Sin embargo, tras unas horas en el hospital, un médico dio de alta a Thompson para que volviera a la cárcel. Así pasó de ser un paciente de salud mental a un recluso de la prisión del condado de Dauphin. A partir de ese momento, se esperaba que cumpliera las órdenes, o que se le obligara a hacerlo.

A las pocas horas de regresar a la cárcel, Thompson se enzarzó en una pelea con los guardias. Su historia es uno de los más de 5,000 incidentes de “uso de fuerza” que se registraron en 2021 en las cárceles de los condados de Pennsylvania.

El caso de Thompson figura en una investigación, efectuada por WITF, que revisó 456 incidentes de “uso de fuerza” en 25 cárceles de condados en Pennsylvania, durante el último trimestre de 2021. Entre los casos revisados, casi 1 de cada 3 involucraba a una persona que sufría una crisis psiquiátrica o que padecía una enfermedad mental.

En muchos casos, los guardias utilizaron armas, como pistolas paralizantes y aerosoles de pimienta, para controlar y doblegar a presos con condiciones psiquiátricas graves que podrían haberles impedido seguir órdenes, o entender lo que estaba sucediendo.

Los registros muestran que cuando Thompson intentó huir del personal de la cárcel durante un intento de palparlo en busca de armas, un agente le roció con gas pimienta en la cara y luego intentó tirarlo al suelo.

Según la documentación, Thompson se defendió por lo que llegaron otros agentes para esposarlo y ponerle grilletes. Un oficial cubrió la cabeza de Thompson con una capucha y lo sentó en una silla, atándolo de brazos y piernas, y unos 20 minutos después, otro policía notó que Thompson no respiraba bien. Lo llevaron de urgencia al hospital.

Días después, Thompson murió. El fiscal del distrito no presentó cargos. El fiscal del distrito, el alcaide de la prisión y los funcionarios del condado que supervisan la cárcel no respondieron a las solicitudes de entrevistas sobre el tratamiento de Thompson, o se negaron a hacer comentarios.

La mayoría de los casos de uso de fuerza en las cárceles no conducen a la muerte. En el caso de Thompson, la causa de la muerte fue “complicaciones derivadas de una arritmia cardíaca”, pero la forma en que se produjo fue “indeterminada”, según el forense del condado.

En otras palabras, no pudo determinar si la muerte de Thompson se debió a que le rociaron gas pimienta y lo sujetaron, pero tampoco dijo que Thompson muriera por causas naturales.

El vocero del condado de Dauphin, Brett Hambright, también declinó hacer comentarios sobre el caso de Thompson, pero señaló que casi la mitad de las personas en la cárcel padecen una enfermedad mental, “junto con un número significativo de individuos encarcelados con tendencias violentas”.

“Siempre va a haber incidentes de uso de fuerza en la cárcel”, indicó Hambright. “Algunos de ellos involucrarán a reclusos con enfermedades mentales”.

Durante la investigación, expertos legales y en salud mental declararon que las prácticas empleadas en las cárceles del condado pueden poner a los presos y al personal en riesgo de sufrir lesiones, y pueden dañar a personas vulnerables listas para regresar a la sociedad en cuestión de meses.

“Algunos presos con enfermedades mentales quedan tan traumatizados por los malos tratos que nunca se recuperan; otros se suicidan, y a otros se les disuade de llamar la atención sobre sus problemas de salud mental porque denunciar estos problemas suele dar lugar a un trato más duro”, afirmó Craig Haney, profesor de psicología de la Universidad de California-Santa Cruz, especializado en las condiciones de los centros penitenciarios.

Los expertos afirman que el uso de la fuerza es una opción para prevenir la violencia entre los encarcelados, o la violencia contra los guardias.

Sin embargo, los informes de los funcionarios de las 25 cárceles de condados de Pennsylvania muestran que solo el 10% de los incidentes de “uso de fuerza” se produjeron en respuesta a la agresión de un preso a otra persona. Otro 10% informa de un preso amenazando a miembros del personal.

WITF descubrió que uno de cada cinco casos de uso de fuerza (88 incidentes) tuvo que ver con un preso que intentó suicidarse, autolesionarse o que amenazó con autolesionarse. Entre las respuestas más comunes del personal penitenciario figuró el uso de las mismas herramientas utilizadas con Thompson: una silla de inmovilización y gas pimienta. En algunos casos, los funcionarios utilizaron dispositivos de electroshock, como pistolas paralizantes.

Además, la investigación descubrió 42 incidentes en los que el personal penitenciario observó que un recluso mostraba problemas de salud mental, pero los guardias igual utilizaron la fuerza cuando no obedeció las órdenes.

Los defensores de estas técnicas afirman que salvan vidas al prevenir la violencia o las autolesiones; pero algunas cárceles de Estados Unidos han abandonado estas prácticas, y los administradores han afirmado que las técnicas son inhumanas y no funcionan.

El costo humano puede extenderse más allá de la cárcel, alcanzando a las familias de las personas encarceladas que mueren o quedan traumatizadas, así como a los funcionarios implicados, apuntó Liz Schultz, abogada de derechos civiles y defensa penal en la zona de Philadelphia.

“E incluso si el costo humano no fuera suficiente, los contribuyentes deberían preocuparse, ya que las demandas resultantes pueden ser costosas”, agregó Schultz. “Pone de relieve que debemos garantizar unas condiciones seguras en las cárceles, y que deberíamos ser un poco más juiciosos sobre a quién encerramos y por qué”.

“Solo necesitaba a una persona a mi lado”

La experiencia de Adam Caprioli comenzó cuando llamó al 911 durante un ataque de pánico.

Caprioli, de 30 años, vive en Long Pond, Pennsylvania, y ha sido diagnosticado con trastorno bipolar y trastorno de ansiedad. También lucha contra el alcoholismo y la drogadicción, según declaró.

Cuando la policía respondió a la llamada al 911, en otoño de 2021, llevaron a Caprioli al correccional del condado de Monroe.

Dentro de la cárcel, la ansiedad y la paranoia de Caprioli aumentaron. Dijo que el personal ignoró sus pedidos de hacer una llamada telefónica o hablar con un profesional de salud mental.

Tras varias horas de angustia extrema, Caprioli se ató la camisa al cuello y se asfixió hasta perder el conocimiento. Cuando el personal penitenciario lo vio, agentes entraron en su celda, con chalecos antibalas y cascos. El equipo de cuatro hombres tiró al suelo a Caprioli, que pesaba 150 libras. Uno de ellos llevaba una pistola de aire comprimido que dispara proyectiles con sustancias químicas irritantes.

“El recluso Caprioli movía los brazos y pateaba”, escribió un sargento en el informe del incidente. “Presioné el lanzador de Pepperball contra la parte baja de la espalda del recluso Caprioli y le impacté tres (3) veces”. El abogado Alan Mills explicó que los funcionarios suelen justificar el uso de la fuerza física diciendo que intervienen para salvar la vida de la persona.

“La inmensa mayoría de las personas que se autolesionan no van a morir”, señaló Mills, que ha litigado casos de uso de fuerza y es director ejecutivo del Uptown People’s Law Center de Chicago. “Más bien se trata de algún tipo de enfermedad mental grave. Y, por lo tanto, lo que realmente necesitan es una intervención para desescalar la crisis, mientras que el uso de la fuerza provoca exactamente lo contrario y agrava la situación”.

En Pennsylvania, Caprioli contó que cuando los agentes entraron en su celda sintió el dolor de las ronchas en su carne y el escozor del polvo químico en el aire, y se dio cuenta de que nadie le ayudaría.

“Eso es lo peor de todo”, dijo Caprioli. “Ven que estoy angustiado. Ven que no puedo hacerle daño a nadie. No tengo nada con lo que pueda hacerte daño”.

Finalmente, lo llevaron al hospital, donde, según Caprioli, evaluaron sus lesiones físicas, pero no recibió ayuda de un profesional de salud mental. Horas después, estaba de nuevo en la cárcel, donde permaneció cinco días. Al final se declaró culpable de un cargo de “embriaguez pública y mala conducta” y tuvo que pagar una multa.

Caprioli reconoció que sus problemas empeoran cuando consume alcohol o drogas, pero dijo que eso no justifica el trato que recibió en la cárcel.

“Esto no debería ocurrir. Solo necesitaba a una persona a mi lado que me dijera: ‘Hola, ¿cómo estás? ¿Qué te pasa?’ Y nunca me lo dijeron, ni siquiera el último día”, añadió.

El alcaide del correccional del condado de Monroe, Garry Haidle, y el fiscal del distrito, E. David Christine Jr., no respondieron a las solicitudes de comentarios.

Algunas cárceles prueban nuevas estrategias

La cárcel no es un entorno adecuado para el tratamiento de enfermedades mentales graves, afirmó la doctora Pamela Rollings-Mazza. Trabaja con PrimeCare Medical, que presta servicios médicos y conductuales en unas 35 cárceles de condados en Pennsylvania.

El problema, según Rollings-Mazza, es que las personas con problemas psiquiátricos graves no reciben la ayuda que necesitan antes de entrar en crisis. En ese momento, puede intervenir la policía, y quienes necesitaban atención de salud mental acaban en la cárcel.

“Así que los pacientes que vemos están muchas veces muy, muy, muy enfermos”, explicó Rollings-Mazza. “Por lo que nuestro personal debe atender esa necesidad”.

Los psicólogos de PrimeCare califican la salud mental de los presos en una escala de la A a la D. Los que tienen una calificación D son los más gravemente enfermos.

Rollings-Mazza indicó que constituyen entre el 10% y el 15% de la población total de las cárceles atendidas por PrimeCare. Otro 40% de la población tiene una calificación C, también indicativa de enfermedad grave.

Añadió que ese sistema de clasificación ayuda a determinar la atención que prestan los psicólogos, pero tiene poco efecto en las políticas de las cárceles.

“Hay algunas cárceles en las que no entienden o no quieren apoyarnos”, dijo. “Algunos agentes no están formados en salud mental al nivel que deberían”.

Rollings-Mazza explicó que su equipo ve con frecuencia llegar a la cárcel a personas que “no se ajustan a la realidad” debido a una enfermedad psiquiátrica y no pueden entender o cumplir órdenes básicas. A menudo se les mantiene alejados de otras personas, entre rejas, por su propia seguridad, y pueden pasar hasta 23 horas al día solos.

Ese aislamiento prácticamente garantiza que las personas vulnerables entren en una espiral de crisis, afirmó la doctora Mariposa McCall, psiquiatra residente en California que ha publicado recientemente un artículo en el que analiza los efectos del aislamiento.

Su trabajo forma parte de un amplio conjunto de investigaciones que demuestran que mantener a una persona sola en una celda pequeña, todo el día, puede causar daños psicológicos duraderos.

McCall trabajó durante varios años en prisiones estatales de California y dijo que es importante comprender que la cultura de los funcionarios de prisiones prioriza la seguridad y la obediencia por encima de todo. Por lo que pueden llegar a creer que quienes se autolesionan, en realidad, tratan de manipularlos.

Muchos guardias también ven a los presos con problemas de salud mental como potencialmente peligrosos.

“Y así se crea un cierto nivel de desconexión con el sufrimiento o la humanidad de las personas, porque se alimenta esa desconfianza”, señaló McCall. En ese entorno, los agentes se sienten justificados para usar la fuerza, sin importarles que la persona encarcelada les entienda o no.

Jamelia Morgan, profesora de la Facultad de Derecho Pritzker de la Universidad Northwestern, afirmó que, para comprender el problema, es útil examinar las decisiones tomadas en las horas y días previos a un incidente de uso de fuerza.

Morgan investiga un número creciente de demandas por uso de fuerza en las que están implicados presos con problemas de salud mental. Los abogados han argumentado con éxito que exigir que una persona con una enfermedad mental cumpla órdenes, que puede no entender, es una violación de sus derechos civiles. Esas demandas sugieren que las cárceles deberían proporcionar “soluciones razonables”.

“En algunos casos, es tan sencillo como que responda el personal médico, en lugar del personal de seguridad”, apuntó Morgan.

Los casos individuales pueden ser difíciles de litigar debido a un complejo proceso de quejas que los presos deben seguir antes de presentar una demanda, indicó Morgan y apuntó que para resolver el problema, los alcaides tendrán que redefinir lo que significa estar en la cárcel.

Esta investigación incluyó solicitudes de “derecho a saber” presentadas en 61 condados de Pennsylvania, y el equipo de investigación realizó un seguimiento con los guardias de algunos de los condados que publicaron informes sobre el uso de la fuerza. Ninguno accedió a hablar sobre la formación de sus funcionarios o sobre si podrían cambiar su forma de responder a las personas en crisis.

Algunas cárceles prueban nuevas estrategias. En Chicago, el departamento penitenciario del condado de Cook no tiene alcaide. En su lugar, tiene un “director ejecutivo” que también es psicólogo.

Este cambio forma parte de una revisión del funcionamiento de las cárceles después de que un informe del Departamento de Justicia, de 2008, revelara violaciones generalizadas de los derechos civiles de los presos.

En los últimos años, el sistema penitenciario del condado de Cook ha eliminado el confinamiento solitario, optando en su lugar por poner a los presos problemáticos en zonas comunes, pero con medidas de seguridad adicionales siempre que sea posible, declaró el sheriff del condado, Tom Dart.

La cárcel incluye un centro de transición de salud mental que ofrece alojamiento alternativo, un “entorno universitario de cabañas Quonset y jardines”, como lo describió Dart. Allí, los presos tienen acceso a clases de arte, fotografía y jardinería. También hay formación laboral, y los gestores de casos trabajan con agencias comunitarias locales, planificando lo que ocurrirá una vez que alguien salga de la cárcel.

Igualmente importante, según Dart, es que la dirección de la cárcel ha trabajado para cambiar la formación y las normas sobre cuándo es apropiado utilizar herramientas como el gas pimienta.

“Nuestro papel es mantenerlos seguros, y si tienes a alguien con una enfermedad mental, no veo cómo las pistolas Taser y el espray [de pimienta] pueden hacer otra cosa que agravar los problemas, solo deberían utilizarse como la última opción”, dijo Dart.

Las reformas del condado de Cook demuestran que el cambio es posible, pero hay miles de cárceles locales en todo Estados Unidos, y dependen de los gobiernos locales y estatales que establecen las políticas penitenciarias y que financian, o no, los servicios de salud mental que podrían evitar que personas vulnerables fueran a la cárcel.

En el condado de Dauphin, en Pennsylvania, donde murió Ishmail Thompson, las autoridades afirmaron que el problema, y las soluciones, van más allá de los muros de la cárcel. Hambright, vocero del condado, señaló que la financiación se ha mantenido estancada mientras aumenta el número de personas que necesitan servicios de salud mental. Eso ha llevado a una dependencia excesiva de las cárceles, que “siempre están disponibles”.

“Ciertamente nos gustaría ver a algunos de estos individuos tratados y alojados en lugares mejor equipados para tratar la especificidad de sus condiciones”, añadió Hambright. “Pero debemos utilizar lo que nos ofrece el sistema lo mejor que podamos con los recursos que tenemos”.

Esta historia es parte de una aliuanza que incluye a WITF, NPR, y KHN.

Brett Sholtis recibió la Rosalynn Carter Fellowship for Mental Health Journalism 2021-22, y esta investigación recibió apoyo adicional de The Benjamin von Sternenfels Rosenthal Grant for Mental Health Investigative Journalism, en alianza el Carter Center and Reveal del the Center for Investigative Reporting.

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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“Honestamente, no quería pasar 10 días solo en una habitación, lo llaman el agujero”, dijo Ramírez-Cecena, quien espera que decidan si es deportado a México o puede permanecer en los Estados Unidos, en donde ha vivido por más de dos décadas.

Poco antes de que Ramírez-Cecena se enfermara, los funcionarios del Servicio de Inmigración y Control de Aduanas (ICE) de la instalación le negaron su solicitud de alta médica. Es VIH positivo, que según la lista de los Centros para el Control y la Prevención de Enfermedades es una afección que puede aumentar el riesgo de enfermar gravemente por covid.

Ahora, frente al tercer invierno pandémico, reza para no contraer covid mientras está detenido. “Todavía da miedo”, dijo.

En todo el país, la posibilidad de desarrollar una enfermedad grave o morir por covid ha bajado, por las vacunas de refuerzo actualizadas, las pruebas en el hogar y las terapias. La mayoría de las personas pueden sopesar los riesgos de asistir a reuniones o viajar.

Pero para las aproximadamente 30,000 personas que viven en espacios cerrados en la red de instalaciones de inmigración del país, covid sigue siendo una amenaza constante.

El ICE actualizó su guía de pandemia en noviembre. Pero las instalaciones han ignorado las recomendaciones anteriores de usar máscaras y equipo de protección, tener pruebas y vacunas disponibles, y evitar el uso del confinamiento solitario como cuarentena, según detenidos, grupos de defensa e informes internos del gobierno federal.

Según los protocolos de ICE, el aislamiento por covid, utilizado para evitar que otros detenidos se enfermen, debe estar separado de la segregación disciplinaria.

La agencia no abordó este punto, pero dijo en un comunicado a KHN que a los detenidos se los coloca en una “sala de alojamiento médico individual” o en un “una habitación de aislamiento médico de infecciones transmitidas por el aire”, cuando esté disponible.

La atención médica en los centros de detención de inmigrantes ya era deficiente antes de la pandemia. Y en septiembre, las personas médicamente vulnerables en los centros de detención de ICE perdieron una protección, con la expiración de una orden judicial que requería que los funcionarios federales de inmigración consideraran la liberación de los detenidos con riesgo de covid.

La agencia “ha renunciado por completo a proteger a las personas detenidas de covid”, dijo Zoe Bowman, abogada supervisora ​​de Las Américas Immigrant Advocacy Center en El Paso, Texas.

El uso de la detención de inmigrantes en el país se disparó a fines de la década de 1990 y creció después de la creación de ICE en 2003. Los centros de detención —unos 200 complejos privados, instalaciones administradas por ICE, cárceles locales y prisiones repartidas por todo el país— retienen a adultos que no son ciudadanos estadounidenses mientras disputan o esperan la deportación.

La duración promedio de la estadía en el año fiscal federal 2022 fue de aproximadamente 22 días, según la agencia. Los defensores de los inmigrantes han argumentado durante mucho tiempo que las personas no deberían ser detenidas y, en cambio, se les debería permitir vivir en comunidades.

El Centro de Detención de Stewart, un vasto complejo rodeado de cercas con alambre de púas en los bosques de Lumpkin, tiene una de las poblaciones de detenidos más grande del país. Cuatro personas bajo la custodia del centro han muerto por covid desde el comienzo de la pandemia, el mayor número de muertes por covid registradas en estos centros.

Cuando funcionarios de inmigración transfirieron a Cipriano Álvarez-Chávez al centro de Stewart en agosto de 2020, todavía confiaba en la máscara que tenía después de ser liberado de la prisión federal en julio, según su hija, Martha Chavez.

Diez días después, el sobreviviente de linfoma de 63 años fue llevado a un hospital en Columbus, a 40 millas de distancia donde dio positivo para covid, según su informe de defunción. Murió después de pasar más de un mes conectado a un ventilador.

“Fue pura negligencia”, dijo su hija.

Dos años después de la muerte de Álvarez-Chávez, grupos de defensa y detenidos dijeron que el ICE no ha hecho lo suficiente para proteger de covid a los detenidos, una situación consistente con el historial de atención médica deficiente y falta de higiene de las instalaciones.

“Es desalentador ver que no importa cuánto empeoran las cosas, nada cambia”, dijo la doctora Amy Zeidan, profesora asistente en la Facultad de Medicina de la Universidad de Emory, quien revisa los registros de salud de los detenidos y realiza evaluaciones médicas para las personas que buscan asilo.

Una investigación bipartidista del Senado reveló en noviembre que las mujeres en el Centro de Detención del Condado de Irwin en Georgia “parecen haber sido sometidas a procedimientos ginecológicos excesivos, invasivos y, a menudo, innecesarios”.

En el Centro de Procesamiento de Folkston, también en Georgia, el ICE no respondió a las solicitudes médicas de manera oportuna, tuvo una atención de salud mental inadecuada y no cumplió con los estándares básicos de higiene, incluidos baños funcionales, según un informe de junio de la Oficina del Inspector General de Seguridad del Departamento de Asuntos Internos. Y una denuncia presentada en julio por un grupo de organizaciones de defensa alegó que una enfermera del centro Stewart agredió sexualmente a cuatro mujeres.

El ICE defendió su atención médica en un comunicado enviado por correo electrónico, diciendo que gasta más de $315 millones anualmente en atención médica, y que garantiza la prestación de los servicios médicos necesarios e integrales.

Aún así, muchas instalaciones carecen de personal y están mal equipadas para manejar las necesidades médicas a largo plazo de la gran población de detenidos, dijo Zeidan. La atención tardía es común, la atención especializada es casi inexistente y el acceso a la terapia es limitado, dijo. El cuidado de covid no es diferente.

En sus protocolos para covid, el ICE recomienda el uso de anticuerpos monoclonales, que ayudan al sistema inmunológico a responder de manera más efectiva a covid, para el tratamiento. Pero no reconoce ninguno de los otros tratamientos recomendados por los CDC, incluidos los antivirales como Paxlovid, que pueden reducir las hospitalizaciones y las muertes entre los pacientes con covid.

“Durante décadas, el ICE ha demostrado ser incapaz y no estar dispuesto a garantizar la salud y la seguridad de las personas bajo su custodia”, dijo Sofia Casini, directora de monitoreo y defensa comunitaria de Freedom for Immigrants, un grupo de defensa. “Covid-19 solo ha empeorado esta horrible realidad”.

Once personas han muerto por covid bajo custodia de ICE. Pero ese número puede ser una subestimación; defensores de los detenidos han acusado a la agencia de liberar a las personas o deportarlas cuando están gravemente enfermas como una forma de evadir las estadísticas de muertes.

Antes de la pandemia, Johana Medina León fue liberada de la custodia de ICE cuatro días antes de su muerte, según un artículo de mayo en Los Angeles Times. Vio a un médico unas seis semanas después de su primera solicitud, decía el artículo, pero ICE aceleró su liberación solo unas horas después de que su condición empeorara.

Este otoño, los detenidos recluidos en instalaciones de todo el país llamaron a la línea directa de detención de Freedom for Immigrants para quejarse de las condiciones de covid, que varían de una instalación a otra, dijo Casini. “Incluso en la misma instalación, puede cambiar de semana a semana”, dijo.

Según Casini, muchas personas que habían dado positivo para covid estaban recluidas en las mismas celdas que las personas que habían dado negativo, incluidas las personas médicamente vulnerables. Este verano, el grupo encuestó a 89 personas a través de su línea directa y descubrió que alrededor del 30% de los encuestados tuvieron problemas para acceder a las vacunas mientras estuvieron detenidos.

Ramírez-Cecena dijo que le dijeron que es elegible para una segunda vacuna de refuerzo de covid, pero que, a diciembre, aún no la había recibido. Un detenido en el Centro de Procesamiento de Moshannon Valley en Pennsylvania dijo que a un guardia se le permitió interactuar con los detenidos mientras estaba visiblemente enfermo, dijo Brittney Bringuez, coordinadora del programa de asilo de Physicians for Human Rights, quien visitó las instalaciones este otoño.

La orden judicial que requería que ICE considerara la liberación de personas con alto riesgo de covid ha ayudado a los detenidos con afecciones médicas graves, dijeron los defensores. Según la orden, ICE liberó a unos 60,000 detenidos médicamente vulnerables en dos años, dijo Susan Meyers, abogada sénior del Southern Poverty Law Center, uno de los grupos de defensa que ayudó a presentar la demanda que resultó en la orden judicial.

El ICE dijo en un comunicado que aún considerará los factores de riesgo de covid como una razón para la liberación. Pero los abogados dijeron que las instalaciones de ICE a menudo no cumplían con la orden judicial cuando estaba vigente.

El año pasado, el ICE negó la solicitud de liberación de Ricardo Chambers del Centro de Detención de Stewart. Chambers, de 40 años, tiene enfermedades psiquiátricas graves, consideradas un factor de riesgo según la orden judicial. También tiene problemas para respirar y se ahoga mientras duerme, como resultado de una lesión nasal que sufrió en un ataque antes de ser detenido. A dos años de estar detenido, todavía no recibió atención para esa lesión.

Ha presentado quejas sobre los protocolos para covid de Stewart, incluidas las condiciones de hacinamiento y la falta de uso de máscaras u otro equipo de protección por parte del personal.

Al negar su liberación, el ICE dijo que Chambers era una amenaza para la seguridad pública debido a sus antecedentes penales, según su abogada Erin Argueta, abogada principal de la oficina de la Iniciativa de Libertad de Inmigrantes del Sureste del Southern Poverty Law Center en Lumpkin. Chambers ya cumplió sus condenas, dijo, y hay una familia en Nueva York que lo acogería.

A principios de este año, fue enviado a confinamiento solitario durante unos 10 días después de dar positivo para covid, dijo. Pero Chambers, quien está luchando contra una orden de deportación a Jamaica, dijo que su experiencia con covid no fue diferente de las otras veces que estuvo en aislamiento.

“Serás tratado como un animal, enjaulado y sin tener culpa de nada”, dijo Chambers.

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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“Honestly, I didn’t want to go spend 10 days by myself in a room — they call it the hole,” Ramirez-Cecena said. He is being held at the center as he waits to learn whether he will be deported to Mexico or can remain in the United States, where he has lived for more than two decades.

Shortly before Ramirez-Cecena got sick, officials from U.S. Immigration and Customs Enforcement at the facility denied his request for a medical release. He is HIV-positive, which is on the Centers for Disease Control and Prevention’s list of conditions that make a person more likely to get seriously ill from covid.

Now, heading into the third pandemic winter, he’s praying he doesn’t get covid while detained. “It is still scary,” he said.

Across the country, the chance of developing severe illness or dying from covid has fallen, a result of updated booster shots, at-home tests, and therapeutics. Most people can weigh the risks of attending gatherings or traveling. But for the roughly 30,000 people living in close quarters in the country’s network of immigration facilities, covid remains an ever-present threat.

ICE updated its pandemic guidance in November. But facilities have flouted past recommendations to use masks and protective equipment, to make testing and vaccines available, and to avoid the use of solitary confinement for quarantining, according to detainees, advocacy groups, and internal federal government reports.

Under ICE’s pandemic protocols, covid isolation, used to keep other detainees from falling ill, must be separate from disciplinary segregation. The agency didn’t address claims that facilities have used solitary confinement areas to isolate detainees who have tested positive for covid but said in a statement to KHN that detainees are placed in a “single, medical housing room” or a “medical airborne infection isolation room” when available.

Medical care in immigration detention facilities was deficient even before the pandemic. Then, in September, medically vulnerable people in ICE detention facilities lost a source of protection, with the expiration of a court order that had required federal immigration officials to consider releasing detainees with covid risks.

The agency has “completely given up on protecting people in detention from covid,” said Zoe Bowman, supervising attorney at Las Americas Immigrant Advocacy Center in El Paso, Texas.

The country’s use of immigration detention exploded in the late 1990s and rose even more after the creation of ICE in 2003. Detention facilities — made up of about 200 privately run complexes, ICE-run facilities, local jails, and prisons scattered across the country — hold adults who are not U.S. citizens while they contest or await deportation. The average length of stay in the 2022 federal fiscal year was about 22 days, according to the agency. Advocates for immigrants have long argued that people shouldn’t be detained and instead should be allowed to live in communities.

Stewart Detention Center, a vast complex surrounded by rows of barbed wire in Lumpkin’s forests, has one of the largest populations of detainees in the country. Four people in the center’s custody have died from covid since the start of the pandemic — the highest number of recorded covid deaths among detention centers.

When immigration officials transferred Cipriano Alvarez-Chavez to the Stewart center in August 2020, he was still relying on the mask he had after being released from federal prison in July, according to his daughter, Martha Chavez.

Ten days later, the 63-year-old lymphoma survivor was taken to a hospital in Columbus, 40 miles away, where he tested positive for covid, according to his death report. He died after spending more than a month on a ventilator.

“It was pure neglect,” his daughter said. His death “shattered our world.”

Two years after Alvarez-Chavez’s death, advocacy groups and detainees said ICE has not done enough to protect detainees from covid, a situation consistent with the facilities’ history of poor medical care and lack of hygiene. “It’s disheartening to see that no matter how bad things get, they don’t change,” said Dr. Amy Zeidan, an assistant professor at Emory University School of Medicine, who reviews detainee health records and performs medical evaluations for people seeking asylum.

A bipartisan Senate investigation revealed in November that women at Georgia’s Irwin County Detention Center “appear to have been subjected to excessive, invasive, and often unnecessary gynecological procedures.” At the Folkston Processing Center, also in Georgia, ICE did not respond to medical requests in a timely manner, had inadequate mental health care, and failed to meet basic hygiene standards, including working toilets, according to a June report from the Department of Homeland Security’s Office of Inspector General. And a July complaint filed by a group of advocacy organizations alleged that a nurse at the Stewart center sexually assaulted four women.

ICE defended its medical care in an emailed statement, saying that it spends more than $315 million on health care annually and ensures the provision of necessary and comprehensive medical services.

Still, many facilities are understaffed and ill-equipped to handle the long-term medical needs of the large detainee population, Zeidan said. Delayed care is common, specialty care is almost nonexistent, and access to therapeutics is limited, she said. Covid care is no different.

In its covid protocols, ICE recommends the use of monoclonal antibodies, which help the immune system respond more effectively to covid, for treatment. But it recognizes none of the other CDC-recommended treatments, including antivirals such as Paxlovid, which can reduce hospitalizations and deaths among covid patients.

“For decades, ICE has proven itself incapable and unwilling to ensure the health and safety of people in its custody,” said Sofia Casini, director of monitoring and community advocacy at Freedom for Immigrants, an advocacy group. “Covid-19 has only worsened this horrifying reality.”

Eleven people have died from covid in ICE custody. But that number may be an underestimate; advocates for detainees have accused the agency of releasing people or deporting them when they are seriously ill as a way to suppress the death statistics.

Before the pandemic, Johana Medina Leon was released from ICE custody four days before her death, according to a May article in the Los Angeles Times. She saw a doctor about six weeks after her first request, the article said, but ICE expedited her release only hours after her condition grew dire.

This fall, detainees being held at facilities across the country called Freedom for Immigrants’ detention hotline to complain about covid conditions, which vary facility to facility, Casini said. “Even in the same facility, it can change week to week,” she said.

Many people who had tested positive for covid were being held in the same cells as people who had tested negative, including people who were medically vulnerable, according to Casini. The group surveyed 89 people through its hotline this summer and found that about 30% of respondents had trouble accessing vaccines in detention.

Ramirez-Cecena said he was told that he’s eligible for a second covid booster shot but had yet to receive it as of December. A detainee at Moshannon Valley Processing Center in Pennsylvania said a guard was allowed to interact with detainees while visibly sick, said Brittney Bringuez, asylum program coordinator at Physicians for Human Rights, who visited the facility this fall.

The court order that required ICE to consider releasing people with covid risks has helped detainees with serious medical conditions, advocates said. Under the order, ICE released about 60,000 medically vulnerable detainees in two years, said Susan Meyers, senior staff attorney at the Southern Poverty Law Center, one of the advocacy groups that helped bring the lawsuit that resulted in the court order.

ICE said in a statement it will still consider covid risk factors as a reason for release. But lawyers said ICE facilities often failed to comply with the court order when it was in place.

Last year, ICE denied Ricardo Chambers’ request for release from Stewart Detention Center. Chambers, who is 40, has serious psychiatric illnesses, considered a risk factor under the court order. He also has trouble breathing and chokes in his sleep — the result of a nasal injury he sustained in an attack before he was detained. It has yet to be repaired during the two years he has been at the detention facility.

He has filed complaints about Stewart’s covid protocols, including crowded conditions and failures by staffers to wear masks or other protective equipment. In its denial of his release, ICE said Chambers was a threat to public safety because of his criminal history, according to his lawyer Erin Argueta, lead attorney for the Southern Poverty Law Center’s Southeast Immigrant Freedom Initiative office in Lumpkin. Chambers has served prison time for his criminal convictions, she said, and there’s a family in New York that would take him in.

Earlier this year, he was sent to solitary confinement for about 10 days after testing positive for covid, he said. But Chambers, who is fighting a deportation order to Jamaica, said his covid experience was no different from the other times he had been in solitary.

“You’ll be treated like an animal, caged, and for no fault of your own,” Chambers 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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She shows up to build trust with those she encounters and offers water, condoms, referrals to services, and opportunities to be tested for HIV — anything she can muster that might be useful to someone in need.

She has seen firsthand how being proactive can combat an HIV outbreak that has persisted in the city and nearby areas since 2018. She also has witnessed the cost of political pullback on the effort.

Parker, 38, is a care coordinator for the Ryan White HIV/AIDS Program, a federal initiative that provides HIV-related services nationwide. Her work has helped build pathways into a difficult-to-reach community for which times have been particularly hard. It’s getting increasingly difficult to find a place to sleep for the night without being rousted by police. And many in this close-knit group of unhoused individuals and families remain shaken by the recent death, from complications of AIDS, of a woman Parker knew well.

The woman was barely in her 30s. Parker had encouraged her to seek medical care, but she was living in an alley; each day brought new challenges. If she could have gotten basic needs met, a few nights’ decent sleep to clear her head, Parker said, she would have more likely been open to receiving care.

Such losses, Parker and a cadre of experts believe, will continue, and maybe worsen, as political winds in the state blow against efforts to control an expanding HIV outbreak.

In August 2021, the Centers for Disease Control and Prevention concluded its investigation of an HIV outbreak in Kanawha County, home to Charleston, where people who inject opioids and methamphetamine are at highest risk. The CDC’s HIV prevention chief had called it “the most concerning HIV outbreak in the United States” and warned that the number of reported diagnoses could be just “the tip of the iceberg.”

HIV spreads easily through contaminated needles; the CDC reports the virus can survive in a used syringe for up to 42 days. Research shows offering clean syringes to people who use IV drugs is effective in combating the spread of HIV.

Following its probe, the CDC issued recommendations to expand and improve access to sterile syringes, testing, and treatment. It urged officials to co-locate services for easier access.

But amid this crisis, state and local government officials have enacted laws and ordinances that make clean syringes harder to get. In April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and required that they present an ID. Charleston’s City Council added an ordinance imposing criminal charges for violations.

As a result, advocates say, a substantial number of those at highest risk of contracting HIV remain vulnerable and untested.

Public health experts also worry that HIV infections are gaining a foothold in nearby rural areas, where sterile syringes and testing are harder to come by.

Joe Solomon is co-director of Solutions Oriented Addiction Response, an organization that previously offered clean syringes in exchange for contaminated ones in Kanawha County. Solomon said the CDC’s recommendations were precisely what SOAR once provided: co-location of essential services. But SOAR has ceased exchanging syringes in the face of the efforts to criminalize such work.

Solomon, who was recently elected to the Charleston City Council on a platform that includes measures to counter the region’s drug crisis, said the backlash against what’s known as harm reduction is “a public attack on public health.”

Epidemiologists agree: They contend sidelining syringe exchanges and the HIV testing they help catalyze may be exacerbating the HIV outbreak.

Fifty-six new cases of HIV were reported in 2021 in Kanawha County — which has a population of just under 180,000 — with 46 of those cases attributed to injection drug use. By the end of November, 27 new cases had been reported this year, 20 related to drug injection.

But the CDC’s “tip of the iceberg” assessment resonates with researchers and advocates. Robin Pollini, a West Virginia epidemiologist, has interviewed people in the county with injection-related HIV. “All of them are saying that syringe sharing is rampant,” she said. She believes it’s reasonable to infer there are far more than 20 people in the county who’ve contracted HIV this year from contaminated needles.

Pollini is among those concerned that testing initiatives aren’t reaching the people most at risk: those who use illicit drugs, many of whom are transient, and who may have reason to be wary of authority figures.

“I think that you can’t really know how many cases there are unless you have a very savvy testing strategy and very strong outreach,” she said.

Research shows sustained, well-targeted testing paired with access to clean syringes can effectively slow or stop an HIV outbreak.

In late 2015, the Kanawha-Charleston Health Department launched a syringe exchange, but in 2018 shuttered it after the city imposed restrictions on the number of syringes that could be exchanged and who could receive them. Then-Mayor Danny Jones called it a “mini-mall for junkies and drug dealers.”

When officials abandoned the effort, SOAR began hosting health fairs where it exchanged clean syringes for used ones. It also distributed the opioid overdose-reversing drug naloxone; offered treatment, referrals, and fellowship; and provided HIV testing.

But when the new state restrictions and local criminal ordinance took effect, SOAR ceased exchanging syringes, and attendance at its fairs plummeted.

“It’s indisputable and well established. It’s comprehensive; it’s inclusive,” Pollini said of research supporting syringe exchange. “You can’t even get funding to study the effectiveness of syringe service programs anymore because it’s established science that they work.”

Syringe exchanges are credited with tamping down an HIV outbreak in Scott County, Indiana, in 2015, after infections spread to more than 200 intravenous drug users. At that time, then-Gov. Mike Pence — after initially being resistant — approved the state’s first syringe service.

A team of epidemiologists worked with the Scott County Health Department on a study that determined that discontinuing the program would result in an increase in HIV infections of nearly 60%. But in June 2021, local officials voted to shut it down.

In Kanawha County, SOAR was making inroads. Interviews with numerous clients underscore that people felt safe at its health fairs. They could seek services anonymously. But most acknowledge that the promise of clean syringes was what brought them in.

Charleston-based West Virginia Health Right operates a syringe exchange that Dr. Steven Eshenaur, executive director of the Kanawha-Charleston Health Department, credits with helping reduce the number of new HIV diagnoses. But advocates say the imposed constraints — particularly the requirement to present an ID, which many potential clients don’t have — inhibit its success.

HIV diagnoses are up this year in nearby Cabell County and Pollini worries that without more aggressive action, an HIV epidemic could take root statewide. As of Dec. 1, 24 of West Virginia’s 55 counties had reported at least one positive diagnosis this year.

HIV is preventable. It’s also treatable, but treatment is expensive. The average cost of an antiretroviral regimen ranges from $36,000 to $48,000 a year. “If you’re 20 years old, you could live to be 70 or 80,” said Christine Teague, director of the Ryan White program in Charleston. That’s a cost of more than $2 million.

Saving lives and money, Pollini said, requires being both proactive — ongoing, comprehensive testing — and reactive — ramping up efforts when cases rise.

It also requires “meeting people where they are,” as it’s commonly put — building trust, which opens the door to education about what HIV is, how it’s spread, and how to combat it.

Teague said it also requires something more: addressing the fundamental needs of those on the margins; foremost, housing.

Parker agrees: “Low-barrier and transitional housing would be a godsend.”

But Teague questions whether the political will exists to confront HIV full force among those most at risk in West Virginia.

“I hate to say it, but it’s like people think that this is a group of people that are beyond help,” she said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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This story can be republished for free (details).

His parents sued the Kool Smiles dental clinic in Yuma, Arizona, and its private equity investor, FFL Partners. They argued the procedures were done needlessly, in keeping with a corporate strategy to maximize profits by overtreating kids from lower-income families enrolled in Medicaid. Zion died after being diagnosed with “brain damage caused by a lack of oxygen,” according to the lawsuit.

Kool Smiles “overtreats, underperforms and overbills,” the family alleged in the suit, which was settled last year under confidential terms. FFL Partners and Kool Smiles had no comment but denied liability in court filings.

Private equity is rapidly moving to reshape health care in America, coming off a banner year in 2021, when the deep-pocketed firms plowed $206 billion into more than 1,400 health care acquisitions, according to industry tracker PitchBook.

Seeking quick returns, these investors are buying into eye care clinics, dental management chains, physician practices, hospices, pet care providers, and thousands of other companies that render medical care nearly from cradle to grave. Private equity-backed groups have even set up special “obstetric emergency departments” at some hospitals, which can charge expectant mothers hundreds of dollars extra for routine perinatal care.

As private equity extends its reach into health care, evidence is mounting that the penetration has led to higher prices and diminished quality of care, a KHN investigation has found. KHN found that companies owned or managed by private equity firms have agreed to pay fines of more than $500 million since 2014 to settle at least 34 lawsuits filed under the False Claims Act, a federal law that punishes false billing submissions to the federal government with fines. Most of the time, the private equity owners have avoided liability.

New research by the University of California-Berkeley has identified “hot spots” where private equity firms have quietly moved from having a small foothold to controlling more than two-thirds of the market for physician services such as anesthesiology and gastroenterology in 2021. And KHN found that in San Antonio, more than two dozen gastroenterology offices are controlled by a private equity-backed group that billed a patient $1,100 for her share of a colonoscopy charge — about three times what she paid in another state.

It’s not just prices that are drawing scrutiny.

Whistleblowers and injured patients are turning to the courts to press allegations of misconduct or other improper business dealings. The lawsuits allege that some private equity firms, or companies they invested in, have boosted the bottom line by violating federal false claims and anti-kickback laws or through other profit-boosting strategies that could harm patients.

“Their model is to deliver short-term financial goals and in order to do that you have to cut corners,” said Mary Inman, an attorney who represents whistleblowers.

Federal regulators, meanwhile, are almost blind to the incursion, since private equity typically acquires practices and hospitals below the regulatory radar. KHN found that more than 90% of private equity takeovers or investments fall below the $101 million threshold that triggers an antitrust review by the Federal Trade Commission and the U.S. Justice Department.

Spurring Growth

Private equity firms pool money from investors, ranging from wealthy people to college endowments and pension funds. They use that money to buy into businesses they hope to flip at a sizable profit, usually within three to seven years, by making them more efficient and lucrative.

Private equity has poured nearly $1 trillion into nearly 8,000 health care transactions during the past decade, according to PitchBook.

Fund managers who back the deals often say they have the expertise to reduce waste and turn around inefficient, or moribund, businesses, and they tout their role in helping to finance new drugs and technologies expected to benefit patients in years to come.

Critics see a far less rosy picture. They argue that private equity’s playbook, while it may work in some industries, is ill suited for health care, when people’s lives are on the line.

In the health care sphere, private equity has tended to find legal ways to bill more for medical services: trimming services that don’t turn a profit, cutting staff, or employing personnel with less training to perform skilled jobs — actions that may put patients at risk, critics say.

KHN, in a series of articles published this year, has examined a range of private equity forays into health care, from its marketing of America’s top-selling emergency contraception pill to buying up whole chains of ophthalmology and gastroenterology practices and investing in the booming hospice care industry and even funeral homes.

These deals happened on top of well-publicized takeovers of hospital emergency room staffing firms that led to outrageous “surprise” medical bills for some patients, as well as the buying up of entire rural hospital systems.

“Their only goal is to make outsize profits,” said Laura Olson, a political science professor at Lehigh University and a critic of the industry.

Hot Spots

When it comes to acquisitions, private equity firms have similar appetites, according to a KHN analysis of 600 deals by the 25 firms that PitchBook says have most frequently invested in health care.

Eighteen of the firms have dental companies listed in their portfolios, and 16 list centers that offer treatment of cataracts, eye surgery, or other vision care, KHN found.

Fourteen have bought stakes in animal hospitals or pet care clinics, a market in which rapid consolidation led to a recent antitrust action by the FTC. The agency reportedly also is investigating whether U.S. Anesthesia Partners, which operates anesthesia practices in nine states, has grown too dominant in some areas.

Private equity has flocked to companies that treat autism, drug addiction, and other behavioral health conditions. The firms have made inroads into ancillary services such as diagnostic and urine-testing and software for managing billing and other aspects of medical practice.

Private equity has done so much buying that it now dominates several specialized medical services, such as anesthesiology and gastroenterology, in a few metropolitan areas, according to new research made available to KHN by the Nicholas C. Petris Center at UC-Berkeley.

Although private equity plays a role in just 14% of gastroenterology practices nationwide, it controls nearly three-quarters of the market in at least five metropolitan areas across five states, including Texas and North Carolina, according to the Petris Center research.

Similarly, anesthesiology practices tied to private equity hold 12% of the market nationwide but have swallowed up more than two-thirds of it in parts of five states, including the Orlando, Florida, area, according to the data.

These expansions can lead to higher prices for patients, said Yashaswini Singh, a researcher at the Bloomberg School of Public Health at Johns Hopkins University.

In a study of 578 physician practices in dermatology, ophthalmology, and gastroenterology published in JAMA Health Forum in September, Singh and her team tied private equity takeovers to an average increase of $71 per medical claim filed and a 9% increase in lengthy, more costly, patient visits.

Singh said in an interview that private equity may develop protocols that bring patients back to see physicians more often than in the past, which can drive up costs, or order more lucrative medical services, whether needed or not, that boost profits.

“There are more questions than answers,” Singh said. “It really is a black hole.”

Jean Hemphill, a Philadelphia health care attorney, said that in some cases private equity has merely taken advantage of the realities of operating a modern medical practice amid growing administrative costs.

Physicians sometimes sell practices to private equity firms because they promise to take over things like billing, regulatory compliance, and scheduling — allowing doctors to focus on practicing medicine. (The physicians also might reap a big payout.)

“You can’t do it on a scale like Marcus Welby used to do it,” Hemphill said, referring to an early 1970s television drama about a kindly family doctor who made house calls. “That’s what leads to larger groups,” she said. “It is a more efficient way to do it.”

But Laura Alexander, a former vice president of policy at the nonprofit American Antitrust Institute, which collaborated on the Petris Center research, said she is concerned about private equity’s growing dominance in some markets.

“We’re still at the stage of understanding the scope of the problem,” Alexander said. “One thing is clear: Much more transparency and scrutiny of these deals is needed.”

‘Revenue Maximization’

Private equity firms often bring a “hands-on” approach to management, taking steps such as placing their representatives on a company’s board of directors and influencing the hiring and firing of key staffers.

“Private equity exercises immense control over the operations of health care companies it buys an interest in,” said Jeanne Markey, a Philadelphia whistleblower attorney.

Markey represented physician assistant Michelle O’Connor in a 2015 whistleblower lawsuit filed against National Spine and Pain Centers and its private equity owner, Sentinel Capital Partners.

In just a year under private equity guidance, National Spine’s patient load quadrupled as it grew into one of the nation’s largest pain management chains, treating more than 160,000 people in about 40 offices across five East Coast states, according to the suit.

O’Connor, who worked at two National Spine clinics in Virginia, said the mega-growth strategy sprang from a “corporate culture in which money trumps the provision of appropriate patient care,” according to the suit.

She cited a “revenue maximization” policy that mandated medical staffers see at least 25 patients a day, up from 16 to 18 before the takeover.

The pain clinics also overcharged Medicare by billing up to $1,100 for “unnecessary and often worthless” back braces and charging up to $1,800 each for urine drug tests that were “medically unnecessary and often worthless,” according to the suit.

In April 2019, National Spine paid the Justice Department $3.3 million to settle the whistleblower’s civil case without admitting wrongdoing.

Sentinel Capital Partners, which by that time had sold the pain management chain to another private equity firm, paid no part of National Spine’s settlement, court records show. Sentinel Capital Partners had no comment.

In another whistleblower case, a South Florida pharmacy owned by RLH Equity Partners raked in what the lawsuit called an “extraordinarily high” profit on more than $68 million in painkilling and scar creams billed to the military health insurance plan Tricare.

The suit alleges that the pharmacy paid illegal kickbacks to telemarketers who drove the business. One doctor admitted prescribing the creams to scores of patients he had never seen, examined, or even spoken to, according to the suit.

RLH, based in Los Angeles, disputed the Justice Department’s claims. In 2019, RLH and the pharmacy paid a total of $21 million to settle the case. Neither admitted liability. RLH managing director Michel Glouchevitch told KHN that his company cooperated with the investigation and that “the individuals responsible for any problems have been terminated.”

In many fraud cases, however, private equity investors walk away scot-free because the companies they own pay the fines. Eileen O’Grady, a researcher at the nonprofit Private Equity Stakeholder Project, said government should require “added scrutiny” of private equity companies whose holdings run afoul of the law.

“Nothing like that exists,” she said.

Questions About Quality

Whether private equity influences the quality of medical care is tough to discern.

Robert Homchick, a Seattle health care regulatory attorney, said private equity firms “vary tremendously” in how conscientiously they manage health care holdings, which makes generalizing about their performance difficult.

“Private equity has some bad actors, but so does the rest of the [health care] industry,” he said. “I think it’s wrong to paint them all with the same brush.”

But incipient research paints a disturbing picture, which took center stage earlier this year.

On the eve of President Joe Biden’s State of the Union speech in March, the White House released a statement that accused private equity of "buying up struggling nursing homes” and putting “profits before people.”

The covid-19 pandemic had highlighted the “tragic impact” of staffing cuts and other moneysaving tactics in nursing homes, the statement said.

More than 200,000 nursing home residents and staffers had died from covid in the previous two years, according to the White House, and research had linked private equity to inflated nursing costs and elevated patient death rates.

Some injured patients are turning to the courts in hopes of holding the firms accountable for what the patients view as lapses in care or policies that favor profits over patients.

Dozens of lawsuits link patient harm to the sale of Florida medical device maker Exactech to TPG Capital, a Texas private equity firm. TPG acquired the device company in February 2018 for about $737 million.

In August 2021, Exactech recalled its Optetrak knee replacement system, warning that a defect in packaging might cause the implant to loosen or fracture and cause “pain, bone loss or recurrent swelling.” In the lawsuits, more than three dozen patients accuse Exactech of covering up the defects for years, including, some suits say, when “full disclosure of the magnitude of the problem … might have negatively impacted” Exactech’s sale to TPG.

Linda White is suing Exactech and TPG, which she asserts is “directly involved” in the device company’s affairs.

White had Optetrak implants inserted into both her knees at a Galesburg, Illinois, hospital in June 2012. The right one failed and was replaced with a second Optetrak implant in July 2015, according to her lawsuit. That one also failed, and she had it removed and replaced with a different company’s device in January 2019.

The Exactech implant in White’s left knee had to be removed in May 2019, according to the suit, which is pending in Cook County Circuit Court in Illinois.

In a statement to KHN, Exactech said it conducted an “extensive investigation” when it received reports of “unexpected wear of our implants.”

Exactech said the problem dated to 2005 but was discovered only in July of last year. “Exactech disputes the allegations in these lawsuits and intends to vigorously defend itself,” the statement said. TPG declined to comment but has denied the allegations in court filings.

‘Invasive Procedures’

In the past, private equity business tactics have been linked to scandalously bad care at some dental clinics that treated children from low-income families.

In early 2008, a Washington, D.C., television station aired a shocking report about a local branch of the dental chain Small Smiles that included video of screaming children strapped to straightjacket-like “papoose boards” before being anesthetized to undergo needless operations like baby root canals.

Five years later, a U.S. Senate report cited the TV exposé in voicing alarm at the "corporate practice of dentistry in the Medicaid program.” The Senate report stressed that most dentists turned away kids enrolled in Medicaid because of low payments and posed the question: How could private equity make money providing that care when others could not?

“The answer is ‘volume,’” according to the report.

Small Smiles settled several whistleblower cases in 2010 by paying the government $24 million. At the time, it was providing “business management and administrative services” to 69 clinics nationwide, according to the Justice Department. It later declared bankruptcy.

But complaints that volume-driven dentistry mills have harmed disadvantaged children didn’t stop.

According to the 2018 lawsuit filed by his parents, Zion Gastelum was hooked up to an oxygen tank after questionable root canals and crowns “that was empty or not operating properly” and put under the watch of poorly trained staffers who didn’t recognize the blunder until it was too late.

Zion never regained consciousness and died four days later at Phoenix Children’s Hospital, the suit states. The cause of death was “undetermined,” according to the Maricopa County medical examiner’s office. An Arizona state dental board investigation later concluded that the toddler’s care fell below standards, according to the suit.

Less than a month after Zion’s death in December 2017, the dental management company Benevis LLC and its affiliated Kool Smiles clinics agreed to pay the Justice Department $24 million to settle False Claims Act lawsuits. The government alleged that the chain performed “medically unnecessary” dental services, including baby root canals, from January 2009 through December 2011.

In their lawsuit, Zion’s parents blamed his death on corporate billing policies that enforced “production quotas for invasive procedures such as root canals and crowns” and threatened to fire or discipline dental staff “for generating less than a set dollar amount per patient.”

Kool Smiles billed Medicaid $2,604 for Zion’s care, according to the suit. FFL Partners did not respond to requests for comment. In court filings, it denied liability, arguing it did not provide “any medical services that harmed the patient.”

Covering Tracks

Under a 1976 federal law called the Hart-Scott-Rodino Antitrust Improvements Act, deal-makers must report proposed mergers to the FTC and the Justice Department antitrust division for review. The intent is to block deals that stifle competition, which can lead to higher prices and lower-quality services.

But there’s a huge blind spot, which stymies government oversight of more than 90% of private equity investments in health care companies: The current threshold for reporting deals is $101 million.

KHN’s analysis of PitchBook data found that just 423 out of 7,839 private equity health care deals from 2012 through 2021 were known to have exceeded the current threshold.

In some deals, private equity takes a controlling interest in medical practices, and doctors work for the company. In other cases, notably in states whose laws prohibit corporate ownership of physician practices, the private equity firm handles a range of management duties.

Thomas Wollmann, a University of Chicago researcher, said antitrust authorities may not learn of consequential transactions “until long after they have been completed” and “it's very hard to break them up after the fact.”

In August, the FTC took aim at what it called “a growing trend toward consolidation” by veterinary medicine chains.

The FTC ordered JAB Consumer Partners, a private equity firm based in Luxembourg, to divest from some clinics in the San Francisco Bay and Austin, Texas, areas as part of a proposed $1.1 billion takeover of a rival.

The FTC said the deal would eliminate “head-to-head” competition, “increasing the likelihood that customers are forced to pay higher prices or experience a degradation in quality of the relevant services.”

Under the order, JAB must obtain FTC approval before buying veterinary clinics within 25 miles of the sites it owns in Texas and California.

The FTC would not say how much market consolidation is too much or whether it plans to step up scrutiny of health care mergers and acquisitions.

“Every case is fact-specific,” Betsy Lordan, an FTC spokesperson, told KHN.

Lordan, who has since left the agency, said regulators are considering updates to regulations governing mergers and are reviewing about 1,900 responses to the January 2022 request for public comment. At least 300 of the comments were from doctors or other health care workers.

Few industry observers expect the concerns to abate; they might even increase.

Investors are flush with “dry powder,” industry parlance for money waiting to stoke a deal.

The Healthcare Private Equity Association, which boasts about 100 investment companies as members, says the firms have $3 trillion in assets and are pursuing a vision for "building the future of healthcare.”

That kind of talk alarms Cornell University professor Rosemary Batt, a longtime critic of private equity. She predicts that investors chasing outsize profits will achieve their goals by “sucking the wealth” out of more and more health care providers.

“They are constantly looking for new financial tricks and strategies,” Batt said.

KHN’s Megan Kalata contributed to this article.

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

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Ahora, varios estados del oeste del país, como California, buscan cambiar esta situación con nuevas políticas de inscripción continua para los miembros más jóvenes de Medicaid. La posibilidad de cambiar estas normas, vigentes por décadas, surge cuando los estados valoran los cambios causados por la pandemia.

Los legisladores de California han aprobado una propuesta —pendiente de la autorización federal— para que los niños que cumplan los requisitos para recibir Medicaid se inscriban al nacer y permanezcan inscritos hasta los 5 años, a partir de 2025.

Oregon ya ha conseguido la aprobación de una política similar. En 2023, cuando se espera que termine la emergencia de salud pública, Oregon se convertirá en el primer estado en permitir que los niños elegibles para recibir Medicaid se inscriban al nacer y permanezcan en el programa hasta que cumplan 6 años, independientemente de los cambios en los ingresos familiares y sin tener que volver a solicitarlo.

“Se trata de una medida obvia en términos de apoyo a los niños”, dijo Jenifer Wagley, directora ejecutiva de la organización Our Children Oregon. Según Wagley, mantener a los niños con cobertura —sobre todo temprano en su desarrollo— garantizará que no pierdan importantes chequeos y cuidados debido a las brechas en la cobertura.

En julio, el estado de Washington pidió permiso al gobierno de Biden para ofrecer cobertura continua a los niños hasta los 6 años, y se aguarda una decisión en las próximas semanas. Por su parte, Nuevo México ha solicitado comentarios públicos sobre un plan para mantener a los niños inscritos hasta los 6 años y se espera que solicite el consentimiento federal a finales de este año.

La inscripción en Medicaid ha alcanzado niveles récord después que el gobierno federal prohibiera a los estados dar de baja a sus miembros durante la emergencia de salud pública, a menos que murieran o se trasladaran fuera del estado. Esta norma ha contribuido a que la tasa de no asegurados del país alcance un mínimo histórico.

De las casi 90 millones de personas que reciben Medicaid y el Programa de Seguro de Salud Infantil (CHIP), unos 41 millones son niños. CHIP es un programa federal-estatal que cubre a los niños de hogares con ingresos superiores a los que se pueden acoger a Medicaid.

Joan Alker, directora ejecutiva del Centro para la Infancia y la Familia de la Universidad de Georgetown, calificó el hecho de que los estados pasen a tener períodos más largos de cobertura continua para los menores como “una consecuencia positiva de la pandemia”.

Señaló que desde el cuarto trimestre de 2020 hasta el primero de 2022, la proporción de niños sin seguro en Estados Unidos se redujo del 6,7% al 3,7%, en gran parte debido a la norma de emergencia que ha impedido a los estados dejar sin cobertura a los inscritos en Medicaid.

“Los estados tendrán que hacer mucha divulgación sobre esta nueva política para que todos los bebés salgan del hospital con seguro médico y los padres no tengan que preocuparse por la cobertura hasta que el niño vaya al jardín”, señaló Alker.

Si la emergencia de salud pública finaliza el año que viene, casi 5,3 millones de niños podrían perder la cobertura de Medicaid, según un análisis federal publicado en agosto. De ellos, alrededor de 1,4 millones saldrían de las listas porque ya no cumplen los requisitos, pero casi 4 millones de niños que reúnen los requisitos perderían la cobertura por motivos administrativos, como no haber presentado la documentación a tiempo.

Dado que los umbrales de ingresos familiares de Medicaid suelen ser más altos para los niños que para los adultos, es menos probable que los niños pierdan la cobertura por pequeños cambios en los ingresos. Pero pueden perder su derecho a la cobertura si los padres no la renuevan cada año, o no responden cuando el estado busca información para confirmar que los ingresos de la familia se han mantenido lo suficientemente bajos pra mantener la elegibilidad.

Por lo general, los inscritos en Medicaid deben informar de cualquier cambio en los ingresos de la familia u otros criterios que puedan afectar a su elegibilidad durante el año, y los estados deben actuar sobre estos cambios.

Esto supone un reto para los beneficiarios de Medicaid y las agencias estatales, ya que los ingresos de las personas suelen fluctuar. Como resultado, los inscritos pueden perder la cobertura, verse obligados a cambiar entre Medicaid y la cobertura subvencionada del mercado de seguros de la Ley de Cuidado de Salud a Bajo Precio (ACA), o experimentar brechas de cobertura si el papeleo resulta difícil de completar.

Para solucionar este problema, casi la mitad de los estados dan a los niños un año de elegibilidad continua de Medicaid, independientemente de los cambios en los ingresos familiares. Ese grupo incluye estados controlados tanto por republicanos como por demócratas, y estados como Alabama y Mississippi, que no han ampliado Medicaid bajo ACA.

Antes de pasar a la cobertura continua para los niños hasta los 6 años, Oregon les ofrecía 12 meses de elegibilidad continua. Sin embargo, los funcionarios estatales de Medicaid estiman que en 2019, antes del comienzo de la pandemia, más de 70,000 menores de 6 años —un tercio de los inscritos— entraron y salieron de Medicaid. Alrededor de 29,000 de esos niños tuvieron lagunas de cobertura que superaron los seis meses, según dijeron funcionarios estatales a KHN.

Los funcionarios de Oregon estiman que, tras cuatro años de aplicación, la nueva política de inscripción beneficiará a más de 51,000 niños en 2027, a un costo de $177 millones.

“La emergencia de salud pública ha demostrado claramente el valor de tener un seguro de salud continuo, particularmente para las poblaciones que experimentan disparidades de salud y han tenido barreras históricas para el acceso a la atención médica”, afirmó Elizabeth Gharst, vocera de la Autoridad de Salud de Oregon, que supervisa el programa estatal de Medicaid.

La garantía de seis años también reducirá los costos administrativos de Oregon, ya que no tendrá que tramitar algunas solicitudes cada año. Y los funcionarios esperan que reduzca los gastos médicos del programa, ya que los niños que permanezcan en Medicaid tendrán acceso a servicios de atención primaria y preventiva que pueden reducir la necesidad de tratamientos relacionados con los atrasos en la búsqueda de atención.

Oregon ofrece cobertura de Medicaid y CHIP a los niños de familias con ingresos de hasta el 300% del nivel federal de pobreza, que es de $83,250 para una familia de cuatro miembros.

Lori Coyner, asesora principal de políticas de Medicaid en Oregon, dijo que el cambio reducirá las desigualdades en materia de salud porque ayudará a los niños de color a conservar la cobertura y el acceso a la atención médica.

Además de mantener a los niños en Medicaid durante más tiempo, Oregon obtuvo la aprobación federal en octubre para convertirse en el primer estado en dar a los niños de 6 años o más y a los adultos dos años de elegibilidad continua, independientemente de los cambios en los ingresos de su hogar.

A nivel nacional, KFF estima que alrededor del 11% de los niños inscritos en Medicaid perdieron su cobertura durante al menos un día en 2019. El estado de Washington también reporta un 11%.

En California, funcionarios de Medicaid estiman que unos 64,000 —el 6%— de los inscritos menores de 5 años fueron retirados de las listas y luego volvieron a inscribirse en el mismo año.

Mike Odeh, director de salud del grupo Children Now de California, espera que el estado se sume pronto. “Preferiríamos que el estado pagara para que los niños recibieran atención en lugar de pagar por el papeleo”, señaló, y añadió que tener que volver a inscribirse cada año puede ser un obstáculo para las familias de bajos ingresos. “Queremos que estén sanos y preparados para la escuela”, afirmó Odeh.

El Departamento de Servicios de Atención Sanitaria de California, que supervisa Medi-Cal, calcula que el cambio de política costaría $39,1 millones en 2025, suponiendo que se aplique en enero, y $68 millones para el año fiscal 2025-26. El estado todavía está sopesando cuándo buscar la aprobación federal.

Los funcionarios de Medicaid en el estado de Washington aseguraron que hace tiempo que consideran la posibilidad de dar a los niños elegibilidad continua durante varios años. “Las familias de Medicaid están muy ocupadas, y lo último en lo que pueden pensar es en renovar su cobertura, por lo que esto queda relegado al final de su lista de prioridades”, explicó Amy Dobbins, directora de sección en la Oficina de Elegibilidad y Política de Medicaid.

Dobbins señaló que la emergencia de salud pública por covid, durante la cual más niños han tenido cobertura y han recibido servicios de salud, fortaleció la idea de la elegibilidad continua.

Dianne Hasselman, directora ejecutiva interina de la Asociación Nacional de Directores de Medicaid, piensa que algunos estados serían cautelosos a la hora de seguir el ejemplo de Oregon. “A los legisladores estatales también les podría preocupar el aumento de las inscripciones en el programa Medicaid, especialmente en un momento en el que las inscripciones ya han crecido significativamente”, expresó.

Además, los legisladores no verían con buenos ojos ampliar la cobertura a personas con otras opciones de seguro, como el del lugar de trabajo de los padres, agregó Hasselman.

Aunque se alegra de que algunos estados mantengan a los niños en Medicaid hasta los 6 años, Alker, de Georgetown, subrayó que la nueva política de Oregon entrará en vigor —al final de la emergencia sanitaria— justo cuando millones de niños pierdan la cobertura.

“Los estados que no presten atención a las necesidades de los niños cuando termine la emergencia de salud pública probablemente verán un aumento masivo de niños sin seguro”, señaló Alker. “Así que se avecinan situaciones muy diferentes”.

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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This story can be republished for free (details).