According to the Jamaica Health and Lifestyle Survey for 2016/17, about 1 in 3 adult Jamaicans have hypertension, with more prevalence in women (35.8 per cent) than men (31.7 per cent). The survey further highlighted that 60 per cent of men and 26 per cent of women were unaware of their blood pressure status. The Centers for Disease Control and Prevention, USA, in 2021 reported that hypertension was a major cause of nearly 700,000 deaths in the US.

In today's column we will discuss blood pressure monitoring at home. How should this be done? How often? And what do the numbers mean?

Managing high blood pressure, or hypertension, has long been recognised as an essential component of heart health care. According to older research, blood pressure may be higher while lying down, but more recent studies have contradicted this finding and suggest that blood pressure may be lower while lying down versus sitting.

As defined by the American Heart Association (AHA) and American College of Cardiology, normal blood pressure for adults measured in a seated position is a systolic reading of less than 120 mmHg and a diastolic reading under 80 mmHg. Readings fluctuate throughout the day, though.

The "gold standard" for accuracy of blood pressure measurement is ambulatory blood pressure monitoring, which takes readings throughout the day. But that requires wearing a monitor for 24 hours.

Over the years, research has shown repeatedly that night-time blood pressure measurements are one of the best predictors of cardiovascular disease. But it's hard to get such readings. Currently, the American Heart Association recommends that blood pressure readings be taken when you're sitting down. But getting an accurate reading from a seated position can be complicated, and several investigators now question whether a sitting position is indeed the best way to check blood pressure in healthy patients.

How should blood pressure be measured, and what is the evidence?

Traditional teaching states that blood pressure is best measured in the sitting position with a recommendation to sit with your back straight and supported and feet flat on the floor with the legs uncrossed. Your arm should be supported on a flat surface, such as a table, with the upper arm at heart level. This classical approach has recently been challenged by some scientific data suggesting that lying flat or standing may be as appropriate or even more accurate and more desirable. In a recent study, scientists at UT Southwestern (UTSW) have suggested that measuring blood pressure while standing rather than sitting provided a more accurate or reliable reading and could lead to significant improvements in early detection of high blood pressure in healthy adults.

UTSW researchers measured the blood pressure of 125 healthy patients ages 18-80 with no history of hypertension, previous use of blood pressure medication, or other comorbidities, and used statistical methods to assess the overall accuracy of each test in diagnosing hypertension. Their findings revealed that measuring standing blood pressure either on its own or in addition to sitting blood pressure significantly improved diagnostic accuracy.

In all patients studied, blood pressure was determined through 24-hour ambulatory blood pressure monitoring (ABPM), seated in the doctor's office, and standing in the office. Using 24-hour ambulatory pressure measurement as the gold standard the accuracy in detecting high blood pressure and the accuracy in detecting absence of hypertension in the seated measurements were 43 per cent and 92 per cent, while in the standing measurements accuracy of detection or absence were 71 per cent and 67 per cent.

In another recent study, investigators sought to determine whether simply having people lie down in the clinic during the day might identify those at higher risk of cardiovascular disease, similar to blood pressure measurements taken during sleep.

Using data from a large, longitudinal study, researchers found that when compared with readings taken while sitting, readings that showed high blood pressure in people who were lying down did a much better job of predicting stroke, serious heart problems and death.

These findings were surprising and suggest that having people lie flat to measure their blood pressure could potentially help identify people who need treatment, despite seemingly normal readings taken while seated.

The findings imply that checking supine blood pressure might unveil hypertension that would otherwise be missed in the doctor's office.

Whether sitting, lying down, or standing, what is important is to make sure that you are still, in a noise-free zone, and that the bottom of the cuff is placed directly above the bend of the elbow. Follow your monitor's instructions for an illustration or have your health-care professional show you how.

It is preferable that you do not smoke, drink caffeinated beverages, or exercise within 30 minutes before measuring your blood pressure. Empty your bladder and ensure at least five minutes of quiet rest before measurements. For more reliable assessment of variations in blood pressure readings, it is recommended that readings are performed at the same time each day - for example, mornings and evenings. Multiple readings over a period of two weeks are ideal for a more informed assessment of blood pressure status.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Send correspondence to info@caribbeanheart.com or call 876-906-2107.

A premature infant is defined as a baby born before 37 completed weeks of pregnancy. One in 10 newborns are delivered prematurely for a variety of reasons, including maternal, foetal, and at times unknown causes. In 2020, 13.4 million babies were born preterm globally and accounted for one million newborn deaths in 2021 (Born too soon: a decade of action on preterm birth 2023).

Prematurity is associated with many complications related to underdevelopment of the baby's organs. These babies are often critically ill and require neonatal intensive care admission and extensive support. Complications include but are not limited to problems with breathing and with the gastrointestinal tract; blindness; brain injury resulting in cerebral palsy; intellectual, learning and behavioural challenges.

Despite advances in medicine, the incidence of prematurity has not changed over the years, and the associated morbidity and mortality rate continues to be a financial, emotional, mental and social burden to families and the health-care system. Additionally, inequity in health-care resources between resource-limited and developed countries creates an unacceptably large survival gap for babies born preterm. Preterm birth rates were 9.9 per cent in 2020 vs 9.8 per cent in 2010. Notably, there has been little change in the preterm birth-related burden in the most heavily impacted areas of the globe.

In Jamaica, according to PAHO, the incidence of low birth weight in Jamaica in 2023 was 11.6 per cent. Despite these challenges, there have been considerable advances in the care of newborn infants, and infants at much younger gestational ages are surviving - however, much of this progress has been in high-resource countries.

The most recent Born Too Soon report has set an ambitious mandate to reduce the burden of preterm birth, with recommendations for a holistic approach. Caring for Miracles Foundation, in an attempt to align with these recommendations, adopts neonatal intensive care units in low- and middle-income countries, and partners with local government and other organisations to build capacity through support for the purchase of equipment, education of health-care staff, and by nurturing resilience in the health-care teams and the families that they serve.

The foundation's first adoptee is the Neonatal Intensive Care Unit at the University Hospital of the West Indies. This year the foundation has partnered with European Foundation for the Care of Newborn Infants (EFCNI) and other international organisations to spread awareness about the burdens and challenges of prematurity as well as the stories of miracles that occur daily.

In recognition of World Prematurity Day on November 17 the foundation hosted an information booth at Churchill Square, UHWI, where attendees got an opportunity to interface with health-care workers and parents of preterm infants, as well as some of the actual miracles. In addition, the third annual virtual Caring for Babies Born Too Soon Symposium will be held on November 25, 2023 under the theme: 'Protect the brain; change the trajectory. What's new in neuroprotection for the preterm neonate?'

This symposium, which will feature a multidisciplinary panel of international speakers and the perspective of parents of former premature infants, seeks to provide attendees with up to date evidence on approaches to protecting the vulnerable brains of these infants. It has become increasingly clear that even routine care practices may have a long-term impact on brain development and outcomes, and evidenced-based measures to mitigate this will be discussed.

The symposium targets all health-care providers involved in perinatal and neonatal care, including obstetricians, neonatologists, paediatricians and paediatric residents, neonatal and paediatric nurses and midwives, radiologists, anaesthetists, the allied health team, medical and nursing students. All parents and families of preterm infants, and any interested community partners are welcomed. Attendees will hear from the parents of premature infants and interface with the expert panel.

You may register by clicking on the link: https://www.caringformiracles.com/

This article was prepared by Dr Jillian M Lewis, consultant neonatologist, University Hospital of the West Indies; associate lecturer, University of the West Indies; and founder/chair Board of Directors, The Caring for Miracles Foundation.

In a document, he expressed that the operations and interventions have impacted 5,670 people, with the application of vaccines, 4,457, kit with liquid and paste chlorine to purify water, placement of oral rehydration serum, and prevention. He said that the laboratory results of the Bahoruco and La Palmita rivers showed positive results for fecal coliforms, E. coli, and pseudomonas but negative for vibrio cholera. “However, we recommend not to consume these waters given the contamination.”

He assures that the health authorities “approach this situation with the utmost seriousness. Our medical teams are on the ground, attending to each case with the objective of providing the appropriate treatment to preserve the lives of patients.”

Dr. Nelson Rodriguez Monegro
Refused to admit
Since Saturday 4, the Ministry of Health has been notified by the Provincial Directorate about the appearance of this outbreak but has insisted that it was amebao or shigelas. The population blamed Inapa for the problem due to carelessness with the collapsed aqueduct.

The doctor had already said.
What is happening is an outbreak of cholera, given that the amoeba and echerichacolis do not have those characteristics, said Nelson Rodriguez Monegro, former director of the National Health Service (SNS), before the report.

“It is worrying and calls attention to the attitude of the authorities, which is apparently their norm, in the face of an epidemic outbreak. At the time, the same thing happened with dengue,” he said.

He recalled that they began by denying the increase in the number of epidemic cases, then that “everything was under control, that the cases are decreasing, and the opposite is true. He warned that these diseases have different characteristics than cholera. He explained that the parasitosis has a fever, gas, abdominal pain, willful desire to evacuate, pain in the hypogastrium, semi-solid evacuations with mucus, and may be accompanied by blood.

People with cholera present vomiting without nausea, abundant watery evacuations similar to rice water, and there is no abdominal pain. They may have muscle cramps due to loss of electrolytes.

“They are different pictures, and the diagnosis is made with laboratory tests. Without a doubt, it is cholera.”

The relocation, which involves doctors from crucial departments such as orthopaedics, surgery, and emergency care, is set to last for a period of 60 days, spanning between November 15 and January 20.

Also Read:Fee Hike but not Stipend Hike: Kerala PG doctors to go on 24 hour strike on 8th November

The reassignments include a notable shift of three out of five orthopedic surgeons from the Ernakulam MCH to Konni MCH for a duration of 60 days. Additionally, around 40 doctors from the Thiruvananthapuram MCH, 10 doctors from the already short-staffed Alappuzha MCH, and nearly 30 doctors from the Kottayam MCH will be serving at Konni MCH during the Sabarimala pilgrimage season.

The decision to redirect medical personnel to Konni MCH, a key healthcare facility during the Sabarimala pilgrimage, has raised concerns about the potential impact on emergency care services at the doctors' home institutions. Notably, doctors responsible for critical services, including those in Intensive Care Units (ICUs), have also been included in the temporary staffing adjustment. The 60-day deployment of doctors, including those from emergency care units, has prompted concerns about the immediate and long-term effects on patient care.

KGMCTA state president Dr Nirmal Bhaskar also told the daily, "Pathanamthitta General Hospital used to be the base hospital during Sabarimala season. Now it is MCH, Konni. MCH doctors will be posted at medical facilities in Sannidhanam, Pamba, Appachimedu, and Neelimala. This means that a majority of them will be at Sabarimala and this will affect the functioning of other MCHs."

Also Read:Kerala doctors to go on token strike over pay revision

The Kerala Government Medical College Teachers' Association (KGMCTA) strongly opposes these temporary postings, citing concerns related to tertiary care and potential disruptions to academic sessions. The association stated that it will approach the government soon to address the issue. Most of the doctors deployed at Konni MCH for the pilgrimage duty are originally from Thiruvananthapuram, Kottayam, Alappuzha, Manjeri, and Ernakulam MCHs. Dr Binoy S, former state president of Kerala Government Medical College Teachers Association (KGMCTA) told Times of India, "We have a National Medical Council-approved punching system and hence a doctor posted at Thiruvananthapuram MCH cannot punch from Konni, which will affect their medical registration."

Barahona.- The ongoing outbreak of diarrheal illness in the La Ciénaga municipality and other communities in the Barahona province of the Dominican Republic may be exacerbated by the heavy rains caused by a potential tropical cyclone. The Minister of Public Health, Daniel Rivera, has expressed concerns about the impact of the rains on the already dire situation.

Rivera stated that they are aware that the rains could worsen the outbreak, and they have been holding meetings with members of neighborhood associations in the affected area to warn them against consuming water directly from rivers. He urged the population in Barahona to consume only water provided by the National Institute of Drinking Water and Sewage (Inapa) and advised boiling water before consumption and ensuring thorough cooking of food to prevent further casualties.

The minister assured that health teams are continuing to support the affected communities, and he announced that they would provide an update on the total number of deaths from the outbreak and other relevant details at noon on Friday.

Meanwhile, the potential tropical cyclone has brought heavy rains to various locations in the Barahona province, which is under a yellow alert, along with seven other provinces in the Southern region of the Dominican Republic. Carlos Confidente, Regional Director of Civil Defense, reported that evacuations have not been necessary so far, but the authorities are monitoring the situation closely. They have been clearing ravines to prevent flooding and providing guidance to residents to prepare for possible emergencies.

Santo Domingo.- The Ministry of Health in the Dominican Republic has issued a call to action in response to the anticipated heavy rains expected over the coming weekend. They are urging the population to take proactive measures to mitigate potential health risks associated with inclement weather. The Ministry has activated its Prevention and Rapid Response Plan and is coordinating efforts to address potential health hazards linked to heavy rainfall.

During periods of intense rainfall, the country typically experiences a surge in epidemic outbreaks of diseases, including dengue, malaria, chikungunya, acute respiratory infections, leptospirosis, acute diarrheal diseases, and gastrointestinal issues. To counter these threats, the Ministry is advocating for several precautionary measures to be taken.

Firstly, they recommend chlorinating drinking water to ensure its safety. Additionally, they advise checking the expiration dates of food items, especially canned goods, and thoroughly washing fruits and vegetables before consumption. Cooking food thoroughly is also emphasized.

The Ministry encourages residents to have an adequate supply of medications on hand, particularly for individuals with chronic illnesses or those undergoing treatment. People should be cautious around stagnant water, mud, or flooded areas, as these can increase the risk of contracting leptospirosis.

In terms of general safety, it’s advised to avoid touching electrical cables and wet walls. Homes should be secured, including doors, windows, ceilings, and any objects in the vicinity that could pose a danger. Special attention should be given to protecting vulnerable groups such as children, the elderly, and individuals with disabilities or immunosuppressed conditions.

This proactive stance comes as the director of the National Meteorological Office (Onamet), Gloria Ceballos, reports that an atmospheric phenomenon approaching the country has a 60% probability of developing into a tropical depression or cyclone. The climatic event is expected to affect border regions, provinces in the southwest, and Santo Domingo, starting on Friday. Consequently, the COE Emergency Operations Center has placed 14 provinces on alert, heightening preparedness efforts.

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

Congress narrowly avoided a federal government shutdown for the second time in as many months, as House Democrats provided the needed votes for new House Republican Speaker Mike Johnson to avoid his first legislative catastrophe of his brief tenure. But funding the federal government won’t get any easier when the latest temporary patches expire in early 2024. It seems House Republicans have not yet accepted that they cannot accomplish the steep spending cuts they want as long as the Senate and the White House are controlled by Democrats.

Meanwhile, a pair of investigations unveiled this week underscored the difficulty of obtaining needed long-term care for seniors. One, from KFF Health News and The New York Times, chronicles the financial toll on families for people who need help for activities of daily living. The other, from Stat, details how some insurance companies are using artificial intelligence algorithms to deny needed rehabilitation care for Medicare patients.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Among the takeaways from this week’s episode:

• Congress passed a two-part continuing resolution this week that will prevent the federal government from shutting down when the current CR expires Nov. 18 at 12:01 a.m. The new measure extends some current spending levels, including funding for the FDA, through Jan. 19. The rest of federal agencies, including most of the Department of Health and Human Services, are extended to Feb. 2.
• House Speaker Mike Johnson (R-La.) has said he wants to use the next two months to finish work on individual appropriations bills, none of which have passed both the House and Senate so far. The problem: They would deeply cut many popular federal programs. They also are full of changes to abortion restrictions and transgender policies, highlighting the split between the GOP caucus’ far-right wing and its more moderate members.
• In the wake of abortion rights successes in passing abortion rights ballot initiatives, new efforts are taking shape in Ohio and Michigan among state lawmakers who are arguing that when Dobbs turned this decision back to states, it meant to the state legislatures — not to the courts or voters. Most experts agree the approach is unlikely to prevail. Still, it highlights continuing efforts to change the rules surrounding this polarized issue.
• Sen. Tim Scott (R-S.C.) — who was the only remaining Republican presidential candidate pushing for a national, 15-week abortion ban — suspended his campaign last week. He, along with former Vice President Mike Pence, who bowed out of the race at the end of October, were the field’s strongest anti-abortion candidates. This seems to suggest that the 15-week ban is not drawing voter support, even among Republicans. Meanwhile, former President Donald Trump, the GOP’s front-runner by miles, continues to be willing to play both sides of the abortion debate.
• Amid increasing concern about the use of artificial intelligence in health care, a California class-action lawsuit charges that UnitedHealth Group is using algorithms to deny rehabilitation care to enrollees in its Medicare Advantage program. The suit comes in the wake of an investigation by Stat into insurer requirements that case managers hew to the AI estimates of how long the company would pay for rehabilitation care, regardless of the patient’s actual medical situation.
• More than 10 million people have lost Medicaid coverage since states began reviewing eligibility earlier in the year. Advocates for Medicaid patients worry that the Biden administration has not done enough to ensure that people who are still eligible for the program — particularly children — are not mistakenly terminated.

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

Julie Rovner: KFF Health News’ “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts,” by Amy Maxmen.

Alice Miranda Ollstein: The New York Times’ “They Wanted to Get Sober. They Got a Nightmare Instead,” by Jack Healy.

Rachel Cohrs: Stat’s “UnitedHealth Pushed Employees to Follow an Algorithm to Cut Off Medicare Patients’ Rehab Care,” by Casey Ross and Bob Herman.

Joanne Kenen: ProPublica’s “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards,” by Isabelle Taft, Mississippi Today.

Also mentioned in this week’s episode:

• KFF Health News’ “Facing Financial Ruin as Costs Soar for Elder Care,” by Reed Abelson, The New York Times, and Jordan Rau.
• JAMA Internal Medicine’s “Excess Death Rates for Republican and Democratic Registered Voters in Florida and Ohio During the COVID-19 Pandemic,” by Jacob Wallace, et al.

Click to open the transcript

Transcript: Congress Kicks the (Budget) Can Down the Road. Again.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 16, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.

Joanne Kenen: Hi everyone.

Rovner: No interview this week, but more than enough news, so we will get right to it. So the federal government is not going to shut down when the current continuing spending resolution expires at 12:01 a.m. Saturday. In basically a rerun of what happened at the end of September, new House Speaker Mike Johnson ended up having to turn to Democrats to pass another CR. This one extends a bunch of federal programs until Jan.19 and the rest of them until Feb. 2. Most of HHS [the Department of Health and Human Services] is in the latter category, but the FDA, because it’s funded through the Department of Agriculture, its spending bill would be in the group that’s funded only through Jan. 19. Don’t worry if you don’t remember that.

The stated goal here is to use the next two months, minus what’s likely to be a sizable Christmas break, to finish work on the individual appropriation bills, of which exactly zero of 12 have passed both the House and Senate and been sent to the president. Meanwhile, in just the last week, House Republicans have been unable to pass any of the individual appropriations they have brought to the floor and a few haven’t been able to even get to the floor. Yesterday, Republican leaders pulled the plug on the rest of the week’s floor schedule, literally in the middle of a series of votes on the HHS spending bill. So Democrats are not going to bail them out on these individual bills the way they have on the relatively clean continuing resolutions because the individual bills include very deep spending cuts and lots of abortion and transgender and other culture wars riders. So what exactly do they think is going to change between now and the next deadline?

Ollstein: Well, there’s been a lot of chatter about how cranky members of Congress have gotten because they worked 10 weeks in a row. Most of us work 10 weeks in a row without destroying each other, but there it is. And so there’s the hope that when they come back …

Rovner: Yes, there were threats of physical violence this week.

Ollstein: And allegedly some actual physical violence. Most of us work 10 weeks in a row without assaulting our colleagues, but we are not members of Congress. So the idea is they could take some time to cool off and come back and be more collaborative, but really this is a problem the Republican Caucus has not been able to solve. You have dissent on the right of the caucus and the sort of more moderate left or more left side of the caucus. You have moderate members who are worried about getting reelected in districts that voted for [President Joe] Biden who are not wanting to vote for these spending bills that are full of anti-trans and anti-abortion provisions, which you could easily picture that being used against them in campaign ads. And then you have folks on the far right in the Freedom Caucus who are sort of tanking these individual bills to protest the overall trajectory of spending and the overall process. So this is not going away anytime soon. And, like you said, Democrats are not bailing them out here.

Cohrs: One other point I wanted to make, sorry, Julie, on the deadlines is that for people who are interested in health policy and PBM [pharmacy benefit manager] reform and DSH [Medicaid’s Disproportionate Share Hospital] cuts, all of those. Those all have a Jan. 19 deadline. So those will come with the first round. So I think for the people out there who are worried about those policies, community health centers, extenders, that will happen with the first deadline even though the full Labor, HHS preparations aren’t until the second one.

Rovner: Yeah, these continuing resolutions do carry some of these extraneous, what we like to call “extender,” provisions that would otherwise have expired. And so they’ll keep them going for another couple of months and keep lobbyists busy wringing their hands and keep all of our inboxes full of emails of people warning of terrible things that will happen if these programs aren’t continued. But I want to go back to the underlying problem here, though, is that first of all, the conservative Republicans say they want to put the budget on a different trajectory. Well, discretionary spending, which is what we’re talking about here with the 12 spending bills, is a tiny portion of what makes up the budget and the budget deficit. So even if they were to cut all of these programs as dramatically as they like, they wouldn’t have much of an impact on the overall budget. I’m sort of mystified that people don’t keep pointing that out.

Ollstein: Well, and they’re also cutting things that won’t save money. I mean, they wanted to cut things like IRS enforcement, which would lose money because then the IRS wouldn’t be going after wealthy tax cheats and recouping that government spending. And so some of this is ideological. They’re going after health care programs that support LGBT people, for instance, and that doesn’t save that much money. But there’s been a lot of speeches from Republicans railing against the substance of the programs and calling them “woke” and inappropriate and such. And so, yes, some of this is fiscal, but a lot of it is also ideological.

Kenen: Yeah, it’s a relatively small portion of federal dollars, but a relatively large portion of culture war.

Rovner: Yes, I think that is a very good way to put it because, of course, it’s a place where they can put culture war things because they have to come up every year. But yeah, I think that’s why we end up fighting over this. All right, well this fight has been put off until 2024, although it’ll be the first thing when we get back.

Kenen: Yeah. And nothing’s really going to change except maybe cooler heads prevail. Anyone see any cooler heads around there? They may come back a little bit more personally tolerant when they’ve had some time off over the holidays. But the basic ideological and political alignment and the loggerheads, it’s like the only thing that changes between November, December, and January is it’s colder here then.

Rovner: Yeah, that’s exactly correct. Yeah. The far right of the House Republican Caucus is going to have to realize that there is a Senate and there is a president and they all get a say in what these final bills look like too. So they can’t just dictate we’re going to make all these cuts and, if not, we’re going to close down the government, unless that’s what they decide to do.

Kenen: But I think they skipped that session in their orientation.

Rovner: Yeah. Apparently.

Kenen: They’re not finding, “OK, where’s the compromise? What do we really, really, really want? And what are we willing to trade that for?” They’re not doing that. If you give and take, everybody gets some victory, and you have to identify what victory you can get that satisfies you. But there’s no sign of any kind of realistic grasp that this is divided government.

Rovner: Right. And they yet to figure that out. All right, well let us turn to abortion, where there is always news. We are going to start in Ohio, where last week voters, by a pretty healthy margin, approved a ballot measure to enshrine abortion rights in the state constitution. Now, though, some anti-abortion lawmakers in Ohio say, “Never mind, we can overrule that.” Really, Alice?

Ollstein: So there are efforts going on in both Ohio and Michigan to block, undo, undermine what voters voted for in these referenda and, based on talking to sources, it seems like neither of these really have legs. They’re sort of seen as just messaging. But I think that even the attempt to try to undermine or undo what voters overwhelmingly approved is telling and interesting. And, of course, it builds on all of the attempts leading up to the votes that we saw from these same forces to try to change the rules, make it more difficult. So I think when state legislatures around the country come back into session in January, we’re going to be watching closely to see if they pass things that aim to block these votes. So definitely something to keep an eye on.

Rovner: I did see that this speaker of the Ohio House has poured at least some cold water on this effort. The argument had been from some of these lawmakers that because the Supreme Court gave this decision back to the states, that means only state legislatures and not the courts and not the voters directly. Am I interpreting that right?

Kenen: Yeah, the speaker was pretty firm. He said … what did he say? It was “Schoolhouse Rock”? He basically said that the voters, they matter.

Rovner: Yeah.

Ollstein: And what’s interesting is that the court that they want to cut out of this in Ohio is very conservative. And so this isn’t like, “Oh, we want to block these liberal activist judges from weighing in here.” This is “We want to keep this solely in the hands of the legislature and not have, really, courts have a role in it at all,” although the courts are very conservative and tilt in the anti-abortion direction anyway, which I think is notable.

Rovner: We’ll definitely watch that space in the upper Midwest/Great Lakes. Well, elsewhere, in Alabama, in a story that I didn’t think got the coverage it deserved, the Justice Department is joining a case brought by an abortion fund and some former abortion providers about whether the state might be able to prosecute them for helping women travel to obtain an abortion in another state. Department of Justice says, “Of course, states can’t prevent people from traveling to other states for things that are legal in another state, but not in their state. Otherwise, very few people would be able to go to Las Vegas.” But the state attorney general has yet threatened to try to prosecute, has he not?

Ollstein: Yeah, so this is happening in a few states, but it’s sort of come to a head in Alabama in terms of treating groups that either provide material support for people to travel across state lines for an abortion or even just information, even just “Here’s a clinic that you can call in this other state.” Not even a formal referral, medical referral, but just information about where to go. The attorney general has threatened to consider that kind of a criminal conspiracy to violate Alabama’s abortion ban.

So this is an interesting test, and I think it may — like the travel bans we’ve been seeing proposed and even implemented in some cities, states, et cetera. They’re sort of trying a bunch of different things. But these are basically impossible to enforce. And so, really, what’s happening here is an attempt to undo some of the chilling effect of these laws. Right now, people are so afraid of being charged with criminal conspiracy that they’re holding off on, even providing publicly available information that’s likely protected by the First Amendment. And so they’re hoping that a court ruling saying “You do have the right to at least discuss this and even give people support to travel” will undo some of that chilling effect. And yeah, I think that’s sort of the key here.

Rovner: Yeah. Well, moving on to Texas, where a lot of these other travel bans have been tried, at least in some cities and counties, we want to go back to that case where a half a dozen women who couldn’t get care for pregnancy complications, because of the state’s abortion ban, sued. Well, now there are 22 plaintiffs in that case, including two doctors and a then-medical student who discovered her fetus’s lethal abnormalities at an 18-week scan. The Texas Supreme Court is supposed to hear this case later this month, but, Alice, this could really end up before the U.S. Supreme Court, couldn’t it? This is the concern of women who are not trying to have abortions. They were basically trying to complete pregnancies and have had things go terribly wrong. And, as you just said, doctors are afraid to treat them for fear that they’re going to be prosecuted.

Ollstein: Yeah. And so this is where state abortion bans are running up against federal protections for … you have to treat a patient who comes in who’s experiencing a medical emergency. This is the EMTALA, a federal law, and these things are in conflict. Anti-abortion groups and advocates say that they are not, and that medical care in these situations is already protected. But as we’ve seen with this chilling effect, doctors are afraid to act in these situations and they’re telling patients to go away and come back when things are more dire. And that, in some cases, in these plaintiff’s cases, has led to pretty permanent damage, damage to their future fertility, threats to their lives. And so these cases are not seeking to get rid of the abortion bans entirely, as some other lawsuits are, but they are seeking to really make clear, because it’s not clear to medical providers right now, make clear what is allowed in these really sensitive and precarious medical situations.

Rovner: Yeah, I keep hearing a lot of the anti-abortion forces saying, “Well, it’s not technically an abortion in these cases. If it’s an ectopic pregnancy or something or the woman’s water has broken early and she’s going to get septic.” And it’s like, “Except that medically, yes, they are. A termination of pregnancy is termination of pregnancy.” And that’s why the doctors are saying, “You can call this anything you want. We’re the ones who are going to get thrown in jail and lose our medical licenses.” All right. Well, before we move on, I want to talk some abortion politics. Sen. Tim Scott of South Carolina, who had been the only Republican presidential candidate strongly pushing for a federal 15-week abortion ban, suspended his campaign this week after what happened in Virginia last week, which we talked about at some length. When Republican Gov. Glenn Youngkin tried to win back the state legislature for Republicans by promising to sign his own 15-week ban and lost spectacularly. Where does that leave Republicans on abortion going into 2024? Obviously, the 15-week ban as a compromise doesn’t seem to be flying.

Ollstein: No, it’s certainly not. And Tim Scott and Mike Pence were some of anti-abortion groups’ favorite candidates who were saying what they wanted to hear, and both of their campaigns have now ended. And so, meanwhile, you have the people who have been a little more squishy, from anti-abortion advocates’ perspective anyways, like Nikki Haley and [former President Donald] Trump himself, doing the best. DeSantis also sort of middling right now on the downward trajectory, seemingly.

Rovner: DeSantis, who signed a six-week ban in Florida.

Ollstein: Exactly, but was also kind of unclear about what he would do as president, which the anti-abortion groups did not like. It’s interesting, maybe telling, that the people who were sort of the staunchest anti-abortion voices have not seemed to do well in this moment, but let’s be real. Trump is the far-and-away front-runner here. It’s most important to examine Trump. And he’s sort of trying to have it both ways. He’s both touting his anti-abortion bona fides by talking about appointing the justices to the Supreme Court that overturned Roe v. Wade, taking credit for that. And at the same time sort of pushing this line of, “Oh, we’ll strike some sort of compromise.” He really talks up exemptions for rape and incest, which, by the way, a lot of anti-abortion groups don’t want those. And so he’s sort of speaking out of both sides of his mouth, but, at least according to the polls, it seems to be working.

Rovner: Yeah, maybe that’s the answer for Republicans is tell everybody what you think they want them to know. I guess we will see going forward. Well, I want to move on. I’m calling this next segment, “Getting Old Sucks: Ask Me How I Know.” I want to start with a joint project that KFF Health News has out this week with The New York Times called “Dying Broke.” It’s about, and stop me if you’ve heard me say this before, the fact that the U.S. has no policy to help pay for long-term care, save for Medicaid, which only pays if you basically bankrupt yourself and your family.

There is a lot in this series, and I highly recommend it, but one of the things that jumped out to me is that the cost of long-term care has risen so much faster than incomes that even if you started saving for retirement in your 20s — I started saving for retirement in my 20s — you’d still be unlikely to have enough to self-insure for long-term care when you’re 75 or 80. Joanne, you’ve spent as much time as I have, probably more, writing about our lack of a long-term care policy. Anything jump out at you from this project?

Kenen: It was a terrific, terrific story, and it brought to life that even people who are definitely what you would think of as economically comfortable, it’s not enough. It’s just the luck of the draw, right? I mean, if you die fast, you can at least leave money to your kids. If you die slow, you can’t. It was a really good story. But what I always am left with when I read these stories is it doesn’t make a difference. Congress does not want to deal with this. Julie and I actually did a panel for a health group a few weeks ago, and one of the state … someone from California came up to talk about us and asked, “Why doesn’t the United States have a long-term care policy? I’m going to change that.” And we were trying to be polite, but it was like, “OK, good luck with that.” And this is not a partisan issue. Republicans and Democrats both get old and Republicans and Democrats both end up needing long-term care, whether it’s in the nursing home or assistance in your own home. Republicans and Democrats both get Alzheimer’s and other forms of dementia. They both get disabled. And we have a government that just plugs up its ears because it costs so much money and it’s an entitlement and they just don’t even want to deal with it. And generation after generation, it’s a disaster. It’s inhumane.

Rovner: And, of course, there was this brief effort in the Affordable Care Act with the CLASS Act that everybody was very excited …

Kenen: To nibble around the edges of it. The CLASS Act was good, but it wasn’t even solving the problem.

Rovner: And it went away because they discovered that even that was going to be too expensive. It could not be self-sustaining. And that’s been the problem with the private long-term care insurance market too, that you basically can’t get private long-term care insurance anymore because insurers cannot afford to sell it. They lose too much money on it, and therefore it would be too expensive if they actually charged what they needed to to even break even.

Kenen: Right. And there is an idea circulating, but it’s not getting any traction. It’s circulated in the past too, a joint approach, a reinsurance approach, that you’d try to strengthen the private long-term care insurance market, which is very broken. You’d try to fix that, but you wouldn’t expect the private insurance market to do the whole problem, so that there’d be reinsurance from the government. So for people who had maybe, I don’t know exactly how it works, say a year or two of expenses that private insurance would kick in and we would make that market work better and be there when you needed it. But then if you were somebody who had multiple years and you exhausted that benefit, there would be a backup entitlement.

Rovner: But I’ve heard this talked about for at least 10 years, and it’s never gone anywhere.

Kenen: It’s revived and it’s not getting … I don’t think it has a sponsor in this Congress. It did in the last Congress. There’s no discussion. There’s no … a lot of people think that Medicare actually pays for nursing homes, and then that’s a pretty big surprise because it only pays for very limited … it pays, like if you have surgery and you need some rehab at a nursing home for, what is it? Is it 12 weeks? I forget what it is, but it’s short-term. It’s a couple of months. It’s not dementia care. And even the other thing is when you read about the cost of long-term care, that’s just the room and board, that doesn’t include your doctors’ bills, your medication, clothing, personal aide, because people who are complicated and need a lot of care often need a personal aide in addition to the staff. It’s just a phenomenal amount of money. My kids don’t understand when I say we need to save money, they say, “Don’t you have enough?” And no, nobody has enough. Bill Gates has enough.

Rovner: Yeah, Warren Buffett has enough. Well, so, as I mentioned, one of the big problems with long-term care is that there’s essentially no private insurance for it anymore because it’s so expensive and because so many people end up needing it. That’s very different from Medicare Advantage, where insurers are and have been making lots of money providing benefits that would otherwise be paid for by the federal government. But Rachel, some of your colleagues have discovered that, and in at least some cases, those insurers are making all that money because they’re denying care to patients who need it. This is your extra credit this week, but I want you to talk about it now.

Cohrs: I’ll talk about it early. Yes. So my colleagues, Casey Ross and Bob Herman have been digging into the role of algorithms in insurance decisions for the past year. And they just released a new story this week about — with internal documents of a subsidiary called naviHealth of UnitedHealth — showing that the company was instructing managers to keep care timelines for a really expensive rehab that older people, I think, need after having injuries or something like that within 1% of the time that this algorithm was predicting, regardless of what their actual human doctors were saying. And truly, the stories behind these care denials are just really horrifying … of somebody who had a knee surgery and was expected to slide on their butt down the stairs because they weren’t paying for rehab. Families who’ve had to pay tens of thousands of dollars out of their own pocket after this care was denied because they saw that their loved one clearly needed money, and there was a class-action lawsuit filed, then after the story was published, by people who had deceased relatives who had UnitedHealthcare MA plans, and were denied rehab and later died. And so I think it’s just really eye-opening as to the actual instructions by managers inside the company saying that this is your expectation, and if you’re not keeping coverage care rehab timelines within this 1% margin, then you aren’t performing up to our standards.

Rovner: So this is basically AI being used to deny care. We keep talking about AI and health care. This is it, right? This is an algorithm that says, “Person who goes into rehab with these kinds of problems should only need 19 days.” And if you need more than that, tough. That’s essentially what’s going on here, right?

Cohrs: And the lawsuit did highlight as well that when people did appeal, they won most of the time, but most people didn’t appeal, and the company knew that. And so I think that was also part of the lawsuit that came up. It’s hard to prove intent with these things or what is a denial based on an algorithm? But I think this lays out the case in as explicit terms as we’ve ever seen from the internal side.

Rovner: It does. All right, well let us move on from Medicare to Medicaid, the unwinding — involving reviewing everyone on the program to make sure they’re still eligible now that the pandemic emergency has expired — continues with more than 10 million people now having lost their coverage, according to the tracker being updated by my KFF colleagues. And state Medicaid directors are predicting a year-over-year decrease in enrollment of 8.6%, which is pretty dramatically large. We also know that more than 70% of those being disenrolled may in fact still be eligible, but the state was unable to locate them or they didn’t file the right paperwork. Ironically, even with a much smaller caseload, state Medicaid spending is likely to rise because the additional payments that were provided by the federal government also expired at the end of the public health emergency. So states are basically having to pay more per enrollee than they were paying even when they were leaving everybody on the rolls. Advocates have been complaining all year that the Biden administration isn’t doing enough to ensure that states aren’t tossing people off who should still be covered. Has anything changed on that front? I know that the administration is sort of caught between this rock and a hard place. They don’t want to come out guns blazing and have states saying that they’re making this politicized. On the other hand, the numbers are getting pretty big and there’s increasing evidence that a lot of the people who are being relieved of their coverage should still have it.

Ollstein: Including a lot of children who absolutely did not do anything wrong in this situation. And so it kind of reminds me of some stuff during covid, where the Biden administration did not want to get into a public fight with GOP-controlled states and was trying to negotiate behind the scenes to get the policies they wanted to protect people. But at the same time, not wanting that open confrontation means that a lot of this is continuing to go on unchecked. And so the data is coming out showing that a lot of people who are losing coverage are not reenrolling in other coverage. Some are, but a lot are not. And so I think now that we’re getting, going to get into Obamacare open enrollment, I think that’ll be really key to see — can we scoop up a lot of these newly uninsured people?

Rovner: And we did, we saw the administration put out a press release saying that the early part of open enrollment has seemed very large, much larger-than-expected enrollment. And you kind of wonder, I’m kind of wondering, how many of those people were people who got kicked off of Medicaid. And, of course, we know that when people got kicked off of Medicaid, they were supposed to be steered to the Affordable Care Act, for which they would’ve obviously been eligible. But I’m wondering whether some of those people didn’t get steered and now that they’re seeing that enrollment is open, it’s like, “Oh, maybe I can get this.” I have not seen anybody answer that question, but it’s certainly a question in my mind.

Cohrs: Right. And coverage is more affordable as well because subsidies from the covid-era spending bills do extend through 2025. But again, people might see increases in costs once those end, if Congress doesn’t extend them. So even if we do see some people moving from Medicaid to ACA enrollment, then there’s a chance that they could see spikes in a pretty short amount of time.

Rovner: Yeah, I’ll be curious to see as open enrollment continues, whether they can break down where some of those people are coming from. All right, now it is time for “This Week in Health Misinformation.” I have chosen a KFF Health News story, which is also my extra credit this week, from science journalist Amy Maxmen, called “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts.” It seems that in Texas health departments and other organizations funded by the states are now prohibited from advertising or recommending covid vaccines or even saying that they are available, unless that’s in conjunction with telling them about other vaccines that are available, too. In Florida, as we have talked about here before, the health department has issued specific guidance recommending against the new covid vaccine for children and teens and now men under the age of 40. Unless you think this hasn’t had any impact before the vaccines were available, Democrats and Republicans were dying of covid in roughly equal proportions in Florida and Ohio, according to a study published earlier this summer in the journal JAMA Internal Medicine.

But by the end of 2021, which was the first full year that covid vaccines were widely available, Republicans had an excess death rate of 43% higher than Democrats. So medical misinformation has consequences. All right, now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Rachel, you’ve done yours already. Alice, why don’t you go next?

Ollstein: Sure. So I have a very depressing one out of The New York Times by Jack Healy and it’s called “They Wanted to Get Sober. They Got a Nightmare Instead.” And it is about these fraudulent, scammy addiction treatment facilities in Arizona, but it notes that they do exist in other states as well, that have been bilking the state Medicaid program for just millions and millions and millions of dollars and providing inadequate or nonexistent treatment to really vulnerable people in need, with very deadly consequences. And the places profiled in this piece really went after Native American folks specifically. So very sad report, but it sounds like more attention on this is leading to the state cracking down on places like this. So, hopefully, we’ll make some progress there.

Rovner: Yeah, quite a story, Joanne.

Kenen: This is a story, part of an ongoing series from Mississippi Today, in conjunction with ProPublica’s local reporting network: “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards.” It’s by Isabella Taft. In Mississippi, if you’re unfortunate enough to have such serious mental illness that a court orders you to have treatment and there’s no room in a state hospital, they put you in jail while you wait for a room in state hospitals. And sometimes they’re housed in these facilities or rooms that are meant for people with severe mental illness, but they’re awful. And sometimes they’re just housed with a regular prison population. And the sheriffs say, “Wait a minute, it’s not really our problem to be housing … state hospitals have to fix this.” And they have a point! But in the meantime, that’s who they have. That’s where they end up. They end up in these jails, these local jails, and the sheriffs are responsible. And only one hospital meets the state certification for what these people need.

And some of these stays. They’re not like two days, they can be prolonged. There’ve been a lot of deaths, there’ve been a lot of suicides. It’s a really pretty disturbing situation. It’s sort of the mental health crisis and the mental health provider shortage and countrywide really writ large among some of the most vulnerable people.

Rovner: All right, well, we’ve had four grim extra credits this week, but they’re all good stories. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks this week to Zach Dyer for filling in as our technical guru while Francis [Ying] takes some much-deserved time off. We’re going to take next week off, too, for the Thanksgiving holiday. As always, you can email us your comments or questions or your suggestions for our medical misinformation segment. We are at whatthehealth@kff.org. Or you can still find me at X, @jrovner, or @julierovner at Bluesky and Threads. Alice?

Ollstein: @AliceOllstein on X, and at AliceMiranda on Bluesky.

Rovner: Rachel.

Cohrs: I’m @rachelcohrs on X and rchohrsreporter on Threads.

Rovner: Joanne.

Kenen: @JoanneKenen on X, and I’m increasingly switched to Threads at @joannekenen1.

Rovner: We will be back in your feed in two weeks. Until then, be healthy.

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