KEOKUK, Iowa — Folks in this Mississippi River town hope a new federal program can revive the optimism engraved long ago in a plaque on the side of their hospital.

“Dedicated to the Future of Health Care in the Tri-State Area,” the sign declares. “May 11, 1981.”

More recent placards posted at the facility’s entryways are ominous, however. “Closed,” they say. “No Trespassing.”

The Keokuk hospital, which served rural areas of Iowa, Illinois, and Missouri, closed in October 2022. But new owners plan to reopen the hospital with the help of a new federal payment system. The Rural Emergency Hospital program guarantees hospitals extra cash if they provide emergency and outpatient services but end inpatient care.

“We’ve been without a hospital for over a year — and I don’t think anybody in Keokuk or the surrounding areas will be picky in any way, shape, or form,” said Kathie Mahoney, mayor of the town of about 9,800 people. She said residents would prefer to have a full-service hospital with inpatient beds, even though those types of beds had been used sparingly in recent years.

The revival of the Keokuk hospital would mark a small victory in the nationwide struggle to save rural hospitals, which continue to close due to staffing shortages, low reimbursement rates, and declining patient numbers. The new federal program, which went into effect in January 2023, is meant to stem the closures. But there have been growing pains, said George Pink, deputy director of the North Carolina Rural Health Research Program, which tracks hospital closures and conversions.

Just 18 of the more than 1,700 eligible rural hospitals nationwide have applied for and won the new designation. Many hospitals are reluctant to give up inpatient services entirely, and some are concerned about how other payment streams could be affected, rural health leaders say. The new designation’s unclear definition of “rural” has also caused confusion.

“We are still in an era of rural hospital closures,” Pink said. Nine hospitals closed in 2023, and that number could rise in 2024, he said. An influx of federal relief funds during the pandemic kept struggling hospitals afloat, but now that money is largely gone.

The Rural Emergency Hospital program is the first new federal payment model for hospitals since 1997. Dora Hughes, acting chief medical officer of the Centers for Medicare & Medicaid Services, said the new model’s criteria are outlined by statute and “hospitals should consider specific circumstances before making the decision to apply.”

The federal agency is providing outreach to rural communities and welcomes feedback, Hughes wrote in an email to KFF Health News.

Now, rural health leaders and federal lawmakers are working quickly to tweak the new program to attract more applicants, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association.

Currently, facilities that convert to rural emergency hospitals receive a 5% increase in Medicare payments, plus an average annual payment of about $3.2 million, in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds, like Keokuk’s, that closed after the law was signed on Dec. 27, 2020, are eligible to apply for the program and reopen with emergency and outpatient services.

More than 100 rural hospitals nationwide have inquired about converting, said Janice Walters, interim executive director for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to hospitals that want to apply.

But only about a quarter of those inquiries are likely to become a rural emergency hospital, and persuading more troubled hospitals to make the leap would require regulators to make changes, Walters said.

Her advice? “Give them 10 beds to just take care of their community.”

In a journal article published last year, general surgeon Sara Schaefer worried about the unintended consequences of getting rid of rural inpatient beds. Schaefer, who spent six months of medical school at a small rural Idaho hospital, said she saw firsthand how difficult it was for the hospital to transfer patients to bigger facilities, which were often too full to take them.

“There has to be a better way,” said Schaefer, who is also a research fellow at the Center for Healthcare Outcomes & Policy at the University of Michigan.

The rural health association’s Cochran-McClain said lawmakers are considering changes that could allow the hospitals to:

• Keep overnight beds for patients who need moderate levels of care, such as those with pneumonia or in need of physical therapy after surgery.
• Allow participation in a federal drug discount program called 340B, which provides hospitals with extra revenue.
• Keep inpatient psychiatric or rehabilitation units open.
• Clarify eligibility, including which facilities qualify under the definition of “rural” and whether the hospitals that closed before the 2020 date in the law can apply.

Updates to the law could affect communities nationwide. In Fort Scott, Kansas, where the hospital closed in late 2018, Mayor Matthew Wells said the community wants the eligibility date pushed back. U.S. Sen. Jerry Moran (R-Kan.) introduced a bill in December that, if passed, would push eligibility back to 2015.

“This is a matter of life and death to my community,” Wells said. “I see a clear path, but the federal regulations in particular make that path nearly impossible.”

In Holly Springs, Mississippi, hospital chief executive Kenneth Williams said he doesn’t understand the federal definition of “rural.” His hospital, Alliance Healthcare Hospital, was one of the first to win the new Rural Emergency Hospital designation in early 2023. He laid off staff and shut down his inpatient beds. Then, CMS officials called to tell him they had made a mistake.

“And I said, ‘Wait a minute,’” Williams said. The hospital, which is about an hour south of Memphis, Tennessee, doesn’t meet the current criteria of rural, they told him. Williams, an internal medicine doctor, bought the hospital in 1999 and has been trying to keep it running since.

Federal regulators are now asking Williams to convert the facility into another type of Medicare payment model, such as the sole community hospital with inpatient beds that it was before. Williams said that would be difficult: “What kind of transition can I make, especially with reduced services?”

In Keokuk, the hospital fits the current requirements. Insight Health Group, the Michigan company that bought the shuttered facility last March, plans to apply for the new federal designation as soon as it obtains state permits under new Iowa regulations tailored to rural emergency hospitals. It would be the first such hospital in the state.

Like many other rural hospitals struggling to survive, Keokuk’s shuttered several key departments years ago, including its birthing and inpatient psychiatric units. In 2021, the last full year it was open, the hospital averaged fewer than three inpatients per night, according to data posted by the Iowa Hospital Association.

More than half of the three-story building would remain mothballed if the facility reopened under the new designation, but the emergency department could serve patients again as soon as late summer, said Atif Bawahab, Insight’s chief strategy officer.

Bruce Mackie has worked 32 years at the hospital, including 10 years as director of plant operations. The new owners kept him on to watch over the building. Beds, high-tech scanners, and lab equipment remain, but most of the clocks have stopped. “It’s spooky,” he said.

Even if the services are more limited than before, Mackie said, “everybody wants the hospital to reopen. This city needs an ER.”

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

When 17 nursing homes closed in Ohio in fiscal 2023, the Ohio Health Care Association, which represents nursing homes in the state, echoed a refrain often used by the industry to explain closures and get more funding from the state: Medicaid reimbursement rates are too low and it is too hard to find staff.

It’s the same argument that the industry has made on a national scale for decades, but particularly since the COVID-19 pandemic, which saw thousands of residents die while facilities faced increased labor and supply costs.

While staffing and reimbursement issues have certainly contributed to closures in some cases, especially for smaller, rural facilities, experts say the debate often omits some important facts and nuance: specifically, that many facilities that close are poor quality, have high staff turnover and are located in areas where multiple other homes and alternatives exist, making it difficult to fill empty beds. Others turn into assisted living facilities, which are more loosely regulated. A handful were kicked off of the Medicare program for low quality.

“I think that’s one of the most powerful arguments that the industry has used to scare policymakers and senators and other decision-makers, and it’s really disconnected if you think about it,” said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care. “When you actually look at the data, and you look at the homes closing, it’s really because they’re just bad homes providing bad care, and they can’t fill their beds so they’re just closing down.”

Yet, the industry continues to demand more funding from taxpayers. They’ve also used the closures to try to fend off a controversial Biden administration rule that would mandate minimum staffing levels in nursing homes, a standard that currently does not exist.

“We believe that if the Biden staffing mandate is finalized, that it will accelerate the closures of buildings,” said Mark Parkinson, president and CEO of the American Health Care Association, which represents the interests of the nation’s nursing homes.

“Very good nursing homes are closing because they can’t find workers and the reimbursement isn’t enough. And for people to just be out there making these subjective statements that it’s just poor buildings that are closing, it’s just not accurate. It leads policymakers to potentially make poor decisions, and it has real impacts on people’s lives,” Parkinson said.

A changing industry

There are about 15,000 nursing homes in the U.S., and dozens close every year. While experts believe there was likely an uptick in closures during the pandemic, experts think COVID-19 aid to the industry likely prevented more facilities from closing.

Nursing homes have long struggled to recruit and retain staff, largely because of low pay, and understaffing generally leads to poorer health outcomes. The industry has blamed low staffing on Medicaid rates, which are set by states.

And when nursing homes close, that is also blamed on reimbursement rates and workforce shortages.

But the truth is more complicated, experts say.

“In general, the lowest-quality care facilities are the ones that end up closing because they just have lower census,” meaning fewer residents. In those cases, facilities bring in less money, said Robert Applebaum, who studies nursing home closures and quality as part of his role as director of the Ohio Long-Term Care Research Project.

Once a nursing home has a low census or not enough staffing, it can become a spiral that can be difficult to get out of, he said.

“It is a bit of a chicken and egg problem,” he said. “Some are low quality and that reduces the census and revenue, and the spiral continues. Some experience census problems, and that results in lower revenue and cuts to staffing.”

The explosion of assisted living facilities and services that allow people to receive care in their home has also driven down the demand for nursing home beds, Applebaum said.

“It’s primarily a natural evolution of a changing industry,” he said.

There are still nearly 1,000 nursing homes in Ohio. The state’s facilities that shuttered in fiscal 2023 had an average occupancy rate of 60 percent, a rate that would make it nearly impossible to be profitable. Four of the 17 closed Ohio facilities were in the federal government’s special focus program or candidates for the program, which puts poor-performing facilities under extra scrutiny.

Seven had health inspection ratings of one star — the lowest possible rating, which takes into account surveys in a three-year period.

While Medicaid rates do likely play a role, particularly for rural and independently owned facilities, it is unclear how much. It’s infamously opaque how nursing homes spend Medicaid funds. Experts say facilities cut staffing to the bone to increase profits or channel funding into related-party transactions.

In Texas, nursing homes received increased payments during the pandemic, but that didn’t lead to improvements in quality, said Andrea Earl, associate state director of advocacy and outreach for AARP Texas.

“If we don’t know where the dollars went and there’s no accountability, it is really hard for us to say the reason for Texas closures is that they didn’t get enough reimbursement or money here,” Earl said.

Nationwide trends

In fiscal 2023, 188 nursing homes, also known as skilled nursing facilities, closed in the U.S., according to a CQ Roll Call analysis of government data.

Overall, facilities that closed were more likely to have had severe inspection violations, had racked up fines for providing poor care, were rated poorly by state and federal governments and were on lists for extra monitoring.

Some were facing wrongful death lawsuits or had stopped paying their bills.

While some 40 percent of those closed facilities were four or five star facilities, 31 percent of closed facilities were one star or part of the special focus facility program, compared with 23 percent of facilities overall.

The star rating system, created by the Centers for Medicare and Medicaid Services, is intended to help consumers identify poor and high-quality nursing homes; facilities with five stars are considered to be of the highest quality. But the rating system has faced scrutiny. Experts say it is easy for facilities to game the system to get higher ratings.

The sector also is graded on a curve, meaning the lowest 20 percent of nursing homes in a state are considered one star, middle-performing facilities receive three stars and the highest performing facilities in a state receive five stars.

Other metrics that nursing homes are graded on can be more useful to look at, experts say, like results of health inspections, which are unannounced.

Half of the facilities that closed in fiscal 2023 had received code J or higher deficiencies — which indicate serious immediate jeopardy to resident health and safety — compared with 11 percent of facilities overall, according to government data.

Ten percent of facilities that closed in fiscal 2023 had been cited for abuse, compared with 6 percent of facilities overall, while 13 percent of closed facilities were participants in or candidates for the special focus program, compared with 3.5 percent of facilities overall.

One of the most powerful tools CMS has to enforce nursing home regulations is Medicare payment denials. That tool is typically used as a last resort when facilities have otherwise failed to fix deficiencies.

Twenty-two percent of facilities that closed in fiscal 2023 had received at least one payment denial, compared with 13 percent overall.

Kelly Hughes, a research economist at RTI International, said despite the narrative that more nursing homes are closing, “the situation is not as dire as you’d think if you look at the data.”

The data shows there have been no persistent increases in closure rates from 2011 through 2019, although there were increases in 2018 and 2019, Hughes said.

“We’re having less closures than we did a decade ago,” she said.

The number of new facilities that open every year typically offsets the closures, Hughes said, though the impacts of the pandemic on closures are still unclear.

“The goal is not to have zero closures. There’s always going to be supply and demand. There’s going to be some facilities going out of business for reasons like poor quality or oversupply, and there’s also a lot of facilities entering [the market],” Hughes said.

More problematic, said David Grabowski, professor of health care policy at Harvard Medical School, is “when it’s a high-quality facility in a more rural area without any other options.”

Of the 188 nursing homes that closed in fiscal 2023, about 47 percent were in counties defined as rural by the Federal Office of Rural Health Policy.

Efforts to shore up nursing homes should be targeted at those that need it, especially in rural communities, Grabowski said.

“When it’s a closure in a more densely populated area of a lower-quality facility, that is actually good for the health of the residents,” he said.

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©2024 CQ-Roll Call, Inc. Visit at rollcall.com. Distributed by Tribune Content Agency, LLC.

The researchers tested the effects of a daily multivitamin on cognitive changes in older adults, as part of the COSMOS trial (COcoa Supplement and Multivitamin Outcomes Study).

COSMOS is a large-scale trial testing cocoa extract and multivitamin supplements, run by researchers at Mass General Brigham. Two previous studies in COSMOS suggested that a daily multivitamin has a positive effect on cognition.

COSMOS researchers are now reporting the results of a third study in COSMOS — which focused on participants who took in-person assessments. The results showed a statistically significant benefit for memory and cognition among participants taking a daily multivitamin compared to the placebo.

The study suggests that taking a daily multivitamin may help prevent memory loss and slow cognitive aging in older adults.

“Cognitive decline is among the top health concerns for most older adults, and a daily supplement of multivitamins has the potential as an appealing and accessible approach to slow cognitive aging,” said first author Chirag Vyas, instructor in investigation at the Department of Psychiatry at Massachusetts General Hospital.

“The meta-analysis of three separate cognition studies provides strong and consistent evidence that taking a daily multivitamin, containing more than 20 essential micronutrients, helps prevent memory loss and slow down cognitive aging,” Vyas said.

The researchers for the study conducted in-person cognitive assessments among 573 participants in the subset of COSMOS known as COSMOS-Clinic.

The scientists found that there was a modest benefit from the multivitamin on global cognition over two years. There was a statistically significant benefit from the multivitamin for change in episodic memory, but not in executive function/attention.

The researchers estimated that the daily multivitamin slowed global cognitive aging by the equivalent of two years compared to the placebo.

“These findings will garner attention among many older adults who are, understandably, very interested in ways to preserve brain health, as they provide evidence for the role of a daily multivitamin in supporting better cognitive aging,” said Olivia Okereke, senior author of the report and director of Geriatric Psychiatry at MGH.

In 2020, an estimated 5.8 million Americans aged 65 years or older had Alzheimer’s disease. This number is projected to nearly triple to 14 million people by 2060, according to the CDC.

JoAnn Manson, co-author of the research report and chief of the Division of Preventive Medicine at Brigham and Women’s Hospital, said, “The finding that a daily multivitamin improved memory and slowed cognitive aging in three separate placebo-controlled studies in COSMOS is exciting and further supports the promise of multivitamins as a safe, accessible and affordable approach to protecting cognitive health in older adults.”

The study, published on Thursday in the journal Science, adds to our understanding of long COVID, the lingering and often debilitating symptoms experienced by some people. One significant finding revealed shifts in proteins the body produces in response to inflammation that may persist months after infection. Another detected blood clots and tissue injury.

“We identified common patterns in long COVID patients not recovered at six months after acute infection,” compared to healthy patients, wrote the team, a collaboration of scientists from New York City’s Icahn School of Medicine at Mount Sinai, Switzerland, Sweden and London.

There is tremendous need to diagnose and find effective ways to treat long COVID, a constellation of symptoms that include exhaustion, migraines, brain fog and nausea that are not explainable using conventional lab tests.

At a hearing in Washington D.C. this week, senators at the Senate Committee on Health, Education, Labor and Pension agreed that the government must become more involved in long COVID research and support. Sen. Tim Kaine, D-Va., said he has been struggling with symptoms of long COVID for four years.

On March 15, a demonstration is planned at Lincoln Memorial to raise awareness and urge greater funding, preventative measures, research, and treatment strategies.

Although long COVID’s prevalence is difficult to estimate, surveys suggest it may afflict 5.3% to 7.5% of people infected by the virus.  It’s not known why some people develop long COVID and others don’t. But vaccines offer protection. One dose of vaccine reduces risk by 21%, two doses reduce risk by 59%, and three or more doses reduce risk by 73%, according to a recent study.

What causes long COVID? One possibility is that, long after it fends off infection, the immune system is still fighting. It turns on — but doesn’t turn off.

Experts don’t know why. UC San Francisco research suggests that viral genetic material remains embedded in tissues, long after infection. Or perhaps COVID triggers an autoimmune response when the body mistakenly attacks itself. There is mixed evidence for the effectiveness of the antiviral drug Paxlovid in preventing long COVID.

There is a desperate need for a diagnostic test and treatment for long COVID. Currently, doctors are treating the symptoms, rather than the underlying cause.

The new findings are important because “they demonstrate dysfunction, which is important to patients,” said Jaime Seltzer, scientific director at the nonprofit MEAction, which advocates for patients with long COVID and myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS.

“Secondly, they point the way to potential treatments, and even possibly mechanisms” of disease, she said.

This paper builds on our understanding of long COVID by connecting the changes that occur during an acute infection to longer-term abnormalities in markers of blood cell function, said Dr. Michael Peluso, an infectious disease physician at Zuckerberg San Francisco General Hospital, who is studying the biological mechanisms that drive long COVID and the infection’s long-term impact on health.

“It suggests that there is a relationship between the virus, its immune effects, and changes in certain blood coagulation pathways,” he said.

Although the study represents another step forward in understanding the science of long COVID, it will not immediately change the approach to diagnosing or treating the condition, said Peluso.

“We need more investment in larger studies to build upon these findings, as well as clinical trials to test whether altering some of the abnormalities that have been found here could result in symptomatic benefit,” he said.

In the new study, scientists analyzed changes in the blood of 113 patients who either fully recovered from COVID-19 or developed long COVID, as well as healthy people.

Specifically, they measured levels of 6,596 different proteins in study participants over a year, then sampled the blood again six months and a year later.  Proteins act like keys that fit in multiple locks on the surface of cells. Changes in proteins mean that cellular processes are altered.

Immune dysfunction is also suspected to be driving the symptoms in those with other persistent infection-linked illnesses, such as ME/CFS and Lyme Disease, said Seltzer. It’s the body’s way of adapting, she said.

There are caveats. With only 113 patients, the study was relatively small. Many participants were so sick that they needed hospitalization, which could have influenced results. Finally, it only studied changes within a year of infection; three to five years later, there may be different markers in the blood, said Seltzer. Patients’ immune systems may not be able to stay overactive indefinitely.

These features suggest potential interventions, wrote Wolfram Ruf of the Center for Thrombosis and Hemostasis in Germany, in a commentary that accompanied the report. Perhaps anti-inflammatory drugs would help. Anti-coagulants might reduce the risk of dangerous blood clots.

“Eventually, the hope is that some of these findings can translate into the clinic, but we are still a ways away from that,” said Peluso. “We need to keep up the momentum to get answers for the tens of millions of people with this disabling condition.”

Royse, 49, of Bethlehem, Pennsylvania, has been active much of his life: He played college basketball and as an adult he’s been a runner, even doing some marathons. So when his wife got into the paddle sport and then got him to play several casual matches, he didn’t think it was anything his current level of fitness couldn’t keep up with.

“It’s an enjoyable and addicting sport. My 75-year-old mother plays,” Royse said. “I thought it was a little bit goofy from the beginning. It’s like a driveway game, and in some ways it is but in all the good ways.”

But in early August, Royse’s wife asked him to fill in for a league game. Suddenly, his perception of what he’d viewed as just a fun, casual game changed.

“I neglected to think of it as a sport,” Royse said. “I thought I could show up after my third or fourth time playing and now go play it at a really high intensity with folks that really know how to play. I approached it like my kid asking to go play kick the ball in the yard. Next thing you know, I’m playing high-intensity pickleball and I blew my knee out.”

Pickleball, which combines elements of badminton, tennis and ping pong, is the fastest-growing sport in the United States. Last year more than 36 million people played the game, and it is particularly popular among adults 40 and up. It’s helped get people active and exercising as well as helped already active adults stay active. But it’s also a growing reason for sports medicine injuries and orthopedic injuries: It’s estimated there were 67,000 emergency room visits and 9,000 outpatient surgeries related to pickleball injuries in the U.S. last year, according to an analysis by UBS Asset Management.

“I’ve just been really shocked by the number of mostly soft tissue injuries, not necessarily always surgical … the number of people not only playing but the number of people coming in injured seems to be rising exponentially over the last six months,” said Dr. Wayne Luchetti, associate chief of orthopedic surgery at Lehigh Valley Health Network’s Lehigh Valley Orthopedic Institute in Pennsylvania.

Luchetti himself is a pickleball enthusiast and tries to play two or three times a week.

“It’s a different kind of workout for me. I’m a Peloton guy. A lot of days I dread getting on the Peloton for 45 minutes. It’s just mentally hard to do, but I never dread going to play pickleball for an hour and a half because it’s just a fun way to burn calories,” Luchetti said.

He’s also injured himself while playing pickleball, pulling his calf muscle about three weeks after he took up the sport.

The common injuries are to the feet, ankles and knees, with many due to overuse and strain.

Luchetti said he believes there are three main reasons why so many people are getting injured: One, that there are just so many people playing it; two, it involves a lot of side-to-side movement, which can be hard on the knees and ankles; and three, a lot of the people playing are older adults.

He said he sees people of all ages with pickleball injuries but most are in their 60s and 70s.

“You have a lot of older athletes that haven’t necessarily played a sport in 20 years, now they’re addicted to this fun sport,” Luchetti said. “They’re going out two to three days a week and firing muscles they haven’t fired in 20 years. Sometimes they don’t know their limitations.”

How to avoid pickleball injuries

St. Luke’s University Health Network recently opened the St. Luke’s SportsPlex, which is also home to Pickleball Lehigh Valley. John Hauth, St. Luke’s senior administrator for sports medicine relationships, said the SportsPlex has instructors, classes and courses available to help pickleball players avoid injury.

“A hallmark of the program there is offering both quality instruction in pickleball specifically, but also in how to prepare and become stronger, more well balanced as you begin to play the game of pickleball,” Hauth said. “People that haven’t exercised for a long period of time may be deconditioned. They need to start the right way and that’s something we’re emphasizing.”

Luchetti also said strength and conditioning work is crucial to avoiding injury. He sometimes tells his patients who are really serious about playing to see a physical therapist for one session before they play again so they can get advice on what muscle groups they need to strengthen to avoid injuries.

Luchetti added proper footwear is key; shoes worn to play pickleball should fit well and grip the court.

“I see a lot of people slipping and turning their ankle or their knee,” Luchetti said.

And people with joint problems should make sure to wear a brace while playing.

Luchetti also said muscles, tendons and ligaments get tighter as people age and that makes them more prone to injury; to avoid that, stretching before playing is key.

Luchetti’s pickleball injury was partly caused by him not stretching, but now he stretches for 20 to 30 minutes before he steps on the court. Dynamic stretching such as doing hip circles or high stepping is ideal to limber up.

He added that while getting exercise is important, so is giving the body time to rest. Instead of playing the game multiple days in a row back to back, consider spacing out when you play so you get at least one rest day between game days.

And if you feel like something is off or feel pain while you play, stop — don’t play through the injury. If you suffer an injury while playing, immediately stop and rest, apply ice, compress the injury and make sure it is elevated, then seek care as soon as possible.

Hauth said while it’s important to do what you can to prevent injuries, fear of injury or another injury shouldn’t keep people away from the sport.

“People are active because they’re engaged in pickleball. People are moving, which is good for their overall health,” Hauth said.

Royse said he feels the same way. While he has regained the ability to ride a bike, he hasn’t made it back onto the pickleball court, nor has he been able to start running again. But he’s working toward that point. He will be back on the court.

“I’m a former athlete, I’m in pretty good shape and it happened to me so it can definitely happen,” he said. “But I chalk it up to it’s like skiing. A lot of people get injured skiing, but it doesn’t hold you back. You just got to know your limitations, know your craft and take it seriously, but it’s definitely worth it.”

“I assume that this summer when I can go play pickleball, with proper stretching and preparation, I would totally go play and play hard. I don’t want to be fearful in life.”

The instant Tammy Brady felt the lump in her breast in February 2022, she knew it was cancer. With no known genetic predisposition for breast cancer, she suspects 38 years of working in smoky Atlantic City casinos played a role.

“I was just trying to make a living,” said Brady, 56, a dealer and supervisor at Borgata in that New Jersey resort city. “You don’t think, you know, that you’re going to get sick at your job.”

Some casinos continue to allow indoor smoking even as the share of Americans who smoke fell from about 21% in 2005 to 12% in 2021 and smoking is banned in at least some public spaces in 35 states, the District of Columbia, and U.S. territories. Still, 13 of the 22 states and territories that allow casino gambling permit smoking in at least part of their facilities.

Brady is among the casino employees, anti-smoking advocates, and public health experts who argue it is long past time to snuff out casino exemptions from smoking bans, given the dangers of secondhand smoke. But they’ve faced stiff pushback from some gambling industry leaders, including in Missouri, Louisiana, Kentucky, and New Jersey, who argue that smoking bans drive gamblers away — especially in places where patrons can go instead to a casino in a nearby jurisdiction that allows them to light up.

The COVID-19 pandemic renewed this fight and sharpened the arguments on both sides — on the dangers of particulate matter for the anti-smoking side and the vulnerability of revenues for the casino industry, even as the American Gaming Association reported record-breaking revenues in 2022 for in-person casino gambling beyond the growth of sports betting and online gambling.

Casinos were shut down for several months in spring 2020 as part of the nationwide effort to mitigate the spread of the coronavirus. Rules governing reopening, including masking and physical distancing requirements and bans on smoking, varied by state and, in some cases, by casino operator and community.

After suffering pandemic-era losses, some casino executives, and at least one union representing workers, leaned into a 2021 report commissioned by the Casino Association of New Jersey to combat efforts to ban or restrict smoking at their properties. Using data from 2019, the report suggests that as many as 2,500 Atlantic City casino workers could lose their jobs and tax revenue could fall by as much as $44 million in the first year if smoking is banned in New Jersey but not in neighboring Pennsylvania. Both states considered prohibitions on casino smoking in 2023; New Jersey lawmakers didn’t pass their bill and Pennsylvania’s remains in limbo.

Brian Christopher, a social media influencer specializing in casinos and gambling, said he has heard the arguments about lost business before — and is unconvinced. “People are not driving or flying to a casino to have a cigarette,” he said.

Still, officials in some places are persuaded by arguments about depressed tax revenue. Last spring, Shreveport, Louisiana, officials repealed a 2020 ban on smoking in casinos. Those pushing the repeal said local gambling taxes fell when gamblers left for nearby casinos where they could smoke. The new ordinance allows smoking on 75% of the casino floor.

And Churchill Downs Inc. announced in June it was moving a gambling facility planned for empty mall space in Owensboro, Kentucky, to a location outside the city limits. Though the company declined to comment for this article, the city’s mayor told the Messenger-Inquirer newspaper that a primary reason for the move was the city’s long-standing voter-approved smoking restrictions, which do not exempt casinos.

Kanika Cunningham, director of the St. Louis County Department of Public Health in Missouri, was part of an effort last year to end a casino loophole in her county’s 2011 indoor smoking ban. But after pushback from the gambling company Penn Entertainment, a compromise was reached allowing smoking on 50% of a casino’s floor.

“It’s a balance and one that we feel the marketplace should determine, particularly in such a competitive environment with other gaming facilities nearby and in neighboring states,” said Jeff Morris, Penn Entertainment’s vice president of public affairs and government relations.

Penn Entertainment employs “state of the art ventilation systems, extremely high ceilings,” and “adequate separation of smoking and non-smoking areas,” he wrote in an email to KFF Health News.

The problem, Cunningham said, is that secondhand smoke cannot be contained to a single location in a big room.

“There’s no safe amount, and trying to restrict it to a certain area isn’t going to work,” she said.

Filtration systems can remove much of the visible smoke, as well as the odor, from indoor spaces even when lots of people are smoking, creating the impression of clean air. But existing technology does not eliminate the dangerous particulates in cigarette smoke, according to a 2023 report from the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE.

A study published in 2023 for the National Institutes of Health evaluated particulate matter at eight Las Vegas casinos that allowed smoking and one that did not. In casinos where smoking is allowed, particulate levels were significantly higher — even in areas designated as nonsmoking — than at the nonsmoking casino.

And in ventilated casinos where indoor smoking is allowed, one study showed, workers can have nicotine levels as much as 600% higher than employees exposed to smoking in other workplaces.

Secondhand smoke can cause coronary heart disease, stroke, lung cancer, and other diseases. Some studies have shown a link to breast cancer, although more research is needed, according to the National Cancer Institute.

The pandemic raised awareness of the dangers of airborne particulates, giving smoking bans fresh momentum, said Andrew Klebanow, co-founder of the independent industry consulting group C3 Gaming, which produced a report in 2022 largely refuting the economic risk of casinos going smoke-free.

Indeed, more than 1,000 U.S. casinos and other gambling properties now ban smoking, including more than 140 tribal casinos, according to Americans Nonsmokers’ Rights Foundation.

New Mexico’s tribal leaders collectively agreed to maintain smoking bans when pandemic restrictions were lifted, said Denis Floge, chief executive of Acoma Business Enterprises and Sky City Casino in North Acomita Village. Employee health has improved, he said, qualifying the casino for rebates on its insurance premium. Cleaning and replacement costs for carpets and equipment fell, he said, and the tribes “haven’t missed a beat” on revenues.

Some guests have grumbled about having to go outside to smoke, Floge said, but that’s about it. “We don’t have anybody who jumps up and down, or throws a fit and says, ‘I’m leaving and never coming back!’” he said.

Casino executives who oppose smoking restrictions overlook people who want to enjoy the “great food and the great entertainment, but won’t step foot in a casino because they get hit by a blast of smoke as soon as they step in,” said Pete Naccarelli, a Borgata dealer and one of three co-founders of the advocacy organization Casino Employees Against Smoking’s Effects.

He said they founded the group, which has chapters in New Jersey, Kansas, Pennsylvania, Rhode Island, and Virginia, after his casino put out ashtrays at 12:01 a.m. the day the pandemic-related smoking ban officially ended. Borgata did not answer requests for comment.

The industry-commissioned report on New Jersey suggests that while more nonsmokers might frequent casinos once smoking is banned, they probably would not make up for the revenue lost if smokers choose other venues or when smokers take breaks from gambling to light up.

But Brady, now cancer-free after chemotherapy and a full mastectomy, believes that if policymakers spent some time breathing the same air she and her co-workers do they’d act more quickly to ban smoking in casinos, rather than prioritize tax revenues. “Our lives are more important,” she said.

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

“The hip at that time was about 60-70% deteriorated,” Emes said an X-ray done early in 2023 showed. “I could hear the grinding and popping, and the pain was continuous, causing me to get only two to three hours of sleep per night for at least a year. All this had my head spinning.”

His chiropractor, who told him years ago he should consider replacement, said it was time to get the hip addressed by a surgeon.

“I tried everything I could because I didn’t want to have the operation,” Emes said.

Emes, 63, celebrated 26 years of sobriety on Jan. 1.

“I was most afraid, because I have such an addictive personality, that I would easily start using again, once any narcotics would be in my system,” he said. “Addiction owned me for many years, even though I hated myself for it and was killing myself, it defined me. So I was most afraid the world would not understand and I would once again be owned by the craving.”

Emes said his addiction began right out of high school.

“It was everything, anything I could get my hands on — drinking, coke, pot, any kind of pain medicines,” he admitted.

Finally the fear of re-entering the grasp of addiction was not able to compete with the bone grinding pain in his hip

“The days I was really in pain leaving work, I just remember the nights I dreamed I believed I was going to commit suicide, that is how dark it was for me,” Emes said. “The whole mess, the whole dark abyss. Not knowing who to trust and if they would respect my wishes for remaining clean; not knowing really if anyone would say it was possible or that they would do it.”

He did not want that darkness to envelop him any longer.

Emes got second opinions and even entered an online cognitive behavior therapy class for pain management offered through Lehigh Valley Hospital that is part of a five-year research project at Stanford University.

“I’ve been meditating for many, many years, but this was a whole other kind of binaural beats,” Emes said. “That was helping me to focus on the good things in my day and try not to pay attention to the pain.”

Binaural beats is an auditory “illusion created by the brain when you listen to two tones with slightly different frequencies at the same time,” according to Webmd.com. Basically, your brain hears a third tone, which enhances brainwaves.

The American Academy of Audiology states “this enhancement of brainwaves has been studied to determine their effectiveness at reducing stress, anxiety, help in sleep, and increased focus” and there is still debate about its effectiveness.

Emes finally connected with Dr. Stephen Longenecker at the Bone & Joint Care Center in West Reading.

“Dr. Longenecker just looked at me, held my hands and said, ‘If you want to do this pain-medicine free, I am onboard with that,’ ” Emes recalled. “I felt his spirit. I knew he was the one. I had gone to Lehigh to get a second opinion; that guy felt way off for me, didn’t understand what I was after. I just felt it with Dr. Longenecker.”

When he awoke after surgery on July 5, Emes said the only area he felt pain was around the stitches.

“It was so much pain before, I knew it couldn’t be much more pain after,” he said. “At that point I didn’t feel anything inside, it was such a blessing.

“Immediately afterward, the pain was gone. When they got me up at the hospital, I stood — I get a little choked up — because I stood in the middle of the hallway with the physical therapy guy and I started to cry a little bit because the pain inside my bones wasn’t there any more.”

Emes was given prescription medication to take home, just in case he could not stand the pain. He said he didn’t need any of the pills. He managed just fine with Tylenol.

In addition to his physical therapy Emes said he got up every 45 minutes to an hour and walked around the whole yard, an acre in Ruscombmanor Township he shares with his husband, Gordon Weiss. That was something he hadn’t done in a year.

“One of our dogs, she’s a bird dog, and she was my nurse the whole 6-8 weeks,” he said. “It was crazy. She laid right by my side, on my righthand side, she’d do her silent growl at any of the other dogs that came up like she was protecting that part of me.”

Bailey was a constant source of comfort for him during his healing process.

Emes was off work for two months to recuperate. When he returned to the Amazon warehouse in Upper Bern Township in September, he was given accommodative duties for the month. Now he is back to his regular duties.

Another perspective

Rocky S. 66, of Wyomissing, who asked that his full name not be used, has been in recovery for 12 years.

“I’ve actually had two joint replacements to the same shoulder,” Rocky said. “I also had a joint removed from my hand because they couldn’t repair it.”

His addiction recovery was well established by the time he needed the surgeries, he said.

“I immediately told my doctors that I was in recovery and that any type of narcotic may be an issue for me,” Rocky said. “I wanted them to be aware that I was in recovery and that we had to be very sensitive to that.

“When I had my first shoulder replacement done, it was a partial replacement and I worked with the doctor and he told me that basically, at that time, there was very little chance that I would be able to get through the recovery stage without any type of narcotic medication.

“We went into the surgery knowing ahead what the plan was as far as what the narcotic medication was going to be and we stuck to that plan. I was somewhat surprised when I got home at how many pills he actually did prescribe.”

Relapsing was certainly on his mind heading into surgery.

“I’ve always struggled with drug addiction, but frankly what really took me down was my alcoholism,” Rocky confessed.

He said anyone in a good recovery program would be foolish to say they were not concerned about relapsing.

“Just like I can tell you I haven’t had a drink today and I haven’t had a drink in the past 12 years, that’s no assurance that I’m not going to have one tomorrow,” Rocky said.

“What I found extremely helpful was that I told every single person that I was close to,” he said. “I was extremely close to three other guys who were in my recovery network. So I told them what was going to happen, I told them after the surgery what was happening and I talked to them every single day throughout that initial phase of medication.

“So although I wasn’t able to go out and be social at my recovery meetings initially, I did stay in touch with my friends in recovery and my parents, my family, everybody.”

He credits physical therapy with being the key to his pain diminishing quickly.

Rocky’s second shoulder replacement surgery, about three years after the first one, didn’t go quite as smoothly.

“I can’t exactly tell you why,” he said. “When I had that surgery, it was the same physician, we had the same conversation. He prescribed the same medications, but I started thinking differently when I had that second recovery process.

“I can remember thinking to myself, ‘I’m still in pain, a second pill would probably help.’”

That was enough for him to turn over his medications to someone he trusted to dole out the medication as prescribed.

“Unfortunately, in addiction, there’s not always a concrete answer as to why something works one time and the next time it doesn’t,” he said. “The overriding factor throughout those recoveries was continuing to work my recovery program, continuing to stay in touch with my sponsor on a daily basis, continuing to stay in touch with my recovery friends every day and then getting back to meetings as soon as I was able to.”

For his third joint surgery, he was adamant about only using over-the-counter medications. His doctor told him that would be virtually impossible, but he wanted to try it anyway.

“I tried, and within 48 hours I was on the phone with that physician telling him, ‘Oh my God, I had no idea,’ ” Rocky recalled.

“His response was, ‘Rocky I tried to explain this to you, I literally had to cut your thumb off and put it back on.’ He explained to me that there are so many more nerve endings in your hands than most other regions in your body.”

Again, Rocky gave the pain meds to a trusted friend to dispense to him, and things went smoothly.

“I would never tell anyone to avoid surgery while they are in recovery,” Rocky said. “What I would do is to emphasize to them the importance of being open and honest with your surgeon, your physician. I would emphasize the importance of continuing with your recovery routine on a daily basis. I would encourage them to tell their family and their friends in recovery what they are about to go through and what they are going through.”

Preparing

Joint replacement is an invasive procedure, no matter which joint is affected.

“Certainly within orthopedic surgery, joint replacement surgery is kind of a maximally invasive type of surgery because we need the adequate exposures in order to place the components of the implants,” said Dr. Brett Campbell, an orthopedic surgeon at Penn State Health St. Joseph Medical Center in Bern Township. “Typically, we’re using saws and hammers and those types of instruments, so that kind of has that reputation.”

Campbell, who is fellowship-trained in hip and knee replacement, has been in practice since August and said that while performing surgery on patients in recovery is not something he often encounters, he has been taught about it over his years of training.

Treating patients who have an addiction history requires a candid conversation, he said.

“It’s a discussion about how long they have been in recovery, if they’ve had relapses in the past and kind of where their overall comfort is in terms of whether opiates are a reasonable option, even in the short term,” Campbell said. “Another big part of it is the support structure the patient has.”

According to the American College of Rheumatology, there are about 790,000 total knee replacements and more than 450,000 hip replacements performed annually in the U.S.

Dr. Ming R. Wang, associate medical director at Caron Treatment Centers and medical director of the older adults program at the organization’s South Heidelberg Township facility, said a need for joint replacement is common in the population he treats.

“Not everyone in recovery is the same, and we’re talking about people who may be in their early recovery versus someone who might be in solid long-term recovery,” he said. “That’s a very, very different group as far as how they may engage in surgery planning.”

Wang said patients new to addiction recovery may want to jump right into a surgery because they feel better and have completed treatment.

“Establish your recovery first and then think about having an elective surgery, that’s usually what I tell them while they’re with us,” he said.

“One of the big things we do is making sure that we set expectations from the front about how much pain is to be expected and sort of what to expect with the surgery,” said Dr. Kenneth J. McAlpine Jr., an orthopedic surgeon at the Bone & Joint Center and medical director of Reading Hospital’s hip fracture program.

McAlpine said returning patients have it a little easier because the fear of the unknown causes a lot of anxiety and is a stressor that can add to the overall experience of pain associated with surgery.

“If the patients are adamant that they don’t want opioids, at any point, even in the hospital or the acute post-operative setting, then we have to rely on this multimodal pain control in order to provide them with relief,” Campbell said.

Multimodal pain relief

“The first step is typically the use of spinal anesthesia over general anesthesia to provide some additional pain relief and easier recovery,” Campbell said. “Neuraxial anesthesia is kind of the fancy word.”

That involves placing local anesthetic in or around the central nervous system, according to the National Institute of Health’s National Library of Medicine.

“The next step is with the use of peripheral nerve blocks, and those can be done before surgery or after surgery,” Campbell said. “And those provide sensory relief around a knee replacement for some patients. In some patients we can actually leave catheters in place, or like a pump system, that delivers that medication over several days. That can be a better option for anyone who is trying to avoid any kind of opioids.”

Wang said the willingness to discuss those alternatives is a sign of a good surgeon.

“A surgeon who really doesn’t want to talk about that, doesn’t seem to know much about it and says, ‘Oh, we’ll just give you some Dilaudid and you’ll be OK,’ that’s a red flag,” Wang said.

McAlpine said he probably has one patient a month who is in recovery. More often he encounters patients who are just very scared to even start opioids. He attributes that fear to the media attention on opioids or worries about a family history of addiction.

Surgical technique also can affect pain levels, he said.

“One thing that is different is that Dr. Longenecker and I both do more of an anterior approach versus posterior or anterior/lateral,” McAlpine said. “That’s been shown in studies to have much less pain and much quicker recovery in the early postoperative period.”

“Sometimes pain management is needed,” Wang said. “Sometimes it’s unavoidable, just because we are in recovery does not mean that we are denied those medications. If we need it, we need it.”

When Phyllisa Deroze was told she had diabetes in a Fayetteville, North Carolina, emergency department years ago, she was handed pamphlets with information on two types of the disease. One had pictures of children on it, she recalled, while the other had pictures of seniors.

Deroze, a 31-year-old English professor at the time, was confused about which images were meant to depict her. Initially, she was diagnosed with Type 2 diabetes, as shown on the pamphlet with older adults. It would be eight years before she learned she had a different form of diabetes — one that didn’t fit neatly on either pamphlet.

The condition is often called latent autoimmune diabetes of adults, or LADA for short. Patients with it can be misdiagnosed with Type 2 diabetes and spend months or years trying to manage the wrong condition. As many as 10% of patients diagnosed with Type 2 diabetes might actually have LADA, said Jason Gaglia, an endocrinologist at the Joslin Diabetes Center in Boston.

Deroze and three other LADA patients who spoke with KFF Health News, all Black women, are among those who were initially misdiagnosed. Without the correct diagnosis — which can be confirmed through blood tests — they described being denied the medicines, technology, and tests to properly treat their diabetes. Three of them wonder if their race played a role.

“That does seem to happen more frequently for African American patients and for other minoritized groups,” said Rochelle Naylor, a pediatric endocrinologist at the University of Chicago who researches atypical forms of diabetes. “Doctors, like any other person walking this planet, we all have implicit biases that impact our patient experiences and our patient care delivery.”

Black patients have long struggled with bias across the U.S. health care system. In a recent KFF survey, for example, 55% of Black adults said they believed they needed to be careful at least some of the time about their appearances to be treated fairly during medical visits. Hospital software used to treat patients has been investigated for discrimination. Even a common test used to manage diabetes can underestimate blood sugar levels for patients who have sickle cell trait, which is present in nearly 1 in 10 African Americans.

LADA ostensibly has nothing to do with race, but misconceptions about race, weight, and age can all lead doctors to misdiagnose LADA patients with Type 2 diabetes, said Kathleen Wyne, an endocrinologist who leads the adult Type 1 diabetes program at Ohio State University.

Type 2 diabetes develops in people, often over age 45, whose bodies cannot properly regulate their blood sugar levels. Type 2 accounts for at least 90% of diabetes cases in the U.S. and has a high prevalence among African Americans, Native Americans, and Hispanic populations. It can often be managed with lifestyle changes and oral medications.

LADA is more akin to, or even thought to be another form of, Type 1 diabetes, an autoimmune condition once dubbed “juvenile diabetes” because it was most often diagnosed in children. Type 1 occurs when the body attacks its cells that produce insulin — the naturally occurring hormone that regulates blood sugar by helping turn food into energy. Without insulin, humans can’t survive.

LADA is difficult to diagnose because it progresses slowly, Gaglia said. Typical LADA patients are over 30 and don’t require injectable insulin for at least six months after diagnosis. But, like Type 1 patients, most will eventually depend on injections of pharmaceutical insulin for the rest of their lives. That delay can lead physicians to believe their patients have Type 2 diabetes even as treatment becomes less effective.

“If you have someone who comes into your office who is obese and/or overweight and may have a family history of Type 2 diabetes — if you’re a betting person, you bet on them having Type 2 diabetes,” Gaglia said. “But that’s the thing with LADA: It unmasks itself over time.”

Mila Clarke, who lives in Houston, finally saw an endocrinologist in November 2020, more than four years after being diagnosed with Type 2 diabetes. During that visit, she recounted her struggles to manage her blood sugar despite taking oral medications and making significant changes to her diet and exercise regimens.

“‘What you just explained to me, I believe, is a classic case of LADA,’” Clarke recalled being told. “‘Has anybody ever tested you for Type 1 antibodies?’”

Because both Type 1 diabetes and LADA are autoimmune conditions, patients will have antibodies that Type 2 patients typically don’t. But, as Clarke recounted, getting tested for those various antibodies isn’t always easy.

Clarke, now 34, had leaned into her Type 2 diagnosis when she received it in 2016 at age 26. She started a blog with nutrition and lifestyle tips for people with diabetes called “Hangry Woman,” and garnered tens of thousands of followers on Instagram. Clarke said she wanted to fight the stigma around Type 2 diabetes, which stereotypes often associate with being overweight.

“Some of the harshest comments that I had gotten were from people with Type 1 who were like, ‘We’re not the same. I didn’t cause this. I didn’t do this to myself,’” Clarke said. “Well, neither did I.”

Clarke also felt her initial doctor thought she just wasn’t working hard enough.

When she learned about continuous glucose monitors, wearable electronic devices that allow patients to track their blood sugar around the clock, she asked her primary care doctor to prescribe one. The monitors are recommended for patients with Type 1 and, more recently, some with Type 2. “He flat-out told me, ‘No. It’s going to be too much information, too much data for you,’” she recalled.

Clarke switched to a different primary care doctor who she felt listened better and who prescribed a continuous glucose monitor. (Clarke later became a paid ambassador for the company that manufactures her device.) The new doctor eventually referred Clarke to the endocrinologist who asked if she’d been tested for antibodies. The test came back positive. Clarke had LADA.

“In the health care system, it’s really hard to vocalize your needs when you are a woman of color because you come off as aggressive, or you come off as a know-it-all, or you come off as disrespectful,” Clarke said. “My intuition was right this whole time, but nobody believed me.”

Immediately, Clarke noticed an “eye-opening” difference in how she was treated. She started insulin injections and was referred to a dietitian and a diabetes educator. She wondered: Why wasn’t it easier to get tested for antibodies?

Those tests are imperfect and can have false positives, said Gaglia of the Joslin center. Still, Ohio State’s Wyne argued that every diabetes patient should be tested for at least the most common antibody associated with Type 1.

“Aren’t you saving lives if you’re identifying the Type 1 before they come in with DKA and die?” Wyne asked, referring to diabetic ketoacidosis, a serious complication of diabetes most commonly associated with Type 1.

Deroze started asking her doctor for antibodies tests in 2017 after reading about a Type 2 blogger’s experience being newly diagnosed with LADA.

Her endocrinologist denied her requests. She thinks the doctor thought it was impossible for her to have an autoimmune form of diabetes because of her race and weight. She sought a second opinion from a different endocrinologist, who also refused to test her.

“I just felt unseen,” Deroze said.

After a bout with diabetic ketoacidosis in 2019, Deroze finally persuaded her gynecologist to test her for antibodies. The results came back positive. One of the endocrinologists apologetically prescribed insulin and, later, an insulin pump, another ubiquitous piece of technology for people with Type 1.

And for the first time, she encountered the words “diabetes is not your fault” while reading about Type 1 diabetes. It felt like society was caring for her in a way it hadn’t when she was misdiagnosed with Type 2. That’s troubling, she said, and so is how long it took to get what she needed.

“My PhD didn’t save me,” said Deroze, who now lives in the Miami area. “You just see the color of my skin, the size of my body, and it negates all of that.”

___

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

On the presidential campaign trail, former President Donald Trump is, once again, promising to repeal and replace the Affordable Care Act — a nebulous goal that became one of his administration’s splashiest policy failures.

“We’re going to fight for much better health care than Obamacare. Obamacare is a catastrophe,” Trump said at a campaign stop in Iowa on Jan. 6.

The perplexing revival of one of Trump’s most politically damaging crusades comes at a time when the Obama-era health law is even more popular and widely used than it was in 2017, when Trump and congressional Republicans proved unable to pass their own plan to replace it. That failed effort was a big part of why Republicans lost control of the House of Representatives in the 2018 midterms.

Despite repeated promises, Trump never presented his own Obamacare replacement. And much of what Trump’s administration actually accomplished in health care has been reversed by the Biden administration.

Still, Trump secured some significant policy changes that remain in place today, including efforts to bring more transparency to prices charged by hospitals and paid by health insurers.

Trying to predict Trump’s priorities in a second term is even more difficult given that he frequently changes his positions on issues, sometimes multiple times.

The Trump campaign did not respond to a request for comment.

Perhaps Trump’s biggest achievement is something he rarely talks about on the campaign trail. His administration’s “Operation Warp Speed” managed to create, test, and bring to market a COVID-19 vaccine in less than a year, far faster than even the most optimistic predictions.

Many of Trump’s supporters, though, don’t support — and some even vehemently oppose — COVID vaccines.

Here is a recap of Trump’s health care record:

Public Health

Trump’s pandemic response dominates his overall record on health care.

More than 400,000 Americans died from COVID over Trump’s last year in office. His travel bans and other efforts to prevent the global spread of the virus were ineffective, his administration was slower than other countries’ governments to develop a diagnostic test, and he publicly clashed with his own government’s health officials over the response.

Ahead of the 2020 election, Trump resumed large rallies and other public campaign events that many public health experts regarded as reckless in the face of a highly contagious, deadly virus. He personally flouted public health guidance after contracting COVID himself and ending up hospitalized.

At the same time, despite what many saw as a politicization of public health by the White House, Trump signed a massive COVID relief bill (after first threatening to veto it). He also presided over some of the largest boosts for the National Institutes of Health’s budget since the turn of the century. And the mRNA-based vaccines Operation Warp Speed helped develop were an astounding scientific breakthrough credited with helping save millions of lives while laying the groundwork for future shots to fight other diseases including cancer.

Abortion

Trump’s biggest contribution to abortion policy was indirect: He appointed three Supreme Court justices, who were instrumental in overturning the constitutional right to an abortion.

During his 2024 campaign, Trump has been all over the place on the red-hot issue. Since the Supreme Court overturned Roe v. Wade in 2022, Trump has bemoaned the issue as politically bad for Republicans; criticized one of his rivals, Florida Gov. Ron DeSantis, for signing a six-week abortion ban; and vowed to broker a compromise with “both sides” on abortion, promising that “for the first time in 52 years, you’ll have an issue that we can put behind us.”

He has so far avoided spelling out how he’d do that, or whether he’d support a national abortion ban after any number of weeks.

More recently, however, Trump appears to have mended fences over his criticism of Florida’s six-week ban and more with key abortion opponents, whose support helped him get elected in 2016 — and whom he repaid with a long list of policy changes during his presidency.

Among the anti-abortion actions taken by the Trump administration were a reinstatement of the “Mexico City Policy” that bars giving federal funds to international organizations that support abortion rights; a regulation to bar Planned Parenthood and other organizations that provide abortions from the federal family planning program, Title X; regulatory changes designed to make it easier for health care providers and employers to decline to participate in activities that violate their religious and moral beliefs; and other changes that made it harder for NIH scientists to conduct research using fetal tissue from elective abortions.

All of those policies have since been overturned by the Biden administration.

Health Insurance

Unlike Trump’s policies on reproductive health, many of his administration’s moves related to health insurance still stand.

For example, in 2020, Trump signed into law the No Surprises Act, a bipartisan measure aimed at protecting patients from unexpected medical bills stemming from payment disputes between health care providers and insurers. The bill was included in the $900 billion COVID relief package he opposed before signing, though Trump had expressed support for ending surprise medical bills.

His administration also pushed — over the vehement objections of health industry officials — price transparency regulations that require hospitals to post prices and insurers to provide estimated costs for procedures. Those requirements also remain in place, although hospitals in particular have been slow to comply.

Medicaid

While first-time candidate Trump vowed not to cut popular entitlement programs like Medicare, Medicaid, and Social Security, his administration did not stick to that promise. The Affordable Care Act repeal legislation Trump supported in 2017 would have imposed major cuts to Medicaid, and his Department of Health and Human Services later encouraged states to require Medicaid recipients to prove they work in order to receive health insurance.

Drug Prices

One of the issues the Trump administration was most active on was reducing the price of prescription drugs for consumers — a top priority for both Democratic and Republican voters. But many of those proposals were blocked by the courts.

One Trump-era plan that never took effect would have pegged the price of some expensive drugs covered by Medicare to prices in other countries. Another would have required drug companies to include prices in their television advertisements.

A regulation allowing states to import cheaper drugs from Canada did take effect, in November 2020. However, it took until January 2024 for the FDA, under Trump’s successor, to approve the first importation plan, from Florida. Canada has said it won’t allow exports that risk causing drug shortages in that country, leaving unclear whether the policy is workable.

Trump also signed into law measures allowing pharmacists to disclose to patients when the cash price of a drug is lower than the cost using their insurance. Previously pharmacists could be barred from doing so under their contracts with insurers and pharmacy benefit managers.

Veterans’ Health

Trump is credited by some advocates for overhauling Department of Veterans Affairs health care. However, while he did sign a major bill allowing veterans to obtain care outside VA facilities, White House officials also tried to scuttle passage of the spending needed to pay for the initiative.

Medical Freedom

Trump scored a big win for the libertarian wing of the Republican Party when he signed into law the “Right to Try Act,” intended to make it easier for patients with terminal diseases to access drugs or treatments not yet approved by the FDA.

But it is not clear how many patients have managed to obtain treatment using the law because it is aimed at the FDA, which has traditionally granted requests for “compassionate use” of not-yet-approved drugs anyway. The stumbling block, which the law does not address, is getting drug companies to release doses of medicines that are still being tested and may be in short supply.

Trump said in a Jan. 10 Fox News town hall that the law had “saved thousands and thousands” of lives. There’s no evidence for the claim.

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

It sounds like something Elon Musk might have cooked up: “Disease X.”

In fact, the term was coined years ago as a way of getting scientists to work on medical countermeasures for unknown infectious threats — novel coronaviruses like the one that causes COVID-19, for example — instead of just known ones, like the Ebola virus.

The idea was to encourage the development of platform technologies, including vaccines, drug therapies and diagnostic tests, that could be rapidly adapted and deployed in response to an array of future outbreaks with epidemic or pandemic potential.

1. What is ‘Disease X?’

It’s the somewhat mysterious name for an illness caused by a currently unknown, yet serious microbial threat.

The World Health Organization added Disease X in 2017 to a short list of pathogens deemed a top priority for research, alongside known killers like Severe Acute Respiratory Syndrome (SARS) and Ebola.

The issue made it onto the agenda of the World Economic Forum in Davos, Switzerland, with WHO Director General Tedros Adhanom Ghebreyesus joining other health officials to discuss it.

COVID-19, caused by a novel coronavirus, was an example of a Disease X when it touched off the pandemic at the end of 2019. The vast reservoir of viruses circulating in wildlife are seen as a likely source of more such diseases. That’s because of their potential to spill over and infect other species, including humans, giving rise to an infection against which people will have no immunity.

2. What’s the point of studying Disease X?

As the WHO puts it, it’s to “enable early cross-cutting R&D preparedness that is also relevant” for an unknown disease.

The humanitarian crisis sparked by the 2014–2016 Ebola epidemic in West Africa was a wake up call. Despite decades of research, there were no products ready to deploy in time to save more than 11,000 lives. In response, the WHO created an R&D Blueprint to accelerate development of a range of tools for “priority diseases.”

The current list includes: COVID-19; Crimean-Congo hemorrhagic fever; Ebola virus disease and Marburg virus disease; Lassa fever; Middle East respiratory syndrome (MERS) and SARS; Nipah and henipaviral diseases; Rift Valley fever; Zika; Disease X.

3. How’s the research for the next pandemic going?

It took just 326 days from the release of the genetic sequence of the SARS-CoV-2 virus to the authorization of the first COVID vaccine, thanks in part to the work done since 2017 in preparation for Disease X.

Now groups like the Coalition for Epidemic Preparedness Innovations, or CEPI, are supporting rapid response vaccine platforms that could develop new immunizations within 100 days of a virus with pandemic potential emerging under a $3.5 billion plan. Other efforts underway include:

— Updating the International Health Regulations and developing a new global agreement to protect the world from future emergencies.

— A new fund, approved by the World Bank, for pandemic prevention, preparedness and response.

— A WHO Hub for Pandemic and Epidemic Intelligence in Berlin that aims to speed access to key data, and develop analytic tools and predictive models to assess potential threats.

— The Global Virome Project that aims to discover zoonotic viral threats and stop future pandemics.

— A $5 billion U.S. government initiative to develop next-generation vaccines and treatments for COVID-19, called Project NextGen.

— $262.5 million in funding for a U.S. national network for detecting and responding more efficiently to public health emergencies.

— Establishment of global center for pandemic therapeutics.

Still, numerous challenges threaten to undermine these efforts, including depleted and weakened health systems, a growing anti-science movement that has increased vaccine hesitancy, and the potential for governments to eventually deprioritize funding for outbreak detection and preparedness as perceived risks dissipate.

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(With assistance from Marthe Fourcade.)

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