As more states legalize marijuana, more people in the U.S. are buying and using weed — and the kind of weed they can buy has become much stronger.

That concerns scientists who study marijuana and its effects on the body, as well as emergency room doctors who say they’re starting to see more patients who come into the ER with weed-associated issues.

Some 26 million Americans ages 12 and older reported being current marijuana users in 2017, according to the National Survey on Drug Use and Health. It’s not clear how many users have had serious health issues from strong weed, and there’s a lot that’s still unknown about the potential risks. But scientists are starting to learn more about some of them.

The potency of weed depends on the amount of delta-9-tetrahydrocannabinol, or THC, the main compound responsible for the drug’s psychoactive effects. One study of pot products seized by the U.S. Drug Enforcement Administration found the potency increased from about 4% THC in 1995 to about 12% in 2014. By 2017, another study showed, the potency of illicit drug samples had gone up to 17.1% THC.

“That’s an increase of more than 300% from 1995 to about 2017,” says Staci Gruber, director of the Marijuana Investigations for Neuroscientific Discovery (MIND) program at the Harvard-affiliated McLean Hospital in Belmont, Mass. “I would say that’s a considerable increase.”

And some products with concentrated forms of cannabis, like hash and hash oil, can have as much as 80% to 90% THC, she adds.

“I think most people are aware of the phenomenon that ‘this is not your grand daddy’s weed,’ Gruber says. “I hear this all the time.”

But people might not be aware of the potential health risks of highly potent weed. “The negative effects of cannabis have primarily been isolated and localized to THC,” says Gruber. “So it stands to reason that higher levels of THC may in fact confer a greater risk for negative outcome.”

“In general, people think, ‘Oh, I don’t have to worry about marijuana. It’s a safe drug,’ ” says Nora Volkow, director of the National Institute on Drug Abuse. “The notion that it is completely safe drug is incorrect when you start to address the consequences of this very high content of 9THC.”

Pot’s paradoxical effects

THC can have opposite effects on our bodies at high and low doses, Volkow says. Take anxiety levels, for example.

“When someone takes marijuana at a low [THC] content to relax and to stone out, actually, it decreases your anxiety,” she says. But high concentrations can cause panic attacks, and if someone consumes high-enough levels of THC, “you become full-blown psychotic and paranoid.”

Weed can have a similar paradoxical effect on the vascular system. Volkow says: “If you take low-content THC it will increase your blood flow, but high content [THC] can produce massive vasoconstriction, it decreases the flow through the vessels.”

And at low concentrations, THC can be used to treat nausea in cancer patients undergoing chemotherapy. But Volkow says that “patients that consume high content THC chronically came to the emergency department with a syndrome where they couldn’t stop vomiting and with intense abdominal pain.”

It’s a condition called cannabinoid hyperemesis syndrome.

“The typical patient uses [inhales] about 10 times per day … and they come in with really difficult to treat nausea and vomiting,” says Andrew Monte, an associate professor of emergency medicine and medical toxicology at the University of Colorado’s school of medicine. “Some people have died from this … syndrome, so that is concerning.”

Scientists don’t know exactly how high levels of THC can trigger the syndrome, but the only known treatment is stopping cannabis use.

While the number of people who’ve had the syndrome is small, Monte says he and his colleagues have documented a rise in the number of cases at emergency rooms in Colorado since marijuana was legalized there five years ago. A study by Monte and his team found that cyclical vomiting cases made up about 18% of inhaled cannabis-related cases at his ER.

They also found that statewide, the overall number of ER cases associated with cannabis use has gone up. And Monte says his ER has “seen an approximately a three-fold increase in emergency department visits just by frequency. It doesn’t mean we’re getting overwhelmed by these visits due to cannabis, it’s just that means that there are more patients overall.”

Most people show up at his emergency department because of “intoxication” from too much pot, either straight or mixed with other drugs, Monte says. The bulk of these cases are due to inhaled cannabis, though edibles are associated with more psychiatric visits.

“We’re seeing an increase in psychosis and hallucinations, as well as anxiety and even depression and suicidality,” Monte says.

He thinks the increased potency of marijuana plays a role in all these cases. “Whenever you have a higher dose of one of these types of drugs, the patient is at a higher risk of having an adverse drug event. If the concentration is so much higher … it’s much easier to overshoot the low-level high that they’re looking for.”

Not everyone is at equal risk, Monte adds. “Many many people use cannabis safely,” he says. “The vast majority don’t end up in our emergency department.”

Different risks for users

Some people are more vulnerable than others to the potential negative effects of high THC cannabis.

Adolescent and young adults who use recreationally are especially susceptible because their brains are still developing and are sensitive to drugs in general, says Gruber of the MIND program. In a recent review of existing studies, she found that marijuana use among adolescents affects cognition — especially memory and executive functions, which determine mental flexibility and ability to change our behavior.

Medical marijuana users can face unexpected and unwelcome effects from potent weed. “It’s very important for people to understand that they may not get the response they anticipated,” Gruber notes.

Studies done on the medical benefits of pot usually involve very low doses of THC, says Monte, who adds that those doses “are far lower than what people are getting in a dispensary right now.”

David Dooks, a 51-year-old based in the Boston area turned to marijuana after an ankle surgery last year. “I thought that medical marijuana might be a good alternative to opioids for pain management,” he says.

Based on the advice at a dispensary, David began using a variety of weed with 56.5% THC and says it only “exacerbated the nerve pain.” After experimenting with a few other strains, he says, what worked for him was one with low (0.9%) THC, which eased his nerve pain.

‘Start low, go slow’

Whether people are using recreationally or medically, patients should educate themselves as much as possible and be cautious while using, Monte says.

Avoiding higher THC products and using infrequently can also help reduce risk, Volkow adds. “Anyone who has had a bad experience, whether it’s psychological or biological, they should stay away from this drug,” she notes.

Ask for as much information as possible before buying. “You have to know what’s in your weed,” Gruber says. “Whether or not it’s conventional flower that you’re smoking or vaping, an edible or tincture, it’s very important to know what’s in it.”

And the old saying “start low, go slow,” is a good rule of thumb, she adds. “You can always add, but you can never take it away. Once it’s in, it’s in.”

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On Wednesday, Civica Rx, a nonprofit drug company founded last year by a consortium of hospitals and foundations, said it had entered an agreement with a Danish drugmaker to make available injected forms of vancomycin and daptomycin, two antibiotics that are often in short supply.

Civica Rx has plans to become an alternative source of generic drugs for hospitals and provide a steady supply of critical medicines at reasonable prices .

The company’s initial plan is to make 14 drugs and offer them to member health systems. The antibiotics are the first two that Civica Rx has publicly announced.

“Vancomycin is kind of the typical shortage drug because it’s generic and it’s an injectable and it’s critically needed,” says Erin Fox, a pharmacist who studies drug shortages at University of Utah Health, one of Civica Rx’s members. “But we just haven’t had a very good routine supply of it for a while now,” she explains. She also recently joined Civica Rx’s advisory board.

When the heavy-duty antibiotic vancomycin is in short supply, Dr. James Augustine, an emergency physician at Mercy Health hospitals in Cincinnati, gets worried.

“Vancomycin has been our last-ditch antibiotic for quite a few years,” Augustine says. “It is our go-to antibiotic for very, very sick people and those with resistant infections.”

Augustine collects information on drug shortages and shares it with other health care professional across the country. Shortages of key drug are a big and persistent problem for hospitals, he says.

“We have experienced shortages of most every drug,” he says. “It’s getting hard to keep track,” Augustine says. In a survey last year of emergency physicians, 9 in 10 had experienced a shortage in the previous month.

Shortages of vancomycin are a particular problem because it’s a powerful medicine that doesn’t have a good alternative, he says.

It’s unclear why vancomycin, which has been a generic for many years, has experienced shortages, says University of Utah’s Fox.

“Sometimes it’s just some kind of a supply constraint, or one company discontinuing production,” she says. “But we don’t always know the reasons for shortages. The companies won’t won’t tell us. In fact, pharma companies, while they’re required to report a shortage to the [Food and Drug Administration] FDA, they’re actually not required to provide the reason for that shortage to the FDA.”

Neither vancomycin, whose name comes from the same root as vanquish, nor daptomycin drug is on the FDA’s list of drugs in short supply, but they both are on another drug shortage list that Fox helps manage, along with the reasons why, if available. Drug giant Pfizer, for example, lists shortages for both drugs because of “manufacturing delays.”

Civica Rx won’t be making these drugs itself. Instead it has contracted with Danish drugmaker Xellia to make them with a Civica Rx label. Civica Rx’s member health systems currently include 800 hospitals across the country.

Fox says the real innovation here is a new kind of contract between drugmakers and hospitals.

“You can pretty much predict how much product you’re going to need at your hospital, and you can say, ‘Yep, I will purchase, say, 500 packages of this in a year,” she explains. “You would have to sign up for that and say, ‘I’m going to buy that,’ and if you don’t, the company still gets the money.”

That “guaranteed volume” for Civica Rx is supposed to help with the periodic shortages.

How much will the Civica Rx drugs cost? “Pricing will vary based on product,”company spokesperson Debbi Ford said in an email. She declined to provide specific prices.

Vancomycin “right now is a fairly reasonable price,” says Martin VanTrieste, Civica’s president and CEO. “However daptomycin is one of those high-priced drugs, and we’ll be able to bring [it at] a significantly lower price.”

VanTrieste says Civica’s pricing will be based on manufacturing costs, plus a “fair margin” for the drugmaker — in this case, Xellia. “Once we negotiate that price, we go back to our members and say, ‘I have vancomycin 1-gram vials I’m offering to you at “X” price. You want to opt in to purchase that product or opt out?’ “

Dr. James Augustine’s health system, Mercy Health, isn’t a Civica Rx member, although membership is open. It costs $300 per hospital bed to join, according to VanTrieste.

Augustine is encouraged by what Civica Rx is trying to do. “It’s a fabulous idea,” he says.

But the company’s existence underscores for him that up until now, generic drugmakers have failed patients and providers. “They have decided not to make a reliable source of these medicines available and where possible to jack up the prices to to incredible levels,” he said. “It’s disgusting.”

“We always support additional competition to the market,” said Rachel Schwartz, a spokesperson for the Association for Accessible Medicines, a trade group for generic drugmakers, in an email.

Civica Rx’s VanTrieste expects to be able to offer the two antibiotics to member health systems this summer.

That’s when the experiment to prevent drug shortages and bring down prices will be put to a real-world test.

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One of the jazz world’s most enduring artists, the influential 87-year-old guitarist and composer Kenny Burrell, is facing financial ruin and homelessness.

His plight became public after his wife, Katherine Burrell, launched a GoFundMe page on May 9, in which she chronicled a number of overwhelming circumstances that the couple is currently navigating. In her telling, the couple has faced a cataclysmic series of misfortunes — including substantial ongoing medical expenses after a 2016 accident, identity theft and ongoing litigation involving the home owners association group in their community — that has brought them to the brink.

“We are facing possible foreclosure and homelessness,” Katherine Burrell wrote, adding: “It saddens and embarrasses me to desperately need and request help, but it is necessary at this point.” The page’s initial fundraising goal was $100,000; as of Tuesday morning, donations totaled almost $145,000.

Burrell, who was named an NEA Jazz Master in 2005, made his first professional recording in 1951 with Dizzy Gillespie, John Coltrane, Percy Heath and Milt Jackson. Since then, he has recorded hundreds of albums, including nearly one hundred as a bandleader in a discography that spans across the Blue Note, Prestige, Savoy, Columbia, Verve, Fantasy and Concord labels, among others.

Burrell first taught at UCLA in 1978 and in 1996, became the first director of the university’s jazz studies program, which he led for 20 years; the program’s graduates include the likes of saxophonist Kamasi Washington (who has since recorded with Burrell) and vocalist Gretchen Parlato. But in 2016, Burrell suffered an accident following a performance at UCLA’s Royce Hall that, according to his wife, necessitated a two-year recovery and partly triggered the couple’s misfortunes.

But as the Burrells’ dire stated needs became public last week, questions quickly arose in the jazz community about the veracity of the GoFundMe effort. On Friday, the Jazz Foundation of America (JFA) — a national nonprofit that exists in part to provide emergency funding to jazz, blues and roots artists struggling with housing or medical care — felt compelled to issue a statement regarding Katherine Burrell’s campaign.

“We would like to assure anyone concerned about Kenny that this campaign was indeed created by Katherine on his behalf,” the JFA wrote. “The Jazz Foundation has been in contact with Katherine for months. … Kenny and Katherine had been dealing with this situation alone for several years, because, as always, musicians are proud and self-reliant and do things on their own. They did not even contact us to ask for help but were referred by friends. The Jazz Foundation assessed the case, conferred with other helping organizations, and reviewed documents attesting to the financial need described in the GoFundMe post. We couldn’t possibly cover the full scope of the need, and other sources of funding were explored, including a GoFundMe campaign, given how successful and lifesaving they have proven for fellow musicians. As we can see in this outpouring of love for Kenny and Katherine, it has worked.”

The JFA also linked the Burrells’ situation to those being faced by other elder artists. “This is a painful but inspiring example of what we see every day at the Jazz Foundation,” the JFA wrote. “Many of our legends do not have a partner at home to help them. … This is why the organization exists, and we handle 30 emergency cases every day.”

Last September, UCLA’s Herb Alpert School of Music announced that it had received a gift of $1.2 million to create a Kenny Burrell Chair in Jazz Studies, which was funded by a group of over 150 donors. The timing was meant to celebrate Burrell’s 85th birthday, as well as his 20-year tenure as director of UCLA’s jazz studies program.

UCLA has issued a statement to NPR, saying: “UCLA was unaware of Katherine Burrell’s crowdfunding activity on behalf of herself and husband, Kenny. UCLA is concerned and is looking into the circumstances of this matter. Kenny Burrell is a Distinguished Professor of Music and Global Jazz Studies at UCLA’s Herb Alpert School of Music. Professor Burrell is currently on sabbatical, and is scheduled to return to UCLA for the Spring Quarter in March 2020. He remains a full-time faculty member with related compensation and health benefits.”

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Updated at 1 p.m. ET

Amid one of the largest measles outbreaks in the U.S. in recent history, vaccines are on the minds of many Americans.

The Centers for Disease Control and Prevention reported this week that the number of measles cases this year has climbed to 839 in 23 states, affecting mostly unvaccinated people. Most people in the U.S. are vaccinated against measles when they’re children as part of the routine immunizations they get in primary care.

We’re used to kids needing lots of shots to ward off lots of illnesses, but what about adults? The CDC recommends that adults get multiple vaccines for conditions ranging from tetanus to influenza to cervical cancer. The shots can be a bit trickier to keep track of, as many adults go to the doctor less frequently than kids do, but those vaccinations are equally important for staying healthy.

“Many adults are not aware of what vaccines they actually need,” says Dr. Pamela Rockwell, an associate professor of family medicine at the University of Michigan who works with the CDC’s Advisory Committee on Immunization Practices. “That is also balanced by physician unawareness of what vaccines they should be recommending. It’s gotten very complicated, and it is difficult to keep up with all the changes.”

So we’re here to answer some common questions about adult vaccines. Click on each topic to go to that section.

1. Measles 2. Shingles 3. Tetanus 4. Vaccines during pregnancy 5. Before meeting a newborn baby 6. Before visiting the elderly 7. Chickenpox 8. Hepatitis B, A and C 9. HPV

I was vaccinated against measles as a child, but the measles outbreak makes me worry that I’m no longer immune. Do I need to be revaccinated as an adult?

If you received the standard two doses of the modern measles, mumps and rubella (MMR) vaccine, you’re all set. You shouldn’t need to be revaccinated, because you’re considered immune for life.

And if you were born before 1957, doctors assume you were exposed to measles as a child and are already immune.

However, a version of the vaccine produced in the mid-to-late 1960s wasn’t as effective as the current regimen, so if you were vaccinated before 1968, you should talk to your doctor about whether you need another shot. If you were born after 1957 but for some reason never got immunized, you should also get the MMR vaccine.

I’ve heard there’s an effective vaccine for shingles, but my doctor’s office doesn’t have it and it’s out of stock at the pharmacy. What’s going on?

Shingrix is a two-dose vaccine that is upward of 95 percent effective at preventing shingles, a painful rash that tends to affect older adults and immunocompromised people. The vaccine was approved in 2017 and requires two injections. It’s more effective than Zostavax, an older shingles vaccine, so doctors will recommend Shingrix over Zostavax to most patients over age 50.

There has been a shortage of Shingrix for almost as long as it has been available because demand for the vaccine has outpaced the supply. Its manufacturer, GlaxoSmithKline, told the CDC that it’s working to step up its production schedule. But because every dose of Shingrix needs to undergo safety checks, GSK expects that shortages will continue at least through the end of the year.

“The demand was so great they literally couldn’t keep up,” Rockwell says.

If you get the first dose, do your best to get the second one within two to six months. If your local pharmacies don’t have Shingrix in stock, don’t worry — you can use the HealthMap Vaccine Finder to find out where it is available. If you wait more than six months to get the second dose, you don’t need to repeat the first one, but it’s possible the vaccine won’t be quite as effective in preventing shingles.

What’s the deal with tetanus shots? How often do I need them?

Tetanus is a life-threatening disease of the nervous system that’s caused by a toxin-producing bacterium usually found in soil. It can be prevented by a series of five childhood shots, including a booster between ages 11 and 12. Adults then need a booster shot every 10 years. It can be hard to keep track of this if you move or change doctors, so make a note in your calendar and don’t be afraid to ask about it. If you get it early or a year or two late, it isn’t harmful.

If you ever have an injury that might expose you to tetanus — such as stepping on a nail — your doctor will ask when your latest tetanus booster was and may give you another booster shot on the spot. If you’re not up to date on your tetanus vaccines, you may need additional treatment to prevent the disease.

Childhood tetanus shots are combined with a vaccine for diphtheria, a dangerous infection that can affect kids, and one for pertussis, which is known as whooping cough. Your every-10-year tetanus and diphtheria boosters won’t include pertussis, unless you’re pregnant. But when you turn 65, you should again get the shot that protects against all three, which is known as Tdap.

I’m thinking about having a baby. What vaccines do I need?

Make sure you and everyone around you is up to date on standard childhood and adolescent vaccines, including pertussis, since babies are vulnerable to this disease. You should also get a dose of Tdap during prenatal care, since it’s safe in pregnancy.

Everyone also should get an annual flu shot, because pregnant women, who have weakened immune systems, are particularly susceptible to influenza and can get very sick or die from an infection.

Even if you got all the recommended vaccines as a kid, it’s possible your immunity has waned when it comes to some of the vaccine-preventable diseases that can be passed from mom to baby. This is why prenatal doctors and midwives check to make sure pregnant women are immune to hepatitis B, varicella (chickenpox) and rubella.

If you find out you’re not immune before you get pregnant, you should get vaccinated again. The hepatitis B vaccine is safe during pregnancy. But the varicella and MMR (which includes rubella protection) vaccines are not safe for pregnant patients, so your doctor is likely to recommend that you get them after delivery.

I’m planning to visit my newborn nephew. What vaccines do I need?

If you’ve gotten all your recommended vaccines and boosters, you’re almost ready to meet the baby. Babies, like pregnant women, have weak immune systems, so an annual flu shot is important before interacting with a newborn. Adults over 65 should have gotten a pertussis booster (included in the Tdap shot).

What about if I’m visiting my hospitalized, elderly grandmother?

Older, hospitalized adults are similar to newborns in that their immune systems are weak and particularly vulnerable to infections. Follow the same advice as if you’re going to meet a new baby.

I was born before the varicella (chickenpox) vaccine existed. Do I need it now?

The varicella vaccine was approved in 1995, so if you were born before then, there’s a good chance you weren’t vaccinated.

But even if you weren’t vaccinated, you’re probably already immune because there’s a high likelihood you’ve had chickenpox. The CDC says adults born before 1980 don’t need the vaccine and don’t need testing to prove their immunity.

There are some occasions when doctors will want to order blood tests to make sure their patients are actually immune to varicella — for pregnant women and health care workers, for example. If you get tested and the blood test shows you’re still susceptible, your doctor will recommend that you get the vaccine. But because the vaccine is so effective and the blood test isn’t always accurate, getting tested isn’t necessary for everyone.

What do I need to know about all the different hepatitis shots?

Hepatitis means inflammation of the liver, but when we’re talking about vaccines, we’re referring to several types of viruses that infect liver cells and can cause lots of different and potentially life-threatening problems, ranging from diarrhea to liver failure to cancer. Routine childhood immunizations include vaccines for hepatitis A and hepatitis B, meaning virtually all kids in the U.S. are vaccinated against them.

Hepatitis B is transmitted through blood or sex. A vaccine for it has been available since the 1980s, but it’s common for immunity to hepatitis B to decrease over time. If you work in health care or are thinking about becoming pregnant, your doctor might order a blood test that shows if you’re still immune. If you’re not, your doctor may recommend you get revaccinated as an adult.

Hepatitis A is transmitted through the fecal-oral route, meaning that if you eat something that has been contaminated with the feces of an infected person, you can get it. The vaccine for hepatitis A was approved in 1995. If you’re not yet vaccinated and you fall into one of a few groups — including if you’re a man who has sex with other men, you’re traveling to a country where the virus is endemic, you live with a person who has had hepatitis A — you should get the shots.

Hepatitis C is another common viral infection that affects the liver. It’s so common, in fact, that doctors routinely test people born between 1945 and 1965 for the virus. Unfortunately, there’s no vaccine available for it, but it can be treated with an oral medication. If you haven’t been screened for it, ask your doctor if you need to be.

Who should get the HPV vaccine? What’s it for?

This is essentially a cancer vaccine.

The Food and Drug Administration initially approved the HPV vaccine for girls and young women in the early 2000s, but the range of people who should get it has since grown. The FDA recently approved its use for people up to age 45. FDA approval is different from CDC guidelines, however. The CDC still officially recommends that both boys and girls get their first shot by 11 or 12, up until age 26 for women and 21 for men. The CDC adds that men up to age 26 “may be vaccinated” based on a consult with a doctor. If you’re older than 26 and haven’t been vaccinated, again, talk to your doctor about whether you need it.

HPV stands for the human papillomaviruses, which cause a wide variety of conditions, ranging from common warts on hands and feet to cervical and anal cancer. The vaccine helps prevent infection from certain types of HPV, including the strains that are the most likely to cause cancer.

It’s a series of two shots, six to 12 months apart, which is a change from when the vaccine was first approved — it used to require three shots. Children who are late getting the HPV vaccine and receive their first dose after age 15 will still need three doses.

And there’s more.

You may also need vaccines for conditions such as pneumonia or meningitis. Ask your doctor. What your doctor recommends will depend on your medical history and your risk factors, so don’t be afraid to speak up at your next appointment. You can use this CDC quiz to see what might be right for you.

Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine.

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Updated Wednesday at 12:03 a.m. ET

The Alabama Senate passed a bill Tuesday evening to ban nearly all abortions. The state House had already overwhelmingly approved the legislation. It’s part of a broader anti-abortion strategy to prompt the U.S. Supreme Court to reconsider the right to abortion.

It would be one of the most restrictive abortion bans in the United States. The bill would make it a crime for doctors to perform abortions at any stage of a pregnancy, unless a woman’s life is threatened or in case of a lethal fetal anomaly.

The vote was 25-6, with one abstention.

Doctors in the state would face felony jail time up to 99 years if convicted. But a woman would not be held criminally liable for having an abortion.

There are no exceptions in the bill for cases of rape or incest, and that was a sticking point when the Alabama Senate first tried to debate the measure last Thursday. The Republican-majority chamber adjourned in dramatic fashion when leaders tried to strip a committee amendment that would have added an exception for cases of rape or incest.

Sponsors insist they want to limit exceptions because the bill is designed to push the idea that a fetus is a person with rights, in a direct challenge to the U.S. Supreme Court’s landmark Roe v. Wade decision that established a woman’s right to abortion.

“Human life has rights, and when someone takes those rights, that’s when we as government have to step in,” said Republican Clyde Chambliss, the Senate sponsor of the abortion ban.

The amendment has divided Republicans. Lt. Gov. Will Ainsworth, who presides over the Senate, posted on Twitter that his position is simple — “Abortion is murder.” But other Senate leaders have insisted that there be exceptions for rape and incest.

Democrats didn’t have the votes to stop the bill but tried to slow down proceedings during the debate.

Democratic Sen. Vivian Davis Figures questioned why supporters would not want victims of rape or incest to have an exception for a horrific act.

“To take that choice away from that person who had such a traumatic act committed against them, to be left with the residue of that person if you will, to have to bring that child into this world and be reminded of it every single day,” Figures said.

Republican Gov. Kay Ivey has not said whether she will sign it, and said she was waiting for a final version of the bill. She is considered a strong opponent of abortion.

The ACLU of Alabama says it will sue if the bill becomes law. “This bill will not take effect anytime in the near future, and abortion will remain a safe, legal medical procedure at all clinics in Alabama,” the organization tweeted Tuesday night, along with a map showing clinic locations in the state.

“Abortion is still legal in all 50 states,” the ACLU’s national organization wrote. “It’s true that states have passed laws trying to make abortion a crime, but we will sue in court to make sure none of those laws ever go into effect.”

Chipping away at abortion rights

In recent years, conservative states have passed laws that have chipped away at the right to abortion with stricter regulations, including time limits, waiting periods and medical requirements on doctors and clinics. This year state lawmakers are going even further now that there’s a conservative majority on the U.S. Supreme Court.

“The strategy here is that we will win,” says Alabama Pro-Life Coalition President Eric Johnston, who helped craft the Alabama abortion ban.

“There are a lot of factors and the main one is two new judges that may give the ability to have Roe reviewed,” Johnston said. “And Justice Ginsburg — no one knows about her health.”

So states are pushing the envelope. Several, including Alabama’s neighbors Georgia and Mississippi, have passed laws that prohibit abortion once a fetal heartbeat can be detected. But the drafters of the Alabama bill think by having no threshold other than if a woman is pregnant, their law might be the one ripe for Supreme Court review.

The National Organization for Women denounced the ban’s passage.

“This unconstitutional measure would send women in the state back to the dark days of policymakers having control over their bodies, health and lives,” the organization said in a statement. “NOW firmly believes that women have the constitutional right to safe, legal, affordable and accessible abortion care and we strongly oppose this bill and the other egregious pieces of legislation that extremist lawmakers are trying to pass in what they claim is an attempt to force the Supreme Court to overturn Roe.”

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A slight drizzle had begun in the gray December sky outside Community Christian Church as Reta Baker, president of the local hospital, stepped through the doors to join a weekly morning coffee organized by Fort Scott, Kan.’s chamber of commerce.

The town manager was there, along with the franchisee of the local McDonald’s, an insurance agency owner and the receptionist from the big auto sales lot. Baker, who grew up on a farm south of town, knew them all.

Still, she paused in the doorway with her chin up to take in the scene.

Just a few months before, Baker and the hospital’s owner, St. Louis-based Mercy health system, publicly announced that the 132-year-old hospital would close.

“Nobody talked to me after the announcement,” she said.

Baker, who says she has “taken a lot of heat” for how she broke the news, had carefully orchestrated face-to-face meetings with doctors and nurses in the final days of September. On Oct. 1, she met in person with the Mercy Hospital Fort Scott staff and then key community leaders before sending notices to the local newspaper and radio stations.

But for the 7,800 people of Fort Scott, about 90 miles south of Kansas City, Kan., the hospital’s closure was a loss they never imagined possible.

“Babies are going to be dying,” said longtime resident Darlene Doherty, who was at the coffee gathering. “This is a disaster.”

Bourbon County Sheriff Bill Martin stopped on his way out of the morning coffee to say the closure has “a dark side.” And Dusty Drake, the lead minister at Community Christian Church, diplomatically said people have “lots of questions,” adding that members of his congregation will lose their jobs.

Yet, even as this town deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small communities like Fort Scott need a traditional hospital at all? And if not, how will they get the health care they need?

Sisters of Mercy nuns opened Fort Scott’s 10-bed frontier hospital in 1886 — a time when traveling 30 miles to see a doctor was unfathomable and when most medical treatments were so primitive they could be dispensed almost anywhere.

Now, driving the four-lane highway north to Kansas City, Kan., or crossing the state line to Joplin, Mo., and back is a day trip that includes shopping and a stop at a favorite restaurant. The bigger hospitals there offer the latest sophisticated treatments and equipment.

And when patients here get sick, many simply go elsewhere. An average of nine patients a day stayed in Mercy Hospital Fort Scott’s more than 40 beds from July 2017 through June 2018. And these low occupancy numbers are common: Forty-five Kansas hospitals report an average daily census of fewer than two patients.

James Cosgrove, who directed a U.S. Government Accountability Office study about rural hospital closures, said the nation needs a better understanding of what the closures mean to the health of people in rural America, where the burden of disease — from diabetes to cancer — is often greater than in urban areas.

What happens when a 70-year-old grandfather slips on an icy sidewalk and must choose between staying home and driving to the closest emergency department, 30 miles away? Where does the sheriff’s deputy who picks up an injured suspect take his charge for medical clearance before going to jail? And how does a young mother whose toddler fell against the coffee table and now has a gaping head wound get her treated?

There is also the question of how the hospital going out of business will affect the town’s economy, since, as is often the case in rural America, Fort Scott’s hospital has been a primary source of well-paying jobs and attracts professionals to the community.

The GAO plans to complete a follow-up study later this year on the fallout from rural hospital closures. “We want to know more,” Cosgrove said. The original report was requested in 2017 by then-Sen. Claire McCaskill, D-Mo., and Rep. Tim Walz, D-Minn., and has been picked up by Sen. Gary Peters, D-Mich.

In Fort Scott, the answers to these questions are unfolding — painfully — in real time.

At the end of December, the Mercy system closed Fort Scott’s hospital but decided to keep the building open to lease portions to house an emergency department, outpatient clinic and other services. Mercy Fort Scott joined a growing list of more than 100 rural hospitals that have closed nationwide since 2010, according to data from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. How the town copes is a window into what comes next.

‘We were naive’

Over time, the Mercy hospital in Fort Scott became so much a part of the community that parents counted on the hospital’s ambulance standing guard at the high school’s Friday night football games.

The hospital seemed to be everywhere, actively promoting population health initiatives by working with the school district to lower children’s obesity rates as well as with local employers on diabetes prevention and healthy eating programs — worthy but, often, not moneymakers for the hospital.

“You cannot take for granted that your hospital is as committed to your community as you are,” said Fort Scott City Manager Dave Martin. “We were naive.”

Indeed, in 2002 when Mercy decided to build a new hospital, residents raised $1 million for construction. Another $1 million was given by residents to the hospital’s foundation for upgrading and replacing the hospital’s equipment.

“Nobody donated to Mercy just for it to be Mercy’s,” said Bill Brittain, a former city and county commissioner. The point was to have a hospital for Fort Scott, county seat of Bourbon Country.

But today Mercy is a major health care conglomerate, with more than 40 acute care and specialty hospitals, as well as 900 physician practices and outpatient facilities. Fort Scott’s hospital is the second one in Kansas that Mercy has closed.

The hospital’s steady decline in patients, rising expenses and insufficient reimbursement “created an unsustainable situation for the ministry,” said Tom Mathews, vice president of finance for Mercy’s southwestern Missouri and Kansas region.

But Fort Scott is a place that needs health care: One in 4 children in Bourbon County lives in poverty. People die much younger here than the rest of the state and rates for teen births, adult smoking, unemployment and violent crime are all higher in Bourbon County than the state average, according to data collected by the Kansas Health Institute and the Robert Wood Johnson Foundation.

Ten percent of Bourbon County’s more than 14,000 residents, about half of whom live in Fort Scott, lack health insurance. Kansas is one of 14 states that have not expanded Medicaid under the Affordable Care Act and, while many factors contribute to rural hospital closures, the GAO report found states that had expanded Medicaid had fewer of them.

The GAO report also found that residents of rural areas generally have lower household incomes than their counterparts in bigger cities, and are more likely to have chronic health conditions – such as high blood pressure, diabetes or obesity – that affect their daily activities.

The county’s premature birth rate is also higher than the 9.9% nationwide, a number that worries Dr. Katrina Burke, a local family care doctor who also delivers babies. “Some of my patients don’t have cars,” she said, “or they have one car and their husband or boyfriend is out working with the car.”

By nearly any social and economic measure, southeastern Kansas is “arguably the most troubled part of the entire state,” said Dr. Gianfranco Pezzino, senior fellow at the Kansas Health Institute. While the health needs are great, it’s not clear how to pay for them.

Health care’s ‘very startling’ evolution

Reta Baker described the farm she grew up on, south of town, as “a little wide place in the road.” She applied to the Mercy school of nursing in 1974, left after getting married and came back in 1981 to take a job as staff nurse at the hospital. She has “been here ever since,” 37 years — the past decade as the hospital president.

It has been “very startling” to watch the way health care has evolved, Baker said. Patients once stayed in the hospital for weeks after surgery and now, she said, “they come in and they have their gallbladder out and go home the same day.”

With that, payments and reimbursement practices from government and health insurers changed too, valuing procedures rather than time spent in the hospital. Rural hospitals nationwide have struggled under that formula, the GAO report found.

Acknowledging the challenge, the federal government established some programs to help hospitals that serve poorer populations survive. Through a program called 340B, some hospitals get reduced prices on expensive drugs.

Rural hospitals that qualified for a “critical access” designation because of their remote locations got higher payments for some long stays. About 3,000 hospitals nationwide get federal “disproportionate share payments” to reflect the fact that their patients tend to have poor or no insurance.

Fort Scott took part in the 340B discount drug program as well as the disproportionate share payments. But, though Baker tried, it couldn’t gain critical access status.

When Medicare reimbursement dropped 2% because of sequestration after the Budget Control Act of 2011, it proved traumatic, since the federal insurer was a major source of income and, for many rural hospitals, the best payer.

Then, in 2013, when the federal government began financially penalizing most hospitals for having too many patients returning within 30 days, hospitals like Fort Scott’s lost thousands of dollars in one year. It contributed to Fort Scott’s “financial fall,” Baker said.

Baker did her best to set things right. To reduce the number of bounce-back admissions, patients would get a call from the physician’s office within 72 hours of their hospital stay to schedule an office visit within two weeks. “We worked really, really hard,” Baker said. Five years ago, the number of patients returning to Fort Scott’s hospital was 21%; in 2018 it was 5.5%.

Meanwhile, patients were also choosing to go to Ascension Via Christi in Pittsburg, Kan., because it offered cardiology and orthopedic services, Baker said. Patients also frequently drove 90 miles north to the Kansas City area for specialty care and the children’s hospital.

“Anybody who is having a big surgery done, a bowel resection or a mastectomy, they want to go where people do it all the time,” Baker said. Mercy’s Fort Scott hospital had no cardiologists and only two surgeons doing less complicated procedures, such as hernia repair or removing an appendix.

Last year, only 13% of the people in Bourbon County and the surrounding area who needed hospital care chose to stay in Fort Scott, according to industry data shared by Baker.

There were no patients in the hospital’s beds during one weekend in December, Baker said. “I look at the report every day,” she said. “It bounces between zero and seven.” The hospital employed 500 to 600 people a decade ago, but by the time closure was announced fewer than 300 were left.

That logic — and the financial need — for closing didn’t sit well with residents, and Mercy executives knew it. They knew in June they would be closing Fort Scott but waited until October to announce it to the staff and the city. City Manager Martin responded by quickly assembling a health task force the day of the announcement in October, insisting it was “critical” to send the right message about the closure.

Relations between Mercy and the city grew so tense that officials needed attorneys just to talk to Mercy. In all, Fort Scott had spent more than $7,500 on Mercy Closure Project legal fees by the end of 2018, according to city records.

Will Fort Scott sink without Mercy?

When Darlene Doherty graduated from Fort Scott High School in 1962, there were two things to do in town: “Work at Mercy or work at Western Insurance.” The insurance company was sold in the 1980s, and the employer disappeared, along with nearly a thousand jobs.

Yet, even as the community’s population slowly declined, Martin and other community leaders have kept Fort Scott vibrant. There’s the new Smallville CrossFit studio, which Martin attends; a new microbrewery; two new gas stations; a Sleep Inn hotel, an assisted living center; and a Dairy Queen franchise. And the McDonald’s that opened in 2012 just completed renovation.

The town’s largest employer, Peerless Architectural Windows and Doors, which provides about 400 jobs, bought 25 more acres and plans to expand. There’s state state money promised to expand local highways, and Fort Scott has applied for federal grants to expand its airport.

Baker and some of the physicians on the Mercy hospital staff have been busy trying to ensure that essential health care services survive, too.

Baker found buyers for the hospital’s hospice, home health services and primary care clinics so they could continue operating.

Burke, the family doctor, signed on to be part of the Community Health Center of Southeast Kansas, a federally qualified nonprofit that is taking over four health clinics operated by Mercy Fort Scott. She will have to deliver babies in Pittsburg, nearly 30 miles away on a mostly two-lane highway that is under construction to widen it.

Burke said her practice is full, and she wants her patients to be taken care of: “If we don’t do it, who’s going to?”

Mercy hospital donated its ambulances and transferred emergency medical staff to the county and city.

And, in a tense, last-minute save, Baker negotiated a two-year deal with Ascension Via Christi hospital in Pittsburg to operate the Fort Scott hospital’s emergency department — which was closed for two weeks in February before reopening under the new management.

But Baker knows that too may be just a patch. If no buyer is found, the facility will close by 2021.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Uninsured, undocumented immigrants often go to the emergency room for treatment. Since 1986 the federal government has required that patients in the emergency room receive care, regardless of their immigration status or ability to pay.

But caring for chronic conditions such as kidney disease or cancer in the emergency room is expensive. So some states are quietly expanding access for undocumented immigrants to obtain medical treatment beyond the ER.

One of those states is Washington, where an undocumented immigrant named Gonzalo lives with his wife, Ricarda.

Gonzalo is really sick.

“I can’t enjoy the day — go out — because I’m always unwell,” he said in an interview in Spanish.

Gonzalo moved to the U.S. from Mexico about 30 years ago. He’s 60 years old. We’re not using his last name because of his immigration status.

Ten years ago, Gonzalo’s kidneys failed. Since then, he’s gotten sicker and sicker. Five years ago, he had to quit his job as a painter.

“I used to pay the rent. I paid for everything, and we didn’t lack anything,” he said. “But I got sick and everything changed.”

Now, Gonzalo and his wife live with one of their daughters in her apartment south of Seattle.

Across the country, there are about 6,500 undocumented immigrants with kidney failure, according to the National Institutes of Health. What kind of care they get depends on where they live.

In most states, they can only get dialysis in hospital emergency rooms.

That means, every couple of weeks, they go to the hospital when so many toxins have built up in their body it’s life-threatening. Usually, they have to stay overnight so they can be dialyzed twice. That costs nearly $300,000 per person every year.

So seven states, including Washington, have a different system.

“The state of Washington has something called AEM,” said Leah Haseley, a nephrologist — a kidney doctor — in Seattle. She’s talking about Alien Emergency Medical, part of Washington’s Medicaid.

“AEM pays for two things,” she explained. “They pay for dialysis for undocumented people, and they pay for chemotherapy for cancer treatment for undocumented people as well.”

Regular dialysis costs about a quarter of what emergency dialysis does — but it’s controversial.

“The first time that you show up at a hospital with kidney failure, that’s an emergency,” said Matthew O’Brien, with the Federation for American Immigration Reform, a group that advocates for stricter immigration laws. “After that, it’s a chronic condition, and we don’t believe that it’s appropriate to reward lawbreakers with benefits at the expense of U.S. taxpayers.”

But there are others who say even regularly scheduled dialysis isn’t enough: undocumented immigrants who qualify should be given kidney transplants, because the cost of a transplant is less than the ongoing costs of regular or emergency dialysis. But, without health insurance, few undocumented immigrants can afford a transplant.

In 2015, Illinois became the first state with a system for paying for organ transplants for undocumented immigrants.

Dr. David Ansell was a prominent advocate for the change.

“In about a year and a half the cost for a transplant pays itself back,” he said, “but also people can go back to work and contribute to the state.”

So far, more than 200 undocumented immigrants in Illinois have been given access to organ transplants, with their insurance premiums paid for by a non-profit. Now, Dr. Ansell and other public health advocates hope to see a similar program at the national level.

Many who oppose this say, with limited organs available, they should be reserved for citizens and legal immigrants.

But Dr. Ansell says, in Illinois, 75 percent of kidney transplants for undocumented immigrants come from donations from their own family — a much higher rate than the rest of the population.

“If you’re undocumented in Illinois, you can get a driver’s license, and disproportionately the Latino community is signing up to donate their organs,” Dr. Ansell added. “It’s a simple matter of ethics and fairness.”

He said, since Illinois started paying for the transplants, the total number of organs available has increased, because so many more Latinos have signed up for organ donation.

Overall in the US, studies have found that undocumented immigrants donate 2 to 3% of all organs.

Back in the Seattle area, Gonzalo says all three of his daughters are willing to give him a kidney, but he has no way to pay for the transplant.

That’s why his wife, Ricarda, says she’s taken to buying lottery tickets.

She said in Spanish, “I’ve told my husband, ‘If I win the lottery, I won’t think twice. I’m going to get you a kidney.'”

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