There seems to be no end in sight for the current partial government shutdown, the third since the beginning of the Trump administration.

For the vast majority of the federal government’s public health efforts, though, it’s business as usual.

That’s because Congress has already passed five of its major appropriations bills, funding about three-fourths of the federal government, including the Department of Health and Human Services and the Department of Veterans Affairs.

But seven bills are outstanding — including those that fund the Interior, Agriculture and Justice departments — and that puts the squeeze on some important health-related initiatives.

The shutdown itself isn’t about health policies. It’s the result of differences of opinion between the administration and congressional Democrats regarding funding for President Trump’s border wall. But it’s far-reaching, nonetheless. Here’s where things stand:

Funding for “big ticket” health programs is already in place, alleviating much of the shutdown’s immediate potential impact

Since HHS funding is set through September, the flagship government health care programs — think Obamacare, Medicare and Medicaid — are insulated.

That’s also true of public health surveillance, like tracking the flu virus, a responsibility of the Centers for Disease Control and Prevention. The National Institutes of Health, which oversees major biomedical research, is also fine. It’s a stark contrast to last January’s shutdown, which sent home about half of HHS’s staff.

But some other public health operations are vulnerable because of complicated funding streams

Although the Food and Drug Administration falls under the HHS umbrella, it receives significant funding for its food safety operations through the spending bill for the Department of Agriculture, which is entirely caught up in the shutdown.

Last year, that tallied an estimated $2.9 billion to support among other things these FDA oversight efforts, which involve everything from food recalls to routine facility inspections and cosmetics regulation. Not having those dollars now means, according to the FDA contingency plan, that about 40 percent of the agency — thousands of government workers — is furloughed.

The FDA will continue work that’s critical to public health and safety. It will be able to respond to emergencies, like the flu and foodborne illnesses. It will continue recalls of any foods, drugs and medical devices that pose a high risk to human health.

The FDA’s responsibilities for drug approval and oversight are funded by user fees and will continue product reviews where the fees have already been paid. Regulation of tobacco products is also continuing.

Health services for Native Americans are also on hold

Because Congress has yet to approve funding for the Indian Health Service, which is run by HHS but gets its money through the Department of the Interior, IHS feels the full weight of the shutdown. The only services that can continue are those that meet “immediate needs of the patients, medical staff, and medical facilities,” according to the shutdown contingency plan.

That includes IHS-run clinics, which provide direct health care to tribes around the country. These facilities are open, and many staffers are reporting to work because they are deemed “excepted,” said Jennifer Buschik, an agency spokeswoman. But they will not be paid until Congress and the administration reach a deal.

Other IHS programs are taking a more direct hit. For example, the agency has suspended grants that support tribal health programs as well as preventive health clinics run by the Office of Urban Indian Health Programs.

Public health efforts by Homeland Security and the EPA face serious constraints

The Department of Homeland Security’s Office of Health Affairs assesses threats posed by infectious diseases, pandemics and biological and chemical attacks. It is supposed to be scaling back, according to the department’s shutdown contingency plan. This office is just one component of the 204-person Countering Weapons of Mass Destruction Office, which is retaining about 65 employees during the funding gap.

Other DHS health workers are likely to work without pay — for instance, health inspectors at the border, said Peter Boogaard, who was an agency spokesman under the Obama administration. According to DHS’s plan, the vast majority of Border Patrol employees will continue working through the shutdown.

The Environmental Protection Agency has also run out of funding. According to its contingency plan, it’s keeping on more than 700 employees without pay, including those who work on Superfund sites or other activities where the “threat to life or property is imminent.” (More than 13,000 EPA workers have been furloughed.)

That limits the agency’s capacity for activities including inspecting water that people drink and regulating pesticides.

But it’s not just regulation. The public health stakes are visceral — and sometimes, frankly, pretty gross.

Just look at the National Park Service, which has halted restroom maintenance and trash service for lack of funding. On Sunday, Yosemite National Park in California closed its campgrounds. On Wednesday, Joshua Tree National Park, also in California, did the same.

Why? Per a park service press release: “The park is being forced to take this action for health and safety concerns as vault toilets reach capacity.”

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

Let’s block ads! (Why?)

A recent study out of Oregon suggests emergency medical responders — EMTs and paramedics — may be treating minority patients differently from the way they treat white patients.

Specifically, the scientists found that black patients in their study were 40 percent less likely to get pain medication than their white peers.

Jamie Kennel, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was presented in December at the Institute of Healthcare Improvement Scientific Symposium in Orlando.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in this case unconscious bias may be at work.

A few years ago Leslie Gregory, was one of a very few black, female emergency medical technicians working in Lenawee County, Mich. She says the study’s findings ring true to what she’s seen.

She remembers one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that’s when one of her colleagues groaned.

“I think it was something like: ‘Oh, my God. Here we go again,’ ” Gregory says. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

“I am absolutely sure this was unconscious,” adds Gregory, who now lives and works in Portland, Ore. “At the time, I remember, it increased my stress as we rode up on this person. Because I thought, ‘Now am I going to have to fight my colleague for more pain medication, should that arise?’ “

Unconscious bias can be subtle — but, as this new report shows, it may be one of factors behind race-linked health disparities seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients between 2015 and 2017. It found minority patients were less likely to receive morphine and other pain medication compared to white patients — regardless of socioeconomic factors, such as health insurance status.

Gregory is now a physician assistant, and one of her current patients, a black veteran, has cyclic vomiting syndrome. That means he periodically experiences bouts of vomiting he can’t stop without hydromorphone, a potent opioid.

If the man doesn’t get the medicine when he needs it, he could rupture his esophagus and die, Gregory says.

So, he doesn’t call the ambulance anymore. Instead, he goes straight to a hospital emergency department for help. But, Gregory says, the same thing keeps happening — the health professionals in the ER won’t prescribe him the medicine he needs.

“I took his entire medical record and faxed it over to the emergency department director of a local hospital system, in anticipation of this very problem,” Gregory says. “And still, when he presented, it was the same exact thing.”

During a shift-change at American Medical Response headquarters in Portland, I discuss the problem with EMTs and paramedics who are getting their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, tells me she’s heard about the new study. She’s adamant that her work is not affected by race.

“I’ve never treated anybody different — regardless,” says Sanders.

Most of the emergency responders I speak with, including Jason Dahlke , say race doesn’t affect the treatment they give. But Dahlke also says he and some of his co-workers are thinking deeply about unconscious bias.

“Historically it’s the way this country has been,” Dahlke says. “In the beginning we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It’s there.”

Ask Dahlke where he thinks unconscious bias could slip in, and he talks about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient’s house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man’s blood sugar level was low.

“So it’s my decision to treat this blood sugar first. Make sure that number comes up,” Dahlke says.

He gave the patient glucose — but no pain medicine.

Dahlke says he did not address the man’s pain in this case because by the time he’d stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

“When people are acutely sick or injured, pain medication is important,” Dahlke says. “But it’s not the first thing we’re going to worry about. We’re going to worry about life threats. You’re not necessarily going to die from pain, and we’re going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care.”

Dahlke say he is not sure whether, if the patient had been white, he’d have administered pain medicine, though he doesn’t think so.

“Is it something that I think about when I come across a patient that does not look like me? I don’t know that it changes my treatment,” he says.

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiles.

“I wonder that — if, in this study, if we’re talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we’re overtreating white people with narcotic medicines.”

Research has also found African Americans more likely to be deeply distrustful of the medical community, and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, says Leslie Gregory.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” she says.

Gregory wrote an open letter to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a national health crisis.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory notes.

But the CDC told Gregory, in its emailed response, that while it supports government policies to combat racial discrimination and acknowledges the role of racism in health disparities, “racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S.”

Kennel says false stereotypes about race-based differences in physiology that date back to slavery also play a role in health care disparities.

For example, despite a lack of any supporting science, some medical professionals still think the blood of African Americans coagulates faster, Kennel says, citing a recent study of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites.

“An uncomfortably large percentage of medical students said ‘yes, that’s true,’ ” says Kennel.

On top of that, he says, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. “In these situations, providers are much more likely to default to making decisions [based] on stereotypes,” he says.

Disparities in health care are well-documented. Whites tend to get better care and experience better outcomes, whether they’re in a doctor’s office or the ER. But before Kennel’s study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn’t get to know, because the research required ambulance companies to release highly sensitive data.

“We were prepared to maybe not look that great,” explains Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation’s largest ambulance organizations and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel says he controlled for those variables.

So, now that AMR knows about disparities in its care, what can the company do?

“My feeling is we’re probably going to put some education and training out to our folks in the field,” McDonald says.

In addition, he says, AMR is going to hire more people of color.

“We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce,” McDonald says.

AMR’s policies must change, too, he adds. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, a nonprofit news service of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)

With a newly configured U.S. Supreme Court, the stakes are high for abortion-rights battles at the state level. Abortion-rights advocates and opponents are preparing for a busy year — from a tug-of-war over Roe v. Wade to smaller efforts that could expand or restrict access to abortion.

Supreme Court Justice Brett Kavanaugh is known for his conservative record on issues including reproductive rights. And with his confirmation, many abortion-rights opponents see new opportunities to restrict the procedure at the state level.

“The pro-life movement has been talking about more pro-life-friendly courts for years, and we see Kavanaugh really tilting that balance,” says Jamieson Gordon with Ohio Right to Life.

Activists in Ohio just pushed through a law banning a common second-trimester abortion procedure called dilation and extraction. Gordon says her group is feeling optimistic and is working to pass more restrictions in the new year.

“It really has been encouraging for us knowing that if our bill … got picked up to go to the court, that we would have a more favorable court,” she says. “So I do think that we’ve seen the tide turn.”

A “watershed moment”

Abortion-rights advocates also are preparing for a wave of bills to be introduced in statehouses across the country, says Elisabeth Smith, chief counsel for state policy and advocacy at the Center for Reproductive Rights.

“We think this will be a watershed moment in terms of the number [of bills] that are filed, and then potentially the number that will actually be enacted in various states,” Smith says.

She says advocates are working to protect abortion rights, repeal existing restrictions and fight new efforts to limit access to the procedure.

“I think the specter of the Supreme Court will be behind both the proactive bills — in terms of shoring up the right and access [to abortion] at the state level — and on the other side, I think states that are hostile to reproductive rights are going to be jockeying to be the state that sends a law to the Supreme Court,” Smith says.

Tug-of-war over Roe v. Wade

Many abortion-rights opponents say they’re hoping to overturn Roe v. Wade, the 1973 decision that legalized abortion nationwide.

“States want their bill to be the one to go to the Supreme Court. They want to be the one,” says Sue Liebel, state director for the anti-abortion-rights group Susan B. Anthony List.

Possible test cases for Roe already are working their way through the courts — including an Iowa law banning abortion after a fetal heartbeat is detected, and one in Mississippi prohibiting the procedure after 15 weeks.

Liebel says anti-abortion-rights activists want to pass similar bills in as many states as possible.

“So I think they’re hopeful; they’re energized and rarin’ to go,” Liebel says.

If Roe were weakened or overturned, more power for regulating abortion would fall to the states. Several anti-abortion-rights groups are pushing to increase the number of states banning abortion after 20 weeks or earlier.

Meanwhile, lawmakers supportive of abortion rights in several states are sponsoring bills to guarantee the right to abortion in state law, in places including Massachusetts, Virginia and even Texas, according to Smith, with the Center for Reproductive Rights.

“It’s unlikely that [Texas] bill will pass,” Smith says. “But I think more and more state advocates are bringing up this bill — either as a messaging vehicle, or to actually get it enacted.”

Big steps, and small ones

NARAL Pro-Choice America is promoting those bills. But Deputy Policy Director Leslie McGorman says it is also working on incremental efforts to improve abortion access, including legislation allowing a broader range of medical providers — such as nurse practitioners and physician assistants — to provide abortions in more states.

“We know that as long as abortion is sort of a one-off procedure, or care that’s delivered in a standalone clinic and people sort of don’t know what it is, that it’s gonna be this part of health care that’s sort of viewed that way, that’s viewed as sort of marginal,” McGorman says.

Abortion-rights opponents also are continuing to pursue their own incremental strategy.

Americans United for Life has close to 60 model bills aimed at restricting abortion. Among them is the Abortion Reporting Act, which requires medical providers to submit detailed reports to health officials about abortion-related complications.

“This is really designed to make sure that women are informed about those abortion providers that are especially dangerous,” says the group’s president, Catherine Glenn Foster.

Abortion-rights advocates say the requirements are intrusive and vaguely defined. Planned Parenthood sued last summer to block a similar law in Idaho.

“There’s also a big push to defund abortion facilities, to stop them from getting Title X funding,” says Ingrid Duran, of the National Right to Life Committee.

It’s already illegal for federal funds to pay for abortions in most cases, but anti-abortion activists want to ban organizations such as Planned Parenthood, which offer abortions, from receiving any public money for reproductive health services. The Trump administration has proposed blocking such groups from getting funds through Title X, the federal family planning program for low-income people; Duran says similar efforts are underway in many states.

Let’s block ads! (Why?)