At MedStar Washington Hospital Center, doctors and nurses are moving as many patients as they can from intravenous medications to the same drugs in pill form.

If the patients are getting common antibiotics like ampicillin, and they can swallow, they’re likely to be switched to pills, says Bonnie Levin, assistant vice president of pharmacy services for MedStar Health, which includes 10 hospitals in the Washington, D.C. area.

That’s because MedStar, like many hospitals across the U.S., is running low on IV bags, especially the minibags that are used to deliver certain types of medicine. Some of these bags contain saline solution when shipped, and a nurse or hospital pharmacist adds in the drug when it’s ready to be used. Other bags come pre-mixed with commonly used medicines.

“The plain bags, the mixed bags. There are shortages of all kinds of small-volume medications,” Levin says.

The shortage is a direct result of the hurricane damage in Puerto Rico. It’s been eight weeks since Hurricane Maria hit the island, knocking out electricity and wreaking havoc on many roads, homes and other buildings.

The storm damaged many of the island’s more than 100 drug and medical device manufacturers. Puerto Rico produces about $40 billion worth of pharmaceuticals for the U.S. market, according to the Food and Drug Administration — more than any other state or territory.

Three of those plants belong to Baxter, one of the biggest suppliers of IV bags to U.S. hospitals. All three of Baxter’s plants shut down temporarily, the company says, and at least two are still running on generators.

One of Baxter’s factories that makes the minibags for intravenous medicines is very remote.

“It’s atop a mountain, and the roads have been very compromised. They are still running on generators the last we knew, and they are at partial capacity,” says Kristi Guest, who runs the disaster response team for Vizient, a company that, among other things, sources medical supplies for hospitals all over the U.S.

And Baxter isn’t the only company on the island struggling to meet demand.

“The manufacturing environment in Puerto Rico, as far as we are informed, is largely still running on generators — compromised capacity,” Guest says.

Dr. Scott Gottlieb, commissioner of the Food and Drug Administration, said in a speech at the National Press Club on Nov. 3 that most of the plants are operational.

But getting back to normal “is a monumental task given the logistical challenges they face,” he told reporters.

So the manufacturers are rationing the medications and supplies that they do manage to make. The idea is to prevent any one hospital from buying up the entire supply.

For example Baxter has restricted distribution of IV bags to 50 percent of a hospital customer’s usual order, according to Vizient and MedStar.

And Levin says the hospital isn’t even receiving that much.

“I don’t think we’re getting 50 percent, but we’re getting sporadic shipments,” she says. “We used to get shipments every week. One of our hospitals got five cases of IV bags yesterday, and it was an order they had placed a month ago.”

The shortage has become severe enough that the FDA is allowing Baxter to import minibags, amino acids and other products from its plants in Ireland, Australia, Canada, Mexico and England.

The FDA updates its list of medication shortages regularly and many products have been added since Maria hit Puerto Rico. But it’s impossible to know exactly which shortages are linked to disruptions on the island.

Stephanie Hale also works at Vizient, helping the company’s hospital clients manage how they use products that are in short supply

She says she and her colleagues are trying to change how hospital emergency rooms think about the use of IVs.

“Every patient that came into the emergency department, that was admitted to a unit, automatically was placed on fluids to maintain hydration,” she says. “But what we’ve been suggesting to our members more recently and is that they evaluate the actual need and assess patients more specifically and accurately for IV solutions.”

In Washington, D.C., Medstar’s Levin says her hospital has been able to manage the shortages, so far.

“We’re really fortunate in that we haven’t disrupted patient care,” Levin says. “If this went on for two years, I’d have some concerns. We expect supply to return in three to six months.”

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Senate Republicans now plan to try to repeal the Affordable Care Act’s individual mandate as part of a tax overhaul bill.

Several Senate Republicans said Tuesday that including the repeal in tax legislation, currently making its way through a key Senate committee, would allow them to further reduce tax rates for individuals without adding more to the deficit.

The decision was a rapid change of direction for Republicans, who previously believed it would be politically dangerous to add any health care measure to the tax legislation.

Senate Majority Leader Mitch McConnell told reporters Tuesday that members of the Senate Finance Committee believe tacking on the repeal will ensure the bill has sufficient votes to pass when it comes up for a vote in the Senate.

“We’re optimistic that inserting the individual mandate repeal would be helpful,” McConnell said, “and that’s obviously the view of the Senate Finance Committee Republicans as well.”

The Congressional Budget Office said last week that such a repeal would reduce federal deficits by $338 billion over the next 10 years, which would help the GOP avoid exceeding a $1.5 trillion cap on how much the tax bill can add to the deficit over the same time period. The repeal would also increase the number of uninsured by 13 million by 2027, according to the CBO.

Sen. John Thune, R-S.D., a top McConnell deputy, said the savings from the repeal would give Republicans more room to cut taxes for the middle class.

“It will be distributed in the form of middle-income tax relief,” Thune said. “It will probably mean adjusting the rate structure as we have today. We’ll probably still have seven brackets, but they would be at different rates.”

Asked if he was confident such a bill could pass, Thune said yes, adding that leaders had already “whipped” the bill, meaning they already know how their colleagues will vote.

Not all Republicans agree with the decision. Moderate Sen. Susan Collins, R-Maine, said she had not decided how she will vote on the tax bill, but she worries that ending the individual mandate could increase health care premiums.

“I personally think it complicates tax reform to put the repeal of the individual mandate in there,” Collins said. “I’m going to wait and see what the bill says.”

But adding it in could appeal to other skeptics of the legislation, including Sen. Rand Paul, R-Ky., who supports the individual mandate repeal.

The Senate Finance Committee is expected to release an updated version of the legislation Tuesday evening. The committee plans to approve the bill later this week in hopes of holding a vote in the full Senate before Thanksgiving.

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Helen Nez had 10 children. Now she only has three.

Seven of her children died of a disorder called Navajo neuropathy, which is linked to uranium contamination.

“Many people died and some have liver disease, kidney disease and some suffer from cancer as a result,” Nez said through a translator.

When she was pregnant, Nez and her children drank from a spring, located on Navajo Nation in northeastern Arizona, with uranium levels at least five times greater than safe drinking water standards, according to a study published in the journal Environmental Science & Technology in 2015.

Four of her children died as toddlers. Three died in early adulthood. Their stomachs became bloated, and their eyes turned a cloudy gray. The three remaining children, now adults, have health problems.

“It is worrisome and troublesome, and you hope that something will be done,” Nez said.

In a new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, more than 1 in 4 Native Americans say the quality of their drinking water is worse than in other places.

From 1944 to 1986, mining companies blasted 30 million tons of uranium out of Navajo land. When the U.S. Energy Department had stockpiled enough for the Cold War, the companies left, abandoning 521 mines. Since then, many Navajo have died of conditions linked to contamination.

Nez’s sister Sadie Bill drives out to an abandoned uranium mine called Claim 28. Along the way, she points to the site of her neighbor’s home that was so contaminated it had to be hauled away.

“She passed on about 2 1/2 years ago,” Bill said. “And this one over here, she was on dialysis. And she passed on, oh, eight, nine months ago.”

We drive by four more homes where people have died.

“People on the outside world say, ‘What’s wrong with you? Get out of there. Move!’ ” said Chris Shuey, the director of uranium impact assessment at Southwest Research and Information Center. “That’s not economically or culturally feasible. People have been captive to these exposures now for three generations.”

Shuey, an environmental health scientist, has been studying the impacts of uranium mining on the Navajo people for almost four decades. He points out that Navajos are connected by tradition to the land. When a Navajo baby is born, the umbilical cord is buried in the ground, tying them to that place forever.

The community and many others like it want to know why it’s taking the federal government so long to clean up the abandoned mines.

In the NPR poll, 39 percent of Native Americans say discrimination based in laws and government policies is a bigger problem than discrimination based on individuals’ prejudice.

“The slow pace of cleanup is directly related to the law, itself,” Shuey said. “The law places more importance on the relationship between EPA and the companies that caused the problem than it creates a right of sitting at the table of the local affected community. And so on Navajo, that is institutional racism.”

In this case, Shuey said the policies of the Energy Department, the Environmental Protection Agency and the tribe have hurt the Navajo people.

Of the 521 abandoned mines, the EPA has only cleaned up nine so far. And Shuey says cleanup presents a lot of challenges.

“There’s not a lot of places to take this stuff to,” Shuey said. “You invariably put it in somebody else’s backyard.”

The EPA said in a statement that the federal government has reached settlements valued at $1.7 billion with mining companies — enough to clean up about 40 percent of the abandoned mines.

“The EPA is really caught between a rock and a hard place,” said University of New Mexico toxicologist Matt Campen, who is studying the air quality surrounding abandoned mines. “They get attacked by both advocacy groups for not doing enough and by industry for doing too much.”

Campen said it comes down to allocation of resources and authority to get things done. A Navajo group is currently evaluating the cost to remediate the mine near Helen Nez and her sister Sadie Bill’s home.

“We lost too many people,” Bill said. “We don’t want our future young people to have to go through this again.”

At the current rate, it would take multiple generations for the Navajo to be free of uranium contamination. For this family and for many others though, it’s already too late.

Our ongoing series, “You, Me and Them: Experiencing Discrimination in America” is based in part on a poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. We have previously released results for African-Americans, Latinos and whites so far. In coming weeks, we will release results for LGBTQ adults, Asian-Americans and women.

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A California judge could decide Tuesday if Gloria Single will be reunited with her husband, Bill. She’s 83 years old. He’s 93. The two have been married for 30 years. They lived in the same nursing home until last March, when Gloria Single was evicted without warning.

Her situation isn’t unique. Nationwide, eviction is the leading complaint about nursing homes. In California last year, more than 1,500 nursing home residents complained that they were discharged involuntarily. That’s an increase of 73 percent since 2011.

Gloria Single has a number of ailments. One of them is Alzheimer’s disease. So when her son Aubrey Jones comes to visit her in her new nursing home, he brings old photos to show her. She can still recognize faces from long ago — one picture shows her three sons when they were just little kids.

Jones says the photograph makes him and his brothers look like real troublemakers. “You are troublemakers,” his mom teases.

Jones also shows his mother a more recent photo. It was taken at Pioneer House, the nursing home where Gloria Single and her husband Bill lived together before her eviction. They’re gazing into each other’s eyes and smiling.

When Jones tells her he loves that photo, Gloria Single slyly replies that’s “because [Bill’s] got his hand on my knee.”

In court documents, Pioneer House paints a more troubling picture of Gloria Single. They say that she became aggressive with staff and threw some plastic tableware. So Pioneer House called an ambulance and sent her to a hospital for a psychological evaluation. The hospital found nothing wrong with her, but the nursing home wouldn’t take her back. They said they couldn’t care for someone with her needs.

Jones protested his mother’s eviction to the California Department of Health Care Services. The department held a hearing. Jones won.

“I expected action — definitely expected action,” says Jones.

Instead, he got an email explaining that the department that holds the hearings has no authority to enforce its own rulings. Enforcement is handled by a different state agency. He could start over with them.

This Catch-22 situation attracted the interest of the legal wing of the AARP Foundation. Last year, attorneys there asked the federal government to open a civil rights investigation into the way California deals with nursing home evictions. Now, they’re suing Pioneer House and its parent company on Gloria Single’s behalf. It’s the first time the AARP has taken a legal case dealing with nursing home eviction.

“We certainly hope we can get Mrs. Single some relief,” says William Alvarado Rivera, the foundation’s senior vice president for litigation. “But we also hope that there is a lesson to be learned by facilities — that there will be accountability for their failure to respect the due process rights of their residents.”

Nursing home residents have a lot of rights guaranteed in state and federal law. For example, they have to be given 30 days’ notice before they’re moved involuntarily. And the nursing home has to hold their bed for a week if they’re in the hospital.

Rivera says Gloria Single didn’t get any of that. As a result, she was stuck in the hospital for four and a half months before being accepted by another facility. During that time Single received none of the services and activities she would have had in a nursing home. She lost her ability to walk and now relies on a wheelchair.

Rivera says that “in the absence of state enforcement, it will depend on individuals like Mrs. Single having to advocate for themselves to get their rights respected and enforced.”

Fourteen years of public records obtained by NPR show that nursing homes rarely pay a price for illegally evicting residents. Just 7 percent of nursing homes that were found to have violated the law in California were fined by the state. With just a couple of exceptions, the highest fines assessed were $2,000. The majority were $1,000 or less — and most fines were never paid in full.

Diana Dooley, California’s secretary of health and human services, declined NPR’s request for an interview, citing pending litigation against the state on a similar issue.

Frustration with the lack of state enforcement led the California Long-Term Care Ombudsman Association to join the Single lawsuit as a co-plaintiff. The organization represents long-term-care ombudsmen. Those are the public officials who track complaints about nursing homes and advocate for residents. But Leza Coleman, the group’s executive director, says the spike in complaints about evictions is so overwhelming, that it’s “impacting our ability to handle other complaints.”

Coleman believes another reason that eviction complaints are going up, is that the number of nursing homes is going down. State records show there are about 2,300 fewer beds in California than there were six years ago.

“Those residents that are more challenging — those that have to be repositioned often, those that don’t want to sit quietly and watch television — … they’re more expensive,” she says. “They can be very taxing on the staff of a facility, and if a facility has one bed and two people looking at it, they’re going to take the person that’s easier to care for.”

But eviction complaints need to be seen in a different context, says Jim Gomez, CEO of the California Association of Health Facilities. “We have a very low rate of complaints regarding discharge,” he says, adding that roughly 1,500 complaints is “less than a half of 1 percent of some 300,000 discharges” a year.

And when residents are involuntarily discharged, Gomez says, “it’s for the safety of staff and other residents.

“We’ve had many attacks on residents and staff,” he says. “Are you going to allow that person back to the facility?”

Pioneer House and its parent corporation, the Retirement Housing Foundation, declined to be interviewed for this story. They sent a written statement which says, in part, “We intend to vigorously defend the allegation set forth in the lawsuit.”

Meanwhile, Aubrey Jones says the lawsuit is not just about his mother any more.

“If anything,” he says, “I want the dial to be turned a little bit so this thing doesn’t happen again —[so] it’s less likely to happen to someone else.”

Most of all, Jones says, he wants to see his mother and stepfather reunited, so they can be together for the little bit of time they have left.

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Updated at 1:48 p.m. ET

President Trump is nominating a former pharmaceutical executive to lead the Department of Health and Human Services, the agency that, among other things, regulates prescription drugs.

The nomination comes at a time when rising drug prices have become a hot political issue.

On Twitter on Monday, Trump announced the nomination of Alex Azar, who until January had served as president of the U.S. arm of Eli Lilly & Co., based in Indianapolis. He said Azar, whose own Twitter feed is private, would be “a star for better healthcare and lower drug prices.”

Azar, who served as deputy HHS secretary under President George W. Bush, is known as a detail-oriented bureaucrat who understands how to work the regulatory system to get things done.

“He’s precise, highly motivated, he has high standards for performance for himself and for other people,” said Mike Leavitt, who was HHS secretary when Azar was deputy. “He had full responsibility as deputy secretary for the regulatory processes at HHS.”

Leavitt says Azar is likely to use that knowledge to alter the Affordable Care Act, or Obamacare, to make it more friendly to Republican ideals. Azar, he says, can work to “change the ideology under which the existing law is implemented.”

“That’s the place where they have essential unilateral authority, if they follow the administrative rules act,” Leavitt told Shots. “Alex understands that process better than almost anybody and that undoubtedly had some bearing on the president’s decision to appoint him.”

Azar also favors moving authority to the states over Medicaid, the program that provides health care to the poor, elderly and disabled. That means turning over the program to the states to make them “better stewards of the money,” he said in an interview at a February conference on YouTube. “It turns these sovereign states and governors from supplicants to the HHS secretary into people running their own health insurance system for the poor.”

He said at the time that HHS could use its regulatory powers to allow states to customize the rules around Medicaid. Seema Verma, who runs the Centers for Medicare & Medicaid Services and would work for Azar if he’s confirmed, has said she, too, favors giving states waivers to create their own Medicaid systems.

Where Azar stands on drug prices is less clear. President Trump said after his election and before his inauguration that he wants the government to work to lower drug prices and that he wants the Medicare program to use its buying power to negotiate better prices.

Since then, the president hasn’t said much specifically on the subject. But he did mention it when he announced his intention to nominate Azar on Twitter.

Azar spent five years at Lilly, which makes several blockbuster medications, including Cialis, which treats erectile dysfunction; the antidepressant Cymbalta; and several forms of insulin. Insulin prices have drawn particular fire because they keep spiraling higher, even though insulin has been around almost a century.

The prices of Lilly’s insulin drugs Humalog and Humulin, for instance, have both risen about 225 percent since 2011, according to data from the investment research firm Bernstein.

“Drug corporations have undue influence over health policy in America, and they use it to make money on the backs of patients and taxpayers,” said Ben Wakana, executive director of Patients For Affordable Drugs, an advocacy group.

Still, Wakana says Azar has a good track record. “Mr. Azar is well-qualified and has the chance to stand up for patients because he knows exactly how our drug pricing system is broken. If he wants to take meaningful action to lower drug prices, we want to help him.”

While Azar was at Lilly, he also sat on the board of directors of the Biotechnology Innovation Organization, a trade group for biotech companies. Previously, Azar served as general counsel and later as deputy secretary of Health and Human Services during the George W. Bush administration.

If he’s confirmed, Azar would replace Dr. Tom Price, who resigned from HHS in September after a Politico investigation found that he had taken private charter aircraft on work-related trips at times when cheaper commercial flights were available.

Azar, a lawyer, would take over one of the largest federal agencies with an annual budget of more than $1 trillion. The department runs the Medicare and Medicaid programs, is responsible for implementation of the Affordable Care Act and oversees the National Institutes of Health and the Food and Drug Administration.

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As the administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

On Tuesday, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

A study from the Urban Institute may shed some light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

Since graduating from college more than 20 years ago, Wilson has mostly had to pay out of pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson says.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with deeply discounted rate from a nearby hospital, she can’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson says. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as their illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golbertstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7 percentage point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points between 2012 and 2015.

Medicaid, as opposed to private insurance, is the key, says The Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, there aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect that their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell says.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the Administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma says that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what of we’re seeing in our paper,” Caswell says. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she says she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she says.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson says. “It’s hard losing your dreams.”

This story is part of a reporting partnership with NPR, KCUR and Kaiser Health News. Alex Smith can be reached on Twitter at @AlexSmithKCUR.

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