For nurses Kristin Sollars and Marci Ebberts, work is more than just a job.

“Don’t you feel like you’re a nurse everywhere you go?” Sollars, 41, asked Ebberts, 46, on a visit to StoryCorps in May.

“I mean, let’s be honest, every time we get on a plane you’re like, E6 didn’t look good to me. Keep an eye out there.”

Sollars and Ebberts have grown so close while working together that they’ve come to call themselves “work wives.” They first met in 2007, working side by side in the intensive care unit at Saint Luke’s Hospital in Kansas City, Mo.

Now they work closely as nurse educators at the hospital training other nurses in critical care.

“Between us, we’ve taken care of thousands of critically ill patients,” Ebberts said. “You carry a little bit of them with you. And they shape you.”

Sollars and Ebberts reflect on how their work influences their memories.

“When I think about that patient, that is the most seared in my brain, I know exactly what bed but I cannot tell you the patient’s name,” Sollars said. She goes on to remember a particularly unforgettable case: “I always think about CCU (Coronary Care Unit) Bed 2.”

The patient had a cardiac arrest. “We code him, and we get that heart rate back,” she said, describing their resuscitation efforts that stabilized the patient.

“And that was just the first of a dozen times that he coded,” Ebberts remembered.

All the while, his wife was by his side.

“We were giving her the bad prognosis. Things were looking really bad, and she said, ‘Can I be in bed with him?’ ” Sollars said.

But the nurses saw that as a risk. “This man’s got everything we’ve got in the hospital attached to him,” Sollars recalled.

“So many wires and tubes and monitors,” Ebberts added.

Still, they proceeded carefully, slowly lifting everything so she could wiggle in next to him.

“I can just remember her sobbing, saying, you know, I wasn’t a good enough wife. I should have loved you better,” Sollars said.

When the patient again suffered an irregular, life-threatening heart rhythm called ventricular fibrillation, Sollars and Ebberts started another round of chest compressions.

But this time, the patient’s wife asked the nurses to stop trying to resuscitate him. “We’re gonna let him go next time he does that,” Ebberts remembers his wife saying.

As difficult as they can be to witness, Sollars says the rewarding part as a nurse is caring for patients and their families during these crucial life moments.

“To be with people and to create those environments where they get to say their unfinished business to their husband — it’s such a gift of a job,” Sollars said. “Sometimes I wonder why everyone in the world doesn’t want to be a nurse.”

Sollars says nursing levels her sense of what’s important.

“It does impact the way we see the entire world. That person in front of us in the grocery store is all worked up about how that guy bagged their groceries,” she said.

“Nobody’s dying,” Ebberts said, “until someone is. And then we’re ready.”

Audio produced for Morning Edition by Aisha Turner and Camila Kerwin.

StoryCorps is a national nonprofit that gives people the chance to interview friends and loved ones about their lives. These conversations are archived at the American Folklife Center at the Library of Congress, allowing participants to leave a legacy for future generations. Learn more, including how to interview someone in your life, at StoryCorps.org.

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From a planning perspective, Wolfgang Balzer is the perfect health care consumer.

Balzer, an engineer, knew for several years he had a hernia that would need to be repaired, but it wasn’t an emergency, so he waited until the time was right.

The opportunity came in 2018 after his wife, Farren, had given birth to their second child in February. The couple had met their deductible early in the year and figured that would minimize out-of-pocket payments for Wolfgang’s surgery.

Before scheduling it, he called the hospital, the surgeon and the anesthesiologist to get estimates for how much the procedure would cost.

“We tried our best to weigh out our plan and figure out what the numbers were,” Wolfgang said.

The hospital told him the normal billed rate was $10,333.16, but that Cigna, his insurer, had negotiated a discount to $6,995.56, meaning his 20% patient share would be $1,399.11. The surgeon’s office quoted a normal rate of $1,675, but the Cigna discounted rate was just $469, meaning his copayment would be about $94. (Although the Balzers made four calls to the anesthesiologist’s office to get a quote, leaving messages on the answering machine, no one returned their calls.)

Estimates in hand, they budgeted for the money they would have to pay. Wolfgang proceeded with the surgery in November, and, medically, it went according to plan.

Then the bill came.

The patient: Wolfgang Balzer, 40, an engineer in Wethersfield, Conn. Through his job, he is insured by Cigna.

Total bill: All the estimates the Balzers had painstakingly obtained were wildly off. The hospital’s bill was $16,314. After the insurer’s contracting discount was applied, the bill fell to $10,552, still 51% over the initial estimate. The contracted rate for the surgeon’s fee was $968, more than double the estimate. After Cigna’s payments, the Balzers were billed $2,304.51, much more than they’d budgeted for.

Service provider: Hartford Hospital, operated by Hartford HealthCare

Medical procedure: Bilateral inguinal hernia repair

What gives: “This is ending up costing us $800 more,” said Farren, 36. “For two working people with two children and full-time day care, that’s a huge hit.”

When the bill came on Christmas Eve 2018, the Balzers called around, trying to figure out what went wrong with the initial estimate, only to get bounced from the hospital’s billing office to patient accounts and finally ending up speaking with the hospital’s “Integrity Department.”

They were told “a quote is only a quote and doesn’t take into consideration complications.” The Balzers pointed out there had been no complications in the outpatient procedure; Wolfgang went home the same day, a few hours after he woke up.

The couple appealed the bill. They called their insurer. They waited for collection notices to roll in.

Hospitalestimates are often inaccurate and there is no legal obligation that they be correct, or even be issued in good faith. It’s not so in other industries. When you take out a mortgage, for instance, the lender’s estimate of origination charges has to be accurate by law; even closing fees — incurred months later — cannot exceed the initial estimate by more than 10%. In construction or home remodeling, while estimates are not legal contracts, failure to live up to them can be a basis for liability or a “claim for negligent misrepresentation.”

In this case, Hartford Hospital produced an estimate for Balzer’s laparoscopic hernia repair, CPT (current procedural terminology) code 49650.

The hospital ran the code through a computer program that produced an average of what others have paid in the past. Cynthia Pugliese, Hartford Health’s vice president of revenue cycle, said the hospital uses averages because more complicated cases may require additional supplies or services, which would add costs.

“Because it was new, perhaps the system doesn’t have enough cases to provide an accurate estimate,” Pugliese says. “We did not communicate effectively to him related to his estimate. It’s not our norm. We look at this experience and this event to learn from this.”

Efforts to make health care prices more transparent have not managed to bring down bills because the different charges and prices given are so often inscrutable or unreliable, says Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School.

“The charges on there don’t make any sense. All it does is, people get pissed off,” Mehrotra said. “The charge has no link to reality, so it doesn’t matter.”

Resolution: “Because I roll over more easily than my wife does, I’m of the mindset to pay it and get done with it,” Wolfgang said. “My wife says absolutely not.”

Investigating prices, dealing with billing departments and following up with their insurer was draining for the Balzers.

“I’ve been tackling this since December,” Wolfgang says. “I’ve lost two or three days in terms of time.”

For the Balzers, there’s a happy ending. After a reporter made inquiries about the discrepancy between the estimate and the billed charges — six months after they got their first bill — Pugliese told them to forget it. Their bill would be an “administrative write-off,” they were told.

“They repeatedly apologized and ended up promising to adjust our bill to zero dollars,” Wolfgang wrote in an email.

The takeaway: It is a good idea to get an estimate in advance for health care, if your condition is not an emergency. But it is important to know that an estimate can be way off — and your provider probably is not legally required to honor it.

Try to request an estimate that is “all-in” — including the entire set of services associated with your procedure or admission. If it’s not all-inclusive, the hospital should make clear which services are not being counted.

Having an estimate means you can make an argument with your provider and insurer that you shouldn’t be charged more than you expected. It could work.

Laws requiring at least a level of accuracy in medical estimates would help. In a number of other countries, patients are entitled to accurate estimates if they are paying out-of-pocket.

Most patients aren’t as proactive as the Balzers, and most wouldn’t know that the hospital, surgeon and anesthesiologist would all bill separately. And most wouldn’t fight a bill that they could afford to pay.

The Balzers say they wouldn’t have changed their medical decision, even if they had been given the right estimate at the beginning. It’s the principle they fought for here: “There’s no other consumer industry where this would be tolerated,” Farren wrote in an email.

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

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Hey, women: Dr. Jen Gunter wants you to understand your own vagina.

The California gynecologist is on a quest to help women get the facts about their own bodies. It isn’t always easy. In an era of political attacks on women’s reproductive choices and at a time when Internet wellness gurus are hawking dubious pelvic treatments, getting women evidence-based information about their health can be a challenge, she says.

But Gunter isn’t backing down.

“I’m really just trying to give women information so they can make informed choices,” Gunter tells NPR. “Misinformation is the opposite of feminism. Making an empowered decision requires accurate information.”

Gunter started her blog, Wielding the Lasso of Truth, almost 10 years ago, writing on topics that range from abortion politics to the risks to women who eat the placenta after childbirth (yes, really). She rose to Internet fame as she took on the very public task of debunking several treatments touted by Gwyneth Paltrow and her wellness empire, Goop — including $66 jade eggs designed to be inserted into the vagina and a treatment known as “vaginal steaming.” Gunter now writes a column about women’s health for the New York Times.

She spoke about her new book, The Vagina Bible, with NPR contributor and family physician Mara Gordon. The interview has been edited for clarity and length.

The Vagina Bible is coming out at a moment where women’s reproductive health in the U.S. is a huge political issue. Yet this book is more clinical than political. What made you want to take this approach?

I found myself debunking the same myth over and over again: “No, you shouldn’t put yogurt in your vagina. No, you shouldn’t put garlic in your vagina.” I got really fixated on this idea that I wanted women to have a textbook so they could divorce themselves from the cacophony that’s online. … When I went through medical school, Harrison’s Principles of Internal Medicine was the internal medicine Bible. Williams Obstetrics was my obstetrics Bible. That’s how I referred to my resources that I went to over and over again.

You talk about how women are conditioned to think their vaginas are abnormal, saying, “There’s a lot of money in vaginal shame.” You argue that it’s related to marketing of procedures like vaginal rejuvenation, or expensive objects women are told to put in their vaginas, or cleansing gels and wipes they’re encouraged to use. What’s going on?

I have noticed a huge increase in what I can only describe as women being “vaginally hyperaware.” I did a fellowship in infectious diseases in 1995, and since then, I have specialized in vaginitis — irritation of the vagina. The number of patients, the percentage that I see, who have nothing physiologically wrong with them has increased dramatically.

What do they tend to be experiencing?

I would say odor, volume of discharge. … Then there’s also this group of patients who are convinced they have yeast infections. They definitely have something causing their symptoms that’s not yeast — usually chronic vulvar irritation. So what happens when someone comes in and the doctor can’t find anything wrong is that many doctors will just give antibiotics or give antifungals.

Do your patients ever feel like you’re dismissing or not believing their symptoms?

For so many years, women have had their symptoms dismissed. They’ve been told that their normal bodies are wrong. And so there are all these complex messages. I really try to pin down and ask them, “OK, so what’s your bother factor? And then let’s work it out from there.”

An interesting theme in the book is something I see in my own primary care practice: the “well, it can’t hurt” phenomenon. For example, a doctor might tell a woman to only wear white cotton underwear if she’s having recurrent yeast infections, because “Well, it can’t hurt, right?” Doctors suggest a lot of treatments that don’t have any evidence behind them. What’s going on?

I think that it’s really hard for doctors to say, “I don’t know.” That’s something that I learned being a parent of children who had unfixable medical conditions. [My] son has cerebral palsy, and [my] other son has a heart condition that can’t be fixed. … The most valuable thing, actually, a physician ever told me when I was struggling with my kids was, “You know, if we had better therapies to offer you, we’d be offering them to you.” And that was a really profound moment.

How do you approach this as a clinician, when you can’t offer your patients a quick-fix treatment with rigorous research behind it?

I actually have a lot of therapies for a lot of conditions that people think are impossible to treat. But I do get a lot of patients saying, “Is this the best you have?” And I say, “Yes. Yes, it is the best I have.” And I explain why.

Most people can understand the science behind what we’re offering. … The biggest issue is that we don’t have the time to explain it. If you’re only given seven minutes to explain to someone the complexities of chronic yeast infections — because actually, immunologically, it’s a little bit complex — the only way you can do it is in a horrible, patriarchal “Well, just do this” manner.

Let’s talk about your other specialty — women’s pelvic pain. Why is this so hard to treat?

Pain is so complex. When you explain it to patients, you have to be so careful, because it can sound like you are saying their pain is in their head, when that’s not what you mean. It’s in their nervous system. It’s physiologically very hard to explain.

Dealing with pain is very humbling as a physician. We’re really talking about improvement, not fixing. And that’s really very hard for people to accept. We have all of this cool medicine, all these advances, and we can’t fix pain. It’s frustrating.

Doctors don’t have a great track record of taking women’s pain seriously.

We know anxiety and depression amplify pain. It’s well-known. I work with a pain psychologist, and I’ll talk about mind-body medicine. When I say that, a patient often hears that I’m dismissing their pain. What I’m doing is actually taking it very seriously. … People come in and they want scalpels, right? They want a grand thing because when you have pain, it’s huge, it’s all-consuming. And you come in and you hear, “Wait, what? Physical therapy? And managing my anxiety? How can you fix my huge problem with these seemingly little things?” So when you have a huge problem, you think that you need a huge solution, like surgery, like an MRI, because those are big.

We doctors have had a strictly biomedical model for disease for a long time. It’s a pretty recent development that we consider sex, relationships, stress and even sexism within our purview. Do you feel like your patients are eager for you to address those things?

I think that women appreciate knowing the forces that led us here. … I want people to understand that the patriarchy has been everywhere. Medicine is part of everything. So of course medicine has patriarchy. … I personally don’t think that medicine is worse than anything else, but I do think that because medicine cares for people, we have the biggest duty to respond to it fast.

I think that a lot of women are really hungry for a woman physician to stand up and say, “Wait a minute. Wait, wait, wait. I know about women’s bodies. That’s not going to fly, because I know the physiology.”

What is the most absurd vaginal product that you’ve come across in your research?

Ozone getting blown into your vagina. It’s highly toxic for your lungs. … I can’t imagine what it does to your vagina.

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. You can follow her on Twitter: @MaraGordonMD.

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Today, the judge hearing the opioid case brought by Oklahoma against the pharmaceutical giant Johnson & Johnson awarded the state roughly $572 million.

The fact that the state won any money is significant — it’s the first ruling to hold a pharmaceutical company responsible for the opioid crisis.

But the state had asked for much more: around $17 billion. The judge found the drugmaker liable for only about 1/30 of that.

“The state did not present sufficient evidence of the amount of time and costs necessary, beyond year one, to abate the opioid crisis,” Judge Thad Balkman wrote in his ruling.

That’s the big reason for the discrepancy. The judge based his decision on one year of abatement. The state’s plan — and the basis of that $17 billion ask — was looking at abatement for the next three decades.

That 30-year plan was authored by Christopher Ruhm, a professor of public policy and economics at the University of Virginia. He says you can easily get into the billions when you consider the costs of dealing with this epidemic in the long term.

“Take one example,” Ruhm says. “Addiction treatment services, which includes a variety of things — that includes inpatient services, outpatient services, residential care. You’re talking a cost there on the order of $230 million per year. And so if you take that over a 30-year period — and then you discount it to net present value and all the things economists do — you come up with a cost for treatment services of just under $6 billion.”

Just that cost gets you more than a third of the way to $17 billion. The rest comes from all sorts of things, he says: public and physician education programs; treatment for babies who are born to mothers who used opioids; data systems for pharmacists to better track prescriptions grief support groups and more. Ruhm added up all those costs over 30 years, and got more than $17 billion.

“Let’s be clear,” he says. “It is a lot of money. It’s also a major public health crisis.” Nationally, 130 people, on average, die every day from opioid-related overdoses, according to the Department of Health and Human Services.

Ruhm suggests one year of funding for abatement won’t be nearly enough. “Many currently addicted individuals are likely to need medication-assisted treatment for many years, or even for decades. The same is true for many other aspects of the crisis,” he says.

Today’s verdict does not mean Oklahoma is now going to spend the $572 million dollars it was awarded on any particular abatement plan, assuming, even that it sees any of that cash — Johnson & Johnson’s attorneys say they will appeal Monday’s court decision.

Ultimately, it will be up to state officials and lawmakers to decide how to actually use any money the state gets. And that will probably be nowhere near Ruhm’s projection of what’s needed in the long term.

Health economist Kosali Simon at Indiana University says the $17 billion figure didn’t seem outsize to her.

“In general these numbers tend to be large because we’re thinking over a long time period; we’re thinking about a 30-year horizon,” she says. “There isn’t a vaccine or a one-time dose of medication that would completely heal everybody.”

Simon compares Ruhm’s report to what economists did after the Exxon Valdez oil spill in 1989 — estimating what it would cost to return the environment as closely as possible to its pre-spill condition.

Except in this case, there isn’t a single oil spill. There is an opioid epidemic in every state.

“This report is going to be a very important and useful baseline against which other states can consider their own situation,” says Simon.

Nationally, she says, it would cost much more than taking Oklahoma’s numbers and scaling them up to solve the problem. The country needs to invest in research on what treatment options work best, develop better addiction treatment drugs, et cetera.

Then there’s the question — once you’ve fully accounted for all these costs — of who should pay?

“The economist’s job is to think, ‘How much money does it take now to abate the setting?’ ” Simon says. “Whose pocket that should come from is an entirely different and — I think — much more difficult question for society to answer.”

Today the judge said a drugmaker should pay at least some of the costs of abating the crisis — at least for one year.

There are hundreds of other opioid cases around the country, and those judges might come to different conclusions.

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A few years ago, TV celebrity Rachel Maddow was at Rockefeller University to hand out a prize that’s given each year to a prominent female scientist. As Maddow entered the auditorium, someone overheard her say, “What is up with the dude wall?”

She was referring to a wall covered with portraits of scientists from the university who have won either a Nobel Prize or the Lasker Award, a major medical prize.

“One hundred percent of them are men. It’s probably 30 headshots of 30 men. So it’s imposing,” says Leslie Vosshall, a neurobiologist with the university and the Howard Hughes Medical Institute.

Vosshall says Maddow’s remark, and the word “dude wall,” crystallized something that had been bothering her for years. As she travels around the country to give lectures and attend conferences at scientific institutions, she constantly encounters lobbies, conference rooms, passageways, and lecture halls that are decorated with portraits of white men.

“It just sends the message, every day when you walk by it, that science consists of old white men,” says Vosshall. “I think every institution needs to go out into the hallway and ask, ‘What kind of message are we sending with these oil portraits and dusty old photographs?'”

She’s now on a committee that’s redesigning that wall of portraits at Rockefeller University, to add more diversity. And this is hardly the only science or medical institution that’s reckoning with its dude wall.

At Yale School of Medicine, for example, one main building’s hallways feature 55 portraits: three women and 52 men. They’re all white.

“I don’t necessarily always have a reaction. But then there are times when you’re having a really bad day — someone says something racist to you, or you’re struggling with feeling like you belong in the space — and then you see all those photos and it kind of reinforces whatever you might have been feeling at the time,” says Max Jordan Nguemeni Tiako, a medical student at Yale.

He grew up reading Harry Potter books, and in that fictional world, portraits can talk to the characters. “If this was Harry Potter,” he muses, “if they could speak, what would they even say to me? Everywhere you study, there’s a big portrait somewhere of someone kind of staring you down.”

Yale medical student Nientara Anderson recently teamed up with fellow student Elizabeth Fitzsousa and associate professor Dr. Anna Reisman to study the effect of this artwork; the results were published in July in the Journal of General Internal Medicine.

“Students felt like these portraits were not just ancient, historic things that had nothing to do with their contemporary experience,” says Anderson. “They actually felt that the portraits reinforced contemporary issues of exclusion, of racial discrimination — of othering.”

Yale has recently been commissioning new portraits, including one of Carolyn Slayman, a geneticist and member of the Yale faculty for nearly 50 years, as well as one of Dr. Beatrix Hamburg, a pioneering developmental psychiatrist and the first black female Yale medical school graduate. And there’s an ongoing discussion at Yale about what to do with all those old portraits lining the hallways.

One option is to move them someplace else. That was the approach taken at the department of Molecular & Integrative Physiology at the University of Michigan. Ally Cara, a Ph.D. student there, says its seminar room “featured portraits of our past department chairs, which happened to be all male.”

The 10 or so photographs were lined up in a row. “When our interim chair, Dr. Santiago Schnell began his service a couple years ago, he wanted to bring a more modern update to our seminar room,” Cara says, “including bringing down the dude wall and relocating it.”

The photos are now in a less noticeable spot: the department chair’s office suite. And the seminar room will soon be decorated with artwork depicting key discoveries made by the department’s faculty, students, and trainees.

“We really want to emphasize that we’re not trying to erase our history,” says Cara. “We’re proud of the people who have brought us to where we are today as a department. But we also want to show that we have a diverse and inclusive department.”

Changes like this can be a sensitive subject. At Brigham and Women’s Hospital in Boston, one of Harvard’s teaching hospitals, there’s an auditorium that for decades was covered with large portraits of 31 men.

“It made an impression,” says Dr. Jeffrey Flier of Harvard Medical School, who first saw the wall of portraits back in the 1970’s. But recently, he walked in the auditorium and “was taken aback because, instead of this room filled with portraits of historically important figures from the Brigham, the walls were empty.”

The portraits were relocated to different places around the hospital. And while Flier says he understands why there needed to be a change, he prefers the approach taken in another Harvard meeting place called the Waterhouse Room.

It had long been decorated with paintings of former deans, says Flier, and “all of those individuals were white males. I am among them now, hanging up there as the most recent former dean of Harvard Medical School.”

But right up there with Flier’s portrait are photographs of well-known female and African-American physician-scientists, he says, because his predecessor added them to the walls of that room.

“You don’t want to take away the history of which you are justifiably proud,” says Flier. “You don’t want to make it look like you are embarrassed by that history. Use the space to reflect some of the past history and some of the changing realities that you want to emphasize.”

But some argue that the old portraits themselves have erased history, by glorifying white men who hold power while ignoring the contributions to science and medicine made by women and people of color.

One rare exception, and a poignant example of the power and meaning of portraits in science and medicine, can be found at the Johns Hopkins Hospital. There, a black technician named Vivien Thomas worked for a white surgeon named Alfred Blalock. Even though Thomas had only a high school degree, he joined Blalock’s lab in 1930; the pair spent decades developing pioneering techniques for cardiac surgery together.

The last time the two ever spoke, Blalock was in poor health, and in a wheelchair. Together they went to see the portrait of Blalock that had recently been hung in the lobby of the clinical sciences building, which had been named after him.

Soon after that, Blalock died. And a few years later, Thomas received word that a group of surgeons was commissioning a portrait of him. “My first reaction was that surely I must be dreaming,” Thomas wrote in his autobiography, which he originally entitled Presentation of a Portrait: The Story of a Life.

When the portrait was presented to the hospital in 1971, Thomas told the assembled surgeons that he felt proud and humbled. “People in my category are not accustomed to being in the limelight as most of you are,” Thomas said. “If our names get into the print, it’s usually in the very fine print down at the bottom somewhere.”

In his memoir Thomas wrote, “it had been the most emotional and gratifying experience of my life.” He wondered where the portrait would be hung, and thought someplace like the 12^th floor, near the laboratory area, would be appropriate. He was “astounded” when Dr. Russell Nelson, then the hospital president, stated “We’re going to hang your fine portrait with professor Blalock. We think you hung together and you had better continue to hang together.”

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It’s flu shot season. Signs alerting and urging you to get a flu shot now may be up at your pharmacy or workplace. The Centers for Disease Control and Prevention recommends everyone over 6 months old get a flu shot by the end of October, so the vaccine can begin to work before the influenza season begins.

But this week, U.S. Customs and Border Protection said it would not give flu shots to the thousands of migrants now in its detention centers.

“Due to the short-term nature of CBP holding and the complexities of operating vaccination programs,” the agency said in a statement, “neither CBP nor its medical contractors administer vaccinations to those in our custody.”

Dr. Bruce Y. Lee of the Johns Hopkins Bloomberg School of Public Health called the department’s edict, “short-term thinking.”

“Holding a number of unvaccinated people in a crowded space could be like maintaining an amusement park for flu viruses,” he wrote for Forbes. He explains that viruses could spread through the congested, often cold, and unsanitary detention camps, and get passed between those people who’ve been detained — weak, tired and dusty — as well as those who work there.

Viruses spread. They cannot be “detained,” like people.

During a particularly brutal flu season two years ago, the CDC estimated about 80,000 people, including 600 children, died across the U.S. after being infected by influenza. Last season’s flu set records for its length — lasting 21 weeks.

On Aug. 1, a group of six physicians from Johns Hopkins and the MassGeneral Hospital for Children wrote a letter to members of Congress in which they said at least three children infected with influenza have died in U.S. custody since December of 2018.

The children were 2, 8 and 16. They were named Wilmer, Felipe and Carlos.

The doctors advised Congress, “During the influenza season, vaccination should be offered to all detainees promptly upon arrival in order to maximize protection for the youngest and most vulnerable detainees.”

This week I read of the government’s determination not to give seasonal flu shots to migrants in detention centers and had to ask: What possible good will this do? Is it worth the risk to health and life? And what does this policy say about America?

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A little Shakespeare came to mind during a recent shift in the Boston emergency room where I work.

“Good Mercutio, let’s retire,” Romeo’s cousin Benvolio says. “The day is hot, the Capulets abroad, and, if we meet, we shall not ‘scape a brawl.”

It was hot in Boston, too, and people were brawling. The steamy summer months always seem to bring more than their fair share of violence.

But the ER was full of more than just brawlers. Heart attacks, strokes, respiratory problems — the heat appeared to make everything worse.

I wasn’t the first to notice this effect. In 1938, a statistician named Mary Gover found a surprising association between heat waves and increased mortality from all causes. Only about a quarter of deaths during these periods could be attributed to heatstroke, a dangerous form of heat illness that occurs when temperatures outstrip the body’s ability to shed heat.

In heatstroke, proteins begin to unravel once the core temperature exceeds 104 degrees. Enzymes become inert. Cells’ ability to produce energy fails near 106, ultimately causing multiple organ failure, shock and death.

Heatstroke is an important cause of heat-related deaths and tends to get the most attention during extreme heat waves. But other diseases are affected by the heat as well.

Gover found that a majority of the excess deaths occurring during heat waves were from “diseases of the heart, cerebral hemorrhage … and pneumonia.” That observation seemed right to me, and subsequent research has shown that she was on to something.

Three September heat waves in Los Angeles — 1939, 1955 and 1963 — were associated with increased total mortality of 271%, 445%, and 172% more than usual. Death from all causes doubled during a heat wave in New York City in August 1975, with heart attacks and strokes accounting for a majority of the excess deaths.

More recently, total mortality rose 26% in Philadelphia during 10 scorching days in July 1993, with mortality from cardiovascular disease nearly doubling. A 2018 analysis of 23 studies confirmed the association between cardiovascular mortality and heat waves. And in 2013, a study of 12 million Medicare patients found a strong association between heat and exacerbation of chronic respiratory diseases.

Other scientists began looking beyond heat waves. British researchers compared mortality rates with average temperatures throughout the year and found that death rates from heart attack, stroke and pneumonia increased steadily with temperatures over 70.

In 2002, another British team found that total mortality in London increased by roughly 3% for every 1 degree Celsius above 21.5 Celsius, or about 70 Fahrenheit. That same year, a team from Johns Hopkins confirmed that total mortality increases linearly above 70 degrees in a study of 11 U.S. cities.

Why would heat have such a profound effect on cardiovascular disease in particular? It may relate to the body’s own adaptive response to high temperatures.

When body temperature rises, blood becomes a critical means of ditching heat. Vessels near the skin dilate to increase peripheral blood flow. Heat is circulated from the core to the skin, where sweating helps to transfer heat to the environment.

The heart is the engine that drives this adaptation, and the added stress could prove fatal to a damaged one.

Heat also causes dehydration, which could in turn increase the risk of clotting by concentrating coagulation factors within the blood and by triggering the release of molecules that spur inflammation. Any predisposition to clotting could contribute to a heart attack or stroke.

Heat may also exacerbate mental illness. In 2014, Canadian researchers found that ER visits for mental illness increased 29% during periods of extreme heat in Toronto. Vietnamese scientists demonstrated in 2016 that risk of admission to a mental health facility increased 36% during weeklong heat waves. The following year, a team of Korean researchers estimated that nearly 15% of emergency admissions for mental illness over an 11-year period could be attributed to extreme heat.

And what about violence and aggression? Was Benvolio right to warn Mercutio against meeting any Capulets in the heat?

Associations between heat and violent crime have been noted since official crime statistics became available around 1900. In 1997, researchers used modern statistics to confirm that violent crime occurs more often in warmer years. Scientists used FBI crime data in 2004 to show that crime rose 5% for every 10-degree increase in weekly average temperatures. And a 2013 study found that violent crime increased 1% for every degree above average monthly temperatures in St. Louis.

Field experiments have also supported an association between heat and aggression. In 1986, researchers found that drivers were more likely to use their horns when it was hot outside. And in 1994, police officers exposed to elevated temperatures during firearms training were found to exhibit increased aggression and were more likely to discharge their weapons.

These are worrying trends, especially with temperatures projected to rise ever higher in coming years. Benvolio may have put it best. “For now, these hot days,” he says to Mercutio, “is the mad blood stirring.”

Clayton Dalton is a resident physician at Massachusetts General Hospital in Boston.

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Wyoming, which is among the reddest of Republican states and a bastion of free enterprise, thinks it may have found a way to end crippling air ambulance bills that sometimes top $100,000 per flight.

The state’s unexpected solution: Undercut the free market, by using Medicaid to treat air ambulances like a public utility.

Costs for such emergency transports have been soaring, with some patients facing massive, unexpected bills as the free-flying air ambulance industry expands with cash from profit-seeking private-equity investors. The issue has come to a head in Wyoming, where rugged terrain and long distances between hospitals forces reliance on these ambulance flights.

Other states have tried to rein in the industry, but have continually run up against the Airline Deregulation Act, a federal law that preempts states from regulating any part of the air industry.

So, Wyoming officials are instead seeking federal approval to funnel all medical air transportation in the state through Medicaid, a joint federal-state program for residents with lower incomes. The state officials plan to submit their proposal in late September to Medicaid’s parent agency, the Centers for Medicare & Medicaid Services; the plan will still face significant hurdles there.

If successful, however, the Wyoming approach could be a model for the nation, protecting patients in need of a lifesaving service from being devastated by a life-altering debt.

“The free market has sort of broken down. It’s not really working effectively to balance cost against access,” says Franz Fuchs, a policy analyst for the Wyoming Department of Health. “Patients and consumers really can’t make informed decisions and vote with their dollars on price and quality.”

Freewheeling free market system

The air ambulance industry has grown steadily in the U.S., from about 1,100 aircraft in 2007 to more than 1,400 in 2018. During that same time, the fleet in Wyoming has grown from three aircraft to 14. State officials say an oversupply of helicopters and planes is driving up prices, because air bases have high fixed overhead costs. Fuchs says companies must pay for aircraft, staffing and technology, such as night-vision goggles and flight simulators — incurring 85% of their total costs before they fly a single patient.

But with the supply of aircraft outpacing demand, each air ambulance is flying fewer patients. Nationally, air ambulances have gone from an average of 688 flights per aircraft in 1990, as reported by Bloomberg, to 352 in 2016. So, companies have raised their prices to cover their fixed costs and to seek healthy returns for their investors.

A 2017 report from the federal Government Accountability Office notes that the three largest air ambulance operators are for-profit companies with a growing private equity investment. “The presence of private equity in the air ambulance industry indicates that investors see profit opportunities in the industry,” the report says.

While precise data on air ambulance costs is sparse, a 2017 industry report says air ambulance companies spend an average of $11,000 per flight. In Wyoming, Medicare pays an average of $6,000 per flight, and Medicaid pays even less. So air ambulance companies shift the remaining costs — and then some — to patients who have private insurance or are paying out-of-pocket.

As that cost-shifting increases, insurers and air ambulance companies haven’t been able to agree on in-network rates. So the services are left out of insurance plans.

When a consumer needs a flight, it’s billed as an out-of-network service. Air ambulance companies then can charge whatever they want. If the insurer pays part of the bill, the air ambulance company can still bill the patient for the rest — a practice known as balance billing.

“We have a system that allows providers to set their own prices,” says Dr. Kevin Schulman, a Stanford University professor of medicine and economics. “In a world where there are no price constraints, there’s no reason to limit capacity, and that’s exactly what we’re seeing.”

Nationally, the average helicopter bill has now reached $40,000, according to a 2019 GAO report — more than twice what it was in 2010. State officials say Wyoming patients have received bills as high as $130,000.

Because consumers don’t know what an air ambulance flight will cost them — and because their medical condition may be an emergency — they can’t choose to go with a lower-cost alternative, either another air ambulance company or a ground ambulance.

A different way of doing things

Wyoming officials propose to reduce the number of air ambulance bases and strategically locate them, to even out access. The state would then seek bids from air ambulance companies to operate those bases at a fixed yearly cost. It’s a regulated monopoly approach, similar to the way public utilities are run.

“You don’t have local privatized fire departments springing up and putting out fires and billing people,” Fuchs says. “The town plans for a few fire stations, decides where they should be strategically, and they pay for that fire coverage capacity.”

Medicaid would cover all the air ambulance flights in Wyoming — and then recoup those costs by billing patients’ insurance plans for those flights. A patient’s out-of-pocket costs would be capped at 2% of the person’s income or $5,000, whichever is less, so patients could easily figure out how much they would owe. Officials estimate they could lower private insurers’ average cost per flight from $36,000 to $22,000 under their plan.

State Rep. Eric Barlow, who co-sponsored the legislation, recognizes the irony of a GOP-controlled, right-leaning legislature taking steps to circumvent market forces. But the Republican said that sometimes government needs to make sure its citizens are not being abused.

“There were certainly some folks with reservations,” he says. “But folks were also hearing from their constituents about these incredible bills.”

Industry pushback

Air ambulance companies have opposed the plan. They say the surprise-billing problem could be eliminated if Medicare and Medicaid covered the cost of flights and the companies wouldn’t have to shift costs to other patients. They question whether the state truly has an oversupply of aircraft and warn that reducing the number of bases would increase response times and cut access to the lifesaving service.

Richard Mincer, an attorney who represents the for-profit Air Medical Group Holdings in Wyoming, says that while 4,000 patients are flown by air ambulance each year in the state, it’s not clear how many more people have needed flights when no aircraft was available.

“How many of these 4,000 people a year are you willing to tell, ‘Sorry, we decided as a legislature you’re going to have to take ground ambulance?’ ” Mincer said during a June hearing on the proposal.

But Wyoming officials say it indeed might be more appropriate for some patients to take ground ambulances. The vast majority of air ambulance flights in the state, they say, are transfers from one hospital to another, rather than on-scene trauma responses. The officials say they’ve also heard of patients being flown for medical events that aren’t an emergency, such as a broken wrist or impending gallbladder surgery.

Air ambulance providers say such decisions are out of their control: They fly when a doctor or a first responder calls.

But air ambulance companies do have ways of drumming up business: They heavily market memberships that cover a patient’s out-of-pocket costs, eliminating any disincentive for the patient to fly. Companies also build relationships with doctors and hospitals that can influence the decision to fly a patient; some have been known to deliver pizzas to hospitals by helicopter to introduce themselves.

Mincer, the Air Medical Group Holdings attorney, says the headline-grabbing, large air ambulance bills don’t reflect what patients end up paying directly. The average out-of-pocket cost for an air ambulance flight, he says, is about $300.

The industry also has tried to shift blame onto insurance plans, which the transporters say refuse to pay their fair share for air ambulance flights and refuse to negotiate lower rates.

Doug Flanders, director of communications and government affairs for the medical transport company Air Methods, says the Wyoming plan “does nothing to compel Wyoming’s health insurers to include emergency air medical services as part of their in-network coverage.”

The profit model

Other critics of the status quo maintain that air ambulance companies don’t want to change, because the industry has seen investments from Wall Street hedge funds that rely on the balance-billing business model to maximize profits.

“It’s the same people who have bought out all the emergency room practices, who’ve bought out all the anesthesiology practices,” says James Gelfand, senior vice president of health policy for the ERISA Industry Committee, a trade group representing large employers. “They have a business strategy of finding medical providers who have all the leverage, taking them out of network and essentially putting a gun to the patient’s head.”

The Association of Air Medical Services counters that the industry is not as lucrative as it’s made out to be, pointing to the recent bankruptcy of PHI Inc., the nation’s third-largest air ambulance provider.

Meanwhile, Blue Cross Blue Shield of Wyoming is supportive of the state’s proposal and looks forward to further discussion about the details if approved, according to Wendy Curran, a vice president at the health insurance firm. “We are on record,” Curran says, “as supporting any effort at the state level to address the tremendous financial impacts to our [Wyoming] members when air ambulance service is provided by an out-of-network provider.”

The Wyoming proposal also has been well received by employers, who like the ability to buy into the program at a fixed cost for their employees, providing a predictable annual cost for air ambulance services.

“It is one of the first times we’ve … seen a proposal where the cost of health care might actually go down,” says Anne Ladd, CEO of the Wyoming Business Coalition on Health.

The real challenge, Fuchs says, will be convincing federal officials to go along with it.

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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Nearly 2,000 cities, towns and counties across America are currently participating in a massive multidistrict civil lawsuit against the opioid industry for damages related to the abuse of prescription pain medication. The defendants in the suit include drug manufacturers like Mallinckrodt, wholesale distributors McKesson and Cardinal Health, and pharmacy chains CVS and Walgreens.

Evidence related to the lawsuit was initially sealed, but The Washington Post and the Charleston Gazette-Mail successfully sued to have it made public. Pulitzer Prize-winning Washington Post journalist Scott Higham says the evidence, which was released in July, includes sworn depositions and internal corporate emails that indicate the drug industry purposely shipped suspiciously large quantities of drugs without regard for how they were being used.

Higham says one sales director at the pharmaceutical manufacturer Mallinckrodt was jokingly called “ship, ship, ship” by colleagues because of the amount of oxycodone and hydrocodone he sold: “His bonus structure was tied to the amount of sales that he made,” Higham notes. “And that was a time when there was no secret about how many people were dying in places across the country, and the opioid epidemic was raging.”

Higham and his colleagues at the Post were also able to access data from the Drug Enforcement Agency that trace the path of some 76 billion opioid pain pills sold between 2006 and 2012. In analyzing the movement of those pills, they made a gruesome discovery.

“When you line up the CDC death [by overdose] database with the DEA’s database on opioid distribution, you see a clear correlation between the saturation of towns and cities and counties and the numbers of deaths,” Higham says. “A lot of these towns and cities, small cities and counties in places like Ohio and Pennsylvania have just been devastated. … The death rates just soared in those places where the pills were being dumped.”

Interview Highlights

On the picture emerging from recently unsealed DEA database

A lot of people thought they knew that their communities were being saturated by these opioids, but I don’t think they really knew the extent of the saturation, and who was responsible. So this database pulls the curtain back on that for the first time. We obtained data that goes from 2006 through 2012. So over that seven-year period … you can see exactly which manufacturers were responsible, which distributors were responsible, and which pharmacies were responsible. And we took that database and we turned it into a usable, public-facing database, so now anybody in the country can go onto our website and they can see exactly what happened in their communities. …

Dozens and dozens of local news organizations have done stories about their own communities — which companies flooded their communities with pills, which pharmacies were responsible for dispensing the most tablets of oxycodone and hydrocodone. Those are the two drugs that we looked at, because they are the most widely abused drugs by addicts and by drug dealers.

On the communities that were flooded with opioids

It’s just heartbreaking to see these once thriving communities. They’re almost like zombielands, where people are just walking around in a daze and picking through garbage cans and falling down, and overdosing in public parks and inside of cars and inside of streets and on street corners. It’s a very upsetting scene that’s happening. …

These communities need help — desperately need help. Their hospitals need help. Their foster care agencies need help — because so many parents have perished and their kids have no family or [are] being raised by grandparents. Police departments, paramedics, fire departments that used to fight fires all the time now are fighting against the opioid epidemic and carrying Narcan with them, which is an overdose reversal drug, and “Narcaning” people all day long.

On how drug distributors generated billions in revenue from the opioid epidemic

They’re making massive amounts of money. Many of them are Fortune 500 companies. In fact, the No. 1 drug distributor in America, McKesson Corp., is the fifth-largest company in the United States — fifth-largest of all companies in the United States — and it’s a company that most people have never heard of. And they are a huge, huge player in this world, and of the distributors that sent these drugs downstream they were No. 1. And they were followed by two other companies that a lot of folks probably have not heard of. One is called AmerisourceBergen and another is called Cardinal Health. … Together those three companies are the three biggest drug distributors in the United States. And they were followed by Walgreens, CVS and Walmart as the top six drug distributors in the United States.

On “pill mills” that popped up in Florida, where people could get opioids from corrupt doctors — and then resell them on the street

All of a sudden, all these drug dealers realize that there was another way to peddle these pills, and they began to open up these so-called pain management clinics, and most of them were in South Florida, heavily concentrated in Broward County, which is where Fort Lauderdale is. … These things … were basically storefront operations in strip malls where you had corrupt doctors and rogue pharmacists working hand in hand inside of a store. So on one side of the store you’d come in, you’d get a cursory examination, the doctor would write you a script. And you literally go next door and get it filled. And these places just became huge open-air drug markets. The parking lots were filled with people who were driving down from Kentucky and West Virginia and Ohio to pick up their prescriptions. And along the highway that goes up through Florida, I-75 and then also I-95, a lot of these storefronts began putting up billboards along the highway at exit ramps saying, “Pain management clinic, next exit.”

On the Justice Department’s history of fining drug companies instead of filing criminal charges

[Investigators at the DEA’s Office of Diversion Control] started to see a pattern, and it’s a pattern that they see that continues to this day, that there are people within the Justice Department who are not very aggressive when it comes to these cases. They feel that some of them are a little too close to the industry; that maybe some of the people in the Justice Department want to work for the industry one day, so they don’t go as hard against these companies as perhaps they should. … If you take a look at the revolving door between the Justice Department, the DEA and the drug industry, it’s a very impressive revolving door. You have dozens and dozens of high-ranking officials from the DEA and from the Justice Department who have crossed over to the other side and they’re now working directly for the industry or for law firms representing the industry. So if you’re a DEA investigator or a DEA lawyer or a Justice Department lawyer making $150,000 a year, you cross over and you can triple, quadruple your salary overnight.

Amy Salit and Seth Kelley produced and edited the audio of this interview. Bridget Bentz and Deborah Franklin adapted it for the Web.

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