billing, Humana will pay Texas a $700,000 fine for failing to maintain an adequate number of in-network anesthesiologists at its contracted hospitals in four counties. It's the latest development in a running national battle over surprise out-of-network bills, which a bipartisan group of U.S. senators recently targeted with draft legislation. The problem is particularly pronounced in Texas, which lacks a comprehensive system for shielding patients from contract disputes between insurers and providers, unlike California and other large states.
• Cutting Higher Payments to Long-Term Care Hospitals Could Save $4.6 Billion (Tara Bannow, Modern Healthcare, 8-27-18) A trio of economists has a suggestion it says will save taxpayers about $4.6 billion per year with no harm to patients: get rid of higher payments to long-term care hospitals. A National Bureau of Economic Research study released Monday found that despite being reimbursed at much higher rates than skilled nursing facilities and home healthcare providers, long-term care hospitals don't produce better outcomes in three important areas: They don't reduce mortality or length of stay and they leave patients with higher out-of-pocket costs.

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• Mass. Health Care Groups Come Out Against Plan To Help Small Hospitals (WBUR Newsroom, CommonHealth, 7-20-18) Some Massachusetts health care industry groups are coming out strongly against bills approved by the House and Senate designed to support small community hospitals. "Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing."
• EMMA "Providing Market Transparency Since 2008." Get to know this source for hospital financial reports. The official source for municipal securities data and documents--and the official source for comprehensive annual financial reports and operating information about any hospital or health care facility financed by public debt. See AHCJ's webcast about it 8-2-18)
• Hospitals know how to protect mothers. They just aren't doing it. (Alison Young, USA Today, 7-26-18) "Every year, thousands of women suffer life-altering injuries or die during childbirth because hospitals and medical workers skip safety practices known to head off disaster, a USA TODAY investigation has found. Yet hospitals, doctors and nurses across the country continue to ignore them.... As a result, women are left to bleed until their organs shut down. Their high blood pressure goes untreated until they suffer strokes. They die of preventable blood clots and untreated infections. Survivors can be left paralyzed or unable to have more children....Instead, the U.S. continues to watch other countries improve as it falls behind. Today, this is the most dangerous place in the developed world to give birth."

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• Beth Israel-Lahey Merger Would Increase Health Costs By Tens Of Millions A Year, Panel Finds (Martha Bebinger, WBUR, CommonHealth, 7-18-18) A state panel assessing what would be the largest hospital transaction in Massachusetts in more than 20 years finds that the merger could increase health costs by tens of millions of dollars a year. Health economists say hospital reimbursement rates nearly always increase after a merger. The HPC, using hospital records, projects that BILH would treat the smallest share of Medicaid patients and the smallest proportion of nonwhite patients of any large hospital network in eastern Massachusetts. "You don't want to make the situation worse, particularly for vulnerable populations and vulnerable institutions," Altman said. "Savings to the providers does not necessarily result in lower costs and prices to the patient," said GBIO's Bonnie Gilbert.
• Hospital Giants Vie for Patients in Effort to Fend Off New Rivals (Reed Abelson, NY Times, 12-18-17) It’s all about the patient. Or at least about keeping patients and the revenue generated for their medical care. As health care is rocked by deals aimed at shattering traditional boundaries between businesses, some of the nation’s biggest hospital groups are doubling down on mergers that seem much more conventional. Skeptics say some of these hospital deals are more of the same: systems seeking to increase their leverage with insurance companies and charge more for care....But the frenzy of mergers and other alliances taking place also reveals a frantic attempt to court and capture patients as people have more choices about where to go for care. Patients are increasingly relying on walk-in clinics, urgent care centers or an app on their cellphone to check out a nasty rash or monitor their diabetes, and they are looking for places that are both less expensive and more convenient than a hospital emergency room or doctor’s office. The battle is over “the control of the patient,” said Rob Fuller, a heath care lawyer at Nelson Hardiman and a former hospital administrator. As hospital executives see the continued decline of care being delivered within a hospital’s four walls, he said they want to make sure they still have a say over where patients go after a hospital stay or to get treatment for a chronic condition....And the move by the insurers into their traditional territory is making some institutions very nervous. UnitedHealth Group, the giant insurer, is viewed as the greatest threat, underscored by its recent purchase of DaVita Medical Group....The proposed merger of CVS Health, which operates drugstores and a large pharmacy benefit manager, with Aetna, an insurer, also promises to reinvent care by transforming CVS’ roughly 10,000 drugstores into “health care hubs,” where patients can easily seek advice or treatment for anything from a sore throat to heart disease."
• Outsiders Swoop In Vowing to Rescue Rural Hospitals Short on Hope — And Money (Barbara Feder Ostrov, KHN/The Atlantic, 6-6-18) "The community of Surprise Valley, Calif., is torn over whether to sell its tiny, long-cherished hospital to a Denver entrepreneur who sees a big future in lab tests for faraway patients." The woes of Surprise Valley Community Hospital reflect an increasingly brutal environment for America’s rural hospitals, which are disappearing by the dozens amid declining populations, economic troubles, corporate consolidation and, sometimes, self-inflicted wounds. Abundant illustrations.

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• What Physicians Must Consider Before Selling to Hospitals (Aubrey Westgate, Physicians Practice, 2-6-14) "Across the country, hospital representatives are knocking on the doors of private practices. They come bearing attractive offers — higher compensation, simplification of administrative burdens, security in uncertain times. All physicians have to do is sell their practices and become hospital employees. But as physicians who have already made the transition from owner to employee know, many of the perks associated with employment come with big drawbacks." Insights from the doctors' viewpoint.
• A hospital without patients (Arthur Allen, Politico, 11-8-17) The cutting edge of health care is tucked off a St. Louis highway exit. And it's eerily quiet. "Mercy Virtual is arguably the world’s most advanced example of something gaining momentum in the health care world: A virtual hospital, where specialists remotely care for patients at a distance. It's the product of converging trends in health care, including hospital consolidation, advances in remote-monitoring technology and changes in the way medicine is paid for....In the near future, the hospital’s administrators believe, instead of earning fees for each treatment administered, insurers and the government will pay Mercy Virtual to keep patients well. A visit to the hushed carrels and blinking monitors is a glimpse into a future in which hospital systems are paid more when their patients are healthy, not sick."
• How hospitals got richer off Obamacare (Dan Diamond, Politico, 7-17-17) After fending off challenges to their tax-exempt status, the biggest hospitals boosted revenue while cutting charity care. A decade after the nation’s top hospitals used all their advertising and lobbying clout to keep their tax-exempt status, pointing to their vast givebacks to their communities, they have seen their revenue soar while cutting back on the very givebacks they were touting, according to a POLITICO analysis.
• Angered by high prices and shortages, hospitals will form their own generic drug maker (Ed Silverman, Pharmalot, 1-18-18) Angered by rising prices and persistent shortages of generic drugs, four of the nation’s largest hospital systems are forming a new, not-for-profit manufacturer.
• Pharma Has Another Reason To Look Out -- Healthcare Systems Now Plan To Make Their Own Drugs ( John Nosta, Forbes, 1-18-18) Intermountain Healthcare is leading a collaboration with Ascension, SSM Health, and Trinity Health, in consultation with the U.S. Department of Veterans Affairs, to form the company. The five organizations represent more than 450 hospitals around the U.S. "The new company intends to be an FDA approved manufacturer and will either directly manufacture generic drugs or sub-contract manufacturing to reputable contract manufacturing organizations, providing patients an affordable alternative to products from generic drug companies whose capricious and unfair pricing practices are damaging the generic drug market and hurting consumers."

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• The ‘Frequent Flier’ Program That Grounded a Hospital’s Soaring Costs (Arthur Allen, Politico, 12-18-17) In Dallas, Parkland Hospital created an information-sharing network that gets health care to the most vulnerable citizens—before they show up in the emergency room.

"Parkland Center for Clinical Innovation (or PCCI) was a joint effort with community partners such as homeless shelters and food pantries to build a network of what was hoped would eventually be hundreds of community-based social services around Dallas County, with Parkland Memorial at the center of it. A sophisticated software platform would enable the hospital to easily refer homeless people discharged from its emergency room to shelters and pantries, and to let social workers at those places see what their clients were doing: whether they were filling their prescriptions, or getting healthy food, or had a place to sleep, or money for the bus. It would be so much cheaper to meet those needs outside the medical system than to pay for the consequences inside it. Two years into the program, evidence is mounting that PCCI is working."
• 769 hospitals see Medicare payments cut over high HAC rates: 7 things to know (Morgan Haefner, Becker's Hospital Review, 12-22-16) "The federal government will cut 769 hospitals' Medicare payments in fiscal year 2017 for having the highest rates of hospital-acquired conditions."
• Penalty Calculations (Globe1234.info)
• Hospital-Acquired Condition Reduction Program (hospitals getting a 2018 penalty for HAC: HOSPITAL ACQUIRED CONDITIONS are identified in a column near the right edge)
• Hospital Inpatient Quality Reporting Program Hospitals eligible for the Hospital Inpatient Quality Reporting (IQR) Program are included annually in one of three lists.
• Dignity Health and Catholic Health Initiatives to Combine to Form New Catholic Health System Focused on Creating Healthier Communities (DignityHealth.org) Key strategic and reinvestment priorities for the new system will include:
---The expansion of community-based care, offering access to services in a variety of outpatient and virtual care settings closer to home;
---Clinical programs focused on special populations and those suffering from chronic illnesses to keep people and communities healthier for longer; and
---Further advancement of digital technologies and innovations like stroke robots and Google Glass, which create a more personalized and efficient care experience.

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Women's health issues

Birth control, C-sections, hysterectomies, and other female concernsSee alsoAbortion (including medication abortion)Maternal mortality problems in the U.S.

• Hospitals block much-needed birth centers in the South (Anna Claire Vollers, Stateline, 8-11-23) When Katie Chubb announced in 2021 she was planning to open a freestanding birth center in Augusta, Georgia, it seemed like everybody in town was excited about it. But established medical providers use regulatory requirements to quash competition.
Stateline provides daily reporting and analysis on trends in state policy. Since its founding in 1998, Stateline has maintained a commitment to the highest standards of nonpartisanship, objectivity and integrity. Its team of journalists combines original reporting with a roundup of the latest news from sources around the country. In 2023, Stateline transitioned from its longtime home at The Pew Charitable Trusts to States Newsroom.
• Rural Midwives Fill Gap as Hospitals Cut Childbirth Services (Aallyah Wright, Stateline, 12-8-21) For the past year or so, Toni Hill, a midwife in the lowlands of northern Mississippi, has received an influx of calls from women across the state who live in areas with no hospitals and only a smattering of health care providers.
• Ask Me About My Uterus: A Quest to Make Doctors Believe in Women's Pain by Abby Norman. In 2010, Abby Norman's strong dancer's body dropped forty pounds and gray hairs began to sprout from her temples. She was repeatedly hospitalized in excruciating pain, but the doctors insisted it was a urinary tract infection and sent her home with antibiotics. Unable to get out of bed, much less attend class, Norman dropped out of college and embarked on a years-long journey to discover what was wrong with her. It wasn't until she took matters into her own hands--securing a job in a hospital and educating herself over lunchtime reading in the medical library--that she found an accurate diagnosis of endometriosis. See also Endometriosis.
• The Unexpected Grief of a Hysterectomy (Anna Holmes, New Yorker, 4-1-23) My uterus is causing me nothing but discomfort. So why am I so sad to lose it?" A good account of what fibroids are, what trouble they can cause, and how they can be dealt with; of the differences between "total hysterectomies, which involve the removal of the uterus and the cervix; partial hysterectomies, which leave the cervix in place (this is what mine will be); and radical hysterectomies, which remove the uterus, cervix, and part of the upper vaginal canal"; and of why this surgery can be so difficult to face.
• Your Biggest C-Section Risk May Be Your Hospital (Tara Haelle, Consumer Reports, 5-10-18) Consumer Reports finds that your odds of having a c-section can be over nine times higher if you pick the wrong hospital...this study shows that it is possible for women, if properly armed with data, to vote with their feet and send a signal to the medical community by choosing—if possible—a hospital with a lower C-section rate,” explains Doris Peter, Ph.D., former director of the Consumer Reports Health Ratings Center...According to a recent consensus statement by the American College of Obstetricians and Gynecologists (ACOG), there are about four deaths for every 100,000 women after vaginal deliveries and about 13 deaths for every 100,000 women after cesareans....And you don’t just get the freedom to choose a doctor or practice you like. Because doctors are only credentialed to work in certain hospitals, you have to know where you want to deliver as much as which group you want to see."

• The Age That Women Have Babies: How a Gap Divides America (Quoctrung Bui and Claire Cain Miller, NY Times, 8-4-18) "The difference in when women start families cuts along many of the same lines that divide the country in other ways, and the biggest one is education. Women with college degrees have children an average of seven years later than those without — and often use the years in between to finish school and build their careers and incomes....Researchers say the differences in when women start families are a symptom of the nation's inequality -- and as moving up the economic ladder has become harder, mothers' circumstances could have a bigger effect on their children’s futures."
• 7 of the best OTC birth control options (Medical News Today) People can buy over-the-counter birth control without a prescription from drugstores, online retailers, or telehealth companies. Some options protect against STIs, and others can provide 24-hour protection.
• Call The Midwife! (If The Doctor Doesn’t Object) (Anna Gorman, KHN, 1-16-19) Hospitals and medical practices are battling outdated stereotypes and sometimes their own doctors to hire certified nurse midwives. Research shows that women cared for by certified nurse midwives have fewer cesarean sections, which can produce significant cost savings for hospitals. Despite the data supporting the use of nurse midwives, they attend fewer than 9 percent of births in the United States. That’s far lower than in some European countries, where more than two-thirds of births are attended by midwives. Lack of awareness among patients and other providers is a key reason, Professor Laura Attanasio said. “When people hear the term ‘midwives,’ people think you are really talking about home births.” In fact, she said, most midwife-attended births take place in hospitals.
• Pregnant Behind Bars: What We Do and Don't Know About Pregnancy and Incarceration (Jonathan Lambert, Shots, All Things Considered, NPR, 3-21-19) A study published in The American Journal of Public Health found that 3.8 percent of newly admitted women were pregnant and that in a single year, incarcerated women had 753 live births, 46 miscarriages, four stillbirths and 11 abortions. Dr. Carolyn Sufrin, an OB-GYN at Johns Hopkins School of Medicine, comments on the profound health and social consequences for the children of incarcerated mothers. This is a matter of equity, of racial justice.
• A Growing Number of Women Allege Doctors Abused Them During Childbirth (Sarah Yahr Tucker, Vice, 10-16-19) Women are speaking up and raising awareness about obstetric violence, including surgeries, medications, and procedures they didn't consent to. "Obstetric violence is normalized mistreatment of women and birthing people in the childbirth setting. It is an attempt to control a woman’s body and decisions, violating her autonomy and dignity. It has also been termed “disrespect & abuse” by the World Health Organization."~Obstetric Violence (Birth Monopoly)

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Abortion: scales tip on this divisive, embattled, politicized issue
Women's rights (or not) to control their own bodies.

"If you ban abortion before you ban military-style assault rifles that massacre children in schools, you've lost your right to call yourself 'pro-life.' "

See also Covering Abortion (Writers and Editors site) geared to journalists and historians covering healthcare and the politics of healthcare.

• Tracking the States Where Abortion Is Now Banned (NY Times Interactive)
• Interactive Map: US Abortion Policies and Access After Roe (Guttmacher Institute) "The abortion landscape is fragmented and increasingly polarized. Many states have abortion restrictions or bans in place that make it difficult, if not impossible, for people to get care. Other states have taken steps to protect abortion rights and access. Our interactive map groups states into one of seven categories based on abortion policies they currently have in effect." Note: You may need to clear your browser’s cache or open this page in an incognito window to ensure you are viewing the most recent version.
•How Abortion Misinformation Gives Rise to Restrictive Abortion Laws (Irving Washington and Hagere Yilma, Health Misinformation Monitor, 10-24-24) During the presidential debate on September 10, former President Trump falsely claimed that Democrats support “abortion after birth,” equating it to execution. Despite the fact that killing a child after birth is infanticide and illegal in all states, Trump’s statement sparked outrage among anti-abortion advocates who accepted his words as fact. Trump claims abortion is infanticide at election events but in reality, abortions later in pregnancy typically occur because individuals receive new information about their pregnancies, such as the discovery of serious fetal or maternal health issues, or because they were unable to access abortion services sooner.

---Health Misinformation and Trust (KFF) Where to check when you hear doubtful news.
• Is Abortion Still Accessible in My State Now That Roe v. Wade Was Overturned?
• Health Care and the 2024 Elections (KFF Health News, 10-17-24) Among takeaways: Several states have abortion measures on the ballot. Proponents of abortion rights are striving to frame the issue as nonpartisan, acknowledging that recent measures have passed thanks in part to Republican support. For some voters, resisting government control of women’s health is a conservative value. Many are willing to split their votes, supporting both an abortion rights measure and also candidates who oppose abortion rights.
• Abortion-Finder's State-by-State Guide Abortion is still illegal in some states but not in others

• Medication Abortion at Home (Telehealth) (Planned Parenthood of Metropolitan Washington, DC Inc) Abortion at home (via telehealth video appointment) allows you to receive compassionate, expert, abortion care while in the comfort of your own home rather than at a health center. This can be a good option if transportation, childcare, or time off from work make it hard for you to schedule an abortion appointment at one of our health centers. Explains how medication abortion works.
• Supreme Court officially allows emergency abortions in Idaho, for now (Ann E. Marimow and Dan Diamond, Washington Post 6-27-24) Hospitals in Idaho that receive federal funds must allow emergency abortion care to stabilize patients even though the state strictly bans the procedure, the Supreme Court ruled on Thursday, one day after the opinion was prematurely posted on its website. The court’s unsigned, 6-3 decision does not address the substance of the case. Instead, while litigation in the matter continues, the justices temporarily reinstated a lower-court ruling that had allowed hospitals to perform emergency abortions without being subject to prosecution under Idaho’s abortion ban.
• Key facts about the abortion debate in America (Carrie Blazina, Pew Research Center, 7-15-22) Quoting headlines only:

1. A majority of the U.S. public disapproves of the Supreme Court’s decision to overturn Roe.

2. About six-in-ten Americans (62%) say abortion should be legal in all or most cases, according to the summer survey...

3. While Republicans’ and Democrats’ views on the legality of abortion have long differed, the 46 percentage point partisan gap today is considerably larger than it was in the recent past...

4. There are wide religious divides in views of whether abortion should be legal, the summer survey found. "An overwhelming share of religiously unaffiliated adults (83%) say abortion should be legal in all or most cases, as do six-in-ten Catholics. Protestants are divided in their views: 48% say it should be legal in all or most cases, while 50% say it should be illegal in all or most cases. Majorities of Black Protestants (71%) and White non-evangelical Protestants (61%) take the position that abortion should be legal in all or most cases, while about three-quarters of White evangelicals (73%) say it should be illegal in all (20%) or most cases (53%)."

5. Women (66%) are more likely than men (57%) to say abortion should be legal in most or all cases...

6. Relatively few Americans view the morality of abortion in stark terms...

• Texas woman died after being denied miscarriage care due to abortion ban, report finds (Carter Sherman, The Guardian, 10-30-14) Josseli Barnica died days state passed six-week abortion ban and doctors delayed treatment, ProPublica reports. "Although US abortion bans – which more than a dozen states have enacted in the two years since the supreme court overturned Roe v Wade – technically permit the procedure in medical emergencies, doctors across the country have said that the laws are worded so vaguely that they don’t know when they can legally intervene. Instead, many physicians say they have been forced to wait until a patient is on the brink of death – then attempt to pull them back."
• Pregnant Texas teen died after three ER visits due to medical impact of abortion ban (Marina Dunbar, The Guardian, 11-1-24) Neveah Crain died in October 2023 after doctor reportedly called for two ultrasounds to ‘confirm fetal demise.’ "Crain is one of at least two Texas women who died under the state’s abortion ban brought in after the US supreme court overturned the federal right to abortion. Josseli Barnica, 28, died after a miscarriage in 2021.
     "These incidents are seen as evidence of a new reality where US healthcare professionals in states with new tough abortion restrictions are hesitant or even afraid to give care to pregnant mothers over fear of legal repercussions. Texas’s abortion ban threatens prison time for interventions that end a fetal heartbeat, regardless of whether the pregnancy is wanted or not."
• Montana Designs New Hurdles for Abortion Clinics Ahead of Vote To Protect Access (Matt Volz, KFF Health News, 8-1-24) Montana is proposing wide-ranging rules for licensing abortion clinics under a disputed state law, raising a new potential obstacle for patients even as a constitutional amendment to protect access appears headed for the November ballot.
     The proposed rules would set requirements for facilities that perform abortions for or provide medication abortion to at least five patients a year, excluding hospitals and outpatient surgical centers. Clinics would have to meet minimum limits for the size of their rooms and hallways, submit to annual state inspections, maintain written patient transfer agreements with hospitals, and be led by a medical director who is a licensed physician.
    'Nurse practitioner Helen Weems, who runs All Families Healthcare in Whitefish, one of three organizations that provide abortions in Montana, said the proposed regulations were unnecessary and would limit access to abortion in the state. “These requirements, including the requirement that abortion clinics have a physician medical director, are not about patient health or safety — they are purely about creating havoc and hardship for abortion providers,” said Weems, who successfully sued the state in 2018 to strike down a law requiring that abortions be performed only by physicians or physician assistants.'

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• J.D. Vance’s Opposition to Rape Exceptions to Abortion Bans Is Subject of Biting New Campaign Ad (Kylie Cheung, Jezebel, 7-18-24) The Biden-Harris campaign already called Vance "proudly anti-choice." When Hadley Duvall learned years ago that, at 12 years old, she had been impregnated by her stepfather, she says she was able to find comfort in one thing: “First thing that was told to me when I saw that positive pregnancy test was, you have options,” Duvall, who’s now 21, recounts in a new ad for the Biden-Harris reelection campaign that will air on Saturday.

“Trump and J.D. Vance don’t care about women, they don’t care about girls in this situation,” Duvall concludes. This marks the Biden-Harris campaign’s first ad against Vance, who joined the Republican presidential ticket on Monday. Already, the campaign has called Vance “proudly anti-choice.” In 2021, Vance even argued against rape and incest exceptions for abortion bans: “Two wrongs don’t make a right,” he told Spectrum News. In the new Biden-Harris ad, Duvall emphasizes how this position would further traumatize and possibly entrap rape victims like her. When Vance spoke at the Republican National Convention in Milwaukee, Wisconsin, his remarks conspicuously excluded abortion altogether. There wasn’t even a single, vague reference to “life.”
---J.D. Vance Endorsed a National Abortion Ban in the Grossest Way Possible (Andrew Perez, Nikki McCann Ramirez, Rolling Stone, 7-17-24) Trump’s running mate said a national abortion ban was necessary to keep George Soros from flying “Black women” to California for abortions.
---RNC Speakers Proved the GOP Still Doesn’t Care About Women (Kylie Cheung, Jezebel, 7-19-24) At the RNC this week, among the guests chosen to speak on behalf of the GOP, several have railed against no-fault divorce, while others have grossly disparaged sexual violence victims.The decades of sexual misconduct allegations and his sexual abuse conviction in the E. Jean Carroll case should disqualify Trump from office. But as the RNC demonstrated this week, the allegations against Trump make him a hideously perfect fit to lead a political party that’s cozy with abusers and openly supportive of gender-based violence. Vance said that even domestic violence victims should stay in abusive marriages, so their kids won’t be “unhappy.”But Vance is no outlier. Former Housing and Urban Development Secretary Ben Carson, Sen. Tom Cotton (R-AR), and House Speaker Mike Johnson—who all spoke this week—have all similarly criticized no-fault divorce, which can be a lifeline for abuse victims.
In a 2016 sermon, House Speaker Mike Johnson seemed to blame literal school shootings on divorce and abortion: “Do you remember in the late ‘60s when they invented things like no-fault divorce laws, we invented the sexual revolution, radical feminism, we invented legalized abortion in 1973, where the state sanctioned the killing of the unborn? We know that we’re living in a completely amoral society. It’s, people say, ‘How can a young person go into their school and open fire on their classmates?’ Because we taught a whole generation, couple generations now, that there is no right and wrong.”

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• Voters support abortion rights in five states with ballot measures (Brad Dress, The Hill, 11-9-22) "Voters in California, Vermont and Michigan on Tuesday approved ballot measures enshrining abortion rights into their state constitutions, while those in the traditionally red states of Montana and Kentucky rejected measures that would have restricted access to reproductive care. The votes signal support for abortion rights after the Supreme Court in June overturned the landmark 1973 case Roe v. Wade and the constitutional right to the procedure.
"In August, Kansas voters also rejected a ballot measure that would have given the state legislature the authority to restrict abortion access through a state constitutional amendment.

[As one elder in Kansas observes, about votes on post-Dobbs issues: "Some of these were votes against constitutional or other changes that would have forbidden abortion; some were in favor of enshrining women’s bodily autonomy in state law or state constitutions. There will be more such votes."]
"The ballot votes came amid high-profile Senate and House races, with some candidates running for office across the nation with hard-line views on abortion access. Already in post-Roe America, about half of all states have moved to restrict abortion access, even as polls show most Americans approve of the right to abortion."
• “The Alliance for Hippocratic Medicine — a coalition of anti-abortion medical groups that formed in Texas last year — challenged both the FDA’s original 2000 approval of mifepristone, arguing the agency didn’t adequately consider the drug’s safety risks, as well as later agency actions that loosened restrictions on the pills. The groups claim their physician members are harmed by the pills’ availability because they may at some point need to provide follow-up care for a patient who took them and had a complication." ~ (Alice Miranda, Ollstein, Politico, 8-17-23)
• How the Texas Trial Changed the Story of Abortion Rights in America (Sarah Varney, KFF Health News, 8-7-23) “The entirety of abortion rights history is a history of doctors appearing in court to represent their own interests and the interests of pregnant people,” said Elizabeth Sepper, a law professor at the University of Texas-Austin.
"But in July, in a Texas courtroom, the case for abortion was made by women themselves who had been denied abortions and sued the state to clarify the exceptions to its ban, which makes it illegal to perform an abortion unless a patient is facing death or “substantial impairment of a major bodily function.” The aspiring mothers described in vivid, harrowing detail how the state’s abortion ban had endangered their health, traumatized them, and, in the case of Samantha Casiano, forced her to carry and give birth to a baby girl without a formed skull or brain only to watch her die a tortured death four hours later.
"For decades, Christian anti-abortion groups have deployed ultrasound fetal images and grisly photos of what they say are aborted fetuses on highway billboards, protest signs, and online ads to garner sympathy for “unborn children” and advance their religious and political aims. But the Texas hearing, for the first time since the early 1970s, according to legal scholars and historians, trained the camera upward, away from the high-resolution fetal images to the faces of sympathetic women who say they suffered grievously under the state’s abortion ban."
• For one Texas doctor, abortion bans are personal and professional (Selena Simmons-Duffin, Shots, NPR, 8-21-23) Dr. Austin Dennard is one of 13 patients and two other doctors suing Texas over its abortion bans. Last summer, she learned that she was carrying a fetus with anencephaly — a fatal condition in which the skull and brain do not develop fully. She traveled to the east coast for an abortion. After that, one judge's decision temporarily blocked the Texas abortion bans in cases of serious pregnancy complications. Even as she celebrated, she knew it likely wouldn't last long because attorneys for the state of Texas would appeal. Less than 12 hours later, that's what happened.
• Facts Are Important: Identifying and Combating Abortion Myths and Misinformation (ACOG, American College of Obstetricians and Gynecologists) With additional links to information about abortion and abortion myths.
• Facts Are Important: Medication Abortion "Reversal" Is Not Supported by Science (ACOG)
• New York Is Suing Crisis Pregnancy Centers for Promising “Abortion Reversal” (Julianne McShane, Mother Jones, 5-6-24) Anti-choice groups still wield a strong presence in blue states. Attorney General Letitia James is the latest prosecutor to take them on.
---This Doctor Says He Can “Reverse” Abortions Nina Liss-Schultz, Mother Jones, 6-9-17) And pro-life lawmakers are taking notice.

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• Policies to Roll Back Abortion Rights Will Hit Incarcerated People Particularly Hard (Carly Graf. KFF Health News, 8-22-22) After the Supreme Court removed Roe v. Wade’s constitutional protections for abortions, many reproductive services stand to be prohibited altogether, putting the health of incarcerated women who are pregnant at risk.
      That threat is particularly urgent in states where lawmakers have made clear their intentions to roll back abortion rights.
      “Previously there was at least some sliver of legal recourse there for an incarcerated person, but that no longer exists for people who live in states where abortion is or will be severely restricted or illegal,” said Dr. Carolyn Sufrin, an OB-GYN, a professor, and the director of the Advocacy and Research on Reproductive Wellness of Incarcerated People program at Johns Hopkins University.
      The Prison Policy Project, a nonprofit research organization, estimates about 58,000 people a year are pregnant when they enter prisons or jails, or about 4% of the total number of women in state and federal prisons and 3% of those in local jails.
• Abortion Is Shaking Up Attorneys General Races and Exposing Limits to Their Powers (Lauren Weber and Sam Whitehead, KFF Health News, 8-19-22) Democrat Kimberly Graham, an Iowa county attorney candidate, has declared that she would not prosecute doctors or people for abortion care. She noted that the Supreme Court’s June decision in Dobbs v. Jackson Women’s Health Organization has highlighted how little people realize the “scary amount of discretion and power” prosecutors have.
      “The only real accountability to that is called the ballot box,” she said. “Hopefully, among other things, people will start paying more attention to the county attorney and DA races and realizing how incredibly important these positions have always been.”
• What’s at Stake for Access to Medication Abortion and the FDA in the Supreme Court Case FDA v. the Alliance for Hippocratic Medicine? (Laurie Sobel, Alina Salganicoff, and Mabel Felix, Women's Health Policy, KFF, 3-21-24) On March 26, 2024, the Supreme Court is scheduled to hear oral arguments in Food and Drug Administration (FDA) v. Alliance for Hippocratic Medicine (AHM), and Danco Laboratories LLC v. AHM. While the Supreme Court stated in the Dobbs decision that it “returns the issue of abortion to the people’s elected representatives,” the outcome of this case could limit access to medication abortion throughout the country, including in states where abortion is legal and protected.
• How National Political Ambition Could Fuel, or Fail, Initiatives to Protect Abortion Rights in States (Bram Sable-Smith and Rachana Pradhan, KFF Health News, 3-19-24) As money flows to abortion rights initiatives in states such as Montana, some donors focus on where anger over the "Dobbs" ruling could propel voter turnout and spur Democratic victories up and down the ballot.

• Montana, an Island of Abortion Access, Preps for Consequential Elections and Court Decisions (Arielle Zionts, KFF Health News, 3-14-24) A 25-year-old state Supreme Court ruling protects abortion rights in conservative Montana. That hasn’t stopped Republicans and anti-abortion advocates from trying to institute a ban.
• California Pushes to Expand the Universe of Abortion Care Providers (Laurie Udesky, KFF Health News, 3-4-24) A new California law allows trained physician assistants, also called physician associates, to perform first-trimester abortions without the presence of a supervising doctor. The legislation is part of a broader effort by the state to expand access to abortion care, especially in rural areas. Some doctor groups are wary.

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• Faith-based maternity homes ‘create a haven’ in states with strict abortion laws (Anna Claire Vollers, Stateline, 10-3-23)
• Traveling for abortions: The untold story (Katelyn Jetelina, Your Local Epidemiologist, 12-24-23) Forced abortion travel has doubled following Dobbs. And if you’re one of the lucky few who can travel, this journey isn’t without very real challenges that may not be apparent to the unseen eye.

But critics point out the help homes offer comes with strings attached. "Our moms find that it’s difficult to find a job that pays a livable wage, impossible to find a home they can afford and impossible to find child care, never mind child care that’s affordable. This is where these maternity homes are stepping in.... But critics caution that the free help maternity homes provide comes with strings attached." Check out Stateline for more stories about women's
• Olivia Rodrigo hands out emergency contraceptives at concert in Missouri, where abortion is banned (Marlene Lenthang, NBC News, 3-13-24) Concert attendees shared photos on social media showing stickers, information about abortion care, condoms and emergency contraceptive pills available at a booth at the show. Rodrigo posted on her Instagram story that a portion of the proceeds from all ticket sales from the St. Louis show will go towards the Missouri Abortion Fund and Right By You, which helps Missourians access abortion, birth control and birth care.
• “I Never Thought I Would” (Deborah McNabb, Pulse, 7-9-22) "Throughout high school, college and medical school, I was a feminist and supported a woman’s right to bodily autonomy, but I only knew one story. That story involved a young woman who knew that she was not mature enough to parent a child or a woman who needed to finish her education in order to have a future livable wage. My eyes were opened during my OB/Gyn residency where we trained in abortion provision through the entire four years. At the beginning of each day, we gathered the women who were to have their procedures, in one room....

"As each woman told her story, each story more jaw-dropping than the one before, I was overwhelmed by the challenges that they faced in their lives. My life to that point had not been easy, but I could never have imagined the suffering that these women had endured. Over the years of my career, I never asked for stories, but most women offered them.

Almost without exception, every story began with, “I never thought that I would have an abortion, but . . .”
"What if everyone heard these stories? What if everyone knew their friend or loved one had had an abortion? Would hearts and minds change?
• Life of the Mother: How Abortion Bans Lead to Preventable Deaths (ProPublica) When the Supreme Court overturned Roe v. Wade in 2022, doctors warned that women would die, but lawmakers who passed state abortion bans didn’t listen. The worst consequences are now becoming clear.
---Afraid to Seek Care Amid Georgia’s Abortion Ban, She Stayed at Home and Died (Kavitha Surana, ProPublica, 9-18-24) Candi Miller’s health was so fragile, doctors warned having another baby could kill her. She didn't visit a doctor “due to the current legislation on pregnancies and abortions.” Maternal health experts deemed her death preventable and blamed Georgia’s abortion ban.
---Abortion Bans Have Delayed Emergency Medical Care. In Georgia, Experts Say This Mother’s Death Was Preventable. (y Kavitha Surana, ProPublica, 9-16-24) At least two women in Georgia died after they couldn’t access legal abortions and timely medical care in their state, ProPublica has found. This is one of their stories.
• How Do Abortion Pills Work? Answers to Frequently Asked Questions. (ProPublica) The FDA says abortion pills are safe if taken as directed. Here’s what patients should expect.
• How IVF is complicating Republicans' abortion messaging (Lexie Schapitl, NPR, 3-16-24) Listen or read transcript. In-vitro fertilization has become the latest front in the political battle over reproductive rights, and it's left some Republicans grappling with how to square their support for IVF with their past stances on reproductive rights. Kansas Sen. Roger Marshall, a practicing obstetrician, said he welcomes "every day 200 babies that are born because of in-vitro fertilization in this country. But he's also one of the senators who co-sponsored the Life at Conception Act, a bill that would have granted constitutional protection to embryos at "the moment of fertilization." If enacted, that legislation could have threatened access to IVF, during which embryos are often discarded or stored for years.
• “We Need to Defend This Law”: Inside an Anti-Abortion Meeting With Tennessee’s GOP Lawmakers (Kavitha Surana, ProPublica, 11-15-22) Anti-abortion groups helped write and pass laws that kicked in to ban abortion when Roe v. Wade was overturned. The groups see Tennessee’s ban as the country’s strongest — and they want to keep it that way, according to audio reviewed by ProPublica.
• To Protect a Mother’s Health: How Abortion Ban Exemptions Play Out in a Post-‘Roe’ World (Christopher O’Donnell, Tampa Bay Times and KFF Health News, 7-21-23) Every state that bans or restricts abortions has an exception to protect the health of the mother. But recent history in other states suggests that few women will be able to take advantage of such exceptions if Florida’s new law, on hold while tied up by legal challenges, is upheld by the state Supreme Court.

"If Florida’s six-week ban moves forward, rape and incest victims would have to provide their doctor a copy of a restraining order, police report, medical record, court order, or other documentation to get an abortion after that window. However, two-thirds of sexual assault victims do not report the crime, studies show, meaning no police report would exist. An estimated 8 in 10 rapes are committed by someone known to the victim, often leaving victims afraid of reprisals if they report the crime.

"Florida has a long-established law allowing abortions when a fetus has fatal abnormalities. But no exceptions exist for serious genetic defects, deformities, or abnormalities, which were cited as the reason for 578 abortions in the state last year....A June KFF poll found that 61% of OB-GYNs who practice in states with abortion restrictions are concerned about the legal risk when deciding whether to perform an abortion. “It doesn’t make any medical sense,” said Jennifer Griffin, a Tampa physician who provides abortions. “These politicians are not making policy based on science; they’re based on religion.”
• ACOG Guide to Language and Abortion (American College of Obstetricians and Gynecologists) Download free. Why "medical abortion" is preferable to "chemical abortion."
"Through eight weeks after last menstrual period, 'embryo.' After that point until delivery, 'fetus.'"

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• Idaho educators file federal lawsuit over ‘no public funds for abortion’ law (Kelcie Moseley-Morris, Idaho Capital Sun, 8-8-23) A coalition of professors from across Idaho have filed a lawsuit in federal court against the state alleging a law prohibiting the use of public funds to promote or counsel in favor of abortion is “sweeping and unclear” and violates their constitutional free speech and due process rights. It is the fourth lawsuit filed against Idaho for abortion-related laws, with three others challenging the details of the state’s near-total ban on abortion and a so-called “abortion trafficking” bill that restricts adults from taking minors out of state to obtain abortion care. Tuesday’s lawsuit targets the No Public Funds for Abortion Act, which passed in the 2021 session of the Idaho Legislature and prohibited public funds from being used to “procure, counsel in favor, refer to or perform an abortion.”

• ‘Republicans Abandoned Me’: Meet the Dobbs Voters of Michigan (Alice Miranda Ollstein and Politico Magazine, 11-4-22) Nine Michiganders on why they’re energized (pro and against abortion) in this year’s midterms, and how this election cycle has changed their relationship to politics.

Stay-at-home mother of three Jessica Leach, 37, thought of herself, for decades, as a textbook Republican. But when Roe fell, she thought back to her first pregnancy 17 years ago that she considered terminating out of concern she wouldn’t be a good mother. She ultimately decided to see it through. When she first discovered the unintended pregnancy, she recalled, she went to a church-run clinic with her boyfriend, where “they just started pushing scripture at us and telling me not to have an abortion.” Turned off by the pressure campaign, she then visited an abortion clinic, and said the staff there gave her “all the information I needed to make the best choice for me and my life.”

“I love being a mom, but I wonder if I would love it so much if I hadn’t had a choice,” she said. (One of nine stories, both for and against choice.)

Medication abortion, also known as medical abortion or abortion with pills, can be safely used up to the first 10 weeks of pregnancy according to the U.S. Food and Drug Administration.

• Abortion Pills Can Now Be Offered at Retail Pharmacies, F.D.A. Says (Pam Belluck, NY Times, 1-3-23) Mifepristone, the first of two drugs in medication abortions, previously had to be dispensed only by clinics, doctors or a few mail-order pharmacies. Now, if local drugstores or chains like CVS agree to certain rules, they can provide it. Patients will still need a prescription from a certified health care provider, but any pharmacy that agrees to accept those prescriptions and abide by certain other criteria can dispense the pills in its stores and by mail order. With conservative states banning or sharply restricting abortion, the pills have increasingly become the focus of political and legal battles, which may influence a pharmacy’s decision about whether or not to dispense the medication.
• 3 states renew their effort to reduce access to the abortion drug mifepristone (Geoff Mulvihill, AP News, 10-16-24) Three states are renewing a legal push to restrict access to the abortion medication mifepristone, including reinstating requirements it be dispensed in person instead of by mail. The request from Kansas, Idaho and Missouri filed Friday would bar the drug’s use after seven weeks of pregnancy instead of 10 and require three in-person doctor office visits instead of none in the latest attempt to make it harder to get a drug that’s used in most abortions nationally.
• Uphill battles that put abortion rights on ballots are unlikely to end even if the measures pass (Geoff Mulvihill, AP News, 10-17-24) Voters in nine states are deciding next month whether to add the right to abortion to their constitutions, but the measures are unlikely to dramatically change access — at least not immediately. Instead, voter approval would launch more lawsuits on a subject that’s been in the courts constantly — and more than ever since the U.S. Supreme Court in 2022 overturned Roe v. Wade and opened the door to state abortion laws. In some states where the issue is on the ballot, it’s already
• Florida Dems tie their future to abortion ballot measure (Gary Fineout, Politico, 10-16-24) Florida Democrats have launched a multi-million-dollar campaign to urge voters to pass the initiative that would guarantee access to abortion in the nation’s third largest state. The decision by Democrats to invest millions now in ads demonstrates how important state party leaders view Amendment 4 as part of their push to regain relevance in the former battleground state. Democrats — who remain at a significant financial disadvantage to Republicans — have been sharply critical of abortion restrictions pushed into law by Gov. Ron DeSantis and the GOP-controlled legislature.
• Plan C: Find Abortion Pills Through Licensed Providers (NWHN) In several states there are US-based clinicians who currently prescribe and mail FDA-approved abortion pills following an online or phone consultation. PlanC compiled this guide to finding providers based on where you live. Abortion pills can cost anywhere from $40 to $600. See Aid Access.

• Abortion Pill Can Be Dispensed in Retail Pharmacies, FDA Says (Amanda D'Ambrosio, MedPage Today, 1-4-23) Decision allows patients to pick up mifepristone (Mifeprex), one of two drugs used for medication abortion, at brick-and-mortar locations. The rule will not apply to pharmacies in the roughly dozen states that have near-total abortion bans or that restrict access to the abortion pill. However, when the FDA permanently removed the in-person dispensing requirement, it added a condition mandating that pharmacies acquire a special certification to dispense the drug.
• Websites Selling Abortion Pills Are Sharing Sensitive Data With Google (Jennifer Gollan,ProPublica, 1-18-23) Some sites selling abortion pills use technology that shares information with third parties like Google. Law enforcement can potentially use this data to prosecute people who end their pregnancies with medication. While many people may assume their health information is legally protected, U.S. privacy law does little to constrain the kind or amount of data that companies such as Google and Facebook can collect from individuals. (Provides information about both privacy laws and Google practices.)
• One woman's opinion: "While the voters are pretty resoundingly in favor of women’s right to control their bodies, Republican legislatures and a number of judges appointed to conservative circuits by Donald Trump are doing their best to limit or remove those rights. The judges involved are hacks — the latest, in a Fifth Circuit (highly right-wing circuit) appeal re mifepristone, spoke of the injury to the physician’s aesthetic sensibility when the physician was unable to bring a child to birth. It’s drivel of the lowest order. The case was brought by right-wing physicians and medical facilities none of which had true standing to bring it, but by entering the suit in this particular circuit, were allowed to carry it forward. Dobbs has created an unholy mess."

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• When Insurance Won’t Pay, Abortion Assistance Funds Step In (Dan Weissmann, ‘An Arm and a Leg,’ KHN, 11-23-22) Privacy concerns and coverage limits have long made insurance an unreliable option for abortion access. For decades, abortion funds have been stepping in to help people pay for what they see as essential health care.
---National Network of Abortion Funds
---How to Get Help New Orlean Abortion Fund's links to many other resources.
• “We Need to Defend This Law”: Inside an Anti-Abortion Meeting With Tennessee’s GOP Lawmakers (Kavitha Surana, ProPublica, 11-15-22) Anti-abortion groups helped write and pass laws that kicked in to ban abortion when Roe v. Wade was overturned. The groups see Tennessee’s ban as the country’s strongest — and they want to keep it that way, according to audio reviewed by ProPublica.

"The way that many state laws work is they’ll say, ‘Abortion, elective abortion, is generally illegal except in these situations.’ … What y’all did is you said, ‘Elective abortion is illegal all the time.’”

"There has to be medical judgment … [or] you’ve got the legislature practicing medicine, which they have no business at all doing." —Tennessee state Sen. Richard Briggs. His position seems to more closely reflect the attitudes of the majority of Tennesseeans: While 50% identify as "pro-life," 80% believe abortion should be either completely legal or legal under some conditions. To Briggs, the anti-abortion lobbyists were asking lawmakers to respond to legitimate questions from voters with answers that weren't based in science.

The American Cancer Society says scientific evidence does not support the theory that abortions raise the risk of breast cancer. The National Academies of Sciences, Engineering and Medicine reviewed existing research and found the risk of death after a legal abortion is a small fraction of the risk of carrying a pregnancy to term.

A large body of peer-reviewed work finds that having a wanted abortion is not associated with worse health or mental health outcomes. Instead, denying a woman a wanted abortion is linked to worse economic and health outcomes and can strengthen a woman's ties to a violent partner.
• We Cannot Rest Until Abortion Rights Are Restored (Morgan S. Levy, Shira Fishbach, Vineet Arora, and Arghavan Salles, MedPage Today, 12-30-22) As physicians, we have the privilege of bearing witness to the critical role of preserving access to the full spectrum of reproductive healthcare. Access to care is essential not only for our patients, but also for the physician workforce, as our data shows over 1 in 10 physicians have had an abortion. For the patient whose amniotic sac ruptures at 22 weeks' gestation and faces likely sepsis, or the patient with a new diagnosis of pulmonary hypertension for whom a pregnancy would be lethal, or for the pre-med student with aspirations to go to medical school: abortion is essential. We cannot rest until abortion rights are restored.
• Post-‘Roe,’ Contraceptive Failures Carry Bigger Stakes (Sarah Varney, KHN, 11-7-22) With most abortions outlawed in at least 13 states and legal battles underway in others, contraceptive failures now carry bigger stakes for tens of millions of Americans.
• Hospital Investigated for Allegedly Denying an Emergency Abortion After Patient’s Water Broke (Harris Meyer, KHN, 11-1-22) The federal government has launched its first confirmed investigation of an alleged denial of an abortion to a woman experiencing a medical emergency. The case involves a woman whose water broke early in her pregnancy, but the hospital refused to let doctors perform an abortion. She eventually sought medical help outside the state. In the 13 states that have outlawed most abortions that federal law requires them to provide life- or health-saving medical services — including abortion, if necessary — to patients experiencing emergency pregnancy complications. The 1986 EMTALA law requires hospitals and physicians to provide screening and stabilizing treatment in emergency situations.
"HHS cited several emergency pregnancy situations in which abortion might be required to prevent permanent injury or death, such as ectopic pregnancies, severe blood pressure spikes known as preeclampsia, and premature rupture of the membrane causing a woman’s water to break before her pregnancy is viable, which can lead to serious infections and threaten her life."

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• How abortion rights advocates say midterm elections could impact access in Arizona (Kyla Guilfoil, ABC News, 11-7-22) Abortion providers in Arizona have been living in "legal limbo" since the Supreme Court overturned Roe v. Wade. A near-total abortion ban in the state with language dating back to 1864 was never technically repealed after the 1973 ruling of Roe. Who's elected may determine what rights women have to abortions in Arizona
• AG: Disposing embryos outside uterus not against Tenn. law (Kimberlee Kruesi, AP News, 11-4-22) Tennessee’s strict abortion ban does not apply to the disposal of fertilized human embryos that haven’t been transferred to a uterus, according to a recent state attorney general opinion. Unlike many states’ abortions bans, including the one in Texas, Tennessee’s law does not explicitly exempt abortions performed to save a mother’s life. Instead, doctors are required, if charged, to convince a criminal court that an abortion was needed to save the mother’s life or avoid a serious risk of impairing a major bodily function of the pregnant woman.
• Because of Texas abortion law, her wanted pregnancy became a medical nightmare (Carrie Feibel, Shots, NPR, Morning Edition, 7-26-22) New, untested abortion bans have made doctors unsure about treating some pregnancy complications, which has led to life-threatening delays and trapped families in a limbo of grief and helplessness. Today, abortion is also illegal in Texas under an old 1925 law that the state's Attorney General Ken Paxton declared to be in effect after Roe was overturned.

See New Texas Trigger Law Makes Abortion a Felony (NPR 8-27-22) Texas's new trigger law criminalizes providing abortions. It comes with five years to life imprisonment, as well as civil penalties of $100,000 for abortion and administrative penalties in the form of mandatory revocation of a license to practice medicine, do nursing, pharmacy, so on.criminalizes providing abortions. It comes with five years to life imprisonment, as well as civil penalties of $100,000 for abortion and administrative penalties in the form of mandatory revocation of a license to practice medicine, do nursing, pharmacy, so on.
• Florida court blocks teen from getting abortion, must continue pregnancy (Oriana Gonzalez, Axios, 8-16-22) The teenager, who court documents say is "parentless," had sought court approval to bypass a Florida law that requires that a minor get parental consent in order to get an abortion. A lower Florida court had ruled that the teenager, who is unidentified, was not mature enough to decide to get an abortion. The teen then filed an appeal, and the appellate court upheld the previous decision.

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• $80,000 and 5 ER Visits: An Ectopic Pregnancy Takes a Toll Despite NY’s Liberal Abortion Law (Michelle Andrews, KHN, 10-5-22) When Sara Laub learned she was pregnant, she went to a Planned Parenthood clinic because she knew someone could see her immediately there. An ultrasound found no sign of a developing embryo in her uterus. That pointed to the possibility that Laub might have an ectopic pregnancy, in which a fertilized egg implants somewhere outside the uterus, usually in a fallopian tube.
• In Idaho, Taking a Minor Out of State for an Abortion Is Now a Crime: ‘Abortion Trafficking’ (Sarah Varney, KFF Health News, 5-8-23) Under the nation’s first law of its kind, teens must have parental consent to travel for medical care, including in cases of sexual assault or rape. Any adult, including an aunt, grandparent, or sibling, convicted of violating the criminal statute faces up to five years in prison — and could be sued for financial damages.
•As States Impose Abortion Bans, Young Doctors Struggle — And Travel Far — To Learn the Procedure (Sarah Varney, KHN, 3-23-22) A barrage of abortion restrictions rippling across the country, from Florida to Texas to Idaho, is shrinking the already limited training options for U.S. medical students and residents who want to learn how to perform abortion procedures. The clinical skills used in abortion procedures are often the same used to clear the uterine lining after a miscarriage or end a pregnancy in demise that is causing hemorrhaging and other complications that can lead to maternal death. Clinicians who aren’t familiar with abortion procedures are often less skilled at performing these lifesaving procedures, experts said. “Any obstetrician who says there is never need for abortion care is not telling the truth about obstetrics.”
• One Woman’s Abortion (Mrs. X, The Atlantic, 8-65) In 1965, eight years before Roe v. Wade, an anonymous woman described the steps she took to terminate an unwanted pregnancy.
• How a Secretive Billionaire Handed His Fortune to the Architect of the Right-Wing Takeover of the Courts (Andrew Perez, The Lever, and Andy Kroll and Justin Elliott, ProPublica, 8-22-22) In the largest known political advocacy donation in U.S. history, industrialist Barre Seid funded a new group run by Federalist Society co-chair Leonard Leo, who guided Trump’s Supreme Court picks and helped end federal abortion rights. The elderly, ultra-secretive Chicago businessman has given the largest known donation to a political advocacy group in U.S. history — worth $1.6 billion — and the recipient is one of the prime architects of conservatives’ efforts to reshape the American judicial system, including the Supreme Court.

      An ectopic pregnancy in the fallopian tube is never viable. But following the June reversal of Roe by the Supreme Court, reproductive health experts say treatment may be dangerously delayed as some states move to limit abortion services. Understanding hospital charges can be a head-scratcher since they often don't appear to align with the actual cost of providing care. That's true in this case.
• These male politicians are pushing for women who receive abortions to be punished with prison time (Blake Ellis and Melanie Hicken, CNN, 9-21-22) They were adamant that a woman who receives an abortion should receive the same criminal consequences as one who drowns her baby. .
• Letters from an American (Heather Cox Richardson. 9-26-22) "Republicans have managed to keep voters behind their economic program by downplaying it and emphasizing cultural issues, primarily abortion, which reliably turned out anti-abortion voters. Now that the Supreme Court has overturned the 1973 Roe v. Wade decision legalizing abortion, Republicans have a demographic problem: a majority of voters support reproductive rights and are turning out to vote, and there is no longer a reason for anti-abortion voters to show up.
    "So Republican leaders are downplaying abortion....They are also inventing new cultural crises, most notably an attack on LGBTQIA folks but also a renewed attack on immigrants. Trump has gone further, jumping aboard the QAnon train..."
• Abortion Bans Skirt a Medical Reality: For Many Teens, Childbirth Is a Dangerous Undertaking (Sarah Varney, KHN, 10-6-22) The U.S. has one of the highest teen birth rates among developed nations, even after three decades of improvement. And Arkansas, roughly tied with Mississippi, has the highest teen birth rate in the country. Conservative states largely have the highest rates. During adolescent development, the beginning of menarche signals the start of a growth spurt that can take up to four years to complete. During that time, a girl’s uterus and bony structures, including her pelvis, remain narrow, developing slowly as she ages. It’s a precarious moment to give birth. It’s not uncommon for girls to face obstructed labor “because their pelvis is not developed enough to accommodate a vaginal delivery,” said Dr. Sarah Prager.
• Supreme Court Overturns Roe v. Wade: What You Need to Know Planned Parenthood answers frequently asked questions.
• State legislation tracker (Guttmacher Institute) Major developments in sexual & reproductive health. which states require insurance coverage for abortion.
• Why the Defense of Abortion in Kansas Is So Powerful(Sarah Smarsh, NY Times, 8-3-22) "In a state where registered Republicans far outnumber Democrats, the results reveal that conservative politicians bent on controlling women and pregnant people with draconian abortion bans are out of step with their electorates, a majority of whom are capable of nuance often concealed by our two-party system.
      "This is not news to many red-state moderates and progressives, who live with excruciating awareness of the gulf between their decent communities and the far-right extremists gerrymandering, voter-suppressing and dark-moneying their way into state and local office.
      "Too often, election results say more about the conditions of the franchise — who manages to use it, and what information or misinformation they receive along the way — than they do about the character of a place."

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• Abortion in the U.S. Dashboard (KFF) An ongoing research project (and visual mapping) tracking state abortion policies and litigation following the overturning of Roe v. Wade. Among key facts:

---79% of abortions occur before 10 weeks.
---As of the end of June 2022, medication abortion via telehealth was available in 22 states and DC
---A majority of states have at least one restriction on health insurance coverage for abortion services
---Most of the general public (73%) opposes making it a crime for doctors to perform abortions
---In 2021 the median cost of abortion services exceeded $500. Another map tracks states with numerous abortion restrictions.
• Abortion Access (Stateline) Covering state policy on abortion access across the 50 states. See, for example, Abortion opponents push state lawmakers to promote unproven ‘abortion reversal’ GOP-backed laws in more than a dozen states require health providers to tell patients they can change their minds.
• Why SCOTUS’ Abortion Ruling Is a Disaster for Free Expression (Summer Lopez and Nadine Farid Johnson, Daily Beast, 7-17-22) Providing information about abortion access is literally illegal in some states, and the chilling effect could even spread to states where abortion is still legal.

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• Leaked draft of the Supreme Court’s decision in Dobbs v, Jackson Women’s Health that would overturn Roe v. Wade and Planned Parenthood v. Casey and eliminate the federal standard regarding abortion access (Feb. 2022)
---“This Was Not a Surprise”: How the Pro-Choice Movement Lost the Battle for Roe (Alexandra Zayas, ProPublica, 5-3-22) In the wake of a leaked draft opinion indicating the Supreme Court plans to overturn Roe v. Wade, Joshua Prager, author of The Family Roe, discusses the 50-year battle over abortion rights and the strategic decisions that led us here. 'NARAL’s executive director in 1973, when Roe was ruled upon, told her board after the ruling, “The court has spoken and the case is closed.” They saw this as, basically: It’s over. We’ve won. 'The very, very opposite is true of the pro-life, who said: OK, now we have to think about this strategically, how will we go about overturning Roe? As a result of that imbalance, the pro-choice were playing catch up really for 49 1/2 years, as the pro-life (movement has) over and over again come up with many different ways to chip away at Roe and has been remarkably successful.'
---Of Course the Constitution Has Nothing to Say About Abortion (Jill Lepore, New Yorker, 5-4-22) Depending on the official decision in Dobbs v, Jackson Women's Health, abortion is likely to become a crime in at least twenty states. That there is no mention of the procedure in a 4,000-word document crafted by 55 men in 1787 seems to be a surprise to Justice Alito, but there is nothing in that document about women at all. "At the time, women could neither hold office nor run for office, and, except in New Jersey, and then only fleetingly, women could not vote." That "women are missing from the Constitution" is "a problem to remedy, not a precedent to honor." Indeed, "hardly anything in the law books of the eighteen-sixties guaranteed women anything. Because, usually, they still weren’t persons. Nor, for that matter, were fetuses."
• Murky Legal Landscape for Docs Advising Patients on Self-Managed Abortions ( Amanda D'Ambrosio, MedPage Today, 7-26-22) "As new abortion restrictions take effect across the U.S. in the wake of the Supreme Court's decision on Dobbs v. Jackson Women's Health Organization, obtaining an abortion has become nearly impossible in some states, leading many to attempt to terminate their pregnancies outside of the formal healthcare system. "Self-managed abortion methods have been around for decades, and have become increasingly safer due to the widespread availability of the medications mifepristone (Mifeprex) and misoprostol (Cytotec). 'No one can take away their right to dispense medical information'"

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• What the Bible actually says about abortion may surprise you (Melanie A. Howard, Religion News, 7-25-22) Faith can inform opinions about abortion on both sides of the political debate, but the Bible itself says nothing directly about the topic, a biblical scholar explains.
• The Abortion Pill (Planned Parenthood) Medication abortion — also called the abortion pill — is a safe and effective way to end an early pregnancy.
• State Restrictions on Mifepristone Access — The Case for Federal Preemption Patricia J. Zettler and Ameet Sarpatwari, New England Journal of Medicine, 2-24-22) Reproductive autonomy has come under increasing assault in the United States. A strong argument exists that state laws restricting mifepristone access — an important weapon in this fight — are preempted and should be challenged in court. The health of millions of women throughout the country could benefit if these policies are successfully overturned.
• SASS – Self-Managed Abortion; Safe & Supported SASS is the US project of Women Help Women, a global nonprofit organization that supports the rights of people around the world to have information about and access to safe abortion with pills. Abortion pills are a safe and effective way to end an unwanted pregnancy, with or without a clinician. If a person chooses to self-manage their abortion, this website is a source of accurate, up-to-date information to help them be medically and legally safe.

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• Status of Abortion Access in the United States as of July 12, 2022 (Covering Health, Association of Health Care Journalists) Chart featured in article Conflicting state and federal abortion laws put pregnant patients, physicians and hospitals at risk (Kerry Dooley Young and Joseph Burns, AHCJ, Covering Health, 7-15-22)
• Doctors Struggle With State Abortion Restrictions at Odds With Federal Law (Melanie Evans, Wall Street Journal, 7-10-22) "Law requiring doctors to provide emergency treatment to stabilize certain patients may necessitate performing an abortion in some cases. Doctors and hospitals are rushing to reconcile laws in their states barring abortion with a federal law that may require the procedure as part of emergency treatment. How physicians and hospitals are addressing the mandates of the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 in the wake of the overturning of Roe v. Wade. That decision in Dobbs v. Jackson Women’s Health Organization stripped away an almost 50-year-old right to an abortion."
• SCOTUS strikes down Roe as expected; half of states likely to ban abortion (Kerry Dooley Young and Joseph Burns, AHCJ, Covering Health, 6-24-22)
• Irish Eyes Aren’t Smiling (Maureen Dowd, Opinion, NY Times, 7-16-22) "Once, Ireland seemed obsessed with punishing women. Now it’s America. Una Mullally, a columnist for The Irish Times, on Ireland and America swapping roles: Ireland growing less benighted; America more so. Ireland less influenced by the dictates of the Catholic Church; America more influenced, reflecting the views of the five right-wing Catholics on the Supreme Court and Neil Gorsuch, an Episcopalian who was raised Catholic. Ireland once had too much church in the state. Now America does." “People thought there was this American dream but it’s clearly becoming more of an American nightmare.”

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• Seeing Norma: The Conflicted Life of the Woman at the Center of Roe v. Wade (Joshua Prager, NY Times, 7-2-22) Norma McCorvey, the plaintiff in the case that made abortion legal, struggled with her role. Her personal papers offer insight into her life, her thinking — and her continued relevance. As McCorvey began to speak publicly about Roe and her life, she observed over and again, as in these notes from 1989, that access to abortion was often a matter of class.
• After Roe v. Wade: US researchers warn of what’s to come (Mariana Lenharo, Nature,4-24-22) Years of studies point to the negative economic and health effects of restricting access to abortions.
• America Before and After Roe (Fahima Haques NY Times, 6-27-22) Timeline, photos, and links to key stories about the effects of the Supreme Court decision, how far the Supreme Court will go, responses to key questions, abortion access, abortion travel, medication abortions, statehood battles where gerrymandering has given Republicans an advantage, what those who oppose and support abortion rights have to say.
• America Is About to See Just How Pro-life Republicans Actually Are (Elaine Godfrey, The Atlantic, 6-26-22) After the fall of Roe, some abortion opponents think it’s time to focus on expanding America’s social safety net. Will the rest of their movement join them?
• The Abortion Surge Engulfing Clinics in Pennsylvania (E. Tammy Kim, New Yorker, 7-22-22) Patients are travelling to the state from Ohio, Kentucky, and even Louisiana, but how long will that option last?
• Infertility Patients and Doctors Fear Abortion Bans Could Restrict I.V.F. (Jan Hoffman, Roe v. Wade Overturned, NY Times, 7-5-22) The new state bans don’t explicitly cover embryos created outside the womb, but legal experts say overturning Roe could make it easier to place controls on genetic testing, storage and disposal of them.
• Roe Was Flawed. Dobbs Is Worse (Tom Nichols, The Atlantic, 6-22)Yes, Roe was the product of an activist court. But then so was Dobbs v. Jackson Women’s Health Organization. Justice Samuel Alito and the other five conservatives on the Supreme Court were not handing back abortion to the states as if it were some open question for a debate; they knew exactly what was going to happen in states with “trigger” laws the minute they ruled. Despite their legal rationale, these justices were taking sides in a culture war on behalf of a minority of Americans with whom at least some of them happen to agree
"Anti-abortion conservatives huff that the Court has regularly overturned hideous decisions, such as Dred Scott, Plessy, or Korematsu (which wasn’t really overruled but finally disavowed in a 2018 ruling). Roe, they argue, is just another bad case that was due for reversal....Roe, even if poorly decided, has been affirmed in that same court; again, a majority of Americans believe in a right to abortion in all or some cases, and have for a half century. Even now, if the goal was to remedy a Roe overreach, the majority could have found a way to do so while leaving abortion rights intact. This was apparently Roberts’s position, but he was brushed aside by the five other conservative justices.

It's true that abortion is not in the Constitution. A lot of things aren't in the Constitution, including the "right to be left alone," but that hasn't stopped Americans from recognizing that such rights exist.

Friday's decision in Dobbs v. Jackson Women's Health Organization, which overturned nearly a half-century of precedent, will be a seminal case in the annals of law and learning. It will be paired with the 1973 Roe v. Wade landmark that had declared a constitutional right to end a pregnancy, just as the 1954 Brown v. Board of Education, which ended the "separate but equal" doctrine and began desegregation of schools, has long been tethered to Plessy v. Ferguson, the 1896 decision that permitted separate but equal accommodations for Black and White people.
"Yet where Brown ensured rights, of course, Dobbs eliminated them.
"It was a sober, even humble Roberts who wrote -- alone -- as he separated himself both from the conservatives who dissolved a constitutional guarantee and from the liberal dissenters who expressed sorrow for American women and warned of further erosions on privacy. See also Chief Justice John Roberts lost the Supreme Court and the defining case of his generation (Joan Biskupic, CNN, 6-26-22)

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• Abortion Services (Planned Parenthood)
• Repro Legal Helpline
• HHS seeks to protect patient privacy as states outlaw abortion (Kerry Dooley Young, Covering Health, AHCJ, 6-30-22) Among other things, HHS plans to reaffirm limits on medical professionals' sharing of information with law enforcement officials. It also offered tips for protecting health information shared with third-party apps. HIPAA rules generally do not protect the privacy or security of information when it is accessed through or stored on personal cell phones or tablets, with some exceptions for ones developed by organizations covered by federal privacy law.

• My Grandmother’s Desperate Choice (Kate Daloz, New Yorker, 5-14-17) When abortion is criminalized, women make desperate choices.

• The Study That Debunks Most Anti-Abortion Arguments (Margaret Talbot, New Yorker, 7-7-20) For five years, a team of researchers asked women about their experience after having—or not having—an abortion. What do their answers tell us? The Turnaway Study, which began in 2007, included only women 'whose pregnancies were unwanted enough that they were actively seeking an abortion, which meant the researchers were not making the mistake that some previous studies of unplanned conceptions had—“lumping the happy surprises in with the total disasters...

"The over-all impression it leaves is that abortion, far from harming most women, helps them in measurable ways. Moreover, when people assess what will happen in their lives if they have to carry an unwanted pregnancy to term, they are quite often proven right. That might seem like an obvious point, but much of contemporary anti-abortion legislation is predicated on the idea that competent adults can’t really know what’s at stake in deciding whether to bear a child or not. Instead, they must be subjected to waiting periods to think it over (as though they can’t be trusted to have done so already), presented with (often misleading) information about the supposed medical risks and emotional fallout of the procedure, and obliged to look at ultrasounds of the embryo or fetus.

“Some events do cause lifetime damage”—childhood abuse is one of them—“but abortion is not common among these,” Foster writes. In light of its findings, the rationale for so many recent abortion restrictions—namely, that abortion is uniquely harmful to the people who choose it—simply topples.
• Secrets, death and a police interrogation: Women recall illegal abortions before Roe v. Wade (Nina Shapiro, Seattle Times, 5-22-22)

• The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having—or Being Denied—an Abortion by Diana Greene Foster debunks most anti-abortion arguments.
• We asked readers how Roe v. Wade has affected their lives; Here are their stories (Ryan Nguyen, Seattle Times, 5-22-22)

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• Supreme Court's decision on abortion could open the door to overturn same-sex marriage, contraception and other major rulings (Tierney Sneed, CNN, 6-26-22) Friday's decision in Dobbs v. Jackson Women's Health Organization, which overturned nearly a half-century of precedent, will be a seminal case in the annals of law and learning. It will be paired with the 1973 Roe v. Wade landmark that had declared a constitutional right to end a pregnancy, just as the 1954 Brown v. Board of Education, which ended the "separate but equal" doctrine and began desegregation of schools, has long been tethered to Plessy v. Ferguson, the 1896 decision that permitted separate but equal accommodations for Black and White people.
• Is Abortion Sacred? (Jia Tolentino, New Yorker, 7-16-22) Abortion is often talked about as a grave act. But bringing a new life into the world can feel like the decision that more clearly risks being a moral mistake. Important historical insights into attitudes about abortion. For example, "A third of parents in one of the richest countries in the world struggle to afford diapers; in the first few months of the pandemic, as Jeff Bezos’s net worth rose by forty-eight billion dollars, sixteen per cent of households with children did not have enough to eat."
• Skirmishes Over Medication Abortion Renews Debate on State vs. Federal Powers (Victoria Knight, KHN, 6-2-22) The Biden administration may have authority to allow the use of abortion pills even in states where the practice could be outlawed, say legal experts.
• Self-Induced Abortions Shouldn't Be A Crime, Mass. Medical Society Says (Chelsea Conaboy and Carey Goldberg, CommonHealth, WBUR, 5-7-18) At its latest meeting, the Massachusetts Medical Society took a new stand: Women who attempt to end a pregnancy on their own should not be considered criminals. Self-induced abortion is explicitly banned in seven states, and more have laws on the books that could be used to prosecute women for self-induction, according to a recent report....In many countries, the pills are available at pharmacies and even over the counter. Websites like Women Help Women offer support and send abortion pills by mail to women around the world who wish to end an early pregnancy. But not in the U.S., where mifepristone is highly regulated despite its proven safety. It may be dispensed only in a clinical context by a prescriber who has obtained a special certification from the drug distributor. It is not available from retail pharmacies. “There are a lot of women who, for various reasons — including stigma, or just financial or geographic lack of access to care — are really attempting their own abortion.”
Let's not go back to the deadly era of abortion by coat hanger!
• The FDA Is Restricting Access to the Easiest, Safest Form of Abortion (Marie Solis, Health, Vice, 9-4-19) There's a growing consensus that the FDA's regulations on abortion pills aren't medically necessary. See also The Doctor Fighting to Bring You Online Abortion Pills Just Sued the FDA (Marie Solis, Health, Vice, 9-9-19) See also More People Are Starting to Prefer Managing Their Abortions on Their Own And it's not just because of restrictive state laws. (Marie Solis, Health, Vice, 10-17-19)
• California Positions Itself as an Abortion Sanctuary State (listen to April Dembosky, KQED, NPR, and KHN, 6-7-22)

• Understanding America’s cruelty toward women on abortion (Damon Young, WaPo Magazine, 5-31-22) It almost feels like irony again that there’s so much overlap between people on the right who believe they possess a right to dictate women’s bodies, and people who believe the government has no right to mandate they wear a mask. I’m searching for a thousand words when a baker’s dozen will do. "You own your body. Abortion is health care. Health care is a right."
• The State Behind Roe’s Likely Demise Also Does the Least for New Parents in Need (Sarah Smith, ProPublica, 5-16-22) Mississippi is unique among Deep South states for doing the least to provide health care coverage to low-income people who have given birth. Mississippians on Medicaid lose coverage a mere 60 days after childbirth.

• Misinformation Clouds America’s Most Popular Emergency Contraception (Sarah Varney, KHN, 6-7-22) At a moment when half of U.S. states stand poised to outlaw or sharply curtail abortion services, the nation’s most popular emergency contraception brand rests in the unlikely stewardship of two private equity firms.
• Her Ex-Husband Is Suing a Clinic Over the Abortion She Had Four Years Ago (Nicole Santa Cruz, ProPublica, 7-15-22) Nearly four years after a woman ended an unwanted pregnancy with abortion pills obtained at a Phoenix clinic, she finds herself mired in an ongoing lawsuit over that decision.Experts say the Arizona lawsuit shows how civil suits could be used to intimidate providers and punish people who’ve had abortions.

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• What the End of Roe v. Wade Will Mean for the Next Generation of Obstetricians (Emma Green, New Yorker, 5-31-22) An aspiring ob-gyn’s views on abortion might determine what training she seeks out, which specialities she pursues, and where she chooses to live. In a post-Roe world, that self-sorting process would grow even more intense.
• What’s Next if ‘Roe v. Wade’ Falls? More Than Half of States Expected to Ban or Restrict Abortion (Sarah Varney, KHN, 5-3-22)
• Abortion Coverage Under the Affordable Care Act: The Laws Tell Only Half the Story (Guttmacher Institute, 2014)

•The Future of Roe v. Wade: 3 Scenarios, Explained (4-minute video, by Adam Liptak, narrator, Robin Stein, Aaron Byrd, Natalie Reneau, Anjali Singhvi and Jonah M. Kessel, 9-6-18) Clear and interesting analysis for three broad approaches to getting rid of the Supreme Court decision that made abortion legal.

(1a) Nuclear options would flip Roe on its head, saying Constitution prohibits abortion in interest of protecting fetal life (abortion=murder).

(1b) Do away with right to privacy, which is basis for Roe v. Wade, and would flip the issue back to states, allow states to regulate abortion. (Right to privacy is the foundation for many other rights.) If right to privacy doesn't include the right to abortion; states could limit or do away with right to abortion.

(2) Overrule Roe v. Wade. Right to privacy no longer includes right to abortion. States free to limit or forbid abortion.

3) Chip away at abortion rights(most likely scenario). The Supreme Court has already upheld some limits on abortion. More severe restrictons are a perfectly imaginable scenario. States can reinterpret "undue burdens" and poor women in red states would no doubt have a hard time getting abortions.
• She Wasn’t Ready for Children. A Judge Wouldn’t Let Her Have an Abortion. (Lizzie Presser, NY Times, 11-29-22) As abortion access dwindles, America’s “parental involvement” laws weigh heavily on teenagers — who may need a court’s permission to end their pregnancies. At the moment, 14 states are poised to protect the right to abortion and do not have, or do not enforce, parental-involvement laws (Alaska, California, Connecticut, Hawaii, Illinois, Maine, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Vermont and Washington).
• Midwest Abortion Providers Scramble to Prepare for a Post-Roe World (Peter Slevin, New Yorker, 5-7-22) With federal protections imperilled, advocates expect a dramatic influx of interstate “refugees” seeking care.vc cccc
• God Help My Friendship With White Evangelicals After Dobbs (Brittney Cooper, The Cut, 6-24-22) When you grow up in a world where your body, because it is not white, is not treated as sacred, you learn to value every protection, personal and political, against your violation. When the first enslaved Black women arrived in this country, their womanhood became defined solely through their forced reproduction of enslaved, unfree offspring. Forced reproduction cannot mean anything other than slavery to Black women.

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• The Dishonesty of the Abortion Debate (Caitlin Flanagan, The Atlantic, December 2019) "No matter what the law says, women will continue to get abortions. How do I know? Because in the relatively recent past, women would allow strangers to brutalize them, to poke knitting needles and wire hangers into their wombs, to thread catheters through their cervices and fill them with Lysol, or scalding-hot water, or lye. Women have been willing to risk death to get an abortion. When we made abortion legal, we decided we weren’t going to let that happen anymore."
• The Extremes Are Not Unusual (Jill Filipovic, 7-14-22) A 10-year-old in need of an abortion is shocking, but it's not isolated. In Ohio alone, an average of one girl aged 15 and under has an abortion every week — and you can bet that many of these girls are rape survivors. One in nine girls in the US experiences rape or sexual assault at the hands of an adult before she turns 18.

•Why I Provide Abortions (Christine Henneberg, Boston Review, 11-29-21) Why I provide abortions has nothing to do with “viability”—the standard that theoretically protects legal abortion up to about twenty-four weeks. When it comes to the definition, and even the value of life, context matters. If viability means “potential for survival,” we are talking about vastly uncertain potential within different contexts. Covering Abortion (Writers and Editors website)

• The Twenty-First Chromosome and Down Syndrome (Boen Wang, The Sunday Long Read, 9-25-21) Whose life is worth living? Who decides whose life is worth living? Since his son Jamie was born with Down syndrome, Penn State English professor Michael Bérubé has written two memoirs testifying to the richness of Jamie’s life, while also defending reproductive rights. “When parental leave is the law of the land,” he wrote, “when private insurers can’t drop families from the rolls because of ‘high risk’ children, when every child can be fed, clothed, and cared for—then we can start talking about what kind of a choice ‘life’ might be.”

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• Medication Abortion Now Accounts for More Than Half of All US Abortions (Guttmacher Institute, 3-2-22) Medication abortion has gained broad acceptance from both abortion patients and providers, becoming central to US abortion provision, thanks to its track record over two decades of safe and effective use.
• Pregnant, and No Civil Rights (Lynn M. Paltrow and Jeanne Flavin, NY Times, 11-7-14) "The principle at the heart of contemporary efforts to end legal abortion is that fertilized eggs, embryos and fetuses are persons or at least have separate rights that must be protected by the state. In each of the cases we identified, this same rationale provided the justification for the deprivation of pregnant women’s physical liberty, as well as of the right to medical decision making, medical privacy, bodily integrity and, in one case, the woman’s right to life.
"Many of the pregnant women subjected to this mistreatment are themselves profoundly opposed to abortion. Yet it was precisely the legal arguments for recriminalizing abortion that were used to strip them of their rights to dignity and liberty in the context of labor and delivery. These cases, individually and collectively, highlight what is so often missed when the focus is on attacking or defending abortion, namely that all pregnant women are at risk of losing a wide range of fundamental rights that are at the core of constitutional personhood in the United States....We should be able to work across the spectrum of opinion about abortion to unite in the defense of one basic principle: that at no point in her pregnancy should a woman lose her civil and human rights."
• How Missouri Helps Abortion Opponents Divert State Taxes to Crisis Pregnancy Centers (Jeremy Kohler, ProPublica, 6-6-22) Abortion foes praise the nonprofit centers for supporting women and presenting alternatives to ending pregnancies, but supporters of abortion say the facilities mislead women by appearing to offer clinical services and unbiased advice. Millions of tax dollars have been funneled to fight abortion, and tens of millions of dollars more may be moved to that battle — a drain on state revenues that legislative oversight officials failed to forecast.

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• After the end of Roe, a new beginning for maternity homes (Tiffany Stanley, AP News, 8-2-24) There has been a nationwide expansion of maternity homes in the two years since the Supreme Court overturned Roe v. Wade and the federal right to abortion. “It’s been a significant increase,” said Valerie Harkins, director of the Maternity Housing Coalition, a nonprofit anti-abortion network of 195 maternity homes that has grown 23% since the court’s ruling. There are now more than 450 maternity homes in the U.S., according to Harkins; many of them are faith-based. As abortion restrictions increase, anti-abortion advocates want to open more of these transitional housing facilities, which often have long waitlists. It’s part of what they see as the next step in preventing abortions and providing long-term support for low-income pregnant women and mothers.
• What are maternity homes? Their legacy is checkered (Tiffany Stanley, AP News, 8-2-24)
• Cost of stocking birth control strains family planning clinics in some states (Kaitlin Sullivan, NBC News, 8-3-24) Free or low-cost contraceptives are becoming increasingly difficult for women to access as clinics close or struggle with funding problems and policy restrictions. MATERNAL MORTALITY

• What You Need to Know When You Give Birth in a Country With Rising Maternal Mortality Rates (Adriana Gallardo, ProPublica, 5-9-22) Facing a post-Roe landscape, we’re republishing advice collected from women who survived severe complications of pregnancy or childbirth. See also In a Post-Roe America, Expect More Births in a Country Where Maternal Mortality Continues to Rise (Robin Fields and Adriana Gallardo, ProPublica, 5-4-22) The United States has the highest maternal mortality rate among wealthy countries. And it may get worse as abortions become more difficult to obtain, say public health experts.

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• Some birth control could be banned if Roe v. Wade is overturned, legal experts warn (Alicia Victoria Lozano, NBC News, 5-12-22) “The way the draft opinion is written, it opens the doors for a lot of unanswered questions that would allow conservatives to really target contraception," one legal expert said.
     "With trigger laws in 13 states poised to go into effect if the Supreme Court strikes down Roe v. Wade, a new era of restricted access to birth control could unfold in states that narrowly define when life begins, legal experts say. 'This is the new Jane Crow that we’re about to enter,' said Michele Goodwin, a chancellor’s professor of law at the University of California, Irvine, and the author of Policing the Womb: Invisible Women and the Criminalization of Motherhood.
     "While the Constitution does not mention abortion, it also does not mention a right to privacy. The Supreme Court has codified the concept over the years through various decisions, including Roe v. Wade. The idea has also been applied to circumstances that are less socially divisive, including the Fourth Amendment, which prevents police from searching people and their property without probable cause.
     "But terminating pregnancies remains deeply polarizing culturally and legally, leading to what experts have dubbed "abortion exceptionalism." The idea is that abortion is more heavily regulated than other medical procedures because it carries with it a moral question, which leads the courts to weigh in more vigorously about something that would otherwise be left to medical professionals."
• Reversing Roe (Cynthia Gorney, New Yorker, 6-26-06) Is mainstream right-to-life ready for an abortion ban? Gorney gives a brief history of abortion law leading up to Roe and discusses debate among abortion opponents. See also Imagine a Nation Without Roe v. Wade (2-27-05) and Gorney's book Articles of Faith: A Frontline History of the Abortion Wars "Gripping narrative....This beautifully written book uncovers the untidy realities and self-contradictory beliefs and fears lying beneath the rhetoric of absolute right and wrong."~Tessa DeCarlo, San Francisco Chronicle

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• What Are Your Obligations When Your Dog Impregnates Another One? (Kwame Anthony Appiah, The Ethicist, NY Times, 10-20-23) As always, the readers' responses are as interesting as the author's.
• Draft Overturning Roe v. Wade Quotes Infamous Witch Trial Judge With Long-Discredited Ideas on Rape (Ken Armstrong, ProPublica, 5-9-22) Justice Alito’s leaked opinion cites Sir Matthew Hale, a 17th-century jurist who conceived the notion that husbands can’t be prosecuted for raping their wives, who sentenced women to death as “witches,” and whose misogyny stood out even in his time.
• A Midwife in the North Country (Emily Bobrow, Dispatch, New Yorker, 12-22-19) 'Nearly half of U.S. counties don’t have a single practicing obstetrician-gynecologist. The unprofitability of vaginal births, and the fact that insurers often pay midwives less than physicians for equivalent services, has also meant that few midwives can afford to be in private practice unless they refuse in-network insurance, partner with an obstetrician, or both. Meanwhile, the national C-section rate has gone up by at least sixty per cent since 1996. The awkward economics of hospital-based childbirth bears some of the blame....C-sections not only expedite childbirth and reduce some of the uncertainty involved in labor but also earn hospitals around fifty per cent more than vaginal births, as they require more billable treatments and longer hospital stays. “We’ve designed the system backwards, so that it’s set up for the most intense types of treatment,” Shah said, “and we’re poorly resourced to do some of the things that really matter to people, like supporting them through the actual process.”' A must-read article on childbirth.
• Oklahoma Republicans advance near-total abortion ban modeled off Texas law (Carmen Forman,The Oklahoman, 3-23-22) Oklahoma is one step closer to copying a restrictive anti-abortion law implemented in Texas. But legislation advanced Tuesday by the Oklahoma House is even more restrictive than the law adopted in Texas that has forced hundreds, if not thousands, of women to seek abortions in neighboring states. Republican House legislators passed House Bill 4327 that would effectively ban most abortions by allowing private citizens to sue anyone who performs an abortion or "aids or abets" someone who pursues the procedure. The measure is intended to shame, stigmatize and spur fear among vulnerable Oklahomans, said Emily Wales, CEO and president of Planned Parenthood Great Plains. "People who need an abortion will be forced to flee their home state, attempt to end their pregnancies without medical support, and face state-created bounty hunters here at home," she said.

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• How One Clinic in Texas Explains the Threat to Contraception (Joanne Kenen and Alice Miranda Ollstein, Politico, 5-12-22) The looming end of Roe v. Wade comes just as family planning efforts are getting squeezed. The future of broad access to contraception itself remains uncertain.
• Why The Abortion Fight Is Becoming A Battle Over Health Information (Chelsea Conaboy, CommonHealth, WBUR, 5-22-18) As the White House moves to block federal funding for family planning clinics unless they stop providing abortions or abortion referrals, supporters and opponents of abortion rights are gearing up for a familiar and likely protracted fight.

"Women today have access to safe, private, do-it-yourself abortion -- if they know where to look. Or rather, which search terms to type into Google. Abortion pills -- typically a combination of misoprostol and mifepristone, the same drugs used in medication abortions initiated at a clinic -- are widely available for sale from online pharmacies.
That’s reassuring to people who support abortion rights, as President Trump works to make good on a promise to “defund” Planned Parenthood, and as emboldened conservative governors race to pass restrictive state laws, with a legal challenge to Roe v. Wade in mind. But it also raises the stakes for women, if the call to punish those who self-induce abortion grows louder. And it puts a sharp focus on why the battle over abortion increasingly is a battle over health information, because an informed woman can gain access to abortion drugs via the Internet no matter how far she lives from a clinic....
• Period Poverty: The Public Health Crisis We Don't Talk About (Policy Lab, Children's Hospital of Philadelphia, 4-6-21) According to a 2014 UNESCO report, 1 out of every 10 menstruating youth misses school during their menstrual cycle due to lack of access to menstrual products and resources. They often manage their menstrual cycle by using old clothes or tissue because their families can't afford to purchase menstrual products. Paper addresses what should be done to help, which would include public education.
• If Roe is overturned, the ripples could affect IVF and genetic testing of embryos, experts warn (Andrew Joseph, STAT, 6-6-22) The whole fertility field is watching, but there’s an extra layer of concern for people who combine IVF with preimplantation genetic testing (PGT), which is used to help parents have children with the typical number of chromosomes or escape the genetic diseases that might have marked their families for generations.
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• The Tyranny of the Female-Orgasm Industrial Complex (Katharine Smyth, The Atlantic, 4-26-21) What one woman’s quest for sexual satisfaction reveals about desire, hysteria, feminism, and capitalism.
• Does America Hate Working Moms? It Sure Feels That Way. (Amy Klein, Kveller, 7-7-2020) To say things have been hard for working parents during lockdown would be an understatement.

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• Unmasked: Women Write About Sex and Intimacy After Fifty edited by Marcia Meier and Kathleen A. Barry. "Sex for women after 50 is invisible for the same reason that contraception, abortion, and sex between two women or two men has been forbidden: sexuality is supposed to be only about procreation. This lie was invented by patriarchy, monotheism, racism and other hierarchies. Sexuality is and always has been also about bonding, communicating, and pleasure. Unmasked helps to restore a human right." ~ Gloria Steinem
• Rise in delivery complications is increasing hospital costs (Maria Castellucci, Modern Healthcare, 1-6-2020) Women are more likely to experience an unexpected outcome during delivery and it's adding to hospital costs, according to a new analysis from Premier. The rate of women with a severe maternal morbidity factor, which are complications during labor such as sepsis, shock or eclampsia, rose by 36% from 2008 to 2018, Premier found. And those vaginal births cost nearly 80% more on average than those without complications. Additionally, cesarean deliveries for women with a severe maternal morbidity factor cost almost twice as much as uncomplicated C-sections on average.Screening women when they present to the hospital for conditions that make them vulnerable to complications (such as substance abuse disorder or obesity) could avoid issues during labor, experts say.
• The Trying Game: Get Through Fertility Treatment and Get Pregnant Without Losing Your Mind by Amy Klein
• Sarah Zhang Explores the Fallout of a Fertility Doctor’s Secret (Knvul Sheikh, The Open Notebook, National Association of Science Writers, 11-5-19) In the 1970s, when donor insemination was becoming more widely accessible across the United States, doctors continued to advise parents not to share information about the treatments with their children. What they could not have known is that the explosion in consumer DNA testing would eventually reveal these secrets.

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• Who Will Be Able to Take the Breakthrough Drug for Postpartum Depression? (Cynthia Koons, Bloomberg Businessweek, 3-22-19) Zulresso, the world’s first-ever drug for postpartum depression, cleared a major hurdle when it won approval from the Food and Drug Administration this week. Even bigger challenges lie ahead for Sage Therepeutics Inc., the drug’s developer. Zulresso, the brand name for brexanolone, works much faster to treat the condition than anything currently available. Experts have hailed it as “groundbreaking,” a “game changer.” And postpartum depression affects as many as one in nine new mothers. These facts alone would suggest the drug is destined to be a blockbuster. Yet there’s a difference between a drug that works and a drug that sells. Zulresso is administered by a two-and-a-half-day infusion, must be administered in a certified facility, and the company plans to charge $34,000 for it. Considering the price and logistical challenges, she says, it’s not clear how many women will ever get the drug.

• The Unique Dangers of the Supreme Court’s Decision to Hear a Mississippi Abortion Case (Amy Davidson Sorkin, New Yorker, 5-28-21) The most pressing question now may be not whether Roe and Casey can survive but how reproductive rights can be sustained without them. See also A Bipartisan Thank-You to Breyer Masks the Brawling Already Under Way (Amy Davidson Sorkin, New Yorker, 3-3-22) Ketanji Brown Jackson is eminently qualified, but her confirmation hearings will reflect the pernicious and, at times, unhinged discourse in Washington.

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• The Deviousness of Texas’s New Abortion Law (Mary Zeigler, The Atlantic, 9-1-21) The statute is the culmination of a decades-long strategy to end abortion without actually banning abortion.
• The Texas Abortion Ban Hinges On 'Fetal Heartbeat.' Doctors Call That Misleading (Selena Simmons-Duffin, All Things Considered, Shots, NPR, 9-3-21) "At six weeks of gestation, those valves don't exist," she explains."The flickering that we're seeing on the ultrasound that early in the development of the pregnancy is actually electrical activity, and the sound that you 'hear' is actually manufactured by the ultrasound machine." What cardiac activity means — and doesn't mean — early in pregnancy. And 'six weeks' refers not to six weeks from your first missed period, but six weeks from your last period.

• Women Have Always Had Abortions ( Lauren MacIvor Thompson, NY Times, 12-13-19) A mini-history of abortion and abortion laws in the US.
• The Supreme Court doesn’t just abuse its shadow docket. It does so inconsistently. (Steve Vladeck, Washington Post, 9-3-21) Justice Kagan’s dissent cuts to the heart of the problem with the Texas abortion ruling — it undermines the court’s legitimacy.
• Why It’s Become So Hard to Get an Abortion (Margaret Talbot, New Yorker, 3-27-17) When you can’t ban something outright, it’s possible to make the process of obtaining it so onerous as to be a kind of punishment. The book she refers to: About Abortion: Terminating Pregnancy in Twenty-First-Century America by Carol Sanger.
• The Unique Dangers of the Supreme Court’s Decision to Hear a Mississippi Abortion Case (Amy Davidson Sorkin, New Yorker, 5-30-21) "Jackson Women’s Health has another distinction. There is every possibility that the case bearing its name—along with that of Thomas Dobbs, the state health officer of Mississippi—will be the one that either overturns Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey, the two Supreme Court rulings that are the bedrocks of reproductive rights, or renders them powerless." [Emphasis added.]

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• Mexico’s Supreme Court Votes to Decriminalize Abortion (Natalie Kitroeff and Oscar Lopez, NY Times, 9-7-21) The ruling, which sets a precedent for the legalization of abortion nationwide, follows years of efforts by a growing women’s movement in Mexico. Abortion rights advocates said they planned to use the ruling to challenge laws in the vast majority of Mexican states that mandate jail time or other criminal penalties for women who have the procedure.
• Federal judge strikes down rule allowing clinicians to object to abortions for moral or religious reasons (Elizabeth Chuck, NBC News, 11-6-19) A federal judge in New York \struck down a new Trump administration rule that would have allowed health care clinicians to refuse to provide abortions for moral or religious reasons. Women's groups, health organizations and multiple states had sued the Department of Health and Human Services, arguing the exemptions were unconstitutional.
• Stacey Abrams Showed Democrats How to Win the Fight for Abortion Rights (Christina Cauterucci, Slate, 2-6-19) In Tuesday's State of the Union speech, 'Trump said these pieces of legislation would “allow a baby to be ripped from the mother’s womb moments before birth.” This isn’t the first time the president has used these words to conjure up this nonexistent medical procedure.... This is not an accurate rendering of any abortion procedure; what Trump is describing is a cesarean section. The fiction that a woman would carry a fetus for 40 weeks only to decide “moments before birth” to terminate her pregnancy has persisted because it’s a narrative that features conservatives’ favorite anti-abortion talking points: fetuses that look like newborn babies, irresponsible women making rash decisions, and scary, violent surgeries that are worlds away from the nearly half of all abortions that are performed via oral medication.'

• Abortion support remains steady despite growing partisan divide, survey finds ( Ariana Eunjung Cha and Scott Clement, Washington Post, 8-13-19) No more than a quarter of residents in any state support a total ban on the procedure, according to one of the largest-ever polls of Americans, the Public Religion Research Institute survey. Students for Life President Kristan Hawkins said it is “not surprising” that after “hearing only one side of the abortion debate most of the time, some people don’t understand that abortion doesn’t solve problems....For more than 50 years, the abortion lobby has effectively shut down any real discussion of abortion.” Read the article for details.

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• The Growing Toll of the Global Gag Rule (Melody Schreiber, New Republic, 7-3-19) A new study published in Lancet shows abortions actually go up when the U.S. pulls funding from nongovernment organizations (NGOs) offering abortion referrals, "confirming what reproductive health experts have long suspected.... Surveying 26 countries in sub-Saharan Africa between 1995 and 2014 (a time period during which the gag rule was reinstated by Republican administrations and rescinded by Democratic ones), the countries relying heavily on U.S. aid saw much higher rates of abortion—40 percent more—when the gag rule was in place. It has the exact opposite effect of what conservative policymakers say they intend.That's only one way underserved populations suffer... (So far, First Amendment protections have kept conservative administrations from applying the gag rule to U.S.–based organizations, meaning American NGOs like Pathfinder International can continue to offer HIV prevention services with governmental funds while offering abortion services using other funds. But this discrepancy may soon end if the Trump administration’s domestic gag rule proposal continues to survive court challenges.)"
• New Anti-Abortion Measures Could Struggle for Traction in Courts (Jacob Gershman, Wall Street Journal, 3-24-19) Republican-led states are pushing through a raft of new anti-abortion legislation recently, but it’s far from clear that the toughest restrictions will survive judicial scrutiny. States this year have introduced hundreds of anti-abortion bills—including “fetal heartbeat” laws recently enacted in Mississippi and Kentucky—at a rate abortion-rights advocates say is unprecedented. Perhaps most notably, the governors of Kentucky and Mississippi signed bills this month making it a crime for doctors to terminate a pregnancy after an ultrasound detects fetal cardiac activity.
• Dem support grows for allowing public funds to pay for abortions (Jessie Hellmann, The Hill, 3-23-19) Support is growing among Democrats in Congress for allowing abortion coverage in publicly funded health programs. House Democrats, who say they have a “pro-choice majority” for the first time in history, are vowing to end a long-standing ban of abortion coverage in Medicaid. They also want to ensure that future government healthcare plans allow recipients to get abortion coverage. “If you look at the power of women voters, Republicans and Democrats and independents, people want to be able to get their reproductive services, they don't want the government interfering with their decision about what they do with their body.” The Hyde Amendment is attached annually to government spending bills, forbidding the use of public funds for the procedure in Medicaid, the Children's Health Insurance Program, and other health programs, except in limited circumstances.

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• Ohio Cuts Funding for Planned Parenthood After Court OK (AP, New York Times, 3-22-19) The Ohio Department of Health is ending grants and contracts that send money to Planned Parenthood after a divided federal appeals court upheld a state anti-abortion law that blocks public money for the group. The department notified recipients and contractors Thursday that it will end that funding within a month to comply with the law, unless the court delays the effect of its ruling as Planned Parenthood has requested. The health department said the law requires it to ensure state and certain federal funds aren't "used to perform or promote nontherapeutic abortions."
Planned Parenthood of Greater Ohio President Iris Harvey said the funding provides "essential services" to tens of thousands of Ohioans that other health centers can't replace. "This cruel ruling blocks funding that allowed Planned Parenthood to provide essential services that reduce black infant mortality, prevent violence against women, and provide cancer screenings, HIV tests and sex education," she said in an emailed statement.
• How State Policies Limiting Abortion Coverage Changed Over Time (Charts and slides, Kaiser Family Foundation)
• Lawsuits Challenge Rules Limiting Who Can Perform Abortions ( Jacob Gershman, Wall Street Journal, 1-15-19) Abortion-rights activists concerned about the shrinking number of abortion providers are mounting court challenges to longstanding state laws that forbid anybody but doctors to perform the procedure. Lawsuits pending in at least nine states are seeking to strike down statutes that make it a crime for clinicians such as highly trained nurses and midwives to provide early-term abortions. Taken together, the cases represent the strongest push by abortion-rights groups to build upon a recent Supreme Court decision that put more of a burden on states to justify the medical benefit of abortion regulations limiting women’s access.

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• Judge freezes Trump administration contraception rule (Alice Miranda Ollstein and Victoria Colliver, Politico, 1-13-19) The new rules would let employers refuse to cover birth control by citing religious or moral objections. The new rules mark the Trump administration's second attempt to narrow the Obamacare-related requirement that employers must provide FDA-approved contraception in the employee health plan at no cost. The first attempt was halted in 2017 after courts found the administration tried to make the change without giving the public the opportunity to weigh in. Houses of worship and closely-held private companies with religious objections are currently exempted from the birth control coverage mandate; the Trump administration is seeking to make the exemptions much broader. See also AP story. The judge blocked Trump administration rules, which would allow more employers to opt out of providing women with no-cost birth control, from taking effect in 13 states and Washington, D.C. Judge Haywood Gilliam granted a request for a preliminary injunction by California, 12 other states and Washington, D.C. The plaintiffs sought to prevent the rules from taking effect as scheduled on Monday while a lawsuit against them moved forward.

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• When Women Decide to End a Pregnancy, They Can Face Drastically Different Circumstances (Robin Young, Here & Now, WBUR, 1-17-19)
• Kavanaugh, Roberts side with liberal judges on Planned Parenthood case (Alice Miranda Ollstein, Politico, 12-10-18) The Supreme Court declined to review whether states can block Planned Parenthood and other abortion providers from their Medicaid programs, passing on a pair of cases that would have served as the first major abortion test for the court’s new conservative majority. Tim Jost, an emeritus professor at Washington and Lee University School of Law, said it's "noteworthy" that Kavanaugh passed on the cases. "If Kavanaugh was going to deal a major blow to health care rights during his first session on the court, this would have been the case to do it," Jost said. The anti-abortion group Susan B. Anthony List said it was "disappointed" the Supreme Court declined the case, as it called on the Trump administration to quickly finalize rules blocking federal funds to Planned Parenthood and other abortion providers through the Title X family planning program.

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• Iowa Lawmakers Pass Abortion Bill With Roe v. Wade in Sights (Julie Bosman and Mitch Smith, NY Times, 5-2-18) Republicans pressing the Iowa legislation are making a decisive turn away from the smaller, more incremental measures of the past that have, in their view, merely chipped away at abortion rights. They have a new, longer-term goal in their sights: reaching a Supreme Court that could shift in composition with a Republican president in the White House, potentially giving the anti-abortion movement a court more sympathetic to its goal of overturning Roe v. Wade than the current court is....The Iowa Legislature approved what would be the nation’s strictest abortion law in an early-morning vote on Wednesday. The move intended to pose an aggressive challenge to Roe v. Wade and reignite conservative energy before the midterm elections in November.
• Cartoon about birth control, abortion, and the welfare state (Joel Pett and the Cartoonist Group, on Kaiser Health News, 11-12-18)
• Roe v. Wade, Part 1: Who Was Jane Roe? (Audio only, The Daily, NY Times, 7-23-18) "We examine how abortion--and the Supreme Court case that legalized the procedure in the United States--became one of the most politically divisive issues of our time."
• The Future of Roe v. Wade: 3 Scenarios, Explained (video, Adam Liptak explains, with reporting by Robin Stein, Aaron Byrd, Natalie Reneau, Anjali Singhvi, and Jonah M. Kessel, NY Times, 8-10-18) Will a Supreme Court with two Trump-appointed justices overrule the right to an abortion? It's possible, but not the most likely outcome. The three options: the nuclear option, overrule Roe, chip away at Roe. It's unlikely to go after the right to privacy.
• The Health Department’s Christian Crusade (Tessa Stuart, Rolling Stone, 10-24-18) The religious right has infiltrated the office of Health and Human Services, and reproductive rights are the first target
• “Whatever’s your darkest question, you can ask me.” (Lizzie Presser, California Magazine, 3-28-18) Anna became interested in home birth and home abortion after having been poorly treated in a hospital. In Anna’s view and that of many legal scholars, Roe upheld a doctor’s right to perform an abortion, not a woman’s right to choose one. Choice wasn’t just whether a woman could seek an abortion but also how and when she wanted to have it, who she wanted around her, and where she wanted to be.

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• Where Did Ireland Go? Abortion Vote Stuns Those on Both Sides (Kimiko de Freytas-Tamura, NY Times, 5-27-18) 'There are many factors behind Ireland’s dramatic makeover. The most dominant reason is the collapse of the Catholic Church’s influence in most spheres of Irish life. “It’s very important to know that Ireland has been secularizing for a long time,” said Diane Negra, a professor of cultural studies at University College Dublin. The credibility of the church has been battered by a string of scandals, some involving pedophile priests and the cover-up of their crimes. Ireland’s practice of placing thousands of unwed mothers into servitude in so-called Magdalene laundries, designed to rehabilitate what the church considered “fallen” women, did not end until the mid-1990s. And in a case that traumatized the nation, the remains of nearly 800 children born out of wedlock were found in 2014 in a Catholic-run home for mothers and their children in Tuam....The referendum on abortion, many Irish said, was the final crack in the foundation of the old Ireland.'
• What Does Trump's Proposal To Cut Planned Parenthood Funds Mean?
• The Abortion Pill (Planned Parenthood) Medication abortion — also called the abortion pill — is a safe and effective way to end an early pregnancy.

Medication abortion, also known as medical abortion or abortion with pills, can be safely used up to the first 10 weeks of pregnancy according to the U.S. Food and Drug Administration.
• How Anti-Choice Lawmakers Are Getting Around Roe v. Wade (Sarika Chawla, Vice, 4-3-17) Those 20-week abortion bans you keep hearing about are unconstitutional.

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Women's health issues

and reproductive rights and problems

Addressing maternal mortality in the U.S.

• Health department medical detectives find 84% of U.S. maternal deaths are preventable (April Dembosky, Shots, NPR, 10-21-22) Data released by the Centers for Disease Control and Prevention indicate that a staggering 84% of pregnancy-related deaths were deemed preventable. Mental health conditions were the leading underlying cause of maternal deaths between 2017 and 2019, with white and Hispanic women most likely to die from suicide or drug overdose, while cardiac problems were the leading cause of death for Black women. Both conditions occur disproportionately later in the postpartum period, according to the CDC report. The most important policy change underscored by the data has been the expansion of free health coverage through Medicaid. Until recently, pregnancy-related Medicaid coverage typically expired two months postpartum, forcing women to stop taking medications or seeing a therapist or doctor because they couldn't afford the cost out of pocket.
• Lost Mothers: Maternal Mortality In The U.S. (Special series, NPR and ProPublica) Look there for all the stories, only some of which are liked to here.
---To Keep Women From Dying In Childbirth, Look To California (Renee Montagne, Morning Edition, NPR, 7-29-18) As the focus turned from mothers to babies, the trend lines for both diverged. Infant mortality is now at a "historic low," while the maternal mortality rate has continued to rise in recent years. The committee found two well-known complications offered the best chance for survival if treated properly: hemorrhage and the pregnancy-induced high blood pressure called preeclampsia. One early innovation of the California collaborative: toolkits that contain everything needed to tackle an emergency complication, from checklists to equipment to medications. The lesson, delivered over and over again, is that each team member – doctor or nurse – has the power to change the outcome.
---Utilizing AI May Reduce Maternal and Infant Mortality (Matt Eakins, KevinMD, MedPage Today, 10-7-23) Where pregnant and postpartum women live influences their maternal health outcomes. Identifying those at risk is imperative to improving outcomes. The American Rescue Plan Act included a provision that allows states to expand Medicaid coverage to moms up to a year postpartum. Not all states are participating. See March of Dimes state summary report to see if your state is participating.
---Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S. (Katherine Ellison and Nina Martin, ProPublica, 12-22-17)
---Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why (Nina Martin, ProPublica, and Renee Montagne at NPR, 7-25-18)
---The Last Person You'd Expect To Die In Childbirth (Nina Martin, ProPublica, and Renee Montagne, NPR, 7-25-18) American women are more than three times as likely as Canadian women to die in the maternal period (defined by the Centers for Disease Control as the start of pregnancy to one year after delivery or termination), six times as likely to die as Scandinavians. In every other wealthy country, and many less affluent ones, maternal mortality rates have been falling.
---Idaho Banned Abortion. Then It Turned Down Supports for Pregnancies and Births. (Audrey Dutton, ProPublica, 10-3-23) Since the Supreme Court overturned Roe v. Wade last year, the state’s GOP-led Legislature has disbanded a maternal mortality committee, failed to expand postpartum Medicaid coverage and turned down federal grants for child care.

• More U.S. Women Dying From Childbirth. How One State Bucks the Trend. (Michael Ollove, Stateline, Pew Trust, 10-23-18) "Over the past three decades, the world has seen a steady decline in the number of women dying from childbirth. There’s been a notable outlier: the United States. Here the maternal mortality rate has been climbing, putting the United States in the unenviable company of Afghanistan, Lesotho and Swaziland as countries with rising rates. But that trend has been reversed in dramatic fashion in one state: California. The state Department of Public Health calculates that between 2006 and 2013, California lowered its maternal mortality rate by 55 percent from 16.9 to 7.3 deaths for every 100,000 live births...California has made a difference in part by focusing narrowly on problems that arise during labor and delivery, using data collection to quickly identify deficiencies (such as failing to have the right supplies on hand or performing unnecessary C-sections) and training nurses and doctors to overcome them."
• State Laws and Policies on Female Reproductive Issues (The Guttmacher Institute) Covering abortion, abortion bans, abortion method bans, contraception, HIV/STIs, refusal clauses, regulating pregnancy, reporting requirements, teens.
• Data About Women's Reproductive Rights (Status of Women, Institute for Women's Policy Research)
• Reproductive Rights and Abortion (Human Rights Watch)
• Data shines a light on C-sections, maternal mortality(Brenda Goodman, Covering Health, AHCJ, 5-13-14)
• Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis (Linda Villarosa, NY Times, 4-11-18) Villarosa reports that “recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions – including hypertension and pre-eclampsia – that lead directly to higher rates of infant and maternal death.”
• Maternal deaths among black women focus attention on the need for policy and payment reform (Joseph Burns, Covering Health, AHCJ, 1-2-2020) Data from the federal Centers for Disease Control and Prevention show that over the past 40 years, the nation’s rate of pregnancy-related deaths (the death of a woman while pregnant or within a year of the end of a pregnancy) has more than doubled. In a tip sheet for AHCJ, Andrea Collier King points out that for every 100,000 live births, some 11.4 Latinx women die every year and 13 white women die annually. “Yet the number jumps for black women to 42.8 for every 100,000 live births.” That’s 3.3 times higher than the rate for white women. What will it take for the United States to drop the death rate for all mothers and particularly for black women?

In her tip sheet, Collier emphasizes the need for health care policy and payment reform (with examples). She reports on efforts to reform payment models, explaining that the current payment systems fail to cover high-value services adequately, do not hold providers accountable for overall costs and outcomes and do not encourage coordination among providers. H/T to Andrea Collier King and AHCJ's Covering Health for many links on this topic. If you are a health or medical reporter, join the Association of Health Care Journalists so you can get AHCJ's and Andrea's excellent tip sheets on how to cover these issues.

• Cesarean Delivery Rate by State (CDC)
• Vaginal births are safer than C-sections (Childbirth Connection, which summarizes the results of systematic reviews of available evidence to assess the specific harms and benefits of specific practices). When a cesarean is truly needed, its benefits likely outweigh possible downsides. But systematic reviews have found that women with cesareans are more likely than women with vaginal birth to experience:
---Impaired physical health for at least the first two months after birth

---Difficulty becoming pregnant, leading to a lower pregnancy rate
---Not establishing breastfeeding, which benefits both women and babies; this especially occurs when cesareans are scheduled before labor.
In the long term, systematic reviews have found that women who have given birth by cesarean are more likely than those with vaginal births to experience:
---Difficulty becoming pregnant, leading to a lower pregnancy rate
---Difficulty remaining pregnant, leading to a lower birth rate
---A desire to wait longer before becoming pregnant again
---Ongoing pain in the pelvis area.

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• U.S. Women More Likely to Die in Pregnancy and Childbirth and Skip Care Because of Cost, Multi-Nation Survey Finds; C-Section Rates Rank Among Highest (Commonwealth Fund, 12-19-18) Key findings: Pregnancy and childbirth are more dangerous for women in the U.S. than in other high-income nations. U.S. women are more likely to have cesarean sections. Studies show that an elected C-section can increase a woman’s risk for life-threatening complications during childbirth and subsequent deliveries. (That's the bad news. The good news: Women in the U.S. have among the highest breast cancer screening and survival rates, trailing only Norway, Sweden, and Australia.)
• The C-Section Epidemic: What's Tort Reform Got to Do with It? (Illinois Law review) Law professor Sabrina Safrin debunks the conventional wisdom that fear of malpractice claims lead to high C-section rates. And Even though the hospital where a woman gives birth may be her biggest risk factor for having an unnecessary C-section, a new study by Ariadne Labs suggests most women don’t factor hospital quality into their decision making about where to receive care.
• Deadly Deliveries, Hospitals know how to protect mothers. They just aren’t doing it. (Alison Young, USA Today, 11-14-19) Maternal deaths on rise because hospitals and doctors ignore safety measures. High blood pressure took one mom's life. Excessive bleeding left another with a hysterectomy. Would long-known safety practices have saved both?
• New York City Launches Initiative to Eliminate Racial Disparities in Maternal Death (Annie Waldman, Lost Mothers series, ProPublica, 7-30-18) A Central Brooklyn hospital featured in ProPublica and NPR’s “Lost Mothers” series for its high hemorrhage rate will serve as a pilot for quality reforms.
• Helping black babies survive: New Jersey gives $4.3 million to address infant mortality Lindy Washburn, NorthJersey.com, 7-14-18) With the nation's highest racial gap in infant mortality, New Jersey is trying to help more African-American babies survive by investing in childbirth coaches, one-to-one outreach to pregnant black women, and a different approach to prenatal care. Black babies in New Jersey are more than three times as likely to die before their first birthday as white, a tragedy unrelated to income or education. At the same time, black mothers are more than four times more likely than white to die from pregnancy-related complications.
• Lost Mothers: Maternal Mortality In The U.S.
---To Keep Women from Dying in Childbirth, Look to California ( Renee Montagne, NPR, Weekend Edition, 7-29-18) The U.S. has the highest maternal mortality rate in the developed world, but California is leading the charge to reverse that trend. Since 2006, the state has cut its rate by more than half.
---The Last Person You'd Expect To Die In Childbirth (Nina Martin, ProPublica, and Renee Montagne, NPR, Morning Edition, 5-12-17) American women are more than three times as likely as Canadian women to die in the maternal period (defined by the Centers for Disease Control as the start of pregnancy to one year after delivery or termination), six times as likely to die as Scandinavians.
---Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why Nina Martin, ProPublica, and Renee Montagne, NPR, 12-7-17) Systemic problems start with social inequities: differing access to healthy food and safe drinking water, safe neighborhoods and good schools, decent jobs and reliable transportation. The hospitals where they give birth are often the products of historical segregation, lower in quality than those where white mothers deliver, with significantly higher rates of life-threatening complications. Those problems are amplified by unconscious biases embedded in the medical system. But it's the discrimination that black women experience in the rest of their lives — the double whammy of race and gender — that may ultimately be the most significant factor in poor maternal outcomes.
---Many Nurses Lack Knowledge of Health Risks to Mothers After Childbirth (Nina Martin, ProPublica, and Renee Montagne, NPR, 8-17-17) A nationwide survey shows that postpartum nurses often fail to warn mothers about potentially life-threatening complications following childbirth, mainly because they need more education themselves.
---Redesigning Maternal Care: OB-GYNs Are Urged to See New Mothers Sooner and More Often (Nina Martin, NPR, 4-23-18) Sweeping changes in medical practice could improve the dismal U.S. rate of maternal deaths and near-deaths, an influential doctors group says.
---For Every Woman Who Dies In Childbirth In The U.S., 70 More Come Close (Renee Montagne, NPR, video, 5-10-18) More than 50,000 American women nearly die from childbirth every year, according to a CDC estimate. These catastrophic complications can come at a terrible cost emotionally, financially and medically.
---Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S. (Katherine Ellison and Nina Martin, ProPublica, 12-22-17) The rate of life-threatening complications for new mothers in the U.S. has more than doubled in two decades as a result of pre-existing conditions, medical errors and unequal access to care.
• Beyond 'The Preventing Maternal Deaths Act': Implementation and Further Policy Change (Katy Backes Kozhimannil, Elaine Hernandez, Dara D. Mendez, Theresa Chapple-McGruder, Health Affairs, 2-4-19) In August 2018, Sen. Kamala Harris (D-CA) introduced The Maternal Care Access and Reducing Emergencies (CARE) Act, which focuses squarely on dismantling structural racism by creating training programs to address implicit bias among clinicians and encouraging integrated health care services that honor the strength of culture and support pregnant women with evidence-based care. Another key area ripe for policy change to support maternal health is Medicaid policy. Medicaid finances half of births nationally, and more than half of pregnant women with public health insurance coverage at the time of childbirth experience a gap or change in their health insurance coverage in the year after giving birth. Disruptions in health insurance (including postpartum) can have adverse health consequences, and Medicaid expansions have reduced mortality. Legislation introduced by Senator Cory Brooker also recommends Medicaid reimbursement for doula services to improve health and equity by supporting women during and after pregnancy outside of the biomedical, hospital-based model. Etc.
• To Help Fix the Maternal Health Crisis, Look to Value-Based Payment (Clare Pierce-Wrobel and Katie Green, Health Affairs, 7-16-19) Payment reform is one way to fix disparities in maternity health. "The current payment structure is flawed because it does not cover high-value services adequately, does not hold providers accountable for overall cost and outcomes, and does not encourage coordination among providers. Instead, the health care system should use value-based payment models that would replace fee-for-service payment. Value-based payment would pay different rates for high-value versus low-value care, would link reimbursement to maternal outcomes and the total cost of care and would cover payments for mother and newborn that link reimbursement for both maternal and infant quality outcomes and total cost." (AHCJ summary)
• The Rising U.S. Maternal Mortality Rate Demands Action from Employers (Suzanne Delbanco, Maclaine Lehan,Thi Montalvo, Jeffrey Levin-Scherz, Harvard Business Review, 6-28-19) What can employers do? (1) Push contracted health plans to create strong incentives for health care providers to charge a single “bundled” price for the entire episode of maternity care. Since C-sections cost more than vaginal deliveries, a bundled payment would give providers an incentive to avoid unnecessary Cesarean births. (2) Implement benefit designs to connect pregnant mothers with high-value providers (i.e., those who offer the best outcomes at a relatively low cost). (3) Educate employees on the importance of full-term births and the potential adverse health consequences of elective inductions and unnecessary Cesarean deliveries. (4) Push health plans to contract with, provide full coverage for, and offer access to certified nurse midwives. The evidence suggests they deliver high-quality care at lower costs.
• Medicaid Payment Initiatives to Improve Maternal and Birth Outcomes (Medicaid and CHIP Payment and Access Commission, or MacPac, April 2019) Again, discourage cesarean deliveries and early elective deliveries (for convenience), and provide evidence-based prenatal and postpartum care. Also describes payment initiatives focused on improving maternal and birth outcomes, and how these efforts have affected spending and health outcomes.
• New Report on Maternity Care in the U.S. Shows Encouraging Progress Reducing Episiotomies, but None Reducing C-Sections (The Leapfrog Group,5-15-18) The average rate of episiotomies, an incision made in the perineum (birth canal) during childbirth, across all reporting hospitals declined, but the use of these usually unnecessary incisions remains well above Leapfrog’s standard.

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Rural and small-town health care

• Vance Wrongly Blames Rural Hospital Closures on Immigrants in the Country Illegally (Sam Whitehead, KFF Health News, 10-29-24) Experts disputed the claim by Republican vice presidential candidate JD Vance, noting that a range of other issues — from low reimbursement rates to declining patient use — combine to cause these facilities to shutter.
• Tiny, Rural Hospitals Feel the Pinch as Medicare Advantage Plans Grow (Sarah Jane Tribble, KFF Health News, 10-23) More than half of seniors are enrolled in private Medicare Advantage plans instead of traditional Medicare. Rural enrollment has increased fourfold and many small-town hospitals say that threatens their viability.

"Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare. The plans have become dubious payers for many large and small hospitals, which report the insurers are often slow to pay or don’t pay. Private plans now cover more than half of all those eligible for Medicare.
"Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.
• Patients Are Relying on Lyft, Uber To Travel Far Distances to Medical Care (Michael Scaturro, KFF Health News, 10-17-24) Uber and Lyft have become a critical part of the nation’s infrastructure for transporting ailing people from their homes — even in rural areas — to medical care sites in major cities such as Atlanta.
• Buy and Bust: When Private Equity Comes for Rural Hospitals (Sarah Jane Tribble, KHN, 6-15-22) Private equity investors, with their focus on buying cheap and reaping quick returns, are moving voraciously into the U.S. health care system; investments increased twentyfold from 2000 to 2018, and have only accelerated since. Financially distressed rural hospitals like Audrain are targets, putting vulnerable communities at the mercy of firms whose North Star is profit, rather than patient health. A recent report found that 441, more than 20%, were at risk of closing or losing services. Noble Health swept into two small Missouri towns promising to save their hospitals. Instead, workers and vendors say it stopped paying bills and government inspectors found it put patients at risk. Within two years — after taking millions in federal covid relief and big administrative fees — it locked the doors.
• More Mobile Clinics Are Bringing Long-Acting Birth Control to Rural Areas (Arielle Zionts, KFF Health News, 10-16-24) Small-town doctors may not offer IUDs and hormonal implants because the devices require training to administer and are expensive to stock. A small but growing number of mobile programs are aimed at increasing rural access to women’s health services, including long-acting reversible contraception. There are two kinds of highly effective methods: intrauterine devices, known as IUDs, and hormonal implants inserted into the upper arm. These birth control options can be especially difficult to obtain — or have removed — in rural areas.
• Nurse Midwives Step Up to Provide Prenatal Care After Two Rural Hospitals Shutter Birthing Centers (Tony Leys, KHN, 7-15-22) Dozens of Iowa hospitals have closed their birthing units. A team of University of Iowa nurse midwives can’t reopen them, but they’ve found a way to provide prenatal checkups and other crucial services in two towns.
• Forget Fracking—Rural Pennsylvanians Want To Hear About Health Care (Zach Womer, Newsweek, 9-19024) In Pennsylvania, the issue that comes up far more often than fracking is the closure of rural hospitals. When a hospital in Elk County closed earlier this year, thousands of people were left without access to maternity care. Currently, rural Pennsylvania has five times fewer OB-GYN doctors per birth than urban areas. A decade ago, that ratio was closer to two-to-one.To make matters worse, two critical federal programs—the Medicare Dependent Hospital Subsidy and the Low-Volume Hospital Adjustment—are set to expire at the end of this year. Rural health care in Pennsylvania and across the country is on the brink of collapse. Yet neither Kamala Harris nor Donald Trump have addressed this crisis or offered solutions to fix it.
• Montana Creates Emergency ‘Drive-Thru’ Blood Pickup Service for Rural Ambulances (Arielle Zionts, KFF Health News, 6-17-24) The network is aimed at helping rural patients, who face higher rates of traumatic injuries and death but may not live near a hospital with a stockpile of blood. The Montana Interfacility Blood Network allows ambulance crews to pick up blood from hospitals and transfuse it to patients on the way to the advanced care they need.
• Rural Jails Turn to Community Health Workers To Help the Newly Released Succeed (Lillian Mongeau Hughes, KFF Health News, 4-22-24) Cheryl Swapp meets with every person booked into the Sanpete county jail soon after they arrive and helps them create a plan for the day they get out. She makes sure everyone has a state ID card, a birth certificate, and a Social Security card so they can qualify for government benefits, apply to jobs, and get to treatment and probation appointments. She helps nearly everyone enroll in Medicaid and apply for housing benefits and food stamps. If they need medication to stay off drugs, she lines that up. If they need a place to stay, she finds them a bed.
Nationally, 63% of people booked into local jails struggle with a substance use disorder — at least six times the rate of the general population. “We don’t lock people up for being diabetic or epileptic,” said David Mahoney, a retired sheriff in Dane County, Wisconsin, who served as president of the National Sheriffs’ Association in 2020-21. “The question every community needs to ask is: ‘Are we doing our responsibility to each other for locking people up for a diagnosed medical condition?’”
• Operating in the Red: Half of Rural Hospitals Lose Money, as Many Cut Services (Jazmin Orozco Rodriguez, KFF Health News, 3-7-24) In a little more than two years as CEO of a small hospital in Wyoming, Dave Ryerse has witnessed firsthand the worsening financial problems eroding rural hospitals nationwide. In 2022, Ryerse’s South Lincoln Medical Center was forced to shutter its operating room because it didn’t have the staff to run it 24 hours a day. Soon after, the obstetrics unit closed.
• After Appalachian Hospitals Merged Into a Monopoly, Their ERs Slowed to a Crawl (Brett Kelman and Samantha Liss, KFF Health News and The Tennessean, 3-25-24) In the six years since Ballad Health secured the largest state-sanctioned hospital monopoly in the U.S., the time that a patient spends in the ER before being admitted has more than tripled.
• Struggling to Survive, the First Rural Hospitals Line Up for New Federal Lifeline (Sarah Jane Tribble, KHN, 3-6-23) Hospitals in New Mexico, Texas, and Oklahoma are among the first to apply for a new rural hospital payment model that shifts the focus of services away from overnight stays to outpatient and emergency care. Still, experts say the law needs to be amended to provide the right mix of care for rural communities.

More than 140 rural hospitals have closed nationwide since 2010, and health policy watchers aren't sure how many of the more than 1,700 rural facilities eligible for the new designation will apply.

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• Tech giants to offer free cybersecurity services to small and rural hospitals (Aaron Bolton, Montana Public Radio, 6-26-24) Investing in the latest cybersecurity tools is more important than ever for hospitals big and small, says cybersecurity expert Beau Woods. They’ve become prime targets because of valuable patient data that can be sold or held for ransom. Cyberattacks slow doctors’ ability to treat patients and can even force hospitals to send patients elsewhere for treatment, delaying care and putting patients’ lives at risk.
• Broadband subsidies for rural Americans are ending, putting telehealth at risk (Sarah Jane Tribble, Morning Edition, NPR, 6-5-24) Listen or read. The Affordable Connectivity Program last year provided $75 discounts for internet access in tribal or high-cost areas--Myrna Broncho’s internet bill was fully paid by the discount--but the program is out of money.
---End of Pandemic Internet Subsidies Threatens a Health Care Lifeline for Rural America (Sarah Jane Tribble, KFF Health News, 6-5-24) During the covid-19 pandemic, federal lawmakers launched the Affordable Connectivity Program with the goal of connecting more people to their jobs, schools, and doctors. More than 23 million low-income households, including Broncho’s, eventually signed on. More than two-thirds of households had inconsistent or no internet connection before enrolling in the program. Now, the ACP is out of money. The FCC said ending the program will affect about 3.4 million rural and more than 300,000 households in tribal areas.
• Closing the Rural Cancer Care Gap: Three Institutional Approaches : Laura A. Levit, Leslie Byatt, Alan P. Lyss, Electra D. Paskett, Kathryn Levit, Kelsey Kirkwood, Caroline Schenkel, and Richard L. Schilsky, JCO: Oncology Practice, 6-23-20) Increasing rural patients’ access to care requires expanding services and decreasing travel distances, mitigating financial burdens when insurance coverage is limited, opening avenues to clinical trial participation, and creating partnerships between providers and community leaders to address local gaps in care.
• Rural Cancer Disparities in the United States: A Multilevel Framework to Improve Access to Care and Patient Outcomes (K. Robin Yabroff, Xuesong Han, Jingxuan Zhao,Leticia Nogueira, and Ahmedin Jemal, State of Cancer Care in America, JCO Oncology Practice, 6-23-20) "One of the strongest predictors of access to cancer care and better health outcomes is health insurance coverage. Increasing insurance coverage options for rural adults through Medicaid expansion and availability of other coverage options, improving local provider coordination with cancer centers and creating shared resources and expertise through networks such as the National Cancer Institute Community Oncology Research Program and telemedicine, and developing broader community-based resources to support and promote healthy lifestyles may improve access to cancer prevention, screening, diagnosis, and treatment. Coupled with Medicaid coverage of routine care costs for clinical trial participation and travel for care in all states, these efforts may increase trial participation among rural residents and reduce rural cancer disparities."

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• A Rural Hospital’s Excruciating Choice: $3.2 Million a Year or Inpatient Care? (Emily Baumgaertner, NY Times, 12-9-22) A new federal program offers hefty payments to small hospitals at risk of closing. But it comes with a bewildering requirement. The program invites more than 1,700 small institutions to become federally designated “rural emergency hospitals,” an injects monthly payments amounting to more than $3 million a year into each of their budgets, a game-changing total for many that would not only keep them open but allow them to expand services and staff. In return, they must commit to discharging or transferring their patients to bigger hospitals within 24 hours. But there are problems with that scenario.
• It's Getting Harder for Rural Pharmacies to Stay Afloat (AP, MedPage Today, 6-8-24) These pharmacies fill a healthcare gap and can be a touchstone for their communities. Pharmacy benefit managers (PBMs) help employers and insurers decide which drugs are covered for millions of Americans. And the lack of transparency around fees and low reimbursements from PBMs is one of the biggest financial pressures for rural pharmacies.
• New federal guidance is hurting cancer patients, especially those in rural areas (Samyukta Mullangi, Opinion, STAT News, 3-1-24) "Until last year, my patient would have been able to make the hour-long drive to my clinic every four weeks for the injection and have our medically integrated specialty pharmacy send her the oral chemotherapeutics every three weeks by courier to her home." A befuddling rule change has led to serious disruptions in the world of community oncology, where the vast majority of Americans receive their cancer care.

"The Physician Self-Referral Law, originally issued in 1989, is intended to prevent fraud and abuse by prohibiting physicians from referring Medicare or Medicaid patients to a health care entity in which the doctor might have a financial interest. In its guidance, CMS seems to indicate that the actual existence of a medically integrated specialty pharmacy isn’t in violation of Stark. Rather, it’s the shipping or mailing of drugs to patients — in other words, patient-centric activities that, if anything, typically cost the pharmacy in extra postage, and which have no impact on physician prescribing behavior."

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• A Rural Doctor Gave Her All. Then Her Heart Broke. (Oliver Whang, NY Times, 9-19-22) 'Physicians suffer one of the highest burnout rates among professionals. Dr. Kimberly Becher, one of two family practitioners in Clay County, West Virginia, learned the hard way. In Clay County, there is no public transportation, no stoplight, no hospital. Most residents live in a food desert. And as one of only two family doctors in the county, Dr. Becher has an all-encompassing job....She began to run more, sometimes twice a day, for hours at a time, “raging down the road.” She was mad about the widespread distrust of vaccines; mad about teachers who went to school even after testing positive for the virus; mad about the endemic food insecurity, the county’s lack of affordable transportation, the high rate of fatty liver disease....

'One of only two family doctors in the county, Dr. Becher was diagnosed with a stress-related heart condition during the pandemic.

"No one put me in this position. I applied to medical school, I sought a job in rural primary care and I poured my identity into it. Takotsubo's is typically caused by severe acute stress, something traumatic and abrupt. Mine was just from going to work every day and seemed super lame to me in the moment."'

"The primary health issues that her patients faced, Dr. Becher said, were hunger and a poor diet. Most of them had the means to buy healthy food, she added, but many drank multiple cans of soda a day. Some could not afford to fix their car and so were unable to drive to the nearest grocery store, an hour away; others had to choose between paying for internet service or fresh produce. With grants from nonprofits, Dr. Becher began paying some people's bills, but blood-sugar levels and blood-pressure readings kept rising.

"She had begun encountering resistance to Covid science, which added to the strain on her, she said; patients she had seen for years were suddenly questioning her judgment...

"What Covid has done is taken many people who had no margins left and it pushed them over the edge," said Dr. Mark Greenawald, a family doctor in Roanoke, Va., who studies burnout among doctors.

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• Kaiser Health Network (KHN)'s Rural Health valuable site links to up-to-date articles etc. on the topic. For example,
---Fentanyl in High School: A Texas Community Grapples With the Reach of the Deadly Opioid (Colleen DeGuzman, KHN, 11-10-22)
---Trickle of Covid Relief Funds Helps Fill Gaps in Rural Kids’ Mental Health Services (Christina Saint Louis, KHN, 11-23-22)
• ‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles (Eli Saslow, Washington Post, 9-28-19) The federal government now designates nearly 80 percent of rural America as “medically underserved.” Health officials predict the number of rural doctors will decline by 23 percent over the next decade. In Texas alone, 159 of the state’s 254 counties have no general surgeons, 121 counties have no medical specialists, and 35 counties have no doctors at all. Thirty more counties are each forced to rely on just a single doctor. The stress on those rural doctors is captured here in the story of one rural Texas doctor.
• Legal Questions, Inquiries Intensify Around Noble Health’s Rural Missouri Hospital Closures (Sarah Jane Tribble, KHN, 3-23-23) A year after private equity-backed Noble Health shuttered two rural Missouri hospitals, a slew of lawsuits and state and federal investigations grind forward. Missouri Attorney General Andrew Bailey recently confirmed an “ongoing” investigation as former employees continue to go unpaid and cope with unpaid medical claims.
• Mental Health Care by Video Fills Gaps in Rural Nursing Homes (Tony Leys, KHN, 3-21-23) In-person mental health care is hard to arrange in rural nursing homes, so video chats with faraway professionals are filling the gap.
• Wave of Rural Nursing Home Closures Grows Amid Staffing Crunch (Tony Leys, KHN, 1-25-23) Many small-town care facilities that remain open are limiting admissions, citing a lack of staff, while a wave of others shutter. That means more patients are marooned in hospitals or placed far away from their families.
• Addiction Treatment Proponents Urge Rural Clinicians to Pitch In by Prescribing Medication (Tony Leys, KHN, 12-1-22) The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years, and treatment advocates hope to see that trend continue.
• Mental Health Crisis Teams Aren’t Just for Cities Anymore (Tony Leys and Arielle Zionts, KHN, 10-3-22) In many cities, social workers and counselors are responding to mental health emergencies that used to be solely handled by police. That approach is spreading to rural areas even though mental health professionals are scarcer and travel distances are longer.

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• As State Institutions Close, Families of Longtime Residents Face Agonizing Choices (Tony Leys, KHN, 9-13-22) Iowa, under federal pressure to improve care for people with intellectual or developmental disabilities, is set to join 45 other states that have closed most or all of their state institutions for such residents.
• Rural Hospital Rescue Program Is Met With Skepticism From Administrators (Sarah Jane Tribble and Tony Leys, KHN, 7-14-22) A new federal rescue program that pays rural hospitals to shutter underused inpatient units and focus solely on emergency rooms and outpatient care hasn’t generated much interest yet.
• Montana Hires a Medicaid Director With a Managed-Care Past (Katheryn Houghton and Tony Leys, KHN, 6-1-22) Montana, one of about a dozen states still managing its own Medicaid programs, has a new Medicaid director who championed handing the management of the program to private companies in Iowa and Kansas.
• How One Rural Town Without a Pharmacy Is Crowdsourcing to Get Meds (Markian Hawryluk, KHN, 7-1-21) The building that once housed the last drugstore in this Colorado town of fewer than 600 is now a barbecue restaurant. It’s an hourlong drive over treacherous mountain passes to Laramie, Wyoming, or Granby or Steamboat Springs, Colorado — and the nearest pharmacies. With large pharmacy chains buying up independent drugstores and increasingly controlling the supply chain, towns such as Walden have too few residents to attract a chain drugstore and no great appeal for pharmacists willing to strike out on their own. With no local access to prescription drugs, the town of mainly cattle ranchers and hay farmers has crowdsourced a delivery system, taking advantage of anyone’s trip to those bigger cities to pick up medications for the rest of the town. The informal system runs primarily through a Facebook group created in 2013 as a sort of online garage sale.

“It’s just not a really attractive business model anymore,” said Keith Mueller, the institute’s director. In 2013, they found that new Medicare Part D drug plans resulted in low and late reimbursements, replacing direct out-of-pocket payments from customers. That left many pharmacies unable to turn a profit. By 2018, surveys showed pharmacies were struggling more with the narrowing margin between what they paid for the drugs and what they were being reimbursed by health plans.

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• 4 ways to ramp up your reporting on rural hospitals (Margarita Martín-Hidalgo Birnbaum, Covering Health, AHCJ, 7-28-22) When reporting on the state of rural medical facilities, there’s more to the story than the demand for health care services. Other factors influence the survival, closure, or changes to services offered by providers in more sparsely populated areas. The economic prosperity of those regions, for instance, appears to be tightly intertwined with the type and quality of care accessible to the people who live there — who tend to be in worse health than their urban peers. That was among the potential story threads that emerged during a presentation at AHCJ’s Rural Health Journalism Workshop 2022.
• Is the rural hospital system near you succeeding or failing? Check this database (William Heisel, Investigating Health, Center for Health Journalism, 1-21-2020)
• High-Deductible Plans Jeopardize Financial Health of Patients and Rural Hospitals (Markian Hawryluk, KHN, 1-10-2020) Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace since the implementation of the Affordable Care Act as insurers look for ways to keep monthly premiums to a minimum. But in rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower than in urban areas, patients often struggle to pay those deductibles, and hospitals are left with uncollectible "bad debt."
• The Hidden Cost of Health Systems Gobbling Up Rural Hospitals Listen: KHN Editor-in-Chief Elisabeth Rosenthal appeared on the WAMU radio program “1A” to discuss the issue of community hospitals merging with larger, corporate systems and what that means for communities around the country. Rosenthal is the author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. (1-24-2020)
• Readers and Tweeters: Are Millennials Killing the Primary Care Doctor? (Dr. Kevin Walsh, Letters to the Editor, KHN, 10-26-18)
• Critical condition: The crisis of rural medical care (CBS Sunday Morning, 3-10-19) A whole cross-section of America is now facing the very real risk of having no local hospital to turn to. The causes are varied; the population in some of those towns has dwindled to a size that can't support a hospital anymore. "The hospital closes, the emergency room dries up, all the other services that went with that – home health, pharmacy, hospice, EMS – they leave town as well, and now you're left with a medical desert," said Holmes.

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• An Obscure Drug Discount Program Stifles Use of Federal Lifeline by Rural Hospitals (Sarah Jane Tribble, KFF Health News, 5-30-24) Facing ongoing concerns about rural hospital closures, Capitol Hill lawmakers have introduced a spate of proposals to fix a federal program created to keep lifesaving services in small towns nationwide. The 340B program, named after its federal statute, lets eligible hospitals and clinics buy drugs at a discount and then bill insurance companies, Medicare, or Medicaid at market rates. Hospitals get to keep the money they make from the difference. Currently, emergency hospitals are not eligible for 340B discounts. The federal law creating rural emergency hospitals omitted the 340B program, as a “product of bipartisan negotiations.”
• Rural Hospital Closings Are Leaving Millions of People in a Health Care Crisis (Jane Bolin, Bree Watzak & Nancy Dickey, The Conversation via Truthout, 10-5-19) More than 20% of our nation’s rural hospitals, or 430 hospitals across 43 states, are near collapse -- despite the fact that rural hospitals are crucial not only for health care but also survival of their small rural communities. Since 2010, 113 rural hospitals across the country have closed, 18% of them in Texas. Texas and Mississippi had the highest number of economically vulnerable facilities, according to a national health care finance report in 2016.
• Why journalists should go beyond surprise bills and report on narrow networks — especially in rural America (Kellie Schmitt, Remaking Health Care, Center for Health Journalism, 1-22-2020) The costly experience of paying out of pocket isn’t uncommon for people who have insurance but may not understand their network’s limitations until an accident or sudden health problem arises, says Simon Haeder has studied narrow health insurance networks for years. The problem is especially troublesome in rural America, regions already plagued with a sicker and poorer population, less public transport and the devastating toll of the opioid crisis.
• Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model ( Sandra G. Boodman, KHN and Washington Post, 10-9-18) For decades, primary care physicians have been the doctors with whom patients had the closest relationship, a bond that can last years. But some experts warn that moving away from a one-on-one relationship may be driving up costs and worsening the problem of fragmented or unnecessary care, including the misuse of antibiotics. A recent report in JAMA Internal Medicine found that nearly half of patients who sought treatment at an urgent care clinic for a cold, the flu or a similar respiratory ailment left with an unnecessary and potentially harmful prescription for antibiotics, compared with 17 percent of those seen in a doctor’s office. Antibiotics are useless against viruses and may expose patients to severe side effects with just a single dose.

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• New Research Shows Increasing Physician Shortages in Both Primary and Specialty Care (Press release, Association of American Medical Colleges, 4-11-18)
• As doctors age, small towns face critical shortage (David Freed, CHCF Center for Health Reporting, SFGate, 1-2-11) As doctors age with no successors, rural areas face dire shortage.
• Outsiders Swoop In Vowing to Rescue Rural Hospitals Short on Hope — And Money (Barbara Feder Ostrov, KHN/The Atlantic, 6-6-18) "The community of Surprise Valley, Calif., is torn over whether to sell its tiny, long-cherished hospital to a Denver entrepreneur who sees a big future in lab tests for faraway patients." The woes of Surprise Valley Community Hospital reflect an increasingly brutal environment for America’s rural hospitals, which are disappearing by the dozens amid declining populations, economic troubles, corporate consolidation and, sometimes, self-inflicted wounds. Abundant illustrations.
• Rural health care in Calif. nearing ‘crisis’ (Andrew Van Dam, Covering Health, AHCJ, 1-13-11) In a collaboration between the California HealthCare Foundation Center for Health Reporting and the San Francisco Chronicle, the center’s David Freed ventures into rural Mendocino County in northern California to explain and examine the ongoing (and worsening) shortage of physicians in American rural areas.

• Rural areas try to lure doctors to avert shortage (David Freed, SFGate, 1-3-11) Many new doctors today say they would struggle to pay off their student loans practicing in rural areas with a lower-income patient base. See also The Price We Pay: How the Cost of Medical School Contributes to US Healthcare Disparities and Spending ( Caroline Claire Elbaum, Health Policy Musings, Tufts, 4-9-17)
• Bringing local, national perspectives to report on ACA in rural Kentucky (Joanne Kenen, Covering Health, AHCJ, 6-17-14) In impoverished rural areas that stood to gain the most from the greater access to care that the Affordable Health Care (ACA) promised, many residents remained fiercely opposed to the law and the president who pushed it. Against that background, a team of journalists from USA Today and The (Louisville, Ky.) Courier-Journal launched an in-depth examination of how the law began to play out in Appalachian Kentucky.
• Medicaid Is Rural America’s Financial Midwife ( Shefali Luthra, KHN and Kentucky Standard, 4-13-18) Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly. As hospital treatments have become increasingly sophisticated and expensive, health care has become inextricably linked to Medicaid in rural areas, which are often home to lower-income and more medically needy people. Medicaid pays the tab for close to 45 percent of all U.S. births annually, and about 51 percent of rural births. Medicaid payments allow struggling hospitals to maintain vital costly services such as maternity care. Rural hospitals depend heavily on Medicaid dollars. See also Medicaid: What You Need to Know as well as Rural Health Information Hub.
• The Village Where Every Cop Has Been Convicted of Domestic Violence (Kyle Hopkins, Anchorage Daily News and ProPublica, 9-18-19) Dozens of convicted criminals have been hired as cops in Alaska communities. Often, they are the only applicants. In Stebbins, every cop has a criminal record, including the chief. It’s a violation of state public safety regulations, yet it happens all the time. See also Lawless (Kyle Hopkins, Anchorage Daily News, 5-16-19) At least one in three Alaska villages has no local law enforcement. Sexual abuse runs rampant, public safety resources are scarce, and Gov. Mike Dunleavy wants to cut the budget.

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Patients sharing info and opinions about
health care problems, services, and costs

• ClearHealthCosts
• Costs of Care (Twitter thread). See especially GODMeDS
• DocGraph. We bring healthcare data into the open.
• ePatient Dave. A voice of patient engagement. See, for example, New Orleans investigative reporters expose health cost craziness, with ClearHealthCosts
• Why Health Insurance Actually Sucks (Jenny Gold, An Arm and a Leg, 12-4-18) Turns out, insurance companies allow — even encourage — crazy price-gouging by hospitals. For example, the leg brace Blake needed was available for $150 on Amazon. But thanks to his insurance, he paid more than $500. How insurance companies help to keep healthcare prices hidden, and keep them high. Check out the other Arm and a Leg episodes.
• Bad Practice (MedPage Today's weekly roundup of clinicians accused, convicted, or under investigation)
• MedPage Today's "past week in healthcare investigations"
• Healing Well.com (forum)
• PatientsLikeMe. By actively involving people in their own care, we're changing lives…
• Rock Health. The first venture fund dedicated to digital health. We support companies improving the quality, safety, and accessibility of our healthcare system.
• Smart Patients. An online community where patients and their families learn from each other.

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• How Patients Use Social Media (Health journalist Sally James and patient advocate Stacey Tinianov, PNR Rendezvous, National Network of Libraries of Medicine, 2-17-16) Webinar (1 hr) on how patients, as well as clinicians and researchers, increasingly use Twitter and Facebook to find and exchange many kinds of health information: including technical information about diseases, comparisons of treatments, as well as support for survivor issues in chronic and rare diseases. Live chats on these platforms draw thousands weekly. Some researchers break news about peer-reviewed journal articles first on Twitter. Other researchers are recruiting subjects directly on social media. This webinar provides practical examples to help you explore and understand how these resources are used and how moderators “curate” and archive tweets and posts from such conversations so they remain accessible.
• Asthmapolis, now Propeller, moves beyond asthma
• When patients speak – some hear golden tones and others noise
• On Making Patient Reviews of Physicians More Useful (David Harlow, Society for Participatory Medicine, 6-27-15)
• Brookings vs Yelp and E-Patients: They’re All Wrong, but Mostly Brookings (Adams Dudley, The Health Care Blog, 6-20-15) We "found that the relationship between Yelp measures and outcomes like death and readmission for three different conditions were all statistically significant, but lower (-0.13 to -0.39, with the negative sign meaning that, as Yelp scores went up, bad outcomes happened less)....Other people have found that patients’ experience ratings also correlate with the more technical aspects of care. For example, among patients with depression or anxiety, their experience ratings are predictive of also receiving the right counseling or medication."
• Crohnology. A Patient-Powered Research Network that allows any patient to contribute to research for the cure. Currently focused on Crohn's & Colitis. What if we could learn from the collective experience of patients everywhere?

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Your gut and your gut microbiome

• If Your Gut Could Talk: 10 Things You Should Know (Healthline) Is your poop on schedule? Processed foods can cause inflammation in the lining of our GI tract, the exact place where food is absorbed. The problem with gluten. Prebiotics. Sauerkraut. And more.
• You Should Appreciate Germs (Bill Gates, GatesNotes, 3-26-17) Gates talks with British journalist Ed Yong about his book I Contain Multitudes: The Microbes Within Us and a Grander View of Life. "Yong makes clear that only a tiny fraction of microbes have the ability to make us sick. There are approximately 100 species of bacteria that cause infectious disease in humans. But there are hundreds of thousands of species that live peacefully, symbiotically within us, primarily in our gut. Microbes help us digest our food, break down toxins, guide our physical development, protect us from disease, and even speed human evolution. We are utterly dependent on them." “We have been tilting at microbes for too long, and created a world that is hostile to the ones we need,” says Yong. What we're doing wrong: overusing anti-bacterial soaps and sanitizers, antibiotics (“A rich, thriving microbiome acts as a barrier to invasive pathogens,” writes Yong. “When our old friends vanish, that barrier disappears [and] more dangerous species can exploit the … ecological vacancies.”) We don't give our children enough micronutrients (not available in pizza!) "The list of disorders that have been linked to disruptions in the microbiome includes Crohn’s disease, ulcerative colitis, irritable bowel syndrome, colon cancer, obesity, type 1 diabetes, type 2 diabetes, and Parkinson’s disease."

• What to Eat and Drink When You Have Diarrhea Barbara Bolen, VeryWellHealth, 10-19-11) Dealing with a common practical problem! (Pooping is what people are talking about, when they talk about gut health.)
• Why Is Gut Health Taking Over TikTok? (Dani Blum, NY Times, 4-20-22) Despite what social media might have you believe, there is no overnight shortcut to better digestive health. There’s not enough data to prove whether any of these supposed fixes improve digestive functions, gastrointestinal experts said. The gut is linked to the immune system and heart health, and emerging research is examining the link between gut flora and neurological disorders like Parkinson’s disease, said Dr. Reezwana Chowdhury. Why to avoid food containing emulsifiers and artificial sweeteners.
• Bristol Stool Chart (Bladder and Bowel, Jan. 2016) A medical classification of seven groups of poop. You want them to be soft, smooth and sausage shaped. Type 1 has spent the longest time in the bowel and type 7 the least time.
• Should You Get a Microbiome Test? (Anahad O’Connor, Ask Well, NY Times, 10-13-21) While the science looks promising, the evidence is still in its infancy.
• How the Right Foods May Lead to a Healthier Gut, and Better Health (Anahad O’Connor, Ask Well, NY Times, 1-11-21) A diet full of highly processed foods with added sugars and salt promoted gut microbes linked to obesity, heart disease and diabetes.
• How Fermented Foods May Alter Your Microbiome and Improve Your Health (Anahad O’Connor, Ask Well, NY Times, 8-13-21) Foods like yogurt, kimchi, sauerkraut and kombucha increased the diversity of gut microbes and led to lower levels of inflammation. Eating these foods may alter the makeup of the trillions of bacteria, viruses and fungi that inhabit our intestinal tracts, collectively known as the gut microbiome.
• A Changing Gut Microbiome May Predict How Well You Age (Anahad O’Connor, NY Times, 3-18-21) People whose gut bacteria transformed over the decades tended to be healthier and live longer.

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• The gut microbiome is opening a new field of medicine (Abigail Eisenstadt, AAAS meeting coverage, National Association of Science Writers, 3-10-18)
• Gut Health: We Need to Talk About It (Kettering Health Network,10-25-19) '“Gastrointestinal problems in general are not clear-cut,” says Dr. Paul Levy. “You can have 10 different diseases that have similar symptoms, so it’s really important not to try to self-diagnose. If you’re having recurring symptoms, schedule an appointment with your doctor.”...General discomfort and heartburn are some of the classic, well-known symptoms of acid reflux. But there are some lesser-known symptoms to be aware of as well. Dry cough, recurrent sinus infections, and even dental problems can all point to ulcers and reflux.... With gallbladder disease, some of the most common symptoms include discomfort after eating, bloating, pain in the upper right side of the belly, and severe pressure in the chest. “With gallbladder disease, the risk profile is much better if you deal with it as soon as you know about it,” says Dr. Levy. “You really don’t want to ignore symptoms.” Good advice on what to do to have a healthy gut.
• When Hong Kong Commuters Take The Subway, Their Microbes Mix – And Spread (Amina Khan, LA Times, 8-1-18) Humans aren’t the only commuters making use of the metro. A new study that examined the microbiome of the Hong Kong subway system found distinct bacterial “fingerprints” in each line during the morning – distinctions that blurred over the course of the afternoon. The findings, published in the journal Cell Reports, are part of a growing body of work that could have implications for a host of efforts, from managing the spread of disease to designing city infrastructure. (Interesting even if you aren't interested in the topic!)

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• Researchers warn that evidence about microbiome's role is preliminary (Bara Vaida, Covering Health blog, AHCJ, 4-27-18) "Journalists who write about health claims connected to the microbiome -- the army of bacteria that live on and in the body -- should exercise skepticism because most research has yet to determine the microbiome's precise role in health and disease. In fact, the scientific evidence is still so scant, probiotics sold on the market, like Culturelle, are probably not as beneficial as advertised, two scientists who spoke at AHCJ's annual conference said."
• Fecal Transplants: Treat Them Like Tissue, Not Like Drugs (Maryn McKenna, 2-23-14) See also her other articles on C. diff and fecal transplants. She's the go-to journalist for diseases and infections caused by superbugs.
• Drug Companies and Doctors Battle Over the Future of Fecal Transplants (Andrew Jacobs, NY Times, 3-3-19) As pharmaceutical companies seek to profit from the curative wonders of human feces, doctors worry about new regulations, higher prices and patients attempting DIY cures. 'Inspired by the success of fecal transplants for C. diff, scientists are racing to develop similar treatments for an array of ailments and disorders, among them obesity, autism, ulcerative colitis, and Alzheimer’s and Parkinson’s diseases.'
'Dr. Alexander Khoruts, a gastroenterologist at the University of Minnesota, said he feared the F.D.A. was favoring the interests of what he calls the “poop drug cartel,” a group of companies seeking approval for new ways to deliver the active ingredients in transplanted feces. Three of the companies, Rebiotix, Seres Therapeutics and Vedanta Biosciences, have raised tens of millions of dollars from investors and they recently formed an association to advance their interests with the F.D.A. “An obscene amount of money is being thrown around by companies trying to profit off of what nature made,” said Dr. Khoruts. “I don’t think there are clear villains here, but I worry that the regulators are not caught up on the latest science and that the interests of investors may be exceeding those of patients.”
• Microbes in Flux (YouTube video) On that YouTube channel are a dozen YouTube videos about the microbiome.

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• A Frozen Idea To Save Helpful Germs From Disasters (Melody Schreiber, WBUR News, 10-4-18) 'Microbiota are the bacteria colonizing the human body — the gut, skin, mouth, and so on — that often help regulate your health. Researchers call them "beneficial germs."' ...Maria Gloria Dominguez-Bello 'has an idea for how to protect those samples from disasters. She is part of a team that wants to build a freezer vault in the safest place possible and stock it with microbiota collected by scientists around the world — a kind of Noah's Ark for helpful bacteria.Right now, many of our probiotics are made with bacteria from cows and other animals.... In the future, Dominguez-Bello says, probiotics will likely come from humans. People may start saving their own microbiota samples before a surgery, she says. After a course of antibiotics, they could reintroduce their helpful bacteria to keep their immune systems flourishing.'
• How to boost your microbiome (Tim Spector, Science Focus, 1-2-18) Practical, do-able tips.
• Human Microbiome Project Highlights (Human Microbiome Project, NIH) Get a cup of your favorite drink and plan to read lots of useful pieces here.
• Some of My Best Friends Are Germs (Michael Pollan, NY Times Magazine, 5-19-13) "Justin Sonnenburg, a microbiologist at Stanford, suggests that we would do well to begin regarding the human body as “an elaborate vessel optimized for the growth and spread of our microbial inhabitants.” This humbling new way of thinking about the self has large implications for human and microbial health, which turn out to be inextricably linked. Disorders in our internal ecosystem — a loss of diversity, say, or a proliferation of the “wrong” kind of microbes — may predispose us to obesity and a whole range of chronic diseases, as well as some infections....Our resident microbes also appear to play a critical role in training and modulating our immune system, helping it to accurately distinguish between friend and foe and not go nuts on, well, nuts and all sorts of other potential allergens. Some researchers believe that the alarming increase in autoimmune diseases in the West may owe to a disruption in the ancient relationship between our bodies and their “old friends” — the microbial symbionts with whom we coevolved." A long, interesting, informative read.
• The gut microbiome is opening a new field of medicine (Abigail Eisenstadt, AAAS meeting coverage, National Association of Science Writers, 3-10-18).

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• The gut microbiome in health and in disease (Andrew B. Shreiner, John Y. Kao, and Vincent B. Young), PubMed, NCBI, N IH, 1-31-15) "The human microbiome is composed of bacteria, archaea, viruses and eukaryotic microbes that reside in and on our bodies. These microbes have tremendous potential to impact our physiology, both in health and in disease. They contribute metabolic functions, protect against pathogens, educate the immune system, and, through these basic functions, affect directly or indirectly most of our physiologic functions." "Ongoing efforts to further characterize the functions of the microbiome and the mechanisms underlying host-microbe interactions will provide a better understanding of the role of the microbiome in health and disease."
• uBiome. SmartGut is the first sequencing-based clinical microbiome screening test. With SmartGut, you and your doctor can gain valuable insights to better understand what’s going on inside your gut and then take steps to feel better.
• Gut Microbiota for Health (European Society for Neurogastroenterology & Motility, o ESNM) "The word microbiota represents an ensemble of microorganisms that resides in a previously established environment. Human beings have clusters of bacteria in different parts of the body, such as in the surface or deep layers of skin (skin microbiota), the mouth (oral microbiota), the vagina (vaginal microbiota), and so on....Gut microbiota (formerly called gut flora) is the name given today to the microbe population living in our intestine. Our gut microbiota contains tens of trillions of microorganisms, including at least 1000 different species of known bacteria with more than 3 million genes (150 times more than human genes)."
• The Uncounted: Part 1: Off the Radar.(Ryan McNeill, Deborah J. Nelson and Yasmeen Abutaleb, A Reuters Investigation, 9-7-16) 'Superbug' scourge spreads as U.S. fails to track rising human toll. The deadly epidemic America is ignoring. Fifteen years after the U.S. declared drug-resistant infections to be a grave threat, the crisis is only worsening, a Reuters investigation finds, as government agencies remain unwilling or unable to impose reporting requirements on a healthcare industry that often hides the problem.
---Part 2: Costly Crisis One life, two donated organs and $5.7 million in bills – a tale of superbugs’ deadly costs
---Part 3: Running Low As ‘superbugs’ strengthen, an alarming lack of new weapons to fight them
---Part 4: Deadly Silence How hospitals, nursing homes keep lethal ‘superbug’ outbreaks secret
---A Most Unwanted List

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• The incidence of MRSA infections in the United States: is a more comprehensive tracking system needed? (Kevin T. Kavanagh, Said Abusalem, and Lindsay E. Calderon, Antimicrob Resist Infect Control. 2017--PubMed.
• How To Improve Your Gut Microbiome in A Day (Christiane Northrup) Include fermented foods in your diet. Fermented foods seed your gut with healthy bacteria. Eat sauerkraut, pickles, kimchi, kefir, yogurt (not processed), and kombucha. These foods are rich in prebiotics.
• C-Sections and Gut Bacteria May Contribute to Overweight Kids (Nicholas Bakalar, NY Times, 2-28-18) Overweight mothers are more likely to have overweight babies, and the gut bacteria the babies inherit may in part be to blame. Researchers report that overweight mothers are more likely to have a cesarean section, and that babies born by cesarean to those mothers have species of gut bacteria different from those in babies born to normal weight women. And that difference in the gut microbiome — specifically an abundance of bacteria of the family Lachnospiraceae in infants of overweight mothers — may contribute to an increased risk for obesity. Source: Roles of Birth Mode and Infant Gut Microbiota in Intergenerational Transmission of Overweight and Obesity From Mother to Offspring (JAMA Pediatr., 2-19-18)
• Gut: The Inside Story of Our Body's Most Underrated Organ by Giulia Enders with Jill Enders and David Shaw
• Nobody Ever (N)SAID You Weren’t Warned (Pedram Shojai, 6-23-21) NSAIDs (ibuprofen, aspirin, aleve, etc.-- Non-Steroidal Anti-Inflammatory Drugs) are used as a broad solution to many of our problems, but in addition to some of the well-known risks of concentrated and consistent NSAID use, like heightened risk of cardiovascular disorders and bleeding problems, scientists and researchers are exploring the effect they have on the rest of our bodily systems — particularly our gut microbiomes.
• Why the Gut Microbiome Is Crucial for Your Health (Ruairi Robertson, HealthLine, 6-27-17) "While some bacteria are associated with disease, others are actually extremely important for your immune system, heart, weight and many other aspects of health....Most of the microbes in your intestines are found in a "pocket" of your large intestine called the cecum, and they are referred to as the gut microbiome. There are roughly 40 trillion bacterial cells in your body and only 30 trillion human cells. That means you are more bacteria than human."
• Gut bacteria are crucial for liver repair(Newswise, Technical University of Munich, 1-3-23) Microbiota provide important building blocks for cell division

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Making wise medical choices, decisions

and avoiding unnecessary procedures

• Choosing Wisely (Consumer Reports and the American Board of Internal Medicine (ABIM) Foundation) Helps consumers/patients choose care that is truly necessary, is supported by evidence, and doesn’t duplicate tests or procedures already received.
• They Thought They Were Buying Obamacare Plans. What They Got Wasn’t Insurance. (Bram Sable-Smith, KHN, 6-7-22) Some consumers who think they are signing up for Obamacare insurance find out later they actually purchased a membership to a health care sharing ministry. But regulators and online advertising sites don’t do much about it. See Healthcare Navigator (Healthcare.gov) To find a U.S. health insurance plan, visit the federal marketplace, healthcare.gov, or call 800-318-2596. See Find Local Help (healthcare.gov).
• The Heart of the Matter (transcript for a video that is no longer available). Karen Carey is a Perth woman who grew up with a simple heart problem. At 13 she was diagnosed with a mitral valve prolapse. She learned the hard way that health care decisions doctors make for profit affect patients' lives. Later in life she had two strokes caused by clots breaking off from a mechanical heart valve and lodging in her brain. She sued and lost and became a consumer health care advocate, advising people to ask doctors these three questions when faced with a medical decision: What are my treatment options? What are the expected outcomes, including the complications? And how likely is it that each of those outcomes will occur, including success and complications? Karen's doctors had not told her about the cumulative nature of the risk, the fact that with heart valve surgery the risk of clotting and stroke is cumulative--adds on each year.
• Consumer Health Choices (Consumer Reports, free resources for more sensible healthcare decisions)
• Preventing Overdiagnosis (winding back the harms of too much medicine)
• Right Care Weekly (Lown Institute)
• Modifying use of some prescription drugs may reduce fracture risk in older adults (Liz Seegert, Covering Health, AHCJ, 9-13-16) Some fragility fractures – those that occur at standing height – may be preventable by modifying a patient’s prescription drug regimen. 21 drug classes have been associated with increased fracture risk. These include commonly prescribed medications such as antidepressants and antacids.
• When Evidence Says No, but Doctors Say Yes (David Epstein and Pro Publica, The Atlantic, Feb. 2017) Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. "How can a procedure so contraindicated by research be so common?""Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.""“If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.” “Relative risk is just another way of lying.”

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Diseases and conditions
• Diseases and conditions (PubMed Health, alphabetical)
• Blood disorders (National Heart, Lung & Blood Institute)
• Infectious Disease Information, A to Z (CDC National Center for Infectious Diseases)

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The truth about screening tests

Annual physicals and health care screening tests Physicals, yes--just not annually. Definitely get a physical when something is wrong.
• They Trusted Their Prenatal Test. They Didn’t Know the Industry Is an Unregulated “Wild West.” (Anna Clark, Adriana Gallardo, Jenny Deam and Mariam Elba, ProPublica, 12-6-22) As regulators stay on the sideline, a growing industry expands its reach but leaves some pregnant patients feeling misled and heartbroken.

Through her doctor, Amanda had gotten a popular prenatal screening from a lab company. It had come back “negative.” It’s a simple blood draw designed to check for an array of genetic anomalies. But Amanda, a science researcher, read academic articles showing there was a higher risk of inaccurate results than she had realized.

The test Amanda had falls into a regulatory void. No federal agency checks to make sure these prenatal screenings work the way they claim before they’re sold to health care providers. The FDA doesn’t ensure that marketing claims are backed up by evidence before screenings reach patients. And companies aren’t required to publicly report instances of when the tests get it wrong — sometimes catastrophically.

Upwards of half of all pregnant people now receive one of these prenatal screenings. And with many states banning abortions or limiting them to early in pregnancies, the need for fast, accurate information has become more urgent. When ProPublica asked readers to share their experiences with noninvasive prenatal screening tests, often referred to as NIPTs or NIPS, more than a thousand responded. Many said the tests had given them peace of mind. Some said they had provided an early warning about problems.

The distinction between tests the FDA actively regulates and those they don’t can seem nonsensical. It isn’t based on the complexity of the tests, or how people use them. It’s simply a matter of where the test is made. The prenatal genetic screening industry took off almost immediately, powered by an army of aggressive sales representatives. “At the very beginning, obstetricians in practice were being just completely inundated with visits from the sales reps,” said Dr. John Williams, director of reproductive health at Cedars-Sinai in Los Angeles.

The push left many OB-GYNs and patients thinking the screenings were accurate enough to substitute for diagnostic tests, such as amniocentesis or CVS. The FDA released plans proposing to regulate the tests, prioritizing those used to make major medical decisions. The agency has pointed to NIPTs as one of 20 concerning tests. Over the next two years, a coalition of power players urged the FDA to back off. Finally, after a long delay, the FDA cautioned patients about making “critical health care decisions based on results from these screening tests alone.”

Read the full article, if you are planning to make decisions based on the results of such tests.

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• A Check on Physicals (Jane Brody, Well, 1-21-13) A 'Danish team noted that routine exams consist of “combinations of screening tests, few of which have been adequately studied in randomized trials.” Among possible harms from health checks, they listed “overdiagnosis, overtreatment, distress or injury from invasive follow-up tests, distress due to false positive test results, false reassurance due to false negative test results, adverse psychosocial effects due to labeling, and difficulties with getting insurance.”'
• Screening Recommendations of the U.S. Preventive Services Task Force. See, for example, Abdominal Aortic Aneurysm and BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing.
• How to test for local water safety. In a recent discussion of health care journalists (AHCJ), this advice was given: Search for "water testing lab" in your area. The costs could range from about $100 to $1,000, depending on what you want tested. Labs do three categories of tests: bacteria and coliform; general mineral; and organics/volatile organic compounds. You'll likely want the bacteria/coliform test, which is the least expensive. The lab will give you a sterile bottle and you'll take the water sample, which must be returned within a certain period of time. The technicians will culture the water on a petri dish for signs of the bacteria. (H/T S Dremann)
• Is my test, item, or service covered? (Medicare.gov) Which preventive & screening services are covered by Medicare.
• Clinical Preventive Services Across the Life Stages (HealthyPeople.gov) Which screenings and services are recommended, at what life stage?
• Barbara Ehrenreich: Why I’m Giving Up on Preventative Care (Lit Hub, 4-9-18) How Contemporary American Medicine is Testing Us to Death. "What could be more ridiculous than an inner-city hospital that offers a hyperbaric chamber but cannot bestir itself to get out in the neighborhood and test for lead poisoning?" She grudgingly agrees to a bone density scan. "The result was a diagnosis of “osteopenia,” or thinning of the bones, a condition that might have been alarming if I hadn’t found out that it is shared by nearly all women over the age of 35. Osteopenia is, in other words, not a disease but a normal feature of aging. A little further research, all into readily available sources, revealed that routine bone scanning had been heavily promoted and even subsidized by the drug’s manufacturer. Worse, the favored medication at the time of my diagnosis has turned out to cause some of the very problems it was supposed to prevent—bone degeneration and fractures."

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• Can screenings be too much of a good thing? (Liz Seegert, Covering Health, AHCJ, 6-30-15) "For years, evidence has grown about wasted Medicare dollars on needless screenings....Yet despite this news, Medicare continues to reimburse for many common tests like PSA and screenings for breast cancer – as well as MRIs, and CT scans in older adults that are not medically necessary, or sometimes, even appropriate."
• Overkill (Atul Gawande, New Yorker, 5-4-15) An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? Cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.
• Which screening tests are worth getting? sidebar to story Annual physical exam is probably unnecessary if you’re generally healthy (Christie Aschwanden, Washington Post, 2-8-13).
• Private health screening tests are oversold and under-explained (UK physician Margaret McCartney, The Guardian, 9-17-14) The message in this article for the UK is equally valid for the USA: "Health screening can cause more harm than it prevents, so companies have a duty to provide full information to customers." Life Line Screening markets its for-profit tests without providing fair information and an evidence base for taking them. She provides examples and links, particularly to PrivateHealthScreening: What to Think About When You’re Thinking About Screening Tests. (Click on and read all the links there.) Links below (via Gary Schwitzer) get more specific. Unless your doctor recommends them, there are reasons to think twice about screening tests for which you receive marketing material--say, for aortic aneurysms.
• Screening For Asymptomatic Carotid Artery Stenosis (PDF, Agency for Healthcare Research and Quality, Evidence Synthesis No. 50)
• Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force (Annals of Internal Medicine, 9-20-11)
• Effect of Screening on Ovarian Cancer Mortality (JAMA, The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial, June 8, 2011)
• The UK NSC policy on Osteoporosis screening in women after the menopause (Systematic screening in postmenopasual women is not recommended.)
• Liver function tests in patients with computed tomography demonstrated hepatic metastases (Springer, 1989) "Although liver function tests (LFTs) (enzyme levels) are inexpensive and simple to perform, they failed to detect a significant number of patients with liver metastases."
• Incidental Findings on Brain MRI in the General Population (New England Journal of Medicine, 11-1-07). "Incidental brain findings on MRI, including subclinical vascular pathologic changes, are common in the general population. The most frequent are brain infarcts, followed by cerebral aneurysms and benign primary tumors. Information on the natural course of these lesions is needed to inform clinical management." See full discussion.

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• "Preventive health screenings" that are hardly a Life Line (Dr. Kenny Lin, Common Sense Family Doctor, 2-7-11)
• How Doctors and Patients Do Harm (Tara Parker-Pope, Well, NY Times, 4-20-12). "That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does..."
• Articles about screenings (Covering Health, Association of Health Care Journalists).
• Iowa hospitals drop controversial mobile testing firm ( Tony Leys, Des Moines Register, 9-5-14). University of Iowa Health Alliance plans to stop using HealthFair, "a mobile heart-testing company that has been accused of 'fear-mongering' to induce healthy people to undergo scans of their hearts and arteries." This came about after the advocacy group Public Citizen called for an investigation and a halt to recommending tests for most patients. "Such widespread screenings are not recommended by medical experts because each of the six tests either benefits only appropriately selected high-risk patients or has not been scientifically shown to provide any clinically meaningful benefit to anyone.

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Basic healthcare explanations: How things (in the body) work

• Antibodies: Friend & Foe (Thomas Packard, Healthcare in America,12-29-16)
Blood tests and results, explained
• Blood Pressure Monitors (those validated as reliable, dabl Educational Trust)
• Lab Tests Online Various diagnostic tests, explained.
• Types of blood tests (National Heart, Blood, and Lung Institute, NHBLI)
• 12 Medications That Cause Hair Loss (Austin Ulrich, GoodRx, 4-28-22) Read the article for names of specific drugs in these broad categories: retinoids, antidepressants, anticoagulants, anticonvulsants, beta blockers, antithyroid medications, chemotherapy drugs, tamoxifen, arthritis medications, Allopurinol, Levodopa, Bromocriptine.

AARP's list: Anticoagulants; Antidepressants, mood stabilizers, bipolar disorder medications; antimicrobial tuberculosis drugs; Arthritis, inflammation drugs; blood pressure meds; cholesterol-lowering meds; epilepsy and anticonvulsant meds; and meds to treat severe acne and psoriasis.
• So You Might Actually Not Be Allergic to Penicillin (Jeanette Beebe, Daily Beast, 1-16-18) "Nearly 90 percent of patients who had 'penicillin allergy' listed on their medical charts were found to actually have no such allergy at all....The only way to know if you’re actually allergic to penicillin is a skin test. Khan argues that getting the right diagnosis lowers health care costs and weakens antibiotic-resistant bugs (and infections) for all of us."
• Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack (NHBLI)
• Questions and Answers on Cholesterol and Health with NHLBI Nutritionist Janet de Jesus, M.S., R.D. (NHBLI)
• Testosterone (This American Life, Program 220, 8-30-2002) Stories of people getting more testosterone and coming to regret it. And of people losing it and coming to appreciate life without it. The pros and cons of the hormone of desire.
• Doctors Might Stop UTIs from Ever Happening Again (Nicole Wetsman, Precise Welfare, Daily Beast, 6-19-18) There are around 8 million urinary tract infections diagnosed each year in the United States, making up around 25 percent of all infections. Unlike traditional antibiotics, which wipe out good and bad bacteria indiscriminately, precision treatments would target the specific bug responsible for the urinary tract infection, while leaving the rest intact.
• Fighting the Plague: A Story of HIV/AIDS (Thomas Packard, Healthcare in America, 12-2-16)
• Mapping the Secret Lives of Human Cells (Daniela Hernandez, WSJ, 4-6-17) What does a human cell look like? That is somewhat of a mystery because most current cellular models are static and based on limited data, according to scientists from the Allen Institute for Cell Science in Seattle. Until recently researchers lacked the tools to assess cells and their tiny internal structures, known as organelles, in real time on a large scale, they say.
• In Giant Virus Genes, Hints About Their Mysterious Origin (Rae Ellen Bichell, Shots, NPR, 4-6-17) Viruses are supposed to be tiny and simple — so tiny and simple that it's debatable whether they're even alive. They're minimalist packets of genetic information, relying entirely on the cells the infect in order to survive and reproduce. But in 2003, researchers identified a new kind of virus that that turned scientific understanding of viruses upside down, and tested the boundary of what can be considered life.

Thanks to Kaiser Health News (http://khn.org/).
Many of the links posted on this website I became aware of through Kaiser Health News, which I highly recommend. You can subscribe here.

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Vitamins, supplements, and "natural products"

And see below: Vitamin D, the sunshine vitamin (it's the dose that people argue about)

Have you noticed that the price for your vitamins and supplements has been rising? The Food and Drug Administration (FDA) does not regulate the safety and sale of nutritional supplements. Because they're classified as food products, not medicines, they aren't regulated by the strict standards governing the sale of prescription and over-the-counter drugs. So buy them from sources with a good reputation.

• Dietary and Herbal Supplements (National Center for Complementary and Integrative Health, NCCIH, and source of some of the following resources)
• Herbs and Supplements (Medline Plus, alphabetically organized). Browse dietary supplements and herbal remedies to learn about their effectiveness, usual dosage, and potential drug interactions.
• Vitamins and Minerals (National Center for Complementary and Integrative Health, NCCIH)
• Consumer Information on Dietary Supplements (U.S. Food and Drug Administration, FDA)
• ConsumerLab.com. Among sources ConsumerLab.com recommends for buying vitamins, supplements, and "natural products" (but check their site!):
---eVitamins
---Lucky Vitamin
---Swanson Vitamins
---iHerb
---VitaCost
Check the price at your local store against prices for the same product on Amazon. They are often notably higher at the vitamin shop I have frequented.
• Are You Getting Enough Vitamin K? (Michelle Crouch, AARP, 4-9-21) Research shows this lesser-known nutrient helps keep your heart healthy, your bones strong and more — yet many older adults fall short.
• Why You Might Need More B12 and D3 Vitamins (Stephen Perrine, AARP, 6-7-21) "Malabsorption issues can arise at different ages. But generally, people should start paying attention to this after age 50,” Tucker says. By age 65, as many as 4 in 10 adults may have gastric issues that hinder B12 absorption. B12 serves an essential role in nerve function; a shortfall of B12 is associated with depression, dementia and decreased cognitive function, as well as anemia.
• The 3 Supplements You Might Actually Need After 50 (Jeanette Beebe, AARP, 7-21-21) Vitamin C, Vitamin D, and Vitamin B12. Overhyped supplements: Vitamins E and C and folic acid. But read the details and don't overdo Vitamin D. Here's how much vitamin D you need, according to the NIH: 15 micrograms (mcg) / 600 international units (IU) per day for adults 19 to 70 years old 20 mcg / 800 IU per day for 71-year-olds and older
• Dietary Supplements: What You Need to Know (NIH Office of Dietary Supplements and WYNTK)
• 6 Tip-offs to Rip-offs: Don't Fall for Health Fraud Scams (FDA)
• 5 Tips: Natural Products for the Flu and Colds: What Does the Science Say? (National Center for Complementary and Integrative Health, NCCIH)
• Studies Show Little Benefit in Supplements (Jane E. Brody, NY Times, 11-15-16)

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• Knowing What’s Worth Paying For in Vitamins Lesley Alderman, NY Times, Patient Money, NY Times, 12-4-09) Use only what you need: "Popping too many vitamin pills is not only a waste of money but can be bad for your health. Talk to your doctor about what added vitamins or minerals you might require; you can ask for a blood test to learn what you might be lacking." A multivitamin will not provide the level of a vitamin you may be deficient in. If your doctor recommends a specific supplement, like omega-3, ask in what form you should be taking it. Find a reputable source. "Purchase your vitamins from well-known retailers that do a brisk business and restock frequently, whether that’s Costco or Drugstore.com." Price may not indicate quality."ConsumerLab.com says it has found a few patterns that consumers may find helpful. Products sold by vitamin chains tend to be more reliable than drugstore brands, and Wal-Mart and Costco’s vitamin lines are usually worth considering. In a recent test of multivitamins, ConsumerLab.com found that Equate-Mature Multivitamin 50+ sold by Wal-Mart was just as good as the name brand Centrum Silver, but at less than a nickel a day is half the price."
• Are Calcium Supplements Safe? (Richard Klasco, NY Times, 10-12-18) Kidney stones are a known risk, but studies have investigated other potential safety concerns, including an increased risk of death, cancer and heart disease. Many people, especially women, take calcium supplements in the hope of building stronger bones, but whether calcium supplements prevent fractures remains uncertain. "The Women’s Health Initiative, a randomized placebo-controlled trial of calcium and vitamin D in more than 36,000 postmenopausal women, found a 17 percent increase in the incidence of kidney stones. A report prepared for the Preventive Services Task Force supported this conclusion, but noted that the risk disappeared when calcium was taken without vitamin D."
• Supplements Can Make You Sick (Jeneen Interlandi, Consumer Reports, 7-27-16) Dietary supplements are not regulated the same way as medications. This lack of oversight puts consumers' health at risk.
• Vitamin B.S. (Cari Romm, The Atlantic, 2-26-15) How people came to believe the myth that nutritional supplements could make them into better, healthier versions of themselves. From an interview with Catherine Price, the author of Vitamania (for which I've seen two different subtitles: "How Vitamins Revolutionized the Way We Think About Food" and "Our Obsessive Quest for Nutritional Perfection").
• What Heart Patients Need to Know About Herbal Supplements (Lauren Friedman, Consumer Reports, 3-2-17) A new study says they may be an especially risky choice for patients taking heart meds
• Liver Damage From Supplements Is on the Rise (Lauren Cooper, Consumer Reports, 5-19-17) Green-tea extract and bodybuilding pills pose a particular risk, study finds.

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• 15 Supplement Ingredients to Always Avoid (Consumer Reports, 3-21-17) These supplement ingredients can cause organ damage, cardiac arrest, and cancer: Aconite, caffeine powder, chaparral, coltsfoot, comfrey, germander, greater celandine, green tea extract powder, kava, lobelia, methylsynephrine, pennyroyal oil, red yeast rice, usnic acid, yohimbe. A useful chart with "claimed benefits" vs. "risks."
• 4 Supplements to Question After Age 50 (Lauren Cooper, Consumer Reports, 12-16-16) Who might need folic acid, calcium, iron, and vitamin E supplements, do they do what is claimed, and what problems might there be with them (for whom).

• Fish Oil Supplements May Not Help Prevent Heart Disease (Sally Wadyka, Consumer Reports, 3-14-17) Those who already have certain forms of heart disease may benefit, though, a new report finds. "One thing most heart disease experts do agree on: The best way to get the protective benefits of omega-3s is to eat fish rather than take fish oil supplements.Salmon, sardines, mackerel, and other fatty fish, have the highest amount of omega-3s, and are low in mercury. Fish may be protective, says Lipman, not just because of its omega-3 content, but because it is a lean source of protein, low in saturated fat, and rich in other nutrients.:
• ‘Natural’ Sleep Supplements Carry Serious Safety Concerns (Ginger Skinner, Consumer Reports, 12-29-16) There's little research to suggest melatonin and valerian work, plus the popular supplements come with clear risks

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Vitamin D, the sunshine vitamin

(We may have gone a little overboard on this section)Try to get a few minutes exposure to sunshine most days.And eat the right foods.

• Mayo Clinic on Vitamin D The recommended daily amount of vitamin D is 400 international units (IU) for children up to age 12 months, 600 IU for people ages 1 to 70 years, and 800 IU for people over 70 years. Also covered: Evidence that Vitamin D is good (or bad) for a list of specific medical conditions. Safety and side effects. Possible side effects when taken with certain medications.
• Vitamin D supplements: Panacea, placebo or something in between? (Dan Hurley, WaPo, 9-14-15) The public’s faith in vitamin D as a modern panacea has far outpaced what the scientific evidence proves. JoAnn E. Manson, chief of the division of preventive medicine at Brigham and Women’s Hospital in Boston and a professor of medicine at Harvard Medical School, "has led or collaborated on more than a dozen large, randomized, placebo-controlled studies, dating back more than two decades, which found none of the expected protection against cancer, heart disease, dementia or other diseases that scientists once attributed to beta carotene, vitamin E or vitamin C supplements. (She did find, however, that supplementation with folic acid, vitamin B6 and vitamin B12 offered modest protection against age-related macular degeneration and, for those with a diet low in B vitamins to begin with, a hint of protection against the loss of cognitive abilities.) Manson heads the VITamin D and OmegA-3 TriAL (VITAL) at Brigham and Women’s Hospital.

Health News Review's comments: Nuanced portrait of evidence on prevention benefits of vitamin D "This story examines the history of controversy over whether vitamin D has any preventive role in a laundry list of conditions including diabetes, depression and multiple sclerosis. There’s no controversy over its role in bone health. Different studies have reached different conclusions, and the story predicts that large randomized studies might help resolve these disputes a few years from now."
• Some Seek Guidelines to Reflect Vitamin D's Benefits (Rob Stein, Washington Post, 7-3-08) Research from 2008 indicating that Vitamin D might have a dizzying array of health benefits reignited an intense debate over whether federal guidelines for the "sunshine vitamin" were outdated, leaving millions unnecessarily vulnerable to cancer, heart disease, diabetes and other ailments. The new research was provocative; experts argue that the benefits remain far from proven. Vitamin D can be toxic at high doses, and some studies suggest it could increase the risk for some health problems. Some skeptics question whether funding by the tanning, milk, and vitamin industries is biasing some advocates.

But with people spending more time indoors surfing the Web, watching television, working at desk jobs, and covering up and using sunblock when they do venture outdoors, the amount of Vitamin D that people create in their bodies has been falling. Skeptics say the Vitamin D already added to foods may be fueling increases in chronic diseases, such as diabetes and obesity. "The bottom line is we now recognize that Vitamin D is important for health for both children and adults and may help prevent many serious chronic diseases," said Michael F. Holick, a professor of medicine, physiology and biophysics at Boston University.
• What is melatonin and can it help me sleep? (Brian Resnick, Vox, 8-19-16) Melatonin may work best for jet lag and in people who have low melatonin. One reason for caution:Melatonin isn't well regulated. A pat on the back for excellent reporting on melatonin (Health News Review).
• Is Sunscreen the New Margarine? (Rowan Jacobsen, Outside, 1-10-19) Current guidelines for sun exposure are unhealthy and unscientific, controversial new research suggests—and quite possibly even racist. Vitamin D is a hormone manufactured by the skin with the help of sunlight. It’s difficult to obtain in sufficient quantities through diet, and vitamin D supplementation has failed spectacularly in clinical trials. True, the sun worshippers had a higher incidence of [melanoma]—but they were eight times less likely to die from it. Over the 20 years of the study, sun avoiders were twice as likely to die as sun worshippers. In a 2016 study published in the Journal of Internal Medicine, Lindqvist’s team put it in perspective: “Avoidance of sun exposure is a risk factor of a similar magnitude as smoking, in terms of life expectancy.”

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• Risky stimulants turn up — again — in weight loss and workout supplements (Rebecca Robbins, STAT News, 11-8-17) "The ingredients, apparently new, were popping up on the labels of dietary supplements marketed for weight loss and workouts. Sometimes the label said DMHA. Sometimes, Aconitum kusnezoffii. Or other, even harder-to-parse names... Octodrine did indeed show up in one of the products Cohen analyzed. But the others contained three different stimulants, with unknown or potentially risky side effects. They could speed up heart rate and raise blood pressure. And none, including octodrine, has gone through the process required by the FDA to be included as ingredients in dietary supplements...The new findings also highlight just how hard it has been for the FDA to keep potentially unsafe supplement ingredients off the market. For example, regulators warn that the best-known of these stimulants, called DMAA, can cause cardiovascular problems ranging from shortness of breath to a heart attack."
• Fish Oil and Vitamin D Pills No Guard Against Cancer or Serious Heart Trouble (Liz Szabo, KHN, 11-10-18) A widely anticipated study has concluded that neither vitamin D nor fish oil supplements prevent cancer or serious heart-related problems in healthy older people, according to research presented Saturday at the American Heart Association Scientific Sessions.Researchers defined serious heart problems as the combined rate of heart attacks, stroke and heart-related deaths.

The study also suggests there’s no reason for people to undergo routine blood tests for vitamin D. (Vitamin D testing has become a huge business for commercial labs — and an enormous expense for taxpayers.) But Manson's team also found no serious side effects from taking either fish oil or vitamin D supplements. When researchers singled out heart attacks — rather than the rate of all serious heart problems combined — they saw that fish oil appeared to reduce heart attacks by 28 percent, Manson said.

As for vitamin D, it appeared to reduce cancer deaths — although not cancer diagnoses — by 25 percent. (Slicing the data into smaller segments — with fewer patients in each group — can produce unreliable results. The links between fish oil and heart attacks — and vitamin D and cancer death — could be due to chance, Kramer said.)
• The Truth About Calcium and Vitamin D Supplements (Lauren Cooper, Consumer Reports, 7-27-16) Consumers take them to strengthen bones and prevent fractures. Do they work? "Taking daily calcium pills can increase bone density in people over 50 years old by 1 to 2 percent—not enough to prevent fractures. That’s according to a review of 59 randomized controlled trials, published last year in the British Medical Journal. “That small gain is not worth the risks, including an increased likelihood of heart disease, kidney stones, and gastrointestinal problems,” Lipman says."
"The best way to get that calcium is to eat calcium-rich foods including milk, cheese, and yogurt. Good sources of vitamin D are mushrooms, eggs, fortified milk, soy beverages, and salmon. Our bodies also make vitamin D when our skin is exposed to sunlight, so our experts suggest getting 10 minutes of sunshine per day. Exercise is important, too. “Weight-bearing aerobic activities, such as walking and dancing, may slow bone loss."

Experts agree that vitamin D is important for bone health. Consumers who want to reduce their risk of cancer and heart disease can follow other proven strategies. “People should continue to focus on known factors to reduce cancer and heart disease: Eat right, exercise, don’t smoke, control high blood pressure, take a statin if you are high risk,” said Dr. Alex Krist, a professor of family medicine and population health at Virginia Commonwealth University.)

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Telehealth and virtual medical visits

"There's nothing virtual about it. It's technology-enabled actual care."

Richard Zane, M.D., University of Colorado Health

• States Step In as Telehealth and Clinic Patients Get Blindsided by Hospital Fees (Markian Hawryluk, KHN, 4-3-23) Patients who get their labs drawn in a hospital outpatient department are charged up to three times what they would pay in an office, With in-person visits on hold due to the covid-19 pandemic, the Tessos met with a panel of specialists via video chat, needing an evaluation for speech therapy for their three-year-old.Thinking the $676.86 bill they got for the one-hour session was pretty steep, they assumed the second bill, for $847.35, was a mistake, and learned that the second bill was for the costs of being seen in a hospital — the equipment, the medical records, and the support staff, though they never set foot in the hospital. Several states agree such "facility fees" are questionable. States that have implemented or are considering limits on facility fees are Colorado, Connecticut, Indiana, Minnesota, New Hampshire, Ohio, Texas, and Washington.
• COVID-19: Using Telehealth to Reduce Your Risk (Compassion and Choices) An excellent overview.
• What to know about telemedicine fraud (Karen Blum, Covering Health, AHCJ, 8-31-22) When the U.S. Department of Justice (DOJ) announced in July it had levied criminal charges against 36 defendants across the country for more than $1.2 billion in alleged fraudulent telemedicine and other health care schemes, it became the latest in an ongoing series of criminal behavior by scammers in this arena caught by the federal government. Government insurers such as Medicare are among the payers most frequently targeted. The July 2022 roundup, for example, included one case in which the operator of several clinical laboratories was charged in connection with a scheme to pay over $16 million in kickbacks to marketers. In turn, they paid kickbacks to telemedicine companies and call centers in exchange for doctors’ orders.
• Cause for Concern: The Stripping Away of Patients' Rights (Shannon Casey, MedPage Today, 2-18-23) It's increasingly common for healthcare companies to have binding arbitration agreements, which stipulate that if a dispute arises, it will be settled by an arbitrator rather than a judge or jury. Since binding arbitration is a private process, that means that companies can better protect their image and reputation by avoiding negative publicity. Binding arbitration has much more to do with protecting private equity than prioritizing patients' well-being.
• “Out Of Control”: Dozens of Telehealth Startups Sent Sensitive Health Information to Big Tech Companies Todd Feathers, Katie Palmer for STAT, and Simon Fondrie-Teitler for The Markup, 12-13-22) A joint investigation by STAT and The Markup of 50 direct-to-consumer telehealth companies like WorkIt found that quick, online access to medications often comes with a hidden cost for patients: Virtual care websites were leaking sensitive medical information they collect to the world’s largest advertising platforms. On 13 of the 50 websites studied, at least one tracker—from Meta, Google, TikTok, Bing, Snap, Twitter, LinkedIn, or Pinterest—collected patients’ answers to medical intake questions. They found trackers collecting information on websites that sell everything from addiction treatments and antidepressants to pills for weight loss and migraines. It is all but impossible for the average user to know whether the company they’re entrusting with their data is obligated to protect it.
• The Availablists: Emergency Care without the Emergency Department (Catalyst, NEJM, 12-21-22) Covid-19 had an immediate effect on health care systems. Institutions that considered themselves successful by making incremental changes over years were forced to overhaul their operations overnight. The traditional model of predominantly in-person care morphed into a virtual system within days. “Late adopters” were forced to become immediate adapters, learning about new care options that remove traditional barriers to effective emergency care. Well worth reading, whether healthcare provider or patient.
• Telehealth 2.0: How Providence is taking its platform to the next level Becker's Hospital Review, 6-13-22) Telehealth became the prevailing mode for medical providers to see patients during the early days of the pandemic, and while use has leveled off in many areas, virtual care has become a permanent part of the healthcare ecosystem.
• Digital Health + Health IT (Becker's Healthcare podcast about key digital health trends and health information technology
• Intermountain, Boston Children's + more scaling telehealth programs (Becker's Hospital Review, 5-23-22) For example, Idaho-based Teton Valley Health Hospital created TeleBurn, a telehealth program designed to care for both adults and children affected by injuries such as burns, frostbite and skin slouching.
• How telehealth can help inpatient care, and what a hybrid future looks like Healthcare IT News, 6-20-22)mnA telemedicine expert discusses how virtual care will evolve beyond its current use.
• UC startup makes health care more convenient, equitable (UC Cincinnati news release) TeleSMART Health develops platform for remote medical examinations
• How a Texas health system spun up a virtual ICU – just in time for COVID-19 (Healthcare IT News, 1-7-22) Houston Methodist had been planning to implement a virtual intensive care unit (VICU) for several years. The pandemic led the health system to speed up the process. The team used Caregility for their cameras and Medical Informatics Corp.'s Sickbay platform for their artificial intelligence tools. Their intensivists were employed through Equum Medical. They added the community hospitals as they could get carts, and then, eventually, added their cameras. The model allowed the health system to care for the increased volumes of critically ill patients and involved "countless" change-management pieces.

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• Hearing Amazon's footsteps, Walgreens unveils new digital platform to connect patients to doctors (Lisa Schencker, Chicago Tribune, 7-27-18) "Walgreens has unveiled a new digital platform to connect customers to medical services, just weeks after its stock dove on news that Amazon is expanding into the pharmacy business. Deerfield-based Walgreens’ new Find Care Now platform, available online and on the pharmacy chain’s app, allows patients to schedule appointments at its in-store Advocate clinics, talk with doctors and therapists through telehealth company MDLIVE, and schedule online dermatology appointments through online dermatology service DermatologistOnCall. Patients can also get second opinions through the NewYork-Presbyterian health care system and make eye and hearing appointments at Walgreens stores. In other parts of the country, Walgreens has partnered with a number of other regional health care providers. "
• ‘Out of control’: Dozens of telehealth startups sent sensitive health information to big tech companies (Katie Palmer, STAT, and Todd Feathers and Simon Fondrie-Teitler, The Markup, 12-13-22) "After analyzing the data-sharing of 50 direct-to-consumer telehealth sites, they found that 13 had at least one tracker from companies like Meta, Google, TikTok, Bing, Snap, Twitter, LinkedIn, or Pinterest that collected answers to medical intake questions. And 25 telehealth sites — including Ro, Hims & Hers, and Thirty Madison — shared with a big tech company when users had items like prescription medications in their virtual shopping carts or when they had subscribed to a treatment plan."

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• More Than Half of Kaiser Permanente's Patient Visits Are Done Virtually (Kia Kokalitcheva, Fortune, 10-6-16) "For the first time, last year, we had over 110 million interactions between our physicians and our members," said Tyson, adding that 52% of them were done via smartphone, videoconferencing, kiosks, and other technology tools. "What were now seeing is greater interaction with our members and the health care system," said Tyson. "They're asking different questions, they're behaving more like consumers, and medical information now is becoming a critical part of how they're making life choices."
• Charlotte patients take control of their medical records, doctor visits with virtual care (Karen Garloch, Charlotte Observer, 12-20-14) After downloading a new app to her iPhone, within minutes Beth Straeten was talking face-to-face with a physician assistant. As Straeten described the poison ivy rash on her arms, PA Dimple Joshi sat across town at Carolinas Medical Center-Pineville, in front of two computer monitors. On one, Joshi could see Straeten and on the other she could read Straeten’s medical record. This has been called medicine’s “Gutenberg moment” by Dr. Eric Topol, one of the nation’s leading cardiologists. Much like the printing press liberated knowledge from control of the elite class, Topol says digital health technology is poised to democratize medicine in ways that were unimaginable until now. “It goes from being the doctor’s medical record to being the patient’s medical record,” said Dr. R. Henry Capps Jr.
• Telehealth back in the spotlight (Covering Health, Association of Health Care Journalists, 8-7-17) Lack of reimbursement for telehealth has for many years been an impediment to adoption.Three proposed initiatives would remove some longstanding roadblocks to wider adoption of telehealth services. One proposal would eliminate the state-by-state licensure requirement for telehealth delivery for all federal programs, including Medicare (so the patient wouldn't have to be in the same state as the doctor). The proposed Evidence-Based Telehealth Expansion Act of 2017 would waive current Medicare restrictions on telehealth coverage as long as it saves money. The proposed CHRONIC Care Act of 2017 would offer accountable care organizations and Medicare Advantage plans greater flexibility in reimbursement for telehealth services, and eliminate geographic restrictions for telestroke service payments.
• Get Your Checkup by Phone or Video (Beth Howard, The Investing Revolution, US News, 8-26-16) "When 11-month-old Jack Causa's eyes became red and developed a yellow discharge last winter, his mother Izzy immediately recognized the problem: pinkeye. Because the pediatrician's office was closed, she used a service called Teladoc, provided through her health benefits, to reach a physician on her smartphone....Teladoc is one of several services, including MDLIVE, American Well, and Doctor on Demand, offering secure access to a doctor anytime, anywhere to anyone with a smartphone or tablet. " Anothe take: Remote Patient Monitoring (100plus) A sales pitch to healthcare professionals.

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• Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease (Jack S. Resneck Jr, MD, et al., JAMA Dermatology, 5-1-13) Telemedicine has potential to expand access to high-value health care. Our findings, however, raise concerns about the quality of skin disease diagnosis and treatment provided by many DTC telemedicine websites. Until improvements are made, patients risk using health care services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination. We offer several suggestions to improve the quality of DTC telemedicine websites and apps and avoid further growth of fragmented, low-quality care.
• Big business backs virtual doctor visits as Texas loses fight for limits (Jayne O'Donnell, USA Today, 6-3-15) Video or telephone visits with doctors — the practice known as telemedicine — have survived one of their biggest legal challenges yet in Texas, but hurdles remain in Arkansas and some other states.
• The FDA Just Opened Up Abortion Pill Access. Next Up: Webcam Prescriptions (Sarah Zhang, Wired, 3-31-16)
• Telemedicine fans point to CBO's history of cost overestimates (David Pittman, Politico, 12-21-15) The Congressional Budget Office's track record with telemedicine isn’t very positive. Advocates need to find better ways to show CBO their proposed changes work and will save money. “They do seek to be fair, but they’re also careful,” Schwartz said.
• Virtual reality: More insurers are embracing telehealth (Bob Herman, Modern Healthcare, 2-20-16)

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Complementary and alternative medicine

• Complementary, Alternative, or Integrative Health: What’s In a Name? (National Center for Complementary and Integrative Health, NIH)
• Complementary and Alternative Medicine (National Cancer Institute) Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard medical care. Are CAM approaches safe? Natural does not mean safe.
• Health Topics, A to Z (National Center for Complementary and Integrative Health)
• 6 Things To Know When Selecting a Complementary Health Practitioner (National Center for Complementary and Integrative Health)
• Frequently asked questions about dietary supplements (NIH Office of Dietary Supplements)
• What Exactly Is Alternative Medicine? (WebMD's mostly positive description of such practices as acupuncture, chiropractic medicine, energy therapies, magnetic field therapy, Reiki, therapeutic ("healing") touch, herbal medicine, and ayurvedic medicine)
• Naturopathy Is 99.9% Bull$hit, But Here’s What That 0.1% Can Teach Us (Zubin Damania, Medium, 2-18-18). See also Naturopathy vs. Science: Facts edition (Scott Gavura, Science-Based Medicine, 8-28-14) [To Top]

Good e-resources for patients/consumers/patient advocates and e-patients

• Kaiser Health News (best, most thorough coverage of medical news)
• PubMed (reliable information for consumers, providing good basic understanding of specific diseases, with literature searches and references to articles that provide a state of the art overview
• Essential and helpful medical links
• CAAR e-clippings (the Current Awareness in Aging Report) is designed to provide researchers, educators, and professionals in the field of aging with up-to-date information about news and internet resources that are pertinent to the field. The daily E-Clippings service provides subscribers with a daily email message that highlights important news stories related to aging--a daily snap shot of the latest news in the field (not an archive). There is also a CAAR blog. See explanations of the two at Center for Demography of Health and Aging (CDHA, at University of Wisconsin Madison)
• ePatient Dave (a voice of patient engagement). See The New Life of e-Patient Dave "In 2007, supported by an extraordinary team of family, friends, and medical staff, I stomped the snot out of a nasty cancer that was on its way to killing me. I've since learned that the way I did it has a lot in common with the advice of the "e-patients" movement, so I've changed my blogger name from Patient Dave to e-Patient Dave."
• e-patients.net (because providers can't do it alone)
• Charles Ornstein's Morning Health Reads (subscribe, Nuzzel)
• Kevin MD (doctors' voices blog, like medical Op Eds)
• On Symptom Checkers: e-Patient Dave's "A Turing Test for Diagnosis: BMJ evaluates online symptom checkers" ( BMJ 2015;351:h3480). See also Tools to diagnose symptoms online often get it wrong, study finds (Boston Globe).
• Health Net Navigation Never trust a librarian… unless you want good information.
• HealthWeb Navigator ("comprehensive reviews by medical professionals" of health websites.
• Health videos (Medline Plus)
• HealthWeb Navigator
• Medical Encyclopedia (Medline Plus)
• Medical Dictionary (Medline Plus)
• Blogs and news for science and medical writers (WritersAndEditors.com)
• Patiient Empowerment (About.com)
• New America Media (collaboration of 3,000 ethnic news organizati0ns in US) with special sections such as Paul Kleyman's Ethnic Elders or posts on Health.
• Journal of Participatory Medicine
• Empowered Patient (Elizabeth Cohen's column, CNN)
• Not Running a Hospital (Paul Levy, former CEO of a large Boston hospital, shares thoughts about hospitals, medicine, and health care issues)
• The Health Care Blog
• Blogs and news for science and medical writers (Writers and Editors)
• Geek Doctor (life as a healthcare CIO)
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For your medical reference shelf

Sometimes you can't go online. And sometimes the information is not available online. So stock at least one medical reference book. Purchases made from these links provide me a small commission.
• The Body Clock Guide to Better Health by Michael Smolensky and Lynne Lamberg
•The Cornell Illustrated Medical Encyclopedia: The Definitive Medical Home Reference Guide (Weill Cornell Health Series) by Antonio Gotto
• The Johns Hopkins Complete Home Guide to Symptoms & Remedies by Editors of The Johns Hopkins Medical Letter Health After 50
• The Johns Hopkins Consumer Guide to Medical Tests: What You Can Expect, How You Should Prepare, What Your Results Mean by Simeon Margolis
• Know Your Body: The Atlas of Anatomy by Emmet B. Keefe
• Mayo Clinic Family Health Book, 3rd edition, by the Mayo Clinic
• Mosby's Manual of Diagnostic and Laboratory Tests by Kathleen Pagana and Timothy Pagana (this is especially helpful in interpreting lab test results)

Online:
• MedlinePlus Medical Encyclopedia (National Library of Medicine) See version en espanol (Información de Salud de la Biblioteca Nacional de Medicina)
• Cochran Library (evidence-based research).
• Medical Dictionary (Web MD)
• MedTerms (Medicine.Net.com)

Many diseases and conditions are listed on this website (with links) under Coping with chronic, rare, and invisible diseases and disorders . When you reach a blog about a particular condition, look along the right side of the page and you'll usually find a "blog roll," listing other resources on the same subject. Some will provide more reliable information and insights than others, but patient-written blogs (which may certainly contain misinformation) often provide practical insights into how to live with a disease or condition (psychologically and otherwise).
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Dealing with rape and sexual assault and abuse

• National Resources for Sexual Assault Survivors and Their Loved Ones (RAINN--Rape, Abuse & Incest National Network--the nation's largest anti-sexual violence organization) An important list of resources, with links.
• What is sexual assault? (RAINN) "Rape is a form of sexual assault, but not all sexual assault is rape....The majority of perpetrators are someone known to the victim. Approximately eight out of 10 sexual assaults are committed by someone known to the victim, such as in the case of intimate partner sexual violence or acquaintance rape." RAINN answers questions about what is sexual assault, rape, and force.
• Sexual assault (WomensHealth.gov) "Sexual assault is any type of sexual activity or contact that you do not consent to. Sexual assault can happen through physical force or threats of force or if the attacker gave the victim drugs or alcohol as part of the assault. Sexual assault includes rape and sexual coercion. In the United States, one in three women has experienced some type of sexual violence.1 If you have been sexually assaulted, it is not your fault, regardless of the circumstances." Answers to many questions about sexual assault.
• An Unbelievable Story of Rape (T. Christian Miller, ProPublica and Ken Armstrong, The Marshall Project, 12-16-15) An investigative piece. Marie’s case led to changes in practices and culture.
• Why Don't Police Catch Serial Rapists? An Epidemic of Disbelief (Barbara Bradley Hagerty, The Atlantic, Aug.2019) What new research reveals about rape kits, and why police fail to catch serial rapists. Police officers continue to reflexively disbelieve women who say they've been raped. But in 49 out of every 50 rape cases, the alleged assailant goes free—often, we now know, to assault again. Previously, officers didn't bother to test rape kits in so-called acquaintance-rape cases, instances in which the victim knew the assailant. But some of these men are likely repeat offenders; testing their DNA can help solve other cases. When kits go untested, sexual predators can flourish.
• Why the Backlog Exists (End the Backlog) The backlog of untested rape kits represents the failure of the criminal justice system to take sexual assault seriously, prioritize the testing of rape kits, protect survivors, and hold offenders accountable. Here are key factors contributing to creation of the backlog.
• When Abuse Victims Commit Crimes (Victoria Law, The Atlantic, 5-21-19) New laws in New York and elsewhere could keep women out of prison for crimes against their abusers.
• ICE Detention Center Says It’s Not Responsible for Staff's Sexual Abuse of Detainees (Victoria López and Sandra Park, ACLU, 11-6-18) The Prison Rape Elimination Act was passed by Congress in 2003 to protect against sexual assault in prisons and jails across the country. It took the Department of Homeland Security until 2014 to finalize regulations implementing PREA. Immigrants in detention are put at serious risk for sexual violence while they are detained because officials are not doing enough to detect and respond to incidents of sexual abuse. The Trump administration continues to aggressively target immigrants and asylum seekers by stripping away legal protections, ramping up enforcement, and expanding immigration detention.
• ‘An Entire Community Got Together to Rape a Child’: India Recoils at Girl’s Assault (Kai Schultz and Suhasini Raj, NY times, 7-18-18) In the gated community in Chennai, India, a group of men took turns raping an 11-year-old girl.
• Here Are All the Public Figures Who’ve Been Accused of Sexual Misconduct After Harvey Weinstein (Samantha Cooney, Time, 3-27-19)
• ‘Where there is more rape culture in the press, there is more rape’ (Denise-Marie Ordway, Dart Center, 9-7-18) 'Rape occurs more often in communities where the news media reflects “rape culture” — the tone of the coverage and word choices can be interpreted as showing empathy for the accused and blame for victims, according to a new study published in the Quarterly Journal of Political Science.'
• Jesuits identify 33 Alaska clergy and volunteers ‘credibly accused’ of sexually abusing children (Kyle Hopkins, Anchorage Daily News, 12-26-18) Created by Jesuits West, a Dec. 7 report puts names, places and dates to generations of sexual abuse inflicted by ordained priests, church volunteers and employees in 35 villages and cities across Alaska. Many of the offender priests were assigned by the church to tiny Alaska communities, prompting accusations that remote villages here became dumping grounds for predators. Jesuit leaders have denied that the order used Alaska as a hiding place for pedophile clergy. See also Lawless (5-16-19) At least one in three Alaska villages has no local law enforcement. Sexual abuse runs rampant, public safety resources are scarce, and Gov. Mike Dunleavy wants to cut the budget.

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Exercise to stay fit

and a bit about dealing with back pain

• 1-Minute Workouts to Make You Stronger After 50 (Bara Vaida, AARP, 12-21-23) 5 short workouts to increase fitness and reduce risk of heart disease and cancer as you age
• #1 Exercise for Lowering Blood Pressure (Michelle Crouch, AARP, 3-1-24) This type of exercise is best for reducing blood pressure to healthy levels, according to a new study
• 5 Exercises and Stretches for Neck Pain (Bara Vaida, AARP, 4-27-23) When it comes to that nagging pain in the neck, movement and breathing can be keys to relief
• 5 Moves to prevent and relieve neck and back pain (Bara Vaida, Shots, NPR, 1-5-23) 5 specific examples of movements you can do at your desk to prevent and relieve pain.
• DeskFit: 20 Desk Exercises to do without leaving home or workspace (National Aeronautics and Space Administration, 6-10-20) Excellent illustrations. Movement can help relieve and prevent neck and back pain after spending too much time sitting.

Science shows movement works to reduce pain because it hydrates muscles and joints that become ‘sticky’ with lack of movement.
• 8 Exercises to Lose Weight (Kimberly Goad, AARP, 3-20-24) Help to support weight loss by increasing your calories burned
• 8 Exercises for Lower Back Pain Stacey Colino & Aaron Kassraie, AARP, 3-17-22) Learn the causes of lower back pain and stretches to strengthen the area.
• Simple Remedy for Back Pain (Liz Szabo, AARP, 7-11-24) Walking gave relief to hundreds of people in a large new study
• 5 Ways to Exercise Your Bones (Pamela Peeke, AARP, 12-26-23) Easy moves that can help keep your body strong
• The Best Exercises for Achy Backs, Knees, Hips and More (Hallie Levine, AARP, 2-1-19) We asked physical therapists for their pain-busting stretching and strengthening moves
• 7 Surprising Parts of the Body You Need to Exercise Regularly (Michele Wojciechowski, AARP, 1-11-22) Your arms, legs and back aren’t the only areas that need attention. Try our new workout with 12 easy moves

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Yoga for managing pain and improving health

• Yoga overview (National Center for Complementary and Integrative Health)
• 38 Health Benefits of Yoga (Timothy McCall, Yoga Journal, 8-28-07) "Each time you practice yoga, you take your joints through their full range of motion. This can help prevent degenerative arthritis or mitigate disability by "squeezing and soaking" areas of cartilage that normally aren't used. Joint cartilage is like a sponge; it receives fresh nutrients only when its fluid is squeezed out and a new supply can be soaked up. Without proper sustenance, neglected areas of cartilage can eventually wear out, exposing the underlying bone like worn-out brake pads." Here's one I've used: Yoga for back pain.
• What the Science Says About Yoga "Current research suggests that a carefully adapted set of yoga poses may reduce low-back pain and improve function. Other studies also suggest that practicing yoga (as well as other forms of regular exercise) might improve quality of life; reduce stress; lower heart rate and blood pressure; help relieve anxiety, depression, and insomnia; and improve overall physical fitness, strength, and flexibility. But some research suggests yoga may not improve asthma, and studies looking at yoga and arthritis have had mixed results." From Yoga: In Depth
• Here’s Why You Should Be Doing Toe Yoga (Alyssa Hui, VeryWell Health) "Toe yoga is focused on stretches and exercises that can make the muscles around your toes stronger and more flexible. Experts say performing toe yoga can help improve balance, flexibility, and posture, and prevent injuries like plantar fasciitis by keeping the foot flexibleAlthough performing toe yoga is appropriate for a wide range of people, those with injuries or a history of imbalance issues should consult with their podiatrist or healthcare provider first."
• The Parisian Yoga Witch Who Healed My Back (Abigail Rasminsky, Racked, 7-22-15) In which she writes about Noelle Perez-Christiaens, who developed "d'Aplomb" in her studio in Paris, based on her Yoga studies with yoga guru BKS Iyengar (how to be "on the axis").
• Can't Get Comfortable In Your Chair? Here's What You Can Do (Michaeleen Doucleff interviews Jean Couch on Shots, Morning Edition, NPR, 9-24-18) Most chairs are too deep and too soft, says Couch. There are two tricks:

#1: Sit on the front edge. Sit on the front hard part of the chair. Forget about the backrest. Be careful about how you position your legs. Your knee should be below the hip socket. Thats what happens when you're floating in space (when the muscles are most relaxed).

#2 Build a perch. Use a jacket or a pillow. Elevate your back with a wedge-shaped pillow (dense). Great for using in the car. See Couch's book, which has helped many, many people: The Runner's Yoga Book: A Balanced Approach to Fitness by Jean Couch. Do not carry all your weight in your muscles.
• Effectiveness of Iyengar yoga in treating spinal (back and neck) pain: A systematic review. (Crow EM, Jeannot E, Trewhela A, Intl J Yoga, on PubMed, Jan. 2015). "This systematic review found strong evidence for short-term effectiveness, but little evidence for long-term effectiveness of yoga for chronic spine pain in the patient-centered outcomes. "
• Health conditions benefited by yoga (Timothy McCall, MD, from Yoga as Medicine ), a list followed by links to many references.
• Western Science vs. Eastern Wisdom (PDF, Timothy McCall). See also Does Yoga Kill? Yoga, Truthiness and the New York Times, in which McCall argues against New York Times writer William Broad's claims that yoga is responsible for hundreds of strokes per year, the emotional linchpin of his yoga-wrecks-your-body arguments. About which, see next entry:
• How Yoga Can Wreck Your Body (William J. Broad, NY Times, 1-5-12) and this follow-up piece: The Healing Power of Yoga Controversy (William Broad, The 6th Floor: Eavesdropping on the Times Magazine, 1-10-13) "Yet, for all the bad news about yoga, I still see the rewards as outweighing the risks. A century and a half of science shows the benefits to be many — and the serious dangers to be few and comparatively rare."

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Gender and sexuality

Including trans, cis, LGBTQ, queer, and other terms we should understand

• What Is the Difference Between Gender and Sexuality? (Cynthia Vinney, Gender Identity, Verywell Mind, 12-21-21) "Gender is socially constructed and is a person's innermost concept of themselves as a man, woman, and/or nonbinary person. People define their gender identity in a variety of deeply personal ways that can include man or woman, but can also extend to identities such as agender, genderfluid, gender nonconforming, and a variety of others.

"Meanwhile, sexuality refers to who a person is attracted to and can include a plethora of orientations. While being gay, heterosexual, and bisexual are perhaps the most well-known sexual orientations, there are many others, such as asexual and pansexual."
• Gender, gender identity, and gender expression (MyHealth.alberta.ca) "Gender identity is your deeply-held inner feelings of whether you’re female or male, both, or neither. Your gender identity isn’t seen by others. Gender identity may be the same as the sex you were assigned at birth (cisgender) or not (transgender). Clear definitions of terms many of us are unsure about:

Transgender ("your gender identity doesn't match up with the sex you were assigned at birth")

Agender ("you don't identify with any gender")

Gender non-conforming, non-binary, and gender fluid ("you don't identify fully as a man or a boy (male, masculine) or a woman or a girl (female, feminine)."

Gender queer ("you identify or express yourself beyond what is often linked to the sex and gender you were assigned at birth").
• To understand biological sex, look at the brain, not the body (Jennifer Finney Boylan, Washington Post, 5-1-23) "This term, “biological males,” is everywhere now. And it’s not used only by right-wing politicians. People of good faith are also wrestling with the way trans people complicate a world they thought was binary. They’re uncertain about when, and how, sex matters, and just how biological it is. Some want to draw a bright line in areas where maleness and femaleness might matter most — in sports, or locker rooms, or prisons....
"It's not about chromosomes. "Because not every person with a Y chromosome is male, and not every person with a double X is female. The world is full of people with other combinations: XXY (or Klinefelter Syndrome), XXX (or Trisomy X), XXXY and so on. There’s even something called androgen insensitivity syndrome, a condition that keeps the brains of people with a Y from absorbing the information in that chromosome...."
"What's most remarkable about research into trans women's brains "is not that trans women’s brains have been found to resemble those of cisgender women, or that trans men’s brains resemble those of cis men. What the research has found is that the brains of trans people are unique: neither female nor male, exactly, but something distinct."
"All the science tells us, in the end, is that a biological male — or female — is not any one thing, but a collection of possibilities."

• Toilets, bowties, gender and me (video, Audrey Mason-Hyde, TEDxAdelaide, 1-19-18, 10:34min.) "We live in a gendered world, but for Audrey, gender is fluid at best an uncomfortable construct. Is there a way to be less reliant on gender in our interactions with people? And what does this mean when it comes to the clothes we wear, or even which toilet we choose to use? If you met Audrey Mason-Hyde, you might think Audrey was a boy, which isn’t quite correct, but calling Audrey a girl doesn’t feel quite right either."
• Style and media guides about gender identity (Writers and Editors website) Is there a right term to use (for example, "he, she, they") when talking about someone who is lesbian, gay, bisexual, transgender, queer, intersex, asexual? A guide for editors and writers looking for distinctions between terms.
• Half the World Has a Clitoris. Why Don’t Doctors Study It? (Rachel E. Gross, NY Times, 10-17-22) The organ is “completely ignored by pretty much everyone,” medical experts say, and that omission can be devastating to women’s sexual health.
• How Young Is Too Young for Sterilization? (Lisa Selin Davis, Common Sense, 9-28-22) An influential transgender advocacy group (World Professional Association for Transgender Health, or WPATH) has released new recommendations based on politics—not science. Discouraging readers from following the advice in WPATH's long-awaited update to Standards of Care for people seeking “lasting personal comfort with their gendered selves, and with a good overview of what's going on in the Gender Wars, Davis concludes:

"Decades of studies, and experience by practitioners, demonstrate that the vast majority of children with early-onset gender dysphoria outgrow this by the time they emerge from puberty—and that many of these young people grow up to be gay or bisexual. WPATH even acknowledges that “there are no reliable means of predicting an individual child’s gender evolution.” So by promoting the benefits of early social and medical intervention, WPATH advocates preventing the very process of natural physical and mental maturation that has historically resulted in the resolution of most dysphoric children’s distress." Davis is the author of Tomboy: The Surprising History and Future of Girls Who Dare to Be Different.
• What I’ve learned from having balls. (Emily Quinn, video of TEDx talk, TEDxProvidence, 10-25-19, 14:57 minutes) "Emily Quinn has balls, literally. At age 10 she found out she was intersex (that her biology isn’t strictly male or female) and she was told not to tell anyone about it. In this brave, vulnerable talk Emily shares what it’s like to carry the burden of shame while navigating a world where nobody understood her body. Her experience teaches us that bodies are a lot more diverse and complicated than we make them out to be, and leaves us with one question: what's so bad about being different?"

• Gender & Sexuality (Dr. Anne Fausto-Sterling) New ways of thinking about science and human difference. "My approach to understanding gender often challenges established norms. For example, I assert that human sexual development is not always dichotomous and that gender differences fall on a continuum, not into two separate buckets. One way to understand this is through the eyes of human beings born with anatomical characteristics of both sexes. Another is to understand how scientific understanding of the biology of sex and gender has itself been shaped by the culture which produced it."

"In 1993 I published an article titled 'The Five Sexes' that unleashed a firestorm of debate about sex and gender, with a particular focus on the intersex experience. I asserted that 'the two-sex system embedded in our society is not adequate to encompass the full spectrum of human sexuality.' I had intended to be provocative, but nevertheless was surprised by the magnitude of the controversy unleashed. At the time I suggested, tongue in cheek, a five-sex system, which I later amended in The Five Sexes Revisited. Rather than identify a specific number of sexes, in the second paper I wrote “sex and gender are best conceptualized as points in a multidimensional space.”
• The Five Sexes: Why Male and Female Are Not Enough (pdf, Anne Fausto-Sterling, Lecture Notes, Constructing categories of difference, 2000) The emerging recognition that people come in bewildering sexual varieties is testing medical values and social norms.
• The Five Sexes, Revisited (Anne Fausto-Sterling, The Sciences, July/August, 2000)
• The Five Sexes and the Five Sexes Revisited. (PDF, Summary, Jaime Browne, Resources, Writing in the Disciplines) In the articles The Five Sexes and The Five Sexes Revisited, Anne Fausto-Sterling is challenging the long held idea of the two-sex system and the heteronormativity of that construct. Fausto-Sterling proposes the five-sex system where sex is viewed as a continuum as opposed to a rigid two-sex system. She does this by showing that the arguments and assumptions made by the medical community and other members of society are faulty. She confronts the legal and state reinforcement of the parallels of man and woman because it serves their interests. The legality of the two sex system is important because it serves to inform things like draft registration and marriage decrees."
• Sexing the Body a book on the topic by Anne Fausto-Sterling
• Letter to The Sciences RE: The Five Sexes (Cheryl Chase,1993. Letters from Readers. The Sciences, July/August, 3.) Chase encourages intersexuals and those close to them to write to the The Intersex Society of North America (ISNA), "where we are assembling a support group and documenting our lives." ISNA has been replaced by InterACT (Advocates for Intersex Youth)

Suggestions about useful general articles, explanations, stories, etc. are welcome.

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Books about how healthcare professionals train, think, and act

• An Uncertain Inheritance: Writers on Caring for Family edited by Nell Casey. Wonderful writing, excellent insights into the complexities both of caring and of being cared for, during an illness.
• An Unquiet Mind by Kay Redfield Jamison (about manic depression).
• Better: A Surgeon's Notes on Performance by Atul Gawande
• Complications: A Surgeon’s Notes on an Imperfect Science by Atul Gawande
• Emergency!: True Stories From The Nation's ERs by Mark Brown
• Hot Lights, Cold Steel: Life, Death and Sleepless Nights in a Surgeon's First Years, Michael J. Collins memoir of his grueling surgical residency at the Mayo Clinic
• How Doctors Think by Jerome Groopman
• How We Die by Sherwin Nuland (excellent descriptions of exactly how the various body systems fail, when they fail -- a primer even for healthy readers)
• Illness as Metaphor: AIDS and Its Metaphors by Susan Sontag
• Intern: A Doctor's Initiation by Sandeep Jauhar
• In the Country of Hearts: Journeys in the Art of Medicine by John Stone
• Just Here Trying to Save a Few Lives: Tales of Life and Death in the ER by Pamela Grim
• Life Disrupted: Getting Real About Chronic Illness in Your Twenties and Thirties, by Laurie Edwards
• Life Support: Three Nurses on the Front Lines (The Culture and Politics of Health Care Work) by Suzanne Gordon, author of Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, And Medical Hubris Undermine Nurses And Patient Care.
• The Man Who Mistook His Wife for a Hat and Other Clinical Tales, by Oliver Sachs
• The Measure of Our Days: New Beginnings at Life's End by Jerome Groopman
• Medical Detectives, by Berton Roueche
• My Own Country: A Doctor's Story , Abraham Verghese's memoir of being a doctor during the early years of AIDS.
• On Call: A Doctor's Days and Nights in Residency by Emily R. Transue
• Pulse: Voices From the Heart of Medicine - The First Year, ed. Paul Gross and Diane Guernsey (excellent essays, poems and short narratives from the hearts and in the voices of patients and their health care providers, from the online magazine Pulse)
• Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine by Jerome Groopman
• Silence Kills: Speaking Out and Saving Lives , edited by Lee Gutkind (essays about communication failures that lead to potentially lethal medical error)
• Unholy Ghost: Writers on Depression, ed. Nell Casey
• When the Air Hits Your Brain: Tales from Neurosurgery by Frank Vertosick Jr.
• You: The Smart Patient, An Insider's Handbook for Getting the Best Treatment, by Drs. Michael F. Roizen and Mehmet C. Oz, with the Joint Commission (one of a series by the charismatic Oprah favorite, Dr. Oz, and the knowledgeable Dr. Roizen)
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Selected Works

Quick Links

Managing your health, pain, medications, and health care costs

MANAGING PAIN

MEDICAL BILLS 101

HOSPITALS, HOSPITALIZATION, and URGENT CARE

MANAGING HEALTH CARE AND HEALTH CARE COSTS

Charity Care, Transportation Assistance, and Discounted Lodging for Patients and Caregivers

Charity Care

Transportation Assistance

Discounted Lodging for Patients and Caregivers

MANAGING PAIN

Managing ordinary (not chronic) pain

Managing pain medications

Managing pain medications

Practical tips for easing or preventing specific pain (including some back pain)

Managing back pain

Managing chronic pain

Organizations associated with pain management and relief

Dental care and oral health:

What you should (and probably don't) know

Dealing with rape and sexual assault and abuse

The medical use of cannabis

HOSPITALS AND HOSPITALIZATIONWHAT YOU NEED TO KNOW

What you need to know about hospitals

RATINGS AND REPORT CARDS ON U.S. HOSPITALS, DOCTORS, AND HEALTH CARE RESOURCES

INFORMATIVE ARTICLES AND BOOKS ABOUT HOSPITALS AND HOSPITAL ISSUES

Urgent care and emergency care: what you should know (they are not the same)

EMERGENCY CARE: A Broken System? And who should pay?

Managing medical bills: hospital, emergency rooms (ER), urgent care, and "extras"

Pulling Back the Curtain on Surprise Medical Bills

HOW TO CHALLENGE EXCESSIVE MEDICAL BILLS

PROTECTING PATIENTS FROM WRONGFUL MEDICAL BILLING

Charity Care and Medical Assistance

MANAGING HEALTH CARE AND HEALTH CARE COSTS

Bill of the Month and Other Outrageous Medical Bills

Managing hospitalization and after

Hospitals and hospital systems: issues within the industry

Women's health issues

Abortion: scales tip on this divisive, embattled, politicized issue Women's rights (or not) to control their own bodies.

Women's health issues

Addressing maternal mortality in the U.S.

Rural and small-town health care

Patients sharing info and opinions about health care problems, services, and costs

Your gut and your gut microbiome

Making wise medical choices, decisions

The truth about screening tests

Basic healthcare explanations: How things (in the body) work

Vitamins, supplements, and "natural products"

Vitamin D, the sunshine vitamin

Telehealth and virtual medical visits

Complementary and alternative medicine

Good e-resources for patients/consumers/patient advocates and e-patients

For your medical reference shelf

Dealing with rape and sexual assault and abuse

Exercise to stay fit

Yoga for managing pain and improving health

Gender and sexuality

Books about how healthcare professionals train, think, and act

HOSPITALS AND HOSPITALIZATION
WHAT YOU NEED TO KNOW

Managing medical bills: hospital, emergency rooms (ER),
urgent care, and "extras"

Abortion: scales tip on this divisive, embattled, politicized issue
Women's rights (or not) to control their own bodies.

Patients sharing info and opinions about
health care problems, services, and costs