She had delighted in watching her dad, John Schapers, blow out the candles on his 90th birthday cake that February at the West Lawrence Care Center in the New York City borough. Then the home went into lockdown.

Soon her father was dead. The former union painter spiked a fever and was transferred to a hospital, where he tested positive for covid, his daughter said, and after two weeks on a ventilator, he died in May 2020.

But when Trever Schapers sued the nursing home for negligence and wrongful death in 2022, a judge dismissed the case, citing a New York state law hastily passed early in the pandemic. It granted immunity to medical providers for “harm or damages” from an “act or omission” in treating or arranging care for covid. She is appealing the decision.

“I feel that families are being ignored by judges and courts not recognizing that something needs to be done and changed,” said Schapers, 48, who works in the medical field. “There needs to be accountability.”

The nursing home did not return calls seeking comment. In a court filing, the home argued that Schapers offered no evidence that the home was “grossly negligent” in treating her father.

More than four years after covid first raged through many U.S. nursing homes, hundreds of lawsuits blaming patient deaths on negligent care have been tossed out or languished in the courts amid contentious legal battles.

Even some nursing homes that were shut down by health officials for violating safety standards have claimed immunity against such suits, court records show. And some families that allege homes kept them in the dark about the health of their loved ones, even denying there were cases of covid in the building, have had their cases dismissed.

Schapers alleged in a complaint to state health officials that the nursing home failed to advise her that it had admitted covid-positive patients from a nearby hospital in March 2020. In early April, she received a call telling her the facility had some covid-positive residents.

“The call I received was very alarming, and they refused to answer any of my questions,” she said.

About two weeks later, a social worker called to say that her father had a fever, but the staff did not test him to confirm covid, according to Schapers’ complaint.

The industry says federal health officials and lawmakers in most states granted medical providers broad protection from lawsuits for good faith actions during the health emergency. Rachel Reeves, a senior vice president with the American Health Care Association, an industry trade group, called covid “an unprecedented public health crisis brought on by a vicious virus that uniquely targeted our population.”

In scores of lawsuits, however, family members allege that nursing homes failed to secure enough protective gear or tests for staffers or residents, haphazardly mixed covid-positive patients with other residents, failed to follow strict infection control protocols, and brazenly misled frightened families about the severity of covid outbreaks among patients and staff.

“They trusted these facilities to take care of loved ones, and that trust was betrayed,” said Florida attorney Lindsey Gale, who has represented several families suing over covid-related deaths.

“The grieving process people had to go through was horrible,” Gale said.

A Deadly Toll

Ä¢¹½Ó°Ôº Health News found that more than 1,100 covid-related lawsuits, most alleging wrongful death or other negligent care, were filed against nursing homes from March 2020 through March of this year.

While there’s no full accounting of the outcomes, court filings show that judges have dismissed some suits outright, citing state or federal immunity provisions, while other cases have been settled under confidential terms. And many cases have stalled due to lengthy and costly arguments and appeals to hash out limits, if any, of immunity protection.

In their defense, nursing homes initially cited the federal , which Congress passed in December 2005. The law grants liability protection from claims for deaths or injuries tied to vaccines or “medical countermeasures” taken to prevent or treat a disease during national emergencies.

The PREP Act steps in once the secretary of Health and Human Services declares a “,” which happened with covid on . The on May 11, 2023.

The law carved out an exception for “willful misconduct,” but proving it occurred can be daunting for families — even when nursing homes have long histories of violating safety standards, including infection controls.

Governors of at least 38 states issued covid executive orders, or their legislatures passed laws, granting medical providers at least , according to one consumer group’s tally. Just how much legal protection was intended is at the crux of the skirmishes.

Nursing homes answered many negligence lawsuits by getting them removed from state courts into the federal judicial system and asking for dismissal under the PREP Act.

For the most part, that didn’t work because federal judges declined to hear the cases. Some judges ruled that the PREP Act was not intended to shield medical providers from negligence caused by inaction, such as failing to protect patients from the coronavirus. These rulings and appeals sent cases back to state courts, often after long delays that left families in legal limbo.

“These delays have been devastating,” said Jeffrey Guzman, a New York City attorney who represents Schapers and other families. He said the industry has fought “tooth and nail” trying to “fight these people getting their day in court.”

Empire State Epicenter

New York, where covid hit early and hard, is ground zero for court battles over nursing home immunity.

Relatives of residents have filed more than 750 negligence or wrongful death cases in New York counties since the start of the pandemic, according to court data Ä¢¹½Ó°Ôº Health News compiled using the judicial reporting service Courthouse News Service. No other area comes close. Chicago’s Cook County, a jurisdiction where private lawyers for years have aggressively sued nursing homes alleging poor infection control, recorded 121 covid-related cases.

Plaintiffs in hundreds of New York cases argue that nursing homes knew early in 2020 that covid would pose a deadly threat but largely failed to gird for its impact. Many suits cite inspection reports detailing chronic violations of infection control standards in the years preceding the pandemic, court records show. Responses to this strategy vary.

“Different judges take different views,” said Joseph Ciaccio, a New York lawyer who has filed hundreds of such cases. “It’s been very mixed.”

Lawyers for nursing homes counter that most lawsuits rely on vague allegations of wrongdoing and “boilerplate” claims that, even if true, don’t demonstrate the kind of gross negligence that would override an immunity claim.

New York lawmakers added another wrinkle by repealing the immunity statute in April 2021 after Attorney General Letitia James could give nursing homes a free pass to make “financially motivated decisions” to cut costs and put patients at risk.

So far, appeals courts have ruled lawmakers didn’t specify that the repeal should be made retroactive, thus stymying many negligence cases.

“So these cases are all wasting the courts’ time and preventing cases that aren’t barred by immunity statutes from being resolved sooner and clogging up the court system that was already backlogged from COVID,” said attorney Anna Borea, who represents nursing homes.

Troubled Homes Deflect Suits

Some nursing homes that paid hefty fines or were ordered by health officials to shut down at least temporarily because of their inadequate response to covid have claimed immunity against suits, court records show.

Among them is Andover Subacute and Rehabilitation nursing home in New Jersey, which made when authorities found 17 bodies stacked in a makeshift morgue in April 2020.

Federal health officials $220,235 after issuing a critical 36-page report on covid violations and other deficiencies, and the state halted admissions in February 2022.

Yet the home has won court pauses in at least three negligence lawsuits as it appeals lower court rulings denying immunity under the federal PREP Act, court records show. The operators of the home could not be reached for comment. In court filings, they denied any wrongdoing.

In Oregon, at Healthcare at Foster Creek, calling the Portland nursing home “a serious danger to the public health and safety.” The May 2020 order cited the home’s “consistent inability to adhere to basic infection control standards.”

Bonnie Richardson, a Portland lawyer, sued the facility on behalf of the family of Judith Jones, 75, who had dementia and died in April 2020. Jones’ was among dozens of covid-related deaths at that home.

“It was a very hard-fought battle,” said Richardson, who has since settled the case under confidential terms. Although the nursing home claimed immunity, her clients “wanted to know what happened and to understand why.” The owners of the nursing home provided no comment.

No Covid Here

Many families believe nursing homes misled them about covid’s relentless spread. They often had to settle for to connect with their loved ones.

Relatives of five patients who died in 2020 at the Sapphire Center for Rehabilitation and Nursing in the Flushing neighborhood in Queens filed lawsuits accusing the home’s operators of keeping them in the dark.

When they phoned to check on elderly parents, they either couldn’t get through or were told there was “no COVID-19 in the building,” according to one court affidavit.

One woman grew alarmed after visiting in February 2020 and seeing nurses wearing masks “below their noses or under their chin,” according to a court affidavit.

The woman was shocked when the home relayed that her mother had died in April 2020 from unknown causes, perhaps “from depression and not eating,” according to her affidavit.

A short time later, that dozens of Sapphire Center residents had died from the virus — her 85-year-old mother among them, she argued in a lawsuit.

The nursing home denied liability and won dismissal of all five lawsuits after citing the New York immunity law. Several families are appealing. The nursing home’s administrator declined to comment.

Broadening Immunity

Nursing home operators also have cited immunity to foil negligence lawsuits based on falls or other allegations of substandard care, such as bedsores, with little obvious connection to the pandemic, court records show.

The family of Marilyn Kearney, an 89-year-old with a “history of dementia and falls,” sued the Watrous Nursing Center in Madison, Connecticut, for negligence. Days after she was admitted in June 2020, she fell in her room, fracturing her right hip and requiring surgery, according to court filings.

She died at a local hospital on Sept. 16, 2020, from sepsis attributed to dehydration and malnutrition, according to the suit.

Her family argued that the 45-bed nursing home failed to assess her risk of falling and develop a plan to prevent that. But Watrous fired back by citing an April 2020 declaration by Connecticut Gov. Ned Lamont, a Democrat, granting health care professionals or facilities immunity from “any injury or death alleged to have been sustained because of the individual’s or health care facility’s acts or omissions undertaken in good faith while providing health care services in support of the state’s COVID-19 response.”

Watrous denied liability and, in a motion to dismiss the case, cited Lamont’s executive order and affidavits that argued the home did its best in the throes of a “public health crisis, the likes of which had never been seen before.” The operators of the nursing home, which closed in July 2021 because of covid, did not respond to a request for comment. The case is pending.

Attorney Wendi Kowarik, who represents Kearney’s family, said courts are wrestling with how much protection to afford nursing homes.

“We’re just beginning to get some guidelines,” she said.

One pending Connecticut case alleges that an 88-year-old man died in October 2020 after experiencing multiple falls, sustaining bedsores, and dropping more than 30 pounds in the two months he lived at a nursing home, court records state. The nursing home denied liability and contends it is entitled to immunity.

So do the owners of a Connecticut facility that cared for a 75-year-old woman with obesity who required a lift to get out of bed. She fell on April 26, 2020, smashing several teeth and fracturing bones. She later died from her injuries, according to the suit, which is pending.

“I think it is really repugnant that providers are arguing that they should not be held accountable for falls, pressure sores, and other outcomes of gross neglect,” said Richard Mollot, executive director of the Long Term Care Community Coalition, which advocates for patients.

“The government did not declare open season on nursing home residents when it implemented COVID policies,” he said.

Protecting the Vulnerable

Since early 2020, U.S. nursing homes have residents’ deaths, according to Centers for Medicare & Medicaid Services data. That’s about 1 in 7 of all recorded U.S. covid deaths.

As it battles covid lawsuits, the nursing home industry says it is “struggling to recover due to ongoing labor shortages, inflation, and chronic government underfunding,” according to Reeves, the trade association executive.

She said the American Health Care Association has advocated for “reasonable, limited liability protections that defend staff and providers for their good faith efforts” during the pandemic.

“Caregivers were doing everything they could,” Reeves said, “often with limited resources and ever-changing information, in an effort to protect and care for residents.”

But patients’ advocates remain wary of policies that might bar the courthouse door against grieving families.

“I don’t think we want to continue to enact laws that reward nursing homes for bad care,” said Sam Brooks, of the Coalition for the Protection of Residents of Long-Term Care Facilities, a patient advocacy group.

“We need to keep that in mind if, God forbid, we have another pandemic,” Brooks said.

Bill Hammond, a senior fellow at the Empire Center for Public Policy, a nonpartisan New York think tank, said policymakers should focus on better strategies to protect patients from infectious outbreaks, rather than leaving it up to the courts to sort out liability years later.

“There is no serious effort to have that conversation,” Hammond said. “I think that’s crazy.”

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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The first-time mother, a high school teacher in rural Illinois, had developed high blood pressure, a sometimes life-threatening condition in pregnancy that prompted doctors to hospitalize her. Then Crivilare’s blood pressure spiked, and the baby’s heart rate dropped. “It was terrifying,” Crivilare said.

She gave birth to a healthy daughter. What followed, though, was another ordeal: thousands of dollars in medical debt that sent Crivilare and her husband scrambling for nearly a year to keep collectors at bay.

The Crivilares would eventually get on nine payment plans as they juggled close to $5,000 in bills.

“It really felt like a full-time job some days,” Crivilare recalled. “Getting the baby down to sleep and then getting on the phone. I’d set up one payment plan, and then a new bill would come that afternoon. And I’d have to set up another one.”

Crivilare’s pregnancy may have been more dramatic than most. But for millions of new parents, medical debt is now as much a hallmark of having children as long nights and dirty diapers.

About 12% of the 100 million U.S. adults with health care debt attribute at least some of it to pregnancy or childbirth, according to a Ä¢¹½Ó°Ôº poll.

These people are more likely to report they’ve had to take on extra work, change their living situation, or make other sacrifices.

Overall, women between 18 and 35 who have had a baby in the past year and a half are twice as likely to have medical debt as women of the same age who haven’t given birth recently, other conducted for this project found.

“You feel bad for the patient because you know that they want the best for their pregnancy,” said Eilean Attwood, a Rhode Island OB-GYN who said she routinely sees pregnant women anxious about going into debt.

“So often, they may be coming to the office or the hospital with preexisting debt from school, from other financial pressures of starting adult life,” Attwood said. “They are having to make real choices, and what those real choices may entail can include the choice to not get certain services or medications or what may be needed for the care of themselves or their fetus.”

Best-Laid Plans

Crivilare and her husband, Andrew, also a teacher, anticipated some of the costs.

The young couple settled in Jacksonville, in part because the farming community less than two hours north of St. Louis was the kind of place two public school teachers could afford a house. They saved aggressively. They bought life insurance.

And before Crivilare got pregnant in 2021, they enrolled in the most robust health insurance plan they could, paying higher premiums to minimize their deductible and out-of-pocket costs.

Then, two months before their baby was due, Crivilare learned she had developed preeclampsia. Her pregnancy would no longer be routine. Crivilare was put on blood pressure medication, and doctors at the local hospital recommended bed rest at a larger medical center in Springfield, about 35 miles away.

“I remember thinking when they insisted that I ride an ambulance from Jacksonville to Springfield … ‘I’m never going to financially recover from this,’” she said. “‘But I want my baby to be OK.’”

For weeks, Crivilare remained in the hospital alone as covid protocols limited visitors. Meanwhile, doctors steadily upped her medications while monitoring the fetus. It was, she said, “the scariest month of my life.”

Fear turned to relief after her daughter, Rita, was born. The baby was small and had to spend nearly two weeks in the neonatal intensive care unit. But there were no complications. “We were incredibly lucky,” Crivilare said.

When she and Rita finally came home, a stack of medical bills awaited. One was already past due.

Crivilare rushed to set up payment plans with the hospitals in Jacksonville and Springfield, as well as the anesthesiologist, the surgeon, and the labs. Some providers demanded hundreds of dollars a month. Some settled for monthly payments of $20 or $25. Some pushed Crivilare to apply for new credit cards to pay the bills.

“It was a blur of just being on the phone constantly with all the different people collecting money,” she recalled. “That was a nightmare.”

Big Bills, Big Consequences

The Crivilares’ bills weren’t unusual. Parents with private health coverage now face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance, found.

Out-of-pocket costs are even higher for families with a newborn who needs to stay in a neonatal ICU, averaging $5,000. And for 1 in 11 of these families, medical bills related to pregnancy and childbirth exceed $10,000, the researchers found.

“This forces very difficult trade-offs for families,” said Michelle Moniz, a University of Michigan OB-GYN who worked on the study. “Even though they have insurance, they still have these very high bills.”

Nationwide polls suggest millions of these families end up in debt, with sometimes devastating consequences.

About three-quarters of U.S. adults with debt related to pregnancy or childbirth have cut spending on food, clothing, or other essentials, Ä¢¹½Ó°Ôº polling found.

About half have put off buying a home or delayed their own or their children’s education.

These burdens have spurred calls to limit what families must pay out-of-pocket for medical care related to pregnancy and childbirth.

In Massachusetts, state Sen. Cindy Friedman has to exempt all these bills from copays, deductibles, and other cost sharing. This would parallel federal rules that require health plans to cover recommended preventive services like annual physicals without cost sharing for patients. “We want … healthy children, and that starts with healthy mothers,” Friedman said. Massachusetts health insurers have warned the proposal will raise costs, but an independent state analysis estimated the bill would add only $1.24 to monthly insurance premiums.

Tough Lessons

For her part, Crivilare said she wishes new parents could catch their breath before paying down medical debt.

“No one is in the right frame of mind to deal with that when they have a new baby,” she said, noting that college graduates get such a break. “When I graduated with my college degree, it was like: ‘Hey, new adult, it’s going to take you six months to kind of figure out your life, so we’ll give you this six-month grace period before your student loans kick in and you can get a job.’”

Rita is now 2. The family scraped by on their payment plans, retiring the medical debt within a year, with help from Crivilare’s side job selling resources for teachers online.

But they are now back in debt, after Rita’s recurrent ear infections required surgery last year, leaving the family with thousands of dollars in new medical bills.

Crivilare said the stress has made her think twice about seeing a doctor, even for Rita. And, she added, she and her husband have decided their family is complete.

“It’s not for us to have another child,” she said. “I just hope that we can put some of these big bills behind us and give [Rita] the life that we want to give her.”

About This Project

“Diagnosis: Debt” is a reporting partnership between Ä¢¹½Ó°Ôº Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by Ä¢¹½Ó°Ôº, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research wasÌý, which analyzed credit bureau and other demographic data on poverty, race, and health status for Ä¢¹½Ó°Ôº Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase InstituteÌýÌýfrom a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with Ä¢¹½Ó°Ôº Health News on a survey of its clients to explore links between medical debt and housing instability.Ìý

Ä¢¹½Ó°Ôº Health News journalists worked with Ä¢¹½Ó°Ôº public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from Ä¢¹½Ó°Ôº Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

“¡No tenía dientes para sonreír!”, dijo el hombre de 53 años de Independence, Missouri.

Thompson dijo que durante años lidió con punzantes dolores de muelas y una hinchazón en la cara, también muy dolorosa, producto de abscesos, mientras trabajaba como cocinero en Burger King.

Necesitaba desesperadamente ir al dentista, pero dijo que no podía permitirse tomar tiempo libre sin pago. Missouri es uno de los muchos estados que proporcionen licencia por enfermedad paga.

Entonces, Thompson y soportaba el dolor mientras trabajaba sobre la parrilla caliente.

“O vamos a trabajar y tenemos un cheque de pago”, dijo Thompson. “O cuidamos de nosotros mismos. No podemos cuidar de nosotros mismos porque, bueno, estamos atrapados en este círculo vicioso”.

En una nación que estuvo fuertemente dividida sobre los mandatos de salud del gobierno durante la pandemia de covid-19, el público se está sintiendo cómodo con la idea de reglas gubernamentales que proporcionen licencia por enfermedad remunerada.

Antes de la pandemia, tenían leyes que requerían que los empleadores proporcionaran licencia por enfermedad paga. Desde entonces, , , , y han aprobado leyes que ofrecen algún tipo de tiempo libre por enfermedad remunerado. y ampliaron las leyes de licencia paga que ya estaban vigentes. En , y , defensores están presionando para llevar el tema a votación este otoño.

Estados Unidos es que no garantizan licencia por enfermedad paga, según datos compilados por el World Policy Analysis Center.

En respuesta a la pandemia, el la Emergency Paid Sick Leave y el Emergency Family and Medical Leave Act. Estas medidas temporales permitieron a los empleados tomar hasta dos semanas de licencia paga si la enfermedad estaba relacionada con covid y su atención. Pero las disposiciones .

“Cuando golpeó la pandemia, finalmente vimos una voluntad política real para resolver el problema de no tener licencia por enfermedad paga federal”, dijo la economista .

Wething fue co-autora de sobre el estado de la licencia por enfermedad en el país. Descubrió que más de la mitad, el 61%, de los trabajadores peor pagos no pueden tomarse este tipo de licencia.

“Me sorprendió mucho lo rápido que la pérdida de salario, debido a que estás enfermo, puede traducirse en recortes inmediatos y devastadores para el presupuesto familiar”, dijo.

Wething señaló que la pérdida de salarios incluso por uno o dos días puede equivaler a un mes de gasolina que un trabajador necesitaría para llegar a su trabajo, o la elección entre pagar una factura de electricidad o comprar alimentos.

Agregó que presentarse al trabajo enfermo representa un riesgo tanto para los compañeros como para los clientes. Los empleos mal remunerados que a menudo no tienen licencia por enfermedad paga, como cajeros, cosmetólogas, asistentes de salud en el hogar y trabajadores de comida rápida, implican muchas interacciones cara a cara.

“Así que la licencia por enfermedad paga se trata tanto de proteger la salud pública de una comunidad como de proporcionar a los trabajadores la seguridad económica que necesitan desesperadamente cuando deben tomar tiempo libre del trabajo”, dijo.

La National Federation Of Independent Business por enfermedad obligatoria a nivel estatal, argumentando que los lugares de trabajo deberían tener la flexibilidad para resolver el tema con sus empleados cuando se enferman. El grupo dijo que el , el papeleo adicional y la son una carga para los pequeños empleadores.

Según un informe del National Bureau of Economic Research, una vez que estas disposiciones entran en vigencia, los empleados toman, en promedio, al año comparado con antes de que entrara en vigor la ley.

Las reglas de tiempo libre pago de Illinois entraron en vigencia este año. Lauren Pattan es co-propietaria de Old Bakery Beer Co. allí. Antes de este año, la cervecería artesanal no ofrecía tiempo libre remunerado para sus empleados por hora. Pattan dijo que apoya la nueva ley de Illinois, pero tiene que ver cómo pagarla.

“Realmente intentamos ser respetuosos con nuestros empleados y ser un buen lugar para trabajar, y al mismo tiempo nos preocupa no poder permitirnos ciertas cosas”, dijo.

Eso podría significar que los clientes tengan que pagar más para cubrir el costo, agregó Pattan.

En cuanto a Bill Thompson, escribió para el periódico Kansas City Star sobre sus problemas dentales.

“A pesar de trabajar casi 40 horas a la semana, muchos de mis compañeros no tienen hogar”, escribió. “Sin seguro, ninguno de nosotros puede pagar a un médico o un dentista”.

Ese artículo generó atención local y, en 2018, un dentista de su comunidad donó su tiempo y trabajo para quitarle los dientes restantes a Thompson y reemplazarlos con dentaduras postizas.

Esto permitió que su boca se recuperara de las infecciones con las que había estado lidiando durante años. Hoy, Thompson tiene una nueva sonrisa y un trabajo, con licencia por enfermedad paga, en el servicio de alimentos en un hotel.

En su tiempo libre, ha estado recopilando firmas para presentar una iniciativa en la boleta electoral de noviembre que garantizaría al menos por enfermedad paga al año para los trabajadores de Missouri. Los organizadores de la petición dijeron que tienen para llevarlo ante los votantes.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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“I didn’t have any teeth to smile with,” the 53-year-old of Independence, Missouri, said.

Thompson said he dealt with throbbing toothaches and painful swelling in his face from abscesses for years working as a cook at Burger King. He desperately needed to see a dentist but said he couldn’t afford to take time off without pay. Missouri is one of many states that employers to provide paid sick leave.

So, Thompson would and push through the pain as he worked over the hot grill.

“Either we go to work, have a paycheck,” Thompson said. “Or we take care of ourselves. We can’t take care of ourselves because, well, this vicious circle that we’re stuck in.”

In a nation that was sharply divided about government health mandates during the covid-19 pandemic, the public has been warming to the idea of government rules providing for paid sick leave.

Before the pandemic, and the District of Columbia had laws requiring employers to provide paid sick leave. Since then, , , , , and have passed laws offering some kind of paid time off for illness. and expanded previous paid leave laws. In , , and , advocates are pushing to put the issue on the ballot this fall.

The U.S. is that do not guarantee paid sick leave, according to data compiled by the World Policy Analysis Center.

In response to the pandemic, the Emergency Paid Sick Leave and Emergency Family and Medical Leave Expansion acts. These temporary measures allowed employees to take up to two weeks of paid sick leave for covid-related illness and caregiving. But the provisions .

“When the pandemic hit, we finally saw some real political will to solve the problem of not having federal paid sick leave,” said economist .

Wething co-authored a on the state of sick leave in the United States. It found that more than half, 61%, of the lowest-paid workers can’t get time off for an illness.

“I was really surprised by how quickly losing pay — because you’re sick — can translate into immediate and devastating cuts to a family’s household budget,” she said.

Wething noted that the lost wages of even a day or two can be equivalent to a month’s worth of gasoline a worker would need to get to their job, or the choice between paying an electric bill or buying food. Wething said showing up to work sick poses a risk to co-workers and customers alike. Low-paying jobs that often lack paid sick leave — like cashiers, nail technicians, home health aides, and fast-food workers — involve lots of face-to-face interactions.

“So paid sick leave is about both protecting the public health of a community and providing the workers the economic security that they desperately need when they need to take time away from work,” she said.

The National Federation of Independent Business has at the state level, arguing that workplaces should have the flexibility to work something out with their employees when they get sick. The group said the cost of , extra paperwork, and burdens small employers.

According to a report by the National Bureau of Economic Research, once these mandates go into effect, employees take, on average, than before a law took effect.

went into effect this year. Lauren Pattan is co-owner of the Old Bakery Beer Co. there. Before this year, the craft brewery did not offer paid time off for its hourly employees. Pattan said she supports Illinois’ new law but she has to figure out how to pay for it.

“We really try to be respectful of our employees and be a good place to work, and at the same time we get worried about not being able to afford things,” she said.

That could mean customers have to pay more to cover the cost, Pattan said.

As for Bill Thompson, he for the Kansas City Star newspaper about his dental struggles.

“Despite working nearly 40 hours a week, many of my co-workers are homeless,” he wrote. “Without health care, none of us can afford a doctor or a dentist.”

That op-ed generated attention locally and, in 2018, a dentist in his community donated his time and labor to remove Thompson’s remaining teeth and replace them with dentures. This allowed his mouth to recover from the infections he’d been dealing with for years. Today, Thompson has a new smile and a job — with paid sick leave — working in food service at a hotel.

In his free time, he’s been collecting signatures to put an initiative on the November ballot that would guarantee at least of earned paid sick leave a year for Missouri workers. Organizers behind the petition said they have to take it before the voters.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

The Tennessee mother was around 13 weeks pregnant when, according to a lawsuit filed against the state of Tennessee, doctors gave her the devastating news that her baby had .

The genetic disorder causes serious developmental defects and often results in miscarriage, stillbirth, or death within one year of birth. Continuing her pregnancy, doctors told her, could put her at risk of infection and complications that include high blood pressure, organ failure, and death.

But they said they could not perform an abortion due to a Tennessee law banning most abortions that went into effect two months after the repeal of Roe v. Wade in June 2022, court records show.

So Kelly traveled to a northwestern Florida hospital to get an abortion while about 15 weeks pregnant. She is one of seven women and two doctors because they say the state’s near-total abortion ban imperils the lives of pregnant women.

More than 25,000 women like Kelly traveled to Florida for an abortion over the past five years, state data shows. Most came from states such as Alabama, Louisiana, and Mississippi with little or no access to abortion, . Hundreds traveled from as far as Texas.

But a recent Florida Supreme Court ruling paved the way for the Sunshine State to enforce a six-week ban beginning in May, effectively leaving women in much of the South with little or no access to abortion clinics. The ban could be short-lived if 60% of Florida voters in November approve a constitutional amendment adding the right to an abortion.

In the meantime, nonprofit groups are warning they may not be able to meet the increased demand for help from women from Florida and other Southeastern states to travel for an abortion. They fear women who lack the resources will be forced to carry unwanted pregnancies to term because they cannot afford to travel to states where abortions are more available.

That could include women whose pregnancies, like Kelly’s, put them at risk.

“The six-week ban is really a problem not just for Florida but the entire Southeast,” said McKenna Kelley, a board member of the . “Florida was the last man standing in the Southeast for abortion access.”

Travel Bans and Stricter Limits

Supporters of the Florida restrictions aren’t backing down. Some want even stricter limits. Republican state Rep. voted for both the 15-week and six-week bans. He said the vast majority of abortions are elective and that those related to medical complications make up a tiny fraction.

shows that 95% of abortions last year were either elective or performed due to social or economic reasons. More than 5% were related to issues with either the health of the mother or the fetus.

Beltran said he would support a ban on travel for abortions but knows it would be challenged in the courts. He would support measures that prevent employers from paying for workers to travel for abortions and such costs being tax-deductible, he said.

“I don’t think we should make it easier for people to travel for abortion,” he said. “We should put things in to prevent circumvention of the law.”

Both abortion bans were also supported by GOP state lawmaker . As a physician, Rudman said, he has delivered more than 100 babies and sees nothing in the current law that sacrifices patient safety.

“It is a good commonsense law that provides reasonable exceptions yet respects the sanctity of life for both mother and child,” he said in a text message.

Last year, the first full year that many Southern states had bans in place, more than 7,700 women traveled to Florida for an abortion, an increase of roughly 59% compared with three years ago.

The Tampa Bay Abortion Fund, which is focused on helping local women, found itself assisting an influx of women from Arkansas, Georgia, Mississippi, Louisiana, and other states, Kelley said.

In 2023, it paid out more than $650,000 for appointment costs and over $67,000 in other expenses such as airplane tickets and lodging. Most of those who seek assistance are from low-income families including minorities or disabled people, Kelley said.

“We ask each person, ‘What can you contribute?’” she said. “Some say zero and that’s fine.”Ìý

Florida’s new law will mean her group will have to pivot again. The focus will now be on helping people seeking abortions travel to other states.

But the destinations are farther and more expensive. Most women, she predicted, will head to New York, Illinois, or Washington, D.C. Clinic appointments in those states are often more expensive. The extra travel distance will mean help is needed with hotels and airfare.

North Carolina, which allows abortions through about 12 weeks of pregnancy, may be a slightly cheaper option for some women whose pregnancies are not as far along, she said.

Keeping up with that need is a concern, she said. Donations to the group soared to $755,000 in 2022, which Kelley described as “rage donations” made after the U.S. Supreme Court ended half a century of guaranteeing the federal right to an abortion.

The anger didn’t last. Donations in 2023 declined to $272,000, she said.

“We’re going to have huge problems on our hands in a few weeks,” she said. “A lot of people who need an abortion are not going to be able to access one. That’s really scary and sad.”

Gray Areas Lead to Confusion

The is expecting that many women from Southeastern states will head its way.

Illinois offers abortions up until fetal viability — around 24 to 26 weeks. The state five years ago repealed its law requiring parents to be notified when their children seek an abortion.

About 3 in 10 abortions performed in Illinois two years ago — — involved out-of-state residents, up from fewer than a quarter the previous year, according to state records.

The Chicago nonprofit has prided itself on not turning away requests for help over the past five years, said Qudsiyyah Shariyf, a deputy director. It is adding staffers, including Spanish-language speakers, to cope with an anticipated uptick in calls for help from Southern states. She hopes Florida voters will make the crisis short-lived.ÌýÌý

“We’re estimating we’ll need an additional $100,000 a month to meet that influx of folks from Florida and the South,” she said. “We know it’s going to be a really hard eight months until something potentially changes.”

Losing access to abortion, especially among vulnerable groups like pregnant teenagers and women with pregnancy complications, could also increase cases of mental illness such as depression, anxiety, and even post-traumatic stress disorder, said , a licensed marriage and family therapist in Miami.

Kaminsky, who serves as board president of the , said the group has received calls from therapists seeking legal guidance about whether they can help a client who wants to travel for an abortion.

That’s especially true in states such as Alabama, Georgia, and Missouri that have passed laws granting “personhood” status to fetuses. Therapists in many states, including Florida, are required to report a client who intends to harm another individual.

“It’s creating all these gray areas that we didn’t have to deal with before,” Kaminsky said.

Deborah Dorbert of Lakeland, Florida, said that Florida's 15-week abortion limit put her health at risk and that she was forced to carry to term a baby with no chance of survival.

Her unborn child was diagnosed with in November 2022. An ultrasound taken at 23 weeks of pregnancy showed that the fetus had not developed enough amniotic fluid and that its kidneys were undeveloped.

Doctors told her that her child would not survive outside the womb and that there was a high risk of a stillbirth and, for her, preeclampsia, a pregnancy complication that can result in high blood pressure, organ failure, and death.

One option doctors suggested was a pre-term inducement, essentially an abortion, Dorbert said.

Dorbert and her husband were heartbroken. They decided an abortion was their safest option.

At Lakeland Regional Health, she said, she was told her surgery would have to be approved by the hospital administration and its lawyers since Florida had that year enacted its 15-week abortion restriction.

Florida’s abortion law includes an exemption if two physicians certify in writing that a fetus has a fatal fetal abnormality and has not reached viability. But a month elapsed before she got an answer in her case. Her doctor told her the hospital did not feel they could legally perform the procedure and that she would have to carry the baby to term, Dorbert said.

Lakeland Regional Health did not respond to repeated calls and emails seeking comment.

Dorbert’s gynecologist had mentioned to her that some women traveled for an abortion. But Dorbert said she could not afford the trip and was concerned she might break the law by going out of state.

At 37 weeks, doctors agreed to induce Dorbert. She checked into Lakeland Regional Hospital in March 2023 and, after a long and painful labor, gave birth to a boy named Milo.

“When he was born, he was blue; he didn’t open his eyes; he didn’t cry,” she said. “The only sound you heard was him gasping for air every so often.”

She and her husband took turns holding Milo. They read him a book about a mother polar bear who tells her cub she will always love them. They sang Bob Marley and The Wailers’ “Three Little Birds” to Milo with its chorus that “every little thing is gonna be alright.”

Milo died in his mother’s arms 93 minutes after being born.

One year later, Dorbert is still dealing with the anguish. The grief is still “heavy” some days, she said.

She and her husband have discussed trying for another child, but Florida’s abortion laws have made her wary of another pregnancy with complications.

“It makes you angry and frustrated. I could not get the health care I needed and that my doctors advised for me,” she said. "I know I can’t go through what I went through again.”

ThisÌýarticleÌýwas producedÌýthrough aÌýpartnershipÌýbetween Ä¢¹½Ó°Ôº Health News andÌýthe Tampa Bay Times.

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“We shouldn’t be placing youth in facilities without knowing what these children will be subjected to,” Hilton testified Monday to the Senate Human Services Committee in Sacramento. “The Accountability in Children’s Treatment Act is a simple transparency measure that would make a lasting impact and show the world what truly happens behind closed doors.”

Hilton, 43, has become a high-profile advocate for getting tough on what she describes as the “,” which promises to rehabilitate teenagers struggling with substance abuse, mental illness, and problematic behavior. Such programs lack federal oversight and for riots, assaults, and even deaths of minors, prompting a pushback to protect the rights of young people.

After releasing a she faced while attending Provo Canyon School in Provo, Utah, as a teenager, Hilton to the state, strengthening inspection and oversight of the industry. Advocates have successfully passed related laws in , , Montana, and .

Last year, Hilton went to Washington, D.C., to advocate for the federal , which would establish best practices and transparency in youth residential care programs. But national efforts have failed for and the latest proposal has been stalled for a year.

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Now, Hilton and others are eyeing the most populous state as an opportunity for change.

is a bipartisan bill by Republican state Sen. Shannon Grove and authored also by Democratic Sens. Aisha Wahab and Angelique Ashby. The bill aims to protect young people housed in short-term residential therapeutic programs licensed by the California Department of Social Services by requiring the agency to produce a public dashboard by 2026 on the use of restraint and seclusion rooms, and when it results in serious injuries or death. It would also require foster parents and guardians to be notified when restraints and seclusion rooms are used on minors.

“There are complaints of broken arms, slammed hands in doors,” said Grove, who noted that these facilities typically house vulnerable populations, including foster youth. “There’s no data to show what happened and what caused that. And so, the goal is to go after the data.”

There was no formal opposition. The National Association of Therapeutic Schools and Programs, the nation’s largest such member organization, told Ä¢¹½Ó°Ôº Health News that it supports the California bill.

During Monday’s hearing, Hilton shared that while she was housed at facilities in California, Utah, and Montana, she was subjected to abuse disguised as therapy. She said if she tried to tell her parents about the abuse, facility staff would rip the phone from her hand, restrain her, and force her into solitary confinement.

“When I close my eyes at night, I still have nightmares about solitary confinement 20 years later,” Hilton said. “The sounds of my peers screaming as they were physically restrained by numerous staff members and injected with sedatives will also never leave me.”

Zoe Schreiber, another survivor, said she was sent at age 13 to a Utah facility, where she was restrained face down in the mud by six adults for hours in the rain. Schreiber described enduring seclusion, hard labor, and humiliation for four years.

Democratic state Sen. Marie Alvarado-Gil, who chairs the Human Services Committee, said she had worked in such residential treatment facilities and noticed that staff often didn’t have proper training.

“I don’t think they’re all bad, but I do think the ones that are bad, that impact the trauma of our children, that are unregulated, that are unstructured, that do not have evidence-based programming — I wonder how we get away with that here in California,” Alvarado-Gil said.

Wahab said it’s important for California to act in the absence of a federal bill. California to prevent the state from sending foster children to out-of-state facilities.

“I’m hoping that we do some justice to the kids here,” Wahab said.

The Senate Human Services Committee passed SB 1043 on a 5-0 vote. The bill now goes to the Appropriations Committee.

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“We’re seeing more oral disease than the general population. There is a bigger need,” Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

“Federally qualified health centers have a long history of co-locating dental services within their systems,” Braun said. “We’re taking that next step where care is not just co-located, meaning, say, we’re upstairs and dental is downstairs, but we’re integrated so that it becomes part of the same visit for the patient.”

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

“Providing these services during medical visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge of caring for their child’s teeth.” But obstacles remain.

Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to , which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. “Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states — including California, Texas, and Maryland — integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women gain dental coverage with Medicaid and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the “astronomical cost” of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her three others are uninsured, and they couldn’t otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE’s director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” — the process underway to reexamine post-pandemic eligibility for the government program that provides health coverage for people with low incomes and disabilities — has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they’ll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing — midlevel providers who do preventive and restorative care — to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a, particularly for at-risk children. As part of Braun’s program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2½ years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. “It’s about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider — if they have one.”

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“Estamos viendo más enfermedades bucodentales que en el resto de la población. La necesidad es mayor”, dijo Braun sobre los pacientes que trata en el Centro de Salud Familiar Bernard F. Gipson Eastside, que forma parte de Denver Health, el mayor hospital de la red social de Colorado, que atiende a residentes con bajos ingresos, sin seguro de salud o con seguro insuficiente.

Braun forma parte de una tendencia en todo el país que consiste en integrar la salud dental en los chequeos médicos de niños, embarazadas y otras personas que no pueden permitirse o no tienen fácil acceso a los dentistas.

Con financiación federal y privada, estos programas se han ampliado en los últimos 10 años, pero se enfrentan a barreras socioeconómicas, escasez de personal calificado y el reto de atender las necesidades de los nuevos inmigrantes.

Con una subvención federal de cinco años y $6 millones, Braun y sus colegas han ayudado a formar a 250 proveedores de atención primaria en salud bucodental en Colorado, Montana, Wyoming y Arizona.

En Illinois, Michigan, Virginia y Nueva York se están ultimando proyectos similares, financiados por la Oficina de Salud Maternoinfantil (MCHB) de la Administración de Recursos y Servicios de Salud (HRSA).

Además de la evaluación, la educación y la atención preventiva, los proveedores de atención primaria envían a los pacientes a dentistas internos o externos, o trabajan con higienistas dentales integrados en sus consultas.

“Los centros de salud federales tienen un largo historial de servicios dentales integrados en sus sistemas”, afirmó Braun. “Nosotros estamos dando el siguiente paso, en el que la atención no sólo es compartida, es decir, nosotros estamos en el piso de arriba y los dentistas en el de abajo, sino que está integrada en la misma visita del paciente”.

Contar con médicos, enfermeras y auxiliares que evalúen la salud bucodental, hagan derivaciones y apliquen flúor en los centros de salud comunitarios es fundamental para muchos niños que no tienen acceso a la atención dental, dijo Tara Callaghan, directora de operaciones de la Asociación de Atención Primaria de Montana, que representa a 14 centros de salud calificados a nivel federal y a cinco organizaciones Urban Indian.

“Ofrecer estos servicios durante las visitas médicas aumenta la frecuencia de aplicación del flúor”, señaló Callaghan, y “mejora el conocimiento de los padres sobre el cuidado de los dientes de sus hijos”. Pero sigue habiendo obstáculos.

Según Callaghan, debido a la gran extensión geográfica y a la escasa población de Montana, la contratación de profesionales dentales es difícil. Cincuenta de los 56 condados del estado están designados como zonas de escasez dental y algunos no tienen ni un solo dentista que acepte Medicaid, añadió. Montana ocupa uno de los últimos puestos en cuanto al acceso de los residentes al , que puede prevenir las caries y fortalecer los dientes.

Callaghan indicó que, concretamente, los especialistas en odontología pediátrica escasean en las zonas rurales, y las familias a veces tienen que conducir horas hasta los condados vecinos para recibir atención.

Tener higienistas dentales con los médicos es una forma de llegar a los pacientes en una sola visita.

La higienista dental Valerie Cuzella colabora estrechamente con Braun y otros profesionales de Denver Health, que atiende a casi la mitad de los niños de la ciudad y ha incorporado higienistas en cinco de sus clínicas infantiles.

Las normativas estatales varían en cuanto a los servicios que los higienistas pueden prestar sin la supervisión de un dentista. En Colorado, Cuzella puede, entre otras cosas, realizar radiografías de forma independiente y aplicar fluoruro de plata y diamina, una herramienta para endurecer los dientes y frenar la caries. Todo esto lo hace en un acogedor despacho situado en una esquina.

Braun y Cuzella trabajan tan estrechamente que a menudo una termina la frase de la otra. A lo largo del día se envían mensajes de texto, aprovechando las breves pausas en las que Cuzella puede asomarse a una sala de chequeos para detectar enfermedades de las encías o enseñar buenos hábitos de cepillado. También Braun aprovecha oportunidades similares para evaluar la salud bucodental durante sus exámenes, y ambas se centran en educar a los padres.

Tradicionalmente, la atención médica y la odontológica han estado separadas. “Las facultades están mejorando la colaboración y la formación interprofesional, pero en general nos formamos, y ejercemos, por separado”, afirmó Katy Battani, higienista dental y profesora de la Universidad Georgetown.

Battani trata de zanjar esta brecha ayudando a centros de salud comunitarios en nueve estados —entre ellos California, Texas y Maryland— a integrar la atención dental en las visitas prenatales. El embarazo crea oportunidades para mejorar la salud bucodental porque algunas mujeres obtienen y ven a los proveedores al menos una vez al mes, explicó Battani.

En Denver, la inestabilidad de la vivienda, las barreras del idioma, la falta de transporte y el “costo astronómico” de la odontología sin seguro hacen que la atención dental sea inaccesible para muchos niños, la comunidad inmigrante y las personas mayores, explicó Sung Cho, dentista que supervisa el programa dental del Centro de Salud Comunitario STRIDE, en el área metropolitana de Denver.

STRIDE intenta superar estas barreras ofreciendo servicios de interpretación y una escala móvil de pagos para quienes no tienen seguro.

Esto incluye a personas como Celinda Ochoa, de 35 años y residente en Wheat Ridge, que fue a STRIDE para que le hicieran una limpieza dental a su hijo Alexander, de 15 años. Alexander fue seleccionado para el cuidado dental durante un chequeo médico y ahora él y sus tres hermanos ven regularmente a un dentista e higienista en el centro.

Uno de los hijos de Ochoa tiene cobertura dental de Medicaid, pero los otros tres no tienen seguro, y nunca podrían permitirse la atención dental, dijo Ochoa. STRIDE ofrece un examen, radiografías y limpieza por $60 para los que no tienen seguro.

En el último año, Cho ha sido testigo del aumento de inmigrantes y refugiados que nunca habían visto a un dentista antes y necesitan una atención exhaustiva. Los exámenes médicos para los refugiados en STRIDE aumentaron de 1,300 en 2022 a 1,700 en 2023, dijo Ryn Moravec, director de desarrollo de STRIDE. Calcula que el programa ha atendido entre 800 y 1,000 nuevos inmigrantes en 2024.

Incluso con las crecientes necesidades, Cho señaló que el proceso de Medicaid en curso —que reexamina la elegibilidad post-pandemia para el programa gubernamental que proporciona cobertura de salud a las personas con bajos ingresos y discapacidades— ha creado incertidumbre económica. Dijo que le preocupa hacer frente a los costos iniciales de nuevo personal y de sustitución de equipos dentales obsoletos.

En la clínica de STRIDE en Wheat Ridge, dos higienistas trabajan entre odontología y pediatría como parte de la integración médico-dental. Sin embargo, Cho aseguró que necesita más higienistas en otros centros para satisfacer la demanda.

La pandemia creó cuellos de botella que sólo ahora se están resolviendo lentamente, sobre todo porque pocos dentistas aceptan Medicaid. Y, si lo aceptan, a menudo limitan el número de pacientes del programa, dijo Moravec. Idealmente, STRIDE podría contratar a dos higienistas y tres asistentes dentales, añadió.

En 2022, Colorado promulgó una ley para aliviar la escasez de personal que permite incorporar : proveedores de nivel medio que proporcionan atención preventiva y restauradora. Pero Colorado no tiene ninguna escuela para formarlos o acreditarlos.

Antes de los 3 años, los niños deben ir al pediatra para 12 visitas de control, , sobre todo para los niños en situación de riesgo. Como parte del programa de Braun en la región de las Montañas Rocosas, se han aplicado más de 17,000 barnices de flúor y ha aumentado el porcentaje de niños de 3 años o menos que recibieron atención bucodental preventiva al 78%, del 33% en los primeros 2 años y medio.

Callaghan, de la Asociación de Atención Primaria de Montana, es testigo de ello en los mismos centros de salud comunitarios del estado. “Se trata de aprovechar el hecho de que los niños ven a su proveedor médico para una visita rutinaria mucho más a menudo, antes de ver a su proveedor dental, si es que lo tienen”.

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It’s also how much she spent on her monthly internet bill before the federal Affordable Connectivity Program stepped in and covered her payments.

“When you have low income and you are living on disability and your daughter’s disabled, every dollar counts,” said Westman, who lives in rural Illinois.

More than low-income households — urban, suburban, rural, and tribal — are enrolled in the federal discount program Congress created in 2021 to bridge the nation’s digital connectivity gap. The program has provided $30 monthly subsidies for internet bills or $75 discounts in tribal and high-cost areas.

But the program is expected to run out of money in April or May, according to the Federal Communications Commission. In January, FCC Chairwoman Jessica Rosenworcel to allocate $6 billion to keep the program running until the end of 2024. She said the subsidy gives Americans the “internet service they need to fully participate in modern life.”

The importance of high-speed internet was seared into the American psyche by scenes of children sitting in parking lots and outside fast-food restaurants to attend school online during the covid-19 pandemic. During that same period, health care providers and patients like Westman say, being connected also became a vital part of today’s health care delivery system.

Westman said her internet connection has become so important to her access to health care she would sell “anything that I own” to stay connected.

Westman, 43, lives in the small town of Eureka, Illinois, and has been diagnosed with genetic and immune system disorders. Her 12-year-old daughter has cerebral palsy and autism.

She steered the $30 saved on her internet toward taking care of her daughter, paying for things such as driving 30 minutes west to Peoria, Illinois, for two physical therapy appointments each week. And with an internet connection, Westman can access online medical records, and whenever possible she uses telehealth appointments to avoid the hour-plus drive to specialty care.

“It’s essential for me to keep the internet going no matter what,” Westman said.

Expanding telehealth is a common reason health care providers around the U.S. — in states such as Massachusetts and Arkansas — joined efforts to sign their patients up for the federal discount program.

“This is an issue that has real impacts on health outcomes,” said Alister Martin, an emergency medicine physician at Massachusetts General Hospital. Martin realized at the height of the pandemic that patients with means were using telehealth to access covid care. But those seeking in-person care during his ER shifts tended to be lower-income, and often people of color.

“They have no other choice,” Martin said. “But they probably don’t need to be in the ER action.” Martin became and later created a nonprofit that he said has helped 1,154 patients at health centers in Boston and Houston enroll in the discount program.

At the University of Arkansas for Medical Sciences, a federal grant was used to conduct dozens of outreach events and help patients enroll, said Joseph Sanford, an anesthesiologist and the director of the system’s Institute for Digital Health & Innovation.

“We believe that telehealth is the great democratization to access to care,” Sanford said. New enrollment in the discount program .

Leading up to the enrollment halt, Sen. Peter Welch (D-Vt.) led a bipartisan effort to introduce the Affordable Connectivity Program Extension Act in January. The group requested $7 billion — more than the FCC’s ask — to keep the program funded. “Affordability is everything,” Welch said.

In December, federal regulators recipients and found that 22% reported no internet service before, and 72% said they used their ACP-subsidized internet to “schedule or attend healthcare appointments.”

Estimates of how many low-income U.S. households qualify for the program vary, but experts agree that only about half of the roughly 50 million eligible households have signed on.

“A big barrier for this program generally was people don’t know about it,” said Brian Whitacre, a professor and the Neustadt chair in the Department of Agricultural Economics at Oklahoma State University.

Whitacre and others said rural households should be signing up at even higher rates than urban ones because a higher percentage of them .

Yet, people found signing up for the program laborious. Enrollment was a two-step process. Applicants were required to get approved by the federal government then work with an internet service provider that would apply the discount. The government application was online — hard to get to if you didn’t yet have internet service — though applicants could try to find a way to download a version, print it, and submit the application by mail.

When Frances Goli, the broadband project manager for the Shoshone-Bannock Tribes in Idaho, began enrolling tribal and community members at the Fort Hall Reservation last year, she found that many residents did not know about the program — even though it had been approved more than a year earlier.

Goli and Amber Hastings, an AmeriCorps member with the University of Idaho Extension Digital Economy Program, spent hours helping residents through the arduous process of finding the proper tribal documentation required to receive the larger $75 discount for those living on tribal lands.

“That was one of the biggest hurdles,” Goli said. “They’re getting denied and saying, come back with a better document. And that is just frustrating for our community members.”

Of the more than 200 households Goli and Hastings aided, about 40% had not had internet before.

In the tribal lands of Oklahoma, said Sachin Gupta, director of government business and economic development at internet service provider Centranet, years ago the funding may not have mattered.

“But then covid hit,” Gupta said. “The stories I have heard.”

Elders, he said, reportedly “died of entirely preventable causes” such as high blood pressure and diabetes because they feared covid in the clinics.

“It’s really important to establish connectivity,” Gupta said. The end of the discounts will “take a toll.”

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Brambila, a community organizer who emigrated from Mexico a quarter-century ago, had only a sinus infection, but her children had never seen her so ill. “I was in bed for four days,” she said.

Lacking insurance, Brambila had avoided seeking care, hoping garlic and cinnamon would do the trick. But when she felt she could no longer breathe, she went to an emergency room. The $365 bill — enough to cover a week of groceries for her family — was more than she could afford, pushing her into debt. It also affected another decision she’d been weighing: whether to go to Mexico for surgery to remove the growth in her abdomen that she said is as big as a papaya.

Brambila lives in a southwestern Denver neighborhood called Westwood, a largely Hispanic, low-income community where many residents are immigrants. Westwood is also in a ZIP code, 80219, with some of the highest levels of medical debt in Colorado.

More than 1 in 5 adults there have historically had unpaid medical bills on their credit reports, more in line with West Virginia than the rest of Colorado, according to 2022 credit data analyzed by the nonprofit Urban Institute.

The area’s struggles reflect a paradox about Colorado. The state’s overall medical debt burden is lower than most. But racial and ethnic disparities are wider.

The gap between the debt burden in ZIP codes where residents are primarily Hispanic and/or non-white and ZIP codes that are primarily non-Hispanic white is twice what it is nationally. (Hispanics can be of any race or combination of races.)

Medical debt in Colorado is also concentrated in ZIP codes with relatively high shares of immigrants, are from Mexico. that 19% of adults in these places had medical debt on their credit reports, compared with 11% in communities with fewer immigrants.

Nationwide, about 100 million people have some form of health care debt, according to a Ä¢¹½Ó°Ôº Health News-NPR investigation. This includes not only unpaid bills that end up in collections, but also those being paid off through installment plans, credit cards, or other loans.

Racial and ethnic gaps in medical debt exist nearly everywhere, data shows. But Colorado’s divide — on par with South Carolina’s, according to the Urban Institute data — exists even though the state has some of the most extensive medical debt protections in the country.

The gap threatens to deepen long-standing inequalities, say patient and consumer advocates. And it underscores the need for more action to address medical debt.

“It exacerbates racial wealth gaps,” said , a senior attorney with the nonprofit National Consumer Law Center who co-authored a . Haynes said too many Colorado residents, especially residents of color, are still caught in a vicious cycle in which they forgo medical care to avoid bills, leading to worse health and more debt.

Brambila said she has seen this cycle all too often around Westwood in her work as a community organizer. “I really would love to help people to pay their medical bills,” she said.

Health or Debt?

Roxana Burciaga, who grew up in Westwood and works at Mi Casa Resource Center there, said she hears questions at least once a week about how to pay for medical care.

Medical debt is a “big, big, big topic in our community,” she said. People don’t understand what their insurance actually covers or can’t get appointments for preventive care that suit their work schedules, she said.

Many, like Brambila, skip preventive care to avoid the bills and end up in the emergency room.

Doctors and nurses say they see the strains, as well.

, a family physician at Denver Health’s Westwood Family Health Center, part of the city’s public health system, said finances often come up in conversations with patients. Many patients try to get telehealth appointments to avoid the cost of going in person.

Adding to the crunch is , the process of states reexamining post-pandemic eligibility for health coverage for low-income people, Koch-Laking said. “They say, ‘Oh, I'm losing my Medicaid in three weeks, can you take care of these seven things without a visit?’ Or like, ‘Can we just do it over the portal, because I can't afford it?’”

Looking for the Right Fix

Colorado has taken steps to protect patients from medical debt, including expanding Medicaid coverage through the 2010 Affordable Care Act. More recently, state leaders required hospitals to expand financial assistance for low-income patients and barred all medical debts from consumers’ credit reports.

But the complexities of many assistance programs remain a major barrier for immigrants and others with limited English, said Julissa Soto, focused on Latino Coloradans.

Many patients, for example, may not know they can seek help with medical bills from or .

“The health care system is a puzzle. You better learn how to play with puzzles,” said Soto, who said she was sent to collections for medical bills when she first immigrated to the U.S. from Mexico. “Many hospitals also have funding to help out with your debt. You just have to get to the right person, because it seems that nobody wants to let us know that those programs exist.”

She said simplifying bills would go a long way to helping many patients.

Several states, including , have tried to make it easier for people to access hospital financial aid by requiring hospitals to proactively screen patients.

Patient and consumer advocates say Colorado could also further restrict aggressive debt collection, such as lawsuits, which .

New York, for example, banned wage garnishment after finding that the practice disproportionately affected low-income communities. Research there also showed that medical debt burden was falling about as it was on non-Hispanic white communities.

Elisabeth Benjamin, a lawyer with the Community Service Society of New York, said hospitals were garnishing the wages of people working at Walmart and Taco Bell.

Maryland enacted limits on debt collection lawsuits after advocates found that patients living in predominantly minority neighborhoods were being disproportionately targeted. Even in wealthy counties, “the pockets that are being pursued are majority Latino neighborhoods,” said Marceline White, executive director of the advocacy group Economic Action Maryland.

White's group requiring hospitals to pay back low-income patients and avoid the scenario she was seeing, in which hospitals were “suing patients who should have gotten free care.”

Exacting a Heavy Toll

In Colorado, lawmakers are considering a measure to : a modification to the state’s Hospital Discounted Care program that would .

Meanwhile, some consumer advocates say existing protections aren’t working well enough.

State patients who received financial assistance were primarily white. And, though it’s unclear why, 42% of patients who may have been eligible were not fully screened by hospitals for financial assistance.

“What is clear is that a lot of people are not making it through,” said Bethany Pray, deputy director of the Colorado Center on Law and Policy, a Denver-based legal aid group that pushed for the discounted care legislation.

Within the state’s immigrant communities, medical debt — and the fear of debt — continues to take a heavy toll.

“What we’ve heard from our constituents is that medical debt sometimes is the difference between them being housed and them being unhoused,” said Denver City Council member Shontel Lewis. Her district includes the 80216 ZIP code, another place north of the city center that is saddled with widespread medical debt.

Paola Becerra is an immigrant living in the U.S. without legal permission who was pregnant when she was from a Texas shelter a few months ago.

She said she has skipped prenatal care visits because she couldn’t afford the $50 copays. She has emergency health coverage through Medicaid, but it , and she has already racked up about $1,600 in bills.

“I didn't know that I was going to arrive pregnant,” said Becerra, who thought she could no longer conceive when she left Colombia. “You have to give up your health. Either I pay the rent, or I pay the hospital.”

For Rocio Leal, a community organizer in Boulder, medical debt has become a defining feature of her life.

Despite the health insurance she had through her job, Leal ended up with high-interest payday loans to pay for healthy births, wage garnishment, prenatal appointments she missed to save money, and a “ruined” credit score, which limited her housing options.

Leal recalled times she thought they’d be evicted and other times the electricity was cut off. “It's not like we're avoiding and don't want to pay. It's just sometimes we don't have an option to pay,” she said.

Leal said the worst times are behind her now. She’s in a home she loves, where neighbors bring cakes over to thank her son for shoveling the snow off their driveway.

Her children are doing well. One daughter got a perfect GPA for the second semester in a row. Another is playing violin in the school orchestra. Her third daughter attends art club. And her son was recently accepted to college for biomedical engineering. They are covered by Medicaid, which has removed the uncertainty around big medical bills.

But medical debt still haunts Leal, who has Type 2 diabetes.

When she was referred to Boulder Medical Center to get her eyes checked after the diabetes diagnosis, she said she was told there was a red flag by her name. The last time she’d interacted with the medical center was about a dozen years earlier, when she’d been unable to pay pediatrician bills.

“I was in the process of moving and then my wages were garnished,” she recalled. “I just was like, ‘What else do I owe?’”

Heart pounding, she hung up the phone.

Ä¢¹½Ó°Ôº Health News senior correspondent Noam N. Levey contributed to this report.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).