Category: Rehab News

Max Schachter wanted to be close to his son Alex on his birthday, July 9, so he watched old videos of him.

“It put a smile on my face to see him so happy,” Schachter said.

Alex would have turned 21 that day, six years after he and 16 other children and staff at Marjory Stoneman Douglas High School in Parkland, Florida, were shot and killed by a former student in 2018. In the years before the shooting, that former student had displayed concerning behavior that elicited dozens of calls to 911 and at least two tips to the FBI.

“Alex should still be here today. It’s not fair,” Schachter said.

After two weeks of grieving Alex’s death, Schachter, propelled by anger and pain, began advocating for school safety. In part, he wanted to ensure his three other children would never be harmed in the same way. He joined the newly formed Marjory Stoneman Douglas High School Public Safety Commission to improve the safety and security of Florida’s students. And he launched a nonprofit bearing Alex’s name, which advocates for school safety.

Doing that work, he learned about threat assessment teams, groups of law enforcement and school officials who try to identify potentially dangerous or distressed kids, intervene, and prevent the next school shooting. Florida is one of about 18 states that require schools to have threat assessment and intervention teams; a national survey estimates 85% of public schools have a team assigned to the task.

The teams, whose mission and operational strategies often are based on research from the FBI and the Secret Service’s National Threat Assessment Center, or NTAC, have become more common as the number of school shootings has increased. Despite their prevalence for almost 25 years, some of the teams have developed systemic problems that put them at risk of unfairly labeling and vilifying children.

States vary widely in their requirements of threat assessment teams and there isn’t a nationwide archetype. Few school districts and states collect data about the teams, little is known about their operations, and research on their effectiveness at thwarting mass shootings and other threats is limited. But a 2021 analysis by the NTAC of 67 plots against K-12 schools found that people “contemplating violence often exhibit observable behaviors, and when community members report these behaviors, the next tragedy can be averted.”

“School shooters have a long thought process. They don’t just snap. They have concerning behavior over time. If we can identify them early, we can intervene,” said Karie Gibson, chief of the FBI’s Behavioral Analysis Unit.

Yet, Dewey Cornell, a forensic clinical psychologist who in 2001 developed one of the first sets of guidelines for school threat assessment teams, said there have been problems. In many cases, he said, threats have been deemed not serious “but parents and teachers are so alarmed that it is difficult to assuage their fears. The school community gets in an uproar and the school administrators feel pressured to expel the student.”

And in other cases, a school doesn’t do a threat assessment and assumes a student is dangerous when somebody else reports them as a threat, and they may take a zero tolerance approach and remove them from the school, said Cornell, the Virgil S. Ward professor of education at the University of Virginia.

A task force convened by the American Psychological Association found little evidence that zero tolerance policies have improved school climate or school safety and said they may create negative mental health outcomes for students. The task force cited examples of students who were expelled for incidents or school rule violations as minor as having a knife in their lunch box for cutting an apple.

Marisa Randazzo, a research psychologist and the director of threat assessment for Georgetown University, said she has also seen “hyperreactions,” especially among school communities that have experienced a mass killing.

“It’s understandable. People who have been close to an event like this are on higher alert than other people,” said Randazzo, who previously worked for the Secret Service and co-founded Sigma Threat Management Associates.

Threat assessments are supposed to be a graduated process calibrated to the seriousness of a problem, since the majority of student threats are not credible and can be resolved through supportive interventions, according to research from the Secret Service.

Stephanie Crawford-Goetz, a school psychologist and the director of mental health for student support services in the Douglas County School District in Colorado, where a shooting occurred at a charter school in 2019, said her district’s threat assessment process emphasizes a proactive, rehabilitative approach to managing potential threats, as the NTAC suggests.

Crawford-Goetz said her district interviews students before convening the team to assess whether a threat is a misguided expression of anger or frustration and if the student has a plan and means to carry out violence.

Students whose threats are deemed transient receive support, such as help with coping skills, and they may meet with a mental health provider.

If the threat is credible, a student may be temporarily removed from the classroom or school.

Randazzo said the vast majority of kids who make threats are suicidal or despondent: “The process is designed primarily to figure out if someone is in crisis and how we can help. It is not designed to be punitive.”

Crawford-Goetz tells parents about her district’s threat assessment team at the beginning of the school year. Some districts report keeping their teams a secret from parents, which is not how they were designed to operate, said Lina Alathari, chief of the NTAC. Her team encourages schools to educate the whole community about the threat assessment process.

Some advocacy groups contend that threat assessment teams have perpetuated inequities. There has also been widespread concern that children with disabilities can easily get swept into a threat assessment.

In a 2022 report, the National Disability Rights Network, a nonprofit based in Washington, D.C., said some threat assessment teams have become “judge, jury, and executioner,” going beyond assessing risk of serious, imminent harm to determining guilt and punishment.

Expanding their scope allows threat assessment teams to get around civil rights protections, the report says.

Cornell disputed the disability rights group’s conclusion. “This has not been corroborated by scientific studies and is speculative,” he said.

Some states, such as Florida, mandate that threat assessment teams determine whether a student’s disability played a role in their behavior and recommend they include special education teachers and other professionals in their evaluation.

In Texas, which has mandated threat assessment teams, a third of students subjected to threat assessments in the Dallas Independent School District receive special education services.

Yet, the district doesn’t have a special education staff representative on its threat assessment team, according to a March 2023 report by Texas Appleseed, a nonprofit public interest justice center.

Many school districts are developing their own models in the absence of national standards for threat assessments.

Florida revamped its threat assessment system in January 2024 to improve response times, provide consistent data collection, and build in more checks and balances and oversight, said Pinellas County Sheriff Bob Gualtieri, who is also chair of the Marjory Stoneman Douglas High School Public Safety Commission.

The new model requires the teams to work quickly and file uniform, electronic summary reports of threat assessment findings. Those results follow students throughout their school years.

The adjustments are intended to eliminate the risk of not knowing about a student’s past troubling behavior if they change schools, as occurred with the Parkland shooter and a student who shot and killed classmates at a high school near Winder, Georgia, in September, said Gualtieri.

“As parents, you never stop worrying about your kids,” Schachter said.

Virginia mandates that all public schools and higher education institutions, including colleges, have threat assessment teams. In Florida, where one of Schachter’s daughters attends college, threat assessment teams are mandated in all public schools, including charter schools.

“There’s more work to be done,” Schachter said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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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SALINAS — This coastal valley made famous by the novelist John Steinbeck is sometimes known affectionately as “America’s salad bowl,” though the planting and harvesting is done mostly by immigrants from Mexico.

For Taylor Farms, a major global purveyor of packaged salads and cut vegetables, that’s made it a logical place to pioneer a novel type of health care for its workforce, one that could have broad utility in the smartphone era: cross-border medical consultations through an app.

The company is among the first customers of a startup called MiSalud, which connects Spanish-speaking Taylor Farms employees to physicians and mental health therapists in Mexico. Providers aren’t licensed in the U.S. and can’t prescribe medications but instead serve as health coaches who can dispense advice and work with a U.S.-based doctor if needed.

Amy Taylor, who has led the company’s wellness initiative since 2014 and is the daughter-in-law of company founder Bruce Taylor, said about 5,600 of Taylor Farms’ 6,400 employees who work where MiSalud is currently available have signed up for the app, and 2,300 have used the app at least once. The service is free for employees and up to three family members.

Amy Taylor said the company hopes the app, which is part of a broader wellness program, can help employees stay healthier while keeping health care and other labor costs in check. She plans a full evaluation once the program has been in place for two years.

The health of farmworkers is a major concern for the state’s agricultural economy. A 2022 study led by researchers from the University of California-Merced evaluated the health of more than 1,200 farmworkers and found that 37% of men and 47% of women reported having at least one chronic condition, including common conditions such as diabetes, high blood pressure, and anxiety.

Taylor said her company’s employees, ranging from fieldworkers and drivers to retail packaging and office staff, mirror the study’s findings. She said predominant health concerns among workers include obesity, high blood pressure, diabetes, and mental health.

“These are the people who are feeding America healthy food,” Taylor said of the company’s employees. “They should also be healthy.”

MiSalud — or “My Health” — was the inspiration of Bismarck Lepe, a serial entrepreneur and Stanford graduate, who hails from a migrant farmworker family. Until age 6, when his family settled in Oxnard, they would travel between Mexico, California, and Washington state to harvest fruit. He saw that family and friends often delayed health care until they could return to Mexico because the U.S. system was too difficult to navigate, and insurance coverage too expensive or hard to find.

“My mother still prefers to get her health care in Mexico,” Lepe said. “It’s easier for her.”

Lepe and co-founders Wendy Johansson and Cindy Blanco Ochoa launched MiSalud Health in 2021 with $5 million from a venture capital fund backed by Melinda French Gates’ Pivotal Ventures, which focuses on social-impact investing. It has since added Samsung Next and Ulu Ventures as investors.

MiSalud started out by offering consultations with Mexican physicians for individuals who downloaded the app, Johansson said. But people keen enough to find the app, download it, and sign up for the program themselves weren’t ultimately those who needed it most, and in 2023 the company pivoted to offering its service to companies as an employee benefit. (Individuals can still use it too.)

Besides Taylor Farms, the company counts the city of Lynwood among about a dozen other clients, according to Johansson. MiSalud touted that nearly 40% of employees served by its platform say that without the app they would either have ignored their health concerns or waited until they could travel to Mexico to see a doctor.

Paul Brown, a UC-Merced professor of health economics who contributed to the university’s farmworker health study, warned that telehealth consultations aren’t adequate substitutes for in-person care by a primary care physician or a specialist. However, “to the extent that these types of programs can kind of link people into more standard care, that’s good,” he added.

Brown said MiSalud’s approach could be more effective if policies changed to allow Mexican doctors to more easily treat patients in the U.S. A California program begun in 2002 allows Mexican doctors to travel to the Salinas Valley and other heavily Latino communities and treat patients, but cross-border telemedicine, even between states, remains limited.

Even so, Taylor Farms employees say the app has been helpful. Rosa “Rosita” Flores, a line supervisor with the company’s retail operations, said she decided to give MiSalud a try after co-workers raved about it.

A recent company wellness fair, partly sponsored by MiSalud, had alerted her to the importance of monitoring her blood sugar and blood pressure levels, so she booked an appointment on the app to discuss it. “The app is very easy to use,” she said in Spanish. When she had to cancel a video chat after her daughter got sick, the health coaches followed up by text.

Proponents of cross-border medicine say the approach helps bridge linguistic and cultural barriers in health care. Almost half of all U.S. immigrants — about two-thirds of whom are native Spanish speakers — have limited proficiency in English, and research has repeatedly shown that language barriers often discourage people from seeking care.

For example, Alfredo Alvarez, a MiSalud health coach who is a licensed physician in Mexico, pointed to belief in el mal de ojo, or the “evil eye” — the idea that a jealous or envious glance by someone can cause harm, especially to children. An American doctor might be dismissive of the notion, but he understands.

“This isn’t uncommon here,” he said of Mexico. “It’s a belief in traditional medicine.”

It’s not that Alvarez encourages his socios, or members, to pass an egg over the child or make the child wear a special bracelet — traditional ways of diagnosing and treating el mal de ojo. Rather, he acknowledges their traditions and steers them to evidence-based medicine.

MiSalud’s coaches can try to break stereotypes as well. For example, Alvarez said, a Mexican reverence for machismo can translate to the idea that “men don’t do doctor visits.” Meanwhile, he said, women may overlook their health in prioritizing other family members’ needs.

Coaches also try to remove the stigma around seeking mental health treatment. “A lot of our socios have been extremely uncomfortable with or wary of mental health professionals,” said Rubén Benavides Crespo, a MiSalud mental health coach who is a licensed psychologist in Mexico.

The app tries to break through by making it easy to book counseling appointments and asking questions such as whether someone has trouble sleeping, rather than invoking more worrisome or potentially stigmatizing terms like anxiety or depression.

MiSalud representatives say the app saw a 50% increase in requests for mental health support following the November presidential election. A more common request, however, is grief counseling, often following the loss of a loved one.

“Loss requires adaptation,” Benavides said.

For Sam Chaidez, director of operations for a Taylor Farms location in Gonzales, MiSalud is a welcome addition for weight management. The son of fieldworkers, Chaidez graduated from UC-Davis and returned to the Salinas Valley to work for the company in 2007.

In 2019, Chaidez, a new parent at the time, began to understand his risk for diabetes and other health problems because of Taylor Farms’ wellness program. Through diet and exercise and, more recently, coaching by MiSalud, Chaidez has shed 150 pounds.

Chaidez encourages co-workers to walk with him at lunch, and he credits MiSalud coaches for helping him keep the weight off and stay healthy. “It’s been a great help,” he said.

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SALINAS, California. — Este valle costero, que se hizo famoso gracias al novelista John Steinbeck, a veces se conoce cariñosamente como “la ensaladera de Estados Unidos”, aunque la siembra y la cosecha las realizan principalmente inmigrantes de México.

Para Taylor Farms, que es uno de los principales proveedores mundiales de ensaladas envasadas y verduras cortadas, esto lo ha convertido en un lugar ideal para implementar un innovador modelo de atención médica para sus empleados.

Este método, que podría llegar a tener gran utilidad en la era de los teléfonos inteligentes, es una aplicación que permite efectuar consultas médicas transfronterizas.

Taylor Farms es uno de los principales clientes de una startup llamada MiSalud, que pone en contacto a los empleados hispanohablantes de la empresa con médicos y terapeutas de salud mental en México.

Estos profesionales no tienen licencia en Estados Unidos y no pueden recetar medicamentos, pero actúan como consejeros de salud, colaborando, si es necesario, con un médico estadounidense.

Amy Taylor, que dirige esta iniciativa de promoción de la salud de la empresa desde 2014 y es la nuera de su fundador, Bruce Taylor, dijo que unos 5.600 de los 6.400 empleados de Taylor Farms se han registrado en MiSalud y 2.300 han utilizado la aplicación por lo menos una vez.

El servicio es gratuito para los empleados y hasta tres miembros de su familia.

Amy Taylor explicó que la empresa espera que la aplicación, que forma parte de un programa de bienestar más amplio, pueda ayudar a los empleados a mantenerse saludables y, al mismo tiempo, controlar tanto los gastos de la atención médica como otros costos laborales.

Está previsto realizar una evaluación completa de este programa una vez que haya estado en funcionamiento dos años.

La salud de estos trabajadores es una de las principales preocupaciones de la economía agrícola del estado.

Un estudio de 2022, dirigido por investigadores de la Universidad de California-Merced, evaluó la salud de más de 1.200 trabajadores agrícolas y descubrió que el 37% de los hombres y el 47% de las mujeres informaron que padecían al menos una enfermedad crónica, incluidas afecciones comunes como diabetes, hipertensión y ansiedad.

Taylor explicó que los empleados de la empresa, que abarcan desde trabajadores del campo y choferes hasta personal de empaque y empleados de oficina, tienen los mismos problemas que los participantes del estudio. Destacó que las principales preocupaciones de salud entre los trabajadores incluyen la obesidad, la hipertensión, la diabetes y la salud mental.

“Estas son las personas que alimentan a Estados Unidos con comida saludable”, dijo Taylor refiriéndose a los trabajadores de la compañía: “También deberían estar sanos”.

MiSalud fue resultado de la inspiración de Bismarck Lepe, un emprendedor de múltiples proyectos, graduado de la Universidad de Stanford, que proviene de una familia de trabajadores agrícolas migrantes.

Hasta los 6 años, cuando finalmente se estableció en Oxnard, California, toda la familia Lepe viajaba entre México, California y el estado de Washington para cosechar fruta.

Lepe observó que tanto su familia como los amigos a menudo retrasaban la atención médica hasta que podían regresar a México. El sistema de salud estadounidense les resultaba demasiado complicado y el seguro demasiado costoso o de difícil acceso.

“Mi madre sigue prefiriendo recibir atención médica en México”, dijo Lepe. “Para ella es más sencillo”.

Lepe y las cofundadoras Wendy Johansson y Cindy Blanco Ochoa lanzaron MiSalud Health en 2021 con $5 millones de un fondo de capital de riesgo respaldado por Pivotal Ventures, la firma de Melinda French Gates que se enfoca en inversiones de impacto social. Desde entonces, han sumado dos nuevos inversores, Samsung Next y Ulu Ventures.

MiSalud comenzó ofreciendo consultas con médicos mexicanos para las personas que descargaban la aplicación, contó Johansson.

Pero los que podían bajar la aplicación y registrarse por sí mismos no eran, en última instancia, los que más la necesitaban. Por eso, en 2023, la compañía dio un giro para ofrecer su servicio a las empresas como beneficio para los empleados. (Aunque los individuos también pueden seguir utilizándolo).

Además de Taylor Farms, MiSalud tiene entre sus clientes a la ciudad de Lynwood, en California, y a otra docena de empresas. La compañía asegura que casi el 40% de los empleados atendidos por su plataforma admiten que, sin la aplicación, hubieran ignorado sus problemas de salud o hubieran esperado hasta viajar a México para buscar atención médica.

Paul Brown, profesor de economía de la salud de la UC-Merced, colaboró en la investigación sobre el estado físico y  mental de los trabajadores agrícolas que efectuó la universidad. Advirtió que las consultas de telemedicina no sustituyen adecuadamente la atención presencial de un médico de atención primaria o un especialista.

Sin embargo, agregó: “En la medida en que este tipo de programas puedan conectar a las personas con una atención más estándar, son beneficiosos”.

Brown comentó que el enfoque de MiSalud podría ser más eficaz si se modificaran las políticas para permitir que los médicos mexicanos puedan atender a pacientes en Estados Unidos con más facilidad.

Un programa de California iniciado en 2002 permite que los médicos mexicanos viajen al Valle de Salinas y a otras comunidades con gran presencia de población latina para atender pacientes, pero la telemedicina transfronteriza, incluso entre estados, sigue siendo limitada.

Aun así, los empleados de Taylor Farms afirman que la aplicación ha sido útil. Rosa “Rosita” Flores, supervisora de línea de las operaciones minoristas de la empresa, dijo que decidió probar MiSalud después que sus compañeros de trabajo le hablaran bien de la aplicación.

En una reciente feria de bienestar de la empresa, patrocinada en parte por MiSalud, le hicieron notar la importancia de monitorear sus niveles de azúcar en sangre y la presión arterial, por lo que reservó una cita en la aplicación para hablar del tema.

“La aplicación es muy fácil de usar”, dijo. Cuando tuvo que cancelar una videollamada porque su hija se enfermó, los asesores de salud hicieron el seguimiento por mensaje de texto.

Los defensores de la medicina transfronteriza afirman que este enfoque ayuda a salvar las barreras lingüísticas y culturales en la atención médica.

En el país, casi la mitad de los inmigrantes —de los cuales aproximadamente dos tercios son hispanohablantes nativos— tienen un dominio limitado del inglés, y las investigaciones han demostrado muchas veces que las barreras lingüísticas a menudo disuaden a las personas de buscar atención médica.

Por ejemplo, Alfredo Álvarez, asesor de salud de MiSalud que es médico certificado en México, mencionó la creencia en el “mal de ojo”, la idea de que una mirada envidiosa o celosa de una persona puede causar daño, especialmente a los niños.

Un médico estadounidense podría descartar esa idea, pero Álvarez la comprende.

“Esto no es raro aquí”, dijo refiriéndose a  México. “Es una creencia de la medicina tradicional”.

No es que Álvarez anime a sus los usuarios de la aplicación a pasar un huevo por encima del niño o a hacer que el niño lleve una pulsera especial, formas tradicionales de “diagnosticar” y tratar el mal de ojo. Más bien, reconoce sus tradiciones y los orienta hacia la medicina basada en la evidencia.

Los asesores de MiSalud también pueden intentar romper con estereotipos.

Por ejemplo, Álvarez dijo que la arraigada cultura machista de México puede traducirse en la idea de que “los hombres no van al médico”. Mientras tanto, agregó, las mujeres pueden descuidar su salud porque priorizan las necesidades de otros miembros de la familia.

Los asesores también intentan eliminar al estigma que rodea a la búsqueda de tratamiento de salud mental. “Muchos de nuestros ‘socios’ se han sentido extremadamente incómodos o recelosos ante los profesionales de salud mental”, dijo Rubén Benavides Crespo, asesor de MiSalud en este campo y psicólogo titulado en México.

La aplicación intenta romper el hielo facilitando la reserva de las consultas de asesoramiento y haciendo preguntas del estilo de si alguien tiene problemas para dormir, en lugar de invocar términos más preocupantes o potencialmente estigmatizantes como ansiedad o depresión.

Los representantes de MiSalud informaron que la aplicación experimentó un aumento del 50% en las solicitudes de apoyo para la salud mental tras las elecciones presidenciales de noviembre. Sin embargo, una solicitud más común es el asesoramiento para el duelo, a menudo tras la pérdida de un ser querido.

“La pérdida requiere adaptación”, señaló Benavides.

Para Sam Chaidez, director de operaciones de una planta de Taylor Farms en Gonzales, California, MiSalud es un apoyo adicional para el control de peso.

Hijo de trabajadores del campo, Chaidez se graduó en la Universidad de California en Davis y regresó al Valle de Salinas para trabajar en la empresa en 2007.

En 2019, Chaidez, que acababa de ser padre, empezó a comprender el riesgo de padecer diabetes y otros problemas de salud gracias al programa de bienestar de Taylor Farms. A partir de la dieta y el ejercicio y, más recientemente, al asesoramiento de MiSalud, Chaidez ha perdido 150 libras (68 kilos).

Ahora anima a sus compañeros de trabajo a caminar con él a la hora de comer, y atribuye a los asesores de MiSalud el mérito de haberlo ayudado a no recuperar el peso perdido y a mantenerse sano. “Ha sido una gran ayuda”, señaló.

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KFF Health News senior correspondent Arthur Allen discussed what to watch for in Robert F. Kennedy Jr.’s confirmation hearings for secretary of Health and Human Services on CBS News Chicago on Jan. 29.

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KFF Health News editor-at-large for public health Céline Gounder discussed why the CIA has “low confidence” in its assessment of the origins of the covid-19 virus on CBS News 24/7 on Jan. 27.

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KFF Health News senior correspondent Noam N. Levey discussed the Consumer Financial Protection Bureau’s final rule to remove medical debt from consumer credit reports on PBS’ “PBS News Weekend” on Jan. 25.

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KFF Health News contributor Sue O’Connell discussed Montana’s mental health facilities on Billings’ KTVQ on Jan. 24.

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KFF Health News senior correspondent Renuka Rayasam discussed bird flu in Georgia on WUGA’s “The Georgia Health Report” on Jan. 24.

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KFF Health News chief Washington correspondent Julie Rovner discussed the nomination of Robert F. Kennedy Jr. for secretary of Health and Human Services on CBS News on Jan. 22.

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KFF Health News correspondent Molly Castle Work discussed mental health specialists’ role in the Los Angeles wildfire response on America’s Heroes Group on Jan. 22.

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President Donald Trump ratcheted up his administration’s reversal of transgender rights on Tuesday with an executive order that seeks to intervene in parents’ medical decisions by prohibiting government-funded insurance coverage of puberty blockers or surgery for people under 19.

Trump’s order, titled “Protecting Children From Chemical and Surgical Mutilation,” is certain to face legal challenges and would require congressional or regulatory actions to be fully enacted. But transgender people and their advocates are concerned it will nonetheless discourage prescriptions and medical procedures they consider to be lifesaving in some cases, while complicating insurance coverage for gender-affirming care.

“It can’t be understated how harmful this executive order is, even though it doesn’t do anything on its own,” said Andrew Ortiz, a senior policy attorney at the Transgender Law Center. “It shows where the administration wants to go, where it wants the agencies to put their efforts and energies.”

The order is one of several Trump has issued, less than two weeks since taking office, that target the trans community. He has directed his administration to recognize only the male and female sex — and to abandon the term “gender” altogether. He ordered the State Department to issue passports identifying Americans only by their genders assigned at birth. He has encouraged the Justice Department to prosecute teachers and other school officials who help trans children transition, including by using their preferred names. And he signed an order that’s expected to lead to transgender people being banned from military service.

“We’re terrified. We cry every day. Hurting my family and my kid is winning politics for Republicans right now,” said the parent of a transgender child who lives in Missouri and asked not to be identified for fear of being targeted. “Every bone in my body is telling me I can’t keep my child safe from my government anymore, I can’t keep my family safe.”

About 300,000 American children ages 13-17 identify as transgender, according to the Williams Institute at the UCLA School of Law, which researches sexual orientation and gender identity law and public policy. But the number who seek gender-affirming care is believed to be far fewer. An examination by Reuters and Komodo Health of about 330 million health insurance claims filed from 2017 to 2021 found that fewer than 15,000 patients ages 6 to 17 with a diagnosis of gender dysphoria had received gender-affirming hormone therapy and fewer than 5,000 had started puberty-blocking medications — though the annual number of such patients more than doubled over the five-year span.

Trump’s order seeking to disrupt insurance coverage for young people, the Williams Institute said in a brief, “will likely at least limit the availability of gender-affirming care or make it more difficult to access in the short term and could increase risk for both providers and recipients of the care.”

Much of what the order calls for would require rule changes or other federal guidance, which can take weeks to months. Though it is mostly directed toward government health insurance programs, the order could have private-sector implications, too, and is likely to face litigation from states or advocacy organizations.

Specifically, the directive intends to limit insurance coverage for hormonal or surgical treatments that help young people transition.

It directs the secretary of the Department of Health and Human Services to “take all appropriate steps” to end insurance coverage of such treatments. It specifically names several government programs such as Tricare, which serves the military and its dependents; Medicare and Medicaid; federal and postal health benefit programs; and the Foreign Service Benefit Plan.

“The aim here is clearly targeted at federally funded plans, such as Medicare and Medicaid, but there’s a lack of clarity as to whether it would impact other plans, such as exchange plans, where essential health benefits are required,” said Lindsey Dawson, director of LGBTQ Health Policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

State Medicaid programs vary widely in their rules around transgender care, with a variety of limits or restrictions on what types of care can be covered for minors in just over half the states, according to a map provided by the Colorado-based Movement Advancement Project, a nonprofit think tank.

While little is likely to happen immediately from the order — one of more than 100 issued by the president since his inauguration last week — it could, nonetheless, have a chilling effect on medical professionals.

The order directs the Department of Justice to work with Congress to promote legislation that would allow children and parents a “private right of action” — the ability to file a lawsuit — against medical professionals who provide transgender care.

And the Justice Department was also directed to consider the application of existing laws to those who provide or promote access to gender care.

In addition, one section of the order directs agencies to “take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children,” a move that could affect hospitals or medical schools.

Julian Polaris, a partner at the consulting firm Manatt, said the order “displays the federal government’s willingness to use federal programs to restrict access to disfavored services even to providers and patients outside those federal programs.”

The move drew immediate criticism from groups supporting LBGTQ+ people’s rights.

“It is unconscionable that less than 24 hours after trying to take away Head Start programs and school meals for kids, President Trump issued an order demonizing transgender youth and spreading dangerous lies about gender-affirming care,” Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America, wrote in a press release.

Because it defines “youths” as those under age 19, the order would apply the directives to medical treatments provided to 18-year-olds, who otherwise are considered adults in making legal choices, voting, or serving in the military.

“There’s also just a problem with not seeing young people as capable in making decisions around their health and their futures, and so blurring that line and trying to move it up and taking more control over more people is obviously concerning,” Ortiz said. “But having the line hard at 18 also doesn’t make it any better.”

Ortiz noted that the order contains misinformation about medical care for young people who are transitioning and targets a small subset of U.S. residents: transgender youths in families that can access and afford gender-affirming care.

“That should be concerning to everybody,” he said, “that they are pulling out populations to target, to say that, ‘We don’t think that you deserve access to best-practice medical care.’”

Trump’s order explained that the action was necessary because such medical treatment could cause young people to regret the move later, once they “grasp the horrifying tragedy that they will never be able to conceive children of their own or nurture their children through breastfeeding.”

KFF Health News Midwest correspondent Bram Sable-Smith 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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During her annual OB-GYN visit, Callie Anderson asked about getting off the birth control pill.

“We decided the best option for me was an IUD,” she said, referring to an intrauterine device, a long-acting, reversible type of birth control.

Anderson, 25, of Scranton, Pennsylvania, asked her doctor how much it might cost. At the time, she was working in a U.S. senator’s local office and was covered under her father’s insurance through a plan offered to retired state police.

“She told me that IUDs are almost universally covered under insurance but she would send out the prior authorization anyway,” Anderson said.

She said she heard nothing more and assumed that meant it was covered.

After waiting months for an appointment, Anderson had the insertion procedure last March. She paid $25, her copay for an office visit, and everything went well.

“I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she said.

Then the bill came.

The Medical Procedure

According to Planned Parenthood, IUDs and implantable birth control represented nearly 25% of its contraceptive services provided from October 2021 to September 2022, per the latest data available.

There are two types of IUDs: copper, which Planned Parenthood says can protect against pregnancy for up to 12 years, and hormonal, which can last from three to eight years depending on the brand. Hormonal IUDs can prevent ovulation, and both types affect the movement of sperm, designed to stop them from reaching an egg.

A physician or other practitioner uses a tube to insert the IUD, passing it through the cervix and releasing it into the uterus.

Doctors often recommend over-the-counter drugs for insertion pain, a concern that prompts some patients to avoid IUDs. Last year, federal health officials recommended doctors discuss pain management with patients beforehand, including options such as lidocaine shots and topical anesthetics.

The Final Bill

$14,658: $117 for a pregnancy test, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the doctor’s services.

The Billing Problem: A ‘Grandfathered’ Plan

Anderson got a rare glimpse of what can happen when insurance doesn’t cover contraception.

The Affordable Care Act requires health plans to offer preventive care, including a variety of contraceptives, without cost to the patient.

But Anderson’s plan doesn’t have to comply with the ACA. That’s because it’s considered a “grandfathered” plan, meaning it existed before March 23, 2010, when President Barack Obama signed the ACA into law, and has not changed substantially since then.

It’s unclear how many Americans have such coverage. In its 2020 Employer Health Benefits survey, KFF estimated that about 14% of covered workers were still on “grandfathered” plans.

Anderson said she didn’t know that the plan was grandfathered — and that it did not cover IUDs — until she contacted her insurer after it denied payment. Her doctor with Geisinger, a nonprofit health system in Pennsylvania, was in-network.

“My understanding was Geisinger would reach out to insurance and if there was an issue, they would tell me,” she said.

Mike McCullen, a Geisinger spokesperson, said in an email to KFF Health News that with most insurance plans, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”

He did not specify whether it is the health system’s policy to seek such authorizations for IUDs, nor did he comment on the amount charged.

The Pennsylvania State Troopers Association, which offers some retirees the plan that covered Anderson, did not respond to requests for comment. Highmark Blue Cross Blue Shield, the insurer, referred questions to the state.

Dan Egan, communications director for the state’s Office of Administration, confirmed in an email that the insurance plan is a grandfathered plan “for former Pennsylvania State Troopers Association members who retired prior to January 13, 2018.”

A benefit handbook for the plan identifies it as grandfathered and lists a variety of excluded services. Among them are “contraceptive devices, implants, injections and all related services.”

The $14,658 bill, an amount that typically would be negotiated down by an insurer, was solely Anderson’s responsibility.

“Fourteen thousand dollars is astronomical. I’ve never heard of anything that high” for an IUD, said Danika Severino Wynn, vice president for care and access at the Planned Parenthood Federation of America.

Costs for IUDs vary, depending on the type, where the patient lives, insurance status, the availability of financial assistance, and additional medical factors, Severino Wynn said.

She said most insurers cover the devices, but coverage can vary, too. For instance, some cover only certain types or brands of contraceptives. Generally, an IUD insertion costs $500 to $1,500, she added.

Many providers, including Planned Parenthood, have sliding-scale rates based on income or can set up payment plans for cash-paying or underinsured patients, she said.

According to FAIR Health, a cost estimation tool that uses claims data, an uninsured patient in the Scranton area could expect to be charged $1,183 for an IUD insertion done at an ambulatory surgery center or $4,319 in a hospital outpatient clinic.

The Resolution

Anderson texted and called her insurer and Geisinger multiple times, spending hours on the phone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in one message with staff at her doctor’s office.

She said she felt rebuffed when she asked billing representatives about financial assistance, even after noting the bill was more than 20% of her annual income.

“I wasn’t in therapy at the time, but at the end of this I ended up going to therapy because I was stressed out,” she said. The billing office, she said, “told me that if I didn’t pay in 90 days, it would go to collections, and that was scary to me.”

Eventually, she was put in touch with Geisinger’s financial assistance office, which offered her a self-pay discount knocking $4,211 off the bill. But she still owed more than she could afford, Anderson said.

The final offer? She said a representative told her by phone that if she made one lump payment, Geisinger would give her half off the remaining charges.

She agreed, paying $5,236 in total.

The Takeaway

It’s always best to read your benefit booklet or call your insurer before you undergo a nonemergency medical procedure, to check whether there are any exclusions to coverage. In addition, call and speak with a representative. Ask what you might owe out-of-pocket for the procedure.

While it can be hard to know whether your plan is grandfathered under the ACA, it’s worth checking. Ask your insurance plan, your employer, or the retiree benefits office that offers your coverage. Ask where the plan deviates from ACA rules.

With birth control, “sometimes you have to get really specific and say, ‘I’m looking for this type of IUD,’” Severino Wynn said. “It’s incredibly hard to be an advocate for yourself.”

Most insurance plans offer online calculators or other ways to learn ahead of time what patients will owe.

Be persistent in seeking discounts. Provider charges are almost always higher than what insurers would pay, because they are expected to negotiate lower rates.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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El presidente Donald Trump ha reforzado la decisión de su gobierno de revertir los derechos de las personas transgénero. Una orden ejecutiva del 28 de enero busca intervenir en las decisiones médicas de los padres prohibiendo que seguros de salud financiados por el gobierno cubran bloqueadores de la pubertad o cirugías para menores de 19 años.

La orden de Trump, titulada “Proteger a los niños de la mutilación química y quirúrgica”, seguramente enfrentará batallas legales, y requerirá medidas legislativas o cambios reglamentarios para implementarse por completo.

Sin embargo, las personas transgénero y sus defensores temen que la medida desaliente el uso de medicamentos y los tratamientos médicos que, en algunos casos, consideran vitales, además de complicar la cobertura de los procedimientos de afirmación de género.

“No se puede subestimar lo perjudicial que es esta orden ejecutiva, incluso aunque no tenga efecto inmediato por sí sola”, dijo Andrew Ortiz, abogado senior de políticas en el Transgender Law Center. “Muestra hacia dónde quiere ir la administración y en qué áreas pretende que las agencias enfoquen sus esfuerzos y energías”.

La orden  es una de las varias normas dirigidas a la comunidad trans que Trump ha emitido a menos de dos semanas de asumir el cargo. El presidente ha ordenado a su administración que solo reconozca los sexos masculino y femenino, y que abandone por completo el término “género”.

También instruyó al Departamento de Estado para que emita pasaportes que solo identifiquen a los ciudadanos estadounidenses según el género asignado al nacer.

Y alentó al Departamento de Justicia para que procese a los profesores y otros funcionarios escolares que ayuden a los niños trans a hacer su transición, aunque solo se limiten a permitirles usar el nombre que prefieran. Y ha firmado una orden que llevaría a prohibir que las personas trans formen parte de las Fuerzas Armadas.

“Estamos aterrados. Lloramos todos los días. En este momento, para los republicanos es una victoria política lastimar a mi familia y a mi hijo”, dijo el padre de un niño transgénero que vive en Missouri, y pidió no ser identificado por miedo a convertirse en blanco de ataques. “Cada fibra de mi ser me dice que ya no puedo proteger a mi hijo de mi gobierno, ni puedo mantener a mi familia a salvo”, agregó.

Cerca de 300.000 niños estadounidenses de entre 13 y 17 años se identifican como transgénero, según el Williams Institute de la Facultad de Derecho de la UCLA, que investiga las leyes y políticas públicas sobre orientación sexual e identidad de género.

Pero, se cree que el número de quienes buscan atención de afirmación de género es mucho menor.

Un análisis de Reuters y Komodo Health sobre aproximadamente 330 millones de solicitudes de seguros de salud presentadas entre 2017 y 2021 encontró que menos de 15.000 pacientes de entre 6 y 17 años con un diagnóstico de disforia de género habían recibido terapia hormonal de afirmación de género, y menos de 5.000 habían comenzado a tomar bloqueadores de la pubertad.

Aun así, el número anual de estos pacientes se incrementó en más del doble en ese período de cinco años.

Al buscar interrumpir la cobertura para los jóvenes, la orden de Trump “probablemente, como mínimo, limitará la disponibilidad de la atención de afirmación de género o hará que sea más difícil acceder a ella a corto plazo. También podría aumentar el riesgo tanto para los proveedores como para los pacientes”, aseguró en un informe el Williams Institute.

La implementación de la orden ejecutiva podría tardar semanas o meses porque gran parte de lo que exige requeriría cambios normativos o nuevas directrices federales.

Aunque está dirigida principalmente a programas de salud del gobierno, la orden también podría tener implicaciones para el sector privado y es probable que enfrente litigios por parte de los estados o grupos de defensa.

Específicamente, la directiva busca limitar la cobertura para tratamientos hormonales o quirúrgicos destinados a ayudar a los jóvenes en su transición.

La directiva ordena al secretario del Departamento de Salud y Servicios Humanos (HHS) que tome “todas las medidas apropiadas” para eliminar la cobertura de estos tratamientos. Menciona específicamente varios programas gubernamentales como Tricare, que atiende al personal del ejército y sus familias; Medicare y Medicaid; los programas de atención de la salud para trabajadores y jubilados del gobierno federal y del servicio postal, y el Foreign Service Benefit Plan, para empleados del Servicio Exterior.

“El objetivo aquí está claramente dirigido a los planes financiados por el gobierno federal, como Medicare y Medicaid, pero no está claro si la orden afectaría a otros planes, como los del mercado de seguros en los que se garantiza la cobertura de ciertos servicios de salud considerados esenciales”, explicó Lindsey Dawson, directora de Políticas de Salud LGBTQ en KFF.

Los programas estatales de Medicaid tienen reglas muy diferentes sobre la atención médica para personas transgénero. En poco más de la mitad de los estados, existen límites o restricciones sobre los tipos de tratamientos que pueden cubrirse para los menores, según un mapa realizado por el Movement Advancement Project, un grupo de investigación sin fines de lucro con sede en Colorado.

Aunque es poco probable que la orden tenga un impacto inmediato —es solo una de las más de las 100 que el presidente ha firmado desde que asumió el cargo—, podría hacer que muchos médicos se sientan intimidados o temerosos de brindar este tipo de atención.

La orden instruye al Departamento de Justicia para que trabaje con el Congreso en la elaboración de una legislación que permita a los niños y sus padres una “acción de derecho privado” —esto es, la capacidad de presentar una demanda— contra los profesionales médicos que brinden atención a personas transgénero.

Además, se le indicó que considere la aplicación de las leyes existentes a quienes brinden o faciliten el acceso a la atención de género.

Otra sección de la orden les pide a las agencias que “tomen medidas para asegurarse de que las instituciones que reciban fondos federales para investigación o educación terminen con la mutilación química y quirúrgica de los niños”, lo que podría afectar a hospitales o escuelas de medicina.

Julian Polaris, un socio de la firma de consultoría Manatt, comentó que la orden “muestra que el gobierno federal está dispuesto a usar sus programas para restringir el acceso a servicios que desaprueba, incluso para médicos y pacientes que no estén dentro de esos programas federales”.

De inmediato, la medida recibió críticas de grupos defensores de los derechos de las personas LGBTQ+.

“Es inconcebible que, menos de 24 horas después de intentar eliminar programas de alimentación escolar y Head Start para niños, el presidente Trump emita una orden demonizando a los jóvenes transgénero y difundiendo mentiras peligrosas sobre la atención de afirmación de género”, manifestó en un comunicado de prensa Alexis McGill Johnson, presidenta y CEO de Planned Parenthood Federation of America.

Dado que la orden define a “jóvenes” como aquellos menores de 19 años, también afectaría las directrices de los tratamientos médicos proporcionados a los mayores de 18 años, quienes sin embargo son considerados adultos con derecho a tomar decisiones legales, votar o servir en el ejército.

“También es problemático no reconocer a los jóvenes como capaces de tomar decisiones sobre su salud y su futuro. Diluir esa línea y tratar de moverla hacia arriba para tener más control sobre más personas es, obviamente, preocupante”, dijo Andrew Ortiz. “Pero incluso fijar un límite estricto en los 18 años tampoco lo hace mejor”.

Ortiz señaló que la orden contiene información errónea sobre la atención médica para jóvenes en transición y se enfoca a un pequeño grupo de la población: los jóvenes transgénero cuyas familias pueden acceder y costear la atención de afirmación de género.

“Eso nos debería preocupar a todos”, concluyó, “porque están seleccionando poblaciones específicas para atacarlas y decirles que ‘no merecen acceso a una atención médica basada en las mejores prácticas’”.

Trump justificó la orden argumentando que el tratamiento médico para jóvenes trans podría llevar al arrepentimiento en el futuro, “cuando se den cuenta de la horrible tragedia de que nunca podrán concebir hijos propios ni amamantarlos”.

Bram Sable-Smith, corresponsal en el Medio Oeste de KFF Health News, colaboró con este artículo.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

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Robert F. Kennedy Jr., President Donald Trump’s nominee to lead the Department of Health and Human Services, came under sharp questioning from Democrats and some Republicans at his confirmation hearings this week before two Senate committees. Of particular interest were the doubts about Kennedy’s qualifications and past anti-vaccination positions raised by Sen. Bill Cassidy (R-La.), who is a physician — and, notably, a member of the Senate Finance Committee, which is expected to vote next week on whether to advance Kennedy’s nomination to the Senate floor.

 Meanwhile, a federal government memo temporarily freezing a lot of federal grant and loan funding touched off confusion and recriminations at the new Trump administration for its sudden, sweeping actions.

This week’s panelists are Julie Rovner of KFF Health News, Sandhya Raman of CQ Roll Call, and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s episode:

• During appearances before two Senate committees, Kennedy assured lawmakers he would follow science and defer to Trump’s policy preferences. But he also made mistakes that are notable for someone vying to lead the nation’s top health agency, such as confusing the Medicaid and Medicare programs.
• As Kennedy’s second hearing concluded, it was not immediately clear whether he would earn the votes needed to be confirmed by the full Senate — especially as at least one key Republican, Cassidy, seemed less than convinced. If every Democrat and independent votes against him, Kennedy could lose just a few GOP votes and still be confirmed.
• Much of the nation’s health system — alongside many, many other entities that rely on federal funding — experienced a kind of whiplash early this week, as the Trump administration’s Office of Management and Budget issued a memo freezing federal grants and loans until they could be reviewed for adherence to Trump’s priorities. A federal judge temporarily blocked the freeze from taking effect, and OMB revoked the memo — but the White House said Trump’s recent executive orders affecting funding “remain in full force and effect, and will be rigorously implemented.”
• In other Trump administration news, Trump fired a slew of inspectors general late last week — including the one who oversees HHS and the nation’s health system. And an executive order affecting health care for trans children has many parents and advocates on edge.

Also this week, Rovner interviews Nicholas Bagley, a University of Michigan law professor, who explains how the federal regulatory system is supposed to operate to make health policy.

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

Julie Rovner: 404 Media’s “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Costs Six Figures,” by Jason Koebler.

Sandhya Raman: ProPublica’s “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” by Mary Hudetz and Hannah Bassett.

Sarah Karlin-Smith: CBS News’ “Wind-Blown Bird Poop May Help Transmit Bird Flu, Minnesota’s Infectious Disease Expert Warns,” by Mackenzie Lofgren.

Also mentioned in this week’s podcast:

KFF Health News’ “Trump’s Funding ‘Pause’ Throws States, Health Industry Into Chaos,” by Phil Galewitz.

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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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