Most of the front door of Rachel Taylor’s little yellow house in White Sulphur Springs, W. Va., is pasted with paw prints where her dog struggled to get inside during the flood last month. He was too big to carry through the rising waters.

Across the street, nestled between two battered houses, an empty lot is marked by a cross with an array of flowers and photos — a small memorial for a family washed away by the torrent.

Taylor’s dog survived and is now with some of her family members in Kentucky. But those neighbors across the street, the Nicelys, were swept away when their house collapsed; they have since been confirmed dead.

“When I start feeling overwhelmed with this,” Taylor says from her front porch, “I just look across the street at that memorial and I think, there’s nothing that we have lost that can’t be replaced or mended.”

She and her husband spent seven years renovating this 1930s Craftsman house, room by room. They were just about done with renovations when their house flooded a few weeks ago. Today the living room is gutted.

“You know, the first couple of days it was very intense,” Taylor says. “It was kind of ‘crisis mode.’ Maybe that’s the way I would describe it, because you didn’t really have time to think about it and process it.”

But once the full extent of the damage set in, Taylor says, she developed severe nausea and carsickness to the point of not being able to drive.

A number of people, she says, have chalked up her symptoms to nerves. “You know, the stress level. You don’t realize your body is just having a response to this.”

Taylor worries that the houses in her neighborhood will remain abandoned and that she, her husband and her 14-year-old daughter won’t feel safe at home anymore. She plans to rebuild, but says her family will likely sell the house and move.

“The words we use when we talk about it are ‘I don’t know if I have it in me;’ ‘I’m not sure if I can do it again,’ ” she says. “Things like that. And then we just say, ‘Well, we’ll take it one day at a time.’ “

Psychologists say this kind of response is normal following natural disasters.

“It’s a physical aspect of the stress response — it will affect the body’s ability to concentrate, to rest and to be able to function,” says Marcie Vaughan, leader of the state-funded West Virginia Community Crisis Response Team. “Cognition is slowed and impaired,” she adds.

Vaughan’s team offers support, counseling and referrals for further mental health care at local behavioral health centers.

“From the behavioral health perspective, we find we are more in need after the tenth [or] twelfth day,” Vaughan says, “just because immediate needs of food, clothing and shelter take precedence.”

In the first few days following the flood, Vaughan’s team members split their time between helping people replace lost psychiatric medications and looking for signs of mental distress in people at shelters or feeding stations.

“We see fatigue, problems with cognition,” she says. “You have individuals who walk into a supply center and they have no idea what they need.”

A 2012 study published in the journal Social Psychiatry and Psychiatric Epidemiology found that while most people bounce back a few months after a disaster, if their ongoing stressors aren’t addressed — such as a lack of permanent shelter, financial challenges and repeated exposure to the trauma — affected residents will continue to struggle.

In addition to Vaughan’s team, church disaster-assistance teams and Hope Animal-Assisted Crisis Response — a support organization that uses trained therapy pets for comfort — stepped in to help.

“As the fatigue sets in and the frustration, we see an increased need for behavioral health intervention,” says Vaughan.

Unfortunately, that’s just when the work becomes hardest, Vaughan says, and it’s often after national organizations and media have lost interest. Very real, tough problems persist, though only local groups and neighbors remain to extend helping hands.

This story is part of NPR’s reporting partnership with West Virginia Public Broadcasting and Kaiser Health News.

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Editor’s note: This story contains language that some may find offensive.

When a certified nursing assistant in Hubbard, Iowa, shared a photo online in March of a nursing home resident with his pants around his ankles, his legs and hand covered in feces, the most surprising aspect of state health officials’ investigation was this: It wasn’t against the law.

The Iowa law designed to protect dependent adults from abuse was last updated in 2008, before many social media apps existed. It bars “sexual exploitation of a dependent adult by a caretaker,” which would have applied if the photo showed the resident’s genitals. It didn’t.

The nurse assistant was fired from Hubbard Care Center after a co-worker reported her to supervisors, but the state was unable to discipline her at all. She remains eligible to work in any nursing home in the state. Government documents did not name her.

“This was something no one expected,” says David Werning, a spokesman for the Iowa Department of Inspections and Appeals, of the case. The nurse assistant had used Snapchat to send the photo of the resident, who has dementia, to six colleagues, along with the caption “shit galore,” according to government reports.

“What we have is a very disgusting and humiliating situation,” Werning says. “But it does not meet the definition of sexual exploitation, and I think that was a surprise to everybody.”

Now Iowa officials are working to update the law to address changing technology, he says, “so we won’t be caught off-guard again.”

The Iowa incident is just one illustration of how regulators and law enforcement officials nationwide are struggling to respond when employees at long-term care facilities violate the privacy of residents by posting photos on social media websites.

In a story published last year, ProPublica identified nearly three dozen of these cases, the majority involving Snapchat, a social media service in which photos appear for a few seconds and then disappear. We’ve discovered nine more instances since then, including one in which a youth volunteer at a Colorado nursing home shared a selfie on Snapchat that showed a 108-year-old resident urinating. (You can read details of each incident here.)

Following ProPublica’s earlier coverage, Sen. Charles Grassley, the Iowa Republican who chairs the Senate Judiciary Committee, sent letters to social media companies and federal agencies asking what they are doing to stop the abuse. He’s taken Snapchat, in particular, to task because he says its online tool for reporting suspected abuse requires the affected person to file a complaint — a near impossibility for elderly people with dementia.

“When an individual tries to report a safety concern on behalf of someone else, say, an elderly nursing home resident, the tool produces the message: ‘We are unable to take action based on third-party reports,’ ” Grassley wrote to Snapchat on June 28. “An elderly nursing home resident victim is unlikely to have his or her own Snapchat account or have the knowledge or ability necessary to report abusive snaps on his or her own behalf.”

Snapchat’s website gives people several avenues to file complaints. But the pathway to report elder abuse isn’t straightforward, particularly for those unfamiliar with the app, which is popular among teenagers.

In replies to Grassley, Facebook and Snapchat have said they are doing what they can to deal with abusive pictures and videos that violate their terms of service.

“Although we cannot prevent physical abuse from occurring — whether in a nursing home or schoolyard — Snapchat is fiercely committed to terminating the accounts of Snapchatters who we believe have engaged in abusive behavior,” Snapchat’s general counsel Chris Handman wrote to the senator.

Facebook, which also owns Instagram, says it removes images depicting sexual violence and generally prohibits nudity. Anyone can report abusive content, the company says.

Grassley’s pressure also has regulators re-examining their handling of these cases. In a letter to the senator, Assistant Attorney General Peter J. Kadzik wrote that while the Justice Department has gone after nursing homes for poor care, “we have not yet brought any cases involving allegations of nursing home employees misusing social media or electronic devices to record elder residents in compromising positions. We wholeheartedly agree that such conduct is deeply troubling and unacceptable.” The Justice Department said it would share the concern with its Elder Justice Task Forces “to ensure that they are especially attuned to allegations of such conduct.”

Some state and local prosecutors have been more aggressive in pursuing such cases under laws that prohibit elder abuse, sexual exploitation and indecency. In Colorado, for example, the volunteer who took a selfie with the 108-year-old resident who was urinating has been charged in juvenile court with invasion of privacy.

The Office for Civil Rights within the U.S. Department of Health and Human Services could take action in such cases as part of enforcing the federal patient privacy law known as HIPAA. But that agency has not penalized any long-term care facility for photos posted online and has yet to release any social media guidance for nursing homes. An official tells ProPublica that guidelines are in the works.

The nursing home industry isn’t waiting. Last month, the industry’s trade group issued its own suggestions for dealing with such situations, encouraging training and swift responses by these facilities when allegations are brought to light. The group also is holding training events around the country. Dianne De La Mare, vice president of legal affairs at the American Health Care Association, says nursing home companies are “all struggling with this.”

“We don’t want this stuff to happen anymore. To the greatest degree we can stop it, we want to,” she says.

The trade group notes that most instances of abuse have been reported by other staff members — a sign that most workers are diligent and do not tolerate such actions — but that some homes also hire outside companies to monitor social media.

While many facilities ban the use or possession of cellphones by employees when in resident areas, De La Mare says, they’ve also found such rules impractical to enforce

“A lot of the younger people — your phone is like your wallet,” she says. “You would never be without your phone … It’s really difficult for [nursing home officials] to say, ‘We understand you’re a single mom; you need to keep track of your kids, but that stays in your purse.’ It’s a challenge, I have to tell you that.”

As the Iowa case demonstrates, even nursing homes eager to respond to incidents responsibly face obstacles.

When it learned of the photo of its resident covered in feces, Hubbard Care Center contacted its local sheriff’s office. The law enforcement officials did not create a report or press charges; instead they encouraged the nursing home to contact health regulators, says Hardin County Deputy Sheriff Jeffrey Brenneman. The state investigated and initially fined the facility $8,500, which it reduced to $1,000 on appeal. Officials determined there was no evidence the facility knew or should have known that the assistant “might engage in such outrageous actions.”

And state officials learned that the law wasn’t written with these situations in mind.

Kendall Watkins, a lawyer for the nursing home, calls the incident an “isolated act” to which the facility responded quickly and appropriately.

The nursing home has already updated its policy to define “exploitation” of residents to include “transmission, display, taking of electronic images of the dependent adult by a caretaker in a private or compromised situation (i.e. using the bathroom, changing clothes, personal cares) for a purpose not related to treatment or diagnosis or as part of an ongoing investigation.”

Grassley says the incident in his home state troubled him. “It speaks to the lowest instincts of humankind that you never expect people to do,” he says. “If you’re a worker there, if you were really concerned about the patient, why wouldn’t you start immediately cleaning people up?”

Has your medical privacy been compromised? Help ProPublica investigate by filling out a short questionnaire. You can also read other stories in our Policing Patient Privacy series.

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There are a lot of people suffering from a mental health condition who need therapy. And there are a lot of therapists who want to help them. But both sides believe the insurance companies that are supposed to bring them together are actually keeping them apart.

Insurance companies, for their part, say there’s a shortage of therapists.

But it’s not that simple. Especially in urban areas, there are lots of therapists. They just don’t want to work with the insurance companies.

Take Michael Klein, a psychologist practicing in San Francisco for more than 20 years. He considers it his spiritual calling to help people calm their social anxiety and to help couples stop fighting and build trust.

“With the right kind of support, they blossom,” he says.

Klein doesn’t accept insurance. In fact, nearly half of therapists in California don’t take insurance, according to a recent survey from the California Association of Marriage and Family Therapists. The same is true of psychiatrists. There are two reasons why, Klein says.

“One, because the reimbursement rates don’t provide a living wage,” Klein says. “You can’t own a home and drive a car and survive on what in-network providers pay you.”

Most insurance companies pay therapists in their networks between $60 and $80 per session. In the San Francisco area and Los Angeles, therapists say the market rate for therapy is more like $150 or $200 a session.

“The second thing is the paperwork. For an hour of psychotherapy you spend a half-hour on paperwork,” Klein says. “I got into this field because I don’t like paperwork,” he laughs.

On that first point — money — insurance companies acknowledge that they may have to raise their rates to attract more therapists, particularly in rural areas. But they also say it’s on therapists to compromise.

“I think it’s unrealistic to expect either the state of California taxpayers or for health plans to just pay providers whatever they ask to be paid,” says Charles Bacchi, CEO of the California Association of Health Plans, a trade group for the insurance industry.

“That’s not sustainable,” he continues. “So you’re either in the system, and you want to be part of our health care system. Or you want to do concierge service outside of it and just pretend our health care system doesn’t exist. That’s your choice as a provider. Our job is to find providers that are willing to be part of the solution and willing to provide coverage to those of low and moderate income.”

That’s exactly how San Francisco psychologist Jonathan Horowitz feels. He wants to take insurance. But he’s hit roadblock after roadblock. He sent out 10 applications to insurance companies and got nowhere.

“I might knock on Cigna’s door and say, ‘Hey, are you guys accepting any new therapists in 94105?’ ” he says, referring to his ZIP code. “And they might say, ‘No, we’re not doing that. We’re totally full.’ “

Six different companies told Horowitz their networks were full.

So even though a patient might call seven therapists in her insurance network and not be able to get an appointment, insurance companies are telling new and willing therapists that there’s no demand for them.

“I definitely think it’s to control costs,” Horowitz says. “That’s very clear.”

He says he tried for a year, and one company finally said yes. Sort of. Horowitz never got a formal notice saying his clinic was admitted to the network.

“It was just like, ‘Oh wait, it looks like we’re suddenly getting a couple referrals from them. I wonder if we’re in their directory,’ ” he explains.

They were. Sort of. The clinic was listed in the directory. But the therapists who work at the clinic weren’t approved yet, meaning there was no one who was allowed to see the clients calling the clinic.

So Horowitz tried to call the insurance company to clear things up. He tried many, many times. I sat with him during a recent attempt to navigate the automated phone system:

Insurance company automated attendant: First I’ll need your provider identification number. If you need a moment, say, hold on.

Horowitz: Hold on.

Sound familiar? Turns out therapists get the automated run around as much as patients do. Horowitz persevered.

Insurance company: OK, please say or enter your PIN.

Horowitz: My PIN? Is this my PIN? (He enters a few numbers.)

Insurance company: I’m sorry I couldn’t find an account using the info you gave me. Do you already belong to the network?

Horowitz: I think so?

Insurance company: Sorry, yes or no.

Horowitz: Um, I don’t know … yes?

Insurance company: All right. And have you already requested a credentialing application?

Horowitz: Yes.

Insurance company: Sorry, could you repeat that?

These experiences didn’t bode well. “Honestly, I got a really bad feeling about it,” he says.

Horowitz figured, if this is what it’s like just finding out if he’s in the network, how’s it going to be when he has a problem with a claim?

“I could just see that getting out of hand really quickly,” he says. “So at that point we just said, do we really even want to do this?”

Furthermore, he says, the reimbursement rate was even lower than he expected, and the billing was so complicated that he was going to have to hire someone to do it. He says he couldn’t afford that.

“We made the decision that we’re just going to cancel the contract and continue to go with cash,” he says.

Easier said than done. Horowitz hasn’t been able to get through to anyone on the phone to cancel the contract. In the meantime, prospective patients are finding his name on the directory and are calling for appointments. Horowitz says he just has to say no.

This story is part of NPR’s reporting partnership with KQED and Kaiser Health News.

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The Senate is set to approve a bill intended to change the way police and health care workers treat people struggling with opioid addictions.

The bill is an amalgam of more than a dozen proposals passed through the year in the House and Senate. And while it has lots of new policies and provisions — from creating a task force to study how best to treat pain, to encouraging states to create prescription drug monitoring programs — it doesn’t have much money to put them in place.

President Obama had requested $1.1 billion to help pay for more addiction treatment programs and other initiatives. But the version agreed to by House and Senate Republicans last week didn’t include all that money. In the end, it will probably get about half that much.

“It’s clear that efforts to prevent and treat the opioid epidemic will fall short without additional investments,” Sen. Patty Murray, D-Washington, said in a statement after House and Senate negotiators hammered out the final bill.

But Sen. Lamar Alexander, R-Tenn., argued that the money for treatment has been rising for three years.

“Our friends on the other side say, you have to fund it. We are funding it,” he said in a statement on the Senate floor Friday. “And they helped fund it. We’ve increased funding for opioids already by 542 percent.”

Still, Democrats are expected to support the bill even without the additional money.

And that’s a good thing, says Linda Rosenberg, president of the National Council for Behavioral Health, because the bill helps expand treatment in significant ways.

For example, it allows nurses and physician assistants to treat people with addictions using medications, which is considered the evidence-based standard.

“Treatment capacity is really a crisis. There just isn’t enough,” Rosenberg tells Shots. “But what this bill does to address that — it expands the kinds of people who can prescribe medications for addictions. And that’s a very big deal.”

She says that provision alone can help because nonprofit treatment centers will be able to use nurse practitioners and physician assistants rather than trying to hire doctors, who are both scarce and expensive.

The bill also allows the Department of Health and Human Services to give grants to states and community organizations for improving or expanding treatment and recovery programs. It has several provisions that would allow police departments to send people with addiction problems to treatment rather than to jail.

In one of the few areas of the bill that includes funding, lawmakers authorized the Department of Justice to spend $100 million a year for five years to find alternatives to jail for opioid abusers, and to allow prisons to use methadone or buprenorphine to treat inmates with opioid addictions.

Rosenberg says these measures help change the definition of addiction from a crime to a health problem.

“It’s a health care issue and not a moral failing issue,” she says. That’s a big reversal from the “war on drugs” campaigns of a few decades ago.

And the legislation allows more people to have access to naloxone, the drug that can reverse an opioid overdose, reducing the risk of death. Access would be expanded for people working in schools and community centers.

The bill encourage pharmacies to fill standing orders for the drug so that those likely to come in contact with someone suffering an overdose will have the drug on hand, according to Mike Kelly. He is the U.S. president of Adapt Pharma, which sells Narcan, a nasal spray version of naloxone.

“This bill addresses getting Narcan out into the community, outside of emergency and first responders,” Kelly says. “The big thing here is this will fund recovery.”

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More than 4 in 10 working Americans say their job affects their overall health, with stress being cited most often as having a negative impact.

That’s according to a new survey about the workplace and health from NPR, the Robert Wood Johnson Foundation and the Harvard T. H. Chan School of Public Health.

While it may not sound so surprising that work affects health, when we looked more closely, we found one group was particularly affected by stress on the job: the disabled.

More than 60 percent of people with a disability in our poll say their job has a bad impact on their stress level.

Jason Olsen says he’s not surprised by the poll’s findings. As I met him at his home in Gaithersburg, Md., we start trading commuter complaints. Traffic was terrible getting here, I say.

But his story wins out.

“The other day I had to wait 45 minutes to finally get a train where I could get myself and the wheelchair onto the train,” he says. Navigating Washington’s Metro system is always a challenge, he says.

And then there was the time when someone ran their luggage over his foot, breaking it in multiple places.

But because a car accident left Olson paralyzed from mid-chest down, he didn’t realize his foot had been broken.

Another time — a couple of weeks before we meet — he suddenly fell ill at work.

“Three hours later, I’m in the ER, and two hours later I’m in the ICU,” he tells me. “Some of the stuff, you know, when you don’t have the sensation, your body doesn’t give a lot of warning signs.”

Warning signs, in this case, that might have signaled that a cut on his foot had turned into a septic infection. He was ultimately hospitalized for two weeks.

Our workplace and health survey found that 62 percent of people with disabilities say their job adds to their stress level, compared with 41 percent of the non-disabled.

Perhaps more stark is that over a third (35 percent) of disabled workers say their job has a bad impact on their overall health. That’s more than double the rate for their nondisabled peers (15 percent).

Olsen, who works on disability policy for the federal government, says it often isn’t the work that’s stressful, but the time, energy and physical toll it takes to get to the office, sit in a chair for hours, and manage the other demands of living with a disability.

Those demands can require specialized equipment and extra time and care.

For example, because he uses a catheter and other equipment, going to the bathroom can take an hour.

And when he falls ill, it also affects his wife B.J.’s work schedule as an emergency room nurse, adding to the stress.

“I think it’s a double-edged sword,” she tells me. “I want him to go and do work and stuff like that, but then because of his physical problems, it makes it harder to work.”

Jason Olsen’s main sources of stress relief, he says, are his son, Gunnar, and baby daughter, Scottie. They keep him motivated.

“Your option is to sacrifice some of your own self care and health or to live in destitution,” he says. “For me, that’s not a choice.”

Cheryl Bates-Harris says that, on balance, the income, independence and social contact that work provides are good for people with disabilities. She’s an advocacy specialist with the National Disability Rights Network.

“We have study after study that shows that for people with psychiatric disabilities, work is part of recovery, and it helps them,” she says. But she can also see how it adds stress.

“If you’re worried about whether your performance is going to be acceptable, whether they’re going to keep you beyond your probationary period, whether there’s going to be opportunity for advancement, God forbid that you could request some kind of reasonable accommodation, I imagine that could be pretty stressful for people,” Bates-Harris says.

When considering whether to hire a disabled worker, employers worry that accommodating disabilities might cost a pretty penny. In fact, the average cost is only about $500 per person, Bates-Harris she says.

Judy Owens says that persistent misconception is one reason she started Opportunity Works five years ago, helping more than 70 people with disabilities find jobs. She says it can be so hard to find jobs, some people might stick with a bad job.

“You might have five other friends with disabilities who don’t have jobs at all, so you just kind of deal with the bad environment you’re in because at least you have a job,” Owens says.

That was not the case for James Schwonek, who left his previous job in IT after his boss fell ill.

“That actually prompted me to go find a different job,” he tells me, “because I didn’t have the arranged accommodation that was there previously.”

The accommodations in his case were basic: His boss took care to face him when talking so Schwonek could read his lips. Without the boss around, however, the workplace seemed less welcoming. Coworkers ridiculed him, he says, for trying to teach them basic sign language.

His experience appears to be fairly common. According to our survey, just over a third of disabled workers said their workplace policies helped them. But more than half (55 percent) rated their workplace fair or poor in terms of providing a healthy work environment, as compared with 21 percent of the nondisabled.

Still that’s progress, says Clay Bradley. He’s a 51-year-old man who was born missing part of each limb.

He recalls the era before the Americans with Disabilities Act, when buses often didn’t come with ramps.

“Now buses automatically have ramps in them,” he says. “When I was using buses in the 90s or in the 80s, half of them would have ramps and then half of them wouldn’t. So you’d have to schedule your trips for a bus that was going to have a ramp on it.”

Bradley, who works in customer service at a health insurance firm, says other than a ramp, he requires no special equipment.

“I use both arms and I can touch the keys individually, I make mistakes but I’ve used the computer so long I correct them very quickly, so my typing speed is about 35 words per minute,” he says.

And once he’s at work, he says, work is just as stressful for him as the next person.

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Many babies born to mothers who are covered by Medicaid are automatically eligible for that health insurance coverage during their first year of life. In a handful of states, the same is true for babies born to women covered by the Children’s Health Insurance Program.

Yet, this approach is routinely undermined by another federal policy that requires babies’ eligibility for these programs to be re-evaluated on their first birthday. Although they’re likely still eligible for coverage, many of these toddlers don’t get it because of a tangle of red tape.

People often cycle in and out of Medicaid and CHIP, state/federal health programs for low-income residents, as their income or family circumstances change. Such churning is a long-recognized problem. The requirement that people renew their coverage annually may also cause hiccups.

“Many people lose Medicaid coverage for procedural reasons,” says Shelby Gonzales, a senior health policy analyst at the Center on Budget and Policy Priorities. “But there are all sorts of things that are unique about babies turning 1” that present extra challenges.

“You hate any baby to lose coverage,” says Jill Hanken, a lawyer with the Virginia Poverty Law Center who has worked on this issue. “A 1-year-old needs to have consistency with their health care and visits with the pediatrician.” Regular well-baby visits ensure kids are developing properly and get scheduled vaccines, among other things.

One potential snag in retaining toddlers’ coverage is that their first-year review is pegged to their date of birth, which is generally different from the annual renewal date for other family members’ coverage.

In other instances, states that don’t seek babies’ Social Security numbers until they turn 1 may have a tougher time getting the income and other data they need to process the renewal. And some states mistakenly ask for documentation proving the baby’s citizenship, which is not required if Medicaid or CHIP paid for the birth.

Antiquated computer systems sometimes automatically drop babies after their first birthday unless a renewal has been processed. This can be a problem in states that are behind in renewals, which is not uncommon, Gonzales says; some states have scrambled to implement the many requirements of the health law.

It’s hard to quantify the extent of the problem nationally. An analysis of data from the 2014 American Community Survey of 700,000 children found that children between the ages of 1 and 2 were less likely than infants to be covered by Medicaid or CHIP. That suggests “some children may be losing Medicaid/CHIP coverage at their first birthday,” says Genevieve Kenney, a co-director and senior fellow at the Urban Institute’s Health Policy Center.

The experience of the state of Connecticut offers a window on the problem. Connecticut Voices for Children, a policy research and advocacy organization, has tracked the issue closely for several years. In 2008 and 2009, 42 percent of babies who had been considered automatically eligible for Medicaid at birth lost their coverage at the end of the month they turned 1. That’s compared with roughly 6 percent of babies who were in other Medicaid coverage groups, such as those whose mothers had employer-sponsored insurance.

By 2013, when Connecticut Voices revisited coverage gaps, Medicaid and CHIP coverage retention when infants turned 1 had improved significantly. Still, nearly 23 percent of babies with guaranteed coverage for their first year were uninsured after their first birthday. That was true for less than 2 percent of other babies in the state.

During that time the state had revised confusing notices to families that, for example, announced that coverage was ending for infants because, “You are not the right age to be eligible for this program.” Advocates also played a role in improving the troubling statistics by working to alert pediatricians and community services providers about the problem.

Though coverage for 1-year-olds has improved, “the problem still persists,” says Mary Alice Lee, senior policy fellow at Connecticut Voices for Children. Advocates hope that a new eligibility management system, scheduled to roll out next year, will make a difference.

Elsewhere, advocates in Virginia are also awaiting a computer system fix so that infants who were guaranteed Medicaid coverage for the first year aren’t automatically canceled after their birthday. In the meantime, Hanken says, the state changed its policy so that the determination of a newborn’s Medicaid eligibility at 1 year of age is a streamlined renewal, instead of a totally new application for coverage.

“We’re about halfway to a solution,” Hanken says.

Outdated technology is no excuse for states not addressing this longstanding problem, says Tricia Brooks, a senior fellow at Georgetown University’s Center for Children and Families.

These newborns are easily identified, Brooks says, so “if nothing else, [state officials] could go in on a manual basis and trigger a review.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter:@mandrews110.

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Obamacare health plans have been getting a bad rap this year. Critics say the premiums are too high, the out-of-pocket costs are out of control, and the requirements and red tape are too thick.

But now the Obama administration is pushing back.

A study released Tuesday by the Centers for Medicare and Medicaid Services argues that the cost-sharing isn’t nearly as heavy as previous analyses have shown, because most consumers get subsidies that limit their deductibles and copayments.

“This comprehensive analysis makes clear that two key misconceptions about the market are incorrect,” said Christen Linke Young, principal deputy director of the Center for Consumer Information and Insurance Oversight at CMS.

She said those misconceptions are that deductibles are very high and that out-of-pocket costs for consumers are out of control.

The median deductible that consumers actually pay for Obamacare health plans is $850 this year, $50 less than last year, the CMS report shows. A deductible is the amount of health costs a person must cover before insurance kicks in.

The CMS report contrasts with a Kaiser Family Foundation analysis from November 2015 that shows the average deductible for a midlevel health plan, including prescription drugs, is $3,064. That survey didn’t take into account the financial assistance that about 60 percent of Obamacare customers get to cover health costs.

“This shows that the marketplace is more attractive to lower-income people,” says John Holahan, a fellow in health policy at the Urban Institute in Washington.

He said for people with higher incomes, health plans sold on the government run exchanges are often still out of reach because of high premiums and out-of-pocket costs. The report found that 17 percent of people are paying deductibles of more than $5,000 per year.

People whose incomes are 250 percent of the federal poverty level or below qualify for “cost reduction subsidies” under the Affordable Care Act. These subsidies are designed to protect lower-income consumers from unexpected high costs after they buy insurance.

Young says that level can reach families whose incomes are as high as $60,000 a year.

“We’re really not talking about the lowest-income enrollees,” she said on a conference call with reporters.

The CMS report also argues that the health plans are less expensive than the public perception because many services come free to patients even before they meet their deductible. The plans cover annual checkups and vaccines for children and cancer screenings for adults with no copayments. Most also cover primary care visits for adults, most prescription drugs and some specialist visits — with a copay, but before a patient meets a deductible.

“They are able to get the basic services they need without even thinking about the deductible,” Young said.

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Now that the nasal spray FluMist is no longer considered an effective vaccine against influenza, parents will have to resort to the old, unpopular standby for their kids: a shot.

It’s not unusual for a child to have as many as 20 vaccinations by age 5 — all typically administered by injection. The pain of those shots can sometimes be a barrier to getting kids vaccinated, but several studies have shown that the pokes don’t have to be so painful or petrifying, and parents can actually play a big role in soothing the sting.

“There is a whole body of research on children’s pain management that people aren’t aware of,” Christine Chambers, a clinical psychologist and professor whose lab is based at the Centre for Pediatric Pain Research in Halifax, Nova Scotia, tells Shots. “Parents assume that everything possible is already being done — that if there was something more, it would be offered.”

She says a vicious circle can sometimes arise: When parents are asked why they aren’t using pain management techniques, they say their doctors are not suggesting them. When pediatricians are asked why they’re not discussing those pain control options, they say parents aren’t asking.

“In theory, every health professional would be offering these strategies, but we know physicians aren’t very well trained when it comes to pain,” says Chambers.

Chambers is trying to spread awareness of vaccine pain-management techniques via blogs, videos and social media sites. Together with Erica Ehm, publisher of YummyMummyClub, a Canadian online forum for moms, Chambers has launched a social-media campaign called “It Doesn’t Have to Hurt,” which aims to quickly give parents science-backed information on how to help kids better cope with vaccination pain.

Parents need to be honest with their kids about the fact that they’re going to get a shot, says Chambers. But telling them too far in advance gives them more time to worry.

Rebecca Pillai Riddell, research chair of pain and mental health at Toronto’s York University, suggests telling your child on the morning of the shot. “When they’re waking up, getting dressed and eating breakfast, talk about what’s coming up. Make it about the next event: ‘We’re going to go for ice cream afterward.’ It helps them focus beyond the vaccination,” she says.

When it’s time to actually get the vaccination, the most important thing parents can do is remain calm themselves. This can be difficult, as research has shown that nearly a quarter of adults fear needles. When parents are anxious, kids pick up on that right away.

According to a study co-authored by Riddell and published earlier this year in the journal Pain, it is the parent’s behavior rather than the actual pain level of the shot that increases a child’s anxiety in the vaccination room.

And worse, says Riddell, babies who show distress before a vaccination exhibit more post-needle pain, which is measured by signs such as facial expressions, crying, heart rate and blood pressure.

“When kids are riled up, it makes them more reactive,” she says.

Too many verbal assurances have repeatedly been shown in studies to cause higher distress, says Riddell. “When things are OK, parents don’t go walking down the street reminding kids that things are OK,” she says.

A child’s position during the shot can also help set the tone of the experience. Chambers says physicians or nurses can prompt parents to hold kids in a way that’s more like being hugged and less like being restrained. Letting your child remain upright establishes a sense of control and decreases fear.

In babies, skin-to-skin contact, and breastfeeding or pacifiers have been shown in multiple studies to stabilize heart rates, improve oxygen levels and decrease crying during painful medical procedures.

Parents can also try using an over-the-counter topical skin-numbing cream on their kids, making sure to give it time to take effect (this varies depending on which anesthetic you are using.)

Sugar water can provide some relief from pain, though possibly more because it’s a pleasure that compensates for the pain rather than an analgesic that relieves it. Health professionals recommend giving a child sugar water before the shot and, if receiving multiple shots, throughout the entire process.

The order in which vaccinations are given may also help with pain levels. One study found, for example, that starting with the least painful shot produced a lesser pain response in infants than starting with the most painful one.

Older kids can also try the “cough trick.” Coughing once before and once during routine vaccinations helped reduce painful reactions among children receiving their prekindergarten vaccines as well as in those getting shots before middle school, according to a 2010 study published in the journal Pediatrics. Coughing provides a distraction, and the sensory stimuli of the sound and feeling may compete with the pain.

Immediately after the shot, try distraction, suggests Riddell. Let your child play with a favorite handheld video game, watch a cartoon, hug a stuffed animal or sing a song. Blowing a few bubbles might also be helpful, since they’re both distracting and relaxing, says Chambers.

Finally, don’t dwell on the shot once it’s over. “It’s best to emphasize what went well, and then move to the next thing,” she says.

Laurel Dalrymple is a freelance health and science writer based in Fairfax, Va. She’s on Twitter: @ldal

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President Obama on Monday called on Congress to revisit the controversial idea of providing a government-run insurance plan as part of the offerings under the Affordable Care Act.

What’s been described as the “public option” was jettisoned from the health law in 2009 by a handful of conservative Democrats in the Senate. Every Democrat’s vote was needed to pass the bill in the face of unanimous Republican opposition.

But in a “special communication” article published Monday on the website of JAMA, the American Medical Association’s top journal, the president says a lack of competition among insurance plan offerings in some regions may warrant a new look.

“Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited,” Obama writes.

The president calls on Congress to take more steps to rein in the cost of prescription drugs and make government assistance more generous for those who still cannot afford health coverage; he also urges the 19 states that have not yet expanded the Medicaid program under the health law to do so.

The public option has been a point of controversy from the start. It was included in the version of the health law passed by the House of Representatives, and had support from most Democrats in the Senate, before it was dropped. Many liberals hoped — and conservatives feared — that having the government provide insurance alongside private companies would be a step toward a fully government-run system.

Presumptive Democratic presidential nominee Hillary Clinton — under pressure from Sen. Bernie Sanders’ call for a single-payer government system — in February endorsed the idea of including a public option to allow people age 55 and older to purchase Medicare coverage.

On Saturday, as part of a deal with Sanders, Clinton announced she will also “pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan,” which is broader than what Obama is endorsing.

But even if Clinton wins and the Democrats take back control of Congress in November, a public option remains a political long shot.

Obama’s article, titled “United States Health Care Reform: Progress to Date and Next Steps,” is apparently the first by a sitting president to be published by the prestigious medical journal.

Along with these recommendations for further action, Obama’s article includes a justification for the federal health law and statistics on how its implementation has improved insurance coverage for patients and improved health care quality.

Kristie Canegallo, the White House deputy chief of staff for implementation, says the article grew out of a comprehensive review of the law that the president requested from his staff late last year.

The review was to look at “what’s working, what’s not, and what we should do about it,” Canegallo says. Upon receiving the review, she adds, Obama “thought it was important to share some of this publicly.”

Among those parts of the law the administration says are working are the coverage provisions. “The number of uninsured individuals in the United States has declined from 49 million in 2010 to 29 million in 2015,” the president writes.

The article also says that the health law has played a substantial role in slowing the rate of health spending.

“While the Great Recession and other factors played a role in recent trends, the [president’s] Council of Economic Advisers has found evidence that the reforms introduced by the ACA helped both slow health care costs growth and drive improvements in the quality of care,” says the article.

Jason Furman, chairman of the council, says the continuing slow growth in health spending so many years out from the recession makes the argument by some other economists that the turndown in the U.S. economy was mostly responsible for the slowing of health spending “absurd at this point.”

While most of Obama’s journal article is a chart-driven, footnoted recitation of the impact of the health law, he does use his perch to suggest that the current state of politics in Washington threatens progress going forward.

“Any change is difficult, but it is especially difficult in the face of hyperpartisanship,” he writes. “Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported.”

Republicans are continuing their assault on the health law. Just last week, two House committees released a joint investigative report and held two hearings asserting that the administration is illegally providing funds to help lower-income individuals pay for their health coverage.

That claim is also the subject of a lawsuit in federal court.

The White House, however, remains unimpressed by the Republican claim.

“The Department of Justice … has made clear we have a permanent appropriation for this,” Canegallo says.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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So here’s a typical scenario when you have a medical problem. You go to your doctor’s office, then have to run across town to a lab for a blood test and then you also have to get an appointment for an X-ray or MRI. There’s a good chance this will all require a phone call — or a lot of phones calls — with your insurance company.

It’s a hassle and it’s time-consuming.

But for many people it’s even worse than that.

That’s because about a third of working adults say their jobs don’t come with paid sick leave, according to results from the latest poll by NPR, The Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

And for some of those people, taking care of their health needs can lead to a financial crisis.

Take Valerie Hesse, a catering chef in New Orleans. “I’ve had allergies — pollen and dust and everything else — since I was a kid,” she tells Shots. “Over the years it got to the point where I was having frequent sinusitis, sinus infections occasional bronchitis.”

Hesse went to the doctor a lot to deal with sinus and ear infections. She tried to schedule the appointments around her work hours, and sometimes her doctor would give her a break and prescribe antibiotics over the phone.

But sometimes she’d be called in at the last minute. Or she’d have to work an extra shift.

“I had to reschedule, postpone, skip,” she says. “I wasn’t gonna get paid and you gotta work.”

Over time the constant congestion and infections were damaging her hearing, so last year Hesse decided to have surgery to fix the problem. The recovery took weeks.

By the time she was able to get back to work, she had a reputation as sickly and unreliable.

“The owner of the company told me that he had decided to make a management change,” she says. “I was let go.”

Hesse is now living off savings as she makes plans to open her own catering business. She says she needs to be her own boss to be able to take care of herself.

Our poll found that 32 percent of people in the U.S. are like Hesse. They don’t get any paid sick days. And 24 percent have no paid vacation time.

So unless they work odd hours, people without either benefit lose income if they want to take care of their health.

That’s a real problem, but it’s not the only consequence of what Dr. Victor Montori of the Mayo Clinic refers to as the “work” of being a patient.

He says the health care system is designed for the convenience of doctors — and the result is that patients find themselves running between doctor’s offices, labs, imaging centers and back, often carrying their records along with them.

“That is not an organization of care that started by thinking, ‘How do we meet the needs of our patients?’ ” Montori says.

The current setup was created at a time when people saw a doctor for an injury or infection. By contrast, today most people by middle age are dealing with a chronic condition that requires regular care.

So, like Hesse, they have to fit health care into their daily lives. And the system that requires a patient to leave work, go to the doctor, go elsewhere for tests and then go to a pharmacy, isn’t very useful, Montori says.

“For people with chronic conditions, the health care systems is blind to their context,” Montori says. “In particular, it’s blind to the work of being a patient and the capacity that people have to shoulder that work and make it happen.”

And if patients don’t do everything right — if they don’t get their tests, or refill their medications on time, or go to follow up appointments — they are deemed by the health care establishment to be “noncompliant,” he says.

“We just decide that it’s the character of the patient that is to blame and move on,” Montori says. “Rather than reviewing our own behavior as a health care system and see how is it that we have created so much work for people that they no longer can do it.”

Montori and his colleagues are now reviewing that behavior and trying to determine how to make the health care system more responsive. One approach is to put health care providers in schools and workplaces and to make them available during evenings or weekends.

“Once we start thinking about meeting the needs of people, the first thing we say is, ‘Where are these people, and how can we start thinking about meeting their needs where they are?’ ” Montori says. “Can the kid not get the asthma care at school? These kids are at school for hours and hours and hours.”

Many doctors say it’s not just the system they created that is complicated. It’s also complex rules imposed by Medicare and insurance companies that make the work of being a patient harder.

“You can’t do multiple procedures at the same time or on the same day without having the second procedure’s payment cut,” says Kristine Longshore, an ophthalmologist in Doylestown, Pa.

If she wants to operate on both eyes of patient, she’ll be paid less if she does both eyes at the same time than on different days.

Sometimes, she says, she’s not allowed to do two procedures on the same day at all.

“I cannot image the optic nerves and macula on the same day even if the patient happens to have both glaucoma and macular degeneration,” she says. If she does, Medicare won’t pay for one of them.

“And that’s a real hardship for patients. They may have to have the right eye treated and come back the following week to have the left eye treated,” she says.

Longshore says insurers, including Medicare, are already cutting payments to doctors. With their incomes shrinking, doctors may be reluctant to earn even less by doing two procedures at the same appointment.

It’s those insurance company practices that make getting health care cumbersome for Tammy Davenport, who lives outside Houston.

She recently needed an MRI to determine why a year-old ankle injury wasn’t healing properly. Davenport has hemophilia, a disorder where people bleed excessively, often into their joints.

Last year she fell down some stairs and landed on the ankle. She ended up in the emergency room and could barely walk for a month. Now, 15 months later, she was still in enormous pain, so she went to her doctor and he ordered the test.

“It took me eight hours on the phone, one full day of work, to get an appointment for an MRI within 15-20 minutes from our house,” she says.

To control costs, Davenport’s insurance company requires an outside contractor to approves the doctor’s authorization for the test. A second contractor then schedules the test. That company only works with three MRI centers, and all of them were more than 90 minutes from her home.

Davenport says there were several within a few miles on her insurance company’s website, but the company refused to work with them. After hours calling different people — all while she was supposed to be working — she got the appointment.

“Its all just a random phone tag that you have to go through just trying to get an answer to a question,” she says.

But there are signs of change. The health care system is shifting in ways that may make things easier for patients, says Gail Wilensky, an economist who was head of Medicare and Medicaid under the first President Bush.

She says doctors are leaving behind individual practices and joining health care groups that combine specialties and services under the same roof. “The general move toward better integration of care can be a major improvement and convenience for the patient,” she says.

But that transition will take time. It requires doctors and health systems to re-think how they’ve been doing their work for decades.

And in the meantime, people like Valerie Hesse will continue to have to choose between getting healthy and getting paid.

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