ST. CHARLES, Mo. — Democrat Lucas Kunce is trying to pin reproductive care restrictions on Sen. Josh Hawley (R-Mo.), betting it will boost his chances of unseating the incumbent in November.

In a recent ad campaign, Kunce accuses Hawley of jeopardizing reproductive care, including in vitro fertilization. Staring straight into the camera, with tears in her eyes, a Missouri mom identified only as Jessica recounts how she struggled for years to conceive.

“Now there are efforts to ban IVF, and Josh Hawley got them started,” Jessica says. “I want Josh Hawley to look me in the eye and tell me that I can’t have the child that I deserve.”

Never mind that IVF is legal in Missouri, or that Hawley has said he supports limited access to abortion as a “pro-life” Republican. In key races across the country, Democrats are branding their Republican rivals as threats to women’s health after a broad erosion of reproductive rights since the Supreme Court struck down Roe v. Wade, including near-total state abortion bans, efforts to restrict medication abortion, and a court ruling that limited IVF in Alabama.

On top of the messaging campaigns, Democrats hope ballot measures to guarantee abortion rights in as many as 13 states — including Missouri, Arizona, and Florida — will help boost turnout in their favor.

The issue puts the GOP on the defensive, said J. Miles Coleman, an election analyst at the University of Virginia.

“I don’t really think Republicans have found a great way to respond to it yet,” he said.

Abortion is such a salient issue in Arizona, for example, that election analysts say a U.S. House seat occupied by Republican Juan Ciscomani is now a toss-up.

Hawley appears in less peril, for now. He holds a wide lead in polls, though Kunce outraised him in the most recent quarter, raking in $2.25 million in donations compared with the incumbent’s $846,000, according to campaign finance reports. Still, Hawley’s war chest is more than twice the size of Kunce’s.

Kunce, a Marine veteran and antitrust advocate, said he likes his odds.

“I just don’t think we’re gonna lose,” he told KFF Health News. “Missourians want freedom and the ability to control their own lives.”

Hawley’s campaign declined to comment. He has backed a federal ban on abortion after 15 weeks and has said he supports exceptions for rape and incest and to protect the lives of pregnant women. Missouri’s state ban is near total, with no exceptions for rape or incest.

“This is Josh Hawley’s life’s mission. It’s his family’s business,” Kunce said, a nod to Erin Morrow Hawley, the senator’s wife, a lawyer who argued before the Supreme Court in March on behalf of activists who sought to limit access to the abortion pill mifepristone.

State abortion rights have won out everywhere they’ve been on the ballot since the end of Roe in 2022, including in Republican-led Kentucky and Ohio.

An abortion rights ballot initiative is also expected in Montana, where a Republican challenge to Democrat Jon Tester could decide control of the Senate.

On a late-April Saturday along historic Main Street in St. Charles, Missouri, people holding makeshift clipboards fashioned from yard signs from past elections invited locals strolling brick sidewalks to sign a petition to get the initiative on Missouri ballots. Nearby, diners enjoyed lunch on a patio tucked under a canopy of trees in this affluent St. Louis suburb.

Missouri was the first state to ban abortion after Roe fell; it is outlawed except in “cases of medical emergency.” The measure would add the right to abortion to the state constitution.

Larry Bax, 65, of St. Charles County, said he votes Republican most of the time but signed the ballot measure petition along with his wife, Debbie Bax, 66.

“We were never single-issue voters. Never in our life,” he said. “This has made us single-issue because this is so wrong.”

They won’t vote for Hawley this fall, they said, but are unsure if they’ll support the Democratic nominee.

Jim Seidel, 64, who lives in Wright City, 50 miles west of St. Louis, also signed the petition. He said he believes Missourians deserve the opportunity to vote on the issue.

“I’ve been a Republican all my life until just recently,” Seidel said. “It’s just gone really wacky.”

He plans to vote for Kunce in November if he wins the Democratic primary in August, as seems likely. Seidel previously voted for a few Democrats, including Bill Clinton and Claire McCaskill, whom Hawley unseated as senator six years ago.

“Most of the time,” he added, Hawley is “strongly in the wrong camp.”

Over about two hours in conservative St. Charles, KFF Health News observed only one person actively declining to sign the petition. The woman told the volunteers she and her family opposed abortion rights and quickly walked away. The Catholic Church has discouraged voters from signing. At St. Joseph Parish in a nearby suburb, for example, a sign flashed: “Decline to Sign Reproductive Health Petition!”

The ballot measure organizers turned in more than twice the required number of signatures May 3, though, and now await certification from the secretary of state’s office.

Larry Bax’s concern goes beyond abortion and the ballot measure in Missouri. He worries about more governmental limits on reproductive care, such as on IVF or birth control. “How much further can that reach extend?” he said. Kunce is banking on enough voters feeling like Bax and Seidel to get an upset similar to the one that occurred in 2012 for the same seat — also over abortion. McCaskill defeated Republican Todd Akin that year, largely because of his infamous response when asked about abortion: “If it’s a legitimate rape, the female body has ways to try to shut that whole thing down.”

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

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JACKSONVILLE, Ill. — Heather Crivilare was a month from her due date when she was rushed to an operating room for an emergency cesarean section.

The first-time mother, a high school teacher in rural Illinois, had developed high blood pressure, a sometimes life-threatening condition in pregnancy that prompted doctors to hospitalize her. Then Crivilare’s blood pressure spiked, and the baby’s heart rate dropped. “It was terrifying,” Crivilare said.

She gave birth to a healthy daughter. What followed, though, was another ordeal: thousands of dollars in medical debt that sent Crivilare and her husband scrambling for nearly a year to keep collectors at bay.

The Crivilares would eventually get on nine payment plans as they juggled close to $5,000 in bills.

“It really felt like a full-time job some days,” Crivilare recalled. “Getting the baby down to sleep and then getting on the phone. I’d set up one payment plan, and then a new bill would come that afternoon. And I’d have to set up another one.”

Crivilare’s pregnancy may have been more dramatic than most. But for millions of new parents, medical debt is now as much a hallmark of having children as long nights and dirty diapers.

About 12% of the 100 million U.S. adults with health care debt attribute at least some of it to pregnancy or childbirth, according to a KFF poll.

These people are more likely to report they’ve had to take on extra work, change their living situation, or make other sacrifices.

Overall, women between 18 and 35 who have had a baby in the past year and a half are twice as likely to have medical debt as women of the same age who haven’t given birth recently, other KFF research conducted for this project found.

“You feel bad for the patient because you know that they want the best for their pregnancy,” said Eilean Attwood, a Rhode Island OB-GYN who said she routinely sees pregnant women anxious about going into debt.

“So often, they may be coming to the office or the hospital with preexisting debt from school, from other financial pressures of starting adult life,” Attwood said. “They are having to make real choices, and what those real choices may entail can include the choice to not get certain services or medications or what may be needed for the care of themselves or their fetus.”

Best-Laid Plans

Crivilare and her husband, Andrew, also a teacher, anticipated some of the costs.

The young couple settled in Jacksonville, in part because the farming community less than two hours north of St. Louis was the kind of place two public school teachers could afford a house. They saved aggressively. They bought life insurance.

And before Crivilare got pregnant in 2021, they enrolled in the most robust health insurance plan they could, paying higher premiums to minimize their deductible and out-of-pocket costs.

Then, two months before their baby was due, Crivilare learned she had developed preeclampsia. Her pregnancy would no longer be routine. Crivilare was put on blood pressure medication, and doctors at the local hospital recommended bed rest at a larger medical center in Springfield, about 35 miles away.

“I remember thinking when they insisted that I ride an ambulance from Jacksonville to Springfield … ‘I’m never going to financially recover from this,’” she said. “‘But I want my baby to be OK.’”

For weeks, Crivilare remained in the hospital alone as covid protocols limited visitors. Meanwhile, doctors steadily upped her medications while monitoring the fetus. It was, she said, “the scariest month of my life.”

Fear turned to relief after her daughter, Rita, was born. The baby was small and had to spend nearly two weeks in the neonatal intensive care unit. But there were no complications. “We were incredibly lucky,” Crivilare said.

When she and Rita finally came home, a stack of medical bills awaited. One was already past due.

Crivilare rushed to set up payment plans with the hospitals in Jacksonville and Springfield, as well as the anesthesiologist, the surgeon, and the labs. Some providers demanded hundreds of dollars a month. Some settled for monthly payments of $20 or $25. Some pushed Crivilare to apply for new credit cards to pay the bills.

“It was a blur of just being on the phone constantly with all the different people collecting money,” she recalled. “That was a nightmare.”

Big Bills, Big Consequences

The Crivilares’ bills weren’t unusual. Parents with private health coverage now face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance, researchers at the University of Michigan found.

Out-of-pocket costs are even higher for families with a newborn who needs to stay in a neonatal ICU, averaging $5,000. And for 1 in 11 of these families, medical bills related to pregnancy and childbirth exceed $10,000, the researchers found.

“This forces very difficult trade-offs for families,” said Michelle Moniz, a University of Michigan OB-GYN who worked on the study. “Even though they have insurance, they still have these very high bills.”

Nationwide polls suggest millions of these families end up in debt, with sometimes devastating consequences.

About three-quarters of U.S. adults with debt related to pregnancy or childbirth have cut spending on food, clothing, or other essentials, KFF polling found.

About half have put off buying a home or delayed their own or their children’s education.

These burdens have spurred calls to limit what families must pay out-of-pocket for medical care related to pregnancy and childbirth.

In Massachusetts, state Sen. Cindy Friedman has proposed legislation to exempt all these bills from copays, deductibles, and other cost sharing. This would parallel federal rules that require health plans to cover recommended preventive services like annual physicals without cost sharing for patients. “We want … healthy children, and that starts with healthy mothers,” Friedman said. Massachusetts health insurers have warned the proposal will raise costs, but an independent state analysis estimated the bill would add only $1.24 to monthly insurance premiums.

Tough Lessons

For her part, Crivilare said she wishes new parents could catch their breath before paying down medical debt.

“No one is in the right frame of mind to deal with that when they have a new baby,” she said, noting that college graduates get such a break. “When I graduated with my college degree, it was like: ‘Hey, new adult, it’s going to take you six months to kind of figure out your life, so we’ll give you this six-month grace period before your student loans kick in and you can get a job.’”

Rita is now 2. The family scraped by on their payment plans, retiring the medical debt within a year, with help from Crivilare’s side job selling resources for teachers online.

But they are now back in debt, after Rita’s recurrent ear infections required surgery last year, leaving the family with thousands of dollars in new medical bills.

Crivilare said the stress has made her think twice about seeing a doctor, even for Rita. And, she added, she and her husband have decided their family is complete.

“It’s not for us to have another child,” she said. “I just hope that we can put some of these big bills behind us and give [Rita] the life that we want to give her.”

About This Project

“Diagnosis: Debt” is a reporting partnership between KFF 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. 

Additional research was conducted by the Urban Institute, which analyzed credit bureau and other demographic data on poverty, race, and health status for KFF 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 analyzed records 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 KFF Health News on a survey of its clients to explore links between medical debt and housing instability. 

KFF Health News journalists worked with KFF public opinion researchers to design and analyze the “KFF Health Care Debt Survey.” 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 KFF 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.

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

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Bill Thompson’s wife had never seen him smile with confidence. For the first 20 years of their relationship, an infection in his mouth robbed him of teeth, one by one.

“I didn’t have any teeth to smile with,” the 53-year-old of Independence, Missouri, said.

Thompson said he dealt with throbbing toothaches and painful swelling in his face from abscesses for years working as a cook at Burger King. He desperately needed to see a dentist but said he couldn’t afford to take time off without pay. Missouri is one of many states that do not require employers to provide paid sick leave.

So, Thompson would swallow Tylenol and push through the pain as he worked over the hot grill.

“Either we go to work, have a paycheck,” Thompson said. “Or we take care of ourselves. We can’t take care of ourselves because, well, this vicious circle that we’re stuck in.”

In a nation that was sharply divided about government health mandates during the covid-19 pandemic, the public has been warming to the idea of government rules providing for paid sick leave.

Before the pandemic, 10 states and the District of Columbia had laws requiring employers to provide paid sick leave. Since then, Colorado, New York, New Mexico, Illinois, and Minnesota have passed laws offering some kind of paid time off for illness. Oregon and California expanded previous paid leave laws. In Missouri, Alaska, and Nebraska, advocates are pushing to put the issue on the ballot this fall.

The U.S. is one of nine countries that do not guarantee paid sick leave, according to data compiled by the World Policy Analysis Center.

In response to the pandemic, Congress passed the Emergency Paid Sick Leave and Emergency Family and Medical Leave Expansion acts. These temporary measures allowed employees to take up to two weeks of paid sick leave for covid-related illness and caregiving. But the provisions expired in 2021.

“When the pandemic hit, we finally saw some real political will to solve the problem of not having federal paid sick leave,” said economist Hilary Wething.

Wething co-authored a recent Economic Policy Institute report on the state of sick leave in the United States. It found that more than half, 61%, of the lowest-paid workers can’t get time off for an illness.

“I was really surprised by how quickly losing pay — because you’re sick — can translate into immediate and devastating cuts to a family’s household budget,” she said.

Wething noted that the lost wages of even a day or two can be equivalent to a month’s worth of gasoline a worker would need to get to their job, or the choice between paying an electric bill or buying food. Wething said showing up to work sick poses a risk to co-workers and customers alike. Low-paying jobs that often lack paid sick leave — like cashiers, nail technicians, home health aides, and fast-food workers — involve lots of face-to-face interactions.

“So paid sick leave is about both protecting the public health of a community and providing the workers the economic security that they desperately need when they need to take time away from work,” she said.

The National Federation of Independent Business has opposed mandatory sick leave rules at the state level, arguing that workplaces should have the flexibility to work something out with their employees when they get sick. The group said the cost of paying workers for time off, extra paperwork, and lost productivity burdens small employers.

According to a report by the National Bureau of Economic Research, once these mandates go into effect, employees take, on average, two more sick days a year than before a law took effect.

Illinois’ paid time off rules went into effect this year. Lauren Pattan is co-owner of the Old Bakery Beer Co. there. Before this year, the craft brewery did not offer paid time off for its hourly employees. Pattan said she supports Illinois’ new law but she has to figure out how to pay for it.

“We really try to be respectful of our employees and be a good place to work, and at the same time we get worried about not being able to afford things,” she said.

That could mean customers have to pay more to cover the cost, Pattan said.

As for Bill Thompson, he wrote an op-ed for the Kansas City Star newspaper about his dental struggles.

“Despite working nearly 40 hours a week, many of my co-workers are homeless,” he wrote. “Without health care, none of us can afford a doctor or a dentist.”

That op-ed generated attention locally and, in 2018, a dentist in his community donated his time and labor to remove Thompson’s remaining teeth and replace them with dentures. This allowed his mouth to recover from the infections he’d been dealing with for years. Today, Thompson has a new smile and a job — with paid sick leave — working in food service at a hotel.

In his free time, he’s been collecting signatures to put an initiative on the November ballot that would guarantee at least five days of earned paid sick leave a year for Missouri workers. Organizers behind the petition said they have enough signatures to take it before the voters.

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

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HOUSTON — Patients admitted to Houston Methodist Hospital get a monitoring device about the size of a half-dollar affixed to their chest — and an unwitting role in the expanding use of artificial intelligence in health care.

The slender, battery-powered gadget, called a BioButton, records vital signs including heart and breathing rates, then wirelessly sends the readings to nurses sitting in a 24-hour control room elsewhere in the hospital or in their homes. The device’s software uses AI to analyze the voluminous data and detect signs a patient’s condition is deteriorating.

Hospital officials say the BioButton has improved care and reduced the workload of bedside nurses since its rollout last year.

“Because we catch things earlier, patients are doing better, as we don’t have to wait for the bedside team to notice if something is going wrong,” said Sarah Pletcher, system vice president at Houston Methodist.

But some nurses fear the technology could wind up replacing them rather than supporting them — and harming patients. Houston Methodist, one of dozens of U.S. hospitals to employ the device, is the first to use the BioButton to monitor all patients except those in intensive care, Pletcher said.

“The hype around a lot of these devices is they provide care at scale for less labor costs,” said Michelle Mahon, a registered nurse and an assistant director of National Nurses United, the profession’s largest U.S. union. “This is a trend that we find disturbing,” she said.

The rollout of BioButton is among the latest examples of hospitals deploying technology to improve efficiency and address a decades-old nursing shortage. But that transition has raised its own concerns, including about the device’s use of AI; polls show the public is wary of health providers relying on it for patient care.

In December 2022 the FDA cleared the BioButton for use in adult patients who are not in critical care. It is one of many AI tools now used by hospitals for tasks like reading diagnostic imaging results.

In 2023, President Joe Biden directed the Department of Health and Human Services to develop a plan to regulate AI in hospitals, including by collecting reports of patients harmed by its use.

The leader of BioIntelliSense, which developed the BioButton, said its device is a huge advance compared with nurses walking into a room every few hours to measure vital signs. “With AI, you now move from ‘I wonder why this patient crashed’ to ‘I can see this crash coming before it happens and intervene appropriately,’” said James Mault, CEO of the Golden, Colorado-based company.

The BioButton stays on the skin with an adhesive, is waterproof, and has up to a 30-day battery life. The company says the device — which allows providers to quickly notice deteriorating health by recording more than 1,000 measurements a day per patient — has been used on more than 80,000 hospital patients nationwide in the past year.

Hospitals pay BioIntelliSense an annual subscription fee for the devices and software.

Houston Methodist officials would not reveal how much the hospital pays for the technology, though Pletcher said it equates to less than a cup of coffee a day per patient.

For a hospital system that treats thousands of patients at a time — Houston Methodist has 2,653 non-ICU beds at its eight Houston-area hospitals — such an investment could still translate to millions of dollars a year.

Hospital officials say they have not made any changes in nurse staffing and have no plans to because of implementing the BioButton.

Inside the hospital’s control center for virtual monitoring on a recent morning, about 15 nurses and technicians dressed in scrubs sat in front of large monitors showing the health status of hundreds of patients they were assigned to monitor.

A red checkmark next to a patient’s name signaled the AI software had found readings trending outside normal. Staff members could click into a patient’s medical record, showing patients’ vital signs over time and other medical history. These virtual nurses, if you will, could contact nurses on the floor by phone or email, or even dial directly into the patient’s room via video call.

Nutanben Gandhi, a technician who was watching 446 patients on her monitor that morning, said that when she gets an alert, she looks at the patient’s health record to see if the anomaly can be easily explained by something in the patient’s condition or if she needs to contact nurses on the patient’s floor.

Oftentimes an alert can be easily dismissed. But identifying signs of deteriorating health can be tough, said Steve Klahn, Houston Methodist’s clinical director of virtual medicine.

“We are looking for a needle in a haystack,” he said.

Donald Eustes, 65, was admitted to Houston Methodist in March for prostate cancer treatment and has since been treated for a stroke. He is happy to wear the BioButton.

“You never know what can happen here, and having an extra set of eyes looking at you is a good thing,” he said from his hospital bed. After being told the device uses AI, the Montgomery, Texas, man said he has no problem with its helping his clinical team. “This sounds like a good use of artificial intelligence.”

Patients and nurses alike benefit from remote monitoring like the BioButton, said Pletcher of Houston Methodist.

The hospital has placed small cameras and microphones inside all patient rooms enabling nurses outside to communicate with patients and perform tasks such as helping with patient admissions and discharge instructions. Patients can include family members on the remote calls with nurses or a doctor, she said.

Virtual technology frees up on-duty nurses to provide more hands-on help, such as starting an intravenous line, Pletcher said. With the BioButton, nurses can wait to take routine vital signs every eight hours instead of every four, she said.

Pletcher said the device reduces nurses’ stress in monitoring patients and allows some to work more flexible hours because virtual care can be done from home rather than coming to the hospital. Ultimately it helps retain nurses, not drive them away, she said.

Sheeba Roy, a nurse manager at Houston Methodist, said some members of the nursing staff were nervous about relying on the device and not checking patients’ vital signs as often themselves. But testing has shown the device provides accurate information.

“After we implemented it, the staff loves it,” Roy said.

Serena Bumpus, chief executive officer of the Texas Nurses Association, said her concern with any technology is that it can be more burdensome on nurses and take away time with patients.

“We have to be hypervigilant in ensuring that we are not leaning on this to replace the ability of nurses to critically think and assess patients and validate what this device is telling us is true,” Bumpus said.

Houston Methodist this year plans to send the BioButton home with patients so the hospital can better track their progress in the weeks after discharge, measuring the quality of their sleep and checking their gait.

“We are not going to need less nurses in health care, but we have limited resources and we have to use those as thoughtfully as we can,” Pletcher said. “Looking at projected demand and seeing the supply we have coming, we will not have enough to meet demand, so anything we can do to give time back to nurses is a good thing.”

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

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James Lemons, 39, wants the bullet removed from his thigh so he can go back to work.

Sarai Holguin, a 71-year-old woman originally from Mexico, has accepted the bullet lodged near her knee as her “compa” — a close friend.

The Injured They Were Injured at the Super Bowl Parade. A Month Later, They Feel Forgotten.

In the first of our series “The Injured,” a Kansas family remembers Valentine’s Day as the beginning of panic attacks, life-altering trauma, and waking to nightmares of gunfire. Thrown into the spotlight by the shootings, they wonder how they will recover.

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Mireya Nelson, 15, was hit by a bullet that went through her jaw and broke her shoulder, where fragments remain. She’ll live with them for now, while doctors monitor lead levels in her blood for at least two years.

Nearly three months after the Kansas City Chiefs Super Bowl parade shooting left at least 24 people injured, recovery from those wounds is intensely personal and includes a surprising gray area in medicine: whether the bullets should be removed.

Medical protocol offers no clear answer. A 2016 survey of surgeons found that only about 15% of respondents worked at medical facilities that had policies on bullet removal. Doctors in the U.S. often leave bullets buried deep in a person’s body, at least at first, so as not to cause further trauma.

But as gun violence has emerged as a public health epidemic, some researchers wonder if that practice is best. Some of the wounded, like James Lemons, are left in a precarious place.

“If there’s a way to get it out, and it’s safely taken out, get it out of the person,” Lemons said. “Make that person feel more secure about themselves. And you’re not walking around with that memory in you.”

Lemons, Holguin, and Nelson are coping in very different ways.

Pain Became a Problem

Three days after the Chiefs won the Super Bowl, Lemons drove the 37 miles from Harrisonville, Missouri, to downtown Kansas City to celebrate the victory. The warehouse worker was carrying his 5-year-old daughter, Kensley, on his shoulders when he felt a bullet enter the back of his right thigh.

Gunfire erupted in the area packed with revelers, prosecutors later said, after a “verbal confrontation” between two groups. Detectives found “multiple 9mm and .40 caliber spent shell casings” at the scene. Lemons said he understood immediately what was happening.

“I know my city. We’re not shooting off fireworks,” he said.

Lemons shielded Kensley’s face as they fell to the ground so she wouldn’t hit the concrete. His first thought was getting his family — also including his wife, Brandie; 17-year-old daughter, Kallie; and 10-year-old son, Jaxson — to safety.

“I’m hit. But don’t worry about it,” Lemons recalled telling Brandie. “We gotta go.”

He carried Kensley on his shoulders as the family walked a mile to their car. His leg bled through his pants at first then stopped, he said. It burned with pain. Brandie insisted on driving him to the hospital but traffic was at a standstill so she put on her hazard lights and drove on the wrong side of the road.

“She’s like: ‘I’m getting you to a hospital. I’m tired of people being in my way,’” Lemons recalled. “I’ve never seen my wife like that. I’m looking at her like, ‘That’s kinda sexy.’”

Lemons clapped and smiled at his wife, he said, to which she replied, “What are you smiling for? You just got shot.” He stayed in quiet admiration until they were stopped by a sheriff, who summoned an ambulance, Lemons said.

He was taken to the emergency room at University Health, which admitted 12 patients from the rally, including eight with gunshot wounds. Imaging showed the bullet barely missed an artery, Lemons said. Doctors cleansed the wound, put his leg in a brace, and told him to come back in a week. The bullet was still in his leg.

“I was a little baffled by it, but I was like, ‘OK, whatever, I’ll get out of here,’” Lemons recalled.

When he returned, doctors removed the brace but explained they often leave bullets and fragments in the body — unless they grow too painful.

“I get it, but I don’t like that,” Lemons said. “Why wouldn’t you take it out if you could?”

University Health spokesperson Leslie Carto said the hospital can’t comment on individual patient care because of federal privacy laws.

Surgeons typically do remove bullets when they encounter them during surgery or they are in dangerous locations, like in the spinal canal or risking damage to an organ, said Brendan Campbell, a pediatric surgeon at Connecticut Children’s.

Campbell also chairs the Injury Prevention and Control Committee of the American College of Surgeons’ Committee on Trauma, which works on firearm injury prevention.

LJ Punch, a trauma surgeon by training and the founder of the Bullet Related Injury Clinic in St. Louis, said the origins of trauma care also help explain why bullets are so often left.

“Trauma care is war medicine,” Punch said. “It is set to be ready at any moment and any time, every day, to save a life. It is not equipped to take care of the healing that needs to come after.”

In the survey of surgeons, the most common reasons given for removing a bullet were pain, a palpable bullet lodged near the skin, or an infection. Far less common were lead poisoning and mental health concerns such as post-traumatic stress disorder and anxiety.

What patients wanted also affected their decisions, the surgeons said.

Lemons wanted the bullet out. The pain it caused in his leg radiated up from his thigh, making it difficult to move for more than an hour or two. Working his warehouse job was impossible.

“I gotta lift 100 pounds every night,” Lemons recalled telling his doctors. “I gotta lift my child. I can’t work like this.”

He has lost his income and his health insurance. Another stroke of bad luck: The family’s landlord sold their rental home soon after the parade, and they had to find a new place to live. This house is smaller, but it was important to keep the kids in the same school district with their friends, Lemons said in an interview in Kensley’s pink bedroom, the quietest spot to talk.

They’ve borrowed money and raised $6,500 on GoFundMe to help with the deposit and car repairs, but the parade shooting has left the family in a deep financial hole.

Without insurance, Lemons worried he couldn’t afford to have the bullet removed. Then he learned his surgery would be paid for by donations. He set up an appointment at a hospital north of the city, where a surgeon took measurements on his X-ray and explained the procedure.

“I need you to be involved as much as I’m going to be involved,” he remembered being told, “because — guess what — this ain’t my leg.”

The surgery is scheduled for this month.

‘We Became Friends’

Sarai Holguin isn’t much of a Chiefs fan, but she agreed to go to the rally at Union Station to show her friend the best spot to see the players on stage. It was an unseasonably warm day, and they were standing near an entrance where lots of police were stationed. Parents had babies in strollers, kids were playing football, and she felt safe.

A little before 2 p.m., Holguin heard what she thought were fireworks. People started running away from the stage. She turned to leave, trying to find her friend, but felt dizzy. She didn’t know she’d been shot. Three people quickly came to her aid and helped her to the ground, and a stranger took off his shirt and made a tourniquet to put on her left leg.

Holguin, a native of Puebla, Mexico, who became a U.S. citizen in 2018, had never seen so much chaos, so many paramedics working under such pressure. They were “anonymous heroes,” she said.

She saw them working on Lisa Lopez-Galvan, a well-known DJ and 43-year-old mother of two. Lopez-Galvan died at the scene, and was the sole fatality at the parade. Holguin was rushed to University Health, about five minutes from Union Station.

There doctors performed surgery, leaving the bullet in her leg. Holguin awoke to more chaos. She had lost her purse, along with her cellphone, so she couldn’t call her husband, Cesar. She had been admitted to the hospital under an alias — a common practice at medical centers to begin immediate care.

Her husband and daughter didn’t find her until about 10 p.m. — roughly eight hours after she’d been shot.

“It has been a huge trauma for me,” Holguin said through an interpreter. “I was injured and at the hospital without doing anything wrong. [The rally] was a moment to play, to relax, to be together.”

Holguin was hospitalized for a week, and two more outpatient surgeries quickly followed, mostly to remove dead tissue around the wound. She wore a wound VAC, or vacuum-assisted closure device, for several weeks and had medical appointments every other day.

Campbell, the trauma surgeon, said wound VACs are common when bullets damage tissue that isn’t easily reconstructed in surgery.

“It’s not just the physical injuries,” Campbell said. “Many times it’s the emotional, psychological injuries, which many of these patients take away as well.”

The bullet remains near Holguin’s knee.

“I’m going to have it for the rest of my life,” she said, saying she and the bullet became “compas,” close friends.

“We became friends so that she doesn’t do any bad to me anymore,” Holguin said with a smile.

Punch, of the Bullet Related Injury Clinic in St. Louis, said some people like Holguin are able to find a way to psychically live with bullets that remain.

“If you’re able to make a story around what that means for that bullet to be in your body, that gives you power; that gives you agency and choice,” Punch said.

Holguin’s life changed in an instant: She’s using a walker to get around. Her foot, she said, acts “like it had a stroke” — it dangles, and it’s difficult to move her toes.

The most frustrating consequence is that she cannot travel to see her 102-year-old father, still in Mexico. She has a live camera feed on her phone to see him, but that doesn’t offer much comfort, she said, and thinking about him brings tears.

She was told at the hospital that her medical bills would be taken care of, but then lots of them came in the mail. She tried to get victim assistance from the state of Missouri, but all the forms she had were in English, which made them difficult to comprehend. Renting the wound VAC alone cost $800 a month.

Finally she heard that the Mexican Consulate in Kansas City could help, and the consul pointed her to the Jackson County Prosecutor’s Office, with which she registered as an official victim. Now all of her bills are being paid, she said.

Holguin isn’t going to seek mental health treatment, as she believes one must learn to live with a given situation or it will become a burden.

“I have processed this new chapter in my life,” Holguin said. “I have never given up and I will move on with God’s help.”

‘I Saw Blood on My Hands’

Mireya Nelson was late to the parade. Her mother, Erika, told her she should leave early, given traffic and the million people expected to crowd into downtown Kansas City, but she and her teenage friends ignored that advice. The Nelsons live in Belton, Missouri, about a half hour south of the city.

Mireya wanted to hold the Super Bowl trophy. When she and her three friends arrived, the parade that had moved through downtown was over and the rally at Union Station had begun. They were stuck in the large crowd and quickly grew bored, Mireya said.

Getting ready to leave, Mireya and one of her friends were trying to call the driver of their group, but they couldn’t get cell service in the large crowd.

Amid the chaos of people and noise, Mireya suddenly fell.

“I saw blood on my hands. So then I knew I got shot. Yeah, and I just crawled to a tree,” Mireya said. “I actually didn’t know where I got shot at, at first. I just saw blood on my hands.”

The bullet grazed Mireya’s chin, shot through her jaw, broke her shoulder, and left through her arm. Bullet fragments remain in her shoulder. Doctors decided to leave them because Mireya had already suffered so much damage.

Mireya’s mother supports that decision, for now, noting they were just “fragments.”

“I think if it’s not going to harm her the rest of her life,” Erika said, “I don’t want her to keep going back in the hospital and getting surgery. That’s more trauma to her and more recovery time, more physical therapy and stuff like that.”

Bullet fragments, particularly ones only skin-deep, often push their way out like splinters, according to Punch, although patients aren’t always told about that. Moreover, Punch said, injuries caused by bullets extend beyond those with damaged tissue to the people around them, like Erika. He called for a holistic approach to recover from all the trauma.

“When people stay in their trauma, that trauma can change them for a lifetime,” Punch said.

Mireya will be tested for lead levels in her blood for at least the next two years. Her levels are fine now, doctors told the family, but if they get worse she will need surgery to remove the fragments, her mother said.

Campbell, the pediatric surgeon, said lead is particularly concerning for young children, whose developing brains make them especially vulnerable to its harmful effects. Even a tiny amount of lead — 3.5 micrograms per deciliter — is enough to report to state health officials, according to the Centers for Disease Control and Prevention.

Mireya talks about cute teenage boys’ being “fine” but also still wears Cookie Monster pajamas. She appears confused by the shootings, by all the attention at home, at school, from reporters. Asked how she feels about the fragments in her arm, she said, “I don’t really care for them.”

Mireya was on antibiotics for 10 days after her hospital stay because doctors feared there was bacteria in the wound. She has had physical therapy, but it’s painful to do the exercises. She has a scar on her chin. “A dent,” she said, that’s “bumpy.”

“They said she was lucky because if she wouldn’t have turned her head in a certain way, she could be gone,” Erika said.

Mireya faces a psychiatric evaluation and therapy appointments, though she doesn’t like to talk about her feelings.

So far, Erika’s insurance is paying the medical bills, though she hopes to get some help from the United Way’s #KCStrong fund, which raised nearly $1.9 million, or a faith-based organization called Unite KC.

Erika doesn’t want a handout. She has a job in health care and just got a promotion.

The bullet has changed the family’s life in big ways. It is part of their conversation now. They talk about how they wish they knew what kind of ammunition it was, or what it looked like.

“Like, I wanted to keep the bullet that went through my arm,” Mireya said. “I want to know what kind of bullet it was.” That brought a sigh from her mom, who said her daughter had watched too many episodes of “Forensic Files.”

Erika beats herself up about the wound, because she couldn’t protect her daughter at the parade.

“It hits me hard because I feel bad because she begged me to get off work and I didn’t go there because when you have a new position, you can’t just take off work,” Erika said. “Because I would have took the bullet. Because I would do anything. It’s mom mode.”

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When dermatologist Adewole “Ade” Adamson sees people spritzing sunscreen as if it’s cologne at the pool where he lives in Austin, Texas, he wants to intervene. “My wife says I shouldn’t,” he said, “even though most people rarely use enough sunscreen.”

At issue is not just whether people are using enough sunscreen, but what ingredients are in it.

The Food and Drug Administration’s ability to approve the chemical filters in sunscreens that are sold in countries such as Japan, South Korea, and France is hamstrung by a 1938 U.S. law that requires sunscreens to be tested on animals and classified as drugs, rather than as cosmetics as they are in much of the world. So Americans are not likely to get those better sunscreens — which block the ultraviolet rays that can cause skin cancer and lead to wrinkles — in time for this summer, or even the next.

Sunscreen makers say that requirement is unfair because companies including BASF Corp. and L’Oréal, which make the newer sunscreen chemicals, submitted safety data on sunscreen chemicals to the European Union authorities some 20 years ago.

Steven Goldberg, a retired vice president of BASF, said companies are wary of the FDA process because of the cost and their fear that additional animal testing could ignite a consumer backlash in the European Union, which bans animal testing of cosmetics, including sunscreen. The companies are asking Congress to change the testing requirements before they take steps to enter the U.S. marketplace.

In a rare example of bipartisanship last summer, Sen. Mike Lee (R-Utah) thanked Rep. Alexandria Ocasio-Cortez (D-N.Y.) for urging the FDA to speed up approvals of new, more effective sunscreen ingredients. Now a bipartisan bill is pending in the House that would require the FDA to allow non-animal testing.

“It goes back to sunscreens being classified as over-the-counter drugs,” said Carl D’Ruiz, a senior manager at DSM-Firmenich, a Switzerland-based maker of sunscreen chemicals. “It’s really about giving the U.S. consumer something that the rest of the world has. People aren’t dying from using sunscreen. They’re dying from melanoma.”

Every hour, at least two people die of skin cancer in the United States. Skin cancer is the most common cancer in America, and 6.1 million adults are treated each year for basal cell and squamous cell carcinomas, according to the Centers for Disease Control and Prevention. The nation’s second-most-common cancer, breast cancer, is diagnosed about 300,000 times annually, though it is far more deadly.

Dermatologists Offer Tips on Keeping Skin Safe and Healthy

– Stay in the shade during peak sunlight hours, 10 a.m. to 4 p.m. daylight time.– Wear hats and sunglasses.– Use UV-blocking sun umbrellas and clothing.– Reapply sunscreen every two hours.You can order overseas versions of sunscreens from online pharmacies such as Cocooncenter in France. Keep in mind that the same brands may have different ingredients if sold in U.S. stores. But importing your sunscreen may not be affordable or practical. “The best sunscreen is the one that you will use over and over again,” said Jane Yoo, a New York City dermatologist.

Though skin cancer treatment success rates are excellent, 1 in 5 Americans will develop skin cancer by age 70. The disease costs the health care system $8.9 billion a year, according to CDC researchers. One study found that the annual cost of treating skin cancer in the United States more than doubled from 2002 to 2011, while the average annual cost for all other cancers increased by just 25%. And unlike many other cancers, most forms of skin cancer can largely be prevented — by using sunscreens and taking other precautions.

But a heavy dose of misinformation has permeated the sunscreen debate, and some people question the safety of sunscreens sold in the United States, which they deride as “chemical” sunscreens. These sunscreen opponents prefer “physical” or “mineral” sunscreens, such as zinc oxide, even though all sunscreen ingredients are chemicals.

“It’s an artificial categorization,” said E. Dennis Bashaw, a retired FDA official who ran the agency’s clinical pharmacology division that studies sunscreens.

Still, such concerns were partly fed by the FDA itself after it published a study that said some sunscreen ingredients had been found in trace amounts in human bloodstreams. When the FDA said in 2019, and then again two years later, that older sunscreen ingredients needed to be studied more to see if they were safe, sunscreen opponents saw an opening, said Nadim Shaath, president of Alpha Research & Development, which imports chemicals used in cosmetics.

“That’s why we have extreme groups and people who aren’t well informed thinking that something penetrating the skin is the end of the world,” Shaath said. “Anything you put on your skin or eat is absorbed.”

Adamson, the Austin dermatologist, said some sunscreen ingredients have been used for 30 years without any population-level evidence that they have harmed anyone. “The issue for me isn’t the safety of the sunscreens we have,” he said. “It’s that some of the chemical sunscreens aren’t as broad spectrum as they could be, meaning they do not block UVA as well. This could be alleviated by the FDA allowing new ingredients.”

Ultraviolet radiation falls between X-rays and visible light on the electromagnetic spectrum. Most of the UV rays that people come in contact with are UVA rays that can penetrate the middle layer of the skin and that cause up to 90% of skin aging, along with a smaller amount of UVB rays that are responsible for sunburns.

The sun protection factor, or SPF, rating on American sunscreen bottles denotes only a sunscreen’s ability to block UVB rays. Although American sunscreens labeled “broad spectrum” should, in theory, block UVA light, some studies have shown they fail to meet the European Union’s higher UVA-blocking standards.

“It looks like a number of these newer chemicals have a better safety profile in addition to better UVA protection,” said David Andrews, deputy director of Environmental Working Group, a nonprofit that researches the ingredients in consumer products. “We have asked the FDA to consider allowing market access.”

The FDA defends its review process and its call for tests of the sunscreens sold in American stores as a way to ensure the safety of products that many people use daily, rather than just a few times a year at the beach.

“Many Americans today rely on sunscreens as a key part of their skin cancer prevention strategy, which makes satisfactory evidence of both safety and effectiveness of these products critical for public health,” Cherie Duvall-Jones, an FDA spokesperson, wrote in an email.

D’Ruiz’s company, DSM-Firmenich, is the only one currently seeking to have a new over-the-counter sunscreen ingredient approved in the United States. The company has spent the past 20 years trying to gain approval for bemotrizinol, a process D’Ruiz said has cost $18 million and has advanced fitfully, despite attempts by Congress in 2014 and 2020 to speed along applications for new UV filters.

Bemotrizinol is the bedrock ingredient in nearly all European and Asian sunscreens, including those by the South Korean brand Beauty of Joseon and Bioré, a Japanese brand.

D’Ruiz said bemotrizinol could secure FDA approval by the end of 2025. If it does, he said, bemotrizinol would be the most vetted and safest sunscreen ingredient on the market, outperforming even the safety profiles of zinc oxide and titanium dioxide.

As Congress and the FDA debate, many Americans have taken to importing their own sunscreens from Asia or Europe, despite the risk of fake products.

“The sunscreen issue has gotten people to see that you can be unsafe if you’re too slow,” said Alex Tabarrok, a professor of economics at George Mason University. “The FDA is just incredibly slow. They’ve been looking at this now literally for 40 years. Congress has ordered them to do it, and they still haven’t done it.”

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Miguel Divo, a lung specialist at Brigham and Women’s Hospital in Boston, sits in an exam room across from Joel Rubinstein, who has asthma. Rubinstein, a retired psychiatrist, is about to get a checkup and hear a surprising pitch — for the planet, as well as his health.

Divo explains that boot-shaped inhalers, which represent nearly 90% of the U.S. market for asthma medication, save lives but also contribute to climate change. Each puff from an inhaler releases a hydrofluorocarbon gas that is 1,430 to 3,000 times as powerful as the most commonly known greenhouse gas, carbon dioxide.

“That absolutely never occurred to me,” said Rubinstein. “Especially, I mean, these are little, teeny things.”

So Divo has begun offering a more eco-friendly option to some patients with asthma and other lung diseases: a plastic, gray cylinder about the size and shape of a hockey puck that contains powdered medicine. Patients suck the powder into their lungs — no puff of gas required and no greenhouse gas emissions.

“You have the same medications, two different delivery systems,” Divo said.

Patients in the United States are prescribed roughly 144 million of what doctors call metered-dose inhalers each year, according to the most recently available data published in 2020. The cumulative amount of gas released is the equivalent of driving half a million gas-powered cars for a year. So, the benefits of moving to dry powder inhalers from gas inhalers could add up.

Hydrofluorocarbon gas contributes to climate change, which is creating more wildfire smoke, other types of air pollution, and longer allergy seasons. These conditions can make breathing more difficult — especially for people with asthma and chronic obstructive pulmonary disease, or COPD — and increase the use of inhalers.

Divo is one of a small but growing number of U.S. physicians determined to reverse what they see as an unhealthy cycle.

“There is only one planet and one human race,” Divo said. “We are creating our own problems and we need to do something.”

So Divo is working with patients like Rubinstein who may be willing to switch to dry powder inhalers. Rubinstein said no to the idea at first because the powder inhaler would have been more expensive. Then his insurer increased the copay on the metered-dose inhaler so Rubinstein decided to try the dry powder.

“For me, price is a big thing,” said Rubinstein, who has tracked health care and pharmaceutical spending in his professional roles for years. Inhaling the medicine using more of his own lung power was an adjustment. “The powder is a very strange thing, to blow powder into your mouth and lungs.”

But for Rubinstein, the new inhaler works and his asthma is under control. A recent study found that some patients in the United Kingdom who use dry powder inhalers have better asthma control while reducing greenhouse gas emissions. In Sweden, where the vast majority of patients use dry powder inhalers, rates of severe asthma are lower than in the United States.

Rubinstein is one of a small number of U.S. patients who have made the transition. Divo said that, for a variety of reasons, only about a quarter of his patients even consider switching. Dry powder inhalers are often more expensive than gas propellant inhalers. For some, dry powder isn’t a good option because not all asthma or COPD sufferers can get their medications in this form. And dry powder inhalers aren’t recommended for young children or elderly patients with diminished lung strength.

Also, some patients using dry powder inhalers worry that without the noise from the spray, they may not be receiving the proper dose. Other patients don’t like the taste powder inhalers can leave in their mouths.

Divo said his priority is making sure patients have an inhaler they are comfortable using and that they can afford. But, when appropriate, he’ll keep offering the dry powder option.

Advocacy groups for asthma and COPD patients support more conversations about the connection between inhalers and climate change.

“The climate crisis makes these individuals have a higher risk of exacerbation and worsening disease,” said Albert Rizzo, chief medical officer of the American Lung Association. “We don’t want medications to contribute to that.”

Rizzo said there is work being done to make metered-dose inhalers more climate-friendly. The United States and many other countries are phasing down the use of hydrofluorocarbons, which are also used in refrigerators and air conditioners. It’s part of the global attempt to avoid the worst possible impacts of climate change. But inhaler manufacturers are largely exempt from those requirements and can continue to use the gases while they explore new options.

Some leading inhaler manufacturers have pledged to produce canisters with less potent greenhouse gases and to submit them for regulatory review by next year. It’s not clear when these inhalers might be available in pharmacies. Separately, the FDA is spending about $6 million on a study about the challenges of developing inhalers with a smaller carbon footprint.

Rizzo and other lung specialists worry these changes will translate into higher prices. That’s what happened in the early to mid-2000s when ozone-depleting chlorofluorocarbons (CFCs) were phased out of inhalers. Manufacturers changed the gas in metered-dose inhalers and the cost to patients nearly doubled. Today, many of those re-engineered inhalers remain expensive.

William Feldman, a pulmonologist and health policy researcher at Brigham and Women’s Hospital, said these dramatic price increases occur because manufacturers register updated inhalers as new products, even though they deliver medications already on the market. The manufacturers are then awarded patents, which prevent the production of competing generic medications for decades. The Federal Trade Commission says it is cracking down on this practice.

After the CFC ban, “manufacturers earned billions of dollars from the inhalers,” Feldman said of the re-engineered inhalers.

When inhaler costs went up, physicians say, patients cut back on puffs and suffered more asthma attacks. Gregg Furie, medical director for climate and sustainability at Brigham and Women’s Hospital, is worried that’s about to happen again.

“While these new propellants are potentially a real positive development, there’s also a significant risk that we’re going to see patients and payers face significant cost hikes,” Furie said.

Some of the largest inhaler manufacturers, including GSK, are already under scrutiny for allegedly inflating prices in the United States. Sydney Dodson-Nease told NPR and KFF Health News that the company has a strong record for keeping medicines accessible to patients but that it’s too early to comment on the price of the more environmentally sensitive inhalers the company is developing.

Developing affordable, effective, and climate-friendly inhalers will be important for hospitals as well as patients. The Agency for Healthcare Research and Quality recommends that hospitals looking to shrink their carbon footprint reduce inhaler emissions. Some hospital administrators see switching inhalers as low-hanging fruit on the list of climate-change improvements a hospital might make.

But Brian Chesebro, medical director of environmental stewardship at Providence, a hospital network in Oregon, said, “It’s not as easy as swapping inhalers.”

Chesebro said that even among metered-dose inhalers, the climate impact varies. So pharmacists should suggest the inhalers with the fewest greenhouse gas emissions. Insurers should also adjust reimbursements to favor climate-friendly alternatives, he said, and regulators could consider emissions when reviewing hospital performance.

Samantha Green, a family physician in Toronto, said clinicians can make a big difference with inhaler emissions by starting with the question: Does the patient in front of me really need one?

Green, who works on a project to make inhalers more environmentally sustainable, said that research shows a third of adults diagnosed with asthma may not have the disease.

“So that’s an easy place to start,” Green said. “Make sure the patient prescribed an inhaler is actually benefiting from it.”

Green said educating patients has a measurable effect. In her experience, patients are moved to learn that emissions from the approximately 200 puffs in one inhaler are equivalent to driving about 100 miles in a gas-powered car. Some researchers say switching to dry powder inhalers may be as beneficial for the climate as a patient adopting a vegetarian diet.

One of the hospitals in Green’s health care network, St. Joseph’s Health Centre, found that talking to patients about inhalers led to a significant decrease in the use of metered-dose devices. Over six months, the hospital went from 70% of patients using the puffers, to 30%.

Green said patients who switched to dry powder inhalers have largely stuck with them and appreciate using a device that is less likely to exacerbate environmental conditions that inflame asthma.

This article is from a partnership that includes WBUR, NPR, and KFF Health News.

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

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KFF Health News senior correspondent Samantha Young discussed Medicaid and climate change on KCBS Radio’s “On-Demand” podcast on April 29.

• Click here to hear Young on KCBS
• Read Young’s “AC, Power Banks, Mini Fridges: Oregon Equips Medicaid Patients for Climate Change”

KFF Health News contributor Andy Miller discussed Medicaid unwinding on WUGA’s “The Georgia Health Report” on April 26.

• Click here to hear Miller on “The Georgia Health Report”
• Read Phil Galewitz’ “Millions Were Booted From Medicaid. The Insurers That Run It Gained Medicaid Revenue Anyway.”

KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed mortality rates in rural America on The Daily Yonder’s “The Yonder Report” on April 24.

• Click here to hear Rodriguez on “The Yonder Report”
• Read Rodriguez’ “City-Country Mortality Gap Widens Amid Persistent Holes in Rural Health Care Access”

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

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The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The national abortion landscape was shaken again this week as Florida’s six-week abortion ban took effect. That leaves North Carolina and Virginia as the lone Southern states where abortion remains widely available. Clinics in those states already were overflowing with patients from across the region.

Meanwhile, in a wide-ranging interview with Time magazine, former President Donald Trump took credit for appointing the Supreme Court justices who overturned Roe v. Wade, but he steadfastly refused to say what he might do on the abortion issue if he is returned to office.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Alice Miranda Ollstein of Politico, and Rachana Pradhan of KFF Health News.

Panelists Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Rachana Pradhan KFF Health News @rachanadpradhan Read Rachana's stories.

Among the takeaways from this week’s episode:

• Florida’s new, six-week abortion ban is a big deal for the entire South, as the state had been an abortion haven for patients as other states cut access to the procedure. Some clinics in North Carolina and southern Virginia are considering expansions to their waiting and recovery rooms to accommodate patients who now must travel there for care. This also means, though, that those traveling patients could make waits even longer for local patients, including many who rely on the clinics for non-abortion services.
• Passage of a bill to repeal Arizona’s near-total abortion ban nonetheless leaves the state’s patients and providers with plenty of uncertainty — including whether the ban will temporarily take effect anyway. Plus, voters in Arizona, as well as those in Florida, will have an opportunity in November to weigh in on whether the procedure should be available in their state.
• The FDA’s decision that laboratory-developed tests must be subject to the same regulatory scrutiny as medical devices comes as the tests have become more prevalent — and as concerns have grown amid high-profile examples of problems occurring because they evaded federal review. (See: Theranos.) There’s a reasonable chance the FDA will be sued over whether it has the authority to make these changes without congressional action.
• Also, the Biden administration has quietly decided to shelve a potential ban on menthol cigarettes. The issue raised tensions over its links between health and criminal justice, and it ultimately appears to have run into electoral-year headwinds that prompted the administration to put it aside rather than risk alienating Black voters.
• In drug news, the Federal Trade Commission is challenging what it sees as “junk” patents that make it tougher for generics to come to market, and another court ruling delivers bad news for the pharmaceutical industry’s fight against Medicare drug negotiations.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: ProPublica’s “A Doctor at Cigna Said Her Bosses Pressured Her To Review Patients’ Cases Too Quickly. Cigna Threatened To Fire Her,” by Patrick Rucker, The Capitol Forum, and David Armstrong, ProPublica.

Alice Miranda Ollstein: The Associated Press’ “Dozens of Deaths Reveal Risks of Injecting Sedatives Into People Restrained by Police,” by Ryan J. Foley, Carla K. Johnson, and Shelby Lum.

Sarah Karlin-Smith: The Atlantic’s “America’s Infectious-Disease Barometer Is Off,” by Katherine J. Wu.

Rachana Pradhan: The Wall Street Journal’s “Millions of American Kids Are Caregivers Now: ‘The Hardest Part Is That I’m Only 17,” by Clare Ansberry.

Also mentioned on this week’s podcast:

• Time’s “How Far Trump Would Go,” by Eric Cortellessa.
• NPR’s “Why Is a 6-Week Abortion Ban Nearly a Total Ban? It’s About How We Date a Pregnancy,” by Selena Simmons-Duffin.
• NPR’s “’Sicko’s’ Peeno Sees Few Gains in Health Insurance,” by Julie Rovner.
• CNN’s “Walmart Will Close All of Its Health Care Clinics,” by Nathaniel Meyersohn.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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Oregon has started providing air conditioners, air purifiers and power banks to help some of its Medicaid recipients cope with soaring heat, smoky skies and other dangers of climate change.

It’s a first-in-the-nation experiment that expands a Biden administration strategy to take Medicaid beyond traditional medical care and into the realm of social services.

“Climate change is a health-care issue,” Health and Human Services Secretary Xavier Becerra told me, adding that states should be encouraged to experiment with ways to improve people’s health.

But Medicaid’s expansion into social services could lead to abuse, especially when government pays for equipment or services that everyone wants, said Sherry Glied, dean of New York University’s graduate school of public service.

“The challenge here is that air conditioners are something that both healthy people and people who have your really serious condition benefit from,” Glied said. “Most people have air conditioners for reasons that have nothing to do with their health.”

Many states are already spending billions of Medicaid dollars on services like helping homeless people get housing and preparing healthy meals for people with diabetes. But Oregon is the first to spend Medicaid money explicitly on climate-related equipment to help its most vulnerable residents — an estimated 200,000 enrollees.

Recipients must meet federal guidelines that categorize them as “facing certain life transitions,” a stringent set of requirements that disqualify most enrollees. For example, a person with an underlying medical condition that could worsen during a heat wave, and who is also at risk for homelessness or has been released from prison in the past year, could receive an air conditioner. But someone with stable housing might not qualify.

“Each person is going to be looked at as what they need for their particular circumstance,” said Dave Baden, deputy director for programs and policy at the Oregon Health Authority, which administers the state’s Medicaid program, with about 1.4 million total enrollees. The program, part of a five-year $1.1 billion effort that includes housing and nutrition services, also pays for mini fridges to keep medications cold, portable power supplies to run ventilators and other medical devices during outages, space heaters for winter and air filters to improve air quality during wildfire season.

Scientists and public health officials say climate change poses a growing health risk. The federal government’s latest climate assessment projects that more frequent and intense floods, droughts, wildfires, extreme temperatures and storms will cause more deaths, cardiovascular disease from poor air quality and other problems. 

The mounting health effects disproportionately hit low-income Americans and people of color, who are often covered by Medicaid, the state-federal health insurance program for low-income people.

Most of the 102 Oregonians who died during a deadly heat dome that settled over the Pacific Northwest in 2021 “were elderly, isolated and living with low incomes,” a report by the Oregon Health Authority found.

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The Department of Veterans Affairs has long given Vietnam veterans disability compensation for illness connected to Agent Orange, widely used to defoliate Southeast Asian battlefields during the U.S. war.

Less well known: The powerful herbicide combination was also routinely used to kill weeds at domestic military bases. Those exposed to the chemicals at the bases are still waiting for the same benefits and, in some cases, are hitting a familiar obstacle — government opacity.

In February, VA proposed a rule that for the first time would allow compensation for Agent Orange exposure at 17 U.S. bases in a dozen states where the herbicide was tested, used or stored.

But the list excludes about four dozen bases where Pat Elder, an activist and director of the environmental advocacy group Military Poisons, says he’s documented the use or storage of Agent Orange. Among them is Fort Ord, a former Army base in Monterey County, Calif. Documents gathered by Elder and others, including a report by an Army agronomist, a journal article and records related to hazardous material cleanups, establish the use of Agent Orange at the facility.

“In training areas, such as Fort Ord, where poison oak has been extremely troublesome to military personnel, a well-organized chemical war has been waged against this woody plant pest,” reads a 1956 article in the journal the Military Engineer.

“Until Fort Ord is recognized by VA as a presumptive site, it’s probably going to be a long, difficult struggle to get some kind of compensation,” said Mike Duris, a veteran who trained at the base and was later diagnosed with prostate cancer.

VA considers prostate cancer a “presumptive condition” for Agent Orange disability compensation, meaning the agency presumes the illness is linked to exposure to the chemical. It acknowledges that those who served in specific locations were likely exposed and their illnesses are tied to military service. The designation expedites affected veterans’ disability claims.

Agent Orange is a 50-50 mixture of two chemicals known as 2,4-D and 2,4,5-T. Herbicides with the same chemical structure, although slightly modified, were widely available in the 1950s and ‘60s, sold commercially and used on practically every base in the United States, said Gerson Smoger, a lawyer who argued before the Supreme Court for Vietnam veterans to have the right to sue Agent Orange manufacturers.

2,4,5-T contains the dioxin TCDD, a known carcinogen linked to a number of cancers, chronic conditions and birth defects. The Environmental Protection Agency banned the use of 2,4,5-T in the United States in 1979.

VA says it based its proposed rule on information provided by the Defense Department, and that the Pentagon’s review “found no documentation of herbicide use, testing or storage at Fort Ord.”

Patricia Kime contributed reporting.

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MEMPHIS, Tenn. — For many years, Rose Sims had no idea what was going on inside a nondescript brick building on Florida Street a couple of miles from her modest one-story home on the southwestern side of town.

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 —which began operations in the brick building in the 1970s — 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 risk of certain medical conditions, 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 — or “not in my backyard” — 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 KFF 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 — from Athens, Texas, to Groveland, Florida, and Ardmore, Oklahoma — 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 oil refinery spews a steady plume of white smoke. A coal plant has leaked ash into the ground and the groundwater. The coal plant was replaced by a natural gas power plant, and now the Tennessee Valley Authority, which provides electricity for local power companies, plans to build a new gas plant there. 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 Chunrong Jia, a professor of environmental health at the University of Memphis. Almost all the heavy industry in Shelby County — and the associated pollutants — 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.

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Monica Kelly was thrilled to learn she was expecting her second child.

The Tennessee mother was around 13 weeks pregnant when, according to a lawsuit filed against the state of Tennessee, doctors gave her the devastating news that her baby had Patau syndrome.

The genetic disorder causes serious developmental defects and often results in miscarriage, stillbirth, or death within one year of birth. Continuing her pregnancy, doctors told her, could put her at risk of infection and complications that include high blood pressure, organ failure, and death.

But they said they could not perform an abortion due to a Tennessee law banning most abortions that went into effect two months after the repeal of Roe v. Wade in June 2022, court records show.

So Kelly traveled to a northwestern Florida hospital to get an abortion while about 15 weeks pregnant. She is one of seven women and two doctors suing Tennessee because they say the state’s near-total abortion ban imperils the lives of pregnant women.

More than 25,000 women like Kelly traveled to Florida for an abortion over the past five years, state data shows. Most came from states such as Alabama, Louisiana, and Mississippi with little or no access to abortion, data from the Centers for Disease Control and Prevention shows. Hundreds traveled from as far as Texas.

But a recent Florida Supreme Court ruling paved the way for the Sunshine State to enforce a six-week ban beginning in May, effectively leaving women in much of the South with little or no access to abortion clinics. The ban could be short-lived if 60% of Florida voters in November approve a constitutional amendment adding the right to an abortion.

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In the meantime, nonprofit groups are warning they may not be able to meet the increased demand for help from women from Florida and other Southeastern states to travel for an abortion. They fear women who lack the resources will be forced to carry unwanted pregnancies to term because they cannot afford to travel to states where abortions are more available.

That could include women whose pregnancies, like Kelly’s, put them at risk.

“The six-week ban is really a problem not just for Florida but the entire Southeast,” said McKenna Kelley, a board member of the Tampa Bay Abortion Fund. “Florida was the last man standing in the Southeast for abortion access.”

Travel Bans and Stricter Limits

Supporters of the Florida restrictions aren’t backing down. Some want even stricter limits. Republican state Rep. Mike Beltran voted for both the 15-week and six-week bans. He said the vast majority of abortions are elective and that those related to medical complications make up a tiny fraction.

State data shows that 95% of abortions last year were either elective or performed due to social or economic reasons. More than 5% were related to issues with either the health of the mother or the fetus.

Beltran said he would support a ban on travel for abortions but knows it would be challenged in the courts. He would support measures that prevent employers from paying for workers to travel for abortions and such costs being tax-deductible, he said.

“I don’t think we should make it easier for people to travel for abortion,” he said. “We should put things in to prevent circumvention of the law.”

Both abortion bans were also supported by GOP state lawmaker Joel Rudman. As a physician, Rudman said, he has delivered more than 100 babies and sees nothing in the current law that sacrifices patient safety.

“It is a good commonsense law that provides reasonable exceptions yet respects the sanctity of life for both mother and child,” he said in a text message.

Last year, the first full year that many Southern states had bans in place, more than 7,700 women traveled to Florida for an abortion, an increase of roughly 59% compared with three years ago.

The Tampa Bay Abortion Fund, which is focused on helping local women, found itself assisting an influx of women from Arkansas, Georgia, Mississippi, Louisiana, and other states, Kelley said.

In 2023, it paid out more than $650,000 for appointment costs and over $67,000 in other expenses such as airplane tickets and lodging. Most of those who seek assistance are from low-income families including minorities or disabled people, Kelley said.

“We ask each person, ‘What can you contribute?’” she said. “Some say zero and that’s fine.” 

Florida’s new law will mean her group will have to pivot again. The focus will now be on helping people seeking abortions travel to other states.

But the destinations are farther and more expensive. Most women, she predicted, will head to New York, Illinois, or Washington, D.C. Clinic appointments in those states are often more expensive. The extra travel distance will mean help is needed with hotels and airfare.

North Carolina, which allows abortions through about 12 weeks of pregnancy, may be a slightly cheaper option for some women whose pregnancies are not as far along, she said.

Keeping up with that need is a concern, she said. Donations to the group soared to $755,000 in 2022, which Kelley described as “rage donations” made after the U.S. Supreme Court ended half a century of guaranteeing the federal right to an abortion.

The anger didn’t last. Donations in 2023 declined to $272,000, she said.

“We’re going to have huge problems on our hands in a few weeks,” she said. “A lot of people who need an abortion are not going to be able to access one. That’s really scary and sad.”

Gray Areas Lead to Confusion

The Chicago Abortion Fund is expecting that many women from Southeastern states will head its way.

Illinois offers abortions up until fetal viability — around 24 to 26 weeks. The state five years ago repealed its law requiring parents to be notified when their children seek an abortion.

About 3 in 10 abortions performed in Illinois two years ago — almost 17,000 — involved out-of-state residents, up from fewer than a quarter the previous year, according to state records.

The Chicago nonprofit has prided itself on not turning away requests for help over the past five years, said Qudsiyyah Shariyf, a deputy director. It is adding staffers, including Spanish-language speakers, to cope with an anticipated uptick in calls for help from Southern states. She hopes Florida voters will make the crisis short-lived.  

“We’re estimating we’ll need an additional $100,000 a month to meet that influx of folks from Florida and the South,” she said. “We know it’s going to be a really hard eight months until something potentially changes.”

Losing access to abortion, especially among vulnerable groups like pregnant teenagers and women with pregnancy complications, could also increase cases of mental illness such as depression, anxiety, and even post-traumatic stress disorder, said Silvia Kaminsky, a licensed marriage and family therapist in Miami.

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Kaminsky, who serves as board president of the American Association for Marriage and Family Therapy, said the group has received calls from therapists seeking legal guidance about whether they can help a client who wants to travel for an abortion.

That’s especially true in states such as Alabama, Georgia, and Missouri that have passed laws granting “personhood” status to fetuses. Therapists in many states, including Florida, are required to report a client who intends to harm another individual.

“It’s creating all these gray areas that we didn’t have to deal with before,” Kaminsky said.

Deborah Dorbert of Lakeland, Florida, said that Florida's 15-week abortion limit put her health at risk and that she was forced to carry to term a baby with no chance of survival.

Her unborn child was diagnosed with Potter syndrome in November 2022. An ultrasound taken at 23 weeks of pregnancy showed that the fetus had not developed enough amniotic fluid and that its kidneys were undeveloped.

Doctors told her that her child would not survive outside the womb and that there was a high risk of a stillbirth and, for her, preeclampsia, a pregnancy complication that can result in high blood pressure, organ failure, and death.

One option doctors suggested was a pre-term inducement, essentially an abortion, Dorbert said.

Dorbert and her husband were heartbroken. They decided an abortion was their safest option.

At Lakeland Regional Health, she said, she was told her surgery would have to be approved by the hospital administration and its lawyers since Florida had that year enacted its 15-week abortion restriction.

Florida’s abortion law includes an exemption if two physicians certify in writing that a fetus has a fatal fetal abnormality and has not reached viability. But a month elapsed before she got an answer in her case. Her doctor told her the hospital did not feel they could legally perform the procedure and that she would have to carry the baby to term, Dorbert said.

Lakeland Regional Health did not respond to repeated calls and emails seeking comment.

Dorbert’s gynecologist had mentioned to her that some women traveled for an abortion. But Dorbert said she could not afford the trip and was concerned she might break the law by going out of state.

At 37 weeks, doctors agreed to induce Dorbert. She checked into Lakeland Regional Hospital in March 2023 and, after a long and painful labor, gave birth to a boy named Milo.

“When he was born, he was blue; he didn’t open his eyes; he didn’t cry,” she said. “The only sound you heard was him gasping for air every so often.”

She and her husband took turns holding Milo. They read him a book about a mother polar bear who tells her cub she will always love them. They sang Bob Marley and The Wailers’ “Three Little Birds” to Milo with its chorus that “every little thing is gonna be alright.”

Milo died in his mother’s arms 93 minutes after being born.

One year later, Dorbert is still dealing with the anguish. The grief is still “heavy” some days, she said.

She and her husband have discussed trying for another child, but Florida’s abortion laws have made her wary of another pregnancy with complications.

“It makes you angry and frustrated. I could not get the health care I needed and that my doctors advised for me,” she said. "I know I can’t go through what I went through again.”

This article was produced through a partnership between KFF Health News and the Tampa Bay Times.

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

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As a young GI at Fort Ord in Monterey County, California, Dean Osborn spent much of his time in the oceanside woodlands, training on soil and guzzling water from streams and aquifers now known to be contaminated with cancer-causing pollutants.

“They were marching the snot out of us,” he said, recalling his year and a half stationed on the base, from 1979 to 1980. He also remembers, not so fondly, the poison oak pervasive across the 28,000-acre installation that closed in 1994. He went on sick call at least three times because of the overwhelmingly itchy rash.

Mounting evidence shows that as far back as the 1950s, in an effort to kill the ubiquitous poison oak and other weeds at the Army base, the military experimented with and sprayed the powerful herbicide combination known colloquially as Agent Orange.

While the U.S. military used the herbicide to defoliate the dense jungles of Vietnam and adjoining countries, it was contaminating the land and waters of coastal California with the same chemicals, according to documents.

The Defense Department has publicly acknowledged that during the Vietnam War era it stored Agent Orange at the Naval Construction Battalion Center in Gulfport, Mississippi, and the former Kelly Air Force Base in Texas, and tested it at Florida’s Eglin Air Force Base.

According to the Government Accountability Office, however, the Pentagon’s list of sites where herbicides were tested went more than a decade without being updated and lacked specificity. GAO analysts described the list in 2018 as “inaccurate and incomplete.”

Fort Ord was not included. It is among about four dozen bases that the government has excluded but where Pat Elder, an environmental activist, said he has documented the use or storage of Agent Orange.

According to a 1956 article in the journal The Military Engineer, the use of Agent Orange herbicides at Fort Ord led to a “drastic reduction in trainee dermatitis casualties.”

“In training areas, such as Fort Ord, where poison oak has been extremely troublesome to military personnel, a well-organized chemical war has been waged against this woody plant pest,” the article noted.

Other documents, including a report by an Army agronomist as well as documents related to hazardous material cleanups, point to the use of Agent Orange at the sprawling base that 1.5 million service members cycled through from 1917 to 1994.

‘The Most Toxic Chemical’

Agent Orange is a 50-50 mixture of two ingredients, known as 2,4-D and 2,4,5-T. Herbicides with the same chemical structure slightly modified were available off the shelf, sold commercially in massive amounts, and used at practically every base in the U.S., said Gerson Smoger, a lawyer who argued before the Supreme Court for Vietnam veterans to have the right to sue Agent Orange manufacturers. The combo was also used by farmers, forest workers, and other civilians across the country.

The chemical 2,4,5-T contains the dioxin 2,3,7,8-tetrachlorodibenzo-p-dioxin or TCDD, a known carcinogen linked to several cancers, chronic conditions, and birth defects. A recent Brown University study tied Agent Orange exposure to brain tissue damage similar to that caused by Alzheimer’s. Acknowledging its harm to human health, the Environmental Protection Agency banned the use of 2,4,5-T in the U.S. in 1979. Still, the other weed killer, 2,4-D is sold off-the-shelf today.

“The bottom line is TCDD is the most toxic chemical that man has ever made,” Smoger said.

For years, the Department of Veteran Affairs has provided vets who served in Vietnam disability compensation for diseases considered to be connected to exposure to Agent Orange for military use from 1962 to 1975.

Decades after Osborn’s military service, the 68-year-old veteran, who never served in Vietnam, has battled one health crisis after another: a spot on his left lung and kidney, hypothyroidism, and prostate cancer, an illness that has been tied to Agent Orange exposure.

He says many of his old buddies from Fort Ord are sick as well.

“Now we have cancers that we didn’t deserve,” Osborn said.

The VA considers prostate cancer a “presumptive condition” for Agent Orange disability compensation, acknowledging that those who served in specific locations were likely exposed and that their illnesses are tied to their military service. The designation expedites affected veterans’ claims.

But when Osborn requested his benefits, he was denied. The letter said the cancer was “more likely due to your age,” not military service.

“This didn’t happen because of my age. This is happening because we were stationed in the places that were being sprayed and contaminated,” he said.

Studies show that diseases caused by environmental factors can take years to emerge. And to make things more perplexing for veterans stationed at Fort Ord, contamination from other harmful chemicals, like the industrial cleaner trichloroethylene, have been well documented on the former base, landing it on the EPA’s Superfund site list in 1990.

“We typically expect to see the effect years down the line,” said Lawrence Liu, a doctor at City of Hope Comprehensive Cancer Center who has studied Agent Orange. “Carcinogens have additive effects.”

In February, the VA proposed a rule that for the first time would allow compensation to veterans for Agent Orange exposure at 17 U.S. bases in a dozen states where the herbicide was tested, used, or stored.

Fort Ord is not on that list either, because the VA’s list is based on the Defense Department’s 2019 update.

“It’s a very tricky question,” Smoger said, emphasizing how widely the herbicides were used both at military bases and by civilians for similar purposes. “On one hand, we were service. We were exposed. On the other hand, why are you different from the people across the road that are privately using it?”

The VA says that it based its proposed rule on information provided by the Defense Department.

“DoD’s review found no documentation of herbicide use, testing or storage at Fort Ord. Therefore, VA does not have sufficient evidence to extend a presumption of exposure to herbicides based on service at Fort Ord at this time,” VA press secretary Terrence Hayes said in an email.

The Documentation

Yet environmental activist Elder, with help from toxic and remediation specialist Denise Trabbic-Pointer and former VA physician Kyle Horton, compiled seven documents showing otherwise. They include a journal article, the agronomist report, and cleanup-related documents as recent as 1995 — all pointing to widespread herbicide use and experimentation as well as lasting contamination at the base.

Though the documents do not call the herbicide by its colorful nickname, they routinely cite the combination of 2,4-D and 2,4,5-T. A “hazardous waste minimization assessment” dated 1991 reported 80,000 pounds of herbicides used annually at Fort Ord. It separately lists 2,4,5-T as a product for which “substitutions are necessary to minimize the environmental impacts.”

The poison oak “control program” started in 1951, according to a report by Army agronomist Floyd Otter, four years before the U.S. deepened its involvement in Vietnam. Otter detailed the use of these chemicals alone and in combination with diesel oil or other compounds, at rates generally between “one to two gallons of liquid herbicide” per acre.

“In conclusion, we are fairly well satisfied with the methods,” Otter wrote, noting he was interested in “any way in which costs can be lowered or quicker kill obtained.”

An article published in California Agriculture more than a decade later includes before and after photos showing the effectiveness of chemical brush control used in a live-oak woodland at Fort Ord, again citing both chemicals in Agent Orange. The Defense Department did not respond to questions sent April 10 about the contamination or say when the Army stopped using 2,4,5-T at Fort Ord.

“What’s most compelling about Fort Ord is it was actually used for the same purpose it was used for in Vietnam — to kill plants — not just storing it,” said Julie Akey, a former Army linguist who worked at the base in the 1990s and later developed the rare blood cancer multiple myeloma.

Akey, who also worked with Elder, runs a Facebook group and keeps a list of people stationed on the base who later were diagnosed with cancer and other illnesses. So far, she has tallied more than 1,400 former Fort Ord residents who became sick.

Elder’s findings have galvanized the group to speak up during a public comment period for the VA’s proposed rule. Of 546 comments, 67 are from veterans and others urging the inclusion of Fort Ord. Hundreds of others have written in regarding the use of Agent Orange and other chemicals at their bases.

While the herbicide itself sticks around for only a short time, the contaminant TCDD can linger in sediment for decades, said Kenneth Olson, a professor emeritus of soil science at the University of Illinois Urbana-Champaign.

A 1995 report from the Army’s Sacramento Corps of Engineers, which documented chemicals detected in the soil at Fort Ord, found levels of TCDD at 3.5 parts per trillion, more than double the remediation goal at the time of 1.2 ppt. Olson calls the evidence convincing.

“It clearly supports the fact that 2,4,5-T with unknown amounts of dioxin TCDD was applied on the Fort Ord grounds and border fences,” Olson said. “Some military and civilian personnel would have been exposed.”

The Department of Defense has described the Agent Orange used in Vietnam as a “tactical herbicide,” more concentrated than what was commercially available in the U.S. But Olson said his research suggests that even if the grounds maintenance crew used commercial versions of 2,4,5-T, which was available in the federal supply catalog, the soldiers would have been exposed to the dioxin TCDD.

The half dozen veterans who spoke with KFF Health News said they want the military to take responsibility.

The Pentagon did not respond to questions regarding the upkeep of the list or the process for adding locations.

In the meantime, the Agency for Toxic Substances and Disease Registry is studying potential chemical exposure among people who worked and lived on Fort Ord between 1985 and 1994. However, the agency is evaluating drinking water for contaminants such as trichloroethylene and not contamination or pollution from other chemicals such as Agent Orange or those found in firefighting foams.

Other veterans are frustrated by the VA’s long process to recognize their illnesses and believe they were sickened by exposure at Fort Ord.

“Until Fort Ord is recognized by the VA as a presumptive site, it’s probably going to be a long, difficult struggle to get some kind of compensation,” said Mike Duris, a 72-year-old veteran diagnosed with prostate cancer four years ago who ultimately underwent surgery.

Like so many others, he wonders about the connection to his training at Fort Ord in the early ’70s — drinking the contaminated water and marching, crawling, and digging holes in the dirt.

“Often, where there is smoke, there’s fire,” Duris said.

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Hace más de 60 años, legisladores en Colorado adoptaron la idea de que la intervención temprana podría prevenir el abuso infantil y salvar vidas. El requisito del estado de que ciertos profesionales informaran a las autoridades cuando sospechaban que un niño había sido maltratado o descuidado fue una de las primeras leyes de informes obligatorios en la nación.

Desde entonces, estas leyes se han expandido a nivel nacional para abarcar más tipos de maltrato, incluido el abandono, que ahora representa la mayoría de los informes, y han aumentado el número de profesiones obligadas a informar. En algunos estados, se requiere que todos los adultos informen lo que sospechan que pueda ser un caso de abuso o negligencia.

Pero ahora hay esfuerzos en Colorado y otros estados para revertir estas leyes, argumentando que el resultado ha sido demasiados informes infundados, que perjudican desproporcionadamente a las familias que son pobres, negras, indígenas o tienen miembros con discapacidades.

“Hay una larga y deprimente historia basada en el enfoque de que nuestra respuesta principal a una familia en dificultades es reportar”, dijo Mical Raz, médica e historiadora de la Universidad de Rochester en Nueva York. “Ahora hay una gran cantidad de evidencia que demuestra que más informes no están asociados con mejores resultados para los niños”.

Stephanie Villafuerte, defensora del pueblo para la protección infantil de Colorado, supervisa un grupo de trabajo para reexaminar las leyes de informes obligatorios del estado. Dijo que el grupo busca equilibrar la necesidad de informar casos legítimos de abuso y negligencia con el deseo de eliminar informes inapropiados.

“Esto está diseñado para ayudar a las personas que se ven afectadas de manera desproporcionada”, dijo Villafuerte. “Espero que la combinación de estos esfuerzos pueda marcar la diferencia”.

A algunos críticos les preocupa que los cambios a la ley pueda dar lugar a que se pasen por alto casos de abuso. Los trabajadores médicos y de cuidado infantil que forman parte del grupo de trabajo han expresado preocupación sobre la responsabilidad legal.

Aunque es raro que las personas sean acusadas penalmente por no informar, también pueden enfrentar responsabilidad civil o repercusiones profesionales, incluidas amenazas a sus licencias.

El ser reportado a los servicios de protección infantil se está volviendo cada vez más común. Más de 1 de cada 3 niños en el país será objeto de una investigación de abuso y negligencia infantil para cuando cumplan 18 años, según una estimación que se cita con frecuencia, un estudio de 2017 financiado por la Oficina de Niños del Departamento de Salud y Servicios Humanos.

A las familias negras y nativas americanas, las familias pobres y los padres o niños con discapacidades se las mira con lupa. La investigación ha encontrado que, entre estos grupos, los padres tienen más probabilidades de perder los derechos parentales y los niños tienen más probabilidades de terminar en hogares temporales.

En una abrumadora mayoría de investigaciones, no se confirma ningún abuso o negligencia. Sin embargo, los que estudian cómo afectan estas investigaciones a las familias las describen como aterradoras y aislantes.

En Colorado, el número de informes de abuso y negligencia infantil ha aumentado un 42% en la última década, y alcanzó un récord de 117,762 el año pasado, según datos estatales. Aproximadamente, otras 100,000 llamadas a la línea directa no se contaron como informes porque eran solicitudes de información o se referían a asuntos como la manutención de los hijos o la protección de adultos, dijeron oficiales del Departamento de Servicios Humanos de Colorado.

El aumento de los informes se puede rastrear hasta una política que alienta a una amplia gama de profesionales —incluidos el personal escolar y médico, terapeutas, entrenadores, miembros del clero, bomberos, veterinarios, dentistas y trabajadores sociales— a llamar a una línea directa cada vez que tengan una preocupación.   

Estas llamadas no reflejan un aumento en el maltrato. Más de dos tercios de los informes que reciben las agencias en Colorado se desestiman porque no cumplen con el umbral para la investigación. De los niños cuyos casos se evalúan, se comprueba que el 21% ha sufrido abuso o negligencia. El número real de casos confirmados no ha aumentado en la última década.

Si bien los estudios no demuestran que las leyes que obligan a informar mantengan seguros a los niños, informó el grupo de trabajo de Colorado en enero, hay evidencia de daño. “El informe obligatorio impacta desproporcionadamente a las familias de color”, iniciando el contacto entre los servicios de protección infantil y familias que no presentan preocupaciones por abuso o negligencia, dijo el grupo de trabajo.

Este grupo también está analizando si una mejor selección podría mitigar “el impacto desproporcionado del informe obligatorio en comunidades con recursos limitados, comunidades de color y personas con discapacidades”.

También señaló que la única forma de informar preocupaciones sobre un niño es con un informe formal a una línea directa. Sin embargo, muchas de esas llamadas no son para informar sobre abuso en absoluto, sino intentos de conectar a niños y familias con recursos como alimentos o asistencia para la vivienda.

Los que llaman a la línea directa pueden querer ayudar, pero las familias que son objeto de informes erróneos de abuso y negligencia rara vez lo ven de esa manera.

Esto incluye a Meighen Lovelace, que vive en una zona rural de Colorado y que pidió a KFF Health News que no revelara su ciudad natal por temor a atraer la atención no deseada de funcionarios locales. Para la hija de Lovelace, que es neurodivergente y tiene discapacidades físicas, los informes comenzaron en 2015, cuando empezó el preescolar a los 4 años.

Los maestros y proveedores médicos que hacían los informes a menudo sugerían que la agencia de servicios humanos del condado podría ayudar a la familia de Lovelace. Pero las investigaciones que siguieron fueron invasivas y traumáticas.

“Nuestro mayor temor latente es, ‘¿van a llevarse a nuestros hijos?'”, dijo Lovelace, quien es defensora de la Colorado Cross-Disability Coalition, una organización que aboga por los derechos civiles de las personas con discapacidades.

“Tenemos miedo de pedir ayuda. Nos está impidiendo ingresar a los servicios debido al miedo al bienestar infantil”, expresó.

Funcionarios de servicios humanos, estatales y del condado, dijeron que no podían comentar sobre casos específicos.

El grupo de trabajo de Colorado planea sugerir aclarar las definiciones de abuso y negligencia bajo la ley de informe obligatorio del estado. Los que tienen que informar no deben “hacer un informe únicamente debido a la raza, clase o género de una familia/niño”, ni debido a una vivienda, muebles, ingresos o ropa inadecuados. Además, no debe haber un informe basado únicamente en el “estado de discapacidad del menor, padre o tutor”, según la recomendación preliminar del grupo.

También planean recomendar capacitación adicional para los que tienen la obligación de informar, ayuda para profesionales que están decidiendo si hacer una llamada o no, y un número de teléfono alternativo, o “línea directa cálida”, para casos en los que los que llaman creen que una familia necesita ayuda material, en lugar de vigilancia.

Los críticos dicen que estos cambios podrían dejar a más niños vulnerables a abusos no denunciados.

“Me preocupa que agregando sistemas como la línea directa cálida, se nos escabullan los casos en lo que los niños están en verdadero peligro, y que no reciban ayuda”, dijo Hollynd Hoskins, abogada que representa a víctimas de abuso infantil.

Hoskins ha demandado a profesionales que no informan sus sospechas.

El grupo de trabajo de Colorado incluye a funcionarios de salud y educación, fiscales, defensores de las víctimas, representantes del bienestar infantil del condado y abogados, así como a cinco personas que tienen experiencia en el sistema de bienestar infantil. Planea finalizar sus recomendaciones a principios del próximo año con la esperanza de que los legisladores estatales consideren cambios en la política en 2025. La implementación de cualquier nueva ley podría llevar varios años.

Colorado es uno de varios estados, incluidos Nueva York y California, que han considerado recientemente cambios para restringir, en lugar de expandir, el informe sobre supuestos abusos.

En la ciudad de Nueva York, se está capacitando a los maestros para que lo piensen dos veces antes de hacer un informe, mientras que el estado de Nueva York introdujo una “línea directa cálida” para ayudar a conectar a las familias con recursos como vivienda y cuidado infantil.

En California, un grupo de trabajo estatal destinado a cambiar del “informe obligatorio al apoyo comunitario” está planeando recomendaciones similares a las de Colorado.

Entre los que abogan por el cambio están las personas con experiencia en el sistema de bienestar infantil. Incluyen a Maleeka Jihad, quien lidera la Coalición MJCF con sede en Denver, que aboga por la abolición del informe obligatorio junto con el resto del sistema de bienestar infantil, citando su daño a las comunidades negras, nativas americanas y latinas.

“El informe obligatorio es otra forma de mantenernos vigilados por blancos [no hispanos]”, dijo Jihad. A él mismo cuando era niño lo arrebataron del cuidado de un padre amoroso y lo colocaron en el sistema temporal.

La reforma no es suficiente, dijo. “Sabemos lo que necesitamos, y generalmente son fondos y recursos”. Algunos de estos recursos —como vivienda asequible y cuidado infantil— no existen a un nivel suficiente para todas las familias de Colorado que los necesitan, dijo Jihad.  

Otros servicios están disponibles, pero hay que encontrarlos. Lovelace dijo que los informes disminuyeron después que la familia obtuvo la ayuda que necesitaba, en forma de una exención de Medicaid que pagaba por atención especializada para las discapacidades de su hija.

Ahora, la niña está en séptimo grado y le va bien. Ninguno de los trabajadores sociales que visitaron a la familia mencionó la exención, dijo Lovelace. “Realmente creo que no sabían nada al respecto”.

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

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Céline Gounder, KFF Health News’ senior fellow and editor-at-large for public health, discussed the latest bird flu developments on CBS’ “CBS Mornings” on April 25.

• Click here to watch Gounder on “CBS Mornings”

KFF Health News senior correspondent Aneri Pattani discussed the details of Tennessee’s distribution of $80 million in opioid settlement funds on WPLN’s “Morning Edition” on April 22.

• Click here to hear Pattani on “Morning Edition”
• Read Pattani’s series “Payback: Tracking the Opioid Settlement Cash”

KFF Health News contributor Andy Miller discussed water fluoridation on WUGA’s “The Georgia Health Report” on April 19.

• Click here to hear Miller on “The Georgia Health Report”
• Read Miller’s “As Bans Spread, Fluoride in Drinking Water Divides Communities Across the US”

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

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With little pomp, California launched two apps at the start of the year offering free behavioral health services to youths to help them cope with everything from living with anxiety to body acceptance.

Through their phones, young people and some caregivers can meet BrightLife Kids and Soluna coaches, some who specialize in peer support or substance use disorders, for roughly 30-minute virtual counseling sessions that are best suited to those with more mild needs, typically those without a clinical diagnosis. The apps also feature self-directed activities, such as white noise sessions, guided breathing, and videos of ocean waves to help users relax.

“We believe they’re going to have not just great impact, but wide impact across California, especially in places where maybe it’s not so easy to find an in-person behavioral health visit or the kind of coaching and supports that parents and young people need,” said Gov. Gavin Newsom’s health secretary, Mark Ghaly, during the Jan. 16 announcement.

The apps represent one of the Democratic governor’s major forays into health technology and come with four-year contracts valued at $498 million. California is believed to be the first state to offer a mental health app with free coaching to all young residents, according to the Department of Health Care Services, which operates the program.

However, the rollout has been slow. So slow that one of the companies has missed a deadline to make its app available on Android phones. Only about 15,000 of the state’s 12.6 million children and young adults have signed up for the apps, and school counselors say they’ve never heard of them.

Advocates for youth question the wisdom of investing taxpayer dollars in two private companies. Social workers are concerned the companies’ coaches won’t properly identify youths who need referrals for clinical care. And the spending is drawing lawmaker scrutiny amid a state deficit pegged at as much as $73 billion.

An App for That

Newsom’s administration says the apps fill a need for young Californians and their families to access professional telehealth for free, in multiple languages, and outside of standard 9-to-5 hours. It’s part of Newsom’s sweeping $4.7 billion master plan for kids’ mental health, which was introduced in 2022 to increase access to mental health and substance use support services. In addition to launching virtual tools such as the teletherapy apps, the initiative is working to expand workforce capacity, especially in underserved areas.

“The reality is that we are rarely 6 feet away from our devices,” said Sohil Sud, director of Newsom’s Children and Youth Behavioral Health Initiative. “The question is how we can leverage technology as a resource for all California youth and families, not in place of, but in addition to, other behavioral health services that are being developed and expanded.”

The virtual platforms come amid rising depression and suicide rates among youth and a shortage of mental health providers. Nearly half of California youths from the ages of 12 to 17 report having recently struggled with mental health issues, with nearly a third experiencing serious psychological distress, according to a 2021 study by the UCLA Center for Health Policy Research. These rates are even higher for multiracial youths and those from low-income families.

But those supporting youth mental health at the local level question whether the apps will move the needle on climbing depression and suicide rates.

“It’s fair to applaud the state of California for aggressively seeking new tools,” said Alex Briscoe of California Children’s Trust, a statewide initiative that, along with more than 100 local partners, works to improve the social and emotional health of children. “We just don’t see it as fundamental. And we don’t believe the youth mental health crisis will be solved by technology projects built by a professional class who don’t share the lived experience of marginalized communities.”

The apps, BrightLife Kids and Soluna, are operated by two companies: Brightline, a 5-year-old venture capital-backed startup; and Kooth, a London-based publicly traded company that has experience in the U.K. and has also signed on some schools in Kentucky and Pennsylvania and a health plan in Illinois. In the first five months of Kooth’s Pennsylvania pilot, 6% of students who had access to the app signed up.

Brightline and Kooth represent a growing number of health tech firms seeking to profit in this space. They beat out dozens of other bidders including international consulting companies and other youth telehealth platforms that had already snapped up contracts in California.

Although the service is intended to be free with no insurance requirement, Brightline’s app, BrightLife Kids, is folded into and only accessible through the company’s main app, which asks for insurance information and directs users to paid licensed counseling options alongside the free coaching. After KFF Health News questioned why the free coaching was advertised below paid options, Brightline reordered the page so that, even if a child has high-acuity needs, free coaching shows up first.

The apps take an expansive view of behavioral health, making the tools available to all California youth under age 26 as well as caregivers of babies, toddlers, and children 12 and under. When KFF Health News asked to speak with an app user, Brightline connected a reporter with a mother whose 3-year-old daughter was learning to sleep on her own.

‘It’s Like Crickets’

Despite being months into the launch and having millions in marketing funds, the companies don’t have a definitive rollout timeline. Brightline said it hopes to have deployed teams across the state to present the tools in person by midyear. Kooth said developing a strategy to hit every school would be “the main focus for this calendar year.”

“It’s a big state — 58 counties,” Bob McCullough of Kooth said. “It’ll take us a while to get to all of them.”

Brightline’s contract states that the company was required to launch downloadable apps for iOS and Android phones by January, but so far BrightLife Kids is available only on Apple phones. Brightline said it’s aiming to launch the Android version over the summer.

“Nobody’s really done anything like this at this magnitude, I think, in the U.S. before,” said Naomi Allen, a co-founder and the CEO of Brightline. “We’re very much in the early innings. We’re already learning a lot.”

The contracts, obtained by KFF Health News through a records request, show the companies operating the two apps could earn as much as $498 million through the contract term, which ends in June 2027, months after Newsom is set to leave office. And the state is spending hundreds of millions more on Newsom’s virtual behavioral health strategy. The state said it aims to make the apps available long-term, depending on usage.

The state said 15,000 people signed up in the first three months. When KFF Health News asked how many of those users actively engaged with the app, it declined to say, noting that data would be released this summer.

KFF Health News reached out to nearly a dozen California mental health professionals and youths. None of them were aware of the apps.

“I’m not hearing anything,” said Loretta Whitson, executive director of the California Association of School Counselors. “It’s like crickets.”

Whitson said she doesn’t think the apps are on “anyone’s” radar in schools, and she doesn’t know of any schools that are actively advertising them. Brightline will be presenting its tool to the counselor association in May, but Whitson said the company didn’t reach out to plan the meeting; she did.

Concern Over Referrals

Whitson isn’t comfortable promoting the apps just yet. Although both companies said they have a clinical team on staff to assist, Whitson said she’s concerned that the coaches, who aren’t all licensed therapists, won’t have the training to detect when users need more help and refer them to clinical care.

This sentiment was echoed by other school-based social workers, who also noted the apps’ duplicative nature — in some counties, like Los Angeles, youths can access free virtual counseling sessions through Hazel Health, a for-profit company. Nonprofits, too, have entered this space. For example, Teen Line, a peer-to-peer hotline operated by Southern California-based Didi Hirsch Mental Health Services, is free nationwide.

While the state is also funneling money to the schools as part of Newsom’s master plan, students and school-based mental health professionals voiced confusion at the large app investment when, in many school districts, few in-person counseling roles exist, and in some cases are dwindling.

Kelly Merchant, a student at College of the Desert in Palm Desert, noted that it can be hard to access in-person therapy at her school. She believes the community college, which has about 15,000 students, has only one full-time counselor and one part-time bilingual counselor. She and several students interviewed by KFF Health News said they appreciated having engaging content on their phone and the ability to speak to a coach, but all said they’d prefer in-person therapy.

“There are a lot of people who are seeking therapy, and people close to me that I know. But their insurances are taking forever, and they’re on the waitlist,” Merchant said. “And, like, you’re seeing all these people struggle.”

Fiscal conservatives question whether the money could be spent more effectively, like to bolster county efforts and existing youth behavioral health programs.

Republican state Sen. Roger Niello, vice chair of the Senate Budget and Fiscal Review Committee, noted that California is forecasted to face deficits for the next three years, and taxpayer watchdogs worry the apps might cost even more in the long run.

“What starts as a small financial commitment can become uncontrollable expenses down the road,” said Susan Shelley of the Howard Jarvis Taxpayers Association.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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More than 60 years ago, policymakers in Colorado embraced the idea that early intervention could prevent child abuse and save lives. The state’s requirement that certain professionals tell officials when they suspect a child has been abused or neglected was among the first mandatory reporting laws in the nation.

Since then, mandatory reporting laws have expanded nationally to include more types of maltreatment — including neglect, which now accounts for most reports — and have increased the number of professions required to report. In some states, all adults are required to report what they suspect may be abuse or neglect.

But now there are efforts in Colorado and other states to roll back these laws, saying the result has been too many unfounded reports, and that they disproportionately harm families that are poor, Black, or Indigenous, or have members with disabilities.

“There’s a long, depressing history based on the approach that our primary response to a struggling family is reporting,” said Mical Raz, a physician and historian at the University of Rochester in New York. “There’s now a wealth of evidence that demonstrates that more reporting is not associated with better outcomes for children.”

Stephanie Villafuerte, Colorado’s child protection ombudsman, oversees a task force to reexamine the state’s mandatory reporting laws. She said the group is seeking to balance a need to report legitimate cases of abuse and neglect with a desire to weed out inappropriate reports.

“This is designed to help individuals who are disproportionately impacted,” Villafuerte said. “I’m hoping it’s the combination of these efforts that could make a difference.”

Some critics worry that changes to the law could result in missed cases of abuse. Medical and child care workers on the task force have expressed concern about legal liability. While it’s rare for people to be criminally charged for failure to report, they can also face civil liability or professional repercussions, including threats to their licenses.

Being reported to child protective services is becoming increasingly common. More than 1 in 3 children in the United States will be the subject of a child abuse and neglect investigation by the time they turn 18, according to the most frequently cited estimate, a 2017 study funded by the Department of Health and Human Services’ Children’s Bureau.

Black and Native American families, poor families, and parents or children with disabilities experience even more oversight. Research has found that, among these groups, parents are more likely to lose parental rights and children are more likely to wind up in foster care.

In an overwhelming majority of investigations, no abuse or neglect is substantiated. Nonetheless, researchers who study how these investigations affect families describe them as terrifying and isolating.

In Colorado, the number of child abuse and neglect reports has increased 42% in the past decade and reached a record 117,762 last year, according to state data. Roughly 100,000 other calls to the hotline weren’t counted as reports because they were requests for information or were about matters like child support or adult protection, said officials from the Colorado Department of Human Services.

The increase in reports can be traced to a policy of encouraging a broad array of professionals — including school and medical staff, therapists, coaches, clergy members, firefighters, veterinarians, dentists, and social workers — to call a hotline whenever they have a concern.

These calls don’t reflect a surge in mistreatment. More than two-thirds of the reports received by agencies in Colorado don’t meet the threshold for investigation. Of the children whose cases are assessed, 21% are found to have experienced abuse or neglect. The actual number of substantiated cases has not risen over the past decade.

While studies do not demonstrate that mandatory reporting laws keep children safe, the Colorado task force reported in January, there is evidence of harm. “Mandatory reporting disproportionately impacts families of color” — initiating contact between child protection services and families who routinely do not present concerns of abuse or neglect, the task force said.

The task force said it is analyzing whether better screening might mitigate “the disproportionate impact of mandatory reporting on under-resourced communities, communities of color and persons with disabilities.”

The task force pointed out that the only way to report concerns about a child is with a formal report to a hotline. Yet many of those calls are not to report abuse at all but rather attempts to connect children and families with resources like food or housing assistance.

Hotline callers may mean to help, but the families who are the subjects of mistaken reports of abuse and neglect rarely see it that way.

That includes Meighen Lovelace, a rural Colorado resident who asked KFF Health News not to disclose their hometown for fear of attracting unwanted attention from local officials. For Lovelace’s daughter, who is neurodivergent and has physical disabilities, the reports started when she entered preschool at age 4 in 2015. The teachers and medical providers making the reports frequently suggested that the county human services agency could assist Lovelace’s family. But the investigations that followed were invasive and traumatic.

“Our biggest looming fear is, ‘Are you going to take our children away?’” said Lovelace, who is an advocate for the Colorado Cross-Disability Coalition, an organization that lobbies for the civil rights of people with disabilities. “We’re afraid to ask for help. It’s keeping us from entering services because of the fear of child welfare.”

State and county human services officials said they could not comment on specific cases.

The Colorado task force plans to suggest clarifying the definitions of abuse and neglect under the state’s mandatory reporting statute. Mandatory reporters should not “make a report solely due to a family/child’s race, class or gender,” nor because of inadequate housing, furnishings, income or clothing. Also, there should not be a report based solely on the “disability status of the minor, parent or guardian,” according to the group’s draft recommendation.

The task force plans to recommend additional training for mandatory reporters, help for professionals who are deciding whether to make a call, and an alternative phone number, or “warmline,” for cases in which callers believe a family needs material assistance, rather than surveillance.

Critics say such changes could leave more children vulnerable to unreported abuse.

“I’m concerned about adding systems such as the warmline, that kids who are in real danger are going to slip through the cracks and not be helped,” said Hollynd Hoskins, an attorney who represents victims of child abuse. Hoskins has sued professionals who fail to report their suspicions.

The Colorado task force includes health and education officials, prosecutors, victim advocates, county child welfare representatives and attorneys, as well as five people who have experience in the child welfare system. It intends to finalize its recommendations by early next year in the hope that state legislators will consider policy changes in 2025. Implementation of any new laws could take several years.

Colorado is one of several states — including New York and California — that have recently considered changes to restrain, rather than expand, reporting of abuse. In New York City, teachers are being trained to think twice before making a report, while New York state introduced a warmline to help connect families with resources like housing and child care. In California, a state task force aimed at shifting “mandated reporting to community supporting” is planning recommendations similar to Colorado’s.

Among those advocating for change are people with experience in the child welfare system. They include Maleeka Jihad, who leads the Denver-based MJCF Coalition, which advocates for the abolition of mandatory reporting along with the rest of the child welfare system, citing its damage to Black, Native American, and Latino communities.

“Mandatory reporting is another form of keeping us policed and surveillanced by whiteness,” said Jihad, who as a child was taken from the care of a loving parent and placed temporarily into the foster system. Reform isn’t enough, she said. “We know what we need, and it’s usually funding and resources.”

Some of these resources — like affordable housing and child care — don’t exist at a level sufficient for all the Colorado families that need them, Jihad said.

Other services are out there, but it’s a matter of finding them. Lovelace said the reports ebbed after the family got the help it needed, in the form of a Medicaid waiver that paid for specialized care for their daughter’s disabilities. Their daughter is now in seventh grade and doing well.

None of the caseworkers who visited the family ever mentioned the waiver, Lovelace said. “I really think they didn’t know about it.”

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For decades, concerns about automobile pollution have focused on what comes out of the tailpipe. Now, researchers and regulators say, we need to pay more attention to toxic emissions from tires as vehicles roll down the road.

At the top of the list of worries is a chemical called 6PPD, which is added to rubber tires to help them last longer. When tires wear on pavement, 6PPD is released. It reacts with ozone to become a different chemical, 6PPD-q, which can be extremely toxic — so much so that it has been linked to repeated fish kills in Washington state.

The trouble with tires doesn’t stop there. Tires are made primarily of natural rubber and synthetic rubber, but they contain hundreds of other ingredients, often including steel and heavy metals such as copper, lead, cadmium, and zinc.

As car tires wear, the rubber disappears in particles, both bits that can be seen with the naked eye and microparticles. Testing by a British company, Emissions Analytics, found that a car’s tires emit 1 trillion ultrafine particles per kilometer driven — from 5 to 9 pounds of rubber per internal combustion car per year.

And what’s in those particles is a mystery, because tire ingredients are proprietary.

“You’ve got a chemical cocktail in these tires that no one really understands and is kept highly confidential by the tire manufacturers,” said Nick Molden, CEO of Emissions Analytics. “We struggle to think of another consumer product that is so prevalent in the world and used by virtually everyone, where there is so little known of what is in them.”

Regulators have only begun to address the toxic tire problem, though there has been some action on 6PPD.

The chemical was identified by a team of researchers, led by scientists at Washington State University and the University of Washington, who were trying to determine why coho salmon returning to Seattle-area creeks to spawn were dying in large numbers.

Working for the Washington Stormwater Center, the scientists tested some 2,000 substances to determine which one was causing the die-offs, and in 2020 they announced they’d found the culprit: 6PPD.

The Yurok Tribe in Northern California, along with two other West Coast Native American tribes, have petitioned the Environmental Protection Agency to prohibit the chemical. The EPA said it is considering new rules governing the chemical. “We could not sit idle while 6PPD kills the fish that sustain us,” said Joseph L. James, chairman of the Yurok Tribe, in a statement. “This lethal toxin has no place in any salmon-bearing watershed.”

California has begun taking steps to regulate the chemical, last year classifying tires containing it as a “priority product,” which requires manufacturers to search for and test substitutes.

“6PPD plays a crucial role in the safety of tires on California’s roads and, currently, there are no widely available safer alternatives,” said Karl Palmer, a deputy director at the state’s Department of Toxic Substances Control. “For this reason, our framework is ideally suited for identifying alternatives to 6PPD that ensure the continued safety of tires on California’s roads while protecting California’s fish populations and the communities that rely on them.”

The U.S. Tire Manufacturers Association says it has mobilized a consortium of 16 tire manufacturers to carry out an analysis of alternatives. Anne Forristall Luke, USTMA president and CEO, said it “will yield the most effective and exhaustive review possible of whether a safer alternative to 6PPD in tires currently exists.”

Molden, however, said there is a catch. “If they don’t investigate, they aren’t allowed to sell in the state of California,” he said. “If they investigate and don’t find an alternative, they can go on selling. They don’t have to find a substitute. And today there is no alternative to 6PPD.”

California is also studying a request by the California Stormwater Quality Association to classify tires containing zinc, a heavy metal, as a priority product, requiring manufacturers to search for an alternative. Zinc is used in the vulcanization process to increase the strength of the rubber.

When it comes to tire particles, though, there hasn’t been any action, even as the problem worsens with the proliferation of electric cars. Because of their quicker acceleration and greater torque, electric vehicles wear out tires faster and emit an estimated 20% more tire particles than the average gas-powered car.

A recent study in Southern California found tire and brake emissions in Anaheim accounted for 30% of PM2.5, a small-particulate air pollutant, while exhaust emissions accounted for 19%. Tests by Emissions Analytics have found that tires produce up to 2,000 times as much particle pollution by mass as tailpipes.

These particles end up in water and air and are often ingested. Ultrafine particles, even smaller than PM2.5, are also emitted by tires and can be inhaled and travel directly to the brain. New research suggests tire microparticles should be classified as a pollutant of “high concern.”

In a report issued last year, researchers at Imperial College London said the particles could affect the heart, lungs, and reproductive organs and cause cancer.

People who live or work along roadways, often low-income, are exposed to more of the toxic substances.

Tires are also a major source of microplastics. More than three-quarters of microplastics entering the ocean come from the synthetic rubber in tires, according to a report from the Pew Charitable Trusts and the British company Systemiq.

And there are still a great many unknowns in tire emissions, which can be especially complex to analyze because heat and pressure can transform tire ingredients into other compounds.

One outstanding research question is whether 6PPD-q affects people, and what health problems, if any, it could cause. A recent study published in Environmental Science & Technology Letters found high levels of the chemical in urine samples from a region of South China, with levels highest in pregnant women.

The discovery of 6PPD-q, Molden said, has sparked fresh interest in the health and environmental impacts of tires, and he expects an abundance of new research in the coming years. “The jigsaw pieces are coming together,” he said. “But it’s a thousand-piece jigsaw, not a 200-piece jigsaw.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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Durante décadas, las preocupaciones sobre la contaminación automovilística se han centrado en lo que sale del tubo de escape. Ahora, investigadores y reguladores dicen que se necesita prestar más atención a las emisiones tóxicas de los neumáticos mientras los vehículos circulan por las carreteras.

Y primero en la lista de preocupaciones se encuentra un producto químico llamado 6PPD, que se agrega a los neumáticos para que duren más tiempo. Cuando los neumáticos se van desgastando por el roce con el pavimento, liberan 6PPD.

Al entrar en contacto con el ozono, esta sustancia reacciona y se convierte en un producto químico diferente, el 6PPD-q, que puede ser extremadamente tóxico, tanto que se ha relacionado con muertes de peces en el estado de Washington.

Pero los problemas no terminan ahí.

Los neumáticos están hechos principalmente de goma natural y goma sintética, pero contienen cientos de otros ingredientes, que a menudo incluyen acero y metales pesados como cobre, plomo, cadmio y zinc.

A medida que los neumáticos se desgastan, la goma desaparece en partículas, tanto trozos que se pueden ver a simple vista como micropartículas. Las pruebas realizadas por una empresa británica, Emissions Analytics, encontraron que los neumáticos de un automóvil emiten 1,000 millones de partículas ultrafinas por kilómetro conducido: entre 5 y 9 libras de goma por automóvil de combustión interna por año.

Y lo que hay en esas partículas es un misterio, porque los ingredientes de los neumáticos son de propiedad exclusiva.

“Tienes un cóctel químico en estos neumáticos que nadie realmente entiende y que los fabricantes de neumáticos mantienen en secreto”, dijo Nick Molden, CEO de Emissions Analytics. “Nos resulta difícil pensar en otro producto de consumo tan prevalente en el mundo y utilizado prácticamente por todos, donde se sepa tan poco sobre lo que contiene”.

Los reguladores apenas han comenzado a abordar el problema de la toxicidad en los neumáticos, aunque ha habido algunas acciones sobre el 6PPD.

El producto químico fue identificado por un equipo de investigadores, dirigido por científicos de la Universidad Estatal de Washington y de la Universidad de Washington, que estaban tratando de determinar por qué estaban muriendo masivamente los salmones coho que regresaban a arroyos del área de Seattle para desovar.

Trabajando para el Washington Stormwater Center, los científicos probaron alrededor de 2,000 sustancias para determinar cuál estaba causando las muertes, y en 2020 anunciaron que habían encontrado al culpable: 6PPD.

La Tribu Yurok en el norte de California, junto con otras dos tribus nativas de la costa oeste, han pedido a la Agencia de Protección Ambiental (EPA) que prohíba el producto químico. La EPA dijo que está considerando nuevas normas que lo regulen.

“No podríamos quedarnos de brazos cruzados mientras el 6PPD mata a los peces que nos sostienen”, dijo Joseph L. James, presidente de la Tribu Yurok, en un comunicado. “Esta toxina letal no tiene lugar en ninguna cuenca salmonera”.

California ha comenzado a tomar medidas para regular el producto químico. El año pasado comenzó a calificar a los neumáticos que lo contienen como un “producto prioritario”, lo que requiere que los fabricantes busquen y prueben sustitutos.

“El 6PPD juega un papel crucial en la seguridad de los neumáticos en las carreteras de California y, actualmente, no hay alternativas más seguras ampliamente disponibles”, dijo Karl Palmer, subdirector del Departamento de Control de Sustancias Tóxicas del estado. “Por esta razón, nuestro marco es ideal para identificar alternativas al 6PPD que sigan garantizado la seguridad de los neumáticos en las carreteras de California, protegiendo al mismo tiempo las poblaciones de peces y las comunidades que dependen de ellas”.

La Asociación de Fabricantes de Neumáticos de EE.UU. (USTMA) dice que ha movilizado un consorcio de 16 fabricantes para llevar a cabo un análisis de alternativas. Anne Forristall Luke, presidenta y CEO de la USTMA, dijo que “proporcionará la revisión más efectiva y exhaustiva posible de si existe una alternativa más segura al 6PPD en los neumáticos”.

Sin embargo, Molden dijo que hay un inconveniente. “Si no investigan, no se les permite vender en el estado de California”, dijo. “Si investigan y no encuentran una alternativa, pueden seguir vendiendo. No tienen que encontrar un sustituto. Y hoy no hay alternativa al 6PPD”.

California también está estudiando una solicitud de la California Stormwater Quality Association para clasificar los neumáticos que contienen zinc, un metal pesado, como un producto prioritario, lo que requeriría que los fabricantes busquen una alternativa. El zinc se utiliza en el proceso de vulcanización para aumentar la resistencia del caucho.

Sin embargo, cuando se trata de partículas de neumáticos, no ha habido ninguna acción, incluso cuando el problema empeora con la proliferación de automóviles eléctricos. Debido a su aceleración más rápida, los vehículos eléctricos desgastan los neumáticos más rápido y emiten aproximadamente un 20% más de partículas que los de un automóvil de gasolina promedio.

Un estudio reciente en el sur de California encontró que las emisiones de neumáticos y frenos en Anaheim representaban el 30% de PM2.5, un contaminante atmosférico de partículas pequeñas, mientras que las emisiones de escape representaban el 19%.

Las pruebas realizadas por Emissions Analytics han encontrado que los neumáticos producen hasta 2,000 veces más contaminación por partículas en masa que los tubos de escape. Estas partículas acaban en el agua y el aire y a menudo se ingieren. Los neumáticos también emiten partículas ultrafinas, incluso más pequeñas que PM2.5, que pueden ser inhaladas y viajar directamente al cerebro.

Nuevas investigaciones sugieren que las micropartículas de neumáticos deberían ser clasificadas como un contaminante de “alta preocupación”. En un informe el año pasado, investigadores del Imperial College de Londres dijeron que las partículas podrían afectar al corazón, los pulmones y los órganos reproductivos, y causar cáncer.

Las personas que viven o trabajan junto a carreteras, muchas veces de bajos ingresos, están expuestas a más de estas sustancias tóxicas.

Los neumáticos también son una fuente importante de microplásticos. Más de tres cuartas partes de los microplásticos que llegan al océano provienen de la goma sintética de los neumáticos, según un informe del Pew Charitable Trusts y la empresa británica Systemiq.

Y todavía hay muchas incógnitas sobre las emisiones de neumáticos, que pueden ser especialmente complejas de analizar porque el calor y la presión pueden transformar los ingredientes del neumático en otros compuestos.

Una pregunta pendiente de investigación es si el 6PPD-q afecta a las personas y qué problemas de salud, si los hay, podría causar. Un estudio reciente publicado en Environmental Science & Technology Letters encontró altos niveles del producto químico en muestras de orina de una región del sur de China, con niveles más altos en mujeres embarazadas.

Molden dijo que el descubrimiento del 6PPD-q ha generado un nuevo interés en el impacto sanitario y ambiental de los neumáticos, y espera una gran cantidad de nuevas investigaciones en los próximos años. “Las piezas del rompecabezas se están armando”, dijo. “Pero es un rompecabezas de mil piezas, no de doscientas”.

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

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This story can be republished for free (details).