Forty-two boxes of returned mail lined a wall of the El Paso County Department of Human Services office on a recent fall morning. There used to be three times as many.

Every week, the U.S. Postal Service brings anywhere from four to 15 trays to that office in Colorado Springs. Each contains more than 250 letters that it could not deliver to county residents enrolled in Medicaid or other public assistance programs.

This plays out the same way in counties across Colorado. The state estimates that about 15% of the 12 million letters from public assistance programs to 1.3 million members statewide are returned — some 1.8 million pieces of undelivered mail each year.

It falls on each county’s staff, in between fielding calls, to contact the individuals to confirm their correct address and their eligibility for Medicaid, the federal-state health insurance program for people with low incomes.

But last year, state officials decided that if caseworkers can’t reach recipients, they can close those cases and cut off health benefits after a single piece of returned mail.

Medicaid, food stamps and other public benefit programs have avoided the march toward digital communication and continue to operate largely in a paper-based world. That essentially ties lifesaving benefits for some of the most vulnerable populations to the vagaries of the Postal Service.

As returned mail piles up, Colorado and other states take increasingly drastic measures to work through the cumbersome backlog, lowering the bar for canceling benefits on the basis of returned mail alone.

Missouri, Oklahoma and Maryland are among states that have struggled with the volume. And when Arkansas implemented Medicaid work requirements, nearly half the people who lost benefits had failed to respond to mailings or couldn’t be contacted.

At best, tightening returned-mail policies could save states some money, and people cut off from the benefits yet still eligible for them would experience only a temporary gap in their care. But even short delays can exacerbate some patients’ chronic health conditions or lead to expensive visits to the hospital.

But at worst, the returned mail may be contributing to a major drop in Medicaid enrollment and increased numbers of uninsured. Patients dropped from the rolls rarely realize it until they seek care.

“There’s a lot of concern on this issue,” says Ian Hill, a health policy analyst at the Urban Institute, a think tank based in Washington, D.C. “Are they getting purged from the records unfairly and too quickly?”

Taking action

States have been walking a tightrope. While trying to aid their poorest residents, they also are grappling with budget-busting Medicaid costs and pressure from the Trump administration to ensure everyone on public assistance programs qualifies for the benefits.

Some states have sought “procedural denials because it kept their costs down,” says Cindy Mann, who ran the Medicaid program under the Obama administration.

“But we certainly don’t want to cut somebody off while they’re still eligible,” says Mann, who is now a partner with the law firm Manatt, Phelps & Phillips. “It’s penny-wise and pound-foolish.”

Low-income families who depend on public benefits tend to move often, leading to frequent errors in the addresses on file. But if a person moves out of state, the state-administered Medicaid benefit cannot move with them.

“States have always struggled with how to handle returned mail,” says Jennifer Wagner, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. “But we have more recently heard of states pushing a policy to be very aggressive about canceling clients when the state receives returned mail, and that has led to significant disenrollment.”

In April 2018, Colorado lowered its recommended threshold for acting on returned mail from three pieces of undeliverable mail to just one. From May 2017 to May 2019, enrollment in Medicaid and the Children’s Health Insurance Program dropped 8.5% in the state — more than three times the national decline of 2.5%, according to the Medicaid and CHIP Payment and Access Commission, a congressional advisory panel.

It’s unclear how much of the drop was because of returned mail. The enrollment declines could also reflect some combination of a proposed federal rule to deny green cards to immigrants who use public benefits, or cuts in federal funding for outreach to sign people up for health coverage or an improved economy.

Colorado has not set up a way of tracking how many people are losing benefits because of returned mail or what happens to those who do.

“We don’t have one data point that we can track,” says Marivel Klueckman, who oversees Medicaid eligibility functions for Colorado. “That is something we’re building into the future.”

Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.

People cut off from Medicaid benefits may never learn why and may not seek to restore their benefits, which concerns Bethany Pray, health care program director at the Colorado Center on Law and Policy, a Denver-based legal aid group.

“You’re going to lose people who are truly eligible and should never have been taken off and who face barriers to reenrollment,” Pray says.

Mailing woes

The lack of dependability of the Postal Service, particularly in rural areas of the state, adds to the concerns about relying on snail mail for important government correspondence.

Officials from the ski resort town of Snowmass Village, for example, complained last spring that they didn’t have any mail delivered for an entire week.

“We have received over 6 feet of snow in the last two weeks and we still get more complaints about postal delivery than snow removal,” town officials wrote in a March survey conducted by the Colorado Association of Ski Towns. “People aren’t getting bills, jury summons, medications, certified mail.”

In June, three members of Colorado’s congressional delegation sent a letter to the postmaster general, pressing her to address a range of postal issues, including lost or returned mail.

There’s no question that cutting off people after one piece of returned paper mail saves the state money in sending letters and in processing undeliverable mail — though other costs may add up later. Colorado public assistance programs mail more than a million letters each month, at a cost of nearly $6 million annually. That is just a small share of what is spent on the actual assistance, given that Colorado’s Medicaid program alone costs $9 billion a year.

Cutting off assistance after one piece of returned mail also helps the state avoid making monthly payments to regional health organizations for case management and dental services for those who no longer qualify for benefits.

However, Colorado Medicaid’s Klueckman says the state is primarily concerned with making sure eligible residents get their notifications and remain enrolled. The state moved eligibility determinations and renewals online and now offers a mobile app so residents can also receive notifications electronically.

Local discretion

Colorado plans to open a consolidated returned-mail center for the state as soon as July 2020. That could provide some economies of scale and consistency, but it has the potential of increasing the number of people dropped, as local knowledge is replaced by automation.

Counties currently receive guidance from the state on how to process returned mail, but they have leeway to set their own procedures. El Paso County, for example, rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless, such as a shelter or post office.

“They’re the least likely for us to be able to have a phone number to call them,” says Karen Logan, economic and administrative services director for the county.

The county, Colorado’s second largest, used grant money this year to pay staff overtime to whittle down its backlog of returned mail. That has helped the county process more than 48,000 pieces of returned mail in the past year, with more than a third prompting database changes. But officials could not say how many of those resulted in people losing benefits.

“We have some other things that are a little bit higher on the priority scale, so we don’t close as many cases as we probably could,” Logan says. “But I can tell you this: Closing a case and having a person have to reapply two months later takes significantly more work.”

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

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Arline Feilen lost her husband to suicide in 2013. Three years later, she lost her dad to cancer. And this February, she lost her 89-year-old mom to a cascade of health problems.

“We were like glue, and that first Mother’s Day without her was killer. It just dragged me down,” said Feilen, who is 56 and lives in suburban Chicago. “It was just loss after loss after loss, and I just crumbled.”

A few days after that painful holiday, she drank eight or nine light beers in several hours, trying to drown her pain. She sent alarming texts to her sister and friends, raising concern she might harm herself. One friend called 911, summoning an ambulance that took her to Northwestern Medicine Central DuPage Hospital.

Feilen arrived in the emergency room on a mid-May night and was moved to a shared room in the inpatient psychiatric unit the next day. In total, she spent five nights in the hospital.

Feilen underwent a battery of tests: bloodwork, an abdominal ultrasound and an electrocardiogram. She got group counseling, which her sister, Kathy McCoy, said really helped. She also started taking an antidepressant, Remeron.

When she got home, she stopped drinking beer. She kept taking the medication and continued counseling. She came to view her mental health crisis as “another mountain I’ve climbed” — and reminded herself of her accomplishment by keeping her hospital bracelet in her bedroom near a candle. Her grief began to recede.

Then the bill came.

Patient: Arline Feilen, the widow of a veteran, is a part-time, self-employed medical transcriptionist who lives in Carol Stream, Ill. She purchased individual insurance on the open market, not through the Affordable Care Act exchange.

Total Bill: $29,894.50, including $16,480 for room and board in a semiprivate psychiatric room and $3,999 for the ER. After the hospital reduced the bill because her insurance didn’t cover mental health, she owes $21,634.55.

Service Provider: Northwestern Medicine Central DuPage Hospital, a large, acute care hospital in the Chicago suburbs. It’s part of the nonprofit academic health system Northwestern Medicine.

Medical Service: Feilen received inpatient care for a depressive episode, including blood draws, an ultrasound, an electrocardiogram and behavioral health treatment.

What Gives: Feilen has an “association health plan” purchased through Affiliated Workers Association. It’s called SelectCare 1, costs her $210 a month and doesn’t cover mental health care.

This is one type of plan that the Obama administration curtailed. But some like Feilen’s are permitted again since the Trump administration gave the go-ahead for sales of plans previously considered to offer inadequate coverage.

Like other association plans, hers doesn’t have to include the 10 “essential health benefits” required under the federal Affordable Care Act, such as mental health and substance use disorder treatment. In plans that comply with the ACA, those benefits must be treated the same way as physical needs.

Jennifer Snow, acting national director for advocacy and public policy for the National Alliance on Mental Illness, said the type of plan Feilen has is “allowed to undermine the ACA.”

The Trump administration last year issued rules making it easier for small employers to band together to offer insurance through these plans. In March, a U.S. District Court judge sided with 11 states and the District of Columbia challenging the law, invalidating a large chunk of those rules. But association plans are still out there, and some states support broader access to them.

Sheri Boehle, an insurance agent who handles Affiliated Workers Association, said many people buy this type of insurance for a short time period. For the right people, she said, it’s a great option that can protect them from the costs of catastrophic physical health problems.

Boehle said she always gives customers a brochure explaining exactly what’s covered and what’s not, and Feilen said she got one saying treatment for mental health care wouldn’t be covered. Feilen said that was all right with her when she bought the policy years ago because she didn’t expect to need that service.

To keep costs down while hospitalized, Feilen said, she tried to refuse treatments like the ultrasound but was told she needed it. She got no answers when she inquired how much she might pay.

“I’m asking a simple question, and there should be a simple, finite answer,“ she said.

Hospitals generally charge uninsured people much more than they charge people who have insurance. A 2017 report from the Health Care Cost Institute showed that the average negotiated price of an acute mental health admission was $9,293 for a commercially insured patient who stayed, on average, for a week. That’s less than half of Feilen’s bill.

Getting answers about the cost of care can be extremely difficult for patients, even those footing the bills without the help of insurance.

“Hospital pricing is obviously opaque,” said Ezra Golberstein, an associate professor at the University of Minnesota’s School of Public Health. “The easiest prices to get are how much to pay for parking and how much things cost at the snack bar.”

The biggest chunk of Feilen’s bill was $16,480 for four nights in a psychiatric unit room shared with another patient. Adding the night in the ER brings it up to $20,479 — the majority of the entire bill.

McCoy joked that it would have been a lot cheaper for her sister to stay at a Ritz hotel.

That’s true. According to its website, five nights in the fanciest suite at the Ritz-Carlton in downtown Chicago costs $12,895.

Resolution: Without prompting, the hospital reduced Feilen’s bill by $8,968.35 because she lacked mental health coverage.This amount was already taken off the bill when she got it.

Hospital officials provided a statement saying Northwestern Medicine offers a variety of financial assistance programs for uninsured, underinsured and insured patients. Often, they said, a social worker or community partner helps the patient navigate the process, which includes filling out an application and providing supporting information and documents.

“In this case, we have tried numerous times to connect with this patient to provide guidance and assistance,” the statement said.

Feilen said she talked to a social worker at the hospital about costs and began filling out a form for financial help, but stopped when she got to a part that asked about stocks and bonds. Although her annual income is below the poverty level ? and she likely qualifies for Medicaid ? she received a modest inheritance from her parents that she has put into a retirement plan, she said, and thought that meant she wouldn’t qualify.

When she was buying insurance years ago, Feilen said, she started to look into plans on healthcare.gov that offer subsidies to many people with low or middle-class incomes. But she said she found them confusing and gave up.

NAMI’s Snow said it’s sometimes tough for consumers to know whether a plan complies with the health care law. Plans sold outside of healthcare.gov may be labeled “Obamacare” but not have the health law’s guaranteed benefits.

“You have to be really careful you don’t accidentally buy one. They’re always cheaper,” she said. “But if it seems too good to be true, it probably is.”

To find ACA-compliant plans, which must cover mental health, Snow suggested going to HealthCare.gov, the federal marketplace that covers most states. (It will direct you if your state set up its own ACA marketplace.)

The Takeaway: If you’re uninsured, you’ll generally face bigger bills than patients with health insurance because you lack the power of the insurance company to negotiate prices with the hospital. Ask whether you qualify for Medicaid or charity care. If you don’t, negotiate with the hospital anyway to try to lower your bill. Arm yourself with information about the going rate insurers pay for the care you received by consulting websites like Healthcare Bluebook or Fair Health.

When buying insurance, make sure you know what’s covered and what’s not, which can be tricky to determine for plans — many of which can be found on the Internet — that don’t have to follow all the rules of the federal health law.

“On the individual market, it’s very much ‘buyer beware’ for plans that are not ACA-compliant,” Golberstein said. “With short-term or association health plans, really read the fine print.”

If Feilen could go back in time, she said she would have surely bought insurance that covered mental illness, which affects 1in 5 U.S. adults each year.

“I would definitely recommend it. You don’t know what life is gonna bring you,” she said. “I never imagined in a million years that I’d need mental health care.”

NPR produced and edited the interview with Kaiser Health News’ Elisabeth Rosenthal for broadcast. Christine Herman of Illinois Public Media and Side Effects Public Media provided audio reporting.

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

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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Everything old is new again. As open enrollment gets underway for next year’s job-based health insurance coverage, some employees are seeing traditional plans offered alongside or instead of the plans with sky-high deductibles that may have been their only choice in the past.

Some employers say that in a tight labor market, offering a more generous plan with a deductible that’s less than four figures can be an attractive recruitment tool. Plus, a more traditional plan may appeal to workers who want more predictable out-of-pocket costs, even if the premium is a bit higher.

That’s what happened at Digital River, a 650-person global e-commerce payment processing business based in Minnetonka, Minn.

Four years ago, faced with premium increases approaching double-digit percentages, Digital River ditched its traditional preferred provider organization plan in favor of three high-deductible plans. Each had different deductibles and different premiums, but all linked to health savings accounts that are exempt from taxes.

This year, though, the company added back two traditional preferred provider plans to its offerings for workers.

Even with three plan options, “we still had employees who said they wanted other choices,” says KT Schmidt, the company’s chief administrative officer.

Digital River isn’t the only company broadening its offerings. For the third year in a row, the percentage of companies that offer high-deductible plans as the sole option will decline in 2020, according to a survey of large employers by the National Business Group on Health. A quarter of the firms polled will offer these plans as the only option next year — down 14 percentage points from two years ago.

That said, high-deductible plans are hardly disappearing. Fifty-eight percent of covered employees worked at companies that offered a high-deductible plan with a savings account in 2019, according to an annual survey of employer health benefits released by the Kaiser Family Foundation last month.

That was second only to the 76% of covered workers who were at firms that offered a PPO plan. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation; it is not affiliated with Kaiser Permanente.)

When Digital River switched to exclusively high-deductible plans for 2016, the firm put some of the $1 million it saved into the new health savings accounts that employees could use to cover their out-of-pocket expenses before reaching the deductible.

Employees could also contribute to those accounts to save money for medical expenses. This year the deductibles on those plans are $1,850, $2,700 and $3,150 for single coverage, and $3,750, $5,300 and $6,300 for family plans.

The company put a lot of effort into educating employees about how the new plans work, Schmidt says. Premiums are typically lower in high-deductible plans. But under federal rules, until people reach their deductible, the plans pay only for specified preventive care, such as annual physicals and cancer screenings, and some care for chronic conditions.

Enrollees are on the hook for everything else, including most doctor visits and prescription drugs. In 2020, the minimum deductible for a plan that qualifies under federal rules for a tax-exempt health savings account is $1,400 for an individual and $2,800 for a family.

As their health savings account balances grew, “more people moved into the camp that could see the benefits” of the high-deductible strategy, Schmidt says. Still, not everyone wanted to be exposed to costs upfront, even if they ended up spending less overall.

“For some people, there remained a desire to pay more to simply have that peace of mind,” he says.

Digital River’s PPOs have deductibles of $400 and $900 for single coverage and $800 and $1,800 for families. The premiums are significantly more expensive than those of the high-deductible plans.

In the PPO plan with the $400/$800 deductible, the employee’s portion of the monthly premium ranges from $82.37 for single coverage to $356.46 for an employee plus two or more family members. The plan with the $2,700 deductible costs an employee $21.11 for single coverage, and the $5,300-deductible plan costs $160.29 for the employee plus at least two others.

But costs are more predictable in the PPO plan. Instead of owing the entire cost of a doctor visit or trip to the emergency room until they reach their annual deductible, people in the PPO plans generally owe set copayments or coinsurance charges for most types of care.

When Digital River introduced the PPO plans for this year, about 10% of employees moved from the high-deductible plans to the traditional plans.

Open enrollment for 2020 starts this fall, and the company is offering the same mix of traditional and high-deductible plans again for next year.

Adding PPOs to its roster of plans not only made employees happy but also made the company more competitive, Schmidt says. Two of Digital River’s biggest competitors offer only high-deductible plans, and the PPOs give Digital River an edge in attracting top talent, he believes.

According to the survey by the National Business Group on Health, employers that opted to add more choices to what they offered employees typically chose a traditional PPO plan. Members in these plans generally get the most generous coverage if they use providers in the plan’s network.

But if they go out of network, plans often cover that as well, though they pay a smaller proportion of the costs. For the most part, deductibles are lower than the federal minimum for qualified high-deductible plans.

Traditional plans like PPOs also give employers more flexibility to try different approaches to improve employees’ health, says Tracy Watts, a senior partner at benefits consultant Mercer.

“Some of the newer strategies that employers want to try just aren’t [health savings account] compatible,” says Watts. The firms might want to pay for care before the deductible is met, for example, or eliminate employee charges for certain services.

Examples of these strategies could include employer-subsidized telemedicine programs or direct primary care arrangements in which physicians are paid a monthly fee to provide care at no cost to the employee.

The “Cadillac tax,” a provision of the Affordable Care Act that would impose a 40% excise tax on the value of health plans that exceeded certain dollar thresholds, was a driving force behind the shift toward high-deductible plans. But the tax, originally supposed to take effect in 2018, has been pushed back to 2022. The House passed a bill repealing the tax in July, and there is a companion bill in the Senate.

It’s unclear what will happen, but employers appear to be taking the uncertainty in stride, says Brian Marcotte, president and CEO of the National Business Group on Health.

“I think employers don’t believe it’s going to happen, and that’s one of the reasons you’re seeing [more plan choices] introduced,” he says.

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

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Elizabeth Warren has built a reputation as the candidate with a plan for almost anything. Plans are her brand, so much so that her campaign shop sells T-shirts proclaiming “Warren has a plan for that.”

But the Massachusetts senator has not yet rolled out a health care plan of her own. Instead, she has insisted “I’m with Bernie on Medicare for All.” (Recently, after weeks of being hounded by both journalists and her opponents, Warren announced that in the next few weeks she’ll release a plan that outlines the costs for “Medicare for All” and how she intends to pay for it).

Earlier in this campaign cycle, Warren referred to Medicare for All as a “framework,” and seemed open to alternatives, telling CNN’s Jake Tapper that there could be a role for private insurance.

But Warren has also publicly tethered herself to Vermont Sen. Bernie Sanders’ Medicare for All plan, and on the debate stage this summer she raised her hand in support of eliminating private insurance.

In her academic work, Warren has long pointed to health insurance instability and high medical costs as a major cause of bankruptcy. In 2008, she co-authored a book chapter that referred to universal single-payer health care as “the most obvious solution.” But when that statement surfaced, and she was asked about single-payer during her 2012 Senate challenge to Scott Brown, she focused on cementing the then-newly passed Affordable Care Act.

Some voters and old colleagues are convinced that Warren is not as resolute on health care as Sanders, perhaps because of that historic willingness to aspire to a progressive goal, but be open to other options if the goal isn’t politically acceptable.

That flexibility might be a perception, but the frequency with which people bring it up is noteworthy.

“I think we need to improve Obamacare, have a public option, that’s the better way to go,” said Donna Mombourquette, as she grabbed popcorn in between candidate speeches at the New Hampshire Democratic party state convention last month.

Mombourquette, a New Hampshire state representative, said she considers Sanders too “far to the left” for her, particularly on health care. But Warren, who supports the same idea, is one of her top two choices.

“I guess with Elizabeth Warren, for some reason, I think that she’s probably gonna be more open to moderating her positions to bring in more voters,” said Mombourquette, who recently endorsed Buttigieg, but insists she still really likes Warren.

“That inconsistency is hurting”

While some of Warren’s fans might interpret her lack of health care details with their own positive spin, her opponents have not.

“Your signature, senator, is to have a plan for everything. Except this,” the mayor of South Bend, Ind., Pete Buttigieg told Warren in the last Democratic debate as he pressed her over her refusal to concede that Medicare for All would require raising taxes on the middle class.

Public opinion polling has consistently shown that a public option, which would create a broad government-run insurance program like Medicare or Medicaid as an alternative to private insurance, is more popular than a mandatory Medicare for All system that would entirely eliminate the current employer-based insurance system.

Warren supports the less popular health care option, and while that may be an uphill challenge politically, Chris Jennings, who served as a senior health care adviser to both Presidents Obama and Clinton, suggests the bigger challenge for Warren is that her lack of details on health care could undermine her brand.

“This is the one area where her lack of directness stands in contrast with all her other policy visions and message approaches” said Jennings. “To me, that inconsistency is hurting more than even the policy itself.”

Earlier this month, after weeks of sidestepping questions about health care, Warren said that she soon intends to release a plan that explains how she intends to pay for Medicare for All.

Whenever Warren has been asked about a potential tax increase to fund Medicare for All, she tries to reframe the question as a matter of costs, not taxes.

“This much I promise to you: I will not sign a bill into law that does not reduce the cost of health care for middle class families. That’s what matters to them, and that’s what matters to me,” she recently told voters at a townhall in Des Moines.

But as some in the ultra-left progressive flank of the party have begun to suggest that Vermont Sen. Bernie Sanders is the only true believer in Medicare for All, Warren has also made a point to reaffirm her support for the idea itself.

“Medicare for All is the cheapest possible way to provide health care coverage for everyone,” she told voters in that same Des Moines speech. “I want you to hear it from me.”

“She will think clearly about alternatives”

Still, there is a sense among some people who like Warren that her support for Medicare for All is somewhat out of character.

“I was a little surprised recently that she came out in favor of a Medicare for all Plan,” said Tom McGarity, who taught law school with Warren at the University of Texas in the early 1980s and is a fan of her candidacy. “My guess is as the campaign continues, she’ll refine that to some extent.”

“It’s a very expensive proposition, and it’s not well defined. One thing about Liz is, at least politically, usually before she comes out with something … she defines it better,” he added.

The Warren campaign has not responded to questions about whether she could eventually compromise on the issue.

It is not uncommon to meet diehard Warren supporters who are lukewarm about Medicare for All.

Recent polling from NPR member station WBUR finds that Warren is the most popular candidate in her home state of Massachusetts, but her idea of Medicare for All is not. “Medicare for All Who Want It” is a more popular option.

“I’m not sure that Medicare for All is the correct answer. I think a hybrid is perhaps a better answer,” said Kimberly Winick, a former law school research assistant for Elizabeth Warren and a strong supporter of Warren’s candidacy.
“The real question isn’t whether you support every plank of the platform, but whether you think the person standing at the top, is somebody whom you can trust,” she added.

And Winick trusts Warren. She worked closed with the senator in the 1980s on bankruptcy research and feels she has an understanding of her personality and work ethic.

“I also know down the road if it becomes implausible, impractical, impossible to do those things, she’ll consider alternatives,” she said. “And she will think clearly about alternatives, she won’t pretend facts don’t exist.”

Former Senate Majority Leader Harry Reid espoused a similar thinking recently in a podcast interview with David Axelrod, a former strategist for President Obama. Reid, in an attempt to defend Warren from criticism that she’s “too far left,” gave the impression that Warren is not as committed to Medicare for All as she has suggested.

He said he advised Warren that strengthening Obamacare is the best plan for now, and a public option is “as good as Medicare for all, anyways.”

“That’s not what she’s saying though,” Axelrod responded.

“You give her some time,” Reid said. “I think she’s not in love with that, you’ll wait and see how that all turns out.”

“So you think she’s more pragmatic?” Axelrod asked.

“Oh, I know she’s pragmatic, just wait,” Reid insisted.

But pragmatism is not what Warren has been selling on the campaign trail. She often ends her stump speech with a promise to “dream big” and “fight hard.”

It’s not clear how much wiggle room — if any — Warren has on the substance of Medicare for All. But health care consultant Chris Jennings thinks she has a little bit more negotiating space than some of her rivals.

“Her fan base, her voters will give her more credit for trying to go as far as she possibly can on this issue, and then when, and if, she has to trim it back a bit, she’ll have more room for compromise than many other candidates will,” said Jennings. “And I say that because she’s viewed as a fighter, she won’t compromise just to compromise, she’ll compromise to get something done.”

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The dispatch call from the Concord, N.H., police department is brief. A woman returning to her truck spotted a man underneath. She confronted him. The man fled. Now the woman wants a police officer to make sure her truck is OK.

“Here we go,” mutters Officer Brian Cregg as he steps on the gas. In less than three minutes, he’s driving across the back of a Walmart parking lot, looking for a man on the run.

“There he is,” says Cregg. The officer pulls to a stop and approaches a man who fits the caller’s description. Cregg frisks the man, whose name is Kerry. NPR has agreed to only use Kerry’s first name because he may have serious mental health and substance use problems.

“Why were you lying on the ground under a truck?” Cregg demands.

Kerry, head hanging, rocks back and forth, offering quiet one-line answers to Cregg’s questions. There’s a contest, Kerry says. The prize is a new pick-up truck, and he just has to find the truck with a key hidden underneath. He says he’s searched three so far.

“Kerry did you take anything today?” Cregg asks. “You’re not acting right.”

“No, no,” says Kerry, shaking his head forcefully. “I’m just stressed out.”

Cregg watches Kerry, looking for signs — is this meth or a mental health problem? Over the past three or so years, as meth has surged in New Hampshire and across the U.S., it’s become hard to tell. Police in many areas of the country where meth has maintained a steady presence have more experience making an assessment, but in Concord and many parts of the Northeast, the onslaught of meth is new.

Concord police say they need to know whether they’re dealing with a mental health issue or drugs — or both — because it can make a difference in determining the best response.

Concord may send six to eight officers to subdue someone darting through traffic who is high on meth. The calming techniques these officers learned during training for a mental health crisis intervention don’t seem to work as well when someone is out of control on methamphetamine. Several officers are recovering from injuries sustained during meth-related calls.

“Stay right there for me, all right?” Cregg tells Kerry. “I like you too much — stay right there.”

Cregg walks a few steps away from Kerry to speak to one of two other officers called to this scene. It turns out this is the third time in the past few months that alarmed drivers have reported finding Kerry under their car. Cregg decides Kerry’s delusions are mental health issues, and doesn’t call for more backup.

Kerry, now cuffed, climbs into the back of Cregg’s cruiser and they head for the station. Kerry’s suspected crime: prowling.

“Hey, uh, Kerry — man, you feel like you want to go up to the hospital to speak to somebody?” Cregg asks a version of this question four times.

“No, no,” Kerry says repeatedly, “I’ve been through that route years ago; don’t want to do it again.”

Kerry says later that getting stuck in a hospital emergency room — waiting days, maybe weeks for an opening in a psych treatment program — makes his anxiety much worse.

At the station, Cregg finds something that changes his view of the day’s events.

“What is that, Kerry?” Cregg asks, pulling a tiny plastic bag of glistening white shards out of Kerry’s coin pocket. It appears to be meth. “This explains a lot.”

Cregg says what he thought was psychotic behavior likely had more to do with meth.

But “on that call, they mimicked each other. I wasn’t able to tell at first,” Cregg says.

That may be because Kerry is one of the 9.2 million Americans coping with both a mental health problem and a substance use disorder. In this particular case, not being able to tell what fueled Kerry’s delusions didn’t cause any problems for him or the police. Things never got out of hand. But Concord Police Chief Brad Osgood says calls triggered by meth are often more challenging than this one.

“With somebody that’s high on methamphetamine, you want to treat them a little firmer and control them,” Osgood says, “because they often are very volatile and aggressive and you just want to treat that hostility, differently.”

With meth now accounting for 60% of drug seizures in Concord, police say they often default to that firmer approach. Some mental health advocates worry that may mean police are using too much force with their clients. Sam Cochran, a retired major in the Memphis police department who co-founded and now helps lead the crisis intervention police training program, CIT International, says officers aren’t making a diagnosis.

“The officer’s foremost is ‘how do I open up communications?How do I get compliance in order to accomplish safety?’ ” Cochran says.

There are visual signs of longer-term meth use that are less likely to show up among mental health patients: skin wounds and scabs, rotting teeth, dilated pupils. But addiction medicine specialists agree that it is difficult to determine what’s going on, at first glance, with someone who appears extremely agitated.

“The possession of methamphetamine may be a clue, but teasing out the acute effects of methamphetamine versus a long-standing mental illness may take a longer period of time, says Dr. Melissa Weimer, an assistant professor of medicine at Yale School of Medicine. She notes that the effects of meth can last for 72 hours or longer.

Surging meth use is relatively new in New England. Cochran, a veteran of the Memphis police department, has dealt for years with this issue of meth’s effects mimicking mental health issues. He says slowing things down and diffusing fear can work when dealing with people who are high on meth.

“But let’s be real, there are some individuals that are so sick,” Cochran says, that “officers find themselves having to act immediately to protect safety. Sometimes that may mean a hands-on approach.”

Cochran and another mental health advocate, Dr. Margie Balfour, an associate professor of psychiatry at the University of Arizona, say the goal is to only use force as a last resort.

“And then, ideally,” Balfour says, “whether it’s meth or mental health or both … you’re going to be able to take that person to somewhere where they are going to get treatment — and not to jail.”

Balfour is also chief of Quality and Clinical Innovation at Connections Health Solutions. The organization operates a network of psychiatric crisis centers in Arizona where, instead of making an arrest, police can drop off anyone 24 hours a day who is out of control on meth or who has a mental health condition. Balfour says 20% of adults seen at Connections test positive for meth.

Kerry was due in a New Hampshire court last week, where a judge could have ordered drug treatment or an evaluation. Kerry didn’t show up for that arraignment — but says he is trying to reschedule.

This story is part of a reporting partnership that includes WBUR, NPR and Kaiser Health News.

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October marks the start of a new flu season, with a rise in likely cases already showing up in Louisiana and other spots, federal statistics show.

The advice from federal health officials remains clear and consistent: Get the flu vaccine as soon as possible, especially if you’re pregnant or have asthma or another underlying condition that makes you more likely to catch a bad case.

Make no mistake: Complications from the flu are scary, says Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center in Nashville, Tenn., who is part of a committee that advises federal health officials on immunization practices.

“As we get older, more of us get heart disease, lung disease, diabetes, asthma,” Schaffner says. “Those diseases predispose us to complications of flu — pneumonia, hospitalization or death. We need to make vaccination a routine part of chronic health management.”

Federal recommendations, he says, are that “anyone and everyone 6 months old and older in the United States should get vaccinated each and every year.” People 65 and above and pregnant women, along with patients who have underlying medical issues, should make haste to get that shot, if they haven’t already, Schaffner says.

Within a typical year, about two-thirds of people over 65 get vaccinated against the flu, studies show, compared with 45% of adults overall and 55% to 60% of children. But only about half of pregnant women get vaccinated, and immunization rates for people with chronic diseases hovers around 30% to 40%.

Take the case of JoJo O’Neal, a 55-year-old radio personality and music show host in Orlando, Fla., who was diagnosed with adult onset asthma in 2004 at age 40. For years she didn’t get the flu vaccine, figuring her healthful diet, intense exercise and overall fitness would be protective enough.

“I skated along for a lot of years,” O’Neal says, “and then, finally, in 2018 — boom! It hit me, and it hit me hard.” She was out of work for nearly two weeks and could barely move. She was extremely nauseated and had an excruciating headache and aching body, she says. “I spent a lot of time just sitting on my couch feeling miserable.”

O’Neal says it takes a lot to “shut her down,” but this bout with the flu certainly did. Even more upsetting, she says, she passed the virus on to her sister who has chronic obstructive pulmonary disease. Fortunately, neither she nor her sister had to be hospitalized, but they certainly worried about it.

“We have lung issues and worry about breathing, so having the flu created lots of anxiety,” O’Neal says. This year, she’s not taking any chances: She has already gotten her flu shot.

That’s absolutely the right decision, says Dr. MeiLan Han, professor of internal medicine in the division of pulmonary and critical care medicine at the University of Michigan Health System and a national spokesperson for the American Lung Association.

If generally healthy people contract the flu, they may feel sick for a week or more, she says. But for someone with underlying lung conditions, it can take longer to recover from the flu — three to four weeks. “What I worry about most with these patients,” Han says, “is hospitalization and respiratory failure.”

In fact, Han says, 92% of adults hospitalized for the flu have at least one underlying chronic condition such as diabetes, asthma, or kidney or liver disorders.

When people with underlying lung conditions contract the flu, she says, “the virus goes right to the lung, and it can make a situation where it’s hard to breathe even harder.”

Other chronic health conditions — diabetes, HIV and cancer, among them — impair the immune system, Han explains, making people with those conditions unable to mount a robust response to the flu virus without the immunization boost of a flu shot.

That means the inflammation and infection when they get the flu can become more severe, she says.

Even many of her own patients don’t realize how bad a case of the flu can be, Han says.

“People often tell me, ‘That’s not me. I’ve never had the flu. I’m not at risk, and I’m not around people who might give me the flu.’ “

O’Neal says she’d always figured she wasn’t at risk either — until the flu flattened her.

Healthy pregnant women, too, are more prone to complications and hospitalization if they contract the flu and are strongly urged by the Centers for Disease Control and Prevention and OB-GYNs to get vaccinated against both influenza and pertussis. Yet the majority of mothers-to-be surveyed in the United States — 65% — have not been immunized against those two illnesses, according to a recent CDC Vital Signs report.

Some women mistakenly worry that the flu vaccine isn’t safe for them or their babies. “I think some of the fears about safety are certainly understandable, but they’re misinformed,” says Dr. Alicia Fry, chief of the epidemiology and prevention branch of the CDC’s Influenza Division.

The evidence is clear, Fry says: The vaccine is extremely safe. And she points to a recent study showing that immunization against flu reduces the risk of flu hospitalization among pregnant women by 40%.

As for worries that the woman’s vaccination might not be safe for her developing fetus, Fry says the opposite is true. When a pregnant woman is immunized, antibodies that fight the flu virus cross the placenta and can protect her baby in those critical months before and after birth.

“It can prevent 70% of the illness associated with flu viruses in the baby,” Fry says. “So it’s a double protection: Mom is protected, and the baby’s protected.” Infants can’t get the flu vaccine themselves until they are 6 months old.

Now, the vaccine won’t protect against all strains of the flu virus that may be circulating. But Schaffner says the shot is still very much worth getting this year and every year.

“Although it’s not perfect, the vaccine we have today actually prevents a lot of disease completely,” he says. “And even if you do get the flu, it’s likely to be less severe, and you’ll be less likely to develop complications.”

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Editor’s note: This story includes images that some readers may find disturbing.

When photojournalist Lynsey Addario was awarded the MacArthur Fellowship in 2009, she took it as a chance to work on a topic that many photographers and editors shied away from: maternal mortality. Her photos of overcrowded hospitals, bloody delivery room floors and midwives in training illustrate the challenges women face in childbirth and what the global health community is doing to overcome it. The series was featured at this year’s Visa Pour L’image festival in Perpignan, France.

Addario has borne witness to some of the most intense global conflicts of her time. She has worked for publications like The New York Times, National Geographic and Time Magazine and has covered life under the Taliban in Afghanistan and the plight of Syrian refugees. She has been kidnapped twice while on assignment, most recently in Libya in 2011 while covering the civil war.

Every two minutes, a woman dies from childbirth or pregnancy-related causes, and many of these deaths are entirely preventable. While the global health community has made great strides bringing down the rate of these maternal mortalities since efforts intensified in the early 1990s, the reality for many mothers is still harrowing.

We spoke to Addario, author of the 2015 memoir It’s What I Do: A Photographer’s Life of Love and War, about what drives her work and what she’s witnessed over a decade of reporting on this topic. The interview has been edited and condensed for clarity.

How did you get interested in the topic of maternal mortality?

In 2009 I was named a MacArthur Fellow. It was the first time in my career where I was given money to work on a project without an assignment, so I could choose something that I felt was important to cover. I started learning about the incredible number of women who were dying in childbirth every year. It wasn’t a story that was easy to get published — I think most editors felt it wasn’t a sexy topic. Most people just don’t realize what a big deal this is.

[Early in the project,] in the very first hospital I walked into outside of Freetown, Sierra Leone, I literally watched a very young woman, Mamma Sessay, hemorrhage in front of me on camera and die. And I knew that it was a story I had to continue with.

You write in your book Of Love & War that what compels you to do photojournalism is “documenting injustice.” How does that apply in this series?

If you’re a poor woman living in a village where there are no medical professionals around, and you don’t have enough money to get to a hospital, then you run the risk of dying in childbirth. That’s injustice. I think everyone is entitled to a safe delivery. In 2019 there should be medical facilities within reach for anyone to be able to access them, or mobile clinics.

Were you a mother when you started the project?

No. In fact I always used to joke around on the delivery ward that I would never become a mother because I had photographed so many women delivering, and I knew it was such a painful and difficult experience. Then in 2011 I gave birth to my first son, so I ended up doing it anyway. Even though this project made me more scared to actually deliver because I know how many things can go wrong.

Ironically my own delivery in 2011 was not a great experience. I moved to London when I was 32 weeks pregnant and delivered at 37 weeks. I had no doctor, basically just showed up at the hospital nine centimeters dilated and delivered with whatever midwife was on duty. Now that I’ve been doing this project for 10 years, there are so many things I would suggest to first-time mothers — or second-time mothers.

Like what?

Like maybe have a doula or have someone with you who can be an advocate — who can explain to you what’s going on with your body, who can help you navigate the pain. Someone who can understand if something’s going wrong, like the symptoms of preeclampsia: headaches, sweating, swelling. There’s so much that we just don’t know, that we’re not taught. People take childbirth for granted.

What is it like talking to your male colleagues about this project?

Most of them just haven’t paid attention to this work. Colleagues have said things to me about some stories — like the woman giving birth on the side of the road in the Philippines and the Mamma Sessay story — because they’re sensational, but no one really asked me about the work, which is interesting in and of itself. I think people sort of shy away from talking about birth, you know? Unless it’s something happy and positive.

What has surprised you while photographing this series?

How much access people give me. I’ve photographed — I can’t even count how many — probably three or four dozen births. The women invite me into very intimate spaces. I obviously try to be very respectful of how I photograph something like this. It’s one of the most beautiful things I’ve ever witnessed, watching a baby be born. It’s something delicate to photograph because it’s so incredible and at the same time it’s very graphic. It’s hard, and it’s always surprising to me how many people have let me in.

That word “graphic” jumps out at me. I’m looking at one of your photos now, where there’s blood on a delivery room floor, and it’s uncomfortable in a way that’s different than looking at blood from violence.

It is different. It’s different because no one thinks of childbirth like that. They think of childbirth as Hallmark pictures, but there’s a lot that’s not beautiful about it.

You’ve been working on this project for 10 years now. What has changed?

The statistics [for maternal mortality] have gone down, which is incredible, and there’s a lot more awareness. There are so many organizations — like Every Mother Counts, which is Christy Turlington’s organization, and UNFPA and UNICEF — working to fight maternal death. There’s more information, but it’s still too many — one woman a day is too many.

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