Amid contradictory laws, hospitals in one state were unable to explain policies on emergency abortion care, study finds | CNN



CNN
 — 

Oklahoma’s laws restricting abortions have created a confusing, contradictory environment that may have a chilling effect on health care, new research says.

After the US Supreme Court overturned the right to an abortion last year with the Dobbs v. Jackson Women’s Health Organization decision, several states quickly passed laws that restricted such procedures. A report released Tuesday and described in the medical journal the Lancet finds that the laws in at least one state left workers at many hospitals confused about how to proceed.

When the court made its decision, the Oklahoma law that criminalized abortion in 1910 went back into effect, according to the state’s attorney general. Lawmakers then created multiple overlapping laws that further criminalized abortion and increased penalties for those who performed or assisted in an abortion procedure, according to the new report from Physicians for Human Rights, Oklahoma Call for Reproductive Justice and the Center for Reproductive Rights.

The Oklahoma laws allow abortion in the case of a medical emergency, but one doesn’t define a medical emergency. Another says it allows for the “preservation of life in a medical emergency,” defined as causing “substantial and irreversible body of bodily impairment” – which is not a medical term, experts say.

To understand exactly how well Oklahoma hospitals understood the laws, the researchers used a “secret shopper method,” study co-author Dr. Michele Heisler said.

Researchers posed as prospective patients and called 34 hospitals to ask about the emergency pregnancy care they offered.

Heisler said that when the researchers designed the study, she expected the hospitals to tell the patients that they could get help in an emergency but that a second provider might have to sign off on an abortion or that a doctor would have to get the decision past an “onerous” hospital oversight committee.

“What we weren’t expecting is that there would be so much confusion and contradictory information and really not clear information,” said Heisler, who is medical director at Physicians for Human Rights and a professor of internal medicine and public health at the University of Michigan.

The researchers said that none of the hospitals they contacted in Oklahoma was totally able to articulate clear, consistent policies for emergency obstetric care to potential patients.

Specifically, 65% – 22 of the 34 hospitals – were unable to provide information about policies, procedures or the support provided to doctors when it is clinically necessary to terminate a pregnancy to save the life of a pregnant patient.

In 14 of the 22 cases, hospital representatives provided unclear and/or incomplete answers about whether doctors require approval to perform a medically necessary abortion.

Three of the hospitals said they do not provide abortions at all, even though it remains legal in the case of a medical emergency or to “preserve the life” of the pregnant person. Four others provided information that was factually wrong, the report says.

Four hospitals said they had formal approval processes that clinicians must go through if they have a situation in which it is medically necessary to terminate a pregnancy; they cannot make that decision on their own.

Three hospitals indicated that they have policies for these situations but refused to share any information about them.

“Unfortunately, it is being just left up to individual health systems and clinicians to try to make sense of these laws and provide guidance and support,” Heisler said.

The Oklahoma Hospital Association said it has been in conversations with Oklahoma’s medical licensure boards to seek clarity about the state’s conflicting abortion laws.

The association sent guidance to its members in September to explain what it interpreted as “saving the life of a pregnant woman” and what the laws would mean for a person made pregnant through rape or incest, among other issues. The guidance explains that the state’s criminal laws do not make an exception for these circumstances unless it is to save the life of someone who is pregnant in a medical emergency.

The guidance also warns that a person convicted of “administering, prescribing, advising, or procuring a woman to take any medicine drug or substance, or a person convicted of using or employing any instruction or ‘other means whatever,’ with the intent to procure an abortion, shall be guilty of a felony punishable by two (2) to (5) years imprisonment. From August 27, 2022, forward, a person convicted of performing or attempting to perform an abortion shall be guilty of a felony punishable by a fine not to exceed One Hundred Thousand ($100,000.00) and/or imprisonment not to exceed ten (10) years.”

The guidance says the “persons potentially liable” are the provider, not the pregnant person.

Study co-author Rabia Muqaddam, a senior staff attorney at the Center for Reproductive Rights who is working on multiple cases challenging the abortion bans in Oklahoma, called the overlapping laws a “bizarre” situation.

“Aside from the fact that there are so many of them is that they all conflict,” she said. “All of the laws have inconsistent definitions, which is where a lot of the confusion comes from for health care providers. What’s most dangerous for patients is the fact that the definitions of medical emergency and life-preserving abortions is unclear and inconsistent.”

“If I was the hospital general counsel and I was looking at these laws, I have absolutely no idea what my physician could or could not do in any particular circumstance,” she said.

When there is a lack of clarity and when penalties are involved, “what you get is massive chill.”

“Physicians are terrified. They’re terrified that if they make the wrong decision, they’re going to go to jail. They’re going to lose their license. And at the other end of that is that patients are being seriously harmed,” Muqaddam said.

Sonia M. Suter, a professor of law at George Washington University who was not involved in the new research, said recent abortion laws have created “such a mess.”

“You are telling physicians that they have two conflicting obligations,” said Suter, whose scholarship focuses on issues at the intersection of law, medicine and bioethics, with a particular focus on reproductive rights.

There is an obligation to stabilize patients in emergencies that may not always qualify as “life-threatening,” but doctors and hospitals could also risk being sued because the doctors are not following the standard of care, “which you can’t do with how some of these exceptions are worded.”

She said hospitals also don’t know how the laws will be applied. Lawyers typically will instruct institutions to interpret the law as conservatively as possible, and physicians may be equally conservative because they don’t want to risk their licenses or face stiff penalties.

“It’s just devastating for everybody,” Suter said. “It’s just cruel.”

Molly Meegan, general counsel for the American College of Obstetricians and Gynecologists, said state laws to restrict abortion with emergency exceptions are not comprehensive.

“They can’t be applied in a medical situation. They just aren’t practical,” she said. “They have an ethical and personal duty to their patients to do what is best for their patients. It can at times be in direct conflict with whatever the laws are, especially if they’re vague, and most of the ob/gyns throughout the country, including in Oklahoma, are in an impossible situation.”

Meegan and Suter both believe the confusion will lead to the deaths of more women. Those who survive may be left with dire health problems, including losing the ability to have children in the future.

“They already have horrific maternal mortality and infant mortality rates,” Suter said. “It feels like the end of evidence-based medicine.”

According to the US Centers for Disease Control and Prevention, Oklahoma persistently ranks among the states with the worst rates of maternal deaths, even before the new abortion laws went into effect. The state had a maternal mortality rate of 25.2 deaths per 100,000 live births for 2018-20, well above the national average.

For communities of color, the rate is significantly worse, according to the Oklahoma Health Department.

White women had 23.2 maternal deaths per 100,000 live births for 2018-20, the lowest rate overall in Oklahoma. The rates for Black women and Native American women were about twice as high: 49.4 and 44.4, respectively.

Oklahoma is not alone. The 13 states where most abortions are banned generally have some of the highest infant and maternal mortality rates in the country, Heisler said. Even more states could be restricting abortion access soon, the experts believe, with potentially more problems to come.

“The hostile climate many states are creating for the health care field by enacting criminal and other penalties for abortion care is an outcome whose reverberations we are only just beginning to see,” said Kelly Baden, vice president for public policy at the reproductive health nonprofit Guttmacher Institute.

Heisler noted that the researchers don’t blame the hospitals or the doctors for this confusion. Overall, she said, the staffers who talked to the researchers “were wonderful,” despite the circumstances.

“They were empathetic. They said, ‘I completely understand.’ They tried to give answers. They acted in good faith. But really, none of the hospitals were really able to say what we were hoping for, which is to unequivocally state that they would stand behind their clinicians and that clinicians at their facilities would be able to use their best clinical judgment for the individual case and that it would be made as medical decisions should be in collaboration with the patient, taking into account to their needs, their preferences and their values,” she said.

“We are recognizing that hospitals and clinicians are in an untenable situation,” Heisler added.

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The cost of senior care is rising while caregivers are ‘drowning’ without help | CNN



CNN
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For most of her life, Tammy La Barbera has been taking care of someone other than herself. First, it was her two children. Then, it was her brother and father, who both died after being diagnosed with cancer. Now, Tammy is taking care of her 90-year-old mother, Ada, who was diagnosed with dementia five years ago.

In recent months, Ada’s condition deteriorated so quickly that Tammy resigned from her job as an event manager to become a full-time caregiver.

“I don’t have help here, and I know it’s going to get worse,” she said.

Tammy, 53, struggles to provide her mother with the care she needs and would like to place her in a memory care facility equipped to handle the mood swings and outbursts that her mother has due to her condition. But Tammy says she doesn’t expect to ever have enough money to pay for that care.

Recently, she said, she looked into an assisted living facility near her home in Murrieta, California. She says placing her mother at the facility – or others like it – would cost between $7,000 and $10,000 a month out-of-pocket.

Across the country, millions of caregivers like Tammy are looking after a loved one – a relative or a friend. About 53 million US adults are caregivers, according to a 2020 report from AARP.

Sixty-three percent of US caregivers who look after adults said the person they were looking after needed care because of “long-term physical conditions,” the report says.

Since her mother’s diagnosis, Tammy’s life has been turned upside-down.

Ada cannot bathe herself or cook for herself. Most days, she doesn’t even remember who her daughter is.

“All her daily duties are done by me,” Tammy said, caring for her mother all day is like being a prisoner in her own home.

Sooner or later, she said, she will have to move her mother to a long-term care facility and do whatever she can to pay for it.

“I know that I’m reaching a crossroads with my mom’s care, and I’m trying to do this as long as I can,” Tammy said. “But I know the way things are going, and if she’s progressing pretty rapidly, I’m not going to have a choice.”

Ada La Barbera was a teacher for 20 years, so she gets a pension check each month. Tammy puts that money, along with her mother’s monthly Social Security checks, toward bills.

It’s just over $3,300 a month, and along with Tammy’s dwindling savings, it’s barely enough to keep them afloat, Tammy says. She can barely afford her rent.

It’s because of her financial struggles that Tammy has been putting off long-term care for her mother.

Where Tammy and Ada live in California, a home health aide would cost about $137 for one hour of care, according to an online calculator from AARP.

“When you’re on a fixed income, you can’t afford that,” Tammy said. “So I don’t have the luxury to do that.”

A long-term care facility is even more expensive. On average, it costs $10,830 a month to stay at a nursing home and $5,806 per month for an assisted living facility, according to the nonprofit National Investment Center for Senior Housing and Care.

Then there is memory care, where Tammy says her mother belongs.

Memory care facilities are the fastest-growing sector of the senior housing market, according to the National Investment Center. On average, memory care costs just over $7,500 a month, center COO Chuck Harry says.

These facilities offer more hands-on care for people with dementia. They can include special features like locked units that prevent wandering patients from leaving the facility unattended and enclosed outdoor spaces where patients can move about safely.

A nurse comes to see Ada at home every other week. During that 40-minute visit, Ada’s vitals are checked, and her medications are adjusted. Those visits are covered by Medicare, Tammy says.

Medicare is a medical health insurance program that is for people 65 years or older. But Medicare does not cover the cost of a long-term care facility.

And although Ada and Tammy are on a fixed income, Ada doesn’t qualify for other federal safety net programs like Medicaid because Tammy says they are not considered low-income.

For middle-income families, Medicaid goes into effect only after a family has gone through the process of “spending down” their assets until they qualify for the program.

“That is usually the path of anyone going into a nursing home for the long term: spending your own money – which is all out of pocket – and then reaching a Medicaid level of eligibility,” said Susan Reinhard, senior vice president and director of the AARP Public Policy Institute, noting that each state has its own Medicaid program and process.

Until a family qualifies for Medicaid, the program will only cover the medical costs of a stay at a long-term facility, not room and board.

Caroline Pearson, the lead author of a landmark 2019 demographic study called “The Forgotten Middle,” says most middle-income Americans find themselves in a position where they are too “wealthy” to receive Medicaid coverage for long-term care services but too “poor” to afford the out-of-pocket costs of that care.

So why does putting a loved one in a nursing home or an assisted living facility cost so much? Providing long-term care services is expensive, Pearson says, adding that the senior housing industry requires a large workforce of nurses and staff to support it. That is also expensive.

Additionally, as seniors sell their homes and move into these facilities, long-term care facilitators are essentially providing housing, she said. And housing is not cheap.

The senior housing industry also caters to a high-income population, according to Pearson, who is now executive director of the Peterson Center on Healthcare.

“The fit and finish at the buildings … [residents] expect to be really high-end. The amount of amenities and services that are part of that senior housing property … they expect to be high-end,” she said. “The market has seen good returns and then replicated that model.”

And the demand for high-quality, long-term care is only expected to go up as the baby boomer generation continues to age, according to Pearson.

“Most people don’t begin to need long-term care services until between 75 and 85. And so as the baby boomers hit those ages, that is where we’re going to see that demand really explode,” she said.

According to the US Census Bureau, baby boomers – people born from 1946 to 1964 – will all be over the age of 65 by 2030. The oldest members of that generation will be 84 at that point.

In 2019, there were about 8 million middle-income seniors – people 75 and older – living in the United States, Pearson says in her study.

She projects that there will be 14.4 million middle-income seniors in the US by 2029, with 60% expected to have mobility limitations and 20% expected to have “high health care and functional needs.”

“We are going to [have] double the number of middle-income seniors when the baby boomers age,” Pearson said. “Fewer of those baby boomers are going to have spouses or children who live nearby to provide unpaid caregiving support.”

Most family caregivers are spouses or middle-age daughters, the study notes.

At the end of the day, Pearson says, many Americans don’t think about aging until it’s staring them in the face.

“People [think] that they will live healthy and independently until they die, and sadly, that’s just statistically very unlikely for most people,” she said.

Tammy, with her parents and brother, says her family thought they were prepared for the future.

Tammy says her family thought they were prepared for the future.

In 1965, Ada married Tammy’s father, Peter “Jazz” La Barbera, an accountant.

“My dad was a very, very good saver, and he did have a little bit of savings,” Tammy said. “He was set just for the future, not for anything unexpected.”

In 1970, Tammy was born in Queens. She and her older brother, Peter Jr., grew up an hour outside New York City.

“We had a small house, and we lived in that house our whole lives, and … we were the perfect family,” Tammy said.

She eventually moved to California, where she had two kids. Her parents followed, along with her brother and his wife.

Tammy says the physical and mental toll of caring for her husband and son kickstarted Ada's health problems.

But soon after the move, Peter Jr. was diagnosed with cancer, and he died a year later. Two years after that, Tammy’s father received a cancer diagnosis and died within seven weeks.

Tammy believes that the physical and financial toll of taking care of her son and husband kickstarted her mother’s health problems. Shortly after her husband died, Ada had a minor stroke and was diagnosed with dementia.

“It’s almost like her grief was so overwhelming. Especially losing her son. I don’t think her brain had the capacity to deal with anything else anymore,” Tammy said.

The stress associated with taking care of a loved one full-time, or even part-time, can have negative consequences, research has shown.

Some of the physical symptoms associated with taking care of someone with dementia include higher levels of depression and anxiety, worse self-reported physical health, compromised immune function and increased risk of early death, the US Centers for Disease Control and Prevention reports.

Over half (53%) of caregivers indicate that a decline in their health compromises their ability to provide care, according to the CDC.

“I have sacrificed 10 years of my life being a caretaker, and I don’t have a life,” Tammy said. “It’s an honor to take care of my mother. But doing this every single day … it’s a lot.”

Tammy is preparing for her own future by taking part in genetic testing that will tell her whether she is more likely to develop dementia like her mother.

“I would like to prepare as much as I can, whether it’s medication or adjusting my life,” she said. “I just don’t want to put my kids through this.”

She would also like to see changes to the system.

Pearson says the solution to the cost issue is not simple and will probably be resolved only through a combination of incremental Medicaid expansion, changes to the senior housing industry and federal subsidies.

AARP’s Reinhard says tax credits for family caregivers could help people like Tammy get a break. Employers could also help by supporting workers who need to stop working to care for a family member or friend.

In September, the US Department of Health and Human Services, through its Administration for Community Living, announced a national strategy aimed at supporting family caregivers, highlighting nearly 350 actions the federal government will take.

The strategy also includes 150 actions that it says local governments, communities and private businesses can adopt to help build a more supportive system.

“Supporting family caregivers is an urgent public health issue, exacerbated by the long-term effects of the COVID-19 pandemic,” HHS Secretary Xavier Becerra said in a news release. “This national strategy recognizes the critical role family caregivers play in a loved one’s life.”

Gal Wettstein, a senior research economist for the Center for Retirement Research at Boston College, says it would be beneficial for middle-income Americans to speak to a financial adviser as early as possible and transfer assets to a family member if they think they might need to enter a long-term care facility in the near future.

This way, if their only option is to spend down their assets to become eligible for Medicaid, they hit that eligibility sooner.

Long-term care insurance is another option, but experts say it’s rarely sold anymore because it is typically more expensive than other kinds of insurance.

Pearson says Americans can plan ahead by investing in long-term care insurance in their 40s for it to benefit them when they will most likely need it, in their 80s.

Wettstein also recommends long-term care insurance.

“[Long-term care insurance] plans are getting harder and harder to sign, but they do still exist. Some insurers will still sell them,” he said.

Ultimately, covering the cost of senior care comes down to families and how much they save for the future, until changes are made by senior housing providers and policy makers.

“We are so far away from having any sort of swift and universal solution,” Pearson said.

For now, Ada is on a waitlist for a spot at a skilled-nursing home about an hour from where they live. If she moves there, her cost of living might be partially covered through a Medicaid program.

Tammy was told that Ada is one of more than 2,000 people waiting for a spot.

“We’re drowning. We’re care workers, and we’re drowning,” Tammy said. “We don’t have help.”

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Maternity units are closing across America, forcing expectant mothers to hit the road | CNN



CNN
 — 

In picturesque Bonner County, Idaho, Leandra Wright, 40, is pregnant with her seventh child.

Wright is due in August, but three weeks ago, the hospital where she had planned to deliver, Bonner General Health, announced that it would be suspending its labor and delivery services in May.

Now, she’s facing a potentially precarious drive to another hospital 45 minutes from her home.

“It’s frustrating and worrisome,” Wright said.

Wright has a history of fast labors. Her 15-year-old son, Noah, was born on the way to the hospital.

“My fifth child was born on the side of the highway,” Wright said. “It was wintertime, and my hospital at the time in California was about 40 minutes away, and the roads were icy, so we didn’t make it in time.”

By the time she and Noah got to the hospital, about 15 minutes after he was born, his body temperature was lower than normal.

“It worries me not to have a doctor there and worries me to have to go through that,” Wright said.

Residents of Bonner County aren’t the only ones dealing with unexpected maternity unit closures.

Since 2011, 217 hospitals in the United States have closed their labor and delivery departments, according to a report by the health care consulting firm Chartis.

A CNN tally shows that at least 13 such closures have been announced in the past year alone.

Services provided at maternity units vary from hospital to hospital. Most offer obstetrics care in which an obstetrician will deliver a baby, either vaginally or via cesarean section. These units also provide perinatal care, which is medical and supportive care before and after delivery.

Other services provided may include lactation specialists and private delivery rooms.

After May 19, Bonner General Health will no longer offer obstetrical services, meaning there will be zero obstetricians practicing there. Consequently, the hospital will no longer deliver babies. Additionally, the unit will no longer provide 24-hour anesthesia support or post-resuscitation or pre-transportation stabilization care for critically ill newborns.

Some hospitals that have recently closed their maternity units still offer perinatal care, along with routine gynecological care.

Bonner General is planning to establish a clinic where perinatal care will be offered. Gynecological services – such as surgical services, preventative care, wellness exams and family planning – will still be provided at a nearby women’s health clinic.

The Chartis report says that the states with the highest loss of access to obstetrical care are Minnesota, Texas, Iowa, Kansas and Wisconsin, with each losing more than 10 facilities.

Data released last fall by the infant and maternal health nonprofit March of Dimes also shows that more than 2.2 million women of childbearing age across 1,119 US counties are living in “maternity care deserts,” meaning their counties have no hospitals offering obstetric care, no birth centers and no obstetric providers.

Maternity care deserts have been linked to a lack of adequate prenatal care or treatment for pregnancy complications and even an increased risk of maternal death for a year after giving birth.

Money is one reason why maternity units are being shuttered.

According to the American Hospital Association, 42% of births in the US are paid for by Medicaid, which has low reimbursement rates. Employer-sponsored insurance pays about $15,000 for a delivery, and Medicaid pays about $6,500, according to the Health Care Cost Institute, a nonprofit that analyzes health care cost and utilization data.

“Medicaid funds about half of all births nationally and more than half of births in rural areas,” said Dr. Katy Kozhimannil, a public health researcher at the University of Minnesota who has conducted research on the growing number of maternity care deserts.

Kozhimannil says communities that are most likely to be affected by maternity unit closures tend to be remote towns in rural counties in states with “less generous Medicaid programs.”

Hospitals in larger cities are often able to offset low reimbursement rates from Medicaid births with births covered by employer-sponsored insurance, according to Dr. Sina Haeri, a maternal-fetal medicine specialist and CEO of Ouma Health, a company that provides virtual prenatal and perinatal care to mothers living in maternity care deserts.

Many large hospitals also have neonatal intensive care units.

“If you have a NICU, that’s a substantial revenue generator for a hospital,” Haeri said.

Most rural hospitals do not have a NICU, only a nursery where they care for full-term, healthy babies, he said. Due to that financial burden, it does not make financial sense for many rural hospitals to keep labor and delivery units open.

A low volume of births is another reason for the closures.

In announcing the closure, Bonner General noted that in 2022, it delivered just 265 babies, which the hospital characterized as a significant decrease.

Rural hospital administrators providing obstetric care say it takes at least 200 births annually for a unit to remain safe and financially viable, according to a study led by Kozhimannil for the University of Minnesota’s Rural Health Research Center.

Many administrators surveyed said they are working to keep units open despite low birth rates.

“Of all the folks that we surveyed, about a third of them were still operating, even though they had fewer than 200 births a year,” Kozhimannil said. “We asked why, and they said, ‘because our community needs it.’ ”

Another issue for hospital administrators is staffing and recruitment.

The decision to close Bonner General’s labor and delivery unit was also directly affected by a lack of experienced, qualified doctors and nurses in the state, said Erin Binnall, a Bonner General Health spokesperson.

“After May 19th, Bonner General Health will no longer have reliable, consistent pediatric coverage to manage neonatal resuscitations and perinatal care. Bonner General’s number one priority is patient safety. Not having board-certified providers certified in neonatal resuscitation willing to provide call and be present during deliveries makes it unsafe and unethical for BGH to provide these services,” Binnall told CNN by email.

The American Hospital Association acknowledges the staffing challenges some hospitals face.

“Simply put, if a hospital cannot recruit and retain the providers, nurses, and other appropriately trained caregivers to sustainably support a service then it cannot provide that care,” the association said in a statement. “Such challenges are only magnified in rural America, where workforce strain is compounded by aging demographics that in some communities has dramatically decreased demand for services like Labor and Delivery.”

Wright is considering moving because of the lack of maternity and pediatric care available in Bonner County.

More stringent abortion laws may be playing a role in the closures, too.

Bonner General said in a news release last month that due to Idaho’s “legal and political climate, highly respected, talented physicians are leaving. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

According to the Guttmacher Institute, Idaho has one of the strictest anti-abortion laws in the country: a complete ban that has only a few exceptions.

Idaho requires an “affirmative defense,” Guttmacher says, meaning a provider “has to prove in court that an abortion met the criteria for a legal exception.”

No matter the reason, Kozhimannil said, closures in rural communities aren’t just a nuisance. They also put families at risk.

“That long drive isn’t just an inconvenience. It actually is associated with health risks,” she said. “The consequence that we saw is an increase in preterm births. Preterm birth is the largest risk factor for infant mortality. It is a huge risk factor for developmental and cognitive delays for kids.”

Haeri says the decline in maternal care also has a clear effect on maternal mortality rates.

The maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births in the US, compared with rates of 20.1 in 2019 and 23.8 in 2020, according to a report from the National Center for Health Statistics. In raw numbers, 1,205 women died of maternal causes in the US in 2021.

Conditions such as high blood pressure, obesity, and diabetes may raise a person’s risk of complications, as can being pregnant with multiples, according to the National Institutes of Health. Pregnant women over the age of 35 are at a higher risk of pre-eclampsia.

As labor and delivery units continue to shut their doors, possible solutions to the growing problem are complex, Haeri says.

“I think anyone that comes to you and says the current system is working is lying to you,” he said. “We all know that the current maternity system is not good.”

Kozhimannil’s research has found that many women who live in maternity care deserts are members of minority communities.

“When we conducted that research, we found the communities that were raising the alarm about this … tended to be Black and indigenous, or tribal communities in rural places,” she said. “Black communities in the South and East and tribal communities throughout the country, but especially in the West, Mountain West and Midwest.”

Haeri says one possible solution is at a woman’s fingertips.

“I always say if a woman’s got a cell phone, she should have access,” he said.

A 2021 study found that women who live in remote areas of the US could benefit from telehealth visits, which would decrease the number of “in-person prenatal care visits and increase access to care.”

The American College of Obstetricians and Gynecologists recommends 12 to 14 prenatal care appointments for women with low-risk pregnancies, and the study suggests that expansion of prenatal telehealth appointments could help women living in remote areas better adhere to those guidelines.

Ouma works with mothers who are typically remote and high-risk, Haeri says.

He also believes that promoting midwifery and doula services would help bolster maternity care in the US.

Certified nurse midwives often assist remote mothers who are high-risk or who decide to give birth at home, he says.

Midwives not only deliver babies, they often work with medical equipment and can administer at-home physical exams, prescribe medications, order lab and diagnostic tests, and assess risk management, according to the American College of Nurse Midwives. Doulas – who guide mothers through the birthing process – are often present at home births and even hospital births.

“That midwifery model shines when it comes to maternal care. [And] doula advocacy involvement leads to better outcomes and maternity care, and I think as a system, we haven’t made it easier for those two components to be really an integral part of our maternity care in the US,” Haeri said.

After living in Idaho for 10 years, Wright says, she and her fiancé have considered leaving the state. The lack of maternity and pediatric care at Bonner General Health is a big reason why.

“I feel safe being with [my] doctors. Now, I have to get to know a doctor within a couple of months before my next baby is born,” Wright said.

As she awaits the arrival of her new son, she feels doubtful that there is a solution for mothers like her.

“Everywhere – no matter what – everybody has babies,” she said. “It’s posing a problem for people who have babies who don’t have the income to drive or have high risk pregnancies or first-time mothers who don’t even know what to expect.”

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Pediatric hospital beds are in high demand for ailing children. Here’s why | CNN



CNN
 — 

Effie Schnacky was wheezy and lethargic instead of being her normal, rambunctious self one February afternoon. When her parents checked her blood oxygen level, it was hovering around 80% – dangerously low for the 7-year-old.

Her mother, Jaimie, rushed Effie, who has asthma, to a local emergency room in Hudson, Wisconsin. She was quickly diagnosed with pneumonia. After a couple of hours on oxygen, steroids and nebulizer treatments with little improvement, a physician told Schnacky that her daughter needed to be transferred to a children’s hospital to receive a higher level of care.

What they didn’t expect was that it would take hours to find a bed for her.

Even though the respiratory surge that overwhelmed doctor’s offices and hospitals last fall is over, some parents like Schnacky are still having trouble getting their children beds in a pediatric hospital or a pediatric unit.

The physical and mental burnout that occurred during the height of the Covid-19 pandemic has not gone away for overworked health care workers. Shortages of doctors and technicians are growing, experts say, but especially in skilled nursing. That, plus a shortage of people to train new nurses and the rising costs of hiring are leaving hospitals with unstaffed pediatric beds.

But a host of reasons building since well before the pandemic are also contributing. Children may be the future, but we aren’t investing in their health care in that way. With Medicaid reimbursing doctors at a lower rate for children, hospitals in tough situations sometimes put adults in those pediatric beds for financial reasons. And since 2019, children with mental health crises are increasingly staying in emergency departments for sometimes weeks to months, filling beds that children with other illnesses may need.

“There might or might not be a bed open right when you need one. I so naively just thought there was plenty,” Schnacky told CNN.

The number of pediatric beds decreasing has been an issue for at least a decade, said Dr. Daniel Rauch, chair of the Committee on Hospital Care for the American Academy of Pediatrics.

By 2018, almost a quarter of children in America had to travel farther for pediatric beds as compared to 2009, according to a 2021 paper in the journal Pediatrics by lead author Dr. Anna Cushing, co-authored by Rauch.

“This was predictable,” said Rauch, who has studied the issue for more than 10 years. “This isn’t shocking to people who’ve been looking at the data of the loss in bed capacity.”

The number of children needing care was shrinking before the Covid-19 pandemic – a credit to improvements in pediatric care. There were about 200,000 fewer pediatric discharges in 2019 than there were in 2017, according to data from the US Department of Health and Human Services.

“In pediatrics, we have been improving the ability we have to take care of kids with chronic conditions, like sickle cell and cystic fibrosis, and we’ve also been preventing previously very common problems like pneumonia and meningitis with vaccination programs,” said Dr. Matthew Davis, the pediatrics department chair at Ann & Robert H. Lurie Children’s Hospital of Chicago.

Pediatrics is also seasonal, with a typical drop in patients in the summer and a sharp uptick in the winter during respiratory virus season. When the pandemic hit, schools and day cares closed, which slowed the transmission of Covid and other infectious diseases in children, Davis said. Less demand meant there was less need for beds. Hospitals overwhelmed with Covid cases in adults switched pediatric beds to beds for grownups.

As Covid-19 tore through Southern California, small hospitals in rural towns like Apple Valley were overwhelmed, with coronavirus patients crammed into hallways, makeshift ICU beds and even the pediatric ward.

Only 37% of hospitals in the US now offer pediatric services, down from 42% about a decade ago, according to the American Hospital Association.

While pediatric hospital beds exist at facilities in Baltimore, the only pediatric emergency department in Baltimore County is Greater Baltimore Medical Center in Towson, Maryland, according to Dr. Theresa Nguyen, the center’s chair of pediatrics. All the others in the county, which has almost 850,000 residents, closed in recent years, she said.

The nearby MedStar Franklin Square Medical Center consolidated its pediatric ER with the main ER in 2018, citing a 40% drop in pediatric ER visits in five years, MedStar Health told CNN affiliate WBAL.

In the six months leading up to Franklin Square’s pediatric ER closing, GBMC admitted an average of 889 pediatric emergency department patients each month. By the next year, that monthly average jumped by 21 additional patients.

“Now we’re seeing the majority of any pediatric ED patients that would normally go to one of the surrounding community hospitals,” Nguyen said.

In July, Tufts Medical Center in Boston converted its 41 pediatric beds to treat adult ICU and medical/surgical patients, citing the need to care for critically ill adults, the health system said.

In other cases, it’s the hospitals that have only 10 or so pediatric beds that started asking the tough questions, Davis said.

“Those hospitals have said, ‘You know what? We have an average of one patient a day or two patients a day. This doesn’t make sense anymore. We can’t sustain that nursing staff with specialized pediatric training for that. We’re going to close it down,’” Davis said.

Registered nurses at Tufts Medical Center hold a

Saint Alphonsus Regional Medical Center in Boise closed its pediatric inpatient unit in July because of financial reasons, the center told CNN affiliate KBOI. That closure means patients are now overwhelming nearby St. Luke’s Children’s Hospital, which is the only children’s hospital in the state of Idaho, administrator for St. Luke’s Children’s Katie Schimmelpfennig told CNN. Idaho ranks last for the number of pediatricians per 100,000 children, according to the American Board of Pediatrics in 2023.

The Saint Alphonsus closure came just months before the fall, when RSV, influenza and a cadre of respiratory viruses caused a surge of pediatric patients needing hospital care, with the season starting earlier than normal.

The changing tide of demand engulfed the already dwindling supply of pediatric beds, leaving fewer beds available for children coming in for all the common reasons, like asthma, pneumonia and other ailments. Additional challenges have made it particularly tough to recover.

Another factor chipping away at bed capacity over time: Caring for children pays less than caring for adults. Lower insurance reimbursement rates mean some hospitals can’t afford to keep these beds – especially when care for adults is in demand.

Medicaid, which provides health care coverage to people with limited income, is a big part of the story, according to Joshua Gottlieb, an associate professor at the University of Chicago Harris School of Public Policy.

“Medicaid is an extremely important payer for pediatrics, and it is the least generous payer,” he said. “Medicaid is responsible for insuring a large share of pediatric patients. And then on top of its low payment rates, it is often very cumbersome to deal with.”

Pediatric gastroenterologist Dr. Howard Baron visits with a patient in 2020 in Las Vegas. A large portion of his patients are on Medicaid with reimbursement rates that are far below private insurers.

Medicaid reimburses children’s hospitals an average of 80% of the cost of the care, including supplemental payments, according to the Children’s Hospital Association, a national organization which represents 220 children’s hospitals. The rate is far below what private insurers reimburse.

More than 41 million children are enrolled in Medicaid and the Children’s Health Insurance Program, according to Kaiser Family Foundation data from October. That’s more than half the children in the US, according to Census data.

At Children’s National Hospital in Washington, DC, about 55% of patients use Medicaid, according to Dr. David Wessel, the hospital’s executive vice president.

“Children’s National is higher Medicaid than most other children’s hospitals, but that’s because there’s no safety net hospital other than Children’s National in this town,” said Wessel, who is also the chief medical officer and physician-in-chief.

And it just costs more to care for a child than an adult, Wessel said. Specialty equipment sized for smaller people is often necessary. And a routine test or exam for an adult is approached differently for a child. An adult can lie still for a CT scan or an MRI, but a child may need to be sedated for the same thing. A child life specialist is often there to explain what’s going on and calm the child.

“There’s a whole cadre of services that come into play, most of which are not reimbursed,” he said. “There’s no child life expert that ever sent a bill for seeing a patient.”

Low insurance reimbursement rates also factor into how hospital administrations make financial decisions.

“When insurance pays more, people build more health care facilities, hire more workers and treat more patients,” Gottlieb said.

“Everyone might be squeezed, but it’s not surprising that pediatric hospitals, which face [a] lower, more difficult payment environment in general, are going to find it especially hard.”

Dr. Benson Hsu is a pediatric critical care provider who has served rural South Dakota for more than 10 years. Rural communities face distinct challenges in health care, something he has seen firsthand.

A lot of rural communities don’t have pediatricians, according to the American Board of Pediatrics. It’s family practice doctors who treat children in their own communities, with the goal of keeping them out of the hospital, Hsu said. Getting hospital care often means traveling outside the community.

Hsu’s patients come from parts of Nebraska, Iowa and Minnesota, as well as across South Dakota, he said. It’s a predominantly rural patient base, which also covers those on Native American reservations.

“These kids are traveling 100, 200 miles within their own state to see a subspecialist,” Hsu said, referring to patients coming to hospitals in Sioux Falls. “If we are transferring them out, which we do, they’re looking at travels of 200 to 400 miles to hit Omaha, Minneapolis, Denver.”

Inpatient pediatric beds in rural areas decreased by 26% between 2008 and 2018, while the number of rural pediatric units decreased by 24% during the same time, according to the 2021 paper in Pediatrics.

Steve Inglish, left, and registered nurse Nikole Hoggarth, middle, help a father with his daughter, who fell and required stiches, inside the emergency department at Jamestown Regional Medical Center in rural North Dakota in 2020.

“It’s bad, and it’s getting worse. Those safety net hospitals are the ones that are most at risk for closure,” Rauch said.

In major cities, the idea is that a critically ill child would get the care they need within an hour, something clinicians call the golden hour, said Hsu, who is the critical care section chair at the American Academy of Pediatrics.

“That golden hour doesn’t exist in the rural population,” he said. “It’s the golden five hours because I have to dispatch a plane to land, to drive, to pick up, stabilize, to drive back, to fly back.”

When his patients come from far away, it uproots the whole family, he said. He described families who camp out at a child’s bedside for weeks at a time. Sometimes they are hundreds of miles from home, unlike when a patient is in their own community and parents can take turns at the hospital.

“I have farmers who miss harvest season and that as you can imagine is devastating,” Hsu said. “These aren’t office workers who are taking their computer with them. … These are individuals who have to live and work in their communities.”

Back at GBMC in Maryland, an adolescent patient with depression, suicidal ideation and an eating disorder was in the pediatric emergency department for 79 days, according to Nguyen. For months, no facility had a pediatric psychiatric bed or said it could take someone who needed that level of care, as the patient had a feeding tube.

“My team of physicians, social workers and nurses spend a significant amount of time every day trying to reach out across the state of Maryland, as well as across the country now to find placements for this adolescent,” Nguyen said before the patient was transferred in mid-March. “I need help.”

Nguyen’s patient is just one of the many examples of children and teens with mental health issues who are staying in emergency rooms and sometimes inpatient beds across the country because they need help, but there isn’t immediately a psychiatric bed or a facility that can care for them.

It’s a problem that began before 2020 and grew worse during the pandemic, when the rate of children coming to emergency rooms with mental health issues soared, studies show.

Now, a nationwide shortage of beds exists for children who need mental health help. A 2020 federal survey revealed that the number of residential treatment facilities for children fell 30% from 2012.

“There are children on average waiting for two weeks for placement, sometimes longer,” Nguyen said of the patients at GBMC. The pediatric emergency department there had an average of 42 behavioral health patients each month from July 2021 through December 2022, up 13.5% from the same period in 2017 to 2018, before the pandemic, according to hospital data.

When there are mental health patients staying in the emergency department, that can back up the beds in other parts of the hospital, creating a downstream effect, Hsu said.

“For example, if a child can’t be transferred from a general pediatric bed to a specialized mental health center, this prevents a pediatric ICU patient from transferring to the general bed, which prevents an [emergency department] from admitting a child to the ICU. Health care is often interconnected in this fashion,” Hsu said.

“If we don’t address the surging pediatric mental health crisis, it will directly impact how we can care for other pediatric illnesses in the community.”

Dr. Susan Wu, right, chats with a child who got her first dose of the Pfizer-BioNtech Covid-19 vaccine at Children's Hospital Arcadia Speciality Care Center in Arcadia, California, in 2022.

So, what can be done to improve access to pediatric care? Much like the reasons behind the difficulties parents and caregivers are experiencing, the solutions are complex:

  • A lot of it comes down to money

Funding for children’s hospitals is already tight, Rauch said, and more money is needed not only to make up for low insurance reimbursement rates but to competitively hire and train new staff and to keep hospitals running.

“People are going to have to decide it’s worth investing in kids,” Rauch said. “We’re going to have to pay so that hospitals don’t lose money on it and we’re going to have to pay to have staff.”

Virtual visits, used in the right situations, could ease some of the problems straining the pediatric system, Rauch said. Extending the reach of providers would prevent transferring a child outside of their community when there isn’t the provider with the right expertise locally.

  • Increased access to children’s mental health services

With the ongoing mental health crisis, there’s more work to be done upstream, said Amy Wimpey Knight, the president of CHA.

“How do we work with our school partners in the community to make sure that we’re not creating this crisis and that we’re heading it off up there?” she said.

There’s also a greater need for services within children’s hospitals, which are seeing an increase in children being admitted with behavioral health needs.

“If you take a look at the reasons why kids are hospitalized, meaning infections, diabetes, seizures and mental health concerns, over the last decade or so, only one of those categories has been increasing – and that is mental health,” Davis said. “At the same time, we haven’t seen an increase in the number of mental health hospital resources dedicated to children and adolescents in a way that meets the increasing need.”

Most experts CNN spoke to agreed: Seek care for your child early.

“Whoever is in your community is doing everything possible to get the care that your child needs,” Hsu said. “Reach out to us. We will figure out a way around the constraints around the system. Our number one concern is taking care of your kids, and we will do everything possible.”

Nguyen from GBMC and Schimmelpfennig from St. Luke’s agreed with contacting your primary care doctor and trying to keep your child out of the emergency room.

“Anything they can do to stay out of the hospital or the emergency room is both financially better for them and better for their family,” Schimmelpfennig said.

Knowing which emergency room or urgent care center is staffed by pediatricians is also imperative, Rauch said. Most children visit a non-pediatric ER due to availability.

“A parent with a child should know where they’re going to take their kid in an emergency. That’s not something you decide when your child has the emergency,” he said.

Jaimie and Effie Schnacky now have an asthma action plan after the 7-year-old's hospitalization in February.

After Effie’s first ambulance ride and hospitalization last month, the Schnacky family received an asthma action plan from the pulmonologist in the ER.

It breaks down the symptoms into green, yellow and red zones with ways Effie can describe how she’s feeling and the next steps for adults. The family added more supplies to their toolkit, like a daily steroid inhaler and a rescue inhaler.

“We have everything an ER can give her, besides for an oxygen tank, at home,” Schnacky said. “The hope is that we are preventing even needing medical care.”

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Insurance requirements for prior authorization may prompt ‘devastating’ delays | CNN

When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.

Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.

“Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”

Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.

Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.

In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.

Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.

Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.

Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.

The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.

“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”

Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.

Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.

It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.

“I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”

Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.

“It’s a terrible system,” she said.

A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.

Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.

Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.

When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.

“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.

When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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A childbirth myth is spreading on TikTok. Doctors say the truth is different | CNN



CNN
 — 

Ashley Martinez has four sons and is pregnant with the daughter she’s wanted for years.

Last month, she posted a video online imploring doctors to prioritize her life, not the life of her unborn baby, if complications arise when she is in labor and it comes down to that choice.

The San Antonio, Texas, resident is due in May and is one of a number of pregnant people who have recently posted “living will” videos on TikTok.

Martinez had an emergency C-section during her last pregnancy after her umbilical cord came out before her baby, a rare but dangerous condition known as an umbilical cord prolapse that can deprive a baby of vital blood flow and oxygen.

Martinez described her last delivery as terrifying. Eight months after the Supreme Court reversed Roe v. Wade, ending a constitutional right to abortion, she said she worries about what would happen if she faced similar challenges again.

Since the ruling in June, a number of US states have criminalized abortions, leading to some fears that doctors would prioritize the life of the unborn child during a medical emergency.

Martinez lost her mother to non-Hodgkin’s lymphoma at a young age, and the thought of her children going through a similar tragedy terrifies her.

“Having to go into another delivery where I’m going to have a C-section, it’s scary for me,” said the 29-year-old. “My fourth pregnancy was my only C-section. I’ve always thought about not being here for my kids just because of what I went through growing up without my mom.”

More than a dozen US states have banned or severely restricted access to abortions following the Supreme Court’s decision eight months ago. The abortion bans have led to legal chaos as advocates take the fight to courtrooms.

Even so, several ob/gyns told CNN that a hard choice between saving a mother and baby’s lives at childbirth, like the one outlined in the TikTok videos, is highly unlikely.

This trend on TikTok has sparked a flurry of dueling videos among pregnant women and other people. Some have posted videos telling doctors in such situations to prioritize their unborn babies first, and criticizing those who expressed a different view.

Martinez concedes that her mother, who died at 25, would likely have chosen to save her child first if she could.

“My mother, she didn’t have a choice, you know?” Martinez said. “The message that I want to send is just basically nobody is wrong or right in this situation. In both situations, it is a hard decision to pick your children over your unborn baby.”

In Texas, where Martinez lives, abortions are banned at all stages of pregnancy – unless there’s a life-threatening medical emergency.

Dr. Franziska Haydanek, an ob/gyn in Rochester, New York, who shares medical advice on TikTok, said she’s noticed many “living will” videos in recent months.

In most of the videos, a woman appears alongside a written message saying something like, “If there are complications during childbirth, save me before the baby.” Some people, including Martinez, reference their children in their decision and even show them in the video.

One was posted by Tuscany Gunter, 22, a woman whose baby is due in April. Abortion after 20 weeks of pregnancy is illegal in her home state of North Carolina, and Gunter told CNN she filmed her message in solidarity with others who said they would choose themselves first.

“I wanted to make it known where I stand and to stand up with other women who are getting bashed online for saying they would rather be saved first over their baby,” said Gunter, who lives in Fayetteville.

“As a mother to three young children, I cannot dump the emotional trauma of losing their mother on them as children and expect them to cope. While I would be crushed to lose a baby, I need to think of my other living children as well … And I know the baby that passed would be safe without ever having to experience any pain or sadness.”

Another woman, Leslie Tovar of Portland, Oregon, said that even though her state has no legal restrictions on abortion, she posted her video because she feared doctors would prioritize saving her unborn child to avoid legal ramifications in the post-Roe v. Wade era.

“I have two other kids at home who need mom. I can’t bear the thought of my two young boys ages 6 and 4 without their mom,” she said.

All three women said they’ve had these conversations with their partners, who agreed they should be saved first.

Of her husband, Tovar said, “His exact words were, ‘We could always have another baby later in life but there is never replacing the mother of my boys, I couldn’t do this without you.’”

It’s true that complications occasionally come up during a pregnancy that lead doctors to recommend delivery to save the mother’s life, medical experts said.

If this is done before a fetus is viable – under 24 weeks – the chances of the baby’s survival are low, said Dr. Elizabeth Langen, a maternal-fetal medicine physician at the University of Michigan Von Voigtlander Women’s Hospital.

Roe v. Wade’s reversal did make terminating such pregnancies more complicated, Langen and Haydanek say.

In cases involving a baby that’s not viable, it could mean that even when the baby is unlikely to survive and the mom’s health is at risk, the priority will be on saving the baby due to fear of legal ramifications, Langen said.

But both doctors say these scenarios don’t occur during the birth of a viable baby. In that instance, Roe v. Wade is “less involved,” Haydanek said.

“We do everything in our efforts to save both (mother and baby),” she said. “I can’t think of a time where the medical team has had to make a decision about who to save in a viable laboring patient. It’s just not a real scenario in modern medicine – just one we are seeing played out on TV.”

Hospitals have enough resources – obstetrics and neonatal intensive care unit teams, for example – to meet the needs of both the mother and the baby, Haydanek and Langen said.

“We’re usually doing our best to take care of both the mom and the baby. And there’s very rarely a circumstance where we will do something to harm the mom in order to have the benefit of the baby,” added Langen.

“If mom’s health is deteriorating, ultimately, she’s not going to be able to support baby’s wellbeing,” Langen said. “And so generally, what we encourage folks to do is really support mom’s health, because that’s in the best interest of both mother and baby.”

Abortion rights demonstrators hold signs outside the US Supreme Court in Washington after the court overturned Roe v. Wade in June 2022.

Both doctors said it’s important for patients to talk to their health care providers about their medical concerns and share their “living will” wishes with loved ones in case there are complications during labor that require partners to make medical decisions.

However, those decisions will not involve doctors asking your partner whose life should come first, they said.

“Before getting in a fight with your partner about who they choose to save, know that there isn’t a situation where we will ask them that,” said Haydanek, who has called the TikTok trend “horribly anxiety inducing.”

She said it’s come up so many times in recent months that she made her own TikTok video to reassure expectant parents.

“Please don’t feel like you have to make this choice,” she says in the video. “I know firsthand how much anxiety there can be in pregnancy … but it’s just not a situation that you’re gonna find yourself in.”

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Almost half of children who go to ER with mental health crisis don’t get the follow-up care they need, study finds | CNN

Editor’s Note: If you or someone you know is struggling with suicidal thoughts or mental health matters, please call the 988 Suicide and Crisis Lifeline, or visit the hotline’s website.



CNN
 — 

Every night that Dr. Jennifer Hoffmann works as an attending physician in the pediatric ER, she says, at least one child comes in with a mental or behavioral health emergency. Over the span of her career, she’s seen the number of young people needing help grow enormously.

“The most common problems that I see are children with suicidal thoughts or children with severe behavior problems, where they may be a risk of harm to themselves or others,” said Hoffmann, who works at Ann & Robert H. Lurie Children’s Hospital of Chicago. “We’re also seeing younger children, especially since the pandemic started. Children as young as 8, 9 or 10 years old are coming to the emergency department with mental health concerns.

“It’s just mind-blowing.”

The surge of children turning up in emergency departments with mental health issues was a challenge even before 2020, but rates soared during the Covid-19 pandemic, studies show.

ER staffers may be able to stabilize a child in a mental health care crisis, but research has shown that timely follow-up with a provider is key to their success long-term. Unfortunately, there just doesn’t seem to be enough of it, according to a new study co-authored by Hoffmann. Without the proper follow-up, these children too often wound up back in the ER.

For their study, published Monday in the journal Pediatrics, Hoffmann and her co-authors looked at records for more than 28,000 children ages 6 to 17 who were enrolled in Medicaid and had at least one trip to the emergency department between January 2018 and June 2019. They found that less than a third of the children had the benefit of an outpatient mental health visit within seven days of being discharged from the ER. A little more than 55% had a follow-up within 30 days.

Research has shown that follow-up with a mental health care provider lowers a person’s suicide risk, raises the chances that they will take their prescription medicine and decreases the chances that they will make repeated trips to the ER.

The new study found that without a follow-up, more than a quarter of the children had to go back to the ER for additional mental health care within six months of their initial visit.

“The emergency department is a safety net. It’s always open, but there’s limited extent to the types of mental health services we can provide in that setting,” Hoffmann said. “This really speaks to inadequate access to services that these kids need.”

This dynamic can be “devastating” for parents and emergency department staff alike, she said.

“We know what a child needs, but we’re just not able to schedule follow-up due to shortages among the mental health profession. They’re widespread across the US,” she said.

A lack of professional help is a problem for many children. Before the Covid-19 pandemic, the US Centers for Disease Control and Prevention found that 1 in 5 children had a mental health disorder, but only about 20% got care from a mental health provider.

Children’s mental health has become such a concern in the US that the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in 2021.

Hoffmann’s study found that Black children fared worse than their peers. They were 10% less likely to have timely follow-up than White children – “which is very concerning, given that there are many disparities in access to care in our mental health system,” Hoffmann said.

The study can’t pinpoint why there is this racial disparity, but Hoffmann thinks there may be a few factors at play.

Black children are more likely to live in neighborhoods that have shortages of mental health professionals. There is also limited diversity among the mental health work force. Studies show that nearly 84% of psychologists are White, as are nearly 65% of counselors and more than 60% of social workers. And Black children more often rely on school-based mental health services, studies show.

Although the number of school counselors has been increasing over the years, few schools meet the National Association of School Psychologists’ recommended ratio of one school psychologist to 500 students. The national ratio for the 2021-22 school year was 1,127 to 1, the association found.

The new study found that the children who did not have mental health help before their ER visits had the most difficulty finding timely care afterward.

Dr. Toni Gross, chief of the Emergency Department at Children’s Hospital New Orleans, said she wasn’t entirely surprised by the study findings. Her hospital’s beds for with mental health concerns are “always busy,” she said.

“I’m well aware of the fact that we need more providers for these services. We deal with it every day,” said Gross, who was not involved in the new research.

The lack of providers who can do follow-up is a real source of concern. It’s not ideal to hand a phone number to a parent and hope they can arrange care, she said. It often takes weeks or even months to get a first appointment with a child and adolescent psychiatrist.

“It leaves a lot of us feeling like we wish we could do more,” Gross said. “When you always leave asking yourself at the end of the day, ‘did I really do what I set out to do, and that is to help people,’ it’s one of our biggest frustrations, and it may be one of the biggest reasons people in my group of physicians feel burnout.”

Like many children’s hospitals, hers has an active partnership with local school health programs that can provide some mental health care.

Hoffmann said that the amount of support varies by emergency department. Lurie has 24/7 coverage by mental health workers who can do an evaluation and provide recommendations for appropriate care, but not all areas do. For example, many rural emergency rooms don’t have pediatric mental health providers and may have few resources in the community, if any.

Several US counties have no practicing child and adolescent psychiatrists. Primary care physicians can help, but some patients would benefit from more specialized care, Hoffmann said.

President Joe Biden’s administration announced in August that plans to make it easier for millions of children to get access to mental health services by allowing schools to use Medicaid dollars to hire additional school counselors and social workers. He even mentioned the issue in his State of the Union address Tuesday.

But even more will need to be done. Hoffmann hopes her study will prompt policy-makers to invest more so children can access care no matter where they live. Investing in telehealth could also bridge the gap, she said, as would increasing Medicaid reimbursement rates for mental health services and more funding to pay for people to train to work with children as a mental health professional.

In a commentary published alongside the new study, the authors say their research shows that the US “is not meeting the behavioral health needs of our young people.”

“EDs are the last stop when all else has failed, and they, too, lack the resources to support, or even discharge, these patients,” the commentary says.

It points out that research has found this lack of access as far back as 2005.

“This new analysis adds to the overwhelming evidence that there is an urgent need for a dramatic change in our pediatric mental health care system,” the commentary says. “We believe it is time for a ‘child mental health moonshot,’ and call on the field and its funders to come together to launch the next wave of bold mental health research, for the benefit of these children and their families who so desperately need our support.”

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First on CNN: HHS secretary sends letter to state governors on what’s to come when Covid-19 public health emergency ends | CNN



CNN
 — 

Plans are moving forward at the US Department of Health and Human Services to prepare for the end of the nation’s Covid-19 public health emergency declaration in May.

On Thursday, HHS Secretary Xavier Becerra sent a letter and fact sheet to state governors detailing what exactly the end of the emergency declaration will mean for jurisdictions and their residents.

“Addressing COVID-19 remains a significant public health priority for the Administration, and over the next few months, we will transition our COVID-19 policies, as well as the current flexibilities enabled by the COVID-19 emergency declarations, into improving standards of care for patients. We will work closely with partners including state, local, Tribal, and territorial agencies, industry, and advocates, to ensure an orderly transition,” Becerra wrote in a draft of the letter obtained by CNN.

“In the coming days, the Centers for Medicare & Medicaid Services (CMS) will also provide additional information, including about the waivers many states and health systems have adopted and how they will be impacted by the end of the COVID-19 PHE,” he wrote. “I will share that resource with your team when available.”

Declaring a public health emergency in the United States means that certain actions, access to funds, grants, waivers and data – among other steps – can happen more quickly in response to the crisis for the duration of the emergency. A declaration lasts 90 days – unless HHS ends it – and may be renewed.

On January 30, the White House announced its intention to end the Covid-19 national and public health emergencies on May 11, signaling that the administration considers the nation to have moved out of the emergency response phase.

Becerra had agreed to give governors a 60-day notice to prepare for the end of the emergency. Thursday’s letter was sent 90 days ahead of the emergency’s planned end.

“We are having ongoing conversations about what else we need to do in the next 90 days to ensure a smooth transition. I can tell you that every one of our agencies has been working hard on this plan,” an HHS official told CNN. “We’re going to have a series of additional materials that will go out, as well as a series of conversations over the coming days and weeks.”

The end of the public health emergency will affect some Medicare and state Medicaid flexibilities provided for the duration of the emergency. This includes waivers like the requirement for a three-day hospital stay before Medicare will cover care at a skilled nursing facility.

“We’ve been working closely with the governors on the public health emergency. This is a combination of both federal flexibilities that we allow, and the states are often the ones who are using those flexibilities,” the HHS official said.

“Just about every aspect of the pandemic response, I would say, has been in partnership with our state partners. And so, I think they have been, frankly for months now, the ones that we have been going to and the ones that we publicly committed to notifying in advance of changes to the public health emergency declaration.”

But the emergency’s end will not impact the authorizations of Covid-19 devices, including tests, vaccines and treatments that have been authorized for emergency use by the US Food and Drug Administration.

During the Covid-19 pandemic, the FDA has issued about 15 times as many emergency use authorizations as it did for all other previous public health emergencies, Commissioner Dr. Robert Califf said Wednesday in a joint hearing of the House Oversight and Investigations and Health subcommittees.

“Today, we’ve issued EUAs or provided traditional marketing authorizations to over 2,800 medical devices for Covid-19, which is 15 times more EUAs than all other previous emergencies combined,” Califf said. He added that the effects of the end of the emergency declaration will be “modest” because the “EUAs are independent of the public health emergency, so we can keep them going as long as we need to.”

The emergency is slated to end May 11. “What happens on May 12? On May 12, you can still walk into a pharmacy and get your bivalent vaccine,” Dr. Ashish Jha, the White House’s coronavirus response coordinator, wrote on Twitter last week.

He said that at some point, probably in the summer or early fall, the Biden administration will transition from federal distribution of Covid-19 vaccines and treatments to purchases through the regular health care system – but that’s not happening quite yet.

Overall, there are additional Medicaid waivers and other flexibilities that states and territories have received under the public health emergency. Some of those will be terminated. But state Medicaid programs will have to continue covering Covid-19 testing, treatments, and vaccinations without cost-sharing through September 30, 2024.

The end of the public health emergency declaration means Medicare beneficiaries will face out-of-pocket costs for over-the-counter home Covid-19 tests and treatment. However, people with Medicare will continue to have no cost for medically necessary lab-conducted Covid-19 tests ordered by their health care providers.

Covid-19 vaccinations will continue to be covered at no cost for all Medicare beneficiaries.

Those with private insurance could face charges for lab tests, even if they are ordered by a provider, according to the Kaiser Family Foundation. Vaccinations will continue to be free for those with private insurance who go to in-network providers, but going to an out-of-network providers could incur charges once federal supplies run out.

And the privately insured will not be able to get free at-home tests from pharmacies and retailers anymore unless their insurers choose to cover them.

Americans with private insurance have not been charged for monoclonal antibody treatment since they were prepaid by the federal government, though patients may be charged for the office visit or administration of the treatment, according to Kaiser. But that is not tied to the public health emergency, and the free treatments will be available until the federal supply is exhausted. The government has already run out of some of the treatments so those with private insurance may already be picking up some of the cost.

The uninsured had been able to access no-cost testing, treatments and vaccines through a different pandemic relief program. However, the federal funding ran out in the spring of 2022, making it more difficult for those without coverage to obtain free services.

Also, the “ability of health care providers to safely dispense controlled substances via telemedicine without an in-person interaction is affected; however, there will be rulemaking that will propose to extend these flexibilities,” according to the letter’s fact sheet.

One of the most meaningful pandemic enhancements for states is no longer tied to the public health emergency. Congress severed the connection in December as part of its fiscal year 2023 government funding package, which state Medicaid officials had urged lawmakers to do.

States will now be able to start processing Medicaid redeterminations and disenrolling residents who no longer qualify, starting April 1. They have 14 months to review the eligibility of their beneficiaries.

As part of a Covid-19 relief package passed in March 2020, states were barred from kicking people off Medicaid during the public health emergency in exchange for additional federal matching funds. Medicaid enrollment has skyrocketed to a record 91 million people since then.

A total of roughly 15 million people could be dropped from Medicaid when the continuous enrollment requirement ends, according to an analysis the Department of Health and Human Services released in August. About 8.2 million folks would no longer qualify, but 6.8 million people would be terminated even though they are still eligible, the department estimated.

Many who are disenrolled from Medicaid, however, could qualify for other coverage.



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