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Legal Research Reports: Mass Timber Construction

The Law Library of Congress is proud to present the report, Mass Timber Construction

This report examines the use of mass timber, also known as cross-laminated timber, in the construction of buildings in ten countries. According to Natural Resources Canada, mass timber is “a transformative technology made by affixing or gluing together many pieces of wood veneers, flakes or dimension lumber to form larger, stronger pieces such as panels and beams.” The report consists of a comparative summary followed by individual country surveys for ten countries. The countries surveyed are Australia, Austria, Canada, Italy, Japan, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. (September 2022)

Categories: Research & Litigation

Law Library of Congress Report Examines the Canadian Emergencies Act

In Custodia Legis - 10 hours 49 min ago

The following is a guest post by Michael Chalupovitsch, a foreign law specialist at the Law Library of Congress covering Canada and Caribbean jurisdictions.

A recently published Law Library of Congress report, entitled Canada: the Emergencies Act, examines the history and operation of emergency legislation at the federal level in Canada.

Title page of the Law Library’s report “Canada: The Emergencies Act.”

The genesis of the Emergencies Act was the need to reform the previous War Measures Act, which was in force during the two world wars, and the October Crisis of 1970. Critics of the War Measures Act alleged that it trampled on human rights, such as due process, freedom of speech, and freedom of assembly. It was used, for example, to intern Japanese-Canadians during World War II and to detain many sympathizers of the Quebec separatist movement in 1970. With the introduction of the Canadian Charter of Rights and Freedoms in 1982, a new law was needed to address those concerns.

The Emergencies Act, enacted in 1988, grants the government sweeping powers in the event of a public order, public health, international, or war emergency, but the exercise of these powers must be compliant with the constitutional rights guaranteed in the Charter, or, if they run afoul of the Charter, must be “reasonably justified in a free and democratic society” using a proportionality test.

To date, the federal government has only invoked the Emergencies Act once, in 2022, during the occupation of downtown Ottawa and blockade of border crossings by opponents of COVID-19 mitigation measures. The declaration of a public order emergency enabled the federal government to promulgate regulations restricting gatherings, implementing the removal of blockades through force, and freezing the bank accounts of organizers of the blockades.

The declaration also set in motion a variety of accountability mechanisms including parliamentary debate and concurrence in the declaration, a multi-partisan parliamentary committee, and a formal commission of inquiry. The commission is currently hearing from witnesses, including organizers of the blockades, police officials, municipal politicians, and federal politicians including the prime minister. The commission’s report on the circumstances leading up to the declaration and the justification of the declaration is due to be released in February 2023.

The report is part of the Legal Reports (Publications of the Law Library of Congress) collection which contains to date more than 3,000 current and historical reports, authored by Law Library of Congress specialists and analysts on a variety of legal topics.

Law Library of Congress Resources

Block, Eric S. & Goldenberg, Adam, Emergency law in Canada: commentary and legislation, Toronto, Ontario: LexisNexis Canada Inc., 2021,

Legaré, Anne, La crise d’octobre, le monde et nous, Montreal, Quebec, Les Presses de l’Université de Montréal, 2021,

Stranger-Ross, Jordan, ed., Landscapes of injustice: a new perspective on the internment and dispossession of Japanese Canadians, Montreal, Quebec, McGill-Queen’s University Press, 2020,

Subscribe to In Custodia Legis – it’s free! – to receive interesting posts drawn from the Law Library of Congress’s vast collections and our staff’s expertise in U.S., foreign, and international law.

Categories: Research & Litigation

Child Tax Credit Expansion Is Especially Important to Rural Families

Center on Budget and Policy Priorities - Tue, 11/29/2022 - 9:36am
Under current law, an estimated 3 million children living in rural areas are left out of the full $2,000 Child Tax Credit because their families’ incomes are too low. Rural communities would benefit disproportionately from an expansion that makes the credit fully available to children in families with low incomes who currently receive less than the full amount or no credit at all. This crucial investment in children living in rural areas, which includes children of diverse racial and ethnic backgrounds, should be a bipartisan priority during year-end tax negotiations. Additional income such as
Categories: Benefits, Poverty

Keep Out! A Radioactive Waste Primer

In Custodia Legis - Tue, 11/29/2022 - 8:52am

The following is a guest post by Molly Benson, an intern with the Digital Resources Division of the Law Library of Congress. She is a current M.L.I.S. student at the University of Washington

Radiation warning sign in front of A&B No. 3 Mine on Navajo Nation. Source: U.S. Environmental Protection Agency.

Since the rise of the nuclear power industry in the 1950s, radioactive waste has been a contentious subject in the United States, particularly highly radioactive waste resulting from nuclear power and defense. The Atomic Energy Act of 1954 (Pub. L. 83-703, 68 Stat. 919) first established regulation around the disposal of radioactive waste. Later came the Uranium Mill Tailings Radiation Control Act of 1978 (Pub. L. 95-605, 92 Stat. 3021), Nuclear Waste Policy Act of 1982 (Pub. L. 97-425, 96 Stat. 2201), and Low-level Radioactive Waste Policy Amendments Act of 1985 (Pub. L. 99-240, 99 Stat. 1842). These pieces of legislation outline the proper disposal and regulation of radioactive material, which is overseen by the U.S. Nuclear Regulatory Commission (NRC).

Radioactive waste is produced by multiple industries, including nuclear power generation, military defense, research, medicine, and mining. According to the EPA, there are five categories of radioactive waste in the United States, each with different disposal guidelines.

I will provide a brief overview of high-level waste, low-level waste, and uranium mining and mill tailings, which make up most of the radioactive waste in the United States.

High-Level Waste

Nuclear power plant. Highsmith, Carol M. [Between 1980 and 2006]. Library of Congress, Prints & Photographs Division.

Material that can be fatal within short periods of direct exposure is considered high-level waste (HLW). It comes from commercial nuclear power sites and military defense research and development programs. Some of this material continues to be dangerously radioactive for 10,000 years or more (page 28). Most HLW in the U.S. is spent nuclear fuel from commercial power generation.

A spent fuel pool at the San Onofre Nuclear Generating Station near San Clemente, Calif. Source: U.S. Nuclear Regulatory Commission (Public Domain)

Commercial nuclear power plants use fuel rods in their process. When these spent fuel rods are removed from a nuclear reactor they are very hot and highly radioactive. To cool them down and block the radiation, the rods are submerged in large pools of water. After 7-10 years (page 29) of cooling, the spent fuel rods can be transferred to dry storage casks. These storage containers were developed in the 1970s and 80s when many spent fuel pools were reaching capacity at reactor sites across the country.

The final step for disposal of HLW would be burial in a geologic repository deep underground. However, there is currently no geologic repository for HLW in the United States, so most of this type of waste is stored at the site where it was produced. Today, there are approximately 80,000 metric tons of high-level waste stored at 57 operating reactor sites and 23 decommissioned sites.

Low-Level Waste

Most of the waste that comes out of commercial nuclear power generation is considered low-level waste (LLW). The classification of LLW also includes contaminated materials such as clothing, rags, filters, and waste incidental to some medical equipment and research. As the EPA notes: “Much of this waste looks like common items such as paper, rags, plastic bags, protective clothing, cardboard, and packaging material.” The level of radioactivity of LLW ranges broadly from just above background levels to highly radioactive.

Under the Atomic Energy Act of 1954, the NRC can delegate state regulatory authority to participating states, called agreement states. Agreement States manage the regulation of LLW disposal and mill tailings within their state, with the support and oversight of the NRC. There are currently 39 agreement states.

There are four sites in the U.S. currently accepting low-level waste. All are located in Agreement States.

  • EnergySolutions Barnwell Operations, Barnwell, South Carolina
  • S. Ecology, Richland, Washington
  • EnergySolutions Clive Operations, Clive, Utah
  • Waste Control Specialists, Andrews, Texas

In 2020, over one million cubic feet of radioactive waste was disposed of in these four sites. Most of the material went to Clive, Utah, while the site with the highest radioactivity is in Andrews County, Texas.

Uranium Mining and Mill Tailings

A photo of yellow cake uranium, a solid form of uranium. Dec. 1, 2014. Source: Photo by Flickr user U.S. Nuclear Regulatory Commission. Courtesy of Energy Fuels Inc. Used under Attribution 2.0 Generic (CC BY 2.0).

Uranium is the primary source of fuel for nuclear power generation and nuclear defense. Mining and the process of extracting uranium from the raw ore, called milling, produces radioactive waste. Material extracted from uranium mining sites can be dangerously radioactive, and, if not disposed of properly, the radioactive particles from mill waste may be blown by the wind to populated areas and contaminate water sources. Additionally, uranium decays to radium, which emits a harmful gas called radon. The Uranium Mill Tailings Radiation Control Act of 1978 (Pub. L. 95-604, 92 Stat. 3021) added uranium mill tailings to the list of byproduct material regulated by the NRC.

Mill Tailings

In 1995, the NRC updated uranium mill licensing guidelines, expanding the type of material uranium mills could receive beyond ore obtained from uranium mining. An NRC regulatory issuing summary in 2000 (RIS 00-023) made these updated guidelines even more flexible.  A mill can apply for an amendment license to receive “alternate feed” in order to extract uranium from the feed and store the resulting waste in the mill’s impoundments – this feed can be anything from material resulting from rare earth extraction to waste from water treatment systems. The material received must be processed to produce uranium.

Once operations cease at a mill, the impoundments must be closed in a way that ensures the radioactivity level is controlled for at least 200 years, and there must be reasonable assurance that it can be controlled for 1,000 years. Alternatively, all waste must be removed from impoundments and the site decontaminated after closure. Today, most uranium mines and mills in the United States are decommissioned or undergoing decommissioning.

Uranium Mine Clean-Up Projects

The Navajo Abandoned Mine Lands Reclamation Program closed portals like the one shown here at the Charles Keith mine. Source: U.S. Environmental Protection Agency,

Home made from materials containing uranium. Source: U.S. Environmental Protection Agency,











Before 1978, much of the waste from mining was piled up outside of the mine shaft or even used as construction material. In mining towns such as Moab, UT and Grand Junction, CO, several structures were built using mine waste. Many of these abandoned uranium mines and contaminated structures are located on the Colorado Plateau in Utah, Arizona, Colorado, and New Mexico, as well as Wyoming.

Uranium Remembrance Day for the Spill at the UNC Mill. Source: U.S. Environmental Protection Agency,

Since 2007, the Environmental Protection Agency (EPA) has overseen a project cleaning up the 523 abandoned mines and numerous contaminated buildings in the Navajo Nation. The project is funded by enforcement agreements and settlements with parties responsible for the abandoned mines. As of 2018, 46 priority mines have been assessed and 1,100 homes have been screened for radiation and uranium contamination, as well as a number of informational materials created such as Gamma Goat in… The Dangers of Uranium! The contamination by abandoned uranium mines on Navajo land was recently added to the Administrator’s Emphasis List of Superfund Sites targeted for immediate, intense action.

In 2014, the DOE submitted a report to congress on Defense-Related Uranium Mines (DRUM). The report identified 4,225 abandoned mines that operated between 1947 and 1970 and sold uranium to the Atomic Energy Commission (the NRC’s predecessor). Some of these mines have contaminated groundwater and surrounding areas. Roughly 85% of the mines surveyed by the DOE have not been cleaned up or reclaimed.

Total defense-related uranium mines. Source: U.S. Department of Energy,

The DRUM project continues with the purpose of working with other agencies, such as the Bureau of Land Management, Department of the Interior, and Environmental Protection Agency, to mitigate the hazards abandoned mines pose to the public.

Subscribe to In Custodia Legis – it’s free! – to receive interesting posts drawn from the Law Library of Congress’s vast collections and our staff’s expertise in U.S., foreign, and international law.

Categories: Research & Litigation

Congressional Reactions to the Assassination of President Kennedy in the Bound Congressional Record

In Custodia Legis - Mon, 11/28/2022 - 10:00am

On November 22, 1963, President John Kennedy was felled by Lee Harvey Oswald as his motorcade drove through Dealey Plaza in downtown Dallas, Texas. Most Americans who were alive during that time still remember exactly where they were when they learned of this tragic event. Since the 59th anniversary of President Kennedy’s death just occurred, I decided to try to locate the first congressional reactions to the assassination in the Congressional Record. Since I knew the date, I decided to browse the Congressional Record by date rather than perform a keyword search. From the homepage, I clicked on “Congressional Record” at the top. Under “find an issue of the record,” I used the calendar to choose November 22, 1963. I took a look at the Daily Digest, a section of the Congressional Record that provides a summary of the daily proceedings, but did not find much that was relevant. However, when I took a look at the Daily Digest for November 25, 1963, which was the Monday following the assassination, I found these tributes to President Kennedy from Senators Mansfield and Dirksen.

A detail from page 22699 from the November 25th, 1963 Bound Congressional Record.

If you are interested in starting your search with a keyword, as opposed to a date, here is how you can search for and find congressional reactions to historic moments in American history. From the global search box drop-down menu, choose “Congressional Record.” Enter your search terms. You can put the terms in quotation marks to search for them as an exact phrase. On the results screen, click “show keywords in context” at the top left, so you can see snippets of where your search terms appear underneath each result. This will spare you the time of clicking on each individual result. You may also want to use the sort feature at the top to sort by date or the filter menu on the left to narrow down your results to a particular Congress.

The Bound Congressional Record on now provides coverage dating back to the 52nd Congress (1891 – 1893). Have you found any interesting congressional reactions to significant moments in American history? Let us know in the comments.

Subscribe to In Custodia Legis – it’s free! – to receive interesting posts drawn from the Law Library of Congress’s vast collections and our staff’s expertise in U.S., foreign, and international law.

Categories: Research & Litigation

Should Older Seniors Risk Major Surgery? New Research Offers Guidance

Kaiser Health News - Mon, 11/28/2022 - 5:00am

Nearly 1 in 7 older adults die within a year of undergoing major surgery, according to an important new study that sheds much-needed light on the risks seniors face when having invasive procedures.

Especially vulnerable are older patients with probable dementia (33% die within a year) and frailty (28%), as well as those having emergency surgeries (22%). Advanced age also amplifies risk: Patients who were 90 or older were six times as likely to die than those ages 65 to 69.

The study in JAMA Surgery, published by researchers at Yale School of Medicine, addresses a notable gap in research: Though patients 65 and older undergo nearly 40% of all surgeries in the U.S., detailed national data about the outcomes of these procedures has been largely missing.

“As a field, we’ve been really remiss in not understanding long-term surgical outcomes for older adults,” said Dr. Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston.

Of particular importance is information about how many seniors die, develop disabilities, can no longer live independently, or have a significantly worsened quality of life after major surgery.

“What older patients want to know is, ‘What’s my life going to look like?’” Cooper said. “But we haven’t been able to answer with data of this quality before.”

In the new study, Dr. Thomas Gill and Yale colleagues examined claims data from traditional Medicare and survey data from the National Health and Aging Trends study spanning 2011 to 2017. (Data from private Medicare Advantage plans was not available at that time but will be included in future studies.)

Invasive procedures that take place in operating rooms with patients under general anesthesia were counted as major surgeries. Examples include procedures to replace broken hips, improve blood flow in the heart, excise cancer from the colon, remove gallbladders, fix leaky heart valves, and repair hernias, among many more.

Older adults tend to experience more problems after surgery if they have chronic conditions such as heart or kidney disease; if they are already weak or have difficulty moving around; if their ability to care for themselves is compromised; and if they have cognitive problems, noted Gill, a professor of medicine, epidemiology, and investigative medicine at Yale.

Two years ago, Gill’s team conducted research that showed 1 in 3 older adults had not returned to their baseline level of functioning six months after major surgery. Most likely to recover were seniors who had elective surgeries for which they could prepare in advance.

In another study, published last year in the Annals of Surgery, his team found that about 1 million major surgeries occur in individuals 65 and older each year, including a significant number near the end of life. Remarkably, data documenting the extent of surgery in the older population has been lacking until now.

“This opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?” said Dr. Clifford Ko, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

As an example of this kind of decision-making, Ko described a patient who, at 93, learned he had early-stage colon cancer on top of preexisting liver, heart, and lung disease. After an in-depth discussion and being told that the risk of poor results was high, the patient decided against invasive treatment.

“He decided he would rather take the risk of a slow-growing cancer than deal with a major operation and the risk of complications,” Ko said.

Still, most patients choose surgery. Dr. Marcia Russell, a staff surgeon at the Veterans Affairs Greater Los Angeles Healthcare System, described a 90-year-old patient who recently learned he had colon cancer during a prolonged hospital stay for pneumonia. “We talked with him about surgery, and his goals are to live as long as possible,” said Russell. To help prepare the patient, now recovering at home, for future surgery, she recommended he undertake physical therapy and eat more high-protein foods, measures that should help him get stronger.

“He may need six to eight weeks to get ready for surgery, but he’s motivated to improve,” Russell said.

The choices older Americans make about undergoing major surgery will have broad societal implications. As the 65-plus population expands, “covering surgery is going to be fiscally challenging for Medicare,” noted Dr. Robert Becher, an assistant professor of surgery at Yale and a research collaborator with Gill. Just over half of Medicare spending is devoted to inpatient and outpatient surgical care, according to a 2020 analysis.

What’s more, “nearly every surgical subspecialty is going to experience workforce shortages in the coming years,” Becher said, noting that in 2033, there will be nearly 30,000 fewer surgeons than needed to meet expected demand.

These trends make efforts to improve surgical outcomes for older adults even more critical. Yet progress has been slow. The American College of Surgeons launched a major quality improvement program in July 2019, eight months before the covid-19 pandemic hit. It requires hospitals to meet 30 standards to achieve recognized expertise in geriatric surgery. So far, fewer than 100 of the thousands of hospitals eligible are participating.

One of the most advanced systems in the country, the Center for Geriatric Surgery at Brigham and Women’s Hospital, illustrates what’s possible. There, older adults who are candidates for surgery are screened for frailty. Those judged to be frail consult with a geriatrician, undergo a thorough geriatric assessment, and meet with a nurse who will help coordinate care after discharge.

Also initiated are “geriatric-friendly” orders for post-surgery hospital care. This includes assessing older patients three times a day for delirium (an acute change in mental status that often afflicts older hospital patients), getting patients moving as soon as possible, and using non-narcotic pain relievers. “The goal is to minimize the harms of hospitalization,” said Cooper, who directs the effort.

She told me about a recent patient, whom she described as a “social woman in her early 80s who was still wearing skinny jeans and going to cocktail parties.” This woman came to the emergency room with acute diverticulitis and delirium; a geriatrician was called in before surgery to help manage her medications and sleep-wake cycle, and recommend non-pharmaceutical interventions.

With the help of family members who visited this patient in the hospital and have remained involved in her care, “she’s doing great,” Cooper said. “It’s the kind of outcome we work very hard to achieve.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit to submit your requests or tips.

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


This story can be republished for free (details).

Categories: Health Care

When Malpractice Occurs at Community Health Centers, Taxpayers Pay

Kaiser Health News - Mon, 11/28/2022 - 5:00am

Silvia Garcia’s 14-year-old son was left permanently disabled and in a wheelchair after a community health center doctor in New Mexico failed to diagnose his appendicitis despite his complaint of severe stomach pain. The teenager’s appendix ruptured before he could get to a hospital, and complications led to septic shock.

Akimbee Burns had a Pap smear at a community health center in Georgia that showed abnormal cells. But she was not told of the results. About eight months later, she was diagnosed with cervical cancer that had spread to her lymph nodes. She died within two years, at age 38.

Rhonda Jones’ baby was left brain damaged after her Chicago-area medical team, which included community health center doctors, failed to perform an emergency cesarean section quickly enough even though Jones was at high risk for labor complications.

These three incidents — alleged in court documents as part of malpractice lawsuits that were settled without admission of wrongdoing — are among 485 payouts made nationwide involving community health centers from 2018 through 2021. The settlements and judgments totaled $410 million paid to the patients or their families, according to federal data released to KHN through a public records request.

But none of those health centers, and none of the doctors, paid anything. U.S. taxpayers picked up the tab.

The nation’s 1,375 federally qualified health centers, which treat 30 million low-income Americans, are mostly private organizations. Yet they receive $6 billion annually in federal grants, and under federal law their legal liabilities are covered by the government, just as those of the U.S. Department of Veterans Affairs and the Indian Health Service are. That means the centers and their employees can receive immunity from medical malpractice lawsuits and the federal government pays any settlements or court judgments.

As a result, the public is often unaware of malpractice allegations against those centers. The health centers and their employees are not named as defendants in the lawsuits, and the government does not announce when it pays to settle cases or court judgments.

“People should know if these doctors or centers are harming their patients,” said Deirdre Gilbert, national director of the nonprofit National Medical Malpractice Advocacy Association, a consumer advocacy group.

In addition, attorneys who have represented plaintiffs in lawsuits against health centers say federal rules handcuff patients with a short statute of limitations — two years — and do not allow punitive damages.

“The deck is stacked in the government’s favor,” said Regan Safier, a Philadelphia attorney who won a $41.6 million court judgment in 2018 in a case of a birth injury involving a community health center doctor.

Tragedies Hidden From View

From 2018 through 2021, the median payment for malpractice settlements or judgments involving health centers was $225,000, according to the data from the Health Resources and Services Administration, which oversees the community health centers. In 68 of the 485 payouts, the total was at least $1 million.

Many of the lawsuits against health centers involved allegations of misdiagnosis or dental errors. Most large awards were for birth injuries or cases involving children.

Silvia Garcia brought one of those cases. In December 2015, she took her 14-year-old son to First Choice Community Healthcare in Albuquerque, New Mexico, to be treated for severe stomach pain and fever, according to a lawsuit she filed against the government.

The doctor felt the boy’s abdomen but ordered no diagnostic tests, the family alleged. The physician advised Garcia to take the boy to the hospital if his pain worsened.

Two days later, she took him to a hospital emergency room. There, doctors found that his appendix had ruptured. He had developed septic shock that led to brain damage and acute injury to his kidneys.

The teenager was hospitalized for eight months.

Garcia settled the case for $6.8 million, most of which went into a special fund that can be paid out for future medical expenses.

First Choice and Garcia declined to comment. The government said the settlement was not an admission of fault.

Community health centers pushed for — and won — government malpractice protection in the 1990s. They argued their revenues were limited and malpractice insurance would divert money that could better be used for patient care.

The centers differ from other health clinics because they get a federal grant each year. They also receive higher reimbursements from Medicaid and Medicare than do private doctors. In return, the centers are not allowed to turn anyone away, and the fees charged to low-income patients are on a sliding scale. Nearly half of the centers’ patients are covered by Medicaid, and 20% are uninsured.

Malpractice lawsuits are a risk for all health care providers and are just one barometer of quality of care. The settlements and court judgments against the health centers don’t measure the clinics’ overall performance.

Even lawyers who have sued on behalf of health center patients acknowledge the importance of the facilities. Rhode Island plaintiff attorney Amato DeLuca said that the health centers serve a vital role in the health industry and that he had found “a lot of really wonderful, extraordinarily capable people that do a really good job” at the centers. 

Yet everyone must be held accountable for mistakes, DeLuca said.  

Akimbee Burns’ case is an example of a missed diagnosis, according to the lawsuit she filed against the U.S. government. Burns, who made $11 an hour at a utility company, had a Pap smear in 2016 at South Central Primary Care Center, a community health center in Ocilla, Georgia. The test results showed abnormal cells, but she was not informed of the results, according to the complaint. She inquired about the test several times in the following months but still was not informed about the results, she alleged.

About eight months later, the staff at a different health care facility diagnosed advanced cervical cancer. She filed a lawsuit alleging the community health center had been negligent. She underwent radiation and chemotherapy. But she died in April 2019, leaving behind two children, including one minor.

After her death, the government and her estate settled for $2.1 million.

South Central Primary Care Center did not respond to requests for comment, and the government denied any wrongdoing.

Roadblocks for Patients

A patient alleging medical malpractice by a health center must first submit claims to the U.S. Department of Health and Human Services for review. The government can make a settlement offer or deny the claim. If the claim is denied or not settled, or a six-month review period expires, the patient may sue in federal court under the Federal Tort Claims Act, or FTCA.

To get that federal protection, health centers must have quality improvement and risk management programs and must show regulators that they’ve reviewed the professional credentials, malpractice claims, and license status of their physicians and other clinicians.

Ben Money, a senior vice president for the National Association of Community Health Centers, said the process improves care and directs scarce operating dollars toward the needs of patients, versus costly malpractice coverage.

“There are rigorous safeguards in place to ensure that health center grantees are in compliance and that patients are getting the very best care,” he said. “FTCA makes health centers more vigilant on quality and not less.”

About 86% of community health centers were covered under the FTCA for medical malpractice coverage as of September, said Christy Choi, a spokesperson for the Health Resources and Services Administration.

She said the government has implemented “robust quality improvement and patient safety efforts” as part of the program.

The system makes collecting damages more difficult for patients than if they went to state courts for malpractice suits, said attorneys involved in cases against health centers. In addition to the prohibition against punitive damages, such cases are decided by federal judges instead of juries. The lack of a jury is important, they added, because judges are less likely to be swayed by emotion and that can mean lower dollar amounts in the awards.

Plaintiffs are also at a disadvantage because the federal government has unlimited resources to defend cases, unlike the patients and their attorneys, said Christopher Russomanno, a Miami attorney.

“These cases cost hundreds of thousands of dollars for us to get ready for trial,” said Jack Beam, the Illinois attorney who represented Rhonda Jones. “Our record was $900,000 in case costs.”

All these factors can make finding a lawyer an obstacle for patients.

Deborah Dodge, a Missouri lawyer, said some attorneys are reluctant to take the cases because the government caps their fees at 25% of the settlement amount. In contrast, plaintiff attorneys often take about 40% in successful state court malpractice cases.

Rhonda Jones was one of those who received a settlement. Her baby was transported to a children’s hospital soon after being born by emergency cesarean section at West Suburban Medical Center in the Chicago area in December 2016, according to her lawsuit. The baby, Alayna, was treated for brain damage from a lack of oxygen, and she now has cerebral palsy.

Jones showed signs of a high-risk delivery when she arrived at the hospital nearly 39 weeks pregnant: She was 40 years old, this was her 11th child, and she had severe preeclampsia and possibly gestational diabetes.

Her lawsuit alleged that she was not adequately monitored at the hospital and that surgery was not performed in time to prevent injury to Alayna.

Jones agreed to a $21 million settlement, $15 million of which was paid by the federal government because some of the doctors involved were employed by PCC Community Wellness Center. The health center and the hospital declined to comment. In court filings, the government and hospital denied wrongdoing.

The money — most of which is in a trust overseen by the court — provides for Alayna, who will require care throughout her life.

“Before what happened to Alayna, I loved them,” Jones said of the health center where she had gone for several of her previous pregnancies. “They were great for me because they would be open late at night when I was working.”

“I still would tell someone to go to PCC because maybe they will get the right doctors when they go to have their baby,” Jones added.

Alander Rocha and KHN reporter Colleen DeGuzman contributed to this article.

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


This story can be republished for free (details).

Categories: Health Care

The (Legal) History of the Gränna Polkagris (Candy Stick)

In Custodia Legis - Fri, 11/25/2022 - 9:30am

Statute of Amalia Eriksson, Gränna, Sweden. Photo by author Elin Hofverberg. August 2022.

Today, November 25, marks the birthday of Amalia Eriksson (1824-1923), the creator of the Gränna polkagris. This year, her sweet peppermint candy stick (think a straight candy cane but slightly softer) earned protection as a registered  protected geographical indications (PGI) product under the European Union (EU) geographical indications legislation.

This means that only polkagrisar made in Gränna, Sweden, may use the name “Äkta Gränna Polkagrisar” (the Real Gränna Polkagris). The candy may not be as fancy as Champagne or as fought over as Feta cheese but for anyone who has driven down mainstreet (Brahegatan) in Gränna which is home to shops upon shop, all selling and baking polkagrisar, it is easy to conclude that the locals consider this a huge win.

If you don’t have a sweet tooth, you might still have heard of Gränna, it is the birthplace of balloonist Salomon August Andrée who died during an expedition to the North Pole.

Basket of polkagrisar, detail from Amalia Eriksson statute, Gränna, Sweden. Photo by author Elin Hofverberg. August 2022.

Background – Amalia Eriksson, Gränna, and the Polkagris

One does not give justice to the Gränna polkagris candy stick without also describing the plight of its creator Amalia Eriksson (nee Lundström). Born on November 25, 1824, in Jönköping, Sweden, Amelia was orphaned at a young age and worked as a domestic maid before marrying a local tailor, Anders Eriksson. However, the marriage was short-lived. In 1858, the year after their marriage, Amalia’s husband died just days after Amalia gave birth to twins, only one of whom survived the birth. Thus, Amalia was now the sole provider for herself and a one-week-old baby.

At this time, Swedish law did not generally allow women to own or operate a business. However, women could work with their hands in certain exceptional cases in accordance with a royal proclamation (Fabriks och handtwerks Ordning [Factory and Crafts Order](Svensk författningssamling (SFS) 1846:39) also known as Kongl. Handtverksordningen den 22 December 1846).

Fabriks och handtwerks Ordning [Factory and Crafts Order](Svensk författningssamling (SFS) 1846:39). Photo by author Elin Hofverberg.

Accordingly, in 1859, Amelia applied for and received her license, which specified that she could ”as means of livelihood with her own hands conduct bakery operations of coarse and fine pastries as well as to produce so called polkagrisar.”(Translation by author.)

Section 12 of the  Factory and Crafts Order of 1846 (SFS 1846:39). The legal basis upon which Amelia’s license rested. Photo by author Elin Hofverberg.

The name Polkagris is believed to originate from the swirling dance polka and from the word Gris (pig), which was slang for sweets at the time.

The polkagris recipe is straightforward and only includes sugar, water, glucose, vinegar, peppermint oil, and red caramel color.

The making of the polkagris is slightly more intricate however, as can be seen in this video.

Some claim that Amalia invented the candy to alleviate her daughter’s cough and that the original polkagris recipe did not include water or glucose.

After its launch, Amalia’s business became a quick success and earned her fame throughout Sweden. In 1915, Crown Prince Gustaf Adolf (later king of Sweden) visited her bakery together with his wife. Amalia Eriksson successfully exported her candy to a number of countries including the United States, a tradition that continues today.

Kongl. Maj:ts Nådiga Förordning angående utvidgad näringsfrihet (SFS) 1864:41. Photo by author Elin Hofverberg.

In 1864, a few years after Amalia started her business, a royal proclamation was adopted. In the 1864 proclamation, the Swedish king granted expanded freedom of trade (Kongl. Maj:ts Nådiga Förordning angaående utvidgad näringsfrihet, SFS 1864:41) proclaimed that:

A Swedish man or woman may, with the exceptions and restrictions and under the conditions otherwise specified below, in towns or in the countryside perform trade or factory, trade, or other business for the purpose of export or import, or between domestic locations, transport or transport by ship domestically as well as internationally. (Translation by author.)

Legal Protection of the Äkta Gränna Polkagris

Under Swedish law, the designation “Äkta Gränna polkagris” enjoys trademark protection. This term was originally registered as a trademark with the Swedish Intellectual Property Office (PRV) in 1948. It was then owned by the Gränna förening (Gränna association), and can now be used by member companies selling polkagrisar in Gränna. That is why you will find not one shop but an abundance of shops with both “the original” (Äkta Gränna Polkagris) flavor as well as their own specific and more novel flavors such as “trollgodis” (troll candy) along the main street of Gränna.

However, until this summer the Swedish candy was not specifically protected under EU geographical indicators.

Äkta Gränna Polkagrisar with the PGI EU label in blue and yellow. Photo by author Elin Hofverberg.

European Union Geographic Indicators

When referring to geographic indicators and many of us think of Champagne, the sparkling wine made in the region of Champagne, France. Only sparkling wine from this region may be called Champagne although arguably many of the properties of other sparkling wines are similar to that of Champagne. Although Champagne is protected under a different EU regulation (protected designation of origin) than Äkta Polkagrisar, the candy too now enjoys protections based on its geographical creation. Only polkagrisar made in the little town of Gränna (population 2,713) may state that they are Äkta Polkagrisar from Gränna. Thus, no matter if you use the exact same recipe that Amelia used in 1859, you are still not baking Äkta Gränna Polkagris, and you may not sell it as such unless it is made in one of the special shops (polkagriskokeri) in Gränna.

Geographical protection of foodstuff falls under Regulation (EU) No 1151/2012 of the European Parliament and of the Council of 21 November 2012 on quality schemes for agricultural products and foodstuffs. Article 5.1 deals with “designation of origin” protection known as PDOs, whereas article 5.2 deals with “geographic indication” protection, known as PGIs. Äkta Gränna Polkagrisar are protected under article 5.2. The distinction between the products is that products protected under article 5.1 must meet the following requirements:

(a) originate in a specific place, region or, in exceptional cases, a country;
(b) their quality or characteristics are essentially or exclusively due to a particular geographical environment with its inherent natural and human factors; and
(c) the production steps all take place in the defined geographical area

Whereas products, like Gränna polkagrisar, which are not made by wholly Swedish ingredients (sugar may be from Denmark for example) must fulfill the requirements in article 5.2.:

(a) originate in a specific place, region or country;
(b) their given quality, reputation or other characteristic is essentially attributable to their geographical origin; and
(c) at least one of the production steps takes place in the defined geographical area.

There is also a third category, geographical indications for spirits, known as GIs (like whiskey).

To receive protection under any of the three geographical protections, one must apply to register a name for protection. (Art. 40 Regulation (EU) No 1151/2012.) In the case of the Äkta Gränna Polkagris the application was made by Gränna Näringslivsförening, Polkagrisgruppen (the Polkagris group) and supported by Sweden. The application was then reviewed by the Commission and published in the Official Journal of the European Union. (Art. 50 (2).)

Thus, the Äkta Gränna Polkagris is now one of only 12 Swedish products that enjoys EU geographic protection. Of these, four enjoy “designation of origin” protection under article 5.1. , whereas eight enjoy “geographical indication protection” protections under article 5.2.

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Categories: Research & Litigation

Fall Remote Metadata Program: West Coast Team

In Custodia Legis - Wed, 11/23/2022 - 4:49pm

Concluding our introductions of the fall remote metadata program, we have the West Coast team. If you missed the foreign legal gazette program, east coast, or central team introductions, take a look!

Alyssa Key. Photo by Alyssa Key.

Our West Coast team is led by Alyssa Key. Alyssa may soon hold the record for the greatest number of semesters volunteering with the Law Library! This is her fifth remote internship with us, after serving as a remote intern in the spring and summer of 2021, a team lead with the American State Papers project earlier this year, and as a mentor this summer. Alyssa is a life-long California resident who graduated from San José State University’s M.L.I.S. program in May 2021, with an emphasis on public and academic librarianship. Alyssa also holds a B.A. in sociology from California State University, Northridge. In addition to her work here, Alyssa is also currently contributing to the American Library Association Subject Analysis Committee’s Working Group on External Review of LC Vocabularies.

What is your favorite project you’ve worked on?

It is so hard to pick a favorite. During my time on the Statutes at Large, American State Papers, and bill summaries metadata projects, I have learned a lot about how historical documents can be made more accessible for the public’s benefit simply through creating metadata. In turn, this is something I have grown passionate about because I have enjoyed seeing how increasing the accessibility of resources helps make information retrieval, and access standards and methods more equitable and inclusive.

Why do you keep coming back to the Library of Congress?

I started my journey with the Library as a Statutes at Large metadata project intern in the spring of 2021 while finishing my master of library and information science (M.L.I.S) degree at San José State University. So, now to be serving in my second team lead position with the bill summaries metadata project and to have almost five full internships completed with the Library, I can genuinely say I have really enjoyed working with my fellow interns and my supervisor, Jennifer González. In turn, it’s been an easy decision for me to continue volunteering my time to the projects I have been privileged to work on so far.

What is the coolest thing you’ve come across while working with us?

It is hard to choose because all of the digitized historical documents I have handled as part of the Statutes at Large, American State Papers, and bill summaries metadata projects have been really interesting to view. They have given me more perspective on congressional and governmental history that I did not have. So, now to have hands-on experience handling digitized historical documents that detail congressional and governmental history is a real privilege.

What are you hoping to do in the library field?

This is a really big question I have been pondering for a long time! Having spent roughly half of my M.L.I.S degree seeing how the COVID-19 pandemic impacted the field in real time, I have grown passionate about increasing the availability and accessibility of digital collections, services, and resources to patrons, as well as addressing the digital divide impacting the ability of some patrons to access such library offerings on- and off-site. I am also passionate about information and media literacy, technology, and teaching patrons advanced online research strategies and techniques. Thus, I see myself in library roles that not only connect to a lot of my current professional interests, but also utilize many, if not all, of the skills I have cultivated through my library internships and other professional experiences so far.

Why libraries?

Admittedly, when I first joined the library and information science field, I was inspired because I was an avid reader growing up and love reading books and learning, and wanted to share that passion with others as others had done for me as a child. However, as I have gained more field experience, I have found myself incorporating much of what I learned as an undergraduate sociology student into my work. I am passionate about social justice and human rights, and believe everyone should have easy access to credible information, issues which I first explored as a remote student intern with San Francisco Public Library’s Jail and Reentry Services Reference by Mail program in the fall of 2020. I hope to further cultivate those passions, as well in my professional career going forward.

Now meet the team!

Tamah Bartlett. Photo by Kathy Bartlett.


Tamah Bartlett currently lives in Arizona and will complete her M.L.I.S at the University of Arizona (U.A.) in fall 2022 with the goal of entering the archival field. She holds a B.F.A in digital arts from the Santa Fe University of Art and Design and a graduate certificate in archival studies from U.A. Tamah is the marketing officer of the U.A.’s American Library Association student chapter and interns at the U.A. Law Library working on the Navajo Nation Department of Water Resources Library Preservation Project. When not working, she enjoys creating art, researching her family history, and pet sitting.

Leigh Carroll. Photo by Leigh Carroll.


Leigh Carroll holds a bachelor’s degree in English from UC Berkeley and is finishing her M.L.I.S. degree from San José State University. She lives in the Bay Area with her partner and two young kids where she is a volunteer school librarian. She loves libraries of all kinds and working with historical documents. After a career in digital content strategy for companies of all types, she is eager to apply her skills to a cultural heritage institution where she can combine her loves of history and information organization.

Joanna Coelho. Photo by Natalie Baldini.


Joanna Coelho is a master of management in library and information science  (M.M.L.I.S.) student at the University of Southern California, Marshall School of Business. Before pivoting to the world of libraries, she received her B.A. in English at UCLA and worked in book publishing and film production. In addition to her metadata work with the Law Library of Congress, she is also working as a digital asset management intern at USC Gould School of Law.

Emma’s cats, Willow (brown and white tabby) and Pumpkin (torti). Photo by Emma Cogan.


Emma Cogan is from Los Angeles, but has lived in Wisconsin and Denver. She is a current M.L.I.S graduate student at the University of Denver where she is focusing on archival practices. She has professional interests in digitization, metadata, cataloging, and digital asset management. Emma has two cats and enjoys gardening and bouldering (free rock climbing).

Margaret Daab. Photo by Margaret Daab.


Margaret Daab was born and raised in northeast Illinois but has recently moved to Washington State. In 2014, she received her bachelor’s degree in television writing from Columbia College Chicago. After an unexpected move into the public library field, she enrolled in the University of Wisconsin Milwaukee’s online M.L.I.S. program. When she is not studying, Margaret loves hiking, drawing, and binge-watching her favorite shows. She is excited to continue her work in library programming and to gain new skills as she completes her education.

Danielle Dantema. Photo by Shannon Keith.


Danielle Dantema is a California native residing in sunny Orange County. She earned her bachelor of arts degree in English from University of California, Los Angeles, and her M.L.I.S. degree from San José State University. While she currently volunteers in public libraries, she hopes to become a video game archivist and librarian. When she is not busy guiding people on how to fulfill their knowledge quest, archiving important documents, and organizing information from around the world, she enjoys letting her creativity flourish in planning themed parties, pottery, and watercolor painting.

Brenda Esparza, Photo by B. Hollingshead


Brenda Esparza is a graduate student completing her M.L.I.S degree from the University of Arizona. Interning remotely from Phoenix, Arizona, she is interested in metadata management, digitization and digital preservation, and contributing to the development of accessible and discoverable digital projects. In addition to her work with the Law Library of Congress, she works as an outreach specialist for her public library to implement long-term and sustainable early literacy activities in hard-to-reach communities. In her spare time, she enjoys hiking the Phoenix Mountains Preserve, watching British Bake-Off, and playing board games.

Eun Hye Jun. Photo by Trinity Yun.


Eun Hye Jun double majored and earned two bachelor’s degrees in education and sociology from Korea University in Seoul, Korea. She taught social studies in high school for about ten years. She finished her master of science in library science (M.S.L.S.) program from Clarion University of Pennsylvania last spring. Eun Hye is currently participating in the research group of the library and information science department at Clarion University and working with several professors. Her professional interests include information literacy in childhood, digital youth, and the information seeking behavior of teens.

Cashel McGloin. Photo by Cashel McGloin.


Cashel McGloin is long past her intern days, but volunteers for the Library of Congress out of her love for the institution.  She uses her degrees in archaeology as a volunteer archaeologist for a number of organizations around the greater D.C. area, and her experience from growing up in Colorado to rebuild trails in national parks.  When not being paid by museums to handle their collections, she explores, dances, draws, does beadwork, restores antiques, and conducts historic site research.

Hayley Park. Photo by Hayley Park.


Hayley Park (she/they) is finishing her M.L.I.S degree at the University of Washington with an emphasis in digital scholarship, data curation, and knowledge organization. Her academic background is in comparative literature with an emphasis in film studies. Her professional experience primarily comes from working at public and institutional libraries and working at an academic library as a graduate specialist. As an American Library Association Spectrum Scholar, she is drawn to ideas and practices that challenge cultural hegemony and structural inequities and is committed to ensuring equitable access for all people to pursue knowledge essential to each of their sensemaking journey(s).

Belinda Reich. Photo by Belinda Reich.

Belinda Reich is originally from Australia, but has lived in South Korea, Canada, and currently in Los Angeles, U.S. She recently graduated with a master of information studies from Charles Sturt University, with a focus on audiovisual and digital archiving and preservation, data management, and metadata. She also holds a bachelor’s degree in visual arts (electronic and temporal art) from the University of Sydney. This year, she provided metadata description for a newly digitized audiovisual collection at the Australian Museum, and governance research for a government records office in Australia. Her previous professional experience includes film and digital development, and communications. When not looking at a screen, Belinda loves exploring Southern California for its diverse food, neighborhoods, and history, and swimming in the ocean.

Robert Rosas. Photo by Robert Rosas.

Robert Rosas is a Southern California native currently pursuing his M.M.L.I.S. from the University of Southern California. He holds a B.A. in political science from UC Irvine. When not focusing on his studies or working at the UC Irvine Law Library, he enjoys cooking, hitting the gym, and exploring southern California with his corgi, Archie.

Laura Wertz. Photo by Christine Wertz.

Laura Wertz is a lifelong resident of Walnut Creek, California. She is currently working as a remote metadata intern at the Law Library of Congress. Laura earned her master’s degree in library and information science from San José State University (S.J.S.U.) in May of 2021 with a focus on academic librarianship. Her research paper on the fight to desegregate southern U.S. public libraries during the civil rights movement was published in the S.J.S.U. School of Information Student Research Journal. She previously interned as a virtual collection development associate for the Open Access Digital Theological Library. Laura is pursuing a career in academic librarianship. She enjoys spending time with her dog, music, the arts, reading, and is a digital art enthusiast.

Keri Wilkins. Photo by Keri Wilkins.

Keri Wilkins is an Arkansas native, but is currently living in San Diego, California. She is about to graduate with her M.L.I.S. from San José State University in December 2022. She also holds a paralegal certificate from the University of San Diego and a B.S. in psychology from Arkansas State University. Keri has two fur babies and has a huge love for animals. She currently enjoys working in the cataloging world of librarianship. In her spare time, she enjoys traveling, volunteering at animal rescues, and swimming.


Subscribe to In Custodia Legis – it’s free! – to receive interesting posts drawn from the Law Library of Congress’s vast collections and our staff’s expertise in U.S., foreign, and international law.

Categories: Research & Litigation

Trickle of Covid Relief Funds Helps Fill Gaps in Rural Kids’ Mental Health Services

Kaiser Health News - Wed, 11/23/2022 - 5:00am

NELSONVILLE, Ohio — The Mary Hill Youth and Family Center’s building has long been at a crossroads overlooking this rural Appalachian city, but its purpose has evolved.

For 65 years, residents of Nelsonville and the rolling hills of southeastern Ohio traveled to the hilltop hospital seeking care. Then, in 2014, the 15-bed hospital, which was often without patients, closed.

Later, the three-story brick building reopened as a hub for health services. With the help of several funding sources, Integrated Services for Behavioral Health, a nonprofit social service agency, transformed the building into a site for mental health treatment, primary and dental care, and food pantry access.

In June, the organization opened a 16-bed residential mental health treatment program on the former hospital’s top floor. The program serves children in rural southeastern Ohio and gives families an option besides sending their kids far away — sometimes out of state — for residential care.

“For a long time, we’ve been trying to figure out, ‘How do we support services being delivered more locally?’” said Samantha Shafer, CEO of Integrated Services for Behavioral Health. “Because when you have the programs here, the work you can do with families is more successful, health outcomes are better.”

Efforts to offer residential mental health services at Mary Hill Center, and in other rural Ohio towns, were boosted, in part, by a tiny share of Ohio’s $5.4 billion allotment from the American Rescue Plan Act, a federal covid relief law that was passed in 2021.

Congress gave $350 billion to state, local, and tribal governments as part of ARPA, allowing states to decide how they would use the funds. So far, dozens of states have allotted a relatively small portion to improving mental health resources. Ohio is one of a small group of states that further divided their allocation to spend a portion on children’s mental health care.

Experts said that using ARPA funds is just one way for states to support children’s behavioral health during what health professionals have called “a national emergency in child and adolescent mental health,” which was worsened by the pandemic. In an effort led by the American Academy of Pediatrics, multiple organizations wrote to the Biden administration in October, urging it to declare a federal national emergency over children’s mental health.

“At the time that ARPA came out, we were really trying to figure out, as a country, how the mental health, behavioral health systems could be bolstered, because, in my opinion, the systems are really broken,” said Isha Weerasinghe, a senior policy analyst at the Center for Law and Social Policy, a national, nonpartisan group that advocates for policies that help people with low incomes. “And what ARPA was able to do was to provide some foundational dollars to help bolster the systems.”

The center has said that ARPA’s funding provisions are “insufficient to counter deep systemic and historic inequities” in mental health care. Nonetheless, Weerasinghe said an opportunity exists for the money to have a long-term impact on children’s mental health care if applied to organizations that have demonstrated a commitment to maintaining children’s well-being in their communities.

States have until 2024 to allocate their ARPA funding and until 2026 to use it. According to the latest quarterly analysis by the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C., most states have either completed or nearly completed their allocations. Among states, the median allocation to support mental health services is about 0.5%, based on the CBPP data. For states in the Midwest region, the median is about 3%.

The CBPP numbers showed that by August the mental health allocations varied widely in the mostly rural states where suicide rates repeatedly eclipse the national average by double or more. In some of those, including Montana, South Dakota, and Wyoming, officials allocated less than the nationwide median. Meanwhile, lawmakers in Colorado steered nearly 11% of the state’s money toward mental health.

Of the $84 million Ohio officials dedicated to pediatric behavioral health facilities, $10 million will go to rural counties in the state’s southeast. That is less than half a percent of the state’s $5.4 billion ARPA allotment. But clinicians hope it will help address gaps in Appalachian Ohio’s mental health services for children.

In recent studies, the Public Children Services Association of Ohio, a nonprofit advocacy group, found that because of gaps in services, some children with behavioral health needs in Ohio were placed out of state or in a distant county for care. The association surveyed the public children’s services agencies in 19 counties and found that for most of their cases in 2021, the agencies made many calls before finding a residential treatment facility placement for a child.

In April, Ohio Gov. Mike DeWine signed an executive order providing $4.5 million to youth residential treatment facilities to increase their capacity.

In Nelsonville and the rural, hilly country that surrounds it, ARPA money has played a minor role in expanding services.

The new residential treatment facility at Mary Hill Center, which serves 10- to 17-year-olds, was designed for 16 beds. But as of September, because of staffing shortages, the facility operated at limited capacity and had served a maximum of five children at once.

Shafer said non-ARPA money paid for most of the renovations needed to open the floor, but about $1 million from ARPA will help upgrade elevators and bathrooms.

Her organization will use an additional $7 million to build another residential treatment facility — its program modeled after Mary Hill Center’s — in Chillicothe, a city about 55 miles west of Nelsonville. That facility will have capacity for 30 beds, but it will start with a cap of 15. Construction is set to begin in January.

Services at the residential facility in Chillicothe will primarily be reimbursed under a new Medicaid program called OhioRISE, which will pay for behavioral health treatment at psychiatric facilities for young people. But the facility will also treat children who aren’t enrolled in Medicaid.

Before the rural Ohio projects were approved for ARPA funding, they were each reviewed by Randy Leite, executive director of the Appalachian Children Coalition, a nonprofit that advocates for children’s health. He decided which proposals for ARPA-funded projects from the Appalachian region were presented to Ohio’s Department of Mental Health and Addiction Services.

“I told people in Columbus I could give them $300 million of ideas to spend money on, but a lot of that wasn’t practical and doable,” Leite said. Instead, he focused on ideas that were “shovel-ready” — so they could be completed within the ARPA spending time frame — and sustainable.

“A lot of the sustainability is tied to services that are reimbursable,” he said.

Leite and the coalition presented Ohio officials with about $30 million in ARPA investment recommendations, including a project meant to expand telehealth capacity in schools. State officials approved only about a third of the total requested. The money went to the Integrated Services for Behavioral Health facilities and Hopewell Health Centers, a federally qualified health center that received about $1.5 million. That money will pay for renovations to its 16-bed child crisis stabilization unit in Gallia County, south of Nelsonville; an expansion of its day treatment program; and enhancements to its school-based mental health programs — including one in Nelsonville’s school district.

“For students to learn, they have to have good physical and mental health,” said Sherry Shamblin, chief strategy officer of Hopewell Health Centers. “Those supports are really needed for kids to be able to take good advantage of their education opportunities.”

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


This story can be republished for free (details).

Categories: Health Care

A Work-From-Home Culture Takes Root in California

Kaiser Health News - Wed, 11/23/2022 - 5:00am

Even as pandemic lockdowns fade into memory, covid-19 has transformed California’s workplace culture in ways researchers say will reverberate well beyond 2022.

According to new data from the U.S. Census Bureau, working from home for some portion of the week has become the new normal for a large segment of Californians. The data shows high-income employees with college degrees are more likely to have access to this hybrid work model, while lower-income employees stay the course with on-site responsibilities and daily commutes.

At a basic level, that means low-wage workers will continue to shoulder greater risks of infection and serious illness as new covid variants sweep through job sites, alongside seasonal waves of flu and other respiratory viruses. Multiple studies have found that covid took its greatest toll in low-income neighborhoods, whose workers were deemed essential during early pandemic lockdowns — the farmworkers, grocery clerks, warehouse packers, and other service employees who continued to report to work in person.

In addition, researchers say the shift will ripple across the broader economy in ways big and small, as more employees have the flexibility to live farther from a job site and as workplace traditions like lunch outings and bar nights fade or evolve.

The U.S. Census Bureau interviewed roughly 260,000 Americans from June through October, including about 20,000 Californians, as part of a wide-ranging questionnaire called the Household Pulse Survey. Surveyors asked dozens of questions about pandemic-era lifestyle changes, including some about working from home.

The survey found that nearly 20% of California adults lived in households in which at least one person had telecommuted or worked from home five days or more in the previous week. About 33% of California adults lived in households in which someone had worked from home at least one day the previous week.

Nationwide, the survey found that almost 30% of adults lived in households in which at least one person worked from home for some portion of the previous week. About 16% lived in households in which someone worked from home at least five days the previous week.

The results mark a notable shift from previous Census Bureau surveys that asked about working from home, though in different terms. In 2019, before the pandemic, about 6.3% of employed Californians and 5.7% of employed Americans said they “usually worked from home.”

Researchers who specialize in workforce issues said the findings mirror their own and are indicative of a cultural upheaval that will outlive the pandemic.

Jose Maria Barrero is an academic economist and a co-founder of WFH Research, which is documenting the shift toward working from home. Before the pandemic, about 5% of workdays in the U.S. were conducted from home, according to his group’s analyses. In contrast, its surveys this year show that about 30% of working days in the U.S. are now work-from-home days.

The 2022 survey by the Census Bureau revealed disparities in the kinds of families that are adapting to hybrid work, mostly centered around income.

About 64% of California adults in households with annual incomes of $150,000 or higher said at least one household member had worked from home some portion of the week. Nearly 40% of adults in those high-earning households said a household member had worked from home five days a week or more.

By comparison, just 15% of California adults in households with annual incomes of less than $50,000 said a household member had worked from home at least part of the week.

“It’s very hard for you to work remotely if you are a barista in a coffee shop or you’re working in a manufacturing plant,” Barrero said. “The sorts of jobs that people with low education tend to do are jobs that require them to be physically present.”

Racial disparities also exist. Nearly 45% of California adults who identify as Asian and 40% who identify as white lived in households in which someone worked from home some portion of the week, compared with 26% of Black adults and 21% of Latino adults.

The connection between income and hybrid work played out nationally, as well. States with greater portions of high-income residents tended to have more workers who reported telecommuting.

For example, fewer than 20% of adults in Alabama, Arkansas, Kentucky, Louisiana, Mississippi, and West Virginia lived in households in which at least one member had worked from home the prior week. The median household income in each of those states last year was between $48,000 and $56,000.

By comparison, 35% or more of adults in Colorado, Maryland, Massachusetts, Minnesota, New Jersey, Oregon, Utah, Virginia, and Washington lived in households in which at least one member had worked from home. The median household income in each of those states last year was between $71,000 and $91,000.

The disparities also clustered along educational lines. About 56% of California adults with a bachelor’s degree lived in households in which someone worked from home at least one day during the prior week, compared with 17% of California adults with only a high school degree.

The gaps will have consequences.

Andra Ghent, an economist at the University of Utah who studies work-from-home patterns, said tens of millions of Americans are settling into “hybrid” arrangements, in which they work from home a few days a week and occasionally go into the office. Before the home-work option, she said, many didn’t want to live too far from the urban core, concerned that commutes would become unmanageable. But with routine daily commutes out of the picture, many will move to the suburbs or exurbs, where they will have more space, she said.

On the one hand, commuting less, particularly by car, is often good for the health of the environment, Ghent noted. “But if people move to places where the usual mode of transit is cars instead of something that’s more pedestrian- or cyclist-friendly or more likely to use public transit, that’s not such a good thing,” Ghent said. “It sort of increases our urban sprawl, which we know is not good for sustainability.”

When higher-income people move away, cities lose a valuable source of tax revenue. That could exacerbate challenges in urban areas, as resources for social programs and infrastructure shrink. To avoid that fate, cities will need to make themselves attractive places to live, not just work, Barrero said.

“What you don’t want to be is a city of basically office towers, and everybody at the end of the day leaves, and there’s nothing to do in evenings and on weekends,” he said. “Because that means that basically all of the people can be remote or hybrid.”

The migration to telecommuting also allows employers to look to other states or even other countries for hires. Tobias Sytsma, an associate economist at the Rand Corp., recently authored a report detailing how U.S. companies may increasingly “offshore” remote work to employees abroad.

In addition, higher-income workers could see their wages rise or fall, depending on where they live, Sytsma said. High-paid workers in San Francisco will compete for remote jobs with lower-paid workers in places like Fresno, California, or Boise, Idaho.

“So we should start to see these wages fall in cities like San Francisco and New York and Seattle, where they’re already really high,” Sytsma said, “and we’ll probably start to see them rise in more rural areas.”

Barrero said employers recognize that many people have found they prefer working from home — and that it gives companies leverage to ask workers to accept less money in exchange.

He said his research also indicates that today’s work models — for both at-home and on-site employees — are likely to endure for months and years.

“We’ve had in our survey a question asking people, ‘Is this the long-term plan that your employer has, or are you still waiting to implement part of the plan?’” Barrero said. “And consistently we get more than 80% of people saying that they’re already following the long-term plan.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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


This story can be republished for free (details).

Categories: Health Care

‘An Arm and a Leg’: When Insurance Won’t Pay, Abortion Assistance Funds Step In

Kaiser Health News - Wed, 11/23/2022 - 5:00am

Can’t see the audio player? Click here to listen.

Click here for a transcript of the episode.

As Americans choose their insurance plans for next year, some might wonder: How does the recent rise in state abortion restrictions affect insurance plans?

There’s no single answer, but for a lot of people, insurance has rarely helped pay for abortions. Most pay cash, and many can’t afford it.

That’s where abortion funds come in. These organizations have been providing financial and logistical assistance to people seeking abortion care for decades.

The “An Arm and a Leg” podcast spoke with Oriaku Njoku, executive director of the National Network of Abortion Funds, and Tyler Barbarin, a board member with the New Orleans Abortion Fund, to understand the history behind these services and how they’re operating in a post-Roe v. Wade environment.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, StitcherPocket Casts, or wherever you listen to podcasts.

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


This story can be republished for free (details).

Categories: Health Care

Fall Remote Metadata Program: Central Team

In Custodia Legis - Tue, 11/22/2022 - 9:54am

Continuing with our mini-series on the fall remote metadata program, we have the team geographically located between the two coasts.

Katie Colson. Photo by Holly Peterson.

Our central team is led by Katie Colson, a graduate student at the University of Illinois at Urbana-Champaign, and working towards a master’s of science in library and information science degree. She is originally from northern Idaho and began her career in libraries working at the Boundary County Public Library during high school. She was working as a cataloger at the rare book and manuscript library on campus while in school. Last summer, she was part of the Junior Fellows program, and we are glad to have her back as a team lead for the fall!

What is your favorite project you’ve worked on?

It is impossible to pick a favorite of the projects I have worked on for the Law Library of Congress! Both my projects thus far have allowed me to support accessibility to resources, which is central to what I want to add to the library field. Working as a junior fellow this summer, I was able to improve the accessibility of the blog’s resources by adding alt text to images and creating guidelines for adding alt text. This fall, as a remote metadata intern, I get to create metadata for bill summaries that will allow for discovery and exploration of this amazing resource. What could be better?

Why do you keep coming back to the Library of Congress?

I keep coming back to the Library of Congress because, first of all, the people who work here are awesome! In addition I keep working for the Library of Congress because I get to be part of a library that is a leader in the field, and has helped create the standards and best practices I interact with every day. I am also able to support the library that works closely with the government that runs my country, and I feel honored to be part of that. I want to be a part of the future of libraries and working for the Library of Congress feels like a huge step in that direction!

What is the coolest thing you’ve come across while working with us?

There has really not been just one cool thing, but many! Everything I have worked with, from blog posts to bill summaries, has shown me new information about history, our government, and the world we live in! It has been amazing in particular working with the bill summaries and seeing all the work that goes into developing the laws and policies that govern the country.

What are you hoping to do in the library field?

I want to work in supporting information access, and I want to make sure libraries are able to take advantage of the interconnectedness of the digital age. I see that happening through metadata, and I want to create guidelines and explore new areas of application for metadata and allow new, unexpected connections to be made. I envision an interconnected library with the ability to connect patrons easily to diverse, in-depth, multi-perspective, and accurate resources.

Why libraries?

As a voracious reader, libraries have always been an important part of my life, but I first saw my future career in them while working in the library at my undergraduate school, the University of Idaho. I was able to help students find the resources they were looking for and be a part of an entity whose entire goal was information access and fostering connections. I loved diving into new topics with every patron and exploring a wide variety of topics every day. I found my future and I have been pursuing that future and finding my exact niche in this field ever since.

And now, the team!

William Blackerby. Photo by Quez Shipman.

William Blackerby is proud to call Birmingham, Alabama home. A graduate of Sewanee: The University of the South with a B.A. in classical languages, he is in his seventh year teaching Latin and Greek at Indian Springs School just outside Birmingham. He is a second year M.L.I.S. student at the School of Library and Information Studies at the University of Alabama. Outside of work and school, he enjoys playing old time fiddle and spending time with his wife and dog. William hopes to use the skills gained during his master’s program to help libraries and nonprofits find technological solutions to information management problems.

Katie Harper. Photo by Katie Harper.



Katie Harper (she/her/hers) is an Ohio native who holds an M.L.S. degree with a focus in health information from the University of Kentucky and a B.S. in elementary education from the University of Louisville. She currently works for her local public library as a full-time clerk. Before that, she worked at an academic library as a research and instruction assistant, as well as a stack maintenance assistant. In the future, Katie hopes to work in the health information field as a medical librarian.

Renée LaCapria-Harper. Photo by Renée LaCapria-Harper.

Renée LaCapria-Harper is currently pursuing a master’s degree in archiving and records administration from San José State University and a bachelor’s degree in computer science from Wilmington University.  From previous studies, she holds an M.I.S. from University of Phoenix; an M.L.I.S. from San José State University; and a B.A. in communication studies (concentration in rhetoric and argumentation) from California State University, San Bernardino.  She is a technical project manager with dreams of joining others who work diligently to archive the many stories that history produces.  When the workday ends and between university studies, Renée enjoys reading, building websites, and expanding her knowledge in technology, archiving, and digital art.

Sami Luke. Photo by Austin DeRaedt.


Sami Luke is a current graduate student at Wayne State University where she is studying for a master’s degree in library and information science with a specialization in library services such as library systems and infrastructure. Sami went to Michigan State University (M.S.U.) for a bachelor’s degree in English with a minor in women’s and gender studies. While working as a remote metadata intern for the Law Library, Sami also works at the M.S.U. library in the reference and discovery services department. In the future she hopes to continue working with metadata and/or venture into the world of cataloging. 

Sam Mays. Photo by Sam Mays.


Sam Mays lives in Cincinnati, Ohio. He is currently finishing his M.L.I.S. through Kent State University. In addition to this internship, he is a volunteer at Cincinnati History Library and Archives. When not reading or researching, he loves running, watching documentaries, and cooking.

Andrew Reiter. Photo by Andrew Reiter.



Andrew Reiter is a Michigan native currently based in Austin, Texas, where he is in his final year as a master’s student in the school of information at the University of Texas. Andrew is interested in digital libraries, metadata, and the digital humanities and hopes to work at a university or in the government after graduation. In his spare time, he enjoys traveling, reading, and being outdoors as much as the Texas heat allows.

Nancy Sprouse. Photo by Nancy Sprouse.

Nancy Sprouse is a recent M.L.I.S. graduate from Texas Woman’s University, and current resident of San Antonio, Texas. She obtained a bachelor’s degree in animal science from Texas A&M University, and a master’s in biology from the University of the Incarnate Word. She has actively worked in information technology for the past seven years and joins this season’s remote internship to diversify her current skills with metadata experience. When not working, she enjoys spending time with her dogs, cats, and chinchilla, as well as gardening. She currently hopes to obtain a future position that will allow her to utilize her diverse skill sets and plans on continuing her education in the near future to include a Ph.D. in library and information science.

Margaret Stephens. Photo by Margaret Stephens.


Margaret Stephens lives in Chicago, Illinois. She holds a bachelor of science degree in healthcare leadership from National-Louis University. She is completing her coursework for an M.S.L.I.S. at Chicago State University. She enjoys Chicago’s fireworks and the Shoreline Skyline Lake Tours at Navy Pier.

Stacey Weldon. Photo by Stacey Weldon.


Stacey Weldon is currently studying information communication technology at the University of Kentucky. Her current internship at the Law Library of Congress has allowed her to pursue knowledge of metadata related to Congress Research Service bill summaries. She is interested in the topics of finance, data management, and metadata.

Julia Zamarripa. Photo by Nikki Dodge.



Julia Zamarripa is from Houston, Texas, and is currently an M.L.S. student at Texas Woman’s University. She received her B.B.A. in finance from Texas State University. In her free time, she enjoys reading, hiking, and baking.


Subscribe to In Custodia Legis – it’s free! – to receive interesting posts drawn from the Law Library of Congress’s vast collections and our staff’s expertise in U.S., foreign, and international law.

Categories: Research & Litigation

Schools, Sheriffs, and Syringes: State Plans Vary for Spending $26B in Opioid Settlement Funds

Kaiser Health News - Tue, 11/22/2022 - 5:00am

With more than 200 Americans still dying of drug overdoses each day, states are beginning the high-stakes task of deciding how to spend billions of dollars in settlement funds from opioid manufacturers and distributors. Their decisions will have real-world implications for families and communities across the country that have borne the brunt of the opioid crisis.

Will that massive tranche of money be used to help the people who suffered the most and for programs shown to be effective in curbing the epidemic? Or will elected officials use the money for politically infused projects that will do little to offer restitution or help those harmed?

Jacqueline Lewis, of Columbus, Ohio, is wondering exactly that. She lost her son this fall after his 20-year struggle with addiction.

After emptying her retirement account and losing her house to pay for his rehab, court fees, and debts to dealers, she’s now raising her 7-year-old granddaughter while also caring for her 95-year-old mother with dementia, on nothing more than Social Security payments.

When Lewis heard Ohio would receive $808 million in opioid settlement funds, she thought there’d finally be relief for thousands of families like hers.

She was eager to speak with members of the OneOhio Recovery Foundation, which was created to oversee the distribution of most of Ohio’s funds. As they determined priorities for funding, she wanted them to consider perspectives like hers, a mother and grandmother who’d faced addiction up close and saw the need for more treatment centers, addiction education in the workplace, and funding for grandparents raising grandkids as a result of the opioid epidemic.

But she couldn’t find anyone to listen. At an August foundation meeting she attended, board members excused themselves to go into a private session, she said. “They just left the room and left us sitting there.” When she attended another meeting virtually, audience members weren’t allowed to “voice anything or ask questions.”

A local group that advocates for people affected by the opioid epidemic has expressed similar concerns and is now suing the foundation for a lack of transparency, even though few decisions about funding priorities have been made yet.

The strife in Ohio highlights the tensions emerging nationwide as settlement funds start flowing. The funds come from a multitude of lawsuits, most notably a $26 billion settlement resulting from more than 3,000 cities, counties, and states suing manufacturer Johnson & Johnson and distributors McKesson, AmerisourceBergen, and Cardinal Health for their roles in the opioid crisis. Payments from that case began this summer and will continue for 18 years, setting up what public health experts and advocates are calling an unprecedented opportunity to make progress against an epidemic that has ravaged America for three decades.

But, they caution, each state seems to have its own approach to these funds, including different distributions between local and state governments and various processes for spending the money. With countless individuals and groups advocating for their share of the pie — from those dealing with addiction and their families to government agencies, nonprofits, health care systems, and more — the money’s impact could depend heavily on geography and politics.

“It sounds like a lot of money, but it’s going to a lot of places and going to be spread out over time,” said Sara Whaley, a researcher at Johns Hopkins Bloomberg School of Public Health who tracks state use of opioid funds. “It’s not going to magically end this crisis. But if it’s used well and used thoughtfully, there is an opportunity to make a real difference.”

And if not, it could be just another political boondoggle.

Avoiding the ‘Tobacco Nightmare’

The worst-case scenario, many say, is for the opioid settlement to end up like the tobacco master settlement of 1998.

States won $246 billion over 25 years, but less than 3% of the annual payouts are used for smoking prevention or cessation, according to the Campaign for Tobacco-Free Kids. Most has gone toward filling budget gaps, building roads, and subsidizing tobacco farmers.

But there are stronger protections in place for the opioid settlement dollars, said Christine Minhee, founder of a website that tracks the funds.

The arrangement specifies that states must spend at least 70% of the money for opioid-related expenses in the coming years and includes a list of qualifying expenses, like expanding access to treatment and buying the overdose reversal medication naloxone. Fifteen percent of the funds can be used for administrative expenses or for governments to reimburse past opioid-related expenses. Only the remaining 15% is a free-for-all.

If states don’t meet those thresholds, they could face legal consequences and even see their future payouts reduced, Minhee said.

“The kind of tobacco nightmare stuff where only 3% of funds were spent on what they were meant for is legally and technically impossible,” she said. Though, she added, “a different nightmare is still possible.”

Experts tracking the funds say transparency around who receives the money and how those decisions are made is key to a successful and useful distribution of resources.

In Rhode Island, for instance, public comment is a regular part of opioid advisory committee hearings. In North Carolina and Colorado, online dashboards show how much money each locality is receiving and will track how it is spent.

But other states are struggling.

In Ohio, the document that creates a private foundation to oversee most of the state’s funds says that “the Foundation shall operate in a transparent manner” and that meetings and documents will be public. Yet the OneOhio Recovery Foundation has since said it is not subject to open-meetings law. It has adopted a policy that meetings can be closed if the board decides the content is “sensitive or confidential material that is not appropriate for the general public.”

The contradiction between the board’s actions and how it was conceived led Dennis Cauchon, president of Harm Reduction Ohio, which distributes naloxone across the state, to sue the foundation. He said he wants the public to have more say in how the funding is spent.

“The board members are in a closed loop, and they’re having a hard time learning what the needs are,” Cauchon said.

The 29-member board includes representatives of local regions, as well as appointees from the governor, state attorney general, and legislative leaders. Many are city- and county-level politicians, and one is the wife of a U.S. senator. They are not paid for this role.

Nathaniel Jordan, executive director of the nonprofit Columbus Kappa Foundation, which distributes naloxone to Black communities in Ohio, has raised concerns about the board’s lack of racial diversity. Since 2017, Black men have had the highest rate of drug overdose deaths in the state, he said, but only one board member is Black. “What gives?”

Kathryn Whittington, chair of the OneOhio Recovery Foundation, said the board is being “very transparent in what we are doing.” The public can attend meetings in person or online. Recordings of past meetings are posted online, along with the agenda, board packet, and policies discussed — including a draft of the diversity and inclusion policy the board is considering.

People who want to provide input “can always reach out to me as the chair or any other board member,” said Whittington, who added that two of her children have struggled with addiction too. But the best option is to contact one of Ohio’s 19 regional boards, she said. Those groups can elevate local concerns to the foundation board.

“We are still at the very beginning,” Whittington emphasized. No money from the 18-year settlement has been spent yet. The board’s operational expenses — including a $10,000-per-month contract with a public relations firm — is being paid from $1 million from a previous opioid-related settlement.

But Lewis, the woman raising her granddaughter in Columbus, worries that the day for families to speak may never come.

“They keep saying it’s not ready, and before you know it, they’ll be handing out money and it’ll be too late,” she said.

Following the Money

Rhode Island is one of the states working fastest to distribute settlement dollars. Its Executive Office of Health and Human Services, which controls 80% of the funds and works with an opioid advisory committee, released a plan to use $20 million by July 2023.

Although the plan doesn’t specify funding for people raising grandchildren, it does allocate $900,000 to recovery supports, which will include community agencies that serve family members, the department said. The single largest allocation, $4 million, will go to school- and community-based mental health programs.

The investment that has sparked the most interest is $2 million for a supervised drug consumption site. Its location and opening date will be determined by organizations that respond to the state’s request for proposals, said Carrie Bridges Feliz, chair of the opioid settlement advisory committee. At a time when fentanyl, a synthetic opioid 50 times stronger than heroin, is infiltrating most street drugs and overdose rates are high, “we were anxious to make use of these funds.”

In contrast, the process of distributing settlement dollars in Louisiana has barely begun. State Attorney General Jeff Landry announced in July 2021 that Louisiana was expected to receive $325 million from the 18-year settlement but has not released any additional information. His office did not respond to repeated inquiries about the status of the funds.

The governor’s office and state health department said they could not answer specific questions about the funds and had not yet been contacted by the attorney general’s office, which negotiated the state’s settlement agreement. Multiple clinicians who treat substance use disorder and advocates who work with people who use drugs were similarly in the dark.

The state’s written plan says it will create a five-person task force to recommend how to spend the money. Kevin Cobb, president of the Louisiana Sheriffs’ Association, said the group had appointed its representative to the task force, but he didn’t know if other members had been selected or when they would meet.

One decision Louisiana has made so far is to give 20% of the settlement funds directly to sheriffs — a move that has made some people nervous.

“This plays into an increase in support for an authoritarian response to what are public health issues,” said Nadia Eskildsen, who has worked for syringe service programs and other such groups in New Orleans.

She worries that money will be funneled toward increasing arrests, rather than helping people find housing, work, or health care. Meanwhile, almost 1,400 Louisiana residents died of opioid-related causes last year.

K.P. Gibson, the Acadia Parish sheriff who will represent the sheriffs association on the state task force, said his focus is not on punishment, but on getting people into treatment. “My jail problem will resolve itself if we resolve the problem of opioid addiction,” he said.

Many health and policy experts say using settlement funds to pair mental health professionals with police officers or provide medications for opioid use disorder in prisons could reduce deaths.

States’ choices generally reflect a range of local priorities: While Louisiana has carved out funds for law enforcement, Maine is dedicating 3% of its statewide share for special education programs in schools, and Colorado has allocated 10% to addiction infrastructure, like workforce training, telehealth expansion, and transportation to treatment.

Maine requires that some funds be used for special education because school districts also sued the opioid companies, said state Attorney General Aaron Frey.

Patricia Hopkins said she signed on to the lawsuit because she’s seen the impact of the opioid crisis on students over the past decade as superintendent of school district 11, a rural part of central Maine’s Kennebec County with 1,950 students.

A report compiled by her staff in 2019 showed nearly 4% of students have a parent dealing with addiction.

Sixty miles north, in rural Penobscot County, school district 19 social worker Meghan Baker said she knows two siblings who were home when first responders arrived to revive their parents with naloxone, and another set of siblings who lost their mother to an overdose.

Students who experience this trauma often become angry, act out at school, and find it difficult to trust adults. When Baker refers them to counseling services in the community, they encounter waitlists that run six months to a year.

“If we could hire more guidance counselors and social workers, at least we can help some of those kids during the school day,” she said.

It’s clear that many have high hopes for the billions of dollars in opioid settlement funds arriving over the next two decades. But they have questions too, because effectively using this large pot of money requires planning and forethought.

For people like Jacqueline Lewis in Ohio, whose family has lost so much to an epidemic too long ignored, progress feels slow.

As she tries to make do on Social Security, Lewis focuses on the positives: Her granddaughter is a happy child, and her older brother lives with them to help out. But the financial worries gnaw at her. And what if her own health falters before her granddaughter is an adult?

“I might be OK right now, but tomorrow, I never know,” she said.

KHN correspondent Rae Ellen Bichell contributed to this report.

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


This story can be republished for free (details).

Categories: Health Care

California Aims to Maximize Health Insurance Subsidies for Workers During Labor Disputes

Kaiser Health News - Tue, 11/22/2022 - 5:00am

This spring, Chevron workers testified that the company revoked health coverage for hundreds of members of the United Steelworkers Local 5 at the Richmond, California, refinery during a strike that ultimately lasted two months. Thousands of nurses at Stanford Health Care were told in April they would lose their health insurance if they did not return to work during their weeklong strike. More than 300 workers at Sequoia Hospital in Redwood City received a similar message after going on strike in mid-July as contract negotiations stalled.

Freezing health insurance benefits is a common tactic in a labor dispute because without them, workers might be more easily persuaded to concede to management’s demands. But California lawmakers are giving an edge to strikers.

Assembly member Jim Wood, a Democrat, is hoping a new California law he authored will dissuade employers from cutting off health benefits during labor disputes by allowing private-industry workers to maximize state subsidies for coverage purchased through Covered California, the state’s health insurance marketplace. The bill, which takes effect in July, was sponsored by the California Labor Federation, California Teamsters Public Affairs Council, and the Los Angeles County Federation of Labor.

“The goal of the legislation is to say, ‘No you can’t do this,’” Wood said. “Never try it again.”

According to Covered California spokesperson Kelly Green, eligible workers will have their premiums covered as if their incomes were just above the Medicaid eligibility level. The state would factor in the worker’s federal subsidy and cover the difference. For example, a single person making $54,360 a year may pay 8.5% of their income, or about $385 a month, on premiums under a middle-tier health plan. Under the new law for striking workers, that person selecting the same plan would pay nothing in premiums — as if that person made $20,385 a year — for the duration of the strike.

The federal government authorized an enhanced subsidy under the American Rescue Plan Act. The enhanced subsidy will continue through 2025 under the Inflation Reduction Act. The state’s share of the subsidy could increase once the federal boost ends.

One estimate that unions shared with the state suggested the law would cost California an average of $341 a month per worker — with strikes lasting one to two months. Labor groups estimate the bill will affect fewer than 5,000 workers a year. California has nearly 15 million workers in the private sector, and strikes are generally a tool of last resort in labor negotiations.

It’s not clear how businesses will respond. Chevron, Stanford Health Care, and Sequoia Hospital’s operator, Dignity Health, did not respond to requests for comment. The bill met no formal opposition from businesses or taxpayer groups. Covered California’s subsidies are footed by a mix of federal and state funds as part of the Affordable Care Act, so there’s no direct cost to businesses.

Last year, Gov. Gavin Newsom, a Democrat, signed the Public Employee Health Protection Act, which bars public employers from terminating health coverage during an authorized strike. The new law for the private industry is different: There’s no ban on — or financial penalty for — revoking health benefits during strikes.

Nationally, Democrats in the House and Senate have pushed for an outright ban on this practice, but neither bill has advanced out of committee.

When California workers lose their employer-sponsored health benefits, they may become eligible for the state’s Medicaid program, known as Medi-Cal, or qualify to purchase health insurance through Covered California. With the latter option, workers could receive a range of subsidies to help pay for their monthly premiums. Generally, the lower a household’s income, the bigger the subsidy.

But even when workers do qualify for Covered California, that insurance can be much more expensive than the plans they had through their job — sometimes consuming 30% to 40% of their income, proponents said. And striking workers may experience delays since coverage may not take effect until the following month.

“This is one of the drawbacks of having a health care system that is tied to employment,” said Laurel Lucia, health care program director at the University of California-Berkeley Labor Center. “We saw during the pandemic, when there were furloughs or layoffs, people lost job-based coverage when they needed it most.”

Striking Sequoia workers reached an agreement with Dignity Health and returned to the 208-bed facility before health coverage stopped on Aug. 1, but some said they might have stayed on the picket line longer if not for fear of losing their benefits.

“That was pretty scary,” said Mele Rosiles, a certified nursing assistant and a member of the union’s bargaining team who was pregnant at the time. “A majority of our workers felt threatened by this move from our employer to strip our family’s health insurance if we didn’t return to work.”

The California Association of Health Plans raised concerns over an early version of the bill that sought to establish a category for striking workers, but the industry group dropped its opposition once it was determined that Covered California could administer the change without it.

Covered California estimates it will spend about $1.4 million to launch this benefit. The agency said it will create application questions to screen for eligible workers and remind them to stop coverage once they go back to work.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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


This story can be republished for free (details).

Categories: Health Care

Treating Long Covid Is Rife With Guesswork

Kaiser Health News - Tue, 11/22/2022 - 5:00am

Medical equipment is still strewn around the house of Rick Lucas, 62, nearly two years after he came home from the hospital. He picks up a spirometer, a device that measures lung capacity, and takes a deep breath — though not as deep as he’d like.

Still, Lucas has come a long way for someone who spent more than three months on a ventilator because of covid-19.

“I’m almost normal now,” he said. “I was thrilled when I could walk to the mailbox. Now we’re walking all over town.”

Dozens of major medical centers have established specialized covid clinics around the country. A crowdsourced project counted more than 400. But there’s no standard protocol for treating long covid. And experts are casting a wide net for treatments, with few ready for formal clinical trials.

It’s not clear just how many people have suffered from symptoms of long covid. Estimates vary widely from study to study — often because the definition of long covid itself varies. But the more conservative estimates still count millions of people with this condition. For some, the lingering symptoms are worse than the initial bout of covid. Others, like Lucas, were on death’s door and experienced a roller-coaster recovery, much worse than expected, even after a long hospitalization.

Symptoms vary widely. Lucas had brain fog, fatigue, and depression. He’d start getting his energy back, then go try light yardwork and end up in the hospital with pneumonia.

It wasn’t clear which ailments stemmed from being on a ventilator so long and which signaled the mysterious condition called long covid.

“I was wanting to go to work four months after I got home,” Rick said over the laughter of his wife and primary caregiver, Cinde.

“I said, ‘You know what, just get up and go. You can’t drive. You can’t walk. But go in for an interview. Let’s see how that works,’” Cinde recalled.

Rick did start working earlier this year, taking short-term assignments in his old field as a nursing home administrator. But he’s still on partial disability.

Why has Rick mostly recovered while so many haven’t shaken the symptoms, even years later?

“There is absolutely nothing anywhere that’s clear about long covid,” said Dr. Steven Deeks, an infectious disease specialist at the University of California-San Francisco. “We have a guess at how frequently it happens. But right now, everyone’s in a data-free zone.”

Researchers like Deeks are trying to establish the condition’s underlying causes. Some of the theories include inflammation, autoimmunity, so-called microclots, and bits of the virus left in the body. Deeks said institutions need more money to create regional centers of excellence to bring together physicians from various specialties to treat patients and research therapies.

Patients say they are desperate and willing to try anything to feel normal again. And often they post personal anecdotes online.

“I’m following this stuff on social media, looking for a home run,” Deeks said.

The National Institutes of Health promises big advances soon through the RECOVER Initiative, involving thousands of patients and hundreds of researchers.

“Given the widespread and diverse impact the virus has on the human body, it is unlikely that there will be one cure, one treatment,” Dr. Gary Gibbons, director of the National Heart, Lung, and Blood Institute, told NPR. “It is important that we help find solutions for everyone. This is why there will be multiple clinical trials over the coming months.”

Meanwhile, tension is building in the medical community over what appears to be a grab-bag approach in treating long covid ahead of big clinical trials. Some clinicians hesitate to try therapies before they’re supported by research.

Dr. Kristin Englund, who oversees more than 2,000 long covid patients at the Cleveland Clinic, said a bunch of one-patient experiments could muddy the waters for research. She said she encouraged her team to stick with “evidence-based medicine.”

“I’d rather not be just kind of one-off trying things with people, because we really do need to get more data and evidence-based data,” she said. “We need to try to put things in some sort of a protocol moving forward.”

It’s not that she lacks urgency. Englund experienced her own long covid symptoms. She felt terrible for months after getting sick in 2020, “literally taking naps on the floor of my office in the afternoon,” she said.

More than anything, she said, these long covid clinics need to validate patients’ experiences with their illness and give them hope. She tries to stick with proven therapies.

For example, some patients with long covid develop POTS — a syndrome that causes them to get dizzy and their heart to race when they stand up. Englund knows how to treat those symptoms. With other patients, it’s not as straightforward. Her long covid clinic focuses on diet, sleep, meditation, and slowly increasing activity.

But other doctors are willing to throw all sorts of treatments at the wall to see what might stick.

At the Lucas house in Tennessee, the kitchen counter can barely contain the pill bottles of supplements and prescriptions. One is a drug for memory. “We discovered his memory was worse [after taking it],” Cinde said.

Other treatments, however, seemed to have helped. Cinde asked their doctor about her husband possibly taking testosterone to boost his energy, and, after doing research, the doctor agreed to give it a shot.

“People like myself are getting a little bit out over my skis, looking for things that I can try,” said Dr. Stephen Heyman, a pulmonologist who treats Rick Lucas at the long covid clinic at Ascension Saint Thomas in Nashville.

He’s trying medications seen as promising in treating addiction and combinations of drugs used for cholesterol and blood clots. And he has considered becoming a bit of a guinea pig himself.

Heyman has been up and down with his own long covid. At one point, he thought he was past the memory lapses and breathing trouble, then he caught the virus a second time and feels more fatigued than ever.

“I don’t think I can wait for somebody to tell me what I need to do,” he said. “I’m going to have to use my expertise to try and find out why I don’t feel well.”

This story is from a reporting partnership that includes WPLN, NPR, and KHN.

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


This story can be republished for free (details).

Categories: Health Care

Fall Remote Metadata Program: East Coast Team

In Custodia Legis - Mon, 11/21/2022 - 10:11am

This fall, we have two remote programs happening with our interns and volunteers. We introduced you to our foreign legal gazette program participants last month, and during the next three days, we will introduce you to our interns and volunteers working with Congressional Research Service bill summaries in our remote metadata program. This program is a continuation of last spring’s successful project.

Danielle Pytko. Photo by Pauline Pytko.

To organize our work, we have three teams divided geographically across the country, each with a team lead. Our first group is the team on the East Coast, led by Danielle Pytko. This is Danielle’s third semester working with us and her first as a team lead. Danielle is a graduate of the library and information science program at Simmons University. She has worked in public and academic libraries and has a B.A. in English from Mount Holyoke College.

What is your favorite project you’ve worked on?

I’ve participated in two Law Library of Congress internship programs—the creative digital projects program and the metadata program—and greatly enjoyed my experiences in each of them. They also pair very well together. I experienced digital archives from two different points of view: a patron’s point of view while researching for a blog post in the creative digital projects program and from a an archivist’s point of view as a metadata intern and from a professional point of view while working as a metadata intern. This experience gave me a valuable perspective on how researchers’ needs guide the work of library employees.

Why do you keep coming back to the Library of Congress?

I am in awe of all of the history that the Library contains and the work that goes into preserving that history and making it accessible to the public. I am eager to use my skills to contribute to that work.

What is the coolest thing you’ve come across while working with us?

In my first semester as a metadata intern, I worked on summaries of bills introduced in the House of Representatives in 1969. The variety of topics that the bill summaries addressed was interesting—everything from the military draft to bees—and a great insight into that time in history.

What are you hoping to do in the library field?

I am excited about the possibilities of digital platforms for the discoverability, accessibility, and preservation of library materials. I would be especially interested in working as a product manager or in a product owner role where I could contribute to the ideation, development, and implementation of new features for a library’s digital products and services. I also enjoy storytelling and would be interested in a marketing role where I can communicate the benefits of library resources, services, and events to the public.

Why libraries?

Libraries contain many resources white document history. I enjoy working to make those resources more accessible for everyone.

And now, meet the team!

Matt Burke. Photo by Matt Burke.

Matt Burke is a New York native who holds an Associate of Arts (A.A.) degree  from Suffolk Community College, a B.A. degree in history from Stony Brook University, and is currently in pursuit of an M.L.I.S. at the University at Buffalo. Matt has always had a passion for learning history, as well as for politics, and hopes to pursue a career handling collections and archives at the Library of Congress or National Archives. His interests include reading, watching sports, and spending time with family.

Diana Ferguson. Photo by Diana Ferguson.

Diana Ferguson is currently working towards a master of science in information degree at Florida State University. She holds an M.B.A. from Texas A&M International University and a B.A. in psychology from the University of Central Florida. Diana is also certified as a ballet barre fitness instructor. “Solar powered,” she loves living in Florida with her amazing husband and son, and cheering on her favorite hockey team. She loves learning the ways technology can be implemented to solve problems by radically improving processes and making the impossible possible. Working as an intern with the Smithsonian Cultural Rescue Initiative, Diana helped direct FEMA to the most up-to-date information on cultural heritage institutions in the event of a disaster. She loves working with metadata, and in that context, has contributed work to some of our nation’s oldest laws in the Statutes at Large, the American State Papers, and congressional bill summaries for the Law Library of Congress.

Bethany Greenho. Photo by Lori Greenho.

Bethany Greenho is currently pursuing a master’s degree in library and information science with a focus on archives at the University of Maryland. Her interests include arts archives, accessibility, and primary source literacy. In her free time, Bethany enjoys visiting museums, attending the theater, and learning new craft skills.

Taylor Hiltz. Photo by Taylor Hiltz.

Taylor Hiltz will be graduating with an M.L.I.S. degree from the University of Denver in November 2022. She also holds a B.S. in criminal justice from Virginia Commonwealth University and has worked in law enforcement and public and academic libraries. Although she has spent much of her life in Virginia, Taylor’s family has lived in Idaho for generations, she calls “home.” Taylor has two dogs, and in her spare time she loves to read, learn new skills, complete home improvement projects, kayak, and travel. She is passionate about metadata, digital literacy, and digital asset management.

Ashley Jones. Photo by Ashley Jones.

Ashley Jones is a Brooklyn native who holds a B.A. degree from SUNY Albany, where she double majored in political science and criminal justice, with a minor in Africana studies. She is an aspiring archivist, passionate about documenting public memory through photography and oral history. In the future, after attaining an M.L.I.S., she hopes to work with ethnographic archives. In her free time, she enjoys spending time with her cats, studying herbalism, and collaging.

Jacob Neal. Photo by Carolyn Neal.

Jacob Neal is a native of Florida and is currently a graduate student at the University of Missouri, completing a M.L.I.S. degree with an archival emphasis. He has a B.A. degree in history from the University of Florida. In his spare time, he enjoys reading presidential biographies, traveling to presidential libraries and historic sites, and attending various sporting events.

Lily Nisbet. Photo by Lily Nisbet.

Lily Nisbet grew up and attended school in Maryland and in Edinburgh, Scotland. She is a recent graduate of Elizabethtown College with a degree in philosophy with a focus in the humanities. When not working, Lily enjoys Irish step dancing and reading. She currently resides in Maryland with her rescue golden retriever who believes he is the size of a chihuahua.

Kaci Pelias. Photo by Kaci Pelias.

Kaci Pelias currently dwells in Central Florida, but her heart lives in Texas. She has a B.A. in playwriting and a minor in arts administration from the University of Texas at Austin, and is currently pursuing an M.L.I.S. from the University of South Florida. She spends a lot of time at theme parks and enjoys reading, cross-stitching, and drinking coffee. Kaci loves working with children, advocating against book censorship, and learning more about metadata.

Cait Ross. Photo by Petar Kovacevic.

Cait Ross is wrapping up her final year of her M.L.I.S. studies at Simmons University. She holds an undergraduate degree in English literature from the University of Edinburgh. When not on duty as a law library assistant, she can be found drinking coffee with her husband, practicing Serbian, or doodling in her planner. She aims to pursue a career in academic and/or special libraries.

Becky Zarrella. Photo by Becky Zarrella.

Rebecca (Becky) Zarrella is entering her final year of the M.L.I.S. program at the University of Maryland. Her academic interests include open data, digital access and literacy, ethics in artificial intelligence, and the use of assistive technology and universal design to promote information equity. She loves talking accessibility, algorithms, and automation. Becky lives near Baltimore with her husband and their two perfect dogs. In her free time she likes to read, write, play piano, garden, and paint.



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Categories: Research & Litigation

Patient Mistrust and Poor Access Hamper Federal Efforts to Overhaul Family Planning

Kaiser Health News - Mon, 11/21/2022 - 5:34am

JACKSON, Miss. — Two years ago, after an emergency cesarean section at a Mississippi hospital, Sherika Trader was denied a tubal ligation. Trader, now 33, was told that to have her tubes tied, she had to have a second child or a husband’s permission, even though she wasn’t married.

Jasymin Shepherd had heavy menstrual cycles because of a birth control pill prescribed after the birth of her son 13 years ago. The symptoms continued even after she stopped taking the medication. Last year, a doctor in Jackson responded by offering Shepherd, 33, a hysterectomy, which she didn’t want.

The experiences left the women feeling as though providers acted like “robots,” or, worse, they felt stereotyped. Black women already face major barriers to accessing health care, including provider shortages and racial bias rooted in the medical system.

But with contraceptive care, which deals with deeply personal patient preferences, they must also contend with providers who dismiss their concerns. Decisions about whether — or when — to have a baby and how to prevent pregnancy are not as standardized as care for other conditions. Yet providers hand out prescriptions or recommendations while disregarding a patient’s specific circumstances, Shepherd said.

Late last year, the White House made new recommendations for a federal program that provides funding for free contraceptives, wellness exams, and certain cancer screenings. Health officials want to regain the trust of patients like Trader and Shepherd, who feel as though their doctors don’t always listen to them. The goal of the Title X program, which distributes grants to states and other groups for family planning, is to let patients dictate the care they want, said Jessica Marcella, who is the deputy assistant secretary for population affairs at the U.S. Department of Health and Human Services and oversees the Title X program.

“Our belief, and that of the family planning field, is that it is essential that you respect the interests, needs, and values of a client,” she said. Providers shouldn’t force patients to take a birth control method because it’s more effective, she said, or deny them a particular method because they think a patient might want more kids.

“What we don’t want is a provider to create trauma or do unintentional harm,” Marcella said.

In Mississippi, efforts to implement that approach have started with a change in who gets to administer the Title X funds, taking that responsibility from the state and giving it to a four-year-old Jackson-based nonprofit named Converge. The Biden administration’s decision this year to give Converge the $4.5 million grant marks the first time in four decades that Mississippi’s health department hasn’t won the federal family-planning grant.

Converge doesn’t offer family planning services. Instead, the group provides funding to a network of clinics statewide, organizes provider training, helps clinics navigate technology challenges, and keeps them stocked with supplies. For example, when a provider was having trouble printing out a survey that patients took about their contraception preferences, Converge co-founder and co-director Jamie Bardwell shipped the clinic a wireless printer.

But across the South, the attempt to change the culture of family planning care faces old and new obstacles. Some are deeply rooted in the medical system, such as the bias long faced by Black women and other women of color. In addition, contraception care is limited in the conservative South, and the Supreme Court’s June decision to overturn Roe v. Wade has led to the curtailing of abortion access across much of the region.

Black women often feel disrespected and dismissed by their providers, said Kelsey Holt, an associate professor of family and community medicine at the University of California-San Francisco. She co-authored a 2022 study in the journal Contraception in which dozens of Black women in Mississippi were interviewed about their experiences getting contraceptives.

Women told researchers that they struggled to get appointments, faced long wait times, and had to put up with condescending behavior. Many of the women said providers didn’t inform them about alternatives to the contraceptive Depo-Provera, a progestin shot administered once every three months, despite the known side effects and the availability of other, more appropriate options.

Trying to undo decades of such damage — and overhaul how providers deliver family planning care — became even more difficult after the Supreme Court decision and the closure of abortion clinics across the South. Suddenly, women in Mississippi, Alabama, and about a dozen other states could no longer get abortions.

“A major service has been cut off,” said Usha Ranji, associate director for women’s health policy at KFF. Title X funds cannot be used — and have never been used — to pay for abortions. But, she said, clinics can no longer present abortion as an option, hampering their ability to provide comprehensive counseling, a key requirement of the Title X program.

Many Mississippians can’t afford to travel across state lines to terminate an unwanted pregnancy. In 2020, 84% of Title X clients in the U.S. had incomes at or below 200% of the federal poverty level, and 39% were uninsured. Even women in Mississippi with the means to travel will face hurdles in nearby states, like Georgia and Florida, where abortion is not fully banned but access has been scaled back.

Even before the Supreme Court decision, access to family planning care in Mississippi came with hurdles and judgment.

In 2017, when Mia, who didn’t want her last name used for fear of legal and social repercussions, became pregnant for the second time, she called the local health department in Hattiesburg for advice on obtaining an abortion. She had a daughter and wasn’t financially or mentally prepared to have another child. The health department contact sent Mia to a faith-based, anti-abortion center.

“I felt judged,” Mia said about the call. Eventually, she terminated the pregnancy in Jackson, about 90 miles away, at the state’s sole abortion clinic, which closed in July. “Ultimately, I did what was best for me,” said Mia, who went on to have a son several years after the abortion.

The loss of abortion care in Mississippi puts more pressure on family planning providers to win the trust of their patients, said Danielle Lampton, who also co-founded Converge. Patient-centered care is the “bedrock of what we do,” Lampton said.

Both Trader and Shepherd serve on Converge’s patient experience council and receive occasional stipends for providing their perspectives to the nonprofit.

Providers shouldn’t force or pressure low-income patients to use long-term contraception, such as an intrauterine device, to safeguard against pregnancy, said Dr. Christine Dehlendorf, a family physician and researcher at UCSF, who is advising Converge.

Pressuring Black women to use IUDs, implants, and other long-term contraception is reminiscent of a history in which Black women were sterilized against their consent, she said. Even today, studies show that providers are more likely to pressure women of color to limit the size of their families and recommend IUDs to them. These women also have a harder time getting a provider to remove the devices and getting insurance to cover the removal cost, Dehlendorf said.

Too often, Wyconda Thomas, a family nurse practitioner near the Arkansas border, meets patients who are skeptical of birth control because of a bad experience. Many of her patients continued Depo-Provera shots even after they gained an unsafe amount of weight — a known side effect — because they weren’t offered other options.

Even if patients come in for another reason, Thomas talks to them about family planning “every chance I get,” she said. Four years ago, Thomas opened the Healthy Living Family Medical Center in Gunnison, a 300-person town that is 80% Black. The clinic receives Title X funds through Converge. Still, Thomas doesn’t force contraception on patients — she respects their decision to forgo a pill, patch, or implant.

But Title X funds help Thomas stock a variety of contraception methods so patients don’t have to worry about driving to a separate pharmacy.

“My job for them is to get them to understand that there are more methods and there’s no method at all,” Thomas said. “And that’s a whole visit by itself.”

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


This story can be republished for free (details).

Categories: Health Care

Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges

Kaiser Health News - Mon, 11/21/2022 - 5:33am

Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average.

Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.

The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.

Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result.

But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but put that decision off until February.

Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.

Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage. “From the outside, it seems pretty smelly,” he said.

In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”

Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.

The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the government paid the health plan to treat, or if medical reviewers judge the illness is less severe than claimed.

That happened on average for just over 20% of medical conditions examined over the three-year period; rates of unconfirmed diseases were higher in some plans.

As Medicare Advantage’s popularity among seniors has grown, CMS has fought to keep its audit procedures, and the mounting losses to the government, largely under wraps.

That approach has frustrated both the industry, which has blasted the audit process as “fatally flawed” and hopes to torpedo it, and Medicare advocates, who worry some insurers are getting away with ripping off the government.

“At the end of the day, it’s taxpayer dollars that were spent,” said David Lipschutz, a senior policy attorney with the Center for Medicare Advocacy. “The public deserves more information about that.”

At least three parties, including KHN, have sued CMS under the Freedom of Information Act to shake loose details about the overpayment audits, which CMS calls Risk Adjustment Data Validation, or RADV.

In one case, CMS charged a law firm an advance search fee of $120,000 and then provided next to nothing in return, according to court filings. The law firm filed suit last year, and the case is pending in federal court in Washington, D.C.

KHN sued CMS in September 2019 after the agency failed to respond to a FOIA request for the audits. Under the settlement, CMS agreed to hand over the audit summaries and other documents and pay $63,000 in legal fees to Davis Wright Tremaine, the law firm that represented KHN. CMS did not admit to wrongfully withholding the records.

High Coders

Most of the audited plans fell into what CMS calls a “high coding intensity group.” That means they were among the most aggressive in seeking extra payments for patients they claimed were sicker than average. The government pays the health plans using a formula called a “risk score” that is supposed to render higher rates for sicker patients and lower ones for healthier ones.

But often medical records supplied by the health plans failed to support those claims. Unsupported conditions ranged from diabetes to congestive heart failure.

Overall, average overpayments to health plans ranged from a low of $10 to a high of $5,888 per patient collected by Touchstone Health HMO, a New York health plan whose contract was terminated “by mutual consent” in 2015, according to CMS records.

Most of the audited health plans had 10,000 members or more, which sharply boosts the overpayment amount when the rates are extrapolated.

In all, the plans received $22.5 million in overpayments, though these were offset by underpayments of $10.5 million.

Auditors scrutinize 30 contracts a year, a small sample of about 1,000 Medicare Advantage contracts nationwide.

UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.

UnitedHealthcare spokesperson Heather Soule said the company welcomes “the program oversight that RADV audits provide.” But she said the audit process needs to compare Medicare Advantage to original Medicare to provide a “complete picture” of overpayments. “Three years ago we made a recommendation to CMS suggesting that they conduct RADV audits on every plan, every year,” Soule said.

Humana’s 11 audits with overpayments included plans in Florida and Puerto Rico that CMS had audited twice in three years.

The Florida Humana plan also was the target of an unrelated audit in April 2021 by the Health and Human Services inspector general. That audit, which covered billings in 2015, concluded Humana improperly collected nearly $200 million that year by overstating how sick some patients were. Officials have yet to recoup any of that money, either.

In an email, Humana spokesperson Jahna Lindsay-Jones called the CMS audit findings “preliminary” and noted they were based on a sampling of years-old claims.

“While we continue to have substantive concerns with how CMS audits are conducted, Humana remains committed to working closely with regulators to improve the Medicare Advantage program in ways that increase seniors’ access to high-quality, lower cost care,” she wrote.

Billing Showdown

Results of the 90 audits, though years old, mirror more recent findings of a slew of other government reports and whistleblower lawsuits alleging that Medicare Advantage plans routinely have inflated patient risk scores to overcharge the government by billions of dollars.

Brian Murphy, an expert in medical record documentation, said collectively the reviews show that the problem is “absolutely endemic” in the industry.

Auditors are finding the same inflated charges “over and over again,” he said, adding: “I don’t think there is enough oversight.”

When it comes to getting money back from the health plans, extrapolation is the big sticking point.

Although extrapolation is routinely used as a tool in most Medicare audits, CMS officials have never applied it to Medicare Advantage audits because of fierce opposition from the insurance industry.

“While this data is more than a decade old, more recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars,” said Mary Beth Donahue, president of the Better Medicare Alliance, a group that advocates for Medicare Advantage. She said the industry “delivers better care and better outcomes” for patients.

But critics argue that CMS audits only a tiny percentage of Medicare Advantage contracts nationwide and should do more to protect tax dollars.

Doolittle, the former CMS official, said the agency needs to “start keeping up with the times and doing these audits on an annual basis and extrapolating the results.”

But Kathy Poppitt, a Texas health care attorney, questioned the fairness of demanding huge refunds from insurers so many years later. “The health plans are going to fight tooth and nail and not make this easy for CMS,” she said.

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


This story can be republished for free (details).

Categories: Health Care

After Election Win, California’s AG Turns to Investigating Hospital Algorithms for Racial Bias

Kaiser Health News - Mon, 11/21/2022 - 5:32am

SACRAMENTO, Calif. — California Attorney General Rob Bonta sailed to victory in the Nov. 8 election, riding his progressive record on reproductive rights, gun control, and social justice reform. As he charts a course for his next four years, the 50-year-old Democrat wants to target racial discrimination in health care, including through an investigation of software programs and decision-making tools used by hospitals to treat patients.

Bonta, the first Filipino American to serve as the state’s top prosecutor, asked 30 hospital CEOs in August for a list of the commercial software programs their facilities use to support clinical decisions, schedule operating rooms, and guide billing practices. In exchange, he offered them confidentiality. His goal, Bonta told KHN, is to identify algorithms that may direct more attention and resources to white patients than to minorities, widening racial disparities in health care access, quality, and outcomes.

“Unequal access to our health care system needs to be combated and reversed, not carried forward and propagated, and algorithms have the power to do either,” Bonta said.

It’s too early to know what Bonta will find, and his office will not name the hospitals involved. The California Hospital Association said in a statement that such bias “has absolutely no place in medical treatment provided to any patient in any care setting” and declined to comment further.

Advocates have high hopes for what Bonta will find — and for the next four years. “We expect to see a lot more from him in this full term,” said Ron Coleman Baeza, managing director of policy for the California Pan-Ethnic Health Network. “There is much more work to do.”

Last year, Gov. Gavin Newsom appointed Bonta as attorney general after Xavier Becerra left the position to join the Biden administration as secretary of the U.S. Department of Health and Human Services. In the Nov. 8 election, which won him his first full term, Bonta faced Republican challenger Nathan Hochman, a former federal prosecutor who campaigned on prosecuting violent criminals and pulling the deadly synthetic opioid fentanyl off the streets. In contrast, Bonta advocated for gun control and decriminalizing lower-level drug offenses, and in January advised law enforcement officials not to prosecute women for murder when a fetus dies, even if their drug use contributed to the death.

In unofficial results, Bonta had about 59% of the statewide vote, compared with 41% for Hochman.

Bonta, formerly a state legislator representing the East Bay, will be eligible to run for a second full term, which could allow him to serve for nearly 10 years.

His wife, Democratic state Assembly member Mia Bonta, was among the public officials who discussed their abortion experiences after a leaked draft of a U.S. Supreme Court opinion that was published in May revealed the justices would likely repeal Roe v. Wade. After they did, the attorney general threatened legal action against local jurisdictions that tried to adopt abortion bans.

Bonta called health care a right for all Californians and said he wanted to help people of color and low-income communities get more access to doctors and treatments, as well as better care. “It’s something I’ve been actively working on as an elected official my entire career, and even before that,” said Bonta, whose father helped organize health clinics for Central Valley farmworkers.

But health equity remains an elusive goal, even as it has become a catchphrase among advocates, researchers, politicians, and health care executives. And as with most aspects of the state’s mammoth health care system, progress comes slowly.

The Newsom administration, for example, will require managed-care plans that sign new Medicaid contracts to hire a chief equity officer and pledge to reduce health disparities, including in pediatric and maternal care. The state’s Medicaid program, known as Medi-Cal, serves nearly 15 million people — most of whom are people of color. But those changes won’t come until 2024, at the earliest.

State lawmakers are also trying to minimize racial discrimination through legislation. In 2019, for example, they passed a law that mandates implicit bias training for health care providers serving pregnant women. Black women are three times as likely to die from having a baby as white women.

In recent years, researchers started warning that racial discrimination was baked into the diagnostic algorithms that doctors use to guide their treatment decisions. One model predicted a lower rate of success for vaginal births among Black and Hispanic women who previously had a cesarean delivery than among white women, but failed to take into account patients’ marital status and insurance type, both of which can affect the success rate of a vaginal birth. Another, used by urologists, assigned Black patients coming into emergency rooms with “flank pain” a lower likelihood of having kidney stones than non-Black patients — even though the software’s developers failed to explain why.

Some researchers likened such medical algorithms to risk assessment tools used in the criminal justice system, which can lead to higher bail amounts and longer prison sentences for Black defendants. “If the underlying data reflect racist social structures, then their use in predictive tools cements racism into practice and policy,” they wrote in the New England Journal of Medicine in 2020.

Bonta is seeking the hospital industry’s cooperation in his algorithm investigation by framing racial and ethnic disparities as injustices that require intervention. He said he believes that his inquiry is the first of its kind and that it falls under the California Department of Justice’s responsibility to protect civil rights and consumers. “We have a lot of depth,” he said of his 4,500-employee agency.

Coleman Baeza and other advocates for health care consumers said the attorney general should also monitor nonprofit hospital mergers to ensure that health care facilities don’t reduce beds in underserved communities and crack down on predatory medical lending, particularly in dental care.

“They violate existing consumer protections, and that falls squarely within the AG’s jurisdiction,” said Linda Nguy, a senior policy advocate for the Western Center on Law and Poverty.

Nguy urged Bonta to go after underperforming health plans when they fail to contract with enough providers so patients can get timely appointments, even though the California Department of Managed Health Care is the state’s main health insurance regulator.

“During covid, the health plans were essentially given a pause on reporting of their timely access. But that pause is over, and the plans have to meet these requirements,” Nguy said. “He can ask for that utilization data.”

Bonta remains circumspect on a particular issue related to race.

His office has been facilitating California’s reparations task force, which issued a nearly 500-page preliminary report this year that noted that Black Californians had shorter life expectancies and poorer health outcomes than other groups. In surveys of hospitals across the country, Black patients with heart disease “receive older, cheaper, and more conservative treatments” than white patients, the report said.

The task force could recommend cash compensation for Black Californians who can establish ties to enslaved ancestors, but Bonta hasn’t endorsed that plan. The final report is due in July.

“If we can move the needle, then we should,” Bonta said. “There are a whole set of different possible solutions, pathways to get there.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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


This story can be republished for free (details).

Categories: Health Care
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