Like other residents, she got an unwelcome surprise in October 2022 at a public forum held by the Environmental Protection Agency at the historic Monumental Baptist Church, known for its role in the civil rights movement. The EPA notified the predominantly Black community that Sterilization Services of Tennessee 鈥攚hich began operations in the brick building in the 1970s 鈥� had been emitting unacceptably high levels of ethylene oxide, a toxic gas commonly used to disinfect medical devices.

Airborne emissions of the colorless gas can increase the , including breast cancer. Sims, who is 59 and Black, said she developed breast cancer in 2019, despite having no family history of it, and she suspects ethylene oxide was a contributing factor.

“I used to be outside a lot. I was in good health. All of a sudden, I got breast cancer,” she said.

Local advocates say the emissions are part of a pattern of environmental racism. The term is often applied when areas populated primarily by racial and ethnic minorities and members of low-socioeconomic backgrounds, like southwest Memphis, are burdened with a disproportionate amount of health hazards.

The drivers of environmental racism include the promise of tax breaks for industry to locate a facility in a heavily minority community, said Malini Ranganathan, an urban geographer at American University in Washington, D.C. The cheaper cost of land also is a factor, as is the concept of NIMBY 鈥� or “not in my backyard” 鈥� in which power brokers steer possible polluters to poorer areas of cities.

A manager at Sterilization Services’ corporate office in Richmond, Virginia, declined to answer questions from 素人色情片Health News. An attorney with Leitner, Williams, Dooley & Napolitan, a law firm that represents the company, also declined to comment. Sterilization Services, in a legal filing asking for an ethylene oxide-related lawsuit to be dismissed, said the use of the gas, which sterilizes about half the medical devices in the U.S., is highly regulated to ensure public safety.

Besides southwest Memphis, there are nearly two dozen locales, mostly small cities 鈥� from Athens, Texas, to Groveland, Florida, and Ardmore, Oklahoma 鈥� where the EPA said in 2022 that plants sterilizing medical devices emit the gas at unusually high levels, potentially increasing a person’s risk of developing cancer.

The pollution issue is so bad in southwest Memphis that even though Sterilization Services planned to close shop by April 30, local community leaders have been hesitant to celebrate. In a letter last year to a local Congress member, the company said it has always complied with federal, state, and local regulations. The reason for its closure, it said, was a problem with renewing the building lease.

But many residents see it as just one small win in a bigger battle over environmental safety in the neighborhood.

“It’s still a cesspool of pollution,’’ said Yolonda Spinks, of the environmental advocacy organization Memphis Community Against Pollution, about a host of hazards the community faces.

The air in this part of the city has long been considered dangerous. An spews a steady plume of white smoke. A coal plant, which is now closed, leaked components of coal ash, such as arsenic, into the ground and groundwater, according to from the Tennessee Valley Authority. The TVA is proposing to gut an existing gas plant and replace turbines in the facility with new ones.聽A continual stream of heavy trucks chug along nearby highways and roads. Other transportation sources of air pollution include the Memphis International Airport and barge traffic on the nearby Mississippi River.

Lead contamination is also a concern, not just in drinking water but in the soil from now-closed lead smelters, said , a professor of environmental health at the University of Memphis. Almost all the heavy industry in Shelby County 鈥� and the associated pollutants 鈥� are located in southwest Memphis, Jia added.

Sources of pollution are often “clustered in particular communities,” said Darya Minovi, a senior analyst with the Union of Concerned Scientists, a nonprofit that advocates for environmental justice. When it comes to sterilizing facilities that emit ethylene oxide, areas inhabited largely by Black, Hispanic, low-income, and non-English-speaking people are disproportionately exposed, the group has found.

Four sites that the EPA labeled high-risk are in low-income areas of Puerto Rico. Seven sterilizer plants operate in that U.S. territory.

The EPA, responding to public concerns and to deepened scientific understanding of the hazards of ethylene oxide, recently released rules that the agency said would greatly reduce emissions of the toxic gas from sterilizing facilities.

KeShaun Pearson, who was born and raised in south Memphis and has been active in fighting environmental threats, said he is frustrated that companies with dangerous emissions are allowed to create “toxic soup” in minority communities.

In the area where the sterilization plant is located, 87% of the residents are people of color, and, according to the Southern Environmental Law Center, life expectancy there is about 10 years lower than the average for the county and state. The population within 5 miles of the sterilizer plant is mostly low-income, according to the Union of Concerned Scientists.

Pearson was part of Memphis Community Against the Pipeline, a group formed in 2020 to stop a crude oil pipeline that would have run through Boxtown, a neighborhood established by emancipated slaves and freedmen after the signing of the Emancipation Proclamation of 1863.

That campaign, which received public support from former Vice President Al Gore and actress-activist Jane Fonda, succeeded. After the ethylene oxide danger surfaced in 2022, the group changed the last word of its name from “pipeline” to “pollution.”

Besides breast and lymphoid cancers, animal studies have linked inhaling the gas to tumors of the brain, lungs, connective tissue, uterus, and mammary glands.

Last year, with the help of the Southern Environmental Law Center, the south Memphis community group urged the Shelby County Health Department to declare the ethylene oxide situation a public health emergency and shut down the sterilizing plant. But the health department said the company had complied with its existing air permit and with the EPA’s rules and regulations.

A health department spokesperson, Joan Carr, said Shelby County enforces EPA regulations to ensure that companies comply with the federal Clean Air Act and that the agency has five air monitoring stations around the county to detect levels of other pollutants.

When the county and the Tennessee Department of Health did a cancer cluster study in 2023, the agencies found no evidence of the clustering of high rates of leukemia, non-Hodgkin lymphoma, or breast or stomach cancer near the facility. There were “hot and cold spots” of breast cancer found, but the study said it could not conclude that the clusters were linked to the facility.

Scientists have criticized the study’s methodology, saying it did not follow the Centers for Disease Control and Prevention’s recommendations for designing a cancer cluster investigation.

Meanwhile, several people have sued the sterilizing company, claiming their health has been affected by the ethylene oxide emissions. In a lawsuit seeking class-action status, Reginaé Kendrick, 21, said she was diagnosed with a brain tumor at age 6. Chemotherapy and radiation have stunted her growth, destroyed her hair follicles, and prevented her from going through puberty, said her mother, Robbie Kendrick.

In response to proposed stricter EPA regulations, meanwhile, the Tennessee attorney general helped lead 19 other state AGs in urging the agency to “forgo or defer regulating the use of EtO by commercial sterilizers.”

Sims said she’s glad her neighborhood will have one less thing to worry about once Sterilization Services departs. But her feelings about the closure remain tempered.

“Hope they don’t go to another residential area,” she said.

[Clarification: This article was updated at 3:15 p.m. ET on May 1, 2024, to specify which substances leaked into the ground and groundwater and what changes will occur related to the Tennessee Valley Authority’s activities in Shelby County, Tennessee.]

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It’s also how much she spent on her monthly internet bill before the federal Affordable Connectivity Program stepped in and covered her payments.

“When you have low income and you are living on disability and your daughter’s disabled, every dollar counts,” said Westman, who lives in rural Illinois.

More than low-income households 鈥� urban, suburban, rural, and tribal 鈥� are enrolled in the federal discount program Congress created in 2021 to bridge the nation’s digital connectivity gap. The program has provided $30 monthly subsidies for internet bills or $75 discounts in tribal and high-cost areas.

But the program is expected to run out of money in April or May, according to the Federal Communications Commission. In January, FCC Chairwoman Jessica Rosenworcel to allocate $6 billion to keep the program running until the end of 2024. She said the subsidy gives Americans the “internet service they need to fully participate in modern life.”

The importance of high-speed internet was seared into the American psyche by scenes of children sitting in parking lots and outside fast-food restaurants to attend school online during the covid-19 pandemic. During that same period, health care providers and patients like Westman say, being connected also became a vital part of today’s health care delivery system.

Westman said her internet connection has become so important to her access to health care she would sell “anything that I own” to stay connected.

Westman, 43, lives in the small town of Eureka, Illinois, and has been diagnosed with genetic and immune system disorders. Her 12-year-old daughter has cerebral palsy and autism.

She steered the $30 saved on her internet toward taking care of her daughter, paying for things such as driving 30 minutes west to Peoria, Illinois, for two physical therapy appointments each week. And with an internet connection, Westman can access online medical records, and whenever possible she uses telehealth appointments to avoid the hour-plus drive to specialty care.

“It’s essential for me to keep the internet going no matter what,” Westman said.

Expanding telehealth is a common reason health care providers around the U.S. 鈥� in states such as Massachusetts and Arkansas 鈥� joined efforts to sign their patients up for the federal discount program.

“This is an issue that has real impacts on health outcomes,” said Alister Martin, an emergency medicine physician at Massachusetts General Hospital. Martin realized at the height of the pandemic that patients with means were using telehealth to access covid care. But those seeking in-person care during his ER shifts tended to be lower-income, and often people of color.

“They have no other choice,” Martin said. “But they probably don’t need to be in the ER action.” Martin became and later created a nonprofit that he said has helped 1,154 patients at health centers in Boston and Houston enroll in the discount program.

At the University of Arkansas for Medical Sciences, a federal grant was used to conduct dozens of outreach events and help patients enroll, said Joseph Sanford, an anesthesiologist and the director of the system’s Institute for Digital Health & Innovation.

“We believe that telehealth is the great democratization to access to care,” Sanford said. New enrollment in the discount program .

Leading up to the enrollment halt, Sen. Peter Welch (D-Vt.) led a bipartisan effort to introduce the Affordable Connectivity Program Extension Act in January. The group requested $7 billion 鈥� more than the FCC’s ask 鈥� to keep the program funded. “Affordability is everything,” Welch said.

In December, federal regulators recipients and found that 22% reported no internet service before, and 72% said they used their ACP-subsidized internet to “schedule or attend healthcare appointments.”

Estimates of how many low-income U.S. households qualify for the program vary, but experts agree that only about half of the roughly 50 million eligible households have signed on.

“A big barrier for this program generally was people don’t know about it,” said Brian Whitacre, a professor and the Neustadt chair in the Department of Agricultural Economics at Oklahoma State University.

Whitacre and others said rural households should be signing up at even higher rates than urban ones because a higher percentage of them .

Yet, people found signing up for the program laborious. Enrollment was a two-step process. Applicants were required to get approved by the federal government then work with an internet service provider that would apply the discount. The government application was online 鈥� hard to get to if you didn’t yet have internet service 鈥� though applicants could try to find a way to download a version, print it, and submit the application by mail.

When Frances Goli, the broadband project manager for the Shoshone-Bannock Tribes in Idaho, began enrolling tribal and community members at the Fort Hall Reservation last year, she found that many residents did not know about the program 鈥� even though it had been approved more than a year earlier.

Goli and Amber Hastings, an AmeriCorps member with the University of Idaho Extension Digital Economy Program, spent hours helping residents through the arduous process of finding the proper tribal documentation required to receive the larger $75 discount for those living on tribal lands.

“That was one of the biggest hurdles,” Goli said. “They’re getting denied and saying, come back with a better document. And that is just frustrating for our community members.”

Of the more than 200 households Goli and Hastings aided, about 40% had not had internet before.

In the tribal lands of Oklahoma, said Sachin Gupta, director of government business and economic development at internet service provider Centranet, years ago the funding may not have mattered.

“But then covid hit,” Gupta said. “The stories I have heard.”

Elders, he said, reportedly “died of entirely preventable causes” such as high blood pressure and diabetes because they feared covid in the clinics.

“It’s really important to establish connectivity,” Gupta said. The end of the discounts will “take a toll.”

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Do you have experience with ACA plan-switching or a related enrollment issue you’d like to share? to tell your story.

Unauthorized enrollment or plan-switching is emerging as a serious challenge for the ACA, also known as Obamacare. Brokers say the ease with which rogue agents can get into policyholder accounts in the 32 states served by the federal marketplace plays a major role in the problem, according to an investigation by 素人色情片Health News.

Indeed, armed with only a person’s name, date of birth, and state, a licensed agent can access a policyholder’s coverage through the federal exchange or its direct enrollment platforms. It’s harder to do through state ACA markets, because they often require additional information.

“It’s rampant. It’s horrible,” said Ronnell Nolan, president of , a nonprofit trade association representing independent insurance brokers.

The growing outcry from agents who have had their clients switched by rivals 鈥� which can steer monthly commissions to the new agent 鈥� casts a shadow on what otherwise has been a record year for ACA enrollment. More than 21 million people signed up for 2024 coverage.

Federal regulators are aware of the increase in unauthorized switching and say they have taken steps to combat it. It’s unclear, though, if these efforts will be enough.

On Feb. 26, the Centers for Medicare & Medicaid Services sent a “plan switch update” to industry representatives acknowledging “a large number” of 2024 cases and outlining some of its technical efforts to resolve problems when complaints are lodged.

“CMS is committed to protecting consumers in the marketplace,” said Jeff Wu, deputy director for policy for CMS’ Center for Consumer Information & Insurance Oversight, in a written statement to 素人色情片Health News.

His office refused to provide details on how many complaints it has seen or the number of agents it has sanctioned but his statement said when action is taken, CMS reports it to state insurance departments, whose authority includes revoking licenses.

Wu did not answer specific questions about whether two-factor authentication or other safeguards would be added to the federal website, though he wrote that CMS is “actively considering further regulatory and technological solutions to some of these problems.”

In June, that require brokers to get policyholders’ written or recorded verbal consent before making changes, although brokers said they are rarely asked for those documents.

Finding Out the Hard Way

Some unwitting enrollees, like Michael Debriae, a restaurant server who lives in Charlotte, North Carolina, not only end up in plans they didn’t choose but also bear a tax burden.

That happens when enrollees are signed up for coverage that includes premium tax credits paid by the government to insurers, even though the enrollee is ineligible, either because their income was misstated by the broker making the switch, or they had job-based insurance, like Debriae.

Unbeknownst to him, an agent in Florida with whom he had never spoken enrolled him in an ACA plan in March 2023. It was two months after he canceled his Obamacare coverage because he was able to get health insurance through his job. In June, he discovered he had a new ACA policy when his longtime pharmacy said it could not fill a 90-day prescription, which it had done with no problem in the past.

“That’s when I realized something horribly wrong had happened,” said Debriae.

Debriae got contact information for the Florida broker, but when he called, the office said the agent no longer worked there. He filed a complaint with the federal marketplace and canceled the plan. But he still owed the IRS part of the $2,445 in premium tax credits paid to the insurer from March until July on his behalf.

To be sure, some switches could be legitimate, when enrollees choose a different broker or plan. And agents do have a vested interest in raising the issue. They lose out on commissions when their clients are switched by other agents. But brokers whose clients have been switched through unauthorized transactions say the real losers are consumers.

“People literally losing their plans is fraud, absolute fraud, not a squabble between agents,” said Leslie Shields, an insurance broker in Fort Worth, Texas.

Patients’ new plans might not include their doctors or might come with higher deductibles than their former coverage. Because the agent on the policy is generally switched, too, enrollees don’t know whom to call for help.

“You have surgeries that can’t happen, providers that can’t be seen, or have been changed,” said Shields. “, but now it’s literally the worst I’ve seen.”

Ease of access to policyholders’ accounts on the federal marketplace is a double-edged sword, agents say: It aids enrollment, but also makes it easier to switch plans without consent.

“Those bad eggs now have access to all this private information about an individual,” including household income, Social Security numbers, and dependents, said Joshua Brooker, a broker who follows the issue closely as chair of a marketplace committee for the , a trade group.

Complaints gained momentum during the most recent open enrollment period, agents say. One worker in a government office that helps oversee operations of the federal exchange told 素人色情片Health News of personally handling more than 1,200 complaints about unauthorized switches or enrollments in the past three months, averaging about 20 a day. About 30 co-workers are working on similar complaints. It can take multiple days to resolve the most urgent cases, and two to four weeks for those deemed less urgent, the worker said.

Florida, Georgia, and Texas appear to be plan-switching hotbeds, agents say. Florida and Texas officials referred questions to federal regulators. Bryce Rawson, press secretary for the Georgia Department of Insurance, says the state saw no switching complaints last year and has about 30 so far in 2024, a small number but one it is taking seriously: “It’s still an active and ongoing investigation.”

By contrast, states that run their own marketplaces 鈥� there are 18 and the District of Columbia that do 鈥� have been more successful in thwarting such efforts because they require more information before a policy can be accessed, Brooker said.

In Colorado, for example, customers create accounts on the state’s online market and can choose which brokers have access. Pennsylvania has a similar setup. California sends a one-time password to the consumer, who then gives it to the agent before any changes can be made.

Adding such safeguards to healthcare.gov could slow the enrollment process. Federal regulators are “trying to thread a needle between making sure people can get access to coverage and also providing enough of a barrier to capture anyone who is coming in and acting nefariously,” said Brooker.

How Does It Happen?

Many people have no idea how they were targeted, agents say.

Jonathan Kanfer, a West Palm Beach, Florida, agent, suspects names and lists of potential clients are being circulated to agents willing to bend the rules. He said his agency has lost 700 clients to switching.

The agents doing the switching “don’t care about the people,” Kanfer said, only the money, which can amount to a monthly commission of roughly $20 to $25 per enrollee.

“Two weeks ago, someone telemarketed me, gave me a number to call to get leads for Obamacare,” said Kanfer, who turned down the offer. The person told him: “You don’t even have to speak with the people.”

Online or is a way some outfits troll for prospects, who then end up on lists sold to brokers or are contacted directly by agents. Such lists are not illegal. The problem is the ads are often vague, and consumers responding may not realize the ads are about health insurance or might result in their policies being changed. Such ” worth up to $6,400, often implying the money can help with groceries, rent, or gas. Some do mention “zero-dollar” health insurance.

Yet agents say the ads are misleading because the “subsidies” are actually the premium tax credits many people who enroll in ACA plans are eligible for, based on their income.

“They’re portraying it like it’s money going into your pocket,” said Lauren Jenkins, who runs an insurance brokerage in Coweta, Oklahoma, and has seen about 50 switching cases in recent months. But the money goes to insurers to offset the price of the new plan 鈥� which the consumer may not have wanted.

Ambetter Health 鈥� a division of Centene that offers ACA plans in more than two dozen states 鈥� sent email alerts to brokers in September and November. One noted a jump in complaints “stemming from misleading advertisements.” Another warned of “termination actions” against bad actors and directed agents not to collect consumer information or consent via “online forms or social media ads.”

In response to the switching, Ambetter also instituted a “lock” on policies starting at midnight on Dec. 31, meaning the agent on the policy by that deadline would remain on it for all of 2024, according to an email the insurer sent to brokers.

Results are mixed.

Adam Bercowicz, a licensed independent broker in Fort Lauderdale, Florida, said he and his staff worked New Year’s Eve, monitoring their client lists and watching as some were switched before their eyes.

“If I saw one of my clients was stolen from me at, let’s say, 11:57 p.m., I put myself back on,” said Bercowicz, who estimates he’s had 300 to 400 policies overtaken by other agents not connected to his staff in recent months. “And by 11:58 鈥� a minute later 鈥� they were already switched back.”

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

Al menos uno de los proyectos de ley es tan extremo como para proponer que se considere delito que una persona transgénero entre en una instalación que no coincida con el sexo indicado en su acta de nacimiento.

El debate ha estado surgiendo en las legislaturas estatales de todo el país en los últimos meses, especialmente en estados conservadores y rurales, incluida una audiencia del Comité de Servicios Humanos y de Salud del Senado de Arizona en febrero.

Los defensores de la de ese estado, que define “hombre”, “mujer” y otros términos a través de definiciones rígidas de sexo biológico, argumentaron que los derechos de las mujeres están en juego. Los opositores estuvieron en desacuerdo y dijeron que el lenguaje eliminaría a las personas transgénero de los estatutos y removería sus protecciones legales.

El proyecto de ley establece que Arizona puede proporcionar “entornos separados por sexo” para hombres y mujeres, incluidos atletismo, instalaciones para adultos mayores, vestuarios, baños, refugios para víctimas de violencia doméstica y centros de crisis por agresión sexual, lo que significa que se podría prohibir a las mujeres transgénero entrar en esos espacios destinados para mujeres.

Los investigadores han encontrado que las mujeres transgénero a una tasa casi cuatro veces mayor que las mujeres cisgénero.

La última serie de propuestas, como la de Arizona, amplía una ola anterior de “proyectos de ley sobre baños”, cuya meta era restringir el acceso de las personas transgénero a baños públicos y vestuarios. En algunos casos, las leyes propuestas se extenderían mucho más allá del acceso a las instalaciones al excluir a las personas transgénero de las leyes estatales contra la discriminación y dictar la composición de los equipos deportivos.

Expertos en leyes dicen que los nuevos proyectos de ley ponen a los estados en riesgo de violar las leyes federales contra la discriminación, lo que podría poner en peligro miles de millones de dólares en fondos federales para estados y centros de crisis que reciben subvenciones federales.

Al menos un estado 鈥� Utah 鈥� eliminó líneas que mencionaban específicamente refugios y otras instalaciones similares debido a preocupaciones sobre perder estos fondos.

Además del proyecto de ley aprobado en Utah, legisladores presentaron proyectos de ley similares en Idaho, Georgia, Arizona, Nuevo México, Iowa y West Virginia.

Las medidas reflejan un proyecto de ley modelo creado por el Independent Women’s Law Center, una organización sin fines de lucro conservadora que busca reescribir las leyes estatales basadas en el sexo asignado al nacer.

El año pasado, Kansas, Nebraska, Oklahoma y Montana aprobaron versiones de este聽 fueron a través de órdenes ejecutivas o legislaciones. Un proyecto de ley similar también fue por la senadora Cindy Hyde-Smith (republicana de Mississippi) y la representante Debbie Lesko (republicana de Arizona).

聽Jennifer Braceras, vicepresidenta de asuntos legales y fundadora del Independent Women’s Law Center, testificó a favor de la propuesta en Arizona.

“Los estadounidenses comunes saben que una mujer es una hembra humana adulta”, dijo Braceras, refiriéndose a la definición en el proyecto de ley de que una hembra es “un individuo que tiene, tuvo, tendrá o tendría, de no ser por una anomalía del desarrollo o un accidente, el sistema reproductivo que en algún momento produce óvulos”.

Dijo a los legisladores estatales que los activistas buscan convencer a jueces y a otros que los hombres que se identifican como mujeres tienen derecho ilimitado a entrar en espacios de mujeres y dijo que la política es una herramienta para restringir ese acceso.

Braceras agregó que solo porque la legislación modelo no incluya el género en sus definiciones, eso no prohíbe que los legisladores estatales decidan incluirlo en sus leyes. Los defensores conservadores de la legislación enfatizan la diferencia entre sexo y género, diciendo que el primero es un hecho biológico inmutable y el segundo un conjunto de normas culturales.

La estrecha definición de sexo y las disposiciones que declaran que ciertos espacios deben protegerse como “entornos de un solo sexo”, incluidos refugios para víctimas de violencia doméstica y centros de crisis por agresión sexual en algunas versiones estatales de la política, plantean preguntas sobre el cumplimiento de las leyes federales que prohíben la discriminación basada en el sexo o el género.

Anya Marino, directora de igualdad LGBTQI en el National Women’s Law Center, dijo que si un tribunal encontrara que estos estatutos están en desacuerdo con las leyes federales, la ley federal que garantiza protección sobre la base de género prevalecería sobre las leyes estatales.

Más allá de cómo podrían interpretarse o implementarse las leyes, Marino expresó preocupación por otras consecuencias que pueden tener estos debates, incluida la violencia contra personas que “no cumplen con una visión extremista idealista de cómo deberían ser los sexos”, dijo.

“Es parte de un objetivo más amplio de controlar a las personas a través de la vigilancia corporal para determinar cómo aman y cómo navegan en su vida diaria”, opinó.

聽Sin embargo, las ramificaciones legales no están claras. En Montana, donde una de estas propuestas después de que se aprobara la SB 458 durante la sesión del año pasado, los legisladores de violar potencialmente la ley federal y perder miles de millones en financiamiento.

Los analistas fiscales legislativos del estado determinaron que se ponían en juego $7.5 mil millones en fondos federales en el primer año, dependiendo de cómo las agencias estatales implementaran la ley y si esas acciones se consideraban violaciones de las leyes contra la discriminación.

A pesar de todo esto, el proyecto de ley fue aprobado de todos modos y fue firmado por el gobernador republicano Greg Gianforte.

Está pendiente un del estatuto. De todos modos, el Departamento de Salud Pública y Servicios Humanos de Montana (DPHHS) citó la aprobación de la ley como justificación para resucitar una norma que prohíbe a las personas transgénero cambiar la designación de sexo en su acta de nacimiento.

Esta prohibición fue instituida originalmente en 2022 y fue anulada por un juez antes de que se aprobara la nueva ley. “

El DPHHS debe seguir la ley, y nuestra agencia, en consecuencia, procesará las solicitudes para modificar los marcadores de sexo en los certificados de nacimiento según nuestra regla final de 2022”, dijo el director del departamento, Charlie Brereton, en un comunicado del 20 de febrero anunciando el cambio.

Los legisladores en Utah eliminaron el lenguaje que identificaba específicamente a los refugios para víctimas de violencia doméstica y los centros de crisis por agresión sexual como espacios “designados por sexo” que podrían excluir a las personas transgénero después de escuchar sobre la pérdida de fondos federales.

Aunque los legisladores eliminaron la mención de esos lugares específicos en el proyecto de ley, mantuvieron disposiciones que prohíben que las personas transgénero ingresen a baños, duchas públicas o vestuarios designados por sexo que no correspondan con su sexo asignado al nacer a menos que su acta de nacimiento haya sido modificada o hayan pasado por una cirugía de afirmación de género en consecuencia.

El proyecto de ley fue acelerado, aprobado y firmado por el gobernador republicano Spencer Cox dos semanas después que comenzara la sesión legislativa. Más recientemente, los legisladores de West Virginia eliminaron el lenguaje del que nombraba a los refugios para víctimas de violencia doméstica y los centros de crisis por agresión sexual como lugares donde el estado podría distinguir entre los sexos.

La representante republicana Kathie Hess Crouse, patrocinadora principal del proyecto de ley, dijo que el lenguaje se eliminó porque era innecesario. “Al eliminar los ejemplos específicos, estamos dejando extremadamente claro que esta lista no es la lista completa de entornos de un solo sexo que puede tener West Virginia”, dijo. La Cámara de Representantes estatal en febrero y está pendiente de aprobación del Senado.

Cuando se le preguntó sobre los electores que testificaron en oposición al proyecto de ley con preocupaciones de que afectaría negativamente a las personas transgénero, Hess Crouse dijo que estaban mal informados. Afirmó que el proyecto de ley no crea nuevos derechos ni quita ninguno. “El proyecto de ley es un proyecto de ley definitorio para que nuestros tribunales tengan orientación al interpretar las leyes que ya existen en West Virginia”, dijo.

“Si alguien en el estado no está contento con las leyes que ya tenemos en los libros, puede trabajar con su legislador para presentar un proyecto que cambie la ley”. Hugo Polanco, abogado litigante de la oficina del defensor público del condado de Maricopa, testificó en contra del proyecto de ley en Arizona en nombre del capítulo de la Unión Estadounidense de Libertades Civiles (ACLU) del estado.

“Seamos claros”, dijo. “Los derechos trans son derechos de las mujeres. Los avances en los derechos trans derriban barreras basadas en estereotipos de género, creando la oportunidad para que cada uno de nosotros determine su propia historia de vida”.

Alex del Rosario, organizador nacional del Centro Nacional para la Igualdad Transgénero, dijo que esta serie de proyectos de ley daña a las personas transgénero al intentar eliminar protecciones.

“Vigilar los cuerpos de las personas mientras se excluye a las personas transgénero e intersexuales de usar el baño no protege la privacidad de nadie”, dijo. “Los políticos extremistas han estado aprovechándose del público estadounidense, proyectando una imagen falsa de las personas transgénero, especialmente de las mujeres transgénero, para fomentar el miedo y la desconfianza hacia una comunidad que muchas personas no entienden”.

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At least one bill goes so far as making it a crime for a transgender person to enter a facility that doesn’t match the sex listed on their birth certificate.

The debate has been popping up in statehouses across the nation in recent months, predominantly in conservative, rural states, including at a hearing of the Arizona Senate’s Health and Human Services Committee in February. Proponents of that state’s , which defines “male,” “female,” and other terms through rigid definitions of biological sex, argued that women’s rights are at stake. Opponents disagreed and said the language would erase transgender people from state statute and remove legal protections.

The bill states that Arizona may provide “separate single-sex” environments for males and females, including within athletics, living facilities, locker rooms, bathrooms, domestic violence shelters, and sexual assault crisis centers, meaning that transgender women could be prohibited from entering such spaces meant for women. Researchers have transgender women experience assault at a rate nearly four times as high as cisgender women.

The latest round of proposals, like the one in Arizona, expand on an earlier spate of “bathroom bills,” which sought to restrict transgender people’s access to public restrooms and locker rooms. In some instances, the proposed laws would extend far beyond access to facilities by excluding trans people from state anti-discrimination laws and dictating makeup of athletic teams. Legal experts say the new bills put states at risk of violating federal anti-discrimination laws, which could throw billions of dollars in federal funding into jeopardy for states and crisis centers that receive federal grants.

At least one state 鈥� Utah 鈥� removed lines that specifically mention shelters and similar facilities because of concerns about losing federal funding.

In addition to the bill passed in Utah, lawmakers introduced similar bills in Idaho, Georgia, Arizona, New Mexico, Iowa, and West Virginia. The measures mirror a model bill created by the Independent Women’s Law Center, a conservative nonprofit that seeks to rewrite state laws to rely on sex assigned at birth. Versions of the policy were approved through legislation or executive orders last year in Kansas, Nebraska, Oklahoma, and Montana. A similar bill was also by Sen. Cindy Hyde-Smith (R-Miss.) and Rep. Debbie Lesko (R-Ariz.)

Jennifer Braceras, vice president for legal affairs and founder of the Independent Women’s Law Center, testified in support of the proposal in Arizona.

“Everyday Americans know that a woman is an adult human female,” Braceras said, referring to the definition in the bill that a female is “an individual who has, had, will have or would have, but for a developmental anomaly or accident, the reproductive system that at some point produces ova.”

She told state lawmakers that activists seek to convince judges and others that men who identify as women have an unfettered right to enter women’s spaces and said the policy is a tool to restrict that access.

Braceras added that just because the model legislation does not include gender in its definitions, that doesn’t prohibit state lawmakers from choosing to include it in their policies. Conservative proponents of the legislation emphasize the difference between sex and gender, saying the former is an immutable biological fact and the latter a set of cultural norms.

The narrow definition of sex and provisions that declare certain spaces be protected as “single-sex environments,” including domestic violence shelters and rape crisis centers in some states’ versions of the policy, raise questions about compliance with federal laws that prohibit discrimination based on sex or gender.

Anya Marino, director of LGBTQI equality at the National Women’s Law Center, said that if a court found these state statutes at odds with federal laws, the federal law that ensures protection on the basis of gender would supersede the state laws.

Beyond how the laws could be interpreted or implemented, Marino expressed concern about other consequences these debates can have, including violence against people who “fail to conform against an extremist idealistic view of how sexes should appear,” she said.

“It’s part of a larger objective to control people through body policing to determine how they love and how they navigate their daily lives.”

Yet the legal ramifications are unclear.

In Montana, where one of these proposals after SB 458 was approved during last year’s session, of potentially violating federal law and losing billions in funding.

The state’s legislative fiscal analysts determined that $7.5 billion in federal funds were on the line in the first year, depending on how state agencies implemented the law and whether those actions were deemed violations of anti-discrimination laws. The bill passed regardless and was signed by Republican Gov. Greg Gianforte.

A is pending. Regardless, the Montana Department of Public Health and Human Services cited the law’s passage as justification to revive a ban on transgender people changing the sex designation on their birth certificate. The ban was originally instituted in 2022 and struck down by a judge before the new law passed.

“DPHHS must follow the law, and our agency will consequently process requests to amend sex markers on birth certificates under our 2022 final rule,” department director Charlie Brereton said in a Feb. 20 statement announcing the change.

Lawmakers in Utah removed language specifically identifying domestic violence shelters and rape crisis centers as “sex-designated” spaces that could exclude transgender people from local and state leaders about losing federal funding. Though lawmakers removed mention of those specific venues from the bill, they kept provisions that prohibit transgender people from entering sex-designated restrooms, public showers, or locker rooms that don’t correspond with their sex assigned at birth unless their birth certificate has been amended or they’ve undergone gender-affirming surgery accordingly. The bill was fast-tracked, approved, and signed by Republican Gov. Spencer Cox two weeks after the legislative session began.

More recently, West Virginia lawmakers removed language from that named domestic violence shelters and rape crisis centers as places where the state could distinguish between the sexes.

Republican Delegate Kathie Hess Crouse, lead sponsor of the bill, said the language was removed because it was unnecessary.

“By removing the specific examples, we’re making it extremely clear that this list is not the full list of single-sex environments that West Virginia may have,” she said.

The West Virginia House in February and it is pending approval from the Senate.

Asked about constituents who testified in opposition to the bill with concerns that it would negatively affect transgender people, Hess Crouse said they were misinformed. She asserted the bill doesn’t create new rights or take any away.

“The bill is a definitional bill for our courts to have guidance when interpreting laws that already exist in West Virginia,” she said. “If anyone in the state is not happy with the laws we already have on the books, they can work with their legislator to bring a bill that changes the law.”

Hugo Polanco, a trial attorney for the Maricopa County public defender’s office, testified in opposition to the bill in Arizona on behalf of the state’s American Civil Liberties Union chapter.

“Let’s be clear,” he said. “Trans rights are women’s rights. Advances in trans rights tear down barriers based on gender stereotypes, creating the opportunity for each of us to determine our own life story.”

Alex del Rosario, a national organizer with the National Center for Transgender Equality, said this slate of bills harms transgender people by attempting to eliminate protections for them.

“Policing people’s bodies while excluding transgender and intersex people from using the restroom does not protect anyone’s privacy,” they said. “Extremist politicians have been taking advantage of the American public, projecting a false image of transgender people, especially transgender women, to stoke fear and distrust of a community that many people don’t understand.”

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It’s an example of how states are responding to the national controversy over what exceptions to abortion bans actually mean. Critics point to reports of women developing dangerous complications after hospitals in states with strict abortion laws refused to terminate their pregnancies.

South Dakota legislators are moving a bill that would direct the state Department of Health to work with the attorney general and health and legal experts to create educational material, including a video, and publish it on its website.

The legislation is the first of its kind in the country, according to Susan B. Anthony Pro-Life America, an anti-abortion group.

the video would explain how South Dakota law defines abortion. Republican Rep. Taylor Rehfeldt, who introduced the bill, said treatments for miscarriages or an ectopic pregnancy 鈥攚hen a fertilized egg implants outside the uterus 鈥� do not count as abortions, and therefore are allowed.

The video would also discuss conditions that can threaten the life or health of a pregnant woman, and the criteria that providers might use to decide the best course of treatment. Rehfeldt said she expects the video to address when these medical conditions may need to be treated with an abortion, including how sick a patient needs to become.

Rehfeldt, a nurse anesthetist with a personal history of high-risk pregnancies, said she introduced the bill after hearing from health care providers who want guidance about the state’s abortion law.

“They said that they were confused and not sure when they can intervene,” Rehfeldt said. “I think it’s important that we provide that clarification because we all want moms to be taken care of.”

South Dakota has one of the nation’s strictest laws, unless they’re needed to save the life of a woman. There are no exceptions for preventing serious injury to the mother or in cases of fatal fetal anomalies, rape, or incest. Providing an illegal abortion is a felony that can be punished with two years in prison.

The state also has high rates of and mortality, . Some South Dakota women have already been harmed because of the law after they were denied or received delayed abortions, according to Amy Kelley, an obstetrician and gynecologist in Sioux Falls.

Rehfeldt is confident her bill will pass the Republican-controlled legislature because the proposal has support from the governor’s office, health department, one of the state’s largest hospital systems, and state and national anti-abortion groups.

Anti-abortion advocates support the bill even though some groups, such as the Charlotte Lozier Institute, say exceptions to abortion bans are already clear. state laws use language such as “reasonable medical judgment,” terms that hospitals should understand since such standards are often used in malpractice cases.

“Abortion activists have spread the dangerous lie that pregnant women in states with pro-life laws cannot receive emergency care,” Kelsey Pritchard, a South Dakota-based official with Susan B. Anthony Pro-Life America 鈥� which is affiliated with the Lozier Institute 鈥� said in a news release. “This patently false allegation that is used to justify the abortion industry’s agenda for no limits on abortion is putting women’s lives in danger.”

But abortion rights advocates say many doctors are afraid to provide critical care because of vaguely worded exceptions to abortion bans. Many say the only way to protect providers and their patients’ health is to repeal bans.

Nisha Verma is an OB-GYN in Georgia, where abortion is generally banned once fetal cardiac activity can be detected, typically around six weeks. Verma, who has provided abortions, is also a spokesperson for the American College of Obstetricians and Gynecologists.

“I understand the desire to grasp for anything that helps us provide care for our patients,” Verma said. But “there’s no way that you can create a video that talks about any type of inclusive list of conditions where you can and can’t provide care.”

Several other states have tried to clarify exceptions to their bans, but the South Dakota bill is the most comprehensive, Pritchard said.

In Oklahoma, the attorney general’s office sent on the subject to prosecutors and police. It said doctors should have “substantial leeway” to provide lifesaving abortions, and don’t need to wait until a patient is “septic, bleeding profusely, or otherwise close to death.” The memo also says doctors should be prosecuted only if there’s evidence of criminal intent or a pattern of similar behavior.

Kentucky’s attorney general on the topic; Louisiana’s health department listing “medically futile” fetal conditions that can legally justify an abortion. Texas lawmakers for doctors who end ectopic pregnancies or pregnancies of patients whose water breaks too early for the fetus to survive. The legislation does not use the word “abortion,” and as they were passing it.

Texas’ Supreme Court, lawmakers, and several pro- and anti-abortion rights advocates the state’s medical board for more guidance. The board as to whether it will do so, according to the health care publication Stat.

Abortion rights supporters are divided about the value of supplying guidance on exceptions to the abortion law.

“I wish we weren’t having this conversation,” said South Dakota Rep. Oren Lesmeister, a Democrat. “I wish we wouldn’t have had the trigger law” that banned most abortions.

But given that the law does exist, Lesmeister decided to co-sponsor and vote for the bill in hopes it will help doctors and their patients.

Critics of the legislation include the ACLU of South Dakota, the regional Planned Parenthood organization, and the Justice through Empowerment Network, a South Dakota abortion fund.

Verma and Kelley, the obstetricians, said laws, videos, and other guidance can’t capture the complexity of when an abortion may be necessary.

For example, conditions that aren’t fatal on their own can become deadly when combined with other complications, they said. Then there’s the question of when situations become life-threatening, which can happen quickly in obstetrics.

“There’s not a line in the sand where someone goes from being totally fine to acutely dying,” Verma said.

Verma and Kelley said doctors use their own expertise but also take their patients’ views into account when responding to life-threatening situations. That’s because one patient who learns they have a 25% risk of dying might decide against continuing their pregnancy, while another might view it as a risk worth taking, they said.

Some patients are willing to die if it means their baby will live, Kelley said, and “we honor their choice even if we don’t always think that that’s the right choice.”

Rehfeldt said she understands the concerns outlined by Verma and Kelley. But she said her bill would give doctors and hospital attorneys confidence to distinguish between legal and illegal procedures.

“If you have an interpretation that’s coming from collaboration with the attorney general, as well as the pertinent medical professionals, as well as the current governor’s office, I don’t see how you would be worried about being charged with a crime,” Rehfeldt said.

Kelley said it’s difficult to feel assured by any abortion-related guidance from South Dakota government officials when it feels as if they don’t trust doctors. For example, she said, lawmakers to share information with patients that can be opinionated and misleading.

“So, it’s really hard for them to then say, 鈥極h, but trust us, you won’t get in trouble with this law, we’ll go with your judgment,’” Kelley said.

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But when his doctor followed the and increased his dose of Mounjaro 鈥� a drug with a wholesale list price of a month 鈥� Marks’ health insurer declined to pay for it.

Marks had Cigna insurance that he purchased on the federal health insurance marketplace, . After two appeals over a month and a half, Cigna agreed to cover the higher dose. A few months later, he said, when it was time to up his dose once more, he was denied again. By November, he decided it wasn’t worth sparring with Cigna anymore since the insurer was leaving at the start of this year. He decided to stay on the lower dose until his new insurance kicked in.

“That is beyond frustrating. People shouldn’t have to be like, 鈥業t’s not worth the fight to get my medical treatment,’” Marks said.

The process Marks encountered is called “prior authorization,” or sometimes “pre-certification,” a tool insurers say they use to rein in costs and protect patients from unnecessary or ineffective medical treatment. But the practice has prompted backlash from patients like Marks, as well as groups representing medical professionals and hospitals that say prior authorization can interfere with treatment, cause medical provider burnout, and .

In January, the Biden administration announced new rules to streamline the process for patients with certain health plans, after attempts stalled out in Congress, including a in 2022. But states are considering prior authorization bills that go even further. Last year, lawmakers in 29 states and Washington, D.C., considered some 90 bills to limit prior authorization requirements, , with notable victories in and The physicians association expects more bills this year, many with provisions spelled out in the group drafted.

In 2018, health insurers signed a with various medical facility and provider groups that broadly laid out areas for improving the prior authorization process. But the lack of progress since then has shown the need for legislative action, said , past president of the AMA and a current trustee.

“They have not lived up to their promises,” Resneck said.

Resneck, a California dermatologist, emphasized pending bills in , , , , and that include several policies backed by the AMA, including quicker response times, requirements for public reporting of insurers’ prior authorization determinations, and programs to reduce the volume of requests, sometimes called “gold carding.” Legislation has come from both Democratic and Republican lawmakers, and some is bipartisan, .

In Missouri, by Republican state Rep. aims to establish one of those gold carding programs for treatment and prescriptions. Stinnett said she regularly was frustrated by prior authorization hurdles in her work as a speech pathologist before joining the legislature in 2023.

“The stories all kind of look similar: It’s a big fight to get something done on the insurance side for approval,” Stinnett said. “Then sometimes, even after all of that fight, it feels like it may have not been worthwhile because some people then have a change at the beginning of the year with their insurance.”

Under her bill, a medical provider’s prior authorization requests during a six-month evaluation period would be reviewed. After that period, providers whose requests were approved at least 90% of the time would be exempt from having to submit requests for the next six months. The exemptions would also apply to facilities that meet that threshold. Then, she said, they would need to continue meeting the threshold to keep the “luxury” of the exemption.

Five states have passed some form of gold carding program: Louisiana, Michigan, Texas, Vermont, and West Virginia. The AMA is tracking active gold carding bills in 13 states, including Missouri.

A of 26 health insurance plans conducted by the industry trade group AHIP found that just over half of those plans had used a for medical services while about a fifth had done so for prescriptions. They gave mixed reviews: 23% said patient safety improved or stayed the same, while 20% said the practice increased costs without improving quality.

The new federal finalized by the Centers for Medicare & Medicaid Services stop short of gold carding and don’t address prior authorizations for prescription drugs, like Marks’ Mounjaro prescription. Beginning in 2026, the new rules establish response time frames and public reporting requirements 鈥� and ultimately will mandate an electronic process 鈥� for some insurers participating in federal programs, such as Medicare Advantage or the health insurance marketplace. Manual submissions accounted for 39% of prior authorization requests for prescriptions and 60% of those for medical services, according to the 2022 insurance survey.

In Missouri, state and national organizations representing doctors, nurses, social workers, and hospitals, among others, back Stinnett’s bill. Opposition to the plan comes largely from pharmacy benefit managers and the insurance industry, including the company whose prior authorization process Marks navigated last year. A Cigna Healthcare executive saying the company’s experience showed gold card policies “increase inappropriate care and costs.”

The , which represents dozens of employers that purchase health insurance for employees, also opposes the bill. Members of the coalition include financial services firm Edward Jones, coal company Peabody Energy, and aviation giant Boeing, as well as several public school districts and the St. Louis city and county governments.

Louise Probst, the coalition’s executive director, said the prior authorization process has issues but that the coalition would prefer that a solution come from insurers and providers rather than a new state law.

“The reason I hate to see things just set in stone is that you lose the flexibility and the nuance that could be helpful to patients,” Probst said.

On the other side of the state, Marks purchased insurance for this year on the federal marketplace from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed the higher dose of Mounjaro that Cigna had declined to cover. A little over a week later, Marks said, his new insurance approved the higher dose “without any fuss.”

Cigna spokesperson Justine Sessions said the company uses prior authorizations for popular drugs such as Mounjaro to help ensure patients get the right medications and dosages.

“We strive to make authorizations quickly and correctly, but in Mr. Marks’ case, we fell short and we greatly regret the stress and frustration this caused,” she said. “We are reviewing this case and identifying opportunities for improvement to ensure this does not happen in the future.”

Marks’ aim with this higher dose of Mounjaro is to get off his other diabetes medications. He particularly hopes to stop taking insulin, which for him requires multiple injections a day and carries a risk of from low blood sugar.

“I don’t really use the word 鈥榣ife-changing,’ but it kind of is,” Marks said. “Getting off insulin would be great.”

Do you have an experience with prior authorization you’d like to share? to tell your story.

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Medicaid, que cubre a personas de bajos ingresos y discapacitadas, y el Programa de Seguro de Salud Infantil (CHIP) relacionado, crecieron hasta alcanzar un récord de 94 millones de inscritos como resultado de una regla que prohibía a los estados terminar la cobertura durante la emergencia de salud pública por covid.

Pero desde abril pasado, los estados han eliminado a de los programas en un proceso conocido como “desmantelamiento”, según estimaciones de 素人色情片a partir de datos estatales.

Si bien muchos beneficiarios ya no califican porque sus ingresos aumentaron, millones han sido eliminados por razones de procedimiento, como no responder a los avisos o no devolver la documentación necesaria. Pero a la vez, millones se han reinscripto o inscripto por primera vez.

El resultado neto: la inscripción ha disminuido en aproximadamente 9,5 millones de personas desde el máximo histórico alcanzado en abril, según KFF. Eso pone a la inscripción en Medicaid y CHIP en camino de volver a las cifras pre pandémicas: alrededor de 71 millones de personas.

“Lo que estamos viendo no es muy diferente de lo que vimos antes de la pandemia, simplemente está sucediendo a una escala más grande y más rápido”, dijo Larry Levitt, vicepresidente ejecutivo de políticas de salud de KFF.

El cambio en la inscripción ha sido desde hace tiempo una característica de Medicaid. Antes de la pandemia, alrededor de 1 millón a 1,5 millones de personas en todo el país perdían la cobertura de Medicaid cada mes, incluyendo a muchos que aún calificaban pero no renovaban su cobertura, explicó Levitt.

Lo que esta vez ocurre en un período más corto. En algunos aspectos, y en algunos estados, ha sido peor de lo esperado.

La administración Biden predijo que alrededor de 15 millones de personas perderían la cobertura de Medicaid o CHIP durante el período de purga, casi la mitad debido a problemas de procedimiento. Ambas predicciones resultaron bajas. Según los datos informados hasta ahora, perderán la cobertura, según KFF, el 70% debido a problemas con el procedimiento.

Pero alrededor de dos tercios de los 48 millones de beneficiarios a los que se les revisó la elegibilidad hasta ahora renovaron su cobertura. Cerca de un tercio la perdieron.

El gobierno federal ha dado a la mayoría de los estados 12 meses para completar esta purga.

Timothy McBride, economista de salud de la Universidad de Washington en St. Louis, dijo que la históricamente baja tasa de desempleo del país significa que las personas que pierden la cobertura de Medicaid tienen más probabilidades de encontrar una basada en el empleo o de poder pagar un plan en los mercados del Obamacare. “Esa es una razón por la que la caída en Medicaid no es mucho peor”, dijo.

Hay grandes diferencias entre los estados. Por ejemplo, Oregon ha sacado solo al 12% de sus beneficiarios. El 75% ha sido renovado, según KFF. El resto está pendiente.

En el otro extremo del espectro, Oklahoma ha eliminado al 43% de sus beneficiarios, renovando la cobertura para solo el 34%. Alrededor del 24% está pendiente.

Los estados tienen reglas de elegibilidad variables, y algunos facilitan mantenerse inscrito. Por ejemplo, Oregon permite que los niños permanezcan en Medicaid hasta los 6 años sin tener que volver a solicitarlo. Todos los demás inscritos obtienen hasta dos años de cobertura independientemente de los cambios en los ingresos.

Jennifer Harris, defensora principal de políticas de salud para Alabama Arise, un grupo de defensa, dijo que la agencia de Medicaid de su estado y otras organizaciones sin fines de lucro se comunicaron bien con los inscritos sobre la necesidad de volver a solicitar la cobertura, y que el estado también contrató a más personas para manejar el aumento. 素人色情片halló que el 29% de los beneficiarios en ese estado que tuvieron revisiones de elegibilidad fueron eliminados por cuestiones de procedimiento, encontró KFF.

“Las cosas están equilibradas en Alabama”, dijo, apuntando que a cerca del 66% de a los se les renovó la cobertura.

Uno de los pocos estados que se ha negado a expandir Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), Alabama tenía alrededor de 920,000 inscritos en Medicaid y CHIP en enero de 2020. Esa cifra aumentó a alrededor de 1,2 millones en abril de 2023.

Joan Alker, directora ejecutiva del Centro para Niños y Familias de la Universidad de Georgetown, dijo que sigue preocupada porque la caída de la inscripción entre los niños puede ser mayor que lo habitual.

Durante la purga, 3.8 millones de niños han perdido la cobertura de Medicaid, según los datos más recientes del centro. “Muchos más niños están quedando fuera ahora que antes de la pandemia”, dijo Alker.

Y cuando los sacan, muchas familias luchan por volver a inscribirlos, dijo. “Todo el sistema está saturado y la capacidad de las personas para volver a inscribirse de manera oportuna es más limitada”, agregó.

La gran pregunta, dijo Levitt, es cuántas de las millones de personas eliminadas de Medicaid ahora están sin cobertura.

Utah fue el único estado que encuestó a los desafiliados, y descubrió que alrededor del 30% estaban sin seguro. Muchos de los restantes encontraron cobertura de salud por un empleo o se inscribieron en cobertura subsidiada a través de ACA

Lo que ha sucedido a nivel nacional sigue siendo poco claro.

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Medicaid, which covers low-income and disabled people, and the related Children’s Health Insurance Program grew to a record 94 million enrollees as a result of a rule that prohibited states from terminating coverage during the nation’s public health emergency.

But since last April, states have removed from the programs in a process known as the “unwinding,” according to 素人色情片estimates compiled from state-level data.

While many beneficiaries no longer qualify because their incomes rose, millions of people have been dropped from the rolls for procedural reasons like failing to respond to notices or return paperwork. But at the same time, millions have been reenrolled or signed up for the first time.

The net result: Enrollment has fallen by about 9.5 million people from the record high reached last April, according to KFF. That puts Medicaid and CHIP enrollment on track to look, by the end of the unwinding later this year, a lot like it did at the start of the coronavirus pandemic: about 71 million people.

“What we are seeing is not dissimilar to what we saw before the pandemic 鈥� it is just happening on a bigger scale and more quickly,” said Larry Levitt, executive vice president for health policy at KFF.

Enrollment churn has long been a feature of Medicaid. Before the pandemic, about 1 million to 1.5 million people nationwide fell off the Medicaid rolls each month 鈥� including many who still qualified but failed to renew their coverage, Levitt said.

During the unwinding, many people have been disenrolled in a shorter time. In some ways 鈥� and in some states 鈥� it’s been worse than expected.

The Biden administration predicted about 15 million people would lose coverage under Medicaid or CHIP during the unwinding period, nearly half due to procedural issues. Both predictions have proven low. Based on data reported so far, disenrollments , according to 素人色情片鈥� 70% due to procedural reasons.

But about two-thirds of the 48 million beneficiaries who have had their eligibility reviewed so far got their coverage renewed. About one-third lost it.

The federal government has given most states 12 months to complete their unwinding, starting with the first disenrollments between last April and October.

Timothy McBride, a health economist at Washington University in St. Louis, said the nation’s historically low unemployment rate means people who lose Medicaid coverage are more likely to find job-based coverage or be better able to afford plans on Obamacare marketplaces. “That is one reason why the drop in Medicaid is not a lot worse,” he said.

There are big differences between states. Oregon, for example, has disenrolled just 12% of its beneficiaries. Seventy-five percent have been renewed, according to KFF. The rest are pending.

At the other end of the spectrum, Oklahoma has dumped 43% of its beneficiaries in the unwinding, renewing coverage for just 34%. About 24% are pending.

States have varying eligibility rules, and some make it easier to stay enrolled. For instance, Oregon allows children to stay on Medicaid until age 6 without having to reapply. All other enrollees get up to two years of coverage regardless of changes in income.

Jennifer Harris, senior health policy advocate for Alabama Arise, an advocacy group, said her state’s Medicaid agency and other nonprofit organizations communicated well to enrollees about the need to reapply for coverage and that the state also hired more people to handle the surge. About 29% of beneficiaries in Alabama who’ve had eligibility reviews were disenrolled for procedural reasons, 素人色情片found.

“Things are even keel in Alabama,” she said, noting that about 66% of enrollees have been renewed.

State officials have told the legislature that about a quarter of people disenrolled during the unwinding were reenrolled within 90 days, she said.

One of a handful of states that have refused to expand Medicaid under the Affordable Care Act, Alabama had about 920,000 enrollees in Medicaid and CHIP in January 2020. That number rose to about 1.2 million in April 2023.

More than halfway into the unwinding, the state is on track for enrollment to return to pre-pandemic levels, Harris said.

Joan Alker, executive director of the Georgetown University Center for Children and Families, said she remains worried the drop in Medicaid enrollment among children is steeper than typical. That’s particularly bothersome because children usually qualify for Medicaid at higher household income levels than their parents or other adults.

During the unwinding 3.8 million children have lost Medicaid coverage, according to the center’s latest data. “Many more kids are falling off now than prior to the pandemic,” Alker said.

And when they’re dropped, many families struggle to get them back on, she said. “The whole system is backlogged and the ability of people to get back on in a timely fashion is more limited,” she said.

The big question, Levitt said, is how many of the millions of people dropped from Medicaid are now uninsured.

The only state to survey those disenrolled 鈥� Utah 鈥� discovered about 30% were uninsured. Many of the rest found employer health coverage or signed up for subsidized coverage through the Affordable Care Act marketplace.

What’s happened nationwide remains unclear.

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Hackler, a lawyer who sues patients on behalf of the hospital, buzzed through 51 cases, all but a handful uncontested, as is often the case. She bantered with the judge as she secured nearly $40,000 in judgments, plus 10% in fees for herself, according to court records.

It’s a payday the hospital and Hackler have shared frequently over the past three decades, records show. The records indicate McAlester Regional Medical Center and an affiliated clinic have filed close to 5,000 debt collection cases since the early 1990s, most often represented by the father-daughter law firm of Hackler & Hackler.

Some of McAlester’s 18,000 residents have been taken to court multiple times. A deputy at the county jail and her adult son were each sued recently, court records show. New mothers said they compare stories of their legal run-ins with the medical center.

“There’s a lot that’s not right,” Sherry McKee, a dorm monitor at a tribal boarding school outside McAlester, said on the courthouse steps after the hearing. The hospital has sued her three times, most recently over a $3,375 bill for what she said turned out to be vertigo.

In recent years, major health systems in Virginia, , and elsewhere have stopped suing patients following news reports about lawsuits. And several states, such as Maryland and New York, have restricted the legal actions hospitals can take against patients.

But with some 100 million people in the U.S. burdened by health care debt, medical collection across the country, researchers have found. In places like McAlester, a hospital’s debt collection machine can hum away quietly for years, helped along by powerful people in town. An effort to failed in the Oklahoma Legislature in 2021.

In McAlester, the lawsuits have provided business for some, such as the Adjustment Bureau, a local collection agency run out of a squat concrete building down the street from the courthouse, and for Hackler, a former president of the McAlester Area Chamber of Commerce. But for many patients and their families, the lawsuits can take a devastating toll, sapping wages, emptying retirement accounts, and upending lives.

McKee said she wasn’t sure how long it would take to pay off the recent judgment. Her $3,375 debt exceeds her monthly salary, she said.

“This affects a large number of people in a small community,” said Janet Roloff, an attorney who has spent years assisting low-income clients with legal issues such as evictions in and around McAlester. “The impact is great.”

Settled more than a century ago by fortune seekers who secured land from the Choctaw Nation to mine coal in the nearby hills, McAlester was once a boom town. Vestiges of that era remain, including a mammoth, 140-foot-tall Masonic temple that looms over the city.

Recent times have been tougher for McAlester, now home to 12 marijuana dispensaries and the state’s death row. The downtown is pockmarked by empty storefronts, including the OKLA theater, which has been dark for decades. Nearly 1 in 5 residents in McAlester and the surrounding county live below the federal poverty line.

The hospital, operated by a public trust under the city’s authority, faces its own struggles. Paint is peeling off the front portico, and weeds poke up through the parking lots. The hospital has operated in the red for years, according to independent audit reports available .

“I’m trying to find ways to get the entire community better care and more care,” said Shawn Howard, the hospital’s chief executive. Howard grew up in McAlester and proudly noted he started his career as a receptionist in the hospital’s physical therapy department. “This is my hometown,” he said. “I am not trying to keep people out of getting care.”

The hospital operates a , whose webpage notes it has “limited appointments” at no cost for patients who are approved for aid. But data from the audits shows the hospital offers very little financial assistance, despite its purported mission to serve the community.

In the 2022 fiscal year, it provided just $114,000 in charity care, out of a total operating budget of more than $100 million, hospital records show. Charity care totaling $2 million or $3 million out of a $100 million budget would be more in line with other U.S. hospitals.

While audits show few McAlester patients get financial aid, many get taken to court.

Renee Montgomery, the city treasurer in an adjoining town and mother of a local police officer, said she dipped into savings she’d reserved for her children and grandchildren after the hospital sued her last year for more than $5,500. She’d gone to the emergency room for chest pain.

Dusty Powell, a truck driver, said he lost his pickup and motorcycle when his wages were garnished after the hospital sued him for almost $9,000. He’d gone to the emergency department for what turned out to be gastritis and didn’t have insurance, he said.

“Everyone in this town probably has a story about McAlester Regional,” said another former patient who spoke on the condition she not be named, fearful to publicly criticize the hospital in such a small city. “It’s not even a secret.”

The woman, who works at an Army munitions plant outside town, was sued twice over bills she incurred giving birth. Her sister-in-law has been sued as well.

“It’s a good-old-boy system,” said the woman, who lowered her voice when the mayor walked into the coffee shop where she was meeting with 素人色情片Health News. Now, she said, she avoids the hospital if her children need care.

Nationwide, most people sued in debt collection cases never challenge them, a response experts say reflects widespread misunderstanding of the legal process and anxiety about coming to court.

At the center of the McAlester hospital’s collection efforts for decades has been Hackler & Hackler.

Donald Hackler was city attorney in McAlester for 13 years in the ’70s and ’80s and a longtime member of the local Lions Club and the Scottish Rite Freemasons.

Daughter Deborah Hackler, who joined the family firm 30 years ago, has been a deacon at the First Presbyterian Church of McAlester and served on the board of the local Girl Scouts chapter, according to the , which named her “Woman of the Year” in 2007. Since 2001, she also has been a municipal judge in McAlester, hearing traffic cases, including some involving people she has sued on behalf of the hospital, municipal and county court records show.

For years, the Hacklers’ debt collection cases were often heard by Judge James Bland, who has retired from the bench and now sits on the hospital board. Bland didn’t respond to an inquiry for interview.

Hackler declined to speak with 素人色情片Health News after her recent court appearance. “I’m not going to visit with you about a current client,” she said before leaving the courthouse.

Howard, the hospital CEO, said he couldn’t discuss the lawsuits either. He said he didn’t know the hospital took its patients to court. “I had to call and ask if we sue people,” he said.

Howard also said he didn’t know Deborah Hackler. “I never heard her name before,” he said.

Despite repeated public records requests from 素人色情片Health News since September, the hospital did not provide detailed information about its financial arrangement with Hackler.

McAlester Mayor John Browne, who appoints the hospital’s board of trustees, said he, too, didn’t know about the lawsuits. “I hadn’t heard anything about them suing,” he said.

At the century-old courthouse in downtown McAlester, it’s not hard to find the lawsuits, though. Every month or two, another batch fills the docket in the small-claims court, now presided over by Judge Brian McLaughlin.

After court recently, McLaughlin, who is not from McAlester, shook his head at the stream of cases and patients who almost never show up to defend themselves, leaving him to issue judgment after judgment in the hospital’s favor.

“All I can do is follow the law,” said McLaughlin. “It doesn’t mean I like it.”

About This Project

“Diagnosis: Debt” is a reporting partnership between 素人色情片Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.聽

Additional research was聽, which analyzed credit bureau and other demographic data on poverty, race, and health status for 素人色情片Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute聽聽from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with 素人色情片Health News on a survey of its clients to explore links between medical debt and housing instability.聽

素人色情片Health News journalists worked with 素人色情片public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from 素人色情片Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).