The infection of a farm worker in Wisconsin with avian flu has been confirmed by the Centers for Disease Control and Prevention (CDC). (Stephen Ausmus | Agricultural Research Service, USDA)

A Barron County farm worker has been confirmed to have been infected with avian influenza, the state health department reported Friday. The confirmation was made by the federal Centers for Disease Control and Prevention (CDC).

With the CDC analysis in hand, “the case will now be reported as a confirmed human case” of the highly pathogenic avian influenza H5N1, the Wisconsin Department of Health Services (DHS) announced. It is the first reported case of the virus in a human in Wisconsin. 

The presumed infection was first reported Wednesday in a farm worker who was one of 19 people exposed to a poultry flock in Barron County where the avian flu virus was detected. The flock has been destroyed to prevent the spread of the virus. 

The individual has been treated with antiviral drugs and is recovering, according to DHS. 

Since early in the pandemic, people with long COVID have faced challenges in applying for disability benefits, including from their employers, insurance providers and the U.S. Social Security Administration. Applications often take a long time and are denied even for people who clearly have debilitating symptoms, leading to years-long, arduous appeals processes. The same has been true decades prior to 2020 for people with other infection-associated chronic diseases.

To learn more about the disability insurance system, Betsy Ladyzhets spoke to Barbara Comerford, a longtime disability lawyer based in New Jersey who specializes in these cases. Comerford has represented people with myalgic encephalomyelitis (ME, also known as chronic fatigue syndrome or CFS) for more than 30 years, including high-profile cases like that of journalist Brian Vastag.

Comerford discussed how the process works, her advice for putting together applications and appeals, how long COVID has impacted her practice, and more. This interview has been lightly edited and condensed for clarity.

Barbara Comerford: Should we focus on disability insurance, or do you want to focus on Social Security disability, or both?

Betsy Ladyzhets: Both, because people (with long COVID) are applying for both.

BC:  Right. And often, people think they should only apply for one, (but they should apply for both.)

Most of the disability plans that people have are often through their employer. Those plans are known as ERISA plans, referring to Employee Retirement Income Security Act. It was created in the 1970s. … Congress created this regulatory scheme and then immediately created a zillion loopholes that corporations can drive a truck through. Later, ERISA covered all employee benefits in general.

Insurance companies wound up selling policies to corporations saying, “You can get the best people if you offer incentives.” And what’s a better incentive than, if someone gets sick, they can collect a substantial percentage of their salary until full retirement age? These are the sorts of perks that … People think, “If something happens to me, I’ll be protected.” The promise of these policies is that they will give people, usually, between 50% and 80% of their pre-disability income if they satisfy the requirements. Well, that’s a big if.

I’ve been doing this for 38 years. And I can tell you that 38 years ago, these (disability claims) were not problem cases. I used to do them for free for my litigation clients … But over the years, and really starting after 2001 with Sept. 11, all hell broke loose. They (insurance companies) began to get very aggressive. Every time there is an economic downfall, whatever it is, they get extremely aggressive. So you can imagine, with the onset of the pandemic, they knew what was coming.

I did, for many years, advocacy for ME/CFS cases. I represented thousands of people … A lot of my colleagues say, “Long COVID Social Security cases are almost impossible” because they don’t know what to do with them. My office hasn’t found that to be the case. I think the difference is, you have to document these cases with as much objective documentation of symptoms that people have … Get neuropsych testing, cardiopulmonary exercise testing and other tests.

I started doing webinars and seminars (about disability benefit applications) in 2020 because I knew this was coming. At that point, they weren’t calling it long COVID, they were just saying, some people with COVID weren’t getting better. But I knew it was going to turn into another ME/CFS disaster.

BL: How have you found the rise of long COVID has impacted your practice? Do you find you’re more in demand now?

BC: We’ve always had a high volume of cases. Quite a few of them were ME/CFS cases. We did a case, Vastag v. Prudential, in 2018. Brian Vastag, who was a science writer for The Washington Post, was my client, and I could not get over how aggressively Prudential was just dismissing him because it was an ME/CFS case.

And the same is happening with long COVID. We do cases all over the country on long COVID and ME/CFS. It’s my livelihood, so it’s important for me, but it also makes me a little crazy that people get treated the way they do and that they have to hire people like me.

One of the things that people get upset about is that they have to spend money to medically document their symptoms. And worse than that … I see these long COVID clinics, with doctors who are completely ignorant on long COVID, who surreptitiously write notes in the chart that they think it’s a psychiatric case. I don’t know how familiar you are with this.

BL: Unfortunately, I’m very familiar.

BC: It’s awful. Not only is it really hard on my clients …  it triggers them to read things that might not be what they said or might not be pleasant. And the number of times that I have seen that and it has sabotaged cases! I have to reconstruct the cases and have the clients contact the clinic (and get them to make corrections).

Mental/nervous limitations exist in all of these (insurance) policies … They can limit someone’s payments to two years if the case is a psychiatric case or mental/nervous limitation with a DSM diagnosis. 

BL: I wanted to ask also — there’s been a lot of research on long COVID at this point, and there was a report this summer from the National Academies specifically in response to a request from the Social Security Administration about long COVID as a disability, in which they found that this disease can result in inability to work, poor quality of life, all that stuff. Have you seen that report, or other research, like the growing body of research on these diseases, have an impact?

BC: I was asked to comment on that (report). Part of the problem with Social Security’s initiatives in this regard is that every Social Security case goes through what they call “sequential evaluation process.” You have to go through five steps to determine whether or not someone’s disabled. And among those steps is (matching people to a “medical listing of impairments,” but the list doesn’t include major symptoms for ME/CFS and similar diseases).

Years ago, there was an ME/CFS ruling called 99-2p. It offered guidelines (for ME/CFS cases that don’t fit the typical Social Security process). After that, I was asked to present to the national association of Social Security judges, there were 500 judges in the audience. And I asked, “By show of hands, how many of you are familiar with 99-2p?” Two hands went up.

Despite the guidelines, in practice, (the judges aren’t familiar with these diseases). Until there is a time when we can come up with a firm diagnostic criteria for long COVID, and we can say, “This is what you have to document for this illness.” … And it can’t just be a positive COVID test because many people got sick before testing was prevalent or they got sick after people stopped documenting that they were positive.

The other problem for long COVID cases is it’s not like cancer or a broken leg or herniated disc or something that people are accustomed to. Those people are not told they’re crazy. Those people are not told they’re imagining it. Those people are not told, “Well, we just don’t buy it.” This is what happens with (long COVID) and ME/CFS. The psych component that they try to pigeonhole these cases into is really a master stroke by the insurance industry that spends billions of dollars trying to persuade people that anyone who files for these benefits is a crook or fraud.

BL: It’s infuriating, especially when you see how deeply people’s quality of life is impacted by these diseases.

BC: Yes, every part of their life is impacted.

BL: I see what you’re saying about needing diagnostic criteria. In this time where we don’t have that yet, what would you want to see the Social Security Administration or other government agencies do to make it easier for all these people who are applying for benefits with long COVID and ME/CFS?

BC: They should (reevaluate) the sequential evaluation process, which has been there forever, and look at medically determinable impairment in the context of long COVID and ME/CFS. These diseases can be documented by things like neuropsych testing.

I’ll quickly go through the five-step sequential evaluation process. The first step is, “Is the person engaged in substantial gainful activity?” That is something you can do predictably, something that will last at least 12 months, and something that leads to gainful work, where you get paid and you can report for a job either part-time or full-time. In long COVID cases … you have to document that this person is not engaged in substantial gainful activity because they don’t know tomorrow if they’re going to be able to get up and get out of bed and take a shower, never mind report for work.

If you satisfy step one, they go to step two. There, they ask, “Do you have the ability, in light of your disability, to perform basic work-related activity?” Sitting, standing, reaching, pushing, pulling, reading, concentrating, things of that nature. And, “Does the disability negatively impact your ability to do these things?” (You need medical evidence, which can come from) a physician’s evaluation from a long COVID clinic, for example.

If you have that, you go to step three, which is where that horrible “medically determinable impairment” crap comes in. There isn’t (a specific listing) yet for long COVID, although they’re talking about it. Frankly, we’re still waiting for them to do one for ME/CFS, so I’m not holding my breath. That’s the only step in the process where, if they don’t satisfy it, you can still move on to the next step.

The fourth step is, “Is this person capable of performing the work that they performed for the last five years?” Until June of this year, it was the last 15 years … So we go through each job they had, all their symptoms and limitations and why they can’t do (the job anymore). If we document successfully that they can’t perform their past relevant work for the last five years as a result of their disability, we can then go to step five.

Step five, the burden shifts to the Social Security Administration. Social Security has to document that, in light of a person’s age, education and work experience, that there is no work in the national economy that they could perform. (To do this), Social Security has a big graph called the “medical vocational guidelines.” And essentially, the younger you are, the more skills you have, the more education you have, and the more skills that are transferable, generally you are found not disabled. But the graph is not supposed to be used for cases that involve what we call non-exertional and exertional complaints together. Pain, fatigue, things of that nature are all part of the non-exertional limitation.

That is how we lift ME/CFS and long COVID cases out of that graph. Despite the fact that many of our clients are very young, many of them are highly educated, many of them have developed skills that are not only transferable, but are also in high demand in the national economy — (we say that) because they can’t predictably perform sustained work of any kind, the grid should not be used to find them not disabled. But with all of this, every one of these cases, medical documentation of limitations is crucial. I can’t emphasize that enough.

BL: I know a lot of people in the long COVID community, they’ve already sent in their applications, and then it gets denied, and then they have to appeal. What is that process like, and how would you suggest people go about finding someone like you?

BC: It’s really important to do some research. You want to know if the doctor or attorney you’re dealing with has experience in these cases … I do (webinars and one-on-one education) for lawyers all the time because I’d rather them hear what has to be done and understand what happens if they don’t do it.

If I’m giving people advice on appeals … If it’s coming from a United States employer, you’re going to be governed by ERISA. That’s important because people might file a claim without knowing the exact company policy. Despite the fact that federal regulations require employers to give that information to employees, when someone gets sick and files a (short-term) disability claim, they are immediately cut off from the employee benefits portal (that has all the exact policy information). So then I’ve got to write a letter to the employers and fight to get that information.

You can’t even get discovery in these cases … Sometimes they will award benefits, and then six months in they’ll say, “We no longer believe you’re disabled.” Under ERISA, (employers and insurance companies) get all the advantages.

BL: It seems like people should know, if you’re filing against an employer, to save that policy information before you lose access to it. 

BC: When you get the notice of a denial, you can request a complete copy of the administrative record. You are entitled to see everything that the insurance company had on the case, and under federal regulations, they have 30 days to produce it.

And then you have 180 days to appeal that (denial). People say that’s a long time. It’s really not. Because you’ve got to go through thousands of pages of documents. You’ve got to document where they abuse their discretion. It’s not enough to have medical evidence … (The standard you have to push back on is that) the insurance company or the employer has a “reason” to deny the claim.

The lawyer’s job or the claimant’s job is to show all the examples they found in the administrative record that show (mistakes or poor judgment on the part of the insurance company or employer) … Sometimes, you will see reports of experts that they’ve retained to review the case, and the expert will say, “I think it’s a payable claim.” And then the next thing you find is them looking for another doctor who’s a little more receptive to their suggestions. If we see they’ve ignored the opinion of one of their experts, that’s an example of abuse of discretion and arbitrary, capricious conduct. Cherry-picking the evidence is another thing you often see in these cases.

BL: So it’s not just sending your own medical records, you have to show that the company has messed up.

BC: The insurance company or the employer, whoever is paying, you have to show that they abused their discretion.

BL: Is there anything else, any other advice or resources you would give people?

BC: This is really important. If it’s an ERISA case and they do not get that appeal in within 180 days, they’re foreclosed from pursuing it any further … (It’s a big mistake) if you blow those time deadlines.

This article was originally published by The Sick Times, a nonprofit newsroom that chronicles the long COVID crisis.

Have long COVID? Here’s what to know about disability insurance is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.

Bird flu was found in a Kenosha flock of chickens and ducks, which will be destroyed to prevent the spread of the highly contagious virus. (Photo by Stephen Ausmus | Animal Research Services, USDA)

A farm worker in Barron County has tested positive for avian influenza after being exposed to a poultry flock infected with the virus, Wisconsin health officials said Wednesday. The woman is the first person identified with the infection in Wisconsin.

At the other end of the state, a case of the highly contagious disease has turned up in a Kenosha County poultry flock, according to the state agriculture department. The flock has been isolated and will be destroyed.

The risk of illness for the general public remains low, according to the Wisconsin Department of Health Services (DHS), while people working with infected animals or who might be otherwise exposed to them are at higher risk.

Also Wednesday, the federal government reported the first severe case of bird flu in a patient in Louisiana. That was believed to be associated with wild birds, not domestic poultry. 

The infected woman in Barron County was identified through a test at the Wisconsin State Lab of Hygiene. The diagnosis is pending confirmation at federal Centers for Disease Control and Prevention (CDC).

She was exposed to the Barron County poultry flock where the state Department of Agriculture, Trade and Consumer Protection (DATCP) identified an infection with highly pathogenic avian influenza (HPAI H5N1) last week. The flock was destroyed.

After the infected flock was identified, DHS and Barron County Health and Human Services began monitoring farm workers who may have been exposed to the birds, said Thomas Haupt, a DHS research scientist and epidemiologist, in an online news conference Wednesday.

The woman who tested positive was one of two people tested. 

“She had relatively mild symptoms but symptoms that would be consistent with influenza, including sore throat, slight fever, some fatigue, some eye discharge,” said Haupt. He said she was improving after being treated with an antiviral medication and was expected to make a full recovery.

Public health officials are monitoring another 17 people who were exposed.

State public health veterinarian Dr. Angie Maxted said when people are infected with a communicable disease, public health agencies contact family and other household members to test them for the illness and inform them about preventive measures.

The Kenosha flock where an H5N1 infection was reported Wednesday is a “backyard flock” — one that is raised for a family’s own use, with limited, local sales of eggs or other products, said Dr. Darlene Konkle, DATCP state veterinarian. The flock consisted of 88 chickens and five ducks.

Haupt said the Kenosha County residents who might have been exposed are being tested for the virus. There are no concerns that members of the general public were at risk, however. Maxted said that it appears only the flock’s owners were exposed to the birds.

According to DATCP, the birds from the flock where the infection was reported will not enter the food supply.

In addition, poultry within a 10 kilometer (6.2 mile) area of the Kenosha flock will be restricted from being moved on or off any premises, said DATCP, which establishes a control area around any premises where an infection is found.  

DATCP has a mapping tool that poultry producers and owners can consult to learn whether their poultry are in an active control area or surveillance zone.

Concern about the virus has been heightened for the last three years, with reports of infections in both wild and domestic birds in North America since December 2021.

Konkle said DATCP has been sending information to dairy, poultry and other livestock producers all year, encouraging them to improve biosecurity measures to prevent the spread of disease and protect their birds and animals.

The H5N1 HPAI virus is highly contagious and can be fatal to domestic poultry. The severity of the illness varies depending on its strain and on which species of animal it affects, according to DATCP.

The virus spreads by contact with infected birds, commingling with wild birds or their droppings, and through clothing or equipment used by people working with infected birds or animals.

DHS has a web page with guidance for Protective Actions for People. The department can provide a limited amount of surplus personal protective equipment for farm workers, businesses and processors from the department’s medical stockpile through its Office of Preparedness and Emergency Health Care.  

State law requires all Wisconsin livestock owners to register where their animals are kept, which helps health officials alert flock and herd owners.

Avian flu in domestic birds tends to increase late in the year, likely due to weather conditions and the flow of migrating birds through Wisconsin. “There’s more opportunity, when it’s circulating in these wild birds” for the virus to spread, Konkle said.

People who have contact with livestock and animals are at higher risk for exposure to the H5N1 avian flu virus and should avoid contact with sick or ill animals, said Maxted.

When they must be in contact, people should follow “common sense” precautions, washing their hands frequently and wearing protective clothing including gloves, respiratory protection and eye protection, she said, and clothing exposed to animals should be cleaned and disinfected.

Haupt said the DHS bureau of environmental and occupational health has been working with farmers and farm workers to inform them about the risks of avian influenza and precautions to protect themselves from the virus. The agency urges people who do get sick to take time off.

“If someone is sick, if you don’t have to work — don’t work,” Haupt said. “Stay home, give yourself time to heal.”

This report has been updated to correct the number of people in Barron County being monitored after avian flu exposure.

The Centers for Disease Control and Prevention said Wednesday a Louisiana resident is believed to have been infected with a severe case of bird flu through sick or dead birds on their property that were not part of a commercial poultry flock. In this photo, a seagull flies against a coastal backdrop. (Photo by Adrijan Mosesku/Getty Images)

WASHINGTON — A Louisiana resident has contracted the country’s first severe case of highly pathogenic avian influenza in a human, the Centers for Disease Control and Prevention announced Wednesday.

The unidentified person is believed to have been infected with the virus through sick or dead birds on their property that were not part of a commercial poultry flock, though federal public health officials declined to provide more details on a call with reporters, citing patient confidentiality. The virus is also called bird flu, or H5N1.

“Previously, the majority of cases of H5N1 in the United States presented with mild illness, such as conjunctivitis and mild respiratory symptoms, and fully recovered,” Demetre Daskalakis, director of the National Center for Immunization and Respiratory Diseases at the CDC, said during the call.

“Over the 20-plus years of global experience with this virus, H5 infection has previously been associated with severe illness in other countries, including illnesses that resulted in death in up to 50% of cases,” Daskalakis said. “The demonstrated potential for this virus to cause severe illness in people continues to highlight the importance of the joint, coordinated U.S. federal response, the One Health response, to address the current animal outbreaks in dairy cows and poultry and limit the potential of transmission of this virus to humans through animal contact.”

Despite the Louisiana case, Daskalakis said on the call, the CDC believes the threat to the general public remains low.

The Louisiana Department of Health wrote in a press release posted Friday that the person lives in the southwestern region of the state and was hospitalized, but didn’t provide additional information.

Emma Herrock, communications director for the Louisiana Department of Health, told States Newsroom in an email Wednesday the “patient is experiencing severe respiratory illness related to H5N1 infection and is currently hospitalized in critical condition.”

The patient, she said, “is reported to have underlying medical conditions and is over the age of 65.”

61 confirmed cases in humans

The CDC has confirmed 61 human cases of H5N1 throughout nine states this year, but the Louisiana patient is the first severe case of bird flu in someone within the United States. 

Daskalakis declined to say during the call why the Louisiana case is considered severe when a Missouri resident who was hospitalized due to bird flu was not classified the same way.

The Missouri patient, who was admitted to a hospital in August, had significant underlying medical conditions, according to public health officials. That person experienced “acute symptoms of chest pain, nausea, vomiting, diarrhea and weakness,” according to the CDC.

The CDC declined to say Wednesday what symptoms the Louisiana patient was experiencing, citing privacy concerns.

Bird flu has affected wild birds and poultry flocks throughout the United States for years, but it wasn’t until March that dairy cattle began becoming infected with the virus.

The dairy outbreak has affected 865 herds through 16 states this year, according to data from the U.S. Department of Agriculture. There have been 315 new cases in dairy cattle during the last month, with the vast majority of those diagnoses in California, while one herd each tested positive in Nevada and Texas.

Bird flu has affected nearly 124 million poultry throughout 49 states, according to USDA.

Milk testing

Eric Deeble, deputy under secretary for marketing and regulatory programs at USDA, said on the call the nationwide milk testing strategy launched earlier this month has expanded to several states.

The program requires anyone responsible for a dairy farm — such as a bulk milk transporter, bulk milk transfer station, or dairy processing facility — to share unpasteurized or raw milk samples when requested.

California, Colorado, Indiana, Maryland, Michigan, Mississippi, Montana, New York, Ohio, Oregon, Pennsylvania, Vermont and Washington are the 13 states currently enrolled in the program, he said.

In California, Gov. Gavin Newsom on Wednesday proclaimed a state of emergency “to further enhance the state’s preparedness & accelerate the ongoing cross-agency response efforts,” the governor’s press office said. 

“These states represent a geographically conversant list of states, some of which have been affected by H5N1 in dairy cows, and some of which have never detected the disease,” Deeble said. “Additionally, these first two groups of states represent eight of the top 15 dairy-producing states in the country, accounting for nearly 50% of U.S. dairy production. We anticipate continuing to enroll additional states in the coming weeks.”

The USDA also continues to have a voluntary bulk milk testing program for any farms planning to ship dairy cattle across state lines to provide an easier pathway to establishing the herd is negative for H5N1, instead of having to test each cow individually.  

Andrea Deutsch stands in her pet store in Narberth, Pa. Deutsch is one of the millions of people who receive federal aid to help them pay their health insurance premiums on an Affordable Care Act exchange. The extra help is set to expire at the end of 2025, and states say they don’t have the money to replace it. (Courtesy of Andrea Deutsch)

Andrea Deutsch, the mayor of Narberth, Pennsylvania, and the owner of a pet store in town, doesn’t get health care coverage through either of her jobs. Instead, she is enrolled in a plan she purchased on Pennie, Pennsylvania’s health insurance exchange.

Deutsch, who has been mayor since 2018, is paid $1 per year for the job. Her annual income, from Spot’s – The Place for Paws and her investments, is about $50,000. The 57-year-old, who is diabetic, pays $638.38 per month for health care coverage — about half of the $1,272.38 she’d owe without the enhanced federal subsidies Congress and the Biden administration put in place in 2021.

But that extra help is set to expire at the end of 2025. It would cost an estimated $335 billion over the next decade to extend it — a step the Republican-controlled Congress and the Trump administration are unlikely to take as they seek budget savings to offset potential tax cuts.

States say they don’t have the money to replace the federal aid. In Pennsylvania, for example, doing so would take about $500 million per year, according to Devon Trolley, the executive director of the state’s exchange.

“That is a significant amount of money, an insurmountable amount of money,” Trolley said.

The disappearance of the federal help would make coverage unaffordable for millions of Americans, including Deutsch. She said it would be a struggle to pay double what she is paying now.

“You try not to go bankrupt by the end of your life,” Deutsch told Stateline. “You need assets to take care of yourself as you get older and to have a little bit of security.”

Enhanced subsidies

The 2010 Affordable Care Act included some subsidies to help people purchase health insurance on the exchanges created under that law. Under the enhanced subsidies that started in 2021, some people with lower incomes who qualified for the original subsidies have been getting bigger ones. And those with higher incomes, who wouldn’t have been eligible for any help under the original rules, are now receiving assistance.

Thanks to the enhanced subsidies, people making up to 150% of the federal poverty level, or $22,590 for an individual, are now getting free or nearly free coverage. And households earning more than four times the federal poverty level, who didn’t qualify for subsidies before, are getting some help.

The enhanced aid also has helped push ACA marketplace enrollment to record levels, reaching more than 21 million this year. Southern states that have not expanded Medicaid as allowed under the ACA have seen the most dramatic growth in marketplace enrollment since 2020, according to KFF, a health policy research organization. The top five states with the fastest growth are Texas (212%), Mississippi (190%), Georgia (181%), Tennessee (177%) and South Carolina (167%).

If the enhanced subsidies go away, premium payments will increase by an average of more than 75%, according to KFF. Some people, like Deutsch, would see their payments double.

Given those premium hikes, millions of Americans would no longer be able to afford the coverage they’re getting on the exchanges, according to the nonpartisan Congressional Budget Office. CBO estimates that enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 to 15.4 million in 2030. Some of those people would find coverage elsewhere, but others would not.

Edmund Haislmaier, a senior research fellow at the conservative Heritage Foundation, said Republicans view the expiration of the enhanced subsidies as “an opportunity to rework and address some of the basic flaws in the ACA.”

Before the ACA, Haislmaier said, many self-employed people, such as small-business owners and freelancers, were able to find their own private insurance at competitive prices. But the health care law destroyed that market, he said, leaving such people with a selection of expensive and subpar plans.

Haislmaier said it would take time for the Trump administration to determine how it wants to change the ACA — which President-elect Donald Trump unsuccessfully tried to repeal during his first term — but that “you can do that in a way that preserves access and preserves subsidies for the lower-income people who were the primary focus of the ACA.”

States’ limitations

But Jared Ortaliza, a research associate at KFF, said letting the enhanced subsidies expire could result in higher premiums for everyone. That’s because higher prices likely would prompt many healthier people to forgo insurance, he said. Their departure would leave only chronically ill people on the exchanges, and the cost of their care is higher.

“If sicker enrollees need coverage because they need care, they’ll still choose to buy it, potentially. And if the market were sicker as a whole, that could drive premiums upward as well,” Ortaliza told Stateline.

Ortaliza said states might consider keeping premiums down through so-called reinsurance, or reimbursing insurers for their most expensive enrollees. Theoretically, they also could try to replace the expiring federal aid with their own money.

But few if any states have the financial flexibility to do that, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy.

“There might be a couple states who don’t have current state subsidies that might add that, but that will be very nominal,” Tewarson told Stateline, adding that officials from different states have been discussing potential solutions. “They are all assuming that they would just have to absorb the loss of coverage across the population.”

Trolley, the head of the Pennsylvania exchange, said her state is working to provide its own subsidy to make the marketplace plans even more affordable. But even when fully implemented, it would spend only $50 million on that help, a tenth of what it would need to replace the federal aid.

Two-thirds of the 435,000 Pennsylvanians who purchase insurance on the marketplace joined after the enhanced federal subsidies were put in place in 2021. If they expire, Trolley said, she worries that 100,000 or more exchange participants will leave.

Jessica Altman, executive director of California’s exchange, said her state is in a similar situation. California currently receives $1.7 billion annually in enhanced subsidies from the federal government and spends an additional $165 million of its own money to keep costs down.

California estimates that if the subsidies expire, monthly premiums for the state’s enrollees would increase by an average of 63%. More than 150,000 people would no longer be eligible for federal help, and between 138,000 and 183,000 would disenroll, the state estimates.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

The Healthcare.gov website, where people can sign up for health insurance coverage under the Affordable Care Act (ACA). Sunday, Dec. 15, is the deadline to enroll for people who want coverage to start Jan. 1. (Screenshot | Healthcare.gov website)

People who want to sign up for health insurance coverage under the Affordable Care Act in 2025 must do so by the end of the day Sunday, Dec. 15, if they want coverage to start on New Year’s Day.

“For accidents or injuries or when illness strikes, the last thing that anyone should have to worry about is how they’re going to pay for that, or whether they’re going to fall into some sort of medical debt,” said Milwaukee County Executive David Crowley during an online press conference Friday to draw attention to the Sunday deadline.

The Affordable Care Act (ACA) imposed new consumer protection provisions for health insurance plans, among them a requirement that people cannot be denied coverage or charged higher premiums because of their personal health history.

The act also led to the creation of a federal health care marketplace Healthcare.gov, where people can purchase individual health insurance plans if they don’t have health coverage through an employer or some other group source, including Medicaid or Medicare. Healthcare.gov provides information about the plans available in a person’s geographic area.

The ACA open enrollment period for individual plans started Nov. 1. Whether people are enrolling for the first time — because they’ve lost their coverage through work, for example — or renewing their insurance after enrolling previously in 2023 or before, “you should take advantage of this time right now,” said Joe Zepecki of Protect Our Care, a national campaign to support and strengthen the ACA. Protect Our Care organized Friday’s news conference.

People who sign up for a plan at Healthcare.gov must do so by Sunday, Dec. 15, to get coverage that starts Jan. 1.  For people who enroll after Sunday, 2025 coverage won’t start until Feb. 1. The final deadline for enrolling is Jan. 15.

People can get guidance in assessing their choices of plans through the statewide health insurance navigator, Covering Wisconsin (coveringwi.org).  In addition to the website, Wisconsin residents can call 414-400-9489 in the Milwaukee area or 608-261-1455 in the Madison area to reach a navigator with the organization. Both telephone numbers are available to residents anywhere in the state.

As of Dec. 1, 88,189 Wisconsin residents have enrolled in coverage during the current open enrollment period, according to the federal Centers for Medicare & Medicaid Services (CMS). That’s slightly short of the pace at the same time last year, when 99,950 people enrolled by Dec. 2, the Wisconsin Office of the Commissioner of Insurance reported.

Almost 250,000 Wisconsin residents — a record number — have been covered in 2024 under plans provided through the ACA website, Zepecki said Friday.

Expanded federal tax credit subsidies tied to the income of an applicant have reduced the cost of plans purchased through the ACA dramatically. Those subsidies have reduced the cost for about 61,000 Wisconsin residents, Zepecki said, and will remain in effect through 2025, making health plans much more affordable for people.

The enhanced insurance premium tax credit subsidies were first instituted with the enactment in 2021 of the American Rescue Plan Act (ARPA) in the first year of President Joe Biden’s term, and they were extended in the 2022 Inflation Reduction Act.

Zepecki said that for a 45-year-old Wisconsinite making $60,000 a year, the enhanced subsidy would save about $1,442 a year. For a 60-year-old couple with a combined income of $82,000 a year, “the difference in having the premium tax credits and losing them is more than $18,000 a year,” he added. And for a family of four with a household income of 125,000 a year, the premium tax credits would save more than $8,200.

“This helps almost everybody who’s in the [federal health insurance] marketplace,” Zepecki said.

Sen. Tammy Baldwin (D-Wis.) said making the subsidies permanent “will be at the top of my list as something that helps working families across Wisconsin and across the United States” in the 2025 Congress. She said they will be part of “a very robust debate” about the tax code as Republican lawmakers seek to extend tax cuts enacted in 2017 during Donald Trump’s first term as president.

“I know we have some folks who are more focused, sadly, on tax breaks for the wealthy and big corporations,” Baldwin said. “I’m going to be fighting for working Wisconsinites.”

The U.S. Capitol. surrounded by fog, on Tuesday, Dec. 10, 2024. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — The U.S. House handily approved the annual defense policy bill Wednesday, despite late opposition from Democrats over a provision that bans military health insurance coverage for service members’ children seeking transgender care.

Lawmakers passed the historically bipartisan package 241-180. In the end, 81 Democrats supported the bill, and 16 Republicans voted against it. The measure now heads to the Senate.

Congress has approved the must-pass legislation for 63 years straight. President Joe Biden has not issued a statement yet on whether he will sign it into law.

The $884.9 billion bill includes a 4.5% pay increase for all troops, and an additional 10% bump for the military’s most junior enlisted ranks, from private to corporal. The bill also outlines improvements in military housing and child care.

The massive package is a policy bill, meaning it does not provide the Pentagon with funding but rather enshrines the Defense Department’s goals for the upcoming fiscal year. Congressional appropriators still need to approve any actual spending.

‘Lives of thousands of children at risk’

Among the Democrats who opposed the final legislation was the House Armed Services Committee’s top Democrat, Rep. Adam Smith. In a statement after the vote, Smith said he couldn’t vote yes, though there was “much to celebrate” in the text.

“However, the corrosive effect of Speaker Johnson’s insistence on including a harmful provision puts the lives of thousands of children at risk by denying them health care and may force thousands of service members to choose between continuing their military service or leaving to ensure their child can get the health care they need. This will be felt for generations to come,” Smith, of Washington state, said.

All Democrats present for a procedural step to advance the bill Tuesday voted against the defense package.

A four-line provision into the 1,800-page bill bans military TRICARE health insurance coverage for service members’ children who seek “medical interventions for the treatment of gender dysphoria that could result in sterilization.”

Treatment for gender dysphoria — an incongruence between a person’s sex assigned at birth and current gender expression — includes mental health measures, hormone therapy and surgery. The bill does not define which treatments are banned.

Smith, on the floor ahead of the vote, said the measure was included for “ignorant, bigoted reasons against the trans community,” and that it “taints an otherwise excellent piece of legislation.”

House speaker touts ban

Alabama’s Rep. Mike Rogers, chair of the House Armed Services Committee, told reporters on Capitol Hill Tuesday that House Speaker Mike Johnson “didn’t talk to me about it” before including the provision in the final text.

Johnson, of Louisiana, touted the measure Tuesday, as well as other provisions that freeze hiring of diversity, equity and inclusion positions, and prohibit federal funds for certain race relations education in Defense Department institutions.

Human Rights Campaign President Kelley Robinson criticized the House’s approval of the measure in the final bill, saying military members were used as “bargaining chips” for the issue.

“Military servicemembers and their families wake up every day and sacrifice more than most of us will ever understand. Those families protect our right to live freely and with dignity – they deserve that same right, and the freedom to access the care their children need,” Robinson said. 

“Today, politicians in the House betrayed our nation’s promise to those who serve. Not since the ‘Defense of Marriage Act’ passed almost 30 years ago has an anti-LGBTQ+ policy been enshrined into federal law. For the thousands of families impacted, this isn’t about politics. It’s about young people who deserve our support,” the campaign’s president continued.

Space Force controversy

Another provision in the bill will transfer certain Air National Guard functions and personnel to Space Force without permission from state governors — a measure that stirred opposition.

Roughly 1,000 Air National Guard space professionals serve in 14 units across seven states, according to the National Guard Association of the United States, which panned the measure.

The move could affect up to 33 personnel in Alaska, 126 in California, 119 in Colorado, 75 in Florida, 130 in Hawaii and 69 in Ohio.

Retired Maj. Gen. Francis M. McGinn, president of the National Guard Association, said in a statement Monday that the provision is an “existential threat to state authority over the National Guard.”

An amendment to strike the provision offered by Democratic Rep. Joe Neguse of Colorado failed in the House Rules Committee on Monday.

New requirements for blast exposure

The final bill also included a measure to prevent, assess and treat conditions, including traumatic brain injuries, suffered by service members repeatedly exposed to explosion pressure waves.

The legislation requires the Defense Department to establish the Defense Intrepid Network for Traumatic Brain Injury and Brain Health no later than Jan. 1, 2026. Other mandates include creating safety thresholds for blast exposure by early 2027, and establishing policies to encourage service members to seek treatment, without fear of retaliation, for brain trauma.

The department will also be required to report back to Congress on the safety initiatives and numbers of service members who seek treatment, among other data.

The safety provisions were championed this year by Sens. Joni Ernst, an Iowa Republican, and Elizabeth Warren, a Massachusetts Democrat, as well as House Democrat Ro Khanna of California.

States Newsroom interviewed a Washington state Purple Heart recipient in May who was among more than 100 troops who suffered traumatic brain injuries following an Iranian air strike on the U.S. Al Asad Airbase in Iraq in January 2020.

On the campaign trail in October, President-elect Donald Trump downplayed those troops’ injuries as “headaches.” That was not the first time Trump had disparaged the troops’ injuries stemming from the 2020 attack.

Kerrie Hirte, the mother of Cilivea Thyrion, looks over autopsy reports sent by the medical examiner. (Photo | Isiah Holmes)

On a recent chilly November evening, Kerrie Hirte confronted a piece of mail she’d both anticipated and dreaded. Sitting at her kitchen table, beneath a picture of her late daughter Cilivea Thyrion, 20, Hirte examined the contents of an orange envelope from the Milwaukee County Medical Examiner’s Office. Inside were unredacted autopsy reports, with details that raised new questions about her daughter’s death in the Milwaukee County Jail nearly two years ago. 

Hirte invited the Wisconsin Examiner to her Green Bay home to accompany her when she first viewed the unredacted autopsy reports. They show that correctional officers were aware that Thyrion, who died after eating pieces of an adult diaper while on suicide watch, had a previous history of eating the very item she was given the day she died. In autopsy protocol records, the medical examiner also noted evidence of blunt force injuries to Thyrion, including injuries to her head, lower extremities, liver, and ribs. 

The reports described the scene of Thyrion’s death on Dec. 16, 2022. By then, Thyrion had been in the jail just two days short of 10 months. Thyrion was arrested by the Wauwatosa Police Department in February, after getting in a fight at her residence and charged with felony suffocation/strangulation and misdemeanor battery. Thyrion died before she was sentenced for the charges. 

According to the records later mailed to Hirte, medical examiner investigators found Thyrion “lying on a bare metal slate” with her arm “resting on a green mattress pad on the floor.” The green mattress was one of the only items in the cell besides a toilet, sink, a paperback book and intercom. Thyrion had been housed in the jail’s Special Needs Unit, where she’d been on suicide watch since Dec. 11. “It is unknown at this time what [led] to her needing this type of cell and supervision,” the medical examiner’s investigation report states.

On the morning of Dec. 16, Thyrion pushed the assistance button inside her cell to call guards for help. When correctional officers arrived, they saw Thyrion gesturing towards her neck. After gathering other correctional staff, they called 911 as it was apparent that the 20-year-old was suffocating. The medical examiner’s report states that correctional officers performed a Heimlich maneuver to help Thyrion clear whatever she was choking on. The report states that correctional officers called 911 three times, but Thyrion was unconscious by the time medics arrived. 

An investigation by the Waukesha County Sheriff’s Department found that Thyrion had ingested an adult diaper, which correctional officers gave her while she was on suicide watch. Although why the diaper was provided is redacted in Waukesha’s reports, interviews with correctional officers strongly imply that it was to help Thyrion deal with her menstrual cycle. In a letter stating that no charges would be filed for Thyrion’s death, the Milwaukee County District Attorney’s Office wrote that the guards tried unsuccessfully to find underwear made specifically to limit self-harm risks, but could only find an adult diaper. The district attorney’s letter states that “they wanted to meet a basic need for Ms. Thyrion and did not consider that the diaper could be used in a way to self-harm.”

What correctional officers knew about Thryion’s self-harm risks is woven in and out of the redactions in the Waukesha sheriff’s investigation. One interview of a correctional officer noted that the guard “was aware of Thyrion’s history and had conversations with her about [redacted]”, and that the guard was “very sad about the situation because nobody thought that Thryion would hurt herself by [redacted] and they were just trying to make her ‘feel like a woman.’” 

Yet, the medical examiner’s scene report states that “according to Correctional Officers (CO) and jail staff, [Cilivea] had a history of trying to swallow inedible objections (sic) including plastic forks and diapers. She was seen trying to swallow unspecified objects today around 1030 hours and it is believed that she was unsuccessful at actually swallowing anything.” After reading that section of the report Hirte wondered why her daughter would be given a diaper if jail staff were aware of the risk. “They make it sound like they just gave her diapers all the time,” Hirte told Wisconsin Examiner. 

After reading a portion of the reports stating that Thyrion had no next of kin, but that detectives were aware that she’d called an unknown female, Hirte began to weep. While Thyrion was incarcerated, Hirte recalled talking to jail health care staff “several times about Cilivea.” She told Wisconsin Examiner that her daughter had signed “a release of information so that I could find out what was happening to her in there. And when you’re reading that [the medical examiner reports] it makes it sound like they had no idea who she was talking to. When they know darn well it was me.”

According to the medical examiner report, jail staff “stated they were not aware of any triggers, upcoming court proceedings, or recent events that would make Cilivea want [to] harm herself today or for any of the past self harm attempts.” 

Hirte wonders if jail staff knew that Thyrion had swallowed plastic forks and diapers before, and if so,  “why would you give her anything then?”

In late 2023, among Thyrion’s belongings released to Hirte by the jail was a handwritten note from Thyrion requesting to see a nurse. “I think I need a med adjustment,” Thyrion wrote. Electronic messages Thyrion sent jail staff throughout her incarceration also show that she regularly communicated her needs, without many results. The messages were obtained by Wisconsin Examiner through open records requests. 

In late March 2022, Thyrion messaged jail staff asking to be moved to another part of the facility because activity going on in her pod was “mentally upsetting.” The following month in April, Thyrion wrote complaints about jail staff mocking her with “fat jokes” and being rude. In June, Thyrion was denied access to the gym, and made multiple requests for a Bible and hygiene products. 

Redactions in the messages obscure crucial details about Thryion’s needs. Anything related to Thyrion’s mental health history, including the word “suicide” is redacted in most reports. “I have not been [getting] my [redacted] and I don’t know why. I really need it. I have been getting really bad [redacted],” she wrote on June 29, 2022. In August, she reported being verbally threatened by a correctional officer, and asked why she wasn’t getting her mail. When she asked to speak with friendlier and familiar jail staffer, Thyrion was denied. “I promise to be better,” Thyrion wrote in the electronic messages. “I Just need to talk to her please she’s a good friend she’s great to talk to please she was in cell four please I’m sorry.” 

On Dec. 2, 2022, court records show that Thyrion’s sentencing had been scheduled for January 2023. In her last message sent on Dec. 12 to jail staff, just four days before her death on Dec. 16, Thyrion reported that jail staff had used her cell’s intercom system to call her fat, pathetic, and that “no one in my family should have raised an inmate” and that “it all started because I threw up my food and she said that maybe if I stopped eating everything I would not be throwing up.”

Records from the Milwaukee County Jail showing correspondences between Cilivea Thyrion and jail staff during her time at the jail, obtained through open records requests.

Thyrion’s messages to jail staff about harassment and neglect, her note asking for “a med adjustment,” the medical examiner’s note that correctional staff knew about her history of ingesting objects like diapers (seemingly at odds with the district attorney’s letter mentioning that jail staff didn’t consider the diaper to be a self-harm risk), and their subsequent decision to furnish an ordinary diaper rather than one designed to prevent self-harm, raise serious questions about the lack of accountability in her case. Hirte feels what happened to her daughter was intentional, “because they gave her something and then walked away.” 

With many crucial details about Thyrion’s medical history at the jail hidden behind black inked redactions, these various pieces form a picture of what her life inside the jail was like. Normally, the Milwaukee County Medical Examiner’s Office does not release autopsy protocols. As Thyrion’s mother, however, Hirte was sent an unredacted copy which was also reviewed by Wisconsin Examiner. The report notes “blunt force injury” including an abrasion to Thyrion’s head, fractures to four ribs, and contusions or abrasions to her abdomen, liver, left hand, and “lower extremities and the bottom of the right foot.” Instead of food, plastic fragments were found in Thyrion’s stomach, and “a crumpled piece of cloth fabric” in her large intestine. 

“To me,” Hirte told Wisconsin Examiner,  “it’s like, should she have been in the hospital if she had that towel in her large intestines?” A few days after viewing the autopsy reports, Hirte traveled from Green Bay to Milwaukee, to speak before a Milwaukee County committee reviewing an audit of the Milwaukee County Jail. The audit revealed “systemic issues ranging from dangerous suicide watch practices and a mental health challenge to critical staffing shortages and occupant overcrowding.” 

Auditors noticed “unsafe restraining of occupants” on suicide watch, including being handcuffed to benches for hours at a time. Although the jail places an average of 36 people in suicide watch on a weekly basis, mental health assessments were inconsistent. While auditors were visiting the jail, staff realized that someone on suicide watch had not been logged on a white board. “This discrepancy highlights a critical breakdown in communication and procedure,” the auditors wrote. There was also a backlog of 51 people awaiting competency evaluations. Despite there being a high number of pre-trial jail occupants taking psychotropic drugs, suggesting “a significant mental health burden within the jail” according to the audit, medications are distributed in bulk stock, meaning they’re not individually prescribed or even properly labeled with instructions on how to take the drugs. 

The auditors also found a lack of supervision and clear duties for correctional staff in the jail’s restrictive housing units, and found that the jail’s suicide prevention policies — while complying with Department of Corrections (DOC) regulations — lacked “specificity and clarity.” The auditors warned that “this vagueness hinders consistent and effective implementation of critical procedures, particularly those related to suicide watch.” Throughout the audior’s visit, the auditors recommended that the Milwaukee County Sheriffs Office and its contracted jail health care provider Wellpath emphasis suicide prevention training and address staffing shortages, lack of supervison, and the various nonfunctioning light fixtures, graffiti, and damaged windows which create an unfavorable atmosphere within the jail.

Thyrion’s death came as part of a string of six deaths within the jail over a 14-month period. During the audit committee hearing on Dec. 2, Milwaukee County Sheriff Denita Ball said that after each death, the office does a review to see what could be done better. As a result, Ball said before a committee of county supervisors, there hasn’t been a suicide at the jail since January 2023. “We’re putting things in place that is helping,” said Ball. “One death is one too many.” 

After the sheriff spoke, the floor was opened up for public comment. “From what I see from this audit shows all my concerns,” said Hirte. “It shows more. There’s stuff I didn’t even know that I now know. And I hope it opens everybody’s eyes as to why I came back here to fight for my 20-year-old daughter. The only daughter I have died, who died in the Milwaukee County Jail, they say while she was on suicide watch. This basically says how unequipped they were to handle her.” 

In November, days before the jail audit report was sent to Milwaukee County Audit Committee officials, the jail’s contracted health care provider Wellpath filed for bankruptcy.  The Milwaukee County Medical Examiner’s Office declined to comment, and the Milwaukee County Sheriff’s Office also did not respond to multiple requests for comment for this story. 

Arlene Meyer is a busy woman. 

The 86-year-old starts each morning by watching the news in her room at Pine Crest Nursing Home in Merrill, Wisconsin. Then it’s off to the dining hall for breakfast so she can “BS with everybody out there.” She never skips her daily walk and devours books delivered by the public library each week — anything except romance or science fiction. 

The event calendar in Meyer’s room lists a smorgasbord of other options: manicures and mimosas, chair Zumba, trivia, Packers watch parties and beer pong. Meyer spent a recent Friday at an exercise class in an area of Pine Crest that later hosted a happy hour with live music. 

“The concept of old people, it’s out,” Meyer said, adding that “the days go by so fast” — an observation that surprises outsiders with duller expectations for nursing home life.

Meyer moved to Pine Crest in 2023 to recover from pneumonia. She liked it so much she stayed permanently. The nursing home’s social media posts show her holding a lizard, relaxing during a spa treatment and singing a Willie Nelson song at karaoke — photos that brought joy to those who know her.

“Sassy Arlene! Love it!” one person commented on a photo. “Happy you haven’t changed Arlene,” wrote another. 

Lincoln County owns Pine Crest, one of 36 county-owned nursing homes in Wisconsin. They tend to be better staffed, have higher quality of care and draw fewer complaints than facilities owned by for-profits and nonprofits, a WPR/Wisconsin Watch analysis of U.S. Centers for Medicare and Medicaid Services data shows. 

Wisconsin has more county-owned nursing homes than any state but Indiana. But perhaps not for long. 

Over more than three decades, residents in 22 Wisconsin counties lost public nursing homes to sales or closures. This year alone at least five counties — including Lincoln — considered selling, started the sales process or sold.

County leaders say they have only two options while facing financial pressures and staffing shortages: sell or close the homes. Local organizers disagree, arguing counties should continue providing high-quality care for low-income older people and disabled adults. 

Lincoln County’s board voted to sell Pine Crest to a for-profit at the start of this year. After that buyer backed out, the board is planning to find a new one.

Meyer worries about potential disruptions at Pine Crest.

“I love it here,” she said. “I sincerely do.”

A flurry of nursing home sales and closures

Meyer, a former Lincoln County Board supervisor, doesn’t own a phone, but she stays up to date on local happenings. It didn’t take long before she heard rumblings about selling Pine Crest. 

“I was teed off about it because of some of these SOBs,” Meyer said. “They said, ‘well, the cost factor.’ Now I think about what jerks were running this.”

Running a nursing home is expensive, and counties aren’t required to do so — something officials often realize during recessions and inflationary periods.

The financial crisis of 2007 and 2008 was Wisconsin’s busiest stretch for nursing home sales, with four counties selling.

Since inflation started surging in 2021, at least five counties outside of Lincoln have sold or considered selling: 

• Iowa County closed its nursing home in 2022 after failing to find a buyer.
• A private nursing home chain took over Washington County’s nursing home in July. 
• The St. Croix County Board considered selling before voting against it.
• Sauk County’s board this year approved a sale to a for-profit that still requires state health department approval. 
• Portage County heard interest from one prospective buyer but chose not to sell following public pushback. It will decide later this month whether to look for a different buyer.

Meanwhile, dozens of for-profit nursing homes have closed in recent years. 

Lincoln County started debating Pine Crest’s future in 2022 while the board sought budget cuts. Then-board chair Don Friske noticed Pine Crest had for years run substantial annual deficits.

That’s been the case since the 1980s for county-run nursing homes nationwide, said Anne Zahradnik, an associate professor of health administration at Marist College.

Those remaining “are a holdover from an orientation toward government solving problems,” she added. 

From ‘poor farms’ to nursing homes

Wisconsin’s county governments have a long history of housing vulnerable populations. 

Many ran “poor farms” or “poor houses” for residents experiencing poverty starting in the 1800s. Most states eventually created centralized nursing homes to serve older people and those with disabilities from across the state, while Wisconsin prioritized keeping people close to home. A Wisconsin network of local nursing homes and converted poor farms started receiving federal Medicaid funding in 1974, according to a Legislative Audit Bureau report.

Nursing homes for decades were the only long-term care option for populations they served, and people who relied on government assistance had few choices outside of county homes. 

That is changing as people increasingly age at home or in assisted living facilities that offer more independence at a lower cost. Wisconsin’s assisted living options hold more than double the beds of its nursing homes. 

But assisted living, unlike nursing homes, can’t care for people who need regular medical attention. Nor do they offer the same protections against evictions for residents who rely on Medicaid, the joint state and federal aid program to help low-income residents afford care. 

More than a quarter of nursing home beds, on average, at for-profit and county-owned nursing homes sit empty, according to federal Medicaid data.

Almost 40 of Pine Crest’s 120 beds are vacant, but Wisconsin can’t afford to lose them. 

Without nursing homes, hospitals struggle to find housing for their sickest patients, Zahradnik said. The Wisconsin Counties Association projects a need for roughly 10,000 new skilled nursing beds by 2035 as state demographics trend older. 

To keep Pine Crest running, Lincoln County’s board debated converting part of it into assisted living or even knocking it down to build a smaller nursing home with lower operation costs. Both options would require up-front money the county lacks, Friske said. 

The only remaining option the board sees: selling.

Counties struggle to keep up

Medicaid policy is complicated and frequently changes. The program is also how most nursing home residents pay for care. 

Lincoln County’s board lacks expertise on nursing home management, making it hard to keep up, Friske said, echoing officials in other counties.

“We’re horrible at it,” he said.

As the board discussed exiting the nursing home business, it learned the county was short more than $1 million in expected revenue to cover one year’s costs.  

The state has traditionally subsidized county-owned nursing homes, and it started increasing Medicaid reimbursements in 2022. The change shrunk ongoing county deficits to provide care, wrote Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, which distributes the nursing home supplements. 

That was positive. But shrinking those deficits meant counties would get smaller lump sum subsidies for operating nursing homes – something officials in multiple county governments didn’t anticipate, leading to budget shortfalls.

“Just when you think you’re one step ahead, you’re two steps back,” Washington County Executive Josh Schoemann said.

He described the unexpected loss of the subsidies as “just another brick in the wall” for a nursing home the county ultimately sold to a for-profit this year.

Lincoln County used federal pandemic funds to cover the unexpected subsidy loss — a short-lived option.

Despite supporting county-owned nursing homes, state officials don’t always effectively communicate with counties, said Rene Eastman, vice president of financial and regulatory services at LeadingAge Wisconsin, an advocacy group for older adults. 

Still, Eastman said, the recent Medicaid rate reimbursement hikes could ease financial pressures over time.

“If counties hung on for a little bit longer, they would really see the effects of that funding infusion, and they would see the increased need in their communities,” she said.

St. Croix County commits to nursing home

St. Croix County Board Vice Chair Bob Feidler said his colleagues didn’t seriously consider selling its nursing home. But a discussion about that possibility prompted opponents to flood an August board meeting. 

The board voted against selling, deciding that nursing home revenue would likely grow, aided by higher Medicaid rates and a federal grant to open a dementia wing. 

“All of a sudden, we went from what had been a negative revenue to barely a positive revenue, to a more solid projection,” Feidler said.

Many Lincoln County residents hope their board will reach the same conclusion. But increased Medicaid rates alone won’t cover needed costs outside of care, like renovating Pine Crest’s  building, Friske said. That would likely require a property tax increase.

“You can’t just go on a whim, ‘Hey, yeah, we’re going to throw this extra money on the property tax,’ ” Friske said. “People are struggling.”

County leaders have historically asked voters to support nursing homes through ballot measures.

Voters in Green County, for instance, approved an April ballot measure to continue funding their nursing home. 

Portage County voters approved one referendum in 2018 and a $20 million referendum four years later for the construction of a new nursing home — renovations that still haven’t started. Rising construction costs since the delay mean millions more are needed to fund the project, according to county board members who have blocked calls for a fresh referendum.

In Lincoln County, more than 80% of respondents to a 2023 Merrill Foto News and Tomahawk Leader online survey opposed selling Pine Crest.

But the board blocked two efforts to put Pine Crest’s future on the ballot.  

How private homes profit: Cutting staff, benefits 

Friske had gotten unsolicited calls from brokers even before putting Pine Crest on the market, as have officials in other counties. 

Why buy a money-losing nursing home?

For-profits can’t simply build new facilities. The state determines the need for nursing home beds in different communities — requiring newcomers to typically buy a license from an entity already operating a facility. 

Deficits under government ownership don’t mean private companies can’t turn a profit.  

They might find savings by rejecting applicants with behavioral issues who require costlier care. Counties that own a nursing home typically send higher-needs residents there. Counties that don’t own a nursing home still pay to send such residents to another facility that will accept them. 

Private owners frequently reduce staffing and benefits upon purchasing county-owned facilities, Eastman said. Lower staffing correlates with poorer care. 

The Centers for Medicare and Medicaid Services rates nursing home staff on a 1 to 5 scale, considering time they spent with residents and turnover. 

The median staff rating at Wisconsin’s county-owned nursing homes is 5, the highest possible, according to WPR and Wisconsin Watch’s analysis. That’s compared with a median rating of 3 at for-profit facilities in the state.

A sign outside of the Portage County Health Care Center touts its 5-star rating. Grace Skibicki, a resident of 13 years and a former care center nurse, recognizes that as impressive. 

She expects care to decline if a chain with a lower rating purchases it. She wouldn’t plan to stick around. 

“It’s really scary because you don’t know what’s going to happen to you,” Skibicki said.

Staff are also waiting to see what their future holds.

Nursing home work can be grueling with modest pay, accounting for significant staff turnover across the industry. But county-owned nursing homes employ public workers who earn county benefits and access to one of the country’s best-funded retirement systems. That may explain why median turnover trends at Wisconsin’s county-owned homes (41%) are lower than they are at for-profits (51%), WPR and Wisconsin Watch found. 

Wisconsin’s for-profit nursing homes drew a median of three substantiated complaints over the last three years, compared to a median of zero at county-owned facilities, which also fared better than for-profits and nonprofits in health inspection and overall quality ratings.

Nursing homes owned by Lincoln, Portage and Sauk counties all rate above average, but county officials believe private owners could run them better.  

Counties struggle to make quick decisions the fast-changing industry requires, Friske said.

Potential buyers named in Lincoln, Portage and Sauk counties all own multiple facilities across the state. Two own facilities in other states. That setup makes it easier for them to fund repairs or convert rooms to assisted living quickly without repeatedly asking taxpayers. 

Care & Rehab Company, which initially sought to buy Pine Crest, owns six facilities in Wisconsin and Minnesota. Two share Pine Crest’s “much above average” federal rating, but two others received “below average” ratings.  

People for Pine Crest

Dora Gorski kept her husband Ken at home for as long as possible. 

Ken, a father, veteran, martial arts instructor and first responder, was often too proud to admit to falling — even when Dora woke up to find him on the ground.

She initially got help from neighbors and home health aides who warned her about his worsening dementia. Ken eventually ended up hospitalized and in need of a wheelchair. 

When Dora realized she’d have no way to get him into their house upon their return, Pine Crest was her first call.

The woman in admissions knew Ken, who had taught her children aikido. Once he moved in, a maintenance worker recognized Ken as his former martial arts teacher. A caretaker told Dora she knew Ken, too — having worked with him as a phlebotomist. 

It turned out that Arlene Meyer, a fellow first responder who had long known Ken, lived down the hall.

“It was people who not just knew him as a doddering old man who is barely able to talk,” Dora said. “They knew him as a respected instructor.”

Two weeks before Ken’s death in December 2023, Pine Crest hosted his 90th birthday party. His children, former students and friends, including Meyer, packed a community room. 

“That meant a lot to Ken,” said Dora, who still participates in a group called “People For Pine Crest,” which opposes a sale.

“We own it. It’s our place. We all take pride in it being here,” she said.

The group spent 2023 urging the Lincoln County Board to keep the nursing home. Their flurry of petitions, yard signs, T-shirts, public testimonies, phone calls and emails didn’t work. The board voted to sell to Care & Rehab.

But an attorney and ally on the county board noticed a language problem in the sale agreement and sued the county to halt the sale.

Care & Rehab backed out before the case could move forward, offering People For Pine Crest a reprieve. 

But Friske, who lost reelection this spring, sees a ticking clock. He expects Pine Crest will face a fiscal crisis that will force a closure unless it sells. 

He resents any suggestion that his board colleagues don’t care about those who depend on Pine Crest.

“The county board is not a congressman from Missouri, Arkansas and Texas, telling Wisconsin how to live,” Friske said. “What’s happening here is friends and neighbors who are elected to the county board. They live here, their families are here, we’re all here.”

Lincoln County has just two other nursing homes, both in Tomahawk and with lower federal ratings.

Dora Gorski, who lives 20 minutes from Pine Crest, said the short distance allowed her to eat breakfast with Ken most mornings. That routine would have been tough to maintain — doubling the length of her drive — had he lived in one of Lincoln County’s two private facilities or the state veterans home in King, Wisconsin.

The county hopes to keep some nursing home beds in Merrill, said current Lincoln County chair Jesse Boyd, but they won’t be county-owned. He agrees with Friske’s financial outlook. 

“Right now, we’re drowning,” he said. 

The county now has lined up a couple of potential buyers for Pine Crest.

If a sale proceeds? Pine Crest won’t be the same, Gorski expects. For now it’s “full of neighbors and friends and people from our community, people who love us and know us,” she said.  

“You don’t find that in some big city, and you don’t find that in a private, for-profit nursing home.”

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‘We own it. It’s our place.’ Worsened care feared as counties privatize their nursing homes is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.

An aerial view of the The Pentagon, May 12, 2021. (Department of Defense photo by Air Force Tech. Sgt. Brittany A. Chase)

This story mentions suicide. If you or a loved one are suffering from thoughts of self-harm, dial 988 or visit 988lifeline.org to live chat with a mental health professional.

WASHINGTON — House Democrats will face a tough vote this week on the final compromise annual defense bill that includes pay raises for troops but also bans coverage for U.S. service members’ children who seek transgender care.

All Democrats present Tuesday opposed a procedural vote, 211-207, to advance the historically bipartisan legislation, but will need to contend with a final vote as early as Wednesday. Congress has enacted the annual package for the last 63 years.

Rep. Adam Smith, the top Democrat on the House Committee on Armed Services, said in a statement he plans to vote against the massive defense policy bill.

The Washington state lawmaker said that “blanketly denying health care to people who need it — just because of a biased notion against transgender people — is wrong.”

“The inclusion of this harmful provision puts the lives of children at risk and may force thousands of service members to make the choice of continuing their military service or leaving to ensure their child can get the health care they need,” Smith said following the procedural vote.

President Joe Biden has not indicated whether he will sign the bill into law.

Pay raise, housing upgrades

The nearly $900 billion National Defense Authorization Act for fiscal year 2025 is set to green-light an across-the-board 4.5% pay raise to troops, plus a 10% pay hike in April for the military’s most junior soldiers.

The bill would also pave the way for upgrades in military housing and new protocols for preventing and assessing traumatic brain injuries caused by blast exposure.

Also making it into the bill’s final version were a few far-right wishlist items, including a hiring freeze on diversity, equity and inclusion positions, and a prohibition on any federal dollars used for so-called “critical race theory” in military education — though the section carves out academic freedom protections for instructors.

Trans coverage prohibition

Gaining the most attention is a four-line provision in the 1,800-page package that would expressly prohibit coverage for minors under the military’s TRICARE health program for “medical interventions for the treatment of gender dysphoria that could result in sterilization.” The bill does not define which interventions would be prohibited.

Gender dysphoria is defined by the medical community as incongruence between a person’s expressed gender and their sex assigned at birth. The experience often leads to mental distress, including increased risk of self-harm, according to the medical literature.

The chair of the Congressional Equality Caucus, Rep. Mark Pocan of Wisconsin, urged Democrats to vote no on the final package.

“For a party whose members constantly decry ‘big government,’ nothing is more hypocritical than hijacking the NDAA to override servicemembers’ decisions, in consultation with medical professionals and their children, about what medical care is best for their transgender kids,” Pocan said in a statement Tuesday afternoon.

Rep. Teresa Leger Fernández, one of the bill’s managers, spoke on the House floor Tuesday, decrying the provision that “fails to acknowledge that the lack of care leads to death, leads to suicide.”

The New Mexico Democrat accused House Republicans of thinking they know “better than the parent and the doctor as to what care your child should get. That is insulting to our Marines, to those who serve in our Navy, to those who are deployed overseas and in our bases around our own country.”

Speaker praises TRICARE ban

U.S. House Speaker Mike Johnson, during his weekly press conference Tuesday, praised “landmark investments” and the pay increase included in the bill.

“It’s really important right now. We improved housing for our military families and other benefits, and it’s also why we stopped funds from going to CRT in our military academies. We banned TRICARE from prescribing treatments that would ultimately sterilize our kids, and we gutted the DEI bureaucracy,” said the Louisiana Republican.

A Democrat-led effort to strike the transgender coverage provision failed Monday in the House Committee on Rules.

Smith told the committee that the provision is “fundamentally wrong” because gender dysphoria is widely recognized by medical professionals.

“The treatments that are available for it, including puberty blockers and hormone therapy, and also psychiatric help, have proven to be incredibly effective at helping young people, minors, who are dealing with suicidal thoughts, dealing with causes of massive confusion that have led them to have anxiety and depression,” said Smith.

Treatment options include mental health therapy, hormone therapy and surgery, though the World Professional Association for Transgender Health only recommends adolescent surgery under narrow circumstances that must meet numerous criteria. Some gender-affirming surgery causes sterilization, and the association recommends counseling for adolescents and their families about limited options to preserve fertility.

Smith told the committee Monday that anywhere from 6,000 to 7,000 children of U.S. service members are currently receiving treatment for gender dysphoria. The House Armed Services Committee did not respond to a request for further explanation of that number.

Gender-affirming care was not covered by military health insurance for service members’ children until September 2016. A statistical analysis published in JAMA Pediatrics in March 2019 concluded that just over 2,500 military-affiliated youth received the treatment between October 2009 and April 2017 during roughly 6,700 separate office visits.

Photo by Getty Images

For employees of small businesses, health benefits cost more and cover less than they do for employees of large companies, according to a new report released Tuesday.

“Small-firm employees are paying more for their health insurance coverage but getting less financial protection in return,” according to the report, produced by The Commonwealth Fund.

Wisconsin is right in line with the national trend. In 2023, insurance premiums for family coverage cost Wisconsin small business employees just over $1,300 more each year compared with the cost for employees of large businesses, according to the report.

Wisconsin small business employees also absorbed higher health costs up front, paying nearly $1,400 more a year on their health insurance deductibles in 2023 than their big business counterparts.

Those are close to the national average, with a smaller disparity than some states have. According to the report, small-firm employees in some states pay as much as $10,000 more toward their annual health insurance premiums than their large-firm counterparts.

Most large employers provide health coverage, and smaller employers competing with them for workers are motivated to provide coverage as well, but find it a lot more difficult, the report finds.

“Small firm employers have generally been in a tough place because they have so much less leverage than a large firm,” Sara Collins, a coauthor of the report, told the Wisconsin Examiner in an interview. “They have higher administrative costs per employee, and it’s a much more onerous benefit to provide.”

Because of those challenges, the Affordable Care Act (ACA), enacted in 2010, includes requirements for businesses with 50 or more employees to provide health coverage, but exempts smaller employers.

“While all firms face growing premiums, small employers may have less capacity to absorb these rising costs and may pass on greater portions of these costs to their employees,” the report states. “Half of participating small-business owners in a 2024 survey reported raising employee contributions in response to rising health care costs.”

For TJ Semanchin, who owns Wonderstate Coffee, the report’s analysis rings true.

Wonderstate operates a coffee roastery in Viroqua, Wisconsin, as well as three cafes: in Viroqua, Bayfield and Madison. The roastery employs about 30 people, and the three cafés about 20 people each.

“Our current health system is a major competitive disadvantage for small business,” said Semanchin. 

He would like to see a universal, single-payer health care plan. But since that’s not the current reality, “We want to be providing as best we can for our staff as a responsible employer, and we’re also competing for talent.”

The roastery and the cafés are structured as separate corporations and have different health plans.

On the café side, Wonderstate offers a supplemental policy for employees who don’t have health insurance or whose insurance has a high deductible; the policy covers needs such as emergency room visits and a telehealth service.

The business encourages employees to sign up for comprehensive coverage at Healthcare.gov under the Affordable Care Act, where they’re likely to qualify for enhanced tax-credit subsidies that have lowered the premium costs for people whose incomes qualify.

On the roastery side of the business, Wonderstate recently made a major switch after facing the prospect of an 18% increase in premium costs for employees.

“That is on top of years of double-digit increases,” Semanchin said. “That’s not sustainable at all.”

In response, Wonderstate switched to a level-funded plan for roastery division employees — similar to a self-funded plan, in which an employer covers health care costs directly from its revenues.

Wonderstate will pay a fixed amount each month from which the company managing the plan will pay for medical care as it’s needed. There’s company-wide catastrophic coverage if health care costs exceed the budget for the year.

Nationwide, according to the Commonwealth Fund report, about 40% of small-firm employees with health benefits are covered by self-funded or level-funded plans. Those plans are exempt from state insurance regulations and from protections provided by the Affordable Care Act, which prevents insurers from denying coverage or increasing premiums based on a person’s health history.

Semanchin said the provider reviewed the staff medical history before approving the business for the plan.  Wonderstate pays 80% of the premium for individual coverage and 50% of the family coverage premium.

“It’s allowed us to hold costs [down] for the first time in many years,” Semanchin said of the new plan. “If our staff has a bad year for medical bills, we might get kicked off” in future years.

That is not unusual, and the result can have “a very destabilizing effect on the small group market,” Collins said. “The markets function a lot better when everybody plays by the same rules.”

The report lists a number of policy options to help bolster the ability of small employers to provide health coverage for employees.

States that have expanded Medicaid under the ACA to cover people with incomes up to 138% of the federal poverty guideline could require employers to inform workers who would qualify for Medicaid about the option — which has low or no premiums and limited cost-sharing requirements — if it would be more affordable than the employer’s plan.

For states that haven’t expanded Medicaid — including Wisconsin — the report suggests that Congress could create a federal fallback plan covering the same group of people expansion would cover. “This would enable lower-income people with unaffordable employer plans to enroll in Medicaid in those states,” the report states.

Another option the report suggests would be to make enhanced subsidies for low-income purchasers of insurance at Healthcare.gov permanent. The subsidies are now scheduled to end next year. The report also suggests making it easier for workers at small firms with unaffordable or low-quality health plans to become eligible for the subsidies.

Extending the subsidies is already shaping up to be a significant subject of debate in Congress next year. “People are going to see really big increases in their premiums if they aren’t extended,” Collins said. “That will be a real cost shock to families,” leading more people to return to the ranks of the uninsured.

NEW YORK, NEW YORK - DECEMBER 04: Police gather outside of a Hilton Hotel in Midtown Manhattan where United Healthcare CEO Brian Thompson was fatally shot on December 04, 2024 in New York City. Brian Thompson was shot and killed before 7:00 AM this morning outside the Hilton Hotel, just before he was set to attend the company's annual investors' meeting. (Photo by Spencer Platt/Getty Images)

Police in Altoona arrested a “strong person of interest” Monday in the killing of UnitedHealthcare CEO Brian Thompson last week in New York after finding him in a fast-food restaurant with an illegal weapon and false identification, authorities announced.

New York Police Commissioner Jessica Tisch identified the man arrested as Luigi Mangione, 26, with ties to Philadelphia and whose last known address was in Honolulu. Mangione was in possession of what New York police described as a “ghost gun” made with a 3D printer and a “handwritten document that speaks to his motivation and mindset,” Tisch said.

“The suspect was in a McDonald’s and was recognized by an employee who then called local police,” Tisch said. The New York Police Department has published images showing the shooter’s face culled from surveillance camera footage before and after Thompson was shot.

Tisch said Mangione was also carrying a U.S. passport and multiple false IDs including a fraudulent New Jersey ID matching the one the person police believe to be the shooter used to check into his New York City hostel before the shooting incident.

Police also recovered clothing including a mask Tisch said was consistent with those worn by the person sought in connection with Thompson’s killing.

NYPD Chief of Detectives Joe Kenny said Mangione had no prior criminal record and that NYPD detectives traveled to Altoona on Monday to question Mangione.

Kenny said the document Mangione had when he was arrested is in the possession of Altoona police. They did not believe there were specific threats to other people mentioned in the document, “but it does seem that he has some ill will toward corporate America,” Kenny said.

Thompson, 50, was shot several times by a person who authorities believe was lying in wait early Wednesday morning outside the Manhattan hotel where United HealthCare was holding an investors meeting.

Thompson had been CEO of UnitedHealthcare, one of the nation’s largest for-profit health insurance providers, for nearly three years. His killing has prompted an outpouring of criticism of the company and the United States’ health care system generally for denying or unnecessarily complicating medical treatment.

Mangione was arraigned Monday evening at the Blair County Courthouse in Hollidaysburg on charges of carrying a firearm without a license, forgery, records or identification tampering, possession of instruments of crime and presenting false identification to law enforcement.

Pennsylvania Gov. Josh Shapiro said in a news conference Monday evening after the arraignment that attention generated by the investigation helped Pennsylvania police capture the person sought in connection to Thompson’s killing.

“But some attention in this case, especially online, has been deeply disturbing, as some have looked to celebrate instead of condemning this killer,” Shapiro said, noting that Thompson, who was laid to rest Monday in Minnesota, was a father to two, a husband and a friend to many. “And yes, he was the CEO of a health insurance company. In America, we do not kill people in cold blood to resolve policy differences or express a viewpoint.”

“This killer is being hailed as a hero,” Shapiro said. “Hear me on this. He is no hero. The real hero in this story is the person who called 911 at McDonald’s this morning.”

According to a criminal complaint against Mangione: Altoona police were called to the McDonald’s on Plank Road for a suspicious person who resembled the person wanted in connection with Thompson’s shooting. Officers located Mangione sitting at the rear of the restaurant wearing a blue medical mask and looking at a laptop computer on the table.

Officers asked Mangione to pull down the mask to show his face and recognized him as the person in the pictures released by New York police of the person wanted for the shooting. When asked for identification, Mangione provided a New Jersey driver’s license with the name Mark Rosario and a July 1998 birthdate, according to the complaint. Police were unable to find any information with the identity Mangione provided and advised him that he would be arrested for lying about his identity.

Mangione then identified himself. When asked why he had lied, Mangione replied “I clearly shouldn’t have.” He was then handcuffed, searched and taken to the police station. Inside Mangione’s backpack, police said they found the 3D-printed pistol loaded with nine rounds of 9 mm ammunition and a loose hollow-point round. The gun was with a silencer that had also been 3D printed, police said.

A spokesperson for the University of Pennsylvania in Philadelphia confirmed that Mangione is a 2020 graduate of the university’s undergraduate and graduate degree programs, where he studied computer science. A LinkedIn profile in Mangione’s name says he has worked as a data engineer for a Santa Monica, California, online auto sales marketplace.

Mangione comes from a large and high-profile family in the Baltimore area, with branches of the family that own the Turf Valley and Hayfields country clubs in Ellicott City and WCBM Radio, among other businesses, the Capital-Star’s sibling publication Maryland Matters reported.

WBAL-TV in Baltimore reported that Luigi Mangione was valedictorian of the Class of 2016 at the Gilman School and later graduated from the University of Pennsylvania. The office of Del. Nino Mangione (R-Baltimore County) confirmed to the TV station that the lawmaker is a cousin.

Nino Mangione, a radio host at WCBM who was elected to the General Assembly in 2018, did not immediately respond to calls and an email from Maryland Matters seeking comment Monday. The Gilman School did not immediately respond to a request to confirm that Luigi Mangione was a student there.

The arrest Monday was the result of “tireless work of the greatest detectives in the world,” Tisch said, who reviewed thousands of hours of video, followed up on hundreds of tips and processed forensic evidence. The NYPD also deployed assets including scuba divers, drones and electronic surveillance systems.

“This combination of old school detective work and new age technology is what led to this result today,” Tisch said, adding that the media and the public played a crucial role. “We should never underestimate the power of the public to be our eyes and our ears in these investigations.”

Pennsylvania Capital-Star is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Pennsylvania Capital-Star maintains editorial independence. Contact Editor Kim Lyons for questions: info@penncapital-star.com. Follow Pennsylvania Capital-Star on Facebook and X.

Tabitha Crowe’s first child was due in February 2025, but she had a miscarriage in August. (Courtesy of Tabitha Crowe) 

Editor’s Note: This is the sixth installment of an occasional States Newsroom series called When and Where: Abortion Access in America, profiling individuals who have needed abortion care in the U.S. before and after Dobbs. The first installment can be found here, the second installment is here, the third is here, the fourth is here, and the fifth is here.

By Sofia Resnick

Tabitha Crowe said she woke up around 4 a.m. one Thursday in August covered in blood. She was visiting her parents in southern Louisiana when she started miscarrying her first pregnancy. She said her mom and dad drove her to a nearby hospital while she fought dizziness from the blood loss in their back seat.
“I didn’t even know I could bleed that much,” Crowe told States Newsroom.

Over the course of the next few days, Crowe said she passed baseball-sized blood clots and experienced extreme pain and dizziness in two different hospitals, while never being offered a common miscarriage procedure, even after she requested it.

An estimated 10 to 20% of known pregnancies in the U.S. end in miscarriage. In about 80% of miscarriages, women are able to expel the pregnancy tissue naturally over a period of one to eight weeks, according to the American College of Obstetricians and Gynecologists. When intervention is necessary in the first trimester, ACOG recommends abortion medications or procedures such as vacuum aspiration or dilation and curettage (D&C). Later in pregnancy, recommended termination procedures include dilation and evacuation (D&E), which has a high safety record but is condemned by anti-abortion groups and banned in some states.

But increasingly, women say they are being denied routine miscarriage care in states like Louisiana, where doctors face imprisonment if they perform an abortion unless a woman is at risk of dying, and where common miscarriage drugs are now more difficult to access. Doctors in Louisiana and Texas have also reported a rise in patients whose pregnancies are no longer viable receiving more risky and invasive terminations, such as Cesarean sections and inductions, in lieu of abortion procedures. It’s a change in practice some doctors involved in the anti-abortion movement endorse.

And in cases like Crowe’s — where death might not be imminent but failing to intervene could increase the risk for infection or other issues — some doctors are telling patients to finish their miscarriages at home.

“I think they were waiting for me to get in bad enough health,” said Crowe, who attributes her experience to Louisiana’s abortion ban, though she said no medical staff mentioned the law or responded to her requests for a D&C.

But waiting for patients’ conditions to worsen can sometimes be fatal, according to an ongoing investigation by ProPublica, which has reported on five deaths linked to abortion bans, most recently a young mom in Texas who spent hours in the ER but was never offered a D&C that could have saved her life.

As stories emerge linking abortion bans to adverse health effects, some state health departments are working to make these stories harder to learn about.

In Georgia, officials recently dismissed all 32 members of the state’s Maternal Mortality Review Committee following ProPublica’s reporting that the committee linked two women’s deaths to Georgia’s six-week abortion ban. The state said it would reset the committee through a new application process and is considering measures to ensure patient confidentiality.

In Texas, ProPublica reported that at least three women have died because of delays in care caused by the state’s abortion bans. Despite these reported deaths, Texas’ Maternal Mortality and Morbidity Review Committee said it wouldn’t examine any pregnancy-related deaths from 2022 and 2023, the first two years after the state’s near-total abortion ban took effect, according to the Washington Post.

Idaho, shortly after banning abortion, disbanded its Maternal Mortality Review Committee in 2023 after members recommended expanding Medicaid. The recently re-established committee is now backlogged and focused on publishing 2023 data in January before tackling 2022 data. The committee’s last report, based on 2021 data, showed the state’s maternal mortality rate had doubled in recent years and most of the deaths were preventable.

Crowe said her experience has moved her to speak out for better reproductive health care.

“For me to have a miscarriage for the first time, it’s already a very scary process,” said Crowe, who said she eventually got the care she needed outside of Louisiana. “You go to a hospital, you expect care, you expect some type of answers on what’s going on. And I didn’t get that.”

‘I had a sense it was because of the abortion laws’

Crowe and her husband, Noah Holesha, live on the Eglin Air Force Base in the Florida Panhandle. Crowe said her husband is in the Army and she was medically discharged from the military in 2023 and now works as a caretaker. The two married in 2022 and were expecting their first baby in February.

But on the way to LSU Health Lallie Kemp Medical Center in Independence, Louisiana, on Aug. 8, Crowe said she felt she would never get to meet this baby. Two weeks earlier, her 10-week-old fetus only measured 6 weeks. Now in the emergency room, Crowe said medical staff gave her pain medicine, cleared her blood clots, and discharged her to finish miscarrying naturally.

Two days later at her parents’ house, Crowe said she woke up with 10 out of 10 pain.

“I was in excruciating pain again, like screaming and crying pain,” she said.

She said her parents took her back to Lallie Kemp, where they transferred her to St. Tammany Parish Hospital Emergency Department in Covington, about a 45-minute drive, because it was the nearest hospital with a dedicated OB-GYN unit.

“Lallie Kemp Medical Center complies with federal patient privacy laws and therefore cannot discuss specific patients’ care,”  Dr. Matloob Rehman, the hospital’s medical director, said in an email. “Lallie Kemp is a small, rural hospital without a full complement of specialists, including obstetrical surgery. If a patient is in need of such care, it is Lallie Kemp’s practice to refer or transfer the patient to a hospital that can provide such services.”

At St. Tammany, Crowe said she spent the day receiving pain medicine and transvaginal ultrasounds and having her vaginal canal cleared of clots. Medical records Crowe shared with States Newsroom indicate she was given misoprostol to evacuate her uterus, which Crowe said she was not aware of. She said the ultrasounds were still showing she had not completed the miscarriage. Crowe’s cousin had recently miscarried, so she and her family knew to ask for a D&C.

“They did ultrasounds and all that, but they didn’t help make sure that the miscarriage was completing,” Crowe said. “We kept telling them, ‘Hey, can y’all just do this D&C, so like we can be done with this pain?’ They wouldn’t answer.”

Crowe’s sister, a nurse in Texas, where abortion is also banned, suggested in a text that maybe it was because of Louisiana’s abortion ban that she wasn’t being offered a D&C.

“I had a sense it was because of the abortion laws, because by the time they did the canal sweep of blood clots, they didn’t even want to listen that I was in pain anymore. They were like, brushing it off, like, you’ll be fine,” Crowe said. “Even if them not doing it was wasn’t because of the abortion laws, I still didn’t get the treatment that I needed.”

Crowe said she was still dizzy and in pain when St. Tammany released her late on Aug. 10. Her St. Tammany hospital medical records say her miscarriage was completed at St. Tammany, which Crowe disputes. Medical records from the hospital in Florida, where she received the D&C, say the patient had an “incomplete miscarriage with evidence of retained POC [products of conception] on TVUS [transvaginal ultrasound], continued bleeding and anemia.”

The St. Tammany Health System Communications Department declined to comment on Crowe’s account, citing patient confidentiality, and said in a statement: “At St. Tammany Health System, we place our patients and their families’ wellbeing first. Patient privacy rights are established by the Federal Health Insurance Portability and Accountability Act (HIPAA). In compliance with this act, we are not at liberty to provide information or comment.”

Crowe decided to drive the four hours back to Florida. She said her pain had ebbed, but soon after she got home, her husband rushed her to Eglin Air Force Base emergency department, where she said she received a D&C the following day.

The Eglin hospital did not respond to requests for comment.

Crowe said she was still dizzy in the weeks following, and she was confused and angry, believing — without confirmation — that she was denied health care she needed because of a new abortion law. She said she started reaching out to malpractice attorneys, reproductive rights groups, even President-elect Donald Trump.

“I sent everybody emails.” Crowe said. “I reached out to Congress. I reached out to the office of Trump. I reached out to lawyers. It wasn’t anger that I’ve lost the child — because I had a feeling I was going to lose the child — but it was the anger of they didn’t give their 100% care. I was getting in bad shape, health-wise, because of it.”

Louisiana abortion laws affect miscarriage care

Louisiana was one of the first states to ban abortion after the U.S. Supreme Court overturned Roe v. Wade in 2022. And it’s the first, followed by Texas, to reclassify two abortion and miscarriage medications — mifepristone and misoprostol — as controlled substances, even though they haven’t been shown to cause addiction or dependence. In late October, health care workers sued the state, arguing that the new law is unconstitutional and has added barriers to emergency care.

One of the legal advocacy groups representing plaintiffs in that case, Lift Louisiana, co-published a report with Physicians for Human Rights with detailed interviews from patients, doctors and clinicians of how the state’s abortion ban has changed reproductive health care in Louisiana. The report found that some OB-GYN practices are now deferring prenatal care until beyond the first trimester, when miscarriage care is more common. Some clinicians reported an increase in patient referrals from rural hospitals for routine care.

“To avoid the risk of criminal penalties under the bans, nearly every clinician relayed an account

in which they and/or their colleagues delayed abortion care until complications worsened to

the point where the patient’s life was irrefutably at risk,” the report reads.

Crowe said she was grateful she was able to get treated, not a given in Florida, which has a six-week abortion ban and where patients have also reported being denied miscarriage treatment. But she lives on a military base, under federal jurisdiction. With a soon-to-be GOP majority in Washington, D.C., anti-abortion activists are pushing Trump to restrict pregnancy termination at military hospitals.

Though she personally disagrees with abortion after the first trimester, Crowe said she now believes in abortion rights.

“Growing up, I was always pro-life, because I always wanted to have a kid and all that,” Crowe said. “I was also the type that’s like, I’m not going to judge you if you do. Now I’m like … the choice to have an abortion is important because some women … we need this procedure done to save our lives, too. My child was already lost; it lost its life. Because of the abortion laws, you’re keeping me from having my life. … I couldn’t grieve because I was in so much pain.”

Nasal Narcan, used to reverse an overdose, stock the inside of Milwaukee County's first harm reduction vending machine. (Photo | Isiah Holmes)

The Wisconsin Department of Justice has been awarded a $7 million grant from the U.S. Department of Justice to increase access to substance abuse treatment, the agency announced Friday. 

“Making treatment more accessible is important not only for those struggling with substance-use disorder but for public safety as well,” Wisconsin Attorney General Josh Kaul said in a statement acknowledging the grant. “This grant will allow for more to be done to help fight addiction.”

The Wisconsin DOJ was awarded the grant to implement the Wisconsin Deflection Initiative (WDI). The program aims to connect people struggling with substance use disorders to services before they have a crisis, an overdose or a criminal charge, according to the DOJ. 

Key components of the Wisconsin Deflection Initiative include self-referral and officer intervention programs, active outreach to at-risk individuals, better response to overdose incidents, comprehensive support services and coordination between law enforcement and treatment providers, the Wisconsin DOJ said. 

The program will be implemented across multiple Wisconsin jurisdictions and have a focus on urban, tribal and rural communities.

If programs like the Wisconsin Deflection Initiative lead to fewer people with a substance use disorder entering Wisconsin prisons, it would reduce strain on the state prison system’s programming. As of October, substance use disorder programming for incarcerated people had a waitlist of over 11,500. The Wisconsin Department of Corrections’ website says the agency tries to enroll individuals in programming close to their release date. 

“We would like to be able to serve every single person that we come into contact with at the highest level that they need in terms of intervention and more research,” Alisha Kraus, then-director of program services for adult prisons, said in an article published by PBS Wisconsin in June. “More resources would allow us to do that, more efficiently.” 

In the U.S. in 2022, nearly 108,000 people died from drug-involved overdose, including from illicit or prescription drugs. Drug overdose deaths in the United States have declined since then, but the fight against addiction continues. In Wisconsin, drug overdose deaths declined from 1,828 in 2022 to 1,771 in 2023. 

Funds directed toward fighting addiction in Wisconsin have included opioid settlement money from lawsuits against pharmaceutical companies. The Oneida Nation in northeast Wisconsin is considering an emphasis on prevention in the spending of $6.5 million in settlement money it estimates it will receive, to be allocated between 2020 and 2037, the Examiner reported last month. 

Transgender rights opponents and a supporter rally outside of the U.S. Supreme Court as the justices hear arguments in a case on transgender health rights on December 4, 2024 in Washington, DC. The Supreme Court is hearing arguments in US v. Skrmetti, a case about Tennessee's law banning gender-affirming care for minors and if it violates the Constitution’s equal protection guarantee. (Photo by Kevin Dietsch/Getty Images)

A conservative U.S. Supreme Court appeared ready to side with Tennessee Wednesday in upholding the state’s ban on gender affirming care for minors, a case likely to set legal precedent on equal protection for transgender children.

A decision from the court isn’t expected until June 2025, but Republican-appointed justices such as Samuel Alito, Clarence Thomas and Brett Kavanaugh tipped their hands on how they would rule during three hours of oral arguments in Washington, D.C.

They were countered by the court’s liberal justices, Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson, who are outnumbered 6-3.

Conservative justices appeared leery of creating a protected class, but Jackson, for instance, indicated the law clearly discriminates on the basis of sex. Jackson used the Loving v. Virginia case that allowed racially integrated marriages to show that similar arguments were made against those types of unions some 50 years ago.

Three families with transgender children and Memphis Dr. Susan Lacy sued the state, then the federal government intervened on behalf of the plaintiffs who are challenging Tennessee’s ban on puberty blockers and hormone therapy to allow minors to make a sex transition.

Thomas, for instance, asked the federal government’s attorney why the case would be a matter of age classification, as opposed to sex. Alito and Kavanaugh raised questions about the United Kingdom and European countries dialing back support for gender affirming care.

In addition, Roberts said the court is “not the best situated to address issues” such as gender affirming care and should allow legislatures to make those types of decisions.

Tennessee lawmakers passed Senate Bill 1 in 2023 following an uproar over reports by a right-wing radio commentator that Vanderbilt University Medical Center was performing surgeries and administering puberty blockers and hormone therapy to children. Vanderbilt said it wasn’t performing surgical procedures when the issue erupted.

Gov. Bill Lee says Tennessee has a “compelling interest in encouraging minors to appreciate their sex, particularly as they undergo puberty,” and in blocking treatments “that might encourage minors to become disdainful of their sex.

The American Civil Liberties Union, ACLU Tennessee, Lambda Legal and Akin Gump Strauss Hauer & Feld filed suit against Tennessee, claiming the equal protection rights of transgender children were violated. The law was struck down in U.S. District Court, but that decision was overturned by the 6th Circuit Court of Appeals, and the U.S. Supreme Court agreed to hear the case.

Tennessee’s legal strategy is based on the premise that the 2023 law prohibiting puberty blockers and hormone therapy for young people is based on “medical purposes,” not a child’s sex.

In contrast, attorneys for the plaintiffs said Senate Bill 1 created a blanket ban on gender affirming care based entirely on a minor’s desire to change sexes. They pointed out children suffering from gender dysphoria could be prone to suicide if they don’t receive puberty blockers or hormone treatments that enable them to start the transition toward a sex different from their birth sex.

Attorneys for the plaintiffs say the Supreme Court should give the matter “heightened scrutiny,” or a closer examination, because it involves discrimination against transgender children rather than review it under standard “rational basis,” which is typically used when a law doesn’t involve a constitutional right.

Elizabeth Prelogar, solicitor general for the Department of Justice, told the justices the state of West Virginia enacted a law that set up requirements for undergoing gender affirming care, whereas Tennessee passed a blanket ban affecting children seeking to transition to another sex.

Justice Kagan made the point that the law is based on “transgender status” and not sex alone. She also said Tennessee appears to want to “conform to sex stereotypes.”

Kavanaugh stuck with the argument that some transgender people want to switch back to their original sex when they get older but are physically unable to make the change.

“How do we as a court choose which set of risks is more serious when we constitutionalize?” Kavanaugh said.

Tennessee Lookout is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Tennessee Lookout maintains editorial independence. Contact Editor Holly McCall for questions: info@tennesseelookout.com. Follow Tennessee Lookout on Facebook and X.

Brian Thompson. Photo courtesy UnitedHealthcare.

UnitedHealthcare CEO Brian Thompson, 50, was shot and killed Wednesday morning outside the Hilton in midtown Manhattan, where he was set to address investors.

A manhunt is now underway for the gunman who police believe targeted Thompson in the shooting, although a motive remains unclear, according to the New York Times.

Thompson, a Minnesota resident, took the helm of UnitedHealth Group’s insurance division, one of the nation’s largest, in 2021.

He was walking into the hotel for UnitedHealth Group’s annual investor conference when he was shot in the chest by a masked man, who then fled on bicycle, CNN reported. Thompson was taken to Mount Sinai hospital, where he was pronounced dead.

The investor conference was abruptly canceled after the shooting.

“We’re dealing with a very serious… situation,” UnitedHealth Group CEO Andrew Witty said, according to PIX11. “We’re going to have to bring to a close the event today… I apologize for bringing things to a close but I hope you’ll understand.”

UnitedHealth Group is one of the largest corporations in the country, with $372 billion in revenue last year.

New York police commissioner Jessica Tisch called the killing a “brazen targeted attack.”

“This is horrifying news and a terrible loss for the business and health care community in Minnesota,” Gov. Tim Walz posted on X.

Minnesota Reformer is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Minnesota Reformer maintains editorial independence. Contact Editor J. Patrick Coolican for questions: info@minnesotareformer.com. Follow Minnesota Reformer on Facebook and X.

A National Institutes of Health Pediatric Oncology Branch POB researcher's lab jacket. The NIH consists of 27 different centers and institutes that each focus on health challenges facing Americans. President-elect Donald Trump announced Tuesday he would nominate Stanford University researcher Dr. Jay Bhattacharya to lead the wide-ranging agency. (Photo credit: NIH)

WASHINGTON — President-elect Donald Trump said Tuesday he has selected a Stanford University professor of health policy and skeptic of COVID-19 precautions to run the National Institutes of Health, the sweeping federal agency tasked with solving many of the country’s biggest health challenges.

Dr. Jay Bhattacharya will require Senate confirmation before taking over the role officially, but assuming he can secure the votes next year when the chamber is controlled by Republicans, he’ll have significant sway over where the federal government directs billions in research dollars.

“Dr. Bhattacharya will work in cooperation with Robert F. Kennedy Jr. to direct the Nation’s Medical Research, and to make important discoveries that will improve Health, and save lives,” Trump wrote in the announcement. Kennedy is Trump’s pick to lead the Department of Health and Human Services.

Bhattacharya posted on social media that he was “honored and humbled” by the nomination and pledged to “reform American scientific institutions so that they are worthy of trust again and will deploy the fruits of excellent science to make America healthy again!”

In addition to Kennedy, other Trump nominees for health-related positions include former TV personality and onetime Pennsylvania U.S. Senate candidate Mehmet Oz to lead the Centers for Medicare and Medicaid Services, former Florida Congressman Dave Weldon to run the Centers for Disease Control and Prevention, Dr. Marty Makary for commissioner of the Food and Drug Administration and Fox News medical contributor Dr. Janette Nesheiwat as the next surgeon general.

“Together, Jay and RFK Jr. will restore the NIH to a Gold Standard of Medical Research as they examine the underlying causes of, and solutions to, America’s biggest Health challenges, including our Crisis of Chronic Illness and Disease,” Trump wrote in his announcement.

Health economist

Bhattacharya received his undergraduate degree from Stanford University in 1990 before earning his medical degree from its School of Medicine in 1997 and a Ph.D. from the university’s Economics Department in 2000.

He focuses his research on health economics and outcomes, according to his curriculum vitae, the academic version of a resume.

Bhattacharya’s biography on Stanford’s website says that in addition to being a professor of health policy, he runs its Center for Demography and Economics of Health and Aging, in addition to working as a research associate at the National Bureau of Economics Research.

“Dr. Bhattacharya’s research focuses on the health and well-being of vulnerable populations, with a particular emphasis on the role of government programs, biomedical innovation, and economics,” according to the biography. 

Among his research areas is the “epidemiology of COVID-19 as well as an evaluation of policy responses to the epidemic.”

‘A fringe component’

Bhattacharya testified before the U.S. House Oversight Committee’s Select Subcommittee on the Coronavirus Pandemic in February 2023 that he believed there was “near universal agreement that what we did failed.”

“Official counts attribute more than one million deaths in the United States and seven million worldwide,” he said.

Bhattacharya was one of three authors of The Great Barrington Declaration in October 2020, arguing that younger, healthy people should have gone about their normal lives in an effort to contract COVID-19, since they were somewhat less likely to die than at-risk populations. 

The brief declaration says that “(a)dopting measures to protect the vulnerable should be the central aim of public health responses to COVID-19.” But it doesn’t list what those measures should include and never brings up masking, physical distancing, or vaccination.

Several public health officials and researchers rejected the declaration, noting that it didn’t cite any research, data or peer-reviewed articles.

Former NIH Director Francis S. Collins, who ran the agency from 2009 through 2021, told The Washington Post in October 2020 that the Barrington Declaration authors’ beliefs were not held “by large numbers of experts in the scientific community.”

“This is a fringe component of epidemiology. This is not mainstream science. It’s dangerous. It fits into the political views of certain parts of our confused political establishment,” Collins said in the Post interview. “I’m sure it will be an idea that someone can wrap themselves in as a justification for skipping wearing masks or social distancing and just doing whatever they damn well please.”

One of the many reasons public health experts recommended masking, working from home and physical distancing before there was a COVID-19 vaccine was to prevent patients from overwhelming the country’s health care system.

There were concerns during some of the spikes in COVID-19 infections that the country would have so many ill people at one time there wouldn’t be enough space, health care professionals or equipment to provide treatment.

Wide-ranging agency

The NIH is made up of 27 different centers and institutes that each focus on health challenges facing Americans.

The National Institute of Allergy and Infectious Diseases, formerly run by Dr. Anthony Fauci, became one of the more well known institutes during the COVID-19 pandemic, especially when he would regularly appear beside Trump at press briefings.

Other components at NIH include the National Cancer Institute, National Institute on Aging, National Institute of Neurological Disorders and Stroke, and the NIH Clinical Center that’s also referred to as America’s research hospital.

Congress approved $48 billion in discretionary spending for NIH during the last fiscal year, continuing a broadly bipartisan push that for years has increased funding to the agency to provide grants to research some of the most challenging diseases and illnesses facing Americans.

The current NIH director, Monica M. Bertagnolli, testified before Congress in early November about how the agency was working to rebuild trust following the pandemic.

Bertagnolli told U.S. House lawmakers the NIH was focusing some of its research on finding cures for rare diseases, since for-profit companies often don’t have the financial incentive to do so.

She also rejected the notion that NIH leaders have allowed politics to interfere with the agency’s mission.

“First and foremost, NIH concentrates on science, not on politics,” Bertagnolli said. “We actually have an integrity mandate against political interference in our work. That is the law for us and we abide by that completely.”

Oneida Nation General Manager Mark Powless. | Photo by Andrew Kennard

Oneida community members shared wrenching stories about loss and addiction during a community meeting last Thursday evening at the Oneida Nation’s Norbert Hill Center, near Green Bay, Wisconsin.

During the tribe’s community meal and discussion, one man said he was 16 when his brother died of an opioid overdose, and he has five nieces and nephews who don’t have a father. 

The Oneida Nation estimates it will receive about $6.5 million in opioid settlement payments between 2020 and 2037, according to an informational packet provided at the meeting. The money is the result of lawsuits against companies involved in manufacturing and selling opioids in the United States. People who attended the meeting spoke passionately about how the tribe should use the funds. 

Data from 2021 shows that Native Americans and Black people in Wisconsin were hit particularly hard by the opioid epidemic. Native Americans died of opioid overdoses at close to three times the rate of white people, according to the Wisconsin Department of Health Services. Historical trauma, high levels of unemployment and poverty contribute to the vulnerability of Native Americans to addiction.. A total of 1,427 people died of opioid overdoses in Wisconsin in 2021.

“We did a little analysis of individuals that had overdosed in our community, and I want to say that more than 90% of the individuals that overdosed left children behind,” Oneida Nation General Manager Mark Powless told the Examiner.

Oneida data in a packet provided at the meeting showed 20 overdose deaths between October 2022 and September 2023. For each quarter of that year, between 380 and 516 active patients  received substance abuse services. 

Nationally, in 2022, non-Hispanic American Indian and Alaska Native people died from drug overdoses at the highest rate of any racial or ethnic group.

Powless wasn’t surprised by the comments people made at the meeting, he said, but their testimony will contribute toward what the tribe is trying to do. He said he never gets used to hearing stories of losing a child, a parent or another family member to an overdose. 

“There was a few times tonight where I had to quickly regain my composure because it’s just so difficult to hear some of the things that people say and share,” he said. 

‘We want to prevent addiction, not simply treat addiction’ 

Powless told the Examiner about a concerning trend among children 5 years old and younger who are affected by drug abuse. He mentioned Head Start and Early Head Start programs, where staff are encountering families affected by substance abuse.

“Those areas are starting to encounter kids who are coming from homes where there’s either rampant substance use or a loss of a parent due to an overdose,” Powless said. “Or you have kids that were born addicted. So those kids are now entering into our programs and services, and that’s like a growing issue… We’re seeing more and more kids, and it’s more and more difficult to find spaces for them to get the services that they need.”

When you have conversations with the community about children who lost one or both parents to an overdose, you hear about those childrene experiencing challenges, including bullying, Powless said. 

There’s an understanding that only focusing on treatment means never overcoming the addiction problem, Powless told the crowd at the meeting. For the opioid settlement funds, the tribe is proposing an emphasis on prevention. Prevention is often underfunded, he said. 

Family-friendly events, programming in the school system and training about trauma and stigma are among ideas that could be funded by the settlement money. “We want to prevent addiction, not simply treat addiction,” Powless said. 

At the meeting, the man whose brother died from an overdose was disappointed to see the tribe not proposing spending more settlement funds on harm reduction. The only harm reduction proposal outlined would spend $5,000 on harm reduction kits in tribal vehicles. 

He expressed support for having Narcan, a medicine that can treat an opioid overdose, available in more areas in the community to prevent deaths. 

The Oneida Nation’s proposals for the settlement funds aren’t its only plans to prevent overdoses. Narcan is distributed through the Tribal Action Plan and behavioral health services, Powless said.    

“Yes, there is a need for vending machines, other ways to get even more [Narcan] out into the community,” Powless said. “But we haven’t talked about all of the work that is happening, and so some of that is missed in this conversation.”

How might the tribe use the funding?

The tribe has more ideas than it can pay for with the settlement funds and is continuing to add tothe list, Powless said at the meeting.  

There is not yet a final plan for how most of the money will be used, but there is agreement on a few items, he said. These include funding for future community meetings and  buying equipment for Oneida Nation High School students to develop anti-opioid multimedia content. 

“The youth voice and youth participation in this conversation has been really low, so we do want to get our youth engaged in this topic,” Powless said. 

One person at the meeting said that to her, providing transitional housing to people with nowhere to go should be a top priority. There are different models of transitional living the tribe might use to help people overcome substance abuse. 

One model is called “Housing First,” and it welcomes people still struggling with substance abuse and can be tricky to manage, Powless said. The idea is to satisfy a person’s basic needs, then help with recovery, he said.  

Powless isn’t sure if the tribe will go in that direction, but he said it will at the very least provide a safe and sober place to live for people coming out of treatment. This would aim to avoid scenarios where someone goes to treatment and then returns to an environment that may lead to relapse. 

“It’s really those early days of recovery [when] people need a lot of support,” Powless said. 

Some proposals are specific to Oneida culture. One idea Powless described involves people in recovery receiving training in the trades and then helping build a longhouse. Another idea involves hiring apprentices to learn the Great Law of Peace. One person does the majority if not all of the speaking for Oneida at Great Law recitals, Powless said, and the tribe doesn’t currently have people learning to replace him.

“The Great Law is one of the foundations for our culture,” Powless said, “one of the foundations for our community… We do need to pass on that information to other generations.”

State settlement money will help fight addiction 

The Oneida Nation may receive more opioid settlement funding from the state of Wisconsin. This would provide additional funding for a tribe that has more ideas about how to address addiction in the community than it can fund with its settlement money. 

Wisconsin is due to receive over $750 million through 2038 due to national litigation against the pharmaceutical industry, according to the Wisconsin Department of Health Services’ website. 

The state received about $31 million in opioid settlement payments in the state fiscal year 2023. (Wisconsin’s fiscal years run from July 1 to June 30 of each calendar year). Wisconsin’s 11 federally recognized tribes received $6 million for prevention, harm reduction, treatment and recovery services for tribal members. The Oneida Nation received over half a million dollars. 

Earlier this year, the Wisconsin Legislature’s Republican-controlled Joint Finance Committee passed a plan for using the state fiscal year 2025 payments. The state again allocated $6 million to the tribes. 

The Biden administration is proposing to cover drugs like Ozempic, which is used to treat heart disease, diabetes and obesity, under Medicare and Medicaid. (Photo illustration by Mario Tama/Getty Images)

WASHINGTON — The Biden administration announced Tuesday it’s reinterpreting federal law to allow Medicare and Medicaid patients access to anti-obesity medications to reduce their weight over the long term.

The Centers for Medicare and Medicaid’s proposed rule, which the Trump administration would need to finalize before it would take effect, is expected to cost $25 billion for Medicare combined with $11 billion in federal spending and $3.8 billion in state spending for Medicaid coverage throughout the next decade. 

CMS is encouraging states to submit comments to the proposed rule explaining when they could implement the Medicaid provision, since that health care program includes cost sharing between federal and state governments.

Medicare is the federal health insurance program for people 65 and older and some younger people with certain disabilities or conditions. Medicaid provides health care to some low-income individuals.

“People with obesity deserve to have affordable access to medical treatment and support, including anti-obesity medications for this disease; just as a person with type two diabetes can access these medications to get healthy,” CMS Administrator Chiquita Brooks-LaSure said on a call with reporters. “That’s why we’re proposing to revise our interpretation of the law and provide coverage of anti-obesity medications for the treatment of obesity.”

Brooks-LaSure said CMS was reinterpreting the law to view obesity as a chronic condition, which the agency believes provides a pathway for Medicare and Medicaid to cover anti-obesity medications.

“The medical community today agrees that obesity is a chronic disease,” Brooks-LaSure said. “It is a serious condition that increases the risk of premature death and can lead to other serious health issues, such as heart disease, stroke and diabetes.”

More than 40% of Americans have obesity and CMS data shows 22% of Medicare recipients were diagnosed with obesity during 2022, double the number from 10 years ago, she said.

CMS wrote in a fact sheet about the proposed rule that since creation of the Medicare Part D program, which provides prescription drug coverage, the agency has “interpreted the statutory exclusion of ‘agents when used for weight loss’ to mean that a drug, when used for weight loss, is excluded from the definition of a covered Part D drug.”

Trump and RFK Jr.

President-elect Donald Trump hadn’t commented on the proposal as of late Tuesday morning, but his planned nominee for Health and Human Services secretary, Robert F. Kennedy Jr., has repeatedly criticized newer weight loss drugs like Ozempic.

Kennedy was skeptical of studies showing the benefits of weight loss drugs during an appearance on Fox News last month, arguing the federal government would spend less money if it provided healthy meals to all Americans instead of coverage for weight loss drugs. 

“If we spent about one-fifth of that giving good food, three meals a day, to every man, woman and child in our country, we could solve the obesity and diabetes epidemic overnight,” Kennedy said.

CMS expects that about 3.4 million people in the Medicare program would become eligible for anti-obesity medication coverage under the proposed rule that would take effect in 2026 if Trump decides to finalize it.

Dan Tsai, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said during the call the agency hopes states submit comments in the weeks and months ahead detailing “when states would be required to implement this provision.”

“We note in the rule that the rule reinterprets the Medicaid statute, which means this would govern all Medicaid programs,” Tsai said. “But we specifically invite comment on a range of implications and timing for states.”

Cost differs in CBO report

The total cost of the program during the next decade that CMS provided on the call for Medicare was somewhat different from a cost estimate the Congressional Budget Office released last month. CBO is a government agency that provides nonpartisan budget information to Congress.

CBO projected it would cost the federal government $35 billion between 2026 and 2034 to cover anti-obesity medications for Medicare patients.

“Relative to the direct costs of the medications, total savings from beneficiaries’ improved health would be small—less than $50 million in 2026 and rising to $1.0 billion in 2034,” CBO wrote in the analysis.

The report explained that Medicare currently covers “some obesity-related services, including screening, behavioral counseling, and bariatric surgery (a procedure performed on the stomach or intestines to induce weight loss).”

While Medicare does cover anti-obesity medications for recipients with diabetes or cardiovascular disease, CBO wrote, Medicare “is prohibited by law from covering medications for weight management as part of the standard prescription drug benefit.”

The CBO report didn’t include a cost estimate for Medicaid, but noted that weight management drug coverage within that program is optional.

“According to one study, of the 47 states with publicly available lists of preferred drugs, nine had Medicaid programs that covered Wegovy in the first quarter of 2023.”

The National Governors Association and National Conference of State Legislatures both declined to comment on the proposed rule and its effect on state Medicaid programs.

A phamacy student in California administers a TDaP vaccine to prevent whooping cough. Wisconsin public health officials are recommending people check their immunity status and get a vaccine as pertussis cases surge. (Justin Sullivan | Getty Images)

Cases of pertussis — “whooping cough” — have surged in Wisconsin this year, prompting public health officials to reiterate the importance of vaccination and prompt attention to signs of illness.

Wisconsin has reported 1,887 confirmed cases of pertussis as of Nov. 22 this year, according to the state Department of Health Services (DHS) — compared with 51 for all of 2023, and more than three times the state’s last peak year in 2019.

“It’s not unusual to see a spike in cases in any given year, but this is a significant jump,” DHS spokesperson Jennifer Miller said Tuesday in an email message. “We are encouraging people to get pertussis vaccines and to use good hygiene habits to avoid catching and spreading the illness.”

Pertussis is a bacterial upper respiratory illness that spreads easily. It tends to start with a runny nose and a scratchy throat, but after about a week patients develop a persistent cough that can last for weeks.

Pertussis case counts often run in cycles, “so we’ll have years with high case counts and years with fairly low case counts,” Miller said.

In Dane County alone, there have been 281 cases through Monday, Nov. 25, Public Health Madison & Dane County (PHMDC) reported Tuesday. Since 2000, Dane County has reported two peak years for the respiratory illness, with 436 cases for all of 2004 and 302 cases for all of 2012.

By contrast, the county has had case counts as low as 7 for all of 2018, 13 for all of 2019, 0 for 2021 and 2022 and 4 for 2023, according to PHMDC records.

“With the holidays approaching, many families will be traveling and gathering with friends and family,” said Amanda Kita-Yarbro, the county health department’s public health epidemiologist. “This could increase the spread of all respiratory illness, including pertussis, which has been primarily impacting teenagers and college-aged people in recent months.”

Wisconsin’s last peak year for pertussis infections was 2019, when there were 535 cases reported across the state. This year both the state and the county first reported a sharply higher number of cases in July.

Ajay Sethi, faculty director of the Masters in Public Health program at the UW-Madison School of Medicine and Public Health, said Tuesday several factors underlie this year’s surge in cases.

One is lagging rates in pertussis vaccinations. “Under-immunization … was the main reason for our vulnerability for the outbreak we have had this year,” Sethi told the Wisconsin Examiner in an email message.

While pertussis vaccines are available and recommended for people of any age, in October, the Centers for Disease Control and Prevention reported a downturn in childhood vaccination nationwide and particularly in Wisconsin.

According to the report, the rate of childhood vaccination with the DtaP shot — providing combined protection from  diphtheria, tetanus and pertussis — was 85.7% for the 2023-24 school year in Wisconsin — second to lowest among all states. The CDC has set a target for vaccination rates of at least 95% for children entering kindergarten.

The CDC reported that 8% of Wisconsin kindergarteners were granted an exemption from the state’s vaccine requirements overall.

Sethi said the bacteria responsible for pertussis is highly contagious and difficult to stop from spreading. Adults who become infected “may think they just have a cold, so they don’t seek health care immediately, if at all, and spread it to other people (who are likely not up to date on their vaccination),” he added.

There isn’t a rapid test for pertussis, and test results take a couple of days to confirm a diagnosis, Sethi said. Physicians “may rightfully be hesitant to prescribe antibiotics without confirming the cause,” he added.

In July, Dr. James Conway, a UW Health specialist in childhood infectious diseases, told the Wisconsin Examiner that the signature “whoop” coughing sound that gives pertussis its nickname is generally confined to young children, who are also the most vulnerable to the illness.

People of any age can become infected, however, and public health specialists are advising people to take precautions to help prevent its spread, especially to children. Those precautions include getting vaccinated for pertussis, washing hands and covering coughs and sneezes.