California took a major step last month toward regulating dangerous “forever chemicals” in drinking water by proposing new health limits for two of the most pervasive contaminants.

On July 21, state environmental health officials recommended goals of one part per trillion and less — a minuscule amount 70 times smaller than the federal government’s non-binding guideline for drinking water nationwide.

Called “forever chemicals” because they persist in the environment, the contaminants are ubiquitous. Traces of two — perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) — are in the well water of 146 public water systems serving nearly 16 million Californians, a CalMatters analysis found last fall.

Long used to make non-stick and stain-proof coatings, firefighting foams and food packaging, the perfluorinated chemicals have been linked to kidney cancer and other serious health conditions in people drinking contaminated water. They often are found near airports, military bases and landfills.

The announcement sets in motion a multi-year process to develop enforceable state regulations to replace California’s guidelines.

State officials will seek public comments and outside scientific review of the proposed “public health goals” before they are finalized, which could take at least a year, said Sam Delson, a spokesperson for the state Office of Environmental Health Hazard Assessment.

After that, another agency, the state Water Resources Control Board, will develop enforceable standards. Those standards must under state law be set as close as possible to the health goal while considering what is economically and technically achievable. That process could take several years.

The health goals are based on concentrations that would pose “no significant health risk” to people, according to the report by the Office of Environmental Health Hazard Assessment. Attaining them would limit Californians’ risk to one case of cancer per one million people over a lifetime, based on studies of people and lab animals.

“We don’t consider a (public health goal) to be the boundary between safe and dangerous. It is a goal for negligible risk,” Delson said.

The proposed targets are 0.007 nanograms per liter of water for perfluorooctanoic acid (PFOA), which was used to manufacture Teflon, and 1 nanogram for perfluorooctanesulfonate (PFOS), which was formerly used to make Scotchgard.

A nanogram per liter is equivalent to a part per trillion — or one cup of a contaminant in a trillion cups of water.

“Keeping levels low will ensure that those who are most likely to experience adverse health outcomes, like children or people … who live in areas of high exposure, will be adequately protected,” said Jamie DeWitt, a professor of pharmacology and toxicology at East Carolina University, who studies the chemicals but was not involved in California’s analysis.

But cleaning up water to meet stringent standards for perfluorinated chemicals would be expensive. At military sites alone, the US Government Accountability Office estimates that investigating and cleaning up the contamination will cost far beyond the $3.2 billion that the Department of Defense spent in 2020 and expects to pay in 2021.

These chemicals are everywhere, in everyone

Nationwide, the drinking water of up to 80 million people is estimated to contain at least 10 nanograms per liter of the two chemicals combined, according to a study by the Environmental Working Group, an environmental group that focuses on toxic substances.

The chemicals are everywhere, in virtually everyone, in samples taken from pole to pole — they have accumulated not just in water, but also in soil and in human and animal bodies, beginning in the late 1940s, when 3M Co. developed a process to make them.

“They’ve shown toxicity in animals and in humans,” said Elaine Khan, chief of the Water Toxicology Section at the Office of Environmental Health Hazard Assessment. “It’s definitely something that we need to address in terms of protecting public health.”

Olga Naidenko, vice president for science investigations at the Environmental Working Group, said California’s analysis confirms that the chemicals pose health risks at levels lower than the parts per trillion dominating discussions at the national and international levels.

Philippe Grandjean, a renowned environmental health scientist at Harvard University, said the U.S. Environmental Protection Agency has been “exceedingly slow” enacting water standards for perfluorinated chemicals.” He said he hopes that California “will continue the effort to show the way to control or eliminate” them in the environment and in human bodies.

So far, there are no federal enforceable limits on any of the thousands of perfluorinated chemicals. Federal advisories set guidelines for PFOA and PFOS in drinking water of 70 parts per trillion, combined. The EPA announced plans in February to regulate the two chemicals, but standards are still likely years away.

In the absence of federal standards, a patchwork of recommendations and regulations have emerged across the country. Nine states have set guidelines ranging from 8 to 35 parts per trillion for PFOA and 10 to 40 for PFOS, according to an analysis published last year.

Last year, California developed thresholds of 10 parts per trillion for PFOA and 40 parts per trillion for PFOS. These are just guidelines, although a state law empowers regulators to require that water providers either clean up contaminated supplies, shut down tainted wells or notify customers.

CalMatters’ analysis in November 2020 found that nearly 200 drinking water wells, or 15% of those tested, have exceeded the new thresholds in at least one round of testing over the prior year.

The new public health goals don’t change anything for now, said Darrin Polhemus, deputy director of the water board’s drinking water division. “This is the very, very, very first step of the regulatory process,” he said.

But some water providers may want to enforce them, or at least start developing plans to remove the chemicals from their water or blend supplies to dilute them.

“These are really important chemicals to address,” Khan said, “because they are forever chemicals, and they stay around for a very, very long time.”

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AURORA — Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid. But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she’d lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn’t lose her job.

So, Osman came to Mango House, a clinic in Aurora, that caters primarily to refugees and turns no one away, regardless of their ability to pay. Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. reject as too low.

Dr. P.J. Parmar started Mango House 10 years ago to provide health care to refugees in Aurora. But the center goes beyond standard primary care with an entire ecosystem at the site of dentistry, after-school programs, English classes, legal help, nine stores and six restaurants owned and run by refugees. “This is what I call a medical home,” Parmar says. (Ross Taylor for KHN)

Ross Taylor/KHN

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations. When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants.

“This is what I call a medical home,” Parmar said.

Although it’s not part of the formal U.S. refugee resettlement program, Mango House is in many ways emblematic of refugee health care in the U.S. It’s a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population.

Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients’ needs. As a result, Mango House looks nothing like the rest of the U.S. health care system and, at times, draws the ire of the medical establishment.

Health care for older immigrants sees momentum among states

“How do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on? It’s a struggle for sure,” said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. “It’s these heroes, these champions out there, these cowboys that are taking this on.”

Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

“If we ask for an appointment to get Medicaid, P.J. makes the call,” Yussef said. “If we call, we’re on hold for an hour, and then it hangs up. If we go to the ER, it’s a three-hour wait. Here, the majority of people walk in and sit for 30 minutes. It’s good for the community.”

As for Osman’s knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?

“I can almost guarantee it’s arthritis,” Parmar replied. “You could do an X-ray. That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do? It will cost you $100,000.”

Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it’s an imperfect solution. “Most orthopedists don’t take Medicaid,” Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. to qualify for Medicare.

Medicaid, which covers low-income people, generally pays primary health care providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English.

Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients. If he limited his practice to just Medicaid, he said dryly, he’d have guaranteed customers and no competition.

So how does he survive on Medicaid rates? By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries.

Because he takes only Medicaid, he knows how to bill the program and doesn’t have to hire billing specialists to deal with 10 insurance companies.

It’s also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

“Really none of our innovations are new or unique; we just put them together in a unique way to help low-income folks, while making money,” Parmar said. “And then, instead of taking that money home, I put it back into the refugee community.”

The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine. He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street.

“There’s a good three-, four-year dip in the red here, intentionally, as we move from there to here,” Parmar said. “But that red is going to go away soon.”

The covid pandemic has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster.

Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health. Parmar won’t get paid but sees her anyway. Another patient brings paperwork showing he’s being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn’t want creams or ointments; good medicine, he believes, comes through a needle.

“A lot of this is, basically, geriatrics,” Parmar said. “You have to add 20 years to get their age in refugee years.”

When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn’t be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn’t find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar’s creative solutions, however, often rub many in health care the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn’t possible, so hospitals and clinics must pay interpreters themselves. And that’s beyond the capabilities of most refugee clinics, unless they’re affiliated with a larger health system that can absorb those costs.

“It’s a good thing to have the standards, but it’s another thing altogether to implement them,” said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing covid vaccines, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission.

During a recent lull at the clinic, Parmar took stock of that day’s inventory of patients. Six were assigned to Denver Health, one patient’s Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn’t get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill.

“We see the rest of them anyway,” he 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.

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Georgia Gov. Brian Kemp sought to shift blame to President Joe Biden for Georgia’s poor vaccination rate Thursday as COVID-19 infections and hospitalizations continued to sprint upward. The Republican, speaking to reporters, blamed the Democratic president for not doing enough to push the Food and Drug Administration to upgrade its emergency authorization for the vaccines to a permanent authorization. Kemp said urging people to use masks again is a “mixed message” that could discourage vaccination.

Read the full article:
Associated Press 

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Indefinite closure of the WNC Birth Center highlights issues with maternal health in a part of the state that has seen maternity units close in recent years.

By Christian Green

Carolina Public Press

Melissa Fehling’s second child is due Aug. 3. 

She delivered her first child, River, at the WNC Birth Center in Asheville two years ago, and she said she was looking forward to a similar experience there. 

But on June 19, she received an email from the center, announcing an indefinite closure on July 20, just two weeks before her due date.

Fehling, 34, was at home with her son when she read the email.

“I just kept rereading it,” Fehling said. “My brain could not understand what the email was saying. It could not comprehend what was going on.”

Nearby in West Asheville, Francesca Santi, another pregnant mother, received news of the center’s closure. 

“I saw the email, and as I started reading through, I just got this pit in my stomach,” Santi said. “I could just feel the news coming and then when I saw it … it sucked. I felt awful.”

The closure of the birthing center marks the latest in a series of challenges for expectant mothers in Western North Carolina. Reimbursement issues and provider regulations limit choices for pregnant mothers.

Impossible math

The closure was a last resort after all other options were exhausted, said Nancy Koerber, executive director for the birth center.  

“We just couldn’t make it work,” Koerber said. “We’ve really done everything we can. …. We’re 16 women trying to buck an entire system, and it is very, very difficult.”

Although the WNC Birth Center increased its number of deliveries each year for its five years of existence, the center was never able to make the numbers work for financial sustainability.

The struggle came, in large part, because insurers and Medicaid reimburse birth centers at lower rates than hospitals, even when they deliver the exact same service. Koerber estimated her birth center was reimbursed, on average, less than half of hospital reimbursement.

“Compared patient to patient, someone who had an uncomplicated birth here versus a hospital, we are reimbursed half of what a hospital would be for the same resources utilized for that patient,” Koerber said.

Health care facilities like birth centers and hospitals bill for three broad categories when they deliver a baby: a physician fee for prenatal care and the actual work of delivering the baby; a facility fee to cover the infrastructure needed to deliver the baby; and a third fee that pays for care given to the baby after birth.

Nearly half of patients at the WNC Birth Center paid through Medicaid, consistent with statewide and national averages.

For physician fees, the WNC Birth Center earned $1,627 from Medicaid per delivery. The funds covered not just the hours worked by midwives at the time of delivery, but also the seven-13 prenatal consultations that occur over the nine months leading up to birth.

For each delivery, Medicaid paid the center $1,587 in facility fees.

Together, in addition to some smaller fees, Koerber said that the birth center earned $3,712 per birth.

But on average, Koerber estimated the birth center paid about $6,000 in materials and labor to deliver that baby, meaning that the facility incurred a net loss of over $2,000 for every baby delivered to a mother on Medicaid.

Private insurers generally pay higher rates than Medicaid, but even then, Koerber said, the payments were not enough to sustain the center.

For comparison, Medicaid generally pays a hospital somewhere between $8,000 and $11,000 for a routine vaginal delivery.

Koerber said this discrepancy was primarily due to hospitals receiving reimbursement as inpatient services, while health insurers view the birth center currently as an outpatient facility.

Birth centers receive reimbursement at rates similar to hospitals for physician fees, but hospitals receive much higher payments for facility fees, based on the assumption that inpatient services typically cost more to build and maintain than outpatient clinics.

But birth centers, Koerber said, don’t really fit into the inpatient/outpatient dichotomy.

“We’re not a fully inpatient facility, but we’re also not just a walk-in clinic,” Koerber said. “With our infrastructure and staffing, we’re somewhere in between.”

Koerber said the “in-betweenness” of birth centers in the current reimbursement model has prompted discussion of a third alternative category. To date, no such category exists, so birth centers are reimbursed at rates that make it difficult to stay afloat.

“People recognize the problem, but like anything in a system, it just moves so slowly,” Koerber said. “The problem is that, by moving this slowly, they may be actually eradicating a good solution that’s already sitting here right now. That’s the biggest fear.”

Supervisory requirements influence midwives

When WNC Birth Center closed, it became the fifth North Carolina birth center to do so since 2018, according to Koerber.

Only two stand-alone independent birth centers remain in the state, one in Chapel Hill and one in Statesville.

While finances are a major barrier to birth center success, it is not the only one, according to Ami Goldstein, president of the North Carolina Affiliate of the American College of Nurse-Midwives.

Goldstein said the issue of full-practice authority, another barrier for midwives, could be solved more immediately than complicated health insurance reimbursement schedules.

Midwifery was formalized in North Carolina with the passage of the Midwifery Practice Act in 1983, which established certified nurse-midwives, or CNMs, as a class of advanced practice registered nurses, or APRNs.

Like all APRNs in North Carolina, certified nurse-midwives are required by law to practice under the supervision of a licensed physician. In the 1990s, several states such as Oregon, Montana and New Mexico, began to pass legislation to grant full-practice authority to APRNs and end supervision requirements.

Currently, at least 28 states plus the District of Columbia give full-practice authority to APRNs either immediately after completing their education or after some designated period of supervision under a physician.

Within the U.S., North Carolina is one of the most restrictive states when it comes to midwifery.

Studies find the midwife model can lead to better maternal outcomes, including fewer cesarean section deliveries.

Goldstein said full-practice authority legislation is important for all APRNs in the state but is particularly impactful for maternal care in North Carolina because states with fewer restrictions are more attractive to the workforce.

“That makes it an access problem,” Goldstein said. “There are people in the western part of the state who can’t open a practice to provide care to people who really need it because they can’t find anybody who will provide the supervision.”

Full-practice authority also carries a financial benefit.

North Carolina ARPN regulations require that all midwives have a physician sign on to serve as their supervisor. In many cases, independent practices have to pay that provider, even though the supervision requirements mandate that they meet with a supervising physician only once every six months.

“If no physician is willing to sponsor you, you can’t open a midwifery practice,” she said. “If a physician sponsoring you suddenly dies or retires, you can’t touch another patient from that moment on until you find someone else.”

A legislative dispute

A coalition of legislators and advocacy groups already tried to address the full-practice authority issue with legislation in 2015-16 but was unsuccessful.

The bills were heavily opposed by physicians and pro-doctor lobbying groups, who said full-practice authority for advanced practice registered nurses could result in lower-quality care and diminished safety.

Goldstein disputes their arguments. “There’s just no strong evidence to support that idea,” she said. 

None of the states that have granted full-practice authority over the past two decades have reimposed restrictions, and several studies show that APRNs who are acting independently and within the scope of their training deliver care as well as physicians.

An updated version of the SAVE Act has been introduced in both the N.C. House and Senate with broad and bipartisan support. More than 70 representatives signed on as sponsors to the bill in the House, and 25 senators are listed as sponsors.

Though the bills would likely pass if brought to a vote, given the many sponsors, they currently sit in committees, where they died in previous sessions.

Sen. Jim Burgin, (R-Harnett, a primary co-sponsor on the Senate bill, said he hoped the measures make it to the floor for a vote this time around, but that will ultimately depend on broader political negotiations in the General Assembly. 

“We have bills that are over there,” Burgin said of the process.

“They have bills that are over on our side, and there is this trading that goes back and forth. Plus, we have the added aspect of having budget negotiations going on and the horse-trading that goes on in the budget. So, this bill will be something that gets included in all of that negotiation.”

Physicians who do not oppose full-practice authority for certified nurse-midwives may oppose the act because they oppose full-practice authority for other providers such as nurse practitioners and other APRNs, Koerber said.

Koerber is open to legislation more narrowly tailored to just granting full-practice authority to CNMs if that would be more likely to pass, but other organizations such as the North Carolina Affiliate of the American College of Nurse-Midwives disagree, saying that APRNs are stronger together in their fight for full-practice authority.

As the legislative battle continues, the concerns are immediate for expectant mothers in Western North Carolina.

“We just lost what I feel is a very important option for prenatal and maternal care in our area,” said Savannah Talley, who gave birth at the WNC Birth Center just months before it closed. 

“I am so heartbroken for the women in this area, for the women who are in the middle of their pregnancy now and for women in the future who now have one less option.”

Though the center is now closed, Koerber did say that she has hope it won’t be permanent. She is currently in talks with potential partners, whom she declined to name, who hope to be able to bring the center back.

“After we announced we were closing, there was a huge outpouring of grief in the community,” Koerber said. “People have seen the resources we provide, and our results have been recognized. We can’t live on false hope …, but I feel like the community deserves for us to explore every single option and leave no stone unturned.”

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Originally Appeared Here

By Jeremy Redmon

This article is reprinted with permission from the AJC.

Since it opened in 2015, the Clarkston Community Health Center has attracted long lines of impoverished patients, at times becoming so busy that it has been forced to turn some away.

The volunteer-run nonprofit has provided free care to more than 5,500 immigrants, refugees and U.S.-born people without health insurance. Some have traveled from Alabama, South Carolina and Tennessee.

Waiting room at the Clarkston Community Health Center in 2018

 

Now that it has outgrown its 2,200-square-foot building in downtown Clarkston, in DeKalb County, the center is seeking to relocate and expand. Those plans got a big boost this week when a Texas philanthropist pledged $2.5 million for the effort. With that support, the center is preparing to build a much larger medical center just south of Clarkston at 4038 Rockbridge Road Southwest.

The news comes at a critical time for refugees who are fleeing armed conflicts and humanitarian crises abroad and for others who are sick or struggling financially amid the coronavirus pandemic. Georgia — which has the nation’s third-highest rate of uninsured people — is among the 12 states that have not expanded Medicaid under the Affordable Care Act to all poor adults.

“People were lining up at 6 a.m. outside our clinic, and this was pre-COVID,” said Saeed Raees, the CEO and one of the co-founders of the clinic, which also provides dental care and operates a free pharmacy. “We need to grow because there is such a high need out there.”

In May 2020, DeKalb commissioners modified zoning conditions to allow for the new clinic. The next day, Raees’ center bought the 2.5-acre site for $360,000 from the Masjid Rahman Islamic Center.

Two vacant houses on the site must be demolished to make way for the clinic, Raees said. His center intends to seek a land disturbance permit to move forward with the project and hopes for the new clinic to begin operating by the end of next year.

A floor plan for the multimillion-dollar project shows numerous medical and dental examination rooms, a dental lab, a teaching kitchen and a pharmacy. Medical students and other volunteers will continue getting hands-on experience at the clinic, with serves patients who speak more than 30 languages and who are from more than 20 countries.

Dilshad Dhanani of Duluth is among the hundreds of people who have volunteered at the center.

“I have found true contentment results from contributing in any way to the wellbeing of others,” she said.

Struck by what she has experienced at the clinic, she spoke about it with her brother, Shoukat Dhanani, whose family businesses operate hundreds of Popeyes and Burger King restaurants and other enterprises, generating about $2.8 billion in annual revenue. She also sent him articles about the center, including one published in The Atlanta Journal-Constitution about the perseverance of Dr. Gulshan Harjee, one of the clinic’s founders.

Dr. Gulshan Harjee examines Simeon Gahungu, who is from Burundi and who came to the U.S. as a refugee, at the Clarkston Community Health Center in 2017. Photo by Bita Honarvar

 

Shoukat Dhanani visited the clinic for the first time this month and pledged $2.5 million for its relocation. He will be joining its board of directors. For him, the charity is in keeping with his Islamic faith and a way to honor his parents, Hasan Ali and Daulat, and stepmother, Zubeda.

“I am an immigrant also. I have been through a lot of what immigrants go through,” said Shoukat Dhanani, who came to America from Pakistan for college. “We are fortunate enough and we are blessed that we are in a position to help other immigrants. So why not?”

He added: “Overall, helping humanity — that is the main thing.”

The clinic’s relocation and expansion has attracted support from DeKalb commissioners, including Ted Terry and Lorraine Cochran-Johnson.

“I am a huge advocate for the services they provide,” said Cochran-Johnson, who has visited the center and has helped fund it. “I feel they are honestly in many ways unknown by many residents of DeKalb County. And as a commissioner I have just sort of been on my own crusade to ensure that people are aware of this resource.”

Lance Hammonds, chairman of the Rockbridge Coalition, also spoke approvingly about the clinic’s plans.

“We need more health care in our community,” he said. “Having that medical center in the community gives great access to a lot of people.”

The clinic is seeking volunteers and donations so it can expand its services. Those interested can learn more at clarkstonhealth.org.

Jeremy Redmon is an award-winning reporter for the Atlanta Journal-Constitution 

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New Jersey’s local and county health departments are community-based public health service and a first point of contact for questions about public health services or health conditions.

Are you ready to stop?
We can help. Latest health info from the federal government Recognizing the exemplary work being done to improve health outcomes in New Jersey

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US gymnastics superstar Simone Biles shocked the 2020 Tokyo Olympics by withdrawing from women’s team and individual all-around contests, in which she was considered a top contender, over what she said were “mental health concerns”.

The 24-year-old has received widespread praise for bringing attention to mental health, dispelling the stigma that remains around the issue, and highlighting the immense pressure put on elite athletes.

National figures, including former US First Lady Michelle Obama, fellow athletes, and commentators have supported the decision taken by Biles, often lauded as the best gymnast of all time.

“[Simone Biles] we are proud of you and we are rooting for you,” Obama wrote on Twitter.

Spanish basketball star and Olympian Pau Gasol said Biles’ decision underscored an important reality: “Mental health is a key component of our health, and it MUST be a priority always”.

“We need the sports world to focus on emotional and mental well-being a lot more,” he wrote on Twitter. “Thank you for using your platform, you are a true champion!”

All my support to @Simone_Biles. Mental health is a key component of our health, and it MUST be a priority always. We need the sports world to focus on emotional and mental well-being a lot more.

Thank you for using your platform, you are a true champion! #MentalHealth pic.twitter.com/4Ym3E9VAEf

— Pau Gasol (@paugasol) July 28, 2021

Sarah Hirshland, US Olympic and Paralympic Committee chief executive officer, Tweeted: “Simone, you’ve made us so proud. Proud of who you are as a person, teammate and athlete.”

“We applaud your decision to prioritize your mental wellness over all else and offer you the full support and resources of our Team USA community as you navigate the journey ahead.”

. @Simone_Biles you’ve pushed boundaries time and time again. Rest up & take time pic.twitter.com/ktAmF0UmAc

— Max Whitlock MBE (@maxwhitlock1) July 28, 2021

Biles, who won four golds at the 2016 Rio Olympics, on Tuesday withdrew from the women’s team competition – in which the best scores of a country’s team in the four main gymnastics events are combined to determine a winner – after an uncharacteristically shaky vault.

She detailed her decision in a post-event press conference.

“At the end of the day, we’re human, too, so we have to protect our mind and our body rather than just go out there and do what the world wants us to do,” she said. “With the year that it’s been, I’m really not surprised how it played out.”

we love you and we are with you 🇺🇸 @Simone_Biles

— Coco Gauff (@CocoGauff) July 27, 2021

The US women’s team went on to take silver in the event, with the Russian Olympic Committee team taking gold. On Wednesday, it was announced that Biles would also not compete in the individual all-around event – in which individual athletes are judged cumulatively in all four main events: vault, uneven bars, balance beam and floor.

It was not yet announced if Biles would compete in the coming days in the individual events for each of the skills, with the athlete saying she was taking things “day by day”.

‘Not superhuman’

Biles has spoken openly about the pressures of being one of the most visible athletes on the US Olympic team.

The revelation that she was one of hundreds of young women abused by former USA gymnastics doctor Larry Nassar has compounded that public attention.

Several observers have likened Tuesday’s decision to that of tennis star and fellow Olympian Naomi Osaka, who withdrew from the French Open in May, citing her mental health and “bouts of depression”.

Following the example of Biles and Osaka, Washington Post columnist Alyssa Rosenberg wondered if spectators can change their own expectations of greatness.

“Maybe we fans can learn to embrace more expansive definitions of excellence and courage,” she wrote.

New York Times columnist Lindsay Crouse, meanwhile, wrote that Biles was part of a growing group of young athletes who are taking more agency over their careers and unrealistic public expectations.

“Obviously, everyone wants to win. So it’s exciting that many of these stars are also recognising that being the greatest means knowing your own variable limits and when to push through the pain – and when not to force it,” she wrote.

“How many Olympians have we seen push, persevere and then crumble when the Games are over?”

“These young women and men have extraordinary talent and perform under incredible pressure, but they are not superhuman,” she added. “We have no right to expect them to be.”

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Kuala Lumpur, Malaysia – Malaysia has registered the world’s first affordable – and effective – new drug for hepatitis C, offering the hope of accessible treatment to millions of people around the world at risk from a disease that has few early symptoms, is hard to diagnose and is often seen as a “silent killer”.

The drug, ravidasvir, was approved for use with an existing drug, sofosbuvir, in June, five years after the Malaysian government, partnered with the Drugs for Neglected Diseases initiative (DNDi), a collaborative, non-profit drug research organisation to develop the drug.

“We decided to work with middle-income countries to try to develop an effective treatment,” said Jean-Michel Piedagnel, director of DNDi Southeast Asia. “We started the clinical trial in Malaysia and Thailand saying we are also going to put on the market an affordable treatment.”

The new drug is a direct-acting antiviral (DAA) developed with Pharco, an Egyptian generic drug manufacturer, and is an effort to bring more competition into a market dominated by the world’s biggest pharmaceutical companies. Sofosbuvir – the first DAA – secured approval in the United States in 2013.

Some 71 million people around the world are thought to live with Hepatitis C, a blood-borne virus that can lead to cirrhosis and is one of the leading causes of liver cancer, according to the World Health Organization. There is no vaccine against the disease, which often has no particular symptoms until the liver becomes infected.

For years, the disease was treated with an array of drugs that carried debilitating side effects and often made people feel even worse.

DAAs were a “revolution”, according to Piedagnel, offering patients, for the first time, an effective cure and fewer side effects.

But sofosbuvir – under patent to the US drugmaker Gilead – was expensive and out of the reach of many middle-income and developing countries. “Hepatitis C medicines have always been very expensive in the Western Pacific region, because we have only high- and middle-income countries, as categorised by the World Bank,” explained Dr Po-Lin Chan, the WHO’s medical officer for viral hepatitis.

China, Malaysia and Thailand were among countries excluded from Gilead’s voluntary licensing in 2014.

An electron microscope image from the US CDC shows a group of hepatitis virions of an unknown strain. Hepatitis C can cause long-term liver damage and cancer [File: EH Cook Jr/CDC via AP Photo]

That year, a University of Malaya study estimated Malaysia had at least 400.000 people living with hepatitis C.

Among them was 49-year-old Ng Song Ping.

The disease had drained him of all energy.

“Even if I worked just a little I was exhausted, sleepy, I couldn’t work for long,” he said. “Even showering, eating, watching TV made me feel tired.”

Ng was one of 300 people who joined the clinical trial for ravidasvir plus sofosbuvir that began in 2016. Three months after he began the treatment, tests showed no trace of the virus.

“Now, I’m already OK, the tiredness and sleepiness are gone,” he told Al Jazeera. “Now, I work every day, 365 days per year, I don’t take holidays. I made a vegetable farm, I plant the vegetables, harvest them, deliver them to shops every day.”

Shift on patents

Under the legal conditions of the clinical trial, Malaysia was able to access sofosbuvir at an affordable price, importing the drug from Egypt, which had rejected the patent on the drug, allowing it to be produced by generic manufacturers.

In 2017, Malaysia went a controversial step further, issuing a compulsory licence for sofosbuvir, which allowed it to import the drug into the country under World Trade Organization rules.

“In international law, if the product is patented, and a country wants to use that product for public non-commercial use, if it’s a situation of urgency, then there is no need to go and negotiate first with the patent holder,” said Chee Yoke Ling, an international lawyer and executive director of Third World Network, a Malaysian research and advocacy organisation. “In Malaysia, our laws implement that as the rights of government.”

What seemed a controversial decision in 2017 is now becoming more widely accepted thanks to the COVID-19 pandemic, which has changed the way intellectual property in the pharmaceutical field is viewed.

“What happened in Malaysia provides a useful example for other countries. There could be an opportunity to advance the reduction of intellectual property provisions that don’t benefit countries as there’s a shift in how these superpowers are thinking about intellectual property. For example, the US endorsing the TRIPS waiver for COVID-19 technologies,” said Fifa Rahman, who ran hepatitis C advocacy efforts at the Malaysian AIDS Council in 2016 and is now working on the ACT-Accelerator for the global COVID-19 response.

The ravidasvir plus sofosbuvir trial, which was published in The Lancet in April, showed the drug combination to be highly effective and well-tolerated, curing patients in 97 percent of cases.

With the success of the trial, Malaysia has developed a full access strategy for diagnosis and treatment of hepatitis C, targeting local government clinics.

“In the long term, it will also be cost-saving for us to prevent liver cancers, cirrhosis and liver failure, as the treatments for these diseases are more expensive so this is very important for us to invest in public health and this is where prevention comes in”, Dr Noor Hisham Abdullah, Malaysia’s director-general of health and also a director of DNDi, told reporters at a news conference announcing the drug breakthrough.

The government worked closely with the civil society groups, running outreach programmes in affected communities to identify those at risk and facilitate access to screening and treatment.

A screening study conducted in three Malaysian prisons by MTAAG+, a Malaysian HIV and hepatitis C treatment access and advocacy group, revealed inmates as a vulnerable population, leading to the inclusion of people in prison and rehabilitation centres among the priority groups in Malaysia’s national hepatitis C programme.

Hepatitis C is a blood-borne disease that is particularly prevalent among drug users, sex workers and other marginalised groups [File: Kate Mayberry/Al Jazeera]

Comfortable access to screening and treatment for key populations, such as drug users, men who have sex with men, transgender people and female sex workers, was improved through stigma reduction training conducted by the Malaysian AIDS Council.

“I cannot say 100 percent that we have eradicated stigma, but it has been improved,” said Anushiya Karunanithy, who leads the hepatitis C programme at the council.

“The healthcare workers are more welcoming now, they understand about the key populations. We have good family medicine specialists at some of the clinics which are very close to the clients as well, so the clients feel very comfortable with the doctors.”

‘Silent killer’

Starting from mid-2018, when the affordable DAA treatments became available to the Malaysian market, the number of people treated has grown rapidly. “Now, we have treated more than 10,000 patients,” said Dr Muhammad Radzi Abu Hassan, Malaysia’s national head of gastroenterology and hepatology. “Last year itself, despite the COVID-19 pandemic, we managed to treat 4,000 patients. This is incredible, with all the odds that we have.”

Cheaper treatment is also expected to encourage countries to do more testing for hepatitis, which the WHO wants to eliminate as a public health problem by reducing new infections by 90 percent and deaths by 65 percent by 2030.

“When treatment exists but is too expensive, countries usually would not do wide testing because if a person is tested positive. It is unethical not to provide the treatment, especially when it is one that cures,” Chee said. “Without affordable treatment, we end up not testing and in this vicious cycle. Hepatitis C continues to be a long-term silent killer.”

This month, Egypt, which has one of the highest incidences of hepatitis C in the world, also registered the drug and there are expectations that the combination therapy of ravidasvir plus sofosbuvir will secure approval in other countries in Southeast Asia and South America.

DNDi aims to replicate the competitive market created in Malaysia in other middle-income countries.

“We are discussing with a number of international agencies to see if we can use this idea of a value chain to create a coalition in the global south, a kind of a south-south value chain for the elimination of hepatitis C,” Piedagnel said.

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Just days before a contract cutoff date, UnitedHealthcare and Northside Hospital are moving toward a deal that would keep three of the Atlanta-based system’s hospitals in the insurer’s network.

An agreement also would bring Northside’s hospitals in Lawrenceville and Duluth back into the insurer’s fold after five months out of network, a UnitedHealthcare official said.

“We are working closely with Northside to finalize the contract and hope to be ready to announce the agreement soon.” Cole Manbeck, a United spokesman, said Tuesday.

A letter of agreement has been signed between the two parties, which are now working out the exact terms of the deal, Manbeck said.

The agreement, as is, will mean uninterrupted access for United members to Northside’s hospitals in Atlanta and suburban Cumming and Canton. And eventually, a contract will add Northside’s Lawrenceville and Duluth hospitals for the first time to United’s Medicare Advantage network.

A deal would renew a relationship that sometimes looked to be on shaky ground the past month. The impasse sparked concerns among thousands of United members who use Northside providers.

“Northside and UnitedHealthcare have made excellent recent progress in our negotiations,’’ Lee Echols of Northside Hospital said Tuesday. “We look forward to culminating the process. Our patients throughout the Atlanta region are the big beneficiaries, and we hope that the work we’ve done reflects that.”

Northside Hospital Atlanta is an important feature for insurers’ networks, with a reputation of delivering more babies a year than any other community hospital in the country.

Most contracts OK’d at last minute

A contract lapse between an insurer and a hospital system is unusual, with many agreements hammered out just before the renewal deadline.

Northside Gwinnett

But after Northside’s facilities in Gwinnett went out of network, Taylor Carrion, 31, of Buford became worried. She’s a United member whose doctors remained in the insurer’s network. Yet going to Northside Hospital Gwinnett, in Lawrenceville, would have cost her much more to get care.

Without a contract, she said, “if I do decide to have a baby, I’m stuck.’’ During the impasse, she had phoned both the hospital and United to express her concerns.

Carrion called an impending contract deal “great news.’’

Northside Hospital acquired the former Gwinnett system, including the Lawrenceville and Duluth hospitals, in 2019. Gwinnett is the second most populous county in the state.

United had slammed Northside prices

During the dispute, United criticized what it called high prices at Northside facilities.

In a statement last month to GHN, the Minnesota-based insurer said that “Northside’s Atlanta, Cherokee [Canton] and Forsyth [Cumming] hospitals are the most expensive in Atlanta, and for cancer patients, they’re some of the most expensive places in the entire country to receive care.’’

Northside Hospital Atlanta

 

United accused Northside of marking up the cost of physician-administered drugs, “padding its bottom line at the expense of its patients.’’

“Despite these high costs, Northside is demanding a double-digit price hike over the next three years that would significantly increase health care costs,’’ the United statement continued.

Even with such heated language during the dispute, Josh Berlin, CEO of the consulting firm rule of three, said it wasn’t surprising that a contract deal was reached.

“Northside and United striking an agreement is good for the Northside community served, and a must for United’s market presence given the number of insured lives in play,’’ Berlin said, citing increasing competition in metro Atlanta.

“United needed to finalize this arrangement to maintain its competitive positioning in the market.’’

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For Charlie Kjelshus, “the birthday rule” meant that dad Mikkel’s plan ― with a high deductible and coinsurance obligation ― was deemed her primary coverage after her NICU stay as a newborn. Mom Kayla’s more generous plan was considered secondary coverage. This left her parents with a huge bill.

Christopher Smith for KHN

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Christopher Smith for KHN

For Charlie Kjelshus, “the birthday rule” meant that dad Mikkel’s plan ― with a high deductible and coinsurance obligation ― was deemed her primary coverage after her NICU stay as a newborn. Mom Kayla’s more generous plan was considered secondary coverage. This left her parents with a huge bill.

Christopher Smith for KHN

When Kayla Kjelshus gave birth to her first child, the infant spent seven days in the neonatal intensive care unit, known as the NICU. This stressful medical experience was followed by an equally stressful financial one. Because of an obscure health insurance policy called the “birthday rule,” Kjelshus and her husband, Mikkel, were hit with an unexpected charge of more than $200,000 for the NICU stay.

Now, seven months after KHN and NPR published a story about the Kjelshus family’s experience, new parents may be spared this kind of financial uncertainty if lawmakers pass a bill that would give parents more control when it’s time to pick a health insurance policy for their child.

The new proposed law would eliminate the birthday rule. That rule dictates how insurance companies pick the primary insurer for a child when both parents have coverage: The parent whose birthday comes first in the calendar year covers the new baby with their plan first. For the Kjelshuses of Olathe, Kansas, that meant the insurance held by Mikkel, whose birthday is two weeks before his wife’s, was primary, even though his policy was much less generous and based in a different state.

“It’s an outdated policy,” Mikkel Kjelshus said. “Nowadays both parents typically have to work just to make ends meet.” Two jobs often means two offers of health insurance — and while double coverage should be a good thing, in practice, it can lead to a bureaucratic nightmare like the one the Kjelshuses faced.

U.S. Rep. Sharice Davids, D-Kansas, introduced “Empowering Parents’ Healthcare Choices Act,” a bill that would do away with the birthday rule and a “coordination of benefits policy” that trips up first-time parents up when it’s time to sign up a new baby for insurance.

“When I heard about the Kjelshus family’s story, I knew there had to be a way to help,” Davids said. “Parents should have the power when it comes to their new baby’s health care coverage.”

For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a high coinsurance obligation and a network focused in a different state — was deemed her primary coverage. Her mom’s more generous plan was secondary. Confusion over the two plans caused a tangle of red tape for the family that took almost two years and national media attention to resolve.

This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, said Lee Modesitt, director of public affairs with the Kansas Insurance Department. It is a somewhat arbitrary rule that could be fair if all jobs offered health plans with similar coverage. But for many families, one partner’s plan is much more generous.

“It feels awesome,” Mikkel Kjelshus said of the news that a change has been proposed. “We really didn’t want this to happen to anyone else.”

To be enacted, the bill would need to pass the House and Senate before receiving the president’s signature. Davids was elected to Congress in 2018, flipping a seat in Overland Park, Kansas, that had been held by a Republican for a decade. She was reelected in 2020 and is the only Democrat in Kansas’ House delegation.

Ellie Turner, a spokesperson for the congresswoman, said Davids is talking with colleagues in the House to garner additional support.

“It’s becoming clear that the Kjelshus family is not alone in this experience,” Turner wrote in an email. “We are going to continue working to raise awareness and gain momentum for a birthday rule fix, because every family deserves a choice when it comes to their child’s health.”

As they await the arrival of their second child, this time around the Kjelshus family has a better idea of how the health insurance will work. And, much like the first time, they feel prepared.

“We’ve got the crib. We’ve got the baby stuff. It’s a lot less stress this time around,” Mikkel Kjelshus said. “We kind of know what we’re doing.”

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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