Category: Rehab News

Cuando comience el período de inscripción abierta para adquirir cobertura médica en los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio, conocida como Obamacare, un grupo que antes no podía inscribirse será elegible por primera vez: los “Dreamers”. Ese es el nombre de los niños traídos a los Estados Unidos sin papeles que están bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA).

Bajo una normativa de la administración Biden, que ha sido objeto de controversia en algunos estados, los beneficiarios de DACA podrán inscribirse para la cobertura del Obamacare y, si cumplen con los requisitos de ingresos, recibir subsidios para pagar sus primas.

Del medio millón de beneficiarios de DACA, el gobierno estima que alrededor de 100.000 que anteriormente no tenían seguro podrían inscribirse a partir del 1 de noviembre, fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

Sin embargo, el destino de esta normativa sigue siendo incierto. Está siendo impugnada en un tribunal federal por Kansas y otros 18 estados, incluidos varios en el sur y el medio oeste, así como Montana, New Hampshire y Dakota del Norte.

Por otro lado, 19 estados y el Distrito de Columbia presentaron un escrito en apoyo a la normativa de la administración de Biden. Liderados por Nueva Jersey, estos estados incluyen a muchos en las costas este y oeste, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

La normativa, finalizada en mayo, aclara que aquellos que califican para DACA serán considerados como “presencia legal” para el propósito de inscribirse en lo planes médicos bao ACA, los cuales están abiertos a ciudadanos estadounidenses e inmigrantes con papeles.

“El cambio de normativa es muy importante, ya que corrige una exclusión errónea y de larga data de los beneficiarios de DACA para la cobertura de ACA,” dijo Nicholas Espíritu, director legal adjunto del National Immigration Law Center, que también ha presentado escritos en apoyo a este cambio.

El presidente Barack Obama estableció DACA en junio de 2012 mediante una acción ejecutiva para proteger de la deportación y proporcionar autorización de trabajo a algunos residentes sin documentos, que habían sido traídos al país de niños por sus familias. Esto si cumplían con ciertos requisitos, incluidos haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o haber servido en las fuerzas armadas.

Los estados que impugnan la normativa de ACA dicen que causará cargas administrativas y de recursos a medida que más personas se inscriban, y que fomentará que más personas permanezcan en el país sin papeles. La demanda, presentada en agosto en el Tribunal de Distrito de EE.UU. para el Distrito de Dakota del Norte, busca posponer la fecha de entrada en vigencia de la normativa y anularla, argumentando que la expansión de la definición de “presencia legal” por parte de la administración Biden viola la ley.

El 15 de octubre, el juez de distrito de EE.UU., Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, escuchó los argumentos en el caso.

Los estados demandantes están presionando para que se actúe rápido, y es posible que se emita un fallo antes del inicio de la inscripción abierta a nivel nacional, dijo Zachary Baron, experto legal en la Facultad de Derecho de Georgetown, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Sin embargo, el panorama es complicado.

Para empezar, en una batalla legal como ésta, quienes presentan el caso deben demostrar el daño que se alega, como los costos adicionales que la normativa obligará a los estados a absorber. Solo hay alrededor de 128 beneficiarios de DACA en Dakota del Norte, donde se está llevando a cabo el caso, y no todos probablemente se inscribirán en el seguro de ACA.

Además, Dakota del Norte no se encuentra entre los estados que administran su propio mercado de inscripción. Depende del sitio federal cuidadodesalud.gov, lo que hace que sea más difícil cumplir con la carga legal.

“Aunque Dakota del Norte no gasta dinero para adquirir atención médica de ACA, aún están afirmando de alguna manera que están siendo perjudicados,” dijo Espíritu, del centro de leyes de inmigración, que representa a varios beneficiarios de DACA y a CASA, una organización sin fines de lucro de defensa de los inmigrantes, en oposición a los esfuerzos estatales por anular la normativa.

Durante la audiencia, Traynor se centró en este tema y señaló que un estado que administre su propio mercado podría ser un mejor lugar para un caso así. Ordenó a los demandados presentar más información antes del 29 de octubre, y a Dakota del Norte responder antes del 12 de noviembre.

El lunes 28 de octubre, el juez denegó una moción del gobierno federal que le solicitaba reconsiderar su orden de proporcionar al estado, bajo sello, los nombres de 128 beneficiarios de DACA que residen allí, con el fin de ayudar a calcular los costos financieros asociados con su presencia.

Además, es posible que el caso sea transferido a otro tribunal de distrito, lo que podría causar demoras en una decisión, según los abogados que siguen el caso.

El juez también podría tomar decidir en varias direcciones. Podría posponer la fecha de vigencia de la normativa, como se solicita en parte de la demanda, impidiendo que los beneficiarios de DACA se inscriban en Obamacare mientras se resuelve el caso. O podría dejar la fecha de vigencia tal como está mientras el caso avanza.

Con cualquiera de las opciones, el juez podría decidir aplicar el fallo a nivel nacional o limitarlo solo a los estados que impugnaron la normativa gubernamental, explicó Baron.

“El enfoque adoptado por diferentes jueces ha variado”, dijo Baron. “Ha habido una práctica de anular algunas disposiciones reglamentarias a nivel nacional, pero muchos jueces, incluidos jueces de la Corte Suprema, también han expresado preocupaciones sobre que jueces individuales puedan afectar la política de esta manera”.

A medida que el caso avanza, Espíritu dijo que su organización está alentando a los beneficiarios de DACA a inscribirse apenas comience el período de inscripción a nivel nacional.

“Es importante inscribirse lo antes posible”, dijo, agregando que organizaciones como la suya continuarán monitoreando el caso y dando actualizaciones si la situación cambia. “Sabemos que obtener acceso a atención médica buena y asequible puede transformar la vida de las personas”.

Este caso que impugna la normativa es completamente separado de otro caso, presentado por algunos de los mismos estados que se oponen a la normativa de ACA, que busca terminar por completo el programa DACA. Ese caso actualmente está en el proceso de apelación en un tribunal federal.

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KINGSTREE, S.C. — One morning in late April, a small brick health clinic along the Thurgood Marshall Highway bustled with patients.

There was Joshua McCray, 69, a public bus driver who, four years after catching covid-19, still is too weak to drive.

Louvenia McKinney, 77, arrived complaining about shortness of breath.

Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.

Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.

But Brown called them “lucky,” with enough health insurance or money to see a doctor. The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation.

“There is a lot of hopelessness here,” Brown said. “I was trained to keep people healthy, but like 80% of the people don’t come see the doctor, because they can’t afford it. They’re just dying off.”

About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris’ independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.

But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.

The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that constitute the Corridor of Shame, Brown said.

“There is a disconnect between policymakers and real people,” he said. The African Americans who make up most of the town’s population “are not the people in power.”

The U.S. health care system, “by its very design, delivers different outcomes for different populations,” said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities “also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity.”

Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.

And that’s not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people California Healthline interviewed.

Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.

Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.

Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.

And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times as likely to suffer a gun homicide as their white counterparts.

“People are literally dying because of policy decisions in the South,” said Bakari Sellers, a Democratic former state representative in South Carolina.

California Healthline undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.

From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and covid shortened lives even more.

Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.

All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life.

“So much of what we see is the long tail of slavery and Jim Crow,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.

Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: “Who are you to ask for health care?”

Past and Present

The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.

“I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision,” said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.

Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.

Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.

The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to “The Heckler Report,” released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the national academies report.

“When covid was first hitting, it was just sort of immediately clear who was going to suffer the most,” Ducas said, “not just because of differential access to care, but who was in a living environment that’s multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation.”

For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention Director Mandy Cohen, failed to get covid testing to vulnerable Black communities where people were getting sick and dying from covid-related causes at far higher rates than white people.

And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to covid, according to research.

Until McCray, the bus driver in Kingstree, South Carolina, got covid in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted covid in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.

Now he cannot work and at times has difficulty walking.

“I can tell you the truth now: It was only the good Lord that saved him,” said Brown, the rural physician who treated McCray and many patients like him.

Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children’s Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in “The Heckler Report” persist.

When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn’t pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.

She is convinced that being a Black woman made her challenges more likely.

“Think about how many centuries the same thing has been happening,” said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can’t afford to put her 8-year-old son on her health plan, so he’s covered by Medicaid.

“We consistently offer healthcare plans that are on par, if not better, than those available to most Americans through state and federal exchanges,” said Eileen Cassidy Rivera, a Maximus spokesperson.

In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.

President Joe Biden issued an executive order on his first full day in office in 2021 that said “the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America.” Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been “at times facilitated by the federal government.”

“The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities,” said Renata Miller, a spokesperson for the administration.

The CDC, along with some state and local governments, declared racism a serious public health threat.

U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for “Momnibus” legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.

“I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room,” Adams said.

In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.

“You have to have some sensitivity for this work,” Adams said. “And a lot of folks that I’ve worked with don’t have it.”

Governor’s Veto

The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks and a food vendor are the only Black people in the video, even though Black people make up 70% of the town’s population.

But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.

Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.

There is one primary care physician for every 5,080 residents in Williamsburg County. That’s far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.

Edward Simmer, the state’s interim public health director, said that if “you are African American in a rural zone, it is like having two strikes against you.”

Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.

“It is not a panacea,” he said.

But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.

“Every year we look at the data, we see the health disparities and we don’t have a plan to improve,” Brown said. “It has become institutionalized. I call it institutional racism.”

A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.

“Racism is the reason we don’t have Medicaid expansion. Full stop,” said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. “These are not accidents. There is an idea that you can stay in power by using racism.”

South Carolina’s Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be “fiscally responsible.”

Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.

Beyond health care coverage and provider shortages, Black people “have never been given the conditions needed to thrive,” said Barlow, the George Washington University professor. “And this is because of white supremacy.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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On a sweltering afternoon in July 2020, Belinda Ramones got a call that her brother was in the hospital. The call was from a woman at the Florida landscaping business that he had joined that week, the Davey Tree Expert Co., Ramones said. By the time she arrived, she said, “My brother was swollen up from hands to toes.”

Two days later, her brother, Jose Leandro-Barrera, died at age 45 with acute kidney failure caused by heatstroke, according to a report from the Hillsborough County medical examiner. His temperature in the ambulance had been 108 F, said the report.

It described the circumstances preceding his death, as recorded by a nurse. At the jobsite, Leandro-Barrera had advised his supervisor that he was not feeling well, and the supervisor told him to sit in a vehicle until he felt better. While there, he “urinated himself, had seizure like activity” and became unresponsive.

“Employee suffers from heat exhaustion while doing landscaping,” said an investigation into the incident from the Occupational Safety and Health Administration. The agency issued a $9,639 fine to the Davey Tree Expert Co. The company did not respond to requests for comment.

Without national regulations on preventing heat-related illness and death, OSHA has difficulty, in general, protecting workers before it’s too late, said Paloma Rentería, a Department of Labor spokesperson.

Laborers have suffered as summers have grown progressively hotter with climate change. But health policy and occupational health researchers say that worker deaths are not inevitable. Employers can save lives by providing ample water and breaks and building in time for new workers to adjust to extreme heat.

This is the logic behind proposed national rules that President Joe Biden set in motion in 2021, aiming to protect an estimated 36 million workers exposed to extreme heat. The Bureau of Labor Statistics counts about 480 worker deaths from heat exposure each year, on average. But these are “vast underestimates,” according to OSHA, because heat stress is an underlying factor often unaccounted for in medical records.

The advocacy organization Public Citizen estimates that as many as 2,000 U.S. workers die of heat annually, based on extrapolations from heat injury data.

Both estimates are upsetting, said Linda McCauley, dean of the nursing school at Emory University and an occupational health researcher. “No one should go to work expecting that they might die,” she said.

The proposed rules — a heat standard from OSHA — reaches a milestone Dec. 30, when the public comment period closes. But it’s unlikely to be finalized before Biden leaves office.

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Vice President Kamala Harris would likely carry the heat rules forward if she wins the presidency next month, said Jordan Barab, who was OSHA’s deputy assistant secretary during the Obama administration. She advanced heat regulations in California in 2020.

Should Donald Trump win, the rules would stall, Barab predicts. In general, Republicans have opposed workplace safety regulations over the past 20 years, saying they are costly to businesses and consumers. And during the first Trump administration, the number of OSHA inspectors tasked with monitoring workplace safety hit an all-time low across the agency’s 48-year history. Workplace inspections regarding heat stress dropped by half on Trump’s watch, according to an analysis by the National Employment Law Project.

OSHA’s rules would require employers to provide ample, cool drinking water, and shade or air conditioning for breaks, when temperatures exceed 80 degrees. Above 90 degrees, employers would need to provide paid 15-minute breaks every two hours.

Two additional aspects of the standard confront overlooked problems that contribute to heat deaths at work. More than 70% of workers who die of heat do so within their first week on the job. And delayed medical care is a common theme.

“We need to stop telling people who complain of being about to pass out to go sit in the car or take a break,” McCauley said. “Rest breaks are needed to prevent the problem, but once someone has symptoms, they need help fast.”

The proposed rules require employers to allow new workers time to acclimate to high temperatures and to institute protocols, like a buddy system, so that workers get rapid medical care as soon as they show signs of heat illness, like dizziness, confusion, and cramps.

By the time an emergency medical team arrived to help one laborer in July 2021, he had stopped breathing, according to one Department of Labor press release. A supervisor at the ecological restoration company EarthBalance had seen him earlier that day, it said, and he was “sweating heavily, his hands were trembling, and he seemed confused,” He rested. “Only 30 minutes later, the supervisor returned to the man finding him unresponsive.”

That evening, Gilberto Macario-Gimenez died at the hospital, said a medical examiner case report. It noted “the decedent had overheated” and attributed his death to heart disease and hypertension. Heat can exacerbate those conditions.

OSHA investigated the situation. It fined EarthBalance $9,216, finding that “the employer failed to ensure that a person adequately trained to provide first aid to employees [was] working in an area where there was no infirmary.”

EarthBalance did not respond to requests for comment.

OSHA has received at least 12,980 comments on its proposals posted to the federal register. One woman wrote about her cousin who died while clearing shrubs for a rancher in Texas when temperatures exceeded 100 degrees: “He was only 34. There was no water or rest breaks.”

After the comment period ends in December, OSHA will hold a public hearing, incorporate changes, and finalize the rule. If Harris is president, Barab said, the agency may finish the process by 2026. For the rule to work, Congress would need to fund OSHA adequately, so that it can hire staffers to teach employers how to implement the standards, and enough investigators to enforce them.

Several industry groups have opposed the standard. The Associated General Contractors of America called it “unnecessary, unworkable, and impractical.” A single set of rules isn’t fair when climates and jobs vary widely, in addition to workers’ abilities to tolerate heat, the group wrote in an online statement.

Some Republican lawmakers have called the rule government overreach. Rick Roth, a Republican Florida state representative, told Al Jazeera that workers are pushing for paid breaks because they “don’t want to work so hard.” If they didn’t feel safe, they could change jobs. “Go work for somebody else,” he said.

Critics also say that the regulations will cost employers. But a UCLA analysis of workers’ compensation claims in California suggests that a national heat standard saves money overall. The study estimated the cost of heat-related injuries between $750 million and $1.25 billion a year in California alone, including medical bills, lost wages, and disability claims.

Because six states have varying sets of rules to reduce heat-related illness — California, Colorado, Maryland, Minnesota, Oregon, and Washington — researchers and union representatives have been able to see where policies need strengthening. One issue with enforcement is that OSHA largely relies on employees to report hazards. One study found that just 14% of nearly 600 farmworkers surveyed in California knew about acclimatization and how much water they needed when temperatures were high.

Although Florida doesn’t have specific heat regulations, Dominique O’Connor of the Farmworker Association of Florida said the biggest obstacle in ensuring occupational safety is that workers are afraid of getting fired for filing a complaint with OSHA.

This is especially true for farmworkers with H-2A visas, which permit noncitizens to fill temporary jobs. Because these workers depend on their employers not only to remain in the country but often for transportation and housing, retaliation from employers would be life-altering. “This summer we talked with H-2A workers who were only given dirty water on the job,” she said. “They were told to just pretend it was coffee.”

Leaders in several Republican-led states are likely to push back against the federal standard if it’s issued. Last April, Florida Gov. Ron DeSantis approved legislation that blocks local governments from requiring employers to offer workers water and shade when temperatures rise.

And the Supreme Court’s decision to overturn the “Chevron doctrine” this year may embolden employers to challenge OSHA’s ability to enforce the rules. For decades, the Chevron doctrine had required courts to defer to expertise at regulatory agencies when interpreting regulations, but the high court’s ruling ended that. “We are in uncharted territory,” Barab said.

Jeremy Young, senior producer at Fault Lines on Al Jazeera English, contributed to this report.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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En una sofocante tarde de julio de 2020, Belinda Ramones recibió una llamada informándole que su hermano estaba en el hospital. La llamada fue de una mujer de la empresa de jardinería en Florida en donde había comenzado a trabajar esa semana, la empresa Davey Tree Expert Co. Cuando llegó, “mi hermano estaba hinchado de pies a cabeza”, dijo.

Dos días después, su hermano, José Leandro-Barrera, murió a los 45 años por una insuficiencia renal aguda causada por un golpe de calor, según el informe del médico forense del condado de Hillsborough. Su temperatura en la ambulancia había sido a 108 grados Fahrenheit (42 °C), según el informe.

El informe también describía las circunstancias previas a su muerte, según lo registrado por una enfermera. En el trabajo, Leandro-Barrera le informó a su supervisor que no se sentía bien, y el supervisor le dijo que se sentara en uno de los vehículos hasta que se sintiera mejor. Mientras estaba allí, “se orinó, tuvo actividad convulsiva” y perdió la conciencia.

“El empleado sufrió agotamiento por calor mientras hacía trabajo de jardinería”, indicó una investigación del incidente realizada por la Administración de Seguridad y Salud Ocupacional (OSHA). La agencia impuso una multa de $9,639 a la empresa Davey Tree Expert Co. La empresa no respondió a las solicitudes de comentarios.

Sin regulaciones nacionales sobre la prevención de enfermedades y muertes relacionadas con el calor, OSHA tiene dificultades, en general, para proteger a los trabajadores antes de que sea demasiado tarde, dijo Paloma Rentería, vocera del Departamento de Trabajo.

Los trabajadores están sufriendo cada vez más, a medida que los veranos se vuelven progresivamente más calurosos debido al cambio climático.

Pero los investigadores en políticas de salud y salud ocupacional afirman que estas muertes se pueden prevenir. Los empleadores pueden salvar vidas ofreciendo suficiente agua y descansos, y dándoles tiempo a los nuevos trabajadores para adaptarse al calor extremo.

Esta es la lógica detrás de las reglas nacionales propuestas que el presidente Joe Biden puso en marcha en 2021, con el objetivo de proteger a unos 36 millones de trabajadores expuestos al calor extremo. La Oficina de Estadísticas Laborales cuenta un promedio de 480 muertes de trabajadores por exposición al calor cada año. Sin embargo, estas son “vastas subestimaciones”, según OSHA, ya que el estrés térmico es un factor subyacente que generalmente no se registra en los informes médicos.

La organización de defensa Public Citizen estima que hasta 2.000 trabajadores en el país mueren por el calor cada año, según extrapolaciones de datos sobre lesiones por calor.

Ambas estimaciones son alarmantes, dijo Linda McCauley, decana de la Facultad de Enfermería de la Universidad de Emory e investigadora en salud ocupacional. “Nadie debería ir a trabajar esperando que podría morir”, dijo.

Las normas propuestas —un estándar de calor de OSHA— alcanzarán un hito el 30 de diciembre, cuando cierra el período de comentarios públicos. Pero es poco probable que se finalicen antes de que Biden deje el cargo.

La vicepresidenta Kamala Harris probablemente continuaría con las normas sobre el calor si gana la presidencia el próximo mes, dijo Jordan Barab, quien fue subsecretario adjunto de OSHA durante la administración Obama. Ella impulsó regulaciones sobre el calor en California en 2020.

Si Donald Trump gana, las normas se estancarían, predice Barab. En general, los republicanos se han opuesto a regulaciones de seguridad en el lugar de trabajo en los últimos 20 años, argumentando que son costosas para las empresas y los consumidores.

Y durante la primera administración de Trump, la cantidad de inspectores de OSHA encargados de monitorear la seguridad en el trabajo alcanzó un mínimo histórico en los 48 años de historia de la agencia. Las inspecciones de lugares de trabajo relacionadas con el estrés térmico se redujeron a la mitad durante el mandato de Trump, según un análisis del National employment Law Project.

Las normas de OSHA requerirían que los empleadores proporcionen agua potable fresca en abundancia y sombra o aire acondicionado para los descansos cuando las temperaturas superen los 80.6° Fahrenheit (27° C). Por encima de los 89.6° Fahrenheit (32° C), los empleadores tendrían que ofrecer descansos pagados de 15 minutos cada dos horas.

Dos aspectos adicionales del estándar abordan problemas que han sido pasados por alto y que contribuyen a las muertes por calor en el trabajo. Más del 70% de las muertes por el calor ocurren durante la primera semana en que el trabajador comienza en el empleo. Y el atraso en la atención médica es un tema común.

“Debemos dejar de decirle a las personas que se quejan de sentirse a punto de desmayarse que vayan a sentarse en el auto o que tomen un descanso”, dijo McCauley. “Los descansos son necesarios para prevenir el problema, pero una vez que alguien tiene síntomas, necesita ayuda rápida”.

Las normas propuestas requieren que los empleadores permitan a los nuevos trabajadores tiempo para aclimatarse a las altas temperaturas e implementen protocolos, como un sistema para ayudarse entre compañeros, para que los trabajadores reciban atención médica rápidamente tan pronto como muestren signos de enfermedad por calor, como mareos, confusión y calambres.

Para cuando un equipo médico de emergencia llegó a ayudar a un trabajador en julio de 2021, había dejado de respirar, según un comunicado de prensa del Departamento de Trabajo. Un supervisor en la empresa de restauración ecológica EarthBalance lo había visto más temprano ese día, y estaba “sudando mucho, sus manos temblaban y parecía confundido”. Descansó. “Solo 30 minutos después, el supervisor regresó y lo encontró inconsciente”.

Esa noche, Gilberto Macario-Giménez murió en el hospital, dijo un informe del caso del médico forense. Señaló que “el fallecido se había sobrecalentado” y atribuyó su muerte a una enfermedad cardíaca e hipertensión. El calor puede agravar esas condiciones.

OSHA investigó la situación. Multó a EarthBalance con $9,216, encontrando que “el empleador no garantizó que una persona adecuadamente capacitada para brindar primeros auxilios a los empleados estuviera trabajando en un área donde no había enfermería”.

EarthBalance no respondió a las solicitudes de comentarios.

OSHA ha recibido al menos 12.980 comentarios sobre sus propuestas publicadas en el registro federal. Una mujer escribió sobre su primo que murió mientras despejaba arbustos en un rancho en Texas cuando las temperaturas superaron los 100° Fahrenheit (37° C): “Tenía solo 34 años. No había agua ni descansos”.

Después que termine el período de comentarios en diciembre, OSHA realizará una audiencia pública, incluirá cambios y finalizará la regla. Si Harris es presidenta, dijo Barab, la agencia podría finalizar el proceso para 2026.

Para que la norma funcione, el Congreso necesitaría financiar adecuadamente a OSHA, para que pueda contratar personal que enseñe a los empleadores cómo implementar los estándares, y suficientes investigadores para hacer cumplir las normas.

Varios grupos de la industria se han opuesto al estándar. Un único conjunto de normas no es justo cuando los climas y trabajos varían ampliamente, además de la capacidad de los trabajadores para tolerar el calor, escribió la Associated General Contractors of America en una declaración en línea.

Algunos legisladores republicanos han llamado a la norma una extra limitación del gobierno. Rick Roth, representante republicano del estado de Florida, dijo a Al Jazeera que los trabajadores están presionando por descansos pagados porque “no quieren trabajar tan duro”. Si no se sienten seguros, podrían cambiar de trabajo. “Vayan a trabajar para otra persona”, dijo.

Los críticos también dicen que las regulaciones costarán a los empleadores. Pero un análisis de UCLA de los reclamos de compensaciones de trabajadores en California sugiere que un estándar nacional sobre el calor ahorraría dinero en general. El estudio estimó el costo de las lesiones relacionadas con el calor entre $750 millones y $1,25 mil millones anuales solo en California, incluidos gastos médicos, pérdida de salarios y reclamos por discapacidad.

Dado que seis estados tienen conjuntos de reglas variables para reducir las enfermedades relacionadas con el calor —California, Colorado, Maryland, Minnesota, Oregon y Washington—, los investigadores y representantes sindicales han podido ver dónde necesitan fortalecerse las políticas.

Un problema con la aplicación es que OSHA depende en gran medida de que los empleados reporten riesgos. Un estudio encontró que solo el 14% de casi 600 trabajadores agrícolas encuestados en California sabían sobre el período de aclimatación y cuánta agua necesitaban cuando las temperaturas eran altas.

Aunque Florida no tiene regulaciones específicas sobre el calor, Dominique O’Connor, de la Asociación de Trabajadores Agrícolas de Florida, dijo que el mayor obstáculo para garantizar la seguridad ocupacional es que los trabajadores tienen miedo de que los despidan por presentar una queja ante OSHA.

Esto es especialmente cierto para los trabajadores agrícolas con visas H-2A, que permiten a los no ciudadanos cubrir trabajos temporales. Debido a que estos trabajadores dependen de sus empleadores no solo para permanecer en el país, sino a menudo también para transporte y vivienda, las represalias de los empleadores serían un cambio de vida. “Este verano hablamos con trabajadores H-2A a quienes solo se les daba agua sucia en el trabajo”, dijo. “Les dijeron que pretendieran que era café”.

Si llega a emitirse, es probable que los líderes de varios estados controlados por republicanos se opongan al estándar federal. En abril pasado, el gobernador de Florida, Ron DeSantis, aprobó una legislación que bloquea a los gobiernos locales de exigir a los empleadores que ofrezcan agua y sombra a los trabajadores cuando las temperaturas aumentan.

Y la decisión de la Corte Suprema de anular la “doctrina Chevron” este año puede alentar a los empleadores a desafiar la capacidad de OSHA para hacer cumplir las normas.

Durante décadas, la doctrina Chevron había requerido que los tribunales se delegaran a la experiencia de las agencias reguladoras al interpretar regulaciones, pero el fallo de la Corte Suprema terminó con eso. “Estamos en territorio desconocido”, dijo Barab.

Jeremy Young, productor senior de Fault Lines en Al Jazeera English, colaboró con este informe.

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California’s mental health commission on Thursday announced its executive director would resign amid revelations that he traveled to the U.K. courtesy of a state vendor while he sought to prevent a budget cut that would have defunded the company’s contract.

Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, will step down effective Nov. 22. Documents obtained by KFF Health News show that he tried in June to protect state funding for Kooth, a London-based digital mental health company with a contract to develop a virtual tool to help California tackle its youth mental health crisis.

He had been on paid administrative leave pending an investigation since September.

Ewing’s resignation was announced after a four-hour closed session of the mental health commission. During a public hearing before the announcement, advocates for mental health services accused the commission of favoring corporations over serving people with mental health and substance use issues.

The commission is an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services.

“You are being co-opted by big corporations,” said Susan Gallagher, executive director of Cal Voices, a mental health advocacy organization, during Thursday’s meeting. “You’re lobbying behind the scenes for these people to get money. That is not your job. You serve the people.”

Ewing declined to comment.

Kooth last year signed a four-year, $271 million contract with the Department of Health Care Services, which is separate from the commission, to create Soluna, a free mental health app for California users ages 13 to 25.

The app, along with one for younger users by the company Brightline, launched in January to fill a perceived need for young Californians and their families to access professional telehealth free of charge. It’s one component of Gov. Gavin Newsom’s $4.7 billion youth mental health plan.

The apps have seen very slow uptake since their launch in January. In May, the Newsom administration proposed a $140 million budget cut for the apps. Both the state Assembly and Senate budget committees proposed eliminating the entire program to save the state $360 million in the face of California’s $45 billion deficit.

But the funding for Kooth’s app wound up restored. It’s unclear why. Emails and calendars reviewed by KFF Health News showed Ewing pressed legislative staffers in June to restore the proposed cut.

About two weeks later, Ewing was accompanied by MHSOAC commissioners Mara Madrigal-Weiss, Bill Brown, and Steve Carnevale on a trip to London. Public disclosure forms show Kooth paid $15,000 in travel expenses for Ewing, Madrigal-Weiss, and Brown. The forms do not show the company paid for Carnevale’s travel.

While Ewing was in London, a colleague told him that the final state budget was approved with funding restored for Kooth’s app. Ewing emailed a Kooth executive ideas to improve its teletherapy app. About a week later he wrote, “We expect you to be involved in whatever we dream up.”

At Thursday’s commission meeting, Stacie Hiramoto, director of the Racial and Ethnic Mental Health Disparities Coalition, said the public will view the London trip as a serious conflict of interest.

“Maybe there was no wrongdoing, and maybe the company was good,” said Hiramoto, referring to Kooth. “But don’t you understand the appearance of the conflict?”

Carnevale said in Thursday’s meeting that the Newsom administration asked the commission to engage the legislature during budget negotiations.

“The governor’s office reached out to us to ask us to help them support the arguments and that’s what we did,” Carnevale said. “We went back and explained our positions on the digital solutions provided generally, without any particular comment on any company or any product in particular.”

Newsom’s office didn’t immediately respond.

Carnevale said the U.K. trip was not related to the budget. He said the trip “was very successful” for exchanging ideas with mental health policy leaders.

DHCS Director Michelle Baass told lawmakers in May that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps. Together, they had been used for only about 2,800 coaching sessions. The department has not provided more recent figures to KFF Health News.

Madrigal-Weiss defended her support of the mental health apps, lauding the youth-led design. She cited data that a majority of Kooth’s users liked the virtual coaching sessions and more than half were from underserved communities.

According to Kooth’s contract, obtained through a records request early this year, its payment is partially contingent on how many people use its app. Kooth will not get a pay increase until it reaches 366,000 users.

Kooth’s stock price fell about 20% on Thursday after KFF Health News published an article about Ewing’s efforts to restore funding for its contract and the London trip.

Gabe Brison-Trezise contributed to this report.

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Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it gives to more than 40 million people.

Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News, the publisher of California Healthline. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”

The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.

Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.

Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.

Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”

Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats retake control of the House in 2018.

In a KFF poll last winter, two-thirds of the public said it is very important to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.

“You want to make sure that preexisting coverage — conditions — are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.

Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without undermining coverage.

“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.

Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.

People eligible for subsidies would likely buy comprehensive ACA plans because — with the financial help — they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.

He also said that in states that allowed people to buy non-ACA-compliant plans outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.

“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying ‘we’re making it better,’ but it’s all untrue.”

Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office estimated doing so would increase the federal deficit by more than $330 billion over 10 years.

In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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As abortion and other reproductive issues gain more prominence in the looming election, some Republicans are trying to moderate their anti-abortion positions, particularly in states where access to the procedure remains politically popular. 

Meanwhile, open enrollment is underway for Medicare, even as some health plans are challenging in court the federal government’s decision to reduce their quality ratings — with millions of dollars at stake. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Sarah Karlin-Smith of the Pink Sheet, and Victoria Knight of Axios.

Among the takeaways from this week’s episode:

• With polls showing more voters citing abortion as a top voting issue, some candidates with long track records opposing abortion rights are working to moderate their positions.
• Many older Americans will spend less on prescription drugs next year due to a new out-of-pocket pricing cap, among other changes in store as provisions of the 2022 Inflation Reduction Act take effect. But some are realizing the limits on those benefits, as deeper problems persist in drug pricing, insurance coverage, and access.
• The FDA is reconsidering a weight-loss drug decision that caused confusion for patients and compounding pharmacies. Compounded drugs are intended for individual issues, like needing a different dosage — and while the process can be used to augment mass manufacturing during shortages, it is not well suited to address access and pricing issues.
• In abortion news, a comprehensive study shows abortions have increased since the overturn of Roe v. Wade, even among women in states with strict restrictions — and those states are seeing higher infant mortality rates, according to separate research. And an effort is underway to revive in a Texas court the challenge to mifepristone’s FDA approval. The last challenge failed because the Supreme Court found the plaintiffs lacked standing.

Also this week, Rovner interviews Tricia Neuman, senior vice president of KFF and executive director of its Program on Medicare Policy, about Medicare open enrollment and the changes to the program for 2025. 

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: NBC News’ “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks.  

Sarah Karlin-Smith: Vanity Fair’s “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health,” by Katherine Eban. 

Rachel Cohrs Zhang: The Atlantic’s “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch.  

Victoria Knight: NPR’s “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year,” by Rosemary Westwood and Jack Jenkins.

Also mentioned on this week’s podcast:

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This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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